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Review of "The Neuroscience of Psychotherapy"

By Louis Cozolino
W.W. Norton, 2002
Review by Roy Sugarman PhD on Aug 12th 2003
The Neuroscience of Psychotherapy

Louis Cozolino is professor of psychology at Pepperdine University, and a clinical psychologist in private practice. This book is part of a series edited by Dan Siegel, and of course is likely to create much interest in a community of psychologists desperate perhaps to add to the arsenal of what could be considered evidence based practice in a health science in this time of challenge. 

From the outset, for most, Cozolino's book will enthral, but for some there will be a subtle disappointment that creeps in.

Cozolino's approach has a narrative to it.  He begins with a foreword by Series Editor Dan Siegel, and this is then followed by three chapters of an overview, dissecting out the tangled shared web of origins in neurology and psychology, a nice intro for the neophyte, but nothing new here yet for the neuroscientist. 

His theme of rebuilding the brain is introduced in the second chapter, and then the heuristics of various forms of therapy, such as Gestalt, Psychoanalytic theory and so on are used to begin production of a series of working hypotheses at the end of the chapter, a basis for which to begin analysing how the collection of therapies presented produces change at the neural level.  He is setting the stage for what is to come in section two, but that is where a feeling of disappointment comes in, only to be inspirational again, a little further on.

Here, in Chapter 4, a foray into the legacy provided by evolution begins with a 1998 quote from Eric Kandel (Nobel prize 2000), but that is all we will see of his vital work.  Cozolino guides his discussion from micro to macro worlds, from individual cells to systems of cells in networks, passing through brain development and plasticity, to understanding the critical periods of pruning and arborisation, as development unfolds, in a very lightly argued chapter.  Some of the comments, such as an inclusion of a quote on page 81, seem to be in error, without explaining for instance how "In determining brain-behaviour relationships, these measures (CT and MRI) need to be evaluated on the basis of whether they are causes or correlates of the disorder being studied".  Huh? I read back along the pages preceding this, but no enlightenment for me.

A comment in the summary, "The most powerful environment is the one created within intimate relationships with caretakers" (page 82) is never validated in the chapter body, and is of course largely untestable, and probably wrong, but evolves from his hypotheses on page 63.  One can imagine that ADHD must emerge from the caretaking of our parents, but of course this is not the case, or that the most powerful influence in our lives is likely to be our caretaker, but adolescence is also a powerful time of socialisation and neuronal activity, and many therapeutic targets for intervention have enormous impact here, such as the processes which lead to psychosis or mood disorder.  Such perhaps over-inclusive or convenient statements may not be entirely true, and Scott Lilienfeld and colleagues have noted recently that we must be careful of how we interpret hypotheses based on untestable presumptions as if they were science (see Science and pseudoscience in clinical psychology, Scott O Lilienfeld, Steven Jay Lynn and Jeffrey M Lohr, Eds. 2003, The Guilford Press; New York).

The next chapter, which begins by discriminating between the implicit and explicit learning modes of the brain, is well done, but again superficial, with a few case studies and some personal inputs.  Again, for one willing to accept a superficial look into the amygdala-hippocampal-cingulate pathways, this would prove fascinating to a certain point.  The implications of errorless learning (see Barbara Wilson and colleagues from the UK) and emerging work on scaffolding by Konstantin Zakzanis and collaborators from Toronto, are not touched on here, despite the insights they would offer for a more neurologically sourced process of psychotherapy.  More importantly, the style followed here is to fractionate the system of information processing into components that violate the concept of what Flinders University Professor of Neurology William Blessing calls the 'visceral brain', or otherwise the fractionating of the homeostatic systems mentioned in the first part of the book (see page 63), or fractionating of the executive functions (see Barbara Wilson and colleagues again), or the fractionating of the components of the executive, conscious, volitional aspects of the brain (see the various works of Muriel D Lezak on the subject), nor the obvious history of the Soviets, Luria and Vygotsky, all of whom inform importantly on understanding the fascinating process which this chapter really makes a hash of .  This is just too short and fractionating, and while it may enable some understanding for the novice neuroscience student, it will result in flaws that the quoted works of Antonio Damasio have tried to address.  In the worthwhile study of the information processing areas of the brain, punctuation or fractionating obscures the homeostatic nature of these systems, and the student is left, post chapter 4, without any global understanding which would be essential to conceiving how heteromodal information is processed.  Blessing would say that one cannot dissect out the sensation of thirst from the act of seeking out fluid to avoid dehydration, any more than Papez could survive leaving the amygdala out of his formulation of the limbic cortex in 1937.  In the same way, the omission of the vital role of the biogenic amines here suggests that structure and function are conflated, not the least by the use of references dating from the 80's and 90's, many of which have been improved on since in more modern works.  Despite the promise made, Cozolino does not satisfactorily return to the biogenic amines, nor does he address how the expression of DNA relates to LTP, or any of the other vital aspects of neuroscience we now know as fact, post Kandel 2000.

Many comments, such as those about narrative on page 103 are not supported by the work of such luminaries as Claire Penn and her associates, Paradiso and others, where it is clear that appreciation or interpretation of narrative owes much to right hemisphere processing in terms of its underlying algorithms and meanings.  Again, discussions which result in fractionating language or localising language narratives is contrary to other themes that are true to the homeostatic hypotheses, for instance that memory is a widespread function.

The next chapter, on laterality, does mention who it must, namely Michael Gazzaniga, but neglects the fascinating approach to evolution that Gazzaniga presented in 2000, wondering as he did weather the corpus callosum actually enables the human capacity of meta cognition (see Sugarman 2002, Revista Espanola de Neuropsicologia, Executive functions and evolution: why our toolboxes are empty? 4(4), 351-377 for a brief discussion.)  Again, there is just so much more out there, I felt let down by the superficial discussion, even if one is targeting the novice or the mildly uninformed.  The learned Louis Cozolino has such a good structure, the skeleton could have benefited by a lot more meat, meat specifically which addresses the various meta-cognitive abstractions which underpin our experience of ourselves and others. 

He does however take this further, and applies the principles of laterality that he has elucidated to some forms of psychopathology, as he did earlier with TLE and the amygdala, but as one can see by reading the summary at the end of the chapter, he does not accomplish much.  I also note the use of the royal imperative "We" in his summaries, as in "we have moved on", but he seems to be alone on the cover, so I am not sure why "we" are invoked, petty point, but I was left with my cross stitch threads hanging again as on page 81, and so felt again unfulfilled.  After all, invoking a rich repertoire such as Mesulam and Gazzaniga, especially since publishing his excellent and mammoth volume as editor in chief of "The new cognitive neurosciences" in its second edition from Bradford MIT in 2000, without making a meal of it, is saddening.  I felt that so very often, in a book published in 2002, that much recent, most valuable state of the art science has not been included.  I hope there is a second edition, where he can add more substance to his considerable understanding and style in approaching the matter.

The book warms up in part three though, with the organisation of experience within the healthy brain, again a superficial analysis peppered with a few case studies, but unconvincing, even though the complex subject of executive functioning and consciousness is tackled with aplomb in only one and a bit pages of big typeface, and that takes some skill as a writer, which Cozolino clearly possesses.  It is his editor I am being unkind to, he lets the meat burn off: what a nice structure, but where is the depth?  This is emerging as a book written for non-neuroscientists.  None of the facts presented is too advanced, or wrong, just right in fact for its audience.  Even I can find a truffle in a dark forest, when the smell is right, blind hog that I am.

Into this arena, the discussion on the executive brain, comes a discussion of the back-bencher of the heteromodal cortex, the parietal lobes:

"Because behaviour is easily observable and measured, neurologists have focused primarily on the behavioural aspects of brain injury.  However, there is more to the human experience than behaviour; there are also the experiences of self in the world and inner subjective space.  These more subtle and subjective aspects of human experience have received little attention in neurological examinations" (page 145).

Now I have a problem with this.  Neurologists (bless them) have paid scant attention to the behavioural aspects of brain injury until very recently, and behavioural neurology is a relatively recent development, as is neuropsychiatry.  Indeed, the emergence of Kurt Goldstein, Alex Luria, Lev Vygotsky and others following on Freud's neurology and dissections in order to discover the human behavioural outcomes of neurological integration or disintegration, are acknowledged in most textbooks as the antecedents of such knowledge.  Simply put, the neurological exam is the lower end of the neurological spectrum and in no way does the testing of reflexes, cranial nerves, gait, eye, tongue, forearm and finger movements constitute a neurobehavioural assessment as practiced today.  Von Bronin aside (see reference to 1963 work on page 145), the expansion of the parietal rather than the frontal lobes in evolution and the very superficial explanation on page 146 of what Adams & Victor and other neurological tomes consider to be our awareness of our body and its relation to the external world, does not constitute proof that the tertiary association areas and Brodman's 40 and 7 are the seat of our awareness, any more than again, the aging references (1978 & 1987) referred to on page 147 provide any better evidence.  Localising the function of the parietal areas with the human experience of wholeness and position is just silly: the amygdala independently has a huge representation from the gut, the auditory and visual areas, and Antonio Damasio's three recent works are anecdotally influential in making one seek awareness in the feeling, the apperception of visceral emotion, as the seat of our knowing where and how we exist in juxtaposition with the external and internal world, in recursive, second order cybernetic feedback loops within a homeostatic, allostatic, capable organism. I think line of linear reasoning won't do, this won't do, not in 2003. There are many explanations out there in contemporary science, none of which are present here.  As for the "imaginal world", I prefer Russ Barkley's "simulator", which draws on more contemporary views of the brain, even if he largely ignores Damasio too!  Other more recent formulations demonstrate the necessary hierarchy of the executive systems in making sense of the emotions (or our internal, visceral brain) and the feelings of what happens (the integration of the internal with the external extrapersonal space with the internal) that constitutes our awareness of being.  Into this arena, surely, comes the interceding psychotherapist, entering via the spoken word into the mediator.  George Prigatano, the great rehabilitation expert notes what an amazing advantage it was to primitive hominids, to finally develop what Barkley calls a simulator, an internal representational world that can reproduce somewhat faithfully the external reality, and thus bind events across time and take the necessary actions to alter behaviours that will alter the environment, to the advantage of the simulating man.  This, I feel, missing in Cozolino's work, is the arena into which the therapist must walk.  All of that is known today, all of this is accepted, supported by Gaultieri, Barkley, Gazzaniga, Damasio, Shallice, and many others who lead the neuroscience of feeling and interacting.

The rest of the book works on the construction of narrative, and the sculpting of the brain and interpersonal self, and the nature of psychopathological and traumatic brain changes.  Especially this last part is much better in terms of research evidence and writing, such as in PTSD and borderline personality for instance, again, too brief.  Self-injurious behaviour alone would be a wonderful place to begin in this book to support the title, just as Damasio introduces the effect of misplaced electrodes on an aging Parkinson's sufferer in his latest work.

The fifth section, which embarks on the reorganisation of experience, refers to psychologists in their role as clinical neuroscientists, able to create an individually tailored enriched environment to enhance brain development (page 291). They would need to know more than he offers, and this is my gripe with his book overall, good as it is.

That is a noble aspiration if I ever heard such a thing, here is the value in this otherwise vegetarian cookbook for carnivores: students of psychology in their under- and post-graduate years need to go out and buy this book, flawed as it may be in my eyes.  In its way, limited though, it still is a valuable entry-level tool to introduce the unwilling practitioner of psychodynamic thought into the real world of mind and its antecedent brain without engendering a feeling of being overwhelmed by neuroscience, as fascinating as that world is for such as myself. 

For the psychologist who wishes to aspire to the role of scientist-practitioner, this is the launch-pad, unthreatening and flawed as such a start must be, in order to promote some motivation to continue into the vast unchartered world of cognitive and behavioural neuroscience where there indeed be dragons, and of course hippocampi.

Into this arena comes Cozolino and his concept of the manageable stressor of psychotherapy that should promote synaptic or neuronal plasticity (he doesn't distinguish this well enough in terms of either LTP or simulation across time in working memory), but nevertheless I believe any follow-up work should demonstrate with much more depth how he believes the scientist practitioner should accomplish this, case by case, discussing it with the complexity lets say, of the Othmers in1999.  Otherwise we are still left at the level of treating what these latter authors called the 'fat ankle syndrome', and not getting to the core of brain in mind.

What my students would be left with, after reading this work, is a fractionated understanding of the homeostatic autopoeitic, partially open and partially closed system, second order in its cybernetic feedback mechanisms, brain, that we live in.  After all, light ends at the cornea, sound at the tympanum, the outside world at the skin.  Everything after that is our imperfect recreation.  Enabled by the underpinning of working memory, encultured by the combination of the visual and verbal variants of this, human experience ties the cortical knots that constitute our feeling of what happens (conflating Luria and Damasio's terms), our awareness of being physically present in a recreated world constitutes our humanity.  Ideational Darwinism (Barkley's term) implies that much of what we think we know is flawed: therapy needs to address these flaws when they come to confound our thoughts and feelings.

Mutable by construction and deconstruction, such a recreation allows for creativity and error, and thus common humanity arises with all its richness.  I just wish Cozolino had done more to show us how that all works.


© 2003 Roy Sugarman


Roy Sugarman PhD, Clinical Lecturer in Psychiatry, Adelaide University, Senior Cinical Neuropsychologist, Royal Adelaide Hospital Glenside Campus Extended Care