Integrating the Right and Left Brain:

The Neuroscience of Best Practices in Counseling

Thomas A. Field, M.Ed., NCC, LPC Doctoral candidate, James Madison University
AMHCA 2013 Conference, Alexandria, VA

Program Goals
Introduce the relevance of right- and lefthemisphere operations to your counseling practice. Describe the current state of best practices in counseling, which largely operate from a strictly left-hemisphere orientation. Explore how to integrate right- and lefthemisphere processing.
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Havent I heard of this before?

Left- and righthemisphere studies emerged in the 1970s, but marketing and pop culture soon subsumed it The importance of the topic was lost until recently

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Part One.

INTRODUCTION

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Introduction
The status of society: moving toward standardized, rulegoverned procedures for expected professional behavior

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Introduction: Societal Context

Ian 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 over individualization.

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Relevance to Counselors
Neuroscientists such as Allan Schore (2012) have suggested that activities associated with the LH currently dominate mental health services.

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Relevance to Counselors
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 evidencebased practice, and a lack of respect for the counseling relationship in treatment outcomes despite a large body of evidence.
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Relevance to Counselors
Today, counselors must be knowledgeable of best practices.
2005, the American Counseling Associations (ACA) Code of Ethics included a recommendation to use therapies that have an empirical or scientific foundation (ACA Code of Ethics, 2005, C.6.e). In 2009, CACREP mandated that CMHC, MC&FC, and Addictions Counseling students be taught in evidence-based treatments (I.3)
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Relevance to Counselors
If professional counselors use the best available research-based approaches to help clients and students, then counselor effectiveness, client satisfaction and third-party insurer satisfaction all improve. When professional counselors provide effective services, it also helps our professional advocacy and lobbying efforts with federal, state, and local politicians and bureaucrats, and leads to more counseling jobs and higher pay scales.
Dr. Bradley Erford, ACA President, 2012
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Relevance to Counselors
Erford is absolutely correct in his assertions. Counselors must use research to inform practice. The problem facing our profession is not 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 been available to the counseling profession, namely the EBT movement that originated in the field of psychology. I propose a more commensurate roadmap with our professions values and identity: research evidence from neuroscience should also inform counseling interventions. www.thomfield.com

Part Two.

OUR CURRENT DIRECTION: THE LEFT HEMISPHERE PATHWAY

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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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Our Current Direction: The LH Pathway

It should be no surprise that conscious, rational, analytical interventions are therefore the most popular 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 cognitivebehavioral therapy (CBT).
(Field, Farnsworth, & Nielsen, 2011)
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Our Current Direction: The LH Pathway

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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Our Current Direction: The LH Pathway

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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Our Current Direction: The LH Pathway

A 2006 APA Task Force on Evidence-Based Practice intoned: sensitivity and flexibility in the administration of therapeutic interventions produces better outcomes than rigid application ofprinciples (p. 278). A purely LH approach does not work.

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Part Three.

THE RIGHT HEMISPHERE: INTUITION, CREATIVITY, AND RELATIONSHIP

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The Old Question Revisited

Does change have to occur at a conscious, rational level? Examples: cognitive dissonance and persuasion techniques (the foundation of motivation interviewing), EMDR.

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The Right Hemisphere

The right side of the brain is associated with unconscious social and emotional learning, and includes 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 the unthought known, a gut feeling, and a working hypothesis (Bolas, 1987). Lieberman (2000) defined clinical intuition as the subjective experience associated with 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, or having 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).
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Intuition
The difference between novice and experienced counselors: the amount of accumulated experiences from prior client encounters within the unconscious, which sculpts unconscious intuition.

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Intuition
As any experienced practitioner can attest, counselors tend to learn intuitive skills 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 and RH 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 is naturally 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, whose interpersonal 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 from diagnostic criteria.

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Creativity
Without creativity, the counselor is reduced to the role of technician, administering treatments 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 ideas happen 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 the book?

Comparison to the EBT paradigm: relationships in counseling are understood to be the container for the true ingredient of change (model/technique). This is a false assumption.
Even BCBAs value the importance of instructional control
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The Counseling Relationship

Fifty years of research support the centrality of the counseling relationship in client outcomes (Orlinsky et al., 2004). Efforts to promulgate best practices or evidencebased practices (EBPs) without including the relationship are seriously incomplete and potentially misleading (Norcross & Wampold, 2011, p. 423). Magnavita (2006) concluded, the quality of the therapeutic relationship is probably the most robust aspect of therapeutic outcome (p. 888).
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The Counseling Relationship

The rigid technical application of treatment manuals short-circuits this process and impairs the therapeutic relationship, which is crucial to successful counseling outcomes.

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The Counseling Relationship

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 client problems and planning treatment (Cozolino, 2010).

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The Counseling Relationship

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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The Counseling Relationship

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 Counseling Relationship

the moment of contact between counselor and client (Stern, 2004), attention to the external environment (Raz, 2004), empathic resonance of both linguistic content and nonverbal 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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The Counseling Relationship

Since so much of counseling is nonverbal and unspoken, yet known to us, the practice can be better understood as a communication cure rather than a talking cure (Schore, 2012).

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Integration Exercise

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Part Four.

INTEGRATING LEFT AND RIGHT HEMISPHERES

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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 purely spontaneous, individualized, flexible, unconscious, emotionally-activating RH approach would be uninformed by research evidence and would be unethical for this reason.
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Part Five.

CONCLUSION

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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 to best 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 commensurate with 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 American Psychologist, 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 of semantic 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. 2009 Standards. 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 evidencedbased treatments? Results from a national pilot survey. Unpublished manuscript. Grabner, R. H., Fink, A., & Neubauer, A. C. (2007). Brain correlates of self-related originality 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 by emotional 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. American Psychologist, 61, 882-892. McGilchrist, I. (2009). The master and his emissary. New Haven, CT: Yale University Press. Norcross, J. C., & Wampold, B. C. (2011). Evidence-based therapy relationships: Research conclusions and clinical practices. In J. C. Norcross (Ed.), Psychotherapy relationships that work (2nd ed.), pp. 423-430. New York: Oxford University Press.
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References
Orlinsky, D. E., Ronnestad, M. H., & Willutzki, U. (2004). Fifty years of psychotherapy 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 and therapist: 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 using the pupil: Utility and neural correlates. Biological Psychiatry, 69, 726-733. Stern, D. N. (2004). The present moment in psychotherapy and everyday life. New York: Norton. Stoltenberg, C. D., McNeill, B. W., & Delworth, U. (1998). IDM: An integrated developmental model for supervising counselors and therapists. San Francisco: Jossey-Bass. Welling, H. (2005). The intuitive process: The case of psychotherapy. Journal of Psychotherapy Integration, 15, 19-47.
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