Psychiatry's Peculiar Attitude Toward Emotions

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, love, joy, forgiveness, and compassion—which contribute to spirituality. He draws on the neuroscience of these emotions to argue for a spirituality committed to caring relationships and positive attitudes toward society and the universe.

Another thread in the book is psychiatry’s lack of attention to positive emotions. A century ago Sigmund Freud, along with Emil Kraepelin and others, turned psychiatrists’ and psychologists’ attention toward the emotions. Since then, disorders of mood and anxiety have been at the center of psychiatric research and treatment. But even though the positive emotions Vaillant writes about are a large part of our experience and central to the mammalian brain’s operation, psychiatry has paid them little attention. He notes that the 2004 edition of the Comprehensive Textbook of Psychiatry, the major text in the field, gave vast attention to anxiety and depression, much to shame, guilt, anger, and hate, a little to hope and joy, and none to faith, compassion, forgiveness, or love.

We have known for some time that emotions of all colors are central in human experience. Charles Darwin’s The Expression of Emotions in Man and Animals, published in 1872, investigated rage, terror, excitement, astonishment, grief, contempt, joy, disgust, and affection. Twelve years later, William James proposed that emotions—positive and negative—are the mind’s perception of bodily states elicited by perceptions. Not much happened in emotion science for another century, when modern neuroimaging started to map neural circuits and to explore the role of emotions in consciousness, thought, and decision-making.

Psychiatry, however, has been sidetracked on a model of diagnosing and trying to fix negative emotional states. While medications to increase levels of serotonin or norepinephrine and targeted psychotherapies such as cognitive-behavioral therapy (CBT) help many people, as instruments of healing, they are crude and unpredictable. To better treat our patients, we need to understand emotions like anxiety and depression on a much deeper level. Since the brain is highly interconnected, this means understanding all emotions, not just pathological ones.

The medical approach of diagnosing and treating disordered emotional conditions makes sense on one level, for psychiatrists are trained as physicians, and disorders of anxiety and mood are the bread and butter of psychiatric treatment. But as I wrote in my post about conceptual models, the beauty and difficulty of psychiatry is that our patients’ problems occur at multiple levels in the individual, relationships, and society. Psychiatrists who limit themselves to diagnosing and prescribing miss a great deal.

The psychoanalytic movement dominated American psychiatry for half a century, and its overreliance on theories was another constraint on emotion science. Freud read and valued Darwin’s work, but his attitude toward human nature was gloomy, and he saw anxiety as the emotional basis of neurosis.

Psychiatry and psychology have also been limited by our culture’s view of feelings as second-class compared to thought. CBT is popular these days, particularly among those, like some psychopharmacologists, who lack experience with the challenges of practicing CBT at a high level. Its appeal comes not only from its strong research base, but also because its assumption that negative thoughts are the cause of pathological emotionals prioritizes thoughts over feelings. Thinking has an aura of left-brain, masculine logic, while emotions are seen as soft, feminine, and difficult to quantify and research. Emotions, though essential for survival and interpersonal functioning, are associated with weakness and vulnerability.

Recent decades have seen the growth of the positive psychology movement, and “positive psychotherapy” is popular in some countries. My initial reaction was that it was an exhortative approach like to Norman Vincent Peale’s The Power of Positive Thinking or Johnny Mercer singing “Accentuate the Positive.” (Years ago this was also my first reaction to CBT.) While positive psychology has a pop-psychology “feel good” quality, Tayyab Rashid and others have described sophisticated techniques of therapy, with empathic responses to negative experiences in an approach whose overall direction is toward strengthening a patient’s capacities for positive emotions and functioning. Attending to both positive and negative emotions and experiences would seem most consistent with what science is showing us about the brain.

Last year Dilip Jeste, a recent past president of the American Psychiatric Association, and his colleagues published both an article and a book about “positive psychiatry.” They discuss positive mental health outcomes, psychosocial characteristics, genetics, biomarkers, neuro-circuitry, medical outcomes, and clinical applications. Most of the practical points are familiar recommendations for healthy lifestyles. Nevertheless, Jeste and colleagues have pulled together data from many sources to argue for a reorientation of psychiatry toward positive aspects of patients’ functioning. Such a reorientation would take place on many fronts, from basic science to epidemiological studies, clinical trials, practice guidelines, prevention, and education.

I believe the most important questions revolve around how both positive and negative emotions operate in the brain and body and express themselves in conscious experiences, relationships, and society. Understanding at this basic level will give us concepts powerful enough to generate useful hypotheses and convincing enough to change clinical practice. We are fortunate to be around for these exciting changes.

Further reading: George E. Vaillant, Spiritual Evolution: A Scientific Defense of Faith.

Dilip V. Jeste, Barton W. Palmer, David C. Rettew, and Samantha Boardman. Positive Psychiatry: Its Time Has Come. J. Clin. Psychiatry 2015; 76(6):675-683.

Tayyab Rashid. Positive Psychotherapy (PDF)

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