Psychotherapy is a recommended first-line intervention -alone or together with medication- in many mental disorders: depression, anxiety, obsessive-compulsive disorder, psychotic disorder, addictions, borderline personality disorder, among others. Its efficacy in some patients is indisputable, although we know that around 30-50% of them do not respond, have a high dropout rate and around 10% worsen (yes, psychotherapy also has adverse effects and contraindications). The question is: when it works, how do you do it? What structural or functional changes does it produce in the brain, to achieve this improvement?
The fragmentation of schools of psychotherapy will produce disparate answers to this question. Cognitivists, when asked about the mechanism of action of their therapy, will answer that the Socratic dialogue between therapist and client changes the interpretation of reality, questioning and reversing certain automatic thoughts and biases that cause discomfort and symptoms (I am simplifying). This would hypothetically translate into brain changes in the areas involved, especially a hypoactivation of structures such as the amygdala or the cingulate cortex.
Psychodynamic therapists will emphasize the patient’s ability to come to identify and know their own mental mechanisms during therapy, to achieve insight, an awareness of the problem. This self-knowledge or self-analysis has –hypothetically- its cerebral translation, as the incipient studies of neuropsychoanalysis show (I recommend the works of Mark Solms).
Therapists using meditation or mindfulness will point out that the thickening of the insula—a hub network to which many of the body’s connections reach, located deep in the Sylvian fissure—is a product of the integration of sensory and visceral signals of the present, at the cost of reducing useless ruminations about the past and future. Other authors in the field of therapy will answer that what happens in the brain is an insignificant fact, a mere correlation, which is not even interesting to know. We are varied and diverse, it is a fact.
But this multiplicity of voices in psychotherapy -and the frequent fratricidal struggles between them- has been contested for years by the integrative movement, which allows the incorporation of different perspectives and formulations, emphasizing the so-called common factors of therapy, that is, what the different schools have in common, not what separates them. In a meta-analysis that will go down in history, Bruce Wampold dissected the role of common and specific factors in therapy, concluding that the former are much more relevant: the empathy shown from the beginning by the psychologist or psychiatrist, the genuine agreement between therapist and patient about the goals to be achieved, the alliance of work, the validation of the client’s experience, the ability to generate expectations of change and the personal characteristics of the therapist beyond the theoretical model used (the human factor, as Graham Green would say).
Assuming this new paradigm, the study of the mechanisms of action of psychotherapy then focuses on knowing how this therapeutic relationship generates changes in the brain to go from intolerance to stress, emotional dysregulation, dissociation or maladaptive behavior to a state closer to mental health.
One clue is that most of our cortex develops in an experience-dependent way through attachment, that is, interpersonal experience triggers gene transcription. Thus, the child’s neuroplastic brain develops as she dynamically interacts with her attachment figures. And there are factors that favor this development: a secure relationship based on trust, a certain amount of stress (trauma slows down child development, but hyperprotection and the absence of stress too), some emotional and cognitive activation, and -the most important – the co-construction of a new personal narrative (which in the child is the creation of his own identity).
These same factors that promote neuroplasticity in child development are the ones that could act in therapy. The therapist-patient relationship (with its setting, its limits, its transference and counter-transference) acts as an emotionally corrective experience, in which the patient feels listened to, validated, questioned and supported to produce change. After the therapy, at the cerebral level, we see a top-down integration.
Through dialogue that re-evaluates, analyzes, and considers long-term goals, the emotional reactivity of the amygdala is reduced, activating that of the prefrontal cortex to a greater extent. Two prefrontal areas with different functions are also integrated: the dorso-lateral, responsible for the evaluation of the context and the prediction of reality, with the orbito-frontal, related to emotions, motivations and impulses.
We would say that the first and third person perspective is integrated (it is logical, the patient tells himself the story of his life). In therapy—especially for patients with past adverse experiences—high-stress memories (from the amygdala) are integrated with normal, episodic memories (from the hippocampus).
And how does this integration occur? Through the irresistible power of narrative. Just as a child understands a lot of abstract concepts when listening to a story from his father at night, the patient fits, buffers, regulates and integrates many psychic functions to the extent that he co-constructs with the therapist a new story of his life. . The patient comes to consultation with a saturated, exhausted narrative (“I want to die”, “I can’t take it anymore”, etc.) and the safe dialogue that it generates with the therapist favors its transformation and expansion towards a story of the facts more useful, involving more adaptation.
The least important thing, almost, is the myth on which this new construction rests, be it the Oedipus complex or the systemic analysis of the dysfunctional family, the important thing is that it is a new story that resignifies what has been lived. As Will Storr recalls in his recent book The science of storytellingwe humans are taken away by a story that orders our experience, that makes us protagonists and spectators at the same time, in which we come out well (that without a doubt), that recalls founding myths of our biography, milestones and difficulties that we managed to overcome, that gives us a sense of coherence to the chaotic, indecipherable, random vital experience.
Nations need these stories (some based on ancient historical events, others on mythology) to generate national identity. Families have stories -sometimes terrible- that come from the past and that produce in the nephew, in the great-grandson, a strange sense of belonging. Tormented subjects, drowning in pain, need to discover, together with a reliable person, a new story of themselves. Sometimes not necessarily truer, but more useful. That’s why, perhaps, psychotherapy works.
You can follow THE COUNTRY Health and Wellness in Facebook, Twitter and Instagram.
#psychotherapy #work #brain
Leave a Reply