An interpersonal neurobiology approach to psychotherapy

Tags: integration, psychotherapy, neural plasticity, neural basis, domains, New York, NY, Daniel J. Siegel, experience, WW Norton, Guilford Press, interdisciplinary view, social behavior, Siegel DJ, mirror neuron, receptive mind, regions, affective states, Developing Social Brain, Siegel DJ., emotional states, social gatherings, interpersonal experiences, Temporal integration, Development, motor system, Cambridge University Press, PSYCHIATRIC ANNALS, neural integration, internal representations, brainstem, region, middle prefrontal, insular cortex, affective state, Vertical Integration, somatic reality, Interpersonal Neurobiology, mirror neurons, prefrontal cortex, interpersonal relationships, human development, human experience, connections
Content: CME
An Interpersonal Neurobiology Approach to Psychotherapy
Awareness, mirror neurons, and neural plasticity in the development of well-being
Interpersonal neurobiology is a "consilient" approach1 that examines the independent fields of knowing to find the common principles that emerge to paint a picture of the "larger whole" of human experience and development.2 Interpersonal neurobiology attempts to extract the wisdom from more than a dozen different disciplines of science to weave a picture of human experience and the process of change across the lifespan. This article, summarizes the principles of interpersonal neurobiology, with an emphasis on neuroscience findings regarding the mirror neuron system and neural plasticity. The perspective of interpersonal neurobiology is to build a model within which the objective domains of science and the subjective domains of human knowing can find a common home.3 An interpersonal neurobiology approach to psychotherapy draws on the basic framework of this interdisciplinary view in exploring the ways in which one individual can help others alleviate suffering
and move toward well-being. The central idea of interpersonal neurobiology is to offer definitions of the mind and of mental well-being that can be used by a wide range of professionals concerned with Human Development. THE MIND The mind can be defined as a process that regulates the flow of energy and information. Regulation is at the heart of mental life, and helping others with this regulatory balance is central to understanding how the mind can change. The brain has self-regulatory circuits that may enhance directly how the mind regulates the flow of its two elements, energy and information. Mind Emergence The mind emerges in the transaction of at least neurobiological and interpersonal processes. Energy and information can flow within one brain, or between brains. Naturally, other features of our world, nature, and technological envi-
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ronment can affect how the mind emerges. Within psychotherapy, we can see that relationships with another person profoundly shape the flow of energy and information both between two people and within each person. Mind Development The mind develops across the life- span as the genetically programmed maturation of the nervous system is shaped by ongoing experience. We now know
that about one-third of our genome directly shapes the connections within our brains.4 Alhough genes are extremely important in development, experience shapes our neural connections as well. When neurons become active, they have the potential to stimulate the growth of new connections among each other. With 100 billion neurons and an average of 10,000 synaptic connections linking one neuron to others, we have trillions of connections within our brains.
These synaptic linkages are created by both genes and experience. Nature needs nurture. Experience shapes new connections among neurons by the way genes are activated, proteins produced, and interconnections established within our weblike neural system. Mental Well-Being An interpersonal neurobiology view of well-being holds that the complex, nonlinear system of the mind achieves states of self-organization by balancing the two opposing processes of differentiation and linkage. When separated areas of the brain are allowed to specialize in their function and then become linked together, the system is integrated. Integration brings with it a special state of functioning of the whole, which has the acronym of FACES: Flexible, Adaptive, Coherent, Energized, and Stable. This coherent flow5 is bounded on one side by chaos and on the other by rigidity.6 In this manner we can envision a flow or river of well-being, with the two banks being chaos on the one side, rigidity on the other. One way of viewing the symptoms of the Diagnostic and Statistical Manual of mental disorders, fourth edition, text revision7 for psychiatric diagnoses is as manifestations of rigidity or of chaos. This flow of well-being can be seen to reveal the correlations among an empathic relationship, a coherent mind, and an integrated brain as three points on a triangle depicting well-being (Figure, see page 250).
PROMOTING WELL-BEING What does an interpersonal neuro- biology approach to psychotherapy offer as a framework for considering how therapy works and how to work in therapy? Therapeutic experiences that move a person toward well-being promote integration. Deviations from this integrated flow are revealed as rigidity, chaos, or both and result in symptomatic conditions that may be experienced as inflex-
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ible, maladaptive, incoherent, deflated, and unstable. To achieve the goal of promoting integration, it has been helpful to delineate at least nine domains of integration that can remain in the therapist's mind within the process of psychotherapy. After briefly outlining these domains, this article will focus specifically on the nature of interpersonal integration, highlighting recent contributions from the studies of the mirror neuron system and neural plasticity. A fuller description of the clinical implications of these domains within psychotherapy can be found in other publications.8 DOMAINS OF INTEGRATION Integration of Consciousness The mind flows as energy and information are channeled through the process of attention. The nomenclature of science refers to the presence of three general mechanisms of attention: exogenous, endogenous, and executive.9 Exogenous C M E EDUCATIONAL OBJECTIVES 1. Describe an interdisciplinary view of the mind and Mental Health. 2. Identify nine forms of integration and how they pertain to the cultivation of well-being within psychotherapy. 3. Discuss the interplay of mind, brain, and interpersonal relationships in the development of mental well-being. Dr. Siegel is a clinical professor of of psychiatry at the UCLA School of Medicine where he is also on the faculty of the Center for Culture, Brain, and Development and the Co-Director of the Mindful Awareness Research Center at UCLA. Address reprint requests to: Daniel J. Siegel, M.D., Mindsight Institute, 11980 San Vicente Blvd., Ste. 809, Los Angeles, CA 90049; or e-mail [email protected] Dr. Siegel disclosed no relevant financial relationships.
Empathic Relationships
Coherent Mind
Integrated Brain
Figure. An illustration of the dimensions of well-being.
attention is a form of attentional focus driven by the immediacy of an often external stimulus, such as a loud sound. A more sustained, self-generated form is called endogenous attention, in which the individual chooses to focus attention on a particular stimulus. With executive attention, one can create a flexible response not governed by the external world or by a singular focus of attention. The integration of consciousness involves the development of executive forms of attention that are associated with the larger capacities for self-regulation, such as the balancing of emotion, improved stress response, and enhanced social skills. Self-awareness has its roots within the central regulatory systems of the brain and thus may play an important role in various forms of psychotherapy and psychiatric disorders.10 In many ways, how we have developed the capacity to have a receptive, flexible form of awareness enables us to have freedom to focus our attention in ways that are most helpful to us and to those around us. Enhancing this receptive awareness in the present moment is sometimes called "mindful awareness." Mindfulness is defined as paying attention, in the present moment, on purpose, without grasping onto judgments. Mindful awareness has the quality of receptivity to whatever
arises within the mind's eye, moment to moment. Recent studies of mindful awareness practices reveal that it can result in profound improvements in a range of physiological, mental, and interpersonal domains. Cardiac, endocrine, and immune functions are improved with mindful practices.11 Empathy, compassion, and interpersonal sensitivity seem to be improved. People who develop this capacity also develop a deeper sense of well-being and what can be considered a form of mental coherence. Within psychotherapy, the focus of attention on various domains of mental, somatic, and interpersonal life can create neural firing patterns in the brain that enable new synaptic connections to be established. Neural plasticity, the change in neural connectivity induced by experience, may be the fundamental way in which psychotherapy alters the brain. Based on the modification and growth of synapses and the potential differentiation of neural stem cells into fully integrated neurons, neural plasticity reveals how the brain's interconnectedness can change throughout the lifespan. Consciousness may play a direct role in harnessing neural plasticity by altering previously automatic modes of neural firing and enabling new patterns of neural activation to occur.
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The basic steps linking consciousness with neural plasticity are as follows: where attention goes, neural firing occurs. Where neurons fire, new connections can be made. In this manner, learning a new way to pay attention within the integration of consciousness enables an open, receptive mind within therapy to catalyze the integration of new combinations of previously isolated segments of our mental reality.12 Vertical Integration Taking the perspective of the vertical plane of our somatic architecture, we can envision the anatomically and functionally differentiated elements of our bodies to extend from our head to our toes. Vertical integration directly links these elements within awareness so new connections can be established. We know that the mind is embodied, built in part from its roots in somatic reality but often living in the purely nonphysical world we can isolate as "mental." Linking the basic somatic regulatory functions of the brainstem with the limbic circuits' generation of affective states, motivational drives, attachment, and appraisal of meaning and laying down of memory is a first layer of vertical integration. Above the limbic circuitry emerged the neocortex or "outer bark" of our evolving brains. The cortex, unlike the brainstem, is quite underdeveloped at birth and is shaped by genetics and, especially, by experience. In general, the posterior regions of the cortex are specialized for perception of the physical world (our first five senses), and the body itself is registered in the more forward aspects of this posterior region. In the frontal lobe of the cortex are the motor and pre-motor planning areas that enable us to carry out behaviors. The forwardmost part of this frontal lobe is the prefrontal cortex. The side part of this area, known as the dorsolateral prefrontal region, is considered an essential circuit for working memory that enables
Therapeutic experiences that move a person toward well-being promote integration. Deviations from this integrated flow are revealed as rigidity, chaos, or both and result in symptomatic conditions that may be experienced as inflexible, maladaptive, incoherent, deflated, and unstable. us to pay attention to something in the here-and-now. Toward the middle of the prefrontal cortex, just behind the forehead area, are several regions that sometimes are thought to be the "higher part" of the limbic circuitry and a core aspect of the social circuits of the brain: the orbital frontal area behind the eyes, the medial prefrontal cortex behind the forehead, and the anterior cingulate just behind the medial prefrontal cortex. These more midline structures, along with a region called the insular cortex, serve important functions in linking body, affective state, and thought. For the purpose of this discussion, we will refer to these midline structures as the "middle prefrontal cortex," as they generally work as a team. A review of the anatomy of the mid-
dle prefrontal cortex reveals that it has a major integrative function: linking body-proper, brainstem, limbic circuits, and cortex. In this manner, these middle prefrontal circuits may carry out what we are labeling as vertical integration. What does vertical integration really mean? This idea means that fibers physically connect the input of somatic and vertically distributed neural structures with one another. A wide array of independent studies in basic brain research reveals that these middle prefrontal areas are crucial for generating nine processes (Sidebar 1, see page 252). By focusing awareness on the input from the body, our affective states, and our range of thoughts and ideas, the therapist can encourage the first steps toward vertical integration. With a receptive mind, it may be that this vertical integration occurs naturally. For many of those coming to therapy, however, having the intention to pay attention to the body's signals is a purposeful act that can transform a disconnected way of living into a richer, more integrated way of living. It is relevant to note that some of these middle prefrontal functions can be seen to emerge not only with mindful awareness practices but also, for the first seven, with the outcome of secure attachment between child and caregiver.13 This finding may suggest that experiences of "mental attunement" -- interpersonal in the case of attachment or internal in the practice of mindful awareness -- may be at the heart of developing an integrated brain and well-being. Healthy self-regulation, through relationships and self-reflective observation, may depend on the development of the Integrated Circuits of these prefrontal regions.12,14 Mental attunement may depend on a quality of openness to living in the moment that may be essential for the therapist's own stance and serve as a strategic goal for the process of therapy itself.15,16 Of note from the neuroscience literature are preliminary studies that suggest mind-
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SIDEBAR 1. Nine Middle Prefrontal Processes 1. Body regulation: Balance of the sympathetic (accelerator) and parasympathetic (brake) branches of the autonomic nervous system. 2. Attuned communication: Enables us to tune into others' states and link minds. 3. Emotional balance: Permits the lower limbic regions to become aroused enough so life has meaning, but not too aroused that we become flooded. 4. Response flexibility: The opposite of a "knee-jerk" reaction, this capacity enables us to pause before acting and inhibit impulses, giving us enough time to reflect on our various options for response. 5. Empathy: Considering the mental perspective of another person. 6. Insight: Self-knowing awareness, the gateway to our autobiographical narratives and self-understanding. 7. Fear extinction: GABA (an inhibitory neurotransmitter) fibers project down to the amygdala and enable fearful responses to be calmed. 8. Intuition: Being aware of the input of our body, especially information from the neural networks surrounding intestines (a "gut feeling") and our heart ("heartfelt feelings") enables us to be open to the wisdom of our non-conceptual selves. 9. Morality. The capacity to think of the larger good, and to act on these pro-social ideas, even when alone, appears to depend on an intact middle prefrontal region.
ful meditation practice, as one example of a receptive mental state, may lead to enhanced growth of the middle prefrontal regions, as well as preserved neural tissue in these regions with aging.17 Bilateral Integration The nervous system of vertebrates is asymmetric, with left being different from right, in animals from zebra fish to lizards, toads, chickens, pigeons, apes, and humans.18 With more complexity comes more adaptability. Cortical function and structure are driven by the lower asymmetries of the limbic and brainstem areas, and various forms of research have revealed that the right and left cortex perceive and create reality in quite distinct ways. These differences illustrate the importance of bilateral integration. The right hemisphere develops first after birth, its activity and synaptogenesis more robust during the first 2 to 3 years of life.19 After that period, there are a series of cyclical waves of left, then right, then left dominance in growth and
activity.20 In general, the right and left sides of the brain have distinct differentces that have been supported by a range of scientific and clinical investigations. These differences are outlined in Sidebar 2 (see page 253). One proposed manifestation of impaired left­right integration is that the drive of the left hemisphere to tell stories, to explain in a linear fashion using words, would be compromised if the story were about the self. Given the repeated finding of autobiographical memory being primarily mediated within the right hemisphere, what would a life-story be like if the narrating left hemisphere could not easily access the nonverbal autobiographical details of the right side of the brain? Before we turn to such narrative incoherence, we will first look at the integration of memory. Integration of Memory Memory can be defined as the way in which a past experience alters the probability of how the mind functions in the
future. Memory shapes how we experience the present and how we anticipate the future, readying us in the present moment for what comes next based on what we experienced in the past. This broad view enables us to examine the findings of two aspects of memory and explore how their integration can promote well-being. Segregation of these memory functions, in contrast, may be seen as one aspect of the source of mental suffering. Experience creates the activation or "firing" of neurons. This neuronal activation can, in turn, lead to alterations in the connections among neurons, the basis of neural plasticity. Throughout our lives, we embed experience into memory via a first layer of processing called "implicit" or "nondeclarative" memory. Before age 18 months, this early implicit layer of memory is the only form available to the growing infant.21 Even beyond that early age, we continue to create implicit memories, but they are then often selectively integrated into the next layer of processing, called "explicit" or "declarative" forms of memory. Implicit memory involves the perceptual, emotional, and behavioral neural responses activated during an experience. It is likely that our bodily sensations are also a form of implicit memory, but these have not been studied formally. Mental models, or generalizations of repeated experiences called "schema," are also a form of implicit memory. The brain readies itself to respond in a fashion called "priming," in which past experiences shape the way we prepare for the future. Implicit memory encoding does not require focal, conscious attention. A second crucial feature of implicit memory is that when we do retrieve an element of implicit memory into awareness, we do not have the internal sensation that something is being accessed from a memory of the past. We just have the perceptual, emotional, somatosensory, or behavioral response, without knowing that these are
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activations related to something we experienced before. The second layering of memory is called explicit and involves two forms: factual, or semantic, memory; and episodic, the memory of oneself in an episode in the past. Episodic memory has a sense of the self and of time. Both semantic and episodic memory appear to require focal attention for their encoding, and when they are retrieved from storage into present awareness, they do have the internal sensation that something is being activated from the past. The hippocampus may serve an important role in memory integration, as it functions as an "implicit memory puzzle piece assembler" that clusters the basic Building Blocks of the various elements of implicit memory together into framed pictures of semantic and episodic memory. These framed pictures of explicit memory can then be further integrated into autobiographical memory, a function that may involve rapid eye movement sleep as our dreams integrate our past experiences, our daytime events, and the emotional themes of our lives. One proposal about trauma's effects on memory is that it may transiently block the integrative function of the hippocampus in memory integration.22 With massive stress hormone secretion or amygdala discharge in response to an overwhelming event, the hippocampus may be shut down temporarily.23 In addition to this direct effect of trauma of hippocampal function, some people may attempt to adapt to trauma by dividing their conscious attention, placing it only on nontraumatic elements of the environment at that time. The resultant neural configuration of blocked hippocampal processing, when reactivated, can present itself as free-floating, unassembled elements of perception, bodily sensation, emotion, and behavioral response, without the internal sense that something is coming from the past. Beliefs and altered states of mind also
SIDEBAR 2. Right Versus Left Hemisphere Modes of Processing Right A. The right side is holistic, perceiving things in the whole of their essence. B.The right side works well with the visuospatial, proficient at seeing a picture but not decoding the meaning of these words. C. The right side both sends and perceives nonverbal components from others, including eye contact, facial expression, tone of voice, posture, gestures, and timing and intensity of response. D. The right mode has no problem with ambiguity and is sometimes called "analogic," meaning it perceives a wide spectrum of meaning, not just a digital restricted definition of something. It undertakes a wide range of functions, including the stress response, an integrated map of the whole body, raw spontaneous emotion, autobiographical memory, and dominance for the nonverbal aspects of empathy. Left A. Linear: the left loves this sentence, one word following the next. B. Logical: specifically syllogistic reasoning in which the left looks for cause­ef- fect relationships in the world. C. Linguistic: these words are the left's love. D. Literal: the left takes things seriously. In addition, the left is sometimes consid- ered the "digital" side, with on­off, yes­no, right­wrong patterns of thinking.
may enter consciousness as the implicit mental models and priming become activated in response to environmental or internal triggers resembling components of the original experience. This "implicit-only" form or memory is one explanation for the flashbacks and symptomatic profile of posttraumatic stress disorder. The key to memory integration is the neural reality that focal attention allows the puzzle pieces of implicit memory to enter the spotlight of attention and then be assembled into the framed pictures of semantic and self memories. With such reflective focus, what was once a memory configuration capable of intrusion on a person's life can move into a form of knowing that involves both deep thoughts and deep sensations of the reality of the past. Narrative Integration As we continue to grow during the first 5 years of life, explicit autobio-
graphical recollection becomes even further integrated into narrative memory, which involves the detection and creation of thematic elements of our lives. The brain appears to have a narrative function that can detect themes of our life story and draw heavily on prefrontal functions as they integrate neural maps that form the underlying architecture of our episodic and autobiographical memory systems. With narrative reflection, one can choose, with consciousness, to detect and then possibly change maladaptive patterns. In the attachment research world, coherent narratives are the most robust predictor of how children will attach.24 This finding suggests that parents who have made sense of their lives, as revealed by coherent life narratives, will be those that offer their children patterns of communication that promote well-being. In brief, we can summarize the exploration of this finding by suggesting that it is
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the parents' neural integration that helps them create a coherent narrative and helps them be receptive to their child's own mind and communicative signals.25 Such a pattern may reflect the central role of interpersonal and intrapersonal mental attunement in the development of well-being. State Integration As the brain becomes activated in the moment, it coalesces its firing patterns into clusters of activation we can call a "state of mind." These repeated and enduring states of activation of the brain can help define what we see as our personality -- the patterns of perception and emotional and behavioral responses that help us denote who we are. We can embrace the differentiated states of mind and their drive to satisfy different needs for familiarity and comfort, novelty and challenge, connection and love, mastery and exploration. State integration refers to the way we embrace and nurture these different states and their defining needs across time. Late adolescence is thought to be a time of resolution of these conflicting states, with mental well-being emerging when such state integration is done well and mental turmoil present when resolution is not achieved.26 Finding balance in the integration of states enables us to find our needs satisfied and to create meaning in the pursuit of those various dimensions of our lives. Temporal Integration As we move from our earliest years and our prefrontal cortices begin to develop, our capacity for reflection on the nature of time begins to emerge. First available as a form of mental "time travel" that enables an early form of self-knowing awareness, this reflective capacity to link past, present, and future soon reveals itself in an awareness of the finite nature of our time on this planet. We learn that people's lives are limited
to a century or so and that the experience of death is an inevitable part of life. Temporal integration directly confronts this organizational role of time, and our transient lives, in helping us consider the deep questions of purpose in life. Interpersonal Integration and the Mirror Neuron System Our brains are profoundly social. The structure of our neural architecture reveals that we need connections to other people to feel in balance and to develop well.27 As we have seen in the function of the middle prefrontal regions, the brain integrates input from other people with the process of regulating the body, balancing emotional states, and creating self-awareness. This visceral, social, and self integration suggests that our minds are woven from the integration of aspects of reality that on the surface appear to be quite disparate. How could bodily, interpersonal, and mental go together? To explore this dimension, we will use the example of mirror neurons to highlight the integration of these domains of reality.28 Discovered in the mid-1990s, the mirror neuron system reveals how the brain is capable of integrating perceptual learning with motor action to create internal representations of intentional states in others. Initial studies in monkeys revealed that if a monkey sees someone pick up an object, his own motor system will become primed to imitate that same action. In humans, the mirror neuron system is much more complex, and emerging studies reveal many ways in which our internal, one-to-one, and larger social experiences may be shaped by the integrative nature of this system. For example, the mirror neuron system is thought to be an essential aspect of the neural basis for empathy.28,29 By perceiving the expressions of another person, the brain is able to create an internal state that is thought to "resonate" with that of the other person. Resonance
involves a change in physiologic, affective, and intentional states within the observer that are determined by the perception of the respective states of activation within the person being observed. Oneto-one attuned communication may find its sense of coherence within such resonating internal states. In addition, the behavior of larger groups, such as families and social gatherings, may reveal this shared state of internal functioning. The clinical implications of this work are profound12,29 and help therapists understand not only the inherently social nature of the brain but also that their own bodily shifts may serve as the gateway toward empathic insights into the state of another person. Mediated via the insula, perceptions of another's affective expressions may alter our own somatic and limbic states and then be examined through a prefrontal process of interoception, interpretation, and attribution to another's states.30 Being open to our own bodily states as therapists is a crucial step in establishing the interpersonal attunement and understanding that is at the heart of interpersonal integration. The term "countertransference" can be used to refer to this important way in which the clinician's nonverbal shifts in brain state may offer a direct glimpse into the internal world of the patient. The mirror neuron system offers a new vista into the neural basis of not only imitation, Social Behavior, and empathy but also the interpersonal experiences that may promote a state of well-being. Mirror neurons reveal the fundamental integration within the brain of the perceptual and motor systems with limbic and somatic regulatory functions. The mirror neuron system also illuminates the social nature of the brain. This social basis of neural function may offer new pathways for us to understand how psychotherapy leads to the process of change. When two minds feel connected -- when they become integrated -- the
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state of neural firing within each individual can be proposed to become more coherent. Literally, this may mean that the corresponding activations between the body proper, limbic areas, and even cortical representations of intentional states between two individuals enter a state of "resonance" in which one matches the profiles of the other. The impairment of such shared states has been proposed to be a characteristic of forms of psychopathology, including schizophrenia.28 Recent studies of people with autism spectrum disorders31 reveal impairment in the capacity to perceive emotional expressions in others that is associated with markedly diminished mirror neuron activation. With impaired mirror neuron system functioning, the social brain is unable to share in the rapid social interactions that depend on a shared set of neural profiles that create an embedded matrix of both social behavior and nonverbal understanding of the meaning of social interactions. In the process of psychotherapy with a range of people with intact mirror neuron systems, shared states with the therapist may be an essential component of the therapeutic process. As two individuals share the closely resonant reverberating interactions that their mirror neuron systems make possible, what before may have been unbearable states of affective and bodily activation within the patient may now become tolerable within conscious awareness. Being empathic with patients may be more than just something that helps them "feel better"; it may create a new state of neural activation with a coherence in the moment that improves the capacity for self-regulation. What is at first a form of interpersonal integration in the sharing of affective and cognitive states now evolves into a form of internal integration in the patient. With the entry of previously warded off states of being in conscious awareness, the patient can now learn to
A review of the anatomy of the middle prefrontal cortex reveals that it has a major integrative function: linking body-proper, brainstem, limbic circuits, and cortex. In this manner, these middle prefrontal circuits may carry out what we are labeling as vertical integration. develop enhanced self-regulatory capacities that before were beyond their skill set. It may be that as interpersonal attunement initiates a new form of awareness that makes intrapersonal attunement possible, new self-regulatory capacities become available. If the mirror neuron system were to be focused on one's own states of mind, we can propose that a form of internal attunement would allow for new and more adaptive forms of self-regulation to develop. The practice of focusing attention in the present moment on one's own intentions and somatic states, such as the breath, has been a mainstay of mindful awareness practices over thousands of years. The recent findings that such practices are associated with enhanced physiological, psychological, and interpersonal functioning may fit
into the larger framework that integrated states correlate with well-being. A "Mirror Neuron-Mindfulness Hypothesis" can be offered that proposes that the focusing of one's nonjudgmental attention on the internal state of intention, affect, thought, and bodily function may be one way in which the brain focuses inward to promote well-being. As the therapist attempts to achieve such an open, receptive state of awareness toward both internal state changes and interpersonal signals sent by the patient, the patient's own mind may be offered the important social experiences to create a similar state. In this way, the mirror neuron system may serve a powerful role as the neural basis of mental attunement within and between both patient and therapist. As noted earlier, studies of attachment reveal that a parent's openness to a child's signals and the coherence of the parent's own narrative are important predictors of a child's development of security of attachment.13 Such factors seem to promote a form of resiliency in the child that helps self-regulation unfold as the child matures. Psychotherapy may naturally harness these developmental origins of well-being in creating a resonant state in which the therapist is sensitive to the patient's signals and also has made sense of his or her own life. Being open to the many layers of our experience, often involving the nonverbal world of sensation and affect in addition to our verbal understanding, is an important stance for the therapist to create toward the internal and interpersonal worlds. Within this framework, the state of brain activation in the therapist serves as a vital source of resonance that can alter profoundly the ways in which the patient's brain is activated in the moment-to-moment experiences within therapy. Such interactive experiences allow the patient to "feel felt" and understood by the therapist; they also may establish new neural net firing patterns that can lead to neu-
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ral plastic changes. Ultimately, lasting effects of psychotherapy must harness experiences that promote the growth of new synaptic connections so more adaptive capacities for self-regulation and well-being can be established. Transpirational Integration As individuals move forward in achieving new levels of integration across the eight domains described above, clinical experience reveals a fascinating finding in which people begin to feel a different sense of connection to both themselves and the world beyond their previously "skin-defined" sense of self. The term "transpiration" denotes how new states of being seem to emerge as a vital sense of life is breathed across each of the domains of integration. One feeling that many patients have articulated is a sense that they are connected to a larger whole, beyond their immediate lives, than the previous sense of isolation they may have been feeling from others and even from themselves. It may be that our highly evolved mirror neuron systems reveal the fundamental ways in which we are neurally constructed to feel connected to each other. Because neural plasticity appears to enable the brain to change throughout the lifespan, it may be that psychotherapy for individuals at any age can allow for interpersonal experiences to open the door to change. SUMMARY Our work as psychiatrists means we have dedicated our lives to helping alleviate suffering in individuals, couples, and families. We also can become a part of a larger effort to bring integration and healing into the many layers of our interconnections with each other. When we examine the deep layers of our neural selves, we come to glimpse not only the
roots of our mental and social lives but also the essential reality of our selves as part of an integrated whole across the span of life. REFERENCES 1. Wilson EO. Consilience: The Unity of Knowledge. New York, NY: Knopf; 1998. 2. Siegel DJ. The Developing Mind: Toward a Neurobiology of Interpersonal Experience. New York, NY: Guilford Press; 1999. 3. Siegel DJ. Toward an interpersonal neurobiology of the developing mind: attachment, "mindsight," and neural integration. Infant Ment Health J. 2001;22(1-2):67-94. 4. Huttenlocher PR. Neural Plasticity: The Effects of Environment on the Development of the Cerebral Cortex. Cambridge, MA: Harvard University Press; 2002. Perspectives in Cognitive Neuroscience. 5. Thagard P. Coherence in Thought and Action. Cambridge, MA: The MIT Press; 2002. 6. Lewis MD, Granic I, eds. Emotion, Development, and Self-Organization: Dynamic Systems Approaches to Emotional Development. Cambridge, England: Cambridge University Press; 2000. 7. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders [text revision]. 4th ed. Washington, DC: American Psychiatric Publishing; 2000. 8. Siegel DJ. Mindsight. New York, NY: Bantam; In press. 9. Posner MI, ed. Cognitive Neuroscience of Attention. Cambridge, MA: The Guilford Press; 2004. 10. Beitman BD, Nair J. Self-Awareness Deficits in psychiatric patients: Neurobiology, Assessment, and Treatment. New York, NY: WW Norton; 2004. 11. Kabat-Zinn J. Coming to Our Senses: Healing Ourselves and the World Through Mindfulness. New York, NY: Hyperion; 2005. 12. Siegel DJ. The Mindful Brain. New York, NY: WW Norton. In press. 13. Sroufe LA, Egeland B, Carlson EA, Collins WA. The Development of the Person: The Minnesota Study of Risk and Adaptation from Birth to Adulthood. New York, NY: The Guilford Press; 2005. 14. Schore AN. Affect Regulation and the Repair of the Self. New York, NY: WW Norton; 2003. 15. Stern DN. The Present Moment in Psychotherapy and Everyday Life. New York, NY: WW Norton; 2004. 16. Germer C, Siegel RD, Fulton PR, eds. Mindfulness and Psychotherapy. New York, NY: The Guilford Press; 2005. 17. Lazar S, Kerr CE, Wasserman RH, et al.
Meditation experience is associated with increased cortical thickness. Neuroreport. 2005; 16(17):1893-1897. 18. Halpern ME, Gunturkun O, Hopkins WD, Rogers LJ. Lateralization of the vertebrate brain: Taking the side of model systems. J Neurosci. 2005;25(45):10351-10357. 19. Chiron C, Jambaque I, Nabbout R, et al. The right brain is dominant in human infants. Brain. 1997;120(pt 6):1057-1065. 20. Thatcher RW, Walker RA, Giudice S. Human cerebral hemispheres develop at different rates and ages. Science. 1987;236(4805):1110-1113. 21. Bauer PJ. What do infants recall of their lives? Memory for specific events by one- to twoyear-olds. Am Psychol. 1996;51(1):29-41. 22. Solomon M, Siegel DJ, eds. Healing Trauma: Attachment, Mind, Body, and Brain. New York, NY: WW Norton; 2003. 23. Sapolsky RJ, Romero LM, Munck AU. How do glucocorticoids influence stress responses? Integrating permissive, suppressive, stimulatory, and preparative actions. Endocr Rev. 2000;21(1):55-89. 24. Hesse E, Main M, Abrams KY, Rifkin A. Unresolved states regarding loss or abuse can have "second generation" effects: disorganization, role inversion, and frightening in the offspring of traumatized, non-maltreating parents, In: Solomon M, Siegel DJ, eds. Healing Trauma: Attachment, Mind, Body, and Brain. New York, NY: WW Norton; 2003:57-106. 25. Siegel DJ, Hartzell M. Parenting from the Inside Out: How a Deeper Self-Understanding Can Help You Raise Children Who Thrive. New York, NY: Tarcher Penguin; 2003. 26. Harter S. The Construction of the Self: A Developmental Perspective. New York, NY: The Guilford Press; 1999. 27. Cozolino LJ. The Neuroscience of Human Relationships: Attachment and the Developing Social Brain. New York, NY: WW Norton; 2006. 28. Gallese V. The roots of empathy: The shared manifold hypothesis and the neural basis of intersubjectivity. Psychopathology. 2003;36(4):171-180. 29. Iacoboni M, Siegel DJ. The Implications of Mirror Neurons for Psychotherapy [CD]. Santa Rosa, CA: RJ Cassidy Seminar Recordings; 2004. 30. Carr L, Iacoboni M, Dubeau M-C, Mazziotta JC, Lenzi GL. Neural mechanisms of empathy in humans: A relay from neural systems for imitation to limbic areas. Proc Natl Acad Sci USA. 2003;100(9):5497-5502. 31. Dapretto M, Davies MS, Pfeifer JH, et al. Understanding emotions in others: Mirror neuron dysfunction in children with autism spectrum disorder. Nat Neurosci. 2006;9(1):28-30.
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