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Psychotherapy

Review of "How People Change"

By Marion Solomon and Daniel J. Siegel (Editors)
W. W. Norton, 2017
Review by Roy Sugarman, PhD on Oct 10th 2017
How People Change

When I was trained, the topic of change, and thus growth, was entrenching itself in psychology, largely at the hands of Watzlawick and others of similar ilk. Little was known about the neuroscience of it all, let alone neuroplasticity, as in the 60's-70's the doctrine was that the brain did not repair, or change much at the neuronal level, apart from loss and decline with ageing. Ideas of resilience were not much weighted, and concepts of resistance as a form of cooperation, in the Paul Dell sense, were only just coming to the fore.

As Freudian and Winnicott and Melanie Klein and Kohut and Hartman and a whole bunch of therapists that young CBT-ACT minded modern therapists may never have read fade from mind, these editors find a whole older 20th Century group who still recall the elegant formulations of psychodynamia land and apply them to the modern understanding of brain, while still clinging to the general systems theory ideas of self-regulation. This however means that although these editors are stipulating this as part of the choices they have made to include here, the authors themselves still use the sometimes confusing languaging of the psychodynamic years, and hence the integration can be clumsy at times.

Some, like the opening author, Bromberg, as much a luminary and vital as Schore has been, sets out an opening chapter that is a little confusing for most modern practitioners to read, full of what seems to be psychobabble in these days, and with some sentences as confusing as reading early psychanalytic works. I know he is considered a seminal genius, but I find him hard to read, my bad I guess. He investigates two epigraphs that he embarks with in his chapter, and sentences that follow, peppered with dozens of italicized words and phrases, tells you he needs emphasis so you can follow him, and not think he is stoned. For instance: I don't mind him talking about "the other" as a kind of reprise of Martin Buber, but, in referring to Schore's work for instance, I don't place much value in the italics or the convolution of the sentence: "One objective in this chapter is to show how the phenomenon of state-sharing allows the extraordinary phenomenon of self-state communion to take place in a way that allows both partners to include their own and the other's subjectivities within their individual perceptual contexts of what takes place between them in their ongoing relationship" or how state-sharing, dissociation and enactment relate to "right-brain to right-brain state-sharing" when most of the neuro experts I know have disavowed such lateralizing associations.  Nevertheless even Siegel himself will later on refer to lateralization, as well Tatkin and others.

So, this first chapter is a bit off-putting and I am not sure how the change-is-growth mantra is supported, or the references to neurobiology, and unlike the others, his valuing of Schore' seminal works is unclearly formulated in less than plain language or sentence construction, which the others manage much more succintly.

Rescue however immediately comes in the form of the socialization-loneliness guru Louis Cozolino and Vanessa Davis.  His and their clear language and opening and charming story about the difference between humans and rats restored my faith in the book.  Our brains are organs of socialization, and in turn social engagement ties the cortical knots that define us as we grow, in the Vygotskian sense. If we get stuck between our programming, the expectations of our tribe, and our own needs for emotional health and actualization can make us physically and mentally ill, and such explanations from Cozolino are remarkably cogent and clear compared to Bromberg's meanderings through the land of psychodynamia with dim reference to Schore's neurobiology. Here, we learn that therapists must skate the delicate edge between stability, flexibility, rigidity and change, and not an italic anywhere in sight, but with a clear message. Cozolino's view is that when the dogma of psychotherapy is picked apart, it is both right and wrong simultaneously, and like Bromberg, his bent leans toward the psychodynamic, whilst still selectively using elements from other approaches. He points out that what we have learned from neuroscience hasn't supported one approach over the other, and has however challenged us to engage in a higher level of integrative thinking.

Margaret Wilson speaks for the whole-person approach to dynamic psychotherapy, and dives into how people got that way, and how that way leads to a need for change. As with Bromberg, she speaks of dissociation and attachment right up front, but in a clear way, and I like her "drip-drip" term when describing the damage verbal abuse might do to the developing organism. She states the approach clearly when she asserts our task is to mobilize the plasticity of the human brain to enable therapeutic change. She, like Bromberg references Schore's work and Lanius's as well, in terms of the hyperarousal possible during the therapeutic engagement, and the risks of re-traumatising.  She quotes Cozonlino in that he stresses that words are problematic at such times of terror, because decreased activation in Broca's area occurs in such states and the patient literally finds it difficult to speak. Afterward, patients cannot always recall what happened in the session because the encoding for conscious memory as well as unconscious patterns of expectation may be affected in states of such extreme arousal, as it would have been in childhood. This means that the patient and therapist struggle with the task of change within the individual and in the relationship. In contrast, other patients become detached, switched off, deadened, and dissociated from their feelings, unable to express or experience them and hence may respond I don't know etc. when confronted, or may not be able to connect in sessions without losing the plot. Neuroplasticity thus gives Wilson hope about the possibility of change, as she recalls, as I did above, of the days when we were told there was no chance of such rejigging of connectivity. Affect regulation in the therapy room is thus key.  Unlike Bromberg, she can articulate her love for Schore and his integration of neuroscience and psychological practice.

Pat Ogden approaches this from a sensorimotor perspective, believing that nonverbal exchanges are the heartbeat of all relationships, the nonverbal implicit self, standing over the verbal explicit self, quoting here, as the others did, from Schore, and apparently able to interpret Bromberg better than I can, with a pithy quote: "when self-continuity seems threatened, the mind [and body] adaptationally extends its reach beyond the moment by turning the future into a version of past danger".  After a series of sections on the implicit communications of non-verbal activities, she returns to the idea of Self-States Bromberg mentions, and quotes from him again at length. In this way, apart from what is consciously experienced, the implicit selves of the therapist and patient communicate beneath the words and even collude in therapeutic enactments, elusive, unconscious, and usually leads relentlessly to outcomes that were not intended or predicted.

Levine continues that theme with the body and emotion linked to change, so that emotions are rooted in bodily processes, and how neuroscience might inform on the process of change. He investigates the first ideas of emotion from Darwin, via Descartes and Pascal, William James, and others, as to the idea of top-down processing, or what Damasio called Descartes error in the sequencing of experience.  What happens in the first few hundred milliseconds is then later recognized as volition, but it isn't, confronting our rational beliefs as to what happens, or how it happened, as Libet and others demonstrated, and as Williams later described in her Integrated Approach, clearly standing on the shoulders of such giants. There is finally a vital balancing act between expression and restraint necessary to neutralize corrosive emotional states, drawing on the 50's Nina Bull, all the way to modern day Ekman.

Russell Meares addresses relational trauma at what he believes is its core, namely a relative failure of the integration of mental life, a disintegrative core.  What he means by this is a failure of the usual and allostatic coordination of the brain systems we depend on for optimal function, and the need to restore integration via a therapeutic conversation.  This conversation thus depends on what he terms an analogue of connectedness, characterized by the cardinal features of intimacy. Warmth matters. Intimacy here refers to a reciprocal sharing of emotional states that leads to a sense of connectedness between the conversational partners, generating a good feeling, both psychic and relational as he explains it. Again, his starting point is Allan Schore.  Following on others, such as Liotti, proof began to emerge of the impingements (Winnicott's word) that resulted from disorganized attachment experiences in childhood, which did not connect with the internal or immediate reality of the child's take on things. The impact of these experiences would, in the adult, be considered dissociative in nature.  This leads to a traumatic memory system that may be devoid of conscious recall, and made up of subsystems, discrete and autonomous, but they can trigger each other.  Intervention is thus based on Meares' early conversational model which addresses the concept of integration via conversation.

Dan Hughes is up next. He speaks of interweaving communications of curiosity and empathy when dealing with change in children.  Ideas, long established, of a curious therapist engaging with empathy via a conversation, are once again put forward. These elements facilitates the child's integration and development of her self-reflective mind, in order to make sense of the world, and thus the courage and baseline to explore the world in terms of challenge and opportunities. Curiosity from others is the core of self-discovery. In such a view, all therapy results in change in both client and to a lesser extent, the therapist. The elements of this curious conversation includes making no assumptions, each is unique, making no evaluations, it simply is, neither wrong nor right, there is no conversation-induced shame, the voice is that of a story-teller, and contains elements of wonder, suspense and surprise. Case studies follow. Of course, empathy is unconditional.

Martha Stark is slightly more adventurous, precipitating disruption to trigger healing in the face of resistance, as I have noted above, a major feature of psychodynamic endeavours, or what she refers to as ambivalent attachment to a dysfunctional defence that has long since outlived its usefulness, then turning to chaos theory.  I also note within those references here a reference to humans as self-regulating, chaotic but hence cybernetic feedback ecosystems, and so invoking general systems theory.  Disruption here is thus referred to metaphorically as an analogue of debridement of a physical suppurating wounds. Fostered here is the defensive reaction evolving into adaptive responsivity.  As with myself, it is nice to read someone writing across a long lifespan as a therapist, and so able to draw on more than the last decade of CBT and DBT and ACT, none of which she mentions here at all, and yet, go figure, she survives as a therapist with references across the 40's through to recent times, and drawing on the wonderful metaphors that arose from observations of talented minds across the 20th century.

Tatkin moves from the individual dance to the way couples change, with a psychobiological approach to couples' therapy. Referring to a long history of the ineffectiveness as an intervention, he refers, as did Stark, this time directly, to systems theory, but this also fell short of the mark owing to a failure to penetrate the internal phenomenology of the dyadic system. His approach here combines three elements, attachment theory, arousal and affect regulation, and developmental neuroscience. As you might expect, his psychobiological model looks at the capacities of partners to remain self-regulated and maintain safety and security through effective mutual regulation. In that way, the dyad is only successful if it can regulate, interactively, the other's autonomic responses to the systemic integration. He allocates areas of functional balance to various locales in the brain, for example, somatic awareness and interoception which is anterior insula based, or prosody, right hemisphere, and so on. In this way, Tatkin is the first of the authors to truly dive into the aspects of the work as dictated by the title, or the subtitle more correctly: "relationships and neuroplasticity in psychotherapy" which the others seem to pay only passing attention to. So threat detection and attachment needs can come into conflict let's say when primary attachments offer hope alongside danger.

Marion Solomon continues the references to couples' therapy in her work, and explains from her point of view how understanding the brain helps in couples' therapy, seeing the brain as a series of layers of experience which are brought in to new relationships, each partner bringing the neuronal baggage of prior relationships into the current one, so working with two brains instead of just one has its challenges. Complaints, about each other, often reflect a re-enactment of prior conflicts. She demonstrates how she works using some case studies.

Goldstein and Dan Siegel himself then write about feeling that is felt, namely the co-creation (another old but good term) of an emergent experience of connection, safety, and awareness in both individual, and now, group therapy. They see this as applying the lens of interpersonal neurobiology to combine a deep view of conscious awareness with emerging findings from the study of the social brain. Awareness here is felt to be fundamental to the change process, and so they promote the conscious experiences that will promote change that leads to wellbeing and relational health, consciousness itself relating to (that word again) self-organizing function that promote these two goals. We are human doings, rather than human beings, perhaps referring to behavioural activation.

So: for those of us with a sense of history, and a background, albeit early in the 60's and 70's and with later immersion in General Systems Theory and Gregory Bateson and Paul Dell and the family therapy movement and the like, this is a gorgeous book full of nostalgia and docking with modern theory of mind and brain. For Millennials, I am not so sure, the references are academic and philosophical, but they are brought up on manualized therapies and checklists. Nowhere does CBT perhaps set out to penetrate the phenomenology of human experience, or the evidence base of psychiatry really, successfully engaged with human phenomenological experience of suffering as Miller has criticized. These are the musings of old-school psychodynamic therapists loaded with the study of how people think and how this reflects in their behaviour. Recently I discovered a group of young therapists who knew nothing of Cognitive Dissonance or Attribution Errors or anything Festinger or Kleinian or Winnicott: on the other hand, a new group suddenly discovered Vygotsky in didactics and proudly waved those neuroscientific insights around.

As a profession, we need to seriously integrate the elegant formulations of past giants in phenomenology, and I hope these and other editors and authors set out to nail this science to the mast of human experience in better ways as an ongoing endeavour.

 

© 2017 Roy Sugarman

 

Roy Sugarman PhD, Director: applied neuroscience in performance innovation, Team EXOS, Arizona

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