HANDS On 2: A Trip Between Banks

The Insula and Its Role in Therapeutic Transitions

By Kai MacDonald
1. Besides mediating the felt sense of experience, a neural network involving the insula appears to act as a neurobiological circuitbreaker, shifting the flow of energy and information from a network concerned with the exterior world, goals, and inhibition to a self-oriented network concerned with the interior world.

2. Clinically, this transitional network, and the state changes it bridges, is engaged through interoception (attention to the feeling self).

Welcome back, fellow traveler. If, in the interim since our earlier voyage, you have taken sup from the amnesia-inducing river Lethe, I will review. We parted last after a Dantesque descent into the insula, a tucked-away brain region that plays a crucial role in creating the felt sense of self. We explored with our Virgil, A.D. Craig, how this hidden island of cortex plays a role in interoception, decision-making, and may have participated in the evolution of our unique bondedness with others (Craig, 2009). In that first column, I suggested that a review of the functions of the insula anchors AEDP’s focus on feelings in the ground of 21st century neurobiological theories of neural networks, consciousness and the self.

In this column, I will discuss another component of the insula’s function that relates to experiential psychotherapy and AEDP. For it appears that the insula also functions as a critical part of a network that initiates an affect-triggeredtransition between different brain networks. Continuing our stygian metaphor, we are now at the near bank of the river Styx, playing the role of the ferryman Charon, guiding our patients across the river to explore the often-scary land of their emotional experiences (Gendlin [1978] notes that patients often think there are “scary things inside themselves . . . nameless horrors and weird states . . . like poisonous snakes locked in a cage”). We can even summon the three-headed hellhound Cerberus as an avatar for defenses, anxiety, and inhibition (dog whisperers, we). Herein, let’s examine how the insula participates in the bank-to-bank transitions between different neural networks and corresponding states of mind.

A clinical scenario, to anchor these concepts: a patient presents with an important anecdote from the recent past. His attention is directed to events outside the room; he is “telling a story” with a moderate push of speech. You note the phenomenology of anxiety and strong emotion. After acknowledging the gist of the manifest content, you invite the patient to redirect his attention to the felt sense of their experience in the moment: “I notice as we look at this together that you have a lot of feelings about it. Could you tell me how you are feeling ?” After a hesitant, half-step pause, the patient sighs, anxiety lowers, and a shift occurs: we are stepping into the boat together. The calm and pace of the water take over. More feelings emerge, and dyadic regulation and exploration ensue.

The transitional “circuit breaker” or “switch” function of the insula mentioned above relates to the neurobiological observation that the insula is part of a neural network that acts as a “primal circuit breaker” (Sridharan, Levitin, & Menon, 2008), abetting the transition between a coordinated state of activity in one neural network and a different pattern of activity in another. By way of orientation, a word on networks. In the same way that many instruments make a symphony, and many people make a family, current neuroscientific thinking of the functional units in the brain focuses not on singular “hot spots” of activity (i.e., “the insula does this”), but on coalitions of anatomically disparate brain areas whose activity consistently occurs together, similarly to a way the paced and coordinated play of the horns and winds creates a lovely, layered, singular sound. “Hot spots” within these networks (the bright spots on brain scans) are called “nodes” or “hubs” (Sporns, Honey, & Kotter, 2007). These intrinsically connected areas have both significant anatomical connections (tracks of neurons run between them), and functional connections (they fire together in a consistently coordinated pattern). In a very concrete sense, patterns of activity in a neural network corresponds to separable states of mind (Honey, Kotter, Breakspear, & Sporns, 2007; Lutz, Lachaux, Martinerie, & Varela, 2002), dysregulated network connectivity is a model for certain mental illnesses (New et al., 2007), and developmental alterations in these connectivity patterns are a crucial part of brain maturation (Dosenbach et al., 2010).

In our clinical vignette, the first neural network, the bank we are casting off from, is called the central executive network, or CEN. From a functional standpoint, the CEN is the “dealing” end of the “feeling and dealing” dichotomy: it is externally referenced, concerned with problem-solving, context-dependent inhibition (free won’t vs. free will), working memory, goal-directed behavior, and the cognitive control of emotional reactions (Ochsner, 2008; Ochsner, Hughes, Robertson, Cooper, & Gabrieli, 2009; Ochsner et al., 2004; Ridderinkhof, Ullsperger, Crone, & Nieuwenhuis, 2004). Anatomically, the CEN is centered in lateral prefrontal and parietal areas (the front-side and side of the brain; Seeley et al., 2007). Importantly, activity in the CEN is not involved in the interoceptive experience of the felt self; its function is actually diametrically opposed to internally-directed attention. Given that the CEN is involved in context-dependant emotion regulation, the control of working memory and response suppression, I suggest that the CEN network is heavily involved in what we call defenses, especially those defenses that involve lack of direction or redirection of attention away from one’s inner experience (Northoff, Bermpohl, Schoeneich, & Boeker, 2007).

We get from the CEN and external focus to a more inner-directed state by shifting attention. This therapeutic activity—invited interoception, if you will—engages a second important neural network, called the salience network (SN). Here, we push off into the river. The term salience, by the way, comes from the Latin word for leap (salire) and means “important to the brain: self and survival-related.” Salient stimuli—which can be either internal states or external stimuli–capture attention automatically: attention “leaps” to them. Implicitly, salient stimuli engage and elicit emotions, unless, of course, defenses are in operation. From this, we can understand that the SN is a network of brain regions that responds rapidly and reflexively to information that is important or salient to the brain. For example, the SN is activated during social exclusion (Slavich, Way, Eisenberger, & Taylor, 2010), empathy for pain (Singer et al., 2004), and a panoply of other somatic and homeostatic cues (Craig, 2009).

Coming back to the insula, the SN has major nodes in the insula and the dorsal anterior cingulate cortex (mentioned in column 1), and also has significant limbic (emotional centers) and autonomic (regulation of bodily processes) connections deeper in the brain (Fox, Snyder, Zacks, & Raichle, 2006; Golland et al., 2007; Seeley et al., 2007; Sridharan, Levitin, & Menon, 2008). Functionally, the SN is about transitions, and imaging experiments have shown that the SN is uniquely engaged when shifting from the CEN to a more self-related, quiescent brain state. To quote the study that inspired this article: part of this insula-containing SN circuit “may, in fact, be the primal circuit breaker that helps redirect endogenous attention in response to salient environmental stimuli” (Sridharan, Levitin, & Menon, 2008). This neurofunctional description bridges two different levels of observation: 1) the state shifts we see when we attend to feelings with patients; and 2) activity in identifiable brain networks.

The third and final network, the far bank in our metaphoric crossing, is called the DMN or “default mode” network. Its name hearkens to its happenstance discovery: in the hubbub of functional imaging, when neuroscientists were frenetically cataloguing which tasks activated which brain regions in scanners, it was observed that there was a network consistently “turned off” when subjects in a scanner attended outside themselves, and performed goal-directed tasks. This same network fires up spontaneously when subjects are asked to just “lay quietly in the scanner” and let their minds wander (Mason et al., 2007; Raichle et al., 2001). The actual function of the DMN is the least-well-explored of the three networks (though not for long); there is evidence that activity in the DMN is involved with self-judgments, autobiographical memory, social cognition and moral dilemmas: in general, attention toward oneself (Gentili et al., 2009; Gusnard, Akbudak, Shulman, & Raichle, 2001). I am not suggesting that DMN activity is correlated with dyadic exploration of the felt self; I know of no experiments that explore face-to-face, dyadic activity. In one of the experiments that prompted this column, however, the SN’s “transitional” or “switch” role was illustrated in the switch from the CEN to the DMN (Sridharan, Levitin, & Menon, 2008).

Let’s summarize, and bind our bank-to-bank sojourn, our clinical vignette, and the transition between brain networks/states of mind together. I am forwarding the idea that the insula, our featured brain region, plays a crucial role in the salience-triggered transition that occurs with clinical redirection of attention to feeling. This activity shifts patients into a brain state that allows the dyadic exploration of the feeling self, other-aided affect regulation, and access to formative autobiographical memory systems. The trip proceeds from one bank (defenses, external focus), thorough a transition (interoceptive focus), to the bank opposite (dyadic exploration and regulation). Therapeutically, in AEDP and other experiential therapies, shared attention to the felt experience of the patient is one of the key activities that engages networks involving the insula and foments the transition to deeper levels of experience and relatedness (i.e., state shifts;Fosha, 2000).

Thank you, fellow travelers, and smooth waters for your journeys ahead!

Recommended Reading: (free downloads with great illustrations)

  1. Sridharan, D., D.J. Levitin, and V. Menon, A critical role for the right fronto-insular cortex in switching between central-executive and default-mode networks. Proc Natl Acad Sci U S A, 2008. 105(34): p. 12569-74.
  2. He, Y., et al., Uncovering intrinsic modular organization of spontaneous brain activity in humans. PLoS One, 2009. 4(4): p. e5226.


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Fosha, D. (2000). The transforming power of affect: A model for accelerated change. New York: Basic Books.

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