How Much Do Psychotherapists Need to Know About the Brain?

Nature/Nurture, Mind/Brain--It's time to bridge the gaps.

Posted Sep 06, 2014

A small person views a large yellow knot

Can Nature/Nurture or Mind/Brain Be Disentangled?

I had just finished speaking to a small group of therapists on the topic, “How are emotions communicated, and what does the brain have to do with it?”

After fielding a few easy questions, one of the therapists in attendance tossed me a hard one.

“What difference does it make to know about the brain?” he asked. “As a psychotherapist, isn’t a psychological theory as good as a biological one?” His questions were respectful but also challenging.

I fumbled, not quite knowing how to respond. The answer to his questions seemed entirely self-evident, but never before had I been asked to put my underlying assumptions about this into words. 

“How could the brain not be a vital concern for therapists?” I thought to myself.

“Communication of emotion is central to how interpersonal relationships work, including how psychotherapy works.” 

My talk had been about the brain basis of communication, including gesture, facial expression, and language. I had explained how language is comprised of words, grammar, and “music.” The “music” aspect of language is called prosody; it includes nuances of tone, pitch, and cadence that convey subtleties of meaning and emotion.

I had described how modern understanding of the brain traces back to Paul Broca’s discovery that production of words and grammar is centered in a particular brain region, usually in the left hemisphere. Scientists who came after Broca continued to map the hubs and networks of nerve cells in the brain. Production of prosody, for example, is centered on the right, in a mirror-image area to Broca’s. 

Now we have an outline of the brain-basis of a myriad of human behaviors--gesture, facial recognition, social interaction, motivation, attention, and more.

Just as the heart is the organ-basis of cardiology, and the eyes are the focus for ophthalmologists, it follows that the brain is the organ-basis of neurology, psychiatry, and other fields that concern themselves with human behavior. 

Over the years I have thought about how I might have answered that therapist’s important questions. I wish I had said that it helps for psychotherapists to be aware that the words and the music of language are intertwined but neurologically separate functions. Words are easier to consciously manipulate and less emotionally nuanced than prosody. We read prosody as more authentic. 

The words in the therapist’s question had been straightforward and easy to understand. What I read from his prosody was far more complicated. He was aware that he was challenging the basic assumptions of my talk. He knew the stakes were high--for all of the psychotherapies.

Are psychological theories as good as biological ones? I wish I had pointed out that this question contains the assumption that the psychological and the biological are separate. Yet, researchers have elucidated how experiences of every kind--emotional trauma as well as practicing piano, learning the streets of London or being in psychotherapy-- mark our lives by changing the brain and biology. It isn’t either/or. As psychotherapists, we need to bridge the gap between how we think of psychological and how we think of biological. As Michael Tomasello said in The Cultural Origins of Human Cognition, “There is thus no question of opposing nature versus nurture; nurture is just one of the many forms that nature may take.” 

Perhaps the most important reason for psychotherapists to understand the brain-basis of behavior is in order to enhance diagnostic thinking. For example, some people are not adept at reading the subtle messages conveyed through prosody; this leads to problems with social interaction and no obvious cause. Knowing about the brain opens realms of possibility beyond the usual DSM mental disorders categories.

As I was packing up to leave the lecture hall, the therapist who had asked these important questions wondered if I might offer my opinion about a patient he had seen on and off over many years. The therapist described a patient with brief but recurring episodes that involved unusual body sensations and other symptoms that I thought could be caused by focal seizures. The therapist told me he considered these episodes to be “somatic delusions” because they seemed so outside the range of normal experience. He knew the patient was not psychotic. Psychological interpretations had led to no change in the frequency or the nature of these states.

Someone had suggested to the therapist that these episodes might be seizures. What did I think? Yes, this was certainly a possibility and should be investigated neurologically. Sensations of the sort he described might be traced to particular areas in the brain. Moreover, if it was documented that the patient had focal seizures, she could be treated with anticonvulsant medications.

As I was leaving, I thought about how interesting this had been. The big questions can only be answered for oneself. And here indeed, I do believe the questioner had answered his own questions.

Author of:

Unmasking Psychological Symptoms: How Therapists Can Learn to Recognize the Psychological Presentation of Medical Disorders

Masquerading Symptoms: Uncovering Physical Illnesses That Present as Psychological Problems 

About the Author

Barbara Schildkrout

Barbara Schildkrout, M.D., an Assistant Clinical Professor of Psychiatry at Harvard Medical School, is the author of Masquerading Symptoms.

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