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Neurobiology of Improving One’s

Mental Health

Mindfulness & Neurobiological

Tools for Healing - A Training Resource

By Jim Messina, Ph.D., CCMHC, NCC, DCMHS-T

Resources for Mental Health Professionals to use with this material

Rationale for Mental Health Professionals to Use Neurobiology in Treatment of Clients

Neuroscience help us know about the causes of mental health disorders

Science gives neurological explanations for many symptoms

Science provides more evidence-based explanations for the development of many mental health disorders

It is reassuring to clients to have scientific explanations with evidence thus providing us with the authority when we share these findings with clients

De-stigmatizes the mental health disorders for our clients


Concerns in using Neurobiology in Treatment of Mental Health Disorders

We are not neuroscientists

It can be difficult to accurately explain neurological processes

We won’t be able to answer all questions raised

Neuroscience is young and limited as a scientific field

The concern is that clients might feel a lack of responsibility for their disorders

Oversimplifications is inevitable – So we need to know what level of explanation is valuable and helpful and not be too complex for clients to understand


The Mind and Behavior are Familiar Territory for Therapists

Mind: Mental processes (sensations, thoughts, emotions) that are created by the brain

Brain: Physical, visible, biological basis of the mind

Therapists must maintain a focus on sensations, thoughts and feelings

The focus needs to be the Mind and this can change the Brain

Maintain a therapeutic relationship:

  • Listen,

  • Empathize,

  • Identify client goals,

  • Provide support and

  • Don’t intellectualize

Steps in using Neurobiology in Treating Mental Health Disorders
  1. Use neuroscience information to empower and inspire clients

  2. Make sure that the clients use parts of their brains and not just receive lectures

  3. Give rationale for homework and check on compliance

  4. Let clients tell their stories and hold off giving explanations so that they can explore and get in touch with their personal experiences

  5. Give explanations to help clients identify their responses, feelings, interpretations, explanations and beliefs

  6. Let the clients grow in self awareness and insight


Focus on “Changing their Brain” rather than overcoming their disorder

Present neuroplasticity in the context of the change element in the helping relationship

Pointing out the clear relationship of neuroplasticity to clients' goals is essential

Help clients see how they want to and can change their brain

Be clear that hange isn’t just about reacting differently one time or experiencing a situation differently

The goal is to change the way that the brain responds

Focus on what is important to the clients

Ask the clients to set goals

The Promise of Neuroplasticity

Definition of Neuroplasticity: Ability of the brain to change its structures and reorganize its patterns of responding

In Clients’ Language:

“Your brain doesn’t have to react this way.”

“You can make your brain more responsive to your symptoms”

“We can work together to change your brain to stop doing this”

“The circuitry in your brain can be rewired”

"Your brain is capable of changing your (thoughts, feelings & responses)"

Neuroplasticity is about creating the Self

In neurologically informed therapy, our goal is to select strategies that “change the brain” in desired ways
In a way, we are working to create a new self
Clients are creating new, improved circuitry that leads to new responses and capabilities
This knowledge can raise expectancy for improvement
“Rewiring” is a very accurate and accessible concept to explain the change we wish to accomplish


Neuroplasticity Metaphor

A useful metaphor for neuroplasticity that can be shared with clients is that of a rock-strewn hill:

Imagine a craggy hill that is filled with grass, rocks, and uneven surfaces.
Now, visualize what it would be like to push a large rock all the way down to the bottom of this hill.
It would take a lot of effort to push it over or around existing rocks and mashing down the long grass that is in the way.
Now, suppose I continue pushing more rocks down the same pathway over and over and over again. What would happen?

Most clients get the picture and rightly respond that a groove, a rut, or a path would form. Once that rut is in place, it takes almost no energy to push the next rock down the hill. Just set it into the groove and it rolls right down. This is how habits are formed.

Next, suppose I want to push the rock down the hill in a new direction. In other words, I want to create a change of habit!
But this fresh area of the hill is rocky and grassy, and it takes a lot of effort to push the rock down to the bottom. Even after I’ve achieved this, the old rut still remains.
It doesn’t instantly disappear. So, that’s the challenge of re-wiring the brain.
Even as we make progress, the old rut is still there. Fortunately, if we keep pushing the “rock,” or new behavior, down the hill over and over, a new groove or path will eventually form.
Over time, if the old rut is not used, it will get covered over with new grass and obstructions. Now, we’ll be using the new path, but it takes patience and persistence to develop it.

This rocky metaphor actually describes how neuroplasticity works so the brain can wire and then re-wire itself.

Reference: Altman, D. (2014). The Mindfulness Tools Box. PESI Inc. Eau Claire, WI. ISBN: 978-1-9361288-6-0


Neurobiologically Based Therapy is a Model of Reconsolidation
Consolidation: Formation and storage of memories in the brain
  • Based on strengthening connections between neurons
  • When one neuron is firing at the same time as another neuron, calcium channels open and the flow of calcium (i.e., Long term potentiation) stabilizes the connections of the two neurons
  • This takes time but can be disrupted
Reconsolidation: When memories are accessed they are in a labile state and can be modified in ways before being stored again
  • New neuroscience evidence suggests that emotional memories can be modified in ways that we didn’t previously recognize
  • Memories are not like DVD’s that are unchanged by each viewing
  • Each time memories are accessed, they have the potential for change
  • Even emotional memories the brain makes are capable of being modified

Neuropsychologically Informed Cognitive Behavioral Therapy Modalities
  • Cognitive Behavioral Therapy (CBT) has been developed and influenced by a variety of researchers and therapists including Meichenbaum, Beck, and Ellis
  • Neurologically effective techniques include psycho-education, identifying cognitive distortions, use of cognitive restructuring, exercise, sleep, relaxation training, and exposure techniques such as Cognitive Processing Therapy; Prolonged Exposure Therapy & EMDR)
  • Assigned homework is typically a part of treatment, which is consistent with promoting change in a neurologically based model
  • Clients are expected to observe and change their own thoughts and behaviors in exercises outside of the therapeutic setting
  • Skills-based approach with an emphasis on eliciting and practicing new behaviors is also consistent with neurological approach (Strengthens neural connections)
  • Strong focus on the present is also consistent with neurologically informed approach since Too much focus on the past strengthens existing circuitry and makes neurological change less likely
  • Do discuss the past when clients have a strong need to, as when processing trauma and discussing the past will assist therapists to understand relevant history.Discussing the past can also be used to assist clients in understanding where beliefs and reactions were learned
Psychoeducation is an essential part of neurologically informed therapy since it provides:
  • knowledge of brain’s role in creating anxiety and other stress response
  • Understanding of the Fight/Flight/Freeze response
  • New understanding of anxiety & stress which promotes tolerance of it
  • Recognition of thoughts that elicit anxiety & stress
  • New understanding of the relationship between thoughts and the amygdala, the neurological basis of anxiety & stress response
  • Learning to modify thoughts in order to manage anxiety and stress
Expectancy: clients’ thoughts and feelings about how much they will improve and their expectations of the helpfulness of the therapy in reducing symptoms is encouraged by CBT therapies. It has been shown to be a significant predictor of change in treatment
Note: It is an Interesting point that clients with lower expectancy improve more in CBT than in psychodynamic treatment, perhaps because CBT therapists are more likely to target low expectations with cognitive restructuring.Neuroscience explanations can influence expectations when focus is on explaining ways to change the brain.
What causes anxiety?

What creates anxiety in the brain?

How can we influence the process of the brain producing anxiety?

Note: This information is explained gradually over the course of treatment


Identifying Two Pathways to Anxiety & Stress Response
Underlying principle: In general, two separate pathways in the brain can give rise to anxiety
Bottom Up Triggering of Emotion
  • Links between perceptual representations and amygdala
Top Down Emotion Generation
  • Links between high-level cognitive representations of stimulus meanings and amygdala (e.g., cortex processes)
Each pathway needs to be understood and treated for maximum relief
  • All clients experience anxiety through both pathways.
  • Some clients may find their anxiety more frequently arising in one pathway than the other, depending on the specific anxiety they are experiencing.

Recognizing the different pathways can assist in treatment.

  • Different pathways respond to different types of treatment
  • A given treatment may not have an effect on the area of the brain initiating or maintaining anxiety
  • “It’s like looking in the refrigerator to try to figure out why your car won’t start.”

The Goal then with Clients is to:

  •  To explain the differences between the two pathways to anxiety
  • To demonstrate how anxiety is created in each pathway
  • To provide practical ways to modify each pathway in order to make anxiety less of a burden

We want to focus on the parts of the brain that

  • Help clients understand their experienc
  • Help clients have an understanding of important underlying processe
  • Help clients understand how to modify the anxiety response
Explaining the Two Pathways to Anxiety and Stress Response
  • Focusing on amygdala and cortex pathways
  • Both pathways start from sensory information coming in
  • One pathway travels from the thalamus through the detail-focused circuitry of the cortex, and eventually gets to the amygdala, which produces the anxiety response.
  • The other pathway runs directly from the thalamus to the amygdala.
  • The amygdala has a role in each of the two pathways.
Example: Anxiety Responses there are two channels: First is through the Amygdala
The Second Channel for Anxiety is through the Cortex Which is slower and more long lasting

Two Pathways to Anxiety
  • All clients experience anxiety through both pathways
  • Some clients may find their anxiety more frequently arising in one pathway than the other, depending on the specific anxiety they are experiencing
  • Each of the two pathways can lead the amygdala to create anxiety, but each pathway is constructed of circuitry, and certain aspects of the circuitry in each pathway can be modified
  • The different pathways operate on different timetables, with the amygdala pathway being more swift
  • Cortex has few connections to the amygdala, but amygdala has many connections to the cortex
  • This means the cortex has fewer influence on the amygdala than the amygdala has to influence the cortex
About the Amygdala
We have an amygdala on each side of our brain.

Locating the amygdala with eye and ear…

Each is about the size of an almond.- Amygdala means almond in Greek.

The amygdala is made up of hundreds of circuits of cells dedicated to different purposes: love, bonding, sexual behavior, anger, aggression, and fear.


The Amygdala's Role
It attaches emotional significance to situations or objects and forms emotional memories (positive and negative) - Its like adding a post-it note to stored memory.

The amygdala plays a role in both the cortex pathway and the amygdala pathway to anxiety.

Like the conductor of an orchestra, it controls many different reactions in both your brain and body.

Provide clients with an introduction of Fight/Flight/Freeze response since they benefit from understanding the nature and purpose of this response

  • Helps reduce catastrophic interpretations in cortex
  • Helps to reframe experience
  • Helps them to have realistic expectations about controlling responses
The Amygdala controls many different reactions in both the brain and body
It is the home of the Fight/Flight/Freeze response which is activated in response to a trigger before the cortex has time to process the information – It occurs before the person can thinkFight/Flight/Freeze response results form the connections of the amygdala with the hypothalamus and the brainstem and It activates the sympathetic nervous system
  • Increasing the heart rate and respiration
  • Slowing digestion
  • Increasing blood flow and glucose in muscles
It helps reduce catastrophic interpretations in the cortex and helps to reframe experience and to have realistic expectations about controlling response

Amygdala as Protector
  • The amygdala has some pre-programmed responses - Some fears are more readily learned
  • It is also exquisitely sensitive to what happens to you in your life and it responds to your specific experiences.- Your experiences also shape what elicits fear.
  • When you understand how the amygdala learns on the basis of your day-to-day experiences you can train your amygdala to rewire connections in your brain
  • Your amygdala can learn to react differently to situations that cause you anxiety.

The Language of the Amygdala

Alarm/Response System

  • Instead of hearing alarm, one feels it.
  • The system is about creating a bodily response, not thoughts.

Fight/Flight/Freeze response

  • Amygdala’s response to any potential danger is limited.
  • Body is being prepared to run, fight, or freeze.
  • Everyone’s brain is hardwired to allow the amygdala to seize control in times of danger.

The amygdala makes emotional memories.

  • It does this by attaching emotional reactions to certain memories.
  • It learns from your experiences, but makes error in learning
Association is an essential part of the language of the amygdala.
  • The amygdala learns on the basis of pairings.
  • The amygdala is not logical.
  • Amygdala turns certain situations/objects into Triggers for anxiety.
Scientists have not only learned how and where triggers are created in the amygdala, but they have also learned how to train the amygdala to stop responding to triggers.
  • The amygdala needs *experience* to learn.

Triggers are Created in the Amygdala

When a Trigger is paired with a Negative Event, typically something that automatically causes pain, discomfort, or other negative responses, the Trigger comes to elicit fear or anxiety


Pairing can be triggered by association pairing as shown here


Exposure Therapy makes new connections


Managing the Amygdala: Essential for treating all Anxiety and Stress

The activation of the amygdala can be conceptualized as the “fuel” for all anxiety  and stress and what the person does to respond to, and manage, the symptoms of anxiety and stress differs, but amygdala activation underlies and motivates the disordered behavior.
  • Worrying may be used to reduce anxiety or feeling stressed
  • Compulsions may be used to reduce anxiety and stress
  • Avoidance may be used to reduce anxiety and stress
Anything we can do to help  clients become more able to manage amygdala activation is beneficial in managing their symptoms of anxiety and stress

Neuroplasticity of the Amygdala

Some interventions have immediate effects on the activation of the amygdala:

  • Diaphragmatic Breathing
  • Aerobic Exercise
  • Yoga

Some interventions work in a short term way, changing the general level of activation for a period:

  • Regular aerobic exercise
  • Yoga
  • Adequate Sleep

Some interventions rewire the circuitry in the amygdala, producing lasting change:

  • Exposure: Prolonged Exposure Therapy, Cognitive Processing Therapy, EMDR
Amygdala-based interventions: Exposure Therapies e.g. Cognitive Processing Therapy, Prolonged Exposure Therapy, EMDR

Exposure is the way to rewire the amygdala.

  • Some clients become more engaged in Exposure when it is framed as “teaching” the amygdala.
  • Remember: the amygdala is not always accurate, responds in error, and needs to be corrected, not trusted.
  • The amygdala needs *experience* to learn.
  • The amygdala learns on the basis of associations or pairings.
  • Presenting the stimuli that elicit anxiety and having no negative consequences occur (other than anxiety) teaches the amygdala new responses

Push through anxiety to change the amygdala.

  • New connections in amygdala are only made when the circuitry is activated, and this also means anxiety is being experienced.
  • Explain: We need to “Activate” the amygdala to “Generate” new connections.
  • Remember idea of “reconsolidation”
  • Withstanding anxiety can lead to permanent change.
  • Just like you need to get the water hot to make tea, you need to heat up the circuitry to make changes in it
  • When you feel anxiety, you know you have the “amygdala’s attention” -- the circuitry is being placed in a state when changes can be made

Avoidance robs the amygdala of opportunities to learn

  • When an individual avoids a situation or object that elicits anxiety, it prevents the amygdala from having a new experience with that situation or object
  • Avoidance *preserves* the current wiring and the anxious responding
  • New experiences with the situation or object are needed in order to provide the amygdala with learning experiences. *Withstand anxiety to promote learning*

The amygdala needs *experience* to learn!


Rewiring the Amygdala with Exposure Therapy

Exposure: Staying in the presence of a situation, object, thought, or emotion that evokes anxiety and distress (Flooding, EMDR are examples)

Extinction/Habituation: Reduction of fear due to prolonged or repeated exposure

Imagery Practice: Mentally visualizing or experiencing thoughts about the feared situation and the consequences of situation

Response Prevention: Refraining from the behavior that client uses to reduce anxiety about situation (negating, undoing, checking)

Response Repetition: Repeating the behavior typically used to reduce anxiety until it is punitive.


In Exposure Therapies

  • Clients arepresented with objects, cues, situations, that provoke anxiety, which are typically avoided
  • Repeated exposure increases ability of clients to tolerate anxiety-provoking situations and stimuli and ultimately reduces anxiety stress associated with these situations and stimuli
  • It is essential that the clients experience anxiety for exposure to be successful (Activate the circuits!)
  • Exposure is one of the most powerful therapeutic tools in the CBT toolkit
  • Many therapists are reluctant to attempt exposure due to their own fears, and miss an essential tool that accomplishes many changes

Goals of Exposure Therapies

To increase clients tolerance for internal sensations in feared situations

To extinguish fear/anxiety responses by establishing new learning in the amygdala

To provide a new learning opportunity to examine negative predictions about feared outcomes (cortex- based)


Medication use can negatively impact these goals

Decreased activation can prevent change.

Attributions about responding made by the client are important

State-dependent learning can limit effectiveness of treatment

Tips for Exposure Therapy Effectivenss
  • Have client rate situations. Use SUDS rating: 1-10 were 10 is the most stressful
  • Start with situations that have rating around 5 or 8
  • Have Clients stay in situation until fear is reduced by half. May take as long as 45 minutes to an hour. Not typical session.
  • Goal is to experience anxiety, but may use deep slow breathing to calm the amygdala
  • Validate emotions, don’t reassure or minimize
  • Goal is for clients is to learn “If I stay in situation, my anxiety will go down without any action on my part”
  • Once anxiety is reduced when clients are in situation, you can move on to other situations
  • Start with therapist present, then assign homework

Develop Exposure Homework for Amygdala-based Anxiety and Stress Responses

Identify Beliefs that could Interfere: I won’t be able to handle experiencing anxiety.

Discuss/Role Play ways to approach situation

Clearly define expectations for exposure and write them on a note card:

  • What will you do? What are the steps?
  • What will you think when you feel anxiety?
  • What will you do to push through anxiety?
  • Identify potential obstacles to carrying out plan

Write plan for coping with obstacles on note card

Prepare client to accept discomfort that comes rather than waiting for discomfort is over to do the exposure.


Tips for Exposure Therapy Treatment Effectiveness

1. Imagery

  • Useful when you can’t create situation or when therapist can’t visit it– also prepares for in vivo work
  • Ask client to create detailed images of what they are concerned about– actions and consequence
  • Rate distress (0-10) and belief it will occur (0-10)
  • Sharing these images with therapist may be difficult and therapist may need to guess at some and show comfort with discussing them
  • Start by focusing on least distressing scene of those described
  • Record a description of the scene and consequences and have client listen to it repeatedly each day
2. Exposure with Response Repeition (EX/RR)
  •  Client is given option for EX/RP, but if this fails the compulsion is allowed, but *then* must be repeated a specified number of time. Increase as necessary, considering action. 
  • Always try EX/RP first because it makes sense to client, and it also has best evidence of success
  • Only if this approach has been tried and client hab difficulty then the client not offered the EX/RR approach
  • Client does not have trouble complying with compulsions but it makes compulsions under his/her control rather than awkward
  • Dissociation response from anxiety reduction and the repetition makes it unpleasant and punishing

Limitations of Exposure Therpies for the Amegdala

The general interventions recommended (e.g., Cognitive Processing Therapy, Polonged Exposure Therapy, mindfulness, Reconsolidation) are grounded in evidence-based methods that have been demonstrated to be effective in treating anxiety-based disorders and other psychological disorders.

While these interventions are based on empirically supported methods that have been documented to be effective treatments, every individual is unique and the treatment that benefits one client may not help another. These interventions  may not be appropriate for particular clients, or suitable for every clinical situation.

Managing the Cortex: GAD, SAd, OCD, PTSD, but also Depression, Eating Disorders and Substance Abuse
  • The cortex plays an “anxiety igniting” role in many anxiety disorders, as well as other disorders
  • The thoughts and images that the cortex creates result in activation in the amygdala that produces distress
  • Recognizing when activation begins in the cortex, and modifying cortex responding, can reduce amygdala activation.
  • Managing the cortex can prevent anxious responding

Cortex

Curved, gray part of your brain

The “perceiving” and “thinking” part of your brain - processes sensory information received continuously from your senses, putting that information together to enable you to perceive your world and attaches meaning and memories to your perceptions so that you recognize objects, understand words and provides you with the ability to understand and interpret situations and allows you to use logic and reasoning, to understand language, to use your imagination, and to plan ways in which to respond to situations.

Cortex Pathway to Anxiety and Stress Response
  • Begins with our sense organs: our eyes, ears, noses, taste buds, even our skin
  • Information coming from our sense organs is directed to the thalamus, which is like the Grand Central Station of the brain.
  • The thalamus sends the information to the correct location in the cortex to be processed
  • The cortex creates our perceptions of situations
  • Also the cortex can create thoughts and images that go beyond our perceptions

How Does the Cortex Initiate Anxiety and Stress?
  • There can be no anxiety or fear without the amygdala. Cortex may “initiate” but cannot create anxiety
  • The cortex interprets situations and the interpretations often initiate unnecessary anxiety
  • The frontal lobes of the cortex anticipate situations - and the anticipation often creates unnecessary anxiety
  • Right hemisphere produces images that can create unnecessary anxiety
  • The left hemisphere elaborates worries and ruminates, creating and prolonging anxiety
Relationship of Cortex to Amygdala
  • The amygdala gets information from thalamus, but also relies on information from the cortex to assess relevance

Example to show how useful it is to have cortex to activate amygdala: In the figure below the couple is on a date for the first time after the birth of their baby, while at dinner they become fearful for the well being of the baby even though there is no evidence to support this fear.

  • Amygdala errs on the side of caution and will defer to cortex when cortex infers danger
  • Neurology: The amygdala has many connections to cortex, to both *influence* and *monitor* cortex activity
  • Cortex has few connections to influence amygdala