My last two posts looked at what bottom-up research on the brain’s response to simple threats can tell us about clinical work with anxious patients. This week I’ll shift viewpoints to consider an ambitious attempt by the psychiatrist Marc Galanter to use social and cognitive neuroscience to explain the healing that takes place in Alcoholics Anonymous. While necessarily incomplete, his model provides a picture of the recovery process that should be useful to clinicians.
I spent many formative years of my career at a private psychiatric hospital working with a talented group of psychiatrists and other professionals well above the average in training, skills, and commitment to helping patients. At one of my first case conferences there, the staff pressed an alcoholic school principal to explain why she drank. The emotional tone was one of shock and disapproval that someone of our social class could degenerate and harm her mind, body, family, and career. My colleagues recommended in-depth...
Fyodor Dostoyevsky’s Crime and Punishment, published in 1866, contains a wonderful passage about psychiatric treatment:
“There have already been some serious experiments relating to the possibility of treating the insane by means of the simple influence of logical reasoning. . . A certain professor. . .believed that insanity is, as it were, a logical error, an error of judgement, a mistaken view of things. He would refute the arguments of his patient step by step and, would you believe it, it’s said he achieved results that way!”
I’ve tried this method—persuading an anxious patient that his worries don’t make logical sense—and I’m sorry to say it doesn’t work. The patient usually feels better during the session and for a short time afterwards, but at his next visit he’s just as anxious, and he reports he’s continued to worry and avoid whatever he’s afraid of. Patients with enough confidence to speak up soon tell me their treatment isn’t helping.
Last week’s post about positive and negative emotions led me to ask what emotions are and how they arise in the brain. The neuroscientiest Joseph LeDoux’s excellent book, Anxious: Using the Brain to Understand and Treat Fear and Anxiety (2015) lays out what we know about anxiety. Two of his points challenged concepts I have relied on for years: the idea of unconscious anxiety, and that it is the brain’s basic response to perceived threats.
LeDoux insists on defining anxiety as a feeling that occurs in consciousness. This is not semantic hair-splitting—it starts from his rigorous insistence on specifying how we know what we know. Limiting the concept of anxiety to what can be put into words turns out to be useful, for it leads to an exploration of the nonconscious brain events which contribute to the feeling of anxiety but are clearly not themselves anxiety. (I will use LeDoux’s “nonconscious” rather than the psychoanalytic term “unconscious” when discussing brain mechanisms.)
The psychoanalyst and research psychiatrist George Vaillant has taught me a great deal over the years—first in person, when at the end of my psychiatric training he helped orient me in the field of addiction, and since then in wise books like The Natural History of Alcoholism and Adaptation to Life, in which he used long-term follow-up data to show how life unfolds in illness and in health. I recently picked up his 2008 book, Spiritual Evolution, hoping to understand the apparent contradictions in my own spirituality. I’m intellectually convinced that our miraculous consciousness evolved biologically, exists in our brains, and ends with death, which makes me an atheist. Nevertheless, I feel awe when I experience the splendor of nature, a great cathedral, or work of music, or the hymns, scriptures and prayers of my childhood.
Vaillant addresses awe, but most of the book is an explication of the neurobiology, cultural anthropology, and psychology of six positive emotions—faith, hope, lov...