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Journal of Counseling Psychology 2014, Vol. 61, No. 4, 528-533

Neurosciences and Adult Health Behaviors: Recent Findings and Implications for Counseling Psychology Stephanie L. Simon-Dack

Cheri L. Marmarosh

Ball State University

The George Washington University

The current review comprehensively examines recent advances in 2 innovative areas of neuroscience research on healthy adults regarding neuropsychosocial interactions on human cognition and behavior, as well as implications for counseling psychologists conducting research and in practice. Advances in how oxytocin influences prosocial behavior and the mitigation of social stress, and the influence of environ­ mentally mediated gene expressions on the development of attachment disorders are surveyed and discussed in terms of how counseling psychologists might best integrate recent neuroscience research into a framework for therapeutic intervention. Keywords: neuroscience, oxytocin, epigenetics, attachment, mental wellness

social stress. Although initially considered for its effects on the endocrinal system, oxytocin has been found to have a large amount of action in the central nervous system, including in the brainstem, limbic system, and the forebrain (Heinrichs, von Dawans, & Domes, 2009). Initially, oxytocin was researched for its impor­ tance in social bonding and mate-forming behaviors. Many of these studies were conducted with rodents, allowing for the cor­ relation of innate oxytocin levels to social behaviors, and the findings led to an understanding of oxytocin as being involved in social behavior, control of stress and anxiety, parental care, pair­ bonding, social aggression, and social memory (Heinrichs et al., 2009). More recent research on oxytocin in humans has revealed that oxytocin’s most therapeutic applications have to do with its role in stress-attenuation and anxiolytic effects that allow for the promotion of so-called prosocial behavior; that is, the ability to approach and interact with others without fear of negative reper­ cussions such as betrayal or rejection. These behaviors are often classified in the literature as trust behaviors (Heinrichs, Baumgart­ ner, Kirschbaum, & Ehlert, 2003; Kosfeld, Heinrichs, Zak, Fischbacher, & Fehr, 2005). The literature on trusting behaviors and oxytocin is expansive. A seminal study by Kosfeld et al. (2005) demonstrated that individ­ uals given intranasal oxytocin would invest more money in an unseen human partner with no guarantee of receiving a return on their investment as compared with participants given a placebo. The authors hypothesized that oxytocin is thus involved in allevi­ ating betrayal aversion. These findings were further bolstered by Baumgartner, Heinrichs, Vonlanthen, Fischbacher, and Fehr (2008) in a similarly executed trust game study. In comparison to those receiving a placebo, participants receiving feedback regard­ ing betrayal of their investment, who had also been dosed with oxytocin, continued to exhibit the same investment behaviors as before the betrayal feedback. Functional brain imaging conducted during the experiment demonstrated reduced activation in the amygdala, midbrain, and striatum (brain areas involved in fear and reward) postfeedback in those receiving oxytocin as opposed to those in the placebo condition.

In recent decades, progress has been made on comprehending the interactions between neurohormonal activity, gene expression throughout a person’s lifetime, and the emotion and behavior of the individual. This progress has influenced the outlook and emphasis by the neuroscientific/neuropsychological community on core domains of adult mental health, particularly the domains of (a) psychosocial stress management and (b) social relational interactions and how these influence mental wellness. In this current nonexhaustive literature survey, we aimed to promote the dialogue that bridges the gaps between the fields of neurophysiology and counseling psychology so that an understanding of the connections between physiological mech­ anisms and mental wellness may lead to increased efficacy in mental wellness interventions. In the last decade, there has been immense progress in our understanding of two major areas in cognitive neuro­ science: the effects of the neurohormone oxytocin on social interac­ tion and advances in our understanding of gene expression on attach­ ment and behavior. We examine recent advances in these two intensively addressed topics in the field of neuroscience and how our increasingly detailed understanding of these areas may best be applied by practitioners in addressing mental wellness in their clients, partic­ ularly in terms of stress-management and social-relational behaviors.

Oxytocin as a Prosocial Neurohormone and Social Stress Regulation Oxytocin is one of the most researched neurohormones (a hor­ mone produced in the brain and secreted into the blood) in terms of its importance on human social interaction and alleviation of

Stephanie L. Simon-Dack, Department of Psychological Science, Ball State University; Cheri L. Marmarosh, Professional Psychology Program, The George Washington University. Correspondence concerning this article should be addressed to Stephanie L. Simon-Dack, Department of Psychological Science, Ball State Uni­ versity, 2000 West University Avenue, Muncie, IN 47306. E-mail: [email protected]

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Underlying the findings regarding oxytocin’s role in proso­ cial behaviors appears to be its inhibitory affects on the amygdala (Heinrichs et al., 2003, 2009; Kirsch et al., 2005). Kirsch et al. (2005) demonstrated a reduction in amygdala activation in participants dosed with intranasal oxytocin and then undergoing functional imaging while performing a face­ matching task with fearful or angry faces. The authors sug­ gested that reduced amygdala activity is partially what signals that an individual can demonstrate increased trust in a situation. The amygdala is responsible for the fight-or-flight response to stressful stimuli and plays a role in the activation of the hypo­ thalamic pituitary axis, which leads to the secretion of cortisol (a stress-response hormone) into the bloodstream by the adrenal gland. In a study evaluating the effects of oxytocin and social support on performance of a social stress task, Heinrichs et al. (2003) found that social support attenuated cortisol levels, wherein the lowest cortisol concentrations were in participants given oxytocin and whom had brought a friend to the experi­ ment. The social element of reduced amygdala activation via oxytocin release has been of primary interest in terms of our knowledge of oxytocin for prevention and treatment. For instance, it was found that regularly practiced caring physical contact from a spouse induced higher oxytocin activity, decreases in salivary alpha am­ ylase (linked to stress reactivity), and in turn decreased levels of stress (Holt-Lunstad, Birmingham. & Light, 2008). It appears that there is a complex and highly interactive relationship between oxytocin, touch and social support, and stress responses, which then impact mental and physical health. Comprehending oxyto­ cin’s actions in the central nervous system and in modulating the stress response, and how these effects demonstrate the most impact when accompanied by social and physical support, may lead to large leaps in therapeutic treatment strategies for stress and anxi­ ety.

Oxytocin: Clinical and Research Implications for Counseling Psychologists There is a growing literature demonstrating that clients’ brains change following psychotherapy (Linden, 2006) and that brain differences before treatment can influence the responsiveness cli­ ents have to interventions (Cardenas et al., 2011; Wrase et al., 2008). Even more promising is the research being done that can link the neural correlates of treatment interventions in the session to outside behavior change (Feldstein Ewing et al., 2013). Unfor­ tunately, little research has been done to illuminate how counseling or prevention programs can facilitate changes in oxytocin and how these changes can promote social support, ongoing stress manage­ ment, and overall well-being. Although we know that most clients seek treatment due to interpersonal difficulties and histories of relational trauma and that the therapy relationship is one of the most empirically supported contributors to change (Horvath, Del Re, Fliickiger, & Symonds, 2011; Laska, Gurman, & Wampold, in press; Wampold, 2001), we know very little as to how oxytocin plays a role in the therapy relationship, social support, stress reduction, and treatment prog­ ress and outcome. In order to address this question, it is important to first review the current clinical intervention studies that have tested hypotheses derived from the neuroscientific research on

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oxytocin. These studies focus mainly on two different issues: (a) how administering oxytocin alters the functioning of individuals with different disorders and (b) how different individuals respond to oxytocin based on early relational deficits.

Exogenous Oxytocin as an Intervention Although no studies could be found looking at how administer­ ing oxytocin influences counseling outcome, studies have revealed that giving oxytocin facilitates positive changes in people with schizophrenia (MacDonald & Feifel, 2012; Pedersen et al., 2011), social anxiety (Heinrichs et al., 2009), autism (Bartz & Hollander, 2008) , postnatal depression (Mah et al., 2013), and those under­ going social stress (Heinrichs et al., 2003). In one such study, researchers administered oxytocin or placebo to mothers who were depressed after giving birth (Mah et al., 2013). Similar to animal studies, they found that those who received oxytocin reported more positive relationships with their babies compared with the controls, although there were no differences in overall depression. In es­ sence, increasing oxytocin levels increased the attachment mothers felt for their babies, but it did not alleviate the depressed affect. In addition to facilitating mother-infant bonding, Ditzen et al. (2009) found that adult couples engaged in conflict in a lab who were administered oxytocin had greater positive communication and reduced salivary cortisol levels compared with the couples in the placebo condition. In essence, giving oxytocin facilitates relation­ ships and reduces stress during conflict. Again, we see the positive social and emotional effects of increasing oxytocin levels.

Effectiveness of Exogenous Oxytocin: Individual Differences Although the research is promising, not all individuals respond equally well from increasing oxytocin. An interesting study re­ vealed that men who experience early separations from their caregivers were more positively impacted by nasal administration of oxytocin compared with controls (Meinlschmidt & Heim, 2007). In this study, the authors found a significant reduction in cortisol levels, the hormone released during stress, for those men who experienced early parental separations and were given the oxytocin. However, oxytocin did not reduce cortisol levels for those men who had not experienced early separations and who were more likely to have secure attachments (Buchheim et al., 2009) . Bartz, Simeon, et al. (2010) found that giving exogenous oxytocin to people with borderline personality disorder, another group of people who are likely to have early relational trauma, had the reverse effect and made them less trusting and more hypersen­ sitive to negative social cues. Similarly, giving oxytocin to indi­ viduals who have more insecure adult attachments caused them to have worse recollections of their early caregivers compared with those who had secure attachments and had more positive memories after taking oxytocin (Bartz, Zaki, et al., 2010). At this time, only more research will illuminate how oxytocin works for those with different attachment styles and histories of relational trauma, and this research can be initiated by counseling psychologists who are already studying attachments.

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Research and Clinical Implications Buboltz, Deemer, and Hoffman (2010) examined 484 publica­ tions in the Journal o f Counseling Psychology to determine trends in the research between 1999 and 2009. They found that psycho­ therapy process and outcome research accounted for 18% of the publications, that many counseling psychologists study social sup­ port and attachment theory, which accounted for 9%, that multiculturalism/diversity had grown to account for 15% of the research published, and that counseling psychologists were slowly moving into new territory with regards to studying children and adults across the life span. Given the increasing emphasis on diverse populations and the continued emphasis on social support, attach­ ment theory, psychotherapy process, outcome, and training, coun­ seling psychologists have the knowledge to contribute to our understanding of oxytocin and the effects it has on different populations of people at different stages of the lifecycle. Similar to studies already reviewed in this article, oxytocin could be administered to clients with different attachment styles in order to explore how oxytocin moderates the relationship between the therapy alliance and treatment process and outcome. Counsel­ ing psychologists could begin to address the questions regarding how individual differences, such as history of early trauma or attachment style, impact oxytocin levels and the effectiveness of psychotherapy. In addition, counseling psychologists could study how counseling relationships influence oxytocin levels, social support outside of coun­ seling, and stress management over time. On the basis of neuroscienctific research reviewed in this article, we could expect that those individuals with greater relational trauma will have less base levels of oxytocin, may struggle with automatic fight-or-flight responses in the therapy relationship, may have more difficulty tolerating ruptures in counseling, and be more at risk of prematurely terminating from treatment. However, we may also find that these clients benefit most from a positive ongoing secure attachment to the therapist. Research­ ers have found that regularly practiced caring interactions induced higher oxytocin activity and decreases in salivary alpha amylase, and these were linked to decreased sympathetic nervous system activity and in turn decreased levels of stress (Holt-Lunstad, Birmingham, & Light, 2008). We could hypothesize the same changes would be evidenced for clients who receive ongoing positive counseling inter­ actions. Counseling psychologists could follow clients over time and de­ termine how the therapy relationship alters levels of oxytocin and how these increases relate to positive changes in clients’ interpersonal relationships and response to stress outside of counseling. We would expect that functional brain imaging before and after counseling would demonstrate changes in activation in the amygdala, midbrain, and striatum. These studies would also include diverse client popu­ lations that include individuals with different cultural backgrounds, relational histories, and different presenting problems. Bartz et al. (2011) argued that is extremely important to study the contextual and individual-difference factors that potentially modulate the effects of oxytocin on neural responses. Counseling psychologists, particularly experts in the study of race, ethnicity, and culture, could study how these factors influence oxytocin and how it influences people differently. For example, we may hypoth­ esize that individuals who have experienced racism, discrimina­ tion, and oppression have endured more relational trauma over

time, and they will respond better to certain types of interventions with regards to release of oxytocin and neurological changes in stress response. Researchers are likely to find that certain coun­ seling approaches foster oxytocin and reduce stress in some indi­ viduals while activating fight-or-flight responses in others. These studies may shed light on why some clients drop out prematurely or fail to respond positively to counseling interventions. In addition to exploring how oxytocin impacts individuals dif­ ferently, counseling psychologist could start to examine how in­ creasing oxytocin can not only facilitate more positive social interactions and increased ability to cope with distress, but it can foster changes in the entire community by enhancing the attach­ ments these adults have with their children. Epigenetics and attachment theory. Attachment theory, as initially formulated by Bowlby (1969) and later refined by Ain­ sworth (1979), states that early behavior and parenting style will influence a child’s ability to bond and how they approach and interact with other individuals throughout their lifetime. In terms of a psychophysiological approach, Schore and Schore (2008) posited that attachment patterns were biologically and neurally defined by a person’s ability to regulate their emotional states during interactions with others and in autonomous contexts. This view meshes well with the current models of behavioral develop­ ment, which highlight patterns of neural development and genetic expression based on the current and past environmental contexts of a given organism (Lickliter, 2008). In the context of changes of gene expression over the lifetime, the term epigenetics has been coined to generally refer to how environmental and external influ­ ence on an organism will affect the process by which certain genes are expressed by that organism (e.g., Bird, 2007; Champagne 2010). Under this view, parental interactions with the offspring will shape physiologic and behavioral outcomes through regulat­ ing the expression of certain genes. How these genes are expressed in turn provides biological parameters for neural development, which affect emotional regulation and response to social stress, which conceptually reaffirms attachment theory as a theory of neurophysiological self-regulation (Lickliter, 2008; Schore & Schore, 2008). A study by Weaver et al. (2004) demonstrated the flexibility of genetic expression in offspring based on parental behavior. They found that the offspring of mother rats with higher levels of grooming and nursing behaviors are less fearful in adulthood and have a smaller averse reaction to stress. However, infant rats that were not attended to or groomed as extensively had much stronger stress reactivity, with more cortisol released and more stressful behaviors exhibited in adulthood. Upon examination of genetic expression, it was found that the expression of receptors in the hippocampus for a neurotransmitter chemical known to modulate and regulate the stress behaviors was increased indirectly only in the offspring of high-grooming mothers. However, in the offspring of low-grooming mothers, increased suppression of the gene reg­ ulating this substance was observed, leading to a lesser ability for these rats to mediate the stress reaction as adults. These patterns of expression and suppression are maintained in the parent cells to the daughter cells and thus get translated to and inherited by subse­ quent generations. This is specifically relevant to models of stress reactivity and depression (Champagne 2008; Weaver et al., 2004). For instance, Champagne (2008) noted that decreased care by mothers toward their female offspring led to reduced expression of

NEUROSCIENCE AND COUNSELING

estrogen receptors later in life. This in turn led to lower receptivity of estrogen released during the adult offsprings’ own pregnancies, leading to less oxytocin release and fewer bonding behaviors in these mice, in turn, toward their own offspring. This animal model has implications for models of postpartum depression in humans and also models of socioeconomic stressors on parental behavior and transgenerational outcomes. For instance, socioeconomic stressors may influence parental ability to bond with their children, which may in turn influence nurturing behaviors by the parents and the suppression of serotonin, oxytocin, or estrogen receptors in those children. This in turn has implications for these individuals to regulate their own moods and behaviors and bond with their children, genetic traits that can then potentially be passed along generationally. With the examination of animal models of epigenetic transgen­ erational attachment behaviors, the interest in application to human behaviors has increased. It has become clear that human parental treatment of infants influences later responsivity to cortisol, self­ regulation, and social-regulation capabilities later in life that in­ terface with attachment style and that these traits have correlates to genetic expression (e.g., Cacioppo, Tassinary, & Bemtson, 2007; Harper, 2005). Furthermore, such behavioral and genetic patterns appear to carry through several generations and as such have a transgenerational effect on future behavior based on environmental situations not directly experienced by the individual. Finally, par­ enting interventions do seem to have viable and distinctive out­ comes on altering unhealthy attachment interactions with observ­ able differences in the child’s responsivity to stress and assessed attachment style throughout his or her life span (Cicchetti, Rogosch, & Toth, 2011). For example, Cicchetti et al. demonstrated that interventions addressing attachment insecurities in maltreated infants were efficacious regardless of genetic variation in these infants. This indicates that, ultimately, genetics did not inform which maltreated infants would respond best to theoretically guided interventions on parenting and attachment but rather dem­ onstrates that attachment intervention can inform later epigenetic responsivity to stress.

Epigenetics and Attachment Theory: Implications for Counseling Psychologists, Attachment, and Prevention The neuropsychological research supporting the effects of parent­ ing on neurological development during the first 3 years of life has been critical in promoting and financially supporting prevention re­ search for at-risk families. A meta-analysis of 70 different attachmentbased prevention programs revealed that randomized interventions appeared effective at reducing insensitive parenting and enhancing infant attachment insecurity (Bakermans-Kranenburg et al., 2003). The researchers found that the most effective interventions enhanced parental sensitivity and this was what was more effective at increasing attachment security in the child. They also found that interventions involving fathers were more effective than interventions focusing only on mothers. There is clear need for future researchers to examine the effectiveness of family prevention programs. In addition, there is a need for the assessment of long-term change, the delayed effects of prevention programs, and the maintenance of changes that are made immediately after the intervention. Linking to the previous section, it is important to relate how prevention programs may even alter oxy­ tocin and how altering oxytocin influences prosocial interactions

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within a community, positive parenting responses, more securely attached children, and increased emotion regulation during times of stress. One of the things that stand out after reviewing the prevention literature is that many of these prevention studies targeted mothers who were from lower economic status, with mental health con­ cerns, or who were minorities. In essence, the prevention programs were reaching out to underserved populations who are in need of resources and vulnerable to environmental stressors that contribute to insecure attachment and mental illness. Given our knowledge that the behavioral and genetic patterns are transmitted through several generations, these prevention programs aim to alter the trajectories of people’s lives and change the future of entire com­ munities. Counseling psychologists emphasize the importance of prevention as a vehicle for social justice (Vera & Speight, 2003), and attachment-based prevention programs offer opportunities to confront the effects of poverty, neglect, racism, and discrimina­ tion. Prevention efforts will allow counseling psychologists and at-risk communities to develop culturally appropriate attachmentbased interventions within a social justice framework. The impor­ tance of social or cultural context cannot be overlooked when implementing attachment-based prevention programs. Coie et al. (1993) argued that prevention programs that are effective in one culture may be ineffective in other cultures or completely rejected. Counseling psychologists could contribute to the deeper under­ standing of how insecure attachment develops in different cultures (Wang & Mallinckrodt, 2006) and how parents and children from different cultures respond to different attachment-based prevention programs. Important questions that need to be addressed include: (a) What specific prevention programming facilitates positive changes in participants’ attachment? (b) How do interventions influence lev­ els of oxytocin and individuals’ response to stress? and (c) How does the culture of the community influence the effectiveness of different interventions, and are there specific interventions that are more effective for some but not others? A final area that needs to be studied is the influence of prevention programs to alter the transgenerational impact of trauma, neglect, and deprivation in terms of the epigenetic changes. For example, researchers could study how attachment-based interventions facilitate ongoing changes within a community (i.e., influencing not only those who receive the prevention program but also those people interacting with participants such as children, family members, and spouses).

Attachment and Psychotherapy: Implications for Research There is an enormous amount of growing research linking attach­ ment to psychopathology (for a review, see Mikulincer & Shaver, 2010) and the therapy alliance (Diener & Monroe, 2011), but we have much less knowledge about how different interventions/treatments facilitate changes in attachment and how these changes correlate to neurobiological changes. Studies are needed to examine how ther­ apy influences changes in attachment and also how the changes in attachment correlate to changes in the hippocampus and limbic system. For example, Johnson and colleagues (2013) are engaging in research in how couples’ attachment to one another changes before and after couple psychotherapy, and they have integrated functional magnetic resonance imaging (fMRI) analyses

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into their research protocol. They found that before attachmentbased couples therapy, a distressed wife receiving an electric shock was not able to benefit from holding her partner’s hand as evi­ denced by the fMRI scan of her brain. In nondistressed couples, holding the partner’s hand during the stressful situation reduces the distress response in the brain. It appears the partner acts as a secure base in times of distress and alleviates the pain response. In distressed couples, however, holding the partner’s hand actually increases pain and distress. Johnson and colleagues focused on how partners use their relationship to regulate affect and how couple psychotherapy may facilitate changes in distressed couples’ ability to rely on each other to alleviate suffering. In another recent empirical article, researchers investigated brain changes after long-term psychotherapy and found that pa­ tients who received therapy and were exposed to attachment-based images showed a higher activation in the left anterior hippocam­ pus, amygdala, subgenual cingulate, and medial prefrontal cortex before treatment and a reduction in these areas after 15 months of therapy compared with controls (Buchheim et al., 2012). This reduction was related to improvement in depressive symptoms. This is the first study documenting neurobiological changes related to emotional reactivity after long-term psychodynamic psychother­ apy. Future studies are needed to examine changes in attachment that map onto neurobiological changes within the brain (Buchheim et al., 2006) and how these changes relate to different forms of psychotherapy with diverse patients. Counseling psychologists who partner with neuroscientists have the skill and knowledge to engage in these future studies that facilitate our understanding of how attachments change and how these changes relate to neuro­ logical changes. Specific questions that counseling psychologists can pursue include: (a) How do different counseling interventions facilitate or hinder changes in attachment for diverse individuals seeking treatment? (b) How do these changes in attachment relate to changes in the brain (i.e., changes in the amygdala and emotion regulation) and (c) After treatment ends, how long do these psy­ chological and neurological changes remain, continue to grow, or dissipate? These studies could be developed in the wide variety of settings in which counseling psychologists are employed, such as college counseling centers, hospitals, outpatient mental health clin­ ics, and university-based clinics.

Attachment and Psychotherapy: Implications for Practice Regardless of the type of therapy being conducted (cognitive behavioral, behavioral, dynamic, existential, humanistic), the neu­ roscience research shows us that counseling psychologists should be more aware of how early attachment-based experiences in life influence the developing brain and how the clients’ genetic ex­ pression influences future psychopathology, interpersonal func­ tioning, and emotion regulation. Counseling psychologists who embrace neuroscientific research on attachment will have a more nuanced perspective on the issues and resistances many clients bring to therapy. They will have a deeper appreciation for emotion regulation, encourage clients to explore nonverbal experience (i.e., eye contact, heart rate, physical distress), and have a broader repertoire of techniques to address different presenting concerns (Wallin, 2007).

Conclusion Recent research has led to immense gains in our comprehension of the effects of the environmental, behavioral, and epigenetic factors on brain development, neurotransmitter systems, and vul­ nerability to mental health disorders. Specifically, in this review, we addressed two areas of importance for counseling psycholo­ gists in terms of considerations of applied research, therapy pro­ cess and outcome, and prevention. First, new gains in research of the complex mechanisms underlying oxytocin function shed light on how it may be influential as a prosocial hormone, and the potential efficacy of applied exogenous oxytocin within a treat­ ment regiment. Second, gains in the area of epigenetics can direct our understanding of how environmental context and culture in­ fluence the expression of attachment behaviors and thus guide our approach and intervention with those who demonstrate disorders of attachment or emotion regulation. Increasing the dialogue and shared knowledge between the fields of neuroscience and coun­ seling psychology can only increase our understanding of the complexities of the interactions between biological mechanisms, personality, behavior, and mental wellness as well as allowing us to demonstrate increased efficaciousness in our approach and treatment of patients as counseling psychologists.

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Received November 30, 2013 Revision received March 7, 2014 Accepted March 10, 2014 ■

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