There are things in our lives that keep us from fully becoming our best selves, from cultivating the thoughts and actions that will bring us the greatest peace and deepest joy.  Stress for one thing; preoccupations with what others think and with not realizing our own version of success; problems in interpersonal relationships, searching for spiritual meaning. We look for solutions, for wisdom everywhere outside of ourselves.  Whether it be with the latest self-help trends, the next best relationship, a pill… All too often however, the answers have been right there all along, inside of us…The quest is knowing how to cultivate them.

When I was in the middle of my doctoral program my husband and I had to make a very difficult decision. He was offered his dream job which meant moving our family from the Boston area to Pennsylvania – It was an enticing opportunity as it meant our little family could settle down to a quieter pace and better quality of life. The one caveat was that I would have to commute from Philadelphia to Boston for one academic year to finish requirements for my PhD. Needless to say, it was a difficult decision. Although exciting for our family, it was a very stressful period of my life. Every Monday I’d leave at 4 a.m. to take the train into Philadelphia where I’d pick up the Accela fast train for a five-hour ride to Boston and then would reverse commute Thursday nights. I finished the year but was left feeling physically exhausted and mentally fatigued.

The following September as I was beginning a very demanding neuropsychology pre-doctoral clinical internship, the world trade centers were attacked. I remember distinctly the visceral feeling of dread and subsequent anxiety that I felt. Later that year the fatigue I was feeling increased and I struggled to recover from GI symptoms.  Although I understood that the accumulation of several major stressful life events can affect your body, I had never before experienced anything quite like this. I went to my primary care doctor at the time and she immediately said “I know what you need and you have to be on it for a minimum of two years.” There was little discussion, if any about the stress I was under and how it contributed to my symptoms, or any discussion about possibly seeing a therapist.  Instead, my doctor prescribed Paxil, a Selective Serotonin Reuptake Inhibitor (SSRI), an antidepressant. I knew from experience that what I needed was to speak with someone who would understand the stress I’d been under, and that the medication alone would not solve my problem.  I was an over achiever; I was not taking the time to pause and reflect, and I clearly overestimated the level of stress my body could sustain. I knew as a therapist that many women who juggle family, motherhood and career aspirations find themselves overwhelmed with little support, experiencing similar symptoms while trying to cope. I eventually went to an experienced therapist, made some critical self-healing life changes and within a few months was able to regain a greater sense of well-being.

As a consequence of this experience, I decided to conduct research and write my Ph.D. dissertation on the treatment of depression in primary care settings and study the relationship between Selective Serotonin Reuptake inhibitors (SSRI’s) and psychotherapy as recommended treatments. The results of my study revealed that 90 percent of the study participants who went to their primary care doctor and were prescribed an antidepressant had recently experienced several stressful life events. Only a very small fraction was also prescribed therapy. Some participants expressed concerns that their quality of life did not markedly improve after taking prescribed medications. Their symptoms were ameliorated to a degree but continued to suffer from problems of living, thought distortions, and interpersonal relationship problems. My experiences speaking with these participants and understanding their stories has informed my work as a psychologist.

Here are some of the things I learned in all the years of working with clients:

1. Chronic stressful life events can contribute to the onset and maintenance of symptoms of anxiety, depression and to problems with emotional regulation. It can also compromise your immune system.

2. The experience of significant stress and anxiety is typically associated with excessive worry, ruminating thoughts, faster heartbeat or sweating. However, it can also manifest in lesser-known ways that mimic other medical disorders such as:

• • Feeling a weakness of limbs
  • Feeling disoriented
  • Dizziness
  • Having trouble gathering your thoughts
  • Gastrointestinal symptoms
  • Temporary feelings of derealization or depersonalization  (Feeling like you’re not present. Like you are suspended outside your body)

3. When we are in a state of stress and hyper-arousal it’s difficult to have clarity of mind to make the best decisions.  It’s as if we are carrying a load of weights on our backs keeping us from seeing ourselves and the world clearly; preventing us from crossing a threshold toward emotional well-being and a sense of peace.

4. We often ignore warning signs evident in our bodies, thoughts and emotions. Symptoms of anxiety and depression can often manifest as physical symptoms such as fatigue, chest pain. As I always say to my clients, what your mind doesn’t deal with your body will.

5. Our body and brain work collaboratively and have a memory of your experiences with anxiety and depression making these experiences more likely to repeat themselves

6. You can build new and restorative memories to overcome symptoms of anxiety and depression by identifying thought distortions, some of which may be outside your awareness and taking actions that promote corrective emotional experiences. Together these changes help to rewire our thoughts and responses to problem situations preventing the chronic recurrence of these symptoms.

The root of anxiety and depression has long been thought to be a result of chemical imbalances in the brain. Most notably from a deficit of neurotransmitters such as a lack of sufficient serotonin and or norepinephrine. You’ve only had to watch tv commercials over the last few years to see how just by boosting your serotonin levels you can eliminate your depression.

What I found most surprising in my research was that despite this chemical imbalance theory, There’s actually no real consensus among researchers on the genetic or neurobiological mechanisms for depression and anxiety.  Representatives from the National Institute of Mental Health (NIMH) conclude: “We have not identified the genetic and neurobiological mechanisms underlying depression and mania, nor do we understand the mechanisms by which non-genetic factors influence these disorders. In 2020 the NIMH set a strategic plan to further investigate and define the brain mechanisms underlying complex behaviors and what aspects contribute to mental illness. (Nestle et al., 2002; NIMH 2020.)

The truth is the causes of depression and anxiety are clearly more complex. Stressful life events, past traumas, genetic predisposition, an individual’s copings mechanisms, the lack of support systems and the effects of other medications and other medical conditions all can contribute to the onset and maintenance of depression and anxiety.

Currently, the most popular treatment for this neurotransmitter imbalance in the brain have traditionally been with medications called SSRI’s (selective serotonin re-uptake inhibitors). In fact, research shows that with the recent increase and popularity of SSRI’s, there has been a corresponding decline in the percentage of persons receiving psychotherapy from 71% in 1987 to 60.2% in 1997(Olfson, et al., 2002, Marcus SC, Olfson M. National trends in the treatment for depression from 1998 to 2007. Arch Gen Psychiatry. 2010;67(12):1265-1273.)

These trends continue today despite research evidence which clearly shows that combined treatment of psychopharmacotherapy and psychotherapy for depression and associated symptoms are the best practice (Pettit, Voelz, & Joiner, 2003).

Dr Bessel Van Der Kolk (2014) believes that SSRIs can be helpful in overcoming overwhelming emotions in traumatized patients but they also deflect attention from addressing underlying issues which then remain suppressed.  He argues that “the brain disease model takes control over people’s fate out of their hands and puts doctors and insurance companies in charge of fixing their problems”. Despite the increase in antidepressant use the number of people treated for depression has tripled over the last couple decades.

Why are anti-depressants so frequently dispensed?  Understandably, because it’s easier for physicians, readily available and deliver shot-term results.  Typically, however, they do not address the core issues leading to the onset of symptoms. Stressful events, core habitual maladaptive responses in thinking and behavior that lead to anxiety and depressive symptoms remain unchecked. Higher functioning positive, effective and long-lasting strategies for coping and eliminating symptoms are never learned.

What’s been most exciting for me as a psychologist is that the past several decades has seen a rise in studies that point us in another direction and suggest that our psychological experiences, our thoughts and belief systems do actually affect the brain. That is, changes in our psychological processes are reflected by changes in the functions and structures of the brain. Psychotherapy actually changes the brain!

Dr. Eric Kandel, Nobel prize winner in physiology of medicine in 2000, discovered that our experiences can alter gene expressions in the brain so that learning that occurs in psychotherapy can change neuron connections to produce long-term changes in undesirable symptoms and behaviors

The use of technologies such as functional magnetic neuroimaging (FMRI), single photon emission CT (SPECT) and Positron Emission tomography (PET) have made it possible to study changes in the blood flow and metabolisms of the brain as well as brain changes at the molecular level following treatment with therapy (such as Cognitive behavioral (CBT), Interpersonal and Psychodynamic therapy). These therapies have been found to actually create changes in the brain that not only ameliorate depression and anxiety symptoms but also may have longer- lasting effects.

In a research article on how psychotherapy changes the brain, Dr Hasse (2011) reviewed nearly 20 studies on brain changes after psychotherapy for depression, anxiety disorders, and borderline personality disorder. The areas of the brain most studied were the amygdala which controls fear and emotion, the hippocampus which regulates the memories of emotions, and the medial prefrontal cortex which controls high level thinking, problems solving, delayed gratification all which are executive functions and considered important to the development of emotional intelligence. The medial prefrontal region is also associated with self-referential memory;
formed about what type of person one believes themselves to be. These studies support a major hypothesis regarding the effect of psychotherapy, that it has a “top-down” regulating effect on brain functioning. The process of therapy seems to calm the more excitable limbic structure such as that of the amygdala by achieving an increase in prefrontal controls. (Hasse 2011)

Dr. Louis Cozolino PhD (2002; 2017) who wrote “The Neuroscience of Psychotherapy” suggest therapy helps to regulate arousal.  Our more primitive limbic system, in particular the amygdala, becomes aroused from stress and negative self-representations. The amygdala, an area of the brain that contributes to emotional processing, sends a distress signal to the hypothalamus. The more aroused and anxious we become the more cortisol and adrenalin is released. This arousal state has the negative consequence that it can contribute to shutting down our capabilities to learn new information. According to Dr. Cozolino, therapy then gets the brain to its “neuroplastic sweet spot” by calming the hyperexcitability of the amygdala.

When we are stressed, angry, anxious and ruminating, these responses can initially appear to give us some sense of control or even energize us, naturally since they raise cortisol levels. However, these burst of stress responses are short lived and unsustainable over the long term. This hyperexcitable state is not only driven by the brain’s older more primitive limbic system, but is sustained by stories(schemas) we tell ourselves to justify these maladaptive coping strategies. These conditions act like the perfect storm increasing our suffering and making it difficult to develop new rationales. Unable to view ourselves and our relationships from a different perspective we fail to develop calming coping strategies and long-lasting change produced by our higher functioning brain.

Therapy provides the setting to develop a healing relationship where transformational change can happen. The objective is to enhance a patient’s problem-solving capacities, their self-representation (i.e., narratives and interpretations of who they are) and regulation of emotions. This happens when clients safely identify and are able to eliminate self-sabotaging coping mechanisms, sometimes unknown to us, learned as a way to defend against negative and/or traumatic experiences. Through this process new neural connections can develop not only in the frontal lobe but also in the hippocampal region where memories are stored creating long lasting change. When therapy creates new ways of thinking, reductions in our stress level, anxiety or depressive symptoms one can say that therapy has changed the brain.

Cozolino, L. The Neuroscience of Psychotherapy: Building and rebuilding the human brain(New York, U.S.A.: W.W. Norton & Company, 2002).

Cozolino, L. The Neuroscience of Psychotherapy: Healing the social brain (3rd Edition, New York, U.S.A.: W.H. Norton & Company, 2017).

Hasse K. 2011. How Psychotherapy Changes the Brain. Psychiatric Times 28 (8).

Kandel, E (1998). A New Intellectual Framework for Psychiatry? American J. Psychiatry, 1998, 155, p 460.

Kandel, E (2001). The Molecular Biology of Memory Storage: A Dialogue Between Genes and Synapses. Science, 294:1030-1038

National Institute of Mental Health. (2020). Transforming the understanding and treatment of mental illnesses. [Press release]. Retrieved from https://www.nimh.nih.gov/about/strategic-planning-reports/goal-1-define-the-brain-mechanisms-underlying-complex-behaviors.shtml

Nestle E.J.,Gould, E., Husseini, H., et al.2002. Preclinical models: Status of basic research in depression. Biol Psychiatry 52: 503-28.

Olfson, M., Marcus, S.C., Druss, B., Lynn, E., Tanielian, T., Pincus, H.A., (2002).National Trends in the outpatient treatment of depression, Journal of American Medical Association 287 (2), 203-209.

Olfson, M., Marcus, S.C., Druss, B., Lynn, E., Tanielian, T., Pincus, H.A., (2010).National Trends in the outpatient treatment of depression from 1998-2007, 67 (12), 1265-1273.

Pettit, J.W., Voelz, Z.R.,& Joiner Jr., T.E. (2001). Combined Treatments for Depression.  In M.T. Sammons & N.B. Schmidt Z(Eds) (2001). Combined Treatments for Mental Disorders: A guide to psychological and pharmacological interventions (pp.131-159. Washington, D.C.: American Psychological Association.

A. van der Kolk, The Body Keeps the Score: Brain, Mind, and Body in The Healing of Trauma (New York, NY: Penguin Books, 2014).