GROUP PSYCHOTHERAPY & INTERPERSONAL NEUROBIOLOGY AN ATTACHMENT THEORY PERSPECTIVE PHILIP J FLORES, PhD, ABPP, CGP, FAGPA 6065 LAKE FORREST DRIVE SUITE 150 ATLANTA, GA (404)

SCHEDULE 9:00 – 10:00 am: Intro to Interpersonal Neurobiology & Group Therapy 10:00 – 10:30 am: Attachment Theory & Group Therapy 10:30 – 10:45: 15 Minute Break 10: Noon: Demo Group & Large Group Discussion – LUNCH: 12 NOON – 1:30 1:30 – 3:00 pm: Neurogenesis, Brain Plasticity, Implicit Domain & Affect Regulation 3:00-3:15 pm: 15 Minute Break 3:15 – 4:30 pm: Demo Group & Large Group Discussion 4:30 – 5:00 pm: Wrap-Up & Evaluations

THREE IMPORTANT CONTRIBUTIONS FROM THE NEUROSCIENCES ATTACHMENT & RELATIONSHIPS ALTER THE NEUROBIOLOGY & STRUCTURE OF THE BRAIN. –NEUROPLASTICITY & NEUROGENESIS –“CRADLE TO GRAVE” (BOWLBY) MIND-BODY DUALISM IS NOT SUPPORTED BY MODERN NEURO SCIENTIFIC EVIDENCE. –IMPLICIT vs EXPLICIT DOMAIN, POLY VAGAL THEORY & LIMBIC RESONANCE. A “BOTTOM UP” EXPLANATION OF BRAIN FUNCTIONING & HUMAN BEHAVIOR IS MORE ACCURATE THAN A “TOP DOWN” MODEL. –VAST MAJORITY OF COMMUNICATION IS NON-VERBAL

THINGS THAT THE NEUROSCIENCES ARE DISCOVERING THAT ARE BAD FOR THE BRAIN ALCOHOL & DRUGS (especially chronic use) TOXIC RELATIONSHIPS ISOLATION CHRONIC STRESS ( vs short term stress) PASSIVITY, INACTIVITY & IMMOBILITY (BDNF) The conscious act of willfully acting changes the brain. *DULL, MONOTONOUS ENVIRONMENTS *INATTENTION & LACK OF EFFORT “Attention is almost magical in its ability to physically alter the brain.” (BEGLEY, 2011)

IMPORTANT CAVEATS I. EVERYTHING PRESENTED TODAY IS COMPLETELY REDUCTIONISTIC & OVER SIMPLIFIED. II. THIS WORKSHOP SELECTIVELY HIGHLIGHTS RELEVANT AREAS OF NEUROSCIENCE CONNECTING THEM TO ATTACHMENT THEORY AND TO CLINICAL APPLICATION. III. THE NEW DISCOVERIES IN THE NEUROSCIENCE BOTH CHALLENGE AND CONFIRM OUR MOST CHERISHED BELIEFS ABOUT WHAT DICTATES EFFECTIVE PSYCHOTHERAPY IV. INFORMATION PRESENTED IS NOT ORIGINAL, BUT SELECTED FROM LEADING NEUROBIOLOGISTS.

MODERN ATTACHMENT THEORY A. SCHORE (2008) FONAGY (2010) STERN (2004) MAT HAS EVOLVED OVER THE LAST 15 YEARS. RESULTING IN AN EXPANSION OF BOWLBY’S ORIGINAL THEORY WITH ITS FOCUS ON CHILD DEVELOPMENT, STRANGE SITUATIONS, SECURE BASE & ATTACHMENT STYLES. BOWLBY’S CORE IDEAS HAVE BEEN EXPANDED INTO A MORE COMPLEX & CLINICALLY RELEVANT MODEL FOR ADULTS. –REFLECTIVE FUNCTION, MENTALIZATION, ToM, IMPLICIT PROCESS. “MAT HAS BEEN TRANSFORMED INTO AN AFFECT REGULATION THEORY.” (A. SCHORE)

ATTACHMENT: A DEFINITION HUMAN BEINGS ARE SOCIAL MAMMALS & SOCIAL MAMMALS REGULATE EACH OTHER’S PHYSIOLOGY & ALTER THE INTERNAL STRUCTURE OF EACH OTHER’S NERVOUS SYSTEM THROUGH THE SYNCHRONOUS EXCHANGE OF EMOTIONS. THIS INTERACTIVE REGULATORY RELATIONSHIP IS THE BASIS FOR ATTACHMENT.

THE BIOLOGICAL LIMITATIONS OF SELF REGULATION CNS IS AN OPEN FEEDBACK LOOP 1. EVIDENCE IS UNEQUIVOCAL: OUR CNS IS NOT A SELF CONTAINED, CLOSED SYSTEM. 2. ALL SOCIAL MAMMALS REQUIRE EXTERNAL REGULATION TO KEEP THEIR CNS UP & RUNNING AT OPTIMAL LEVELS. 3. IF WE ARE NOT GETTING OUR CNS REGULATED THE WAY EVOLUTION DETERMINED (BY PEOPLE), WE WILL BE MORE VULNERABLE TO EMOTIONAL DYSREGULATION & PSYCHOPATHOLOGY (DEPRESSION, ANXIETY & ADDICTION).

CHILDREN ARE GENETICALLY DESIGNED TO BE CARED FOR BY A CARETAKER—OR MANY CARETAKERS AS IN A TRIBE OR CLAN—IN ORDER FOR THE BRAIN TO DEVELOP & FUNCTION OPTIMALLY. BUT WHAT HAPPENS WHEN RAPID SOCIETAL CHANGES NO LONGER PROVIDES THE FULL RANGE OF ATTACHMENT EXPERIENCES THAT THE BRAIN IS GENETICALLY PRIMED TO EXPECT?

“THE LACK OF SOCIAL INTEGRATION IS THE BIGGEST PREDICTOR OF PSYCHOPATHOLOGY.” GEORGE VAILLIANT’S 60 YEAR LONGITUDINAL STUDY

EARLY INFANT STRESS INCREASES STRESS SENSITIVITY RESULTING IN ENDURING ABNORMALITIES IN HPA-AXIS REACTIVITY (HYPOTHALAMIC-PITUITARY-ADRENAL) INCREASED RISK FOR PSYCHOPATHOLOGY IN ADULTHOOD IS NOT DUE TO PSYCHOLOGICAL CONFLICTS AS MUCH AS IT IS RELATED TO NEURO-BIOLOGICAL DEFICITS PRODUCED BY SUB-OPTIMAL ENVIRONMENTAL RESPONSIVENESS, NURTURING, AND CONTAINMENT (INSECURE ATTACHMENT). SAPOLSKY & HIGH STRESS RESPONDERS & DIFFICULTY RETURNING TO HOMEOSTATIC BASELINE.

“THE BRAIN IS A SURVIVAL MACHINE” SAM WANG (2009) THE BRAIN, MORE THAN ANYTHING ELSE, IS CONSTANTLY ADAPTING TO IT’S ENVIRONMENT. ALL BRAIN ADAPTATIONS ARE ATTEMPTS TO AID SHORT TERM SURVIVAL, OFTEN AT THE COST OF LONG TERM SURVIVAL. THREAT & STRESS DURING INFANCY CREATES MOLECULAR & NEUROBIOLOGICAL CHANGES PREPARING THE ADULT BRAIN FOR SURVIVAL IN A DANGEROUS WORLD. “HARD WIRED” NOT A “SOFTWARE PROBLEM.” –ANGER, ANXIETY, IMPULSE CONTROL, DEPRESSION

NEW SCIENCE OF EPIGENESIS EXPERIENCE CAN TURN GENES “ON OR “OFF” EPIGENETIC: “NEITHER GENES NOR ENVIRONMENT DOMINATES DEVELOPMENT. PHENOTYPES EMERGES AS A FUNCTION OF THIS CONSTANT DIALOGUE, AND ANY EFFORT TO ASCRIBE PERCENTAGE VALUES TO ISOLATED VARIABLES IS LIKELY TO BE BIOLOGICALLY MEANINGLESS. (NATIONAL RESEARCH COUNCIL, 2001, pp ). THE OLD “NATURE VERSUS NURTURE" DEBATE-FOCUSING ON WHETHER HEREDITY OR ENVIRONMENT IS THE MAIN DETERMINANT OF HUMAN CONDUCT IS NO LONGER RELEVANT TO SERIOUS DISCUSSIONS OF DEVELOPMENT OR BEHAVIORAL CHANGE.

“RISKY GENES” & ENVIRONMENTAL (SECURE ATTACHMENT) PROTECTIVE FACTORS

SECURE ATTACHMENT PRIMES THE BRAIN FOR A WHOLE HOST OF ADVANTAGES 1. PROTECTIVE FACTOR FOR RISKY GENES THAT ARE VULNERABLE TO THE DEVELOPMENT OF PHYSICAL & MENTAL HEALTH PROBLEMS. 2. REQUIRED FOR THE DEVELOPMENT OF MENTALIZATION & THEORY OF MIND (ToM). 3. ENHANCED CAPACITY FOR CORRECTLY READING SOCIAL CUES. 4. INCREASE RESILIENCY TO LOSS, TRAUMA & STRESS. 5. INCREASE OPTIMISM (“HIGH PLACEBO RESPONDERS.”) WHICH LEADS TO HIGHER LEVELS OF ENDOGENOUS OPIATES, OXYTOCIN & DOPAMINE.

II. ADVANTAGES OF SECURE ATTACHMENT 6. PROMOTES DEVELOPMENT & MAINTENANCE OF SYNAPTIC STRENGTH. 7. INCREASED FLEXIBILITY IN THE REGULATION OF PSYCHOBIOLOGICAL EMOTIONAL STATES THROUGH INTERACTIONS WITH OTHERS. (DISAGREE W/O BEING DISAGREEABLE) 8. BETTER STRATEGIES FOR SELF-REGULATION. 9. INCREASED VAGAL TONE WHICH PROMOTES: 10. INCREASED CAPACITY TO DERIVE PLEASURE FROM HUMAN INTERACTIONS. – RESULTS IN MORE OXYTOCIN & VASOPRESSIN RECEPTORS IN BRAIN. 11. MORE SATISFYING SEXUAL RELATIONSHIPS.

“MENTAL HEALTH IS A SUBSTANCE THAT ATTRACTS ITSELF AS READILY AS MONEY OR POWER: THE MORE YOU HAVE, THE MORE YOU GET” (Lewis, Amini, & Lannon 2000) Jekyll Island MENTALIZATION – SELF-REFLECTIVE FUNCTION, READING THE MENTAL STATES OF OTHERS, COOPERATION, EMOTIONAL & SOCIAL INTELLIGENCE, ETC.

SECURE ATTACHMENT IS NOT AN END IN ITSELF I. SECURE ATTACHMENT = INCREASED AFFECT REGULATION –AUTO-REGULATION & INTERACTIVE REGULATION II. AFFECT REGULATION = LEADS TO MENTALIZATION & ToM (THEORY OF MIND) III. MENTALIZATION & ToM = EMPATHY & COOPERATION IV. EMPATHY & COOPERATION = SURVIVAL OF SPECIES.

ATTACHMENT IS NOT AN END IN ITSELF, BUT EXISTS IN ORDER TO ALLOW A REPRESENTATIONAL SYSTEM TO DEVELOP THAT AIDS HUMAN SURVIVAL BY EQUIPPING AN INDIVIDUAL FOR THE COLLABORATIVE AND COOPERATIVE EXISTENCE WITH OTHERS FOR WHICH THE HUMAN BRAIN WAS DESIGNED. THE EVOLUTIONARY FUNCTION OF ATTACHMENT IS TO EQUIP THE PERSON WITH THE KIND OF ENVIRONMENT NECESSARY WHICH ALLOWS THE UNDERSTANDING OF MENTAL STATES OF SELF AND OTHERS (ToM) TO FULLY DEVELOP. MENTALIZATION & ToM IS NOT A GIVEN, IT IS A HARD WON DEVELOPMENTAL ACQUISITION.

INSECURE ATTACHMENTS IS A SIGNAL OF LIMITATION IN MENTALIZING SKILLS. “SUBOPTIMAL EARLY EXPERIENCES OF CARE AFFECT LATER DEVELOPMENT BY UNDERMINING THE INDIVIDUAL’S CAPACITY TO PROCESS OR INTERPRET INFORMATION ABOUT MENTAL STATES OF OTHERS THAT IS ESSENTIAL FOR FUNCTIONING IN A STRESSFUL SOCIAL WORLD.” (FONAGY, 2002)

WHEN WE ARE ABLE TO MENTALIZE, WE ARE ABLE TO RECOGNIZE THAT THE INTERNAL WORLD IS SEPARATE FROM, BUT RELATED TO EXTERNAL REALITY. BECAUSE WE FEEL BAD OR FEEL GREAT DOESN’T MEAN THAT WE ARE BAD OR GREAT. EX: FRANK B

STUDIES HAVE SHOWN THAT BPD DO HAVE “RADAR” FOR EMOTIONS (ANGER). EXPERIENCE HAS “ETCHED IN” A WELL PRACTICED NEURAL PATHWAY FOR DETECTING THREAT OR REJECTION (i. e. FACIAL, PROSODY, ETC). HOWEVER, THEIR INTERPRETATION OF THE INFORMATION THEY DETECT IS RIGIDLY DYSFUNCTIONAL. –THEY DO NOT HAVE A WELL DEVELOPED ASSOCIATIVE NETWORK THAT ALLOWS THEM TO RECOGNIZE THAT OTHERS CAN HAVE ALTERNATIVE OR DIFFERENT MEANING & EXPERIENCES (ToM).

fMRI SCAN: MENTALIZING PATHWAYS ARE INHIBITED DURING EMOTIONAL AROUSAL ASK TO THINK ABOUT A PAINFUL EVENT.ASK TO THINK ABOUT A PAINFUL EVENT. –SECURE ATTACHED = REACTION MINIMAL –INSECURE ATTACHED = REACTION MAXIMIZED ASK TO THINK ABOUT POSITIVE EVENT.ASK TO THINK ABOUT POSITIVE EVENT. –INSECURE = BRAIN DOESN’T CHANGE –SECURE = BRAIN LIGHTS UP INSECURELY ATTACHMENT INDIVIDUALS HAVE MORE DIFFICULTY:INSECURELY ATTACHMENT INDIVIDUALS HAVE MORE DIFFICULTY: –1. MANAGING NEGATIVE EMOTIONS. –2. PROMOTING & SUSTAINING POSITIVE EMOTIONS. JEREMY HOLMES (2008) –

NEUROCHEMISTRY OF ATTACHMENT & STRESS DIFFERENCE BETWEEN NEUROTRANSMITTERS & HORMONES. NEUROTRANSMITTERS = FAST (SECONDS) HORMONES = MINUTES, HOURS, DAYS, WEEKS, MONTHS, YEARS, & DECADES.

LIMBIC SYSTEM: THE SOCIAL BRAIN FRONTAL LOBE EXECUTIVE FUNCTION ATTENTION HIPPOCAMPUS EXPLICIT MEMORY LEARNING AMYGDALA EMOTION FEAR/ANXIETY IMPLICIT PROCESSES HYPOTHALAMUS IMPACTS THE EFFICIENCY OF THE OTHER THREE. *HORMONES: CORTISOL & OXYTOCIN THE NEURAL PATHWAYS OF ATTACHMENT & SOCIAL ENGAGEMENT SHARE THE SAME NEURAL PATHWAYS THAT SUPPORT NEURONAL GROWTH, RESTORATION & HEALTH

HORMONES & HYPOTHALAMUS ANTERIOR PITUITARY = GLUCOCORTICOID (CORTISOL) POSTERIOR PITUITARY = OXYTOCIN CORTISOL: BIGGEST INHIBITOR OF NEUROGENESIS & PLASTICITY OXYTOCIN: PROMOTES TRUST, ATTACHMENT & COOPERATION

CORTISOL vs. OXYTOCIN THE BATTLE FOR CONTROL OF THE PFC

HIGHER THE OXYTOCIN, THE HIGHER THE BONDING & MONOGAMY LARRY YOUNG, PhD NATURAL CHILDBIRTH + BREAST FEEDING PRODUCES A HUGE OXYTOCIN RELEASE. OXYTOCIN GIVEN TO HUMAN SUBJECTS PRODUCES NURTURING BEHAVIOR & INCREASED TRUST. HIGH OXYTOCIN DECREASES THE STRESS RESPONSE. –DAMPENS THE RESPONSE INTENSITY OF AMYGDALA. HIGHER LEVELS HELPS THE BRAIN PAY CLOSER ATTENTION TO SOCIAL INFORMATION. INCREASED SKILLS AT PICKING UP FACIAL CUES LEADS TO MORE SATISFACTION & LESS CONFLICT IN RELATIONSHIPS. INCREASED REWARD IN RELATIONSHIPS LEADS TO GREATER OPPORTUNITY FOR ENDOGENOUS OPIOID RELEASE.