Neuroscience Education as a Tool for Improving Stress Management and Resilience

Abstract

Beliefs about stress and coping can play a major role in mental health and resilience. For example, holding a belief that stress or emotions are controllable can improve resilience. One emerging strategy for shifting beliefs and enhancing resilience is neuroscience education (neuro-education or NeuroEd). This paper proposes a NeuroEd model of building resilience in which learning about how the brain regulates internal states like stress and emotions can boost resilience by shifting beliefs. Support for the model comes in part from growing evidence in pain management demonstrating that neuro-education can help reduce pain and disability, with recent evidence that it can also impact beliefs. This paper concludes by introducing a framework for translating neuro-education for pain management into neuro-education for management of other internal states, including fear and anxiety, cravings in addiction, and stress broadly.

Beliefs impact mental health and resilience

The idea that one’s beliefs can play a key role in one’s outcomes is not new [1,2]. For example, holding a belief that stress or emotions are malleable or controllable (sometimes referred to as “growth mindset”) can improve resilience [4–6]. Researchers have identified many types of beliefs and expectations that can impact mental health outcomes [3–9]. As reviewed below, these include beliefs about the usefulness of stress and emotions (distress beliefs) and about the malleability of these internal states (growth mindset), including beliefs about the likely course of ailment (prognostic expectancy) and about the effectiveness of therapy (treatment expectancy), as well as beliefs about one’s own capacity to cope with distress (self-efficacy). In general, positive or optimistic, rather than negative or pessimistic, beliefs and expectancies are related to resilience, mental health, and adaptive coping [10–13].

People who believe stress is harmful are at greater risk of negative mental health outcomes [14–16]. For example, in a survey during the COVID19 pandemic, viewing stress as a threat was positively associated with distress, whereas viewing stress as a challenge was positively associated with growth [17]. Promoting a stress-is-adaptive belief can help [6,18], for example by lowering cardiovascular [19] and endocrine [20] stress responses. Similarly, encouraging individuals to view emotions as helpful can lead to less engagement in maladaptive coping and better rebound after a distressing event [21].

Belief in the malleability of psychological states and personal attributes (growth mindset) is also linked with wellness and recovery [22–24]. Numerous cross-sectional and longitudinal studies have found that viewing distress as uncontrollable is associated with poorer mental health outcomes, such as depressive symptoms (reviewed in [5,25]). People with such “fixed mindsets” believe they cannot change their emotions or improve their abilities and are therefore vulnerable to helplessness and poor management of distress [26,27]. By contrast, having a growth mindset can reduce symptoms of depression and anxiety [28] and predicts better outcome of cognitive behavioral therapy for social anxiety [29]. Importantly, inducing a belief in the malleability of emotions leads to better emotion recovery from distress [30]. In a recent meta-analysis of mindset intervention studies, growth mindset had a medium-sized positive effect (d = 0.32) on mental health outcomes [24].

Relatedly, optimistic beliefs about one’s own abilities or about the potential benefits of treatment may also influence health outcomes. Belief in one’s own capability (self-efficacy) is critical for positive change and maintenance of health behaviors generally and is a key mechanism of symptom reduction in psychotherapy for anxiety, depression, and addiction [11,31]. Across multiple studies, positive expectancies, such as optimism and self-efficacy to cope, are associated with lower levels of posttraumatic stress symptoms [7]. Belief in the efficacy of therapy also impacts treatment outcome, as evidenced by the placebo effect [32]. Patients’ optimistic expectations of treatment are linked to downstream benefits in physical [33,34] and mental [10,35] health. For example, greater optimistic expectancy prior to cognitive behavioral therapy for depression predicted better treatment response [36]; and increases in treatment self-efficacy and in optimistic treatment expectancy throughout psychosocial therapy predicted reductions in anxiety symptoms and improvements in daily functioning [10]. Such positive expectancies can impact treatment outcome in part by increasing patients’ treatment compliance [31,35].

Neuro-education (NeuroEd) as a tool to impact beliefs and resilience

There is growing interest in neuroscience education as a means for improving mental health [23,37]. Many clinicians report that clients are eager for and can benefit from neuroscience education [38–40]. There is now a section in the Journal of Mental Health Counseling called “Neurocounseling” [41]. And there is a National Neuroscience Curriculum Initiative to improve the teaching of neuroscience in psychiatry residency programs [42].

Neuroscience information has a unique potential to persuade. Multiple studies demonstrate that neuroscience information makes explanations of psychological phenomena more appealing and convincing [43–46]. In one study, participants made more favorable judgments of a brief description of a psychological phenomenon when it was presented with a neuroscience explanation compared to no explanation, social science explanation, or natural science explanation [43]. Sometimes even a mere picture of brain imaging findings, compared to a bar graph of the same findings, can increase favorable judgments of scientific findings [45]. Thus, there is a certain “allure” or persuasive power in neuroscience information, and this allure may be leveraged for impacting beliefs towards resilience.

Neuro-education (NeuroEd) may plausibly impact beliefs about the usefulness of stress and emotions by illustrating that exposure to a feared situation or to manageable levels of stress can actually strengthen the brain’s coping circuitry [23,47,48]. NeuroEd can likewise enhance growth mindset, prognostic optimism, and self-efficacy, by demonstrating that “adults can change their brains”. Similarly, treatment expectancy can be improved by showing that “therapy changes the brain” [11]. Indeed, education about the malleability of biological mechanisms of depression has led to lower depression-related prognostic pessimism and to greater self-efficacy of mood regulation, even 6 weeks after the intervention [49]. Similarly, among participants with symptoms of social anxiety or major depression, those who received biomedical explanations of their symptoms reported lower feelings of helplessness than those who received cognitive behavioral explanations [50].

In mindset intervention studies, one way growth mindset is induced is often through neuroscience education, highlighting the ability of the brain to grow and reorganize [51]. NeuroEd is similar to these mindset interventions in its emphasis on neuroplasticity. However, NeuroEd takes this approach further and incorporates additional neuroscientific explanations (see Table 1) that can impact many additional beliefs and expectancies, such as self-efficacy and outcome expectancy. Furthermore, by boosting self-efficacy and positive expectancies, neuro-education may in turn increase treatment compliance [35,40,52].

Table 1.

Learning targets in neuro-education for pain translated into neuro-education for anxiety and addiction.

Pain Neuro-Education	Anxiety Neuro-Education	Addiction Neuro-Education
The pain network that is activated by tissue damage can also be activated by thoughts.	Real and perceived threat activate the same part of the amygdala [48]. That’s why the threat feels so real.	Real and perceived needs activate the same reward network [69]. That’s why the perceived need feels so compelling.
The pain system is “overprotective” and can sound the alarm in the absence of tissue damage.	The amygdala is “overprotective” and can sound the alarm in the absence of real threat [48].	The reward system can be “overdriven”, compelling us to seek past pleasures even if they are not pleasurable anymore [70].
As pain persists, the pain system can become more sensitive, leading to more pain.	As fear and avoidance persist, the fear network can become more sensitive, leading to more fear [71–73].	As addiction persists, the reward system can become sensitized, leading to more craving / wanting [70].
The brain can modulate pain (e.g., impact of context, expectations, mood, stress).	The brain can modulate fear (e.g., impact of context, expectations, mood, stress).	The brain can modulate craving (e.g., impact of context, expectations, mood, stress).
Brains are adaptable / trainable. Moving despite the fear of movement teaches the brain that moving is safe.	Brains are adaptable / trainable. Facing the feared situation helps strengthen the amygdala connections that make it easier to face the fear in the future [74,75].	Brains are adaptable / trainable. Abstinence helps the reward network return to normal [76].
Neural adaptation is likely to be slow. Persistence is key.	Neural adaptation is likely to be slow. Repetition is key [73].	Neural adaptation is likely to be slow. Prolonged abstinence is key [76].

Efforts are now underway to use neuro-education about addiction to help change people’s beliefs about drugs and to ultimately reduce drug abuse [52–54]. One-hour workshops on the neuroscience basis, risks, and addictive potential of commonly abused drugs increased high school students’ perceptions of the addictive potential and harm risk of drugs [54]. In another study, following a one-hour workshop delivered to almost 1,600 middle and high school students, 94% of students found the information helpful, 92% reported that it may influence their approach to substance use, and 76% reported that they would delay or reduce their substance use [53]. In this vein, Ekhtiari et al. [52] have produced a blueprint on how neuroscience education can be incorporated into intervention for addiction, and they have demonstrated that this add-on to standard outpatient therapy is feasible and can increase levels of psychological wellbeing [55].

Preliminary results from ongoing work at UC Irvine (Tabibnia, unpublished) parallel these findings in the context of stress and resilience. Immediately after attending a 45-minute lecture on the neuroscience of stress and resilience, 97% of 83 students in an undergraduate public health course reported that the neuroscience knowledge they gained can have a positive impact on their wellness. In a different survey, four or more days after 36 university students, faculty, and staff attended a 15-minute version of this presentation, 86% reported that the presentation greatly increased their belief that resilience can be learned (growth mindset) and 80% reported that it greatly increased their belief that they are capable of coping with stress (self-efficacy). In a different sample of 16 university students, faculty, and staff, a 25-minute version of the presentation led to a 13% increase in growth mindset (p=0.007), an 8% increase in self-efficacy (p=0.02), and a 7% increase in expected efficacy of psychological therapy for fear or anxiety (p=0.02), immediately after compared to immediately prior to the presentation. Follow-up controlled studies will examine the extent and moderators of the effects of NeuroEd on beliefs and mental health outcomes.

The NeuroEd model of resilience-building proposed here is that neuro-education can boost mental health and resilience by enhancing positive beliefs and expectancies (Figure 1). Thus far, I have reviewed evidence for the impact of beliefs on mental health outcomes and the impact of neuro-education on beliefs. Research is still needed on the impact of neuro-education on mental health outcomes; however, the pain management literature offers some important insights.

Figure 1.

Proposed model of neuroscience education (NeuroEd) as a tool to enhance resilience.

According to the NeuroEd model proposed here, neuro-education can boost mental health and resilience by enhancing positive beliefs and expectancies, such as positive distress beliefs (belief that distress can be beneficial), growth mindset (belief that psychological states and characteristics can change), self-efficacy (belief in one’s own capability), prognostic optimism (positive expectations about the likely course of one’s illness), and treatment optimism (positive expectations of treatment outcome). This model is consistent with “flexibility mindset” models of resilience that include “challenge appraisal of stress” (i.e., positive distress beliefs), coping self-efficacy, and optimism (i.e., positive expectancies) as the key motivational factors underlying flexible adaptation and therefore resilience [77].

Neuro-education helps people with chronic pain

Pain neuroscience education (PNE) is an approach that involves educating individuals with chronic pain about the neurophysiology of pain, with the goal of shifting their conceptualization of pain in order to reduce pain and improve functioning [56]. For example, in a double-blind randomized controlled trial, fibromyalgia patients who received two sessions of PNE, versus two sessions of “self-management” education, reported less pain, better physical functioning, and better mental health, 3 months after the intervention [57]. According to a meta-analysis of 13 randomized controlled trials, PNE for chronic musculoskeletal pain reduces pain, anxiety, disability, and healthcare utilization [58]. Remarkably, in a recent meta-analysis of randomized controlled trials [59], combining PNE with exercise therapy has achieved clinically important and at least medium-size effects on pain intensity (20% reduction), disability (−0.68 Hedge’s g), and kinesiophobia (−1.2 Hedge’s g), compared to exercise therapy alone. Similar effects have been found in a meta-analysis of PNE for fibromyalgia [60], in terms of pain intensity (standard mean difference [SMD] = −1.05), depression (SMD = −0.69) and anxiety (SMD = −0.71). (Note: For both Hedge’s g and SMD, 0.5–0.8 is considered a medium effect size.)

Emerging evidence indicates that PNE may also impact beliefs and attitudes about pain, coping, and therapy. In a non-randomized controlled trial of chronic musculoskeletal pain, PNE plus usual care was more effective than usual care in improving self-efficacy and decreasing pain at 4-week and 4-month follow-ups [61]. In a recent randomized controlled trial of U.S. veterans with chronic lower back pain, PNE compared to traditional education led to greater improvements in pain self-efficacy and in attitudes about pain [62]; even at 8-week follow-up, 69% of the participants in the PNE group showed clinically important difference in self-efficacy, compared to only 21% in the traditional group. PNE can also impact attitudes toward treatment for pain (whether treatment should address tissue pathology or psychosocial factors) immediately after and 6-months after intervention [63].

Part of the success of PNE has been attributed to the intervention’s focus on shifting knowledge structures about pain rather than simply providing information [56]. For example, one of the key learning points is that the brain’s pain network can be modulated not only by tissue damage but also by the mind (e.g., the athlete who gets injured during a game but does not notice it) – that just because there is pain, it does not mean there is injury. NeuroEd for anxiety and even addiction can similarly be designed to shift knowledge structures about fear and craving, respectively.

Translating neuro-education for pain into NeuroEd for fear, craving, and beyond

There is intuitive appeal in the idea that just as neuro-education can improve management of physical pain so too can it improve management of emotional pain. Less intuitive may be the adaptation of neuro-education for management of craving. However, management of emotions and management of cravings are not as different as often conceived. Self-reported craving and anxiety are often correlated, and they share a common neural substrate [64]. Similarly, the abilities to self-regulate in different domains, such as self-regulation of distress and of craving, share neurocognitive substrates [65,66]. Together these findings imply that an intervention that is effective for managing negative affect may be adapted for managing craving (e.g., addiction), and vice versa [67].

Table 1 offers a summary of key learning points of pain neuro-education [56] and how each point could be translated into a learning point for fear (e.g., in anxiety-related disorders) and craving (e.g., in addiction). For example, a key message in PNE is that the pain system evolved to err on the side of caution and can therefore be “over-protective”, sometimes sounding the alarm even when there is no tissue damage or disease – much like a smoke-alarm that goes off in the absence of a dangerous fire. NeuroEd for anxiety can adapt this to a message about how the “fear center” of the brain, the amygdala, can be “over-protective”, sometimes sounding the alarm in the absence of real threat. Similarly, addiction NeuroEd can describe how the reward system evolved to motivate us to repeat behaviors that previously led to a feeling of pleasure and that therefore it can be “over-driven”, compelling us to seek past pleasures even if they are not adaptive or no longer pleasurable.

In theory, NeuroEd has the potential to benefit those suffering from any ailment of self-regulation, whether it is dysregulation of fear and anxiety (e.g., generalized anxiety disorder, post-traumatic stress disorder), mood (e.g., major depression), craving (e.g., substance use disorders), or other impulses (e.g., gambling). It is even worth considering the application of NeuroEd to regulation of implicit and explicit biases, including racial bias, an effort that may ultimately impact our collective wellness and resilience. For example, such an intervention could illustrate how the amygdala responds differently to “outgroup” versus “ingroup” faces and how interventions such as positive contact may mitigate this bias [68].

Despite the potential benefits of NeuroEd, a possible downside is that it risks the dissemination of over-simplified neuroscientific accounts of psychological states (stress, emotions, etc.) that may lead to a misrepresentation of complex and often contentious models of brain function. The challenge of striking the right balance between scientific accuracy and general accessibility is endemic to the art of communicating scientific findings to the public. As with any method of disseminating scientific findings, the hope is that over time inaccuracies will be corrected (e.g., through peer review). To facilitate this process of correction and help reduce misrepresentation of science, NeuroEd materials could include citations so that other experts could evaluate the claims (see Table 1 for example citations) as well as disclosures that the information presented is a simplified version of the current science. It is also important to note that in this era of growing public interest in brain-related information, there will always be a risk of misrepresentations being spread as facts by non-experts. It is therefore incumbent upon the scientific community to take the lead in disseminating this knowledge, in an accessible and responsible way, in order to counter the potential for the spread of misinformation when non-experts attempt to fill the void.

Conclusion

Piecing together evidence from clinical, health, and social psychology on the impact of beliefs on mental health and resilience, cognitive psychology on the power of neuroscience information to persuade, and pain management on the benefits of neuro-education, this paper proposes a translation of the pain neuro-education protocol into a protocol for improving stress management, psychological resilience, and mental wellness broadly. NeuroEd is a highly scalable tool that could be used as an add-on in therapy or as self-help. It has the potential to benefit those suffering from any ailment of self-regulation, including dysregulation of fear and anxiety, mood, craving, and other impulses. In all cases, the benefits could include increased optimistic beliefs and expectations, which may in turn improve resilience outcomes. However, more randomized controlled trials are needed to determine boundary conditions, including individual differences such as clients’ needs and limitations.