Ascap, October, 1997, p
8-11
Goal Setting in Psychotherapy: A Contribution from Evolutionary Biology
"Please give me the strength to change
what can be changed
And
the patience to accept what cannot be changed
And the wisdom to tell the difference."
This is the chosen prayer of Alcoholics
Anonymous, and, even apart from alcoholics, much of psychotherapy is devoted to
helping patients with the components of this prayer. If there are no goals, there is no motivation. If goals are too high, there is failure. The process of achieving a
goal which is seen as worth while and not easy to achieve, but not impossible,
gives satisfaction and mental health.
No controlled study has proved this, but common sense tells us that it
is so.
Edward
Bibring (1953) was the first to emphasise that depressed patients can often be
seen to be clinging on to unachievable goals.
Klinger (1975) suggested that the biological function of depression is
to detach people from unreachable goals.
This view has recently been repeated by Champion and Power (1995). The unachievable goal is sometimes a
representation of the ideal self, which may deviate so far from the real self
that the resulting "credibility gap" is a source of stress. And so psychotherapy addresses itself to making
the ideal self more realistic (Moretti et al.,
1990). In more behavioural terms, the
object is to narrow the gap between aspiration and performance.
Our
evolutionary approach can clarify the relationship between unachievable goals
and mood change. To achieve this we need
two concepts: the
escalation/de-escalation strategy set (Archer and Huntingford, 1994) and Paul
MacLean's concept of the triune brain (MacLean, 1990, 1994).
Depressed mood is a de-escalating strategy
A common quandary of man and his ancestors has
been the imminent collapse of an enterprise, in which the resources already
invested seem not only insufficient to complete the task but are themselves in
jeopardy of being lost. In such a situation
it has to be decided whether to invest more resources in the expectation of
final success, or to cut one's losses and try to rescue whatever can be
salvaged from the failure. These two
strategies, which are conveniently called escalation and de-escalation (Archer
and Huntingford, 1994), are part of the inherited repertory of man, and come
into the category of archetypes (Stevens and Price, 1996), evolved mechanisms
(Buss, 1995) or fixed (modal) action patterns (Eibl-Eibesfeldt,
1975), depending on one's discipline. We
have proposed that the capacity for mood variation evolved in the context of
this strategy set, elevation of mood being related to escalation and depressed
mood to de-escalation (Stevens and Price, 1996).
Depressed mood is a lower level de-escalating
strategy
Paul MacLean (1985, 1990) showed that the brain
is not a single unit but has a three-level or triune structure. There is the lower level "reptilian
brain" which occupies the corpus striatum; the middle level "paleomammalian
brain" which is based in the limbic system; and the higher level "neomammalian
brain" which is represented by the neocortex. Each brain contains its own "central
processing assembly" or decision-making process for dealing with changes
in the environment. For instance, in
response to cold, the lower level may decide to shiver while the higher level
may decide to switch on the central heating.
Clearly, the decisions at the various levels interact, in that turning
on the central heating may either pre-empt or terminate shivering. In fact, if we were in the position of
"treating" shivering, we might ask: "Why has this person not
turned on the central heating?", rather than apply our remedies to the fasciculating muscles themselves.
In the
face of social adversity, the higher, neocortical
level makes what we would call a conscious or rational decision to escalate or
de-escalate. Higher level escalation
strategies involve "sticking to one's guns", deciding to "take
the matter further" or even to go to "the highest court in the
land"; higher level de-escalation
strategies take the form of either acceptance/submission or
escape/withdrawal. At the middle or
limbic level the strategy is manifested by emotion; escalation is characterised by anger or
indignation; de-escalation is manifested
by depressed or dysphoric emotion, which may take the form of shame,
humiliation, guilt, fear or the sense of being chastened. In the lower or reptilian brain the strategy
choice is between elevated mood and depressed mood. Elevated mood provides the basic resources
for escalation such as energy, confidence, optimism and rapid decision-making
capacity. Depressed mood blocks
escalation by taking away these resources, and it also alters thinking and
feeling in such a way that a higher level de-escalation strategy is more likely
to be adopted.
Depressed mood can be conceptualised as the downgrading of three
important biological variables:
resource-holding potential, which is an estimate of fighting ability and
is probably the primordium of human self-esteem; resource value, which is an estimate of the
importance of whatever is being fought over;
and entitlement, which reflects the state of ownership as opposed the
that of being an intruder on someone else's territory (Krebs and Davies,
1993; Archer and Huntingford, 1994; Hack, 1997).
The lowering of these three variables affects the climate of thinking in
the higher brain, inclining it towards de-escalation. The drop in resource-holding potential
favours an evaluation of not being able to succeed, the low resource
value reduces the desire to succeed, and the low sense of entitlement
gives the idea that the individual does not deserve to succeed. Thus, even if at the outset of the
decision-making process, an escalating strategy is adopted at the higher level
and a de-escalating strategy at the lower level, the influence of the lower
brain on the higher brain is likely to induce the latter to switch to a
de-escalating strategy. As a result, in
the normal course of events, there will be a co-ordinated, triune, de-escalating
strategy, and the effect of this is likely to be to resolve the conflict and to
exit from the social adversity. Then,
its work completed, the lower level de-escalating strategy may remit. If, however, for any reason, the
"depressive" influence on the higher brain does not succeed in
getting it to switch to de-escalation, the individual finds himself adopting
incompatible strategies at the different levels, and, in particular, the
reduction in resources due to the lower-level de-escalation prevents the
successful prosecution of the higher level escalation strategy and he is caught
in a chronic losing situation: the lower
level de-escalating strategy becomes both intense and prolonged, and it is then
that it is recognised as "illness" and given the label of depressive
state.
Causes of strategy mismatch
According to our model, the cause of depressive
illness is not social adversity, or losing, or failing, because it is normal
for human beings to lose and fail and to be confronted with adversity. Rather, the cause of depressive illness is
the failure of the triune brain to coordinate its response to social
adversity. A co-ordinated response
ensures either success or successful withdrawal\submission. Often one finds that higher level
de-escalation is being blocked for some reason, either in the patient or by a
third party. For instance:
1.
Higher level de-escalation is blocked by moral scruples.
When someone tries to maintain an impossible
position, or clings on to an unrealisable goal, we call it courage or
stubbornness, depending on whether or not we sympathise with the attempt. Pride, honour and moral scruples are all
reasons for continuing to escalate at the higher level in spite of crippling
de-escalation at the lower level.
In
other cases, the unrealistic aspiration may be to carry on life normally in
spite of illness or disability. Here the
doctor needs to make clear to the patient what should and should not be
attempted. In the case of the depressed
patient who is working longer and longer hours in an attempt to compensate for
depressive slowness and lack of concentration, it is useful to use the analogy
of a broken limb, and to say that the mind should be in a plaster cast until it
is time to start a gradual rehabilitation.
2.
Higher level de-escalation blocked by ignorance or misunderstanding.
Human submission (unlike animal submission)
involves obedience, or actively doing what the other person wants. Sometimes this is impossible. A dominant husband may insist on an
enthusiastic sexual response, a dominant wife may require that her husband give
up an involuntary tic. Sometimes the
patient does not know what to do to please the other: a husband did not want his wife to work
because he was afraid she would meet attractive men, but he was ashamed to
confess this fear, and so he criticised her for laziness and stupidity until
her depression made her unfit for work.
3.
Higher level de-escalation blocked by a third party.
A wife wanted to please her husband, who
insisted that she be at home on Saturday; but her mother, who was even more
powerful than her husband, insisted that she visit and do chores for her on
Saturday. Submission
to one involved resistance to the other.
She wanted to de-escalate in the two most important relationships in her
life, but she was not allowed to. In
this case the depressive illness remitted when her mother died.
4.
Sometimes the patient wishes to escape from an intolerable situation but
cannot do so. Extreme cases are
represented by hostages and torture victims, but minor domestic forms occur in
the school playground, the prison cell and even in the nuclear family. An emotionally battered wife may be unable to
leave because of fear, or because of love for a child.
5.
Middle level de-escalation blocked by a sense of injustice.
Many patients suffer insults and wrongs which
they cannot let go because of resentment or anger over the injustice of it
all. Recent cases of this kind in my
clinic include people sacked unfairly from their jobs, a father accused of
sexually assaulting his daughter, and parents who feel the education authority
has failed their children in some way.
These people feel beside themselves with anger, seething with murderous
rage (Gilbert, 1997). Even if they
choose to de-escalate at the higher level, they are still escalating at the
middle level of emotional reaction, and this prevents the resolution of the
lower-level de-escalation.
Identifying the conflict
At the higher level, there are many areas of
life in which escalating and de-escalating strategies are carried out
independently; for
instance, one may be escalating one's love life by pursuing an affair, while
de-escalating one's parental relationship by agreeing to give up smoking. At the middle level of emotional response,
there is still some variety, in that one can be depressed about one issue at
the same time as being angry about another - one can even be angry and depressed
about the same issue. But at the lower
level, the strategy is unfocused; it is an all or nothing matter, and affects
all activities and strategies.
Depressive mood is pervasive. How
does one decide which of the higher level escalations is producing a situation
which is causing this lower level de-escalation? This is one of the skills of the
psychotherapist. Suffice it to say that
it usually concerns one of the patient's salient goals or relationships. The connection between the blocked goal and
the depression is often not apparent to either the patient or to those close to
the patient.
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Alternative strategies
for dealing with social adversity
Brain level ESCALATING DE-ESCALATING
HIGHER LEVEL Conscious decision Conscious to fight to win decision to give
(neocortical)
or pursue goal up, submit
or escape
MIDDLE LEVEL Be:
angry Be:
chastened
indignant
put down
(limbic)
envious humiliated resentful (depressed emotion)
LOWER LEVEL Increase of energy Reduction of and confidence energy and confidence (striatal) (elevated mood) (depressed mood)
TABLE 1. Strategies to deal with social challenge or
adversity: escalating and de-escalating
strategies at the three levels of the triune brain (neocortical,
limbic and striatal). From
Stevens and Price (1996).
Striatal de-escalation plus limbic escalation = the hostile
depressive. Striatal de-escalation plus neocortical escalation = Edward Bibring's
(1953) depressives who cannot give up unrealisable goals. Striatal escalation plus limbic de-escalation
may give a mixed affective state (Swann et al., 1993).
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escalation of animal fights. In: Potegal, M. & Knutson, J.F. (eds) Dynamics of Aggression: Biological and Social Processes in Dya
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Gilbert,
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John Price,