Creative Psychotherapy

Applying the principles of neurobiology to play and expressive arts-based practice

Eileen Prendiville, Justine Howard, Eileen Prendiville, Justine Howard

• Publisher: Routledge
• Year: 2016
• ISBN:
  9781317397373
• Edition: 1
• Topic: Psychology
• Subtopic: Psychotherapy
• Index: Psychology

Creative Psychotherapy brings together the expertise of leading authors and clinicians from around the world to synthesise what we understand about how the brain develops, the neurological impact of trauma and the development of play. The authors explain how to use this information to plan developmentally appropriate interventions and guide creative counselling across the lifespan.

The book includes a theoretical rationale for various creative media associated with particular stages of neural development, and examines how creative approaches can be used with all client groups suffering from trauma. Using case studies and exemplar intervention plans, the book presents ways in which creative activities can be used sequentially to support healing and development in young children, adolescents and adults.

Creative Psychotherapy will be of interest to mental health professionals working with children, adolescents and adults, including play and arts therapists, counsellors, family therapists, psychologists, social workers, psychiatrists and teachers. It will also be a valuable resource for clinically oriented postgraduate students, and therapists who work with victims of interpersonal trauma.

Part I
Applying the principles of neurobiology to play and expressive arts-based practice

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This part provides an introduction to the ways in which the principles of neurobiology can inform best practice in play and expressive arts-based psychotherapy. The central components of the neurosequential model are introduced, and readers learn how the most effective therapeutic interventions take account of a client’s age, developmental stage, experiences of trauma, as well as presenting clinical issues. A case is made for the importance of play and expressive art-based practice across the lifespan for healing and, in particular, for the development and reprogramming of neural networks. A selection of psychotherapeutic approaches are discussed in relation to the level of direction given to the client. An introduction to the evidence base for these different approaches to psychotherapy is provided for clinical work across the lifespan. Finally, before moving on to more specific evidence-based techniques in Parts II and III, the skills associated with creative psychotherapy are considered, and trauma-informed expressive art therapy (Malchiodi, 2014) is presented as one possible framework for integrating the neurosequential model with play and expressive arts-based practice.

Chapter 1
Neurobiology for psychotherapists

Eileen Prendiville

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This chapter introduces the reader to neurobiology that is relevant to, and informs, a neurosequential framework and emphasizes the importance of using this to shape psychotherapeutic interventions for young children, adolescents and adults, so that corrective, developmentally appropriate and creative experiences can be identified and offered. Planning appropriate, sequential interventions requires that account is taken of the age of the client, their stage of development, any developmental trauma issues and their clinical presentation. The environment shapes neurobiological development and attachment formation; a creative neurosequential approach to therapy maximizes potential for healing and promotes new neurological development by attending to what we now know about neuroscience, interpersonal neurobiology and the biology of both attachment and arousal.

The need for playfulness

An understanding of interpersonal neurobiology, trauma and healing suggests that talk therapy alone will not lead to full recovery: there is a need to engage playfully, incorporate some expressive arts into psychotherapy and pay attention to the physiological impact of trauma (e.g. Gantt and Tinnin, 2009; Gaskill and Perry, 2014; Green and Drewes, 2014; Malchiodi, 2014; Malchiodi and Crenshaw, 2014). In discussing the stress response, Perry and Pate (1994) note that talking cannot translate into changes in the midbrain or the brainstem, the very areas that mediate a range of physiological, hyper-reactivity, behavioural impulsivity, hypervigilance, anxiety, emotional lability and sleep problems.

There are different approaches to therapy: top–down models that focus on cognition, and bottom–up models that attend to the central role of physiological elements and the two-way system of brain–body communication. Both left and right brain are involved in healing. The brain’s right hemisphere is dominant in the early years of life. It is sensory-based and creative and relies on the somatic, embodied aspects of experience rather than verbal language. It processes social and emotional experiences and is significantly involved in emotional- and self-regulation (Cozolino, 2010; Porges, 2011a: 138–40). The right hemisphere is predominantly activated in the recall of both early and disturbing memories (van der Kolk, 2003: 308), suggesting that right brain activities would be helpful in processing unresolved trauma and modifying embodied, implicit memories, particularly when regulation rather than insight is the therapeutic aim.

Beginning with safety

The experience of safety in therapy is vital in facilitating the client’s engagement and healing. That is why play therapists, for example, concentrate so much on structuring responses in the early stages of therapy. Other possibilities include making a contract, agreeing session times, being predictable in responses, using the therapeutic touchstone story (Prendiville, 2014) and embodying Rogers’ core conditions (1957). However, if we agree that feeling safe has both physical and emotional components, then perhaps there may be another dimension to consider in establishing initial safety and facilitating trust building? Given that feeling safe or unsafe is physiological in nature and is directly responsive to the environment, and that feeling unsafe triggers involuntary behaviours that are often problematic, there is a real need for a considered approach to assist clients in becoming regulated so that therapy can take place. Therefore, safety needs to be considered both at the beginning of the therapy process and at the start of each therapy session. Interventions linked to the lower brain regions will be useful in this regard.

Hierarchical development

The neural system develops from the spinal column in a hierarchical bottom-to-top movement, becoming organized from the more primitive lower (brainstem and midbrain), to more sophisticated higher (limbic system and cortical) regions. Stressful intrauterine experiences and/or early developmental trauma negatively impact both this development and the smooth integration of the interconnected functions of the nervous system. This may result in dysregulation and the individual operating from a baseline alarm state in which the frontal cortex (the thinking brain) and the limbic system (the emotional brain) are shut down. This means that only the lower brain areas are activated, and the individual is severely compromised in terms of:

• establishing a feeling of safety;

• processing incoming information;

• successfully engaging with others;

• recognizing emotional states;

• self-regulating;

• organizing their thinking.

Our capacity to regulate levels of arousal, together with our subsequent baseline state, is heavily influenced by our early experiences and emotional environment. Perry (2006) suggests that levels of state arousal range from calm, alert, alarm or fear to terror, depending on which primary and secondary brain areas are in the driving seat. The range here, linked to the five states listed above, is neocortex/ subcortex, subcortex/limbic, limbic/midbrain, midbrain/brainstem and brainstem/ autonomic. The individual’s capacity to think in these states ranges from abstract in the highest level, down to reflexive in the lowest, with concrete, emotional and reactive in between (p. 32). Our baseline state is activated whenever we experience something new or something that triggers earlier stress. It is clear that people whose baseline state is less than calm, and particularly those whose baseline is alarm, fear or terror, will be unable, not unwilling, to formulate appropriate responses or attend to learning or relationships when in a situation that is experienced by them as stressful or novel. Different people experience the same situation in different ways: whereas one person may be fearful or even terrified, another person in the same situation, even at the same time, may well be calm. Reflecting on the personalized responses of individuals is important: it is not appropriate to expect that a traumatized person will be able to pay attention, learn or heal in the same way as others when their baseline state is aroused by incoming sensory triggers.

Creative approaches to therapy can engage effectively with the client’s lower brain areas and positively impact on the modulation of the primary regulatory networks by starting with somatosensory interventions – a bottom–up approach. Suitable activities to calm the nervous system and reinstate a sense of safety, thus making the higher neural networks accessible to relationship, growth and development, include repetitive rhythmic activity such as music and movement, healthy touch and sensorial activities (Jennings, 2011; Gaskill and Perry, 2014; Malchiodi, 2014). Repetitive provision of such experiences builds new, healthy neural networks, promotes synaptic plasticity and modulates lower brain overreact-ivity.

Motivational circuits in the brain

Panksepp (1998) coined the term ‘affective neuroscience’ to refer to the study of the neural mechanisms of emotion. He identifies play, particularly physical play, as a primary process in the more primitive parts of the brain. He describes play as a core emotional action system, intimately linked to somatosensory information processing (1998). It integrates the motor, visual, auditory and other sensory regions of the brain, supporting cortical and subcortical organization, promoting brain development, enhancing cognitive abilities and facilitating long-term emotional change. The development of the play system is inhibited by unmet physiological needs and stress.

Panksepp (1998) suggests that all mammals have seven primitive emotional operating systems in the limbic and reptilian areas of the brain. Each primary process affective system is either rewarding or punishing. The rewarding emotional patterns are SEEKING, LUST (activated in adolescence), CARE and PLAY. The punishing systems are RAGE, FEAR and PANIC/GRIEF/SEPARATION DISTRESS.

Whereas the Seeking circuit is generally activated, activation of other circuits is linked to either being in or out of contact with those we trust; in general, it is not possible to maintain satisfactory contact with others when the punishing systems are activated. Adequate physiological regulation is needed to support capacity for relationship. However, a therapeutic relationship can be maintained while processing and engaging with feelings of rage, fear and panic within a pretend play situation. ‘Although fight/flight and play behaviours both require mobilization, play turns off defensiveness by maintaining face to face social referencing . . . to signal that the intentionality of the movements is not dangerous or hurtful’ (Porges, 2011b: 14). In trauma therapy, the experience of ‘just playing’ inhibits the generalized activation of the survival system and allows for calmness and interpersonal connection, which facilitate the client in gaining empowerment over difficult emotions, sensations and memories (Panksepp, 1998: 283; Porges, 2011a: 276–7).

Porges and the polyvagal theory

The nervous system receives and responds to information from both outside and inside the body. The ‘sixth sense’, that of interoception, is important in sensing internal states and bodily processes. The physiological components of this sense are interoceptors located on the internal organs that detect and transmit messages about sensations arising internally. These sensations may be linked to states of hunger, thirst, pain, tiredness etc.; they may also be the physiological components of emotion. External sensory information is also processed by the nervous system, which must balance the demands of the internal viscera with environmental demands. Sensory processing capacity is very individual, and particular difficulties in detection, modulation, discrimination and integration can exist for clients who have specific conditions, have experienced developmental trauma or have not experienced responsive caregiving.

Neuroception

The capacity to accurately distinguish and process information about current levels of safety or threat directly impacts on our ability to read social cues and regulate our behaviour in the presence of other people. Our nervous system processes incoming information from all our senses and evaluates risk via an unconscious process called neuroception (Porges, 2004): this is more diffuse than perception, relies on neural circuits and assists us in evaluating danger and responding appropriately. Polyvagal theory links social behaviour to the evolution of the autonomic nervous system and provides a model for understanding and treating stress and recognizing the impact of neuroception on emotional well-being, mental health and relationships. Faulty neuroception is linked to faulty reactivity and unnecessary changes in physiology and it results in maladaptive behaviours that are often seen in troubled children and clients within the mental health services. If the environment is experienced as dangerous, social approaches may trigger a response of aggression or withdrawal – the very opposite of behaviours that would be helpful in the making and maintenance of social bonds.

Porges (2004) uses a traffic light metaphor to explain the three possible visceral states that colour our reactions: green for safety, yellow for danger and red for life threat. Each state is associated with environmental stimuli and induces a response that is personalized to the individual and is directly related to the physiological system active at the time. Such responses will either allow us to remain in contact with others or will cause us to disconnect from social engagement. When our neuroception system is working accurately (evaluating risk and modulating vagal output accordingly), we are able to inhibit our defence systems when we are safe, so that we can engage in social interactions and positive attachments, and we can engage our defences when we are unsafe or in the company of untrustworthy people. When in the presence of a frightened or frightening person, a child’s defensive measures may be helpful or ineffective, but they are all that the child can do in the circumstances.

Bidirectionality

Porges’s (2011a) polyvagal theory helps us conceptualize the importance of bidirectionality in the regulation of physiological states and understand how regulation influences our behaviours and social interactions. The processing of information is influenced by both physiological and psychological processes and determines the way we engage in social situations. Emotions have physiological components – they are not just experienced in the brain but throughout the body also. Likewise, physiological experiences impact on our emotions and our behaviour. These simple facts are crucial in understanding the physiological, emotional and involuntary behavioural components and consequences when feelings of safety are compromised, either because of a current threat or a triggered response. When a person is overwhelmed by stress, they often need assistance to ...

Table of contents

• Cover
• Half Title
• Title Page
• Copyright Page
• Table of Contents
• Contributors
• Introduction
• Part I Applying the principles of neurobiology to play and expressive arts-based practice
• Part II Working with the brainstem and midbrain
• Part III Working with the limbic and cortical systems
• Discussion and conclusion
• Index