What has neuroscience done for psychotherapy?

A letter in response to Jon Roiser's cover article for April's issue.

I want to thank Jon Roiser for demonstrating the promise that neuroscience holds for mental health practice (‘What has neuroscience ever done for us?’, April 2015). However, I feel that more could be said about what neuroscience offers psychotherapy given the large proportion of readership either personally or professionally involved in this.

Jon argued that in order to enhance the treatment of mental health problems, we need to understand the neural basis of symptoms. He referred to the neural circuits underlying symptoms as proximal mechanisms because they directly cause symptoms. At the other end of the spectrum, distal mechanisms, such as personality and upbringing, indirectly shape symptoms. This view is undoubtedly useful as it integrates neurobiological and psychosocial frameworks. However, by specifying the neural circuits underpinning symptoms, we remain at a descriptive level, which may not further psychotherapies.

What difference does it make knowing that fixated thinking and stereotyped actions are represented by cortico-basal ganglia circuits in obsessive-compulsive disorders? The target of exposure interventions remains the same. We thus need to go beyond the ‘How’ and ask ‘Why?’ Imagine a car breaking down due to over-revving. We could change the damaged parts of the engine (neural circuits) but we would neglect the underlying cause: the driver’s over-revving habit (underlying emotional conflict).

So should mental health professionals still care about neuroscience? I argue that we can advance psychotherapy by understanding how the brain internalises distal mechanisms, particularly negative psychosocial experiences. Assuming that the consequent emotional conflicts underlie symptoms that are adaptations to these conflicts, can we reshape or even erase conflicts to ease a client’s suffering? Bruce Ecker and colleagues claim to have achieved this by applying the principles of reconsolidation to psychotherapy.

Reconsolidation describes how consolidated, or stable, memories can be modified during their reactivation (Tronson & Taylor, 2007). By identifying and experiencing the implicit memory or conflict-driving symptoms and concurrently experiencing something that sharply contradicts the memory’s expectations, we can overwrite the conflicting memory with an adaptive one (Ecker et al., 2012). Repeating this procedure is argued to deliver profound cessation of symptoms. Despite several laboratory studies in humans demonstrating the erasure of fear learning, clinical trials are needed to assess the validity and utility of this approach.

Of course, both the neural mechanisms that relate to symptoms and those that drive them need therapeutic intervention: residual proximal mechanisms may ignite newly developed conflicts. However, there is no reason why distal mechanisms are not represented by neural circuits, given that ‘the brain is the interface at which genetic and environmental influences interact’.

Matthew Constantinou
University College London

References
Ecker, B., Ticic, R. & Hulley, L. (2012). Unlocking the emotional brain. New York: Routledge.
Tronson, N.C. & Taylor, J.R. (2007). Molecular mechanisms of memory reconsolidation. Nature Reviews Neuroscience, 8, 262–275.

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