Integration

It might have been supposed, in the days before brain scanning, that the brain would have separate areas for processing body sensations, emotions, thoughts and social experience. I think it might have come as a surprise to neuroscientists to discover that there is a location in the brain – and in the highest executive area of the prefrontal cortex! – where the neural pathways for all those functions meet, where all the levels of human consciousness meet, not just symbolically, but literally in physical reality. The integration of this core area of our brain is the fundamental principle behind Daniel J. Siegel’s writings about Mind, Brain and Relationship, and how it applies to the area of psychotherapy and healing.

DANIEL J. SIEGEL’S INTERPERSONAL NEUROBIOLOGY for PSCYHOTHERAPY

Reproduced and adapted from Siegel’s handout, ‘An Interpersonal Neurobiology approach to Psychotherapy’. My editorial additions are in blue print.

Interpersonal Neurobiology is multidisciplinary and interdisciplinary – it extracts experience from over 12 different disciplines of science to produce a picture of the human experience and development over its lifespan. It attempts to allow and integrate both the objective domain of science and the subjective domain of human knowing. Its approach to psychotherapy is to use the model of IPNB to explore ways that one person can help another to alleviate suffering and move towards well-being.

Definition of the Mind – an embodied process that regulates the flow of energy and information. The brain has self-regulatory circuits that directly contribute to the mind’s regulation of its two elements – energy and information, which can flow within one brain or between brains. The mind emerges in and from the transaction of neurobiological and interpersonal processes, as well as from other features of the natural and technological world. Within psychotherapy, we see that the relationship with another person can profoundly shape the flow of energy and information within a person’s mind.

Mind Development – synaptic linkages are created by both genes and by experience. Nature needs nurture. Experience shapes new connections among neurons by how genes are activated, proteins produced, and interconnections established within our spider-web like neural system.

Mental Well-being –

DIFFERENTIATION AND LINKAGE

VERSUS

CHAOS AND RIGIDITY

An interpersonal neurobiology view of well-being states that the complex, non-linear 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 to become linked together, the system is said to be integrated.

The Integration of the parts of the whole has the following characteristic:

The system is Flexible, Adaptive, Coherent, Energized, and Stable.

This coherence and stability is bounded on one side by chaos and on the other by rigidity.

This can be envisaged as “A River of Well-Being” :

The river is the differentiated yet linked components of the neural system (the flow), bounded on either side by two banks – Chaos and Rigidity.

A View of the Diagnostic and Statistical Manual for psychiatric diagnoses:

The symptoms of this manual are manifestations of rigidity or of chaos.

The Triangle that Siegel promotes as one of his symbols of IPNB has as its three points – an empathic relationship, a flexible yet stable mind, and an integrated brain.

Integration

In therapeutic practice, how can we envisage Integration?

Siegel proposes nine ‘domains’ of integration. They are:

Integration of Consciousness
Vertical Integration
Bi-lateral Integration
Integration of Memory
Narrative Integration
State Integration
Temporal Integration
Interpersonal Integration and the Mirror Neuron System
Transpirational Integration

Integration of Consciousness

Attentional focus can be of three kinds: exogenous (driven by the immediacy of an external stimulus, eg, a loud noise); endogenous (self-generated choice to focus on a limited stimulus); and executive (a flexible attention not generated by external stimulus or a single internal focus).

Integration of consciousness emerges from the development of executive forms of attention aimed at improving self-regulation, emotional response, stress response and social skills. Through receptive, flexible forms of awareness we can learn to focus our attention in ways that are most helpful in promoting well-being. A recommended way of doing this is through ‘mindful awareness’ practices – paying attention, in the present moment, without grasping onto judgements. Psychotherapeutic practices that enhance executive forms of attention allow changes in synaptic connections, ie, neural plasticity.

The basic steps linking consciousness with neural plasticity are as follows: Where attention goes, neural firing occurs. And 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.

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 that new connections can be established.

The Vertical elements of the brain:

Brainstem – basic bodily regulatory functions

Limbic area – emotional states, motivational drives, attachment, primary appraisal of meaning, laying down of memory

Neocortex (‘outer bark’) of the evolving brain. Underdeveloped at birth, shaped by both genetics and experiences in the outside world.

The Neocortex (or cortex)

posterior regions: perception of physical world (5 senses)
forward area of this posterior region registers one’s own body
frontal lobe : motor and pre-motor planning so we can carry out behaviours
forward-most part of frontal lobe is the prefrontal cortex.

prefrontal cortex:

side part – dorsolateral region – working memory, so we can pay attention to something in the here and now. Here things are ‘held in mind’ and manipulated to form plans and concepts. Helps set priorities.

Ventromedial region – here emotions are registered and meaning bestowed on perceptions.

Middle part – orbitofrontal cortex , medial prefrontal cortex, anterior cingulate, insular cortex : Siegel classifies these areas together as the ‘middle prefrontal cortex’, working together with these functions:

Anterior Cingulate: helps focus attention. Integrates cognition and emotions. Tunes into thoughts. Awareness of ‘Self’.

Orbitofrontal cortex: Inhibits inappropriate action. Helps postpone reward seeking. Higher part of limbic circuitry, social circuitry, linkage of body, emotional states and thought. Other higher executive functions listed under ‘the Role of Memory in Trauma’.

Middle Prefrontal Cortex ( Orbitofrontal Cortex )

“The Brain in a Fist”

An analogue of the three-part vertical levels of the brain: Photo 1: cross your thumb across your palm. Your lower hand and wrist represents the brainstem. The thumb represents the limbic system. Photo 2: wrap your fingers around the thumb. The fingers represent the cortex, and from the fingernails up to the nuckle nearest the nail is the orbitofrontal cortex. This lower section of the fingers would be right behind the eye sockets.

If you close the finger tips tightly against your palm you will be able to see/feel how anatomically the orbitofrontal cortex, upper limbic area and frontal brainstem area all converge at this point. It is the only area of the brain where all three of these distinct regions are in contact.

A review of the anatomy of the orbitofrontal cortex reveals that it has a major integrative function, linking body-proper, brainstem, limbic circuits, and cortex to each other. In this manner these middle prefrontal circuits may carry out what we are labeling as vertical integration. What does this term really mean? This idea means that fibers literally 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 aspects of life:

Body regulation: Balance of the sympathetic (accelerator) and parasympathetic (brakes) branches of the autonomic nervous system.

Attuned communication: Enables us to tune into others’ states and link minds.

Emotional balance: Permits the lower limbic regions to become aroused enough so life has meaning, but not too aroused that we become flooded.

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.

Empathy: Considering the mental perspective of another person.

Insight: Self-knowing awareness, the gateway to our autobiographical narratives and self-understanding.

Fear extinction: GABA (an inhibitory neurotransmitter) fibers project down to the amygdala and enable fearful responses to be calmed.

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.

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.

It is relevant to note that the first seven of these nine middle prefrontal functions are associated with the outcome of secure attachment between child and caregiver. 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.

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. A client’s movement towards vertical integration can be practised if the therapist encourages focussed awareness on the sensations and feelings of the body itself, in association with emotional states and the thoughts that arise with them. With a receptive mind, it may be that this vertical integration occurs naturally. But for many individuals coming to therapy, learning to pay attention to the body’s signals is new territory and at first has to be a purposeful act. But it can transform a disconnected way of living into a richer, more integrated way of living.

Of note from the neuroscience literature are preliminary studies that suggest that mindful meditation practice, as one example of a receptive mental state, may actually lead to enhanced growth of the middle prefrontal regions as well as preserving neural tissue in these regions with aging.

Sandtray depicting a client’s sense of the way their brain has adapted to childhood trauma, and how the therapy work is bringing about change in the neural network:

“The sense I feel when I look at it this is the way things feel very separate, but also with a non-awareness of separateness when living. It’s like experiencing life like old fashioned slide projections, where once the picture is gone, its gone (with residual memory of having looked at it, then a resurgence of memory when it jumps back in to vision – very stop/start) versus the current style of digital slides that just continue to roll into view. There’s a fluid continuousness to it, a sense of never leaving the ‘show’.” Client description

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 us. 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. In this brief overview these differences will be highlighted to illustrate the importance of bilateral integration. The right hemisphere develops first after birth, its activity and synaptogenesis more robust during the first two to three years of life. After that period, there are a series of cyclical waves of left, then right, and then left sided dominance in growth and activity. In general the right and left sides of the brain have the following characteristics that have been supported by a range of scientific and clinical investigations.

The right mode of processing:

1. Holistic – things are perceived in the whole of their essence.

2. Visuospatial – the right side works well with seeing a picture and is not proficient at decoding the meaning of words.

3. Non-verbal – eye contact, facial expression, tone of voice, posture, gestures, and timing and intensity of response are the non-verbal components of communication that the right mode both sends and perceives from others.

4. A wide range of functions, including the stress response, an integrated map of the whole body, raw, spontaneous emotion, autobiographical memory, a dominance for the non-verbal aspects of empathy. 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.

The left mode of processing:

Linear – the left loves this sentence, one word following the next.

Logical – specifically syllogistic reasoning in which the left looks for cause-effect relationships in the world.

Linguistic – these words are the left’s love.

Literal – the left takes things seriously. In addition, the left is sometimes considered the “digital” side, with on-off, yes-no, right-wrong patterns of thinking.

Research has indicated that under impaired left-right integration, the drive of the left hemisphere to tell stories and explain things in a linear way, fails when the story is about the self, as autobiographical data and its context-dependent emotion is retrieved from the right hemisphere. This is a phenomenon familiar to many survivors of childhood trauma – many are quite functional in their worldly, everyday life, but are almost unable to articulate their right hemisphere-mediated autobiography – which comes out in disconnected fragments, often devoid of its emotional content. In this respect, bi-lateral integration is intimately bound up with memory integration.

4. Integration of Memory

Read Dan Siegel description of ‘Memory as evolution’s survival mechanism’ for the background to Integration of Memory

One proposal about trauma’s effects on memory is that it may transiently block the integrative function of the hippocampus in memory integration. With massive stress hormone secretion or amygdala discharge in response to an overwhelming event, the hippocampus may be temporarily shut-down. 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 non-traumatic elements of the environment at that time. The resultant neural configuration, 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. This “implicit-only” form or memory can be one explanation for the flashbacks and symptomatic profile of Post Traumatic 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 uncontrolled intrusion into the person’s life can move into a form of knowing that involves both deep thoughts and deep sensations of the reality of the past.

5. Narrative Integration

As we continue to grow throughout the first five years of life, explicit autobiographical recollection becomes further integrated into our ‘narrative memory’. Narrative memory involves the detection and creation of thematic elements of our lives. The brain appears to be able to have a narrative function that can detect themes of our life story and to draw heavily on prefrontal functions as they continue to 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 old maladaptive patterns.

In the attachment research world, it is coherent narratives, stories that deeply make sense of our lives, which are the most robust predictor of how children will attach to us. This finding suggests that parents who have made sense of their own lives, as revealed in their coherent life narratives, will be those that somehow 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 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. Such a parent-child pattern may reflect the central role of inter- and intrapersonal mental attunement in the development of well-being.

6. 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, our 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 conflictual states. When such state integration is done well the individual will enter adulthood with a degree of mental well-being. When resolution is not achieved we can expect to see a degree of mental turmoil. Finding balance in the integration of the natural multiplicity of states of mind enables us to satisfy our needs and to create meaning in the pursuit of those various dimensions of our lives.

7. 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. ‘Mental time travel’ enables an early form of self-knowing awareness, a reflective capacity to link past, present, and future. This knowledge soon reveals itself in an awareness of the finite nature of our time on this planet. We learn that people’s lives are often limited to a century or so, and that the experience of death is an inevitable part of each of our lives. Temporal integration directly confronts this organizational role of time, and our transient lives, in helping us consider the deep questions of meaning and our purpose in life.

8. Interpersonal Integration and the Mirror Neuron System

Description

Our brain is the social organ of the body. The structure of our neural network reveals how we need connections to other people in order to feel in balance and to develop well. As we’ve seen in the function of the middle prefrontal regions, the brain integrates a/input from other people, b/regulating the body, c/ balancing emotional states, and d/the creation of self-awareness. This bodily, 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, let’s use the example of mirror neurons to highlight the integration of these domains of reality.

Discovered in the mid-nineteen nineties, the mirror neuron system, mediated via the insular, 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 the many ways in which our internal, one-to-one, and larger social experiences may be shaped by the integrative nature of this mirror neuron system.

For example, the mirror neuron system is thought to be an essential aspect of the neural basis for empathy. By perceiving the expressions of another individual, the brain is able to create within its own body 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. One-to-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 mirror neuron system offers us 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 profoundly social nature of our brains.

Application to Psychotherapy

A. Empathic Attunement

The clinical implications of mirror neuron research are profound and help therapists to understand not only the inherently social nature of the brain but that their own bodily shifts may serve as the gateway toward empathic insights into the state of another person. 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. Mediated via the insula, our perception of another’s affective expression can alter our own somatic and limbic state, which can then be examined through a prefrontal process of interoception allowing us to ‘feel empathically’. The term “countertransference” can be used to refer to this important way in which our own non-verbal shifts in brain state may offer us a direct glimpse into the internal world of our clients.

B. How Empathic Attunement can effect Change

The 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 state of firing of 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.

In the process of psychotherapy, 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 client may now become tolerable with conscious awareness. Being empathic with clients 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 client. With the entry of previously warded-off states-of-being in conscious awareness, the client can now learn to 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.

C. Self Regulation/ Regulation of the Internal System / Mindful Awareness

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, have been a mainstay of mindful awareness practices over thousands of years.

A “Mirror Neuron-Mindfulness Hypothesis” can be offered that proposes that the focusing of one’s non-judgmental 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 for interpersonal signals sent by the client, the client’s own mind may be offered the important social experience 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 client and therapist.

D. Mirror Neurons and Re-parenting the Client

Studies of attachment reveal that the 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 secure attachment. Such factors seem to promote a form of resiliency in the child which helps self-regulation unfold as the child matures. Psychotherapy can harness these developmental origins of well-being in creating a/ a resonant state in which the therapist is sensitive to the client’s signals and b/ a relational environment in which the therapist has made sense of her or his own life.

Within this framework, the state of brain activation in the therapist serves as a vital source of resonance that can profoundly alter the ways in which the client’s brain is activated in the moment-to-moment experiences within therapy. Such interactive experiences allow the client to “feel felt” and understood by the therapist and may establish new neural net firing patterns that can lead to neural plastic changes. Ultimately lasting effects of psychotherapy must harness such experiences that promote the growth of new synaptic connections so that more adaptive capacities for self-regulation and well-being can be established.

9. 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 clients 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 system reveals 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.

Our work as psychotherapists is to dedicate our lives to help alleviate suffering in individuals, couples, and families, and also to be a part of a larger effort to bring integration and healing into the many layers of our interconnections with the world.