Psychiatric Annals

CME Article 

A Social Brain Interpretation of Psychotherapy

John O. Beahrs, MD

Abstract

Mental dynamics vary profoundly with each person's social milieu. When these dynames are disordered, they can often be corrected therapeutically by skillful reframing of their functions within the milieu. By highlighting the workings of the social brain in psychotherapy, the use of a new concept, “sociodynamics,” can correct a conceptual flaw within current psychotherapy practice, point to research areas that are underappreciated in present-day psychiatry, and provide psychiatric practitioners with new guidelines for improving their work.

This article addresses problems inherent in the traditional psychodynamic framework, then summarizes the constituents and rationale of the proposed sociodynamics, and explains how this new research-based conceptual framework aids treatment planning and practice. All psychiatric treatment interactions, including psychotherapy, use social influence and its overlying sociodynamics.

The term “psychotherapy” refers to technologies intended to modify disordered psychological realities through applied social skills. Traditional “psychodynamics” attempts to interpret these processes through internal mental mechanisms, employing a metaphor of mechanistic causation rooted in classical physics. According to this model, a symptom's social effects seemed merely “secondary” gains and costs. Yet psychotherapy's proven efficacy and efficiency arise only because patients' “psychological realities” vary with their social context,1 which can be reframed.2,3 This reframability contrasts starkly with the context-free objectivity of entities within classical physics.4 Different causal rules must therefore apply.

Expanding on work by Sullivan,5 Berne,6 Erickson,3 Watzlawick et al.,7 and others, “sociodynamics” instead provides a perspective that grants relative primacy to external causation through social influence. Presented with a symptom complex, experienced clinicians who use a sociodynamic framework are likely to ask “What social payoffs do the symptoms provide?” and “What social reinforcers keep the symptom complex going?” This perspective allows external “interests” to take priority over internal “drives” as causal forces,8 and “adaptive modules” or “life strategies”9 to replace “defenses” as response determinants. Symptoms' social payoffs represent primary gains, not secondary ones.6,10 Underlying “mental states” secondarily and adaptatively occur, continually shaping and reshaping themselves to help each person optimize individual interests within the social surround.

Using this perspective, the social brain continually calculates and recalculates the person's best interests within his or her social milieu, assesses the strategic armamentarium for strengths and weaknesses, and selects those strategies most likely to improve the odds of optimizing the person's best interests. These processes occur largely outside of overt awareness; that is, they are partly unconscious.

When viewed as classical mechanisms, consciousness and volition turn out as highly anomalous, a fact that further undermines the mechanistic metaphor. Thus, unlike classical biophysical entities, they gain their definition not in terms of their component parts but by contrasting their polar opposites: “unconscious” awareness and “involuntary” action. As vivid as the opposing poles appear, attempts to separate conscious from unconscious or voluntary from involuntary lead to “A/not-A absurdities” in which one pole is shown to be “really” the other.4,11

For example, when a subject carries out a posthypnotic suggestion, the action often feels like the person's free choice, and the person sometimes vehemently rationalizes it as such.12 Conversely, the experience of nonvolition can be constructed easily through sequences of voluntary actions.1,13 In other words, experienced volition is “really” involuntary, and involuntary action is “really” voluntary.14 The same holds for conscious and unconscious. This leaves us with a paradox: how do the dualities of consciousness and volition with their opposites, though illusory, remain ubiquitous and virtually define human experience?

In addition, new data suggest that subjective volition can be decoupled from skeletal muscle movement, and does not cause it.12 “Volition” therefore must serve other functions, probably regulation of social interaction.12,14 The fact that these data contrast starkly with everyday experience suggests an…

Mental dynamics vary profoundly with each person's social milieu. When these dynames are disordered, they can often be corrected therapeutically by skillful reframing of their functions within the milieu. By highlighting the workings of the social brain in psychotherapy, the use of a new concept, “sociodynamics,” can correct a conceptual flaw within current psychotherapy practice, point to research areas that are underappreciated in present-day psychiatry, and provide psychiatric practitioners with new guidelines for improving their work.

This article addresses problems inherent in the traditional psychodynamic framework, then summarizes the constituents and rationale of the proposed sociodynamics, and explains how this new research-based conceptual framework aids treatment planning and practice. All psychiatric treatment interactions, including psychotherapy, use social influence and its overlying sociodynamics.

Psychotherapy and Sociodynamics

The term “psychotherapy” refers to technologies intended to modify disordered psychological realities through applied social skills. Traditional “psychodynamics” attempts to interpret these processes through internal mental mechanisms, employing a metaphor of mechanistic causation rooted in classical physics. According to this model, a symptom's social effects seemed merely “secondary” gains and costs. Yet psychotherapy's proven efficacy and efficiency arise only because patients' “psychological realities” vary with their social context,1 which can be reframed.2,3 This reframability contrasts starkly with the context-free objectivity of entities within classical physics.4 Different causal rules must therefore apply.

Expanding on work by Sullivan,5 Berne,6 Erickson,3 Watzlawick et al.,7 and others, “sociodynamics” instead provides a perspective that grants relative primacy to external causation through social influence. Presented with a symptom complex, experienced clinicians who use a sociodynamic framework are likely to ask “What social payoffs do the symptoms provide?” and “What social reinforcers keep the symptom complex going?” This perspective allows external “interests” to take priority over internal “drives” as causal forces,8 and “adaptive modules” or “life strategies”9 to replace “defenses” as response determinants. Symptoms' social payoffs represent primary gains, not secondary ones.6,10 Underlying “mental states” secondarily and adaptatively occur, continually shaping and reshaping themselves to help each person optimize individual interests within the social surround.

Using this perspective, the social brain continually calculates and recalculates the person's best interests within his or her social milieu, assesses the strategic armamentarium for strengths and weaknesses, and selects those strategies most likely to improve the odds of optimizing the person's best interests. These processes occur largely outside of overt awareness; that is, they are partly unconscious.

When viewed as classical mechanisms, consciousness and volition turn out as highly anomalous, a fact that further undermines the mechanistic metaphor. Thus, unlike classical biophysical entities, they gain their definition not in terms of their component parts but by contrasting their polar opposites: “unconscious” awareness and “involuntary” action. As vivid as the opposing poles appear, attempts to separate conscious from unconscious or voluntary from involuntary lead to “A/not-A absurdities” in which one pole is shown to be “really” the other.4,11

For example, when a subject carries out a posthypnotic suggestion, the action often feels like the person's free choice, and the person sometimes vehemently rationalizes it as such.12 Conversely, the experience of nonvolition can be constructed easily through sequences of voluntary actions.1,13 In other words, experienced volition is “really” involuntary, and involuntary action is “really” voluntary.14 The same holds for conscious and unconscious. This leaves us with a paradox: how do the dualities of consciousness and volition with their opposites, though illusory, remain ubiquitous and virtually define human experience?

In addition, new data suggest that subjective volition can be decoupled from skeletal muscle movement, and does not cause it.12 “Volition” therefore must serve other functions, probably regulation of social interaction.12,14 The fact that these data contrast starkly with everyday experience suggests an underlying deceptive component to the dynamics of our internal experience.

To resolve these anomalies, I hypothesize that the basic unit of human mentation must be more than a simple brain state existing in isolation. Instead, it is both sociodynamic, involving at least two primary interactants, and complex, occurring concurrently on more than one level. Two or more people must be in ongoing interaction — at least three, if the declarative content of their interaction is to spread throughout a population. In addition, the interactants must communicate concurrently on more than one level.

Berne6 differentiated “overt” from “covert” levels, corresponding roughly with what we call “conscious” and “unconscious.” Watzlawick et al.7 differentiated an overt “content” level that includes open information exchange, pastiming, and negotiation from a covert “relationship” level, a largely hidden web of mutual suggestion that defines the parties' personal identities and relative social status. Third-party observers generally ratify this formulation.3,7,15 Incongruity between these levels often provides focal points for psychotherapy.6 A particularly helpful therapist strategy includes searching patients' social networks for patterns of mutual suggestion, noting how they have become pathogenic, then pursuing ways to redefine and redirect them toward healthier patterns that also can become self-sustaining.4,15

Two Underemphasized Basic Sciences

Two basic sciences provide grounding for sociodynamics. Each enjoys a strong scientific tradition and a massive database, although contemporary psychiatry curiously underemphasizes both.

First, human evolutionary biology focuses on how natural selection shaped the foibles of “human nature.”16 Second, social influence research includes the study of persuasion, ideology, socialization, and advertising,17 with hypnosis research representing the paradigmatic set of data for this work.18 Evolutionary biology clarifies selective pressures that guided human evolution; social influence research describes mental phenomena that have evolved as adaptive strategies. The effects of psychological trauma constitute another set of specific scientific questions and treatment dilemmas that interestingly relate these two scientific databases both to one another and to neurobiology.

Reciprocity and Deceit

Among social species, homo sapiens is unique in the extent to which cooperation must be achieved in the face of conflicting interests.8 Reciprocity is the bedrock of cooperation among unrelated people. One benefits from doing another a costly favor, so long as the favor gets returned.19 This tacit contract is vulnerable to deceitful betrayal, which adds selective pressures to distinguish different people, remember their actions, reward cooperators, and punish defectors. Hence, one can predict the concurrent co-evolution of reciprocity, deceit, discriminative skills, explicit memory, police functions, and social emotions such as love and moralistic rage.20

Reciprocity also can become indirect.8 One can do good deeds without expecting return, for example, if one is thereby likely to be defined as a “good person” and therefore treated better by third-party observers. A new selective pressure for reputation, or “status,” therefore arises. Policing also takes on more indirect forms; witness the coercive power of social mores, through which defectors are ostracized and thereby denied society's benefits and stripped of power. One then can seek self-advantage only under the table. This leads to co-evolving skills at deception, detection of deceit, and new ways to deceive while evading detection. Self-deception is predicted to evolve through its ability to make verbal and non-verbal behaviors more congruent, thereby helping deceivers to evade detection.8,20

Mental Realities Based on Shared Self-deception

Anyone seeks relative advantage to the extent one can. Through direct reciprocity, one person may grant another a limited domain for autonomous behavior, expecting in return that one's own be held inviolate.14 We commonly label this tacit contracting positively, as “freedom” and “autonomy.” This creates and extends common interest and increases social bonding. Shared social self-idealizations and aversion to whistleblowers demonstrate such tacit contracts, usually concealed by shared self-deception.

To elaborate, one detects others' deceits but tactfully acts deceived, often denying the awareness even to oneself. This represents a subtle and very important point. The awareness remains, but is hidden even from its bearer. In larger groups, accurate awareness may become increasingly taboo, heightening the divided consciousness. This process predicts the anomaly of an “unconscious” that is “really” conscious at another level. I have hypothesized that such tacit contracting for reciprocal autonomy and shared self-deception contributes to “unconscious” awareness and “involuntary” action,14 to “psychological structures,”15 to social etiquette,21 to specific psychopathologies,22 and to the notorious suggestive malleability of our personal memories.23

Social Influence

Sociodynamics pervade all human relationships and manifest themselves most dramatically in poorly understood interactions that we call “hypnotic.”15,18 Hypnotists' illusion of control conceals a dependency on the subjects' response for what to do next, and subjects' illusion of nonvolition conceals the fact that they and only they decide whether and how to respond.24 These vividly experienced illusions reinforce one another in a folie à deux.15 When legitimized by third parties, the illusions become an emergent “psychological reality.”14,15

Social influence data17,18 show hypnotic elements pervade all waking mentation and social intercourse.1,4,11 All communication carries elements of overt information exchange and covert mutual suggestion in tension.3,4,6,7 One can no more avoid influencing and being influenced by suggestion than one can avoid communicating.7

Mutual suggestion creates entanglements that expand from dyadic interactions to determine an entire society's mores. Largely outside of awareness, individuals adjust their personal beliefs to these mores, which are sufficiently coercive that awareness of what is socially “taboo” tends to be suppressed in one's so-called “unconscious.”8,14,15,21 Psychodynamics thereby arise not as primary drivers but as secondary adaptations to the pressures of reciprocity in human evolution. People who fail to enact them competently do not adjust well, suffer, and impose their suffering on others. In other words, they develop what we call “psychopathology.”

The psychological anomalies described earlier arise from the necessary roles of deception and self-deception: what is inherently social and contractual becomes experienced as internal drives. Psychodynamics thereby do become “real,” at an emergent “psychological” level, through the vividness with which they are experienced, the extent to which they are shared, and the intensity with which they are mutually defended by all participants. They are further stabilized by subsequent “commitment” processes that make successful individuals more trustworthy.25 Once so stabilized, yet-unidentified neurobiological mechanisms will have evolved to implement these processes. “Consciousness” can then acquire new functions, such as long-term planning.8 “Volition” probably comes to mark those behaviors for which we hold offenders culpable.12,14 All cultures develop their idiosyncratic psychodynamic models, whose specific content vary over an ill-defined range.26

Trauma and Illness Status

Psychological trauma intensifies and rigidifies these processes. Re-enactment probably evolved as a learned phenomenon that promotes adaptive rehearsal for emergencies that recur episodically and occasionally, but in rapidly changing milieus, it takes on pathological qualities.27 It resembles chemical addiction and may operate through opioid, dopaminergic, and related systems that are activated by trauma and thereby serve to reinforce its effects.

Trauma also follows from ruptured relationships and notoriously extends throughout one's intimate circle through a type of “contagion.”28 Hypnotizability is enhanced,29 and patterns of mutual suggestion are driven by the added coercive power of traumatic affect. We often feel drawn either to “validate” others' traumas or to deny them, and either way, to denigrate those who do the opposite.30

Competing groups reinforce themselves with hypnotic-like folies à deux, each strengthened by enmity with the other. Each increases the trauma: ratifiers fan the flame (positive reinforcement); deniers suppress it (traumatizing those who seek social validation). Intractible conflict often results. The trauma response thus feeds itself at neurobiological, psychological, and extended social levels. Re-enactment is its fuel, without which slow learned cortical inhibition is more likely to prevail.31

Some traumatized individuals avoid lethal retribution from hostile dominants by adjusting their projected image down the hierarchy, thereby assuring social dominants of no threat. Like everyone, they employ adaptive self-deception to make their image more congruent. When driven by traumatic affect and socially ratified through mutual suggestion, the illness becomes real at the newly evolved psychological level.22 It is known that real illness and the illness role often diverge. This is particularly so for posttraumatic dissociative disorders.22 In these cases, in contrast to major mental illness, therapists may do better not to validate the illness role and instead maximally challenge patients' intact competencies.15,22,32

Psychotherapeutic Implications

Most psychotherapies, whatever their stated rationale, operate principally through sociodynamic processes. As we have long known, one's psychological state is affected by constitutional givens, neurobiology, experience, and social influence — Engel's biopsychosocial model.33 The sociodynamic perspective simply emphasizes the social pull more overtly, looking toward the mutual suggestion for sources of symptomatic behavior and focal points for therapeutic intervention.

Sociodynamic interventions use three anomalous aspects of psychological reality that follow from the theory and data summarized. First, a tension exists between our illusory but all-important sense of autonomous personhood and the hypnotic entanglements through which we're intertwined. Therapists respect autonomy by providing informed consent and contracting for treatment roles, goals, and behavioral safety in a way that concurrently uses indirect suggestion to imply optimum mental health to begin with.34 To do this, therapists recognize that mental realities vary with the act of defining them; this imparts a responsibility to reframe them so as to suggest positive change. Finally, causation works in both directions, defying attempts to define the primary cause, but in return, it grants the flexibility to intervene at “focal points” sometimes remote from the target of desired change.4

Breaking up self-reinforcing vicious circles is the key, and particularly relevant when traumatic reenactment is in play. Therapists may challenge individual patients to identify often subtle problem-maintaining reenactment behaviors, voluntarily abstain from them, and learn new coping techniques to relieve traumatic affect, just as is done in treatment of the addictions. Healthier patterns are further strengthened by supporting significant others in standing firm against patients' associated passive control.10

Intentionality of Patients' Narratives

Patients' narratives seem less the whole truth and more how patients want their audiences to perceive them. Keeping this in mind helps the clinician shift from less productive questions, such as a narrative's truth, and toward more productive questions, such as identifying the patients' social context and preferred strategies and how these work or don't work. Relevant questions include:

  • What does the particular patient want the therapist to believe?
  • How does this symptom predictably affect others?
  • What preferred strategies does the patient generally deploy? How do these cause problems in the patient's current milieu?
  • What principally reinforces the symptoms? How can the treatment redirect the reinforcement?
  • How can one help redefine this symptom complex so as to increase the odds of desirable therapeutic change occurring, as if by itself, and safely?

Such inquiries may help us identify focal points for potent interventions that can yield enduring benefit, even under the excessive systemic constraints that burden most psychotherapeutic practice.

Using Significant Others

Assessing and using patients' immediate social context provides great instruction to the treating physician. I often invite new patients' permission to bring a spouse or significant other to an early follow-up session, with explicit intent not to do couples therapy but to hear how the patients are perceived by knowledgeable third parties, extending the assessment to other perspectives.

Often, the other's report provides corroboration, but often not. When not, I may understand the context far more clearly, relatively soon, and interventions may become self-evident. Simply inviting the collateral visit respectfully implies an intention to keep the option open of viewing the problem from other perspectives than the presenting narrative only. This covert suggestion enhances therapeutic leverage for therapeutic change.

At times, therapists identify potent passive control dynamics, or “symptoms as power tactics,” against which the therapist may bolster significant others' ability to stand firm, thereby putting the ball back in the patients' court.10 Examples include referring families of resistant alcoholics to Al-Anon or those of patients who act out to a mental health center to learn “tough love” and related strategies. Desired change may rapidly ensue with neutralization of problem-maintaining social reinforcements. Most patients welcome family involvement. Even when they do not, many report accurately what family most likely would say, enabling therapists still to hypothesize what social payoffs are in play.

Implying Health and Competency

A quote attributed to Goethe says: “Treat a man as he is, and he will remain as he is. If we treat him as what he ought to be and can be, then he will become what he ought to be and can be.” This describes indirect suggestion, the “relationship message” from the therapist that tends to pull the person in a relevant direction.7 A parental approach implies patients' impairment, and invokes childlike mental states.6 Providing informed consent instead presumes the patients' ability to make personal decisions, implying health and competency whatever the diagnosis.34

Far more than just a legal obligation, giving informed consent is a potent therapeutic technique that pulls patients toward the greater health that the process implies.34 This process illustrates how treatment can use the suggestive component of communication even while negotiating at the most overt conscious level. Milton H. Erickson used this type of indirect suggestion most explicitly,3 although he stated it was just “common sense psychology.”

Transference and Standing Firm

Psychoanalysis — as a sociodynamic intervention — deliberately concentrates the interpersonal entanglement into a dyadic treatment relationship. “Transference,” as Freud noted,35 describes a hypnotic-like relationship in which patients reenact symptomatic relational schemas; these provide a focal point for a comprehensive working through. A critical feature to its efficacy entails the analyst standing firm against reinforcing the disordered schemata; this necessitates that patients use other tactics.10 In other words, the treatment interdicts and redirects vicious circles. Other techniques often accomplish this more efficiently, without the associated dependency.

Setting Therapeutic Boundaries

Eric Berne provided a paradigmatic antithesis to “why don't you, yes but” transactions. He suggested that therapists respectfully turn patients' conflicted requests for advice back onto the patients themselves, asking, for example, “That's an interesting problem; how are you going to solve it?”36 Condensed within this single communication, the therapist permits face saving, respects contrary motivations, speaks to more competent levels of function, declines to ratify a problem-maintaining behavior, asserts interpersonal boundaries, and redirects responsibility onto the patient. By declining to ratify perceived helplessness or to intrude on patients' autonomous domain, therapists lessen the risk of regressive dependency while enhancing their relational stimulus value. Paradoxically, by explicitly disavowing the role of essential change agent, therapists actually become potent stimuli for therapeutic change.

This dynamic may take on the qualities of a treatment modality in its own right, useful for posttraumatic disorders with extreme tension between help-seeking and help-rejecting behavior, otherwise at high risk of malignant regression.32 Thus, as therapists de-emphasize their role as primary change agents, turning responsibility back onto patients, they respectfully challenge patients to define who they are, what they stand for, and where they're headed. The very act of defining the patient's personal identity serves to redefine and thereby change it. This paradox exemplifies the reframability of psychological reality, sometimes providing the most effective, safe, and cost-efficient treatment for even very conflicted and high-risk patients.

Reframing

Strategic2,10,32 and cognitive37 therapies place more emphasis on reframability as a locus of change in its own right. Strategically, the therapist gains rapport at hidden levels through relabeling a liability as an asset, a setback as an opportunity, or resistance as autonomy, casting character traits in more favorable light, and cautioning that any change should be well informed and not done too hastily.2,3,4,10 Although seemingly paradoxical, appropriate positive reframing must be equally or even more true than the liabiltiy, must feel better to the patient, and must imply desirable behavior change.

Of course, for blatantly destructive and disrespectful behaviors, positive reframing has no place. Rather, one must confront those behaviors, while continuing to re-frame basic personal attributes positively.4

Training Recommendations

For psychotherapists to become well grounded in the data underlying the sociodynamic perspective, the basic sciences of evolutionary biology and hypnosis should find their ways into the core curricula of psychiatry and psychology. Within evolutionary biology, Trivers's and Alexander's work on reciprocity and deceit8,19,20 is pivotal for understanding the anomalies of consciousness and volition. A broad evolutionary framework for general psychiatry also is offered by McGuire and Troisi.38

It is equally essential that budding psychotherapists learn the core essentials of clinical and experimental hypnosis. They are thereby enabled to recognize and redirect hypnotic phenomena when they occur spontaneously, to master the therapeutic power and learn the limits of reframing within controlled settings, and to gain confidence in the full range of the applicability of this technique.3,4,15,18,24,39,40 Respected professional societies provide ongoing forums in all of these areas.

Summary

“Sociodynamics” describes the operations of psychotherapy more accurately than the traditional term, “psychodynamics.” Internal psychological states arise from external social causes, more than vice versa. Each person's brain calculates his or her interests in relation to the social milieu, assesses the strategic armamentarium for strengths and weaknesses, selects strategies likely to improve the odds of success, and brings beliefs, desires, and behaviors into congruence — all occurring largely outside of conscious awareness.

Two lines of research data particularly relevant to this process, evolutionary biology and social influence, both curiously are underemphasized in current psychiatry. These data point toward the likelihood that consciousness and volition arise as shared self-deceptions that promote social cooperation where interests otherwise conflict. This hypothesis predicts the otherwise anomalous duality of consciousness and volition, and confirmatory data from reciprocity, hypnosis, and psychological trauma converge to show that mutual suggestion mediates the social and psychological domains.

Most important, psychological realities vary with how they are socially framed. Psychotherapy is made possible by therapists' resulting ability to reframe patients' symptomatology in its social context. It may be rendered more effective and efficient by identifying social payoffs of patients' symptoms, using significant others, redefining patterns of mutual suggestion to imply optimum health, and identifying symptom-reinforcing behavioral complexes that can be modified at biopsychosocial focal points toward greater social functionality, behavioral safety, and personal well-being.

References

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Educational Objectives

  1. Describe how a sociodynamic model explains otherwise anomalous attributes of consciousness and volition.

  2. Explain the reframability of psychological realities.

  3. Discuss how disordered mental states can be modified therapeutically by reframing them within their social context.

Authors

Dr. Beahrs is professor of psychiatry, Department of Psychiatry, Oregon Health Sciences University, and retired staff psychiatrist, Portland VA Medical Center, Portland, OR.

Address reprint requests to: John O. Beahrs, MD, 3318 NE Hancock St., Portland, OR 97212, or e-mail intarts@teleport.com.

An earlier version of this article was presented at the annual meeting of the American Psychiatric Association, May 20, 2002, Philadelphia PA. Dr. Beahrs has disclosed no relevant financial relationships.

10.3928/00485713-20051001-06

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