When therapy clients with borderline personality disorder see faces with neutral expressions, they often assign negative emotions to them, research finds. Meanwhile, other studies demonstrate that these clients have overactive amygdalas, the primitive brain region associated with fear.

A new area of study is combining insights like these in an ambitious project to map the core processes of psychotherapy and the neurobiology underlying them, said University of Missouri-Columbia psychiatry professor Bernard D. Beitman, MD, a presidential program speaker at APA's 2005 Annual Convention.

Practitioners should consider adding this perspective to their toolkits, Beitman maintained, because data show that only 15 percent of therapy success is related to the type of therapy you practice; the therapeutic alliance, environmental factors and even the placebo effect play a far greater role.

For Beitman, the message behind these data is clear: Let's figure out the common denominators of effective therapy--what is actually going on in the neurocircuitry of patients and therapists during therapy--and cease squabbling over whether cognitive-behavioral therapy is better than Freudian psychoanalysis.

"I urge the field to begin to define the core processes of therapy as the definition of psychotherapy itself and the therapy schools as the adjectives further clarifying it," he said. Eventually, he speculated, practitioners will be able to use information gleaned about affected brain circuitry and tailor treatments to modify those circuits though the most efficient means, whether via psychotherapy, medication, meditation or other interventions. A book by Beitman and University of Missouri-Columbia psychology professor, Glenn E. Good, PhD, outlining these ideas--"Counseling and Psychotherapy Essentials"--is due for release by W.W. Norton & Company next fall.

Brain benefits of attachment

Beitman focused on three aspects of the psychotherapy process: therapeutic engagement, dysfunctional patterns and therapeutic change.

Like those with borderline personality disorder, many clients enter therapy with their amygdalas on overdrive, anxiously fearing what the therapy relationship will hold. In the language of neurobiology, said Beitman, the aim is to reduce this hyperactivity and to bolster the activity of the nucleus accumbens, a brain area associated with reward and pleasure.

Various aspects of therapeutic engagement--such as empathically receiving and validating the client's feelings and building a sense of trust--can help to achieve this end, Beitman said. Indeed, several lines of evidence suggest the possibility that the optimal firing of the nucleus accumbens, meaning not excessive and not diminished, mirrors what happens in secure attachment--the bonding with early caregivers that many therapy clients lack.

Once clients feel safe, they can move on to another crucial step in therapy: self-observation, or the calm, noncritical ability to observe one's behavior, Beitman said.

Self-observation rests on the healthy functioning of several brain regions, the "master and commander" of which is the dorsolateral prefrontal cortex, which can integrate a wide array of sensory, emotional and memory data. Understanding how these mechanisms work and eventually finding ways to facilitate their healthy functioning may help therapists encourage clients to more fully access this capacity, Beitman commented.

Changing negative patterns

The new model likewise contributes insights to another therapy objective: defining dysfunctional patterns, said Beitman.

Research finds that any pattern, healthy or unhealthy, is the result of repeated brain activities in response to the same circumstances, Beitman noted. A woman with a social phobia, for example, may have had repeated negative emotional experiences with the same frightening people when she was a child. In reaction, her limbic system's "fight-or-flight" response activated each time she was in the situation, so that eventually, her brain took that route each time she encountered strangers.

Another brain area that can contribute to ingrained behavior patterns is the hippocampus, which compresses complex information, said Beitman. While consolidating neural signals can help us to make sense of potentially overwhelming stimuli, too much consolidation can make them difficult to comprehend in much the same way that it's hard to recognize a photo with too few pixels.

"The remarkable result of these experiential programmings is that we begin to create expectations from neutral circumstances," said Beitman. "We find what we seek because we expect what we are looking to find to be taking place."

While concrete applications for the work are still somewhat distant, the paradigm already is shedding new light on current therapeutic activities, Beitman maintained.

Insight into the brain's inner workings may, for example, help to explain why exposure treatment for phobias may not be permanent.

"You can expose a client to phobic stimuli, but the patterns are still in there," Beitman explained. "Once the memory patterns are in there, we can learn to mute or override them--but a lot of them just stick around, ready to be reactivated under stressful circumstances."

Tori DeAngelis is a writer in Syracuse, N.Y.