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INTERNATIONAL JOURNAL OF NEUROPSYCHOTHERAPY Volume 3 Issue 1 (2015)
47
perspective
neuropsychotherapy:
dening the emerging paradigm of
neurobiologically informed psychotherapy
Matthew Dahlitz
Abstract
Over the past two decades, the theoretical basis and application of psychotherapy has been undergoing a
paradigm shi from a focus on higher cortical/cognitive processes to a new and growing appreciation of
aective phenomena as the locus of behaviour change. e move has been prompted by breakthroughs
in neuroscience that show bottom-up, le-hemisphere neural processes to underpin behaviour, validat-
ing aectively focused clinical practices. is paper examines the theoretical basis of this paradigm shi,
with an emphasis on Klaus Grawe’s consistency theory as central to its early description, and identies
the specic neural underpinnings for an eective clinical application of psychotherapy as established by
contemporary neuroscience.
Keywords: neuropsychotherapy, denition, neurobiology, psychotherapy, neuroscience.
Cite as: Dahlitz, M. J. (2015). Neuropsychotherapy: Dening the emerging paradigm of neurobiologi-
cally informed psychotherapy. International Journal of Neuropsychotherapy, 3(1), 47–69. doi: 10.12744/
ijnpt.2015.0047-0069
Introduction
e late Klaus Grawe (1943–2005) was a leading
gure in the nascent eld of neuropsychotherapy in
the early 2000s (Dahlitz, 2013). His work integrated
the latest neuroscience and clinical psychology, cul-
minating in the publication of Neuropsychotherapy, a
meta-framework of neurobiologically informed psy-
chotherapy (Grawe, 2007). Not to be confused with
a second tradition stemming from northern Europe,
namely the psychotherapy of brain-injured patients by
clinical and neuro-psychologists (Laaksonen & Ran-
ta, 2013), Grawe’s conceptualisation reects a broad
movement that has been described as a “mental health
renaissance” (Rossouw, 2013)—an emerging para-
digm empowering clinicians to use neurobiological
ndings to enhance therapeutic practice.
e practice of looking to neuroscience to estab-
lish empirical grounds for eective psychotherapy has
been gaining momentum over the past decade under
such labels as brain-based therapy (Arden & Linford,
2009), interpersonal neurobiology (Siegel, 2010), and
social neuroscience (Cacioppo, Visser, & Pickett, 2006)
among many others issuing from various individu-
als, groups and disciplines. e literature in English
remains sparse, however, in relation to Grawe’s orig-
inal conceptualisation of neuropsychotherapy and
its underpinning theoretical model. Contemporary
theorists such as Pieter Rossouw (2014) are carrying
the framework of neuropsychotherapy forward with
rened ideas of Grawe’s consistency theory (2007) and
its clinical application.
Grawe grounded neuropsychotherapy in a model
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INTERNATIONAL JOURNAL OF NEUROPSYCHOTHERAPY Volume 3 Issue 1 (2015)
of mental functioning he termed the consistency-the-
oretical model (Grawe, 2007). Drawing on earlier
models of basic psychological needs being serviced by
psychological schemas (e.g., Epstein, 1990), he identi-
ed constructionist-like concepts of developing men-
tal schemas and related them to neural networks that
were identied in his extensive study of the neurosci-
entic literature of the time. Towards the end of his
career he observed, “e empirical evidence suggests
that we ought to conduct a very dierent form of psy-
chotherapy than what is currently practiced” (Grawe,
2007, p. 417).
e current paper takes up Grawe’s observation,
reviewing the literature to determine in what ways the
evidence suggests a “dierent form of psychothera-
py”. To this end the paper considers how this theory,
grounded in neurobiology, informs and renes the
clinical application of psychotherapy.
It is intended that this paper will ll a gap in
the existing literature by disambiguating the term
neuropsychotherapy and provide a concise reference
for the neurobiological elements contributing to the
meta-framework that is shaping psychotherapy today.
1. Neural Underpinnings
Freud began his Project for a Scientic Psychol-
ogy (1895/1966) at the end of the 19th century with
the intention of creating “a psychology which shall
be a natural science” (p. 295), to discover the neural
underpinnings of behaviour. Freud’s psychoanalyt-
ic techniques were concerned with unconscious af-
fective processes—a foreshadowing of the current
neurobiological research into aect. In recent times
Allan Schore, with a similar passion for uncovering
foundational aective processes, has commented that
“no theory of human functioning can be restricted to
only a description of psychological processes; it must
also be consonant with what we now know about bio-
logical structural brain development” (2013, p. 1). is
resonates with Eric Kandel’s (1998) landmark paper
arguing that psychiatric thinking should be tethered
to biological science due to the fact that
therapeutic interactions can elicit struc-
tural changes in the brain. e following
section will consider the physical struc-
tures, networks and processes that form
the neural machinery of the brain, a ma-
chinery that both informs the theory of
neuropsychotherapy and is modulated
by the practice of neuropsychotherapy.
1.1 Neural Communication
e human genome provides an organisational
map for the development of our brains, with some
designation of place and function of neurons xed
(by means of coding genes that constitute the so called
“nature” part of our genetic make-up) and some func-
tional aspects subject to the inuence of experience
(in the form of no-coding genes that make up the so-
called “nurture” part of our genetic expression) (e
Neuropsychotherapy Institute, 2014a). Our genome,
along with epigenetic expression of genes and learn-
ing (memory formation) creates a complex neural
communication system in our brain, which is itself a
complexity of synaptic/dendridic connections mod-
ulated by neurochemicals. e basics of neural com-
munication are described below.
Basic Nerve Cell Communication
In the nervous system there are two main divisions
of cells: nerve cells (neurons), and glial cells (glia). Glial
cells have traditionally been recognised as a “support
network” for neurons, providing many essential func-
tions for the facilitation of the neural network. How-
ever, they have more recently been acknowledged to
form a communication network themselves, working
in tandem with neurons (Keleman, 2012; Verkhratsky
& Butt, 2007). e function of a neuron is determined
by where it is in the brain, how it is connected with
neighbouring cells, and its individual functional char-
acter. By analogy it is like us as human individuals:
our function in society is determined by where we are,
who we are connected to and how we interact with
others and the environment (Cozolino, 2014).
While there are dierent types of nerve cells for
dierent functions, it is helpful to consider a generic
neuron—a model—that represents the fundamentals
of all neurons. Figure 1 illustrates the main compo-
nents of the neuron (see Kandel, Schwartz, Jessell,
Siegelbaum, & Hudspeth, 2013, chapter 2, for a com-
prehensive description of neuron physiology):
Figure 1: Generic model of a neuron
INTERNATIONAL JOURNAL OF NEUROPSYCHOTHERAPY Volume 3 Issue 1 (2015)
49
Neurons communicate using two processes: an
electrical signal within the neuron, and chemical sig-
nals between neurons.
Neurons use various chemicals, known as neu-
rotransmitters, to transmit signals across the very
small gap between cells in an area known as the syn-
aptic cle. Most neurons can send and receive signals
by dierent types of neurotransmitters, and dier-
ent neurotransmitters work at dierent speeds (e
Neuropsychotherapy Institute, 2014a).
e schematic in Figure 2 below is a radically sim-
plied representation of a synapse. e upper part
represents the presynaptic terminal of one cell’s axon,
and the lower part the postsynaptic dendrite of anoth-
er cell. Communication ows from the presynaptic
terminal to the dendrites of a neighbouring cell.Den-
drites are like the branches of a tree that spread out to
reach other cells, and are the main areas for receiving
incoming signals (Kandel et al., 2013).
Figure 2: Simplied representation of a synapse
e synaptic vesicles shown above are packets of
neurotransmitters that migrate to special release sites
termed active zones. ese packets come to the sur-
face of the presynaptic terminal and are released (by a
process known as exocytosis; Kandel et al., 2013) into
the synaptic cle. e chemicals diuse across the
gap, and some molecules are taken up by receptors on
the opposite-facing dendrite.e receptor sites on the
dendrite bind to specic neurotransmitters, and this
binding will have either an inhibiting or excitatory ef-
fect on the receiving cell.is occurs via an opening
of ion channels in the membrane of the cell that essen-
tially produces a membrane potential in the dendrite
(a positive or negative charge within the cell). e
more positively charged a neuron becomes, the more
likely it will pass a certain threshold and “re”. Iono-
tropic receptors, such as AMPA, accept transmitters
that directly alter the receiving cell’s potential, and are
thus fast acting, whereas NMDA receptors require
prior activation of the postsynaptic neuron through
another channel before its ion channel can be opened
(see Grawe, 2007, pp. 36–37).
erefore some neurotransmitters will cause the
receiving dendrite to become more positively charged,
and others will cause the dendrite to become more
negatively charged. e receiving dendrite “sums”
the incoming chemical signals to arrive at a resultant
synaptic potential which is then communicated to
the main body of the cell.All of these “calculations”
or synaptic potentials are summed at the beginning
of the axon (the axon hillock).If the resulting charge
rises above −55 mV (depolarization), an electrical
signal ows from the axon hillock and down to the
presynaptic terminals,causing the membrane of the
each terminal to open up channels allowing calcium
into the cell.is in turn causes the synaptic vesicles
to release their chemicals into the synaptic cle. is
albeit simplied description of the process illustrates
the binary nature of neurotransmitters in either initi-
ating an action potential or not.
Figure 2 also shows some of the neurotransmitters
being reabsorbed into the presynaptic terminal.Such
uptake, via plasma membrane transporters, serves
two purposes: recapturing the chemicals for reuse,
and terminating the synaptic action of the cell (Kan-
del et al., 2013).Drugs used to inhibit the re-uptake of
neurotransmitters will in eect keep the neurotrans-
mitter in the vicinity of the postsynaptic dendrite, so
that when receptors are available for that particular
chemical, they will bind with it.us antidepressants
are designed to inhibit serotonin re-uptake, keep-
ing it in the synaptic cle and prolonging post-syn-
aptic activation (e Neuropsychotherapy Institute,
2014b). Another process whereby neurotransmitters
are removed from the synaptic cle is degradation, a
process of chemical breakdown by enzymes where the
resulting molecules are taken up by the presynaptic
terminal. Within the presynaptic terminal the neu-
rotransmitter is then reassembled for reuse, and re-
packaged for release once again. Finally glial cells also
remove neurotransmitters from the synaptic space
to prevent further interaction with the post-synaptic
cell.
1.1.1 Neurochemicals
A basic understanding of the specic neurochem-
icals that modulate the nervous system is essential
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INTERNATIONAL JOURNAL OF NEUROPSYCHOTHERAPY Volume 3 Issue 1 (2015)
for understanding how certain pathologies are driven
and why certain interventions are eective. e fol-
lowing is a brief introduction to these chemicals (e
Neuropsychotherapy Institute, 2014b):
A) Amino Acid Neurotransmitters (the major neu-
rotransmitters)
1) Glutamates are excitatory neurotransmitters.
Receptor sites are either fast-acting ionotropic
types (AMPA), which primarily activate or inhibit,
or slower-acting N-methyl D-aspartate (NMDA)
types, which facilitate a strengthening of the syn-
aptic connection called long-term potentiation
(Grawe, 2007, pp. 32–40). Glutamates bind with
activating receptors, namely Alpha-amino-3-hy-
droxy-5-methylisoxazole-4-proprionic acid
(AMPA), resulting in fast activation of the postsyn-
aptic neuron (as described above).
2) Gamma-aminobutyric acid (GABA) is an in-
hibitory neurotransmitter. It is fast acting, binding
with GABA receptors to cause an inhibiting eect
on the postsynaptic cell. GABA and AMPA inter-
actions are seen across the brain and result in much
of the fast action of our neural processes—much of
our thought processes and sensory input/process-
ing, for example.
B) Biogenic Amines (monoamines, more localised in
distribution than the amino acids and known to be
released also from non-synaptic sites)
1) Catecholaminestrigger physiological changes
to prepare the body for physical activity such as the
“ght-or-ight” response.
Dopamine has many functions, including mo-
tivation. Most dopaminergic neurons are in the
midbrain and hypothalamus.
Norepinephrine acts as a hormone and a neu-
rotransmitter. It increases heart rate and acts as
a stress hormone aecting the amygdala.
2) Indolamine is the family of neurotransmitters
that includes serotonin and melatonin (derived
from serotonin).
5-HT (Serotonin) is involved in the regulation
of mood, appetite, and sleep, as well as memory
and learning. It is a major antidepressant.
C) Acetylcholine is used by only a few cell groups and
is the major neurotransmitter in autonomic ganglia.
D) Peptides form a large and diverse group of trans-
mitters. Some act as hormones, including enkeph-
alines and endorphins.
E) Others including histamine and epinephrine, to-
gether with over 60 more that have been identied.
1.1.2 Activation Patterns and Neural Systems
A single neuron does not produce much informa-
tion on its own through its binary function of either
ring or not. Firing entails a certain rate, intensity
and resulting neurotransmitter output at the synapse.
A single neuron does not on its own “perceive” any-
thing—perception is a group task in the world of neu-
rons—but rather responds to specic input from oth-
er neurons, or directly from the environment in the
case of sensory cells. To make sense out of the ow
of information coming from our sensory organs, our
neural system is organised into a hierarchy of increas-
ingly complex networks. Individual neurons, boast-
ing, on average, 10,000 connections to other neurons,
together contribute to broader “neural net proles”
that represent an aspect of brain function (such as
perceiving a particular sound), and these proles in-
tegrate with many others to form various functions of
our nervous system, some of which are concentrated
in dierent areas of the brain (Siegel, 2012). Klaus
Grawe (2007) describes as a hierarchical model of in-
formation processing, based primarily on the work of
neurophysiologists David Hubel and Torsten Wiesel
(1959, 1962, 1968), who demonstrated that neurons
could have specic activation patterns in response to
specic stimuli.
e hierarchy of our neural system is organised
from sensory input to the perception of complex ob-
jects/understandings to even more complex cognitive
and aective processes. For example, the “raw” visu-
al data streamed from the sensory input of the reti-
na is recognised by neurons in a fragmented fashion
whereby individual parts of the scene are processed
by neurons tuned to “recognise” small, specic ele-
ments. ese fragments are then assembled by more
complex neural networks involving higher-order cells
that recognise the assembly of the parts. At the top
of the hierarchy are cells and networks in the cortex
that recognise the whole picture. Once this broader
perception is realised, further cognitive/aective pro-
cesses can occur as a result of this input. e ow of
information is not serial but a complexity of parallel
processing that utilises feedback from various brain
regions. ere is no neuron that can recognise the
complexities of an object like a chair. Only the sum-
mation of complex networks, with experience (neural
INTERNATIONAL JOURNAL OF NEUROPSYCHOTHERAPY Volume 3 Issue 1 (2015)
51
net proles), can recognise a chair for what it is. Nor
is there a single area of the brain that handles a spe-
cic mental function in isolation. Just as neurons do
not perceive on their own, neural proles activate and
integrate with other regions across the nervous system
(Siegel, 2012).
e brain is further organised into functional sys-
tems that to some extent can be identied by elements
of the physical architecture of the central nervous sys-
tem. From a single sensory input neuron, the scale of
operations increases to complex hierarchies of neural
networks that form maps representing input features
in specic areas of the cortex. ese complex signals
are in turn processed within broad functional systems
of organisation according to the physical architecture
of the brain. Such functional architecture is current-
ly being mapped by the Human Connectome Project
(http://www.humanconnectomeproject.org).
A well-known division of the human brain is that
described by neurologist Paul MacLean as the triune
brain (MacLean, 1990). is evolutionary view of the
brain describes three main regions in an evolution-
ary hierarchy: the primitive “reptilian” complex (the
brainstem), the “palaeomammalian” complex (the
limbic system), and the “neomammalian” complex
(the cortex). e reptilian complex is fully developed
at birth, while the palaeomammalian complex is part-
ly developed and continues to develop during early
childhood, and the neomammalian complex is mostly
underdeveloped at birth and is the last part of the tri-
une brain to develop (e Neuropsychotherapy Insti-
tute, 2014c). e implications of the model are that the
survival instincts of the palaeomammalian complex
(the limbic system) are signicantly developed during
the early years of life, distinct from the later-develop-
ing cognitive processes of the neomammalian com-
plex (Rossouw, 2011). More sophisticated contempo-
rary models of the brain and behaviour do not fully
support MacLean’s evolutionary model; however, the
“bottom-up” perspective of development remains in-
structive for a corresponding bottom-up therapeutic
approach (Rossouw, 2011). is bottom-up approach,
as distinct from a top-down, cognitive approach,
looks to establish safety through down-regulation of
sympathetic over-arousal and activation of a state of
parasympathetic security, resulting in increased cor-
tical blood ow to the le frontal cortex for eective
activation of cognitive abilities, and limiting “looping”
activity within the limbic system (Rossouw, 2011, p. 4)
to allow for eective new learning.
Iain McGilchrist, in his noteworthy book e
Master and His Emissary: e Divided Brain and the
Making of the Western World (2009), describes the
asymmetry of the brain and the very dierent natures
of the le and right hemispheres. is horizontal un-
derstanding of the mental system, as opposed to the
vertical triune perspective, gives us insight into the
distinctly dierent yet complimentary functions of the
two hemispheres. In short, the right hemisphere han-
dles broad attention (what we attend to comes rst to
us through the right hemisphere); is good at making
connections so that we can appreciate the wholeness of
dynamic structures and relationships that change over
time; is attuned to emotion; and is empathic, intuitive,
and moral. In contrast, the le hemisphere has narrow
attention; is good at deconstructing things into parts;
and has an appreciation for static, decontextualized,
inanimate structures and abstractions. McGilchrist
summarises the “two worlds” of the hemispheres in
this way:
e brain has to attend to the world in two com-
pletely dierent ways, and in so doing to bring
two dierent worlds into being. In the one [that
of the right hemisphere], we experience—the
live, complex, embodied world of individu-
al, always unique beings, forever in ux, a net
of interdependencies, forming and reforming
wholes, a world with which we are deeply con-
nected. In the other [that of the le hemisphere]
we “experience” our experience in a special way:
a “re-presented” version of it, containing now
static, separable, bounded, but essentially frag-
mented entities, grouped into classes, on which
predictions can be based. is kind of attention
isolates, xes and makes each thing explicit by
bringing it under the spotlight of attention. In
doing so it renders things inert, mechanical,
lifeless. But it also enables us for the rst time
to know, and consequently to learn and to make
things. is gives us power. (McGilchrist, 2014,
p. 31).
Allan Schore explains that the early-maturing right
hemisphere is the locus of attachment formation and
essentially the gateway to aect regulation later in
life—so much so, indeed, that developing an expanded
capacity for right-hemisphere processing (an empha-
sis on right-brained aective skills rather than a le–
cognitive bias) is central to clinical expertise (Schore,
2012). In a similar vein Badneoch (2008) warns ther-
apists to be grounded in right-brain engagement with
clients or run the risk of being disengaged from the
regulating and integrating inuence of right brain-
to-right brain connection with clients. She further
encourages therapists to widen their window of tol-
erance (see section 1.1.6.1), be conscious of implicit
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INTERNATIONAL JOURNAL OF NEUROPSYCHOTHERAPY Volume 3 Issue 1 (2015)
vulnerabilities, and develop mindfulness to be present
with both the client and self. ere is a place for le-
brain focus when thinking about specic interven-
tions, but as McGilchrist admonishes, the le should
remain servant to the master right hemisphere.
1.1.3 Memory Formation
e formation of implicit emotional memories
lies at the heart of approach/avoidance motivational
schemata (discussed in section 1.1.5) and constitutes
a primary target for therapeutic change. It is there-
fore pertinent for the psychotherapist to understand
something of how memory is formed on a neural level
and what conditions might be necessary for change.
e hippocampus has been extensively studied
and veried as a critical component of memory for-
mation (Berger et al., 2012) but not the seat of memo-
ry storage. Various theories have been put forward as
to how the hippocampus encodes memory and pro-
duces an output that is eventually stabilised as a long-
term memory in other areas of the brain (Berger et
al., 2012), likely across the cortex (Moss, 2013; Moss
& Mahan, 2014). is structure is particularly sensi-
tive to the stress response (increased cortisol levels),
and in cases of severe violation or emotional abuse
the hippocampus has been found to atrophy, inhibit-
ing processes dependent on it such as synaptogenesis
(Rossouw, 2012a). e critical role and sensitivities of
the hippocampus become central to the formation of
psychopathology, particularly in cases of early child-
hood abuse, neglect and trauma.
It has generally been agreed that memories are dy-
namic across time, in that new memories are in a la-
bile state for a short time, when they are referred to as
short-term memory (STM), aer which they become
“consolidated” into the physical structure of the brain
to form long-term memory (LTM) (Nader, 2003).
Of particular importance in the transformation of
memory from STM to LTM is the transcription factor
cAMP-response-element-binding protein (CREB) for
memory stabilisation, including for emotional memo-
ries (Alberini, Milekic, & Tronel, 2006). Until recently
it was believed that once a memory was stabilised into
LTM, especially in the case of consolidated emotional
learning, the neural circuits were xed and the mem-
ory indelible (LeDoux, Romanski, & Xagoraris, 1989).
is view has since given way to the understanding
that memory is a dynamic process rather than a xed
state (Alberini, 2013).
e formation of emotional memory is of partic-
ular interest in psychotherapy, as it is the right-later-
alised, non-verbal, implicit yet highly meaning-mak-
ing memories of this type that shape foundational
understandings of self and the world and determine
how we anticipate the future.
1.1.4 Memory Reconsolidation
Memory research has demonstrated that memory
is by nature a dynamic process to the extent that estab-
lished memories can enter states of transient instabili-
ty once reactivated and, from this state of instability, be
modied before reconsolidation to a more stable state
(Nader, 2013). An atypical isoform of protein kinase
C called M zeta (PKMζ) is thought to be critical in
sustaining LTM (Sacktor, 2008, 2010). Typically, per-
sistent action of PKMζ maintains LTM via the contin-
ual regulation of GluR2-containing AMPAR receptors
postsynaptically (Migues et al., 2010), and transient
inactivation of PKMζ results in a loss of LTM (Nader,
2013). Of special interest for the practice of psycho-
therapy is that retrieval of a consolidated memory in
juxtaposition with a prediction error or mismatch (see
Ecker, 2015) can cause the memory to enter an un-
stable state, following which a restabilisation process,
now referred to as reconsolidation, must take place
for the memory to once again become stable (assum-
ing continued PKMζ-AMPAR action) pending future
recall into a liable state under the right circumstances
(Alberini, 2011; Dudai, 2012; Lee, 2013; Nader, 2013;
Nader, Hardt, Einarsson, & Finnie, 2013). It has been
demonstrated that interrupting the reconsolidation
process can impair the consolidating memory (Nader,
2012; see also Zhao, Li, Peng, Seese, & Wang, 2011,
for an example of reconsolidation interruption using
stress, and Ecker, 2015 for the necessity of a prediction
error to be in juxtaposition with the retrieved memo-
ry to induce a liable state).
e implicit emotional memories (procedural
memory) known to contribute strongly to motiva-
tional schemata are formed in the presence of strong
emotion and stored in subcortical implicit memory
circuits where they prove to be exceptionally durable
(Roozendaal, McEwen, & Chattarji, 2009). However,
when such memory is activated and enters a liable
state—a temporarily deconsolidated state or “recon-
solidation window” that is opened up via a “mis-
match” condition and lasts from four to ve hours
(Ecker, Ticic, & Hulley, 2012; Pedreira, Perez-Cuesta,
& Maldonado, 2002)—it can be radically unlearned.
e opportunity to interrupt or modify memory in
this way has obvious implications for psychotherapy,
especially in regard to those memories that make up
core motivational schemata. is “discovery of the
INTERNATIONAL JOURNAL OF NEUROPSYCHOTHERAPY Volume 3 Issue 1 (2015)
53
brain’s ability to delete a specic, unwanted emotion-
al learning, including core, non-conscious beliefs and
schemas, at the level of the physical, neural synaps-
es that encode it in emotional memory” (Ecker et al.,
2012, p. 13) can lead to the complete and permanent
elimination of psychological symptoms.
1.1.5 Approach/Avoid Networks
e approach and avoidance motivational systems
operate independently of one another and have inde-
pendent neural substrates and mechanisms. ey can
be activated in a parallel fashion, although equally
strong systems will tend to mutually inhibit each oth-
er.
Basic needs have a neural foundation from birth
that initiates behaviour like crying, sucking, and wig-
gling the body to meet those needs (Panksepp & Biv-
en, 2012). ese genetically governed behaviours are
the beginning of what will develop into much more
personal and sophisticated motivational goals. e
rst need that develops into an “approach” goal is the
need for proximity of the primary attachment gure.
As the infant experiences encounters with her moth-
er, she starts to develop a repertoire of behaviours to
inuence the mother to meet her needs. Neural acti-
vation patterns emerge that represent this and other
goals, and are strengthened with the help of oxytocin
and dopamine. Both baby and mother are rewarded by
oxytocin and dopamine release when in loving, mutu-
ally satisfying connectedness. e increasing strength
and complexity of these neural patterns continues to
form circuits that become more easily activated, lead-
ing eventually to very sophisticated and spontaneously
activated schemas.e specic groups of motivational
schemas that develop to satisfy the basic needs of an
individual are innitely richer and more multifaceted
than what might be suggested by the classication of
just a few attachment styles. As the individual grows,
motivational goals are shaped by his or her wider en-
vironment along with social expectations, limitations,
and other cultural forces, shaping the neural architec-
ture of personal motivational schemas.
On a physiological level, approach goals are associ-
ated with the le dorsolateral prefrontal cortex (PFC),
while avoidance is more closely aligned with the right.
For the processing of emotions, the le ventromedial
PFC is associated with positive emotions and the right
for negative emotions. ese motivations and evalua-
tions of approach/positive and avoidance/negative are
in other words physiologically lateralised across the
brain. ere are more correlations to this same later-
alisation in the deeper limbic system, giving credence
to the theory that approach and avoidance are indeed
neurally independent systems.
As they relate to pleasure maximisation (approach)
and pain minimisation (avoidance), approach and
avoidance schemas may seem to be opposites, like
a positive and negative charge, but are just dierent
goals with dierent modes of operation. e approach
schema is about closing the gap between a desired
goal and perceived reality to attain that goal which
satises a need. ere is oen progress toward a goal,
with rewards along the way, and then attainment or
not of that goal. However, the avoidance schema is
about increasing the distance between something un-
desirable and perceived reality, oen to preserve or
protect a basic need—a goal frequently not achieved,
but nonetheless necessitating a state of continuous
surveillance. When pursuing a positive goal, like
completing a university course, it is relatively easy to
determine whether one has come closer to the goal;
there are subgoals and markers (such as completing
a semester) along the way to the nal destination of
the goal. However, avoidance goals require constant
control, as well as distributed, instead of focused, at-
tention. For example, a husband may be anxious to
avoid an argument with his wife; he has to keep vig-
ilant, watch what he says, be careful to read the signs
of a possible argument, and he can never reach the
goal of avoidance because there is always the possibil-
ity that conict may come in the future. is sort of
avoidance is more a matter of continuous attention,
and oen anxious tension, than simply apprehend-
ing a concrete goal. Individuals with strongly formed
avoidance goals (or with a dominance of avoidance
over approach goals) experience fewer positive emo-
tions and less satisfaction of need because of the dis-
proportionate amount of energy and focus invested
in avoidance. In fact, strongly developed avoidance
tendencies, both implicit and explicit, have many un-
favourable eects on mental health, self-esteem and
general well being (Grawe, 2007)
From a neuropsychotherapeutic perspective, there-
fore, therapy should aim to reduce the use of avoid-
ance goals and promote more positive approach goals
to satisfy basic needs. e behaviour of depressed cli-
ents can frequently be attributed to a hyperactivation
of avoidance schemas, inhibiting approach schemas
and inviting the negative impact of stress hormones
that damage the hippocampus and deactivate the an-
terior cingulate cortex. A therapy that can weaken
the established avoidance tendencies and gradually
reactivate the approach system will revitalise activity
in the anterior cingulate cortex and strengthen PFC
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connections—concrete developments that will likely
result in a positive change for the client.
Neural Mechanisms of Approach and Avoidance
Learning
In a typical neural learning scenario the hypothal-
amus informs the PFC of physiological states (e.g.,
the system has a low blood sugar level), and the de-
cisions made in the PFC (e.g., getting something to
eat) are transmitted to the nucleus accumbens, which
in turn triggers a process eliciting and strengthening
behaviour (behaviour reinforcement mediated by
dopamine). e nucleus accumbens integrates in-
formation coming from the amygdala (representing
emotion), and hippocampus (location/context), and
makes a decision to activate or terminate a behaviour.
If the nucleus accumbens has given the “go” signal to
get something to eat, then the act of eating and sat-
isfying hunger releases dopamine, and the dopamine
binds with receptors involved with motor actions
and perceptions of eating. rough second-messen-
ger cascades an elevated synaptic transmissions en-
sues, and the whole network that has been activated
is strengthened, making it easier for the same net-
work to activate in the future. Dopamine is the rein-
forcing agent in this scenario and represents neural
motivation, or motivational salience in establishing
behaviour. Any behaviour that is reinforced involves
the release of dopamine. Because dopamine is essen-
tial for motivation and learning (establishing and re-
inforcing synaptic connections), in therapy, learning
must have high motivational salience to be eective.
In real terms, without the activation of the dopamine
system, substantial positive long-term learning will
not take place. Dopamine is the intrinsic motivator
and energiser of approach/avoidance schemas and
is therefore of central importance to the therapeutic
process.
1.1.6 e Social Brain
Human beings are social creatures. We collectively
form families, communities and cultures that dene
us as much as we dene those systems. Relationships
nurture us and shape us into who we are. In this sec-
tion I consider what Cozolino (2014) has termed the
“social brain”: those neural systems that form and per-
form within the scope of interpersonal relationships.
e social brain revolves around what Siegel calls
the middle prefrontal region that includes the insu-
la, orbitofrontal cortex, ventromedial prefrontal cor-
tex, and the anterior cingulate cortex (Siegel, 2012).
is region is the interface between other integrating,
planning and thoughtful parts of the cortex and the
limbic system (Siegel, 2012). e middle prefrontal
region, in conjunction with ventral vagal activation
(see discussion below), constitutes the neurophysiol-
ogy of the social system that mediates attuned com-
munication, exible responsiveness, aect regulation,
empathy, insight, morality, and intuition (Badenoch,
2008). When the limbic system is not strongly inte-
grated with the middle prefrontal region, limbic-bi-
ased swings of emotion, fuelled by established implic-
it emotional memories to external cues, can result in
self-reinforcing loops of aective responsiveness. Hy-
pothalamic-pituitary responses match the emotional
tone of the initial response, producing changes in the
body that reinforce and intensify the emotional re-
sponse (Badenoch, 2008). On the other hand, a strong
middle prefrontal cortical inuence over amygda-
la reactions (mediated by a strong GABA response)
can eectively modulate an otherwise emotionally
over-reactive response.
e most primitive functions of the social brain
are grounded in the aectively and somatically biased
right hemisphere, where subcortical “bottom-up”
processing of emotional and social information dom-
inates (Cozolino, 2014). Navigating the social world
eectively requires good integration between le and
right hemispheres as well as between cortical and sub-
cortical systems. is important concept of neural in-
tegration will be explored in section 4.
1.1.6.1 Window of Tolerance and the Ventral/
Dorsal Vagus
e “window of tolerance” (Siegel, 1999) describes
a model of autonomic arousal levels in which an op-
timal arousal zone, or window of tolerance, operates
between hyper- and hypoarousal of the autonomic
nervous system (Ogden, Minton, & Pain, 2006). is
model can also be conceptualised according to the
polyvagal theory of Porges (2011), which views the
autonomic nervous system as organised into three
levels of activation: the ventral vagus/parasympathet-
ic branch, the sympathetic branch, and the dorsal va-
gus/parasympathetic branch (Ogden et al., 2006). Of
the three, the ventral vagus is known as the “social en-
gagement system” (Porges, 2011; see Figure 3).
Maintaining arousal within the window of toler-
ance ensures integration of top-down and bottom-up
processing while keeping the social engagement sys-
tem “online” (Ogden et al., 2006). When the window
of tolerance is narrow, as can oen be the case with
INTERNATIONAL JOURNAL OF NEUROPSYCHOTHERAPY Volume 3 Issue 1 (2015)
55
those who have experienced trauma, there can be a
tendency to move into a hypo- or hyperaroused state
in reaction to stimuli that activate implicit traumatic
memories. In such states there is reexive defensive
reacting, rather than prefrontally mediated integrative
and exible responding to the stimuli (Siegel, 1999).
Rapid oscillations between hyper- and hypoarousal
can take place in a desperate attempt to achieve regu-
lation—a situation that has been likened to a “biphasic
rollercoaster” (Corrigan, Fisher, & Nutt, 2010).
From a neuropsychotherapy perspective, the im-
portance of widening a client’s window of tolerance,
especially in the case of trauma, becomes a central
goal. Achieving this will increase a capacity to tolerate
and integrate thoughts and feelings and keep the ven-
tral vagal social engagement system operative.
2 Consistency
Consistency is the overarching concept of systemic
agreement that can be considered a “core principle of
mental functioning” (Grawe, 2007, p.168). e myri-
ad simultaneously occurring processes in the nervous
system function optimally only to the extent that the
various elements of the system remain in harmony
and are not conicted. is is a foundational principle
of neuropsychotherapy.
e now famous Stroop test (Stroop, 1935) is a clas-
sic example of activating conicting mental processes
and thus compromising performance speed as the
anterior cingulate cortex and the dorsolateral prefon-
tal cortex (Milham, 2003) work through inconsistent
patterns to arrive at a resolution. On a more complex
level, an individual’s experience of the world, inter-
nal model of the world, and meeting of needs can be
in conict—a state of internal inconsistency
from which dissatisfaction and stress arise. It
is with an induced state of controlled incongru-
ence within a system striving for consistency,
that we can eect neural, and therefore thera-
peutic, change.
2.1 Consistency eory Model
e consistency theory (Grawe, 2004, 2007)
view of mental functioning is derived both from
broadly accepted ndings that goals and sche-
mas govern mental activity and from Grawe’s
own argument that goal formation is developed
to satisfy four basic psychological needs: at-
tachment, orientation & control, avoidance of
pain/maximisation of pleasure, and self-esteem
enhancement. e core constructs of consis-
tency and congruence are the keys to understanding
the development and maintenance of both normal
and pathological mental processes.
Consistency is described as the “compatibility of
many simultaneously transpiring mental processes”
(Grawe, 2007, p.170), and is a systemic demand, on
a neural level, for harmonious neural ow. When the
relationship between intrapsychic processes and states
is harmonious, there exists a state of consistency. e
human nervous system strives to avoid inconsistency
and develops various mechanisms to move from a dis-
sonant, inconsistent state to a more harmonious state.
Consistency regulation is predominantly unconscious
and only rises to conscious awareness under excep-
tional circumstances. e mechanisms an individu-
al uses to avoid or correct signicant inconsistencies
have been termed defence mechanisms, coping strate-
gies, or aect regulation.
Congruence, a construct that is expressed under
the umbrella of consistency, is the harmony or com-
patibility between motivational goals and current
perceptions of reality. According to Powers (1973),
incongruence signals are generated from the feedback
mechanism that contrasts our perceptions with our
goals. Grawe argues that “an elevated incongruence
level can be regarded . . . as a highly complex stress
state” (Grawe, 2007, p. 172).
A motivational schema is a neural network devel-
oped to satisfy and protect basic needs. ere are many
such schemas, but they may be broadly divided into
two classes: approach schemata and avoidance sche-
mata (see gure 4). Approach and avoidance schemata
operate on dierent neural pathways (Grawe, 2007).
If an individual grows up in an environment where
Figure 3: Window of tolerance
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needs have been met, especially during the critical
early attachment phase, then approach schemas of in-
teracting with the environment are likely to develop,
resulting in approach-oriented behaviour. Conversely,
an individual whose needs are continually threatened
and violated is likely to develop avoidance schemas
that will motivate insecure, anxious, and avoidant
behaviour. Attachment theory (Bowlby, 1988, 2008)
furnishes a critical understanding of the foundation
of mental schemata, explaining how securely attached
children develop primarily approach motivational
schemas and insecurely attached children develop
avoidance motivational schemas.
According to consistency theory, there are three
ways the mental system can experience inconsistency:
through approach incongruence, avoidance incongru-
ence and discordance. ese upset the neural harmo-
ny of the system, creating a system demand to reduce
such stress or dissonance.
Approach Incongruence: If an individual has a
tendency to use avoidance motivational schemas—
that is, if there is an established neural propensity
to avoid perceived threats to basic needs rather than
seek to satisfy those needs— he or she can experience
incongruent signals due to unfullled approach sche-
mas. To illustrate, consider a young woman who has
a desire to meet a man, but fear of rejection prevents
her from placing herself in situations where she may
meet a potential partner. e avoidant motivational
schema is well established to protect her from the pain
of rejection by another human being, and prioritises
the maintenance of whatever self-esteem and control
over circumstances she has. However, there is at the
same time a desire represented in another motivation-
al schema to approach, to apprehend, to secure a lov-
ing relationship with a partner and satisfy the need for
attachment. It is when this latter desire is suppressed
or overridden by the stronger avoidance schema that
the individual experiences approach incongruence.
Avoidance Incongruence: When attempts at
avoidance ultimately fail, and what was feared actu-
ally happens, the individual experiences
avoidance incongruence. To continue
the previous illustration, if the young
woman does go to a local dance to meet
a potential partner and is, aer all, re-
jected, she will experience avoidance
incongruence—the very undesired con-
sequences her avoidance schema had
motivated her to protect herself from.
Discordance: Discordance occurs
when two or more motivational sche-
mas are activated simultaneously and
are incompatible with one another. is
is not an incongruence between percep-
tion and goal but rather two incompati-
ble goals being activated simultaneous-
ly.
Incongruence and discordance, and
the aect that accompanies them, can
occur implicitly or explicitly and create inconsistency
in the system. Continual inconsistency can impair an
individual’s eective engagement with the environ-
ment and lead to increasingly avoidant tendencies,
stress, negative emotions, anxiety, and a range of seri-
ous mental diculties, as limbic survival mechanisms
dominate to protect the individual who is descending
into a highly complex state of stress.
e consistency model conceptualises behaviour
as an attempt to attain or protect the object of basic
needs through motivational schemas that have been
shaped by earlier experiences (of attachment in par-
ticular), in a way that provides agreement with our
perception of the world and our internal model of the
world and ourselves.
ere are current attempts to rene Grawe’s mod-
el so that the basic psychological needs are portrayed
in a less linear fashion and are seen as overlapping in
their neural arrangement, with the superimposition
of the basic needs yielding a higher-order construct
of “self ”. Figure 5 shows a particular renement by
Rossouw (2014) where the higher-order construct of
“self” emerges from the neural milieu of needs and
motivational schemata.
Figure 4: Consistency-eoretical Model (Grawe, 2007, p. 171)
INTERNATIONAL JOURNAL OF NEUROPSYCHOTHERAPY Volume 3 Issue 1 (2015)
57
2.2 Motivational Schemas
A motivational schema is a construct, or more
concretely a neural network, developed to satisfy and
protect basic needs. Such a schema can generally be
classied in terms of either approach or avoidance
tendencies. Approach and avoidance motivation has a
long history; the concept rst appeared in the writings
of Greek philosopher Democritus of Abdera (460–
370 B.C.E.), broadly seeking to explain behaviour as
directed either toward positive stimuli (approach) or
away from negative stimuli (avoidance) (Elliot, 2008).
In the full spectrum of approach–avoidance motiva-
tion there are orientating exteroceptive reexes such
as the startle response, salivary reex, and pain with-
drawal, but for the purposes of neuropsychotherapy
such schemata are psychological orientations toward
or away from stimuli (concrete objects/events/pos-
sibilities, or abstract subjective representations) that
may or may not have a corresponding
somatic movement or action. Further-
more, “movement toward” can represent
either gaining something positive that is
currently absent or keeping something
positive that is currently present (in
functional terms, continuing toward).
Likewise, “movement away” can rep-
resent either keeping away from some-
thing negative that is currently absent
(functionally, continuing away from) or
getting away from something negative
that is currently present (Elliot, 2008, p.
8).
e consistency theory model con-
ceptualises all behaviour as the product
of approach and avoidance motivations.
e somewhat binary nature of this view
may seem oversimplistic at rst glance,
but its complexity lies in the fact that
many approach and avoidance schema-
ta can be operating in parallel (as in the
case of motivational discordance, Grawe,
2007, p. 171) and in a hierarchical man-
ner (Elliot, 2006) to service not only our
basic psychological needs, but also phys-
iological reexes, as we navigate our ex-
periences of the world.
Hemispheric dierences exist in re-
gard to approach/avoidance motivations
whereby the le hemisphere is biased to-
ward approach (positive) emotions and
the right biased toward avoidance (neg-
ative) emotions (Canli, Desmond, Zhao,
Glover & Gabrieli, 1998; Davidson 1992;
Paradiso et al., 1999).
In the neuropsychotherapy conceptualisation
of the mechanisms of change, it is the motivation-
al schemata that are the cause of distress and, con-
sequently, the target for change. ey are developed
through right-lateralised implicit emotional learning
during attachment, represented by neural networks,
and changed in a therapeutic setting by intersubjec-
tive right brain-to-right brain regulation that uses
controlled incongruence to shi neural and memory
reconsolidation, thereby transforming existing neural
networks.
2.3 e Science of Aect
Of primary signicance to the theoretical under-
pinnings of neuropsychotherapy is the paradigm shi
Figure 5:
Integrated Model of the Base Elements of the eory of
Neuropsychotherapy (Rossouw, 2014, p. 57)
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in psychotherapy from explicit, le-brained, con-
scious, cognitive processes to implicit, right-brained,
unconscious, aective–relational processes (Schore,
2014). For over two decades Allan Schore has been
at the leading edge of neurobiological research on
emotional and social process, in particular how neu-
robiologically informed attachment theory is essen-
tially right-brained, implicit, and aective in nature
(see Schore, 2012, for a comprehensive review of this
work). e development of a right-lateralised “social
brain” represents the most important substrate of hu-
man unconsciousness, which is fundamentally aec-
tive in nature and the most salient focal point for ther-
apeutically mediated change (Cozolino, 2014; Schore,
2014).
According to modern attachment theory (Schore
& Schore, 2008), the development of the self occurs in
the context of attachment relationships with another
brain and involves aect regulation through “episodes
of right-lateralized visual-facial, auditory-prosodic,
and tactile-gestural nonverbal communications” be-
tween infant and primary care giver (Schore, 2014,
p. 389). is regulating developmental mechanism,
which is primarily an implicit right brain-to-right
brain process, is central to all later aspects of devel-
opment and to social-emotional functions (Schore,
1994, 2003a, b, 2012, 2014) and consequently of pri-
mary importance in the therapeutic setting. is is
due to the fact that such right-lateral implicit memo-
ries form an internal working model that becomes the
“nonconscious strategies of aect regulation” (Schore,
2014, p. 389)—the construct Grawe conceptualised as
approach/avoidance motivational schemata (Grawe,
2007). ese schemata, through early social-emotion-
al experiences, can be developed in a neurologically
disadvantaged manner (Watt, 2003) whereby dysreg-
ulating, insecure attachment experiences create right
cortical-subcortical networks (Schore, 2014) that are
primarily negative (avoidance) aective states and en-
dure into adulthood (Grawe, 2007).
In adults the right lateralized prefrontal system
represents the highest order of aect regulation, spe-
cically activated in the therapeutic alliance, and
plays an important role in psychotherapeutic change
via implicit communication between therapist and
client (Schore & Schore, 2008; Stern et al., 1998). is
process, described as “intersubjectivity” (Schore &
Schore, 2008), highlights the importance of noncon-
scious, nonverbal right-brain communication in the
two-way process of change (a point expanded on in
section 3.2), where the right prefrontal cortex plays a
vital part in relating self with the world amid distur-
bances in such two-way personal relatedness (Feing-
berg & Keenan, 2005). Given that clients in therapy
are likely to have motivational schemata of avoidance,
and that the therapeutic alliance directly connects
the therapist and client in a right brain-to-right brain
aect-regulating process, the intersubjective mecha-
nism of change is a core focus of neuropsychotherapy.
3. Basic Psychological Needs
Klaus Grawe developed a view of mental function-
ing that combined insights from mainstream contem-
porary psychology with an understanding that “the
goals a person forms during his or her life ultimately
serve the satisfaction of distinct basic needs” (Grawe,
2007, p. 169). Inuenced by Seymour Epstein’s cog-
nitive-experiential self-theory (Epstein, 1973, 1980,
1991 1993, 1994, 1998; Teglasi & Epstein, 1998), Grawe
dened four key psychological needs that provide the
motivation for behaviour: the need for attachment,
the need for control/orientation, the need for plea-
sure/avoidance of pain, and the need for self-enhance-
ment (Grawe, 2007; see also Epstein, 1994, p. 715 for
the origins of these four needs). As outlined above,
implicit motivational schemas are designed to satis-
fy these four psychological needs via approach-driv-
en (primarily cortical processes) or avoidance-driven
(primarily limbic processes) behaviour in what Ep-
stein describes as an emotionally driven experiential
system (Epstein, 1994).
3.1 Attachment
John Bowlby (1973, 1988) clearly demonstrated
that the basic need for an infant is the physical prox-
imity of a primary attachment gure, bringing the im-
portance of attachment into mainstream psychology.
Bowlby (1973) described the basis of this attachment
theory into three central postulates that could be sum-
marised like this: a) A child with an available, trusted
caregiver will be less anxious than one without such a
caregiver; b) trust or lack of trust in the availability of
the caregiver will translate into a similar expectancy
of relationships later in life; and c) the expectations a
child has of a caregiver are relatively true of the actual
experiences of the caregiver.
Bowlby referred to this theory of attachment as
the internal working model, a concept taken from
Kenneth Craik, who proposed an organism carries
a “small-scale model” of external reality in its head
(Wallin, 2007, pp. 26–27). In essence, early dyadic re-
lationships, especially with primary caregivers, form
implicit memories from which a child constructs
INTERNATIONAL JOURNAL OF NEUROPSYCHOTHERAPY Volume 3 Issue 1 (2015)
59
schemas, or ways of understanding and interacting
with the world. e way parents approach their infants
shapes the very structure of their developing brains
(Schore, 2012) through a resonant system of proximity
and gaze. As Bonnie Badenoch puts it, “What is alight
in the parental brain lights up in the newborn brain. It
is as though the parent is passing on the family’s emo-
tional legacy in regards to relationships through these
initial rings and wirings” (Badenoch, 2008, p. 53).
Mary Ainsworth, a colleague of Bowlby, devel-
oped an empirical method for assessing attachment
in infants called the Strange Situation Protocol, based
on Bowlby’s attachment theory (Ainsworth, Ble-
har, Waters, & Wall, 1978). Ainsworth observed the
behaviour patterns of young children when they were
separated and then reunited with their mothers in a
controlled environment. Several attachment styles
were identied to this point: secure attachment, inse-
cure-avoidant attachment, and insecure-ambivalent
attachment (Ainsworth et al., 1978; Badenoch, 2008;
Grawe, 2007). Later, Mary Main and colleagues (Main
& Solomon, 1986) identied another style they called
insecure-disorganised/disorientated attachment.
e children who were found to thrive in life were
those children with secure attachment patterns rather
than those with insecure patterns. Attachment pat-
terns start to form in the rst months of life—a time
when brain development is extremely rapid, the sym-
pathetic nervous system is dominant, and right-hemi-
sphere limbic learning is critical (Badenoch, 2008)—
and lay a foundation for motivational schemas that
ultimately drive behaviour.
3.2 Orientation and Control
According to Epstein (1990), the need for orienta-
tion and control is the most fundamental of all human
needs. In accordance with Powers’ (1973) perceptu-
al control theory, this need plays out in a pervasive
striving for perceptions of reality that are consistent
with the individual’s goals, and this striving is a major
driver of behaviour and mental life. To attain such a
goal requires control over our environment, or at least
our perception of the environment. Grawe (2007) fur-
ther explains that control, in this context, is not just
about manipulating or regulating the environment or
relationships to achieve goals, but also to have a max-
imum number of options available to us that we are
free to act upon. How we choose to take up the op-
tions available to us will be determined by our moti-
vational schemas.
A sense of control begins with the infant, in the
context of attachment, having the volition to manip-
ulate the environment to meet his or her needs. For
example, an infant crying when hungry has the de-
sired outcome of bringing Mother who then feeds the
child. If the child cries for food and no food comes,
there is an incongruence (the gap between what the
child needs and what she perceives she has) within
the child, and with such a violation of the need for
attachment there is a corresponding violation of the
need for control. A satisfaction of the need for con-
trol, on the other hand, causes a reduction in distress,
which in turn strengthens the sense of control.
ere is a component, or an understanding, of
control that can be described as the need for orien-
tation, that is, to be able to have an accurate appraisal
of a situation, and to understand what is going on. To
gain such clarity about one’s situation, and what can
be done to improve it, is an important aspect of con-
trol. It is a common experience in psychotherapy to
see a better sense of control gained simply from un-
derstanding a situation with greater clarity. In view of
this need for orientation, eective (disorder-specic
and problem-specic) therapeutic interventions are
always accompanied by a more optimal satisfaction of
the need for control.
3.3 Pleasure Maximisation and Pain
Minimisation
Freud, in his theory of personality, postulated a
single fundamental need that he characterised as the
pleasure principle: the need to maximise pleasure and
minimise pain (Freud 1920/1959). Epstein consid-
ered this a core need (1994), as did Grawe (2007).
e basic premise of this need is that we are mo-
tivated to attain pleasant experiences or states and
avoid unpleasant or painful ones. ese states may
be physical, psychological, emotional, or social. Neu-
rologically there is an automatic implicit evaluation
of experience as either “good” or “bad”, to the degree
that there is a continual monitoring of our experi-
ences (one aspect of this process is known as feed-
back-related negativity, see Hajcak, Moser, Holroyd,
& Simons, 2006; Nieuwenhuis, Slagter, Von Geusau,
Heslenfeld, & Holroyd, 2005). Humans have a moti-
vation to maximise experiences of the good and limit
the bad, even in the case of suering “for the greater
good”—the denial of some pleasures to attain some-
thing of greater worth further down the track. What
constitutes “good”, pleasurable, beautiful, and the like
is dependent upon the individual and how his or her
experience of things is consistent with the satisfaction
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INTERNATIONAL JOURNAL OF NEUROPSYCHOTHERAPY Volume 3 Issue 1 (2015)
of the other basic needs. Grawe contends that the in-
dividual is in a maximal state when his or her “current
perceptions and goals are completely congruent with
one another, and the transpiring mental activity is
not disturbed by any competing intentions” (2007, p.
244). is maximal state, a state of pleasure, is compa-
rable to Mihaly Csikszentmihalyi’s concept of “ow”
(1991) that describes our intrinsic motivation to align
our perception of experience with our intentions.
Just how a person will size up the world around
him is dependent on both his prior experience and
his momentary state. For example a hot drink on a
very hot day may be evaluated more negatively than
an ice-cold drink, and vice versa on a cold day; this is
a state-dependent evaluation. By contrast, the experi-
ence of going on a roller-coaster is likely to be far less
state-dependent—to one individual it may be evaluat-
ed as bad and to another as good,according to each
individual’s prior experiences with roller-coasters. e
relearning of taste preferences is a complex process
inuenced by motives such as social compliance and
positive self-evaluations, yet the same automatic eval-
uative process is in play. e development of a taste
for wine, for example, may be motivated by a need for
social acceptance (attachment and self-esteem), but
ultimately becomes an automatic preference for wine
as part of the neural evaluative process.
When a situation is evaluated either positively or
negatively, it triggers an approach or avoidance ten-
dency, meaning that our mental activity is primed in
a certain direction. For example, someone who eval-
uates New York cab drivers as bad on the basis of past
negative experiences may be primed to “jump” at the
sudden lane changes made by the driver. Another per-
son with a more positive evaluation of New York cab
drivers may not be startled or fearful at all at the same
sudden lane changes. is motivational priming is the
orientation of the motivational system to be either
more approach or more avoidant toward certain cues
in our environment.
Mental processes transpire more easily and quickly
when the good/bad evaluation is compatible or syn-
chronised with the behavioural approach–avoidance
orientation. When evaluations and behavioural ori-
entations are consistent, the mental system works
more eciently and with less stress.
3.4 Self-Esteem Enhancement
e need for self-enhancement or self-esteem has
been regarded as a fundamental function of our hu-
manity and has been called the “master sentiment”
(McDougall, 1936, p. 224) and “the basic law of hu-
man life” (Becker, 1971, p. 66), as the only one of the
four needs that is distinctly human. Self-esteem has
been dened as “an individual’s subjective evaluation
of her or his worth as a person. If a person believes
that she is a person of worth and value, then she has
high self-esteem, regardless of whether her self-eval-
uation is validated by others or corroborated by ex-
ternal criteria” (Trzesniewski, Bonnellan, & Robins,
2013, p. 60). ere has, however, been debate as to
the importance of this construct, with some arguing
that self-esteem is essential (Orth, Robins, & Wida-
man, 2012) and others considering it of limited val-
ue in that it is likely a reection of other processes
(Boden, Fergusson, & Horwood, 2008, Zeigler-Hill,
2013). e self-esteem that Grawe conceptualised as
a basic need is a global one that is secure and congru-
ent as opposed to unstable, narcissistic, or discrepant
(see Park & Crocker, 2013). It is possible, however,
that self-esteem is a complex construction emerging
from more fundamental needs, closer to an outcome
of self-perception than a universal basic need, indeed
a perception that may be a culturally driven construct
that does not qualify as a “basic” need (Dahlitz & Ros-
souw, 2014).
In some cases, to preserve the greatest number
of needs, one need may be “sacriced” for the ben-
et of the others. For example, the maintenance of
low self-esteem may be an avoidance pattern utilised
to full another need such as preventing pain or pre-
venting loss of control, or to protect existing self-es-
teem from further degradation. An activated avoid-
ance schema may be sacricing high self-esteem to
attain another need, such as attachment through ac-
ceptance, and being accepted, in a roundabout way,
serves to satisfy some aspect of self-esteem. So the
tendency to self-esteem enhancement can be regard-
ed as part of the approach system, and self-esteem
protection can be regarded as part of the avoidance
system. e exact reasons for an individual maintain-
ing low self-esteem may be complex, but in context
with other needs, this may very well be a compromise
strategy to achieve overall need fullment/protection
as best the individual can.
ose who do satisfy the need for enhanced
self-esteem are characterized by better mental health.
ese people will take opportunities to enhance their
self-esteem through approach motivational schemas.
Individuals with a healthy self-esteem will evaluate
themselves more positively than objective observers.
It has also been observed that having unrealistic per-
ceptions of self satises the self-esteem enhancement
need, and is a good indicator of overall mental health.
INTERNATIONAL JOURNAL OF NEUROPSYCHOTHERAPY Volume 3 Issue 1 (2015)
61
Mentally healthy individuals also have a skewed per-
ception of reality with regard to themselves, oen see-
ing themselves as “above average” within the gener-
al population. People with high self-esteem will also
take advantage of opportunities to further enhance
their self-esteem. Because those who have a healthy
sense of self regard themselves better than average in
a multitude of areas, striving for an absolutely realistic
self-evaluation may not be in their best interests for
mental wellbeing. Deluding oneself in the meeting of
basic needs can lead to positive feelings and in turn to
attaining a better state, a bit like a self-fullling proph-
ecy. Depressed individuals, however, who have a more
pessimistic view of reality, do not share this delusion
and are prone to further mental problems. Operating
out of avoidance schemas, these individuals experi-
ence life, and take on roles, in a way oen detrimental
to self-esteem.
e meta-framework of neuropsychotherapy is
necessarily a multidisciplinary perspective that re-
quires the psychotherapist to have a broad under-
standing of the elements discussed here, from basic
neural communication and networks to psychological
needs and how we go about enhancing and protecting
them. e following section goes on to describe the
clinical implications and applications of this knowl-
edge.
4. Clinical Application of
Neuropsychotherapy
A focus on the neural underpinnings of behaviour
provides an opportunity in therapy for neurobiological
empathy between client and therapist, reducing any
stigma or self-blame that may have come from a pa-
thologising perspective, and allowing for better con-
ceptualisations of psychotherapeutic techniques and
theory (Grawe, 2007). e clinical application of
neuropsychotherapy focuses on strengthening clients’
resources from the core of their motivational system
to facilitate an increasingly robust approach to self and
the world (Flückiger, Wüsten, Zinbarg, & Wampold,
2009). Such approach motivation ultimately leads
to better need satisfaction and subsequent mental
well-being.
Pragmatically, this entails establishing a “safe” ther-
apeutic alliance to facilitate approach patterns that
will satisfy basic needs, down-regulate stress activa-
tion, and optimise new, positive neural connections
while reinforcing existing ones (Rossouw, 2014).
4.1 Controllable Incongruence as the Lever for
Change
From a clinical perspective it is controllable in-
congruence that becomes the mechanism of change
within the therapeutic dyad. As stated above, incon-
gruence is the discrepancy between an individual’s
perception of reality (his or her actual experience)
and beliefs, expectations, and goals (Grawe, 2007).
Such incongruence will cause inconsistency within
the mental system. Controllable incongruence is a situ-
ation of incongruence that one believes is within their
capacity to cope with—it may be a challenge, but not
an overwhelming one. Uncontrollable incongruence,
on the other hand, is a circumstance that exceeds
one’s ability to cope, or belief that one can cope, with
the mismatch between what is experienced and one’s
goals.
Uncontrollable incongruence, then, is a stressful
state that heightens arousal potentially beyond one’s
window of tolerance and, if not resolved, can result
in a hyperactivated HPA-axis cascade, releasing dam-
aging amounts of glucocorticoids into the system.
In a regulated stress response, a feedback loop will
down-regulate the HPA-axis activation and attenu-
ate the release of stress hormones (Kandel, Schwartz,
Jessell, Siegelbaum, & Hudspeth, 2013). In a state of
continued stress—as with unresolved uncontrollable
incongruence—this feedback mechanism is overrid-
den and a continued ow of glucocorticoids can in-
hibit the formation of new synapses (new learning)
while degenerating existing glutamate synapses, es-
pecially in the hippocampus, destabilising previously
formed neural connections (established learning) and
even inducing complex negative structural changes in
various brain regions (Lupien, McEwen, Gunnar, &
Heim, 2009; Popoli, Yan, McEwen, & Sanacora, 2012).
To limit such a destructive cascade of events, the in-
troduction of a sense of control can reduce arousal
and in turn restore HPA-axis regulation.
Controllable incongruence is a state in which a
stressor (the incongruence) is raising arousal levels
through sympathetic excitation and noradrenergic
activation and may exceed a certain threshold to ac-
tivate the HPA-axis, but the situation is perceived as
manageable, and feedback loops to down-regulate the
stress response in a timely manner are intact. Such a
controlled stress reaction causes a moderate amount
of adrenalin to permeate the nervous system, includ-
ing the neurons, glia, and endothelial cells, which can
facilitate a constructive response to the incongruence
in the form of learning. As adrenergic receptors are
stimulated at blood vessels and astrocytes, glucose
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INTERNATIONAL JOURNAL OF NEUROPSYCHOTHERAPY Volume 3 Issue 1 (2015)
release is increased with a corresponding increase in
metabolism. is metabolic increase in conjunction
with the release of neurotrophic factors from astro-
cytes (Verkhratsky,& Butt, 2007) and stimulation of
adrenergic receptors will help stabilize neural connec-
tions activated when coping with the incongruence
(in a process representing existing coping strategies)
and also improve the facilitation of new neural con-
nections (new coping strategies)—the opposite to
what occurs in the uncontrollable situation. In fact,
rising to the challenge of controlling incongruence is
essential to “the formation of ever more complex and
dierentiated neural circuits to an optimal expression
of [one’s] genetic potential” (Grawe, 2007, p. 222).
As one continues to deal with a controllable in-
congruent situation, coping behaviour becomes more
established, and eventually such situations will no
longer elicit a stress response, as the neural networks
required to eectively assess and cope with the situ-
ation are well established. is is a key goal of thera-
py: to strengthen existing coping skills and facilitate
new ones on a neurobiological level of resilience. Such
learning is not possible, on a neural level, in the over-
whelming situation of uncontrollable incongruence
where an overabundance of cortisol is hampering,
even degenerating, synaptic connections. Within the
safety of the therapeutic alliance, however, stress re-
sponses can be down-regulated to a state of optimal
learning, and incongruence can be broken down into
controllable, manageable parts to which new strate-
gies can be applied.
In considering how to facilitate an eective thera-
peutic environment, Grawe (2007) points to what he
calls motivational priming and resource activation as
key elements for a controllable incongruence learning
state (see also Flückiger, Caspar, Grosse Holtforth &
Willutzki, 2009; Flückiger, & Grosse Holtforth, 2008).
Motivational priming is the priming of the approach
system via positive emotional experiences within the
therapy session. Such a strategy would focus on pos-
itive need-satisfying experiences that are compatible
with the client’s goals, particularly at the beginning of
the session, to provide some positive satisfaction of
orientation/control, attachment, pain avoidance, or
self-esteem enhancement needs. Establishing an eec-
tive therapeutic alliance is one example of a positive
activation of a need (attachment) that would prime the
client toward approach-orientated tendencies within
the session. Resource activation is the therapists skill
of identifying existing resources, characteristics, and
abilities of the client that can be positively emphasised
during the session in order to enhance the client’s feel-
ings of control or self-esteem and increase his or her
tolerance for short-term increases in inconsistency
during therapy (Smith & Grawe, 2003). is focus on
the client’s healthy psychological attributes is in con-
trast to the problem activation that is stressed in all
major therapy schools, yet both play a role in explain-
ing therapeutic change (Gassmann & Grawe, 2006).
“Upon starting therapy or counseling, people seeking
help oen feel hopeless and have given up believing
in their own problem-solving resources. It is therefore
the counselor’s job to reactivate the experience of that
person’s self-eectiveness. A counselor should pick up
on the person’s existing strengths and skills” (Flücki-
ger, Wüsten, Zinbarg, & Wampold, 2009, p. 2). Ideally,
motivational priming and resource activation should
be facilitated early in the therapy process and empha-
sised throughout sessions. In this atmosphere of acti-
vated resources, therapy has a much greater chance of
being eective (Gassmann & Grawe, 2006).
e feeling of safety within the therapeutic dyad is
of fundamental importance to attenuate the destruc-
tive stress responses described above and to take ad-
vantage of controllable incongruence as a mechanism
of change. A client who is held in a space of trust and
security and can engage within their window of toler-
ance will be able to take advantage of the brain’s nat-
ural neuroplasticity. Research has shown that “a safe,
enriched environment actually facilitates the develop-
ment of new neural patterns, which, in turn, leads to
enhanced attachment and control, and stress reduc-
tion. Psychotherapeutic approaches that provide safe
environments will thus enhance the positive social in-
teraction that is an essential element of healthy neural
proliferation” (Allison & Rossouw, 2013, p. 23). To es-
tablish such a safe environment requires a down-reg-
ulation of avoidance motivational schemas that may
be activated. is is essentially a bottom-up approach
of dealing with the physiological stress response be-
fore being able to facilitate eective neural change
and proliferation (Allison & Rossouw, 2013; Rossouw,
2012b, c, 2013b). e aectively focused right brain-
to-right brain therapeutic relationship, mediated via
so-called “mirror neuron” activity, can be eective
at establishing safety for a client by down-regulating
limbic reactivity and communicating an empathic,
supportive relationship that satises the basic need
for attachment (Schore, 2012). A safe therapeutic rela-
tionship creates the ideal environment for facilitating
neural proliferation in an integrative manner, as the
nervous system is essentially a social-centric system
that thrives on interpersonal love, acceptance, and se-
curity (Cozolino, 2014; Schore, 2012, Siegel, 2012).
When anxiety increases, there is a decrease in cor-
tical blood ow in the le PFC and an increase in the
INTERNATIONAL JOURNAL OF NEUROPSYCHOTHERAPY Volume 3 Issue 1 (2015)
63
right PFC, inhibiting the ability of the le PFC to mod-
ulate emotional arousal. When the le PFC is engaged
and activated, as it can be in a safe therapeutic envi-
ronment, more cortical blood ows to it, allowing it to
modulate arousal generated by right cortical and lim-
bic areas (e Neuropsychotherapy Institute, 2014d).
is economy of blood ow within the central nervous
system can eectively take certain areas such as the le
PFC “oine” in order to provide a richer blood sup-
ply to more essential areas such as the right PFC and
limbic areas in times of threat or danger. is works in
much the same way that a sympathetic response can
cause peripheral shut-down to shunt more blood to
essential organs (e Neuropsychotherapy Institute,
2014d). Obviously a problem arises when the oine
system is the very system required to down-regulate
an over-reaction elicited by an overactive amygdala, in
which case the feeling of uncontrollable incongruence
only increases.
One of the ways to mitigate the problem of hav-
ing an essential control system like the PFC go oine
in times of stress is to increase its integrative connec-
tivity to those areas that need higher-order control,
such as the amygdala. Mindfulness is one practice
that can achieve this. Described as focused attention
in the present without judgment (Kabat-Zinn, 1994,
2013), mindfulness can increase mid-PFC and right
anterior insula activity and thickening, and increase
activity in the superior temporal gyrus and anterior
cingulate (Badenoch, 2008). e result is an increased
integration of these systems with the limbic system,
providing better modulatory control over amygdala
overreactions and fostering a propensity to approach
rather than avoid challenging situations (Siegel, 2012).
Such an increase in control brings previously over-
whelming situations back into the realm of control-
lable incongruence. Research suggests that meditative
practices like mindfulness not only increase the inte-
gration and plasticity of neural networks, but can also
oset ageing processes and increase our ability to be
present, attuned and compassionate with others (Bad-
enoch, 2008).
Siegel (2007) suggests another “mindful” strategy to
gain greater prefrontal management of limbic respon-
siveness that involves a change in our language. Rather
than saying, for example, “I am sad”, the self-talk that
provides more separation between the self and the
emotion would be “ere is a feeling of sadness right
now.” Placing the emotion as an objectively observable
phenomenon that is apart from the “observing self ”
elicits a greater sense of control over what would oth-
erwise be an immersive emotional experience.
Whatever particular mindful strategy is utilised,
there are some common outcomes to such practices:
less dysregulation and reactivity to emotional expe-
riences; remaining present with feelings, thoughts or
actions without being distracted; the ability to label
beliefs, opinions, emotions, and expectations; and
having a nonjudgmental stance toward our experi-
ences (Badenoch, 2008; Baer, Smith, Hopkins, Kriete-
meyer, & Toney, 2006).
Motivational priming, resource activation, cre-
ating safety, and techniques like mindfulness are all
designed to bring the client into a place of optimal
learning where incongruence is perceived as with-
in the client’s window of tolerance, controllable, and
therefore an opportunity for new learning and posi-
tive change.
4.2 Two-Person Psychology
ere is an emerging emphasis on “two-person”
psychology in therapy (Schore, 2003c), where right
brain-to-right brain, embodied, aective, autonom-
ic change between therapist and client becomes cen-
tral to the therapeutic process (Marks-Tarlow, 2012;
Montgomery, 2013; Schore, 2014). is places the
spotlight on the neural integration within the thera-
pist, in the sense that he or she must eectively oper-
ate out of a wide window of tolerance for the benet
of modulating clients on both an unconscious and a
conscious level. In this context, therapy becomes less
about the le hemisphere’s desire to categorise and x
by applying discrete therapeutic interventions, and
more about a right-hemispheric capacity for broad af-
fective awareness, empathy, and connectedness. Such
a perspective liberates the therapist from manualised
techniques of intervention, yet necessitates the critical
work of self-integration and the experientially devel-
oped intuition of attunement (see Badenoch , 2008,
2011; Marks-Tarlow, 2012, 2014 for resources to de-
velop such integration and intuition). Vertical and bi-
lateral integration of one’s own neural systems is the
rst step toward an interpersonal integration within
the dyad of psychotherapy. Vertical integration is the
linking of body, limbic region, and cortex, thus in-
creasing neural connectedness and facilitating a great-
er ability to stay in touch with empathic connections
(resonance circuits). “When our middle prefrontal re-
gion is steadfast in its linkage with our limbic circuits
and bodies, the ow of nonverbal information coming
to us from our patients has a much greater chance of
being held, with empathy as the most consistent un-
derlying state. . . . Such interpersonal richness encour-
ages GABA-bearing bers to grow from patients’ or-
bitofrontal cortex to the amygdala, calming old fears”
64
INTERNATIONAL JOURNAL OF NEUROPSYCHOTHERAPY Volume 3 Issue 1 (2015)
(Badenoch, 2008 p. 156). Bilateral or horizontal in-
tegration (Siegel, 2007) is the eective and balanced
communication between le and right hemispheres
where the le hemisphere is receiving a complete ow
of information from subcortical and cortical regions
on the right and contributes a complimentary yet sub-
servient perception and response in accordance with
the right’s “big picture” perception. If such integration
is intact within the therapist, he or she will be better
placed to mediate a similar vertical and horizontal in-
tegration within the brain of the client.
Change within this two-person psychological sys-
tem of client and therapist is primarily a right-brained,
embodied, emotional, autonomic process within the
dyad. Such biopsychosocial processes of aect regula-
tion between therapist and client are forming the basis
for a more integrative approach to treating mind and
body. e somatic aspect of aect regulation is also
becoming increasingly important in therapy (Schore,
1994, 2003a, 2012); for example, when the ventral va-
gal-mediated social engagement system is activated
in a previously hyperaroused client by the regulat-
ing warmth and empathy of the therapist, the client’s
cortisol levels may return to the normal range while
oxytocin and opioids validate the safe connection ex-
perience (Badenoch, 2008; Sunderland, 2006). e
somatically attuned therapist will pick up cues from
the face, body posture and reexes of the client, and
so focus on the eect of his or her own body posture,
tone of voice, gaze, and so on in an attempt to bring
the client back into a workable window of tolerance
where the right amount of arousal can elicit optimal
learning.
5. Dening Neuropsychotherapy
Many aspects to the meta-framework of
neuropsychotherapy have been outlined in this pa-
per, and reducing such a comprehensive approach to
a succinct description is no easy task. e denition
oered below is an attempt to capture the essence of
neuropsychotherapy.
Neuropsychotherapy is a neurobiologically in-
formed framework for psychotherapy that con-
ceptualises thought and behaviour as emerging
from the inuence of motivational schemata
developed to preserve or enhance basic psycho-
logical needs. erapeutic processes start from
the development of a safe and enriched environ-
ment to activate positive approach motivation-
al schemata utilising a bottom-up neurological
approach, and proceed from a top-down ap-
proach to facilitate long-term change in neural
architecture.
Summary
e pioneering work of Grawe introduced an ap-
proach to psychotherapy that was based on contem-
porary neuroscience (Rossouw, 2014). Shore, Siegel,
and others have also established a scientic basis to
psychotherapy with a particular emphasis on aective
development and phenomena over cognitive process-
es. e rapid, implicit emotional processing of deep-
er brain structures requires the therapist to engage in
psychotherapy that goes well beyond the traditional
cognitive–behavioural understanding. In the me-
ta-framework of neuropsychotherapy, clinical prac-
tice is informed by insight that has been gleaned by
contemporary neuroscience and related disciplines.
Grawe’s challenge that “we ought to conduct a very
dierent form of psychotherapy than what is current-
ly practiced” (Grawe, 2007, p. 417) is today being ad-
dressed by a more sophisticated understanding and
appreciation of the right-brained, aective, embodied,
autonomic, and implicit processes involved in psy-
chotherapeutic practice. Change is increasingly being
conceptualised as a relational-aective process within
the therapeutic dyad. e consistency theory model
has provided a sound point of reference for the dy-
namics of mental functioning, possible sources of un-
desirable processes, and eective steps toward change.
e continual development of a neuropsychotherapy
perspective in conjunction with breakthroughs in
neuroscience is even now providing clinicians with
an unprecedented theoretical and pragmatic basis for
eective client change.
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