Psychiatric Annals

CME Article 

The Social Brain in Clinical Practice

Johan Verhulst, MD; Russell Gardner Jr., MD; Beverly Sutton, MD; John Beahrs, MD; Jacob Kerbeshian, MD; John Looney, MD; Alan Swann, MD; Fred Wamboldt, MD; Group for the Advancement of Psychiatry Research Committee, 2005

Abstract

The concept of the “social brain” calls forth a brain that evolved in the selective pressures of social group living. Such a brain endows each person with complex propensities for dealing with the social environment expressed through formative relationships in childhood and continually shaped by social experiences. A growing body of research and theoretical thinking supports this view of the brain as the substrate of evolutionary, developmental, and ongoing, lifelong social interactions, embedded in an evolving cultural environment.1,2 This article focuses specifically on clinical psychiatry and treatment.

Medical specialties tend to be organized by organ systems. Since Griesinger's famous statement that “mental illnesses are illnesses of the brain,”3 psychiatrists have considered the brain to be their organ of interest. Indeed, psychiatrists presently need great knowledge of the brain's anatomy and physiology, with the molecular biology of information processing carrying special relevancy. However, the brain is hardly a closed system, and anatomy and physiology make sense only if one considers the brain in interaction with its environment. We have proposed that the primary focus of psychiatry is on the social brain — that is, the brain as a part of the human social environment.4,5

Although psychiatry proper deals with people, the social brain perspective extends to nonhuman animals. A broader biological definition holds the social brain as “the brain in interaction with conspecifics” (members of the same species). Indeed, the brains of all animals mediate their social and reproductive lives. Furthermore, it would be difficult to separate out a brain part or system not figuring in social interaction. For example, body posture, mediated by the motor system, exhibits great communicative effect for other members of a same species. Clearly, this perspective differs from conceptions that represent the “social brain” as a subset, focusing on portions that might be impaired in such disorders as autism, for example, where communicational impairments typify the condition.6 Such facets of communication represent fine tunings, whereas the concept in this issue reflects a more general view.

We have proposed that seeing psychiatry's core organ as the “social brain” refines and extends the basic science of psychiatry.4 In this article, we first briefly review the relevance of this perspective for understanding psychiatric disorders and their treatment, and for developing integrated, etiological models of psychiatric conditions. Then, we illustrate more elaborately how the concept of the social brain helps clinical practice, using depression as an example.

Social interactions structure the human brain, which seems elaborately designed to mediate social functioning. The brain conducts an ongoing process of interpreting the social situation and responding to it; thus, in turn, it influences the environment and alters the input it receives. Dysfunctions of the human social brain reflect cognitive-emotional interpretations and behaviors that are maladaptive to the social situation. From the disruptions of conduct disorder to the interpersonal alienation of schizophrenia, and from the troubled interactions of patients with personality disorders to the substance abuser's abandonment of norms and responsibilities, psychiatric symptoms are rooted in social discourse.

The communicative significance of symptoms often gains transparency in light of the brain's propensities for social adaptation. For example, despair, typically communicated by depressed people, may signal social appeasement, while manic patients express superiority and social dominance.7,8,9 These communications are pathological because they do not fit with the reality of the patient's situation. In a different social context, however, such messages may possess obvious adaptive meaning, not only as normal parts of interaction but also as positive features of social behavior. Even so, as we will discuss, even though a patient's response may be inappropriate, the social context often contains elements that meaningfully elicited the…

The concept of the “social brain” calls forth a brain that evolved in the selective pressures of social group living. Such a brain endows each person with complex propensities for dealing with the social environment expressed through formative relationships in childhood and continually shaped by social experiences. A growing body of research and theoretical thinking supports this view of the brain as the substrate of evolutionary, developmental, and ongoing, lifelong social interactions, embedded in an evolving cultural environment.1,2 This article focuses specifically on clinical psychiatry and treatment.

Medical specialties tend to be organized by organ systems. Since Griesinger's famous statement that “mental illnesses are illnesses of the brain,”3 psychiatrists have considered the brain to be their organ of interest. Indeed, psychiatrists presently need great knowledge of the brain's anatomy and physiology, with the molecular biology of information processing carrying special relevancy. However, the brain is hardly a closed system, and anatomy and physiology make sense only if one considers the brain in interaction with its environment. We have proposed that the primary focus of psychiatry is on the social brain — that is, the brain as a part of the human social environment.4,5

Although psychiatry proper deals with people, the social brain perspective extends to nonhuman animals. A broader biological definition holds the social brain as “the brain in interaction with conspecifics” (members of the same species). Indeed, the brains of all animals mediate their social and reproductive lives. Furthermore, it would be difficult to separate out a brain part or system not figuring in social interaction. For example, body posture, mediated by the motor system, exhibits great communicative effect for other members of a same species. Clearly, this perspective differs from conceptions that represent the “social brain” as a subset, focusing on portions that might be impaired in such disorders as autism, for example, where communicational impairments typify the condition.6 Such facets of communication represent fine tunings, whereas the concept in this issue reflects a more general view.

We have proposed that seeing psychiatry's core organ as the “social brain” refines and extends the basic science of psychiatry.4 In this article, we first briefly review the relevance of this perspective for understanding psychiatric disorders and their treatment, and for developing integrated, etiological models of psychiatric conditions. Then, we illustrate more elaborately how the concept of the social brain helps clinical practice, using depression as an example.

Psychiatric Conditions as Disturbances of the Social Brain

Social interactions structure the human brain, which seems elaborately designed to mediate social functioning. The brain conducts an ongoing process of interpreting the social situation and responding to it; thus, in turn, it influences the environment and alters the input it receives. Dysfunctions of the human social brain reflect cognitive-emotional interpretations and behaviors that are maladaptive to the social situation. From the disruptions of conduct disorder to the interpersonal alienation of schizophrenia, and from the troubled interactions of patients with personality disorders to the substance abuser's abandonment of norms and responsibilities, psychiatric symptoms are rooted in social discourse.

The communicative significance of symptoms often gains transparency in light of the brain's propensities for social adaptation. For example, despair, typically communicated by depressed people, may signal social appeasement, while manic patients express superiority and social dominance.7,8,9 These communications are pathological because they do not fit with the reality of the patient's situation. In a different social context, however, such messages may possess obvious adaptive meaning, not only as normal parts of interaction but also as positive features of social behavior. Even so, as we will discuss, even though a patient's response may be inappropriate, the social context often contains elements that meaningfully elicited the symptomatic communication.

Moreover, because statements, postures, and actions socially communicate for people afflicted with conditions such as depression and mania, they possess great meaning for the people in the patient's environment. Consequently, the psychiatrist may consider the common meanings of the patient's verbal and nonverbal messages rather than merely disregard them as signs of pathology.

Traditionally, psychiatric symptoms trace back to intrapsychic processes, or to events in the patient's “inner life.” However, one's inner life emerges from, and grows through, relationships with others. One's sense of identity and ego develop in interaction with how one is defined by others; the “id” mostly represents fundamentally adaptive social impulses for sex, status, attachment, and other relational proclivities; and the “superego” represents internalized social norms. Personality traits represent patterns of social perception, expectation, and behavior. In fact, even the hermit's actions, thoughts and feelings perform before an “audience” of internalized people.

The social brain concept entails the integration of personal, social, and organ-cell biological processes, whereas the notion of a “mental life” reinforces an unbridgeable chasm between biological and psychological phenomena. This chasm pervaded 20th century psychiatry and related disciplines yet has increasingly lost plausibility with research advances on every one of these levels. Of course, saying that psychiatric disorders reflect disturbances in the interface between brain and social environment does not imply that their etiology lies exclusively in the social brain domain. Hypothyroidism, stroke, or drugs affect the brain. However, because social interactions formed the organ, the symptoms of these conditions possess interactional meanings and relational repercussions.

Treatment of the Social Brain

Psychiatric symptoms disturb one's social life. Therefore, healing the patient's interactions with the social environment represents a primary goal of treatment. The brain — the organ that interprets the social environment and responds to it — can be influenced therapeutically through different channels. One strategy uses chemical compounds to target social brain processes, changing how the patient perceives the social reality and acts in it. A different strategy might be to influence the social brain through verbal engagement (psychotherapy) or by altering the input from the family or another social network. Sometimes, the brain's capacity for adaptive social behavior can be restored by treating an underlying medical condition such as hypothyroidism. (Note that, even with such an etiological treatment, the patient may still need personal assistance in healing the relationships, damaged during illness.) Although somatic treatments may target specific subcortical areas and psychotherapy may work primarily through the prefrontal cortex, these areas interconnect to form an integrated whole with the rest of the body, as well as with the social environment.10,11

A well-known example from primate research may clarify these points and illustrate the interface between brain physiology and social interaction. Dominant animals in groups of male and female vervet monkeys living in cages possess dramatically higher whole blood serotonin as long as they regularly receive submissive signals from other males in the cage. However, if a serotonin-affecting antidepressant (fluoxetine) is adminstered to a low-ranking male, he is likely to assume a dominant position.12 This example usefully links normal brain physiology with social behavior. It even provides a “language” for discussing some forms of depression with the patient. Indeed, it suggests possible etiological pathways (changes in neurotransmitters leading to social dysfunction and vice versa), provides a rationale for pharmacologic and psychotherapeutic treatment, and can guide the patient's ideas about recovery and side effects. Thus, when the recipient of serotonin-affecting drugs behaves more assertively, he or she elicits countervailing responses in the social world, so that relationships may need to be renegotiated or the treatment modified.

An important asset of the social brain perspective is its potential to facilitate discussion between doctor and patient. If one wishes the patient to trust in, and be committed to, a treatment plan, one needs to first establish a shared understanding of what the problem is and why a particular treatment approach is proposed. Furthermore, an explanation in terms of normal brain physiology and its social expression carries a different and more positive meaning than simply labeling the disorder and attributing it to “a chemical imbalance.” Because the latter is a vague construct, devoid of scientific meaning, it incites in the patient idiosyncratic and sometimes antitherapeutic fantasies of where that imbalance might come from and what it implies.

Psychiatry has long recognized that social interactions influence mental symptoms and that even the most biological of treatments can be enhanced or undermined by what happens in the doctor–patient relationship.13 The sometimes extraordinary placebo effect exemplifies this.14 Consequently, an essential practitioner attribute is skill in establishing rapport and forming a therapeutic alliance with the patient. Indeed, psychiatrists normally must demonstrate proficiency in this skill to gain psychiatry board certification.

Psychiatry and the Adaptations for Living in Social Groups

Almost a century ago, biologist D'Arcy Thompson succinctly stated, “Everything is the way it is because it became that way.”15 This is true ontologically for any one individual but also spans evolutionary time, as our ancestors bequeathed their characteristics through genomic inheritance, stretching back to the earliest living entities. The concept of the social brain derives from the notion that the evolution of the human brain has resulted from adaptations for living in social groups, leading to symbolic language and to the cultural environment that humans both create and adjust to. At any point in time, then, the social brain “is the way it is” because of several elements.

First, a person's social brain expresses evolutionary propensities for social interaction shared with other animals (as a result of having common ancestors). The expression of these propensities depends on “the nurturance of nature,” especially during childhood.16 Neglect or trauma can affect such ontogenetic expression dramatically.17 Ongoing life experiences further shape the brain, as well as the behaviors it mediates. Second, other people share these same propensities, which makes meaningful communication possible, and, through interaction, allows more or less stable patterns of social perception, experience, and behavior to develop. Finally, these patterns determine how one perceives and remembers the past, senses and appreciates the present, and anticipates future interactions and experience.

John Bowlby's ethological research18 represents work directly ancestral to this point of view. He established that infants demonstrate an innate propensity to seek and maintain proximity to a caregiver. The infant's behavior elicits specific parental responses in the adult and, in turn, takes shape from these responses. Although the attachment pattern that develops through these interactions shows some flexibility and may change with new experiences, it generally remains surprisingly stable over the life span. It structures one's subsequent social relations, from intimate partnerships to the doctor–patient relationship.19

Bowlby's way of thinking has proven valuable for psychiatric practice, and with the social brain concept we propose widening this ethological focus. Indeed, other social propensities qualify equally as adaptations to social group living.20,21 We expect high dividends from additional research on these common propensities, listed in the Sidebar (see page 807). Consequently, the construct of the social brain suggests a research agenda with direct bearing on clinical practice. This agenda, while addressing the full range of social propensities, should deploy modern attachment research as a model to be followed.

Sidebar

Human Propensities Related to the Social Brain22

  1. Humans are inclined to form attachments and to maintain closeness to a preferred partner.

  2. Humans tend to form alliances with others throughout the life span.

  3. Humans tend to adjust to existing social rank orders, and to insert themselves into new ones.

  4. Humans desire to pursue sexual encounters and to engage in them.

  5. Humans long to reproduce, to bring up children, and to assist others in the raising of their children.

  6. Humans care for relatives and for other people in need of help.

  7. Humans tend to identify with an “in-group” (eg, one's family and the religious, national, ethnic or other groups to which one belongs).

  8. Humans incline to exclude “out-group” people (ie, humans of other families, especially those belonging to different religious, national, or ethnic groups.) Members of the out-group often are demonized and treated with contempt or fear.

  9. Humans tend to defend personal territory, with occurrences on many levels of abstraction, from the body buffer zone (the point where another's approach becomes uncomfortable) to possessions and resources, and even to areas of expertise (one's “turf”).

Human Propensities Related to the Social Brain

Clinical Application: Evaluating Depression

To demonstrate the usefulness of the social brain perspective in psychiatric practice, we will turn to a common clinical task: conducting the initial interview of a patient with major depressive disorder. Overall, any psychiatrist is a “social brain psychiatrist” when interviewing the patient. The psychiatrist establishes rapport, focusing on the phenomenology and history of illness and its course, and exploring “the four Ps”: predisposing factors (family history, early childhood, and so forth); precipitating factors (stressful events and life situation); and perpetuating and protective factors (support structure, strengths and weaknesses). However, the social brain construct influences the interview in several areas.

First, the social brain concept facilitates consideration of the dynamic interplay between the “four Ps.” Indeed, it reflects a way of thinking in which the brain–environment system is parsed into social interactions at different levels of organization. Such a unifying perspective guides the interview so that the case formulation reached at the end likely involves causal links between these factors. Rather than a formulation consisting of a diagnosis and a list of intervening factors, the social brain perspective reaches for a tentative and hypothetical, yet coherent and etiological, explanation of the patient's condition. Such a formulation, stemming from the idea that psychiatric problems reflect disturbances of social interaction and that these interactions “are the way they are because they became that way,” takes on the causal structure of a story. The importance of having an explanatory hypothesis for the patient's condition will be discussed further.

The social brain construct also emphasizes the unity of nature and nurture and focuses on interactions23 and on the relationships between people, rather than keeping the clinician trapped in a tunnel vision that centers exclusively on intra-psychic dynamics or isolated biochemical processes. Further, it facilitates a special attunement to the relationship with the patient. Indeed, the concept implies that the psychiatric interview itself changes the patient's brain. Maximizing the possibility of exerting a healing influence and minimizing the risk of creating an illness-perpetuating experience therefore represent essential tasks of the psychiatrist. We will see that the deliberate pursuit of a therapeutic alliance with the patient possesses prime importance in this respect.

Pursuing an Explanatory Story

A psychiatric examination usually starts with a review of the presenting complaint; in this case, depressed mood. While exploring the phenomenology of depression, the clinician will pay special attention to how the patient experiences his or her social connectedness, as well as to how the social environment is responding to the patient's expressions of depression.

Generally, patients with depression experience a deep sense of social loss. Some report having lost a relationship and being left with a most painful void; others express primarily an inability to care and to love or a total lack of the capacity to assert oneself and to influence others. These patients feel isolated and excluded, as if they no longer belong to the social group. Earlier in this article, we presented some basic patterns of social interaction; it appears that the patient with depression experiences failure in all of them — failures of attachment, desire, resources, belonging, and status and respect. If that is the patient's perception of the social situation, understandably, he or she expresses defeat and communicates submission and appeasement in relationships with others. This produces important consequences for the course of depressive illness.

Although the sense of social loss and the communication of submission may typify patients with depression in general, the clinical presentation nevertheless varies endlessly. Sometimes the patient's perception of the social situation appears psychotic, or totally out of touch with reality, while at other times it reflects so many real losses and adversities that one easily relates to the depressed feeling. Deep depression may paralyze some patients, while others show anxious agitation and still others hide behind smiles and routine behaviors. In addition, some depressions are chronic and persistent, others limited to distinct time periods. Constructing an explanatory story for each unique clinical presentation requires the psychiatrist to explore the differential “weight” of various interacting etiological and contributing factors.

The following cases exemplify how the social brain's thinking and reasoning may help development of explanatory hypotheses. As these examples demonstrate, the social focus allows clinicians to formulate etiological hypotheses as stories of interactions over different levels of organization, rather than having to parse the clinical reality into different, separate, and even alien elements such as the brain, interpersonal conflicts and defense mechanisms, learning, attachment styles, stress or diathesis characteristics, and so on.

Case #1

Mrs. R developed melancholia with severe psychomotor retardation after the death of her pet canary bird. On examination, we could find no reason to suspect that her brain had been influenced by a general medical condition or by environmental chemicals; furthermore, this was her fifth episode of major depression. The discrepancy between the nature of the loss and the depth of her depression indicates clearly that the situational stressor of losing a pet had much less etiological weight than her natural predisposition toward depression. Thus, the canary's death triggered her condition, perhaps merely an eliciting factor or potentially signifying a much deeper disturbance of social attachment. In this case, however, no evidence showed how the attachment system might have been affected negatively by trauma or neglect during childhood, while the family history showed a high loading for mood disorders. This depression could be thought of as a recurrent, genetically inherited, medical disease.

Nevertheless, there was more to the case than it being a “medical disease.” When depressed, Mrs. R communicated total defeat, despair, and submission. How had her social environment, and especially her husband, reacted to such messages? As it happens, her husband initially tried to refute and counteract her position by trying to cheer her up and being extra affectionate. When his efforts failed miserably, he increasingly resented her stubborn self-devaluation. A pleasant man, he did not express anger and resentment directly. Instead, he would become distant and withdraw from the relationship. Consequently, whenever Mrs. S became depressed, her behavior would elicit the withdrawal of her primary relational partner, which increased her sense of social loss, escalated her depression, and potentially countered the effects of treatment.

In summary, this patient's story evokes an image of a social brain disturbance, probably influenced by a familial inherited condition. Experiencing a “minor” social loss triggered massive depression, then aggravated by her husband's response of withdrawal.

Case #2

Mr. T, in his early forties, became seriously depressed for the first time in his life after a series of losses. During the previous year, he was fired from his job, his father died unexpectedly, and his teenage son disappeared and remained missing.

Mr. T presented not with an “adjustment reaction with depressed mood” but with full-blown major depression. Consequently, it was important to consider how situational factors had impinged on a social brain somewhat vulnerable to depression from an (epi)genetic fragility or secondary to difficult attachment interactions in early life. A case formulation, composed of these elements, would support treatment with both psychotherapy and medications.

Case #3

Ms. A, a young adult woman, presented with major depression that she described as an exacerbation of chronic despair and “moodiness.” A history suggested that early childhood social interactions might have played an etiological role; she had been severely physically abused by both her parents. Research has shown that such experiences influence later depression and alter the levels of serotonin and other neurotransmitters in the social brain.24 Interestingly, Nemeroff and colleagues25 have shown that, when depression stems from abuse influencing the social brain during a patient's formative years, psychotherapy clearly outweighs antidepressant medication as the treatment of choice.

Major additional factors in Ms. A's depressive syndrome hinged on how she dealt with her moodiness and on how her social environment responded to it. Normally, children learn to operate in a mood-independent fashion; whether one is having a good or bad day, the same expectations are set, and the same performance is expected. This patient had learned, and had been allowed (from neglect), to live “mood dependently” — that is, on good days, she would try to accomplish whatever needed to be done, but on bad days, she stayed in bed, feeling all effort would be wasted anyway. However, staying in bed made her feel useless, guilty, and socially cut off, which increased her depressive mood.

Her mood-dependent behavior also revealed an inability to link her internal mood state with external life events. She wondered whether what she called “mood swings” indicated bipolar illness, even though she never experienced even modest hypomania. Her mood-dependent response style acted as a potent perpetuating factor during periods of major depression and needed to be addressed with activation and social rhythm psychotherapy.26

Reciprocal Influencing

The depressed patient's expressions of submission and defeat affect not only the immediate family or work environment; they trigger similar responses in physicians and therapists, thus leading to comparable depressive interaction patterns. In other words, depression readily induces countertransference in both professional and nonprofessional communication partners.

In an initial interview, the patient's expression of submission and despair first tends to elicit a feeling of compassion and the desire to help. (As a clinician stated, “I know that a patient is depressed when I find myself doing all the work during the session.”) In chronic and treatment-resistant depression, however, feelings of concern more likely give way to feelings of frustration because of the patient's stubborn and inflexible depressive communication. Healers may feel embarrassed by their own hostile response. Some overcompensate by showing extra compassion and intensified efforts to help. Others respond by retreating from the patient (as well as from their frustration) into a neutral and businesslike professional role, focusing only on medication management, for example. The therapist's response, of whatever type, will affect the patient's social brain and thus the course of the illness.

Indeed, the social brain concept emphasizes that — in a very concrete, biological sense — the diagnostic interview alters the patient's brain. Such influence is “for better or for worse”; at the end of the examination, the patient may have made a step towards healing or retreated further into illness. The psychiatrist therefore should make a deliberate attempt to ensure that the effects of the conversation are as positive as possible. Some psychiatrists adhere exclusively to an “objective, scientific-medical model” and define their role in terms of observing and gathering “data” without affecting the patient.27 Although these psychiatrists may decide not to recognize this, they nevertheless are influencing the patient's brain. Still, even if the psychiatrist makes no conscious attempt to monitor and direct that influence, whether it is positive or negative will depend solely on the patient's subjective interpretation of the psychiatrist's communicative behavior.

For the psychiatrist, a key area of influence during the initial interview concerns the interpretation of the illness. In the following discussion, we first emphasize the importance of doctor and patient reaching a consensus about the illness and its causes. Next, we call attention to the pervasive influence of sociocultural schemas on the formulation. Finally, we highlight the value of establishing a therapeutic alliance. In other words, what follows deals with the psychotherapy of the initial psychiatric interview.

The Story of the Illness

A crucial target of therapeutic influencing concerns the image that the patient has in mind about the illness experience.28 Indeed, humans have a compelling propensity to make sense of the world by constructing explanatory interpretations. Human conscious experience involves causal attributions. No patient enters a doctor's office without at least some hypothesis about what the problem is, where it came from, and what sort of help to expect, and no patient leaves the doctor's office without at least some reconsideration of that hypothesis.

Psychiatry is dominated by a diagnostic system, the Diagnostic and Statistical Manual of Mental Disorders (DSM). From the third edition on, the designers decided to avoid all etiological hypothesizing. Nevertheless, a psychiatrist always makes some implicit or explicit causal assumptions about a patient's condition. In the initial interview, the psychiatrist collects information and constructs an internal story of understanding that is then summarized in the formulation. A treatment plan appears to be rational and to make sense when it is congruent with the story of understanding.

Similarly, the patient and the family must construct some story about the problem and its origins. That story organizes all help-seeking and illness behavior. A prescribed treatment that does not fit with the patient's understanding is unlikely to be followed. On the other hand, if the patient and the psychiatrist can reach an agreement about the nature of the problem and its cause, the proposed treatment plan is likely to inspire confidence and adherence. Negotiating such an agreement is a core psychotherapeutic task in the initial psychiatric interview.29

It is useful to consider how the patient and the psychiatrist build their stories. At first view, it seems that the patient's story could be quite idiosyncratic, while the psychiatrist's formulation is assumed to be based on a fund of clinical knowledge and theoretical insights. Still, both the patient and the psychiatrist share cultural schemas about illness in general, and mental illness in particular, that play a role in the diagnostic process.

In Western culture, mental disorders as medical diseases commonly are distingushed from mental disorders as problems of living. These are basic schemas with implied causal attributions. They also involve social role expectations for everyone involved with the illness; for example, it is the physician's role to determine whether or not the illness is a medical disease and to prescribe the treatment. Having a disease usually accords the “sick role,” which exempts the patient from social obligations but also requires commitment to treatment.30 On the other hand, if the illness is due to “problems of living,” such as being trapped in an impossible situation or having developed unproductive patterns of dealing with the world, then the patient is considered responsible for his or her behavior and must take an active role in resolving the issues. Medications may provide symptom relief but the real work involves counseling and psychotherapy.

Any “story of understanding” or other conclusion that the psychiatrist conveys to the patient at the end of the interview is prone to trigger one of these cultural schemas and social role expectations. If the clinician talks about a “chemical imbalance in the brain,” the “disease” schema is likely to emerge. Concluding the interview with a proposal for psychotherapy, by contrast, may activate a “problem of living” schema. Because each schema comes with social role expectations, each influences the behavior of the patient (as well as the patient's family), thus changing the social brain and potentially determining the course of illness.

Clearly, the psychiatrist should aim for a diagnostic formulation that the patient can agree to and that, at the same time, taps into a cultural way of thinking and behaving that fosters healing and rehabilitation. To clarify this, we return to the examples of major depression described previously.

In the case of the patient with melancholic depression, the psychiatric formulation gives special weight to a probable hereditary predisposition, which made her sensitive to even minor losses. Such a formulation relates to the “medical disease” schema. The patient, however, sees her condition as an insurmountable problem of living. Because she is “stuck” in her story, her personal failings justify despair and foreclose the future.

Psychiatrists are very familiar with conditions where agreement is impossible because of a patient's psychotic interpretation of reality. The issue then becomes whether or not the patient can be cajoled into accepting treatment. In this case, the psychiatrist may try to convince the patient that the illness is primarily a “medical disease” with arguments such as, “Your experience and symptoms are fully described in the psychiatric handbooks. They are present in all the people that have this disease. Therefore, they are not uniquely related to you as a person. This is a disease that you have and not something you are.”

In addition, the psychiatrist may explain that, although this disease primarily requires medical/biological treatment, it is a disease of the social brain and therefore is experienced as a failing of social connectedness. In other words, interactions with others directly affect the illness. Therefore, focused psychotherapeutic interventions, directed at social interaction and behavior, may be indicated at some later point, both for healing and for prevention of relapse. Sometimes, however, no minimally workable agreement can be reached and the patient may need commitment to a hospital for safety and treatment.

Negotiating a shared story of understanding with the man who decompensated into a major depression under the weight of multiple losses is probably easier, as he is more than aware of needing help with the situational problems. He may still need to be convinced, however, that major depression by itself instills a sense of hopelessness and a lack of energy that often responds to medications.

The formulation of the case of the young woman with a history of severe abuse is more complex. One story concernes how the abuse and its concomitant biochemical changes caused a serious disturbance of the social brain, invoking a “disease” metaphor, but another story relates how her attempts at dealing with the trauma and with her social environment aggravated this disturbance, implying “problems of living.” The psychiatrist may wish to emphasize the problems of living (ie, her learned behaviors and dysfunctional interaction patterns). Indeed, overly eliciting a disease schema and the social role that goes with it risks ushering this patient toward a state of complete and persistent disability.

In summary, it is important that the psychiatric interview result in the construction of a story, a formulation about the problem and its origins, and a possible treatment plan that is agreed upon and shared by physician and patient. The interview should also induce hope, (ie, the perception that positive change is possible). Furthermore, the psychiatrist needs to be aware of the social schemas that are triggered by the formulation. Leaving the notion that a deep depression is a personal failing unchallenged, or allowing a patient to think of the illness as being primarily a medical disease when a “problem of living” approach fosters the best treatment, can have serious adverse consequences.

The Therapeutic Alliance

How does the psychiatrist negotiate a formulation with the patient? Clearly, this is a process that does not only take place at the end of the initial interview. Causal hypothesizing starts at the beginning of the interview, and the psychiatrist pays particular attention to areas with potential etiological relevance. The chosen line of questioning may already cue the patient in, suggesting either a “disease” or “problems of living” approach. Nevertheless, a discussion of the physician's story of understanding, as well as the patient's, is almost always indicated.

Regardless of the psychiatrist's skill in arguing the formulation of the illness, suggestions tend to be credible and potentially acceptable only in the context of a therapeutic alliance with the patient. In other words, negotiating the story of understanding must stem from an empathic and collaborative relationship.

Empathic interactions seem related to the propensity for social attachment. They express a capacity for symbolic sharing that may be an extension of the human touch. Psychiatric empathy involves an interaction pattern in which the patient self-discloses and the therapist expresses understanding, which leads to further self-disclosure. The skill of engaging in empathic interactions is essential for psychiatric practice.

It is not unusual, however, for the patient to reject a psychiatrist's attempt at empathic engagement. Usually this is because of distrust resulting from psychosis or from repeated experiences of empathy being used to hurt or exploit. In the case of major depression, it can be a result of the patient's inflexible position of despair and defeat and the continuous expressions of submission and appeasement. In such instances, the main focus of the psychiatrist's efforts may need to be on attempting to establish a basic alliance using expressions of empathy that do not necessarily invite empathic engagement by the patient.

Establishing an alliance connects with a basic human propensity to seek partners in dealing with life's challenges. Often the therapist can more easily tap into the patient's propensity to form alliances than the propensity to accept an empathic connection. Indeed, alliances are more practical and instrumental and less intimate. The psychiatrist may stress the professional nature of the relationship or acknowledge that the alliance is based on an exchange of money for help. In general, though, expressions of basic goodwill, acceptance, caring, and concern remain invaluable. Furthermore, establishing oneself as a professional who is knowledgeable about the psychiatric condition and is able to recognize the patient's experience has therapeutic value in helping to break down the patient's sense of disconnection and social isolation.

Summary

Aspects of the social brain concept have relevance in clinical practice on several levels. One application is in the common psychiatric task of the initial evaluation of patients with major depression. Specific case examples, while singular in nature, advocate a focus on interactions and social relationships, and evidence clinical gains from employing a unifying concept that bridges biological, psychological, and social phenomena and that facilitates etiological hypothesizing. These cases also highlight the value of the therapeutic alliance not only as a more pleasant and desirable context for an interview but also as an essential vehicle to reach a shared formulation and to influence the social brain directly.

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Educational Objectives

  1. Define the “social brain” as a conceptual tool for psychiatric practice.

  2. Discuss the value of the therapeutic story in clinical work.

  3. List three implications of the social brain concept for psychiatric treatment.

Sidebar

Human Propensities Related to the Social Brain22

  1. Humans are inclined to form attachments and to maintain closeness to a preferred partner.

  2. Humans tend to form alliances with others throughout the life span.

  3. Humans tend to adjust to existing social rank orders, and to insert themselves into new ones.

  4. Humans desire to pursue sexual encounters and to engage in them.

  5. Humans long to reproduce, to bring up children, and to assist others in the raising of their children.

  6. Humans care for relatives and for other people in need of help.

  7. Humans tend to identify with an “in-group” (eg, one's family and the religious, national, ethnic or other groups to which one belongs).

  8. Humans incline to exclude “out-group” people (ie, humans of other families, especially those belonging to different religious, national, or ethnic groups.) Members of the out-group often are demonized and treated with contempt or fear.

  9. Humans tend to defend personal territory, with occurrences on many levels of abstraction, from the body buffer zone (the point where another's approach becomes uncomfortable) to possessions and resources, and even to areas of expertise (one's “turf”).

Human Propensities Related to the Social Brain

Authors

Dr. Verhulst is associate professor emeritus, Department of Psychiatry and Behavioral Sciences, University of Washington, Seattle, WA. Dr. Gardner is past chairman, Research Committee, Group for the Advancement of Psychiatry, and clinical professor, University of Wisconsin Medical School, Madison, WI. Dr. Sutton is chairman, Research Committee, Group for the Advancement of Psychiatry, and director, Child and Adolescent Psychiatry Training Program, Austin Medical Education Programs, Austin TX. Dr. Beahrs is professor of psychiatry, Oregon Health & Science University, Portland, OR. Dr. Kerbeshian is clinical professor of neuroscience, University of North Dakota School of Medicine and Health Sciences, Grand Forks, ND. Dr. Looney is professor of psychiatry and behavioral science, Duke University Medical Center, Durham, NC. Dr. Swann is Pat R. Rutherford Jr. Professor and Vice Chair for Research, Department of Psychiatry and Behavioral Sciences, University of Texas Health Science Center, Houston, TX. Dr. Wamboldt is acting vice chair, professor of medicine, and head of the Division of Psychosocial Medicine, National Jewish Medical and Research Center, Denver, CO.

Address reprint requests to: Johan Verhulst, MD, University of Washington Psychiatry Outpatient Clinic, Suite 306, 4225 Roosevelt Way NE, Seattle, WA 98105; or e-mail verhulst@u.washington.edu.

The authors have disclosed no relevant financial relationships.

10.3928/00485713-20051001-05

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