Эффективность моделирующей психотерапии (26) Therapy Isn't Brain Science

“OK,” I said. “Let’s imagine that I’m hooked on drugs. Help me improve my self-concept. Help me out. What should I do?”

“Well, you could use operant conditioning,” someone suggested.

“Great!” I responded. “Condition me. Show me what you can do to help me improve my self-esteem.”

The room got quiet again. “I’d start by helping you heal your past traumas,” another person eventually volunteered.

“OK,” I said. “Let’s imagine that I was sexually abused as a child. Show me how to build up my self-concept in a way that’ll heal that.”

Again, the room went quiet. My point in keeping up this line of questioning for almost 20 minutes was to make a clear distinction between what psychologist and communications theorist Paul Watzlawick called descriptive language—which tells you about something—and injunctive language—which tells you what to do. It’s the difference between describing a meal to someone and handing over a recipe.

The newest edition of the Diagnostic and Statistical Manual has more than 900 pages describing the different kinds of disorders that people have, but not a single page telling us what to do to resolve them. As therapists, we’re useless to our clients if all we can do is describe what’s wrong with them. We need to create vivid, living experiences for them that’ll help them change. All the expert knowledge in the world about therapy or different psychiatric conditions isn’t worth a thing if we don’t know what to do with it.

Nothing reflects this fundamental truth more than the current infatuation with brain science. I think it’s wonderful that we now have at least some understanding of neural connectivity, synapses, brain chemistry, and mirror neurons—all of which help us understand our ability to change the way we think and act, and to experience empathy and compassion. I have great respect for the value of doing valid research in such an inherently complex field. However, what I’ve found in a close reading of original neuroscience studies is that many of the uncertainties and complexities in brain science research don’t appear in the popularized material written for the general public—and for therapists. Even if we set aside all the uncertainties and assume that current neuroscience studies are valid and won’t be revised substantially by further research, the key question remains: What can neuroscience tell us about what to do differently when we’re working with a client?

In recent years, I’ve listened to many of the current experts in neuroscience talk about their interesting discoveries, and I’ve watched therapy demonstrations by the few who’ve tried to apply findings from the brain-imagery lab to actual therapy with a client, but so far, I haven’t seen any persuasive direct application of neuroscience to the practice of therapy.

Physicists found a while ago that the cosmos is made up of subatomic particles that interact in peculiar ways, and they went on to develop detailed and sometimes frighteningly effective recipes to put that information to practical use—think cell phones and hydrogen bombs. However, brain science has yet to translate its findings into effective or practical recipes for therapists. For instance, a lot of therapists are enthusiastic about the fact that they now know that a panic attack involves overactivation of the amygdala, but this knowledge doesn’t make them better therapists. Would they do their therapy any differently if they were told that a panic attack actually involved overactivation of the liver—or even the pineal gland, which Descartes believed to be the seat of the soul and the place where all thinking originated? I don’t think so.

The neuroscience information that’s currently in vogue seems primarily useful in convincing clients that we’re “experts”—that we have hard scientific knowledge about what’s actually happening inside their skulls. Telling them about the impact of brain function on their emotional lives can certainly help normalize their problems and convince them that they can take steps to change how their brains operate, though “brain talk” may also convince them that the solution is to take medications. Another danger inherent in this fascination with the brain is that therapists will use neuroscience to convince themselves that they know more than they really do, and thus must be practicing effective therapy.

Many of our clients’ problems are far simpler than most people realize, and the therapeutic interventions needed to resolve them are often equally simple. Current neuroscience is irrelevant to our understanding of both the problems and their solutions. After all, therapists were doing helpful, healing work long before neuroscience made its official debut at psychotherapy workshops and conferences and the field developed a collective case of “brain fever.”

Good therapists have always known that to help people change the way they feel and behave, we have to help them change the way they use their brains every day, not tell them about their neural processes. By actively creating vivid, impactful therapeutic experiences, we can transform our clients’ perceptions of their own reality, shifting the way they think and feel about themselves and their capacity for change. Some of the most effective techniques for creating this shift, like the two described below, were in use long before neuroscience was even a distant speck on psychotherapy’s horizon.

John was a drug and alcohol counselor and a Vietnam vet. His worst experience during the war occurred in the marketplace in Pleiku while waiting to join his troops. When a teenage boy reached for the wallet in John’s hip pocket, he grabbed the boy’s arm. Suddenly, he heard someone shout, “Grenade!” and felt something push hard against his back. When he regained consciousness, he was leaning against a tree, still holding the boy’s arm. “But that’s all I was holding,” he said, “because the rest of him was gone.”

After returning home, John had all the symptoms of post-traumatic stress disorder (PTSD). He regularly woke from nightmares of being back in Vietnam, thrashing and screaming. Sometimes his wife had to sleep in another room to avoid being hit. After this kind of night, John would be 10 times as tired the next day as he’d been when he’d gone to bed. Once, at an outdoor flea market, he’d had a waking nightmare that started when he heard people speaking Vietnamese. When he looked up, he saw a large Vietnamese family walking toward him. This sight, he said, “clicked me right back to the most violent incident that occurred to me in Vietnam. Then, suddenly, everyone around me was Vietnamese.” He’d panicked and run back to his car. Since returning from Vietnam, he’d found himself increasingly avoiding all people and things Asian. And he had an exaggerated startle response: if anyone unexpectedly touched or spoke to him from behind, he’d jump and have to restrain himself from hitting them.

John had struggled with these symptoms for years and had tried every kind of therapy he could find, yet after a single session with my wife, Connirae, he experienced immediate relief from his symptoms after going through a simple process that taught him how to view his worst memory as if he were a distant bystander. A one-trial learning, not a treatment based on some complex neurological insight, transformed his life.

In brief, Connirae asked John to imagine being in a movie theater sitting way back from the screen and then to float out of his body and up to the projection booth, from which he could see both the movie screen and himself sitting in the theater below. From this position, she told him to watch a black-and-white movie of himself that spanned the incident in that marketplace in Pleiku but ended later, giving him a longer perspective. Finally, she instructed him to leave the projection booth, step inside the movie at the end, and run it backward in color very quickly, in about a second and a half. This step reverses the cause-and-effect stimulus–response sequence, so that the feeling responses come before the triggers for them, changing their meaning.

This method is a simple process instruction that can be done without any knowledge of the content of the traumatic event, making it straightforward and respectful of a client’s privacy. The session with John took about 40 minutes, most of which was spent convincing him to try the process, since he’d previously been through hundreds of hours of therapies that had required him to relive the horror fully, but hadn’t changed his response.

In a videotaped follow-up interview about a month after the session, John said that the day after the session, he went to a weekend seminar with his wife. At the end of the first day, she said to him, “What’s happened with you? You’re different. You used to jump when people came up behind you, and you’re not doing that anymore.” Thinking back, he realized that she was right, but he hadn’t noticed it. This response is typical for people who make a thorough and congruent change: the new normal is so unconscious that they often don’t notice the difference unless someone else points it out.

John reported that he was now sleeping well and waking up rested, and that his nightmares were a thing of the past. He added that the first time he’d watched the movie The Boys from Company C, about the Vietnam War, “It was hell for two weeks.” When he watched it again after the session, he didn’t have any problematic responses. Also, he’d become good friends with two Asian people, and had gone to a Japanese restaurant, where he’d ordered the meal in Japanese, a language he hadn’t used in a dozen years. Deeply moved, he said how grateful he was for his renewed ability to connect with Asians as people, rather than as reminders of past horrors.

Putting neurobiological analysis aside, the structure of John’s problem was simple: he’d been through horrible experiences, and when he remembered one, it was as if it were happening to him again in the present. The solution to his problem was just as simple: teaching him how to view the horrible memory at a distance, as if it were happening to someone else in a movie. This technique is often called “being objective.” Seeing himself experiencing horrible feelings out there implies that he doesn’t have to experience them here in his body.

Seeing things objectively is a mental skill that everyone has, but few people realize it, and fewer still can use it selectively to neutralize their responses to unpleasant events. This skill gives people the ability to remember horrible events while leaving behind the terrible feelings, retaining for their own protection whatever needs to be learned from these experiences. This process becomes a life skill that clients can apply to many other difficult experiences beyond the scope of their presenting problems.

John didn’t have to continue to rehearse the process or consciously use this skill with each of his awful memories one at a time. Research in cognitive linguistics shows that we typically put all similar memories into a single category—which can include subcategories and may overlap with other categories—and that we use a prototype experience to represent the entire category. Typically, in the case of repeated trauma, the worst example of it—which is often the first example because of the shock and surprise—will become the prototype for that category. If you change this prototype, all the other examples in the category will change, and this happens instantly.

Of course, we could describe the therapeutic process John went through in neurological terms by calling it memory reconsolidation. He did, in fact, recode his past traumatic memories. But that wouldn’t tell us how to do anything we don’t already know how to do, and it wouldn’t help us get the same results with someone else suffering from PTSD. Even if we assume that most of our current neuroscience information is valid, as the proponents of memory reconsolidation do, it remains to be seen how any part of this knowledge could have improved on the changes that John experienced from a simple visualization process.

Working with grief provides an interesting contrast to working with PTSD. Although grief certainly can be disturbing and traumatic, the internal experience of it is structurally the opposite of PTSD. With PTSD, people reexperience a horrible memory as if it were happening again in the present. With grief, they experience a wonderful memory, but are separated and distanced from it. As a result, they experience feelings of emptiness when they remember the person they loved, instead of feelings of love and connection. With PTSD, the solution is to be more objective; with grief, it’s to be more subjective—by reliving the positive feelings of loving connection in the present moment.

David was still troubled by the death of his only child, who’d died a few minutes after birth. A year earlier, just before the birth, the doctor had told him, “You’re looking at a 99-percent chance of losing the baby, and a 50-percent chance of losing your wife.”

“When I heard that,” David said, “I was absolutely terrified. I was fixing to lose my family, the whole kit and caboodle. I immediately clicked into my logic mode and pretty much just stayed there from then on.” He’d first learned the trick of suppressing emotions in the face of loss when he was 12 and his beloved grandfather died. “The day before he died, we didn’t know anything was wrong. He sat me down and said, ‘One of these days, I’m going to die and you’ll have to become the man of the family.’ When he died, my response was to separate completely from feeling anything.” Since then, David had experienced the deaths of about a dozen people close to him, including his child, and his response had always been the same: “Keep a good lid on it.”

Most therapeutic approaches teach clients to get in touch with their feelings of grief and express them fully, which can result in uncontrollable, hysterical weeping. Although there’s a certain value in this kind of extended emotional outburst, it’s often deeply painful, and even if a client is willing to go through it, the process takes a long time. More importantly, fully expressing feelings of loss seldom resolves the loss.

Resolving grief effectively requires reconnecting a client with the positive feelings of being with a lost loved one. To begin this process with David, Connirae elicited his experience of loss and grief by asking him what he saw when he thought of his child. He became tense as he responded, “I’ve got a picture of the grave, and a little closer to me is a transparent form of the way the baby would look now, if he’d lived. It’s located up and to my right, and it’s sort of like seeing the image through a tunnel. There’s black all around, and no sound.”

When Connirae next asked him to think of someone special he still felt connected to, but who was no longer alive or present in his life, he became more relaxed and animated as he said, “It’s an old college professor; he’s right in front of me—just, you know, life-size, in motion, outdoors, with cars and buildings in the background. I can talk to him and interact with him, and I feel a lot of warmth.” This image elicited a positive response of warmth and the felt presence of his professor, and proved to David that he could experience a person he’d lost as if he were physically present.

In the course of a single session, David learned how to take the image of his baby and see it straight in front of him, give it the same movement and other positive sensory qualities that the image of his professor had. Once he envisioned his baby this way—closer, life-size, and moving—his emotional response transformed spontaneously.

In a recorded interview two days later, David reported what had happened immediately following the session. “I was still processing, and I went off by myself to eat lunch at a restaurant. At the next table over, there was a family with a little baby. And I’m sitting there, and I’m looking over at it, and it dawned on me: I’m playing with this child! I’m playing the look-away game. And I got all excited.”

Six weeks later, David said that he’d continued to feel comfortable interacting with young children. His sense was that the process had an across-the-board impact on his life, and his wife had noticed that he seemed calmer and more settled. He felt he could loosen up and have fun, whereas before the session, he’d been chronically serious and somber. About six months later, he reported that his wife was pregnant and they were both eagerly looking forward to the birth.

As with John, the change David made is easily understood without any reference to the underlying neurological changes, and I don’t see how any application of current neuroscience could have improved the process or its outcome. Until neuroscience can tell us specifically what we should be doing differently in therapy, it’s about as relevant to our work as particle physics or the migration of butterflies.

If you’re really listening to your clients, you’ll realize that they’re often being quite specific about what their problem is and what kind of solution would be useful. If a client speaking about his wife’s infidelity says, “It’s in my face, and I’d really like to put it behind me,” that isn’t just a metaphor: he’s telling you that the image of his wife enjoying sex with someone else is right in front of him, where he can’t possibly ignore it, and that if the same image were literally moved far behind him, where it would be less obtrusive, he’d pay less attention to it and respond less intensely.

Similarly, if a client discussing her memory of abuse says, “I feel frozen in that moment, and I need to get some distance from it,” she needs to allow her still image of the event to become a movie, so that it can change as time passes and then recede into the distance, becoming smaller, dimmer, and less disturbing. This approach isn’t rocket science, nor is it neuroscience. Instead, it’s a simple matter of finding out exactly what the structure of someone’s personal experience of a problem is—rather than the content within that structure—and then experimenting with useful ways to change it.