Facilitating Processes and Experiential Learning in Psychotherapy
The above lines of study in the science of mind deepen our appreciation of the ways in which the experiential opportunities of psychotherapy potentially bring about change and growth across the foundational schools of thought. Drawing on developmental concepts and empirical findings in the fields of neuroscience and developmental psychology, psychotherapy research, and clinical observation, we can identify core elements of the therapeutic process that would appear to be fundamental in fostering neural plasticity, growth, and integration. I outline formulations in five areas that offer points of reference for our reviews of clinical theory and concepts of therapeutic action. In doing so I expand working hypotheses proposed by clinical scholars in the field of interpersonal neurobiolog}' centering on four domains of experience believed to promote neuroplasticity: the core conditions of the therapeutic relationship; moderate levels of arousal or “optimal stress;” the activation of cognition and emotion; and the coconstruction of narratives that foster an affirming sense of self and possibility (Cozolino, 2017; Schore, 2019b; Siegel, 2020). We will consider these ideas more fully in our discussions of theoretical concepts and case studies in the following chapters.
The Therapeutic Relationship, Interactive Experience, and the Constancy of Care in the Holding Environment
As we have seen, the attachment bond and early caretaking experience shape the architecture of the brain, playing a formative role in the development of core integrative and regulator}' structures. In light of our growing appreciation of the dynamics of neuroplasticity, however, we assume that relational experience continues to mediate the organization and strength of neural connections throughout life. Converging lines of study in neuroscience suggest that the core conditions of the therapeutic relationship earn' the potential to activate bonding processes instrumental in attachment, creating an optimal biochemical environment for neural plasticity (Cozolino, 2017; Schore, 2019b; Solms, 2018a).
In line with current research, clinical scholars propose that the empathic attunement and synchrony of the therapeutic relationship, the constancy of care in the holding environment, and the interactive experience of the therapeutic process—particularly forms of communication mediated by the right hemisphere —potentially reinstate neural growth and development, helping patients strengthen capacities to process and integrate subjective experience, regulate emotion, and negotiate the dynamics of relational life (Cozolino, 2017; Schore, 2019a, 2019b; Siegel, 2020).
Following developments in attachment research and affective neuroscience over the last decade, clinical scholars increasingly emphasize the role of unconscious, non-verbal, emotional processes rather than conscious, verbal, cognitive processes in their reformulations of therapeutic action, change and growth. What matters most, as Allan Schore has emphasized, is our way of being in the clinical situation, especially in times of vulnerability and fear.
The right hemisphere is critical in processing the “music” carried in our words, as Schore explains, urging clinicians to expand concepts of therapeutic action to encompass non-verbal domains of interactive experience that regulate bodily states and emotion. Prosody conveys nuances of meaning through variations in stress and pitch, independent of the grammar and words. The non-verbal elements of language—intonation, inflection, tone, pitch, force, and rhythm—evoke states of self, sometimes associated with implicit memories and reactions in early life. More broadly, non-verbal communication includes body movement, posture, gesture, and facial expression (see Dorpat, 2001, for an account of primary process communication). The right hemisphere mediates the more fundamental forms of communication in the therapeutic process, and right brain to right brain intersubjective transactions lie at the core of the therapeutic relationship, mediating what Louis Sander describes as “moments of meeting” between the clinician and the patient (Sander, 1992, cited in Schore, 2012, p. 39).
Challenge, Optimal Stress, and Emotion
Clinicians have recognized the crucial role of emotion in change and growth from the start of therapeutic practice. In their formulation of the cathartic method at the end of the 19th century, Freud and Josef Breuer proposed that “abreaction” of traumatic experiences in their full intensity would release “strangulated” emotion and alleviate symptoms that had perpetuated problems in functioning (see Chapter 4).
In developing his conceptual framework for psychotherapy, Jerome Frank proposed that emotional arousal facilitates change in a variety of ways (Frank & Frank, 1991, p. 46). The experience of emotion may strengthen the patient’s motivation to engage in the therapeutic process; challenge patterns of defense; support efforts to process, formulate, and integrate experience, and facilitate the development of more functional ways of managing vulnerability and problems in living. In the domain of the humanities, Frank considers the potential importance of healing emotions generated by our experience of literature and art as well as creative arts therapies involving music, dance, painting, sculpting, and writing. We consider the therapeutic functions of these activities and practices further in Chapter 9.
As we will see, all therapeutic approaches intensify emotion through different methods and procedures. In psychodynamic psychotherapy, for example, clinicians challenge the dynamics of defense through exploration of emotion, processing of interactive experience, and interpretation of behavior. In classical cognitive approaches, clinicians challenge ways of processing and interpreting experience that fail to take account of actual circumstances and realistic prospects. Behavior therapists introduce methods of exposure in their efforts to help patients challenge avoidant behavior and engage feared domains of inner and outer experience that perpetuate problems in functioning.
Research findings indicate that moderate levels of arousal and “optimal stress” foster neurobiological conditions that promote plasticity, learning, and neural integration. Moderate levels of arousal activate the production of neurotransmitters and neural growth hormones believed to enhance long-term potentiation, learning, and cortical reorganization (for review of empirical findings see Cozolino, 2017). The ebb and flow of emotion over the course of therapy, as Cozolino observes, “reflects the underlying rhythms of growth and change” (2017, p. 48). Acceptance, support, and challenge are thought to be crucial elements in change and growth across all forms of psychotherapy.
Engagement of Sensation, Emotion, Imagery, Cognition, and Behavior in the Therapeutic Process
Clinical scholars have proposed that simultaneous or alternating engagement of emotion and cognition fosters the development and reorganization of underintegrated neural networks believed to perpetuate dysrégulation, dissociation, and dysfunction; 1 expand this formulation to encompass the domains of sensation, imagery, and behavior in order to take account of the wider range of phenomena in human experience. As we repeatedly focus our attention on various aspects of experience, researchers assume that we activate neural firing associated with conditions and circumstances, creating new synaptic connections, reorganizing neural networks. Presumably, the engagement of underdeveloped or under-regulated networks fosters the integration of neural structures and functions in accord with Hebb’s proposal that activation of neural circuits in real time creates or strengthens connections that link and coordinate their functioning (see Cozolino, 2017, p. 49). As we will see, Freud prefigured these findings in elaborating his concepts of therapeutic action, described most fully in his seminal paper “Remembering, repeating, and working through” (1914/1958; see further discussion in Chapter 4).
The capacity' to tolerate emotion and regulate states of self creates conditions for neural growth and integration across the course of life; as Cozolino observes, we can think of emotional regulation as a crucial outcome of help and care across all therapeutic approaches because it allows us to make use of experiential opportunities and relationships that foster growth (2017). The greater the integration of neural networks, presumably, the greater the capacity' to experience, tolerate, and make use of sensations, feelings, images, and thoughts previously dissociated or managed through other defensive processes.
Formulations of Experience and Co-Construction of Narratives
Language is a core constituent of neural and psychological development, instrumental in the formation of memory' and self-identity', and we can think of narratives as natural cognitive and linguistic forms that facilitate ongoing efforts to formulate experience and create meaning across the course of life (Borden, 1992, 2000, 2010; Bruner, 1990). Although we remain largely unaware of the
Neuroscience and Therapeutic Action 63 interpretive processes that underlie the construction of life stories, ongoing narratives about self and life events serve as filters for perception, processing, organization, and understanding of experience. From a developmental perspective, personal narratives help us preserve a sense of coherence, continuity, and unity in sense of self and identity through the life course, helping us define who we have been, who we are, and who we may become in the future.
Researchers propose that ongoing formulations of experience and co-crea-tion of narrative accounts over the course of the therapeutic process engages the functions of the left and right hemispheres, fostering the integration of neural networks throughout the brain. As Siegel explains, the autonoetic, analogical, context-dependent, mentalizing functions of the right hemisphere shape the themes and imagery' of the narrative process, while the left hemisphere mediates interpretive and linguistic processing of content. He proposes:
The left hemisphere’s drive to understand cause-effect relationships is a primary motivation of the narrative process. Coherent narratives, however, require participation of both the interpreting left hemisphere and the mentalizing right hemisphere. Coherent narratives are created through interhemispheric integration.
(2020, p. 455)
Enriching Relationships, Activities, Practices, and Places in the Outer World
Beyond the experiential opportunities of the therapeutic process itself, we increasingly recognize the crucial role of enriching relationships, activities, and practices in everyday life that potentially foster neural integration, change, growth, and well-being. Clinicians describe a range of “bottom-up” practices believed to engage subcortical regions of sensation and emotion, including meditation, walking, yoga, tai chi, prayer, and artistic and musical activities (Van der Kolk, 2014; Wallin, 2007; Walsh, 2011).
Researchers continue to explore the experience of place and nature as a potential source of healing, change, and growth. The emerging field of environmental neuroscience is documenting the ways in which the features of natural surrounds influence neural function, mood, well-being, and patterns of behavior (for review of orienting perspectives and empirical findings see Berman, Stier & Akcelik, 2019; for reviews of research on the healing functions of place, see Sternberg, 2009; for review of research on the effects of nature on cognition and mood, see Williams, 2017). I explore these concerns further in discussion of integrative approaches in Chapter 9.