By Julie Le Franc – Psychoanalytic Psychotherapist and Psychologist
Neuro-psychotherapy is unique and a different approach from other theoretical models as it focusses on the neural processes that underlie human responses such like; memory, thoughts, emotions, behaviours, sensations and interactions. As a Neuro-psychotherapist and a psychoanalytic psychotherapist I use an eclectic approach and utilise neurobiological, cognitive, emotional, social, and environmental information to base or enhance psychotherapeutic interventions.
Case
Jane, a fifty-one-year-old married woman was referred to me by her Doctor for work stress, reactive depression and anxiety.
She reported that she was no longer enjoying work. She worked with her father in a family specialist retail business; her father died and she took over the running of the Company. Jane had loyal, long-standing employees and customers. She sold the business and continued working with her loyal staff. The new owners did not care about their employees and Jane felt responsible to the staff and felt emotional, stressed and anxious. The stress had an impact on her health and she went on stress leave. As the days progressed, she became more negative and could not see a future for herself. The Contract of Sale prohibited her from operating or working in a similar business for two years. She felt depressed and was unable to concentrate; she had self-doubts and low self-esteem and found it difficult to focus on anything. Her Doctor started her on an antidepressant for her depression. Since stopping work she has not been able to return. She then received a Letter of Termination. She sought legal advice.
Brief History
Jane, born in Tasmania was an only child. Her parents separated when she was twelve years of age. She described her father as distant, critical and emotionally absent but a good boss. Her father died of cancer; Jane was forty-eight years of age. Jane was close to her mother; her mother had depression and spent many days in bed; her mother was dependent on her from a young age. When her parents separated she lived with her mother; her father moved to Queensland. Jane left Tasmania and went to live with her father when she was twenty years of age and worked in the business; she has a child with her husband of twenty-two years. Her mother did not want to relocate to Queensland. Jane was carrying guilt for leaving Tasmania and not being there for her mother.
Formulation
Jane presented with a range of signs and symptoms including depression and anxiety. She had difficulty initiating sleep and had interrupted sleep, nightmares, poor memory and irritability. She was ruminating over irrational thoughts’ and had become socially withdrawn. Her concentration was impaired, she had decreased self-esteem and confidence and excessive self-criticism. She was ruminating over the way she was treated. She felt ashamed and helpless with low self-worth. She felt responsible for the employees that were leaving the business due to stress. She could not see a future for herself.
Neuro-psychotherapeutic aspects related to the presentation
Jane experienced an insecure attachment style; she was a pleaser and felt sensitive to people’s responses and reactions. Her earlier lack of a secure attachment; and a sense of abandonment and rejection have led to feelings of loss, shame, anger and guilt. Her environment as a child was compromised due to; her mother’s depression and ill health, her parents' separation and her father leaving; and her need to be an adult to her mother from twelve years of age. Compromised environments constantly activate threat or risk of not surviving resulting in over-activation of protective patterns; the over-activation is clearly seen in stress responses (Rossouw, 2014).
Jane’s insecure attachment would have predisposed her to high anxiety, with stronger cortisol response. Insecurely attached children can continue to experience difficulty with affect regulation as adults, and their attachment needs can remain unsatisfied (Rossouw, 2014).
I described to Jane the plasticity of the brain and how sleep, nutrition and exercise can affect how the brain worked. Jane felt comfortable in the therapeutic alliance and safety was established, down-regulating the stress response, and activating cortical blood flow to the left frontal cortex in order to engage (Rossouw, 2014). Jane had withdrawn to the safety of her home and spent most of her days feeling anxious about what she was going to do. Her inner critic had strengthened and she was avoiding social situations. Her repeated self-doubts and reproachful thoughts had reinforced the neural firing patterns associated with her beliefs. Over-activation of this fear response was thought to facilitate activity in the anterior cingulate areas resulting in excessive patterns of avoidance (Rossouw, 2014).
Withdrawing and avoidance behaviour had, in turn, maintained her anxiety and activated strong neural loops and rather than feeling better, her sense of self-worth, confidence, control and orientation had declined and her anxious feelings worsened. She kept activating a 2 to 1 system, impulsive brain back to survival brain (Rossouw, 2016). When the primitive (survival) systems are activated (by a threatening environment) the survival responses take priority in neural patterns; blood flow reduces in the frontal regions and increases in fear based (limbic) regions (Rossouw, 2014).
Therapy process
The sessions focussed on neuro-psychotherapy and how the brain worked including the idea of neuroplasticity, the activation of neural pathways in the brain and the Hebbian Principle of “neurons that fire together, wire together’ as well as the corollary that ‘neurons that fire apart, wire apart’. We also discussed the role of avoidance patterns in her brain that kept her anxiety active. For people suffering from depression and anxiety and experiencing significant neural loops, they can be assisted to establish new neural firing patterns and new neural activity that lead to new patterns of activation. For these patterns to become stronger, ongoing activation is needed over a period of time.
I drew the brain and then I drew a circle in the middle area of the brain to indicate the limbic system. I explained the functions of the limbic system, how it initiated the stress response and prepared the body to handle stressful events (fight/flight) response and the release of stress chemicals (adrenaline and cortisol). I explained the amygdala in relation to the regulation of emotions and the importance of sleep, connecting with people and nature, food and activities.
Neuro-psychotherapy is also closely aligned with research focusing on the changes in electrical activation of the brain. The principles of action potentials and synaptic potentials are still the very basic drivers of neural systems (i.e., helpful activation patterns as well as the unhelpful patterns or psychopathology) (Rossouw, 2014). The importance of neural principles based on the electrical theory; neuro-science has also uncovered a second key player in neural activation – the role of neurochemicals. Neuro-psychotherapy acknowledges the role of neurochemicals in the development of psychopathology (e.g. the up-regulation of distress chemicals corticotrophin releasing factor (CRF), adrenocorticotrophic hormone (ACTH) and cortisol that can lead to neural damage and compromise the effective operation of frontal cortical systems). It also acknowledges the role of medications to counter the effects, e.g. the use of benzodiazephines to facilitate a state of calm and selective serotonin re-uptake inhibitors (SSRIs) to inhibit serotonin reuptake and enhance serotonin flow to frontal cortical systems (Rossouw, 2014).
We actively addressed her need to please, her sense of self and her fears of being judged and I explained defensive behaviours. Life started to take on a new meaning. As Jane’s insight grew, she was better able to understand her avoidant behaviour and started to challenge her distress and avoidance as a matter of survival. She started to feel safe in her environment and started attending the gym.
In short as safety was established, Jane shifted towards avoiding pain and distress to maximizing well-being and pleasure. Research indicates that this principle is enhanced by effective neural networks between the limbic structures (especially the amygdala and hippocampus) and the anterior and pre frontal cortical areas. This is further enhanced by neurochemical changes. Increased flow of serotonin from lower brain regions to the neo cortex enhances communication and effective down-regulation of distress with effective problem-solving and social skills. Increased production of dopamine is linked with an enhanced sense of wellbeing, pleasure and reward (Rossouw, 2012).
Activating the left pre-frontal cortical areas facilitated her ability to explore her story with awareness and insight. Working through her past and building new neural networks helped her to expand more memory and she was able to move from the primitive pathway to a thriving response. She was correcting the patterns of trying to be perfect and please and was engaging in daily activities. She was more motivated to do those things she enjoyed.
Jane came to see me more recently and she reported that she was sleeping well and for longer and was more effective with her family. She said that she was focussing on her strengths and emotional well-being.
For further information, contact Julie Le Franc on 0407 385 005
References
Montgomery Arlene (2013). Neurobiology essentials for clinicians: What every therapist needs to know. New York: W.W. Norton & Company.
Rossouw, P. J. (2012). Neuropsychotherapy in Australia. The Australian Journal of Counselling Psychology, 15 – May/June 2012.
Rossouw, P. J. (2013). The neuroscience of talking therapies: Implications for therapeutic practice. The Australian Journal of Counselling Psychology, 13, 1, pp. 40-50.
Rossouw, P. J. (2014). Neuropsychotherapy: Theoretical Underpinnings and Clinical Applications. Sydney: Mediros Pty Ltd.
Rossouw, P. J. (2016). Certification Training: Clinical neuropsychotherapy practitioner. Workbook. Queensland Australia. Mediros Pty Ltd.