A Transtheoretical Psychotherapist Dialectic:

Dual Processing and the Functional Neuroanatomy of the Human Brain

Part 1

Jack C. Anchin

doi: 10.12744/tnpt(4)100-107

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Transtheoreticism seeks to advance psychotherapeutic efficacy by bringing to bear perspectives on theory, practice, research, and training, which go beyond those encapsulated by specific theoretical frameworks—psychodynamic, cognitive–behavioral, humanistic–existential, multicultural, for example—and focus instead on processes, phenomena, and/or issues shared by virtually all therapeutic approaches.  Despite the argument put forward by Wosket (2006) that “integration is now a useful umbrella term to accommodate a range of approaches that extend beyond purist forms of therapy to include pluralism, transtheoreticism, common factors, eclecticism, relational, and deconstructionist approaches” (p. 5), in the present context I prefer the term transtheoreticism over integration because it denotes perspectives designed explicitly to transcend specific theoretical orientations.  While a transtheoretical conception does not by any means obviate the value of specific theoretical approaches to psychotherapy, it does provide a scaffold for incorporating and integrating constructs and methods from multiple theories into a more overarching structure with functional benefits.

            The Transtheoretical Model (TTM) of Prochaska, DiClemente, and Norcross (1992; see also Norcross, Krebs, & Prochaska, 2011) is a quintessential exemplar.  In TTM, behavior change is conceptualized as a temporally unfolding process in which the patient progresses through a series of five stages (precontemplation, contemplation, preparation, action, and maintenance), each associated with different change processes (Norcross et al., 2011).  As these authors elaborate, “Change processes are overt and covert activities that individuals engage in when they attempt to modify problem behaviors.  Each process is a broad category [e.g., consciousness raising; self-liberation; reinforcement] encompassing multiple techniques, methods, and relationship stances traditionally associated with disparate theoretical orientations” (Norcross et al., p. 281).  As touched on elsewhere (Magnavita & Anchin, 2014), examples of other domains of transtheoretical interest include

  • bridging the gap between research and practice;
  • methodological pluralism through the incorporation of mixed methods (such as qualitative and quantitative methodologies) in clinical research;
  • pantheoretical constructs—mental representations;
  • factors such as the therapeutic alliance, and measures of processes and mechanisms of change in psychotherapy; and
  • the desirability of a common language system for psychotherapy.

This article is the first of a two-part article aimed to describe and contextualize the framework of transtheoreticism.  Here, in Part 1 of the article, I argue that, by virtue of the functional neuroanatomy of the human brain and its intersection with the mass of stimuli and the complexity of tasks inherent to doing psychotherapy, engaging in dialectical thinking is organic to psychotherapeutic functioning, regardless of theoretical orientation.  In offering this conception, crystallization of the core meaning of dialecticism will be followed by a brief discussion of the dialectical nature of human information processing and its anchoring in the brain’s intrinsic neuroanatomy.  To illustrate the framework more fully, this formulation will then be applied to an analysis of psychotherapeutic functioning in a specific clinical situation.  In Part 2 of the article, to be published in the next issue of The Neuropsychotherapist, I will discuss specific ways in which knowledge and understanding of this inescapable dialectic in the realm of information processing, and its hardwired neuroanatomical underpinnings, can beneficially inform psychotherapeutic practice and supervision.

The Dialectic

For some 35 years, theorists and practitioners (e.g., Downing, 2000; Hanna, 1994; Linehan, 1993; Magnavita & Anchin, 2014; Rychlak, 1976) have been articulating an array of conceptual and interventional benefits that derive from bringing an explicitly dialectical frame to the vast domain of psychotherapeutic phenomena.  As I have explained elsewhere (Anchin, 2008), the dialectic is a metaconstruct that fundamentally denotes bipolarity, wherein two elements stand in direct opposition or contradiction to one another, but through their dynamic interplay they create a holistic system (Rychlak, 1976).  Hegel’s “thesis–antithesis” duality is the prototypical embodiment of this configuration, which has been depicted variously as “binary oppositions” (Dunning, 1997, p. 4), “internal opposing forces” (Linehan, 1993, p. 32), and “unified opposites” (Baxter & Montgomery, 1998, p. 4).  A dialectical framework, as described by Downing (2000), “assumes that the oppositions which we see are inherent in nature” (p. 258), or, as Linehan (1993) stated, “Reality is not static, but is comprised of internal opposing forces . . . . [W]ithin each one thing or system, no matter how small, there is polarity” (p. 32). The inverse of this conception—and thus fundamental to dialecticism—is the highlighting of “interrelatedness and wholeness.  Dialectics assumes a systems perspective on reality” (Linehan, 1993, p. 31).  Emphasis is thus placed on holism and totality—yet, at the same time, recognizes “the splitting of a totality into its contradictory parts and the examination of the parts as they relate to each other [Lenin, 1915/1977]” (Greenberg & Pascual-Leone, 1995, p. 169).

In this view, therefore, dialectical understanding of a given phenomenon, or process, proceeds through undertaking a dialogue—tacking back and forth—between the opposing sides of the bipolarity, recognizing that each, being an integral part of the whole, contributes important knowledge about the phenomenon or process under consideration (Downing, 2000).  As Erbes (2004) put it, “Rather than focus on one idea, issue, or pole of a dialectic, dialectical thought suggests that we understand the world by looking at both sides of any dialectic.  Only by studying their dynamic interplay as a whole can a phenomenon be understood” (p. 205).

The Dialectics of Brain Neuroanatomy: Dual Processing and the X- and C-Systems

            An array of dual-process theories of the human mind have been developed in cognitive and social psychology over the past three decades.  Comprehensive reviews and analyses by Evans (2008), and Gawronski and Creighton (2012), make abundantly clear that these theories are far from homogeneous; nevertheless, these scholars also concur that sufficient commonalities exist to enable one to identify generic features of dual-processing theories.  It is these generic commonalities that are emphasized in the present context.

Fundamentally, dual-process theories posit that the mind is characterized by two different systems of information processing—one characterized by automatic, the other by controlled, processing. Automatic processing is unconscious, implicit, relatively effortless and rapid, emotion-tied, concrete, and occurs unintentionally, whereas controlled processing is conscious, explicit, relatively effortful and slow, rational, abstract, and intentionally initiated (Evans, 2008; Gawronski & Creighton, 2012; Lieberman, 2007).

Work by Lieberman and his colleagues (e.g., Lieberman, 2003; Satpute & Lieberman, 2006; Spunt & Lieberman, 2013) has been groundbreaking in solidifying the case for the dual-process distinction by linking it to findings from social cognitive neuroscience.  By characterizing automatic processing as reflexive and controlled processing as reflective, Lieberman (2007) presents evidence that these systems are independent in that each recruits distinctly different neural structures.  Thus, the neurobiological underpinnings of automatic processing, labeled the X-system (based on the x in reflexive) involve the amygdala, basal ganglia, lateral temporal cortex, ventromedial prefrontal cortex, and dorsal anterior cingulate cortex; and the neurobiological underpinnings of controlled processing, labeled the C-system (based on the c in reflective) involve the rostral anterior cingulate cortex, lateral prefrontal cortex, posterior parietal cortex, and the medial temporal lobe, including the hippocampus.  Importantly, Lieberman also makes the crucial point that “the systems are independent in the sense that they rely on different neural structures, but they are not independent in the sense that there is no interaction between them.  In most everyday experiences, it is likely that both systems are operating and contributing to ongoing thought and behavior, albeit in different ways” (Lieberman, 2007, p. 305); or, as he states more succinctly elsewhere, “In everyday life, these two systems are often working together and simultaneously” (p. 299).

Dichotomous yet complexly interactive, the X- and C-systems literally embody a dialectic in nature in action.

 

Psychotherapeutic Complexities and the Necessity for Dual Processing

The prototypical situation that characterizes psychotherapy is fraught with tremendous complexity.  Consequently navigating its multiple concurrent, sequential, and nonlinear processes in ways that ultimately produce therapeutic benefits for the patient renders dual information processing on the part of the psychotherapist a must.  To appreciate explicitly the volume of stimuli and the intimately related multiplicity of tasks with which the therapist is confronted—and must process over the course of a single session—let us imagine that a patient, in treatment with an experienced therapist, begins a session by describing a very recent argument with his wife, prompted by a particular comment she made about something he had said the previous day.  In the course of this narrative, different painful emotions experienced at the time and during the session are verbalized, illustrated by the following: “I felt hurt . . . I was so frustrated and angry . . . I felt like I was about to lose it and was really afraid of what I might say . . . I’m so pissed off . . . I’ve just about had it!”, along with attributions about his wife’s intent, for example: “I think she’s bent on belittling me . . . She purposely says these kinds of things to get me angry”.  Concurrently, multiple nonverbal channels of communication—facial expressions, volume, tone, speech prosody, posture, bodily movements—are firing away with additional expressive meanings.

While the patient is describing the argument, the therapist is engaging in diverse covert processes: she is listening closely to the patient’s description of the conflict; tracking and assigning meanings to the patient’s nonverbal behavior; attuning empathically to what the patient was and is experiencing, while at the same time she is experiencing her own emotional reactions to the nature of the argument being described.  For example, within the context of her recent therapeutic work, she is experiencing frustration triggered by the patient again engaging in an interpretive distortion, which has again resulted in painful consequences for himself and his spouse.  Further, based on her evolving understanding of the patient and his history, as well as facets of his marriage, she is covertly generating hypotheses about the patient’s interpersonal and intrapersonal dynamics that may have been at play relative to this particular conflict, and is considering options on how to address this between-session incident in a way that turns it to advantage—that is, to advance the patient towards greater mental and interpersonal health.  Amid this assortment of covert activities the therapist is also overtly active: interjecting specific questions to gather more information about the argument and the patient’s thoughts and feelings as it played out then and afterwards; responding nonverbally to the patient’s verbal and nonverbal communications; and offering brief comments, observations, and utterances, at times spontaneously and at times strategically: “I can see how her saying that got things rolling . . .  Sounds like you didn’t know where she was coming from when she said that . . . Yeah . . . Mm-hmm”.

When the patient has completed his narrative, and the therapist believes she has a sufficient sense of what transpired during the argument, she then intervenes with a specific technique that she judges has the potential to be beneficial.  In this case, mindful of the patient’s history of frequently being criticized in his family of origin, and his consequent hypersensitivity, the therapist decides first to pursue a psychodynamic direction aimed to help the patient attain insight into his interpretation of his wife’s comment and his reaction to it, which had caused the argument.  Together, the therapist and her patient explore connections between his family’s frequent criticism, the hypersensitivity this has fostered, the meaning he attributed to his wife’s comment, and the behavior that ensued.  With the patient resonating to this approach, and accepting these understandings, the therapist then transitions into a cognitive restructuring intervention centered, in part, on having the patient generate alternative interpretations of his wife’s comment, and weigh the evidence for and against each of these alternatives, while explicitly contemplating a range of modifications to his affective and behavioral reactions that might have ensued from each of these different interpretations.  Throughout, the therapist implements this integrated sequential intervention process in a relational fashion that is noncritical, accepting, and authentically supportive.

In the face of an ever-shifting configuration of interpersonal, cognitive, emotional and motivational processes and content, further complicated, in the words of Schraagen, Klein, & Hoffman (2008), by “uncertainty, time pressure, risk, and multiple and changing goals [e.g., immediate, short-term, and long-term treatment goals]” (p. xxv), how is the therapist able, during the course of the session, to carry out this complex array of covert and overt therapeutic tasks in a way that is efficient, organized, and therapeutic?  If the therapist had to consciously prioritize, recall, process, and coordinate each of the domains of information required to perform each of these tasks, the processing demands would be psychologically overwhelming.  This consideration, in conjunction with the amount of time it would take to explicitly engage in these processes, would render the conduct of even a single psychotherapy session unfeasible.  Hence, to understand how a psychotherapist of any theoretical orientation is able to handle such a heterogeneous abundance of stimuli and processing demands in a given session, the dialectical interaction between automatic and controlled processing—and the X- and C-systems that neurobiologically subserve these operations—provide a parsimonious and internally consistent explanation.

Examples of Dual Processing and the Underlying Neuroanatomical Dialectic in Action

As illustration, the above vignette is analyzed in terms of four different facets of the therapist’s functioning: (a) the link between motivation and technique-related judgments and decision making; (b) processing of emotion; (c) knowledge of theory, generating hypotheses, and empathy; and (d) knowledge of techniques and their idiographic tailoring to the patient at hand.  Individually and collectively, these brief examples barely begin to scratch the surface or plumb the depths of the amazing biopsychosocial complexities involved in a single session of psychotherapy.

            Motivation and technique-related judgments and decision making.

The person of the therapist, in the role of psychotherapist, is predisposed to be therapeutic—she does not need to consciously think about whether or not her intention should be to help the patient.  This motivation is implicit—and it automatically guides the therapist’s thinking towards consideration of intervention options for promoting constructive change.  Her experience enables her to identify different options, judge their potential outcomes in this specific context, and choose among them with relative haste, yet not without some degree of controlled processing—perhaps at times more at the forefront and at other times more in the background of the therapist’s awareness—but on the whole transpiring more consciously than not.  The therapist’s implicit motivation to foster therapeutic change, and explicit processes of generating, weighing, and selecting techniques for doing so, illustrates the coupling of automatic and controlled processing.  Correspondingly, the involvement of the X-system’s amygdala in motivation (Cunningham & Brosch, 2012; Power & Starkstein, 2013; Tye & Janak, 2007), and its reciprocal connectivity to the C-system’s anterior cingulate cortex and lateral prefrontal cortex (Klavir, Genud-Gabai, & Paz, 2013; Pessoa, 2008, 2009; Posner et al., 2011)—both of which are recruited in executive control functions (e.g., planning, strategizing, decision making; see Pessoa, 2008; Rosenbloom, Schmahmann, & Price, 2012; Sallet et al., 2011; Swick & Jovanovic, 2002)—provides tantalizing suggestive evidence that this interplay is hardwired in a substrative neurobiological dialectic.

            Processing of emotion.

The therapist’s processing of emotion can similarly be distinguished as falling more towards the automatic or controlled pole of this dialectical processing gradient—although in real time these poles dynamically interact to facilitate an effective therapeutic process.  In this regard it is important to note that, in the clinical situation described above, the therapist’s effective functioning necessitates not only that she is attuned to, seeks to understand, and works with the patient’s various emotional states, but that she is also aware of, and manages, her own emotional states aroused in the process.  To cite just one example from these realms of emotion processing—as in-session material unfolds, the therapist assigns emotional meanings to the patient’s shifting facial expressions, and does so largely (though not necessarily exclusively) through automatic, implicit processing enabled by recruiting X-system structures such as the amygdala and basal ganglia (see, e.g., Adolphs, 2002a, 2002b; Rauch et al., 2010).  However, the regulation of certain of her own emotions (e.g., down-regulating and inhibiting expression of her frustration) is conscious and intentional, reflecting controlled processing subserved by emotion-regulatory capacities supported by (among other C-system structures) the lateral prefrontal cortex and anterior cingulate cortex (Gyurak, Gross, & Etkin, 2011; Ochsner & Gross, 2005).

            Knowledge of theory, generating hypotheses, and empathy.

As a third example based on this illustrative vignette, both the psychodynamic–interpersonal and cognitive theories guiding the therapist’s formulation encompass conceptual knowledge contained within semantic memory, and which has been shown to be linked to a number of X-system neural structures (e.g., the lateral temporal cortex and ventromedial prefrontal cortex; see Binder, Desai, Graves, & Conant, 2009).  These implicit domains of knowledge are automatically activated (cf., Bargh &Williams, 2006) by content presented by the patient, and serving in turn as bases for the therapist’s consciously generated and explicitly formulated hypotheses that—in the argument with his wife—the patient was enacting a maladaptive transaction cycle (Anchin & Pincus, 2010; Kiesler, 1996; Magnavita & Anchin, 2014) etiologically embedded in his family of origin and containing, among its components, a propensity to misinterpret the meaning of certain types of statements as critical, triggering shame and anger.  Then, held in working memory—a C-system process (Lieberman, 2007; however, cf., Hassam, 2006)—and enhanced by the down-regulation of her frustration noted above, this understanding facilitates the therapist’s shift to empathic attunement to emotions experienced by the patient.

Empathy is a strikingly multifaceted process whose neuroanatomical underpinnings are complex and continue to be unraveled (see, e.g., Decety, 2011; Rameson & Lieberman, 2009; Zaki & Ochsner, 2012); however, extrapolating from this emerging literature, it seems reasonable to say that empathic attunement and experience characteristically involve varying mixtures of controlled and automatic processing on the part of the therapist.  For example, recruiting C-system neural structures, the therapist, however briefly, consciously reflects on what the patient may have been experiencing when his wife made the comment he described and—by imagining herself in that situation—gets in touch with the feeling of shame, and labels it.  This set of covert operations is undertaken intentionally and explicitly, and is reflective of controlled processing; but the therapist does not have to consciously contrast shame with other emotions in order to know what shame feels like—she has experienced this painful emotion in her own life, thus the empathic subjective experience of this feeling kicks in automatically through X-system neural processes.

            Knowledge of techniques and their idiographic tailoring.

As a final example, the therapist’s semantic memory of specific techniques associated with these theoretical orientations is implicit—as is her body of conceptual knowledge of psychodynamic–interpersonal and cognitive theory, and her procedural memory for the sequence of concrete operations necessary for their execution.  Thus, from her learning and experience about how to foster insight, the therapist knows implicitly the kinds of questions that need to be asked to help the patient access memories of family-of-origin experiences hypothesized as being pertinent to his present-day readiness to perceive and experience criticism.  Intimately related to this, she has automatic knowledge structures about the sequencing of questions—both to facilitate the patient’s making explicit connections between those earlier experiences and his reflexive interpretation of his wife’s comment as critical, and to attune him to specific emotions he experienced immediately pursuant to this interpretation.  Knowledge of the concrete operational elements constituting that procedure of cognitive restructuring, such as examining evidence for and against his interpretation of his wife’s comment, generating alternative interpretations, and weighing evidence for and against each, is also tacit and stored in procedural memory.  Nevertheless, while knowledge and access to the operational architecture of different therapeutic techniques is handled by automatic processing instantiated in X-system neural structures, tailoring real-time implementation of these techniques with respect to this particular patient necessitates ongoing interaction with C-system-mediated controlled processing.

As illustration—after 15 seconds of silently reflecting on a particular question about his family of origin (asked by the therapist in the context of attempting to foster insight), the patient begins to slowly shake his head, indicating “no”, with an accompanying look of disgust.  Although by virtue of implicit knowledge the therapist can automatically interpret this combination of negative head nodding and the nature of the facial expression as expressing disgust, she has no idea as to what this “hot” emotion is about for this patient, at that moment.  Consequently, making an explicit judgment that (at that immediate point in time) it would be better to know than to not know what the patient is thinking, she makes a conscious decision to inquire, saying: “It looked to me like you were just feeling disgust; what was going through your head?”  Whether the therapist’s ensuing response (be it a statement, or question, or perhaps active silence) arises more from automatic or controlled processing will depend in part on the nature of the patient’s combined verbal and nonverbal response to the therapist’s initial inquiry.

Concluding Thoughts

An observation shared by Lieberman (2003), citing Cacioppo & Gardner (1999), is especially interesting in light of the above analyses: “No matter how automatic and controlled processes are interacting, the resulting judgment or behavioral response will reflect a unified product that will look more or less automatic overall” (p. 45).  Indeed, this seems to be especially so in the case of psychotherapy, given how the sequential flow of the process appears to unfold.  Nevertheless, embedded in Lieberman’s observation is another reality highly germane to psychotherapy: while certain judgments, decisions, and actions are handled automatically through X-system processing, idiographic considerations associated with a specific patient and the context at hand will—as in the example above—invariably also necessitate deliberate C-system processing in the course of making clinical judgments and decisions and engaging in therapeutic processes, both within and across sessions.  More generally, while knowledge of personality, psychopathology, psychotherapy theory, technique, and relational processes may be realms of elaborate implicit knowledge automatically activated and drawn on by the therapist in the course of doing psychotherapy, controlled processing may occupy an especially central role, as these complex knowledge structures are intentionally and planfully adapted and tailored to the unfolding particularities and vicissitudes of the individual case.  Exquisitely orchestrated by the brain’s neuroanatomical structure and functional dynamics, this continuous dialectical dance between automatic and controlled processing is fundamental to psychotherapy as both art and science.

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