Neurobiology Essentials for Clinicians: What Every

Therapist Needs to Know (Norton Series on Interpersonal

Neurobiology)

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“In Neurobiology Essentials, Montgomery displays her gift for making
extremely complex concepts clear and accessible. Her extensive use of case
material makes for a compelling read and explicates otherwise inscrutable
neurobiological processes; she guides her reader through “moment to
moment” interactions with clients, elucidating the neurobiological
underpinnings of theories and interventions along the way. The result is a
contemporary, innovative, research-based framework for clinical practice
that will be the “go-to” neurobiological text for practitioners and students
alike. This is an impressively scholarly work that makes a neurobiological
perspective human.”
—Susan Bliss, Ph.D., L.C.S.W., Assistant Professor, Molloy College
 The Norton Series on Interpersonal Neurobiology
Allan N. Shore, PhD, Series Editor
Daniel J. Siegel, MD, Founding Editor

The field of mental health is in a tremendously exciting period of

growth and conceptual reorganization. Independent findings from a
variety of scientific endeavors are converging in an interdisciplinary
view of the mind and mental well-being. An interpersonal
neurobiology of human development enables us to understand that the
structure and function of the mind and brain are shaped by experiences,
especially those involving emotional relationships.
The Norton Series on Interpersonal Neurobiology provides cutting-
edge, multidisciplinary views that further our understanding of the
complex neurobiology of the human mind. By drawing on a wide range
of traditionally independent fields of research—such as neurobiology,
genetics, memory, attachment, complex systems, anthropology, and
evolutionary psychology—these texts offer mental health professionals
a review and synthesis of scientific findings often inaccessible to
clinicians. The books advance our understanding of human experience
by finding the unity of knowledge, or consilience, that emerges with the
translation of findings from numerous domains of study into a common
language and conceptual framework. The series integrates the best of
modern science with the healing art of psychotherapy.
 Dedication
To my husband, Seth H. Montgomery.
Thank you. Really.
 Contents

Cover
Title Page
Dedication
Foreword by Allan N. Schore
Preface

PART I
Foundational Neuroscience Concepts
Chapter 1: Affect Regulation and the Autonomic Nervous System:
Illustrations from a Case History
Chapter 2: Defense Mechanisms and the Limbic System
Chapter 3: Threat Management and the Amygdala
Chapter 4: Therapeutic Engagement Issues and the Vagal System
Chapter 5: Personality Disorders as Affect Management Strategies

PART II
Special Populations and Topics
Chapter 6: The Adolescent Brain: Selected Functions That Differ from the
Adult Brain
Chapter 7: Working with Groups: How Selected Principles of Regulation
Theory Can be Applied to Group Work
Chapter 8: Integrating Selected Neurobiological Concepts into the
Supervisory Process
Epilogue
Appendix A: Identifying Defense Mechanisms Worksheet
Appendix B: Diagnostic Criteria
References
Index
Copyright
 Foreword
Allan N. Schore

For a number of years I have been scouring the planet for potential authors
for the Norton Series on Interpersonal Neurobiology. Many of these authors
have well-established international reputations as scholars and renowned
clinicians, but an equal number of others are new voices in the field. These
extremely curious, dedicated individuals have, through their own intensive
study, mastered both a large body of interdisciplinary scientific knowledge
and a broad and deep range of clinical experience.
Arlene Montgomery is a prime example of a new, exciting voice. For well
over a decade, this gifted clinician-academic has been teaching interpersonal
neurobiology to students at the University of Texas at Austin’s School of
Social Work, and continually attracting overflow classes. Over the years the
course has been grounded in my first book, Affect Regulation and the Origin
of the Self, no easy read for first- and second-year graduate students who are
just entering the profession. These students are challenged by her course to
absorb large amounts of clinical knowledge and to gain an understanding of
the relevance of neuroscience to their emerging psychotherapeutic skills.
Montgomery’s extraordinary talent as a master teacher and skilled
psychodynamic psychotherapist is expressed in her creative use in the
classroom of personally relevant, day-to-day and, indeed, moment-to-
moment subjective bodily-based emotional experiences that lie at the core of
her students’ conscious and unconscious worlds. Her teaching style thus
encourages more than the accumulation of a large body of explicit knowledge
about the connections between psychology and biology—it also calls for an
inwardly focused reflective function, one that attends to the student’s implicit
processes. To demonstrate the ubiquity of these “hidden” nonconscious and
nonverbal brain/mind/body processes, she also utilizes an interpersonal
neurobiological perspective to analyze the images the culture is generating,
(for example, by having the class attend to rapid facial, prosodic, and
gestural right-brain communications in highly affective scenes from popular
films).
In the following pages Montgomery organizes, synthesizes, and integrates
her extensive academic knowledge and clinical skills in order to offer a
coherent, well-researched, theoretically based, and clinically relevant
volume on neurobiology essentials for clinicians. Although the volume
provides a valuable text for the training of mental heath professionals across
a wide spectrum of disciplines (social work, psychology, counseling,
psychiatry, and psychoanalysis), each chapter breaks new ground in
providing fresh and creative interpersonal neurobiological models of a
number of complex clinical problems, which advanced clinicians will find
provocative and stimulating.
The reader will note that, although Montgomery cites a large number of
neuroscientific and clinical authors, she utilizes the perspective of regulation
theory to organize both her neurobiological and clinical data. At the very
beginning of my most recent volume, in this same IN Series, I stated that
regulation theory is offered as a systematic exposition of the general
principle of a science. Specifically, it is a formulation of an explanatory
conception of the process of development, as it moves along the life span.
Thus regulation theory, including its developmental variant, modern
attachment theory, serves as a source of testable hypotheses for scientific
research, but also as a potential source of more complex and efficient models
of clinical intervention.
The opening chapters in the first half of the book (Foundational
Neuroscience Concepts) build upon and expand regulation theory’s modeling
of a number of well-known yet enigmatic clinical phenomena. Utilizing an
interpersonal neurobiological lens, Montgomery’s curious and synthetic mind
focuses upon a number of essential developmental brain/mind/body
processes that appear in the therapeutic alliance: the re-expression of right-
lateralized autonomic components of the attachment system in heightened
affective moments, the role of the right amygdala in unconscious subcortical
threat processing, the arousal-regulating functions of a variety of defense
mechanisms, and the communication of conscious and unconscious affects via
projective identification. In the latter section of the book, regulation theory is
used to generate novel interpersonal neurobiological understandings of
personality disorders, the adolescent brain, group work, and supervision. Let
me provide a glimpse of the upcoming chapters, and speak more to the point
of where this book breaks new ground.
Among clinicians of all schools there is currently an intense interest in not
only brain but also body. The key to understanding bodily processes is the
neural control of bodily processes by the autonomic nervous system (ANS).
The nonconscious regulation of bodily-based autonomic arousal is a central
aspect of the early developing emotion-communicating attachment
mechanism. Indeed this is a central theme of Chapter 1, which overviews the
functions of both the right brain and its deep connections to the ANS, and
then describes the clinical expressions of this mechanism in a transcript of a
psychotherapy session. The author boldly asserts, “Tracking
psychophysiological arousal can be a very valuable assessment exercise
leading to diagnosis and intervention considerations. . . . This repetitive
experience of synchronizing appropriate arousal management strategies with
the brain of another has the potential to actually change brain functioning for
the better.” It is often forgotten that affects have two dimensions, valence
(positive–negative, pleasant–unpleasant, approach–avoidance of discrete
emotions) and arousal (intensity, energy, calm–excited). My sense is that
clinicians have focused too much on the former, which has impacted clinical
models. But arousal—especially somatic, peripheral, autonomic arousal—is
what is essentially transmitted and regulated in a relational context, and in
this book it gets the attention it deserves.
In light of the clinical fact that the patient’s defense mechanisms impact
what can be taken in relationally, and that defenses themselves can become
more complex with clinical work, Montgomery devotes the bulk of the
opening chapter to the role of the autonomic nervous system in defense
mechanisms. This work builds upon my own earlier model of defense
mechanisms as nonconscious strategies of emotional regulation for avoiding,
minimizing, or converting affects that are too difficult to tolerate, with an
emphasis on dissociation and projective identification that prevents entrance
into “dreaded states” charged with intense affects that can potentially
traumatically disorganize the self system. Keep in mind that defenses are
utilized on both sides of the therapeutic alliance, jointly acting upon the
therapeutic change process, and that the earliest core defenses are shaped for
better or worse by the patient’s and clinician’s own attachment experiences.
Tying this into early interpersonal neurobiological attachment mechanisms, in
my first book I proposed that the insecure-avoidant infant excessively utilizes
a parasympathetic-dominant state in passive avoidance, gaze aversion, and
conservation-withdrawal, thereby biasing the maturing limbic–autonomic
system to low arousal energy-conserving states. On the other hand, at times
of relational stress the insecure-resistant infant’s maturing ANS is
sympathetically based.
Moving the model significantly forward, Montgomery asserts that at the
most basic neuropsychobiological level, all defense mechanisms are
modulators of emotional arousal. She then presents a model of dividing the
defense mechanism into four types of nonconscious arousal strategies used by
the various attachment typologies: homeostatically balanced defenses that
under stress resiliently shift between sympathetic (SNS) and parasympathetic
(PNS) components of the ANS (secure), parasympathetically driven defenses
that attempt to decrease arousal but cannot manage higher levels of relational
stimulation (insecure-avoidant), sympathetically driven defenses that attempt
to increase arousal but cannot easily manage lower levels of relational
stimulation (insecure anxious-ambivalent), and disorganized defenses in
which the SNS and PNS are frequently uncoupled, arousal levels are
extreme, and defenses seem to appear without a predictable strategy
(disorganized-disoriented). Regarding these defensive biases Montgomery
notes, “What this means in practical terms is the underutilized branch may be
avoided in a predictable fashion.” Indeed, in an extended table in Chapter 2
the author uses this model to characterize every known defense in terms of
these arousal dimensions, including internalization, sublimation, suppression,
dissociation, intellectualization, repression, acting out, splitting, and undoing.
To add to the power of the model the author then presents numerous cases
that demonstrate the unique forms of expression of arousal modulating
defenses with different types of patients in various therapeutic contexts. In
this conceptualization, pathology is defined as the rigid use of the same
restricted set of defenses, regardless of the context, and resilience is defined
as the capacity to manage increasingly difficult intensities of affective
arousal without resorting to pathological defense mechanisms and behaviors.
To demonstrate the psychoneurobiological model of defenses, she presents
the verbatim transcript of various patient-therapist interactions, and then an
analysis of the right-brain-to-right-brain limbic-autonomic arousal
communications at another preverbal level beneath the words. Montgomery
states, “A focus on typical ways that each client manages emotions will
generally uncover defense mechanisms that have been used to protect the
client emotionally.” I would add that the focus is also upon the therapist’s
defenses against affective arousal. This format of utilizing case descriptions,
dozens of them, to demonstrate precisely how regulation theory translates
into clinical practice is used throughout the book.
In later chapters Montgomery continues to expand her clinical model,
describing, in some detail, the unique role of the right amygdala, a major
subcortical center for threat appraisal and management. Noting that threat can
originate either from the external environment or from internal thoughts and
feelings, she observes, “The personality can eventually become patterned by
the level of arousal that is mobilized to meet most situations and can remain
dominated by amygdalar functions that respond to the most minimal hint of
threat, leading to chronic over/under/ erratic reacting.” Keeping in mind that
the right amygdala interacts directly with both the sympathetic and
parasympathetic components of the ANS, she then discusses the relationship
between autonomic arousal and the sympathetic-dominated personality
disorders, parasympathetic-dominated personality disorders, and uncoupled
ANS oscillating personality disorders. This work represents a significant
elaboration of ideas put forth in my first book, that borderline personality
disorder reflects an uncoupled nonreciprocal mode of autonomic control,
while a parasympathetic-dominant autonomic mode prevails in narcissistic
personality disorder. Indeed, in Chapter 5 Montgomery forges an even tighter
linkage between the autonomic arousal defenses used in the four attachment
typologies and the primary autonomic defenses of thirteen different
personality disorders. Along the way she offers rich case examples of ANS
arousal in both childhood attachment and equivalent adult attachment
categories. To strengthen the argument of continuity of defensive orientations,
she frequently offers clinical sessions with the same patient, some over
different decades.
The second half of the book (Special Populations and Topics) contains
chapters on the application of regulation theory to three other areas of
clinical import. A chapter on the continual evolution of the early forming
attachment limbic-autonomic circuits in the adolescent brain includes an
extended table summarizing selected functions of the adolescent and adult
brain. Most models of the development of the adolescent brain focus on
cognitions and behavior, but here Montgomery highlights the changes in the
“emotional brain,” both cortically and, even more important, subcortically.
She notes that particular circuits that psychobiologically support defensive
strategies are epigenetically sculpted in infancy, but in adolescence they are
further pruned by the social environment. In this manner the autonomic bias
resulting from the early critical period over- or under-pruning of SNS and
PNS circuits influences the nature of the later adolescent pruning. This
limbic-autonomic circuit pruning is a central mechanism that impacts the
emergence of Axis I psychiatric and Axis II personality disorders in
adolescence.
The later chapters discuss the use of regulation theory in understanding
group dynamics and the change mechanism embedded in group
psychotherapy, an area that has been overlooked by most writers, and in
exploring “the professional use of the self” in the supervisory process. Here
the author discusses the role of autonomic arousal in adaptive and defensive
projective identification in the parallel process between the supervisee and
supervisor and the client-clinician relationship. Again, she uses an analysis
of clinical material with an adult–most fascinatingly, the same patient who
was seen as a child in an earlier chapter. A bonus is that throughout the book
the patients represent a broad spectrum of different cultural backgrounds and
varying socioeconomic levels.
In addition to the considerable advances in theory and practice to the
discipline of interpersonal neurobiology, another significant contribution of
this work is reflected in Montgomery’s creative, innovative, and synthetic
structural organization of the book. Numerous extensive tables summarize a
large body of interdisciplinary research that directly relates to various
clinical processes, including functions and characteristics of the amygdala,
selected functions of the upper right cortex, comparison of selected functions
of the adolescent and adult brain, attachment categories of childhood as
managed by the autonomic nervous system, relationship between arousal
branches of the autonomic nervous system and various personality disorders,
the arousal modulating biases of a spectrum of different defense mechanisms,
and steps involved in projective identification during a therapeutic encounter.
Montgomery states that these can be used for teaching purposes with
therapists at all levels of clinical experience. The presentation of data in this
holistic form is an efficient strategy for portraying the integrative functions of
the right lateralized neurobiological mechanisms that operate in the rapid,
nonlinear, nonconscious subjective realm. An appendix includes a worksheet
on identifying defense mechanisms in any clinical encounter.
A second creative contribution of the book is the novel method by which
the author describes the rapid nonverbal right-brain dynamics that underlie
and precede later left-brain verbalizations and behavioral actions. The
author asserts, “Almost line by line, each case examines the clinician and
client interactions in terms of related neuroscience knowledge in an attempt
to explain the kind of interaction, the intensity of the affect, or what the client
is unconsciously trying to elicit from the clinician.” Indeed, throughout the
book, Montgomery’s focus is on the structures and functions of the right
lateralized system that operates beneath awareness, at a level deeper than the
conscious minds and spoken words of both members of the therapeutic dyad.
Toward that end, each vignette is accompanied by a dual tracking of both the
conscious verbal and nonconscious nonverbal emotional communications
between client and therapist. Thus, beneath each segment of a verbal
transcript, Montgomery offers a simultaneous analysis of the affective
arousal alterations associated with the right-brain-to-right-brain
communications of one relational unconscious to another relational
unconscious. This format highlights the energetic transmissions embedded
with transfers of emotion within a co-created intersubjective field, and it
demonstrates how nonconscious defenses alter the expression and reception
of these affective communications.
The ambitious goal of the book is to more deeply understand the nonlinear
bodily-based dynamics of the “social,” “emotional” right brain, the
biological substrate of the human unconscious. Arlene Montgomery has
herein made a number of important contributions toward that goal.
Allan N. Schore
 Preface

Working as a clinical social worker has been one of the most gratifying
and frustrating experiences in my life. It has been gratifying to be part of
experiences that were clearly helpful, if not healing, for clients; the
frustration has come from efforts to explain why that help or healing was the
case without relying on “practice wisdom,” an oft-criticized source of data.
In the mental health field there were many ways to acquire the wisdom of our
clinical foremothers and forefathers, but until the past two decades, there
was scant scientific support for what experienced practitioners knew
significantly helped those struggling with biopsychosocial issues. There was
also much criticism for interventions that did not have scientific support,
particularly those therapies of longer duration. The hard sciences have not
traditionally been particularly accessible to those who studied the social
sciences. Though a wealth of information that could have explained, from a
neurobiological perspective, the personal psychology of clients who sought
help with their emotional and behavioral issues, until recently, that interface
was not readily available.
I imagine that for many of us in the field, there were turning points that led
to our pursuing training as mental health practitioners. Looking back on my
own experience, I remember the day—actually, the moment—that I changed
my major from nursing (I was in my last semester in the program) to social
work. I was going through my mental checklist preparatory to moving to
another city to finish the last rotation in nursing. I remember walking to my
car from a weekend of work with emotionally disturbed adolescents at a
residential psychiatric hospital. At 21 years old, I was still an adolescent
myself, but working my way through college at the hospital made me feel
years older that my teenage charges. I looked around the campus at the kids
eating their supper in the dining hall, and it hit me that I was much more
interested in their psychological world than I was in their blood pressure and
heart rate. I realized that I had been working for several years in the
environment in which I was best suited to work as a professional.
Although the social workers, psychologists, psychiatrists, and nurses had
less contact with the residents than I did as a child-care staff member,
nonetheless I could see that they were helping them and that their patients
were bonded to them. I was already (fairly unconsciously) trying to reconcile
the therapists’ influence with what I was seeing in the relationships with
those of us who actually lived in their lives on the dorm, the soccer field, the
classroom, and various off-campus activities that we chaperoned. It is still
surprising to me now how little we can “know” and still have a positive
impact on another person’s compromised psychological organization.
Later, after I was a social worker working in yet another residential
psychiatric hospital, I read Trieschmann’s The Other 23 Hours. I knew that
my musings and intuition about the possibility of the healing potential of
relationships (not simply techniques) was beautifully captured in
Trieschmann’s insistence that no child could recover from his or her
traumatic experiences with just 1 hour of therapy per week. It would take the
entire milieu. Today, I translate the writings of Trieschmann and others (e.g.,
Redl and Winemann) into the current findings on the neurobiology of
attachment. The “practice wisdom” of those with years of success in treating
people with all manner of developmental insults is supported by the
explosion of current research on the brain revealing the physiology through
which humans attune and connect. How to integrate scientific findings about
the nervous system with the multiplicity of treatment theories is the current
challenge in the mental health field.
As have many other clinicians, I have eagerly tried to keep up with the
rich research and literature on the ways neurophysiology affects clinical
work—a sometimes discouraging yet also satisfying endeavor. The reason
for the excitement is obvious. The discouragement comes from there being so
many discoveries every day and in fields in which most social scientists
have little or no scientific background to understand. This book represents an
effort to choose a few vital functions of the brain and nervous system that
critically impact psychological clinical interventions. It is not an exhaustive
catalogue or discussion, but a selective one, with multiple references
provided for those who wish to read more extensively on various related
topics.
 In an intellectually friendly way, I want to share my experience in trying to
teach students and supervise interns and new licensees about basic and
important neurobiological facts as related to such areas as child
development, attachment, personality development, and resilience in the face
of various kinds of trauma. The more I have tried to integrate relevant
scientific findings with clinical work, teaching, and supervision, the more
convinced I have become that the information cuts across most, if not all,
theoretical treatment strategies and interventions. The usefulness of learning
basic brain functions and applying that knowledge to most current theories is
exciting and inclusive. My hope is that graduate students, their faculty, agency
supervisors, and those in practice whose education or training did not
include the current neuroscience research will find this book an easy
reference. I have tried to provide something for a variety of interests.
For example, the beginning of each chapter addresses certain related brain
structures and their functions. I recommend that those who are not
comfortable starting with the science proceed to the second part of each
chapter and read the case. Almost line by line, each case examines the
clinician and client interactions in terms of related neuroscience knowledge
in an attempt to explain the kind of interaction, the intensity of affect, or what
the client is unconsciously trying to elicit from the clinician. After reading the
case, the beginning of the chapters may seem more user-friendly, as many
examples of the neuroscience were detailed in the case notes. There are also
tables that can be used on clinical material of all kinds. I like to use, for
example, a list of right-brain functions (Table 6.1) to study various
Hollywood movies because the facial expressions and body language are
easy to see. I rewind many times for teaching purposes. I have come to prefer
this format to that of printed cases because the students or workshop
participants can also focus on their own reactions to the evocative characters
and situations, as we examine the brain-to-brain interactions in the movie.
Part I covers the topics of affect regulation, defense mechanisms, threat
management, and therapeutic engagement issues in terms of their neurological
underpinnings. Chapter 1 illustrates the functioning of the autonomic nervous
system through the history of Cori, a 15-year-old girl whose family lost
everything in Hurricanes Katrina and Rita. The affect regulation strategies of
Cori and other family members were altered by a series of losses that
included her stepfather, the family dog, the city of New Orleans, the state of
Louisiana, their home, and all their belongings. Despite also having
experienced the loss of her father as a child, from the history, the family’s
resilience via family and community support seemed clear. However, as the
family tried to establish roots in Texas, their emotional management
strategies underwent changes such that Cori began faltering in school.
Chapter 2 continues to try to understand Cori by examining the defense
mechanisms (managed by the limbic system) she exhibits in a therapy
session. The brain-to-brain neurobiological experiences of the therapist in
relation to Cori is the focus.
Chapter 3 examines a session between a medical doctor and his patient,
Mr. Ryan, who is a fireman whose uncharacteristically poor judgment
contributed to severe burns. The exercise speculates on Mr. Ryan’s emotional
self states and somatic (bodily) states as managed by the amygdala and also
speculates on his doctor’s various ways of processing affect-related meaning
as expressed by Mr. Ryan’s behavior.
Two case illustrations in Chapter 4 attempt to explain issues of social
engagement as enhanced or hindered by “neuroception” (Porges, 2011),
which is a subtle, out-of-consciousness assessment of safety or danger
indicating approach or avoidance, respectively. One case considers Baby
Ruth, a career criminal who may be a psychopath or at least an antisocial
personality organization. This is in contrast to Bebe, who has some similar,
but not as severe, automatic and unconscious ways of managing unbearable
affect via the vagal system.
Personality organization as an affect management strategy is the topic
explored in Chapter 5. Using 14 cases, we consider the physiological arousal
system when it has become organized into certain expectable, rigid
behaviors. The secure and insecure attachment strategies of childhood and
adulthood are each explored via a case example. The attachment strategy is
compared to certain diagnosable disordered personality organizations. The
arousal strategies to manage affect are seen to be quite similar in the
attachment strategies and the personality organization. For example, the
childhood avoidant attachment style relies on defense mechanisms that
attempt to keep affect quite low; therefore, the low arousal branch of the
autonomic nervous system, the parasympathetic branch, is the more reliable
branch for affect management. In adulthood, the avoidant behaviors may
become organized in a schizoid personality organization, among other
possible personality disorders. It seems to be the case that all attachment
categories (which are essentially affect management strategies) are affected
by the high or low arousal systems.
Part II examines special populations, including adolescents, group work,
and clinical supervision. In Chapter 6, the session notes of Cori from Chapter
2 are examined a second time to contrast adolescent and adult brain
functioning. Table 6.2 compares adolescent and adult neurobiology. It is
intended to be used for teaching or other purposes.
Chapter 7 selects a recent textbook on group psychotherapy (Rutan, Stone,
& Shay, 2007) to review how selected neurobiological principles of
regulation theory (Schore, 2003b, pp. 279–281) undergird stages of group
development (i.e., formative, reactive, mature, termination); group dynamics
(i.e., group culture, norms, roles); therapeutic factors (i.e., supportive
factors, learning factors); mechanisms of change (i.e., internalization,
transference); and therapeutic processes of change (i.e., confrontation,
clarification, interpretation, working through).
Integrating selected neurobiological concepts into the clinical supervisory
process is the focus of Chapter 8. Explored are such concepts as projective
identification and dissociation and ways they are related to the transference
and countertransference experiences of two dyads: the intern–client and the
supervisor–intern relationships. Ways that neurobiological processes support
the clinical work and the clinical supervision are examined via case material
between the student intern and also through a recording of supervision
between the supervisor and intern.
My personal goal is to bring certain information to bear on “practice
wisdom,” which I now consider to be both an oral and written tradition of
socializing new clinicians into techniques and strategies that seemed to have
stood the test of time in helping people, but which did not have a body of
scientific measurement or testing behind them until recently. A large research
literature exists for evidence-based short-term cognitive and behavioral
techniques and strategies. To date, little of this research has included an
extensive look at the neurobiology, particularly those right-hemispheric
functions underpinning the interventions. The material in this book aims to
detail experiences common to any type of face-to-face therapy and has an
interpersonal component, regardless of theoretical orientation. I hope that
many of the tables will be used to study and teach the neurobiology of
clinical material. For me, the learning has come about from the repetition of
applying to clinical examples the information about how structures in the
brain function to promote or create obstacles to constructive and satisfying
interpersonal contact and personal functioning.
 PART I
Foundational Neuroscience Concepts
 CHAPTER 1
Affect Regulation and the
Autonomic Nervous System
Illustrations from a Case History

This chapter focuses primarily on the clinical usefulness of learning about

the functions of the autonomic nervous system and its branches, the
sympathetic nervous system and parasympathetic nervous system. Certain
other areas and functions of the brain are briefly addressed as well, including
left–right hemisphere specialization and the major divisions of the brain,
including the cerebral cortex. The neurobiological substrates of selected
phenomena are illustrated in case material. These clinical phenomena
include interactive, self- and autoregulation; attunement, bonding, and
attachment; cultural issues; resiliency; shame; and protective behaviors,
particularly defense mechanisms.
Throughout this chapter a clinical case history is used to speculate on how
certain experiences of the client and her family may exemplify
neurobiological processes, particularly the management of emotional
arousal. Most clinicians know that the application to clinical work of
information about brain structure and function can be a tedious and daunting
undertaking, particularly in the moment-to-moment tracking of client and
clinician interactions. And to what end, anyway? Tracking
psychophysiological arousal can be a valuable assessment exercise leading
to diagnosis and intervention considerations. Some clients’ brains will need
to repetitively “borrow” the arousal system management of the clinician in
order to manage arousal in nonproblematic ways. This repetitive experience
of synchronizing appropriate arousal management strategies with the brain of
another has the potential to actually change brain functioning for the better.
Some clients will not need to make such basic changes, but rather will need
to reestablish a previous level of arousal management that was temporarily
disrupted. And, of course, many clients will fall somewhere in the middle.
Below is a brief history of Cori, who was referred to the school
counselor because her grades had “dropped off” after making all A’s the first
6 weeks she was in school. The commentary on Cori’s family history and
recent traumatic experiences is similar to any clinician’s thinking process. As
an outside observer, the initial effort involves trying to speculate on
explanations for certain behaviors of clinical interest. At this point in most
clinical encounters, the attempt to understand the significance of a client’s
history can be a rather distant, intellectual effort—in contrast to
deconstructing the actual experience between the client and the clinician,
especially regarding emotional arousal management issues as related to
behavior, defense mechanisms, or symptoms. As the evaluation continues,
more information is collected about how events, stressors, and other relevant
factors have influenced the management of emotions. At issue is discerning
the degree and kind of corrections, changes, or improvements needed in the
client’s emotional management system. Will the initial intervention consist of
problem-solving and psychoeducation components, which tend to be more
intellectual and cognitive in nature? Or will there be a need to use the
treatment relationship to change and improve the client’s brain capacity to
manage arousal in nontroublesome ways? Or something in between?
When first making tentative hypotheses about linking neurobiological
concepts to clinical dynamics, I recommend working with others, whether
you are a teacher, supervisor, and/or clinician or student, intern, or
supervisee. For handy reference, helpful tables, figures, and summaries of
brain structure and function are provided throughout the chapters. Throughout
this chapter, selected neurobiological concepts are often illustrated with case
history about an adolescent whose family had survived Hurricanes Katrina
and Rita.

Case of Cori
At the time of treatment, Cori was a 15-year-old girl whose family had settled in Austin,
Texas, after fleeing Hurricanes Katrina and Rita in August of 2005. She lived with her
12-year-old sister, her mother, and her paternal grandmother. Cori was in the eighth
grade of a local middle school, though she should have been in the ninth grade. Her
family was bussed to Houston, where they lived in FEMA (Federal Emergency
Management Administration) housing for several months after leaving the New Orleans