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Is it OK to Break the "Rules" of Psychotherapy?
By Jason von Stietz
November 28, 2014
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May neurofeedback practitioners are also psychotherapists, or started as one. Does Freud's conceptualization of the psychotherapist as a blank slate still apply today? Currently, many struggle with whether or not to abandon Freud’s old axiom. A recent article in The New York Times discussed this dilemma from the viewpoint of a psychiatrist:


When Julia first appeared in my office, she was approaching her 35th birthday. She had resolved it would be her last.


A hard-working surgeon at a nearby hospital, Julia endured a monastic, grueling existence even in the best of times. Then a deep depression struck. Soon it had shut out all remnants of pleasure, robbing her nights of sleep and locking her features into a mask of anguish. She began to think about suicide. Finally, a colleague of hers insisted she seek help.


From the start of therapy, and despite her weariness, Julia mustered the determination to protest what she called the “rules of therapy” — especially the notion that I would not disclose personal information about myself during her treatment. She’d manage a faint, defiant smile and rattle off interrogations: “Don’t you get bored listening to us mental patients?” “You’re holding your head in your hand — do you have a headache?” “Do you have children? How many?”


She hadn’t learned this rule from me. She came to treatment under the assumption I would adhere to it. This was understandable; the caricature of the infuriating Freudian analyst, stroking his beard and deflecting the patient’s question with another question (“And how do you feel about that?”), pervades popular culture.


And in fact, the rule originated with Freud. In a 1912 paper, he advised doctors practicing psychoanalysis that the physician “should be opaque to his patients, and, like a mirror, show them nothing but what is shown to him.”


In psychoanalysis, there is a specific rationale for this rule. The theory holds that patients tend to re-enact with therapists the relationships they had with their parents. This is called transference. By paying careful attention to this unfolding drama — as it plays out, right there in the office — the therapist and patient can uncover and resolve childhood conflicts. If a therapist interjects information about herself, she clouds the mirror and compromises the process.


But I’m not a psychoanalyst. I’m a psychiatrist, a medical doctor who treats mental illness with both medication and psychotherapy. And Julia had a biological illness — major depressive disorder — that required in part a biological treatment. Freud’s dictum was not necessarily central to my work with her.


Yet she doggedly tried to wrest confidences from me. Why?


Julia agreed to take antidepressant medication, which reduced her most immobilizing symptoms. Yet sitting in my office, wrapped in an afghan I had there for warmth, she looked like a sad and lonely waif. What was the origin of her melancholy? Unless we could better understand it, it would probably continue to predispose her to severe depressive episodes. So we embarked on more intensive psychotherapy.


Here, Julia’s instincts about my willingness to talk about myself were partially correct. I’m not doctrinaire, but neither am I one to divulge much about my private life.


Even if you’re not a classical Freudian analyst, there are good reasons for a therapist to adopt a posture of neutrality. For one thing, patients need to be free to take the discussion anywhere, including uncomfortable or taboo territories. If therapy were reciprocal, therapists might close off avenues of conversation that they themselves might want to avoid.


So I tended to be my usual “therapist self” with Julia: attentive, open and, I hoped, warm — yet neutral and withholding when it came to my own life. But the more I withheld from her, the harder she pressed me to open up. It was impossible not to wonder what lay behind her insistence.


Julia looked to the outside world like the very picture of competence. Her voice had a lovely composed timbre that seemed to be saying, “I’ll handle this.” And people routinely accepted this implicit offer. She was the solution to everyone’s problem.


But I quickly learned that behind this facade of proficiency was a fragile soul. During the most vulnerable developmental stages of Julia’s life, beginning in infancy, her mother had suffered from severe mental illness and a personality disorder that rendered her erratic and narcissistic. She was never completely present for Julia. Indeed, Julia was the one called on to calm her down. Julia had parlayed that skill into becoming what she termed a Sherpa — someone so skilled at carrying weight for others that no one knew anything of her burdens.


Julia presented me with a therapy challenge. She had honed the art of shifting the valence of a conversation toward the other person, hiding herself. She desperately wanted to attach to me, and this was her tried and true method of establishing intimacy — or her approximation of it. But by persistently asking me personal questions, she also threatened to repeat the dynamic that left her feeling isolated and alone in the outside world.


It seemed she was once again trying to be the Sherpa.


When I pointed this out to her, she withdrew. No matter how gently I offered this observation, she experienced it as a rebuke, a hurtful break in our growing closeness. However, if I failed to point out these moments, I feared she wouldn’t see that she was unconsciously trying to mold our relationship into yet another of those unsatisfying one-way relationships in her life. I was in a quandary.


There is a quotation from the psychiatrist D. W. Winnicott, the wisdom of which, at that point in my development as a psychiatrist, I had yet to appreciate. “It appalls me to think how much deep change I have prevented or delayed,” Winnicott wrote, “by my personal need to interpret.”


With Julia, I began to learn Winnicott’s lesson. As therapy continued with her, I heard how flat and tinny I sounded whenever I attempted to analyze what was going on between us. When I lapsed into too clinical a mode, our connection would wobble, and her alienation became palpable.


In contrast, as I began, in the face of her challenges, to let down my guard, our alliance grew stronger, and she became open to treatment. We would laugh together about her bringing me just the right greeting card or a flower from her garden — exhibiting her need to challenge “the rules” and exposing my need to interpret her actions. These interactions helped develop her capacity to observe herself in action, as she courted me in her Sherpa style.


I may have been a slow student, but eventually I understood: I was the one who had to change. From then on, when she saw that look in my eyes, I said yes, I did have a migraine. We followed episodes of the TV show “ER” together, and I told her where I was going when I left for vacation.


When I worried out loud that, in her engagement with my life, she was treading too close to a denial of the importance of her own, she answered, “I trust that you won’t let me go there.” With her heightened awareness of her pattern of creating intimacy, perhaps things could change for her.


Many years have now passed. What’s become of Julia? She inhabits a life unrecognizable from this vignette, a life changed in many ways for the better. Alas, she still has a chronic relapsing illness — severe depression — for which there is yet no magic cure. But she has succeeded in training me to become a better doctor for her, and she continues to come to me for treatment. Though modern psychiatry can’t always cure every disease, I can at least help Julia do some of the heavy lifting.


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Ventral Striatum Involved in Choking Under Pressure
By Jason von Stietz
November 21, 2014
Photo Credit: Getty Images


Athletes can train a lifetime to accomplish their goals. However, when the moment of truth comes the pressure can often be too much. How is it that even the most physically gifted and skilled athletes can "choke" under pressure? Recent reseach has found that the ventral striatum mediates the relationship between incentives and performance. The findings were discussed in a recent article in the Huffington Post: 


Choking is a common, though agonizing, story for most professional athletes and performers. And it usually has nothing to do with a lack of skill, but rather, the pressure of the immense gains or losses that are at stake.


“Choking isn’t just poor performance,"University of Chicago psychologist Sian Beilock, author of Choke, toldSmithsonian. "It is worse performance than you are capable of precisely because there is a lot on the line.”


Moments of "just messing up" in high-pressure situations may seem random and uncontrollable, but scientists are beginning to demystify just why it is that we choke, and how we might be able to prevent such high-stakes errors.


It turns out that being too attached to winning may have been what caused Maroney to choke, according to some new research from neuroscientists Johns Hopkins University.


Whether you choke under pressure might have more to do with your motivation: specifically, to what extent that you are driven by a desire to win or by a desire to avoid losing. If you're very loss-averse -- meaning that you hate losing more than you love winning -- your chances of choking will be lower. But for those who value the rush of winning over the pain of losing, the likelihood of choking is often higher.


The Johns Hopkins study found that those who hated losing the most choked when told that they stood to win the most, while those who cared more about winning choked when they stood to lose something significant. In other words, it's all about how you frame the incentive: as a loss or as a gain.


“We can measure someone’s loss aversion and then frame the task in a way that might help them avoid choking under pressure,” Vikram Chib, Ph.D., assistant professor of biomedical engineering at the Johns Hopkins University School of Medicine, said in a statement.


The researchers explain this phenomenon by looking at the ventral striatum, a brain region that may connect incentive-driven motivation and the execution of physical performance. The activity of this brain region suggests that an individual's attachment to winning is key to how they perform under pressure.


They proved it with this experiment: 26 adult participants, between the ages of 20 and 30, were tested on two consecutive days. They learned a brief but difficult video game requiring precise hand control on the first day. On the second day, the participants were placed in an MRI machine. Before each two-second round of the game, they were told what the stakes for that round would be: Losing $100 in cash, gaining $100 or anything in between, based on how they performed. The amount of money that the subjects got to take home was determined at random based on their performance on one of the 300 rounds, which gave them an incentive to perform their best in each round.


Separately, the participants were asked a series of theoretical questions about what they would gamble and how much risk they'd take for various outcomes, so that the researchers could determine their level of loss aversion.


“We found that the way we framed an incentive -- as a potential gain or loss -- had a profound effect on participants’ behavior as they performed the skilled task,” Chib said in the statement. “But the effect was different for those with high versus low aversion to loss.”


High loss aversion actually helped participants when they faced increasing losses -- they didn't choke, even when the loss was up to $100. Those with high loss aversion performed well when there were potential gains of $25 or $50, but when offered a $100 reward, they choked. The opposite happened to those with low loss aversion: their performance improved with both increasing prospective gains and increasing prospective losses, but they choked when threatened with a $100 loss.


While all of this was happening, MRI images were being taken of the participants' brains, focusing on the ventral striatum, that small area of the brain associated with reward processing and movement control. They saw that when both loss and gain incentives were presented, ventral striatum activity increased with the magnitude of the stakes.


More loss-averse participants had lower striatal activity (and thus performed worse) when playing for large potential wins, whereas more winning-attached participants had less striatal activity (and worse performance) when attempting to avoid losing.


"We have known from previous studies that the ventral striatum is responsible for representing information about incentives and motor performance, but this study shows how it mediates the relationship between incentives and performance," Chib explained in an email to the Huffington Post. "We show that in the situations when people choke under pressure there is a break down in the connectivity between ventral striatum and the motor cortex (the are responsible for coordinating our movements). These breakdown in communication between these areas could be causing individuals to choke under pressure."


So how can we apply this information to improve our own performance? One way would be to use cognitive strategies to reframe high-stakes situations so as to help minimize your chances of poor performance. So if you're someone who plays to win, try to avoid framing the situation more in terms of what you could stand to lose.


"From this study, it seems that knowing an individuals’s loss aversion could be used to determine the best way to frame incentives in the workplace," Chib added.


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Curiosity Enhances Learning
By Jason von Stietz
November 14, 2014
Photo Credit: Getty Images


Many teachers understand that when students are curious they are more likely to get engaged with the material. “Exactly what does the term dinosaur mean?” and “What are the physics involved in a sunset?” are both questions designed to pique the curiosity of students and spark a thought provoking discussion. Researchers often find that curiosity enhances learning. A recent article by nprED discussed the findings of several studies on curiosity and learning:  


How does a sunset work? We love to look at one, but Jolanda Blackwell wanted her eighth-graders to really think about it, to wonder and question.


So Blackwell, who teaches science at Oliver Wendell Holmes Junior High in Davis, Calif., had her students watch a video of a sunset on YouTube as part of a physics lesson on motion.


"I asked them: 'So what's moving? And why?' " Blackwell says. The students had a lot of ideas. Some thought the sun was moving; others, of course, knew that a sunset is the result of the Earth spinning around on its axis.


Once she got the discussion going, the questions came rapid-fire. "My biggest challenge usually is trying to keep them patient," she says. "They just have so many burning questions."


Students asking questions and then exploring the answers. That's something any good teacher lives for. And at the heart of it all is curiosity.


Blackwell, like many others teachers, understands that when kids are curious, they're much more likely to stay engaged.


But why? What, exactly, is curiosity and how does it work? A studypublished in the October issue of the journal Neuron suggests that the brain's chemistry changes when we become curious, helping us better learn and retain information.


Our Brains On Curiosity


"In any given day, we encounter a barrage of new information," says Charan Ranganath, a psychologist at the University of California, Davis and one of the researchers behind the study. "But even people with really good memory will remember only a small fraction of what happened two days ago."


Ranganath was curious to know why we retain some information and forget other things.


So he and his colleagues rounded up 19 volunteers and asked them to review more than 100 trivia questions. Questions such as, "What does the term 'dinosaur' actually mean?" and "What Beatles single lasted longest on the charts, at 19 weeks?"


Participants rated each question in terms of how curious they were about the answer.


Next, everyone reviewed the questions — and their answers — while the researchers monitored their brain activity using an MRI machine. When the participants' curiosity was piqued, the parts of their brains that regulate pleasure and reward lit up. Curious minds also showed increased activity in the hippocampus, which is involved in the creation of memories.


"There's this basic circuit in the brain that energizes people to go out and get things that are intrinsically rewarding," Ranganath explains. This circuit lights up when we get money, or candy. It also lights up when we're curious.


When the circuit is activated, our brains release a chemical called dopamine, which gives us a high. "The dopamine also seems to play a role in enhancing the connections between cells that are involved in learning."


Indeed, when the researchers later tested participants on what they learned, those who were more curious were more likely to remember the right answers


Curiosity Helps Us Learn Boring Stuff, Too


There was one more twist in Ranganath's study: Throughout the experiment, the researchers flashed photos of random faces, without giving the participants any explanation as to why.


Those whose curiosity was already piqued were also the best at remembering these faces.


The researchers were surprised to learn that curious brains are better at learning not only about the subject at hand but also other stuff — even incidental, boring information.


"Say you're watching the Breaking Bad finale," Ranganath explains. If you're a huge fan of the show, you're certainly really curious to know what happens to its main character, Walter White.


"You'll undoubtedly remember what happens in the finale," he says, but you might also remember what you ate before watching the episode, and what you did right after.


This is a phenomenon teachers can use to their advantage in the classroom, says Evie Malaia, an assistant professor at the Southwest Center for Mind, Brain and Education at the University of Texas, Arlington.


"Say a kid wants to be an astronaut," she says. "Well, how do you link that goal with learning multiplication tables?" A teacher may choose to ask her class an interesting word problem that involves space exploration, Malaia says.


At the end of the class, students may remember the answer to the word problem, but they'll also remember how they found the answer through multiplication.


"This way kids basically get into the driver's seat," Malaia says. "They feel especially good if they discover something, if they construct knowledge themselves."


Teachers have been using this technique instinctively for years, she adds, and now the science is backing that up. "Curiosity really is one of the very intense and very basic impulses in humans. We should base education on this behavior."


What We Still Don't Know


There's a lot scientists still don't understand about curiosity. "There's only a handful of studies on curiosity," Ranganath says. "It's very hard to study."


Researchers don't know, for example, why exactly we get such a high off learning, through Ranganath says it makes sense from an evolutionary standpoint. "We might have a basic drive in our brain to fight uncertainty," he says. The more we know about the world, the more likely we are to survive its many perils.


Scientists are also trying to figure out how long the effects of curiosity last — if a kid's curiosity is piqued at the beginning of the school day, will she be good at absorbing knowledge all day long? Or will she lose interest?


What Ranganath wants to know most is why some people seem naturally more curious than others. Lots of factors, including stress, aging and certain drugs can affect dopamine processing in the brain, he says. Genetic factors may also influence how inquisitive we are.


"If we could figure these things out, it would have a huge impact. We could help those who may just seem bored," Ranganath says.


Blackwell, the science teacher in California, says she doesn't have to deal with that problem too often.


She says her students love exploring the mysterious unknowns in science: What happens when a car crashes? Why does one car get more beat up than the other? Why do some people look more like their aunt than their mom? How do rainbows work?


"I tell my kids there's no dumb questions," Blackwell says. "That's science: asking questions and seeking answers."


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Unconscious Information Impacts Conscious Decision Making
By Jason von Stietz
November 4, 2014
Photo Credit: iStockPhoto


Do people really know why they make the decisions that they do? Researchers at the University of South Wales examined the impact of unconscious processing on conscious decision-making. Findings indicated that unconscious information can be accumulated over time and mixed with conscious information to boost decision-making processes. MedicalXpress discussed the study in a recent article:


Psychologists (and others) have debated for a long time whether the conscious decisions people make are influenced by unconscious information. Does some part of our brain hold information that somehow has a backdoor to our conscious thought-making process, without our knowing it? Some prior research has suggested that might be the case—it might explain, for example, why people make seemingly illogical decisions sometimes.


To better understand what might be going on, the researchers placed a dynamic dichoptic mask on each volunteer—it allowed for showing different imagery to each eye. Volunteers were shown images of moving dots and were asked to tell the researchers which direction they were moving—left or right. The catch was that the movement was nearly imperceptible at first, only growing more apparent over time. The earlier a volunteer could identify which way the dots were moving, the more accurate their score. During some experiments, colored dots moved randomly in front of one eye, while grey dots moving either left or right were shown to the other. The colored dots overwhelmed the brain with information causing the imagery from the grey dots to be obscured. Prior research has shown that when faced with such a setup, the human brain does in fact "see" what is going on with the grey dots—but only unconsciously, the person isn't aware of it. In this new study, the researchers tested whether offering some prior information unconsciously via the two types of exposure could cause changes to the accuracy of imagery presented afterwards. They found that indeed it did—the volunteers more accurately figured out which way the grey dots were moving when they saw them beforehand while the colored dots were moving, but didn't know it. Thus, the unconscious information somehow helped improve their accuracy, which is an example, the team claims, of unconscious information impacting decision making.


Interestingly, the researchers also found that the degree of confidence in the accuracy by the volunteers wasn't changed regardless of whether they were being impacted unconsciously or not. They suggest that if similar processes are going on everyday for everyone it could have broad implications for interpreting how humans think in general.


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