Altered States:

          In the 15 years that I’ve been following developments in neuroscience, the most compelling clinical lesson I’ve learned is likely to rub you the wrong way. An overwhelming body of research now suggests that we clinicians rely too much on insight and understanding – and too little on repetitive practice – in promoting lasting change. This wasn’t welcome news to me. I’m a couples therapist, and I got into this business because I loved transformative moments when intimate partners’ defenses crumbled and their deep emotions emerged. That was what juiced me – not, getting couples to do the same things over and over again. Yet, year after year, I watched couples let go of judgment and blame for an instant, only to show up for the next session as miserable, critical, or withdrawn as ever. They didn’t even remember the profound insights they’d had that I felt sure were going to rock their worlds. Then I encountered a series of studies published by neuroscientist Jack Panksepp, from Bowling Green State University , and came to understand that when they were upset, my clients were in the grip of one of seven major body-brain mood states, which he calls “executive operative systems.”

Our Brains’ Executive Systems
            Panksepp uses the terms rage, fear, seeking, lust, care, panic, and play to describe the signature emotion of each system. But they’re more than passing moods. They’re complex neurochemical cascades, in which hormones race through the body and brain and electrical impulses fly over familiar neural synapses, shaping what we feel, do, and think. When one of these systems becomes active, emotions, motivation, and thoughts take over in the service of the goals it’s programmed to achieve. It’s as though we’ve gotten on a plane to Paris , and no amount of fiddling with the seatbelt is going to change the plane’s direction before the wheels touch down at Orly .
            Four of the systems are wired for love: they draw us together. One of these is old-fashioned lust. Another promotes spontaneity and play. A third, the instinct to nurture others, which Panksepp calls care, is activated by the release of the hormone oxytocin into the bloodstream and brain. Another mood system Panksepp calls “panic” is experienced as yearning or even abandonment, when an intimate partner leaves on an unexpected business trip or storms out of the house during a fight.
            Most of these mood states can help promote emotional bonding during couples therapy. But the states that therapists find the most frustrating in the consulting room – and often the most common – are two other body-brain mood states that used to be called fight or flight. Activated by the amygdala, they produce self-protective thinking and action. Fight, which Panksepp calls rage, quickens the breathing, sends blood to the muscles in preparation for striking out, and releases adrenaline and noradrenaline into the bloodstream and brain. It sharpens some mental functions and leads a person to think in decisive, impulsive, blaming, oversimplified ways. It’s accompanied by the attitude “You’re wrong, and I’m right.”
            This hormonal cascade can be lifesaving in the appropriate situation – in the face of a dangerous driver, say, or a possible mugger or rapist. But in intimate relationships, it’s often toxic. In its grip, men (and some women) can become physically abusive; others yell, nag, blame, and complain. And as almost everyone knows, it’s much easier to get on this particular tiger than to get off.
            The second self-protective cascade, which Panksepp calls fear, produces feelings ranging from anxiety to intense fright, along with worried thoughts and the impulse to freeze, flee, withdraw, or hide. It, too, is accompanied by critical thoughts about the intimate partner. A man in the grip of this neurochemical cascade may exhibit sullen, disgusted, or spacey withdrawal in the face of a barrage of angry complaints from his wife.
            Hence my frustration. I couldn’t understand why couples continued in these patterns when they’d learned – in those magical moments of insight – that blaming or withdrawing didn’t help them get what they wanted. It seemed so irrational. But when people are in the grip of these emotional takeovers, certain parts of the prefrontal cortex (the folded outer layer of the brain behind the forehead) are less active than when they’re calm. The prefrontal cortex is the seat of free will and self-awareness. It allows us to plan, strategize, imagine the results of our actions, and choose to do one thing rather than another. When portions of it are inactive, as they appear to be when we’re in the grip of one of our executive operating systems, our inner switchmaster is asleep: we simply can’t shift from one state or course of action to another. So the wife keeps blaming, like a hamster in its treadmill, and the husband, in an equally mechanical state, keeps staring out the window.

Learning to Shift Mood States
            When I first encountered this information in the early ‘90s, I worked at getting clients to shift out of these powerful mood states. When I got frustrated, I reminded myself that they were caught in neurochemical reactions beyond their control. I’d usually have one partner wait in the waiting room for a few minutes while I worked with the other, finding that a few minutes of concentrated empathy, validation, and acceptance would often calm someone down. Under these conditions, they could hear me say – in a soothing tone – that blaming would only stimulate the other’s defensiveness and not get them what they wanted. We could then brainstorm more pragmatic ways of communicating. I was training them to reactivate the neocortex – the inner switchmaster – in the face of strong emotion.
            I assumed the lessons would stick, but I was disappointed. I’d underestimated the hardwired nature of my clients’ automatically activated, neural-response programs, ingrained through years of relating to each other. They needed far more practice than a weekly therapy session could provide.
            It wasn’t enough for my clients to rehearse new thoughts in calm moments. They needed to practice new ways of thinking under “game conditions” – when they were actually upset and least able to think clearly. And they’d have to do this over and over: most neuroscience researchers agree that the brain acquires new habits through repetition. One of the most enduring concepts in neuroscience is Hebb’s Law, named after the pioneering McGill University neuroscientist Donald Hebb, who stated that brain processes that occur together over and over again become grafted together, and are more likely to occur in conjunction in the future. According to Hebb’s Law, if my clients engaged in new thinking processes while they were upset, and did this enough times, the new thinking processes would begin happening spontaneously each time they became upset.

Audio-Facilitated Change
            Then one of my clients, a registered nurse named Judy, who kept struggling to tame her tendency to get enraged with her husband, said to me, “If only I could take you home with me!” When she was furious, she was in the grip of the delusion that her anger was her empowering friend, only to find that her outbursts actually disempowered her. She asked me to make an audiotape for her to listen to precisely at the moments when she became upset with her husband. In this audiotape, I offered encouraging words and reminded her repeatedly that she was far more influential and powerful when she stood up for herself in ways that didn’t put her husband down.
            She loved the tape and listened to it not only when she was upset, but also when she was driving in her car and on a Walkman, while she was doing the laundry and cleaning house. Within three weeks, she experienced a dramatic shift in a lifelong destructive pattern.
            I made more elaborate tapes for Maria and Tony, who trudged into my office one crisp October evening for their fourth session. Maria was so upset that she refused to speak to Tony. She’d had elective surgery the previous week, and had gone into rage mode when Tony left her alone in the hospital one night to go home and get some sleep. I asked Tony to stay in the waiting room while Maria told me how incredibly selfish he was for thinking of himself when she was in so much distress. In the grip of her amygdala-driven cascade, she couldn’t see that her attack was sending Tony into disgusted withdrawal as usual. I sympathized with her feelings, and then simply suggested that although her attitude was perfectly understandable, she’d need to drop the idea that he’d done something wrong, and simply tell him how she felt. She struggled inside for a moment and then relaxed. Her eyes moistened and she said softly, “Okay, I think I can do it.” When Tony joined us, Maria spoke from a different place inside, and Tony responded instantly with an apology.
            I then made an audiotape that essentially repeated the words that had helped Maria shift during this session, and asked her to listen to it each time she became upset with Tony during the following week. The next day, she got off work early, pulled into the driveway, and saw her children playing at the neighbor’s house, even though Tony had agreed that he wouldn’t let the kids go out to play after school until they’d finished their homework. She felt a surge of anger, but as she reached for the car door, she remembered the audiotape in her purse. She paused for a split second, torn between the urge to vent and the desire to avoid going down the same old path.
            Reluctantly, she plugged in the tape and listened in the car. After 10 minutes, she realized that she was in no frame of mind to talk to Tony, and decided to take a walk around the block. After 20 minutes, she felt calmer, and by the time she saw Tony, she was able to keep an open mind and simply ask him why the kids were playing, rather than accuse him of breaking their agreement.
            What happened during Maria’s walk around the block? Frankly, I don’t know. In Maria’s audiotape, I didn’t tell her what to do or how to shift her attitude, I simply reminded her of a few reasons she might want to try. The decision was hers. Clients often have difficulty describing how they get shifts to happen. Most report a willingness to let go of control and a momentary surrender to the fact that you can’t make life go exactly according to your plans. The shift is usually accompanied by physical relaxation and a release from obsessive thinking. The client returns to the present moment, and is able to respond to what’s actually happening, rather than what they fear is going to happen. The most important ingredient in getting an attitude shift to happen is desire. When clients decide they truly want to shift, they do. 

Ancient Wisdom
            What clients report helps them shift brain states has something in common with many repetitive religious practices – from praying “Thy will be done” to practicing mindfulness, kissing a St. Christopher medal before going up to bat, or making a list each night of things one is grateful for. All of these approaches help people create enough of a pause to free them from the grip of intense rage or fear and to generate states of generosity, acceptance, and trust. Like them, my audiotapes allow the body and brain to calm down, and they serve as timely reminders that it’s in the client’s best interest to try to shift.
            Maria, for instance, used her tape as regularly as some people light candles at mass. She told me that she often could feel an attitude change beginning as soon as she heard my calm, confident tone. It reminded me of what attachment researchers speak of when securely attached children evoke images of their caregivers to soothe themselves. In her third week of using the tapes, Maria told me that she began to spontaneously hear my voice inside her head every time she got upset.
            Some clients need little more than a verbal reminder. Others require vivid images or metaphors. Tony, for instance, once told me that when he reflexively defended himself, he felt like he was swatting Maria’s complaints back at her with a baseball bat. In a minisession without Maria, I helped him imagine turning the bat into a pillow. The image worked, and when Maria returned, he was better able to absorb and digest what she had to say.
            I put the pillow image on a tape for Tony. Then we got Maria to record a tape full of her complaints – a litany about how Tony didn’t keep his word, didn’t fix things around the house, and hadn’t kept the kids quiet on Saturday morning after promising he’d let her sleep in. In a solo session, I had Tony listen. As soon as he began feeling defensive, we’d stop the tape and he’d focus on how his body felt; he’d tremble and go into a sort of disgusted shutdown. Then he’d practice trying to shift, seeing the pillows, relaxing physically, reminding himself that there might be some validity to her point of view. Then we’d start the tape up again and repeat the process. Tony used the tape regularly in his truck and became so adept at generating a state of acceptance and compassion that one of his employees remarked that he’d undergone what seemed like a spiritual shift.
            I still love the drama of transformative experiences, and my favorite moments are still the tearful ones, when partners drop their defenses and exchange heart-felt expressions of love. But nowadays, I see these moments as just the beginning. They give clients the motivation for the real work of change, which is much less dramatic. I rarely get to see it because it doesn’t happen in my office. It happens a little bit at a time, day in, day out, as clients practice letting go of the critical judgments that arise with the brain’s self-protective mood states.
            My happiest clients make shifting a daily practice, not unlike prayer. The tape recorder, and all my modern knowledge about neuroscience, have ended up supporting the practice of routine and ritual, largely ignored by modern psychotherapists, but intuitively known and practiced by sages since the beginning of time.