The Neuropsychotherapy of Crisis Counseling
By Mike Caverly
Facilitating control is one of the primary treatment objectives of many therapeutic approaches. Using mindfulness-based stress reduction to help manage anxiety during a crisis is one way to achieve this end. In this article I take a neuropsychotherapy (NPT) approach to a client in crisis and emerging research on the neuroscience of mindfulness. I propose that an NPT approach to crisis counseling can validate mindfulness and provide clinicians and clients alike with tangible reasons to engage the coping skill that many may have felt too existential.
Let me begin with the neuroscience of a crisis. Grawe (2007) highlights the amygdala and hippocampus as key areas of focus during a therapeutic intervention. During a crisis, the amygdala up-regulates and dominates the individual’s attention. This results in a down-regulation of the prefrontal cortex (PFC)—specifically the ventromedial prefrontal cortex (vmPFC), dorsomedial prefrontal cortex (dmPFC), and posterior cingulate cortex/precuneus (PCC)—which affects the client’s ability to engage in higher-order cognition. These areas are implicated in self-referential processing (Northoff et al., 2006; Goldin, 2012). During a crisis, the vmPFC, dmPFC, and PCC are adversely affected by anxiety in the brain, shaping self-concept in a negative way. The dorsal anterior cingulate cortex (dACC) is also implicated in cognitive control and may be compromised due to high anxiety and amygdala up-regulation. Then there is the superior parietal lobe (SPL), which recent research has linked to self-talk (Goldin, 2012). During a crisis, self-talk focuses on self-preservation, which may include avoiding the experience of anxiety itself. To complicate things, up-regulation of the amygdala due to anxiety may adversely affect self-talk in the SPL. A default neural pattern of amygdala up-regulation and threat avoidance may lead to even greater anxiety, negative self-talk, altered self-referential processing, loss of psychological control, and inability to engage higher-order cognition.
In counseling, it is the role of the therapist to help a client negotiate his or her subjective experience of a crisis and subsequent distress. In light of the above, one sensible way to begin is with deep breathing and mindfulness-based stress reduction (MBSR) to mitigate the neurobiological effects of the crisis. Once the immediate effects are managed in this way, a neuropsychotherapist can explain how the various brain regions are affected by anxiety, which in itself can facilitate a degree of control. In fact, explaining the brain’s reaction to deep breathing and MBSR can not only validate and normalize the experience of a crisis but also validate the use of MBSR and deep breathing as a primary coping skill.
Goldin (2012) was not the first to find neurobiological evidence that MBSR can reduce anxiety, but he was one of the first to suggest that suicidality, emotional dysregulation, and resulting rumination are the result of amygdala activity, down-regulation of the PFC, and poor bottom-up neurobiological functioning. The crisis dominates attention, and the client cannot stop ruminating in this default neural pattern. MBSR down-regulates the amygdala, influencing the PFC, the SPL, the dACC, and the neural systems implicated in a conceptual view of self. But allow me to go a step farther with Goldin’s findings and propose that the use of deep breathing in conjunction with MBSR could be the key to a successful approach. From a neurobiological stance, the brain stem controls breathing, while deep breathing circumvents the limbic system through a bottom-up approach to managing a crisis. The brain stem would slow amygdala up-regulation, which would in turn effect change in the higher cortical areas (vmPFC, dmPFC, PCC, SPL, and dACC) due to the absence of anxiety.
In a nutshell, MBSR coupled with deep breathing and NPT could prove effective for crisis counseling. If a clinician is able to explain the brain’s reaction to MBSR, this could validate the use of the coping skill; however, it is clearly better to manage the emotional reactions to a crisis before diving into the neuroscience. One thing is certain: Crisis counseling and an understanding of the brain go hand in hand. MBSR can help a client feel more in control, while the adjunct of NPT can validate the crisis and MBSR as a long-term coping skill.
Grawe, K. (2007). Neuropsychotherapy: How the neurosciences inform effective psychotherapy. Mahwah, NJ: Lawrence Erlbaum.
Goldin, P. (Speaker). (2012, March 21). The mindful brain: If the Buddha was a neuroscientist [Video podcast]. Nerd Nite SF. Retrieved from https://vimeo.com/65171562
Northoff, G., Heinzel, A., de Greck, M., Bermpohl, F., Dobrowolny, H., & Panksepp, J. (2006). Self-referential processing in our brain: A meta-analysis of imaging studies on the self. NeuroImage, 31, 440–457.