Acad Psychiatry DOI 10.1007/s40596-014-0062-6

IN DEPTH ARTICLE: COMMENTARY

Neuroscience in the Residency Curriculum: The Psychoanalytic Psychotherapy Perspective Brendon O. Watson & Robert Michels

Received: 31 May 2013 / Accepted: 16 December 2013 # Academic Psychiatry 2014

Abstract Educators of future psychiatrists tend to teach an array of approaches to the mind and brain, including among them the neurobiologic perspective and the psychoanalytic perspective. These may be considered at opposite ends of many spectra, including the fact that psychoanalysis takes a large-scale and treatment-oriented perspective and has helped countless patients over the years, while neuroscience has tended to be reductionistic, focused on understanding, and has helped very few people. A tension, therefore, exists for the educator in teaching neuroscience: is it wise to spend valuable time and energy teaching this interesting but, thus far, impractical field to future practitioners? Here, we argue that neuroscience is re-orienting itself towards more psychoanalytically relevant questions and is likely, in future years, to give new insights into the nature of basic drives and social relations. We additionally argue for balance on the part of providers in both acknowledging biologic underpinnings for clinical phenomena and yet continuing to take a stance oriented towards appropriate change. Given the burgeoning new focus within neuroscience on topics directly relating to the human internal experience and the novel challenges in both understanding those advances and appropriately using them, we encourage educators to continue to give future psychiatrists the educational foundation they need to follow neuroscientific discoveries into the future. Keywords Psychoanalysis . Residents: Neurosciences . Residents: Psychotherapy Psychiatric educators commonly believe that a psychiatry resident in the second decade of the 21st century should be educated about neurobiology. The notion underlying this B. O. Watson (*) : R. Michels Weill Cornell Medical College, New York, NY, USA e-mail: [email protected]

stance is that the brain and the nervous system are the fundamental biological substrate of mental life and behavior, of psychopathology, of changes that occur in development, and of changes that occur in response to therapeutic interventions. It is anticipated that neuroscience knowledge will be clinically relevant before the end of the resident’s career, and that someone entering the field is interested in the future as well as in the essentials of contemporary practice. Of course, residents should also learn about theories of mental illness and of the treatments used in contemporary psychiatry—physical, pharmacological, psychologic, and social. Psychotherapies are among the most prevalent treatments used in contemporary psychiatry, and residents should learn about these. At the convergence of these two curricula, there is a belief that there will be a synergy in which neuroscience may eventually inform psychiatry in general, as well as psychotherapy in particular. From an educational standpoint, it is sensible to teach on the basis of these ideas. However, the fact is that to this point neuroscience has contributed little, if at all, to psychotherapeutic interventions or to psychodynamic thinking. Neuroscience has provided some contributions to our understanding of gross brain disorders, psychopharmacology, and some other biological treatments, but even there, an argument might be made that the clinical world has informed itself with little assistance from pure neuroscience. (One notable exception is the science-directed deep brain stimulation for refractory depression [5].) There is tension between the notion that neuroscience will benefit the clinical psychiatrist of the future and the fact that so far neuroscience has done very little to inform contemporary clinical care. Psychoanalysis seems, at least as distant, if not more distant, from neuroscience as any other part of psychiatry. We will examine current states of psychoanalytic thinking and of neuroscience to better answer whether and how these two fields may eventually meet.

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To gain a better sense of the potential impact of neuroscience on psychoanalysis, it is worth summarizing the current state of psychoanalytic thought, which is not as brain-oriented in its theory as it was when Freud, a trained neurologist, created it. Psychoanalysis began with a brain and nervous systemcentered model of behaviors, pathology, and treatment. Concepts of basic drives, psychic energy, and mental structures were borrowed from the then-contemporary speculation about the brain. Today, most psychoanalytic theories have moved away from the speculation about what is going on in the patient’s mind, or brain, and towards a focus on what is going on in the consultation room—relationship, alliance, transference, resistance, countertransference, interpretation, and so on. It has evolved from being largely based on a one-person or one-mind psychology to placing much greater emphasis on the clinical transaction, a two-person psychology. Certainly, psychoanalytic theory has also placed emphasis on childhood and psychological development, on the assumption that early experiences influence the development of the mind, and it remains interested in basic motivational systems—first sex, then aggression, and, more recently, attachment. An argument may be made that there is little left to learn. Current psychoanalytic concepts encompass what psychoanalysts have been able to understand over more than 100 years of close observation of their patients. Humans are astute observers of other humans and may have learned most of what there is to know about each other’s behavior at the level of abstraction relevant for psychotherapy. We understand the importance of interpersonal interactions, much about those interactions, and how to intervene. We are one of the most social species of mammals, and our highly developed brain has evolved to let us hone in on other people [8]. There is a temptation to think that a scanner, electrode, or microscope is unlikely to pick up much about human nature that a task-evolved brain cannot. From this perspective, it is difficult a priori to imagine what neuroscience can add to psychodynamic thinking. However, we believe that traditional neuroscience, thus far, has not so much failed as not seriously tried. Many of the most powerful and more recently developed neuroscientific tools have been aimed at other directions—towards visual processing, motor control, learning and memory systems, and the molecular aspects of synaptic communication. There have been a handful of psychotherapeutically relevant studies including those oriented towards animal behavior and the neuroscientific understanding of the N-methyl- D -aspartate (NMDA) receptor in memory formation that have led to the application of the NMDA receptor agonist D-cycloserine to aid in extinction memory formation in patients with posttraumatic stress disorder [9]. But it was not until recently that the most powerful tools neuroscience has to offer have been sufficiently established that they can be aimed at the more poorly definable problems

of high-order cognitive and emotional processing. Further, there has been a recent re-awakening of interest in the neuroscience of social interactions, empathy, fear, and positive affect states as demonstrated by recent publications and poster abstracts [7]. In particular, neuroscientists have found fascinating models of empathic fear [3] and pro-social behavior [1] in rats, and efforts are underway to assess the neural macroand microcircuitry underlying these. Additionally, aggression circuits in the hypothalamus which had not been studied in-depth for decades are now under finer analysis, and new discoveries are being made about aggression control in the forebrain [4]. Communication between distressed or mutually-interested rodents has been found to be mediated by ultrasonic vocalizations [6], and the neural response to these vocalizations has been explored by a number of groups. Some aspects of the neuroscience of sharing and valuation of positive rewards for others are beginning to emerge [2]. Studies focusing on affiliative drives and social place [11], as well as on dominance hierarchies [10], are becoming more common, accepted, and even popular in the neuroscientific literature. Such studies may imply ideas about basic drives that exist in animals as well as in humans. The assumption is that innate drives in rats may also be innate in humans. The findings that rats and mice appear to show altruism/empathy, that they show less agitated behavior when other individuals are present, that they are more agitated when they are singled out as the least fortunate, and that they closely track place in hierarchy imply that such behaviors in humans are basic drives, and yet many of them are not currently recognized as such by the psychoanalytic community. We would argue that simple behavioral observations of rats may not convince many but that neuroscience promises to contribute more through mechanistic studies. We are therefore hopeful that the world of psychoanalytic psychotherapy may have something to learn from neuroscience in the future. This is based on the notion that neuroscience as a field may be refocusing towards domains more related to subjective human life: social interactions, cognitions, and affects. For decades, neuroscience focused on very highly tractable questions with easily quantifiable inputs or outputs such as primary motor or sensory systems. But now it seems to have established a foundation that allows it to be open to less well-defined but perhaps more crucial questions which may actually inform the thinking of clinicians about their patients. There are cautions in casually transferring knowledge across the mind–brain barrier. Patients may present with complaints of a “chemical imbalance in the brain,” and therapists may wonder about “cortical–amygdalar balance,” but in psychotherapy the primary issue is not objective reality but rather the patient’s subjective experience of that reality—its meaning and the psychologic function that that meaning serves. We have long recognized that this is the case when patients speak of abusive parents or unempathic spouses. It is also true when they provide quasi-neurobiologic explanations for their

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problems. The psychotherapist’s question is not whether the explanation is valid but, rather, why the patient has selected it and what meaning it has for him or her. Like the theories of early trauma or deficiency in interpersonal empathy, neurobiologic formulations are frequently employed to defend against anxiety and guilt or to disavow agency—“it is not me; it is my brain or my genes or my neurotransmitters that did it.” It may be particularly difficult for the therapist who finds the neurobiologic explanation plausible to deal with this, just as it can be difficult for the therapist who shares the patient’s belief that trauma or victimization is the cause of the problem to explore how the patient uses these beliefs. Where does this leave a psychiatric educator? First, we remain enthusiastic that both psychoanalysis and neuroscience will remain relevant for the foreseeable future and that both deserve the time and attention of students of psychiatry. Moreover, we believe that neuroscience has begun to tack in a direction that makes it more likely to become relevant to the life of general psychiatrists and even psychoanalysts of the future. Thus, it is reasonable for a psychiatric educator to keep an eye on developments in neuroscience that may be able to inform our understanding of patients as people. Implications for Educators & Neuroscience holds promise for future contribution to psychiatry, yet it has yet to make sizable contributions to the fields of psychoanalytic thinking and even general psychiatry; it is therefore difficult for psychiatric educators to determine whether and to what extent to teach neuroscience. & Many researchers in the field of neuroscience are redirecting their efforts towards topics related to interpersonal and basic motivational questions that are more directly related to psychoanalytic questions. & We therefore recommend that educators should provide basic neuroscience education to psychiatrists in training, bearing in mind and looking out for the new movements in neuroscience towards answering novel classes of questions relevant to psychiatrists and psychoanalysts.

Disclosure Brendon Watson has been awarded the American Psychiatric Association–Eli Lilly research fellowship for 2013–14, which supports his salary for the 2013–14 academic year.

References 1. Ben-Ami Bartal I, Decety J, Mason P. Empathy and pro-social behavior in rats. Science (New York NY). 2011;334(6061):1427– 30. doi:10.1126/science.1210789. 2. Chang SWC, Gariépy J-F, Platt ML. Neuronal reference frames for social decisions in primate frontal cortex. Nat Neurosci. 2013;16(2): 243–50. doi:10.1038/nn.3287. 3. Jeon D, Kim S, Chetana M, Jo D, Ruley HE, Lin S-Y, … Shin H-S. Observational fear learning involves affective pain system and Cav1.2 Ca2+ channels in ACC. Nat Neurosci. 2010;13(4):482–8. doi:10.1038/nn.2504 4. Lin D, Boyle MP, Dollar P, Lee H, Lein ES, Perona P, et al. Functional identification of an aggression locus in the mouse hypothalamus. Nature. 2011;470(7333):221–6. doi:10.1038/ nature09736. 5. Lozano AM, Mayberg HS, Giacobbe P, Hamani C, Craddock RC, Kennedy SH. Subcallosal cingulate gyrus deep brain stimulation for treatment-resistant depression. Biol Psychiatry. 2008;64(6):461–7. Retrieved from http://www.sciencedirect.com/science/article/pii/ S0006322308007038. 6. Panksepp JB, Lahvis GP. Rodent empathy and affective neuroscience. Neurosci Biobehav Rev. 2011;35(9):1864–75. doi:10.1016/j. neubiorev.2011.05.013. 7. Pubmed.gov. (2013) Search trend results. Retrieved November 01, 2013, from http://www.ncbi.nlm.nih.gov/pubmed?term= (((socialinteraction)ORempathy)ORfear)ORpositiveaffectstates 8. Reader SM, Laland KN. Social intelligence, innovation, and enhanced brain size in primates. Proc Natl Acad Sci U S A. 2002;99(7):4436–41. doi:10.1073/pnas.062041299. 9. Rodebaugh TL, Lenze EJ. Lessons learned from D-cycloserine: the promise and limits of drug facilitation of exposure therapy. J Clin Psychiatry. 2013;74(4):415–6. doi:10.4088/JCP.13ac08464. 10. Wang F, Zhu J, Zhu H, Zhang Q, Lin Z, Hu H. Bidirectional control of social hierarchy by synaptic efficacy in medial prefrontal cortex. Science (New York NY). 2011;334(6056):693–7. doi:10.1126/ science.1209951. 11. Watanabe S. Empathy and reversed empathy of stress in mice. PloS one. 2011;6(8):e23357. doi:10.1371/journal.pone.0023357.

Neuroscience in the residency curriculum: the psychoanalytic psychotherapy perspective.

Educators of future psychiatrists tend to teach an array of approaches to the mind and brain, including among them the neurobiologic perspective and t...
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