Therapy and the Brain

It seems ironic that after Freud, as a neurologist, abandoned his studies on brain functioning to replace them with the studies of the unconscious — and that he actually abandoned his studies on traumatization — the trauma therapy world is arriving to a point comparable to the point where he started: the understanding of the brain as the basis of understanding the mind.

Trauma therapy is leveraging neuroscience because having an understanding of how traumatization affects the brain helps to not only dismantle common misconceptions and to stop victim-blaming statements, but it also explains many of the common behaviors and experiences of survivors experiencing either excessively stressful events, or prolonged intensely dysregulating circumstances.

After a focus on treating the brain with drugs (medication), and the mind with words (talk therapy), today neuroscientists have broadened the scope by studying the molecular, cellular, developmental, structural, functional, evolutionary, computational, psychosocial and medical aspects of the nervous system.

These advances are finally finding solutions in the same ways that the father of psychology was trying to find them almost a hundred years ago. Wilhelm Wundt (1832-1920), a physician, physiologist, and philosopher, started his interest in human behavior as an assistant of Hermann Helmholtz, one of the principal founders of experimental physiology, when psychology was part of philosophy and biology. Helmholtz was interested in neurophysiology and was conducting studies on the nervous system and the speed of neural transmission. That influenced Wundt to use equipment of the physiology laboratory to conduct his studies, which helped him in founding the first formal laboratory for psychological research in 1879.

Many other scientists of the 19th century were studying brain functioning in ways that helped psychology methodology and treatment to develop. Unfortunately, electroshocks and lobotomies were thought to offer great solutions and discredited the studies later on.

With the creation of psychoanalysis — and Freud’s strong personality — most of the attention diverted from the laboratory to the couch, and from the brain into the exploration of the unconscious, and, therefore, the world of thoughts.

In the same decade that the Berlin Psychoanalytic Institute was founded (1920), Hans Berger — a German neurologist and psychiatrist — published human electroencephalogram (EEG) data for the first time in history. He described a pattern of oscillating electrical activity recorded from the human scalp and demonstrated that alterations in consciousness correlate with EEG shifts.

Berger felt that the EEG could be useful diagnostically and therapeutically by measuring the impact of interventions, thinking that the EEG was analogous to the EKG (electrocardiogram). That type of investigation was cut off from the psychiatric world for reasons that escape my understanding.

Wouldn’t it be just logical to think that if every regular doctor uses technology for diagnosis like the EKG, every mental health professional would use the same type of support to have a better understanding of how the brain is working?

It was not until the beginning of the 1970s that the discoveries of the relationship between brain and mind started to bear fruit; neuroscience and the advances in neuroimaging have contributed in a way that allow mental health professionals to realize that understanding the brain adds perspective to the therapeutic modalities that already exist, and complement them.

Diagnosing Trauma

Reviewing the literature on psychotherapy, the importance of the Diagnostic and Statistical Manual of Mental Disorders (DSM) since its creation in 1952 is notable. The current DSM-5 came out after fourteen years of discussions — and battling criticism — based on all previous experience to regulate the assessment of mental difficulties.

Still, some professionals state that this latest version is likely the one that clinicians have given the least attention to, probably because it is the least useful for the treatment of mental problems (Pickersgill, 2013). We have seen many symptoms and disorders come and go into the different versions of the manual, and we are still lost in terms of identifying what’s normal, what’s treatable, what’s deviant, and what should be covered by insurance as a curable mental condition. Even insurance companies stopped using it to classify billable disorders, using the WHO manual instead.

The problem with the DSM is not whether we find a consensus in how to call or classify human behavior; the problem is that the DSM is what sets the tone for developing treatments. We can take the words of Walker & Kulkarni from Monash University, who wrote the following about Borderline Personality Disorder: “BPD is better thought of as a trauma-spectrum disorder — similar to chronic or complex PTSD.” That’s also the case with several other disorders that are treated as flaws in the personality or behavior instead of addressing the origin of the issue as traumatization and problems in the functioning of the brain and nervous system.

Nassir Ghaemi, author, and Professor of Psychiatry at Tufts and Harvard University School of Medicine calls the DSM a failure and states that the “DSM-5 is based on unscientific definitions which the profession’s leadership refuses to change based on scientific research.” There is a clear connection between that statement and the fact that the DSM refuses to recognize traumatization and its consequences on the nervous system, as well as ignoring trauma’s phenomenological relevance in the mental health arena.

Mostly because of this, the majority of therapies (and therapists) have not yet moved from treating behavior and thoughts to treat what propels those actions and ways of thinking. For treatment to be successful, the alterations on brain functions, and their relationship with all aspects of personality, emotional experiences, and thought processes, need to be included in treatment, together with the identification of the dysregulation of the autonomic nervous system (ANS).

Trauma Spectrum

Part of the challenges of trauma therapy is to recognize the type of alterations that the person suffers from. We don’t count with enough diagnoses to use them as road maps. Trauma therapists need to go deep into investigating circumstances in order to find out what type of traumatization the client had to endure.

The same way there are different events that cause trauma, there are different types of manifestations of traumatization, depending on what branch of the ANS got more damaged and suffered the more severe alterations.

  • If the caregiver is emotionally absent even if caring and dedicated, the baby can suffer from lack of attunement and develop attachment trauma. This type of traumatization can go undetected for years and has terrible consequences in the health and mental health of the person that never learned to regulate the balance between the branches of the ANS.
  • When there are just few concepts, but mainly disturbing body sensations and emotional needs, not receiving response to a discomfort — like hunger — or not getting the child’s despair consoled, could be paramount and seed the root of developmental trauma. The nervous system stays in constant confusion, feeling the need to attach and the fear of rejection, over activating the parasympathetic nervous system and staying a long time in immobilization mode. That causes brain developmental issues, dissociation, depressive mood, learning disabilities, etc.
  • If the stressful events are recurrent and for a prolonged period in life, the traumatization can be as significant as if the events were terrible and can be the origin of developing complex trauma. This type of traumatization can have either branch of the ANS overriding the other and presenting extremes on hyper or hypo arousal.
  • If someone fears the impact of his/her participation in society because of her/his skin color, racial trauma can be in the making. The ANS manifests similar activation as complex trauma, but the expression seems to be more acute.
  • When a parent’s high levels of anxiety significantly interfere with the child’s developmental progress, and the child’s self-image and object relations are also obviously affected by the image of the parents, the child’s shame or confusion about their parents or previous generations can evolve as historical or intergenerational trauma.
  • When a person suffers from different types of traumatization early in life, the combination of the dysregulation and its behavioral manifestations combined with temperament can end up manifesting as personality disorders.

Neurobiology-Informed Trauma Treatment

Trauma treatment is informed by the sequelae of alteration on the ANS after traumatization, and proceeds accordingly. The symptoms are treated as components of trauma treatment as opposed as separated disorders. The modality chosen depends on the area that needs improvement (cognition, affect, memory, identity, agency, mood, etc.) and on the phase the treatment is at.

Ruth Lanius is one of the clinicians that is using all sorts of modalities with her clients, including EEG and neurofeedback (NFB) as the basis to understand the brain and regulate it. As the director of the PTSD Research Unit at the University of Western Ontario she conducts research focused on studying the neurobiology of PTSD and treatment outcome research examining various pharmacological and psychotherapeutic methods. She is presenting great results reprogramming brain functioning with NFB among others.

Trauma therapy works against the stigma of mental health by repairing the malfunctioning of some areas of the system instead of working on finding character flaws and fixing the “defective” person. Using a compassionate and scientific lens, trauma therapy helps clients develop self-compassion and acceptance.