Psychotherapy and Therapeutic Techniques

Psychotherapy and the Brain

• Lecture 18, 2024-11-18
• Topics covered: notable brain areas, cognitive models of anxiety/depression, neurocognitive correlates of change in CBT.

The Brain

• Higher cognitive hierarchy: Prefrontal Cortex, Anterior Cingulate Cortex
• Lower cognitive hierarchy: Hippocampus, Amygdala

Definitions

• Top-down processing: Slow, deliberate, explicit processing using rule-based knowledge; mediated by prefrontal cortex; main target in CBT.
• Bottom-up processing: Automatic, effortless, implicit, and pre-conscious processing based on salient features or stimulus and situational cues; mediated by lower-order brain structures.

Psychotherapy and the Brain (Linden)

• Cognitive restructuring increases top-down control over negative emotion; medication decreases bottom-up reactivity.
• CBT primarily reduces symptoms by impacting higher-order executive functions (e.g., problem-solving, cognitive reappraisal, self-referential thinking).

Depression

• CBT alters activity in dorsolateral, ventrolateral, and medial prefrontal cortices, and anterior and posterior cingulate cortices.
• Mostly higher-order areas.
• Modulates encoding, retrieval of negative associative memories (rumination), and overprocessing of irrelevant information.

Anxiety

• CBT alters activity in the same higher-order regions as well as the amygdala, hippocampus, and anterior and medial temporal cortices.
• More modulation of bottom-up structures in CBT for anxiety.
• PTSD: Increased activity in anterior cingulate cortex and decreased activity in amygdala after exposure plus restructuring
• Social anxiety: Decreased activity in amygdala-hippocampal region after CBT or medication treatment
• OCD decreases activation in orbitofrontal cortex, dorsolateral prefrontal cortex, and anterior cingulate cortex with CBT or medication.

Basic Mechanism: Cognitive Control of Emotion

• Higher-order cortical regions are involved in cognitive control of emotion.
• Cognitive reappraisal involves increased activation of dorsolateral and ventrolateral prefrontal cortex and anterior cingulate cortex, decreased activity of amygdala
• Using strategies to regulate emotions activates top-down processes consistent with CBT.

More recently...

• Neuroscience research has examined functional connectivity changes in relevant brain regions after therapy.
• Shou et al. (2017): CBT increased resting-state connectivity between amygdala and fronto-parietal network in patients with MDD and PTSD.
• Young et al. (2017): Symptom improvement in CBT or ACT for SAD correlated with increased amygdala-vm/vl-PFC connectivity during emotion regulation tasks.
• Mason et al. (2016): CBT for psychosis associated with greater connectivity between amygdala and dlPFC in social threat tasks.
• Gotnik et al. (2016): Systematic review of 11 studies examining brain changes after 8-week MBSR program showed increases in volume, activity, and connectivity of prefrontal cortex, cingulate cortex, insula, and hippocampus, and decrease in amygdala activity and increased connectivity with prefrontal cortex.

Other "Brain" Interventions

• Psychopharmacology: Selective serotonin reuptake inhibitors (SSRIs) are first-line treatment for depression; have a milder side effect profile compared to previous generations. They benefit most with severe depression; most people stop taking them within 3 months.
• Deep-brain stimulation: Neurostimulator implanted in brain sends electrical impulses to specific subcortical regions affecting subgenual cingulate. Mayberg (2005) showed a sustained response or remission for 4 out of 6 people with treatment-resistant depression using DBS for 6 months. Being used for OCD and anorexia.
• Psychedelics: Reiff et al. (2020): scoping review of 161 studies on clinical application of psilocybin, LSD, ayahuasca, and MDMA for psychiatric disorders. Psychedelics-assisted therapy includes preparatory therapy, psychedelic session(s), integrative therapy. Dworkin (2023) examined combination of psychedelics and psychotherapy to explore synergistic effects.
• Narratives about Psychotherapy and the Brain: Perricone et al. (2024): Study to look at beliefs about psychotherapy; tested 3 conditions – brain-level psychotherapy explanation, mind-level explanation and inactive control.

Scaling Up Psychotherapy for Greater Reach

• Kazdin (2017): Survey research showing a treatment gap in mental health care
• Novel models of delivery for mental health services include task-shifting, best-buy interventions, disruptive innovations (e.g., tele-medicine), and interventions in everyday settings.
• Use of technology: psychoeducation, digital treatments, digital assessment, digital training.
• Important to make programs cost-effective, feasible, and appropriate to implement in various settings to increase reach of psychotherapeutic services.
• Schleider et al. (2022): Nation-wide RCT of online single-session interventions for adolescent depression.

Process-Based Therapy: Personalizing Therapy

• Goal is to personalize treatment to target patient mechanisms of change (e.g., cognitive restructuring, or mindfulness in therapy).
• Research has gone toward process-based psychotherapy and not on what does the therapy work for average patients.
• Stumpp & Sauer-Zavala (2021): Explored dimensions of diagnosis, symptoms, psychological processes, personality, and response to, and changes during the treatments.
• Unified Protocol for Emotional Disorders: Farchione et al., (2012) demonstrated effectiveness of UP; but with limitations in comparison groups.
• Sauer-Zavala et al. (2022): Examined a SMART design (sequential multiple assignment randomized trial) in a cohort of patients with emotional disorders and treatment conditions focused on capitalization, compensation, and standard care.

Dialectical Behavior Therapy (DBT)

• Background: Designed to treat chronic suicidality and parasuicidality not responding to other treatments.
• Most patients with chronic suicidal behaviours have borderline personality disorder (BPD).
• Based on Linehan's Biosocial theory of borderline personality disorder.
• The central dilemma in DBT is to accommodate patients' emotional experience while helping change problematic behaviours.
• Therapy involves weekly individual sessions, a weekly skills group session, telephone contact, and therapist consultation team meetings.
• There are several facets of enhancement in capabilities (e.g., enhancing life skills in their groups sessions) to generalize skills outside sessions.

Mindfulness-Based Therapies and Acceptance and Commitment Therapy

• Aims to increase client's awareness of their thoughts, emotions, and physical sensations, accepting them rather than fighting them.
• Mindfulness-based interventions are offered within the framework of Acceptance and Commitment Therapy (ACT). CBT interventions are used as a complementary tool, rather than replacing the existing therapies.
• Hoffman et al., (2010) and Khoury et al., (2015) used both standardized treatment methodologies and large group practices when conducting their research.

Contemporary Psychodynamic and Humanistic Therapies

• Short-term psychodynamic therapy:Focuses on the current emotional state of the patients; aims to help the client understand their personal issues and develop coping strategies with limited treatment sessions.
• Emotion-focused therapy: Targets the emotional experiences and reactions of patients to elicit an emotional response with the ultimate goal to improve interpersonal and behavioral patterns.
• Interpersonal Psychotherapy: Focuses on improving interpersonal relationships and coping in order to improve the client's mental health and wellness.
• Evidence shows effectiveness of different types of psychotherapy for different types of disorders.

CBT for Eating Disorders

• Transdiagnostic approach: Addresses common characteristics across eating disorders. CBT-E uses several modules to address symptoms and external factors.
• "Starting well" involves collaborative formulation, psychoeducation about treatment, self-monitoring, and regular eating.
• Transdiagnostic formulation involves assessing over-evaluation of shape and weight, behaviours, and their impact.
• Self-monitoring, weekly weighing, and regular eating are encouraged.

Behavioural Activation for Depression

• Behavioural models of depression focus on the interaction between the environment and behaviour to promote a particular effect.
• Behavioural activation is a treatment model that aims to increase the client's engagement in positive reinforcement, activities, and goals to improve mood and reduce avoidance behaviours involved in depression.
• Dimidjian et al. (2017) demonstrated effectiveness of BA for pregnant women.
• Ekers et al. (2014) studied effectiveness compared to other treatments for moderate-severe depression.

Exposure Therapy for Anxiety Disorders

• Brief history of exposure therapy, including the work of Joseph Wolpe.
• Proposed mechanisms of change – habituation, extinction, and learning of corrective information.
• Various types of exposure therapies (e.g., graded, systematic, prolonged) and modes of delivery (e.g., in vivo, imaginal, virtual reality).