At Psych Garden, we are constantly reading research, learning what new discoveries could help our patients, and questioning our assumptions. We thought it would be nice to share some of our learning every now and again. This paper is neat because it addresses a BIG question: what kind of therapy works for whom? There are camps and schools in therapy where loyalties are split. Two main camps are the behavioral folks and the emotionally-focused folks. Should you work on changing one’s thoughts and behavior and then they will feel better, or should you help them feel differently about themselves and then they’ll behave and think differently? At Psych Garden we try to use whatever works for a given patient, and often find ourselves combining behavioral and emotionally-focused models at different phases of treatment. Perhaps we’ll work on some alcohol moderation plan and then go deep into someone’s feelings to stimulate hope and pride or motivate change.
In this study, by two once-upon-a-time teachers of mine, the problem was panic disorder and the two approaches under scrutiny were emotion and behavior-based. While emotion-based therapy aims to get past the patients’ defenses to feel their emotions and then assist understanding and behavioral change, exposure-based therapy exposes patients to their trigger/anxiety sources in an attempt to sit in their anxiety and become desensitized. Which works better? And for whom? As part of the series of studies, researchers looked at the hippocampus, which is involved in memory and integrates context and maps of space and meaning. I never knew it was divided into anterior and posterior parts (it’s a really hard structure to work with as it’s such a tricky shape – it means ‘seahorse’).
Recent studies have found that different areas of the hippocampus carry out different functions: the posterior hippocampus (PH) is linked to areas of the brain that are involved in executive and cognitive tasks, and was more critical for exposure-based treatments of panic. The anterior hippocampus (AH) is linked to more limbic or emotional areas of the brian – like the amygdala and hypothalamus – and was crucial for emotion-focused treatments. Prior to this study, the roles of the PH and AH in different treatment was unknown. Suarez-Jimenez et al. (2019) hypothesized that AH volume would predict outcome of affect-focused treatment, while PH would predict exposure-based treatment outcome. To test this hypothesis, two independent clinical trials were conducted using 35 PTSD patients and 24 panic disorder patients, where the participants underwent MRI scans followed by randomized affect-focused or exposure-based treatments. The findings indicate that AH volume (the bit connected to emotion centers) predicts clinical improvement for affect-focused treatments, but not exposure-based treatments. Specifically, smaller AH correlates with greater affect-focused treatment improvement.
This study provides a remarkable demonstration of how we are manifested in our brain’s wiring, and how change depends on that plastic architecture. Maybe it is possible to customize treatment options for patients based on measurable brain patterns (as determined by MRI or other diagnostics). Of course, you can’t pop everyone into a scanner. But people with different brains feel different. In addictions and trauma, many people have alexithymia. They don’t notice how they feel, and so they can’t identify their emotions and put them into words. These people definitely need different approaches. You can’t jump in with feelings-oriented work as they may become bewildered or overwhelmed. Perhaps they have different brain structures and need more behavioral treatment first, followed by more feelings-based work.
We have found that the most effective treatments do not look at these approaches as distinct entities with different implications: the treatments are much more interconnected. For example, some of our clinicians at Psych Garden have trained in deep emotional approaches like Accelerated Experiential Dynamic Psychotherapy (AEDP) or Internal Family Systems (IFS). These tend to use BOTH experiential evocative approaches and then exposure to these painful or feared emotions, so that the person can be more self-compassionate and bear feelings without impulsivity. Maybe we are rewiring their seahorses, tip to tail.
Click below for the full PDF of the journal article by Suarez-Jimenez et al. (2019).