CPPNJ - The Center for Psychoanalysis and Psychotherapy of New Jersey

Articles

Brain Research & Recent Studies Supporting Psychodynamic
Psychotherapy: A three-part series

By Harlene Goldschmidt, Ph.D. and Debi Roelke, Ph.D.

This is the first of a series of three articles focusing on scientific studies and brain research that support psychodynamic treatment. This first article serves as a general overview of research relating to psychodynamic psychotherapy. The hope is that as psychodynamic therapists, we will expand our “comfort zone” in talking about science and the brain as it relates to psychodynamic treatment. This will give us more ways to demonstrate the unique benefits of psychodynamic therapy to other health professionals, patients, prospective candidates, policy makers, and the community we wish to serve.

The second article will look at relational trauma, how brain functioning is affected and the ways in which psychodynamic therapy provides reparative experiences (Spring edition). The third and final article will look at unconscious processes like dreams, and how we can better understand the inner workings of the brain in terms of memory, desire, and regulating emotions (Summer edition).

Recent Review of Research Showing Efficacy of Psychodynamic Therapy
Psychodynamic therapists have received some welcome support from the scientific community documenting the benefits of psychodynamic treatment.  A recent paper in the American Psychologist by Jonathan Shedler (Feb. 2010) looks at dozens of studies all showing that psychodynamic therapy has the same or greater effectiveness when compared to other evidence based treatments, i.e., cognitive behavioral (CBT) and dialectical behavioral therapy (DBT).  In addition, results from a large group of well crafted studies involving over 2,000 patients showed that improvements from psychotherapy increased significantly  after termination. Follow-up intervals were anywhere from one to five years. This increase was not shown for CBT treatment, where in fact some of the treatment improvements “decayed”  (Shedler, 2010).

Shedler describes research showing that the “active ingredients”  of all therapy approaches seem to be psychodynamic factors, namely, the therapeutic alliance and “experiencing” (becoming aware of and articulating emotions in the session). He argues that these "active ingredients" explain therapeutic change in treatment modalities other than psychodynamic approaches. Rotely applied manualized treatments were shown to be the least effective of all. In studies comparing psychodynamic treatment with DBT for patients with borderline personality disorder, the psychodynamic therapy not only produced symptom improvement but also showed changes in underlying psychological mechanisms – reflective functioning and attachment organization. In other words, psychodynamic therapy helped patients to learn important psychological skills that support profound changes in how one relates to oneself, as well as others.

Shedler comments that he is “struck” by the fact that psychodynamic therapy is often depicted as lacking empirical evidence, and that “historically psychoanalysts have been dismissive of this line of research,” when in fact there is a sizable and growing body of “…high-quality empirical evidence supporting psychodynamic concepts and treatment.” Shedler writes passionately, “ Such attitudes are changing, but they cannot change quickly enough “ (2010, p.107).

 

Emerging Support of Psychodynamic Treatment from Brain Research
In parallel with the increasing empirical validation of psychodynamic psychotherapy, there is another expanding area of research addressing changes in the brain that correlate with psychotherapeutic benefits. More specifically, the emerging field of neuropsychoanalysis is confirming what we intuitively understand about our patients’ emotional lives and the healing power of the therapeutic relationship. This convergence between the study of neurology and psychotherapy is emerging in two different ways: (1) studies that directly examine changes in the brain via imaging techniques in correlation with psychotherapy, and (2) developmental studies inferring a link between the brain systems responsible for key psychological capacities (affect regulation, self-reflection) and functional changes associated with the positive changes produced by psychodynamic psychotherapy.

The first line of evidence is a growing number of imaging studies that document positive changes in brain metabolism attributed to the effects of psychotherapy. Eric Kandel, Nobel prize laureate in neuroscience, described two such studies of patients with OCD and with depression in which pre-treatment abnormalities in the metabolic activity of relevant brain structures (the basal ganglia, limbic region, for OCD, and different parts of the prefrontal cortex for depression) were reversed over a course of psychotherapy (2006). Other major contributors to the field, Mark Solms (Solms and Turnbull, 2002) and Alan Schore (2003), both discuss imaging studies focusing on the prefrontal cortex in which there are not only positive changes in metabolic activity over a course of psychotherapy, but these changes are correlated with symptom relief.

All of the studies referred to here use imaging techniques (fMRI, PET scans) to examine brain functioning, and used CBT as the psychotherapeutic technique. Kandel, Solms and Schore all extrapolate these findings to psychodynamic psychotherapy as well. As Shedler (2010) reported, the “active ingredients” in both CBT and psychodynamic therapy (and other therapies as well) are psychodynamic elements (therapeutic alliance and experiencing) – the variables shown to be most predictive of positive outcomes in treatment. This consistency suggests that it is reasonable to infer similar brain changes in psychodynamic therapy as those documented using CBT. Shedler also notes that the common use of CBT in outcomes studies results from a “mismatch” between the often subjective aims of psychodynamic treatment and the typical experimental variables used in research design. With greater awareness of these nuances in assessing the effectiveness of psychotherapy, the availability of psychodynamic research is increasing. Neuroimaging studies that directly involve psychodynamic psychotherapy are beginning to appear in the literature, and will reveal more about mind/brain and functional changes as well.

The second line of thinking in brain research supporting psychodynamic treatment is inferential, and it goes like this: certain brain areas are associated with certain psychological capacities. For example, the orbitofrontal cortex (OFC) with its cortical and subcortical connections (i.e., anterior prefrontal cortex, the limbic system, and the basic arousal systems in the brainstem) is associated with emotional modulation and reflective functions. These psychological capacities are underdeveloped or impaired in psychological disorders. Psychodynamic psychotherapy is both explicitly concerned with increasing these capacities and is documented to produce such improvement (Shedler, 2010). The neural science literature demonstrates that the development of these capacities is tied to development in their associated brain areas during infancy and early childhood. We may infer that if psychotherapy produces improvements in these psychological capacities, there are corresponding positive changes in the functioning of the relevant brain areas (Schore, 1994, 2003; Siegel, 1999; Solms, 2002)

In terms of development, the OFC starts “wiring up” in the brain around 12 months – Mahler’s practicing phase, when the baby begins relating independently to the mother and the external world. This is an important development in laying the foundation for a differentiated sense of self (Schore, 1994). The OFC continues to actively establish connections deep within several key areas of the brain until age 25 or so, although it retains some plasticity through the end of life: hence, the opportunity for psychotherapy to continue to effect functional brain change. This self -observing part of the mind is one of the most important neural regulating centers of the brain. Anatomically, it is perfectly situated to control the linkages between higher cortical functions, emotions and the body. The OFC provides top-down regulation of the brain stem (involved with basic organic functioning ie breathing, heart rate, sleep) and the autonomic nervous system (involved, among other things, in fight, flight or freeze). The OFC is also extensively interconnected with the limbic system, which is intrinsic to emotional life as well as learning and memory. The OFC integrates both emotional and bodily information with the planning, symbolizing and problem-solving functions of the prefrontal cortex, making it a powerful seat of reflective functioning. Reflective functioning is, in turn, a core concern of psychodynamic psychotherapy.

As Siegel notes, “The therapist must always keep in mind that interpersonal experience shapes brain structure and function, from which the mind emerges” (1999, p. 300). Siegel and Schore both attribute this to the ability of the therapist to be psychobiologically attuned to the patient’s internal state, both emotional and physiological. By virtue of this attunement, patient and therapist are able to make verbal, cognitive meaning via left hemisphere analytic, interpretive functioning out of the more implicit, sensing right hemisphere autobiographical representations. In other words, we make the unconscious become conscious. Schore (2003) explains, “’It is not the past we seek, but the logic of the patient’s own state regulating strategies.’”

One of the most important learning and healing experiences occurs when the patient and therapist both become dysregulated in session, and then after a time the disruption is repaired. This healing interaction is mediated by the right brain to right brain attuned therapeutic connections. The impact on the patient’s internal working models for attachment relationships is stored as implicit, unconscious memory. Through attunement, mis-attunement and re-attunement cycles, the unconscious memory of dysregulated states become more conscious. Schore notes that “opportunities for dyadic interactive repair are expanded in longer term treatment. In the context of an extended relationship, interactive transactions can be internalized, allowing for the emergence of an adaptive mechanism that can, under periods of stress, be accessed for self-comforting” (1994, p. 473).

Concluding Remarks
Science is not the only way of knowing how to make sense of events:  the scientific method is one way of understanding, as is intuitively responding to a patient’s communications.   Both logical thinking and intuitive knowledge are valuable tools in clinical work.  In this spirit, we attempt to describe some of the emerging brain science that supports the challenging work we do as psychodynamic therapists. It is possible to speculate on Shedler’s report not only of lasting changes from psychodynamic psychotherapy but of continued improvements beyond termination. We might infer that these gains are supported by ongoing neuroplasticity and neurogenesis (the growth of new neurons later on in life). Certainly there is controversy in adopting this line of thinking: some writers caution against being overly reductionist in attributing psychotherapeutic change to functional changes in the brain.  Any discussion in this area must contain the tension between the desire to understand as well as a great respect for the infinitely intricate nature of both our brain and our psyche.

References

Kandel, E.R. (2006). In search of memory: The emergence of a new science of mind. NY: Norton.

Schore, A.N. (1994). Affect regulation and the origin of the self: The neurobiology of emotional development. Hillsdale, NJ: Erlbaum.

Schore, A.N. (2003). Affect regulation and the repair of the self. NY: Norton.

Shedler, J. (2010, February). The efficacy of psychodynamic psychotherapy. American Psychologist.

Siegel, D.J. (1999). The developing mind: How relationships and the brain interact to shape who we are. NY: Guilford.

Solms, M. and Turnbull, O. (2002). The brain and the inner world: An introduction to the neuroscience of subjective experience. NY: Other Press.