by John B. Arden and Lloyd Linford
Review by Roy Sugarman, Ph.D. on Aug 11th 2009
As I noted in a review to their companion book on adults (Brain-Based Therapy with Adults: Evidence-Based Treatment for Everyday Practice), that following on Louis Cozolino and others these Kaiser Permanente Medical Center-based psychologists believe that neuroscience is set to inform the world of psychological practice, and I would imagine that KP with their network of providers under the leadership of Dr Dennis Ostrem and others is well set to support this initiative given the mindset of that organization. Bigger organizations such as OptumHealth Behavioral Solutions (part of United Health Group) led, in their innovation led Dr David Whitehouse have also followed up on beginning to use applied neuroscience in their offerings. This coincides with changes in culture, as exemplified by the lead of Steve Hyman and others from the current NIMH in their ponderings as to how applied neuroscience could be incorporated into the DSM-V.
What is becoming more impressive is that the above managed health care organizations are beginning to pay for these brain-based interventions in behavioral science as a way of reducing the costs associated with the care-as-usual approach. These authors in this new volume see the value in integrating the biological and psychological in a more seamless way, to both inform and drive the integrated approach further: this book is their first foray forward, and one on adults is also about the marketplace.
As is commonplace now, the important sensitivity and neuroplasticity of the brain is acknowledged up front, and any such approach recently has emphasized what Elizabeth Gould has been showing in primates at Stanford, namely, that the brain is as much a creation of genes as it is of the environmental impacts of its daily environment. Eric Kandel noted that genes need a playground, and the brain is one such place which is uniquely sensitive to the demands of the world. Within that growing brain-demanding world environment are multiple and important opportunities for attachment and in this case poor editing: Page 5 has the comment "This pattern is what students of dynamics call an attractor...." and one paragraph later: "Students of dynamics call these patterns "attractors" ...." Which just goes to show that relationships, like proof reading, depend on the quality.
As with Cozolino's recent work on living with a long-lived brain, Romanian orphanages get bad press, and the cortisol levels of the children are examined like the entrails of goat's to see which way the highly self organized systems which interact with the world will go.
The Hawaiians also get some press, with the competence of mother's caregiving coming under scrutiny, a judgment I always find untenable, and pages later, more studies of Romanian orphanages. Therapists are therefore being guided to consider both the wider environment and parenting, but I remain skeptical that this new foray into how we grow and mature should always come to comment on the quality of the mother, rather than the entire family, as a source of care. Surely, as with most children in the world who are not raised in a western nuclear family, the entire environment which includes a host of other carers, and the effect on children when this is not the case, might be a good place to start, the modern environment lacking in that respect, when compared to clans and kinship-based raising.
Whatever, the point being made is that there are complex entities for the therapist to attend to, with multiple inputs providing or failing to provide a good source of input for the developing brain, or rather, the experience-dependent brain, a term that sums up most of the childhood development discussed briefly in the beginning of the book.
The authors then discuss theories of temperament and then how this might arise from the environment (back to the Romanian orphans) with the ideas that if traits come to exist in critical periods, they are likely to be permanent aspects of temperament. Or, more likely, they are things to be overcome in order to ditch them as qualities in adult life terms. This would apply to both genetic and acquired traits, much as Suomi's monkeys did when given surrogate mothers, with some suggestion here that we can develop resilience through these experiences rather than pathologies that define us necessarily. The role of emotion and relationships is also briefly mentioned.
As is usual in such books now emergent, not just Bowlby and the Romanian orphanages are discussed, but Freud, Klein and Winnicott are back. This Freud is Anna, and the authors are thus back in institutions, in this case, the ones Freud was exposed to just prior to the death of her father, during the infantile depravations of wartime London. Klein however, was a different story, arriving long before Freud and anti-Semitism made an impact on her, and she was not interested in the child homes during the Blitz. Rather, she dealt with children and their families, one of whom went on to grow to become Winnicott himself. The point of these figures was that children and their primary carers, their mothers, can both engage in attuning and attaching and even children have competencies for this. And again there is the comment about good-enough relationships, although somewhat less direct in its blaming capacity when directed towards parenting. Another of Klein's supervisees was the abovementioned Bowlby, who brought attachment to the table after Klein and Winnicott developed their separate views.
This takes us then on to rupture and repair, the extension of the attachment and emotion regulation of the previous chapter. Here, the authors make the point, developed somewhat before, that the brain is the organ responsible for the child's attunement and attachment responses, as it moulds and develops around the formative events of the interactions of infancy and childhood. Danya Glaser did an excellent review in 2000 at Great Ormand Street Children's Hospital of the brain changes noted in the literature in response to childhood abuse and neglect, and the specialization that occurred, together with permanent changes in the HPA axis, as noted by John Ratey elsewhere in his review of the personality disorders. Ratey has more recently of course worked on another book, Spark, in which he discusses the repair capacity of the brain in response to exercise, movement and nutrition.
These authors in their turn discuss maternal depression and the effects of other deprivations in childhood. Cortisol, brain derived neurotrophic factor, the anterior cingulate, the usual characters in such discussions all are discussed here, as well as narratives as patterns of human behaviors and communication. In this way, the development of emotion management systems emerges as a co-creation of reality, and blends into the theory of mind discussions.
Outside of early development, the role of early life stressors notwithstanding, adolescence is a far more turbid period of growth, and hormones, sex and brain expansion and consolidation are a major focus of attention. Not only is the prefrontal cortex destined here to make up for the prematurity of the human fetus, but connectivity and pruning are needed to harmonize and help consolidate the child brain into the young adult brain, so that the mature brain can begin the process of dying off into late adulthood. The brain can now do far more elaborate and abstract trains of thought, and so enters into a period where it is capable of supplying future parenting roles in society itself, barely out of diapers as it were. Parenting of these adolescents in return is the last of the series of advances that parents must make. Authoritarian and permissive parents (active or passively) are not good parents, and authoritative parents are regarded here as better: they allow for independent reasoning and encourage good, enforce boundaries, and restrict bad in terms of what is set outside of these boundaries and the consequences that follow.
So far, interventions have not been discussed by these KP specialists. They introduce a BASE model here, referring to the Brain, Attunement, System, Evidence base in their acronym. Various parts of the brain, as well as spindle cells and their role, are discussed as being a focus for this approach, and the self organization of self regulation in therapy. Attunement, from Winnicott, could perhaps best be described as the offshoot of the massive so called Barlow studies for the NIMH in the USA, namely, that the warmth of the relationship in therapy counts, as attunement taps into empathy and effectance, mastery and metacognition. Systems is not part of the second order cybernetic sort, but more of the 'there are multiple systems' around the client approach. This includes racism, diagnostic categorical systems, and so on, a weird concoction. Evidence base is self explanatory.
Chapter 7 gets more specific, with a discussion on attention and self regulation. Nothing much is added by these authors that is not already out there. In a similar vein, their discussion about the anxiety disorders is also pretty mainstream, including the case histories, but the approach which included forced hyperventilation and motivational interviewing elements felt familiar to most experts who heretofore might have ignored the brain. What is a little different I guess to some USA-based therapists is not so to those of us outside the USA, namely a more wide ranging approach to dealing with behavioral issues than the DSM and medication. This is of course what Cozolino and Ratey and others have been talking about, and Ratey himself mentions that a PCP in the United Kingdom is more likely to resort to medication at a much later stage. I suppose the message supposedly emanating from this BASE approach is to view the process of therapy as a much wider eclectic, and once again a true, biopsychosocial reality. The idea is that therapists would have to include a greater awareness of the brain as a social and environmental organ, and pathology, as a more neural rather than a psychodynamic organ based thing, more of a bad brain than bad person entity. So as Ratey has argued prior, personality is more an issue of brain-environ relationships than some more esoteric or arcane process.
It is hard however to fathom the unique approach here, as distinct from pretty much a biopsychosocial one.
What is clear, as the anxiety chapter waxes and wanes, and then the mood chapter does the same, is the authors' attempts to always bring it back to the brain or at least to the neurodynamic level. This is not the approach entirely of brain that is offered in the books, and more seems to be offered in the road show that both authors are now embarked on, one element of which is to Australia. The flier seems to promise a more comprehensive approach over two days.
Again, in the approach to depression vignette, I could not determine how the approach was much different because of the BASE based intervention, from what anyone else might have done.
The appendix gives a rough outline of the brain, as perhaps as limited as offered elsewhere, but there is a lot more in the body of the work.
A good idea, these two books, as are Louis Cozolino's latest offerings, and I am sure the next editions will be better, and add value from their experiences on the road show.
For those of us more on the side of the Ratey integrationist style of brain body, there could be more here. Taking it to their logical conclusions, integrating the brain into therapy should by all reasonable forms of argument include bringing bodily wellness and resilience into the mix, and approaching anxiety and mood disorders by integrating body and brain together, something perhaps for the authors to consider in future volumes. Moving therapy from its current silos to a new, brain silo, is still not a fully integrated approach, and the book will move forward to a more logical space. Our children are more and more sedentary, thanks to TV, Laptops and face book-style socialization, with home telephones falling out of favor: the result of sedentary living is cytokine, CRP, interleukin disaster, with the effect on the brain and body huge and increasingly dangerous, as Ratey has pointed out, and as mainstream psychiatric journals are beginning to review: this is where the boys from Kaiser need to tread.
© 2009 Roy Sugarman
Roy Sugarman, Ph.D., Consultant: Applied Neuroscience, Human Performance Institute, Australia