Neurobiology of Improving One’s
Mental Health
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Mindfulness & Neurobiological
Tools for Healing - A Training Resource
By Jim Messina, Ph.D., CCMHC, NCC, DCMHS-T
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Resources for Mental Health Professionals to use with this material
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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:
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Listen,
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Empathize,
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Identify client goals,
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Provide support and
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Don’t intellectualize
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Steps in using Neurobiology in Treating Mental Health Disorders
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Use neuroscience information to empower and inspire clients
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Make sure that the clients use parts of their brains and not just receive lectures
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Give rationale for homework and check on compliance
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Let clients tell their stories and hold off giving explanations so that they can explore and get in touch with their personal experiences
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Give explanations to help clients identify their responses, feelings, interpretations, explanations and beliefs
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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
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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
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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)
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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
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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
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Understanding of the Fight/Flight/Freeze response
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New understanding of anxiety & stress which promotes tolerance of it
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Recognition of thoughts that elicit anxiety & stress
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New understanding of the relationship between thoughts and the amygdala, the neurological basis of anxiety & stress response
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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.
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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 experience
- Help clients have an understanding of important underlying processes
- 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.
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Example: Anxiety Responses there are two channels: First is through the Amygdala
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The Second Channel for Anxiety is through the Cortex Which is slower and more long lasting
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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
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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.
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The amygdala learns on the basis of pairings.
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The amygdala is not logical.
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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.
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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
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Pairing can be triggered by association pairing as shown here
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Exposure Therapy makes new connections
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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
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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 Repetition (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 Therapies for the Amygdala
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.
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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.
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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
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Relationship of Cortex to Amygdala
- Some anxiety begins in the cortex: the amygdala is not initially activated but becomes activated by cortex
- Explain to clients that thoughts or images from the cortex can “scare” the amygdala
- Also, the amygdala may be activated from sensory input, and the cortex interpretations worsen the activation
- Dissociating from Amygdala: Clients can understand the idea of not activating their amygdala.
- Rather than argue about the logic of their thoughts, focus can be placed on the impact of thoughts on the amygdala. “Don’t scare your amygdala!”
The Cortex can Make a Safe Experience provoke Anxiety
Here’s an example (see figure below).
A high school senior who had applied to several colleges looked at the mail and saw an envelope from one of the colleges he’d applied to.
Imagining that the envelope contained a rejection letter, he had a few very anxious moments before opening the envelope.
As it turned out, he’d been admitted and had even been awarded a scholarship. Nevertheless, his cortex initiated an anxiety response by interpreting the sight of the envelope in a way that created distressing thoughts, and these thoughts activated his amygdala.
This type of cortex-based anxiety depends on the cortex’s interpretation of the sensory information it receives.
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The Cortex can make a safe experience provoke anxiety: E.g.College applicant sees letter in mailbox and does not read it but has an anxious response to it which it turns out was wrong
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The Cortex can create Anxiety and Stress in the Absence of any Relevant Experiences at all
The cortex can even initiate an anxiety response without the involvement of any specific external sensations.
For example, when worries or distressing thoughts are produced in the cortex, this can activate the amygdala to produce an anxiety response even though the person hasn’t seen, heard, or felt anything that’s dangerous.
An example would be parents, presented earlier, of an infant who leave their little boy with a babysitter to go out for dinner. — Even though there is no evidence of problems, the parents suddenly begin to have concerns about their child’s safety. The boy is perfectly safe, but the parents imagine that he’s in distress or being neglected by the sitter.
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Example: Parents leave child with babysitter to go out on a date and even though no evidence of problems the parents suddenly begin to have concerns about their child’s safety.
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Identifying Specific Cortex-base Contribution to Specific Disorder
Knowing the nature of the typical cognitive distortions associated with various disorders can be helpful to the therapist
Anxiety is associated with thoughts about threat likelihood and severity
Specific beliefs, attitudes, and interpretations are often associated with a given disorder
An awareness of these cognitions can assist the therapist in recognizing them in the treatment process and helping clients to identify and resist them
If these beliefs, attitudes, and interpretations can be questioned by the clients anxiety is less likely to be ignited in the cortex
Thoughts that are a focus of concer is Social Anxiety Disorder (SAD)
Common cognitions associated with SAD include expectations about being judged by others, expectations of failure or embarrassment
Mind reading: Conjectures about what others are thinking and drawing conclusions based on this
Anticipatory Thoughts: Conjectures about what is likely to occur in an upcoming situation
Anticipatory thoughts are commonly about
- Others closely observing one
- Criticism/Rejection
Thought that are often the focus of concern in the Cortex in OCD
Doubt/Uncertainty: The fact that the person is not sure of an outcome. Could be own performance, others’ reactions, general intolerance of uncertainty.
Incompleteness: Need for an action or event to be completed, in a symmetrical or correct manner.
Thought/Action Fusion: Belief that a thought indicates that a behavior is likely to occur
Guilt: Feeling responsibility, blame and shame for behaviors or even thoughts.
Contamination: Thoughts about being exposed to dirt, germs, illness
Thought that are often the focus of concern in the Cortex in GAD
Anticipatory Thoughts: Conjectures about what is likely to occur in an upcoming situation
Mind reading: Conjectures about what others are thinking and drawing conclusions based on this
Worry: A thought that something could potentially occur. Could be safety or health related. Could also be academic or occupational.
Doubt/Uncertainty: The fact that the person is not sure of an outcome. Could be own performance, others’ reactions, general intolerance of uncertainty
Thought that are often the focus of concern in the Cortex in PTSD
Guilt: Feeling responsibility, blame for something that occurred.
Shame: Feeling that one is unworthy, dirty, evil, a monster, etc. (Zayfert & Becker, 2007)
Belief that Fear means Danger: Intepreting feelings of fear or anxiety to mean that a danger exists
Hopelessness: A belief that one cannot be helped or that the future is bleak
The world is an Unsafe Place: A belief that danger is constant and that people can’t be trusted
Self Doubt: Difficulty trusting oneself to handle events
Neuroplasticity in the Cortex
The learning processes that affect the cortex are much more understood by clients.
The cortex can respond to education, logic, and argument, as well as experience.
Discussion and exploration of ideas can produce changes in cortex – which does not occur with amygdala.
Some cognitive interventions (e.g., explanation) have immediate effects on anxiety.
- Identifying the reason for anxiety symptoms reduces anxiety-eliciting thoughts.
Some cognitive interventions take some time for client to recognize pattern and modify schemas.
- Recognizing that anticipatory anxiety is not a prediction of danger or failure.
Some interventions require clients to be more comfortable with having anxiety provoking thoughts
- Reducing Cognitive Fusion and increasing Mindfulness
Overall, the best way to rewire the circuitry in the cortex is for clients to practice the thoughts and interpretations they want to strengthen.
*Note: Survival of the busiest*
Cortex-based Interventions: Survival of the Busiest
The circuitry that is the most used becomes the circuitry that is strongest and survives
This suggests to clients that their ability to interrupt and change their thinking processes is not just a short- term form of anxiety reduction- it rewires the cortex.
Cognitive Restructuring methods…
With practice they are decreasing the likelihood of some thoughts and increasing the likelihood of whatever thoughts they are thinking.
Same applies to images…
Aaron Beck’s Cognitive Therapy approach examines how cognitions mediate our emotional reactions.
The focus is on challenging and changing the cortex-based beliefs that we have about the event.
Event -> Interpretation -> Reaction
The event can be an experience or situation, but it can be also thought or mental imagery, especially in OCD
Important to recognize the cortex’s interpretation leads to the reaction (typically anxiety), not the event
Interpretations
The way we interpret events can initiate anxiety
- Pessimism
- Catastrophizing
- Obsessing
- Worrying
- Perfectionism
- Guilt and Shame
Also, cortex’s interpretations of anxiety responses can often worsen anxiety or prolong it
- I’m having a heart attack
- I’m going crazy
- I’m going to fail at this
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Cortex-initiated Anxiety: Way we interpret:Pessimism; Catastrophizing; Worrying; Perfectionism; Guilt & Shame; Worsen/Prolong anxiety: I’m having a heart attack; I’m going crazy; I’m going to fail at this!
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How is Cortex Increasing a Person's Anxiety?
- Overestimation of danger
- Ask about likelihood 0-10
- Awfulness of situation
- Ask about awfulness 0-10
- Feeling responsibility for danger
- How at fault would you feel? 0-10
- Underestimation of ability to cope
- How much do you feel prepared to cope? 0-10
- Being STUCK in a certain perspective
Therapist needs to challenge these!
Cognitive Interventions Target the Cortex
Just discussing these thoughts allows client to examine the logic, likelihood of ideas
When client argues with self, make sure you hear both sides– like a phone conversation, you may only hear one side.
Work to modify client’s INTERPRETATION of the event and its significance
What did this event or thought mean?
How much do you believe your interpretation is correct?
How did it affect you?
How did you deal with the event or thought? ***
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Cortex-based Interventions
1. Fighting Anticipation and Worry
When interpreted as activating the amygdala, worries and anticipatory thoughts can be conceptualized as “frightening the amygdala”
Watching the “Anxiety Channel”
- Think of your cortex as cable television: Do you really want to watch this particular channel?
"Channel” idea helps clients to see that the situations and events that they think about are not the problem– the thought process itself is the problem.
Change the channel!
2. Fighting Anticipation
Anxiety-provoking anticipatory thoughts in client’s life need to be identified.
Identify the process of anticipation, which is a human ability that occurs in frontal lobes
Has been helpful, but causes much suffering
Encourage client to determine the accuracy of anticipatory thoughts in the recent past.
Invite client to see the “shape” of anxiety, recognizing that it peaks BEFORE an event
Don’t assume that anticipatory anxiety predicts outcome– or even future anxiety (e.g., Public speaking)
3. The Appropriate Use of Worry
Challenge client assumption that worry is motivating or preventative.
Schedule worry if necessary, to help bring it under control
“Worry Channel” idea helps clients to see that the situations that they are worried about are not the problem– the anticipation/worry itself is the problem.
Activates amygdala
Worry is only helpful if it leads to a plan and stops.
4. Cognitive Defusion
Cognitive Fusion is a useful topic to address
Treating a thought or feeling as if it were a reality, in absence of evidence.
Difference between “Thoughts about Events” and “Events Themselves”
Mark Twain: “I’ve lived through some terrible things in my life– some of which actually happened.”
Cognitive Defusion Strategy
Don’t confuse thoughts with reality.
“I need to be careful of this pesky thought, because it is likely to activate my amygdala.”
5. Provide Alternative Interpretations
Anxiety is proportional to the perception of danger
Challenge client’s assumption that the thought necessarily has a negative impact
- “Uncertainty can be a positive state of mind.”
- “Feelings of attraction can be a good thing to have.”
Alternate interpretations of thought
- Clouds in the sky or waves on a beach
- Birds in branches – don’t let them nest
- Trucks going by on the street – don’t jump in front!
Metaphors are cognitive enhancements– Using vivid images and ideas improves recall
6. Coping Thoughts
There is no way to stop activation in circuits by activating those circuits (E.g., Don’t think about pink elephants.)
“You can’t erase– You must replace.”
Learning Coping Thoughts to replace worries
- My anxiety always goes away eventually.
- I will get through this.
- Don’t worry– it never helps anything.
- No one is perfect.
- It’s normal to make mistakes.
- Anxiety is a feeling, it doesn’t mean anything.
- This “feeling” has been wrong before.
- Pleasing everyone is impossible
7. Coping Thoughts in OCD
We want clients to replace their perspective:
Client’s view: “I am a horrible parent because I have thoughts of harming my child.”
Alternate view: “I’m a loving parent who gets worried about thoughts of harming my child.”
Client’s view: “I am contaminated by germs and will get sick and die.”
Alternate view: “I am a healthy person who is afraid of getting contaminated and sick.”
To help client remember coping thoughts, we can record sessions and have them listen to them repeatedly outside of session.
8. Develop Behavioral Experiments for Cortex-based Anxiety
Identify Belief: My friends don’t want to spend time with me and decline my invitations
Discuss/Role Play ways to talk with/meet friends
Clearly define expectations for experiment and write them on a note card:
- What will you try?
- What will you think/feel if they agree?
- What will you think/feel if they don’t agree?
- What will you do in each case?
Identify potential obstacles to carrying out plan
Prepare to accept discomfort that comes rather than
9. Distraction
Distraction: Keeping the cortex focused on something that is engaging to stop it from creating/activating anxiety-producing thoughts and memories
Can be a controversial approach because distraction is not the FIRST approach one should use
If distraction is used while client believes the thoughts are dangerous, it can serve to reinforce this belief
Distraction will not be effective if client believes the thought is dangerous and is engaging in avoidance
Client must understand that the thought is not dangerous and is not worth spending time or effort on
Keep the cortex focused on engaging thoughts to stop it from activating the amygdala
The focus here is on managing the cortex, not to prevent “dangerous” thoughts
Note that the goal is NOT to distract oneself from anxiety itself– this typically occurs before anxiety
Client needs to learn to feel anxiety and accept that anxiety can be tolerated.
Caution: Distraction is *not* appropriate during exposure because it reduces amygdala activation
Keep the cortex focused on something that is engaging that will benefit the person in general
Focus on *Living Your Life* rather than anxiety
- What do you need to do today?
- What would you like to do today?
Intellectual pursuits
Playing- Need permission?
Positive Imagery to compete with right hemisphere negative imagery
Caution again: Distraction is *not* appropriate during exposure because it reduces amygdala activation
10. Left vs. Right Hemisphere Interventions
Left Hemisphere:
Most of the interventions discussed are based in the left hemisphere:
- Cognitive Restructuring
- Modifying Interpretations
- Cognitive Defusion
- Coping Thoughts
- Correct Use of Worry
- Distraction (depending on the distraction)
But we should not neglect the right hemisphere’s potential contributions to anxiety creation… and resistance.
Right Hemisphere:
Neuroimaging studies show right hemisphere activation is strongly associated with anxious arousal and immediate threat
Right hemisphere is ;
- More focused on nonverbals
- The source of imagery in the brain
- Area of the brain that processes music
- Focused on processing whole rather than parts
Each of these can be activating to the amygdala…
To reduce right hemisphere activation, seek activities that engage the left hemisphere
- Watching amusing programs,
- Reading thought-provoking articles,
- Playing games, especially word or logic games.
Can effectively use music to improve mood.
- Listening to Music
- Singing
Replace negative images with art work or images that engage the right hemisphere.
11. Mindfulness Approaches
What if cortex gives up the goal of controlling anxiety, and allows anxiety to happen?
Responding with acceptance
Acceptance is the antidote to anxiety
Anxiety is often perpetuated by cortex’s secondary reactions
Mindfulness strategies reduce anxiety in the moment
Mindfulness also produces changes in the cortex that makes cortex more resistant to anxiety
Interesting that amygdala responding doesn’t change– prefrontal areas in cortex no longer respond in the usual way
Apply the Cognitive Model to OCD
Event -> Interpretation -> Anxiety -> Ritual
In OCD, the compulsion or ritual is a fourth step— a behavior that reduces anxiety temporarily, but it does not help in the long run
- This solution to the problem becomes part of the problem, and creates more difficulties
Help clients see that their selected *solution* to the problem of OCD is what is really threatening their ability to have productive lives--not the Event itself or the Anxiety.
- They can live with OCD if they change their *interpretation* rather than trying to change anxiety
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Over View of Treatments with the Amygdala & Cortex
Events Negative Emotional Ritual/Compulsion
Interpretations Reaction
Exposure Cognitive Strategies Mindfulness Response Prevention
Mindfulness Cognitive Resturcturing Response Prevention Scheduling
Thought Stopping Relaxation Response Repetion
SSRIs
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Trauma and the Brain
Neglect and Abuse impair the development of integrative fibers of the brain.
The timing of traumatic experience shapes which fibers are affected.
Integrative impairment leads to classic PTSD symptoms including dissociative processes.
Trauma results in the mind developing negative core beliefs* which need to be altered to positive core beliefs to enable clients to grow in the trust and belief that they can change and grow (2018, Otis, Willimas & Messina).
How does Childhood Trauma fit into this Picture
We know that Adverse Childhood Experiences have a major impact on the functioning of children under 18 years of life which can impact both their emotional and physical health over their lifetime. This is because these children have embedded in their cortex negative messages about themselves due to having one or more of these negative ACE Factors in their life:
Abuse
1. Emotional Abuse
2. Physical Abuse
3. Sexual Abuse
Neglect
4. Emotional Neglect
5. Physical Neglect
Household Dysfunction
6. Mother was treated violently
7. Household substance abuse
8. Household mental illness
9. Parental separation or divorce
10. Incarcerated household member
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Within the Cortex Negative Core Beliefs are retained by these trauma victims
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*Reference: Otis, H.G., Williams, S. & Messina, J.J. (2018). Key Core Beliefs – Unlocking the HEART of Happiness & Health. Colorian Press, Highland Utah. ISBN 978-1-7323638-0-3
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The Impact of Trauma on these Youth also impacts their Levels of Human Attachment
Four levels of Human Attachment
1. Secure Attachment: These youth with no major childhood trauma feel: Seen, Soothed, Safe and Secure – up to 60% of our populations
2. Avoidance Attachment: These youth do not feel seen, not soothed and are forced into premature autonomy - 20% of our population
3. Ambivalent Attachment: Too little differentiation, filled with uncertainty, clinging, seen as needy, peers see them as insecure – 15% of our population
4. Disorganized Attachment: Overlaps with the other 3 forms of attachment - 5-15% of our population – 80% of this group come from dysfunctional families in which their Negative Core Beliefs are nurtured
- Teachers find them not good under pressure and stress
- Fellow peers find them unstable
- They suffer from depersonalization, derealization, numbing and many have major personality disorders such as Dissociative Personality Disorder
Therapeutic Strategies of Intervention
The psychotherapeutic relationship “SNAGs” the brain toward
Integration:
S timulates
N euronal
A ctivation &
G rowth
Integration: A simple but powerful framework
Integration is Linkage Of Differentiated Parts
Secure Attachment is dependent on Integration
Integrative Functions of the Prefrontal Cortex
1.Bodily Regulation
2.Attuned Communication
3.Emotional Balance
4.Fear Modulation
5.Flexible Responding
6.Insight
7.Empathy
8.Morality
9.Intuition
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When a mind is integrated it is a flowing river but if not integrated the mind is either Chaos (blocked linkage) or Rigidity (blocked differentiation)
The mind is not just in the brain we are all part of a larger system
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Strengthening the Mind
To strengthen the mind entails: Enhancing Regulation through:
Monitoring
Modulating
Trauma and Impaired Integration
Linking fibers are damaged
Epigenetic changes often occure
Self-reinforcing interpersonal behaviors emerge post trauma
A “Tapped Mind” caught in a neutrally and interpersonally reinforcing loop of potentially maladaptive, destructive and addictive behaviors
It is this loop of the tapped mind that sets up Negative Core Beliefs in the individual which are self-defeating and debilitating and need to be restructured in the healing process
Domains of Integration
1.Consciousness
2.Vertical
3.Bilateral
4.Memory
5.Narrative
6.State
7.Interpersonal
8.Temporal
9.Transpirational
Strategies of Ways to Change a Brain
The Focus of Attention activates specific circuits
A Sense of Trust enhances receptive learning
Memory Retrieval as a Memory Modifier
Unlearning and Learning
Deep Practice and Skill
Working on changing Negative Core Beliefs to Positive Core Beliefs
Helpful Interventions on the Pathways to Anxiety and Stress - Relaxation
Techniques that promote relaxation, such as breathing exercises and meditation, reduce activation in the amygdala.
Clients are often skeptical about breathing exercises
Explain how fMRI images demonstrate reduced activation in amygdala due to simple breathing exercises
Reducing muscle tension counteracts sympathetic activation produced by amygdala and promotes parasympathetic responding
Yoga combines these processes of breathing, relaxation
Goal is to use proactively to establish healthy level of amygdala activation– the goal is not to escape all distress
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Peripheral Nervous System (PNS)
Affects heart & muscles & directs communications between skin & brain.
Skin is vital for receiving data about external environment and safety of body.
Changes in pressure, temperature and other environmental factors cause both conscious automatic adjustments to environment.
Norepinephrine activates PNS which then activates heart, muscles and extremities
As norepinephrine increases so does heart rate & blood pressure and anxious symptoms such as sweating, flushing & trembling
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Autonomic Nervous System (ANS)
The ANS enervates and controls action of all internal organs. It consists of three parts:
1.Sympathetic nervous system (SNS) which is responsible for arousal of brain and body. It is important in creating physical responses of arousal under stress and trauma
2.Parasympathetic nervous system (PSNS) which inhibits arousal. It restores balance to internal organs and stress response systems
3.Diffuse enteric nervous system which controls digestion and peristaltic action
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Relaxation Breathing and the Vagus Nerve
Diaphragmatic breathing also promotes parasympathetic responding.
When a person uses belly breathing, the lungs are pressing on the diaphragm wall and the diaphragm is pushing the abdomen out.
The abdomen also pushes out in the back, although you can’t see it, putting pressure on the spine.
This puts pressure on the vagus nerve, the longest cranial nerve, which reaches all the way into the brain.
The pressure quiets the vagus nerve down and turns on the relaxation system.
When the Vagus Nerve Quiets
Lowers blood pressure, heart rate, and respiration.
Removes lactate from the blood (lactate can increase feelings of anxiety).
Increases alpha brain waves (associated with calm alertness).
Releases serotonin (neurotransmitter that is stored in stomach lining and intestines and can increase feelings of satisfaction and pleasure).
Also activates the prefrontal cortex after 10+ minutes All this from breathing deeply!
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Exercise – Amygdala-based Intervention
After only 20 minutes of exercise, a decrease in anxiety can be measured.
Exercise makes a certain kind of serotonin receptor in amygdala less active.
Exercise is like “reset button” in the amygdala, which is designed to elicit the programmed fight/flight/freeze response. Exercise completes the circuit.
Regular exercise reduces sympathetic nervous system activation, counteracting amygdala activation.
Sleep - Amygdala-based Intervention
Sleep deprivation increases activation in amygdala.
REM sleep is particularly correlated with amygdala reactivity. More REM sleep, less reactivity.
Help clients see the effects of sleep deprivation and adequate sleep on their amygdala.
Point out how important REM sleep is, and how*extended* and uninterrupted sleep is essential to obtain the needed REM sleep.
More REM sleep results in less amygdala reactivity.
Effective Sleep Strategies
1. Before you go to bed, practice the same relaxing rituals to train your brain for sleep.
2. Eliminate light stimulation for at least one hour before bed. (This includes screens!)
3. Exercise during the day.
4. Establish a consistent bedtime and waking time.
5. Avoid napping.
6. If you have trouble falling asleep, replace activating thoughts with relaxing ones.
7. If worries haunt you at bedtime, schedule a worry time during the day.
8. Ensure that your sleeping environment is conducive to sleep.
9. Avoid caffeine, alcohol, and spicy foods in the late afternoon and evening.
10. Use relaxing breathing techniques to prepare for sleep.
11. If you can’t fall asleep after thirty minutes in bed, get up and do something relaxing in the dark.
12. Avoid prescription sleep aids. Melatonin is ok
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Mindfulness: Using awareness & the focus of attention to transform
It will impact:
- The Brain
- The Immune System
- Sense of well-being
- Attention
- Relational Function
- Epigenetic Regulation
- Telomerase levels
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Presence and “Mindful Awareness”
- A form of awareness that comes from paying attention, on purpose, non-judgmentally to the present moment
- A loving awareness and a kind attention
- Focusing attention on intention
- Awareness of awareness itself
- Training the Mind to focus on inner experience
- Fundamentally Integrative: Differentiating sensory awareness from observing/narrating awareness and linking attentional practice
Integration, Presence and Health
1. Studies of Well-Being reveal the interconnected connectome (integration of the brain), or linkage of differentiated regions best predictor
2. Studies of impaired well-being reveal impaired integration of the brain;
3. Neural integration is the mechanism beneath regulation (mood, emotion, thought, attention, behavior, relationships, morality)
4. Integrated Relationships ->Neural Integration ->Health
5. Coordination and Balance in the brain
Integrative Prefrontal Cortex Functions
- Bodily regulation
- Attuned Communication with self or others
- Emotional Balance
- Fear extinction
- Flexibility
- Insight
- Empathy
- Morality
- Intuition
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