Should therapy treat the brain or the mind?

A false dichotomy, but an important theoretical question

Photo by Cottonbro on Pexels

Hey there everyone —

I’m traveling this week, so I thought I’d re-post something I wrote in the early days of this newsletter, because I’m guessing a number of you haven’t read it.

The post talks about the ways therapy at once positions itself as if its treatments are able to help everyone in the same way, and at the same time recognizes that the context through which the person in therapy understands who they are, their identities, their relationship to power and privilege, and what they need to claim or reclaim their power and agency is highly specific.

So there’s this tension, then, between the idea that a “treatment” can be applied in the same way, in all contexts, (universalism) and the fact that in doing so, the way the person understands what happened to them, and who they are in culture, is likely being sidelined or erased from the room, to allow the treatment to “work.”

In medicine, this tension is resolved by splitting: there’s a divide between the doctor, who treats the body as the source of disease, and the public health specialist, who takes on the same problem at the level of the population. By framing structural inequality as the source of “health disparities,” public health takes on the structure and frees the physician to just focus on heart surgery. The doctor doesn’t have to take into account the fact that the person getting heart surgery likely has hypertension because it’s a common response to chronic unrelenting structural violence—the doctor just prescribes the statin and moves on. The doctor isn’t tasked with solving for structural violence. What this means is that it’s unlikely the doctor will have been trained to look for the effects of structural violence in his or her patients before it shows up as a health condition.

When we look at the training of therapists, and the foundational disciplines from which therapists spring, we can see that many therapists are trained to think of themselves as “doctors of the mind.” When therapists talk about treating the “brain,” they are positioning themselves in the same theoretical camp as the heart surgeon. They are trained to look at the individual, or the family, but not to take on the system.

But therapists also talk about the “mind,” the source of narrative, meaning, and consciousness. We know that childhood sexual abuse shrinks the hippocampus, making it harder for traumatized folks to recall memories. We know it changes the amygdala, as well. But we also know that how we story the trauma we’ve experienced is inextricable not only from the family systems in which we were raised, by also the dominant culture’s representations of trauma and the subcultures that shaped our embodiment, our selfhood, our sense of possibility and futurity. We also know that clients don’t come to therapy and ask to fix their hippocampus; they want to know why the same story loops on repeat, why they don’t think they can change.

I’m fascinated by the ways therapy crosses the structural and the individual, the brain and the mind, the medical and the philosophical, and I think the love affair our dominant culture has with science and medicine means that too often, “universal” treatments are said to be “evidence-based,” while those that attend to power and oppression and systemic violence are not. What do we gain from neurobiology, and what is left out? What do we gain from attending to ideological violence and oppression, and how do we talk about larger structures and still leave room for the unexpected, the sudden burst of creativity, power, and against-all-odds transformation that happens at the same time?

In this earlier post, I talk about the different ideas about what the body “is,” in various treatment approaches, and how important it is to make these theoretical distinctions visible to ourselves, because they shape our ideas about what “healing” is and how it might happen.