there is a widespread belief that neuroscience represents a“next frontier” for psychology, and also widespread reluctance to adopt neuroscience principles in treatment, leading to enthusiasm for this discipline with often little clinical translation (Arbuckle et al., 2017; Cooper et al., 2019). Consistent with this, psychiatry residency training directors have reported an increase in neuroscience content in residency curricula but also a perception of the relevance of neuroscience to clinical practice in the future, rather than in the present (Roffman et al., 2006). Here, we assess the nature of this gap and begin to create bridges across it by (a) surveying mental healthcare professionals’ attitudes toward neuroscience and its clinical use and (b) describing a dialogue between a clinical practitioner and a translational neuroscientist as they consider the survey’s results.
Why Neuroscience
Advances in neuroscience have increased our understanding of neural correlates of mental illness and treatment, providing opportunities for integrating this knowledge into a biopsychosocial approach to clinical practice (De Raedt, 2020). Neuroscience can inform procedural aspects of existing interventions or indicate novel treatments. For example, neuroscience findings have led to optimized approaches to exposures for anxiety (Kircanski et al., 2012) as well as new interventions that directly target neural functioning, such as deep brain stimulation or transcranial magnetic stimulation (Lewis et al., 2016). Neuroscience knowledge can also inform a biopsychosocial integrated case formulation and psychoeducation for patients (Cooper et al., 2019; ; Ross et al., 2017). For example, for a patient with childhood trauma, a case formulation may include a prolonged stress response associated with dysregulation of related neurobiological circuits (e.g., hypothalamic-pituitary-adrenal axis) following early trauma (Ross et al., 2017). Patient-provider discussions of etiology may include neural vulnerabilities, such as amygdala reactivity (Stevens et al., 2017), among other contributing factors. Discussions regarding therapy mechanisms may draw on neuroscience evidence of neural plasticity, changes in the brain as a result of psychosocial treatment, and may include functional changes of neural processes associated with cognitive control and regulation of negative emotions (Porto et al., 2009; Ross et al., 2017).
Why Reluctance
Although neuroscience knowledge has value in clinical practice and research, several obstacles impede its use by providers, including terminology differences among researchers and clinicians (Siegle et al., 2019), reported need for additional training in neuroscience (Fung et al., 2015), concern regarding patient beliefs that biological entities cannot change (Gershkovich et al., 2018), and concern regarding the validity and reliability of neuroscience observations ().
The Current Project
In an effort to reduce obstacles to integrating neuroscience into clinical practice, the project objective is to inform and encourage continued inter-stakeholder discussion. Interviews of neuroimaging and mental health stakeholders have identified differing perspectives regarding the clinical application of neuroscience (Anderson et al., 2013). In light of diverging stakeholder perspectives, additional empirical data as well as a discussion between stakeholders in a public format, to encourage a climate of transparency and reciprocity (Illes et al., 2010), may be beneficial. For the current project, we surveyed mental healthcare professionals’ attitudes toward neuroscience and its clinical use and provided survey results to inform a dialogue between a translational neuroscientist and a clinical practitioner. The neuroscientist-practitioner dialogue provides bi-directional opportunities for continued progress toward translation, as neuroscience findings can inform clinical practice and clinical observations can inform clinically relevant neuroscience.
The project was specific to Association for Behavioral and Cognitive Therapies (ABCT) affiliates, as discussions regarding neuroscience’s role in clinical practice and research have been ongoing within the organization, with diverse opinions represented. One salient example of ABCT’s diversity of opinions was a public discourse on the topic spanning articles of the Behavior Therapist. A 2015 special issue of the Behavior Therapist, entitled “The Biomedical Model of Psychological Problems,” included a series of articles that highlighted limitations and controversies with neurobiological research and its application to clinical practice and the larger clinical psychology discipline (). The Neurocognitive Therapies and Translational Research (NTTR) Special Interest Group (SIG) later provided a public response to the criticisms presented in that special issue and outlined opportunities for integrating neurobiology into psychological research and treatments (Price et al., 2015). The 2015 discourse on the integration of neuroscience into clinical research and practice is just one example among a number of other articles within the Behavior Therapist expressing critical or favorable views on the topic (Feldman, 2002; Hickey, 2014; Hsu, 2017; Ilardi, 2002; Kircanski, 2017; Pearson et al., 2017; Richards et al., 2011; Richey et al., 2013). To our knowledge, despite seemingly diverse opinions present within ABCT, no survey regarding the clinical application of neuroscience has been administered within the organization. Thus, the organization’s landscape of opinions is unknown.
Survey
To obtain information about ABCT affiliates’ knowledge of and attitudes regarding neuroscience, we administered an anonymous survey on neuroscience and its application to clinical practice. The survey contained demographic and multiple-choice questions pertaining to neuroscience research and its clinical translation, prior clinical experiences, and clinician identity. For developing the survey, NTTR SIG leadership generated a list of potential questions, and the discussants decided which questions would be included. Survey questions are listed in the online supplementary document (https://www.neu-rocognitive-therapies.com/the-behavior-therapist). Members of the NTTR SIG leadership later wrote multiple-choice options for the questions. For recruitment of survey responses, we sent emails to the ABCT list serve and ABCT’s Dissemination and Implementation (DIS) SIG list serve. We included the DIS SIG list serve in recruitment because multiple survey questions asked opinions about implementation. The emails contained a brief study description and link to the anonymous survey. We also posted a study description and survey link to ABCT’s Twitter and Facebook pages. The University of Pittsburgh’s Institutional Review Board approved survey administration. We obtained survey responses from 109 mental healthcare professionals affiliated with ABCT. Figure 1 provides a summary of survey responses; author impressions of responses are presented alongside related sections of discussant dialogue. More detailed results are available in online materials (https://www.neurocognitive-therapies.com/the-behavior-therapist).
Figure 1.
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Survey results as well as discussant and author impressions of results should be considered in light of methodological limitations such as small sample size and potential for selection bias. The sample (N = 109) is a small subset of ABCT affiliates. For comparison, the ABCT social media platforms used in recruitment have between 9,000 to over 13,000 followers, suggesting the sample represents less than 1% of the population of interest. In addition to small sample size, survey responses may be subject to selection bias, as people who are interested in neuroscience may be more likely to participate in a survey about neuroscience, resulting in more favorable responses. In an effort to obtain more representative results, recruitment emails and posts included neutral language, with the purpose stated as “to understand mental healthcare professionals’ attitudes toward neuroscience and neuroscience-informed clinical interventions.” In addition, we chose recruitment sources we believed to be more neutral regarding the topic and did not recruit from the NTTR SIG’s social media accounts or list serve. Despite methodological limitations, survey results provide a preliminary assessment of opinions among ABCT affiliates and an opportunity for continued inter-stakeholder dialogue.
Discussants
Jacqueline B. Persons, Ph.D.
Dr. Jaqueline Persons is the founder and Director of the Oakland Cognitive Behavior Therapy Center and Clinical Professor in the Department of Psychology at the University of California at Berkeley. Dr. Persons is a private practitioner, clinical researcher, teacher, supervisor, consultant, and author. She specializes in CBT for anxiety and mood disorders, and provides training in CBT and consultation for clinicians. She conducts research studying the change process and outcome of naturalistic CBT. She has authored three books on case formulation and CBT techniques more broadly. She is a past president of ABCT and the Society for a Science of Clinical Psychology.
Kerry J. Ressler, M.D., Ph.D.
Dr. Kerry Ressler is the Chief Scientific Officer and James and Patricia Poitras Chair in Psychiatry at McLean Hospital and a professor of psychiatry at Harvard Medical School. In his administrative roles, he oversees McLean Hospital’s research enterprise and works toward increasing the hospital’s integration of neurobiological research and clinical care. Dr. Ressler has published over 400 research manuscripts related to translational neuroscience, spanning molecular neurobiology, genetics, and neural functioning as it relates to fear processing and anxiety/stress disorders. He is a member of the National Academy of Medicine, is a past president of the Society for Biological Psychiatry, and is presidentelect for the American College of Neuropsychopharmacology (ACNP).
Editing Process
MS edited the dialogue text to (1) organize it thematically, (2) remove text that was not relevant to primary themes, and (3) remove text around interjections from other attendees (GS, AF, MS). Summaries of survey results precede related sections of dialogue. Summary statements represent author (MS) impressions of descriptive estimates (valid percent). Summaries describe ABCT affiliates’ knowledge of neuroscience and opinions regarding neuroscience research, clinician identity, prior clinical experiences, and practical considerations in neuroscience implementation.
Dialogue Between Drs. Persons and Ressler
First Impressions of Survey Results
Survey summary:
The majority of participants are knowledgeable of neuroscience, believe neuroscience is not outsidethe scope of mental health practice, and believe neuroscience aligns—at least moderately—with their clinician identity.
Persons:
It was encouraging to see people’s openness and receptiveness to neuroscience on the whole, which sounds like a contrast to the Behavior Therapist article and opinions from some years ago. An initial thought I have is that the question of “Are we receptive to findings from neuroscience?” is actually a larger issue, which is, “Are we receptive to all of the information that is available? Or do we need to hide ourselves from some of it?” That whole approach is unappealing to me, and I’m surprised that it would be appealing to scientists more generally. So, this openness and receptiveness seems important, both to the content area of neuroscience but also to learning and development, case conceptualization and understanding our patients, and understanding psychopathology more generally. The more we understand it, and of course neuroscience can add to our understanding, the more ability we will have to treat psychopathology effectively.
Ressler:
I, similarly, was pleasantly surprised by what I felt was a very positive overall response. It made me wonder if prior perspectives were specific to ABCT’s history or represent the split from the psychodynamic versus biological psychiatry movement in the 60’s and 70’s. It is true that early in the biological psychiatry movement, we understood very little about neuroscience. A model in which the brain is a “bag of chemicals” and you “take an SSRI to correct a chemical imbalance” isn’t accurate, nor is it a particularly useful model for understanding cognitive behavior therapy. But now that we have a much better understanding of neural circuits of emotion regulation, cognition, extinction, threat, and reward, we can start to have languages that are very similar across therapy and neuroscience approaches. There is the opportunity now for complementarity of fields that didn’t exist—at least to this extent—20 years ago and certainly not 30 to 40 years ago.
Discussing Neuroscience Findings With Patients
Survey summary:
The majority of participants discuss neuroscience findings related to emotion regulation and psychiatric disorders with patients, and the primary observed benefits are increased patient understanding and application of skills and increased engagement in treatment. Opinions are mixed regarding its effect on patient stigma.
Ressler:
There is a lot of power in psychoeducation for patients, to say “This is why we use this approach, because this is the way people’s brain and behavior work.” We can talk at the surface level about data on threat learning and extinction. “This is conserved across all mammals, a thing that we’ve evolved to do to keep us safe. Anxiety is an example where it goes awry, and these are the kinds of circuit mechanisms underlying fear and anxiety.” I think that gives a lot of validity for a patient to then have more buy-in to the therapeutic process because they can appreciate the broader picture.
Persons:
It reminds me of one of my patients with a history of childhood sexual abuse. The amount of shame that she has about her symptoms is just kind of overwhelming. So, when I talk to her about neural pathways, and “your brain learned to do this, and so of course, it does do it, and your experience fits with what we know about what happens with children who are exposed to these types of events. What you’re experiencing is, from that point of view, totally normal.” That idea is so grounding to her, and it’s so helpful and therapeutic. I wish I knew more and that I could tell her more than just that, but that’s what I’ve got. It’s very helpful to her.
Ressler:
I think in the same way, for people who might be in treatment and not engaged, for example with diabetes or hypertension or other illnesses that we know result from environment and biological interactions, the patient and clinician often know that there are things they could do to help improve their health, such as diet, exercise, and medication. There doesn’t have to be shame and guilt about it, it’s like “this is a disease, and this is what we do for it.” As we understand our psychiatric and psychological issues and the circuits involved in similar ways, I think that will also create more power for patients, as you said.
Persons:
Yeah, and it’s very anti-shaming. It’s like “Oh, these are the mechanisms and they work like that, and that’s just how it is.”
Response to Insufficient Empirical Support as Communication Obstacle
Survey summary:
The primary obstacle to communicating neuroscience with patients is insufficient empirical support.
Ressler:
One of the areas of neuroscience we know the most about is neuroplasticity and synaptic change and axonal change. For example, with CBT and trauma, there is a lot of evidence from animals to humans, of both dynamic changes in synapses as well as long-term structural changes regarding top-down regulatory circuits—the cortical areas that interact with and regulate the emotional areas. There’s a lot of evidence about how trauma disrupts such circuits, and how addiction disrupts them, and how rebuilding those networks and neural processes through therapy actually changes some of that connectivity at a functional level, and even at a structural level. I think there’s a number of papers that would be good for people to be able to know about, that show pre- and post-therapy neuroimaging both at a structural and functional level, for example. Just talk therapy rewires and changes the functional process of the brain. I think that could be a very powerful thing for people to be aware of and use in their communication with patients.
Persons:
Absolutely. What I need as a clinician is more access to those papers because I don’t read the neuroscience literature, so if there is some way where you all could write some review papers for tBT or post information about them on your SIG’s website to highlight those articles, that could be so helpful for clinicians. I need that information and more access to it to be able to use it, but the kind of evidence that you are describing, Kerry, is just the information clinicians need!
Neuroscience Resources for Clinicians and Next Steps For Integration
Survey summary:
Another commonly reported obstacle to communicating neuroscience with patients is uncertainty regarding how to provide information.
Ressler:
In terms of next steps, identifying ways for bringing useful neuroscience training in bite-size packages to therapists is going to be important. The NNCI, the National Neuroscience Curriculum Initiative (nncionline.org), was put together by a number of psychiatrists focusing on the same problem that we’re having in residency training. Even though residents and psychiatrists have medical training and have more of a biological training than most Ph.D. therapists, nobody can keep up with neuroscience unless one is a Ph.D. neuroscientist, and even we can’t keep up with the literature because it’s rapidly and exponentially growing. In trying to figure out how to better train residents, the NNCI program put together a lot of specific—both small and large—curricula, podcasts, and many things trying to bring together topics such as: “What’s the big question?” “How would an expert in the field talk about it?” “What are some critical experiments so that one could get good knowledge and trustworthy knowledge in bite-sized packages that would be useful for therapists and patients?” I think that’s one good model, and it would be great to think of ways to integrate that model into the therapy and psychology communities.
Persons:
That sounds like a super useful thing. When I was first approached for this interview, I said, “Well, I’m not sure I’m the best person to interview, because I don’t know anything about neuroscience!” Then Dr. Siegle told me I know as much as most therapists. But I just have little bits and pieces of knowledge, and I would like to have more. Maybe because I am interested in case conceptualization and the change process in treatment, I’m especially interested in change mechanisms. For example, if I am doing exposure-based treatment, and my goal is to accomplish expectancy violation, then what are the indices of change in my patient that I’m looking for and what neuroscience mechanisms are underpinning that? Because, if I understand that, it’s going to help me understand better the whole change process. The better the understanding I have of the change process, the more power I’m going to be having to notice when it’s going awry, whether we are making good progress, whether the patient is learning the right thing.
Ressler:
It sounds like it would be helpful having a resource that had relatively brief summaries of why it matters and then the full paper for people to read if they want. At least reporting that this is the literature that has been peer-reviewed, and it’s robust, could help in telling these stories and having a better understanding of these processes. And then, there’s other things like ketamine and other drugs that can enhance cognitive processing and enhance synaptic plasticity, which may allow enhancement of either the rapidity of exposure therapy, learning, or expectancy violation, or help conquer learning ties more fully. That is the theory behind combining ketamine with PTSD psychotherapy, that maybe it’s actually enhancing plasticity and thus enhancing the therapeutic learning process.
Persons:
Oh my goodness! See, now as soon as you tell me that, I have to get these papers. I am one of these people who’s hungry for knowledge. I just need the information. It sounds like there’s some other people who aren’t sure they want the information or that it’s helpful to them. Although, the survey results are encouraging in that regard.
Ressler:
My guess is that hesitancy to combine neuroscience and therapy is less about active avoidance, but instead, more find it scary or they think they’re not going to have time to learn this whole literature. “I don’t want to know just enough of something that then can be dangerous by telling my patients the wrong thing.” I think it’s partly having the right resources that they can trust.
Evidence Needed for Neuroscience Integration
Survey summary:
For neuroscience integration, the most common reported type of sufficient evidence were multiple randomized controlled trials (RCTs) and endorsement by a psychological society for treatments; prediction in clinical samples and relationship with standard measures were most common for assessments.
Persons:
Tome, some of the most compelling evidence is mechanism studies of the sort that Kerry is describing, that is, studies that show neural plasticity, and changes in brain mechanisms following cognitive and behavioral interventions. Those, to me, are especially compelling, and not the same as randomized trials, and far superior to endorsement by professional societies. I personally am very suspicious of endorsements. I’m exaggerating perhaps when I use the word “suspicious,” but what I mean is, I’m not interested in proof by authority. I’m interested in the data. But I want some studies of mechanism change during treatment. That would be the kind of evidence that would be especially appealing to me, but it wasn’t one of the response options on the survey.
Ressler:
Yeah, and I wonder if we’re conflating things in the way the question was interpreted as, “if there were a new treatment that was neuroscience-based, would you use it?” And then yes, I think it’s the right answer—you want to have RCTs to support the new treatment approach. But I really think there’s two conversations, or I guess three buckets, right? There’s a bucket of, “if there’s data that enhances one’s understanding of mechanism of what you’re currently doing for the therapists, would this help you in how you talk about it to the patient?” Separately, “would this kind of data help the patient for better understanding what’s happening to them and maybe enhance their alliance?” And then, third, “will understanding lead to new treatments in which therapies, and other kinds of biological-somatic interventions, could be combined for new approaches?” I think all of those are useful, but they may have interpreted that question as a bit of all three of those. I guess the flipside would be, “do 91% of people believe that there must be an RCT of knowing if neuroscience information is useful or not before they talk to their patients about neuroscience, the prefrontal cortical-amygdala circuits, the top-down regulation and extinction of exposure therapy. So then what would the trial be?” I guess you could have a group of therapists that just talk about “general psychology” principles versus those who talk about neuroscience. You could do an RCT on that. Whether that’s a fundable RCT or whether it’s worthwhile, I’m not sure. But it seems like there should be a place for some sort of mechanistic understanding if it’s supported in the right kind of mechanistic literature that could be helpful.
Different Empirical Standards: Neuro-Literacy vs. Neuroscience-Based Treatments
Survey summary:
“Multiple RCTs” is most commonly reported as the type of evidence sufficient for neuroscience integration into treatments. The question did not distinguish between neuro-literacy and neuroscience-based treatments.
Persons:
I think it’s a helpful distinction, but I would flesh out the neuro-literacy notion to distinguish studies of change mechanisms in treatment, and studies of mechanisms driving symptoms of psychopathology, which are different things. Both types of evidence, but especially studies of change mechanisms in treatment, would be especially useful to me as a clinician. I would probably want randomized trials if I’m going to endorse or adopt a new treatment. But to have evidence or information about psychopathology and how it works, and treatments that I’m already using and how they work from a neuroscience point of view, I don’t need randomized trials. It’s hard to even think of what the randomized trial would be, as Kerry pointed out.
Ressler:
Yeah, and I think another sort of nuance is there are going to be some areas for which science has made considerable advances, but others where we have much further to go. For example, you can point to a lot of the exact circuity behind the reflex in a panic attack that helps people understand why they have heavy breathing, why they are sweating, and why they are feeling like they have to run away and other panic/fear symptoms. Similarly, with addictive behavior—why the craving and the compulsion and how all of that works from a neuroscience perspective. From your earlier example, it can be very freeing to the patients who realize that this is the way my brain has become wired, as I’ve gotten stuck in these ruts. Again, the therapeutic mechanism of extinction may not be that downstream. It may be up-stream, top-down regulatory processes, but both of those could be very helpful. There are other kinds of disorders, schizophrenia, bipolar, and to some extent personality disorders, that we don’t even know or have much neuroscience about, so we might have to be more agnostic on those since the field just is not as far along yet with those disorders.
Concluding Statements
Persons:
I think neuroscience has great potential for helping us do better clinical work. I’m happy to see this translational effort going forward. Getting information about neuroscience to clinicians can increase the help we give to our patients.
Ressler:
I very much agree with that. For me, the concluding remark would be that while we absolutely have a long way to go—we certainly don’t have an understanding of the neuroscience of all behavior, of all psychopathology and all treatments by any means—the field is in a very different place than we were even just a couple decades ago in terms of having useful, explanatory neuroscience models that are well-supported by data. I do think some of this knowledge would be helpful to both the therapy community and to patients, both in reducing stigma and self-blame and in increasing treatment alliance by understanding these processes. Not to mention that once this conversation starts, I think it will then leverage and excite a lot more translationally relevant collaborations that I think will then help the next generation of neuroscience. I am very optimistic.
Survey and Dialogue Takeaways
Findings from the survey and inter-stakeholder dialogue highlight important considerations and practical recommendations for integrating neuroscience into clinical practice. One project takeaway is the importance of neuroscience educational resources for both providers and patients. Many participants reported having at least some knowledge of neuroscience with openness toward learning more. Dr. Persons similarly expressed interest and receptivity toward clinically relevant neuroscience findings in an accessible format. In an effort to provide more accessible education/training materials, we provide online resources (clinician-oriented neuroscience article repository, link to NNCI trainings mentioned in the dialogue, and videos of neuroscientists talking of the clinical relevance of their work) for interested readers (https://www.neurocognitive-therapies.com/the-behavior-therapist). In addition, incorporating neuro-literacy in patient care stood out as one immediate opportunity for clinical translation. Dr. Ressler provided several specific examples for incorporating neural processes of psychopathology and treatment-related changes in patient psychoeducation. Similarly, the majority of participants stated that they had communicated neuroscience with patients in the past and had observed benefits. The survey and dialogue also emphasize the importance of bi-directional inter-stakeholder feedback in translation efforts. Dr. Ressler highlighted that advances in the neuroscience of clinical phenomena such as extinction, reward, and emotion regulation have provided new opportunities for a complementarity of fields via a shared language. To capitalize on new opportunities for inter-field communication, it is important to receive clinician feedback and work to understand and communicate neuroscience findings in a clinical science framework. Consistent with this, Dr. Persons expressed wanting to understand the neural processes of expectancy violation to inform her exposure work for patients with anxiety, and participants expressed interest in research of treatment-related neural changes. The dialogue on defining sufficient evidence for integrating neuroscience highlights important areas for continued inter-stakeholder discussion regarding what research is needed for clinician use and what “integrating neuroscience into clinical practice” encompasses.
Footnotes
The authors have no conflicts of interest or funding to disclose.
Contributor Information
Marlene V. Strege, University of Pittsburgh School of Medicine
Jacqueline B. Persons, Oakland Cognitive Behavior Therapy Center and University of California at Berkeley
Kerry J. Ressler, McLean Hospital and Harvard Medical School
Rebecca A. Krawczak, University of Pittsburgh Medical Center
Angela Fang, University of Washington.
Philippe Goldin, University of California Davis.
Greg J. Siegle, University of Pittsburgh School of Medicine
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