Neuroplasticity and Implications for Mental Health

2-3 March 2018

This paper is about how to capitalize on the biggest asset in your practice; your brain. In particular, how to use the plasticity of your brain to improve your mental health and well-being. It also discusses particular mental health issues within the context of neuroplasticity, how we deal with challenges, the role of our genetic makeup, as well as the importance of cultivating a safe environment.

The Bar is not an easy life. Many barristers seem to alternate between being anxious that they have too much work on and they will never get it all done, or that there is not enough work and their practice is dead. The different kinds of challenges you face in your profession demand strong coping skills, and you would not have come this far if you did not have them.

But even then, things may get away from you sometimes. If you seek help, you might get advice that works for people in normal jobs; take some leave, don’t push yourself so hard, exercise more, work less. All well intended, but not really possible if you are in the middle of a long trial. So you might instead stop sharing your difficulties, knuckle down and get on with it, thinking “this is just the way it is being a Barrister, and I need to harden up or give it up.”

What I hope you will get out of this paper on neuroplasticity and its implications for mental health, is hope that things can improve, and that improvement can be achieved incidentally within the context of your existing busy lives. You can use your capable brains to change your brains. To do this you need knowledge, which I am providing an introduction to here, awareness, which I will tell you how to develop, and discipline, which you already have in spades.

Neuroplasticity

The focus of this paper is neuroplasticity. I should therefore briefly explain the background and content of that concept.

The human brain has evolved over millions of years. The basic function and structure of the modern human’s brain has not changed since the Cognitive Revolution some 70.000 years ago. Its predominant function is to keep us alive for long enough that we can reproduce. It cares about survival, not self-fulfillment and happiness. It will only allow such indulgent emotional states while there is no threat around, so in order to thrive and not just survive in the modern world we need to wire the brain to only react to real threats, and not to the difficult but not life-threatening challenges. In your case, practice at the Bar. How is that possible?

Until a couple of decades ago, despite plenty of evidence to the contrary, the ruling paradigm in Neuroscience was that the brain develops until you are in your early twenties. Then it remains unchanged until it deteriorates with injury or old age.

One study amongst many that finally caused a paradigm shift was conducted on four Swedish men dying of cancer. In the last days of their lives they learned a new skill; knitting. Post mortem examination revealed that a brand new neural network had developed in their brains. The study proved that new neural networks can form in the brain through to the very last breath (for an overview of pioneering studies on neuroplasticity, see Doidge, 2010).

In a newborn the rate of neurogenesis is a staggering 100,000 new neurons per second. By the age of 25 this number has dropped to 800 per day (Rossouw, 2016). The process of building new neurons from stem cells and producing new neurotransmitters, is enhanced by the following (please see Appendix A for more details):

• good quality sleep;
• regular intake of good nutrients;
• exercise;
• using the brain in new and varied ways; and
• limited intake of CATS (Caffeine, Alcohol, Tobacco, Sugar/Sweeteners)

Some parts of the brain, namely the cortex and parts of the limbic system, develop and change constantly through our experiences. Repetition of a specific pattern of neural firing leads to a neural network forming and strengthening. For example, you may have heard of “Pavlov’s dogs.” Pavlov rang a bell just before feeding his dogs, and after repeating this for a period of time, the dogs would start to drool when he just rang the bell, even when there was no food. This process is called the “Hebbian Principle No.1” after Mr Hebb who wrote about this as early as 1949: Neurons that fire together, wire together.

However, the opposite is also true; if we change something, the old neural network will eventually disintegrate. If Mr Pavlov continued to just ring the bell and not give food, the dogs would eventually stop drooling at the sound of the bell. This process is called the “Hebbian Principle No.2:” Neurons that fire apart, wire apart.

The brain does not discriminate between “good” patterns and “bad” patterns. Whatever we keep repeating gets stronger, whether that is functional or dysfunctional. What we stop doing gets weaker. It is constantly a game of “use it or lose it”.

The significance of neuroplasticity for mental health

This is significant because it shows that negative emotions and challenging mental states can be changed. They are patterns of neural firing that have formed over time by being repeated, and if we start repeating different patterns instead we will over time change the structure of the brain. If repetition involves focused attention the process of change is quicker.

What is required in order utilize plasticity in a helpful way, is awareness. Once we have identified something as helpful we can strengthen that pattern by focusing our attention and repeating it every day. Once we have identified something as unhelpful we can choose to focus our attention on something else, and the unhelpful pattern eventually disintegrates. This is harder than it sounds.

The brain likes what is familiar, even if it is quite dysfunctional or destructive. New patterns will generally feel a bit uncomfortable at first, even if they are good for us, because it takes on average two weeks for the new pattern to activate the release of dopamine, which gives us a sense of reward and motivates us to do more of the same. Think for example of how hard it can be to start exercising or eating healthy after a long period of over-indulgence. It takes a while before squats and carrots are associated with a sense of wellbeing. Some substances on the other hand are very easy to get used to because they give an immediate release of lots of dopamine, like cocaine or chocolate, for example. The quicker and bigger the release of dopamine, the higher the risk of addiction.

It only takes about two weeks of daily activation for a new neural network to form. Within 2-3 months of regular use, this network becomes the default network, a habit. If the new habit replaced an old one, within another 2-3 months, the old network will have disintegrated from not being used. You have successfully replaced an old habit with a new one. And even old dogs can learn new tricks, it just takes a bit longer. Dr. Dan Siegel describes a case in his book Mindsight of a 92 year old man — who just happened to be a lawyer — learning to become affectionate for the first time by activating his Right Pre-Frontal Cortex (RPFC) on a daily basis.

For changing the brain short and often is more efficient than long and infrequent. If you are learning something new, like playing a new instrument, daily practice is significantly better than a one hour practice on the weekend. For adults 12 minutes per day is enough, for children only 6 minutes of focused attention on the new skill is required in order to efficiently build a new neural network. This does not even have to be in consecutive minutes, you can break it up as much as you like. If you are learning to drive a car shorter segments are not convenient, but if you are practicing emotional awareness or down-regulation of stress, you could with benefits do this for one-minute twelve times throughout the day, or in 24 segments of 30 seconds!

If your resistance has now hit the roof by this talk of practicing new skills, it is good to remember that your mental health can improve not only by practicing new skills, but equally by not continuing to do what you are already doing that is unhelpful. Back to Hebbian Principle number 2; what fires apart, wires apart.

Whatever you focus your attention on frequently becomes a strong neural network that is easily activated, with the thoughts, images, emotions and bodily sensations that go with it. Think for example of the neural network called “I can’t do this.” This thought may lead to thoughts of being humiliated in Court, images of angry faces and a strong sense of dread in your stomach. This network may be activated increasingly often with increasingly devastating effect. You end up wasting precious time and energy, and it does not feel good either.

We cannot control what comes up in our mind. But it is good for you to know that it is only your attention that will keep it there! If you do not give attention to an unhelpful thought that comes up, it will go away by itself. On the other hand, the thoughts that you do give attention stay and grow in intensity, and they will also come up more frequently. Your attention is like the fertilizer, sun and water in the garden of your mind. Make sure you don’t give attention to the weeds!

Good mental health is an integrated brain; a system that self-regulates to maintain homeostasis (equilibrium) with the Pre-Frontal Cortex (PFC) engaged. We improve our mental health by increasing awareness of what is going on in our body and our mind, of how things affect us, and whether reactions are helpful or unhelpful.

By observing what is going on internally and responding in a helpful way, we build and strengthen:

• connection between different parts of the brain; and
• neural patterns that with frequent use become default functional coping mechanisms.

To illustrate the importance of good connection between different parts of the brain I am now going to show you a highly sophisticated model of the brain…Here it is… your hand (Siegel, 2010).

Close your hand over your thumb into a fist. Your wrist is the brainstem, also called the Survival brain, sending signals down to the body. The thumb is the Limbic system, also called the Emotional or Impulsive brain, where the alarm goes off if there is a threat. Your fingers are the cortex wrapping around the lower parts of the brain. At the front is the Smart brain, the Left Pre-Frontal Cortex (LPFC) and RPFC.

Communication in the brain is determined by proximity and strength of connection. You can see how the middle finger representing the Middle Prefrontal Cortex (MPFC) touches the Limbic system, the Brainstem and Left and Right hemisphere. When all is calm in the Limbic system there is good cortical blood-flow to all parts of the brain and the MPFC is relaying information to the Smart brain and regulating activity in different parts of the brain. However, if the alarm bells are suddenly ringing like crazy in the Limbic system, all the blood-flow is sucked into the Survival brain and the MPFC is temporarily disengaged and flips up! We “flip the lid”! We have no executive control, we are completely in “Fight or Flight” mode. Whilst it may feel quite satisfying at the time to flip the bird, it can be a bit embarrassing to think back on once we have calmed down. It is not nice to feel that we have lost control, and maybe we realize that we said or did things that we regret once we have calmed down and can think again.

When you carry out practices that increase self-awareness and self-regulation, the MPFC is activated. Activated frequently, the MPFC grows in size and connectivity to right and left hemisphere, Limbic system and Brainstem. The stronger your MPFC is, the easier it is to prevent it from flipping. The functions of the MPFC include: body regulation, attunement, insight, empathy, morality and intuition (Siegel, 2010). All good to have, especially around other people.

Developing the capacity to self-regulate

Like any skill, the capacity for self-awareness and self-regulation develops through disciplined practice. When you practice observing what goes on in your mind and in your body without reacting to it or doing something with it, you develop the capacity to respond in a deliberate manner rather than react in an impulsive manner. This kind of practice underpins the notion of Mindfulness, which has been so much talked about. It is called practice, not perfect. In the same way that you are practicing as a Barrister and I am practicing as a Psychologist, we all practice to develop in that capacity. We don’t have to be perfect at it, in all our pursuits it is continued practice in a conscious, reflected manner that makes us better at what we do.

In these practices the objective is not to blank your mind but to keep re-directing your focus back to where you want it each time you get distracted. If your mind is very agitated, consider it good a resistance training opportunity for the mind! Each time your monkey-mind hops onto something else, you notice what caught your attention and return the focus to your breath, your bodily sensations or whatever your chosen object of attention is. When you focus on the breath, the breath will slow down naturally. When the breath slows down, the mind slows down and it is easier to maintain focus.

Mindfulness practices are very simple but very hard to do at first. You can start off by using a guided Mindfulness or Meditation — there are a few suggested in the reference list – but eventually you will be able to do it on your own for longer and longer. In the beginning it is easier to practice while your mind is already relatively calm, for example just before going to sleep or when you first wake up. You are also then not taking up precious work time with mental hygiene, for those who are reluctant to do so at this point. The opportunity cost is low. You may also find it easier to keep your focus if you include the body. You may for example try focusing on your movements and breath whilst swimming, walking, practicing yoga or stretching. You can also include it in normal daily activities, for example each time you go to the bathroom or have a drink of water.

It may not happen the first few times that you practice, but you will after relatively few attempts experience a sense of calm and clarity. Having a personal positive experience of these kinds of practices will be more motivating than anything that I can tell you. If something is pleasant we want to do more of it.

These kind of practices can have significant immediate effects in terms of down-regulating the stress response, as well as strengthening the MPFC in the long term. The Hand-on-Heart practice described below can calm down a panic attack in less than a minute. You have neurons around your heart and in your belly, just like in your brain. Depending on how you are wired, one of the hands placed on the heart will change the heart variability rate, ie calm you down (Siegel, 2013). Also a bit of oxytocin (the cuddle hormone) is released this way, which relaxes the body and improves the mood. About two thirds of us are wired for the right hand on top, but it will generally be the one you place there spontaneously.

Hand-on-Heart Practice (Graham, 2013)

1. Close your eyes.

2. Put one hand on your heart and one on your lower belly.

3. Breathe out slowly and fully. Pause, and then the inhalation happens by itself. Repeat this three times, just focusing on making the exhalation as long as possible that still feels comfortable.

4. Bring a half-smile to your face.

5. Feel the warmth from your hands, your heartbeat, and the rise and fall of your breath.

6. Notice how you feel in your body. Keep breathing out slowly.

If you have a bit more time, you could add this:

7. Think of a peaceful, safe place. Either a real or an imagined one.

8. Think of being with a person who loves you, this can be a real person from the present or the past, or a spiritual figure. Somebody who embodies compassion.

9. Feel this person’s love and compassion flood through your body, and feel gratitude for being loved in this way.

10. Again, notice the warmth from your hands and how you feel in your body. Notice your breathing, deep and slow.

11. Start to wiggle your toes a bit and notice the room around you, and when you feel ready, you can open your eyes.

This whole practice can be done in just 1 minute, but even just one conscious long exhalation activates the Parasympatic Nervous System and gets you out of “Fight or Flight” mode temporarily. It is like rebooting the computer. Each time you do this, this network gets stronger and easier to do, with greater effect. Eventually it can replace the old response to for example the negative thought “I can’t do this.”

Here are some good reasons why the Hand-on-Heart is good to practice:

It is a lot more pleasant than, for example, playing the broken record of imagining being humiliated in Court and having to sell your house because your career is over. Playing that broken record achieves absolutely nothing else than to reduce the blood flow to your LPFC, making it extremely hard to do your work.

Doing the Hand on Heart practice releases the GABA neurotransmitter — the breaking system in the brain – thus reducing the agitation. You end up feeling more calm and clear and can focus on one thing, for example your work. An extra bonus is that you have temporarily switched from the Sympatic Nervous System (also called “Fight or Flight”) to the Parasympatic Nervous System (PNS; the “Rest and Digest” mode). Practicing this shift throughout the day means that you can easier switch to the PNS when you are eating so that you can digest your food properly, and at night so that you can get good quality sleep. You are no longer completely stuck in “Fight or Flight” mode, but can fluctuate between the two states.

Lastly, there is one more huge advantage to practices like the Hand on Heart practice: you switch to a positive mind state.

The brain operates in very different ways depending on whether you are in a positive or negative mind state (Fredrickson, 2012). Whilst our survival as a species is attributed to the negative mind state, our climb to world dominance is mainly due to the positive mind state.

Operating with a negative mind state we:

• avoid risk; and
• rely on old well-proven ways and methods

Operating with a positive mind state we are:

• creative and innovative;
• hopeful that things will work out; and
• open to trying something new

Based on what I know about your work, the latter mind state is likely to be more useful when you have to think on your feet.

Genes

Some of you might say, this is all very well and good, but I am doomed anyway because of my genes. That is probably NOT true. There are only about 10,500 single strain, genetic disorders, most of them extremely rare, and an endless number of multi-strain disorders that are linked to the environment and your experiences (Rossouw, 2016).

Eric Kandel got the Nobel Prize in 2000 for his discovery that the environment and experiences plays a role in whether genes express or not. Whilst he studied the Californian sea slug (Kandel, 1998), the same applies to humans. For example, you may have drawn the short straw and inherited the short rather than the long allele making you genetically predisposed to low serotonin and depression. But then you draw the long straw and grow up in a safe, enriched environment, so that genetic predisposition does not express! Moreover, you will now pass on the long allele to your offspring (Rossouw, 2016)!

In the context of Neuroplasticity I will now discuss some common mental health problems that decrease productivity and wellbeing. As with many physical health problems, like bad backs, mental health problems can cause suffering and impairment even if they are not clinically significant. We have an extraordinary ability to get used to and put up with discomfort. In addition, the brain likes what is familiar, so there is often a resistance to change unhelpful patterns.

Generalised Anxiety

Prolonged stress can lead to Generalised Anxiety; anxiety that is fairly constantly present and cannot be pinned on anything specific but may be worse in certain situations. During long periods of high stress the brain is constantly flooded by cortisol, which is toxic to the brain. Cortisol excites the Amygdala, the Security Guard that sits in the Limbic system. This leads to hyper-vigilance and the alarm bells go off at things the Amygdala would normally ignore, resulting in further release of the stress hormones adrenaline, noradrenaline and cortisol.

The Hippocampus, which is the Administration Office in the Limbic system, is inhibited by cortisol. The Administrator cannot effectively put experiences in time and context and form explicit memories when flooded by cortisol. We end up feeling a bit upset most of the time without really knowing why, and past experiences feel like a blur. The Administrator’s relay of information to the Chief Executive Officer sitting in the Left Prefrontal Cortex is also compromised so the executive part of the brain is not fully in charge. When anxiety peaks our mind goes blank and we cannot think of what to say or do, as there is no activity in the executive part of the brain (Rossouw, 2016; Schore, 2012).

There are many sources of anxiety in your profession but they all tend to result in worries about not being good enough, making a mistake, being publically criticized and humiliated and your career being over.

Big challenges with uncertain outcomes always cause some level of anxiety. Your work consists of exactly that, and although you work your hardest, you constantly risk being criticized and held accountable for things that are often outside of your control. So it is good to know that a certain level of anxiety is normal when you are doing something difficult in an unsafe environment.

The higher the anxiety level is, the more the thinking and perception circuits of the brain are adjusted so that what you perceive and think fits in with that anxiety. Homeostasis is maintained, and the brain cares more about that than your long term happiness. The thoughts and perceptions by the anxious brain tend to generate more anxiety, as they create a negative rather than objective view of yourself and your situation.

This negative bias is what underlies the so-called “Imposter Syndrome,” which is quite common in professions where you constantly feel at the edge of your potential. “I have been lucky to get away with it until now, but I am sure they will find out how useless I really am this time.” You cannot be objective about yourself when you are anxious about your performance. Your self-appraisal will always be more negative than other people’s appraisal of you, no matter how good your actual achievements are.

Anxiety tends to get worse over time if left to develop. The more you worry about the future and ruminate about the past, the more you strengthen the neural networks that fuel your anxiety. Learning to recognize how anxiety tends to manifest itself for you is important in order to catch it early and manage it. Your early symptoms may be bodily tension and restlessness, or irritability, frustration and anger, or social withdrawal, or excessive worry and rumination, or changes to appetite and sleep patterns, or problems with concentration and memory.

Awareness of our general anxiety level can help us to predict over-reactions and prompt us to down-regulate before responding to situations. We can say to ourselves “I am pretty stressed or anxious right now, so things will seem worse than they really are. My automatic reactions to things will be off the mark and need to be held on a short leash.”

When significant anxiety is identified, the first step is always to down-regulate, for example with the Hand-on-Heart practice or just breathing out slowly. Once we start calming down, which in itself is a LPFC function, we can gradually activate more complex processes in the LPFC, such as analysis and problem solving. We also regain full access to our functional coping strategies, which we can keep improving on all our lives. But the first step is always to calm down in order to bring cortical blood flow to the Smart brain, otherwise we will “flip the lid” and react to high levels of anxiety with our automated survival responses, no matter how sophisticated our coping mechanisms normally are.

Some anxiety is situation specific, usually due to a negative past experience priming us to feel anxiety before and during a similar experience (see “Difficult Memories” below). Situation specific anxiety often involves anticipatory anxiety, including negatively biased and catastrophic thinking. Identifying which specific situations cause anxiety for you can help you to predict and ignore negative thoughts and remind you to down-regulate before and during the event. As a general rule it helps to be process oriented rather than goal oriented. In Court for example, thoughts of “I must win, I must be excellent, I must get everything right” which are goal oriented, lead to anxious thoughts about “what if I don’t.” Instead you could try to stay process oriented in Court: e.g. breathe out, take notes, speak slowly, maintain eye contact. Focus your attention on the present.

In summary, rewire your brain to be less anxious by:

• Normalise anxiety; it is inherent in your work.
• Down-regulate frequently, many times every day – enhances the MPFC and the Hippocampus, increasing integration and lowering your base cortisol level amongst other things!
• Stay aware of signs of anxiety/stress and how it makes you over-reactive and negatively biased.
• Reduce your intake of caffeine — you have enough nervous energy already (norepinephrine).
• When worry and rumination comes up, refocus on something else.
• Identify and rewire difficult memories.
• Stay Process Oriented, stay present.

Continued…