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Brain-Based Therapy with AdultsReview - Brain-Based Therapy with Adults
Evidence-Based Treatment for Everyday Practice
by John B. Arden and Lloyd Linford
Wiley, 2009
Review by Roy Sugarman, Ph.D,
May 5th 2009 (Volume 13, Issue 19)

Following on Louis Cozolino and others these Kaiser Permanente Medical Center-based psychologists believe that neuroscience is set to inform the world of psychological practice, and I would imagine that KP with their network of providers under the leadership of Dr Dennis Ostrem and others is well set to support this initiative given the mindset of that organization.  Bigger organizations such as OptumHealth Behavioral Solutions (part of United Health Group) led, in their innovation led Dr David Whitehouse have also followed up on beginning to use applied neuroscience in their offerings.  This coincides with changes in culture, as exemplified by the lead of Steve Hyman and others from the current NIMH in their ponderings as to how applied neuroscience could be incorporated into the DSM-V.

Pretty much, the field has relied on these categorical nosologies and vague comments about chemical imbalances and serotonin hypotheses for some time, but now even psychosurgery is making a comeback, albeit in the hands of Helen Mayberg and her tenth cranial nerve interventions by pacemaker and deep brain stimulus interventions.

What is becoming more impressive is that the above managed health care organizations are beginning to pay for these brain-based interventions in behavioral science as a way of reducing the costs associated with the care-as-usual approach. These authors in this new volume see the value in integrating the biological and psychological in a more seamless way, to both inform and drive the integrated approach further: this book is their first foray forward, and one on children and adolescents is also about the marketplace.

As good psychologists should, the name of the game in this brave new world is the same as the transient old one: Change, and this is where the first chapter takes as its point of departure.  It includes the value of gene and evolutionary studies, and early ideas since then, from behaviorism, psychoanalysis, and cognitive psychology, leading them briefly into a more brain-based approach versus the theory-based approaches before, based on the unifying and emerging neuroscience.

The next chapter constitutes a primer on brain function, focusing on a modular approach to the neuronal systems underpinning the social cognitive aspects of the brain, and its general cognitive and emotion processing sub-cortical counterparts.

Chapter three considers the issue of the separation at birth of neuroscience and psychotherapy. The implication is that science and psychotherapy suffered an artificial, I suppose political disconnect which even the work of Cozolino, Siegel, Score and others have failed to heal entirely.

As Scott Lilienfeld has shown, the pronouncements of Eysenck on therapy’s poor value actually galvanized psychotherapy practitioners to begin to seek to produce the kind of evidence that would demonstrate the value of their interventions in a scientific way, providing guidelines for best practice and outcome measurement, and the building of an evidence base for psychotherapy.  Forms of therapy that could be manual-ized would be the easiest to evaluate, so Cognitive Behavior Therapy would be the most studied.  Psychoanalytic views would be contrasted with Roger’s client centered therapy, and CBT with its dissecting elements would lend itself to the outcome measurement approach heretofore scorned. 

Beck’s work then dovetailed with Spitzer’s DSM-III and the psychoanalytically loaded terms such as neurosis were left behind as the categorical nosology of such terms as Panic and Anxiety replaced them as treatable entities.  In the years that followed, the authors and likeminded practitioners began to seek out what might be best practice in what they call the years of the Pax Medica and do so within the supportive umbrella of Keiser Permanente. Smith, Glass and Miller were able to demonstrate arguments against the Eysenck-founded ink in the water pessimism, but little attention was given to these latest findings, or at least, there was not an immediate and powerful swing in the positive direction. 

This more powerful swing came at the hands of the Barlow studies that identified 18 candidates for CBT in the DSM.  This in effect shattered the pax medica by setting up a set of straw dogs for others to attack, claiming other therapies, that share much in common with the eclecticism of CBT, had also demonstrated efficacy and targets in the signs and symptoms venue provided by the DSM, but also in the miserable but non-pathological groups that seek out psychological intervention.  The question of what treatment approaches work better in what settings or relationships had not been answered.

This begs the question as what constitutes a therapeutic relationship, since what comes in the door is a person, an interpersonal entity, not a DSM defined species, as it would if the germ theory of diagnosis in medicine held for what Othmer et al have called the mistake of “fat ankle syndrome type thinking (see BRAIN FUNCTIONS AND PSYCHIATRIC DISORDERS, A CLINICAL VIEW.  Psychiatric Clinics of North America, Volume 21, Issue 3, Pages 517-566).

The fourth chapter thus looks at the nature of this relationship and how it evolved across time, including of course the critical insertions by attachment theorists and client-centered therapists, building on ideas of resistance and transference, to finally psychotherapy, neuronal growth and integration drawing on the capacities for social appraisal and social relatedness that are built into our brain circuitry. Mirror neurons are the most likely next step when such discussions get going and this is the case here.

A primer chapter on memory and emotions follows making the very strong statement that much of what constitutes our human awareness reflects the confabulated re-creation of ourselves using the left pre-frontal cortex.  Patients who accomplish a more integrated sense of identity and emotional regulation will therefore, it is postulated, be ‘better’ in some important ways, harmonizing the subsystems of these important areas, rewriting semantic memory in some ways during the therapeutic relationship. Since one is talking about a story, the next most logical step is to discuss the narratives that this entails, drawing of course on the Adelaide based therapist, the late Michael White.  His work addressed the concerns inherent in addressing a person as if they were a bearer of pathology, or their signs and symptoms as defining them as internalizing some pathology (see The New York Times for a brief comment on White’s and Epston’s work).

Such discussions lead to an attempt to describe what dysregulation of such a neurological system might represent. This is dealt with in the next chapter.  Feelings are related back to neurotransmitters that are the precursors to such feelings, and the amino acids (biogenic amines) that are in themselves the precursor molecules for those neurotransmitters. Blood sugar, thiamine (co-enzyme of the Kreb’s cycle) caffeine, and the damaging effects of alcohol and other substances are briefly discussed.  A side bar in the form of a case study introduces concepts such as BASE, stages of change and engagement, harm minimization and other approaches to dealing with somewhat complex cases, which could have benefited from expansion and explanation as to how these become wise ways of engaging with the adult brain in the form of a live patient.  Another insertion that may have enhanced the outcomes of this chapter might have been the effect of brain on behavior on the brain, perhaps in the way that Nutt and others have done in discussing the effects of alcohol in their reviews and the complex way the brain biogenic and regulatory systems integrate around this behavior.

A fairly detailed discussion on the effect of stress on the brain then follows, but interesting is the absence at this juncture of the book, any discussion of brain derived neurotrophic factors, the roles of medication which interact with BDNF, COMPT and other substances and their genetic interactors, with brain factors defining treatment, the work of Sapolsky, Nottebohm. Frisen, Gould, and others on neuroplasticity, which occurs later to some extent.

Full chapters are then devoted to the anxiety disorders, and then to depression.  This chapter finally brings the role of BNDF to the fore, Gage and Mayberg also introduced here.  CBT and brain based therapies are connected in this chapter, based on its ability to enhance regulatory and attentional processes in the aforementioned left prefrontal cortex, and the ability to build behavioral activation as well.  Despite earlier comments, most of this discussion of the treatment is of mood and anxiety based on DSM signs and symptoms definitions.

But the authors are not finished.  A truly integrated approach will also take into account the role of exercise, sleep and mindfulness, the target of Chapter 11.  Mindfulness dominates the closing words, with its capacity to help regulate brain processes underlying mood and anxiety, but particularly autonomic nervous system balance.

What is missing is real and detailed attention to biofeedback and neurofeedback, surprising as surely these methods of dealing with brain based disorders epitomize an integrated approach, with neither term mentioned. Some comments on breathing and breathing retraining are made, but interestingly nothing on resonant frequency or heart rate variability which are real existing exemplars of how brain and body can be directly integrated, as their colleagues in California have been demonstrating for years (see Schwartz and Andrasik (Eds), 3rd edition, Biofeedback: A practitioner’s guide, Guilford Press 2003) which demonstrates this. 

Otherwise, Arden and Linford have covered their field well, and like Cozolino, have played their part in bringing such possibilities to the attention of the world, as has done Badenoch, with endorsement by the aforementioned Siegel, before them.

Changing the prevailing cultures in the world is a non-enviable task, but I think, from my vantage point in the world of Integrated Neuroscience, their task is not going to be that difficult, as the worldview of the behavioral world has shifted in that direction anyway.

© 2009  Roy Sugarman

Roy Sugarman PhD, Director: Behavioural Solutions, Brain Resource Limited, Ultimo, Australia


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