CENTER ON BEHAVIORAL MEDICINE
Traditional Approaches-Psychological: Related Paper
Psychotherapy, Neuropsychology and the Mind-Body Connection
|Permission graciously given by the author to reproduce this
Mark R. Zuccolo
One example of the current debate between mind-based and body-based interventions can be found in the interpretation of the mechanisms of relaxation. Some practitioners maintain that relaxation is a psychological treatment, more akin to behavior modification (Cohen-Katz, 2004; Krasner, 2004); others view it as biophysical, similar to the effects of a pharmaceutical drug (Ehrnrooth, Zacharia, Svendsen, Jorgensen, Yishay, Sorensen, Poulsen, & von der Maase, 2002). Relaxation techniques can reduce the symptom of anxiety, but do they do so by acting on the psyche, or at the molecular level? The current consensus of opinion appears to be that relaxation is a near-perfect example of the interactions mind-body and mind-brain and that the therapist who administers a relaxation treatment is operating on the mind and on the body at the same time.
It is a well documented controversy that psychological interpretations are often in contrast, sometimes in clear opposition, to strictly biological diagnoses. Suffices here to recall the decades-long debate on the etiology of depression: does it have biological or psychological causes, or both? If the cause is strictly psychological, it follows that its most effective treatment must be purely psychological in nature. If instead depression is viewed as a biological disease of the brain, a mainly psychopharmaceutical intervention may be the most ethically acceptable standard of care. The preeminence of drugs vs. psychotherapies, and vice versa, has been debated with fervor and conviction (Covi, Lipman, Alarcon, & Smith, 1976; Hollon, Nierenberg, Thase, Trivedi, & Rush, 2005). The most sensible approach accepts the possibility of integration, while attempting to resolve the underlying debate that one of the two is, however, the true curative intervention (DeRubeis & Gelfand, 2000; Dinan, 2001; Friedman, Detweiler-Bedell, Leventhal, Horne, Keitner, & Miller, 2004).
Sigmund Freud's Project for a Scientific Psychology (1950), originally published in 1895 and now over a century old, began this debate within the context of a scientific approach to psychoanalysis. On the basis of the then scarce knowledge of neurology, Freud attempted to construct a model that could explain the workings of the human mind and of its disorders. But the scientific underpinnings were too weak for an attempt of this sort. Freud recognized this limitation and declared that he would set aside his attempt to explain behavior in terms of its biological-cerebral determinants, but that a day may come when the progress of science would make it possible. He then set out to study psychological phenomena by traveling down the royal road of dreams and towards the unexplored unconscious. A century of studies and experiments later, the interdisciplinary approach of psychobiology, focused on brain physiology but without neglect to the workings of the mind, has made remarkable progress (Hurwitz, 2004). Nonetheless, practitioners in the fields of mental health often have not kept up with these developments, and they contribute to perpetuating the debate between the old dichotomous view and the new biopsychosocial paradigm.
Psychoneurologists have advanced the frontiers of research on neurotransmitters, changes visible in CAT and PET scans, physiological components of pathologies that range from depression to schizophrenia, models and interpretations that support the cause of certain serious mental disorders as at least partially organic (Kalat, 2004; Kandel, 1999). Data provided by molecular genetics are revolutionizing our understanding of the brain, and a psychotherapist may be surprised in learning that a psychotherapy lasting as little as a few weeks can modify biological structures and functions in the brain. For the time being, no direct proof exists of this modification, since no empirically tested investigation has been made on the brain of a patient undergoing psychotherapy at these levels. But the clues are numerous and with the careful piecing together of neurobiological, neuropharmacological and psychobiological data we are on the threshold of momentous discoveries (Kandel & Squire, 2000). The implications of these theories, if confirmed by actual discoveries, can be disturbing. For example, there are behavioral experiences that are speculated to affect mechanisms of genetic transcription. There are data from neurobiological studies conducted in the last ten years that could conceivably revolutionize what we know about the relationship between psychological factors and cancer (McNeil, 1998). Even though we are far from thinking that tumors are psychogenic or psychosomatic, there is however a growing body of data that point to psychogenic effects reaching deeply into the biological strata, perhaps even into the DNA itself. It is of these days the news that scientists at the Hutchison Cancer Research Institute in Seattle have linked risk-taking behavior in mice to a specific gene (Harmon, 2006). A growing understanding of the human DNA structure and almost daily news stories on the power of genes in determining behavior appears to absolve certain behaviors and act as an antidote to guilt and self-blame in certain individuals, while others are feeling powerless in the face of a genetic structure that seems unassailable to anything but the most powerful medication (Rangell, 2002).
This type of conceptual revolution on the problem mind-body and mind-brain is further illustrated by the development of psychoneuroimmunology. The nervous system and the immune system have been shown as linked in the tightest possible way (Bakács, Mehrishi, Szabados, Varga, & Tusnády, 2001). Although the development of psychoneuroimmunology came of age in the Eighties, its general outlines were postulated by researchers many years before (Ayd, 1991). If its concepts had been presented to an immunologist twenty years ago he might have said that there probably was something to it but that it was simply not possible to determine exactly what. Today the old walls that separated psychology, neurology and immunology have been revealed as barriers erected merely by incomplete knowledge. Confronted with a cell that produces lymphokines as well as neuropeptides, that influences other hormones and can autonomously modify its behavior, that has its own memory and can be conditioned by means of learning, that is sensitive to psychological as well as physical stimuli, the neurologist, the immunologist, the psychiatrist and the endocrinologist have stopped arguing as to who is most competent to explain it (Carels, Cacciapaglia, Pérez-Benítez, Douglass, Christie, & O'Brien, 2003; Carlson, 2005). They are now beginning to work together as a team, grasping a truth far more complex than the knowledge of just a few years ago had suggested, when the neuron belonged to the neurologist, the hormone to the endocrinologist, the psyche to the psychiatrist, and the lymphocyte to the immunologist (Badaracco, 2006). The effects of this conceptual revolution are slowly trickling down into the mental health field. They are showing up with a certain degree of cautiousness in university teaching. More than a century after Freud, neuroscience is, in effect, the new frontier of the biopsychosocial paradigm (Felder, Francis, & Zhang, 2003). Anyone interested in the relationship mind-body must take its discoveries into accounts.
Psychosomatic medicine is another experimental field in which exciting new studies are conducted. Questions that have been asked for decades are now producing new answers (F. Alexander, 1962; J. M. Alexander, Fabricius, Fleming, Zwahr, & Brown, 2001). How can an episode of serious affective loss produce an immunosuppressive reaction, or be the cause of “death of a broken heart? “ (Clements, DeRanieri, Vigil, & Benasutti, 2004) Interactions between the structures and functions of the immune system and those of the cardiovascular system are providing the answer (Frasure-Smith & Lesperance, 2005). In the last 20 years remarkable progress has been made in recognizing the close relationship between brain and immune system and brain and cardio-circulatory system (Cooney, 1998). Researchers have identified, described, and experimentally tested substances that mediate and transmit stress reactions from the periphery to the center and vice versa (Ginsberg, 2005; Peress, 1998). Sensory systems (cortex, limbic system, hypothalamus-pituitary gland) that through the four primary systems of mind-body interaction (autonomic nervous, muscular, neuroendocrine, and immune systems) convert emotional stimuli in modifications of parameters that were once thought as completely independent (Blomhoff, Holven, & Brosstad, 2004; Blumenthal, Sherwood, Babyak, Watkins, Waugh, Georgiades, Bacon, Hayano, Coleman, & Hinderliter, 2005). A minor episode of stage fright is sufficient to see these mechanisms in action as they produce transitory but significant modifications of arterial pressure and cardiac frequency (Blodgett, 1985). A little less obvious, but no less certain in light of recent discoveries, is that events and situations of stress can alter the equilibrium of the immune system and increase the susceptibility to infectious diseases or to certain types of cancer (Cohen & Rabin, 1998; Courtnenay, 2000). Perhaps because it is necessary to dedicate time to the development of interdisciplinary knowledge, perhaps because traditional medical models have given preeminence to the cell, the tissue, the organ, perhaps because western civilization has developed a division between mental and the physical, the relationship between psychological and physical factors remains a matter of debate (James & Folen, 2005). Psychosomatic medicine has had to fight an uphill battle, collecting data upon data, in order to demonstrate connections that clinical observation had already hypothesized (F. Alexander, 1950). The biopsychosocial model can offer medicine and psychotherapy new ways to address old problems, but not without clearing significant hurdles thrown in its path by ignorance, prejudice, and structural resistance to change (Corey, Corey, & Callanan, 2003).
Is it really possible to connect events and circumstances that belong to heretofore separate epistemological realms? Such an integrative approach requires multiple levels of integration. The first level is observable behavior: we see the phenomena that the individual manifests to us (Robbins, Spence, & Clark, 1991). The second level is comprised of all the meanings attributed to the behavior (Columbus, 2001). A third level is the environment in which the behavior takes place, with events and situations of life acting as precipitating or mitigating factors (Culen & Volk, 2000). Even from this simple conceptualization, we can see that our attention can be divertedtowards singular aspects rather than on the whole. Behavioral theory focuses on observable and measurable behaviors (Melmed, 2003). Cognitive theories and to some extent dynamic theories focus on the world of meaning. Psychosocial theories focus on interpersonal events and life situations. Biological theories focus on genetic factors (Pert, 2002). Other theories are based on neurobiological aspects of behavior and on the biological mediators of emotions (Tugade, Fredrickson, & Barrett, 2004). Can integration occur among these theories? One example that illustrates this bridging of various theories and points of view is the psychological development of the child, for whom a suitable affective milieu is fundamental. Early researchers from various orientations, from Freud to Bowlby, from Klein to Mahler, had perceived this convergence (Bieber, 1996; Harrington, Block, Block, & Albert, 1992). Recent research shows that the importance of affect and attachment in child development extends to neurobiological factors (Kerr, 2003). The psychological, the affect, the attachment pattern appears to translate into structural modifications and it is perhaps written in the blueprint of the brain’s molecular structure. Serious consideration is being given to the possibility that patterns of childhood attachment may profoundly affect the child’s neurophysiological structure, and therefore the biochemistry of the brain. Today, most of the evidence for this hypothesis comes from animal studies. However, it appears now probable that patterns of psychological development may be encoded in the biochemical structures of the child’s brain, that is, in the neurotransmitter system and its reactivity to external stimuli (Hiramoto, Rogers, Demissie, Hsueh, Hiramoto, Lorden, & Ghanta, 1997). This being the case, adult patients that suffer from a depressive syndrome may be exhibiting an altered neurotransmitter response that could date from their childhood. This and other similar assumptions remain to be empirically verified, but much progress has already been made in this crucial integrative process (Mayeux & Cillessen, 2003).
What significance should traditional psychotherapy attribute to these developments? The challenge is not in the data, but in the complex interaction of factors. An analogy may illustrate this dilemma. A wave is created in the ocean, generated by winds and currents. It obeys precise laws of physics and mechanics, but it also depends for some of its behavior on the changing composition and chemical properties of water. The noradrenergic neurotransmitter apparatus is an analogous system with anatomical (physical), chemical, and mechanical (receptor dynamics) properties. Like the wave, it is also a phenomenon generated by winds and currents: the winds are the attributions of meaning and the swirling of events are the currents of life, activated in a biochemical substrate. It seems therefore possible that neurotransmitters may be more than a static biochemical system that responds to stimulation in a deterministic fashion, and that they may be part of a dynamic set of forces that influence behavior and meaning-making, in a milieu that is composed of what is present, what is past, of genetic predispositions, as well as of what is happening at the molecular level. This integrated understanding enables us to take interesting, valid data from the biological sciences and read them from a psychological perspective, and can allow us to grasp how such apparently unrelated biochemical phenomena can have profound influences on affective and cognitive-behavioral expressions of the psyche (Krasner, 2004). The holy grail of this complex integrative process, as of today incompletely supported by empirical evidence, is that traditional talk therapy (psychodynamic, behavioral, or interpersonal as it may be) may have the power to modify cerebral neurochemistry. Months and years may be necessary for this deep molecular change to take place, but the notion that the relationship and affective tie with the therapist and the intrapsychic work within the patient may have an impact on noradrenalin production, or on stabilizing serotonin levels, is a tantalizing prospect. In this light, the relationship between psychotherapy and brain neurochemistry appears reciprocal in nature, although the latter may be regulated by its laws and biological determinants.
Alexander, F. (1950). Psychosomatic medicine: Its principles and applications: W. W. Norton & Co, Inc.
Alexander, F. (1962). The development of psychosomatic medicine. Psychosomatic Medicine, 24(1), 13-24.
Alexander, J. M., Fabricius, W. V., Fleming, V. M., Zwahr, M., & Brown, S. A. (2001). The development of metacognitive causal explanations. Learning and Individual Differences, 13(3), 227-238.
Allen, J. G. (2004). Does stress damage the brain? Understanding trauma-related disorders from a mind-body perspective. Bulletin of the Menninger Clinic, 68(2), 189-190.
Andreasen, N. C. (1997). Linking mind and brain in the study of mental illnesses: A project for a scientific psychopathology. Science, 275(5306), 1586.
Ayd, J. F. J. (1991). Stress, neuropeptides, and systemic disease. JAMA: Journal of the American Medical Association, 266(2), 280.
Badaracco, M. A. (2006). Psychiatry, psychoanalysis, and the new biology of mind. The American Journal of Psychiatry, 163(1), 165.
Bakács, T., Mehrishi, J., Szabados, T., Varga, L., & Tusnády, G. (2001). Some aspects of complementarity in the immune system. International Archives of Allergy and Immunology, 126(1), 23.
Bieber, M. R. (1996). Psychoanalytic pioneers. The American Journal of Psychiatry, 153(10), 1363.
Blodgett, N. (1985). Stage fright. ABA Journal, 71(10), 26.
Blomhoff, S., Holven, K. B., & Brosstad, F. (2004). Psychological factors and cardiovascular disease. Journal of Thrombosis & Haemostasis, 2, 201-203.
Blumenthal, J. A., Sherwood, A., Babyak, M. A., Watkins, L. L., Waugh, R., et al. (2005). Effects of exercise and stress management training on markers of cardiovascular risk in patients with ischemic heart disease: A randomized controlled trial. JAMA: Journal of the American Medical Association, 293(13), 1626-1634.
Carels, R. A., Cacciapaglia, H., Pérez-Benítez, C. I., Douglass, O., Christie, S., et al. (2003). The association between emotional upset and cardiac arrhythmia during daily life. Journal of Consulting and Clinical Psychology, 71(3), 613-618.
Carlson, L. E. (2005). Introduction to psychoneuroimmunology. Canadian Psychology, 46(1), 53-55.
Clements, P. T., DeRanieri, J. T., Vigil, G. J., & Benasutti, K. M. (2004). Life after death: Grief therapy after the sudden traumatic death of a family member. Perspectives in Psychiatric Care, 40(4), 149-154.
Cohen-Katz, J. (2004). Mindfulness-based stress reduction and family systems medicine: A natural fit. Families, Systems & Health, 22(2), 204-206.
Cohen, S., & Rabin, B. S. (1998). Psychological stress, immunity, and cancer. Journal of the National Cancer Institute, 90(1), 3.
Columbus, F. (2001). Advances in psychology research (Vol. 7): Nova Science Publishers, Inc.
Cooney, J. M. (1998). Stress, stress hormones and the immune system. The International Journal of Social Psychiatry, 44(2), 156.
Corey, G., Corey, M. S., & Callanan, P. (2003). Issues and ethics in the helping professions. Pacific Grove, CA: Brooks/Cole.
Courtnenay, W. H. (2000). Behavioral factors associated with disease, injury, and death among men: Evidence and implications for prevention. Journal of Men's Studies, 9(1), 81.
Covi, L., Lipman, R. S., Alarcon, R. D., & Smith, V. K. (1976). Drug and psychotherapy interactions in depression. American Journal of Psychiatry, 133(5), 502-508.
Culen, G. R., & Volk, T. L. (2000). Effects of an extended case study on environmental behavior and associated variables in seventh- and eighth-grade students. Journal of Environmental Education, 31(2), 9-15.
DeRubeis, R. J., & Gelfand, L. A. (2000). Medications versus cognitive behavior therapy for severely depressed outpatients: Mega-analysis of four randomized comparisons. American Journal of Psychiatry, 157(6), 1025-1026.
Dinan, T. G. (2001). Novel approaches to the treatment of depression by modulating the hypothalamic-pituitary-adrenal axis. Human Psychopharmacology: Clinical and Experimental, 16(1), 89-93.
Ehrnrooth, E., Zacharia, R., Svendsen, G., Jorgensen, M. M., Yishay, M., et al. (2002). Increased thymidylate synthase mRNA concentration in blood leukocytes following an experimental stressor. Psychotherapy and Psychosomatics, 71(2), 97-103.
Felder, R. B., Francis, J., & Zhang, Z.-H. (2003). Heart failure and the brain: new perspectives. American Journal of Physiology [H.W. Wilson - GS], 284(2), R259.
Frasure-Smith, N., & Lesperance, F. (2005). Depression and coronary heart disease: Complex synergism of mind, body, and environment. Current Directions in Psychological Science, 14(1), 39-43.
Freud, S. (1950). Project for a scientific psychology (Vol. 1): Standard Edition.
Friedman, M. A., Detweiler-Bedell, J. B., Leventhal, H. E., Horne, R., Keitner, G. I., et al. (2004). Combined psychotherapy and pharmacotherapy for the treatment of major depressive disorder. Clinical Psychology: Science & Practice, 11(1), 47-68.
Ginsberg, A. B. (2005). Negative feedback of the hypothalamic-pituitary-adrenal axis: Glucocorticoid modulation of stress-induced gene expression in the paraventricular nucleus and pituitary gland. University Microfilms International.
Harmon, A. (2006, June 15). That wild streak? Maybe it runs in the family. The New York Times, pp. 1, 19.
Harrington, D. M., Block, J. H., Block, J., & Albert, R. S. (1992). Testing aspects of Carl Rogers's theory of creative environments: Child-rearing antecedents of creative potential in young adolescents. In Genius and eminence (2nd ed.). (pp. 195-208): Pergamon Press, Inc.
Hiramoto, R. N., Rogers, C. F., Demissie, S., Hsueh, C.-M., Hiramoto, N. S., et al. (1997). Psychoneuroendocrine immunology: Site of recognition, learning and memory in the immune system and the brain. International Journal of Neuroscience, 92(3), 259-286.
Hollon, S. D. J., Robin B., Nierenberg, A. A., Thase, M. E., Trivedi, M., & Rush, J. A. (2005). Psychotherapy and medication in the treatment of adult and geriatric depression: Which monotherapy or combined treatment? Clinical Psychiatry, 66(4), 455-468.
Hurwitz, T. A. (2004). Neuropsychiatry: Grasping the body-mind and mind-body problems. Canadian Journal of Psychiatry, 49(3), 155-156.
James, L. C., & Folen, R. A. (2005). The primary care consultant: The next frontier for psychologists in hospitals and clinics: American Psychological Association.
Kalat, J. W. (2004). Biological Psychology (8th ed.). Belmont, CA: Thomson Wadsworth.
Kandel, E. R. (1999). Biology and the future of psychoanalysis: A new intellectual framework for psychiatry revisited. The American Journal of Psychiatry, 156(4), 505.
Kandel, E. R., & Squire, L. R. (2000). Neuroscience: Breaking down scientific barriers to the study of brain and mind. Science, 290(5494), 1113.
Kerr, M. (2003). One family's story: A primer on Bowen theory. Washington, DC: Bowen Center for the Study of the Family.
Krasner, M. (2004). Mindfulness-based interventions: A coming of age? Families, Systems & Health, 22(2), 207-212.
Mayeux, L., & Cillessen, A. H. N. (2003). Development of social problem solving in early childhood: Stability, change, and associations with social competence. The Journal of Genetic Psychology, 164(2), 153.
McNeil, C. (1998). Stress reduction: Three trials test its impact on breast cancer progression. Journal of the National Cancer Institute, 90(1), 12.
Melmed, R. N. (2003). Mind, body, and medicine: An integrative text. American Journal of Psychiatry, 160(3), 605-606.
Peress, N. (1998). Neuroinflammation: Mechanisms and management. The Quarterly Review of Biology, 73(4), 538.
Pert, C. B. (2002). The wisdom of the receptors: Neuropeptides, the emotions, and body-mind. Advances in Mind-Body Medicine, 18(1), 30.
Rangell, L. (2002). Mind, body, and psychoanalysis: The science of psychotherapy. Psychoanalytic Psychology, 19(4), 634-650.
Robbins, A. S., Spence, J. T., & Clark, H. (1991). Psychological determinants of health and performance: The tangled web of desirable and undesirable characteristics. Journal of Personality and Social Psychology, 61(5), 755-765.
Susman, E. J. (2001). Mind-body interaction and development: Biology, behavior, and context. European Psychologist, 6(3), 163-171.
Tugade, M. M., Fredrickson, B. L., & Barrett, L. F. (2004). Psychological resilience and positive emotional granularity: Examining the benefits of positive emotions on coping and health. Journal of Personality, 72(6), 1161-1190.