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Review of "Being a Brain-Wise Therapist"

By Bonnie Badenoch
W.W. Norton, 2008
Review by Roy Sugarman, Ph.D, on May 12th 2009
Being a Brain-Wise Therapist

Medical clinicians in the USA, particularly in California, have assured me that although Interpersonal Psychotherapy is held high in their esteem, as is CBT, and these therapies are recommended in APA guidelines, they can make up to 25 phone calls in search of a practitioner of these skills who is available for any particular patient. It would be nice to have more of them.

Daniel Siegel, in his foreword, describes Badenoch as a frontline therapist who writes like a poet and has the understanding of science usual only in academics.  He describes her interpersonal neurobiology approach as an eclectic mix of the above attributes and more.

Siegel’s warning applies to any science of integrationist applications: “Applying scientific ideas to the field of psychotherapy is no easy task.  Without rigor, it is easy to slip into overly simplistic views of complex conditions.  This risk is always present when we draw on objective research findings and attempt to create clear conclusions that then can be applied to the subjective world of clinical interventions.” (page xi).  Siegel sees Badenoch as an artist who can do this well, creating a ‘beautiful balance’ between science and applied science (clinical work).

The core pages are somewhere around pages 37-40, where she discusses the core neurobiology of integration, namely the interaction between emotion, the insula, mirror neurons, and ingrained bias.  Given the comments from Siegel above, it is predicable she will divide the book into two sections, the first, covering almost half of the book, are what she calls laying the theoretical foundations, which draws more on research into the brain rather than theory, and then the practical application of this science, which is really a theoretical approach to how one might work with these insights.

The approach to diagnosis is interesting, making reference to the damage done to the brain by seemingly trivial events such as a father fiddling with a newspaper while the mother does the dishes, her back to the child, leading it seems to a lack of neuronal integration in parts of the brain that deal with such things.  The concept of the acquired disorder is now to be integrated with this lack of neuronal integration, in an attempt to remove the stigma of the word ‘disorder’.  In the fascinating discussion that follows such assertions, e.g. page 119 onward, it is a little worrying that she draws so much on Siegel’s representations, dropping in a few here and there from others. It is also worrying, as I discuss later on here, that the therapy room is to be contrasted as a place of genuine love and warmth, as opposed to such families: this is hard to swallow.

While the teaching and insights she provides are fascinating, and she does indeed write like a poet, what flows from these insights is a series of inferences, rather than objective appraisals.  If the things she writes about on pages 37-40 are correct from an integration point of view, and Siegel’s 6 or 7 works she draws from are definitive, and if the human response is limited to say, depression, anxiety, dissociation and addiction drawing on a model of disturbed regulation and integration of the social and general cognitive processes, then where is the applied science?

Matarazzo (http://www.ncbi.nlm.nih.gov/pubmed/2221576) dealt with this in some ways in 1990 in his plenary address to the APA (the psychological one) when he spoke of the suspicions that clinicians using the art of inference instead of proven clinical constructs could fall foul of their own subjectivity.

Turning Matarazzo on his head, then, the use of standardized instruments to establish a clinical baseline in a client turning up for therapy might be an essential starting point for a true brain integrationist who wishes to incorporate the putative neuropsychiatric mechanisms described by Badenoch into a therapeutic clinical interpersonal pathway. Understanding the brain and actually engaging with the brain are two distinct points on that pathway. Otherwise, I fear Badenoch is merely, as an ‘artist and poet’ in Siegel’s terms, making inferences about the effect the father’s newspaper and mother’s dishwashing might have had: where is the science of objectivity here, rather than the subjective and emotionally biased insights of both therapist and patient? Here, are we back to transference and counter-transference and the art of inference and the concept of resistance?

The point about translating this neuroscience, neurobiology, Siegel’s, Damasio’s, Cozolino’s and others (see recent works by Arden and Linford as well, summarizing these) is data. Data has two problems: one, data is usually group analysis, and says nothing about the individual. Clinical work is about the individual.  The second problem is more complex.

We do know for instance that ADHD and OCD share the same loops in the brain, hence respond to the same drug treatments, and one can talk about hyper and hypoglutamatergic systems, but the treatments outside of drugs are different (see Mary Carlsson, Acta Psychiatrica Scand 2000;102:41–3). The difficulty with clinical applications of science remains, why has THIS patient, presented with THESE symptoms, at THIS time of THEIR lives: the personalization of medicine and science is not easily answered even if the brain is the platform of reference.  I don’t believe that Badenoch has answered these questions, and probably cannot without a baseline assessment of the putative brain mechanisms she is putting forward as the playing field of a neurobiological approach to therapy.  Brain-wise, certainly, but what then?

The Othmer family (Othmer, Othmer and Othmer, 1998, Psychiatric Clinics of North America, Volume 21, Issue 3, Pages 517-714) wrote of the issues that failing to correctly apply brain insights in psychiatric conditions might create, especially in the context of diagnoses, as worried Badenoch on page 119.  The emphasis has to be on brain processes, the understanding that Badenoch is giving is designed to create awareness, a brain-wiseness, but the elements of science appear to be the result of translating the process and organizing the content around brain, rather than a theory of psychodynamic or personality as an epistemology, but a new, brain based one.

My own thoughts here though center on what Paul Dell called “falling through the ceiling” when one confronts an epistemology, or what one might consider to be the factual matter one studies, which, in Dell’s formulation, results in a confronting ontology, or what one might consider to be the ‘facts’. These facts, namely what exact brain processes in an individual case, might make the difference.

So in trying to apply Badenoch’s approach, let us take the case of a woman in her 20’s who approaches a psychologist.  She does not appear too depressed or anxious, but asserts she is, picks at her clothes as she talks.  She appears to not have a DSM-IV diagnoses, but has a troubled and traumatic childhood. An IQ-type assessment shows she does very poorly, but she is studying at the undergraduate level and doing okay. We know, let’s say from Danya Glaser’s work at the Great Ormond Street Hospital for Children in London (see 2000, Journal of Child Psychology and Psychiatry, 41 (1) 97-116) that such trauma might lead to changes in her limbic structures.  Drawing on van der Kolk in Boston, John Ratey at Yale, Bruce Perry and perhaps even Martin Teicher’s work, we expect poor verbal processing, a left sided hippocampal deficit in volume compared to the right, permanent disruption to the hypothalamic-pituitary-adrenal axis, a unique sensitivity to stress, and so on. This is what being brain-wise might tell us. Mood swings might follow her menstrual cycle in a catamenial way, who knows?  The question is how do we quantify her unique situation and deliver a personalized approach? It is not enough to say that such a patient arrives with their “right hemispheres in tatters” (page 141), which smacks of, well, phrenology.

The answer is, if we are brain wise, we would like to quantify the putative effects of her developmental history, so we can objectively measure what, if any intervention she might need, given the likelihood of a tentative diagnosis of personality disorder and the difficulties with treating that in the one to one setting.

Objective brain assessment might provide the answers.  A Gur-like non-conscious emotion faces identification and recognition assessment might show a Disgust and Anger slowing, as the hard wiring of her brain slows her down to that which she is prone to, and her Fear response might be hypervigilant, owing to the trauma she was exposed to, as in PTSD.  The Disgust response, a typical more Insula response might signal obsessiveness, or too much self-reflection in her interpersonal space, or even anorexia as in the studies done by Gur, his daughter and their collaborators at Brainnet.net.

Why bother with such assessment? The answer is perhaps provided by Assoc Professor Les Koopowitz at Adelaide University in Australia: making the patient brain-wise appears to help engagement and motivation enormously (personal communication).  Formal assessment may provide a rich supply of information to the client about their brain and the reasons for their perhaps otherwise arcane behavior. No longer a bad person, but a bad brain? Is that helpful as a reframe?

There is no doubt that Badenoch, Siegel, Cozolino, Arden and Linford, Damasio and many others are driving the brain into the forefront of behavioral medicine, as Othmer et al (1998) have indicated might be wise, but what is lacking is the provision of real data to the client.  I am not sure it is helpful to reframe the right hemisphere as a target for tattering, or to make statements, as poetic as they are that “our ability to consistently hold their deeper minds can slowly rebuild lost neural structures” (page 141).  The description of dissociative identity disorder is peppered with inner-mother-parent dyadic references, which is fine if you accept that the disorder exists, and doesn’t just emanate from a few sources in the USA as Scott Lilienfeld suggests in his writings.

The reference to the much-quoted right prefrontal areas is interesting, but no mention is made of the glutamate receptors, or the influence of the ketamine-like, and hence dissociative-anasthesia-inducing of the glutamate antagonists such as NaG that respond to the chronic overload of the glutamates, or of the CA3 field sensitivity of the limbic cortex to kainate and other excitotoxic compounds. Localization has its hazards, and referring to circumspect areas of the brain as being in control of, or generating responses to putative stimuli is probably based on non-real time studies by fMRI and not integrative studies using a combination of methods which might include multiple imaging or testing techniques in the same individual, and might demonstrate systems of interaction in the brain around various insults and the collaboration of genes and other components of brain response both cortical and subcortical. 

So a single perception might involve the influence of tertiary areas in the brain, the entorhinal and perirhinal areas, the CA3 fields and the mamillary bodies, arches of the fornix, or perhaps the CA and the Schaeffer collaterals, the subiculum, with input from the insula, cerebellar vermis, prefrontal cortex, serotonin from the raphe nuclei, dopamine and noradrenaline, not just the sympathetic and parasympathetic branches of the ANS, and so on, a very complex arena, ignoring the fast field responses of the corticothalamic loops and the amygdala; metaphors of GABA and the amygdala notwithstanding (see page 203-204), there is a complex interaction with glutamate and this tri-laminar organelle and GABA and multiple other areas.  A simple formulation of the right hemisphere in tatters might just be a selective reading of the literature.

So overall while I applaud using the brain and its putative mechanisms as a metaphor, I find it hard to see the value of the sandpit, the narratives, the other techniques; overall, using the brain in this way is kind of treating it as a tinker-toy, as almost a fad, a fun thing to do.  This is what publicizing the brain does, as the mechanisms of engagement put forward by Badenoch are no different to what we, as rehabilitationists or therapists do anyway, and a clear understanding of putative brain mechanisms is interesting but doesn’t change what I do tomorrow when I hang out my shingle.

A practical guide, that is how the book is put forward, it does that well, and as far as making one brain-wise, that too.

I do have some real issues with it, though.  Statements like “when children are in the company of someone who genuinely cares about them” on page 303 is dangerously close to the parent-bashing of the psychodynamics heyday, and exemplifies the “warm” environment of therapist(s) and toys as a stark contrast (page 304) and paragon of virtue, the bon dieu syndrome we were warned of as students of medicine and psychology. Worse, this is a very linear equation, this suggestion that ‘bad’ parents ruin children and do not genuinely love them, and we therapists provide a better home for them, a therapeutic home with genuine love, whereas this means the parents didn’t.

Such formulations are not helpful, and seriously introduce value system statements that most would regard as arrogant, and in some cultures reading this, would mean seriously instilling the desire to run for the hills and the safety of less judgmental healing folk. I understand, I hope, the basic tenets of IPT, and I hope the tenets of IP neurobiology, intrapersonal neurons do not detract from this. My understanding being that IPT does indeed take its structure from psychodynamic psychotherapy, but also from contemporary cognitive behavioral approaches in that it is time-limited and employs homework, structured interviews, and assessment tools. I do not believe I saw this blame lauding in the literature to date, and would not suggest we go back to the psychology theories of violent but subtle issues related to the perceived distant father and mother rustling their newspapers and rattling their dishes (gender role stereotyping aside) and parent blaming that this approach here implies in the crooning and preening of page 303-304.

Badenoch is a marriage and family therapist.  My understanding of the Family Therapy approach was that it was non-linear in terms of its theories of causality, and avoided such pronouncements of interpersonal actions as being good or bad.  Also, the modern concept of resilience of the brain is another issue. This last gets one mention, citing Siegel, in the whole book.  All families are full of the kind of back-turned pathology, happening more often than not, and only a few get upset enough to need psychotherapy.

The book therefore seems to lack anything more than Siegel’s approach, laudable as it is, and does certainly bring the brain in to the discussion, but I think misses in terms of truly integrating the field, or fields, of neurobiology and interpersonal theory and biology.  It is however a great way to engage with a first pass at neurobiology, not in the same genre as the other books doing the same or similar as mentioned above, but a good first start.  I would however suggest skipping some annoying parts such as above, which detract from the good work Badenoch is attempting, and from my point of view as a reader, such lapses into neural-epicentrism stimulate some deep, non-conscious biases of my own that lead me to cast unfavorable judgment.

© 2009  Roy Sugarman

Roy Sugarman PhD, Director: Behavioural Solutions, Brain Resource Limited, Ultimo, Australia