6 The Neuropsychotherapist Vol 4 Issue 1, January 2016

Why Therapy Works

Louis Cozolino

Evolution is a problem-creating as well as a problem-solving process.

Jonas Salk

I
f necessity is the mother of invention, then what necessities gave rise to the invention of
psychotherapy? The answer to this question lies in our evolutionary history and how it is
expressed in our biology, relationships, and day-to-day experiences. While evolution is a
process of adaptation, each adaptation leads to new challenges for which new adaptations
need to arise. As most of us have experienced, things that seemed like a good idea initially
can have unforeseen consequences and prove to be problematic down the road.

The human mind is made up of a tapestry of genetics, tion, survival-based selections were made, allowing our
biology, and relationships that allow us to be interwo- species to adapt to new challenges. These adaptations
ven into the superorganisms we call families, tribes, and also set the stage for new problems to arise in the fu-
cultures. Our deep evolutionary history accounts for the ture. Alas, evolution is not a strategic plan for the future
profound connections among our bodies, minds, and but an adaptation to present conditions.
the nature and quality of our relationships. It has also Here are several evolutionary artifacts that account
provided us with the ability to heal others in psycho- for much of the psychological distress that brings us and
therapy. our clients to psychotherapy. Although they are divided
Anatomically, modern humans evolved from our here for the purposes of definition, you will soon realize
primate ancestors around 100,000 years ago. It seems that these aspects of brain functioning are interdepend-
to have taken another 50,000 years for our brains and ent and mutually reinforcing. These core principles serve
cultures to evolve sufficient complexity to make us ca- as the conceptual foundation for the chapters ahead.
pable of language, planning, and creativity. But alas,
this very complexity led to new challenges. The more
recently emergent powers of logic, imagination, and Evolutionary Strategies That Result in
empathy are built upon primitive mammalian and rep- Psychological Stress
tilian networks that drive our fears, superstitions, and
prejudices. Coordinating scores of neural systems from
different stages of evolution creates such a high level of #1 The Vital Half Second
complexity that our brains are extremely vulnerable to
dysregulation, dissociation, and errors in thinking and Man is an over-complicated organism who may die out
Dazdraperma/Bigstockphoto.com

judgment. for want of simplicity.

The artifacts of human prehistory displayed in muse- Ezra Pound
ums, such as skulls, jewellery, and stone tools, pale in
comparison to those inside our heads. Through a mil- As Freud, Charcot, and many before them recog-
lion years of conservation, innovation, and mutation, nized, our brains have multiple parallel tracks for pro-
our brains have become a patchwork of old and new cessing conscious and unconscious information. The
systems, many with different languages, operating sys- first is a set of early evolving, fast systems for our senses,
tems, and processing speeds. At each point in our evolu- motor movements, and bodily processes that we share

www.neuropsychotherapist.com The Neuropsychotherapist 7

with other animals. These primitive systems, which are of behavior. Examples of this process are attachment
nonverbal and inaccessible to conscious reflection, are schema and transference, where the brain uses past
referred to as implicit memory, the unconscious, or so- relationships to shape our perceptions of the thoughts,
matic memory. These are the memories that we do not feelings, and intentions of others. Distortions embed-
consciously remember, but never forget. These fast sys- ded within this projective process can damage a life-
tems are likely all that our ancestors had until the recent time of relationships without us ever being aware that
emergence of conscious awareness. it is taking place. The fact that so much of our conscious
The later-evolving systems involved in conscious experience is based on unconscious brain processing
awareness, also called the slow systems, eventu- makes us extremely vulnerable to misperceptions and
ally gave rise to narratives, imagination, and abstract misinformation that our minds assume to be true. The
thought. This slow system, which developed as a result greater the distortions, the more difficult it is to success-
of complex social interactions and the larger brains they fully love and work. Making the unconscious conscious
require, gave rise to self-awareness and self-reflection. was Freud’s primary goal, while correcting biases in im-
The difference in processing speed between the fast plicit processing is at the heart of Cognitive-Behavioral
and slow systems is approximately one half second. This Therapy. All therapies attempt to address the process-
vital half second is one of the primary reasons that we ing biases created by the vital half second in their own
need psychotherapy. Let me explain. way.
A half second may not seem like much, but it is a long
time for the brain. While it takes 500–600 milliseconds #2 The Primacy of Early Learning
(half a second) for brain activity to register in conscious
awareness, our brains process sensory, motor, and emo- There is no present or future, only the past happening
tional information in 10–50 milliseconds. This is because over and over again, now.
conscious processing requires the participation of so Eugene O’Neill
many more neurons and neural systems. Evidence of
the activity of the fast system is with us every day. If we Not only did the fast systems evolve first, but they
touch a hot stove or are cut off while driving, our bodies also develop first during childhood. These fast sys-
react faster than conscious awareness. This is difficult to tems learn, remember, and influence how our brains
comprehend because our minds also construct the illu- and minds construct conscious experience for the rest
sion that we are in conscious control of these reflexes. of our lives. Because remembering what we learn is a
Although a half second is a long time in terms of neu- function of the later-developing slow systems, we don’t
ral communication, it is barely perceptible to conscious consciously remember what we learned as infants and
awareness. During this vital half second, our brains work young children. This is one of the reasons why early
like search engines, unconsciously scanning our memo- learning has such a powerful influence on us throughout
ries, bodies, and emotions for relevant information. In our lives. Psychotherapy is an opportunity to do some
fact, 90% of the input to the cortex comes from inter- mental time travel to find out what we learned as young
nal neural processing, not the out- side world. This half children and to learn the enduring effects that these les-
second gives our brains the opportunity to construct sons have had on us.

Not only did the fast systems evolve first, but they also develop first during
childhood. These fast systems learn, remember, and influence how our brains and
minds construct conscious experience for the rest of our lives.
our present experience based on a template from the Even before birth, primitive regions of our brains are
past that our minds view as objective reality. The result deeply affected by our biological, social, and emotional
is that we feel like we are living in the present moment experiences. In fact, much of our most important learn-
when, in reality, we live half a second behind. The pro- ing occurs during our first few years of life when our
cessing gap between the two systems also helps us to primitive brains are in control. For example, the amyg-
understand why so many of us continue in old, ineffec- dala (our executive center for fear processing) is fully
Friday/Bigstock.com

tive patterns of behavior despite repeated failures. mature by eight months of gestation. The amygdala
By the time we become consciously aware of an ex- also happens to be a central component in the develop-
perience, it has already been processed many times, ment of our attachment and social status schema, our
activated memories, and initiated complex patterns ability to regulate our emotions, and our sense of self-

8 The Neuropsychotherapist Vol 4 Issue 1, January 2016

worth. On the other hand, the cortical networks that will communications and patterns of responding to the in-
come to regulate and inhibit the amygdala will take two fant’s basic needs shape the baby’s brain and how the
decades or more to mature. baby perceives the world. In good times and with good
The fact that so much learning occurs at the begin- enough parents, this early brain building will serve the
ning of life is one of nature’s standard operating proce- child well throughout life. The bad news comes when
dures. In the womb, the child’s biology is shaped by the factors are not so favorable, such as in the case of paren-
mother’s day-to-day experiences. After birth, the brain tal psychopathology, where the brain may be sculpted
is shaped by the baby’s interactions with the mother, in ways that later become maladaptive.
other caretakers, and the physical environment. This Misattuned parents, brutal social systems, war, and
strategy allows each human brain to adapt to a very prejudice can have a tremendous impact on early brain
specific environment. Culture, language, climate, nutri- development. For most of us, these memories remain
tion, and parents, factors that may differ radically from forever inaccessible to conscious consideration or modi-
culture to culture, generation to generation, and even fication. We mature into self-awareness years later,
day to day, shape each of our brains in unique ways. This having been programmed by early experiences with
is highly adaptive because, unlike most animals, every feelings, perceptions, and beliefs that we automati-
human baby can learn to fit in to whatever physical and cally assume to be true. In the absence of an ability to
social environment he or she is born into. consciously connect our feelings and thoughts to past
Because the first few years of life are a period of experiences, our negative feelings and behaviors seem
exuberant brain development, early experience has a to arise without cause from within. We are left to make
disproportionate impact on the development of the sense of our confusion, fear, and pain with negative at-
brain’s information super-highways. Parents’ nonverbal tributions about ourselves and the world based on bi-

Because the first few years of life are a period of exuberant brain development,
early experience has a disproportionate impact on the development of the brain’s
information super-highways.

www.neuropsychotherapist.com The Neuropsychotherapist 9

ased and inadequate information. to internalize a deep sense of bonded belonging. As a
As adolescents and adults, we seek therapy because result, people with core shame feel damaged, unlov-
we find ourselves unable to form meaningful relation- able, and abandoned. Thus, core shame becomes a cen-
ships, manage our emotions, or feel worthy of love. The tral factor in the perpetuation of insecure attachment
reasons for our struggles often remain buried in net- and social status schema.
works of implicit memory, inaccessible to conscious re- During the first year of life, parent-child interac-
flection. Psychotherapy guides us in a safe exploration tions are mainly positive, affectionate, and playful. As
of our early experiences and helps us create a narrative infants grow into toddlers, their increasing motor abili-
that associates these early experiences with the ways in ties, impulsivity, and exploratory urges lead them to
which our brains and minds distort our current lives. In plunge headfirst into danger. The unconditional affec-
the process, our symptoms come to be understood as tion of the first year gives way to loud exclamations of
forms of implicit memory instead of insanity, character “No,” “Don’t,” “Stop” and a shift in the use of the child’s
pathology, or plain stupidity. This process can open the name from a term of affection to a command or warn-
door to greater compassion for oneself, openness to ing. This parent-to-child warning mechanism, seen in
others, and the possibility for healing. many animals, is designed to make children freeze in
their tracks in order to protect them from predators and
#3 Core Shame other dangers. This freeze response is reflected within
the autonomic nervous system by a rapid transition
Nothing you have done is wrong, and nothing you can do from sympathetic curiosity to parasympathetic inhibi-
can make up for it. tion. Experientially, children are snapped from a mode
Gershen Kaufman of exploration to a startled freeze. As a result, the child
stops, looks downward, hangs his head, and rounds his
The experience of shame is a central aspect of early shoulders.
social and emotional learning. Core shame needs to be This state of submissive inhibition is the same as
differentiated from appropriate shame and guilt that when a dog hunches over, pulls his tail between his legs,
emerge later in childhood. Appropriate shame is an and slinks away after being scolded. Similar postures
adaption to social behavior required by the group. Core occur in reaction to social exclusion, helplessness, and
shame, on the other hand, is an instinctual judgment submission in virtually all social animals. It is nature’s
about the self, and it results in a sense of worthlessness, way of expressing what an adult might articulate by say-
a fear of being found out, and a desperate striving for ing, “Please don’t hurt me” or “Okay, you’re the boss.”
perfection. In essence, core shame is tied to our primi- But for many children, this rapid shift from sympathetic
tive instinct to be a worthy part of the tribe; it is a failure exploration to parasympathetic withdrawal is internal-

Luna Vandoorne/Bigstock.com

10 The Neuropsychotherapist Vol 4 Issue 1, January 2016

ized as “I’m not lovable,” and “my membership in the the desirability or danger of things in our world and to
family is in question,” both of which are life threatening motivate us to move toward or away depending on its
to a child, whose survival depends upon unconditional decision.
acceptance. A parallel to these experiences may occur When the amygdala becomes aware of danger, it
in early attachment relationships when a child’s excit- sends signals to the autonomic nervous system to pre-
ed expectation of connection is met with indifference, pare to fight or flee. Half a second later, we consciously
disapproval, or anger from a parent or caretaker. This experience anything from anxiety to panic. Some things
misatunement in the attachment relationship likely trig- that trigger fear signals in the amygdala, such as snakes
gers the same rapid shift from sympathetic to parasym- and heights, appear to be hard-wired, genetic memories
pathetic dominance, and it is translated by the devel- that harken back to our tree-dwelling ancestors. Others
oping psyche as shame, rejection, and abandonment. are learned associations based on experience that are
Differences in temperament or personality between activated during the vital half second that can make us
parent and child and the resulting misattunement can avoid dogs, public speaking, or intimacy.
contribute to the development of core shame. In other It appears that evolution has shaped our brains to err
families, parents who were abandoned, neglected, or on the side of caution whenever it might be remotely
abused as children may use shaming, criticism, and sar- useful. Not such a bad idea for prey animals in the wild,

Fear inhibits executive functioning, problem-solving abilities, and emotional

regulation. In other words, fear makes us rigid, inflexible, and dumb.

casm as a predominant parenting style with their own but a really bad idea for humans. We have really big
children. This is quite common among rigid and authori- brains that create large societies filled with complex-
tarian parents, religious cults, military families, or whenity and stress. The amygdala reacts to traffic jams, the
there is mental illness or unresolved trauma in one or thought of asteroids hitting the earth, or getting a B on
both parents. an exam as threats to life and limb, a design flaw that
What began as a survival strategy to protect our provides psychotherapists with an abundance of job se-
young has become part of the biological infrastructure curity.
of later-evolving psychological processes related to at- Fear inhibits executive functioning, problem-solving
tachment, safety, and self- worth. This is why the fun- abilities, and emotional regulation. In other words, fear
damental question “Am I safe?” has become interwoven makes us rigid, inflexible, and dumb. We become afraid
with the question “Am I lovable?” With core shame, the of taking risks and learning new things, leading us to
answer is a painful “No!” As a result, people with core remain in dysfunctional patterns of behavior, to hold
shame often have difficulty taking risks, choose abusive onto failed strategies, and to remain in destructive re-
or nonsupportive partners, and cannot tolerate being lationships. The amygdala seems to use survival as vin-
alone. Although core shame may not be cured, therapy dication of its strategy, leading the agoraphobic to as-
gives clients the skills to reality test their maladaptive sume, “I haven’t set foot outside my house in 10 years,
beliefs, behaviors, and emotions. and I’m still alive, which must be because I haven’t set
foot outside my house in 10 years.” The amygdala’s job
#4 The Anxiety Bias and the Suppression of is to keep us alive, and it has the neural authority to veto
Language Under Stress happiness and well-being for the sake of survival. Psy-
chotherapy has to break into this closed logical loop by
Evolution favors an anxious gene. interrupting the cycle of dysfunctional thinking and re-
Aaron Beck inforcement.
When animals hear a loud or threatening sound, they
The prime directive of survival for every living thing, startle, freeze in their tracks, scan the environment for
from single-cell organisms to human beings, is to ap- danger, and become silent. The logic is quite clear—avoid
proach what sustains life while avoiding what puts us at detection, locate the source of danger, and respond.
risk. The better and faster a species is at discerning be- These ancient responses, along with the structures that
tween the two, the more likely it is to survive. Reptiles support them, have been con- served in humans. Dur-
evolved a structure called the amygdala that has been ing high states of arousal, the brain area responsible
conserved in later-evolving mammals, primates, and for expressive speech (Broca’s area) becomes inhibited.
humans. The primary job of the amygdala is to appraise This may explain a variety of human phenomena, from

www.neuropsychotherapist.com The Neuropsychotherapist 11

becoming tongue-tied when talking to the boss to the that our thinking is biased in self-favorable and anxiety-
speech- less terror associated with trauma. reducing ways. In fact, it has often been suggested that
While the momentary inhibition of sound production depression results from perceiving reality too accurate-
may have no negative consequences for other animals, ly—a sort of denial deficit disorder. Groupthink, halo ef-
it can be disastrous for humans. For us, shutting down fects, and humor also grease the social wheels, allowing
sound means losing the language we need in order to us to put a positive spin on the behavior of our family
connect with others and to organize our conscious ex- and friends.
periences. Language serves the integration of neural While self-deception decreases anxiety, it also in-
networks of emotion and cognition that supports emo- creases the likelihood that we will successfully deceive
tional regulation and attachment. Putting feelings into others. If we believe our self-deceptions, we are less
words and constructing narratives of our experiences likely to give away our real thoughts and intentions via
make an invaluable contribution to a coherent sense of nonverbal signs and behaviors. Reaction formation, or
self. behaviors and feelings that are opposite to our true de-
Central tenets of psychotherapy include expressing sires, are often quite effective in deceiving others. Thus,
the unexpressed, making the unconscious conscious, we are all naturally born con men, who first and fore-
and integrating thoughts and feelings. Experiences that most deceive ourselves.
occur before we develop speech or in the context of In short, distortions of conscious awareness are not
trauma remain unintegrated and isolated in dissociated character flaws, but preprogrammed by-products of our
neural networks. By stimulating Broca’s area, connect- evolutionary history based on their proven survival val-
ing words with feelings, and helping clients to construct ue. They help us to be strong, assertive, and confident in
a coherent narrative of their experiences, we help re- the face of threat. Our distortions allow us all to believe
store a sense of perspective and agency and an ability that we are above average and for two warring nations
to edit dysfunctional life stories. Language has evolved to both believe that god is on their side. The downside
to connect us to each other and to ourselves, a primary of these distortions comes when we have so much con-
reason for the success of the talking cure. fidence in our point of view that we repeat the same
dysfunctional behaviors in spite of all evidence to the
#5 Illusion contrary. The prevalence of illusions, distortions, and
misperceptions is why reality testing is so important in
We do not live to think. . . . We think in order that we may almost all forms of therapy. The most naive observer, let
succeed in surviving. alone a trained therapist, can see many things about us
José Ortega y Gasset more clearly than we can see them ourselves. Question-
ing one’s assumptions, internalizing interpretations,
Our minds are masters of illusion. Highly dedicated and learning about how the brain mismanages informa-
psychoanalysts, neuroscientists, and Zen Buddhists tion are all potential roads to positive change.
have spent their lives trying to penetrate these illusions As therapists, we attempt to provide our clients with
in order to discern the nature of reality. However, using alter- native perspectives and new information in order
an illusion generator to see beyond illusions has its limi- to disrupt a closed and self-reinforcing logical system.
tations. While much still remains a mystery, one thing is And when therapy is at its most useful, clients are able
clear—conscious experience is full of distortions. While to internalize perceptions and insights from others that
many of these distortions are designed to enhance sur- improve their ability to test the reality of their experi-
vival, they also make us vulnerable to many forms of ence beyond their habitual distortions. Psychotherapy
suffering that bring people to psychotherapy. provides us with an opportunity to make our uncon-
Defense mechanisms and all of the attribution biases scious conscious, creating a platform for the exploration
discovered by social psychology provide ample proof of our maladaptive illusions.
Melpomene/Bigstock.com

12 The Neuropsychotherapist Vol 4 Issue 1, January 2016

 Why Therapy Works plasticity in the brains of clients—to make new
connections, inhibit others, and link previously
dissociated neural net- works.
The only person who is educated is the one who has
3. 3. Together, we co-create narratives that support
learned how to learn to change.
neural and psychic integration while creating a
Carl Rogers
t e m - plate to guide experience into the future.
Through the co-construction of co-
Fortunately for us, the same evolutionary processes
herent self-stories, we are able
that gave rise to the sources of our emotional suffering
to enhance our self- reflective
also provided us with the tools to heal: our abilities to
capacity, creativity, and matu-
connect, attune, and empathize with others. Psycho-
ration. It is especially valuable
therapy is not a modern intervention, but a relation-
in coming to understand our
ship-based learning environment grounded
past, for the consolidation of iden-
in the history of
tity, and to heal from trauma.
our social
brains.
The Tools for Healing

#1 The Social Brain

Everything can be found in isolation

except sanity.
Friedrich Nietzsche

An interesting thing happened dur-

ing the evolution of our social brains.
The primitive processes of neuroplasticity
became interwoven with the more recently
evolved aspects of sociality. In other words, the
quality of attachment relationships has evolved
to regulate neuroplasticity and learning. Secure
Thus, attachment relationships support flexible, adap-
the roots tive learning and higher-order executive functioning;
of psychother- insecure attachments sup- port reactive behavior and
apy go back to mother- rigid, trauma-based learning. This is why establishing a
child bonding, attachment secure attachment within the therapeutic relationship
to family and friends, and the guidance of wise elders. serves as the matrix for positive change. So the essence
The potential success of therapy relies on three fun- of what we do as therapists is to connect with our clients
damental mechanisms of brain, mind, and relationships. in an exchange of emotions and information. Like neu-
rons, we send and receive messages from one another
1. The brain is a social organ of adaptation, shaped across a synapse—the social synapse.
by evolution to connect with and change through To establish a bridge of attunement, we rely on many
interactions with others. Psychotherapy lever- neural systems that receive and send social and emo-
ages the ability of brains to attune and learn from tional information. We use all of this information to cre-
one another in the service of adaptive change. ate theories about what is on the minds of others. We
This intimate interaction between human con- establish internal representations of what is happening
nection and learning has been forged over the within them by simulating their internal states within
eons in the crucible of social evolution. us. We rely on attachment circuitry to establish bonds
and to know how to apply the optimal balance of chal-
digitalista/Bigstock.com

2. Change depends upon the activation of neurplas-

tic processes. For any change to occur, our brains lenge and support to help our clients grow. We utilize
have to undergo structural changes that will be all of the networks of our social brains in an attempt to
reflected in our thoughts, feelings, and behav- articulate experiences that clients are presently unable
iors. Thus, the success of psychotherapy depends to articulate themselves.
upon the therapist’s ability to stimulate neuro- As discussed earlier, an important remnant of our

www.neuropsychotherapist.com The Neuropsychotherapist 13

evolutionary past, the amygdala, rests at the core of the Most generally, neuroplasticity refers to the birth,
brain. This ancient executive center has retained veto growth, development, and connectivity of neurons—
power over our modern cortical executive centers when the basic mechanisms of all learning. Existing neurons
it detects a threat. It is also like an elephant; it never for-
grow by connecting their projections (dendrites) during
gets. The only chance we have at getting over a fear is learning. Neurons inter- connect to form neural net-
to do what my grandfather suggested to me as a child: works, and neural networks, in turn, integrate with one
“Get back on the horse that threw you.” This folk wisdom another to perform increasingly complex tasks.
embodies the knowledge that fear becomes reinforced Because a brain is such a complicated government of
through avoidance and inhibited by confrontation. This systems, the possibilities of disconnections, misconnec-
is why a decrease in avoidance behavior is highly corre- tions, and failures of adaptation are almost endless. And
lated with therapeutic success. because our brains depend so much on experience to
Approaching danger and surviving inhibits the amyg- help them develop properly, a lot can go wrong. When
dala’s tendency to trigger the fight-flight response. one or more neural net- works necessary for optimal
Such situations can range from picking up a spider, to functioning remain undeveloped, unregulated, or unin-
finishing the last class to get a degree, or going out on ategrated with others, we experience the complaints and
first date. Risking new and seemingly dangerous experi- symptoms for which we seek therapy.
ments in the service of positive change requires a com- We now assume that when psychotherapy results in
bination of courage, emotional support, and the ability symptom reduction or experiential change, the brain
to imagine success. Thus, successful therapists learn to has, in some way, been altered: new connections have
be “amygdala whisperers” by leveraging the social brain been made, dysfunctional systems altered or inhib-
in order to help clients face their fears in experiments ited, or disconnected networks reintegrated. This sug-
that are developed collaboratively during sessions. gests that all psychotherapists are neuroscientists who
work to change the structure of the brain. Although the
#2 Neuroplasticity principles of plasticity have not been understood until
recently, the practices and strategies of psychotherapy
Plasticity . . . means the possession of a structure weak have been guided by their invisible hand since the be-
enough to yield to an influence, but strong enough not to ginning. Through trial and error, therapists have learned
yield all at once. what works and what doesn’t work, and we continue
William James this work individually with our clients. What works is
what optimizes plasticity and leads to positive change—
we are all experimental neuroscientists.

14 The Neuropsychotherapist Vol 4 Issue 1, January 2016

 Openness and trust are fragile creatures, even with tachments. Further, shared stories contain images and
the people we love most. The training of the therapist ideas that stimulate imagination and link individuals to
and the therapeutic context itself are designed to in- the group mind.
crease neuroplasticity in networks of the social brain to Narratives are also powerful because they allow us to
enhance support, trust, and availability. It turns out that have an objective distance on direct experience, creat-
a secure and positive therapeutic alliance generates a ing the possibility of alternate viewpoints. Through sto-
double neuroplastic punch. A positive emotional con- ries, we can escape the emotions and influences of the
nection stimulates metabolic processes that activate moment and take time to reflect on our experience. We
plasticity while inhibiting stress. can also share versions of possible selves with others to
Thus, safe and attuned connections create the pos- receive input about our experiences and perspectives.
sibility for both short-term and long-lasting modifica- Finally, we can experiment with new emotions, actions,
tion of the brain. Through the security of a safe relation- and language as we edit the scripts of our lives.
ship, something new can be introduced into a previously Although it seems that children are little scientists
closed and dysfunctional system. This is one of the ways discovering the world, we often miss that they are pri-
in which relatives, friends, and tribe members enhance marily engaged in discovering what the rest of us al-
survival and lead to the emergence of culture. This is ready know about them. As children we are told by oth-
also why relationships are the most challenging aspect ers, and we gradually begin to tell others, who we are,
of life. Although there is endless debate about the rela- what is important to us, and what we are capable of.
tive merits of different forms of therapy, they all depend This serves the continuity of culture from one genera-
on the same underlying biopsychosocial-developmental tion to the next as parents reflexively strive to re-create
mechanisms of change. themselves. This can be both good and bad depending
on the parents and the goodness of fit with their chil-
#3 Language, Storytelling, and Co-constructed dren. Stories are powerful organizing forces that serve
Narratives to perpetuate both healthy and unhealthy forms of self-
identity. There is evidence that positive self-narratives
There is no greater agony than bearing an untold story aid in emotional security while minimizing the need for
inside you. elaborate psychological defenses.
Maya Angelou The role of language and narratives in neural inte-
gration, memory formation, and self-identity make
Human beings are natural storytellers, and the roots them powerful tools in the creation and maintenance
of the talking cure harken back to gatherings around of the self. Putting feelings into words has long served
ancient campfires. Through countless generations, we a positive function for many individuals suffering from
have shared stories of the hunt, the exploits of our an- stress or trauma. Even writing about your experiences
cestors, and morality tales of good and evil. The urge supports top-down modulation of emotion and bod-
to tell stories and gossip is embedded in our psyches, ily responses. In listening to our clients, we reflexively
wired into our brains, and woven into our DNA. This is analyze their narratives for inaccurate, destructive, and
why People magazine will always outsell Scientific Amer- missing elements. We then attempt to edit their narra-
ican. For most of human history, oral communication tives in a manner we feel would better support their ad-
and verbal memory were the repository of our collec- aptation and well-being.
tive knowledge. The drive of elders to repeatedly tell
the same stories is matched only by the desire of young #4 Self-Reflective Capacity
children to hear the same stories again and again. This
lock-and-key information highway carries memories, The key to growth is the introduction of higher dimen-
ideas, and values across generations. sions of consciousness into our awareness.
Stories also serve as powerful tools for neural net- Lao Tzu
work integration. The combination of a linear story line
and visual imagery woven together with verbal and Self-reflective capacity, the ability to think about our
thoughts, feelings, and behaviors, has been found to
animaxx3d/Bigstock.com

nonverbal expressions of emotion activates circuitry

of both cerebral hemispheres, cortical and subcortical correlate with both secure attachment and successful
networks, the various regions of the frontal lobes, the psychotherapy. This same ability has been called psy-
hippocampus, and the amygdala. This integrative neu- chological mindedness by psycho-analysts and mind-
ral processing may also account, in part, for the positive fulness in the self-help world. Self-awareness is derived
correlations between coherent narratives and secure at- from and reinforced by parents and therapists through

www.neuropsychotherapist.com The Neuropsychotherapist 15

the creation of narratives that include subjective states collaboration with parts of the prefrontal cortex, appear
as objects of communication. We also come to learn to have allowed us to do three things that border on the
that we are capable of evaluating old habits and attain- miraculous. First, we are able to construct three-dimen-
ing a more objective view of the expectations of others sional models of external objects in our imaginations.
and the mandates of our childhoods. Therapy attempts Second, we can manipulate and modify these models
to leverage this metacognitive vantage point to make in our heads. Third, we can transform these objects of
new and more adaptive decisions. imagination into objects in the external world. We can
The purpose of sharing our stories with others is to apply our imagination, not only to external objects, but
gain active participation in the co-construction of new to ourselves.
narratives. Our own stories tend to become closed sys- Thus, humans are capable of imagining alternative
tems in need of new input. Therapists hope to teach selves, creating new narratives to become these selves,
their clients that not only can they edit their present sto-
and then using narratives as blueprints for changing
ry, but they can also be authors of new stories. With the their lives. Countless blueprints are created and dis-
aid of self-reflection, we help clients to become aware of carded during development as children and adolescents
narrative arcs of their life story and then help them un- try on different identities. As we progress, we naturally
derstand that alternative story lines are possible. As the outgrow old identities like a snake outgrows its skin. As
writ- ing and editing processes proceed, new narrative we grow older, we often forget that we can change our
arcs emerge along with the possibility of experimenting stories, and we may become symptomatic when an old
with more adaptive ways of thinking, feeling, and act- identity no longer fits who we’ve become.
ing. Our imaginations allow us to escape the present mo-
ment, create alternative realities, and then begin our
#5 Abstract Thought and Imagination journey to find our new narratives. The hero’s journey,
found in the literature of every culture, is a reflection of
Imagination is more important than knowledge. an ancient drive to explore new worlds, which allowed
Albert Einstein early humans to survive and spread around the globe.
As therapists, we can leverage this heroic instinct in the
As the size of primate groups expanded, grooming, service of our clients to assist them in facing their fears
grunts, and hand gestures were gradually shaped into and creating a new life story. This is the hero’s journey
spoken language. Language made far more precise, of every culture—with shamans, medicine women, wise
complex, and subtle forms of communication possible. elders, and psychotherapists serving as guides.
As social groups grew larger and language became more
complex, more cortical space was required to process a ***
greater amount of social information. This expanded to-
pography was a contributing factor in the emergence of The preceding excerpt is from Why Therapy Works:
abstract thinking and imagination. Using Our Minds to Change Our Brains, by Louis Cozo-
The human brain is characterized by the growth of lino, reprinted with permission of the publisher W. W.
an area called the inferior parietal cortex. This area, in Norton & Co.

16 The Neuropsychotherapist Vol 4 Issue 1, January 2016

 Why Therapy Works
Using Our Minds to Change Our Brains
Louis Cozolino
The story of why psychotherapy actually works. That psychotherapy works is
a basic assumption of anyone who sees a therapist. But why does it work? And
why does it matter that we understand how it works?
In Why Therapy Works, Louis Cozolino explains the mechanisms of psy-
chotherapeutic change from the bottom up, beginning with the brain, and
how brains have evolved—especially how brains evolved to learn, unlearn, and
relearn, which is at the basis of lasting psychological change.
Readers will learn why therapists have to look beyond just words, diagnoses,
and presenting problems to the inner histories of their clients in order to discov-
er paths to positive change. The book also shows how our brains have evolved
into social organs and how our interpersonal lives are a source of both pain and
power. Readers will explore with Cozolino how our brains are programmed to
connect in intimate relationships and come to understand the debilitating ef-
fects of anxiety, stress, and trauma.
Finally, the book will lead to an understanding of the power of story and nar-
ratives for fostering self-regulation, neural integration, and positive change.
Always, the focus of the book is in understanding underlying therapeutic
change, moving beyond the particular of specific forms of therapy to the com-
monalities of human evolution, biology, and experience.
This book is for anyone who has experienced the benefits of therapy and wondered how it worked. It is for anyone
thinking about whether therapy is right for them, and it is for anyone who has looked within themselves and mar-
veled at people’s ability to experience profound transformation.

“Why Therapy Works is a tour de force. Too often today the public thinks that one can read a book or watch a
documentary and be transformed psychologically. Unfortunately, that is not how the human mind works. Humans
require other minds for change and change is hard. We are ‘embodied and embedded’ in an interpersonal matrix.
To understand the human experience and create change, we must move from a single-skull understanding to an
intersubjective context of two or more minds. Louis Cozolino explains this phenomenon in a manner easy to digest,
taking the reader from the evolutionary heritage of human psychology to an understanding of the experience of
psychotherapy applied in common clinical circumstances.” — Drew Pinsky, MD, Internist/Addictionologist and Host
of Dr. Drew on HLN

“There are so many important concepts and ideas, that I found myself underlining and highlighting sections. I
was intrigued with Cozolino’s concept that we can change our brain. And, his explanations about attachment and
healing are excellent. . . . [H]e offers his own experiences to illuminate his ideas. This makes him human, believable,
and likeable. . . . I look forward to rereading this book. It will be useful to review reference-specific issues. I recom-
mend it to both colleagues and students.” — The Milton H. Erickson Foundation Newsletter

“[A]n authoritative guide. . . . Anyone interested in therapy and the brain will find much compelling information
here . . . . [A]n intriguing look at how anxiety, stress, and trauma affect the brain and . . . how psychologists can help
their patients ‘connect and heal.’” — Booklist

Published by W. W. Norton & Co. November 2015 -Hardcover; ISBN 978-0-393-70905-6; 5.8 × 8.6 in / 288 pages

www.neuropsychotherapist.com The Neuropsychotherapist 17