Psychotherapy and brain plasticity

Abstract

In this paper, I will review why psychotherapy is relevant to the question of how consciousness relates to brain plasticity. A great deal of the research and theorizing on consciousness and the brain, including my own on hallucinations for example (Collerton and Perry, 2011) has focused upon specific changes in conscious content which can be related to temporal changes in restricted brain systems. I will argue that psychotherapy, in contrast, allows only a focus on holistic aspects of consciousness; an emphasis which may usefully complement what can be learnt from more specific methodologies.

Full text

MINI REVIEW ARTICLE
published: 06 September 2013
doi: 10.3389/fpsyg.2013.00548
Psychotherapy and brain plasticity
Daniel Collerton1,2*
1Clinical Psychology, Northumberland, Tyne and Wear NHS Foundation Trust, Gateshead, UK
2Newcastle upon Tyne, Newcastle University, UK
Edited by:
Elaine K. Perry, Newcastle
University, UK
Reviewed by:
Ursula Voss, Rheinische
Friedrich-Wilhelms University Bonn,
Germany
Elaine K. Perry, Newcastle
University, UK
*Correspondence:
Daniel Collerton, Clinical Psychology,
Northumberland, Tyne and Wear
NHS Foundation Trust, Bensham
Hospital, Saltwell Road, Gateshead,
NE8 4YL, UK
e-mail: daniel.collerton@ncl.ac.uk
In this paper, I will review why psychotherapy is relevant to the question of how
consciousness relates to brain plasticity. A great deal of the research and theorizing on
consciousness and the brain, including my own on hallucinations for example (Collerton
and Perry, 2011) has focused upon specific changes in conscious content which can be
related to temporal changes in restricted brain systems. I will argue that psychotherapy,
in contrast, allows only a focus on holistic aspects of consciousness; an emphasis which
may usefully complement what can be learnt from more specific methodologies.
Keywords: plasticity, psychotherapy, functional magnetic resonance imaging, multivoxel pattern analysis,
emotion, consciousness
INTRODUCTION
For the last century or so, psychotherapy has aimed to change
the mind. And if it has been effective in doing so, it must have
lead to lasting changes in conscious content, and potentially in
the process of consciousness itself. Few other human endeavors
seek so systematically to produce predictable enduring variation
in emotion, cognition, behavior and somatic perceptions; changes
which can persist for many years beyond the end of therapy. Over
the last few decades, as methods have become available for mea-
suring brain structure and function, it has provided a potential
real-life method by which meaningful changes in consciousness
can be related to measures of brain function. Admittedly, thus
far interest has been on understanding what brain function can
tell us about how psychotherapy works (for example, Joki´
c-Begi´
c,
2010) rather than the aim of this paper—what psychotherapy can
tell us about how the brain and mind are linked. However, in
theory, it should be possible to assess consciousness, or at least
some aspects of it, before and after psychotherapy, and to relate
these to brain changes. And indeed, as described later, such stud-
ies have been done. The evidence is still sporadic and somewhat
contradictory, but there is more potential now than ever before
to correlate psychotherapy-related changes in mind to changes in
brain.
In this paper, I will survey the current situation, outlining the
formidable conceptual and practical difficulties which still need to
be overcome, and suggest a potential strength of psychotherapy
as a tool for understanding consciousness which, in combina-
tion with advances in functional imaging analysis, may give a way
forwards.
CHALLENGES OF DEFINITION AND MEASUREMENT
There are a number of intractable definitional and measurement
issues in this field which have been only partially solved.
Consciousness itself is a fuzzy concept—and its components
are no clearer, as illustrated by the continuing discussions on
whether it even exists as a meaningful phenomenon. James explic-
itly posed the question in the first, 1904, volume of the Journal of
Philosophy, Psychology, and Scientific Methods and over a cen-
tury later the answer is still not clear. As exemplified by Newell
and Shanks (in press), the nature and role of consciousness and
its relationship to behavior are still under discussion.
The term psychotherapy equally lacks definition. It has been
applied to an exceptionally wide range of approaches with dif-
fering models, techniques, goals, and outcomes. Feltham and
Horton’s (2012) Handbook, for example, surveys some 23 major
approaches from Dialectical Behavior Therapy to Psychodrama.
Finally, though methods of investigating in vivo brain function
are incomparably better than even a decade ago, they are still lim-
ited in cognitive, temporal, and spatial resolution, while the large
and intrusive technology involved limits applications to settings
which bear little relationship to everyday life.
In the face of fuzzy concepts and methods, there is a scientific
temptation to retreat into investigating relatively specific, easily
measureable, aspects of consciousness and the brain. However,
looked at in another way, this very lack of focus may be a strength
rather than a weakness in that it forces attention to holistic
changes in consciousness which can then be related to systemic
changes in neural networks.
THE EFFECTS OF PSYCHOTHERAPY
Within the vast variety of psychotherapies, Cognitive Behavioral
Therapy (CBT) has become the most widely accepted approach,
and has amassed a strong body of evidence of effectiveness (Butler
et al., 2006). It leads to long lasting, reproducible changes in emo-
tion, cognition, behavior, and somatic symptoms across a range
of mood and other psychological disorders. This strongly sug-
gests that CBT is a powerful means of changing consciousness.
CBT has always had a marked emphasis on measurement and it
is also the therapy whose effects have most often been related to
brain changes. For these reasons, I will take it as the exemplar
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Collerton Brain plasticity and psychotherapy
psychotherapy for the purpose of this paper, while acknowledging
that other approaches may be equally valid.
If we want to relate the effects of psychotherapy on conscious-
ness to brain changes, it would seem necessary to know the
changes it produces and how it does so. Consciousness itself is
not directly accessible of course, so, as summarized in Tab l e 1 ,
researchers have taken a number of routes to inferring what is
in the consciousness of a patient. Self-report, observer report,
behavioral measures, and experimental tasks can be used to more
or less directly infer changes in the content of patient’s con-
scious thought. Taken together, these methodologies have pro-
duced good evidence that the complex combinations of emotions,
cognitions, behaviors and somatic symptoms which characterize
mood disorders do shift as a result of CBT.
WHAT CHANGES AS A CONSEQUENCE OF
PSYCHOTHERAPY?
However, evidence is lacking as to what specifically changes as a
consequence of psychotherapy (see, for example, Murphy et al.,
2009). Despite the range of different ways of measuring the effects
of psychotherapy noted above, it is striking how closely these are
related. Thus, change in one symptom area, for example cogni-
tion, is accompanied by changes in other symptom areas such as
emotion or behavior; at least as averaged over the timescales and
group numbers common in treatment trials.
Similarly, though there is evidence that different modalities of
therapy may have different levels of effectiveness (see Tolin, 2010
for a meta-analytic comparison of CBT with other therapies),
where this does occur this appears to be more a quantitative than
a qualitative difference. The outcomes of psychodynamic, person-
centred, and behavioral psychotherapy are broadly equivalent
despite their varieties of approaches and targets for therapeu-
tic change (Stiles et al., 2008; Budd and Hughes, 2009)perhaps
because they work via common final paths (Mansell, 2011).
Even treatments as different as CBT and pharmacotherapy
appear to have broadly similar outcomes in, for example, depres-
sion (DeRubeis et al., 2008)withnoreliableevidenceofthe
differential effects of CBT on negative cognitions or medication
on somatic symptoms as might have been expected from their
mechanisms of action. Attempts to predict which patients might
benefit from any specific intervention have not been successful.
Taking all of these comparisons together, there is very lit-
tle evidence that specific areas of consciousness can change in a
meaningful way without these effects rippling through the rest of
consciousness. This suggests that trying to fractionate the effects
of psychotherapy on consciousness into components might not
be possible. It is the totality of consciousness which changes as a
result of CBT rather than one specific aspect of it.
IMPLICATIONS FOR LINKING THE EFFECTS OF
PSYCHOTHERAPY TO BRAIN PLASTICITY
This has implications for relating the effects of CBT to brain
plasticity. Traditionally, neuroscience has adopted a reductionist
approach to the brain; relating specific psychological functions
to specific brain areas. This has been enormously successful with
many psychological functions. Amongst many other pairings,
neuropsychological localization has linked learning to the hip-
pocampus and other structures in the medial temporal lobe,
object perception to the ventral visual stream, and language to
the left temporal cortex. However, the localization paradigm has
left in its wake the binding problem—how the functions of dis-
parate brain areas are tied together to produce the usual subjective
sense of a single coherent consciousness. In this context, perhaps
the holistic effects of CBT and other psychotherapies on con-
sciousness become a means of side stepping the binding problem.
If significant changes in bound consciousness can be related to
restricted changes in brain function, that might narrow down the
candidate brain areas which may underlie consciousness.
EFFECTS OF CBT ON MEASURES OF BRAIN FUNCTION
The plasticity in human brain which underlies individual,
idiosyncratic and instantaneous elements of consciousness—
specific words, thoughts, images, feelings, and memories—comes
from tiny, subtle, and dynamic changes which are embedded
within and across networks of microscopic cells. In comparison,
our ways of measuring plasticity in the human brain have to trade
off cognitive (the ability of scans to resolve precise psychological
states, particular memories for instance), spatial, and tempo-
ral resolutions with even the best resolution vastly greater than
the fundamental mechanisms of plasticity. The spatial resolution
limit of a Magnetic Resonance Imaging (MRI) scan, our best cur-
rent means of directly assessing brain structure and function,
contains somewhere around 9 million brain cells (deCharms,
2008).
However, this has not prevented functional imaging, partic-
ularly functional MRI (fMRI) to identify which areas of the
brain change following psychotherapy. (There have been a rather
small number of structural imaging studies of the effects of psy-
chotherapy, mainly in eating disorders, but many of these have
been confounded by the effects of weight gain and loss on brain
structure (Lobera, 2011) making it difficult to interpret their
results).
The dominant paradigm has been to compare levels of brain
activity pre and post CBT to see what changes. This approach
has mainly been used in depression and has identified that
changes are localized to specific frontal, cingulate, and limbic
areas. There is decreased activity in the limbic system, especially
Table 1 | Indicators of consciousness used in CBT outcome studies.
Type of measure Example measures Illustrative study
Self-report Structured questionnaires e.g., Beck Depression Inventory (Beck et al., 1988)Elkin et al., 1995
Observer report Structured observer ratings e.g., Hamilton Depression Rating Scale (Bagby et al., 2004)Teasdale et al., 2000
Behavioral measures Observable behavioral change e.g., return to employment Della-Posta and Drummond, 2006
Experimental tasks Measures of perceptual distortion e.g., body morphing (Benson et al., 1999)Cornelissen et al., 2013
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Collerton Brain plasticity and psychotherapy
the amygdala, with dorsolateral prefrontal cortex becoming rela-
tively more active and orbitomedial and cingulate cortex less so; a
move toward normality from patterns observed before treatment
(Ochsner et al., 2002; Goldapple et al., 2004; Malhi et al., 2004;
Ritchey et al., 2011; Höflich et al., 2012) and consistent with what
is know of the processing of emotional stimuli (Simpson et al.,
2000; Northoff et al., 2004; Leppänen, 2006; Beck, 2008). Pre-
treatment levels of cingulate activity can even predict response
to CBT with some reliability (Konarski et al., 2009; Ritchey et al.,
2011; Siegle et al., 2012).
There have not been comparisons between the effects of differ-
ent types of psychotherapy on the brain (potentially interesting
in view of their equivalent effects on consciousness), but there
are conflicting reports of the effects of pharmacotherapy; similar
changes in brain activity to those following psychotherapy were
not seen after antidepressant treatment by Goldapple et al. (2004)
though they were identified by Furmark et al. (2002); opening up,
but not confirming, the possibility that different brain changes
might have similar effects on consciousness.
Taken as a whole, this evidence would suggest that the holistic
changes in consciousness seen after psychotherapy for depression
are associated with changes in a relatively restricted number of
brain areas; mainly frontal, cingulate, and limbic cortex, with the
implication that plasticity in those areas is particularly associated
with persistent variations in consciousness.
However, a one to one correspondence between change in
depression and change in specific brain areas may be over stated
(Linden, 2006; Frewen et al., 2008; Dichter et al., 2012). For
example, very similar changes in those brain areas are seen after
CBT and other psychological treatments for anxiety (Furmark
et al., 2002; Paquette et al., 2003; Straube et al., 2006; Porto
et al., 2009; Freyer et al., 2011), schizophrenia (Wykes et al.,
2002), eating disorders (Vocks et al., 2011) and Irritable Bowel
Syndrome (Lackner et al., 2006). This is consistent with a con-
sciousness network which depends upon these brain areas (and
no doubt others) but it also suggests that there is a large over-
lap in the brain changes associated with different holistic states
of consciousness. At present, fMRI data would suggest that, sim-
ply put, CBT is associated with a decrease in emotionality (less
limbic activity) and an increase in thoughtfulness (increased dor-
solateral frontal activity), as would be expected from its aims
and methods (Clark and Beck, 2010). Though we may be able to
link consciousness to a subset of anatomical structures using psy-
chotherapy as an investigative tool, we appear to lack specificity in
our account of how different states of consciousness could arise. Is
it that in using psychotherapy to localize holistic changes in con-
sciousness to a restricted set of brain structures, we have lost the
ability to account for why consciousness is so idiosyncratic and so
changeable?
APOTENTIAL WAY FORWARD
An analogous challenge has arisen in fMRI studies of visual per-
ception. Early attempts to localize specific perceptions to specific
brain areas worked only for grossly different stimuli—visualizing
navigating a house compared to imagining playing tennis (Owen
et al., 2006)—or for simple stimuli in early, highly specialized,
visual areas (Kay et al., 2008). More latterly, however, multivoxel
pattern analysis (MVPA), in which patterns of activity across wide
areas of the brain are analyzed, has produced a significant increase
in cognitive resolution. Fairly similar stimuli, for example chairs
and shoes (Norman et al., 2006; deCharms, 2008; Poldrack, 2011),
or over-riding categories of images such as living or non-living
(Naselaris et al., 2012) can now be recognized from pattern infor-
mation fMRI (Formisano and Kriegeskorte, 2012) data. Not only
perceptions, but also images and memories (Chadwick et al.,
2012; Rissman and Wagner, 2012) are starting to be distinguished.
Beginnings are starting to be made in reproducing data across
as well as within subjects (Accamma and Suma, 2012; Raizada
and Connolly, 2012). Significantly, cognitive resolution appears
to increase as the focus of the analysis is widened to include more
brain areas.
MVPA might therefore lead to the ability to map holis-
tic changes in consciousness to patterns within and across the
regions that classic fMRI has identified as responsive to psy-
chotherapy (Siegle et al., 2007). Thus it may provide the mech-
anism to bridge holistic and specific variations in consciousness
and brain.
CONCLUSIONS
It is clear that CBT, and probably other psychotherapies, alters
consciousness in personally important, lasting, and measurable
ways. Brain function and brain structure are different after CBT.
Looking at functional changes in the brain suggests that con-
sciousness changes in response to plasticity in the linked systems
of the frontal, cingulate, and limbic cortices. However, we do not
know how modulations in those areas link to different states of
consciousness. Using the most recent imaging analysis to map
activity simultaneously across these regions might give the miss-
ing specificity; allowing whole brain changes to be mapped to
holistic changes in consciousness.
In order to do this, our next challenge will be to develop ways
of capturing the experience of consciousness as a whole rather
than, as we have tried to do in the past, the individual thoughts,
images, and emotions which are bound together to produce it.
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Conflict of Interest Statement: The
author declares that the research
was conducted in the absence of any
commercial or financial relationships
that could be construed as a potential
conflict of interest.
Received: 31 January 2013; accepted:
02 August 2013; published online: 06
September 2013.
Citation: Collerton D (2013)
Psychotherapy and brain plasticity.
Front. Psychol. 4:548. doi: 10.3389/fpsyg.
2013.00548
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