Currently I am teaching a class for a psychology graduate program called, "The Biological Basis of Behavior". At the end of today's lecture, a student asked the inevitable question what is the purpose of psychologists-to-be learning all this science? How is it relevant to the practice of psychology? In short, why do we need to know this?
My answer was to tell a story about a woman who recently came to my office for help with severe anxiety. Whenever I see someone for the first time, I often ask, "How do you make sense of what is happening to you? How do you explain your severe anxiety? When you ask, "why me, why now, what do you say to yourself?"
The woman looked at me as if I were from Mars. She spoke in a matter of fact, irritated way, as if talking down to a child. "My brain chemicals are out of balance."
"And how did they come to be that way?" I asked, trying to sound as neutral as possible.
"I was born this way," she shot back, sounding even more irritated than before.
"Do you mean to say that you've been feeling this severe anxiety since birth?" I asked gingerly, verbally skirting her annoyance.
"Of course not," she snapped back. "I meant I'm this way because of genetics. "What are you, stupid or something?"
"No, no," I countered, backtracking. "It's just my usual question to understand how people explain their condition to themselves."
"You should know this," she said, glaring suspiciously at me. "You're supposed to be a psychiatrist. Didn't you learn anything in school? " I mumbled something conciliatory. "Now how are you going to treat me?"
Neuroscience, albeit bad neuroscience, had entered the consulting room with this woman as she crossed my threshold. She had a story about her anxiety, one that is rampant in popular North American culture. Therapy involves the negotiation of stories. In these days of science worship, we must negotiate bad stories by providing better stories, and these stories had better be plausible. They must stand up to scrutiny by skeptical family members, general practitioners, and other doctors. Our stories must have some support in what is generally recognized as science. If psychotherapists don't know some neuroscience and don't stay current with what is being discussed in the field, they may also fall prey to the stories running amok in the popular culture.
How would we counter this "bad" story, which takes all agency away from the one who is suffering and places the responsibility for fixing a damaged brain in the hands of an expert professional?
First, we would know enough to counter the chemical imbalance story, which is definitely not true. In fact, pharmaceutical companies have been fined by the U.S. Food and Drug Administration for using that story in their advertising. We don't really know how any of the drugs we use actually work to change mood and behavior. We know many of the things that they do, but we don't know how those actions of the drug correlate with the behavioral changes we see. We do know that anxiety is not as simple as too much or too little of a neurotransmitter in relation to other neurotransmitters. We know that it has to do more with learning and the maintenance of learning and the communication patterns of various brain regions than it has to do with the ratios of neurotransmitters to each other. "Mental illness" is more related to communication dysfunctions among brain circuits and systems. One current theory of anxiety disorders comes from the laboratory of New York University neuroscientist Joseph LeDoux, also known for his rock-and-roll band, The Amygdaloids. LeDoux studies the role of the lateral amygdale nucleus in anxiety. This brain area is where "unconditioned stimuli" get paired with "conditioned stimulu" to create a behavioral response. For pitiable, defenseless laboratory rats, this consists of a 10 second tone followed by a half second shock through the floor grid. After sufficient trials, the rats produce a response to the tone alone, similara to their response to the shock even though no shock is delivered. The sound stimulus and the shock stimulus come from different sensory systems and through different brain circuits to converge in the lateral amygdale where they are paired, resulting in the sending of a message to the central nucleus of the amygdale to tell the body to "freak out" since all hell is about to break loose. The body responds even though all hell doesn't come. It's easy to see how a child of an alcoholic parent could develop these kinds of responses, pairing beatings with the opening of a door at night, a harsh tone of voice, the sound of a beer bottle opening, and the like. Rats, however, are easier psychotherapy subjects than people. After a sufficient number of times of sound without shock, the rat starts to relearn the meaning of the sound. Eventually the sound gains a new meaning unconnected to shock. It no longer produces a fear response. We call this "extinction", even though we know that extinction doesn't actually happen. What happens is that new learning overshadows old learning and the unused synapses eventually wither up and drop away. Those neuronal connections that are used, persist. Those that are unused, disappear.
Humans are more difficult because our big brains can keep the pairing alive and even elaborate on it by inventing all manner of disaster scenarios that we can send to the amygdale to keep us in a constant state of fear. The hippocampus, which is supposed to modulate the amygdalar response by providing contextual information, gets confused. We lose track of whether we are reacting a real snake on the path before us or a stuffed snake in a museum (metaphorically speaking). Nevertheless, the bottom line of LeDoux's neuroscience is that the fear response can be decoupled or unpaired. We can stop being inappropriately afraid. We can learn to re-contextualize our responses so that we are no longer afraid in contexts that don't merit fear. This is the story I want to tell the woman sitting across from me as I search for diplomatic ways to introduce a new (and hopefully better) story about anxiety.
I could, of course, also invoke an epigenetic explanation for her. I could tell her how gene expression is regulated by social experience, and that even the genes that make one person more susceptible to trauma than another, can be modified by life experience.
The first decade of the 21st century has been the decade of neuroplasticity. This developing story shows us that environmental demands shape our brains to meet them, for better or for worse. We can collaboratively reshape our brains to be how we wish them to be. UCLA neuroscientist Jeremy Schwartz (see The Mind and the Brain) has designed a very successful behavioral program for reducing obsessive thinking and compulsive behaviors that is entirely non-pharmacological. His program relies upon neuroplasticity and the new awareness that our thoughts themselves change the structure of our brains. Schwartz tells people who cannot stop checking doors and windows to see if they are locked, that his neuro-imaging studies have shown that a switch in the caudate nucleus is stuck in the "On" position. This explains why they can't turn off their sense of dread that something is wrong or that something terrible will happen and why they keep checking the stove or the door or the windows. They are trying to relieve that sense of dread, which happens to most of us the first time we assure ourselves that the stove has been turned off or that the door is locked. Schwartz tells his clients that they must force the switch closed after the third check. They must force themselves to stop checking. The cognitive part of this relies upon telling themselves a neuroscience story nothing is amiss in the word; rather, the "dread switch" is stuck on the "On" position. Schwartz helps people find their own unique ways of distracting themselves from the dread (singing, counting, jumping up and down, dancing, humming, walking, running), while telling themselves over and over that the dread they feel is just the result of a faulty switch that they are now resetting. The program is wildly successful. Without the neuroscience story, people wouldn't believe Schwartz enough to bear the suffering of changing. Having the neuroscience story provides people with a rationale for doing something that is initially very uncomfortable.
Once upon a time, we didn't need science stories to grow and change. We used spiritual stories or ethical stories. Sigmund Freud invented fantastic stories based upon hydraulic and mechanical metaphors. Today we are a science-based culture. Science stories are required to convince people that they can change and that they will change.
