Dr. Cozolino, what got you interested in the neuroscience of psychotherapy?
Dr. Cozolino: About 20 years ago, I was very interested in working with adults who suffered trauma as children, especially those from cult situations or with sadistic parents. From there I became interested in memory and how the brain organizes information.

How do you actually use your knowledge of neuroscience to help your psychotherapy patients?
Dr. Cozolino:   I’ve found it useful to have a scientifically based, if not totally correct, explanation for what I think is happening in my clients’ brains. These explanations are all still at the level of hypotheses, but they allow clients to have nonshaming explanations for what is going on with them.

You discuss “enhancing neuroplasticity” in your book.What is neuroplasticity?
Dr. Cozolino:   Neuroplasticity refers to the brain’s ability to change its functional architecture by creating new neurons (neurogenesis) or making new neural connections. Neuroplasticity is the hub of the integration of psychotherapy and neuroscience.

You talk about psychotherapy as “rebuilding the brain.” What do you mean by that? 
Dr. Cozolino:   The brain is an organ of adaptation. The brains of primates, especially  humans, have an extended period of post-natal development, unlike the brain of a giraffe, for example. The giraffe is ready to join the herd 10 minutes after birth. A human’s immature brain adapts to the early social environment of the family. This is good news if the social environment is functional and adaptive; then the brain that is built in childhood continues to adapt to the environment over time. It is bad news when the family creates traumatic experiences that may not be typical of the environment that we move into later in life.

And this inability to adapt causes what kinds of problems?
Dr. Cozolino:  A person comes to therapy because life isn’t working for some reason. Often, the reason is that the brain adapted to an environment that is not like the life he or she wants. For example, if a person is used to experiencing trauma and doesn’t have it, he may recreate it because that is where he feels most comfortable. So we use plasticity in therapy to remodel the brain to get the person to where he wants to be instead of continuing to live in the past.

Can you describe a clinical example?
Dr. Cozolino:   A typical example from my practice is the young woman in her late 20s or early 30s who can’t maintain a relationship. After about three or four months with someone, something goes wrong and she gets out. So we talk about her early life and her history of relationships, and we typically find that she enters relationships with optimism, joy, and attraction, but at some point she realizes the attraction is gone, so she finds a reason to end the relationship. This can go on for 10 or 15 years before she realizes the only thing that’s the same in all of these relationships is her, and maybe it’s her problem and not the boyfriends’.

This certainly describes several patients I’ve seen. What is the neurocircuitry hypothetically underlying this behavior pattern?
Dr. Cozolino:   Somewhere early in life there has been the experience of intimacy and dependency that was then lost. A parent may have died, or left the family, or become emotionally unavailable for some reason. In the brain, the amygdala’s job is to remember these emotional experiences. We believe that the key circuit for attachment is between the amygdala and the orbital-medial prefrontal cortex. When a child is born, the amygdala is fully developed, but it takes years for that child to learn to build the cortical processes that inhibit and regulate fear. This is why children depend on parents to soothe and regulate them. In the case of our hypothetical patient, the amygdale paired intimacy with the expectation of abandonment, loss, and pain. So her strategy is to “do unto others before they do unto her.” She is not aware of the underlying emotional process, but she finds a way to escape relationships.

So what do you do in therapy in order to help her?
Dr. Cozolino:  In therapy, I work with her to deconstruct that period of time when she shifts from attraction to repulsion. Assuming that she has a good partner and not someone who is abusive, we think together in terms of where she checked out of the present and where the past started to take over.

So the theory is that her maladaptive relationship pattern developed because the circuit between her amygdala and prefrontal cortex developed abnormally. But how could a psychotherapist presume that simply through a series of one-hour sessions once a week, which would amount to a very small part of this person’s life, she could actually change the way the neurons connect to one another?
Dr. Cozolino:   Because, while it’s true that our attachment circuitry is developed early on in life, we also know that this circuitry remains plastic. We continue to be able to form very strong attachments even late in life—ask any grandparents how they feel about their grandchildren, and you know that you are never too old to fall in love. In my opinion, the emergence of psychotherapy is related to this process. Psychotherapy didn’t just come out of nowhere. It came out of a tradition of priests, rabbis, shamans, and wise men and wise women in the tribe. Our brains are biologically social organs, and we evolved to learn from such caring others. Cortical learning—the type of learning that is flexible and can occur in psychotherapy—depends on the plasticity of frontal neurons, and requires moderate states of anxiety.

Effective psychotherapy actually requires some degree of anxiety in patients?
Dr. Cozolino:   Yes. The basic psychological research on this phenomena is about 100 years old, when researchers gave varying amounts of stress to rats and saw how it affected their abilities to learn how to negotiate a maze to receive food. Over time, they found that at low levels or high levels of arousal or stress, the rats didn’t learn; but at moderate levels of arousal they did (Yerkes R M & Dodson JD, J Compar Neurol Psychol 1908;18:459–482). There is this bell-shaped curve (termed the Yerkes-Dobson curve), that is the sweet spot of learning, which means there is this sweet spot of neuroplasticity, too.

And to apply this idea to therapy, we want to somehow get our patients into the sweet spot of stress in order to help them to make progress?
Dr. Cozolino:   Right, and a good therapist uses the therapeutic relationship to regulate that level of arousal. Fritz Perls called psychotherapy “a safe emergency.” There is this dichotomy that you are stressing or challenging someone, but you are holding them at the same time. We see this process in most schools of therapy. Cognitive behavioral therapy and the use of systematic desensitization is a perfect example. You teach people how to relax; but simultaneously you expose them to the things they are afraid of. You regulate them; you keep monitoring their internal states to make sure that they are not at too high a level of stress.

Going back to the woman with the series of failed relationships, what can we do to enhance her neuroplasticity in a beneficial way?
Dr. Cozolino:  We can help her understand what is going on in her relationships, so that when she begins to have those flight or fear responses, she becomes consciously aware of that and can make decisions about where the fear is coming from. Is this fear due to the present relationship, or is it due to anachronistic memories? And then, of course, she has to be willing to tolerate the anxiety of staying in the situation even though she wants to run. As therapists, we do this by teaching patients how to relax in challenging situations. My clients often tell me something like: “I am in this situation and I hear your voice saying, ‘This is just a memory; this isn’t real.’” In other words, in therapy we help our clients develop an internal narrative to re-regulate themselves and get back into that sweet spot of arousal. And if our patient can stay in that situation and allow herself to stay exposed, her amygdala can re-learn and begin to pair the experience of an intimate relationship with survival, as opposed to pairing running away with survival.

What’s the value of talking about the neuroscience of psychotherapy with this patient? Does she really need to know what’s going on with her amygdala?
Dr. Cozolino:   For some people just using everyday language is enough. But when people feel like they are crazy or have a character flaw and become ashamed of themselves, I say: “Wait a minute; there is a brain that we all share, and here is how it has evolved in ways that make us vulnerable to all kinds of problems.” And so I use this language as an anti-shame device. And it also creates a rationale for intellectualized people to understand why they have to feel things that are uncomfortable in order to make progress in therapy.

One of the interesting conclusions from your book is that there really isn’t as much of a difference between psychopharmacology—often considered a “biological” approach, and psychotherapy—often considered a “psychosocial” approach. Both presumably cause changes in the brain, and yet they go about it in different ways.
Dr. Cozolino:   Right. And in fact, one can go further and make the provocative argument that psychotherapy is actually a biological intervention, and that psychopharmacology is largely a social intervention. 

How so?
Dr. Cozolino:  Because we know from the placebo-controlled antidepressant research that in many cases a large part of the therapeutic response to medication is due to placebo factors, and this depends to a large extent on how well the physician connects with the patient. Which parallels the old Rogerian notion about the importance of warmth, caring, and positive regard in psychotherapy.

Thank you, Dr. Cozolino.