I am fortunate to have a challenging job that requires flexibility and creativity, but it’s often difficult and sometimes downright exhausting. One time I complained about this effortful experience to our former chief of staff, Richard Munich, and he responded, “That’s why they call it work!” I find Dick’s matter-of-fact attitude toward the difficulty of work to be consoling, and I repeat his words to myself when I struggle to marshal the required effort.

Living requires brain power, and challenging work pushes brain power to the limit. Of all our body organs, the brain uses the most energy. Compared to other animals, the human prefrontal cortex occupies a disproportionate amount of brain territory. This brain region plays a key role in challenging work, and its activity consumes a lot of energy.

Demanding work

I was dumbstruck when I came across a list of specific challenges that tax our prefrontal cortex; I thought immediately, “That’s work!” Here’s the list that grabbed my attention, compiled by Paul Burgess and colleagues at University College London:

1. A number of discrete and different tasks have to be completed.
2. Performance on these tasks needs to be dovetailed in order to be time-effective.
3. Due to either cognitive or physical constraints, only one task can be performed at any one time.
4. The times for return to task are not signaled directly by the situation.
5. There is no moment-by-moment performance feedback … failures are not signaled at the time they occur.
6. Unforeseen interruptions, sometimes of high priority, will occasionally occur, and things will not always go as planned.
7. Tasks usually differ in terms of priority, difficulty and the length of time they will occupy.
8. People decide for themselves what constitutes adequate performance.

Broadly speaking, these challenges call for multitasking. These prefrontal capacities are called “executive” functions, and the list I just quoted would be as familiar to “executives” at work as it was to me. We are all executives. In our increasingly multitasking world, this list is typical of the demands of many persons’ daily lives, going far beyond professional work. Review the list while holding in mind the demands of raising children and running a household.

The prefrontal cortex and mentalizing

Consider also challenging interpersonal situations with this list in mind. A common example is working on a complicated project while trying to forge collaboration among several group members — or family members. Yet much of the list also pertains to difficult negotiations in a relationship, for example, parents coordinating the demands of work, childcare and household responsibilities. As you may have noticed, relating to people can be hard work. Mentalizing — attending to mental states in others and yourself — is part of this interpersonal work. Consistent with the complexity of interpersonal problem solving — and managing our own desires, thoughts, and feelings — the prefrontal cortex plays a key role in mentalizing.

Unfortunately, common psychiatric disorders impair the functioning of the prefrontal cortex, thereby compromising the capacity to engage in complex problem solving — intellectual and interpersonal — that our contemporary multitasking world demands. Thus it is not surprising that psychiatric disorders can be associated with significant disability in occupational and social functioning.

Some appreciation of their neurobiological basis helps us take psychiatric disorders seriously as physical illnesses, which can help combat stigma. Fortunately, treatment of psychiatric disorders — not only with medication but also psychotherapy — normalizes brain function, enabling patients to resume the challenging work of everyday living.

Editor’s note: If you enjoyed Dr. Allen’s post, please check out some of his other recent posts:

• POT: What’s new in plain old therapy?
• Was the Sandy Hook mass shooting “evil?”
• Can’t AND won’t

Reference                 

Burgess, P.W., Gonen-Yaacovi, G., & Volle, E. (2012). Rostral prefrontal cortex: What neuroimaging can learn from human neuropsychology. In B. Levine & F.I.M. Craik (Eds.), Mind and the frontal lobes: Cognition, behavior, and brain imaging, pp. 47-92. New York: Oxford University Press. (The list of challenges is quoted from page 81.)

More than two years ago, I wrote a post on this blog entitled, “Is psychotherapy going to POT?” Tongue in cheek, I was protesting the proliferation of brand-name, evidence-based therapies with all their acronyms: CBT, DBT, ERP, EMDR and the like. There’s no way any therapist can learn to practice 150+ brands, and a half-century of research attests to the difficulty of demonstrating that any one brand is generally superior to any other. Accordingly, I declared myself a practitioner of plain old therapy — relatively unstructured “talk therapy” without any special technical procedures. And I liked the acronym.

This post led to an interchange on the blog with my colleague, Tom Ellis, an expert therapist and research-minded psychologist who expressed some reservations. In his post, “Make my psychotherapy plain, but with a twist,” he took issue with the implication that there is nothing new happening in the field of therapy and pointed out the benefits of recently developed specialized procedures and treatments for certain disorders, such as panic and obsessive-compulsive disorder.

POT vs. BEER?

In conversation, Tom expressed concern that I might be communicating to therapists that whatever they’ve been doing all along is perfectly fine and they don’t need to learn anything new. I responded with another post, “Can we grow more potent POT?” In so doing, I acknowledged the need to continue refining psychotherapy on the basis of new knowledge, which I had aspired to do in homing in on mentalizing in the context of attachment relationships as a common therapeutic factor that cuts across different brand-name therapies. “Mentalizing” refers to being aware of mental states such as desires, feelings and thoughts in oneself and others, and “attachment” refers to relationships with strong emotional bonds, such as parent-child relationships, romantic partnerships and patient-therapist relationships. Tom responded with a second rejoinder, “Psychotherapy: Bring on the POT, but don’t forget the BEER,” a new acronym for “But Empirical Evidence Required.” In other words, Show me the data!

Therapists like POT

There was a playful quality to this blog-post interchange, but Tom and I are equally serious about current debates in psychotherapy, often pitting two broad camps against one another, that is, the clinicians versus the researchers. Tom and I share allegiance with both camps. After this initial foray in the blogosphere, I started to take the idea of plain old therapy more seriously, and for the past two years I’ve been talking about it in presentations and workshops locally, nationally and internationally. As intended, “POT” elicits amusement, but I’ve been surprised at therapists’ sheer enthusiasm for it. I went public in print, responding to an invitation to write for the “From the Expert” column in Psychiatric News with an editorial, “Reviving Plain Old Therapy.”¹ Ultimately, I took it so seriously that I wrote a book about it, entitled Restoring Mentalizing in Attachment Relationships: Treating Trauma with Plain Old Therapy.²

Why POT?

I have a few ideas about the basis of therapists’ enthusiasm:

1. Like me, many therapists are put off by the implication that they should learn a whole bunch of different therapies.
2. Many of the brand-name therapies were developed to treat specific psychiatric disorders and, like me, many therapists are generalists who work with patients with diverse problems, many of whom struggle with multiple disorders at the same time. We generalist therapists are the counterparts to general practitioners in medicine. Such physicians, too, must refer patients to specialists when indicated.
3. My emphasis on plain old therapy is consistent with the well-demonstrated contribution of the therapeutic relationship to the treatment outcome³ as well as a current humanistic counter-reaction to increasingly technological approaches to psychiatry, now abetted by enthrallment with neuroscience.⁴
4. I use the “old” in plain old therapy with some irony, because I find a substantial evidence base supporting the effectiveness of plain old therapy in contemporary attachment theory and research, including the recent work in mentalizing.⁵ When I discuss this work on attachment with patients and clinicians, many find it intriguing and eye-opening. Hence I was pleased when my colleague, psychiatrist Robert Fischer, who is executive director of the Optimum Performance Institute commented in an article that plain old therapy “actually is the most novel approach I have heard in the past 15 years!”⁶

Notwithstanding my confidence in the value of reviving plain old therapy, we therapists have no reason to be complacent about our work. The fact that a half-century of horseraces comparing different brand-name therapies has failed to reveal champions and that their commonalities are therapeutically significant does not mean that all are equivalent for a given individual.⁷

In the face of disagreement among proponents of different approaches as well as between clinicians and researchers, there is considerable consensus on one point: We are far from understanding the specific psychological and interpersonal processes that render psychotherapy effective.^{8, 9} I think mentalizing in the context of attachment relationships points us in the right direction, and new research supports this path.¹⁰ Indeed, we always desire more empirical evidence but, meanwhile, I think plain old therapists stand on solid ground.

Editor’s note: If you enjoyed this post from Dr. Allen, please check out some of his other recent posts:

• Was the Sandy Hook mass shooting evil?
• Can’t AND won’t
• Can’t OR won’t?

References 

1.       Allen JG. Reviving plain old therapy. Psychiatric News. 2012;47(10):3.

2.       Allen JG. Restoring mentalizing in attachment relationships: Treating trauma with plain old therapy. Washington, DC: American Psychiatric Publishing; 2013.

3.       Norcross JC, ed Psychotherapy relationships that work: Evidence-based responsiveness. Second ed. New York: Oxford University Press; 2011.

4.       Bracken P, Thomas P, Timimi S, et al. Psychiatry beyond the current paradigm. British Journal of Psychiatry. 2012;201:430-434

5.       Allen JG. Mentalizing in the development and treatment of attachment trauma. London: Karnac; 2013.

6.       Fischer R. Reflections on “Reviving plain old therapy”—A recent article featured in psychiatric news. Optimal Performance Institute. 2012;June 7.

7.       Budd R, Hughes I. The Dodo bird verdict—controversial, inevitable and important: A commentary on 30 years of meta-analyses. Clinical Psychology and Psychotherapy. 2009;16:510-522.

8.       Kazdin AE. Mediators and mechanisms of change in psychotherapy research. Annual Review of Clinical Psychology. 2007;3:1-27.

9.       Mansell W. Core processes of psychopathology and recovery: “Does the Dodo bird effect have wings?” Clinical Psychology Review. 2011;31:189-192.

10.     Rossouw TI, Fonagy P. Mentalization-Based Treatment for self-harm in adolescents: A randomized controlled trial. Journal of the American Academy of Child and Adolescent Psychiatry. 2012;51:1304-1313.

We naturally strive to understand actions that are out of the ordinary—we can’t help it. If we see a woman suddenly slap a man in a restaurant, we will speculate about her state of mind, her reasons and their relationship. Perhaps he said something rude and she felt insulted. Perhaps tension had been building in the relationship over the course of weeks or months. We have a technical term for this natural inclination: “mentalizing,” our ability to understand our own and others’ behavior as based on mental states, such as needs, desires, feelings, thoughts and beliefs.

Mass shootings, and especially the senseless and gratuitous slaughter of young children, strain our mentalizing capacity. Such acts seem incomprehensible, unfathomable. The Sandy Hook killings are so horrifying that we recoil from thinking about them—we have a strong aversion to imagining the children’s and staff’s experience, the families’ experience, the first responders’ experience or the neighbors’ experience. And I find Adam Lanza’s state of mind unimaginable. Efforts will be made to try to reconstruct his mental state, but whatever we learn is nevertheless likely to defy our capacity to empathize with him—to put ourselves in his mental shoes during the time of his actions.

Understanding evil

We all have had far too much exposure to such horrifying acts, and they inevitably get labeled by someone as “evil.” The perpetrator is liable to be branded an “evil person.” Then the label, evil, evokes someone else’s ire. Does this label further our understanding or hinder it? Perhaps our most condemning word, “evil” demonizes and sets the individual apart as alien—other, inhuman, beyond comprehension and perhaps redemption.

Yet, setting aside any supernatural connotations, some philosophers and psychologists have endeavored to understand evil in a way that might point in the direction of prevention. Susan Neiman contended that, whenever we conclude that something ought not to have happened, we are on the path to evil. Introducing clarity into this potentially inflammatory discourse, Claudia Card dispassionately construed evil as producing foreseeable intolerable harms, and she focused on the gravity of the harm rather than the perpetrators’ psychological states as the distinguishing factor of evil. I became interested in the literature on evil because of specializing in trauma. Consistent with Claudia Card, I concluded that evil is evil by virtue of the trauma it wreaks. By this descriptive standard, the Sandy Hook tragedy was evil indeed—traumatic to the extreme on a large scale.

Mindblindness & mentalizing

There is no simple explanation of the basis of evil actions, and they must be understood from social-cultural and neurobiological as well as psychological perspectives. The psychology alone is enormously complex. John Kekes conducted in-depth case studies of evil actions and identified several common motives: faith, ideology, ambition, honor, envy and boredom. In conjunction with understanding traumatizing behavior, I am inclined to focus on what’s missing—namely, an empathic connection with the experience of the persons being traumatized. I like Simon Baron-Cohen’s term, “mindblindness,” to identify what’s missing, and Baron-Cohen also has concentrated on the lack of empathy as a central contributor to evildoing. This lack of psychological awareness or attunement to the victim’s suffering boils down to a failure to mentalize. Mentalizing puts the brakes on whatever inclination we might have to inflict pain on others.

I first appreciated the connection between evil, trauma and mentalizing failures when I read Hannah Arendt’s account of Eichmann’s role in the Holocaust. Arendt did not view Eichmann as monstrous but rather was struck by his extraordinary shallowness and his inability to think—which I translate as an inability to mentalize. Similarly, Roy Baumeister made a systematic study of perpetrators of evil actions, and he was struck by their seeming ordinariness; he estimated that only about 5 percent committed violence in cruel pursuit of sadistic pleasure. Most were oblivious to the damage they wrought.

In itself, the term, evil, explains nothing; it calls for an explanation. If we’re going to use the term—as many traumatized persons do—we should use it mindfully. We have the work of many scholars to guide us. If we are to make progress in prevention and intervention, we must have faith that the seemingly incomprehensible can be comprehended. We might not acquire enough information to glimpse Adam Lanza’s state of mind, although it looks like enormous efforts will be made in the service of understanding. Mental illness is being explored, and additional attention to the pervasive need for improved mental health services will be all to the good—with the possible downside of exacerbating stigma.

Yet the diagnosis of a psychiatric disorder will not go far in explaining Adam Lanza’s actions, inasmuch as violence is not characteristic of psychiatric disorders. Indeed, this level of violence—as much as it compels our attention—is so extraordinarily rare that it is not characteristic of any single condition, such as genetic risk, poverty, abuse, neglect, access to weapons, immersion in violent videogames, much less any form of mental illness. Some tragic, complex combination of circumstances must occur. Hence prevention must occur on many fronts, bit by bit.

Empathy as antidote

Consistent with my focus on mindblindness and mentalizing failure in evildoing, Baron-Cohen points to enhancing empathy as the ultimate antidote to evil. Rightly, Baron-Cohen considers empathy to be the most valuable resource in our world. As much as they underscore our propensity for evildoing and mindblindness, these mass shootings and other acts of terrorism invariably underscore what is far more prevalent in our nature and culture: empathy and human goodness, glaringly evident in the community’s and nation’s response to this tragedy. I was invited to go to Oklahoma City soon after the bombing of the federal building there and, even more than the extraordinary horror of the scene, I found the outpouring of help and support to be overwhelmingly powerful. To carry on with hope and to pursue the long, hard work of prevention, we must hold on to this balance of perspective on our human condition.

Editor’s note: For more on the Sandy Hook tragedy, check out:

• Where is providence in the midst of tragedy?
• Shifting Sandy Hook information landscape means understanding will have to wait
• Responding to the Sandy Hook tragedy: What of the soul?

References

Allen, J.G. Restoring mentalizing in attachment relationships: Treating trauma with plain old therapy (chapter 6, existential-spiritual perspectives). Washington, DC: American Psychiatric Publishing; 2013.

Allen, J.G. Evil, mindblindness, and trauma: Challenges to hope. Smith College Studies in Social Work, 77, 9-31; 2007.

Arendt, H. Eichmann in Jerusalem: A report on the banality of evil. New York, Penguin; 1963.

Baron-Cohen, S. Mindblindness: An essay on autism and theory of mind. Cambridge, MA: MIT Press; 1995.

Baron-Cohen, S. The science of evil: On empathy and the origins of cruelty. New York: Basic Books; 2011.

Baumeister, R.F. Evil: Inside human violence and cruelty. New York: Freeman; 1997.

Card, C. The atrocity paradigm: A theory of evil. New York: Oxford University Press; 2002.

Kekes, J. The roots of evil. Ithaca, NY: Cornell University Press; 2005.

Neiman, S. Evil in modern thought: An alternative history of philosophy. Princeton, NJ: Princeton University Press; 2002.

In “Can’t or Won’t?” I wrote about the challenge of making judgments about whether persons struggling with psychiatric disorders are best regarded as being unable to do better (can’t) or unwilling to do better (won’t). Should we think of the alcoholic as being unable to stop drinking or unwilling to do so—can’t or won’t stop drinking? Regarding the depressed person: can’t or won’t get out of bed? We should be wary of such either-or dichotomies; we need to make room for can’t and won’t.

In framing this dilemma, I am putting us therapists and patients in the territory of the problem of free will. Beware: As philosopher John Searle¹ wrote,

“The problem of free will is unusual among contemporary philosophical issues in that we are nowhere remotely near to having a solution.”

But we have a way forward that is helpful for us mental health professionals, owing to the work of another philosopher, Peter Strawson, who made what I consider something of an end run around the problem of free will.

Juggling causes and choices

Strawson’s seminal paper, “Freedom and Resentment,” was first published in 1962² and remains a subject of continuing discussion.³ As I will explain, when responding to problematic behavior—associated with mental illness, for example—we must juggle two perspectives, scientific and moral. In short, we must juggle causes and choices, pitting determinism against free will. Strawson helpfully distinguished two contrasting attitudes toward behavior: emotionally detached (i.e., scientific, objective, based on causes) and emotionally reactive (i.e., moral, subjective, based on choices). We must accommodate both attitudes in the field of mental health and elsewhere.

Science deals with causes and laws. To take the extreme determinist position, owing to the laws of physics, the course of the universe—including all our behavior—was set in stone with the Big Bang: all causes, no choices. The deterministic idea that, in principle, the future is entirely predictable from the past has been undermined by quantum indeterminacy and chaos theory, but randomness and unpredictability in our behavior hardly gives us free will (genuine choice).

Strawson⁴ summarizes the detached, scientific-deterministic view as follows:

“To see human beings and human actions in this light is to see them simply as objects and events in nature, natural objects and natural events, to be described, analyzed, and causally explained in terms in which moral evaluation has no place.”

From this perspective, treatments for psychiatric disorders, based on scientific research, constitute an additional set of causes, changing patients’ thoughts, feelings and behavior in the grand causal chain of determinism. As Strawson² put it, from the standpoint of treatment, the person is to be “managed or handled or cured or trained.” This emotionally detached approach has the advantage of avoiding condemnation of patients with psychiatric disorders and stigmatizing them in the process. With alcoholism in mind, consider Strawson’s point:

“What from one [reactive] point of view is rightly seen as a piece of disgraceful turpitude, an appropriate object of a reaction of moral disgust, is, from the other [detached] point of view, rightly seen as merely the natural outcome of a complex collocation of factors, an appropriate object of scientific, psychological and sociological analysis and study.”

Not so fast! Strawson² made the compelling argument that we naturally respond to others as persons with intentions who are free agents, make choices and are responsible for their behavior. Indeed, he proposed that we cannot altogether avoid the emotionally reactive attitude. Of course, as Strawson made clear, in our judgments and feelings, we take into account the possibility of accidents and unwitting actions—it makes a big difference if someone steps on your foot on purpose or not. And he also allowed for factors that limit the capacity for freedom of action, including compulsions and psychiatric disorders; in such situations, we might “suspend our ordinary reactive attitudes toward the agent, either at the time of his action or all the time.” And he allowed for degrees of mitigation; in suspending the ordinary reactive attitudes, we might feel less perturbed rather than not at all perturbed.

In contrast with our scientific detachment, our reactive attitudes are embedded in our engagement with each other. Such engagement is based on our natural proclivity to mentalize, that is, to interpret others’ actions as based on intentions, desires, feelings, and beliefs—with the implicit assumption that their actions reflect at least some degree of free agency and choice. Freedom of choice always comes in degrees; our choices always take place in the context of constraints⁵—we are constrained by external circumstances and by personal limitations, for example, in capacities or vision. I like philosopher Daniel Dennett’s⁶ view of freedom as our remaining elbow room in the face of constraints; plainly, psychiatric disorders such as alcoholism and depression limit the individual’s elbow room, but I believe that these disorders do not entirely eliminate elbow room—certainly not at every moment.

No either/or

To return to the starting point, we must not be caught in a forced-choice way of thinking about can’t and won’t; as Strawson² maintained, we must be able to straddle the detached and reactive attitudes. Strawson took the psychoanalyst as an example of such straddling; he pointed out, ironically, that the aim of adopting the detached attitude and suspending the morally reactive attitude is to “make such suspension necessary or less necessary” by virtue of “restoring the agent’s freedom.” Wisely, he made the same observation regarding parents, who must straddle the two perspectives to support the “progressive emergence of the child as a responsible being.”

In sum, as we use our scientific knowledge to better understand the constraints associated with psychiatric disorders (the “can’t”), we must find the arenas of elbow room and use our psychotherapeutic influence to help transform “can and won’t” into “will.” I find that when patients know that we fully appreciate their limitations—the extent of “can’t” and the sheer difficulty of “can”—they are less resentful and oppositional and thus more willing to use their elbow room to do what they can.

References

 1. Searle JR. Freedom and neurobiology. New York: Columbia University Press; 2007.

2. Strawson PF. “Freedom and resentment.” In: Watson G, ed. Free will. New York: Oxford University Press; 1982:59-80.

3. Russell P. “Moral sense and the foundations of responsibility.” In: Kane R, ed. The Oxford handbook of free will. Second ed. New York: Oxford University Press; 2011:199-220.

4. Strawson PF. Skepticism and naturalism: Some varieties. New York: Columbia University Press; 1985.

5. Ayer AJ. “Freedom and necessity.” In: Watson G, ed. Free will. New York: Oxford; 1982:15-23.

6. Dennett DC. Elbow room: The varieties of free will worth wanting. Cambridge, Mass: MIT Press; 1984.

Like the proverbial moth drawn to the flame, I am attracted irresistibly to unanswerable questions. I’m in good company; as philosopher Hannah Arendt stated, “Man’s need to reflect encompasses nearly everything that happens to him, things he knows as well as things he can never know.”¹ Yet we can benefit by thinking more clearly about our perplexity.

My colleague Roger Verdon’s brilliantly poignant blog post on Amy Winehouse’s fatal addiction inspired the present post. The question, “Can’t or won’t?” was an implicit subtext throughout Roger’s reflections: Can’t stop using or won’t stop using? 

This question pervades our clinical practice: Can’t or won’t stop smoking, drinking, drugging, spending, thieving, bingeing, worrying, obsessing, counting, checking, avoiding, withdrawing, cutting or attempting suicide? Can’t or won’t stop being arrogant, oppositional, obstructionistic, submissive, self-sacrificing, self-defeating, reckless or impulsive? In my view, this can’t/won’t question strikes at the core of a quandary about our professional identity: Are we technologists or ethicists?

Intending to be provocative, and expanding on a previous post,² I will state the polar extremes in caricature form in this post, hoping to evoke conflict. In a subsequent post, aspiring for moderation, I’ll search for some middle ground.

Can’t stop?

Ostensibly, we mental health professionals make our living on the “can’t” side of this quandary: You are ill; let us treat you with our scientific technology. The number of human problems we diagnose as psychopathology has increased with each new iteration of the Diagnostic and Statistical Manual of Mental Disorders, now in its fourth edition.³ This enterprise is scientific: Through research,

• we distinguish among disorders;
• we develop technology to treat them (i.e., treatment manuals); and
• we study the effectiveness of the treatments.

Neuroscience now drives home the point that these disorders are real—addictions included. All in your head, indeed, but increasingly evident in altered brain structure and function.

Won’t stop?

Now for won’t: not enslaved by illness but rather making bad choices. Here’s a book title that rankles me: Depression is a Choice.⁴ In this vein, decades ago, psychiatrist Thomas Szasz⁵ caused an uproar with his outrageously titled book The Myth of Mental Illness. If one had any doubt, neuroscience now demonstrates that mental illness is no myth. But I never thought we needed neuroscience to refute the idea that mental illness is a myth; clinical observation was enough to do so for me. Hence I couldn’t stand Szasz’s book—until I read it recently.

His extremism notwithstanding, Szasz made a compelling point in arguing that psychotherapy is not suited for treating (mythical) illness but rather for addressing problems in living. More specifically:

Psychiatrists are not concerned with mental illnesses and their treatments. In actual practice they deal with personal, social and ethical problems in living.

Here is a point I find persuasive: “Psychologists and psychiatrists deal with moral problems which, I believe, they cannot solve by medical methods.”

In light of Szasz’s provocative claim, I find it fascinating that, two millennia ago, what we now call psychotherapy was the province of ethicists. In her illuminating book The Therapy of Desire, philosopher Martha Nussbaum⁶ documented the venerable history of psychotherapy in the practice of ancient Greek and Roman philosophers, as exemplified by Socrates.

Using collaborative discourse as a therapeutic tool, the classical ethicist worked with individuals as well as groups. Consider the following problems in living addressed in ancient ethics: dependency, love, sexuality, jealousy, anger, resentment, loss, death and suicide. Sound familiar? Long antedating Freud in their struggles to promote self-exploration, the Romans and Greeks were attuned to unconscious conflicts, including unconscious resistances to self-knowledge and to change.

To put the point most provocatively, as philosopher Charles Taylor⁷ has done, we mental health professionals are part of a social movement that is converting sin into sickness. Karl Menninger⁸ made a similar argument earlier in his powerful book Whatever Became of Sin? Stating it somewhat less provocatively, we have aspired to put science and technology in place of philosophy and ethics. I have no doubt about the potential benefits of this conversion, but I worry that we’ve gone too far. I think our justifiable fascination with neuroscience can contribute to the imbalance to the extent that we become excessively enthusiastic and reductionistic, caught up in biomania.⁹ The extreme version of can’t: My brain made me do it (or prevented me from doing it).

In pursuit of scientific explanations, do we want to shed responsibility? With responsibility and choice comes dignity. Might we be better off opting for won’t?

References

1. Arendt H. The life of the mind: I. Thinking. New York: Harcourt; 1971.

2. Allen JG. “What’s become of sin?” SayNoToStigma.com. Houston: The Menninger Clinic; 2010.

3. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision (DSM-IV-TR). Washington, D.C.: American Psychiatric Association; 2000.

4. Curtiss AB. Depression is a choice. New York: Hyperion; 2001.

5. Szasz TS. The myth of mental illness: Foundations of a theory of personal conduct (Revised Edition). New York: Harper and Row; 1974.

6. Nussbaum MC. The therapy of desire: Theory and practice in Hellenistic ethics. Princeton, N.J.: Princeton University Press; 1994.

7. Taylor C. A secular age. Cambridge, Mass: Harvard University Press; 2007.

8. Menninger KA. Whatever became of sin? New York: Hawthorn Books; 1973.

9. Allen JG. “Biomania: A protest.” SayNoToStigma.com. Houston: The Menninger Clinic; 2010.

The legendary Whitney Houston

My treasured colleague, Tom Ellis, wrote an impassioned post protesting simple-minded thinking about Whitney Houston’s death. I, too, am irked by glib media interpretations of the behavior of stars. I find it challenging to fathom the complexity of individual patients who courageously confide their inner life in psychotherapy; I am loath to pretend to understand anyone I observe only from afar. And diving into the murky territory of death wishes in my part is a prime example of fools rushing in where angels fear to tread. Far more foolish than angelic, I proceed.

Muddling through

I agree with my colleague in some respects. We can kill ourselves in the quest for pleasure — witness heart-stopping doses of cocaine. I am partial to the idea that addictive drugs “hijack” the normal brain reward systems. And there is no reward greater than escape from unbearable pain. Karl Menninger viewed nonsuicidal self-injury as “anti-suicidal” behavior. Cutting, banging or burning oneself can reduce emotional distress dramatically. Such behavior appears “self-destructive” only to the outside observer; to the person engaging in the behavior, it is self-preservative, a way of muddling through to live another day. The same might be said of addiction.

Penchant for self-destruction

I am less sanguine than my colleague about a thoroughgoing constructive orientation in human nature. He writes, “…All of us have the same basic agenda to find happiness and manage physical and psychic pain the best we can.” I find myself more sympathetic than he with Freud’s view of divided forces in our nature, constructive and destructive. Freud gave us a naturalized version of the age-old battle between good and evil, an enduring contest. I find ample evidence that destructiveness can be self-directed.

Granted, we are the products of evolution, and survival is the engine of evolution. But we should be humbled by the fact that well over 99 percent of species that ever lived are now extinct. Evolution does not necessarily lead to progress, much less to perfection. Perhaps we humans are not unflawed in our orientation toward life. We are hardly single minded, as Freud well understood.

Our capacity for gaining knowledge through science is stunning, but we also are developing increasingly sophisticated, life-threatening technology. Prescient about the human species’ capacity for self-annihilation and the anxiety that goes with it, Freud wrote before the advent of nuclear weapons. I wish our sociological knowledge were keeping pace with our dangerous technological advances. We humans might be unique among species in our seeming penchant for self-destruction. Above all, we need to learn how to cooperate before we join the other 99 percent (not the non-super-rich, the extinct).

Death instinct

I have no idea what was on Whitney Houston’s mind in the hours, days, weeks, months and years before her death. And I have no idea if Freud’s idea about the death instinct is best regarded as crazy or as something we should take very seriously as we witness horrific destructiveness across the globe. Our consciousness is misleading; we are aware of a tiny fragment of our mental activity, and we have little idea what our brains are up to. I think we should be more modest in our conjectures about others and, as Freud showed us, even about our own motivations. And we must be careful about generalizing about addicted persons or any other group in light of enormous individual differences — another engine of evolution.

I am not ready to throw up my hands in the face of destructiveness and self-destructiveness. I cannot fathom solutions to global problems. I cling to one uncommonly wise young woman’s reply when I asked patients in an educational group, “What gives you hope?” She replied, “I can be surprised!” But I take heart in small-scale victories. Day in and day out in this clinic, we help patients grapple more successfully with their self-destructiveness.

Current trends in the delivery of mental healthcare bring this question to the fore. We have long known that psychotherapy is a limited resource, plainly inadequate to meet mental health needs. This limitation is true not only of individual psychotherapy but also of all forms of psychotherapy combined: individual, group, couples and family. Not only is the distribution of mental health services grossly uneven geographically, the pervasive limitations of resources have also become more glaring in the context of healthcare debates and global economic woes.

New service delivery mechanisms

Thus, not without justification, Alan Kazdin and Stacey Blase argue that we must develop and disseminate a far broader array of non-psychotherapeutic interventions, even if the magnitude of their effectiveness is more limited than psychotherapy. Small effects with wide reach are better than no effects, given the unmet needs for mental health services. Joining a venerable chorus, these authors also advocate greater emphasis on prevention as well as the benefits of early intervention.

Yet, as a committed practitioner of Plain Old Therapy, I’m jarred by their advocacy of impersonal interventions now made possible by burgeoning new technologies. Telephone therapy is not new, and enhancing it with video seems eminently sensible; this expansion of service delivery can greatly enhance the likelihood of developing therapeutic relationships. How much is lost (or gained?) in video versus face-to-face interactions is an empirical question. But, as Kazdin and Blase review, we now have an expanding array of web-based interventions and smart-phone applications, for example, to monitor mood and promote coping skills, which are derivatives of cognitive-behavioral therapies.

Key limitation of technology

I find persuasive Kazdin and Blase’s basic point that we need to expand the reach of mental health services and that any form of help we can provide—even if modest in its effectiveness—is all to the good. Moreover, as these authors state, new technologies can serve well as adjuncts to psychotherapy. Books have done so for decades.

Although we don’t seem to be able to live without them, computers don’t mentalize—hold mind in mind. For that, we need parents, friends, romantic relationships and—especially when things have gone wrong to the point that these ordinary relationships cannot adequately provide needed help and support—psychotherapists.

Reference

Kazdin, A. E., & Blase, S. L. (2011). Rebooting psychotherapy research and practice to reduce the burden of mental illness. Perspectives on Psychological Science, 6, 21-37.

In my last post, “Why can’t we just be neurotic?” I complained about problems applying the Diagnostic and Statistical Manual of Mental Disorders¹ (DSM) to patients who suffer with a combination of severe depression and intense anxiety. That is, sometimes we are forced to diagnose depression over anxiety when patients have both. Where do we put the anxiety? In the quest for precision, the diagnostic manual has pulled apart problems that belong together.

This post has two aims: first, to tangle and disentangle anxiety and depression; and second, to underscore the importance of appreciating the role of anxiety in depression.

Putting anxiety and depression in perspective

In my previous post, I emphasized the comingling of anxiety and depression. But readers should be aware that the image of simultaneous disorders oversimplifies; we need a developmental perspective. Anxiety and depression occur in episodes over the lifetime; either one is equally likely to precede the other.² Moreover, the occurrence of one is likely to increase the likelihood of the subsequent occurrence of the other.^{2, 3} Anxiety begets depression, and depression begets anxiety. Thus we see a cascade of episodes: as time goes on, an individual who has a lifetime history of either disorder is increasingly likely to have a history of the other.⁴

Back to the comingling problem. The diagnostic system forces us to put symptoms into boxes and to decide which box offers the best fit. But the contents seem to spill over from one box to another.

Psychologists come to the rescue. We are less keen on chopping up nature into categories and more inclined to measure everything in degrees—not “intelligent” versus “unintelligent” but rather a full range of IQ scores. So it is with anxiety and depression: We have innumerable scales to measure each in fine degrees. And when we do so, we find a high degree of overlap (i.e., statistical correlation). The more depressed you are, the more anxious you also are likely to be, and vice versa.

Using scales to measure different facets of depression and anxiety

By fancy statistical methods such as factor analysis, psychologists can use multi-item scales measuring different facets of depression and anxiety in degrees to sort out what goes together and what does not. Such studies consistently reveal what has been called a “tripartite” model of emotional disorders,⁵ and, more recently, a “quadripartite” model.⁶ The tripartite model is enough to fill our hands for now. This model includes three relatively distinct factors, each of which is measured in degrees:

1. aspects of anxiety that are separable from depression;
2. aspects of depression that are separable from anxiety; and
3. a great deal of overlapping experience.

The separable aspects of anxiety relate to physiological hyperarousal (e.g., racing heart, dizziness, shortness of breath and sweating); these anxiety symptoms are rooted in fear.⁷ The separable aspects of depression relate to a lack of capacity for positive emotional experience, such as interest, pleasure and excitement.⁸

As psychologist Paul Meehl⁹ presciently put it in the Bulletin of the Menninger Clinic decades before the role of neurotransmitters in reward circuits was fully appreciated, depression entails a lack of cerebral joy juice. Meehl’s phrase parallels William Styron’s characterization of his depression as dank joylessness in his poignant memoir, Darkness Visible.¹⁰

It’s the third factor that interests me: the overlap between anxiety and depression. Here we can welcome vagueness back in. This factor has been variously named: negative emotionality, distress, dysphoria, neuroticism (the one I miss) and anxious misery⁶ (now my favorite).

Treatment development & the DSM

This conspicuous overlap between anxiety and depression relates to another major problem in the field of psychotherapy. Clinical researchers have put enormous energy into developing disorder-specific treatments aligned with the diagnostic manual, resulting in separate treatments for anxiety and depression. Thus we have a proliferation of “empirically supported treatments”—indeed, we have so many of these treatments that therapists cannot possibly learn them all, or even a significant subset of them.¹¹

Accordingly, there is a counter move toward “integrative” treatments, which are consistent with the overlap among ostensibly separable disorders. Keenly aware of the overlap between anxiety and depression, David Barlow has proposed a Unified Protocol for the treatment of “emotional disorders” based on cognitive-behavioral treatments.^{12, 13} Being content with even more vagueness, I have argued for a return to “Plain Old Therapy” (POT).^14-16

DSM-V

Frustration with the diagnostic manual is widely shared by mental health professionals, psychiatrists and psychologists alike. I do not want to appear dismissive of the manual; research on its categories has moved understanding and treatment forward dramatically—ironically, in part by revealing the problems with the categories, a process that leads to continual refinement.

The overlap between depression and anxiety that has flummoxed me is a case in point. A workgroup devoted to sorting out this problem in the next iteration of the manual, DSM-V,¹⁷ has contributed to considerable refinement in our understanding that promises to lead to helpful revisions.¹⁸ The current proposal for DSM-V includes mixed anxiety-depressive disorder as a bona fide diagnosis, now listed under depressive disorders rather than anxiety disorders NOS. Yet this mixed disorder will be applied only to patients who do not meet full criteria for major depression.

Thinking more like psychologists, the workgroup is considering another straightforward proposal: including a rating of severity of anxiety for persons with major depression. Apart from a categorical diagnosis, this additional assessment of anxiety severity is important, because severe anxiety intermingled with depression can prolong the course of the depressive episode, create greater disability, contribute to physical health problems and increase the risk of suicide.¹⁷

Hence this last proposal is perfect: this patient suffers from major depression and also is very very anxious. Neurotic indeed, with plenty of good company on this planet.

References

1. Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision (DSM-IV-TR). Washington, DC: American Psychiatric Association; 2000.

2. Kessler RC, Gruber M, Hettema JM, Hwang I, Sampson N, Yonkers KA. Major depression and generalized anxiety disorder in the National Comorbidity Survey follow-up survey. In: Goldberg D, Kendler KS, Sirovatka PJ, Regier DA, eds. Diagnostic issues in depression and generalized anxiety disorder: Refining the agenda for DSM-V. Arlington, VA: American Psychiatric Publishing; 2010:139-170.

3. Fergusson DM, Horwood LJ. Generalized anxiety disorder and major depression: Common and reciprocal causes. Diagnostic issues in depression and generalized anxiety disorder: Refining the research agenda for DSM-V. Arlington, VA: American Psychiatric Publishing; 2010:179-189.

4. Goldberg D. The relationship between generalized anxiety disorder and major depressive episode. In: Goldberg D, Kendler KS, Sirovatka PJ, Regier DA, eds. Diagnostic issues in depression and generalized anxiety disorder: Refining the research agenda for DSM-V. Arlington, VA: American Psychiatric Publishing; 2010:355-361.

5. Goldberg D. Psychometric aspects of anxiety and depression. In: Goldberg D, Kendler KS, Sirovatka PJ, Regier DA, eds. Diagnostic issues in depression and generalized anxiety disorder: Refining the research agenda for DSM-V. Arlington, VA: American Psychiatric Publishing; 2010:109-123.

6. Watson D. Differentiating the mood and anxiety disorders: A quadripartite model. Annual Review of Clinical Psychology. 2009;5:221-247.

7. Andrews G, Charney DS, Sirovatka PJ, Reiger DA, eds. Stress-induced and fear circuitry disorders: Refining the research agenda for DSM-V. Arlington, VA: American Psychiatric Publishing; 2009.

8. Watson D. Mood and temperament. New York: Guilford; 2000.

9. Meehl PE. Hedonic capacity: Some conjectures. Bulletin of the Menninger Clinic. 1975;39:295-307.

10. Styron W. Darkness visible. New York: Random House; 1990.

11. Chambless DL, Ollendick TH. Empirically supported psychological interventions: Controversies and evidence. Annual Review of Psychology. 2001;52(685-716).

12. Barlow DH, Allen LB, Choate ML. Toward a unified treatment for emotional disorders. Behavior Therapy. 2004;35:205-230.

13. Wiliamoska ZA, Thompson-Hollands J, Fairholme CP, Ellard KK, Farchione TJ, Barlow DH. Conceptual background, development, and preliminary data from the unified protocol for transdiagnostic  treatment of emotional disorders. Depression and Anxiety. 2010;27:882-890.

14. Allen JG. Is psychotherapy going to POT? SayNoToStigma.com. Houston, TX: The Menninger Clinic; July 21, 2010.

15. Allen JG. Can we grow more potent POT? SayNoToStigma.com. Houston, TX: The Menninger Clinic; August 9, 2010.

16. Allen JG. Preserving hope. Bulletin of the Menninger Clinic. 2011;75:185-204.

17. www.DSM5.org.

18. Goldberg D, Kendler KS, Sirovatka PJ, Regier DA, eds. Diagnostic issues in depression and generalized anxiety disorder: Refining the research agenda for DSM-V. Arlington, VA: American Psychiatric Publishing; 2010.

I miss neurosis. It’s long gone from the official manual for psychiatric diagnosis, the Diagnostic and Statistical Manual of Mental Disorders, now in its fourth iteration, DSM-IV.¹ Unfortunately, taking neurosis out of the manual has not eradicated it from the human condition. I can attest to that fact from personal experience, and I’ve had many occasions to observe it in others.

The concept of neurosis was too tied to psychoanalysis, and the diagnosticians deliberately aspired to divorce diagnoses from any particular psychological theory. More germane to this blog post, however, the concept of neurosis was too vague. The diagnosticians properly strived to make psychiatric diagnoses as precise as possible. Precision fosters agreement. It’s important for patients that diagnosticians agree on their condition, and it’s important for researchers that different research projects are all studying patients with disorder x defined in the same way. We have enough disagreement in research results as it is, without having even more due to the fact that different studies are conducted with dissimilar groups of patients ostensibly with the same disorder. Here’s an irony: The quest for precision has backfired when it comes to eliminating neurosis. The diagnostic manual has separated problems that belong together. We need more vagueness.

Diagnostic interviews

At The Menninger Clinic, the research department routinely administers the Structured Clinical Interviews for DSM-IV Disorders^{2, 3} to all patients. The systematic and thorough nature of these interviews aids the clinical process. We do not use research interviews to make final diagnoses—that’s up to the treating psychiatrist, as it should be. Rather, the results of the interviews inform the treating psychiatrist’s diagnosis, along with much other information about the patient. Yet doing these diagnostic interviews, while endeavoring to hew to precise rules, has us occasionally aspiring to do something akin to figuring out how many angels can dance on the head of a pin. One such challenge pertains to neurosis.

Depression + anxiety

Here’s what drives me nuts. Our most common diagnosis at The Clinic is major depressive disorder (MDD). Extensive research attests to two facts. First, in combination with genetic vulnerability and a history of stress exposure, episodes of major depression commonly are triggered by stressful life events and difficulties.^{4, 5} Second, although the depressed person may appear inactive and placid, this appearance is misleading; depression is a high-stress state, as evidenced by patterns of brain activity associated with stress⁶ and elevated stress hormones.⁷ Hence many patients who are in the midst of depressive episodes also are anxious. Yet, despite their conspicuous anxiety, by precise criteria many of these patients with major depression do not qualify for a diagnosis of a specific anxiety disorder, such as generalized anxiety disorder (GAD), obsessive-compulsive disorder, social phobia or posttraumatic stress disorder. We can resort to what we sometimes derogate as a “wastebasket” diagnosis, anxiety disorder not otherwise specified (NOS). But this seems like a cop-out and isn’t very satisfying—vagueness indeed!

Depression trumps anxiety

This paragraph you are about to read (or quit reading) will give you a taste of the complexities in diagnosing psychiatric disorders. Here’s our trap: One basis for diagnosing anxiety disorder NOS is the presence of a mixed anxiety-depressive disorder.¹ This highly appealing option seems to get us off the hook. But there’s a catch: We cannot make this diagnosis when the patient’s symptoms meet the criteria for a specific mood disorder or a specific anxiety disorder. So, if they have major depression, we can’t diagnose mixed anxiety-depressive disorder. Moreover, patients with MDD cannot also be diagnosed with GAD—even if they meet the criteria—if their anxiety is confined to the time frame of the depressive episode. Depression trumps anxiety, for reasons that are unclear.⁸

To complicate matters even further, the time frames for diagnosing MDD and GAD differ: two weeks of symptoms are required for MDD and six months for GAD, a problem that confounds research on their overlap.^{8, 9} Furthermore, it seems arbitrarily to put mixed anxiety-depressive disorder into the anxiety disorder group rather than the mood disorder group. Moreover, while tucked into anxiety disorder NOS, the mixed anxiety-depressive disorder also is relegated to an appendix of the diagnostic manual, “Criteria Sets and Axes Provided for Further Study.” It’s unofficial.

One of several books about depression and trauma by Dr. Allen.

Here’s the analogue to how many angels can dance on the head of a pin: How much more anxious must a patient with major depression be beyond the ordinarily highly anxious depressed person to qualify for an additional diagnosis of anxiety disorder NOS which, technically, we shouldn’t be using anyway? Sometimes I feel like throwing away the book! I’ll point to a way out of these traps in a subsequent post, “Anxious Misery.” 

References 

1. Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision (DSM-IV-TR). Washington, DC: American Psychiatric Association; 2000.

2. First MB, Spitzer RL, Gibbon M, Williams JBW. User’s guide for the Structured Clinical Interview for DSM-IV Axis I disorders: Clinician version, SCID-I. Washington, DC: American Psychiatric Press; 1997.

3. First MB, gibbon M, Spitzer RL, Williams JBW, Benjamin LS. User’s guide for the Structured Clinical Interview for DSM-IV Axis II personality disorders: SCID-II. Washington, DC: American Psychiatric Press; 1997.

4. Brown GW, Harris TO. Social origins of depression: A study of psychiatric disorder in women. New York: Free Press; 1978.

5. Hammen C. “Stress and depression.” Annual Review of Clinical Psychology. 2005;1:293-319.

6. Drevets WC. “Prefrontal cortical-amygdalar metabolism in major depression.” Annals of the New York Academy of Sciences. 1999;877:614-637.

7. Nemeroff CB. “Psychopharmacology of affective disorders in the 21st century.” Biological Psychiatry. 1998;44:517-525.

8. Goodyer IM. “Episodes and disorders of general anxiety and depression.” In: Goldberg D, Kendler KS, Sirovatka PJ, Regier DA, eds. Diagnostic issues in depression and generalized anxiety disorder: Refining the research agenda for DSM-V. Arlington, VA: American Psychiatric Publishing; 2010:257-269.

9. Moffitt TE, Caspi A, Harrington H, et al. “Generalized anxiety disorder and depression: Childhood risk factors in a borth cohort followed to age 32 years.” In: Goldberg D, Kendler KS, Sirovatka PJ, Regier DA, eds. Diagnostic issues in depression and generalized anxiety disorder: Refining the research agenda for DSM-V. Arlington, VA: American Psychiatric Publishing; 2010:217-239.

I had the good fortune recently to participate in a think tank and conference in The Netherlands with Jim Coan, a talented clinical psychologist at the University of Virginia who is conducting pioneering neurobiological research on attachment. I think the results of his research have profound implications for stress management and for treatment; I inform patients about his work every chance I get.

Clever experiment

Jim and his colleagues¹ conducted a remarkably clever experiment with married couples published with the inviting title, “Lending a Hand.” The couples were carefully selected to be highly satisfied in their marriage. In the experiment, the women were exposed to a stressful situation: They had electrodes fastened to their ankles and periodically were given electric shocks. Before the shocks, they were given one of two signals:

1. a safety signal indicating that they would not be shocked or 
2. a threat signal indicating that there was a 20 percent chance of being shocked (and they were shocked on some trials).

This procedure enabled the researchers to compare patterns of the women’s brain activity (with functional magnetic resonance imaging) under two conditions:

1. when they were feeling threatened versus 
2. when they were feeling safe.

Here is the clever part: at different points during the threatening procedure, the women were permitted to hold their husband’s hand, a stranger’s hand or no one’s hand. Also of interest, even though these couples were highly satisfied with their relationship, the researchers assessed differences in degree of satisfaction within the group (i.e., more satisfied or less satisfied). These differences make a difference.

Complex results

The details of the findings are complex, as the researchers studied more than a dozen different areas of brain activity. In broad terms, they studied activity in areas that indicate emotional response to threat as well as areas that are known to regulate or control emotional distress. Complex as they may be, the gist of the findings is elegant and important: the more the woman was on her own while she was feeling threatened, the greater the number of brain areas showing elevated activity. The brain was least active when the woman was holding her husband’s hand and most active when she had no hand to hold. Moreover, even though all couples had a good relationship, the women who were in a less satisfying relationship showed more elevated brain activity when holding their husband’s hand than those who were in a more satisfying relationship.

Efficient distress management

Jim came to a simple conclusion: When we are threatened, a feeling of connection with a person to whom we are securely attached is our most efficient way of regulating distress. His social baseline theory² proposes that we humans are hard-wired to use social proximity as a default strategy for regulating emotional stress. He also notes that we share this default strategy with many other mammalian and bird species. This strategy evolved not only because there is safety in numbers but also because reliance on trusted companions for help and support lessens the load on our individual resources. True, we must learn to manage distress on our own to a considerable degree. Ironically, one of the best ways to cope with emotion is to be tolerant and accepting of emotional distress; fighting it makes it worse.³ But the experiment’s results demonstrate clearly that managing on our own—however we may do it—is a costly strategy; it is effortful. Attachment can cut off stress at the pass. Mere proximity to another person in a threatening situation is of some help, but proximity to a familiar person is more help and proximity to a trusted attachment figure is most helpful.

Extensive neuroimaging research shows that the prefrontal cortex plays a major role in regulating stress. The prefrontal cortex also uses a great deal of energy. Hence we can conserve energy by relying on attachment relationships—to use an apt economic metaphor, we “outsource” stress regulation to our social networks.⁴ This attachment strategy frees up brain resources to engage in problem solving: We have more capacity to deal effectively with the source of threat if we don’t have to invest so much energy in regulating our distress. Being more accepting of stress rather than trying to suppress it might be one way of conserving some energy. But attachment is another. Yet there is a caveat: The attachment strategy works best when the partner is emotionally attuned, as partners in highly satisfying marriages are likely to be. Seeking comfort from someone to whom you are insecurely attached is liable to increase stress.⁵

It’s best to let Jim speak for himself; he neatly summarizes his thinking as follows: 

The social baseline model proposes that social forms of emotion regulation are not ‘down-regulatory’ in the same sense as self-regulation efforts. Rather, it proposes that social resources alter perception-action links associated with intervening in the environment, such that there is less perceived alarm when perceived social resources are high, which corresponds in turn to fewer actions needed to meet demands associated with the stressor. This, I have argued, conserves metabolically costly operations in the prefrontal cortex and elsewhere, either by simply conserving neural resources or freeing them to be devoted to other problems, thus increasing the efficiency of coping with a potentially dangerous and uncertain world.^{2(p. 620)} 

Implications for practice

I find especially provocative a point he⁶ makes about the implications of this theory and research for clinical practice. We put a lot of effort into developing treatment methods to help patients become more adept at self-regulation of emotions. Prominent examples include mindfulness practice,⁷ dialectical behavior therapy⁸ and cognitive-behavior therapy.⁹ No doubt, we all need to be adept at self-regulation; we can’t be holding our attachment figure’s hand whenever we feel threatened! Yet self-regulation is not the most efficient or powerful means of emotion regulation. Accordingly, we should be putting as much—or more—effort into developing treatment approaches that enhance attachment relationships and promote security in those relationships.

In the past decade, considerable effort has gone into applying attachment theory and research to psychotherapy.^10-14 Yet, now buttressed by Jim’s research, Sue Johnson^{15, 16} has made a compelling case for working on attachment relationships directly in marital, couples and family therapy to enhance emotional connection and security—handholding that works. Thanks to evolution, we have a remarkable ability to rely on attachments to manage stress by merely feeling connected. My advice: Strive to develop, maintain and make full use of secure attachment relationships, and give your overworked brain a break—and your body as well, given the toll stress takes on your health. 

References 

1. Coan JA, Schaefer HS, Davidson RJ. Lending a hand: Social regulation of the neural response to threat. Psychological Science. 2006; 17:1032-1039.
2. Coan JA. The social regulation of emotion. In: Decety J, Cacioppo JT, eds. Handbook of social neuroscience. New York: Oxford University Press; 2011:614-623.
3. Hayes SC, Strosahl KD, Wilson KG. Acceptance and Commitment Therapy: An experiential approach to behavior change. New York: Guilford; 1999.
4.  Coan JA. Adult attachment and the brain. Journal of Social and Personal Relationships. 2010; 27:210-217.
5. Mikulincer M, Shaver PR. Attachment in adulthood: Structure, dynamics, and change. New York: Guilford; 2007.
6. Coan JA. Toward a neuroscience of attachment. In: Cassidy J, Shaver PR, eds. Handbook of attachment: Theory, research, and clinical applications (Second Edition). New York: Guilford; 2008; 241-265.
7. Kabat-Zinn J. Full catastrophe living: Using the wisdom of your body and mind to face stress, pain, and illness. New York: Delta; 1990.
8. Linehan MM. Cognitive-behavioral treatment of borderline personality disorder. New York: Guilford; 1993.
9. Barlow DH, Allen LB, Choate ML. Toward a unified treatment for emotional disorders. Behavior Therapy. 2004; 35:205-230.
10. Allen JG, Fonagy P, Bateman A. Mentalizing in clinical practice. Washington, DC: American Psychiatric Publishing; 2008.
11. Holmes J. Exploring in security: Towards an attachment-informed psychoanalytic psychotherapy. New York: Routledge; 2010.
12. Obegi JH, Berant E, eds. Attachment theory and research in clinical work. New York: Guilford; 2009.
13. Slade A. The implications of attachment theory and research for adult psychotherapy: Research and clinical perspectives. In: Cassidy J, Shaver PR, eds. Handbook of attachment: Theory, research, and clinical applications (Second Edition). New York: Guilford; 2008; 762-782.
14. Wallin DJ. Attachment in psychotherapy. New York: Guilford; 2007.
15. Johnson SM. Couple and family therapy: An attachment perspective. In: Cassidy J, Shaver PR, eds. Handbook of attachment: Theory, research, and clinical applications (Second Edition). New York: Guilford; 2008; 811-829.
16. Johnson SM, Courtois CA. Couple therapy. In: Courtois CA, Ford JD, eds. Treating complex traumatic stress disorders: An evidence-based guide. New York: Guilford; 2009; 371-390.