“Psychotherapy is a biological treatment, a brain therapy. It produces lasting, detectable physical changes in our brain, much as learning does.” –Dr. Eric Kandel (Professor Columbia University and recipient, 2000 Nobel Prize in Physiology or Medicine)
This is the third in a series of articles about children of alcoholics who remain trapped in an alcoholic lifestyle as adults. Parts 1 and 2 explained that children who grow up in addicted families are likely to reproduce harmful features of their families of origin in their adult lives. When they involve themselves with destructive partners and activities that evoke feelings and patterns of behavior similar to those they witnessed and experienced as children, their lives become unmanageable. I examined the neurological and psychological underpinnings of this painful “infinite loop” of chaos and disappointment that captures and captivates many adult children. In brief, neurological changes caused by traumatic experiences in childhood remodel the brain, producing chronic states of emotional distress that are difficult to soothe. Moreover, parental neglect and abuse depress self-esteem and leave children feeling valueless, mistrustful and confused about how to construct rewarding relationships.
This week I’ll begin a discussion of “exit strategies” that adult children from addicted families can employ to escape the infinite loop. These strategies hinge on exciting research about neuroplasticity that are a result of advances in the field of functional neuroimaging, including single photon emission CT (SPECT), positron emission tomography (PET), and functional MRI. Mental health theorists and clinicians once believed that changes in the brain occur only during early childhood. Now that we can obtain actual pictures of the structure and activity of the brain, we understand that it continues to respond, throughout life, to events and interactions with others, by creating new neural pathways and altering existing ones. So, while adverse events in childhood severely roil emotions and disrupt perception and behavior by changing the brain, we know now that there are activities people can undertake, even in adulthood, to normalize the brain.
It is very important for adults who were highly stressed and traumatized in addicted families to identify activities and experiences that facilitate neural growth and positive brain change, because, as last week’s post highlighted, anxiety and depression that stem from childhood trauma cause ongoing damage to brain circuitry. That is, there is the potential for “negative plasticity” in adult life, as well as positive brain change. And, as Dr. Robert Sapolsky, a neurobiologist at Stanford pointed out, “Early-life stress and the scar tissue that it leaves, with every passing bit of aging, gets harder and harder to reverse. You’re never out of luck in terms of interventions, but the longer you wait, the more work you’ve got on your hands.”
What does it take to change the brain for the better? There is growing evidence for the effectiveness of several interventions, including individual and group psychotherapy, support groups, meditation, exercise and nutrition, as well as so-called alternative treatments, such as biofeedback, and neurofeedback. The focus in this post will be on the benefits of psychotherapy.
First, let’s review some important highlights from Part 1 of this series about the impact of childhood trauma on the brain. Brain imaging studies reveal that adverse childhood events cause the release of stress hormones that produce significant changes in the hippocampus, the amygdala and the prefrontal cortex. There is shrinkage in the hippocampus, a proliferation of cells in the amygdala and a weakening of the connections between the hippocampus, the amygdala and the pre-frontal cortex. People who have been highly stressed as children live much of their lives in a state of great distress, because the fear centers of the brain have been overstimulated and the pathway between these areas and the parts of the brain that make it possible to evaluate perceived threats and think about what to do about them are damaged. This is especially true when present events, or people in the present are somehow reminiscent of the traumatic past, and evoke feelings that are associated with humiliating or terrifying events that occurred during childhood. These are times when the “executive functions” located in the prefrontal cortex are most likely to be overwhelmed and impulsive and damaging decisions are most likely to be made, including impulsive re-enactments of traumatic scenes from childhood.
Most forms of psychotherapy recognize that people who struggle in their relational and work lives have emotional pain that distorts their thinking and leads to self-defeating, sometimes self-endangering behavior. Most therapies aim to improve patients’ quality of life by enabling them to solve problems in the past and present that are causing them pain so that they can think and behave in more effective ways. For example, while the approaches used by practitioners of three of the most popular forms of psychotherapeutic treatment–cognitive-behavioral therapy (CBT), psychodynamic therapy and dialectical behavior therapy (DBT)—differ, their overarching goals are really quite similar. Cognitive-behavioral therapy aims to help patients “modify their distorted thinking, dysfunctional behavior, and distressing affect” Psychodynamic treatment seeks to increase “client’s self-awareness and understanding of the influence of the past on present behavior” in order to remove barriers to more rewarding relationships and more effective functioning in life in general. Dialectal Behavior Therapy is a form of CBT that “helps (people) identify thoughts, beliefs, and assumptions that make life harder” so that they can regulate strong emotions more successfully, reduce self-harm and improve communication with their family and friends. CBT practitioners would say they are helping people to think more rationally about their feelings while psychodynamic therapists would say they are clarifying unconscious motives that drive dysfunctional behavior. DBT therapists would say they are helping patients develop mindfulness and employ cognitive strategies to deal with powerful emotions. But all three treatments are what is known as “top-down” approaches to behavioral change. The fundamental idea is to help people strengthen cognition in order to better manage strong feelings that are emanating from the emotional centers in the brain.
There was already a great deal of research to indicate the effectiveness of psychotherapy. Now there is now a great deal of proof that one of the reasons psychotherapy is able to relieve psychic suffering and improve functioning at home and work is because it reverses the kind of trauma-induced damage described above. One study that Dr. Kandel (the Nobel laureate quoted above) was quite excited about was performed by Dr. Helen Mayberg and colleagues at Emory University. Dr. Mayberg used positron emission tomography (PET) scans to study patients’ response to two standard forms of depression treatment: cognitive behavior therapy (CBT) and escitalopram (Lexapro), an antidepressant that increases the amount of the neurotransmitter serotonin in the brain. Dr. Mayberg found that if a depressed patient’s pre-treatment resting brain activity was low in the front part of an area called the insula, on the right side of the brain, it signaled a significantly higher likelihood of remission with CBT and a poor response to the drug. On the other hand, hyperactivity in the insula was associated with a good response to the antidepressant and a poor response to CBT. Read more at http://goo.gl/yQPQ2
Dr. Kandel was enthused about this study because it showed that psychotherapy produces detectable changes in the brain and because it demonstrated that it is possible to predict the outcome of different treatments, in this case, psychotherapy and medication. This is something that could be of great value in the future.
In fact, there are now many studies that show the brain responds to psychotherapy and that allow researchers to identify which areas of the brain change. Most of these studies are similar to Dr. Mayberg’s research in that they examine levels of brain activity before and after subjects receive cognitive-behavioral therapy. Daniel Collerton, in an article on Psychotherapy and Brain Plasticity points out that that the data from fMRI studies performed so far indicate that CBT leads to “a decrease in emotionality (less limbic activity) and an increase in thoughtfulness (increased dorsolateral frontal activity)…” As Dr. Collerton says, this result is in line with the “aims and methods” of CBT. Collerton adds that, “It is clear that CBT, and probably other psychotherapies, alters consciousness in personally important, lasting, and measurable ways.”
Another review, by Hasse Karlsson, published in The Psychiatric Times, reported similar results from nearly 20 studies of brain changes after psychotherapy for depression, anxiety disorders, and borderline personality disorder. He found that cognitive-behavioral therapy, dialectic behavior therapy, psychodynamic psychotherapy, and interpersonal psychotherapy were all capable of altering brain function in patients studied. Most of the research he looked at showed that psychotherapy and fluoxetine (Prozac) had similar effects on the brain. Like Collerton, Karllson found that CBT’s effect on the brain was consistent with the aims of this form of treatment.
How psychotherapy accomplishes the aim of quieting an overactive limbic system and improving cognitive control is an extraordinarily complex topic. But theorists in the field of interpersonal neurobiology believe strongly in the old axiom: brain cells that fire together wire together. That is, the connection between neurons strengthens when they communicate frequently. For example, repeated experiences of abuse and neglect in childhood create pathways in the brain that allow the experience of fear to be automatically aroused at the sight or memory of people, places and things associated with these negative experiences. Eventually, this traumatic circuitry is so strong that even a faint reminder of the past can trigger a full-blown flashback to the original trauma, and make it feel like it is happening in real time. I well remember an extremely traumatized young man who said to me, “You know, I think most people need something bad in the here and now to break them down. I can see leaves falling on a windy day and feel like I’m right back in my home town in the middle of all that mess I grew up with.” But repetitions of positive interactions in psychotherapy can re-wire the brain, causing healthful loops to develop, improving resilience and growing the capacity for joy–much as repetitions at the gym build up muscle tissue and make the body stronger and healthier. A psychotherapist who clearly sees and validates both your strength and your suffering teaches you something new and hopeful about yourself: that you have gifts as well as great challenges; that your feelings and thoughts matter and are deserving of attention; and the behaviors that are harming you now developed as understandable defenses against the things and people that harmed you in the past. Consistently rewarding interactions with your therapist teach you something else, too: relationships with others can be relieving and rewarding and need not lead to disappointment, rejection, neglect or abuse. Over time, all of this new information, as well as the image of a warm and accepting other, becomes structuralized in the brain. Your mental representation of yourself is different, and when you think about yourself and the past, there is less shame, more self-compassion and more hope that you are capable of building a better future. The new mental representation of the world of relationships that has formed in your brain also becomes a source of hope for the future. Moreover, while therapy is helping you to construct new mental representations of yourself and others that help you to believe the past is actually over and that it is possible to change your life for the better, it is also teaching you the strategies that are necessary to effect such change. These strategies become new neural structures as well. Let’s return to the exercise analogy for a moment: One of the reasons exercise is protective against heart disease is that it leads to angiogenesis—the production of new blood vessels from existing vessels. These new structures promote better circulation and may help the heart to survive if blockages do develop elsewhere. Similarly, when you are consistently understood and accepted, new pathways in the brain develop that bypass the fear and lead to more positive feelings about yourself and others. Your therapist’s empathy and respect for you becomes a more easily accessible part of your mental apparatus and eventually, positive feelings about yourself and others come to mind more easily and quickly than the feelings of worthlessness, shame and mistrust that you internalized (structuralized) in your family of origin. With enough time and sufficient repetition, all of this new circuitry modifies and eventually transforms the old, negative loop of self-loathing, fear and distrust of others that was formed in the context of adverse childhood events.
So psychotherapy is an excellent choice for adult children of alcoholics who are seeking to heal the wounds of childhood stress, abuse and neglect—wounds that are encoded in the brain and need active intervention in order to heal. There are even intensive residential workshops, such as the Breakthrough program at the Caron (Pennsylvania) for ACOAs that are designed to help people begin the process of changing patterns of thought and behavior that are interfering with healthy relationships. Such programs are good sources of referrals for people who are trying to find therapists familiar with the impact of familial alcoholism. There are other activities and interventions that are highly therapeutic for those who suffered childhood trauma, and I will address these in future posts. Ultimately, many adult children will need to utilize a combination of neuropositive interventions in order to deal effectively and efficiently with the legacy of childhood trauma. But it’s well worth the effort.