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“Why does my brain hate me?”
Resistance as relearning
Derrick L. Hassert
Periodically, clients have confronted me with a question that is both challenging and thought-provoking: “Why does my brain hate me?” Sometimes this sentiment takes on other forms: “Why is my brain trying to sabotage me?” or “Why doesn’t my brain want me to get better?” Often the assertion is much blunter and more pessimistic: “My brain just doesn’t want me to be happy.” These comments and the experiences behind them highlight that the psychotherapeutic journey can be a tumultuous one: therapy is seldom a wholly linear and unidirectional process. Desirable change in psychotherapy is quite often distressingly punctuated by periods when the old ways of functioning burst back onto the scene as though they had never left the stage, leaving the client feeling as though they have fallen off the wagon, undoing any progress made up to that point, and perhaps revealing an unspoken assumption that change or therapeutic progress must be without error for it to be real or meaningful. The question and the challenge for both client and therapist is rooted in Why? Why do such things occur, especially when there is an explicitly stated desire to charter a new emotional, behavioral, or cognitive course?
The Ubiquitous Phenomenon of Resistance
Therapists have long recognized that there are times when clients can appear to be one of the most significant impediments to their own adaptive change. In the classic psychoanalytic framework such instances of self-defeating behavior are often characterized as resistance. Schlesinger comments that “what therapists commonly call resistance is behavior that manifestly opposes what the patient believes the therapist wants to do or wants to happen”. While in the psychodynamic tradition this resistance is often verbal in form, it can be expressed nonverbally and emotionally as well and is considered “a ubiquitous phenomenon in all psychological treatments”. The longing for therapeutic change is not just that of the therapist, it is also the want of the client, in that they are the one seeking assistance, and yet their behavior is strikingly at odds with this expressed intention. It could be added that quite often the client will declare that they are relatively unware as to why they are feeling or behaving in opposition to the therapist’s wishes, most notably because they themselves have explicitly espoused these same sentiments for change. For this reason, the emergence of resistance and the why of its occurrence are often said to be beyond the awareness of the client, beyond consciousness.
Insight Often Isn’t Enough
Once clients have observed themselves engaging in specific behaviors they are then usually able to describe and verbalize this behavior, both to themselves and to their therapists. Taking note of one’s behavior, verbalizing it, and perhaps even noticing patterns in the behavior (or accepting the reality of patterns pointed out by others) is sometimes enough to produce a notable behavioral change—something a psychodynamic therapist could liken to the concept of insight and a behavioral therapist might consider an instance of reactivity. For example, a client may take note that they tend to eat mindlessly and perhaps excessively during the day when bored or stressed, only coming to this realization by carefully monitoring and reflecting upon their own behavior over an extended period or by being open to the observations of others observing those patterns. Bringing the behavior into the spotlight of conscious awareness may be enough to curtail it substantially. Nevertheless, insight (or conscious recognition) regarding behavioral patterns and/or behavioral reactivity to self-monitoring doesn’t always produce lasting cognitive, behavioral, or emotional alterations. In the example just mentioned—that of mindless eating—the client may fall back into not paying attention to their eating behavior, leading to a relapse of sorts into the old and undesirable ways when fatigued, hurried, bored, or otherwise stressed. The client may fault themselves for “knowing better” and yet not “behaving better” when they realize the problematic behavior has reinstated itself.
A classical psychoanalytic position may have interpreted such problematic behavior as an unconscious desire to remain the same—to stay in the old way of doing things due to an allusive and long-standing intrapsychic conflict. Where the older position is correct is that it is true that parts of the brain (and therefore parts of the psychological functioning of the individual) are indeed in very real conflict: one functional system of the brain is at odds with another and wants to stay the same while another system of the brain wants the behavior to change. It could be said that there are indeed long-standing and largely nonconscious reasons why undesirable behaviors persist, and these reasons are rooted in the way the brain functions as a multilayered information-processing and response system. Many modern psychodynamic theorists recognize that because so many emotional responses and social behaviors are learned prior to the full developmental and functional emergence of the explicit memory systems of the frontal lobes and the hippocampus, for the most part they function independently of the explicit memory systems:
The declarative system (which is usually assumed to contain ideas and experiences that have been repressed) constitutes a relatively small proportion of the unconscious mind. More extensive by far is the procedural unconscious, which consists of nonverbal aspects of experience that were never repressed, because they were shaped outside of awareness from the beginning, and are inaccessible to introspection and thus to interpretation.
Indeed, these emotional, procedural, preverbal, and pre-explicit systems form the backdrop for the later verbal cognitive functions and behaviors because those systems emerge prior to explicit awareness. Given the current state of knowledge in psychology and neuroscience this is no longer very surprising as it is now widely acknowledged that much of human mental processing and behavior is acquired and operates in a largely nonconscious manner.
These patterns of behavior emerged and persisted because they were beneficial for the individual, at least in some contexts. In the example above we were addressing one behavior (eating) that is based upon multiple behavioral choices, reinforced daily and going back decades, which early in that person’s development made them very happy or very sad, thus providing a strong emotional connection to the behavior. The learning of the behavioral repertoires that comprise these habits and the emotional connections to the behaviors are formed before the development of language and hippocampal-dependent explicit memory, making a behavior such as eating more dependent upon context and consequence than upon verbal rules and logic. Like other behavioral, cognitive, and emotional responses that emerged adaptively prior to the development of expressive language and the more fully developed capacity for explicit memory, the eating behaviors were prompted and reinforced subtly yet substantially in a manner that didn’t require later conscious recollection. Even after the emergence of language and explicit memory, the shaping and perpetuation of such behaviors can continue in the same fairly mindless way, open to the influence of contextual cues we are not fully aware of and yet firmly rooted in the structure of operant conditioning.
Social Behavior and Operant Conditioning
Most of us are quite familiar with the distinction between classical (or Pavlovian) conditioning and operant (or Skinnerian) conditioning. A rather simplistic way of distinguishing between the two has been to state that classical conditioning is involuntary and operant conditioning is voluntary. To some degree this is true when considering neurologically intact individuals. Complex behaviors such as riding a bike, driving a car, or playing a musical instrument generally involve a great deal of mental effort, attention, and intention when we set about learning them: the focusing of this attention and effort is arguably the purview of the prefrontal cortex. And yet, once they are learned, these behaviors can be executed automatically in an appropriately and adaptive fashion. Research into the neuropsychology of operant conditioning when contrasted with classical conditioning has revealed that both forms of learning can be acquired without conscious memory of the conditioning being necessary for the behavior to be subsequently repeated. Famously, patient HM, after bilateral ablation of the temporal lobes, was able to acquire and improve learned motor behavior over repeated trials, all without explicit memory of the previous exposures to the learning context. Neuropsychological patients with temporal lobe damage, like HM, have been able to learn operant conditioning tasks without conscious recollection of the acquisition. While temporal lobe damage does not impair learning of this sort, damage to the basal ganglia notably does.
To more fully appreciate the extent to which socially significant behaviors are created and maintained by elements of operant conditioning, we could look to instances where adaptive nonverbal social behavior notably and consistently fails, specifically in the behavior of those meeting the diagnostic criteria for autistic spectrum disorders. The behavioral omissions that parents often notice first are the failure of the child to make eye contact or to produce and/or respond to facial emotional displays. Such methods of communication are employed before verbal communication has developed, and, for most children, are inherently reinforcing or punishing. When these behaviors fail to progress adaptively, one of the ways that has been shown to therapeutically address these deficits (though not in a universally effective manner) is the utilization of operant conditioning techniques through applied behavior analysis—essentially taking the social behaviors that we often take for granted and breaking them down into discrete units and unambiguously reinforcing these units.
Social Learning, Operant Conditioning, and the Basal Ganglia
In our daily life we are reinforced continuously by the social displays of other people, responding to their facial expressions, their body posture, their tone of voice, and so forth. The behaviors that elicit desirable responses will, in time, become habitual, an unspoken but essential part of the fabric of our social and emotional lives. In the language of behavioral psychology, these behaviors are instances of stimulus–response (SR) associative learning, dependent upon the basal ganglia, and usually acquired in an incremental fashion. Evidence suggests that the basal ganglia may be sensitive to probabilistic occurrences of reinforcement comparable to the rates of reinforcement one would receive in social situations: people won’t laugh at every joke you tell, smile every time you smile at them, or respond in a caring manner to your every emotional display. In general, however, such behavioral displays match the overall outcomes, even if the outcomes are only “generally” successful. The hippocampal-based declarative memory system can contradict the SR association but, “as the cue–response habit strengthens, the striatal memory system could guide behavior more accurately with potentially less effort”. The execution of important elements of social behavior, such as responding to direct eye contact or the head position of others, have been demonstrated to occur outside the realm of explicit awareness. Such rapid behavioral responses, if socially adaptive, would likely be quite beneficial to the individual.
In relation to psychotherapy, explicitly knowing that something isn’t the right response would—in terms of the impact on behavior—perhaps pale in comparison with the individual’s history of repeated, probabilistic patterns of social and emotional reinforcement within the environment. Through repetition, the behaviors become comfortable, safe, inherently reinforcing, and embedded in the functioning of the brain. This behavioral repetition is the basis of resistance. What will ultimately overcome this dominant response is the establishment of a new pattern of behavior, with the new behavior encountering probabilistically consistent reinforcement through social interaction—a corrective emotional experience that many psychodynamic therapists have historically highlighted, which serves to
. . . re-expose the patient, under more favorable circumstances, to emotional situations which he could not handle in the past. The patient, in order to be helped, must undergo acorrective emotional experience suitable to repair the traumatic influence of previousexperiences.
The acquisition of new operant behavioral responses in such situations appears to be regulated largely by the basal ganglia. While the basal ganglia is a heterogeneous structure comprised of several subunits and pathways receiving input from the entirety of the cerebral cortex, as noted by Leisman, Braun-Benjamin, and Melillo, there are three loops that originate in the frontal lobes that are of particular importance to the behavioral issues and changes seen in psychotherapy, namely:
- the dorsolateral prefrontal circuit originating in Brodmann’s areas 9 and 10, projecting to the head of the caudate, and thought to be involved in organizing behavioral responses and using verbal skills in problem solving;
- the lateral orbitofrontal circuit projecting to the ventromedial caudate nucleus, playing a major role in mediating empathetic and socially appropriate response; and
- the anterior cingulate circuit projecting to the ventral striatum which appears to play an important role in motivated behavior, and it may convey reinforcing stimuli to diffuse areas of the basal ganglia and cortex via inputs through the ventral tegmental areas and the substantia nigra pars compacta.
These findings regarding the neurobiology of operant conditioning being rooted heavily in the basal ganglia are of great importance to the psychotherapist. Historically, the circuity of the basal ganglia and its links to the frontal cortex have been implicated in several psychiatric conditions, most notably obsessive–compulsive disorder, wherein anxiety-provoking thoughts lead to compulsive behaviors performed to reduce (at least temporarily) the anxiety suffered by the individual, resulting in an increase in the frequency of the compulsive behavior due to negative reinforcement. Specific phobias may be maintained by a similar operant conditioning mechanism. Anxiety produced by thoughts of the feared object can be reduced by avoiding the feared object or stimuli with which it is associated.
While we may think of the basal ganglia as being dysfunctional in these conditions, it is nevertheless functioning in a way that makes a great deal of sense in relation to operant conditioning: behavior that has been and is being reinforced, either through positive or negative reinforcement, is subsequently going to increase in frequency. With this principle in mind, we must also acknowledge that many of the issues that bring people into psychotherapy are well-established, deeply rooted (in the neurological as well as the psychological and behavioral uses of the phrase) patterns that have been reinforced repeatedly over extended periods of time. If, for many years, two people in a relationship have engaged in arguably dysfunctional ways of communicating with one another (blaming, passive aggressive speech and actions, yelling, abusive language, etc.), it would come as no surprise that if that particular relationship came to an end that one or both of the individuals would carry these behaviors into new relationships, possibly producing the same types of problems they experienced in the old relationship. The reason that the dysfunctional patterns emerged and continued for as long as they did may have been because they served some sort of immediate function and produced some manner of desired result for one or both parties; in other words, the behaviors were operantly reinforced, either through gaining something (positive reinforcement) or avoiding something (negative reinforcement). Let’s say that in the past a woman’s husband began every confrontational interaction with the phrase, We need to talk. Over time, the wife would develop a defensive bodily posture, vocal tone, and facial expression whenever that phrase was uttered by the husband. If the couple divorced and then the woman began dating someone else and that new partner began a discussion with We need to talk, the response from the woman would likely be defensive, although in this new situation perhaps not deservedly so. The new person in the relationship with the woman may be upset at such defensiveness, not understanding why they are now bearing the brunt of the flaws and faults of the previous partner. Overcoming this pattern of responding may be quite difficult, even if the woman understands, at an explicit cognitive level, that This is not my ex-husband and He’s just trying to talk, he’s not wanting to start an argument.
Resistance: Relapse, Relearning, and the Frontal Lobes
The development of new and more adaptive cognitive, emotional, and behavioral responses will take varying degrees of time, depending on the amount of reinforcement the behavior has received, for how long, and in what contexts. It’s a bit like learning to drive in one car and driving that car for a decade or more, only to switch to another car and finding yourself reaching for a control that is either in another location or completely absent in the new automobile. You know at an explicit level of awareness that it isn’t there, but when you’re not paying attention it feels as though you can’t help but reach for it. Your body “knows” it ought to be there, and your bodily responses may be quite at odds to what you know verbally. Learning to feel comfortable in the new vehicle will take place gradually, and at the beginning of the process will require more effort and attention. It is not so much a matter of unlearning the old behaviors as of modifying existing behaviors and placing new patterns of responding atop the old ways of responding, modifying some existing pathways and establishing others. Even as new behavioral and emotional ways of responding are laid down in the nervous system (and the repertoire of the individual), there will be times when the old patterns re-emerge and wreak havoc on the perceived progress that the client has made. Maroda, when confronted with the question as to whether psychotherapy will be a cure for whatever issue is being addressed, comments that she tells clients “that no matter how much better they get, under duress, the old fears, bad habits, and negative attitudes will return”. The neurological explanation for this may be due to the degree of involvement of the frontal lobes and executive control this portion of the brain must exert upon other underlying structures during the learning process, especially in its nascent stages. As was mentioned above, the basal ganglia circuits that are potentially responsible for the acquisition of many socially relevant behaviors receive input from all regions of the cortex, most notably from different regions of the prefrontal cortex, and these regions may be most critical for preventing resistance and explaining why it occurs.
Heterogeneously speaking, the prefrontal cortex is involved in working memory (keeping things in mind while they are being “worked on”), planning, understanding language, and generally adapting behavior to both the environment and the consequences of the perceived future. Historically, the prefrontal cortex has also been characterized by its capacity to adaptively inhibit emotional and habitual responses. This too is an important element to note when addressing change, resistance, and relapse in psychotherapy. Damage or inhibition of one or more of the subregions of the frontal lobes will frequently disinhibit a more emotional or habitual response from the individual. When the dorsolateral prefrontal cortex is experimentally inhibited via transcranial magnetic stimulation, language comprehension is significantly diminished, yet the ability to perform a language production task involving naming (arguably a well-learned and automatic capacity) is improved. Induced inhibition of the anterior prefrontal cortex by this method results in more activity in the amygdala (via the removal of inhibition) and also results in participants committing significantly more errors when they are required to follow rule-guided responses and override emotionally evoked responses.
Damage to the orbital frontal cortex (OFC) in human patients has long been implicated in emotional disinhibition since the case of Phineas Gage. The role of the OFC in inhibition has gained prominence more recently as a result of research on the neural correlates of social and emotional processing, with evidence suggesting that the lateral OFC “facilitates successful goal-oriented behavior by inhibiting the influence of emotional information in the context of physical sensation, selective attention, emotion regulation, judgement and decision-making, and social relationships”. While experimental procedures that inhibit the functioning of the frontal cortex (chemical or electrical inactivation, ablation, etc.) are unlikely to occur in the normal course of daily events, the main culprit that humans encounter out and about in the real world—and quite often when dealing with other humans in social contexts—appears to be stress, with even mild amounts of acute stress potentially undermining the executive functioning and inhibitory control of the frontal lobes. The frontal lobes, via the various subregions, assist in directing the basal ganglia to select and establish new associations and patterns of adaptive responding. When the prefrontal cortex is inhibited, more habitual verbal and emotional responses come to the fore. Encountering stress is inevitable in our day-to-day lives, and it appears that stress can be a potent natural inhibitor to the functioning of the prefrontal cortex, with relapse and what may appear to be resistance to change likely emerging at these times.
Neuro-Education as Explanation, Not Excuse
Attempting to approach this issue from a brain-centered perspective is not in any way meant to diminish the significance of the client’s subjective experience of difficulty in implementing and consistently maintaining behavioral, emotional, and cognitive change through psychotherapy. Instead, elaborating and clarifying this neurocognitive approach to the client is meant to normalize the experience of this phenomenon as well as highlight that the challenges of altering long-standing patterns of behavior are to be expected with a nervous system that safeguards what has been found to be most useful and adaptive for so long. This is the way the human nervous system functions: it holds on to what has worked and what has allowed the organism to remain adaptive in its environment.
The last two decades of neuroscientific research have revealed the mammalian brain to be a remarkably plastic organ, capable of astonishing feats of reorganization, and provided physiological support and an anatomical basis for what psychotherapists have long known—that the process of psychotherapy can produce lasting change. Neuroscientific research has also revealed the brain to be a multilayered and arguably multidimensional organ with systems that, while interconnected, appear to serve distinct functions and learn at different rates. The highest neural structures responsible for human forethought, cognition, and planning are built atop other structures whose primary function is rooted in the capacity to keep the organism alive and safe in the here and now (rather than in some abstract future time and context). It is largely inevitable that conflict would arise between these different systems with their disparate purposes, especially at times when the individual feels stressed and overwhelmed attentionally and/or emotionally. Providing information as to reasons for these conflicting emotions could make an immense difference in helping the client weather the behaviors that may emerge, the emotional responses they produce, and the setbacks they may incur, allowing clients to be more patient and gentler with themselves during the process of psychotherapeutic change. Ginot nicely summarizes the usefulness of such neurocognitive insight, which provides a clear mechanism behind the patterns that the client and the therapist may observe:
Often, becoming aware of how various parts of our mind work together—how we automatically resort to defensive and self-protective behaviors, how we do not learn from our current situation and still cling to old patterns, how susceptible we are to negative affective states and their attack on our sense of self—is the most important part of making the unconscious conscious.