Western medicine has made relentless progress in the use of scientific understanding of disease to develop more effective treatments. In mental health, Psychiatry has ardently desired to follow the same trajectory, but has not made the same kind of progress. In its all out attempt to do so, it has all but abandoned psychotherapy, once the central feature of psychiatric practice. Brain science has been the great hope. Resources have been devoted almost exclusively the study of the structure and neurophysiology of the central nervous system, while information processing, after all, the central function of the brain, has been neglected. That information processing is what we call mind.
In the early 70s, Albert Einstein in New York, was a storied place for psychoanalytically based training, but in the middle of my residency years there, the newly appointed, biologically oriented Chairman declared that the only use of psychotherapy was to induce patients to take their pills. My cohort of residents finished before he was able to dismantle the teaching, but in the 50 years since then, my profession has moved ever further away from psychotherapy and the mind.
Seeing gold, the pharmaceutical and insurance industries have taken full advantage of this prolonged trend to promote cheap but profitable drug treatment over everything else. Through advertising, they have brought a substantial portion of the public with them, into believing every problem can be treated with a miracle medication.
Oversold and Underdelivered
Today, unrealistic hopes have collided with an ever increasing need for relief from emotional suffering. Thomas Insel, former head of the National Institute of Mental Health, shockingly, but truthfully, pronounced psychiatry’s failure to achieve its goal despite $20 billion spent on brain research. In his book he sums it up thus: the ‘house is on fire’ yet we were thinking ‘about the chemistry of the paint.’ The problem, it turns out, is that, while genes clearly have an important role in susceptibility to mental illness, many genes are related to any given condition, and we are a long way from explaining how implicated genes might actually lead to problems. Lacking understanding of the causation of major mental illnesses, the hope of further improvement in biological therapeutics remains elusive, with no great breakthrough in sight. In the meantime, emotional distress is overflowing. An epidemic is colliding with lack of progress towards a cure.
Untangling the Mess
To further compound today’s difficulties, a number of factors including pharmaceutical advertising have cultivated a confusion between brain problems and mind problems. We humans have both. Some individuals have biologically-based susceptibility to emotional problems. Others suffer from the mind’s maladaptive attempts to cope. A large, third group have some of both.
A first step is to distinguish between the targets of biological treatments and of psychotherapy. A perfect example is anxiety, where some individuals clearly have an inborn predisposition to develop more intense symptoms of anxiety. Biological treatments are of some value in bringing that physiology under better control. On the other hand, the human tendency to focus on avoiding anxiety is increasingly recognized as maladaptive. Those who face their emotions improve their ability to cope and often do better in the long run. In general, the aim of psychotherapy is to help people trade less effective coping, especially avoidance, for better ways of mastering situations our non-conscious information processing identifies as threats.
In contrast, biological treatments are aimed at the physical substrate that supports the mind’s information processing. Confusing the two, for example, failing to distinguish between depression that is primarily biological versus depression mainly in response to meanings attributed to circumstance, has made it easier for pharmaceutical companies to sell the idea that drug treatment and other biological interventions are the best way to treat all kinds of emotional distress.
In spite of the inseparable connection between mind and body, when it comes to treatment, a clear distinction can be made. Mind is a function of information processing. The human mind does marvelous things, but among them, it often comes up with less than optimal solutions to problems. In working with information drawn from present circumstances, evaluated in the light of past experience, it regularly produces responses that are maladaptive. Some are automatic and instinctive, such as avoiding situations associated with anxiety or emotional pain. Others may have been adaptive when first acquired, but are no longer so, as circumstances have changed. A third group of maladaptive coping strategies are so because of the cognitive limitations of the young mind at the time they were first developed. When these forms of “coping gone awry” are significantly “entrenched,” that is, resistant to change, they require sophisticated professional help, and that is the job of psychotherapy.
Another man-made obfuscation is “medical necessity.” Used as a test to distinguish between problems that don’t deserve insurance reimbursement from others that are so deserving, the concept has meaning only when the vast suffering due to entrenched maladaptive patterns of response is labeled as not “medical.” Medical treatment has always been aimed at helping relieve unnecessary human suffering. When maladaptive coping is so entrenched as to require highly trained professional treatment, it is, arguably, as “medical” as anything else.
One argument to the contrary is the view that people “should” be able to master their entrenched maladaptive patterns through willpower alone. This view has been thoroughly debunked. Another argument is based (erroneously) on the notion that medicine is “scientific,” while psychotherapy is not. Strides have been made in western medicine, but a great deal of practice remains far from scientific. That psychotherapy has no scientific basis used to be true, but let’s keep an eye out for the dark horse.
The Science of Psychotherapy.
As Thomas Kuhn has described their development, most sciences have progressed from a “pre-paradigmatic” phase to what he calls “normal science.” What does that mean? In the early days of any science, theories are, of necessity, “coherentist,” meaning that they rely on intuitively derived concepts that are internally coherent but lacking a basis outside their own world. They are self-referential. The humoral theory of mental illness is a good example, where black bile was thought to be the source of “melancholia,” but had no other basis than conjecture. Descartes said that was not good enough. Science needs to be “foundational,” meaning built on top of more basic and established concepts. In a current interpretation, examples would be biology built on the theory of evolution and chemistry, built on notions of the behavior of atoms.
One of the first and most classic examples of medicine becoming truly scientific was the germ theory of disease. Not only was a new understanding of illness built on the science of tiny living organisms, but that understanding led to improvement in therapeutics. Surgeons began to wash their hands before operating. For major mental illnesses, that simply hasn’t happened. Brain science has made a lot of progress, but not to the point of having a precise understanding of causation, nor major improvements in care. Contemporary treatments for mental illness are still based largely on chance discoveries with incremental progress in the choice of side-effect profiles.
A Fortuitous Coincidence
If the brain is too complicated to understand, then the mind must be even farther out of reach. It has been assumed that the mind, that is, human information processing, must be far too complex and definitely beyond the reach of science. To most, it appeared that psychotherapy would, for the foreseeable future, remain too fuzzy for scientific study or explanation beyond statistical correlations. Theories of the functioning of the mind seemed likely to remain coherentist as they are today, that is, self-referential and internally consistent but incompatible with one another. Schools of therapy would continue to compete with each other for disciples with little difference in their results.
Meanwhile, under the radar, a set of events would lead towards a science of psychotherapy.
- Evolution made it more clear that the basic function of the brain is not as much rational thought, as it is the prediction of opportunities and threats and generation of adaptive responses, much like the brains of other mammals.
- The arrival of general purpose computing machines pointed the way to understanding how all forms of data are encoded and stored in neural networks, available for processing in the light of past experience.
- Growing awareness of the seriousness of trauma soon outgrew the boundaries of branded therapies and showed that post-traumatic problems, including distortions of personality, grew out of the mind’s automatic and non-conscious attempts to cope.
A central awareness growing out of these foundational threads of science is that Freud was right. Much of human irrationality is a product of non-conscious information processing, evolved for adaptation in a complex and changing world, and that the non-conscious problem solving mind does not always reach the best conclusion. Our 18th century love affair with rational thinking was finally giving way to the more modest view that our minds are similar to those of our mammalian cousins to a far greater extent than we might have wished.
Out of this awareness comes an essential element, necessary for the application of science to psychotherapy. We need a single notion of what psychotherapy aims to treat. Traditional schools of psychotherapy had no agreement on the problems they treat. Psychodynamic treatment aims to resolve “intrapsychic conflict,” while CBT seeks to correct “irrational thoughts.” The field of trauma at last spawned a universal definition of what psychotherapy is primarily designed to address: entrenched maladaptive patterns of response.
Within the first quarter of the 21st Century, brain researchers were looking at the specific neurochemistry of a phenomenon first noted by Pavlov, the learned fear response. In this experimental paradigm, animals and humans are exposed to a natural stimulus, let’s say an electric shock, paired with an arbitrary one such as a bell ringing. They soon learn to respond to the bell whether or not the shock is administered. When the shock is stopped, the subject continues to react, now inappropriately, as if it is about to receive a shock. Over time, in the absence of the shock, the subject gradually ceases to react. What is most remarkable is that the subject’s continuing to react is a true example of “coping gone awry,” that is, a response that is no longer useful since the circumstances have changed. Furthermore, the paradigm is no different between animals and humans, meaning that experiments only possible in animals can shed light on humans as well. From a scientific point of view, this is extraordinary. How often do we find an animal model that is not simply an analogue but an actual instance of the human problem we want to study? Could this model apply to other examples of maladaptive coping?
The key is broad agreement among neuroscientists that all mammalian coping passes through the limbic system. More precisely, a single, necessary step stands between the appraisal of circumstances and the generation of a response. Most significantly, that necessary link turns out to be the main location where changes in the learned fear response take place.
Studies of the learned fear paradigm have identified the precise chain of events going from hearing the bell to a visible fear response. From an information perspective, the mind/brain goes from a prediction of danger to generation of an appropriate response. Complex information processing compares actual inputs to prior experience to identify circumstances associated with danger. The final conclusion that harm might be imminent takes place in limbic nuclei such as the amygdala and consists of activation of a few nerve cells. That essential activation then triggers another bout of complex information processing to produce a coordinated response consisting of bodily changes, automatic actions, and, in humans, thoughts, impulses, and feelings that seem to “pop” into consciousness.
Most remarkably, while the entire chain of events is exceedingly complex, the simplest component is the required limbic activation, the central, necessary link. Without that neural activation, no response can take place. As it turns out, that one, relatively simple link is also the main locus of change. Focusing there, neuroscientists were able to characterize the precise mechanisms behind Pavlov’s observation of the eventual cessation in the inappropriate fear response. That is the change mechanism called “extinction,” in which the cortex learns to send inhibitory impulses to prevent a response, even though cells in the amygdala are still activated, indicating the ongoing prediction of danger. Because danger is still being identified in the brain, the fear response eventually returns, meaning that the benefit of extinction is not permanent unless further reinforcement takes place.
More importantly, Nader and his collaborators were interested in the known phenomenon of reconsolidation in which already established neural links could later be modified. What they found was that reconsolidation involved a very different mechanism, namely change in stored procedural memory in the limbic system. In the case of the learned fear response, this is primarily in the amygdala. In memory reconsolidation, information carrying synapses become volatile and subject to change over a period of 4-6 hours if subjected to the influence of disconfirming information. In this case, the change is permanent and, once established, does not require further reinforcement.
Circling around to longstanding clinical wisdom, that same formula, juxtaposition of affective activation of the old pattern with exposure to new, disconfirming information, can be found occupying a central role in essentially every brand of psychotherapy. Could it be coincidence alone that universal elements throughout psychotherapy describe in various ways the precise neurophysiological requirements for the change mechanism of memory reconsolidation?
To summarize, identification of a class of human emotional problems as maladaptive responses to perceived threats has allowed those patterns to be identified with the learned fear response. Scientific study of the learned fear response and how it could be modified has clarified the precise requirements for change by memory reconsolidation within the limbic system. Those requirements are the activation of the original prediction of danger (clinically observable as affect) juxtaposed with the presentation (at a limbic level) of disconfirming information. Finally, as if to confirm the relevance of the new science, the requirements for memory reconsolidation are a strong match with central features, universally described, though in different terms, in a wide range of psychotherapies.
A few thoughtful individuals, aware of this research, realized that erasure of the learned fear response could have important implications for clinical practice. Among them two members of SEPI, the Society for the Exploration of Psychotherapy Integration, Bruce Ecker (2012), and Richard Lane (2015) took an interest in the two conditions required for change to take place. They both recognized those conditions as present in a wide variety of instances of change in psychotherapy.
My own excitement in this discovery grew out of a longstanding interest in how therapy works. In the early 80s, I had experimented with computer-based neural networks. In 2005 I wrote a paper on the conditions required for detoxification of traumatic memories, seeing that process as exemplifying psychotherapeutic action in general. In 2014 I had just completed a first book on emotional healing and growth in which I surveyed my four decades of practice and came to the conclusion that the problems psychotherapy sought to change consisted of avoidance of affect. At a conference that year, when a speaker mentioned Ecker’s work, I recognized that memory reconsolidation corresponded exactly to the change process I had described clinically. I devoured Ecker’s book, then found Lane’s 2015 paper and have worked since then to apply the principles to the practice of psychotherapy and to its “nondenominational” teaching.
Of course there are those who are unconvinced by the relevance of memory reconsolidation to clinical practice. Here’s the thing. Theories are often not proven when first put forth. Einstein’s theory of relativity was unproven at first, but with time it has yielded predictions that have gone on to become proofs. Furthermore, as clinicians, we are not bound by the research standard of proof, “beyond reasonable doubt.” Rather, dealing with complex phenomena, we have no choice but to follow the “preponderance of the evidence” in our decision making, given realities not directly represented in research studies. If a theory is clinically useful, we can and should put it to work, until or unless it turns out not to fit with reality.
Does it enhance therapeutics?
The new science of change processes in psychotherapy proposes a solution to the greatest mystery in our field, how psychotherapy actually works. The first practical benefit is that the new science shows how all therapies make use of the same few change mechanisms. By providing a universal explanation of much of therapeutic action, it undermines the destructive and illusory divisiveness between competing therapies and orientations. Becoming truly trans-theoretical, clinicians can focus on supporting change processes rather than following set methods. Furthermore, they can, at last, mix techniques rationally and coherently to better match technique to client.
A second and much greater potential benefit is yet to be fully realized. Knowing the requirements and parameters of change processes allows for both clinical intuition and future research to explore how best to optimize technique for the dual goals of activating entrenched maladaptive response patterns and improving the delivery of disconfirming information.
The Dark Horses Surges Ahead
While biological psychiatry remains mired in the complexity of disease causation, the field of psychotherapy is moving into the lead. Unexpectedly, we are able to enter the territory of what Thomas Kuhn calls normal science, that is, doing the detail work of exploring the application and optimization of a new theory, this time, one that is foundationalist, that is, based on underlying science independent of the field of psychotherapy itself.
Now that psychotherapy has a scientific basis, where are we?
This is only the beginning. When the discovery of oxygen invalidated the phlogiston theory of combustion, holdouts clung to the old theory for decades. Today, the old idea that psychotherapy has no scientific basis still prevails. Too many still believe that biological psychiatry is the only path that will be able to bring science to mental health. They are wrong.
Meanwhile, let’s step back to look at what we have. How much of the world’s suffering comes from entrenched maladaptive responses, the ones psychotherapy aims to treat? Yes, a percentage of the world’s population suffers from schizophrenia, bipolar illness, autism, and biologically based susceptibility to anxiety and depression. But when we consider the breadth and depth of suffering caused by entrenched patterns of maladaptive coping, those that our clients are unable to change on their own, the potential for improvement in health seems vast.
Appreciating the importance of maladaptive coping in human life may have an effect on how we look at disease. The classic model of modern scientific medicine is the germ theory of disease in which illness is seen as the individual being attacked by a destructive organism. Discovery of the offending pathogen defined the disease. Today, this is seen as an oversimplification, but it still prevails. On the other hand, maladaptive coping is not the product of an external pathogen. It is a glitch in software that leads either to an erroneous identification of a threat or the generation of a response that is less than optimal. Just as computer bugs are unique to each program, instances of entrenched maladaptive coping represent individual failures of information processing along with specific factors working against change.
While there are similarities between individuals, effective treatment focuses on the specifics of each case. The science of change by memory reconsolidation shows us that generic the treatment is less effective. Words are like a scalpel, activating precise appraisals and supplying disconfirming information tuned to the exact elements that need to change. That is why vast amounts of self-help wisdom dispensed every day on the internet have not significantly improved the world’s mental health.
The one most important future changes is for this relatively new science to be taught as “basic science” in medical schools, residencies and other training programs for therapists. That change, alone, will inexorably undermine the importance of polarized schools of therapy, while leading to improvement in practice and research on how to optimize treatment matching and technique. As young therapists become more focused on process than set methods, existing silos and divisiveness will naturally fade in relevance. Beyond that, bringing maladaptive coping back into the mainstream of medicine can have an impact on the mental health of the world.
Jeffery Smith MD
Ecker, Bruce. Unlocking the Emotional Brain: Eliminating Symptoms at Their Roots Using Memory Reconsolidation. Routledge, 2012.
Lane, Richard, et al, The integrated memory model: A new framework for understanding the mechanisms of change in psychotherapy. Behavioral and Brain Sciences, 2015
Smith, Jeffery. How We Heal and Grow: The Power of Facing Your Feelings, Libentia Press, 2014
Photo Credit: Mathew Schwartz, Unsplash
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