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Review - The Neuroscience of Human Relationships Attachment and the Developing Social Brain by Louis Cozolino W. W. Norton, 2006 Review by Roy Sugarman, Ph.D. Mar 27th 2007 (Volume 11, Issue 13)

If you thought the title was about boy meets girl, its not, it's about mum meets baby and baby meets mum in a reciprocal bonding and attachment relationship, and the neuronal plastic adaptations that follow, enabling adult interactions with the social environment. As Luria wrote, more than half a century ago, socialisation ties the cortical knots that make up who we are in our culture.

Now, Cozolino writes that it is the power of being with others that shapes our brains. By attachment, in its reciprocity, we bind to another and establish ourselves in terms of our 'self'. Psychotherapy has long paid attention to bonding, since Bowlby: (see Treating Attachment Disorders: From Theory to Therapy, 1999)

Louis Cozolino has written before about the neuroscience of psychotherapy (see The Neuroscience of Psychotherapy: Building and Rebuilding the Human Brain, 2002). In a somewhat similar vein he takes on another psychosocial encounter, but one which is natural, and less contrived. In this book Cozolino evaluates how we live in the perception of the 'I' have relationships, with an influence on the subjective experience of being with others from our perspective, and also how we are created in terms of these encounters, with our evolution as social creatures inextricably bound up with our biology.

The first examination of this topic takes place in the context of the brain as a social creation, first emerging in the 1970's. We survive because initially we have others such as the mother as our primary environ, driven by drives to protect us, and later instruct us, for personal as well as altruistic, group reasons. In many ways the drives that nurture are non-selfish, enhancing the well being and continuity of the group, or immediate species. Here now follows the first of many vignettes that Cozolino uses to illustrate his point. This first one includes a dying father and his distressed child, with Cozolino joining in for a few tears at the deathbed when confronting his and the father's emotions around the emerging affection the therapist felt for the boy. He describes himself as a wooden cello with strings that resonate with the family, in an empathic resonance. As with my readings of the narrative therapists, who also seem to shed a tear or two, I wonder why I have felt like

crying at times, but never did, with my patients: in a way I felt it was disrespectful, that I was just visiting their lives, not living it with them, and hence my tears were irrelevant to them. I note the Motivational Interviewing experts do warn against thinking that we are not just visiting their problems. I remain ambivalent. As poignant as the writing is, and as much as I empathise with Cozolino, I hear the words of the old mentor, Kubler-Ross: when you find yourself crying, it's your own unfinished business, not empathy necessarily.

Nevertheless the vignette is poignant, and demonstrates Cozolino's humanness as a social creature, after all, which is I am sure what he is striving for.

The second chapter refers to an evolving brain, namely one which is not born with any real maturity, and thus takes time to evolve with the creature into an independent self. An interesting fact is expressed about the whites of our eyes, which he asserts evolved so that others could see where we were looking, as opposed to those with unicolour eyes, predators, whose prey needed to not see where they were looking.

Other methods that evolved enabling us to demonstrate to others that we are not just blank tablets, include blushing and pupil dilation. He goes on to discuss the triune brain and hemispheric specialisation, and heads for the phenomenon of evolving social communication. This chapter ends with another vignette, briefer, and more to the point about how we engage with our environment.

Part Two and thus Chapter Three covers basic ideas on neuronal systems and then the social changes in that most hectic time for neuronal development, adolescence, namely increases in white matter and decreases in gray matter. He relates this to the changes in social interaction that make demands of the teenager. He carries on in a similar way enlightening on the change in adult brain, and finishes with a vignette about a woman who finds, as recent research has done, that while memory and other functions may slip, the rewards are the disconnected emotional working memory and wisdom strengths that emerge. Another point made here is how essential socialisation is to survival. Most of this is now becoming mainstream information in aging, and valuable in ways to boost the aging brain it seems; (see the video "Brain Health" with Roy Sugarman for a brief summary).

In keeping with the theme, Cozolino moves from chapter 4 onward into a more up close neuronal view of the brain, and the more macro structures and systems of the social brain are examined, in particular the sensory, motor and affective systems and their integration, and again, a vignette of psychophysiological illness to illustrate.

Chapter Five is taken up by 'social and emotional laterality'. By this, he means the emergence of the hemispheric biases of the brain, with left leaning more toward approach, social emotions and positive affect, the right toward bonding, avoidance, self awareness, personal emotions, negative affect, facial

expression and reading gaze, facial recognition and intonation. Here, he documents how the growth spurts between birth and 12 years wind their way back and forward between the right and left sides, always in concert with the environmental interactions and stimuli. Emotions and cognition integrate, and 'Pedro' rounds off the chapter. Interestingly, with one side of his face paralysed, Pedro cannot feel the full valence of his emotions. If you want to know which side, you will have to buy the book, but any Neuropsychologist will tell you which it is most likely to be, contralateral to which hemisphere. Or you could email Michael Gazzaniga.

Part Three refers to the social synapse, or what Cozolino will investigate in terms of neuronal plasticity that is dependent on socialisation. Predictably and reasonably, this begins with the influence of parenting and protection early in the postnatal period, and the focus on social engagement in the maturing child. The vagal system as a regulating 'brake' is closely annotated, and Charlie, who was born to be wild, is the vignette of note here. Worryingly is the return to parent blaming, with a referral to good-enough parenting, without much other than passing comment. From here on, Cozolino will introduce one part or system of the brain as a putative neuronal substrate for the topic, a little taste of modern localization-ism.

Chapter Seven begins with an examination of the primal sources of attachment, the unspoken things that begin right away and drive connectedness. These include smells, pheromones, sounds and sights, instincts, and as with a vagal focus in the previous chapter, he focuses here on the cingulate cortex and its putative role in monitoring and labelling salience in interpersonal interactions. Joaquin is helped to understand the body-brain-mind interactions.

Chapter Eight deals with love: attention is given to the role of social regulators and chemical modulators, including here neurotransmitters and other chemistry. An interesting foray into the biochemistry of social motivation is a focus here, in terms of how we analyse rewards as opposed to just feeling them, a novel approach I think. In this way relationships come to regulate us in the same way that biological rewards did, earlier on. We won't mention Stan here, who was addicted to love. I think Cozolino dates himself here, with a wide range in music from The Easy Rider to Robert Palmer, but we are spared more catchy titles in later vignettes.

Systems of memory, such as implicit memory, are reinvented with social memory added in and on. A brief chapter, some interesting assertions, fleshed out with Brian, who has a headache of sorts.

Bowlby is finally introduced in Chapter Ten by way of a quote. The chapter covers ways of bonding, meant here as the practice of measuring attachment by observation of mothers in various interactions both past and present, as relationships become biological structure, another very brief chapter with the inevitable illustrative vignette, this time about a couple, as opposed to a single patient. I wonder however about the role of Dads in this modern age, and how attachment applies to males in a patriarchal world, or at least one where men feel 'Stiffed' in the Susan Faludi genre. After all, how does this all work when men increasingly take paternity leave, where the idea of a mothering instinct

has long been trashed, where parents are more likely to be of mature age, and most fathers today have never seen Peter Fonda fall off his motorcycle while dying to be wild. It seems that older theories do not account for fathering, and less bonding in tighter nuclear families, in a post-modern and postfeminist world, with all of its backlashes. In a modern world, with its social interactions, families are speaking with different voices, as Carol Gilligan would agree, and as far as narrative goes, it is different now, and perhaps Bowlby and others who followed would see the family and parenting a little differently. Certainly, more interesting philosophies are flowing from the primates in Elizabeth Gould's laboratory in Stanford, primates she goes nowhere near, but reinforcing Cozolino's insights into the brain-social environ interaction. Perhaps, more of the Mother-as-social-environment in the modern world would make more sense, with the insights of modern neuroscience, not Bowlby.

Part Four, Chapter Eleven returns to an earlier annotated set of facts, namely that of gaze in evolution, with focus here on the amygdala and a vignette in the middle of the chapter, increasing the place for these as the book hots up.

Faces dominate Chapter Twelve, with a detailed review of facial recognition, both for the structure as well as the function of conveying and recognising emotions. No vignette here.

Just as I was wondering, having seen him refer to mirror neurons and empathy before, he brings it back in Chapter Thirteen, with the unfortunate subtitle of 'monkey see, monkey do' a kind of cheap shot in many ways, our referential primates being who they are, namely apes, there are no monkeys in my heritage as far as I know, looking at my resume. Nelson is the vignette here, with theory of mind, as well as language, reviewed briefly here. A nice addition is the brain regions involved in Theory Of Mind.

Chapter Fourteen is a further exploration of Empathy and related topics such as resonance and 'attunement', redolent of his earlier referral to himself as a wooden cello with strings: I think he means cognition with emotion, which are separate issues in our heads. By now, the vignettes are in the middle of the chapter, and Suzanne who was depressed, and cared too much, equally does well. The neural focus here, most helpful, as always in his chapters, is the insula and its activations.

Chapter Fifteen and Part Five study disorders of the brain, with an interpersonal, social perspective. This begins with the impact of early stress, including prenatal stress and maternal depression. These are reviewed as interactive, not focussed on individual pathology. The HPA axis is predictably the focus here, and Stephan leads us into a discussion of childhood abuse and neglect as interpersonal trauma in Chapter 16. References predicably include De Bellis and Teicher, as well as Perry, but Danya Glaser's excellent review is missing, which I think he would have enjoyed. He focuses on the hippocampus here, but the HPA axis would have been a good repeat analysis to explain why the dissociation in his two chapters is a feature.

A good place to go to now is exactly where he does, with social phobia dominating Chapter 17. The vignette is understandably upfront, given the controversy in this diagnosis on both sides of the Atlantic, with differing epidemiology as to incidence. The amygdala is brought back for a guest focus, with fast and slow circuits examined, which is good. A surprising inclusion is racism, as a form of social phobia, again a good idea I think.

Again, prediction dictates Borderline Personality Disorder should now be introduced, and it is, in Chapter 18, and again, a good idea to have the vignette of Jasmine up front. Brains of the borderline sufferers are discussed, and opinions rendered on self harm and self loathing. Endorphins, earlier discussed in respect to bonding, are reintroduced as evidence of the anaesthesia of self injurious behaviour, but no mention of glutamate and other excito-toxic mechanisms that may have explained the damage seen on scans by Teicher and others.

Chapter 19 looks at psychopathy and the antisocial brain, with the focus on the prefrontal cortex. Autism, Aspergers, Williams and other syndromes are discussed, before Part Six and Chapter 21 emerge. Now, he becomes more serious and detailed, with the messenger systems of the brain discussed in humans, and the regulatory effect this has on facilitation of human interpersonal connection and regulation, from neurons to narrative, as he terms it. This emerges via an integration of systems, with elements of metaphor and narrative used as vehicles as we attempt to regulate our emotions and experience of challenges, such as the little engine that could. The 'planes' of neural integration are represented here by a simplistic reductionist graphic, but he uses this well to illustrate what he means in terms of neuronal integration at different levels of abstraction. He will argue in the rest of the chapter for such integration, and the ways in which neuroscience may advance the practice of therapy but not neglecting the brain, a theme from a previous book noted above.

To this end, the next chapter is devoted to healing relationships, and one can again see the continuity of his prior books, and this one. He refers to loving and fearing brains, with love activating the brain's social engagement and reward systems, fear doing the opposite and creating other problems. Healing relationships thus involve learning to not be afraid, and also learning to love and I presume, trust.

Chapter 23 is the last, where it would be expected that he brings together his thoughts on social brain, and 'group mind', he instead focuses on culture, and storytelling, wisdom and the evolution of consciousness, all in brief, and the book ends.

Overall an interesting and readable book, with a lot of more in depth information that if included, would've have strengthened the previous book on the neuroscience of psychotherapy, that left one most dissatisfied. This is much better, but his next edition should include a musing sense of closure, rather than introducing a whole host of fascinating stuff, which he hardly then deals with. A closing, summarising of all of the complex and novel things he introduces, would strengthen the book.

I am also wary of the way he uses older theories with more modern information, a reasonable and interesting approach, but one which produces more questions than answers, and at times seems tenuous no matter how he jazzes it up with useful vignettes.

However, when you finish this book, you would have learned a lot that you already knew, just put differently, and in a readable form, and with some valuable insights for both student and graduate, worth the money, if not right on the money.

2007 Roy Sugarman

Roy Sugarman PhD, Director of Clinical and Neuropsychological Services, Brain Resource Company, Ultimo, Australia