The process of change: psychotherapies as environmental stimuli

Neuronal development in infancy depends on environmental stimulation. Early studies with animals demonstrated the importance of early external stimuli for the functional development of perceptual systems. Later animal studies showed that social environments (i.e. inputs from carers or peers) are important in the development of neuronal cytoarchitecture, and that early social deprivation damages the development of neural networks in the parts of the brain that regulate social function (Reference KraemerKraemer 1992).

Kandel’s original work demonstrated the effect of learning new information on gene expression for proteins active at neuronal synapses involved in hippocampal networks (Reference KandelKandel 1999). Similar studies have examined how hippocampal gene expression is affected by childhood experience of stress and medication (e.g. Reference Alfonso, Frick and SilbermanAlfonso 2006; Reference Szyf, McGowan and MeaneySzyf 2008). There is evidence from both animal and human research that the expression of a gene affecting arousal regulation is directly affected by the caregiving environment in which the affected individual is raised (Reference Barr, Newman and ShannonBarr 2004; Reference Caspi and MoffittCaspi 2006).

Other research suggests a direct effect of external stimuli on brain plasticity. Early experience of pain affects the sensitivity of children to pain, suggesting that early stress experience fundamentally alters the rate of firing of pain neurons in a way which persists over time (Reference Hermann, Hohmeister and DemirakçaHermann 2006). Fear and pain experiences affect the development of the neural architecture of the right orbitofrontal cortex; the neurohumoral stress responses to pain alter the rate and degree of arborisation and dendritisation of developing neurons, affecting the organisation of neuronal networks. Such pathological disorganisation persists into adulthood, resulting in affective dysregulation and impaired neuronal connections between the frontal executive neocortex and the limbic system (Reference SchoreSchore 1996, Reference Schore2001).

In adulthood, pain responses can be altered by external perceptual stimuli such as reassuring words or visualising images that, by a learning process, induce the expectation that pain will be reduced (Reference Benedetti, Mayberg and WagerBenedetti 2005; Reference Colloca, Siguado and BenedettiColloca 2008). Such studies are consistent with the work of Reference Ramachandran and BlakesleeRamachandran & Blakeslee (1999) on the relief of phantom limb pain. By presenting images of the unaffected limb to the brain on a repeated basis, patients can alter their neural maps of how the affected limb is represented in the brain. The way they ‘see’ their limb in their internal world can be altered by repeated learning tasks, which (presumably by new gene expression) facilitates the development of new neural growth in the brain.

Reference DoidgeDoidge (2008) speculates that in reflective therapies, the patient is either (a) repeatedly presented with new verbal images of himself in relationships or (b) learns new information about images from non-verbal implicit memory systems which have been transferred into verbal explicit systems during the process of therapy. This new information acts as a stimulus to gene expression of protein synthesis, allowing new synaptic connections to be made, which then results in a change to associated neural networks.

Psychotherapy

Psychotherapeutic techniques are effective because they change both minds and brains. We believe that the talking therapies exercise their therapeutic effects via a benign impact on mentalisation (Reference Allen, Fonagy and BatemanAllen 2008). Consider the example in Box 1. Here a person in distress uses both the reflective process and the cognitive review process in group therapy to do a number of mentalising tasks. First, she identifies her self-experience, and then names and considers both feelings and thought. Next, new information from the environment stimulates new thoughts and experiences, and any temporary related affective distress is validated, supported and explored. The patient considers both her own conscious intentions and those of others, but also is invited to reflect on parts of her mind that she cannot see, but others can. In this way, she is able to take a different perspective on her own distress, which gives her options in terms of her interpersonal functioning.

Attachment

The therapy process, however, begins with attachment to a secure base from which mentalising can occur. Psychotherapy across a range of modalities attempts to enhance mentalisation, in part by activating an attachment context, which in humans (as we have seen) provides the relational basis for finding out about minds: our own minds as well as those of benign others. Numerous interpersonal features, which are present to a degree in all forms of therapy, are likely to elicit the universal dynamic for creating affectional bonds described by Reference BowlbyBowlby (1977). Reference BowlbyBowlby (1969) attributed the strength of this need to the extended period of immaturity in human development where the urgent subjective need for interpersonal proximity, triggered by fear, serves the evolutionary function of ensuring the child’s safety. According to Reference BowlbyBowlby (1988a), attachment to a particular individual continues to be created in adulthood, especially in those situations where caregiving is elicited. Reciprocal care-eliciting and caregiving activates the behavioural system for attachment.

So attachment is likely to be powerfully activated by any situation where an individual in distress requires assistance with self-regulation from an identified caregiver. Attachment is further activated by extensive discussions of current and past attachment relationships, which intensifies internal working models of attachment relationships. This means that any psychological technique that explores affects, cognitions and memories will stimulate the attachment system, and provide the psychological framework for mentalising.

Improved mentalisation

There are a number of ways in which the therapist offers assistance with mentalising. First, the therapist helps with the patient’s regulation of affect, most often through contingent marked responding to the patient’s affect (Box 2) and by creating a safe and sensitive interpersonal environment (Reference Gergely, Mayes, Fonagy and TargetGergely 2007). Next, regardless of orientation, the therapist explicitly creates alternative perspectives on mental experience in the context of the therapeutic encounter, whether by interpreting the transference or while recovering from misunderstandings or ruptures of the therapeutic alliance. In general, the therapist has the overarching goal of generating a safe and sensitive interpersonal environment that assists with the patient’s regulation of affect.

In some treatments, the therapist explicitly encourages the patient to develop an attachment bond to the therapist or the therapy programme. Although this may hardly be necessary for some patients, other patients may struggle to engage with therapy, and avoid treatment and the attachment entailed (Reference Dozier, Lomax and TyrrellDozier 2001; Reference Tyrer, Mitchard and MethuenTyrer 2003). Attachment within therapy is usually achieved through implicitly implemented verbal and non-verbal strategies (there is ‘therapese’ in much the same way that most mothers quickly learn to speak ‘motherese’ to their infants). In the context of group therapy, the therapist may also attempt to engender attachment bonds between members of the group, and with the group as a whole (Reference GlennGlenn 1987).

Cognitive therapy

In cognitive therapy, mentalisation is never far from being the central concern. All cognitive therapies employ techniques that encourage learning by restructuring dysfunctional thought patterns, and enhance basic self-reflective skills, such as second-order thinking and naming of thoughts. For example, in drawing attention to automatic negative thoughts and their influence on mood, the therapist does more than address the named maladaptive processes. The therapist also enhances the patient’s awareness of how their mind works. Similarly, reflecting on habitual thought patterns involves mental elaboration — making what had been preconscious now functionally fully conscious. Even the most behavioural features of cognitive therapy, such as taking an empirical attitude towards the validity of one’s thoughts and challenging global negative thinking, in addition to addressing these dysfunctional features, promote curiosity, inquisitiveness and flexibility in thinking.

Mindfulness training

More recently, mentalising and other activities that are so closely related as to be almost indistinguishable have taken centre stage in CBT. Mindfulness training (Reference Teasdale, Segal and WilliamsTeasdale 2000; Reference Segal, Williams and TeasdaleSegal 2002; Reference Brown and RyanBrown 2003; Reference Hayes, Follette and LinehanHayes 2004; Reference Lynch, Chapman and RosenthalLynch 2006; Reference Choi-Kain and GundersonChoi-Kain 2008) for depression explicitly aims to change the patient’s relationship to depressive thoughts and feelings rather than the content of the thought. In doing so, mindfulness training enhances awareness of thoughts and feelings and promotes a mentalising stance by drawing attention to the unceasing flux in mental states. Mindfulness training is highly effective in preventing relapse in depression; those skilled in these techniques have enhanced right orbitofrontal function (associated with improved capacity to regulate negative affects) compared with those who are untrained (Reference Davidson, Kabat-Zinn and SchumacherDavidson 2003).

Interpersonal psychotherapy

Techniques that promote mentalising in interpersonal psychotherapy are also fairly close to the declared focus of the treatment (e.g. Reference Mufson, Weissman and MoreauMufson 1999; Reference Markowitz, Bleiberg and PessinMarkowitz 2007). Interpersonal psychotherapy implicitly draws attention to mentalising in relation to others’ mental states, while also promoting self-awareness with an eye to interpersonal problem-solving in the here and now. There are numerous specific techniques that we would expect to promote mentalising in interpersonal psychotherapy, such as the encouragement of affect to help patients understand, regulate and express their feelings; the extensive use of clarification of interpersonal experience, which in turn often includes communication analysis; and the use of the therapeutic relationship for identifying such problems.

Patient-centred therapy

Similarly, we do not have to look far to find specific techniques that promote mentalising in patient-centred therapy. In fact, one might consider the patient-centred approach to be the prototypical mentalisation therapy, as it has sensing the perspective of the patient (i.e. empathy) as its pivotal point. The inquisitive stance (as described in Reference Bateman and FonagyBateman (2004, Reference Bateman and Fonagy2006)) echoes Carl Reference RogersRogers’ (1951) recommendation that empathic comments be conveyed tentatively.

Beyond this issue of style, patient-centred therapists work to clarify their patient’s position in order to enable them to create a congruent and integrated self. In so doing, they will inevitably help the individual to develop greater mentalising capacity.

Behaviour therapy

We could even make the case that classical behaviour therapy involves mentalisation. When patients are taught new responses to fear-inducing stimuli, changes occur in the ventral prefrontal cortex and amygdala, which are involved in fear reactions (Reference LeDoux, Iwata and CicchettiLeDoux 1988). Techniques that involve non-verbal or physical interventions probably also engage the brain in learning new meanings, either directly through neural networks in the amygdala or indirectly by improving symbolic function (i.e. the translation of affect into cognitive imagery). Naming feelings reduces amygdala activation and therefore changes both synaptic function and the experienced level of distress (Reference Costafreda, Brammer and DavidCostafreda 2008; Reference Vrticka, Andersson and GrandjeanVrticka 2008).

Benefits and risks in the psychotherapeutic process

There is a certain amount of evidence to indicate that effective psychotherapeutic treatment is associated with improvements in mentalisation (Reference Target, Fonagy, Leuzinger-Bohleber, Dreher and CanestriTarget 2003; Reference Levy, Clarkin and YeomansLevy 2006a,Reference Levy, Meehan and Kellyb). In randomised controlled trials, mentalisation-focused treatments have been shown to be effective for disorders such as borderline personality disorder (Reference Bateman and FonagyBateman 2008) and preventive interventions for violence (Reference Fonagy, Twemlow and VernbergFonagy 2005, Reference Fonagy, Twemlow and Vernberg2009). Even in severe mental illnesses, such as schizophrenia, psychological therapies that improve basic reflective function lead to improved social performance (Reference Lysaker, Dimaggio and CarcioneLysaker 2010).

However, from the perspective of the mentalising model of psychotherapeutic efficacy, the hyperactivation of the attachment system calls for caution. There is good evidence that intense activation of the neurobehavioural system underpinning attachment is associated with deactivation of arousal and affect regulation systems (Reference Nolte, Guiney and FonagyNolte 2011), as well as deactivation of neurocognitive systems likely to generate interpersonal suspicion, i.e. those involved in social cognition or mentalisation, including the lateral prefrontal cortex, medial prefrontal cortex, lateral parietal cortex, medial parietal cortex, medial temporal lobe, and rostral anterior cingulate cortex (Reference Bartels and ZekiBartels 2000, Reference Bartels and Zeki2004; Reference MayesMayes 2000, Reference Mayes2006; Reference Satpute and LiebermanSatpute 2006; Reference LiebermanLieberman 2007).

The saying that love is blind exists in most human languages and encodes the incompatibility of powerful activation of the attachment system with meaningful (as opposed to ruminative) contemplation of mental states. Put simply, as attachment intensifies and arousal increases, mentalisation switches from a primarily controlled, reflective, internally focused, cognitively complex, prefrontally guided process to an automatic, externally focused, emotionally intense, posterior cortically and subcortically driven one.

How might this affect psychotherapy?

Given that the overarching aim of psychotherapy is to enhance the capacity for mentalisation, if overactivation of attachment aspects of the therapeutic relationship undermines mentalising capacity in the patient, then the patient may no longer benefit from either the treatment or the relationship it offers. At that point the enactments of insecure relationship patterns come to dominate the patient’s mind and colour their experience of the therapeutic relationship: the resulting (mis)perceptions are experienced ‘as if real’ in the non-mentalising transferential heat of the disorganisation of therapeutic attachment. Patients may complain that the therapy is unhelpful or unpleasant, may actively see the therapist as abusive, and/or drop out of therapy altogether. Alternatively, patients may make intense attachments to therapists, who are then idealised and/or seen as ‘perfect’ sexual partners.

How might the therapist address this problem?

The intensification of attachment aspects of the therapist–patient relationship will initially play an important role in strengthening the patient’s focus on mental states. To benefit from this focus on mental states, the therapist has to retain a capacity for marked mirroring. This means that the therapist (like the securely attached mother) is able to indicate attunement and compassion for the patient’s affects, rather than feeling these emotions themselves (or feeling overwhelmed by them) (Reference Strathearn, Fonagy and AmicoStrathearn 2009). In addition, the therapist must be able to indicate attunement and compassion while communicating self–other differentiation by ‘marking’ their mirroring with indications of coping in their affect displays (e.g. exaggerated, slowed-down, schematic or only partial motor execution of their primary canonical motor pattern (Reference Gergely and WatsonGergely 1996, Reference Gergely2004, Reference Gergely, Mayes, Fonagy and Target2007, Reference Gergely, Unoka, Sharp, Fonagy and Goodyer2008; Reference Fonagy, Gergely and JuristFonagy 2002)). Work on filmed short-term therapy has demonstrated that experienced and effective therapists show less obvious affect on their face when with patients than inexperienced therapists (Reference Anstadt, Merten and UllrichAnstadt 1997). Perhaps experienced therapists are more aware that showing too much empathy could overstimulate the patient. To be optimally effective, they must be able to stop short of attachment system hyperarousal and must avoid intensifying attachment relationships to the point that risks disorganisation.

When working with patients with highly disorganised self-structures (e.g. severe personality disorder), the therapist must be aware of moment-to-moment changes in the patient’s mental state and must be ready to step back from the heat of the encounter (Reference Bateman and FonagyBateman 2006). Tragically, as noted elsewhere (Reference Fonagy and BatemanFonagy 2006), interpretations demanding considerable reflective capacity are often given when the patient is least able to adopt an intentional stance to parse and implement the implication of the therapist’s comment.

How is psychotherapy unique, and is there a clue as to how it might work?

If psychotherapy demands the paradoxical activation of two normally mutually inhibitory systems within the brain, what does this achieve? Why is it essential for therapy to activate the attachment system? Why is therapeutic alliance a necessary condition for change? Why is it that stronger alliance predicts greater change, with early alliance predicting improvement in symptoms at the end of treatment (Reference Orlinsky, Ronnestad, Willutzki and LambertOrlinsky 2004)?

Therapeutic technique activates systems associated with negative emotions, whereas social and moral judgement and mentalising will be partially inhibited by the attachment system. The patient is asked to look at memories and thoughts about themselves, while making use of the wired-in connections of the attachment system to ‘anaesthetise’ the patient from the full reality of the experience. Unless the attachment system is overaroused, the patient looks at himself through rose-tinted spectacles that the attachment system (when moderately active) may evoke.

Psychotherapy thus entails intense thinking about feelings, thoughts and beliefs in the context of attachment. The activation of attachment feelings creates a brain state that removes the dominance of constraints on the present from the past (long-term memory) and creates the possibility of re-thinking and re-configuring intersubjective relationship networks. In psychoanalytic discourse, authors have used Winnicott’s concept of ‘transitional space’ (Reference WinnicottWinnicott 1953) to denote this particular therapy-specific mental state (e.g. Reference Gaddini and GaddiniGaddini 1970; Reference ElmhirstElmhirst 1980; Reference AdlerAdler 1989; Reference Auerbach and BlattAuerbach 2001).

In considering the origins of dynamic psychotherapy, Reference Freud and StracheyFreud (1900) came upon the following comment by Schiller, published in 1788:

Freud believed this to describe the phenomenon of deactivated constraints on cognition that we are also attempting to describe here. Reference Freud and StracheyFreud (1900) goes on to recognise explicitly the same phenomenon, but misses the crucial role that attachment (the therapeutic relationship) has in making the process possible:

We can bring no evidence to bear on the extent to which Freud’s statement about his ability to achieve this state of mind by himself can be considered veridical. Let the record state, however, that since Freud, few have found self-understanding and insight readily on their own without the presence of another mind skilfully working to create and maintain a setting within which acute self-perception is possible because overwhelming moral scrutiny is reined in.