What Happens in the Brain During Psychotherapy?

This week I'm pleased to announce the first publication from a study that I've been working on for several years, with my colleague Dr. Deb Sandella from the RIM Institute in Denver. The paper itself is worth a look, even though I'm going to summarize it below. It has some of the coolest figures I have ever published, from brainwave data that we collected during the study!

In this study we recruited nursing students who wanted to talk about difficult experiences -- it could be any kind of stressor past or present, although a high percentage of our participants did have past trauma of some kind. Many also talked about family or relationship issues, and the challenges of the nursing role that they were learning. We met in my office, where Dr. Deb used her Regenerating Images in Memory approach to help the students generate images and access difficult memories, and then to re-integrate these into their sense of self (the method is described in more detail in our paper, and in Dr. Deb's book Goodbye, Hurt and Pain). In contrast to traditional insight- or learning-oriented psychotherapies, RIM is a strengths-based approach that seeks to draw out the participant's own intuitive solutions by first surfacing the source of trauma and then re-encoding it in memory in a more adaptive way. We used a 5-lead electroencephalogram (EEG) device to monitor participants' brainwaves throughout the RIM procedure, because our main interest was in understanding the mechanisms by which RIM helps people to overcome traumatic memories and distress. 

There were three major findings of the study: First, the students all said that RIM was very helpful based on several pre-post questionnaires. This was what we expected, because other pre-post studies, one nonrandomized controlled trial, and one small randomized trial have all found benefits of RIM for a range of different patient groups (prior studies on RIM can be found here). But this wasn't a randomized trial designed to prove causal effects, so we shouldn't over-interpret the large treatment effects. Besides the study design, it's important to note that RIM was delivered in our study by its original developer, who clearly believes in the method and is the primary trainer who helps other clinicians to develop their skills in delivering it. Still, if the approach hadn't worked, then it wouldn't have made sense to ask questions about why and how it did so.

Second, the EEG results showed a clear and consistent pattern: As students went deeper into their experience of imagery, sensation, and emotion during RIM, the Narrative-Mind areas of their brain calmed down and let go of control. This could be seen through decreased overall activity in the brain's frontal lobes, as well as a shift into the type of slow-wave EEG readings (theta and delta waves) that are commonly associated with meditation or sleep. It's noteworthy that this was also the part of the RIM procedure when the most intense and personally relevant imagery tended to occur -- when the conscious mind was essentially sleeping (many participants in fact said that they felt sleepy at the end of the session). At the same time, the Intuitive-Mind areas of participants' brains became much more active, with increased overall activity as well as more fast-cycle brainwaves (alpha, beta, and gamma) in the temporal lobes. All of this is very consistent with what we expected based on Two Minds Theory, showing that changes in participants' self-reported symptoms went along with a shift into the Intuitive Mind. The fact that people had more intense experiences while their conscious, language-using, Narrative minds were less active is consistent with other research on topics like near-death experiences. It's also similar to what has been shown to happen in the brain during aerobic exercise, which is a very effective treatment for depression. At the end of the RIM procedure, participants' frontal lobes kicked back into gear, but their temporal lobes also stayed active, an interesting finding that might suggest better integration across the full brain, where people's Narrative and Intuitive capabilities can both be brought to bear on problems.

Finally, we had a fortuitous finding based on the fact that Colorado happened to legalize psychedelic medications during the time that we were conducting this study. We were hearing a lot about psychedelic treatment from our colleagues in psychiatry, so we decided to add a mystical experiences questionnaire to our study. We were surprised to see that people rated their experience during RIM to be just as intense as what people often report when taking psychedelics -- a good quarter of participants said that these experiences were "as strong as I've ever felt," while they were sitting in my desk chair having a conversation with Dr. Deb. People also scored particularly high on subscales such as ineffability (the sense that an experience cannot be put into words) and numinous quality (the sense that an experience felt "more real" than everyday reality), which are associated with therapeutic improvement in the psychedelic literature. It's also interesting that our participants had psychedelic-like experiences without the use of any drug. In fact, one participant who had previously tried psychedelics told us that her RIM experience was in some ways more intense, while also including a greater sense of control and feeling more integrated with her usual ways of thinking.

Overall, this study shows that something very interesting happened in people's brains while they were participating in RIM, and that these brain changes co-occurred with strong self-reported improvements in the symptoms that brought them to our study. The study supports predictions made by Two Minds Theory with regard to how change happens -- the first time that we have hard data from brain measurements in support of this theory's predictions. We are currently working on a follow-up qualitative study to look at brainwave correlates of particular "change points" or insights that occurred during the RIM process, and we have a grant application under review for a follow-up study with firefighters. That grant would allow us to use a more precise form of brain measurement (fMRI), and would provide the randomized controlled trial infrastructure that was lacking for treatment-outcome conclusions in the current paper. 

RIM is of course not a "typical" psychotherapy -- it is much more imagery-based and body-focused than most talk therapy approaches. It has some of the common factors usually seen in psychotherapy, which might account for part of its effects, but as our article documents the existing psychotheraputic approaches to trauma using cognitive-behavioral therapy are actually not that great. (I also argued in a previous blog post that even those effects can be largely accounted for via Intuitive-Mind mechanisms). The benefits might be limited to trauma, which has some unusual effects on experience and memory because of the way it re-wires the brain, although prior RIM studies have also shown benefits for people with other treatment goals. Our students were also a subclinical population. Despite these limitations, RIM is an exciting treatment approach, and I'm looking forward to future research on this psychotherapeutic method.