Why Therapy Works: Using Our Minds to Change Our Brains (Norton Series on Interpersonal Neurobiology) Written by Louis Cozolino, 2016,

Reconciling Neuroscience and Talking Therapy?

Review by Steve Minett, Phd

I found this a very rich and engaging book, filled with the creative tensions generated by at least two fault lines which run through it: at a practical level the objective of the book is somewhat ambivalent. At one level, it can be read simply as a manual for practitioners of psychotherapy, especially of the ‘talk’ variety. On the other hand, the statement in its title, ‘Why therapy works’, certainly implies an ambition to grapple with the scientific and philosophical problems of consciousness studies (which is my particular area of interest), such as whether our behaviour is totally determined by our genes, our environment (especially in early infancy) plus an element of chance, or whether there’s scope for us to exercise some element of free choice. (The amount of space Cozolino devotes to the novel therapeutic technique known as Eye Movement Desensitisation and Reprogramming, despite conceding that he has no idea how it works, definitely weighs on the practitioner manual side.)

The second fault line is more concerned with theoretical perspectives. It seems to me that, in this book, Cozolino is trying to reconcile two distinct, long-standing and antagonistic traditions in human psychology; firstly, the psychodynamic tradition (starting with Freud) which empathises the overwhelming impact which infantile trauma has on the course and quality of adult life. Secondly, the cognitive, neuroscience tradition (which grew out of behaviourism). This seeks to account for the human brain and behaviour from a rigorously positivist, ‘hard’ science perspective. (On the issue of infantile trauma, the book does a very good job of re-educating us regarding Post Traumatic Stress Disorder: we customarily think of this as only affecting adults who’ve been exposed to combat, accident or disaster scenarios. Cozolino, however, asserts that abuse and neglect in infancy can have just as devastating an impact.)

To start with this second, and perhaps more productive fault line, Cozolino has long promoted an understanding and integration of modern neuroscience with psychotherapy. An example in this book is his explanation of neurosis via ‘an unfortunate twist of evolutionary fate’; namely, the fact that, “the amygdala is mature at birth while the systems that regulate and inhibit it take many years to develop and mature. Thus, we enter the world totally vulnerable to overwhelming fear with no ability to protect ourselves.” [p.192]  (He suggests that an effective therapist needs to become ‘an amygdala whisperer’.) Following this reference to the well-established neuroscience finding that the amygdala is the organ of instant fear, warning and alarm, however, he goes on to resolve this evolutionary dilemma via a thoroughly psychodynamic solution; namely that, “… we are capable of attuning with caretakers who can regulate our fear circuitry until our own brains are ready to take on the job.” [p.192]

I’m personally convinced that Cozolino’s explanation is the correct solution to the dilemma. (Neurosis arising, of course, where the quality of attunement is inadequate.) I also, however, think that; a) this ‘attunement’ solution would not be widely accepted in the cognitive neuroscience community and b) Cozolino does not do any of the theoretical ‘heavy-lifting’ necessary to justify it. While Cozolino devotes a lot of effective time to explaining individuals’ denial and resistance to the impact of infantile trauma on their personal lives, he doesn’t refer to the paradigm-based, cultural and institutional denial and resistance to this phenomenon. (See below for further explanation.)

A second example of the contradictions raised by Cozolino’s appeal to would-be ‘hard science’ explanations is his division of people into ‘alphas’ and ‘betas’ (essentially, ‘natural’ leaders and followers). This is, I assume, taken from evolutionary psychology and, again, I can agree with a lot of it, especially when Cozolino introduces a nuanced four category version; 1) naturally confident and competent leaders who enjoy being the centre of attention (charismatic is probably the right term) 2) naturally passive and content followers who are happy to abide by the rules and avoid the burdens of responsibility (I’m most dubious about this category) 3) ‘Pseudo-alphas’ who believe that they have all the qualities necessary for leadership but really don’t (Trump would be a classic example) 4) Aspiring Alphas who find themselves trapped in beta social roles but feel frustrated and under-valued.

As Cozolino very correctly points out, the people who voluntarily enter psychotherapy are almost exclusively Aspiring Alphas. (Pseudo-alphas sometimes are ordered into therapy because of the problems they cause for other people.) However, having set out the alpha/beta categories as ‘natural’ (and possibly, thereby, opening himself to accusations of American cultural bias), Cozolino then proceeds to a chapter entitled, “Helping clients become alphas”: many an evolutionary psychologist might well argue that converting aspiring betas into alphas via the therapeutic process amounts to subverting the ‘natural order’ of society. Again, this strikes me as another example of Cozolino having his hard science cake while eating his humanist therapeutic role.

I find these paradoxes fascinating because I agree whole-heartedly with the interpretations of the human mind-brain and behaviour which Cozolino articulates so clearly: he goes so far in the right direction, but without any safety net of theoretical justification. But what would such a ‘safety net’ consist of? It would, in my view, have to entail tackling head-on the nature and function of consciousness. At one point Cozolino (veering to the side of practitioner-manual) avers that consciousness is, “too big a question for me”. However, if your ambition is to explain why talking therapy works, you have to assume that certain conscious states of mind, as induced by therapeutic dialogue, have the causal power not only to heal the mind, but also (as Cozolino explicitly claims) to restructure the brain. (He has a chapter on ‘The Power of Coherent Narratives’.)

Explaining the causal efficacy of consciousness is of course a vast and controversial topic, but I hope I can conclude by saying a couple of things that can point us in the right direction: many philosophers reduce the problem of consciousness to the two component issues of ‘qualia’ and the self: qualia can be summed up in what’s become known as the ‘hard problem’; “why should anything feel like something?” In relation to Cozolino, let’s apply this question to the emotions. Why should the observable and measurable neurophysiological processes that generate human emotions, also produce ‘affect’, the subjective experience of emotion? For many decades the very existence of affect was flatly denied by the scientific and philosophical communities and still is by some prominent representatives, such as Daniel Dennett, who states that; “we seem to have qualia, but really we don’t!”

As to the self, the work of Jaak Panksepp opens up some highly ‘therapy-friendly’ perspectives. Panksepp argues that affect and the self are natural outgrowths of the physiological process of homeostasis. They exist in order to regulate the neurophysiological emotions, which for infants can manifest themselves in catastrophic forms. The self and its affects are the interlocutor to whom the good parent (and the psychotherapist) is whispering. (The amygdala is, after all, only a biological organ!) Greenspan and Shanker argue that this affect nurturing of infants by caregivers has a crucial and evolutionarily significant role for the human species. I could also mention Sarah Hrdy and many others. My point is that the theoretical structure for Cozolino’s safety net has now become available. If his book is, in fact, just a handbook for practitioners, it’s probably too big an ask for him to have incorporated it. That book remains to be written.

Steve Minett teaches Theories of Consciousness and runs the website http://www.consciousnesstheories-minett.com

To read an extract of the book go to http://www.neuropsychotherapist.com/why-therapy-works/

For where to buy the book go to https://www.amazon.co.uk/Why-Therapy-Works-Interpersonal-Neurobiology/dp/0393709051/ref=sr_1_1?s=books&ie=UTF8&qid=1499143831&sr=1-1&keywords=cozolino