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Integrating the Right and Left Brain:The Neuroscience of Best Practices in Counseling

Thomas A. Field, M.Ed., NCC, LPC

Doctoral candidate, James Madison UniversityAMHCA 2013 Conference, Alexandria, VA


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Havent I heard of this before?

Left- and right-

hemisphere studies

emerged in the 1970s,

but marketing and popculture soon subsumed

it

The importance of the

topic was lost until

recently

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INTRODUCTION

Part One.

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Introduction

The status of society: moving toward standardized, rule-governed procedures for expected professional behavior

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Introduction: Societal ContextIan McGilchrist: The Divided Brain

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Introduction: Societal Context

McGilchrist (2009): A left-brain world would lead

to increased bureaucracy, a focus on quantity and

efficiency over quality, valuing technology over

human interaction, and valuing uniformity overindividualization.

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Relevance to Counselors

Neuroscientists such as

Allan Schore (2012)

have suggested that

activities associatedwith the LH currently

dominate mental health

services.

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This is evidenced by the

manualization of counseling,

undue influence of insurance companies in

defining acceptable forms of treatment,

a reductionist and idealistic view of evidence-

based practice,

and a lack of respect for the counselingrelationship in treatment outcomes despite a large

body of evidence.

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Today, counselors must be knowledgeable ofbest practices.

2005, the American Counseling Associations

(ACA) Code of Ethics included a recommendationto use therapies that have an empirical orscientific foundation (ACA Code of Ethics, 2005,C.6.e).

In 2009, CACREP mandated that CMHC, MC&FC,and Addictions Counseling students be taught inevidence-based treatments (I.3)

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Ifprofessional counselors use the best availableresearch-based approaches to help clients andstudents, then counselor effectiveness, client

satisfaction and third-party insurer satisfactionall improve. When professional counselorsprovide effective services, it also helps ourprofessional advocacy and lobbying efforts with

federal, state, and local politicians andbureaucrats, and leads to more counseling jobsand higher pay scales.

Dr. Bradley Erford, ACA President, 2012www.thomfield.com


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Erford is absolutely correct in his

assertions. Counselors must use

research to inform practice.

The problem facing our profession isnot one of lacking a destination, but of

lacking the necessary road map to get

there.

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Our common destination is

research-informed practice.

Until recently, only one

road map has beenavailable to the

counseling profession,

namely the EBT

movement that

originated in the field of

psychology.

I propose a more

commensurateroadmap with our

professions values and

identity: research

evidence from

neuroscience should

also inform counseling

interventions.www.thomfield.com


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OUR CURRENT DIRECTION: THELEFT HEMISPHERE PATHWAY

Part Two.

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Our Current Direction: The LH Pathway

The left side of the

brain is responsible for

rational, logical, and

abstract cognition,known as conscious

knowledge.

The Left Hemisphere

interpreter

Schore, 2012; Cozolino,

2010

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It should be no surprise that conscious, rational,analytical interventions are therefore the mostpopular in todays environment

The majority of EBTs are forms of CBT(Society of Clinical Psychology, 2012)

In an unpublished national pilot survey, only 6%(n = 3) of National Certified Counselors who used

EBTs did not report using a form of cognitive-behavioral therapy (CBT).

(Field, Farnsworth, & Nielsen, 2011)

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The apparent fit between CBT and the EBT

movement can be understood via

neuroscience

Following a manualized protocol and using

conscious verbal analysis (CBT) are both LH

functions

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Studies have found a link between CBT and

activation in the dorsolateral prefrontal cortex

of the LH (Siegle, Steinhauer, Friedman,

Thompson, & Thase, 2011).

Put simply, CBT activates the LH, and the EBT

movement values LH over RH processing.

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What does Aaron T. Beck think?

You cant do cognitive

therapy from a manual

any more than you can do

surgery from a manual.

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A 2006 APA Task Force on Evidence-Based

Practice intoned: sensitivity and flexibility in

the administration of therapeutic

interventions produces better outcomes thanrigid application ofprinciples (p. 278).

A purely LH approach does not work.

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THE RIGHT HEMISPHERE: INTUITION,CREATIVITY, AND RELATIONSHIP

Part Three.

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The Old Question Revisited

Does change have to

occur at a conscious,

rational level?

Examples: cognitivedissonance and

persuasion techniques

(the foundation of

motivationinterviewing), EMDR.

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The Right Hemisphere

The right side of the

brain is associated with

unconscious social and

emotional learning, andincludes intuition,

empathy, creativity, and

flexibility.

Schore, 2012; Cozolino,2010

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Intuition

Clinical judgment

the application of

rational and analytical

reasoning when working

with clients (LH function)

Clinical intuition

the attunement to

unconscious and implicit

knowledge when

working with clients (RH

function; Bolte &

Goschke, 2005).

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Intuition

Often difficult to

articulate, intuition has

been commonly

described as theunthought known, a

gut feeling, and a

working hypothesis

(Bolas, 1987).

Lieberman (2000)

defined clinical intuition

as the subjective

experience associatedwith the use of

knowledge gained

through implicit

learning (p. 109)

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Hand Exercise

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Intuition

Welling (2005) wrote, no therapist can

reasonably deny following hunches,

experiencing sudden insights, choosing

directions without really knowing why, orhaving uncanny feelings that turn out to be of

great importance for therapy (p. 19)

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Studies on counselor development have found

that experienced counselors tend to rely more

on intuition than manualized protocols

(Rnnestad & Skovolt, 2003; Stoltenberg,

McNeill, & Delworth, 1998).www.thomfield.com


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Intuition

The difference between novice and

experienced counselors: the amount of

accumulated experiences from prior client

encounters within the unconscious, whichsculpts unconscious intuition.

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Intuition

As any experienced

practitioner can

attest, counselors

tend to learn intuitiveskills such as timing

and word choice with

experience.

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Intuition

We know that effective counseling requires

both conscious knowledge of research

evidence and unconscious clinical intuition

in other words, the integration of the LH andRH of the brain (Keenan, Rubio, Johnson, &

Barnacz, 2005; MacNeilage, Rogers, &

Vallatorigara, 2009).

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Intuition

Bowlby (1991) once

wrote, clearly the best

therapy is done by the

therapist who isnaturally intuitive and

also guided by the

appropriate theory (p.

16).

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Creativity

Creativity has also been associated with the

RH (Grabner, Fink, & Neubauer, 2007), and

occurs when counselors are attuned to

implicit memories.

For creativity to occur, counselors must trust

their unconscious, where novel ideas are

generated, based on environmental cues.

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Creativity

Counselors often cannot fully prepare for

what the client brings to the session. Every

session therefore requires some degree of

creativity by the counselor, whoseinterpersonal contact with the client is crucial

to establishing a deep and sustained

therapeutic bond.

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Creativity

Some of us have experienced moments with

clients when we instinctively know what

diagnosis or problem they are experiencing,

without formally checking off symptoms fromdiagnostic criteria.

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Creativity

Without creativity, the

counselor is reduced to

the role of technician,

administeringtreatments in a

consistent yet rote and

rigid manner.

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Creativity

The power of metaphor: The brains amazing

way of processing emotional events

The dissertation dream

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Creativity

The unconscious mind

has a lot to offer us.

Its not a coincidence

that my best ideashappen right at that

sweet spot before I drift

off to sleep.

Kerouac: first thought,

best thought.

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The Bedtime Conversation

"That book is about life lessons,right?"

Main underlying theme of thebook?

Comparison to the EBT paradigm:relationships in counseling areunderstood to be the containerfor the true ingredient of change(model/technique). This is a falseassumption.

Even BCBAs value the importanceof instructional control

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The Counseling Relationship

Fifty years of research support the centrality ofthe counseling relationship in client outcomes(Orlinsky et al., 2004).

Efforts to promulgate best practices or evidence-

based practices (EBPs) without including therelationship are seriously incomplete andpotentially misleading (Norcross & Wampold,2011, p. 423).

Magnavita (2006) concluded, the quality of thetherapeutic relationship is probably the mostrobust aspect of therapeutic outcome (p. 888).

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The rigid technical

application of

treatment manuals

short-circuits thisprocess and impairs the

therapeutic

relationship, which is

crucial to successfulcounseling outcomes.

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By the end of the 1990s, counseling was

beginning to move toward a two-person

interpersonal model in place of a one-person

intrapersonal model for conceptualizing clientproblems and planning treatment (Cozolino,

2010).

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In a two-person relational system, the

interaction between counselor and client is at

the core of effective counseling.

Effective counseling is not only determined by

what the counselor does or says; it is also

determined by the quality of the counselors

interaction with the client (Bromberg, 2006).

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Two-Person Exercise

Me You

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Because the LH is specialized to manage

ordinary and familiar circumstances while

the RH is specialized to manage emotional

arousal and interpersonal interactions(MacNeilage et al., 2009), many (if not most)

counseling interventions stimulate RH

processing

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the moment of contact between counselor and client(Stern, 2004),

attention to the external environment (Raz, 2004),

empathic resonance of both linguistic content andnonverbal behavior (Keenan, Rubio, Johnson, & Barnacz,

2005), mental creativity (Asari, Konishi, Jimura, Chikazoe,

Nakamura, & Miyashita, 2008),

social learning (Cozolino, 2010),

emotional words (Kuchinke, Jacobs, Vo, Conrad, Grubich, &Herrmann, 2006), and

emotional arousal (MacNeilage, Rogers, & Vallatorigara,2009).

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Since so much of

counseling is nonverbal

and unspoken, yet

known to us, thepractice can be better

understood as a

communication cure

rather than a talkingcure (Schore, 2012).

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Integration Exercise

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INTEGRATING LEFT AND RIGHTHEMISPHERES

Part Four.

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Integration

A balance needs to be

struck between the

extreme polarities of

structured vs. spontaneous

approaches,

fidelity to manuals vs.

individualization,

rigidity vs. flexibility,

conscious vs. unconscious,

cognitions vs. emotions,

LH vs. RH.

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Integration

Radical adherence to either polarity is less

effective. We need a balance.

At one polarity, fidelity to a structured,

manualized, rigid, conscious, LH-activating

cognitive treatment would lack the flexibility

and individualization necessary to establish a

strong counseling relationship.

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Integration

At the other extreme,fidelity to a purelyspontaneous,individualized, flexible,

unconscious,emotionally-activatingRH approach would beuninformed by research

evidence and would beunethical for thisreason.

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CONCLUSION

Part Five.

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Conclusion

The RH and LH often function in tandem with

one another. Both hemispheres are integral to

problem solving; the RH generates solutions,

while the LH decides on a single solution tobest fit a problem (Schore, 2012).

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Conclusion

The best practices movement exists in the

context of a societal push for standardization

and rule-governed behavior

Counselors can use best practices without

neglecting the importance of RH processes

that are foundational to effective counseling

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Conclusion

Counselors must develop sensitivity to client

variables when following a manualized protocol

and adjust their approach accordingly, such as

Preference for structured/unstructured approaches, Learning styles (auditory, visual, kinesthetic)

Cultural variables (racial/ethnic identity, gender, age,

social class, sexual/affective orientation, and religious

or spiritual values)

Unique features of the two-person relational system

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Conclusion

And while it is never easy to value both

structure and spontaneity, or uniformity and

individuality, achieving this balance will result

in a destination that is more commensuratewith the counseling professions values and

identity, of prizing the counseling relationship

as the core ingredient to therapeutic change.

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References

American Counseling Association. (2005). Code of Ethics. Alexandria, VA: Author. American Psychological Association Presidential Task Force on Evidence-Based

Practice. (2006). Evidence-based practice in psychology. The AmericanPsychologist, 61, 271-285.

Asari, T., Konishi, S., Jimura, K., Chikazoe, J., Nakamura, N., & Miyashita, Y. (2008).Right temporopolar activation associated with unique perception. NeuroImage,41, 145-152.

Beck, A. T. (2004). Pills or talk? If youre confused, no wonder. Published June 8,2004 in New York Times. Retrieved from http://www.nytimes.com

Bolas, C. (1987) The shadow of the object: Psychoanalysis of the unthought known.New York: Columbia University Press.

Bolte, A., & Goschke, T. (2005). The speed of intuition: Intuitive judgments ofsemantic coherence under different response deadlines. Memory & Cognition, 33,

1248-1255. Bowlby, J. (1991, Autumn). The role of the psychotherapists personal resources in

the therapeutic situation. In Tavistock Gazette.

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References

Bromberg, P. M. (2006).Awakening the dreamer: Clinical journeys. Mahwah, NJ:Analytic Press.

Burgoon, J. K. (1985). Nonverbal signals. In M. L. Knapp & C. R. Miller (Eds.),Handbook of interpersonal communication (pp. 344-390). Beverly Hills, CA: Sage.

Council for Accreditation of Counseling and Related Educational Programs. 2009Standards. Retrieved from http://www.cacrep.org.

Cozolino, L. (2010). The neuroscience of psychotherapy: Healing the social brain(2nd ed.). New York: Norton.

Erford, B. T. (2012, September). Wheres the beef?! Counseling Today, 55(3), 5.

Field, T. A., Farnsworth, E. B., & Nielsen, S. K. (2011). Do counselors use evidenced-based treatments? Results from a national pilot survey. Unpublished manuscript.

Grabner, R. H., Fink, A., & Neubauer, A. C. (2007). Brain correlates of self-relatedoriginality of ideas: Evidence from event-related power and phase-locking changes

in the EEG. Behavioral Neuroscience, 121, 224-230. Keenan, J. P., Rubio, J., Racioppi, C., Johnson, A., & Barnacz, A. (2005). The right

hemisphere and the dark side of consciousness. Cortex, 41, 695-704.

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References

Kuchinke, L., Jacobs, A. M., Vo, M. L. H., Conrad, M., Grubich, C., &Herrmann, M. (2006). Modulation of prefrontal cortex activation byemotional words in recognition memory. NeuroReport, 17, 1037-1041.

Lieberman, M. D. (2000). Intuition: A social neuroscience approach.Psychological Bulletin, 126, 109-137.

MacNeilage, P. F., Rogers, L., & Vallortigara, G. (2009). Origins of the left

and right brain. Scientific American, 301, 160-167. Magnavita, J. J. (2006). In search of the unifying principles of

psychotherapy: Conceptual, empirical, and clinical convergence.AmericanPsychologist, 61, 882-892.

McGilchrist, I. (2009). The master and his emissary. New Haven, CT: YaleUniversity Press.

Norcross, J. C., & Wampold, B. C. (2011). Evidence-based therapyrelationships: Research conclusions and clinical practices. In J. C. Norcross(Ed.), Psychotherapy relationships that work(2nd ed.), pp. 423-430. NewYork: Oxford University Press.

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References

Orlinsky, D. E., Ronnestad, M. H., & Willutzki, U. (2004). Fifty years ofpsychotherapy process-outcome research: Continuity and change. In M. J. Lambert(Ed.), Handbook of psychotherapy and behavior change (5th ed.). New York: Wiley.

Raz, A. (2004). Anatomy of attentional networks.Anatomical Records, 281B, 21-36.

Rnnestad, M. H., & Skovolt, T. M. (2003). The journey of the counselor andtherapist: Research findings and perspectives on professional development.

Journal of Career Development, 30(1), 5-44.

Schore, A. N. (2012). The science of the art of psychotherapy. New York: Norton.

Siegle, G. J., Steinhauer, S. R., Friedman, E. S., Thompson, W. S., & Thase, M. E.(2011). Remission prognosis for cognitive therapy for recurrent depression usingthe pupil: Utility and neural correlates. Biological Psychiatry, 69, 726-733.

Stern, D. N. (2004). The present moment in psychotherapy and everyday life. NewYork: Norton.

Stoltenberg, C. D., McNeill, B. W., & Delworth, U. (1998). IDM: An integrateddevelopmental model for supervising counselors and therapists. San Francisco:Jossey-Bass.

Welling, H. (2005). The intuitive process: The case of psychotherapy.Journal ofPsychotherapy Integration, 15, 19-47.

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