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Psychotherapy research 

Psychotherapy research
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Psychotherapy research
DOI:
10.1093/med/9780199608386.003.0011
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Psychotherapy research

Research in psychotherapy

What is research?

Research is a systematic process of inquiry leading to new knowledge or new ways of thinking about a concept. It usually involves the collection and analysis of information or data to establish, confirm, or refute hypotheses, as well as to support known theories and to generate new theories.

Approaches to research vary according to epistemology, or theory of knowledge, usually split between the sciences and the humanities. Scientific research tests theories that generate explanations of the nature and properties of the world. Scientific research is broadly empirical in the sense of measuring and gathering data that are observed by the researcher. In contrast, research in the humanities is more conceptual in nature and is based on detailed exploration of argument, counter-argument, and the analysis of the strengths and weaknesses of argument. Research in the humanities tends to focus on issues and questions that change according to human context (e.g. social, political, cultural, historical), whereas research in the sciences focuses on experiments that take place in highly controlled environments. Research in the humanities employs methodologies such as hermeneutics (study of text interpretation) or semiology (study of signs and symbols), whereas scientific research favours categorizing, counting, and statistical comparisons.

Research in psychiatry typically uses approaches from both the biosciences and the humanities, reflecting the experience of both patients and psychiatric professionals. Although professionals find it useful to gather objective data about patients’ symptoms and signs of disorder, the patients’ subjective experience is also essential to study empirically. Humanities-based research is also crucial because of psychiatry’s theoretical cross-over with philosophy, law, and sociology.

Research typically involves a number of steps, including:

  • Identification of a potential research issue

  • Review of the literature

  • Specifying the purpose of the research

  • Determining specific research questions

  • Specifying the conceptual framework, usually a set of hypotheses

  • Choice of methodology

  • Data collection

  • Analyzing and interpreting the data

  • Reporting and evaluating the research

  • Communicating the research findings.

Why do research in psychotherapy?

Patients, commissioners, and policymakers rightly demand that psychological treatments have robust evidence to show that they are effective, safe, and delivered by competently trained therapists. However, psychotherapists themselves should also be curious to know whether their treatments work and the mechanisms of how change occurs. Although a therapist’s individual experience may convince them of the validity and efficacy of their treatment method, their views may be biased by the support of like-minded colleagues, a limited sample of patients seen and clinical problems posed, and the particular modality or setting in which they work. Research provides a necessary external, more objective perspective; an opportunity to validate or disprove hypotheses; and a reflective space in which new ideas may be generated.

Research in psychotherapy is essential to address the following questions:

  • Does change occur in therapy? Is it ‘therapeutic’ change? Does it bring about a good outcome for the patient?

  • What happens in therapy? How does the process of change occur?

  • Are the psychological therapies offered safe and of high quality? How will we assess quality?

  • What is the patient’s experience of therapy?

  • Are the psychological therapies that are offered cost-effective?

  • Are our therapies outmoded or based on unproven theories and practices?

  • Can we use research to communicate better with colleagues, commissioners, and patients?

  • Can we refine existing therapies and develop new therapies for specific patient groups and settings?

  • How can we improve and protect the professional reputation of psychotherapists?

Research in psychotherapy: a historical overview

The history of research into psychological therapies can be divided into the following phases (see Orlinsky and Russell, 1994):

  • Phase I (c.1927–54): establishing a role for scientific research

    The earliest research focused on trying out modifications to the psychoanalytic method, and theoretical discussions of Freud’s concepts. The earliest research on psychoanalytic methods were published as early as 1924. The single-subject case study was the main research method at this time used to document and communicate evolving theory; however, psychoanalysts in the 1930s, such as Otto Fenichel in Berlin, Ernest Jones in London, and Franz Alexander in Chicago, also published larger-scale outcome reports of patients being treated in their local institutes.

    An important technical development was the application of psychoanalysis to groups during the Second World War. The first experiments in group analysis were carried out by Wilfrid Bion, Harold Bridger, and Tom Main in the context of their work as military psychiatrists. Later in the same period, Maxwell Jones introduced the concept of social therapy for soldiers with war neuroses, and SH Foulkes developed group analysis as a method in the late 1950s. Research methods remained confined to before-and-after assessments of patients, often with crude measures of outcome (see Psychotherapy research Group therapy and group analysis in Chapter 2, pp. [link][link]; Therapeutic communities in Chapter 2, pp. [link][link]).

    Other challenges to Freudian psychoanalysis came from Carl Rogers’ client-centred therapy (1942), which proposed that the change process came from the patient’s potential for self-healing within a positive therapeutic relationship characterized by warmth and empathy, rather than from the therapist’s theoretically based interpretations. This was followed by the growth of learning-based approaches which focused on behavioural change, a more active stance of the therapist than that of the traditional psychoanalyst, and briefer treatments lasting weeks or months, rather than years. From the outset, both the Rogerian and learning-based approaches were actively interested in evaluating their therapies—Rogers’ research groups audio-recorded therapy sessions, and learning-based therapists tried to link outcomes to therapist interventions. Such methodology was, for the most part, disapproved of by the psychoanalytic community, due to their belief that it interfered in the treatment process by disrupting the therapeutic relationship and transference.

  • Phase II (c.1955–69): searching for scientific rigour

    In 1952, the British psychologist Hans Eysenck reviewed 24 studies of psychoanalysis. He found that patients in these studies improved no more than untreated controls, and famously declared that psychoanalysis was less effective than no treatment. This provocative claim spurred a dramatic increase in the quantity and quality of scientific research in psychotherapy over the next two decades, including more studies comparing treated patients to control subjects and techniques to reduce bias such as randomization and blinding of outcome measurements.

  • Phase III (c.1970–83): expansion, differentiation, and organization

    This period was marked by the development of more formal and systemic research endeavours, including the establishment of scientific organizations devoted to psychotherapy research and increased sophistication in conceptualization and methodology. By 1980, Eysenck’s conclusion that psychological therapies were ineffective had been refuted by many well-controlled studies and meta-analyses, which showed the effectiveness of such therapy, compared to untreated controls. Many of these studies were in cognitive therapy, advocated by Ellis and Beck, which emerged in the 1970s, partly from the disillusionment with psychoanalytic treatments, but also due to concerns that learning-based therapies focused too much on behaviours, rather than cognitions (see Psychotherapy research Cognitive behavioural therapy in Chapter 2, pp. [link][link]).

  • Phase IV (1984–94): consolidation, dissatisfaction, and reformulation

    Although empirical research methods in psychotherapy continued to advance, doubts began to emerge regarding their relevance to the study of human psychology. The field became split between those advocating empirically based objective or quantitative methods drawn from medicine, psychology, and other scientific disciplines and those advocating more subjective or qualitative methods of inquiry. Other discourses, such as the sociological, hermeneutic, and relational, became popular and were offered as more suitable alternatives to the scientific paradigm in exploring subjectivity and meaning. The rapid proliferation of the many different modalities of therapy led to competition and fragmentation of the field, and a preoccupation in demonstrating which specific modalities were superior in efficacy to other less ‘evidence-based’ therapies (see Psychotherapy research Medical psychotherapy modalities in Chapter 2, pp. [link][link]).

  • Phase V: contemporary psychotherapy research—from evidence-based practice to practice-based evidence

    Within most of the UK, NICE makes recommendations for evidence-based practice in health care by reviewing research into treatments for specific disorders and publishing recommendations in the form of clinical guidelines to determine the types of treatment available in the NHS (Scotland has a similar body, the Scottish Intercollegiate Guidelines Network or SIGN). Commissioners are increasingly requesting that the health services that they fund, including psychological therapy services, adhere to NICE guidelines.

No practising psychotherapist can therefore escape the imperative to ensure that the treatments they deliver have a sound evidence base which demonstrates their efficacy, safety, and cost-effectiveness. Psychotherapists who avoid engagement in the evidence base discourse risk specific therapies and services being decommissioned, leading to a decrease in patients’ choices of the range of therapies, especially in the public sector, and the risks of a one-size-fits-all approach. Some psychological therapists have questioned NICE’s ‘top–down’ approach in which therapeutic practice is expected to change according to the evidence produced from meta-analysis of RCTs, rather than patient-based data. They complain that evidence based on quantitative studies and statistical analyses seems disconnected from individual therapy encounters concerned with the subjective, experiential, and relational.

Although NICE guidelines are meant to enhance, not replace, clinical judgement, its approach has been controversial. In its choice of the type of evidence reviewed for any particular treatment, NICE prioritizes evidence from RCTs, which is the standard means of looking at treatments in other branches of medicine. However, in mental health, there are many therapies and therapeutic techniques that are established and accepted in clinical practice but have not been subject to RCTs. Furthermore, it is hard to see how many psychological therapies that rely on patient engagement and commitment could be assessed using randomization methods that undermine autonomy and choice. Barkham has suggested that the historical discourse in psychotherapy has progressively shifted from (a) justification (is psychotherapy effective?) to (b) specificity (which psychotherapies are effective?), then to (c) efficacy and cost-effectiveness (can therapies be made more effective within limited resources?), and on to (d) a current focus on effectiveness and clinical significance. Many therapy practitioners today challenge the claim that the RCT is the optimal source of evidence to address clinical significance. Instead they promote practice-based evidence in which evidence is created from within the therapeutic setting, rather than outside of it.

Practice-based research is more pragmatic and enables therapists to adopt a research-oriented approach within their naturalistic environment, leading to a sense of ownership of outcomes that seem more meaningful to their work. In practice-based research, using patient-based data routinely will not only improve the quality of local day-to day psychotherapy practice, but will filter upwards to enhance the scientific evidence for the effectiveness of that therapy.

An active current example of practice-based evidence is the routine administration of outcome measures in psychotherapy services. These may be clinician-rated outcome measures (CROMs) or patient-rated outcome measures (PROMs), which are administered either pre- and post-intervention or on a session-by-session basis to provide real-time feedback on patient progress. Most commissioners now expect routine outcome monitoring with performance feedback to be embedded within service delivery to enhance the quality of the service and patient care. Practice-based networks in which practitioner–researchers pool data from disparate settings have developed to produce large data sets that may make significant contributions to the evidence base. Benchmarking allows similar services to compare outcomes with each other. One measure, the Clinical Outcomes in Routine Evaluation (CORE), developed by a multidisciplinary group of practitioners and researchers, has been prominent in offering a cost-free practical system of psychotherapy service quality evaluation and support for service quality development (see Psychotherapy research Assessing the outcome of therapy in Chapter 4, pp. [link][link]).

Research methodology

A basic knowledge of research terminology and methodological approaches is needed to negotiate the psychotherapy research literature, and to understand and communicate the main findings of research in psychotherapy.

  • Efficacy measures how well an intervention or treatment works in clinical trials designed to show internal validity, so that causal inferences may be made.

  • Clinical effectiveness is the extent to which an intervention or treatment improves the outcome for patients in everyday clinical practice. There is often a gap between efficacy and effectiveness.

  • Effect size refers to the difference between treatment and control groups, expressed in standard deviation units. An effect size of 1.0 indicates that the average patient receiving the treatment under consideration is one standard deviation healthier on the normal distribution than the average patient receiving no treatment. An effect size of 0.8 is considered a large effect; 0.5 is considered moderate, and 0.2 is small.

  • Meta-analysis is a widely accepted method used in medicine and psychology to strengthen the evidence about treatment efficacy. It refers to the statistical analysis of a collection of results for the purpose of summarizing and integrating the findings of independent studies of a specific treatment that, in themselves, are too small or limited in scope, to come to a conclusion about treatment efficacy.

Quantitative research

Quantitative research is the systematic measurement of observable phenomena via statistical, mathematical, or numerical data or computational techniques. These phenomena are typically manipulated or observed under different types of controlled environmental conditions, and comparisons made between different data sets. This is the main approach to research used in the biomedical sciences.

It begins with a hypothesis which generates data through measurement, which, following analysis, allows a conclusion to be drawn by deduction. Quantitative studies typically involve the collection of many forms of data from large numbers of experimental subjects. Data are analysed using statistical manipulations that describe trends, compare groups, and relate variables, as well as compare results with past research.

Qualitative research

Qualitative research also develops hypotheses and utilizes an empirical approach to data. However, in qualitative research, it is assumed that the data to be gathered are context-dependent and subject to different levels of interpretation, depending on perspective. The numbers of research participants is smaller, and the subjective nature of the data is not controlled experimentally. It is assumed that there is not an infinite number of potential measurements, but that an in-depth investigation of a small number of human responses can yield a wide range of data, which will be generalizable to other similar contexts. Typically, different kinds of data are collected from different sources.

Qualitative research is most often used to gather an in-depth understanding of human behaviour and the reasons that govern such behaviour. It focuses on subjective experiences, collecting data from people in their natural environments, and investigates how social, cultural, and other factors influence experience and behaviour. Data collection may involve interviews (structured, semi-structured, guided, or unstructured), focus groups, telephone interviews, and observation (direct observation by researcher; indirect, e.g. via video-recording of sessions). In qualitative research, samples tend to be smaller and more focused than in quantitative research, and results are typically reported in words, rather than in numbers. Conclusions are drawn from induction.

Qualitative methodologies

  • Grounded theory: a research method used most commonly in the social sciences employing a ‘bottom–up’ or inductive approach in which theory is developed from data, moving from the specific to the more general. As data are progressively collected and reviewed, repeated ideas are tagged as codes, which may then be grouped into concepts, and finally into categories, which may become the basis for new theory.

  • Thematic analysis: focuses on identifiable themes and patterns of lived experience or behavior, e.g. identifying patterns of experience from transcribed conversations in a therapy session.

  • Content analysis: word frequency count in transcribed conversations/therapy sessions, assuming that the words most mentioned reflect the greatest concerns.

  • Discourse analysis: analysis of the underlying social structure contained in conversations.

Quantitative and qualitative research are not mutually exclusive but should be viewed as complementary. Mixed methods research employs both quantitative and qualitative methods and aims to investigate the phenomena in more depth. Triangulation involves the application and combination of several different methodologies in the study of the same data source or sample, so that the area under investigation is looked at from different perspectives, and intrinsic bias is reduced.

Outcome versus process research

Research in psychotherapy is traditionally divided into outcome research and process research:

  • Outcome research looks at the results of psychotherapy, how much a particular therapeutic intervention has helped or benefitted the patient, i.e. is it effective? The term ‘outcome’ refers to all aspects of change that patients can make in psychotherapy. Outcomes chosen to measure will depend on the perspective of the person assessing change (e.g. patient, therapist, commissioner), as well as the goals of treatment and treatment model. Outcome research, also described as ‘efficacy’ or ‘evaluation’ research, usually involves quantitative methods (see Psychotherapy research Assessing the outcome of therapy in Chapter 4, pp. [link][link]).

  • Process research looks at what goes on within the psychotherapy process, i.e. how does it work? Process research may involve quantitative methods, such as questionnaires or rating scales completed at the end of sessions by patients or therapists, or using external researchers to independently rate processes occurring in transcripts or video-recordings of therapy sessions, or may involve qualitative methods such as grounded theory analysis of the patterns of discourse in the transcripts of therapy sessions or interviews with patients and therapists.

  • Process–outcome research looks at the relationship between process and outcome in attempting to identify the specific ingredients or technique of therapy (process) responsible for therapeutic change (outcome) using a correlational approach. Such studies tend to assume a ‘drug metaphor’ logic, in that effective treatments should contain large amounts of the therapeutic ingredient (strength); be delivered in a pure manner (integrity); and that causality is linear and runs in one direction from process variable to influence outcome. Psychotherapy, however, involves complex interpersonal interactions which may not be a linear process but involves bidirectional, reciprocal, relational influences, as both the patient and therapist respond to each other in complex ways.

Psychotherapy study designs

The investigation of clinical problems in psychotherapy may draw on a range of different methodologies and study designs, depending on the stage of investigation of a therapy or the specific research question of interest. The types of study design are ranked below, from strongest to weakest, according to the hierarchy of evidence reflecting their relative validity or the strength of their findings in the evaluation of the effectiveness of clinical interventions.

  • A randomized controlled trial (RCT) is a trial comparing two or more groups constituting different treatment conditions to which patients or participants have been randomly assigned, as a means of minimizing bias. Any differences in outcome (the dependent variable) that emerge between the treatment groups may be attributed to the effects of therapy (the independent variable), as all other factors should have remained constant or ‘controlled’ via the randomization process, given a large enough sample size and power calculation. The RCT is widely held to be the ‘gold standard’ of study designs used in empirical research, as it is the most reliable method of demonstrating causality.

    However, the RCT may be more suited to drug trials than studies of psychotherapy, in which the administration of the therapy under investigation may vary widely in practice according to the experience and characteristics of the therapist. For this reason, methods to standardize psychotherapeutic treatments are employed, such as treatment manuals and assessing therapist competence and adherence to the specific therapeutic model of interest. RCTs have high internal validity and are the most reliable method of determining the efficacy of a therapy. However, this is often at the price of sacrificing external validity, in that the narrowly defined participant entry criteria and tightly controlled trial conditions may not reflect everyday clinical practice where clinical populations and therapeutic interventions are less clearly defined and categorized.

  • Dismantling studies form part of process–outcome research and attempt to identify the specific components of therapeutic change in a treatment package. Two or more therapies that are identical, except for the inclusion of one or a few specific techniques, are compared, e.g. a group of patients with BPD receiving psychodynamic therapy with a high frequency of transference interpretations per session is compared to a group of similar patients receiving psychodynamic therapy with a lower frequency of transference interpretations.

  • Quasi-experimental designed studies are studies comparing similar groups of patients in which there was no random assignment, but who were assigned to different treatments on some other basis than randomization. For example, patients suffering from a similar condition, such as depression, may be allocated to different treatments available at different sites. These studies may be more feasible to conduct in practice than RCTs but will always contain variables which will not be controlled for, and therefore confounded with the variable of interest, so that causality cannot be assumed.

  • Naturalistic, observational, or practice-based studies provide a means of gathering information on outcomes of therapy that is more faithful to everyday conditions. They focus on real clinical settings and tend to examine uncontrolled groups or cohorts of patients, who are not usually preselected and who are given treatments which are not manualized. These studies have high external validity in being more representative of routine clinical practice, but internal validity is weaker, and therefore causal inferences should be treated with more caution. Naturalistic studies may be cohort studies in which a group of patients who are linked in some way (e.g. diagnosed with depression) and exposed to a particular variable (the therapy under investigation) are followed over time. This group may then be compared to a similar group that has not been exposed to the variable.

  • Case control studies compare people with a certain health problem, such as BPD, or outcome (cases) and a similar group without the problem (controls), and seek associations between the outcome and exposure to a particular risk factor (e.g. childhood sexual abuse). These studies are usually retrospective and concerned with elucidating the causes of disease or health condition.

  • Clinical case studies were the standard medical research tool in Freud’s day and, for some psychotherapists, remain the standard research approach for investigating psychotherapeutic theory and practice. Although an accessible means of communicating ideas, they are limited methodologically. Case report construction is subject to the individual practitioner’s selective bias for recalling or distorting clinical data to fit the author’s views, and/or excluding important information that does not fit. There are also important ethical issues about the ownership of clinical information; it is now deemed to be ethically and legally unjustifiable to publish a case history of a patient without their consent. Nevertheless, single case studies may be a valid starting point in researching a particular therapy, technique, or clinical situation, in which hypothesized ideas may be initiated and explored through clinical observation and theoretical inference. In recent years, there has been a resurgence of interest in the value of clinical case studies in offering a meaningful source of evidence to confirm a clinical theory. Single or small-sample case studies may be better able than larger-scale studies to examine the complexities of the therapeutic process and track how changes unfold over time. Contemporary systematic case study research employs a formal set of principles, including the construction of a data set from different sources and analysis of the data set by a team of researchers (which may include the therapist and/or patient).

Difficulties in doing research in psychotherapy

Many psychotherapists have been reluctant to embrace a research agenda. This may be due to a variety of reasons, including suspicion of research methodology and fears that it may interfere with effective and ethical clinical practice; viewing narrowly defined trial criteria and research conditions as non-representative of clinical practice (the gap between efficacy and effectiveness); and a reluctance to give up beliefs about theory and technique based on selective experience, and accept empirical findings which may challenge established practice.

Although we believe that empirical studies of psychotherapy are essential for its survival as credible forms of treatment, it is important to be aware of some of the problems and limitations inherent in psychotherapy research which include the following:

  • The gap between efficacy and effectiveness: the strictly controlled conditions of an RCT may be hard to apply in routine clinical practice where patients and treatments delivered are less well defined

  • Research yields generalities or probabilities, rather than specifics or certainties: the results of a trial may predict that, on average, the treatment under investigation is effective in the population studied, but this does not mean that any individual patient will definitely improve with this specific treatment

  • Positive correlations do not always confirm causality, due to undetected confounding factors

  • Splits between academics who do research and clinicians who do therapy: much of the psychotherapy research is generated by academics based in universities, and may not be easily accessible or appear relevant to therapists in practice

  • Splits between therapists/modalities who have embraced research and those who have not: there are ten times more RCTs of CBT than of psychoanalytic psychotherapy, and many of the latter are of poor quality. However, lack of evidence does not equate with lack of efficacy

  • Allegiance effect: researchers and clinicians inevitably have assumptions and agendas, including a loyalty for the therapy that they are researching, which may lead to significant bias in the interpretation and dissemination of results. Any allegiances should be declared in publications

  • Therapeutic change is not linear: progress in therapy is unlikely to proceed in an orderly constant manner but involves a more complex trajectory involving periods of progress, followed by regression; shifting and reciprocal changes in affect regulation, impulse control, and awareness of self and others; and a deepening of insight and reflective capacity

  • Medical model/categorical diagnoses: research often focuses on ‘pure’ categories of mental disorder according to a medical model which assumes that discrete conditions have different aetiologies and warrant different treatments. However, such categories may not reflect the types of patients and problems, particularly in the relational realm, seen in everyday clinical practice. Moreover, co-morbid conditions and more complex psychopathology, particularly personality disorders, tend to be excluded from such studies

  • Manualization: promoting strict adherence to a prescribed model of therapy may not reflect how therapy is more flexibly and responsively delivered according to the vicissitudes of everyday practice. Manualization may also inadvertently lead to therapists refusing to discuss themes or issues that are ‘not in the manual’, which may be clinically dangerous and distorting of the therapeutic process under study

  • Limitations of measures: measures are more easily designed to identify overt symptomatic or behavioural change but may fail to capture more complex intrapsychic or interpersonal processes that underlie personality difficulties and relationship problems. This is a particular issue with self-report measures

  • Research methodology may interfere with the treatment model under investigation: for example, the recording of sessions or administration of patient-completed measures during therapy may influence the transference–countertransference dynamics between the patient and therapist which are the focus of psychodynamic psychotherapy

  • Length of treatment studied: most studies focus on brief treatments which are easier to research, rather than longer-term therapies, and do not study long-term follow-up

  • Variation in quality and standards of training in psychotherapy: this may be an impediment to research if it is not known how good the therapists are in delivering the treatment under investigation.

Outcome research in psychotherapy

(See Psychotherapy research Assessing the outcome of therapy in Chapter 4, pp. [link][link].)

Does psychotherapy work?

There is now extensive evidence that psychological therapies produce positive change, compared to untreated controls, and are effective for a number of different disorders and clinical problems. The use of meta-analyses in pooling the results of outcome studies has been conclusive in demonstrating the efficacy of psychotherapy in general. One of the first most influential meta-analyses was published by Smith et al. (1980), which summarized the results of 475 outcome studies of psychotherapy giving an effect size of 0.85 for treated patients, compared to untreated controls.

In 1991, McNeilly and Howard disproved Eysenck’s assertion that psychotherapy was no more effective than spontaneous remission, using Eysenck’s original data. Since then, hundreds more meta-analyses have been published, summarizing the positive outcomes of therapy in general, as well as results for specific therapies, specific disorders, and specific treatment settings. Therapies appear to be equally effective for adults, young people, and children, with outcomes as good as, and sometimes superior to, medication. Many studies have also demonstrated the cost-effectiveness of psychotherapy, as well as convincing evidence that positive gains can last years after the termination of treatment.

However, a proportion (20% to 40%) of patients in these studies do not improve with treatment, and a minority (5% to 10%) deteriorate. Evidence also suggests that, in routine clinical practice, patients do not fare as well as those in formal clinical trials, with deterioration rates reported as high as 14% with adults, and 24% in children, treated with psychotherapy. Not all such deterioration can be accounted for by therapist activities but may depend on individual patient characteristics such as patients who are already on a negative trajectory at the time of entering treatment. Nevertheless, in general, therapists tend to overrate their patients’ progress, and may miss signs of patient worsening and do not take the necessary actions to address this. Where negative patient change is due to therapist factors, this is usually due to therapist actions within the therapeutic relationship of a rejecting nature.

How much therapy is needed?

Researchers have also looked at the length of therapy necessary for positive change to occur. ‘Dose effectiveness’ studies and meta-analyses of such studies have suggested that around 50% of patients improve after 20 sessions of therapy, and 75% after 50. Moreover, different levels of functioning respond differentially to treatment, with symptomatic and behavioural change responding more quickly than personality difficulties and interpersonal functioning, which may need longer and more intensive treatments.

Are some therapies more effective than others?

(See Psychotherapy research Medical psychotherapy modalities in Chapter 2, pp. [link][link].)

As well as demonstrating the efficacy of psychotherapy in general, researchers have also investigated the differential effectiveness of different modalities, such as CBT, and psychodynamic and humanistic therapies, in comparative studies. Here, however, results have been consistently inconclusive, in that no therapy has been convincingly shown to be superior in effectiveness to any other. This has been termed the equivalence paradox, or dodo bird effect, after the dodo’s pronouncement ‘Everyone has won, and all must have prizes’ in Lewis Carroll’s story Alice in Wonderland.

Early meta-analytic reviews showed some evidence that CBT was more efficacious than psychodynamic and interpersonal models of therapy, but later more sophisticated meta-analyses which controlled for investigator allegiance and case severity suggested that there were no significant differences between CBT and other therapies in terms of outcome, thus supporting the equivalence verdict.

Critics of such meta-analyses assert that they are not comparing like with like, that studies should be conducted by genuinely independent bodies to eliminate allegiance bias, and that the dodo effect is due to a failure to measure real differences that exist between different therapies but have eluded detection because our measures are inadequate. However, others have concluded that, although different therapeutic modalities overtly differ in theory and technique, these are, in fact, less important than ‘common factors’, i.e. techniques and mechanisms common to all therapies, which may go unnoticed but which constitute the real agents of change.

Process research in psychotherapy

How does psychotherapy work?

Process research looks at what happens in psychotherapy and whether therapies differ in their processes, and tries to identify the effective ingredients or mutative agents, how they effect change, and how change develops and is experienced by patients as they progress through treatment. The process research field has been marked by a proliferation of thousands of different instruments, measures, and classification systems catering to different theoretical orientations, treatment modalities, target populations, measurement and data formats, and communication channels, which may appear bewildering to the uninitiated. Nevertheless, consistent findings regarding both common and specific therapy factors have emerged which are summarized below.

Common factor research

It has been estimated that modality-specific factors account for as little as 8% of positive outcome for psychotherapy, and that the majority of change processes in therapy are due to ‘non-specific’ or ‘common’ factors. Various attempts have been made to define and quantify these, based on theoretical considerations, studies of the literature, surveys, and empirical findings, and may be summarized as:

  • Therapy relationship factors

  • Patient characteristics

  • Individual therapist characteristics

  • Placebo effect

  • Extra-therapeutic factors.

  • The therapeutic relationship

(See Psychotherapy research Therapeutic alliance in Chapter 3, p. [link]).

Most of the research into common factors has investigated aspects of the therapeutic relationship, including the treatment alliance, and therapists’ attitudes and behaviours towards the patient. Such research has consistently shown that the quality of the therapeutic relationship is a crucial determinant of positive outcomes in psychotherapy and can also mitigate against premature dropout from therapy. These results hold true for both therapies that are overtly relationally oriented (e.g. psychodynamic, interpersonal) and therapies that are not primarily relationship-focused (e.g. CBT).

The therapeutic alliance may be defined by the extent to which therapists and patients agree and collaborate on the tasks and goals of therapy, as well as the existence of a positive affective bond between the patient and therapist. The strength of the alliance is strongly related to positive outcome in therapy and should be established before more challenging interventions are introduced (e.g. interpretation of the negative transference). Addressing, within the therapeutic frame, disruptions or ruptures in the alliance that are generated from patients’ negative reactions to the therapist and/or treatment process is critical to the repair and maintenance of a positive therapeutic alliance and is more likely to lead to better therapeutic outcome.

Generic relational skills or attitudes linked to positive outcome include therapists’ levels of empathy, positive regard, and levels of congruence (also referred to as ‘genuineness’, ‘authenticity’, or ‘openness’). More specific therapist relational skills and techniques, such as the capacity to repair alliance ruptures, the ability to manage countertransference reactions, giving modest, rather than high, levels of self-disclosure, giving positive feedback, and making fewer, rather than more, frequent, transference interpretations per session, have also been shown in empirical studies to be associated with positive therapeutic outcome.

  • Patient characteristics

    Research on common factors related to the patient or client show that those who are more motivated to engage in therapy and are motivated to change, and those with a clear sense of goals and focus of therapy tend to have better outcomes. Patients who are able to frame their problems in psychological terms and have faith in the possibility of change through therapy, but also have realistic aims and recognize that therapy can be difficult, also tend to do better. Other factors, such as secure attachment style, supportive social network, and previous positive relational experiences, have also been demonstrated as correlating with positive outcomes of therapy.

    Demographic characteristics, such as age, gender, sexual orientation, socio-economic class, and ethnicity, have not been shown to substantially influence therapy outcome, although there is some evidence that patients from black and minority ethnic backgrounds and those of lower socio-economic class may not access psychotherapy services so often, as well as have higher rates of premature dropout when they do engage in therapy.

  • Therapist characteristics

    Many studies have found that marked differences exist in therapeutic success with patients between therapists of the same theoretical school or orientation, even amongst therapists delivering manualized treatments. Much of this variation appears to be related to the therapist’s ability to form a positive therapeutic alliance with their patients. Where the quality of the alliance is poor, this is more likely to be due to factors associated with the therapist than with the patient, and is associated with poorer outcome than where there is a stronger therapeutic relationship. Therapists’ characteristics which may account for the capacity to form a strong therapeutic alliance, or are independently associated with good outcome, are not clear—there is some evidence that therapists with higher levels of psychological well-being and those demonstrated to have more secure attachments, as well as those with more professional experience as a psychotherapist, have better patient outcomes, although the effect sizes observed in studies are small. Age, gender, a therapist’s personal experience, and personality traits appear to have little influence on therapy outcome.

  • Patient–therapist matching (see Psychotherapy research Choice in Chapter 4, p. [link])

    Patients sometimes request therapists with particular characteristics such as gender, ethnicity, or sexual orientation. However, the research findings on ‘patient–therapist matching’ are inconclusive. Matching of patient and therapist by sex does not appear to influence outcome. There is some evidence that patients who identify themselves as lesbian, gay, bisexual, or transgender report better outcomes, when matched with therapists who have a similar sexual orientation. Similarly, there is some evidence that therapist–patient matching on ethnicity does contribute to better outcome, as well as to lower dropout rates. Regarding age, there is no strong evidence that matching of patient and therapist by age affects outcomes, although a couple of studies have indicated that therapists who are 10 years or more younger than their patients may have less good results than those who are within 10 years of their patients’ age. Studies have also shown that matching of specific attachment styles between therapist and patient may predict psychotherapy process and outcome. For example, patients who have a therapist who is opposite to them on the preoccupying to dismissing dimension of attachment on the AAI tend to have better outcomes than patient–therapist pairs who do not (see Psychotherapy research Theories of personality development: attachment theory in Chapter 8, pp. [link][link]).

  • Placebo effect

    The placebo effect in psychotherapeutic research is less easy to determine than in pharmacological trials where it is more feasible to construct placebo control conditions that do not contain the putative curative substance (i.e. the drug under investigation). However, as psychological factors are assumed to account for the placebo effect in any trial, it is less easy to disentangle these from psychological factors that may constitute some of the ‘common factors’ accountable for positive outcome in psychotherapy. Placebo factors have been defined as the generation of belief in the treatment, the expectancy of positive outcome, the installation of hope, a decrease in demoralization, and an increase in experience of self-efficacy.

    Many studies have been conducted to explore the relative benefits of therapies, compared to placebo controls. Recent meta-analyses have concluded that, although placebo conditions do contribute to positive outcome, the effects of these factors are smaller than those of therapy-specific factors, and it is difficult to disentangle which placebo-specific factors are responsible for any positive change.

  • Extra-therapeutic factors

    Finally, unexpected positive and negative life events that occur during therapy may lead to change that is not connected to specific therapy factors, but may account for some of the variance found in common factor research.

Research into therapy-specific techniques

Thousands of studies have examined the effects of specific techniques (i.e. a defined therapeutic procedure designed to bring about a specific goal) and have shown that many techniques are linked with psychological improvement, compared to control or placebo conditions. As well as having a direct impact, certain techniques have also been shown to strengthen the therapeutic alliance and therefore offer an important mediating effect on positive outcome.

However, as noted above, researchers have estimated that specific technique and psychotherapy orientation factors account for only a small proportion of the overall outcomes of psychotherapy, and studies comparing the outcomes of different modalities (which assume the delivery of modality-specific techniques) rarely yield significant differences. Studies asking patients to describe what they found most helpful in therapy have found that factors associated with a positive relationship (e.g. ‘the therapist was warm and caring’) are reported more frequently than technological factors. Dismantling studies rarely find that the presence or absence of specific techniques makes much difference to overall outcome, and studies comparing one technique with another also seldom find significant differences.

Nevertheless, there is some evidence that specific techniques are effective, the strongest being for cognitive behavioural techniques, particularly exposure-based interventions for anxiety. For psychodynamic therapy, carefully worded interpretations embedded in a strong therapeutic relationship have been consistently linked to positive therapeutic outcomes, and more specifically transference interpretations at moderate, rather than high, levels or ‘doses’. Both directive and non-directive approaches in therapy have been shown to be beneficial, although extremes of either are associated with poorer outcome. Generic techniques and practices, such as listening, paraphrasing, and encouraging, are usually experienced by patients as helpful, whereas the therapist asking questions or giving advice is less frequently experienced by patients as positive.

More recent innovative research has demonstrated that giving therapists feedback about their patients’ progress may produce dramatic improvement in patients exhibiting distress, at risk of deteriorating, or disengaging from therapy. Such feedback is generated by systems that track patient progress on a session-by-session basis, by giving patients a brief outcome measure at every therapy attendance. The results are then computer-processed and fed back to the therapist before the next session. If the patient is ‘not on track’, the therapist is expected to proactively respond by, for example, focusing attention on repairing therapeutic alliance ruptures.

Finally, although research into therapies delivered by different modes of communication is in its infancy, a growing body of studies indicates that telephone and Internet-based therapeutic interventions may be as effective as face-to-face therapies.

What constitutes good therapy?

Lambert and Bergin have identified and integrated many of the factors and interventions that are empirically associated with positive outcomes into a useful phasic model of what constitutes good therapy by dividing common factors into support, learning, and action factors. ‘Support factors’ are mainly concerned with aspects of the therapeutic relationship and should be present in all therapies before change may occur. Support factors include catharsis/release of tension, identification with the therapist, mitigation of isolation, reassurance, release of tension, provision of a safe and structured environment, therapeutic alliance, therapist/client active participation, therapist expertness, therapist warmth, and trust/open exploration. ‘Learning factors’ include interventions and strategies that facilitate changes in belief systems and attitudes and emotional regulation, and may be specific to particular therapies. Learning factors include advice, affective experiencing, cognitive learning, correctional emotional experience, exploration of internal frame of reference, feedback, insight, rationale, and reframing of self-perceptions. Learning factors, in turn, lead on to behavioural changes subsumed under ‘action factors’. Action factors include behavioural/emotional regulation, cognitive mastery, facing fears, mastery efforts, modelling, practice, reality testing, success experiments, taking risks, and working through.

New ways forward

As in any evolving and creative area of research, researchers in the psychotherapy field generate as many questions as they answer. One of the most pressing and affectively charged questions remains that of the dodo bird—are all therapies equally efficacious, or are some therapeutic orientations and specific techniques more effective than others? At the same time, many other research questions regarding common factors warrant further exploration: How do the therapist, the patient, and the therapeutic relationship variables influence each other? How are they related to outcomes in specific disorders and settings? Which kinds of patients do best in which types of therapies? How do cultural and social factors influence patients’ responses to therapy?

The following list represents some of the most promising areas that future researchers might wish to focus on in attempting to address these and the multitude of other questions and challenges posed by contemporary psychotherapy research:

  • More integrative approaches

    Competing epistemological discourses (e.g. outcome/process, subjectivity/objectivity, qualitative/quantitative, scientific/hermeneutic, positivism/relational, specificity/pluralism) should be replaced by more collaborative and integrative approaches to avoid further unnecessary fragmentation; elucidate common methodologies, mechanisms, and areas of interest; and engender respect and enquiry for real differences where they are found.

  • Neuroscience (see Psychotherapy research Neuroscience and psychotherapy in Chapter 11, pp. [link][link])

    One of the most exciting and fertile interdisciplinary areas in recent years has been the collaboration between psychotherapy and neuroscience researchers in exploring how the psychological workings of the mind are linked to the anatomical structures and biochemical processes of the brain. Psychological experiences are no longer viewed as solely the products or epiphenomena of brain function, but are now known to directly alter brain structure and function via neural plasticity, synaptic rearrangement, and genetic expression.

  • Attachment paradigm (see Psychotherapy research Theories of personality development: attachment theory in Chapter 8, pp. [link][link])

    Attachment theory is one of the most promising and convincing theoretical paradigms guiding contemporary psychotherapy treatment and research. It provides a coherent model in which the findings on the influence of the therapeutic alliance and the effects of other psychotherapeutic techniques may be conceptualized, integrated, and further empirically tested. The developmental perspective of attachment theory provides a framework for psychotherapy, in which the therapist is experienced as a secure base and temporary attachment figure for the patient (a strong therapeutic alliance), enabling him to explore past and current relationships, external to and within the therapy, with the opportunity to revise internal working models, leading to better adaptation and interpersonal relating. Although certain specific psychodynamic psychotherapies, such as IPT, transference-focused therapy, and MBT, have developed as explicitly attachment theory-based interventions, one can argue that attachment theory implicitly guides all psychotherapies in improving the patient’s capacity for mentalization or self-reflective functioning, which is dependent on the person’s early developmental attachment experiences, and is a key component of all psychotherapies.

  • Transdiagnostic methods

    Psychotherapy research is moving from single disorder-focused manualized approaches towards ‘transdiagnostic’ treatments which focus on similarities amongst disorders, particularly in a similar class of diagnoses (e.g. anxiety disorders). Transdiagnostic treatment protocols have been pioneered by CBT-oriented researchers but are also relevant to other therapeutic modalities such as psychodynamic psychotherapy, as they focus more on the core underlying processes of mental conditions in general, an understanding of which may be more easily applied to the less well-defined diagnostic categories and co-morbidities seen in clinical practice.

  • Challenging the supremacy of the RCT paradigm

    On the one hand, as long as influential bodies, such as NICE, prioritize RCT evidence, more RCTs evaluating the efficacy of non-CBT therapies are needed to ensure that a wider range of effective therapies are commissioned and available for patients to choose. On the other hand, the dominance of the RCT paradigm marginalizes other research methodologies, such as single case studies and qualitative research, which may be more suited to exploring essential components of the therapeutic process and are easier to apply in clinical practice.

  • Closing the gap between research and practice

    Not all practising psychotherapists will have the opportunity or be inclined to engage in formal research, but we should aim for a situation in which the majority of therapy practitioners are not only ‘research-aware’, but are also more confident, inspired, and excited by the findings of research and what they can offer to clinical practice. To some extent, this has been achieved by translating more research ideas into practice-based therapy, but further work needs to be done to embed research teaching in psychotherapy trainings, establish more research-practitioner networks linking academics with clinicians, and apply competency frameworks without losing therapeutic flexibility and expertise gained from clinical experience.

  • Involving service users (see Psychotherapy research Service user involvement in Chapter 10, pp. [link][link])

    More involvement in psychotherapy research of service users or ‘experts by experience’ with lived experience of psychological distress and its therapeutic treatment may help bridge the gulf between research and practice. The service user perspective is increasingly recognized as valuable and influential in all stages of research, including study design, testing proposed measures, data collection, and the analysis and interpretation of findings. Patients participating in research trials may be more amenable and reliable to having measures administered by service users than by research assistants, and a growing number of service user organizations are able to offer training in research methodology and skills.

Recommended reading

Aveline M, Strauss B, and Stiles WB (2006). Psychotherapy research. In: Gabbard GO, Beck JS, and Holmes J (eds). Oxford Textbook of Psychotherapy. pp. 449–62. Oxford University Press: Oxford.Find this resource:

    Cooper M (2008). Essential Research Findings in Counselling and Psychotherapy: The Facts are Friendly. Sage: London.Find this resource:

      Eysenck HJ (1952). The effects of therapy: an evaluation. Journal of Consulting Psychology, 16, 319–24.Find this resource:

      Lambert MJ (ed) (2013). Handbook of Psychotherapy Behaviour and Change, sixth edition. John Wiley & Sons: Hoboken, NJ.Find this resource:

        McNeilly CL and Howard KI (1991). The effects of psychotherapy: a re-evaluation based on dosage. Psychotherapy Research, 1, 74–8.Find this resource:

        Orlinsky DE and Russell RL (1994). Tradition and change in psychotherapy: notes on the fourth generation. In: Russell RL, ed. Reassessing Psychotherapy Research. pp. 185–214. Guildford Press: New York.Find this resource:

          Reeves A (2014). Research in individual therapy. In: Dryden W and Reeves A, eds. The Handbook of Individual Therapy, sixth edition. pp. 577–602. Sage: London.Find this resource:

            Smith ML, Glass GV, Miller TI (1980). The Benefits of Psychotherapy. John Hopkins University Press: Baltimore, MD.Find this resource:

              Neuroscience and psychotherapy

              Almost 15 years ago, Glen Gabbard wrote in the British Journal of Psychiatry that ‘advances in neuroscience research have led to a more sophisticated understanding of how psychotherapy may affect brain functioning. These developments point the way towards a new era of psychotherapy research and practice in which specific modes of psychotherapy can be designed to target specific sites of brain functioning’. A few years later, Eric Kandel and colleagues wrote that ‘with the advent of neuroimaging techniques with high spatial and temporal resolution, the ability to probe the biological consequences of psychotherapeutic interventions has begun to come within reach, and with it the ability to document psychotherapy’s effectiveness, to follow its course, and to refine its appropriate applications for selected patients and disorders. Psychotherapy is a controlled form of learning that occurs in the context of a therapeutic relationship. From this perspective, the biology of psychotherapy can be understood as a special case of the biology of learning’.

              Freud originally practised as a neurologist in Vienna, whilst developing his interest in understanding all aspects of mental functioning more fully. He wanted to be able to integrate his knowledge of brain functioning with his evolving interest in mental phenomena and with the new evolving science of psychoanalysis. Unfortunately, the available knowledge of the brain and the means to explore this further at the end of the nineteenth century were not adequate for this task. Freud therefore resolved to concentrate his efforts on understanding mental functioning more fully and left it for posterity to attempt to integrate this understanding with a fuller understanding of brain development when the time and the means of investigation were right.

              Since the early 1990s, a variety of imaging technologies have revolutionized brain research. These technologies let scientists see what is happening inside subjects’ brains without having to open up their skulls. Researchers can ask subjects to perform specific mental tasks, then ‘watch their brains think’ as they perform these tasks in real time.

              There have been major advances also in our knowledge of genetics since the discovery of the double helical structure of deoxyribonucleic acid (DNA) by Watson and Crick in 1953. Molecular biology is a hybrid discipline of genetics and biochemistry that attempts to understand life processes at the level of the macromolecules of the cell and at the level of their structure and function.

              Our genes are seen to have two functions. ‘The template function’ allows our genes to replicate and make copies that are passed from generation to generation. ‘The transcription function’ refers to a gene being turned on to make a new protein that alters the structure and function of the cell. This transcription function is influenced by what we do or think. Information inherited through encoding on DNA can be activated or suppressed by other genetic or environmental elements. Information is also remembered through the actions of messenger ribonucleic acid (mRNA) but is not transmitted genetically to other generations in this way.

              The practical applications of this knowledge to our clinical work are varied. When psychotherapy changes people, it does so through learning. It produces changes in gene expression that alter the strength of synaptic connections. In an exciting link to attachment theory, polymorphism in the serotonin transporter gene (5-HTTLPR) has been typed and is seen to be clinically relevant. Attachment patterns in infants were explored on the basis of the genetic expression of the serotonin transporter gene. For short allele (ss/sl) infants, low responsiveness in the mother predicted a particularly high risk for insecure attachment, and high responsiveness offset that risk. For infants homozygous for the long allele (ll), there was no association between responsiveness and attachment organization. Homozygous infants were securely attached, whatever the responsiveness of the mother (see Psychotherapy research Theories of personality development: attachment theory in Chapter 8, pp. [link][link]).

              The complexity of the molecular biology of the neuron is illustrated by the intricacies of chemical transmission of impulses across synaptic gaps between neurons and by the impact of the chemical involved in the biochemistry of the post-synaptic neuron. There are nine different types of classical neurotransmitters and more than 50 types of neuroactive peptides. Most neurons produce multiple neurotransmitters, which act on very different timescales. Genes are activated within the cell nucleus to start producing new proteins. These proteins facilitate excitability of previously activated synapses and enhance the production of neurotrophins that lead to the formation of additional synapses around previously activated synapses.

              Freud would probably be very happy to be alive in our age of advancing knowledge of brain development and mental functioning. There has been a massive expansion in knowledge about the development and functioning of the brain and body, about the sensorimotor and autonomic nervous systems, about the neurodevelopment of attachment and of personality, and about experiences that lead to likely disorders of functioning. This paradigmatic shift in understanding when linked with an active awareness of communicating styles leads to effective clinical interventions with particular patient groups.

              The brain

              Brain structure and function

              The concept of the triune brain has evolved over the past 50 years. According to this theory, the following three distinct brains emerged successively in the course of evolution and now co-inhabit the human skull:

              • The reflex or reptilian brain is the oldest of the three and consists of the structures of the brainstem and the cerebellum. It controls the body’s vital functions such as heart rate, breathing, body temperature, and balance. The reptilian brain is reliable but tends to be somewhat rigid and compulsive in function.

              • The feeling or limbic brain emerged in the first mammals and consists of areas of brain cells and their connections known as the hippocampus, the amygdala, and the hypothalamus. It records memories of behaviours that produce agreeable and disagreeable experiences. It is responsible for what are called emotions in human beings. The limbic brain is the seat of the value judgements that we make, often unconsciously, that can exert such a strong influence on our behaviour.

              • The thinking brain or the neocortex first assumed importance in primates. It culminated in the human brain with its two dominant large ‘cerebral hemispheres’. These hemispheres have been responsible for the development of human language, abstract thought, imagination, and consciousness. The neocortex is flexible and has almost infinite learning abilities. Learning is a process that will modify a subsequent behaviour. Memory is basically nothing more than the record left by a learning process. The neocortex is what has enabled human cultures to develop.

              These three parts of the brain do not operate independently of one another. They have established numerous interconnections through which they influence each another. The neural pathways from the limbic system to the cortex, for example, are especially well developed.

              Experiences arriving at areas of our brains through our senses are laid down as ‘memories’ in specific areas of the brain, and integrated through neural connections across a number of functional systems in our brains. We gain sensory experiences through our senses of vision, hearing, touch, taste, and smell. Each motor experience is likewise registered in specific parts of the brain and integrated across a number of brain areas and functional systems necessary for the finer control of movement and actions. An infant learns to control head movements, turn over, sit up, crawl, walk, run, control hand movements, develop precise hand coordination, vocalize, make words, link words, make sentences, and make verbal sense all in the first 3 years of life. All such progress is registered in neural networks of the brain.

              The blueprint for brain development is genetically mediated. Genetics determine the form and structure of our brains, especially what we understand as our reptilian brain. Our limbic brain is likewise to a great extent genetically determined, but it is also directly influenced by experiences we have as infants. Such experiences are laid down in neural networks within the limbic structures, and in the neural networks that connect to the limbic structures. The timing of patterns of brain growth and development is genetically determined, but it is also influenced by experiences and by environmental factors.

              The building blocks of the brain are neurons, nerve cells that each makes thousands of connections with other nerve cells. Chemicals, known as neurotransmitters, make connections across the gaps between cells, known as synapses. Small electrical impulses are transmitted quickly down long fibre-like outgrowths, known as axons, from the body of the nerve cell, which connect with thousands of other neurons. These mechanisms of neuron development and action are genetically laid down in DNA, the genetic material of the neurons. Neurons are supported, in turn, by other cells in the brain, which ensure the presence of the correct environment and the correct nourishment for neural growth and activity. Some of these supporting cells coat the axon of the neuron with a protective covering that quickens the transmission of nerve impulses down the axon. This process is known as myelinization and makes for more effective and more efficient nerve impulse transmission.

              The capacity of neurons and neuronal networks to respond to the environment is genetically determined. When neurons fire (are activated), they fire off neighbouring neurons connected via axons, synaptic gaps, and neurotransmitters. Repeated firing of particular neurons makes future firing more likely. Neurons that fire together are primed to repeatedly further fire together, forming networks of neurons. These neural networks, if repeatedly activated, continue to develop further connections with other neurons and with other neural networks. ‘Neurons that fire together wire together’. Such connections are the forerunners of memory systems in the brain.

              The human brain is a very complicated three-pound mass of matter. It contains over 100 billion neurons and another one trillion support cells. There are up to 10 000 synapses on each neuron. Each neuron contains the entire genome, and approximately 35 000 genes can have a direct impact on brain development. The size of our brains, and those of our primate cousins, correlates with both the length of our juvenile period and the complexity of our social structure. Long childhoods and complex societies make for larger brains.

              Likewise, relational experiences, emotional experiences, verbal experiences, and thinking experiences are both registered in, and made possible by, brain activity. All this activity represents growth and development in our brains made possible through our genetic potential and made actual by our experiences in life. It is a clear example of a process where both nature and nurture are seen to be essential elements for normal growth and development to occur.

              The right hemisphere generally processes non-verbal communication; it allows us to recognize faces and read facial expressions, and it connects us to other people. It thus processes the non-verbal visual cues exchanged between a mother and her baby. It also processes the musical component, or tone, of speech by which we convey emotion. Our right hemisphere dominates the activity of the brain for the first 2 years of our lives. Brain scans show that, during the first 2 years of life, the mother principally communicates non-verbally with her own right hemisphere to reach her infant’s right hemisphere.

              The left hemisphere generally processes the verbal linguistic elements of speech, as opposed to the emotional musical ones, and analyses problems using conscious processing. The left hemisphere dominates activity in the brain from 2 years onwards, whilst language is actively developing.

              Periods of brain growth and development

              Whilst the evolution of the structures of the brain has happened over millions of years, an individual’s brain develops over a lifetime of about 85 years. There are three stages of particularly rapid brain growth and development during this time. The first stage is the time spent in the womb, when we develop from the joining of two cells at fertilization, to a very complex living organism at birth 9 months later. The second rapid stage of brain growth and development occurs during the first 3 years of life. The third stage of significant brain development occurs during our adolescent years. The brain, however, continues to develop throughout life.

              The brain continues to mature during our ‘adult years’. All activities become much easier with practice. This is reflected in the degree of activity measurable in the brain. Many areas of the brain are seen to ‘light up’ on neuroimaging when we attempt something new. With practice, the areas and neural networks in the brain that are activated to achieve the same result become more defined and refined. Sometimes, as when motor movement and activity are involved, the necessary brain functioning takes place mostly in non-cortical brain areas such as areas in the brainstem and cerebellum. When some ‘higher executive functioning’ uses areas of the prefrontal cortex (PFC) to achieve a desired result, the area of the PFC used by adults is smaller to achieve the same result than that used by adolescents. Brain functioning becomes more efficient with practice.

              Throughout adult life, a small region of the hippocampus, the dentate gyrus, continues to generate new differentiated nerve cells from stem cells. Antidepressants may exert their effects on behavior, in part, by stimulating the production of neurons in the hippocampus.

              How does this apply to clinical practice?

              Memory and learning

              Understanding memory as a representation and record of altered brain functioning is helpful in the context of learning. A child’s brain functions very differently to an adult’s brain. Memories and emotional reactions early in childhood are based on a more ‘immature and primitive’ mechanism of brain functioning. Brainstem reflexes and limbic activity organize much of the infant’s experiences. Development of more primitive brain structures precedes the development of later evolving ones. Early experiences influence the wiring that is installed in the brain, whilst later adult learning usually influences how already established wiring fires. Once neural networks are established, new learning often relies on the modification of these established patterns.

              The basic feature of the intercellular memory process is the pairing of neurons with each other. When two connecting neurons fire at the same time, they are more likely to fire together again in the future, because the strength of the connections between them will be greater. When two connected neurons fire frequently together, they develop new synaptic connections. These memory processes seem likely to be the basis for what is known as implicit (procedural, non-hippocampal) learning (see Psychotherapy research Memory and emotions in Chapter 11, pp. [link][link]).

              Simple repetition can effect change, even in the absence of reasoning or logic to support the change. The development of associations between events and emotions is an example of non-hippocampal learning based on simple pairing, even in the absence of awareness and insight. Non-hippocampal learning will not readily change despite the presence of new insight. When implicit memory associations weaken, they are likely to do so slowly and incrementally over time. Memory is highly influenced by affect.

              Explicit (sometimes called declarative or autobiographic) memory (see Psychotherapy research Memory and emotions in Chapter 11, pp. [link][link]) is based in the hippocampus and affiliated structures. When two neurons both innervate a third neuron, the process of long-term potentiation can, in effect, form a bond between them, even though they are not directly connected. Pyramidal cells are neurons that receive input from extremely high numbers of other neurons. They are structured in a way that facilitates development of such new connections. These cells occur in high numbers in the hippocampus, as well as in the outer surface layers of the cerebral cortex.

              Connections between the hippocampus and frontal cortical areas appear to support conscious processing and decision-making, and the area as a whole is particularly well suited to establish novel connections supporting new learning. Hippocampal learning coincides with declarative and explicit conceptualizations of learning, whilst non-hippocampal learning coincides with implicit memory formation. Hippocampal learning supports efficient processing of incoming information and integration of new information with information previously stored in the brain. It also supports flexible retrieval of stored information.

              The concept of the ‘remembered present’ suggests that much of what we take to be perception is, in fact, memory. We adults project our expectations onto the world all the time. We largely construct, rather than perceive, the world around us. Memory traces may be unconsciously activated all the time. One does not have to explicitly retrieve a memory for it to be active and for it to influence cognition and behaviour.

              Memory and emotions

              The early sensory–motor and emotional memories of infants and toddlers are mediated via the amygdala, thalamus, cerebellum, and orbital medial prefrontal structures. This system organizes and retains primitive vestibular–sensory–emotional memories of early care taking, rendering them of permanent psychological significance. These early implicit memories come to serve as the emotional background against which subsequent psychological development takes place. Implicit memory is usually non-verbal, non-symbolic, and is not available for conscious reflection. Implicit memory can be understood as ‘knowing how’, rather than ‘knowing what’. Its content involves emotional responses, patterns of behaviour, and skills. As the brain matures, the hippocampus, temporal lobes, and lateral prefrontal lobes begin to organize the systems of explicit memory. Hippocampal–cortical networks need to be functioning for the conscious recollection of the learning process. This usually happens somewhere between the ages of 3 and 4 years old. Explicit memory can be consciously retrieved, reflected upon, verbalized, and symbolic, and contains information and images.

              The distinction between explicit and implicit, as outlined above in relation to memories, can be applied also to other mental processes such as learning, emotions, emotional regulation, motivation, action control, and interpersonal behaviour. Implicit processes are independent of the capacity limitations of working memory. Many implicit processes can happen simultaneously, without interfering with one another. They typically happen quickly and without effort, are not error-prone, and do not require attention and conscious awareness. They are typically linked to a specific sensory modality. They cannot easily, if at all, be controlled volitionally. They are typically learnt more slowly than explicit mental processes. They need many repetitions to be learnt. It is difficult to change them, once they are well ingrained.

              Lack of recall in adults of details of their childhood experiences strongly suggests high levels of anxiety during childhood that mitigate against the consolidation of long-term memory. A lack of recall is associated with attachment styles that are anxious, ambivalent, and dismissing. Insecure and traumatized children have a difficult time self-regulating their emotions and suffer from anxiety, depression, and a variety of other symptoms. What the mind forgets, the body often remembers in the form of fear, pain, or physical illness.

              The amygdala is a key component of emotional memory throughout life. The direct and rapid neural connections of the amygdala with the hypothalamus and limbic–motor circuits rapidly translate the rapid appraisal of threat into bodily states and action. The primary role of the amygdala is to modulate vigilance and attention in order to gather information, remember emotionally salient events and individuals, and prepare for action. The emotionally expressive face is an increasingly important transmitter of information across the social synapse. The amygdala networks with circuits throughout the brain to ‘read’ information from the eyes, direction of attention, gestures, body postures, and facial expressions. The amygdala becomes activated to both sad and happy faces but appears to be vital for recognizing fear. Faces judged to be untrustworthy, as well as verbal and written threats, automatically activate areas of the amygdala.

              The amygdala and orbitomedial prefrontal cortex (OMPFC) are major players in the regulation of our experience of safety and danger. The amygdala connects negative experiences with autonomic arousal, generating anxiety, fear, panic, and flashbacks. The OMPFC assesses the reality of the danger and is capable of inhibiting the amygdala activation when a fear response is deemed unnecessary. The OMPFC and amygdala have a reciprocal regulatory relationship.

              Evolution seems to be far more interested in keeping us alive than keeping us happy. Overall, negative emotions trump positive ones and weigh more heavily on our evaluation of people and situations. A single highly charged affective moment may predispose any of us to be anxious for the rest of our lives. Learning not to be afraid can take years of struggle. The amygdala is quick to learn and slow to forget. Learnt fears are tenacious and tend to return when we are under stress. Based on our neurobiology, fear outranks and outwits love in a number of ways. Fear is faster, automatic, unconscious, spontaneously generalized to other stimuli, multisensory, and resistant to extinction. Whereas the hippocampus is constantly remodelled to keep abreast of current environment changes, the role of the amygdala is to remember threat, generalize it to other possible threats, and carry it into the future.

              Memory and attachments

              (See Psychotherapy research Theories of personality development: attachment theory in Chapter 8, pp. [link][link].)

              Memory is intimately connected with the development of attachment patterns and behaviours. Communication between individuals occurs via smells that influence identification, attraction, and repulsion; via sounds such as grunts, groans, sighs, and laughter, and vary according to volume, tone, prosody, rhyming, and song; via touch that influences affection, nurturance, grooming, sex, support, soothing, and calming; and via visual stimuli such as facial expressions, smiling, gestures, pupil dilation, and blushing. The activation of networks of the brain by these multiple streams of information occurs in the internal systems facilitating interpersonal connection and regulation.

              Louis Cozolino, in his book Attachment and the Developing Social Brain, notes that, even though we cherish the idea of individuality, we live with the paradox that we constantly regulate each other’s internal biological states. Our interdependence is a constant reality of our existence. The individual neuron or single human brain does not exist in nature. Without mutually stimulating interactions, people and neurons wither and die. He helpfully describes the human brain as a social organ criss-crossed with neural networks dedicated to receiving, processing, and communicating messages across what he terms the social synapse—or the space between us as individuals.

              Positive social interactions result in increased metabolic activity, mRNA synthesis, and neural growth. Relationships can create an internal biological environment supportive of neural plasticity. Early neglect, stress, and trauma all impact on developmental processes in negative and destructive ways. Neglect and abuse decrease the growth of experience-dependent neural circuits, especially of the OMPFC, anterior cingulate, and insula cortex. We are individuals, but the architectural structures of our brains are records of our interpersonal histories.

              Mirror neurons are neurons that fire when observing others performing a task. They are most likely involved in the learning of manual skills, the evolution of gestural communication, spoken language, group cohesion, and empathy. Thus, we can learn by observation. Mirror neurons were first discovered in the 1990s by recording the firing of single neurons in monkeys’ brains, whilst they were awake, alert, and interacting with other monkeys. Specific neurons in the PFC were seen to fire when a monkey was both observing an action in another and when the monkey itself performed the same action. Non-invasive scanning technologies have been used to extend these findings to human brains. Brain regions involved in perceptual action mirror systems are now thought to include the premotor cortex, motor cortex, cerebellum, basal ganglia, somatosensory cortex, parietal lobe, Broca’s area, amygdala, and the frontal lobe. Observing becomes a way to rehearse. Resonance behaviours, triggered by mirror systems, are automatic responses that are reflexive, implicit, and obligatory. Reflexively looking up or yawning when we see others do the same are examples. Therapists unconsciously mirror the facial expressions, tone of voice, and body postures of their clients. Resonance reactions occur before we are consciously aware of them. Fears, anxiety, and phobias can all be passed from one person to another, especially from parents to children, through observation of their behavioural manifestations in the other.

              The ability to link feelings and words does not come automatically but relies on relationships to build connections between separate neural networks dedicated to affect and language. Language, in combination with emotional attunement from primary caregivers, creates the opportunity to support neural growth and network integration. The normal development of the mind is dependent on the intersubjective process of emerging psychological awareness between the child and his primary caregivers in the context of a secure attachment. The caregiver’s empathic ability to reflect on the infant’s state of mind facilitates the infant’s capacity to understand his own mind and that of others (theory of mind). The child becomes increasingly aware of his own mind through his growing awareness of the mind of his mother via her capacity to demonstrate to him that she thinks of him as a separate person with his own distinct intentions, beliefs, and desires. The capacity to ascribe meaning to human behaviour ultimately shapes our understanding of others and ourselves, and develops through experiencing our internal states being understood by another mind.

              The most important aspects of child rearing are, firstly, love and attachment, and secondly, being curious about who your children are. In this way, you learn how to play with them and how to encourage their imaginations. Every child is an experiment of nature. Children need their parents’ curiosity about them as an avenue of self-discovery. Attunement, secure attachment, curiosity, and affect regulation go hand in hand with neural plasticity in the brain.

              Memory and early trauma

              (See Psychotherapy research Trauma-related conditions in Chapter 7, pp. [link][link].)

              Early trauma, especially at the hands of caretakers, may begin a cascade of effects that result in a complex post-traumatic reaction. Some abused children learn not to look at faces and are less skilful at decoding facial expressions. When they do look at faces, they are hypervigilant to any signs of negativity or criticism. In the face of early interpersonal trauma, all of the systems of the social brain may become shaped for offensive and defensive purposes. Regulatory systems become biased towards arousal and fear, and prime our bodies to sacrifice well-being in order to stay on full alert at all times. Reward systems designed to make us feel good by contact with loved ones are manipulated with drugs, alcohol, compulsive behaviours, and self-harm.

              The development of theory of mind, or a capacity to mentalize, is compromised when children are abused and neglected. Both neural growth and integration are impaired, leading to the abnormal development of experience-dependent structures such as the cerebral cortex, corpus callosum, and hippocampus.

              Some antisocial or ‘psychopathic’ individuals seem to have less activation to aversive stimuli when either they or others are experiencing it. They react with abnormally low autonomic activation to social stimuli such as faces and expressions of emotions. These individuals demonstrate only superficial amygdala activation in response to faces and are less accurate in recognizing fearful faces. Antisocial patients do have a theory of mind of the other, but, instead of using it to connect empathically, they may use it to manipulate others to get their way. General damage to the PFC at any time during life can result in a loss of empathic capacities (see Psychotherapy research Antisocial personality disorder in Chapter 8, pp. [link][link]).

              Consciousness

              Consciousness may be understood from a neural perspective. We experience as conscious only those processes that occupy working memory for at least a few seconds. Working memory has a very limited capacity, is localized in the PFC, and works in close collaboration with the anterior cingulate cortex, which plays a key role in the internal control of attention. The stream of consciousness is characterized temporally by continuity and simultaneously by consistency, because the current content of working memory largely determines what will enter into working memory next. External events that enter the focus of attention also influence working memory. All forms of consciousness are linked to the associative cortex where internal connections far outweigh those that it has to and from the outside (by about five million to one!). The close interconnections of neurons and networks within the associative cortex are the main neuroanatomical bases for our subjective experience of consciousness and allow us to generate internal states that rely very little on external input. Unconscious processes that are beyond our conscious control precede our conscious acts of will in many instances.

              The left hemisphere usually takes the lead in semantic and conscious processing, whilst social and emotional processing happens mainly in the right hemisphere. Mammals are characterized by a right hemispheric bias in the control of emotion, bodily experience, and autonomic processes in the cerebral cortex, subcortical, and brainstem structures. The right cortex is far more densely connected with subcortical regions than the left. Right brain functions are similar to Freud’s notion of the unconscious. They develop earlier and are guided by emotional and bodily reactions, and their non-linear mode of processing allows for multiple overlapping realities akin to Freud’s conception of primary process thinking. The right brain responds to negative emotional stimuli prior to conscious awareness. Thus, unconscious emotional processing based on past experiences invisibly guides our moment-to-moment thoughts, feelings, and behaviours. The phenomena of projection and transference are generated through these networks. The dominance of the right hemisphere for bodily and emotional functioning and its ability to process this information reflexively and unconsciously have freed the left cortex to attend more to the environment and to engage in logical and abstract reasoning.

              Learning throughout life

              The plasticity of the brain leads to a continuing capacity for learning throughout our lives. As we learn, our individual neurons alter their shape and strengthen the synaptic connections between them. When we form long-term memories, neurons change their anatomical shape and increase the number of synaptic connections they have to other neurons. Appropriate spacing of learning is a key factor in developing long-term memory. For short-term memories to become long-term, a new protein has to be made. The more we use a skill like playing the piano, the more space and brainpower it gets. Repetition alone is not enough, however, for plastic change to occur. Close attention is also necessary.

              Brain-derived neurotropic factor (BDNF) plays a critical role in triggering the brain’s ability to absorb and learn. When a child’s body releases a lot of BDNF, keeping the brain constantly stimulated to absorb new information, the child’s brain remains engaged and absorbent. At the end of a critical period, release of increased quantities of BDNF triggers an effective shutdown of the critical period. We are designed to stop effortlessly learning past a certain point in adulthood, as it would be difficult to function if we were constantly distracted by new learning and therefore unable to determine priorities and ‘accumulate wisdom’.

              The brain’s ability to grow new nerve cells, forge plastic change, and learn new skills is not completely shut off in adults. There are three steps required to effect change in the brain. Firstly, considerable focus and attention are required to activate the nucleus basalis to produce acetylcholine and choline acetyltransferase, which, in turn, instructs the brain to fix the memories being formed. Secondly, a mental challenge that leads to a sense of satisfaction and reward is also needed for the brain to produce dopamine, the second ingredient required for plastic change. Thirdly, targeted training is then required. Acetylcholine and dopamine prompt the growth of new nerve cells in the dentate gyrus of the hippocampus and create conditions under which the brain can change. The way in which the brain actually grows and changes depends on what we are doing to stimulate that growth. Training exercises that strengthen and improve core brain functions can generate lasting improvements in our mental ability.

              Many everyday activities stimulate neural growth and help us stay mentally fit. Studying a new language, tackling puzzles and brain teasers, or learning a new skill, however, is not as directed and effective as that produced by a carefully designed brain training programme. The practical applications are many and varied. Learning specialists use brain training software to help children reverse learning deficits. Senior centres offer brain training resources to their customers, reversing memory loss and delaying or preventing the onset of Alzheimer’s symptoms and dementia. Progressive school systems have introduced brain training to help optimize classroom study. Individuals have taken to brain training as a way to maintain and improve their mental agility. The factors that can influence and train the brain to engage in, and to gain maximally from, psychotherapy now remain to be explored more fully.

              Learning of new information, whether by students, trainees, or patients, is more likely to be effective when:

              • Their degree of vigilance, alertness, attentiveness, and concentration is sufficient to engrave information into memory

              • Their interests, strength of motivation, and needs all enhance learning

              • Noticeable affective values are associated with the informational to be memorized, and the individual’s mood and intensity of emotion at the time facilitates memory. If an event is very upsetting, a vivid memory of it is likely to be formed

              • The location and accompanying light, sounds, smells, and entire context are recorded, along with the information being memorized. One can very often recall information by first recalling its context. Forgetting rids the brain of information that will not be needed in future

              • Perceptions are consciously experienced to the degree that attention is devoted to them. It is so much easier to learn things that we actually desire to learn.

              Getting information across well

              • Keep it simple

              • Do not present a lot of information at one go

              • Alternate information giving with activity

              • Structure the information to make it meaningful

              • Connect with what already exists

              • Exploit beginnings and endings.

              Applications to the practice of psychotherapy

              Psychotherapy as a learning experience

              Psychotherapy is fundamentally a learning experience for patients and for therapists, and involves the triggering of structural changes in specific neurons and neuronal pathways. Whatever the modality, there are a number of patterns associated with change in psychotherapy. Clarification of meaning addresses the causation and presentation of psychological difficulties. A sense of mastery develops from the concrete experience of learning to cope with situations previously experienced as very difficult or anxiety-provoking. The patient’s problems can be changed most effectively through being activated, experienced, and understood in the present, and within the transference and countertransference relationship in psychoanalytic psychotherapy. The activation of resources in the patient can be harnessed to support change.

              The therapeutic relationship

              (See Psychotherapy research Therapeutic alliance in Chapter 3, p. [link]; Common factor research in Chapter 11, pp. [link][link].)

              The work of psychotherapy depends on the development of a therapeutic relationship between a therapist and a patient. The therapist provides consistency and reliability in setting, in behaviour, and in attitudes; warm, caring, positive regard, and an ability to see value in what the patient offers; repeated opportunities to develop a positive therapeutic alliance; and optimal circumstances to facilitate fresh learning. The patient brings her difficulties and her strengths as part of who she is; some difficulties she wants to address in her life; some preparedness to risk involving herself in a therapeutic relationship; some recognition of her part in the development and continuation of these difficulties; and some wish to seek an understanding of why these difficulties continue to impact directly on her life.

              Concepts of change arising from the neurosciences

              Changes in mental functioning resulting from the practice of psychotherapy include structural changes evidenced by rigid mental functioning becoming more flexible; conflictual internal object relationships becoming less concrete, less highly charged, more complex, and more highly differentiated; and a gradual assimilation of conflict. From a psychodynamic point of view, conflicts become accessible to consciousness; conflictual internal object relationships are increasingly understood to be part of the self; there is increasing acceptance of the loss of ideal images; losses are mourned, and guilt is worked through; ambivalence is tolerated, and a capacity for concern develops; in Klein’s terminology, ‘paranoid schizoid functioning’ shifts to become predominately ‘depressive functioning’; change occurs as a result of a process of containment and interpretation (see Psychotherapy research Psychoanalytic psychotherapy in Chapter 2, pp. [link][link], and in Chapter 5, pp. [link][link]).

              How may these therapeutic changes observed clinically be understood and translated into changes in the brain’s function and structure?

              • Psychotherapy helps people put their unconscious procedural memories and actions into words and into context, so they can better understand them. In the process, they plastically retranscribe these procedural memories, so that they become conscious explicit memories, sometimes for the first time. Patients then no longer need to ‘relive or re-enact’ them. Repetition or working through is required for long-term neuroplastic change.

              • New ways of relating have to be learnt through wiring new neurons together. Old ways of responding have to be unlearnt through the weakening of neuronal links. Emotions and the patterns we display in relationships are part of the procedural memory system. When such patterns are triggered in therapy, it gives the patient a chance to look at them and change them. Positive bonds appear to facilitate neuroplastic change by triggering unlearning and dissolving existing neuronal networks, so the patient can alter his existing intentions.

              • Psychotherapy can result in detectable changes in the brain. Brain scans done before and after psychotherapy show that the brain plastically reorganizes itself in treatment. The more successful the treatment, the greater is the resultant change.

              • Implicit mental processes have both advantages and disadvantages. They are independent of the capacity limitations of working memory; they can happen simultaneously without interfering with one another; they typically occur quickly and without effort; they are not error-prone and do not require attention and conscious awareness; they are linked to a specific sensory modality and cannot easily, if at all, be controlled volitionally; they are learnt more slowly than explicit memory contents; they need many repetitions to be learnt, and it is difficult to change them once they are well ingrained.

              • The explicit mode of functioning is better for relearning. The most important function of conscious awareness is the facilitation of new learning. The qualities linked with the explicit mode of functioning, such as conscious reflection, intention formation, planning, volitional control, and verbal communication, can all be viewed as resources for therapeutic change. The formation, facilitation, and maintenance of appropriate goals and intentions in the patient are important therapeutic tasks.

              The plasticity of the brain

              The brain responds to injuries and stimuli with a great deal of adaptability. Very well-developed brain structures that are not used over a long period of time begin to atrophy. With sufficiently intensive stimuli and experiences, new self-sustaining structures emerge in the brain, which then become the foundation for enduring changes in experience and behaviour. The intensity, duration, and mode of delivery of therapeutic interventions have a significant bearing on the development of structural changes in the brain. Intense new learning in psychotherapy associated with structural changes in the brain requires conscious, volitional, self-motivated patient collaboration, and functioning in the explicit mode. Structural changes in the brain occur only as the result of intensive and long-lasting influences.

              Implications for psychotherapy technique

              (See Psychotherapy research Chapter 5; What constitutes good therapy? in Chapter 11, p. [link].)

              • The therapeutic relationship is central to positive change, regardless of the theoretical orientation of the therapist. A safe and trusting relationship with an attuned, resonant, empathic therapist reactivates attachment circuitry in a patient and makes it available to neuroplastic processes. Training of therapists might usefully emphasize the development of resonance, attunement, and empathy as central to the relationship we have with patients.

              • The more the dialogue follows the patient’s patterns, the more easily the patient will engage in meaningful communication with the therapist; however, the patient needs to be challenged in addition for long-term changes to occur at the neuronal synapses.

              • Change requires the intense, frequent, repeated activation of synaptic connections that are not yet well established; this opens up the N-methyl-D-aspartate (NMDA) receptors and kicks off a second messenger cascade, particularly if dopamine receptors are simultaneously activated.

              • The activation of cognition and emotion together allows frontal systems to re-associate and re-regulate the various neural circuits that organize thinking and feeling—those very circuits that are most vulnerable to dissociation.

              • The maintenance of moderate levels of arousal maximizes the biochemical processes that drive protein synthesis necessary for modifying neural structures.

              • Therapy is most effective when it is focused only for a short time on the identification and activation of problems and then predominantly on altering the problem and on facilitating new thoughts, behaviour patterns, and emotions.

              • This activation of new neural connections must be repeated as often as possible.

              • Permanent facilitation of new patterns of experience and behaviour on the neural level requires a concentrated and long-lasting effort to establish and maintain these new experiences and behaviour patterns.

              • Using the concept of inhibition of something problematic, rather than extinction, shifts the focus from that which is problematic to that which should be put in its place instead.

              • Seeking to shift the brain towards a state that is maximally incompatible with fear involves developing a secure attachment relationship with a therapist who conveys competence, understanding, and personal engagement.

              • The therapist should provide the patient with intense and varied perceptions that support his therapeutic goals and should structure the therapeutic situation to utilize a patient’s own resources.

              • The construction of narrative that reflects a positive, optimistic self creates an evolving language for experience that can modify self-image, aid in affect regulation, and serve as a guide for positive behaviour.

              • The malleability of memory and the potential to rewrite history can be extremely helpful in psychotherapy. As long as patients are capable of understanding the difference between accurate history and therapeutic co-constructed narratives, many patients may be able to transform their oppressive memories into healing stories.

              • Differing and multiple inputs can influence the brain in complementary and additive ways. Therefore, using more than one modality simultaneously in a way that is complementary and cohesive, such as concurrent group work, family work, or psychosocial nursing work with individual therapy, creates opportunities for further learning and experimentation by the patient. Patients may be actively encouraged to be physically active and aware of their physical condition. Medication may also be used judiciously to support the work of psychotherapy. The use of lifestyle changes, relaxation exercises, yoga, or medication reduce levels of arousal and maximize neuroplastic potential.

              • Educating patients about their brains—teaching them about how the brain works, explaining to them the impact of early learning on the brain and on the body, explaining the workings of memory and the biases of the amygdala, discussing vulnerabilities to prejudice and to phobias—can create a common less-threatening language between the patient and therapist within the working relationship.

              • Therapy, at times, necessitates the teaching of new skills and competencies to patients. This may mean that psychotherapists may themselves need to learn a range of new skills and competencies centred on teaching and educational skills.

              Table 11.1 gives some examples of how psychodynamic concepts may be understood in terms of brain development and functioning.

              Table 11.1 Exploring psychodynamic concepts using the language of brain development and brain functioning

              Psychodynamic principles

              Alternative understanding using brain developmental language

              Examples and explanatory notes

              Unconscious

              • Unconscious

              • Not conscious

              • Preconscious

              • Implicit or procedural memory and functioning

              Examples:

              1. 1. ‘Social brain’ functioning involving:

                • Perception of danger,

                • Recognition of facial expressions,

                • Determinants of relationships

              2. 2. ‘Non-hippocampal’ memory systems

              Transference

              Implicit relating

              • Explanatory notes:

              • Initially a ‘conversation’ between areas of ‘right social brain functioning’ in patient and therapist

              • Worked with to make it explicit and available to the higher executive brain functioning (HEBF) of therapist and patient

              Countertransference

              Implicit pressure to react and relate in complementary ways

              • Explanatory note:

              • There is value in understanding the pressure, making it explicit and available to HEBF of the therapist and patient

              Defence mechanisms (DMs)

              Usually the less mature DMs are active in situations where fresh learning is not achieved or is not possible

              • Explanatory note:

              • Generally DMs are functional and healthy, whether ‘depressive’ or ‘paranoid schizoid’ in nature

              • Psychotic/immature or primitive DMs:

              • Denial

              • Splitting

              • Idealization

              • Dissociation

              • Projection

              • Projective identification

              • Introjective identification

              • Old implicit neuronal pathways are stimulated, strengthened, and reinforced

              • Fight/flight limbic system functioning is dominant

              • Explanatory note:

              • There is activation of the limbic system with little explicit HEBF in the patient

              • Neurotic/more mature DMs:

              • Repression

              • Identification

              • Reaction formation

              • Regression

              • Conversion

              • Restriction

              • Intellectualization

              These DMs involve mainly implicit limbic functioning but include some implicit cognitive processing in the PFC

              • Explanatory note:

              • Activation of HEBF, alongside some manageable limbic influences, make these mechanisms explicit and open to influence by the HEBF of the PFC

              • Mature/healthy DMs:

              • Sublimation

              • Art

              • Humour

              New fresh learning is usually present alongside use of mature DMs

              • Explanatory note:

              • HEBF is linked with manageable limbic functioning and leads to fresh learning

              Focusing on the interpretation of DMs seems increasingly less central to the current practice of psychoanalytic psychotherapy

              • Focus on situations and conditions that make fresh learning possible

              • Avoid stimulating fear and overwhelming limbic activity, as this is incompatible with learning

              • Create circumstances conducive to new learning

              • Explanatory note:

              • It may be possible to bypass DMs by finding non-threatening ways to contain, think, and talk about the underlying issues that stimulate them

              Working through

              Frequent repetition leads to new learning, via the laying down of new pathways (hard wiring) by a process of ‘neurons that fire together wire together’

              • Explanatory notes:

              • This is hugely important. Old ways of coping are never fully relinquished and may come into play again at times of particular pressures and stress

              Recommended reading

              Cozolino L (2010). The Neuroscience of Psychotherapy: Healing the Social Brain. WW Norton & Co: New York.Find this resource:

                Gabbard GO (2000). A neurobiologically informed perspective on psychotherapy. British Journal of Psychiatry, 177: 117–22.Find this resource:

                Ogden P, Minton K, and Pain C (2006). Trauma and the Body: A Sensorimotor Approach to Psychotherapy. WW Norton & Co: New York.Find this resource:

                  Schore A (2012). The Science of the Art of Psychotherapy. WW Norton & Co: New York.Find this resource:

                    Siegel DJ and Solomon M (eds) (2013). Healing Moments in Psychotherapy. WW Norton & Co: New York.Find this resource: