Psychodynamic Psychotherapy in the Scanner?

Arrangement for psychotherapy fMRI studies using the couch of Sigmund Freud.

[No not really, although the authors did stretch the implications of their findings in the Discussion...]

Whether the proprietors of this blog want to admit it or not, neuropsychoanalysis appears to be a new field of study. What does psychoanalysis do to the brain? In a new Psychotherapy Research paper, Loughead et al. (2010) collected autobiographical relationship narratives from 16 healthy control participants free of any psychiatric or neurological ailments. These types of vignettes were used as stimuli because "people in psychotherapy spontaneously recall and tell stories about their relationships with other people..." A series of 14 one minute narratives was collected from each subject using the Relationships Anecdotes Paradigm (RAP) method, a structured interview designed to elicit descriptions of meaningful life events with another person. The participants then rated each episode on a 5-point Likert scale for positive and negative emotions.

The investigators rated the narratives in another fashion to extract common themes. The core conflictual relationship theme (CCRT) method (Luborsky & Crits-Christoph, 1998) is a psychotherapy instrument used to measure patterns within interpersonal relationships:

From a content analysis of the relationship narratives, it is possible to identify three kinds of relationship components: (a) wishes (wishes, intentions, goals of the individual or self); (b) responses from the other to the self; and (c) responses of the self to the other...

The main CCRT relationship patterns are defined as the most repetitive relationship themes across an individual’s relationship narratives, usually those ranking first and second in frequency across the narratives. These main CCRTs have been a focus for the conduct of both psychotherapy and psychotherapy research (Luborsky & Crits-Christoph, 1998).

Then a neuroimaging study was conducted with 11 of the participants (5 were ultimately tossed out for various reasons). It's notable that all subjects were free of psychiatric disorders, and none were in therapy. So the direct application of the results to psychotherapy practice is questionable. That said, what were the experimental procedures? For the narratives,

The two most repetitive wishes (W), responses from others (RO), and responses of self (RS) were identified for each participant’s set of 14 narratives. These repetitive themes are hereafter referred to as the main CCRTs. Weighted scores were then assigned to each narrative based on the frequency with which the participant’s main CCRT themes appeared in her or his 14 narratives. For example, if a participant’s main RO was "hurt me" and it appeared in seven of 14 narratives, then each narrative containing the RO "hurt me" received a weighted score of 7....

The weighted scores for the other elements were tallied up, and 3 narratives each were selected for the high and the low CCRT/emotion conditions [NOTE: these two factors could not be distinguished from each other]. In addition, narratives from one of the excluded participants served as the control, non-autobiographical relationship episodes:

...The control episodes were selected to be similar to the personal condition in narrative structure, emotion, and CCRT content and yet have no autobiographical relevance to the participant.

The three types of stimuli were presented in a block design: six 30-s blocks of personal narratives and six 30-s blocks of control narratives (half high, half low CCRT/emotion), with resting baseline thrown in for good measure. A sample CCRT narrative is shown below (click on image for a larger view).


Figure I (Loughead et al. (2010). Sample CCRT relationship episode.

The fMRI results came as no surprise to anyone: personal autobiographical memories activate the brain to a greater extent than someone else's memories. Wow!

The network of frontal and parietal regions observed for the main effect of narrative type, which includes the anterior cingulate, precuneus/posterior cingulate, inferior frontal gyrus, inferior parietal lobule, and middle frontal gyri, is consistent with the existent neuroimaging literature on recall of autobiographical memories (Buckner & Carroll, 2007...).

Figure II (Loughead et al. (2010). Brain images showing group main effect for narrative type (personal, control). Statistical parametric maps are displayed in radiological convention (left is right) standardized into Talairach space. ACC, anterior cingulate; Inf Front, inferior frontal gyrus; Mid Front, middle frontal gyrus; Inf Parietal; inferior parietal lobule. No voxels were above threshold for CCRT/emotion (high, low) main effect or the interaction.

And there was absolutely no difference in brain activity elicited by the low CCRT and high CCRT conditions. So much for the CCRT method, at least in this non-psychiatric population. However, exploratory analyses showed correlations between BOLD signal and CCRT score in the left hippocampus, parahippocampal gyrus, and middle occipital gyrus. Not in the amygdala, however. The lack of main effect or interaction for the main variable of interest did not prevent the authors from speculating wildly:

Our exploratory analysis suggests that narratives characterized by increasing amounts of the most repetitive (i.e., main CCRT patterns) are special from a neurobiological perspective... When narratives are high in CCRT content, this is somewhat akin to exposing, or reflecting back, the main CCRT themes to a patient (i.e., providing a transference interpretation). Thus, an area of further study suggested by these results is how exposure to the main CCRT themes (or transference interpretation) could modulate brain activation in the medial temporal and occipital lobes in treatment populations.

Never mind that no psychotherapist was involved at all, since none of the participants were In Treatment. And what wild speculation would be complete without... MIRROR NEURONS!

Memories, the self, and emotion have long been of interest to psychotherapy, and theory of mind/mentalization and the mirror neuron system have been proposed as specific mechanisms of psychotherapy process (Fonagy & Bateman 2006...). These results demonstrate that the essential psychotherapy activity of recall of autobiographical relationship episodes engages neural substrates for systems that have been identified by research as central for psychotherapy process.

References

Buckner RL, Carroll DC. (2007). Self-projection and the brain. Trends in Cognitive Sciences 11:49-57.

Fonagy P, Bateman AW. (2006). Mechanisms of change in mentalization-based treatment of BPD. Journal of Clinical Psychology 62:411-430.



Loughead, J., Luborsky, L., Weingarten, C., Krause, E., German, R., Kirk, D., & Gur, R. (2010). Brain activation during autobiographical relationship episode narratives: A core conflictual relationship theme approach. Psychotherapy Research, 1-16 DOI: 10.1080/10503300903470735

Luborsky L, Crits-Christoph P. (1998). Understanding transference: The core conflictual relationship theme method (2nd ed.). Washington, DC: American Psychological Association.