by Rebecca Aponte
The outspoken author of Brain-Based Therapy discusses the value of integrating therapeutic approaches, including neuropsychology, nutrition, exercise, CBT, motivational interviewing, and the therapeutic alliance.
RA: Let’s walk through a hypothetical. I come to see you because I feel depressed and generally anxious, and this has been going on for some months now. Where would you start to look for the cause of my feelings and some relief?
JA: It’s interesting that you say depressed and anxious, because under Pax Medica, if you were depressed and anxious together we would have two diagnoses on Axis I—a comorbid problem. Well, you’re one person. Are these two genetic disorders you have? What a silly idea. And the prescribed pharmacological agents actually work against one another. These stupid benzos, which are really a nuisance in the mental health world, would actually contribute not only to addiction, tolerance, and withdrawal problems, but also to depression. And then you’d toss in an SSRI or something like that, so you’d have this weird cocktail.
There is an interesting neurochemistry that occurs with anxiety and depression. For example, for 90 minutes after you experience a severe stressful incident, your levels of dopamine, norepinephrine, and serotonin will be down. Let’s say that you’ve just found out that you can’t get into school. All the PhD programs have turned you down. That’s a pretty big blow, right?
So you’re going to get a downregulation of all those neurotransmitter systems, and you’re going to withdraw a little bit. But it’s what you do with that neurochemistry and those neurodynamics that can tumble you into more anxiety and more depression, or get you out of it. If you do things that kindle up the same systems that would get you more anxious and depressed, you’ll get more anxious and depressed.
Now, we’re going to have bumps in the road. It’s what you do in response—it’s that resiliency. Some of the positive psychology spinoffs are paying attention to that, and of course the counseling psychologists have long done that.
RA: So, if I were your client, would you want me to tell you about something stressful that happened and what I did afterwards?
JA: I often do that, just to get an idea of how people react to certain events in their lives—to get a characteristic description. I’m also paying attention to the way they describe them to me, because that interaction between us is so important. It replicates other relationships they’re having that might have great continuity with the earlier attachment-based relationships. It tells me a lot about how I can intervene, because I don’t want to create more resistance. I do like Milton Erickson a lot—that indirect approach. I’m not going to want to shut you down and have you screen me off, but rather do somemotivational interviewing to some degree—which is very Rogerian, in fact. Bill Miller was a Rogerian from the school that I came from.
RA: Out of curiosity, did you study with him at UNM?
JA: No, I didn’t. In fact, I didn’t know about him until after I left. I don’t know if he was there then—that was 30 years ago. But had he been there and I missed him, I would have been disappointed, because I really like his contribution to the substance abuse community.
RA: And substance abuse is one thing that we haven’t really touched much on in terms of what neuroscience is really teaching us. There’s big debate about whether addiction is a genetic disorder.
JA: There is some literature to suggest that if you have two alcoholic parents, your vulnerability to become an alcoholic is heightened. But let’s say the concordance rate is 50 percent. Well, what about the other 50 percent? It isn’t a one-and-one factor.
In a discussion I had with Fred Blume, one of the pushers of the alcohol gene concept, I asked, “How about an acquired disease? You guys are really into this disease concept.” AA’s really into it. AA and NA are the most powerful self-help groups in the world, in my opinion. My sister-in-law’s life was saved as a result. Fantastic groups. I love their little jingles and all that. But they’re too into this disease concept. It’s useful in early recovery, but you could create a disease. It’s bidirectional. The more I drink alcohol, the more I feel like I need alcohol, because my biology changes. I downregulate various neurotransmitter systems, so now I feel like I need to mellow out because now I’m downregulating the synthesis of GABA. That means I need more GABA-like effect because I’m always dampening down glutamate.
What I think therapists ought to be paying attention to is how these various substance abuse habits, if you want to call it that, create psychological symptomatology. [quote:I see all sorts of people here in the North Bay who are suffering from anxiety and/or depression, and I find out they’re just drinking a glass or two of wine at night.
RA: That’s a lot of wine, though.
JA: I think it’s a lot of wine. I drink a glass every week or two. It would be nice if you could have two glasses of wine a night, but my sleep gets all messed up. You get the mid-sleep-cycle awakening and all that. And that’s a small snapshot. What about the next week? These are subtle effects, but when I used to do neuropsychological testing and psychological testing, and then later teach it, we used to say, “Don’t test a wet brain for up to three months after your last drink.” There are all sorts of artifacts to subtle alcohol consumption.
And red wine isn’t that cool, you know. It’s the resveratrol in the skin of the red grape. You can drink Welch’s grape juice and still get the same effect. You don’t need the alcohol.
RA: And what about other drugs? I haven’t heard too many therapists saying that they necessarily ask their clients, “Do you smoke pot?”
JA: Everybody here does. And pot is one that I really pay close attention to in the North Bay, because of all these people on medical marijuana cards. They have a sore back. Well, give me a break. So do I, but I don’t smoke marijuana now. I did 40 some years ago as a young hipster, but I’m glad I stopped 40 years ago, because otherwise I’d be muddled and kind of down. THC is chemically structured like a neuromodulator called anandamide, which is Sanskrit for “bliss.” It orchestrates the activity of a number of neurotransmitters, so when you’re stoned you get what we call virtual novelty. “Look at this cup! God, that is so incredible. Look at the way it’s shaped, and the colors! This is amazing.” Then the next day you get what we would call in the ’60s “jelly brain,” because everything’s downregulated now. And you never get the same high.
So now what we see are all these people smoking medical marijuana who have low-grade depression. They can’t remember much, because they downregulate the acetylcholine release in their hippocampus and have symptoms very much like ADD. God, I get people with ADD evals all the time who are smoking marijuana.
So with regard to substance abuse, psychotherapists should perform a full analysis of everything the clients are doing, instead of saying such things as, “Do you abuse alcohol?” I want to know what they’re consuming rather than ask blanket questions.
RA: Well, what’s abuse? “Yeah, I have five beers a night, but I’m fine.”
JA: Exactly. But if somebody’s drinking two, I’m concerned about that, especially if she’s anxious or depressed. Or if somebody’s taking a toke of marijuana a night, and he’s coming in with this low-grade depression, muddled thinking, and attentional problems, I’m concerned about that.
Defining Therapeutic Success
RA: In the way that you’re visualizing therapy, how do you define therapeutic success?
JA: We’re always a little too symptom focused. I still think we ought to be paying attention to symptoms—that’s an important part of the picture—but we also ought to pay attention to what clients are telling us about their overall improvement and their perspective in life: “I’m feeling so much more hopeful and so much more resilient and I’m not as easily stressed.” And we’re getting more of that from the outcome management process, instead of, “You originally came in with these panic symptoms. How’s the panic doing?” “Oh, I don’t have those panic symptoms anymore.” Well, that’s good. That’s only part of the picture, though. There’s got to be a larger look at things: is the relationship improved, for instance?
You change the brain by getting out of your comfort zone. You don’t want to stay in a state of low-stress, boredom or depression -nor be in a state of high stress or anxiety. You should strive for a level of optimum stress.
Be on the look out for periods of flux or readiness for change. Work with the person wherever they are and as early as possible.
Relationship-there was a study done that concluded that the therapist’s relationship with the client was more important to the client’s functioning than the relationship between the medication and the client.
Harm can be done when the therapist makes the therapy process too comfortable for the client. Again, you need to be pushed out of your comfort zone to grow. “Safe Emergency.” Sometimes you need to risk the relationship to gain a relationship.
30% of waking hours are spent daydreaming or ruminating. This is when you use your Default Mode Network.
If you avoid what makes you anxious, you will become more anxious over time. If you do what you feel like doing, you will get worse. You’ve got to get out of your comfort zone.
Worries are possibilities not probabilities.
The Pre-Frontal Cortex
It is the last part of the brain to myelinate. This explains some teenage behavior.
Left Frontal Lobe
Label thoughts and feelings
Develop new narratives to alleviate anxiety and stress
Right Frontal Lobe
Exercise can increase neurogenesis.