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John M. Watkins, Ph.D. © 2010

On Aphasia, the Danger Situation, and Contemporary Efforts to Link Psychoanalysis and

Neuroscience

John M. Watkins, Ph.D.

Institute of Contemporary Psychoanalysis

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Abstract

Over one hundred years after Freud abandoned his Project for a Scientific Psychology, in

which he famously attempted to delineate the neural substrate of his emerging

psychoanalytic theory, recent scientific advances are leading to renewed efforts to

integrate psychoanalysis and neuroscience. The abandonment of the Project represented

a dramatic shift in Freud‘s focus of inquiry away from studies of focal cortical lesions

and toward a more expansive general theory of mental life and psychopathology. The

collapse of Freud‘s attempt to bridge neurology and psychology left a legacy of dualism

that remains with psychoanalysis and much of psychology today—a dualism that was

absent from his earlier neuropsychological work. Spanning Freud‘s neuropsychological

and psychoanalytic theories is a methodology based on the detailed analysis of single or

small series case reports; a method that remains at the heart of many critical historical

shifts in both psychoanalysis and neuropsychology. Intrinsic to this method is an effort to

make sense of individual experience. This paper explores the problems inherent in

bridging psychoanalysis and neuroscience by examining a single case report from the

perspective of two crucial points in Freud‘s career. First, early in his career, Freud

presented a neuropsychological theory relating brain structure to language and

perception. With this theory, Freud formulated a view of brain-behavior relationships

that still has currency today. Much later in his career, with no reference to the brain,

Freud reformulated his theory of anxiety in which he described the ―danger situation‖,

thus providing the paradigmatic precursor to modern attachment theories. Though absent

from much of modern neuroscience explanation, psychoanalysis provides a framework

that allows us to make sense of individual experience—the attachments, development,

and experience of a sense of self that shape and organize the emergent nature of our

perceptions, personal history, and memories, defining the intersubjective dimension of all

social experience

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Introduction

Soon after writing the Project for a Scientific Psychology in 1896, Freud

abandoned attempts to integrate neurology with psychoanalysis, even refraining from

publishing the Project. In its place, Freud developed his sweeping metapsychology,

together with a more modest method of observation in the psychoanalytic interview.

After a one hundred year hiatus, recent scientific advances have encouraged modern

neuroscientists and psychoanalysts to revisit the Project and to mount new efforts to join

neuroscience and psychoanalysis. These efforts have included influential papers by

neuroscientists examining the implications of neuroscience research for the future of

psychoanalysis (Kandel, 1998, 1999, 2005), as well as books and papers by

psychoanalysts applying neuroscience concepts to the psychotherapeutic process and,

more broadly, to the problems of development that concern psychoanalysts (cf. Pally,

1998; Pulver, 2003; Palombo, 2001; Schore, 1994, 2002; Solms & Turnbull, 2002; Stern,

2004). The direction of theoretical influence reflected in these efforts is predominately

from neuroscience toward psychoanalysis; that is, the effort has been to add neuroscience

to psychoanalysis, rather than visa versa, although the neuroscientist Kandel (1999)

ruefully observes that the integrated view developed by Freud ―still represents the most

coherent and intellectually satisfying view of the mind that we have‖ (p. 505).

The current interest in returning to the neurobiology of the Project is emerging at

a time of sharply declining influence of psychoanalysis on clinical practice and on the

broader culture (Kandel, 1999). Further, psychoanalytic metapsychology, the all-

encompassing general theory of mind and psychopathology first developed by Freud, has

been gradually supplanted in many contemporary psychoanalytic approaches by a focus

on the processes of the analytic relationship itself. These newer approaches, often

grounded in hermeneutic philosophy, rely on data that emerges directly from the

psychoanalytic relationship and emphasize relational concepts, including meaning,

mutuality, and intersubjectivity.

Recently, there is increased questioning, coming even from within relational, self

psychology, and intersubjective approaches, of whether hermaneutic and other

alternatives to psychoanalytic metapsychology have, in a sense, gone too far in excluding

neuroscience. One view holds that in rejecting Freud‘s metapsychology the new

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relational approaches have thereby lost the ability to provide a coherent view of the

human condition and as a consequence lost influence in the larger society (Kandel, 1999;

Strenger, 2006). Another critique points to new data emerging from attachment theory

and neuroscience research that supports a ―need to refashion a psychoanalytic metatheory

that is consistent both with the new research base and with a more fluid, mutual, and

constructivist view of relational change in adulthood‖ (Lyons-Ruth, 1999: 577). A third

view cites psychoanalytic case reports that are not easily accounted for without including

a neuroscience perspective, including case reports of patients with focal brain injuries and

learning disorders (Kaplan-Solms & Solms, 2000; Miller, 1991; Palombo, 2001). Even

in a mainstream textbook on psychoanalytic case formulation, McWilliams (1999)

presents a brief, but fascinating example of the interplay between human relationships

and brain injury (pp. 54-55).

Historical Obstacles. Any attempt to bring neuroscience into psychoanalytic

theory runs counter to three powerful historical trends. First, Freud‘s grand attempt to

formulate a psychoanalytic theory based on the contemporary neurology of his time

failed dramatically and, some would say, decisively directed psychoanalysis away from

brain-based explanation. Freud abandoned the Project early in his career, and never

returned to any of his efforts to incorporate neurological variables into the data base of

his theory (e.g., On Aphasia). Instead, Freud came to favor explanation that was

composed of mental constructs grounded in observations that emerge from the

psychoanalytic situation, including his self analysis (Breger, 2000). Although ideas

initially developed in the Project appeared in Freud‘s later writing (Basch, 1975; Holt,

1989: 215), there was no necessary mapping of Freud‘s later constructs onto specific

underlying neural processes. Moreover, his theory did not reference any specific

methodological or epistemological constraints that depended on fundamental biological

principles (e.g., natural selection), although the implication of a biological grounding

may have been assumed (Holt, 1965; Kandel, 1999; Solms & Salig, 1986; Sulloway,

1979), particularly in that portion of Freud‘s work referred to as the metapsychology

(Gill, 1976).

Second, Kohut, like Freud originally a neurologist, rejected psychobiology at the

same time he abandoned drive theory, setting in place a pattern that has been followed by

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subsequent relationally-based theories, including self-psychology, relational psychology,

and intersubjectivity. For Kohut, biological influences in psychoanalysis, represented by

drive theory, were eschewed because they produced, ―severe distortions in our perception

of man‘s psychological essence without yet achieving a true integration of analysis with

biology and medicine‖ (1982, p. 405). For Kohut, exploration of the domains of meaning

and of the physical world does not require the use of different methodologies and

languages. This position led Kohut to insist that he was employing a scientific method

when he described his cases, thus defining a boundary between his theory and

hermeneutics.

Third, the influence of hermeneutic philosophy on psychoanalysis leaves little

room for neuroscience-based theorizing, because hermeneutics sharply delimits

psychoanalytic inquiry to include primarily material intrinsic to the analytic relationship.

The emergence of hermeneutic philosophy as an organizing framework for the

psychoanalytic process coincided with increasing calls by non-hermeneutic thinkers

within psychoanalysis, including George Klein, to shed the mechanistic explanations of

Freudian metapsychology and move to a more circumscribed theory of personal meaning

and action in the psychoanalytic situation (Guntrip, 1967; Klein, 1976).

The term metapsychology can be found scattered through various parts in Freud‘s

scholarly writings and letters, especially in Chapter 7 of The Interpretation of Dreams

(Freud, 1900) and in a series of papers published between 1915 and 1917 (Freud 1915 a,

b, c; 1917), in which Freud famously outlined the dynamic, economic, and structural

aspects of his theory. But despite the seeming centrality of metapsychology to

psychoanalysis, Holt (1989) in an exhaustive review of Freud‘s writings on

metapsychology, points out that, ―Freud used the word ‗metapsychology‘ (or any variant

of it) less than once a year, on average, and in only nine works‖ (p. 26). Consistent with

the limited use of metapsychology in Freud‘s writings, Gill (1976), in an influential

paper, proposed that the term metapsychology should be used to circumscribe the subset

of Freud‘s writings that were originally neurobiological and cast within a natural science

framework, as distinct from ―psychological propositions [that] deal with intention and

meaning‖ (p. 103). Gill believed that the metapsychological propositions in Freud‘s

theory reflected a ―direct connection with neurological and biological assumptions‖ (p.

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75), whereas the clinical propositions of psychoanalytic theory were rooted in the

analysis of intention and meaning.

As Basch (1975) points out, the emergence of clinical theory as a distinct position

was gradual, beginning as early as 1959, as data from scientific laboratories began to

illuminate contradictions within psychoanalytic drive theory (Klein, 1959). Hermeneutic

philosophy, under the influence of Dilthey (1926), emerged earlier as a general approach

to defining the scope and purpose of the human sciences, in contrast to the natural

sciences, and was adopted by psychoanalysts as an alternative framework to

metapsychology. In contrast to the natural sciences, which are preoccupied with causal

mechanisms, the human sciences require recognition of the role of the observer in the

field under observation. With the observer and observed contained within the same

system, the primary hermeneutic task is investigation and interpretation—the effort to

find meaning and understanding within the finite existential bounds of language and

human relationships. The hermeneutic tradition thus provided a coherent, bounded

interpretive framework for understanding the feelings, perspectives, and history of

individuals in the psychoanalytic situation and has formed the foundation of

intersubjectivity theory (Stolorow & Atwood, 1994), as well as related approaches (Stern,

2004).

This essay examines the analysis of a 22 year old man, who presented with

complaints of unremitting headache pain, from the perspective of theories developed at

two critical points in Freud‘s career—at the beginning of his career when he developing a

neuropsychological theory relating brain structure to language function in On Aphasia

(Freud, 1891) and much later during a time of theoretical crisis when he famously

reformulated his theory of anxiety in Inhibitions, Symptoms, and Anxiety (Freud, 1926).

The case material examined here uses a clinical theory perspective as a starting point.

Psychoanalysis and neuropsychology are contrasted as sometimes overlapping,

sometimes competing, frameworks for understanding individual differences,

developmental history, and the analytic process, focusing on clinical theory in

psychoanalysis and on the historical study of clinical syndromes and deficits in

neuropsychology. The case study is presented in three sections, separated by an

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examination of the neuropsychological theory from On Aphasia, and later by an

examination of Freud‘s analysis of anxiety and the danger situation.

Building Blocks of Theory: The Case Study in Psychoanalysis and Neuropsychology

Case reports have always been at the heart of both psychoanalysis and clinical

neuropsychology. At one time, both fields even shared the same cases. Freud‘s brilliant

early studies of aphasia were based on case reports of both adults and children with focal

brain lesions that disrupted the use or development of language (Freud, 1891, 1897).

These often poignant and colorful reports of the effects of focal brain damage on the lives

of patients were part of a clinical-scientific tradition in the early part of the 20th

century

that eventually formed the foundation of clinical neuropsychology in the work of A. R.

Luria, Lev Vygotsky, and a generation of later clinician researchers.

There are important reasons for the centrality of the case study. Unique

developmental histories--the source of the perspectives, contexts, and meanings that

shape psychoanalytic formulation--are impossible to replicate in group studies. Studies

of localized lesions in unique brains at particular points in development tend to produce

effects that, at least in the early stages of theory making, can often only be captured in an

individual case study. Training in both psychoanalysis and neuropsychology is organized

around intensive work with individual cases. Finally, clinical practice in these fields

ultimately involves application to individual patients.

Perhaps more important than serving as a source of support for developing

clinical and scientific theories, case studies can challenge established ways of thinking.

Luria‘s cases examining soldiers with head wounds challenged strict localizationist

orthodoxies in neurology by first demonstrating the ways in which symptoms changed

dramatically with subtle contextual shifts in task conditions, then showing how those

same symptoms changed over time during a process of recovery (cf. Luria, 1980; Luria &

Tsvetkova, 1964). In psychoanalysis, Heinz Kohut (1971) broke through accepted

doctrines about analyzability and the Oedipus complex through presentation of a few key

cases that resonated with the experience of a generation of clinicians. Atwood and

Stolorow (1993) effectively turned the case report process on its head when their re-

analysis of a few famous cases threw new light on the sources of psychoanalytic theories.

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The Case of P: P was a 22 year old young who reluctantly agreed to a

consultation at the urging of a clinical social worker who had been following P since

shortly after his traumatic withdrawal from a prestigious Ivy League university. P‘s

chief complaint was severe daily headaches, which were experienced as so painful that he

often felt it impossible to get out of bed or leave his house. P said little at the initial

office visit, punctuating long periods of silence with a concise summary of the facts that

defined his recent history—beginning at the age of 18, unremitting pain, located at the

center of his head, had caused him to drop out of college and remain out of school and

living at his parent‘s home despite multiple medical interventions and several

unsuccessful attempts to resume his studies. P‘s plainspoken delivery and familiarity

with medical terminology gave a hint that this ground had been covered before; as did his

earnest plea that he would try anything to get rid of this pain, though he was convinced

that nothing would. At the time of referral, P generally stayed confined to his house. His

sleep schedule was disturbed, with late sleep onset and late awakening. He reported

feeling chronically anxious. He had ceased to travel because of a fear of flying and, more

recently, he was afraid to venture outside. During a neighbor‘s construction project, P

become afraid of noise, dust and of getting enough air; so he sat in a darkened room with

a fan continually blowing sustaining air into his face.

P was the oldest child in a family of four children. His two younger brothers were

away attending prestigious universities and his sister was living at home and in her last

year of high school. P s father was a physician and university professor with an

international reputation in his specialty, so no effort was spared in obtaining the best

medical care for his son. As a result, P had a lengthy history of prior medical evaluations

and treatment at renowned university medical centers across the country. No clear

medical cause for the symptoms had been uncovered by these evaluations and the

diagnosis was simply ―daily headaches‖ or ―atypical migraine‖. As a result, treatments

had been empirical and palliative, consisting of a series of antidepressants, anxiolytics,

and analgesics, as well as biofeedback and psychotherapy. Many of these treatments

resulted in short-term improvement, but each was invariably followed within days or

weeks by disappointment and a return of symptoms.

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P came to the initial consultation sessions accompanied by his mother. He was

always neatly dressed in a slacks and short sleeved shirt. As I greeted him in the waiting

room, eye contact was fleeting and his impassive expression rarely changed. His gait and

posture reflected some tension, even stiffness, particularly in his left shoulder. He was

polite and cooperative, but seemed unsure about the purpose of the consultation. He said

that he came to the consultation because of his parents request that he try one more

expert. Most of all, he reported wanting concrete solutions to his headaches, specifically

to have some recommendations for medications to control them. P‘s thinking seemed

logical and coherent and he was obviously exceptionally intelligent. P drank constantly

from a water bottle and sessions were interrupted about once every 20 to 30 minutes for P

to go to the bathroom. His water drinking was more frequent at the beginning of each

session, less toward the end of sessions.

A neurological and general medical evaluation that accompanied the consultation,

including a full set of laboratory studies, was consistent with previous evaluations in

showing nothing specific that was contributory to the headaches.

At initial presentation, P‘s case contains many elements of that would support a

recommendation for psychological treatment, including the recent onset of symptoms and

the dualistic idea, delivered by multiple medical specialists, that a psychological cause

could be assumed because no known physical cause could be ascertained. Psychological

data assembled in the various evaluations tended to point to a ―psychosomatic‖

explanation, including more than a hint of ―secondary gain‖ in his avoidance of a return

to his studies after his shocking failure at the university. However, the formulation

promoted by previous specialists that the pain was ―psychological‖, together with various

attempts at psychological treatment, had yielded, if anything, a worsening of symptoms.

Developmental History as a Foundation for Treatment. Perhaps nothing defines

psychoanalysis as fundamentally as the focus on early development. Basch (1988) put it

this way: ―Psychotherapy, as I see it, is applied developmental psychology‖ (p. 29). In

the early history of neuropsychology, Luria (1976) and Vygotsky (1978) built their

theories on the idea that the activities of the brain could not be understood in isolation

from social and developmental context.

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In psychoanalysis, personal history emerges gradually, in a progression that

stretches over an extended series of sessions. No particular order can be imposed on the

emergence of this narrative; chronology bends and folds back on itself in a pattern of

iterative reflection that follows its own intersubjective organizing principles. A full

accounting of a fleeting few moments of experience can stretch across days of sessions;

months of lived experience might be summarized by a phrase or even a gesture, or never

be mentioned at all. When we recount a patient‘s history in case presentations, it is

nearly impossible to convey this quality of remembered experience, where a shift in tone

at the end of a phrase, a sideward glance, or a shift in tempo—wordless symbols that are

the breath of life in all relationships-- convey more emotional truth than our best efforts

with language. Clinical histories, therefore, are almost always confined to a brief sketch

of the word-part of the patient‘s related experience.

The words that P brought to the first series of consultation sessions were focused

on a specific area of experience—headache pain. Sessions were a series of sips from the

water bottle and trips to the bathroom, punctuated by long periods of silence alternating

with brief, though clear, answers to my inquires. Feelings, other than pain, were never

mentioned and P‘s face conveyed sphinx-like neutrality. Sometimes P sneezed, straight

at me, without covering his mouth. At the end of sessions, P always requested my card,

on which he asked me to write our next appointment. The initial sessions were always at

the same time, Mondays and Thursdays. As I handed him the card, he slipped it into his

wallet and usually said ―Thank you‖, without making eye contact, as he walked down the

hall. The relative dearth of words used by P to relate his early history implied a focus on

the nonverbal, implicit dimension of his relationships, including the emerging

relationship with me. Perhaps the relational pattern of attachment, soothing, and

management of the dangers of transition that filled these early sessions encoded the most

essential information about P‘s early relational history.

By report from the referring clinical social worker, P was raised in a loving,

caring family, the oldest son of a medical school professor and a homemaker. The family

provided stability, care, and structure. Devoutly religious, intellectually oriented, and

active in their community, the family offered a stimulating home environment, with the

educational opportunities that were necessary for P to express his exceptional intellectual

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strengths--abilities that led him to excel in elementary school, to receive honors and

recognition in high school, and to obtain entrance to a prestigious Ivy League university.

Records provided by the family indicated that P was a normal, securely attached,

healthy baby who adjusted easily to a regular feeding and sleeping routine.

Developmental milestones were entirely within normal limits. P attended preschool,

where he apparently had no difficulties. P taught himself to read by about age 3. He

attended religious schools. He was recognized as exceptionally bright early in school and

always tracked with the more advanced students.

At six years of age P and his father were walking near a street corner when an

elderly man lost control of his car as he backed out of a parking space, hitting both P and

his father. P recalled that he had been hospitalized, but he was unable to describe any

other details of the accident or subsequent treatment. P did not recall whether or not his

father suffered any significant injuries.

Following the injury, P returned to school without any noticeable interruption to

his progress. The school program was highly structured and he was able excel and gain

recognition as an outstanding, even brilliant student. Still, P recalled that he took many

years to learn to read a clock and he recalled having difficulty discriminating left from

right. From the perspective of the family, as P moved through adolescence, he was the

idealized, prized, and cared-for oldest son who carried with him their hopes and dreams.

For one year, between high school and college, P attended a religious seminary more than

a thousand miles from his home. He describes this as the happiest year in his life. After

seminary, P enrolled in college where he studied engineering. After only a year away at

college, P was failing in his mechanical engineering classes.

His first medical evaluation for headaches was during the second semester of his

first year at university. During the second semester of his second year, the headaches

became more severe and P returned home from the university.

The Legacy of On Aphasia

As Freud moved away from neurology and developed his psychoanalytic theory,

he shifted his attention to patients who were remarkable for the absence of focal

neurological abnormalities, exemplified most dramatically in his studies of hysteria.

These were crucial transitional cases in the development of psychoanalysis, because they

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sought to demonstrate the powerful role of mental forces in shaping dramatic disorders in

motor and sensory functioning, in the absence of observable neuropathology. Yet even

as Freud sought to delineate a boundary between his psychoanalytic theory and those of

his neurological contemporaries, the ghost of his earlier brain-lesion based theories

continued to influence his work in the form of an implicit null assumption—that focal

neurological abnormalities were not present in the new psychoanalytic cases. This

implicit dualistic assumption has continued to underlie and even define psychoanalytic

case formulation up to the present time, evident in the nearly complete lack of reference

to neurological factors in most psychoanalytic case presentations, as well as in tedious

debates about what constitutes ―analyzability‖.

In contrast to his later disavowal of the influence of neurological factors on

critical elements of his cases, early in his career as a neurologist, Freud (1891/ 1953)

published a theoretical analysis of a series of case studies of patients with aphasia, a

disorder in which the comprehension and production of language is disrupted by lesions

in the left hemisphere. Freud‘s thesis in On Aphasia was a radical departure from the

strict localizationist approach that was emerging within neurology at the turn of the 20th

century, epitomized in the discoveries of the neurologists Paul Broca and Carl Wernicke,

who provided the prototype method of characterizing the association between brain

lesions and language function for the next 100 years. The localizationist theories of Broca

and Wernicke emerged before the idea of function had been clearly formulated as a

conceptual bridge between brain structures and mental constructs (Fodor, 1983). As a

result, their descriptions had the quality of describing a nearly isomorphic association

between deficits in speech and language, as they understood these faculties in the 19th

century, and the locations of brain lesions, usually established through postmortem

examination.

Freud saw this model as all too tidy and convenient for an organ as complex as

the brain. Given the immense variability of human behavior, if we were to take seriously

the type of model proposed by Broca and Wernicke, a brain populated with invariate

centers of functioning, such as the speech and language comprehension centers, would

quickly take over our geographical map of the brain, leading to a kind of reverse reducio

ad absurdum. In a brilliant set of observations of the organization of perceptual and

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language functions, Freud (1891/ 1953) contrasted aphasic patients‘ disorders of naming

with disorders of visual recognition associated with posterior cortical lesions. Freud

coined the term ―agnosia‖ to describe the latter condition—a term which is still used in

clinical neurology and neuropsychology to describe this condition (Benton & Trannel,

1993). Freud‘s model of aphasia, like the earlier model developed by Hughlings Jackson

(1864), implied some plasticity in brain structure-function relationships—a prerequisite

for recovery of function after brain injury. Freud‘s distributive model contained

redundancy, because the neural components were composed of distributed primitive

elements, as well as hierarchical and developmental organization, allowing for different

levels of complexity (Freud, 1891, 1897).

Freud‘s account of brain structure-function relationships in On Aphasia

foreshadowed modern views of brain organization defined by changing patterns of

connectivity, as opposed to strictly localizable faculties (Dick et al., 2001; Greenberg,

1997; Freidman, Ween, & Albert, 1993: 40). It is a fascinating irony that while Freud‘s

metapsychology has virtually no currency in modern cognitive neuroscience (McNally,

2003), his model for relating brain structure to psychological function in On Aphasia has

emerged as a ―remarkably prescient‖ analysis that set the stage for contemporary

distributive processing models of language (Dick, Bates, Wulfeck, Utman, Dronkers, &

Gernsbacher, 2001).

Why was Freud successful in articulating an enduring and viable method of

relating psychological functions to brain structure in On Aphasia, but not in The Project?

Freud was attempting to explain the consequences of brain lesions in On Aphasia,

whereas he was attempting to explain intact brain functioning, without reference to

deficits or to a lesion paradigm, in The Project. On the surface, this appears to be simply

a difference in methodology. But on closer inspection, explanation of intact functioning

involves a process of scientific inference that may differ in significant ways from

explanation of neuropathological findings and deficit, even if both are ultimately aimed at

accounting for the universals of normal brain functioning (Sarter et al., 1996). The lesion

imposes a bottom up structure on the explanation, because the ―experimental‖

manipulation, the lesion, involves a change at the neural level, which is then used to

explain changes in at a higher level of psychological functioning. For example, Freud

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used lesions in the parietal and temporal lobes to explain changes in the patient‘s ability

to recognize and label visual percepts—his discovery of visual agnosia—in On Aphasia.

The change at the ―bottom‖, the neural level, is used to explain subsequent alterations in

higher level functioning—in this case in perceptual functioning. In contrast, Freud

attempted to manipulate higher level constructs related to perception and the unconscious

in The Project. Freud then attempted to map those higher level phenomena to brain

substrate—a top down approach. Explanation originating at the top necessarily involves

an indeterminacy that complicates efforts to map constructs down onto brain structure—

the very problem Gall failed to recognize in his phrenology (Sarter et al., 1996), but

Freud obviated when he abandoned The Project and along with it any reference to the

neural level of explanation.

Perhaps of greater significance than the shift in data base and methodology,

however, the constructs upon which Freud built his theory in The Project were posited to

operate at an entirely different level within the central nervous system, than the constructs

advanced in On Aphasia. In The Project, Freud was concerned with defining the neural

substrate of high level constructs, such as unconscious and preconscious, whereas in On

Aphasia, Freud focused on defining a limited set of abnormalities in speech, language,

and visual recognition. The constructs in The Project involved a much more complicated

and widespread distribution in the brain than those restricted to language functioning. It

is likely that Freud was acutely aware of the differences, both in level of conceptual

abstraction and level of organization within the brain, that were involved in speech versus

the unconscious. Freud based much of his model in On Aphasia on the hierarchical

model of neural organization formulated by Hughlings Jackson (1864). The neural

plasticity envisioned in Freud‘s model was substantially based on Jackson‘s principle of

hierarchical re-representation, a principal that held that a function is not completely

ablated by a lesion, but instead it re-emerges in an altered form that follows it‘s

representation at lower levels of the nervous system. Freud‘s emerging conception of the

unconscious might have meshed well with the idea of re-representation if it were not for

the drive-motivation that sat on top of the unconscious. How would one represent that

motivational system, functioning as it did at the top, at lower levels of the nervous

system?

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Freud was never reticent in presenting bold ideas, so it is unlikely that his

exclusion of neural systems from his emerging psychoanalytic theory reflected a demure

tempering of his ambition. Especially in light of his rejection of the doctrine of strict

localization and his embrace of a hierarchical distributive model in On Aphasia, as he

attempted to write The Project, Freud could not have failed to recognize that the neural

representation of the unconscious was an order of magnitude more complex than the

neural representation of speech. Freud (1891/ 1953) concluded On Aphasia with an

explicit recognition of the difficulties involved in abandoning a strict localizationist

model for a complex hierarchical and distributive model: ―I have endeavoured to

demolish a convenient and attractive theory of the aphasias, and having succeeded in this,

I have been able to put into its place something less obvious and less complete‖ (p. 104).

Perhaps Freud‘s ultimate abandonment of efforts to link the brain and his psychoanalytic

theory was foreshadowed in the final words of On Aphasia: ―It appears to us, however,

that the significance of the factor of localization for aphasia has been overrated, and that

we should be well advised once again to concern ourselves with the functional states of

the apparatus of speech‖ (p. 105). Freud was shifting away from structure and toward an

analysis of functional states—to a psychological level of analysis. When Freud

abandoned the more rigid model of localization that was of necessity emerging in The

Project, he was also tacitly leaving behind the more complex, distributive model of

localization that he innovated in On Aphasia. This observation puts the dualism implicit

in Freud‘s psychoanalytic theory in sharp relief — in order to move on to the grander

ideas of psychoanalytic theory, Freud had no choice but to abandon his unique model of

brain localization and with it a unified model of mind-brain functioning. In this light, his

abandonment of The Project and On Aphasia seems daring, for its move to far grander

conception of the mind, yet tragically misdirected in its failure to anticipate the pitfalls of

dualism.

Freud ultimately developed a psychoanalytic theory in which the mind was

universal and the brain a cipher. The idea of deficit and the related methodology of

examining patients with brain lesions may have seemed incompatible with a search for a

grand, universal theory of the mind. For his emerging psychoanalytic theory, Freud did

not pursue experimental manipulations at the level of neural operations and brain lesions,

16

with its implied bottom up approach to scientific inference. Instead, as he formulated his

metapsychology and broader psychoanalytic theory, Freud envisioned manipulations at a

much higher level—the level of transference, drives, complexes, and the tripartite model

of id, ego, and superego. The Project was Freud‘s first and last effort at a top down

approach to linking his new higher level constructs with the brain. On a practical level,

Freud‘s view of pathology as associated with excesses (drive theory) had little in

common with the neurological view of pathology as associated with deficits, so there was

no role for patients with focal brain lesions, or for any other form of neurological

theorizing, in validating classical psychoanalytic theory.

The Case of P: A Return to the Scene of the Accident

From the first moment of contact, in psychoanalysis and probably most other

clinical endeavors, all information is mutually developed—even silence has to be co-

constructed. The developmental history in analysis arrives little-by-little, a varied array of

information-packages--words, gestures, and small acts--that come to define the emerging

emotional connection that is the essence of analysis. Sometimes an important message

emerges from the pattern revealed in the silences and gaps in action. In other instances, a

message might be worn or displayed, like a piece of clothing. For some forms of

nonverbal information, the history is there for all to see, if only we had the tools for

translating the wordless symbol-data to a form of representation that we can understand.

From the first day of consultation, I recognized that the subtle left sided stiffness

and awkward bearing as P walked to my office told a story, possibly connected to the

accident at age six when P and his father were struck by a car. Yet P never mentioned the

accident, indeed had no recall of it or of any problems resulting from it. Still, the

information conveyed by P‘s posture was there for anyone to see and I was trained to

understand that this, taken together with the history of difficulty learning to read a clock

and lack of any use of feeling words, possibly meant that the accident had left a more

permanent effect than P and his family were able to acknowledge. Though he made no

reference to the accident, P worried that despite the negative findings of past medical

evaluations, there might literally be something wrong with his brain—a logical thought

given that his presenting and constantly repeated symptom was headache. We began to

17

gather information to make sense of this question and a more detailed history then began

to emerge.

From the family and medical records, we learned that P had no memory of the

accident and subsequent recovery because he was in a coma for approximately three

weeks. A coma of this duration is invariably followed by a period of post-traumatic

amnesia, during which memory for new information, as well as recall of information

from the immediate past, is impaired.

P‘s parents remembered that in the hospital, P had stitches on his head and he was

black and blue under both eyes. A CT scan shortly after the accident showed brain

swelling, but no clear-cut focal findings. Upon emerging from the coma P had difficulty

with speech and movement. Left sided upper and lower extremity weakness and left arm

spasticity were noted. Some difficulty with facial muscle control was also noted. No

sensory abnormalities were reported. The parents report that speech remained difficult

for P during the immediate recovery period. There was no formal assessment of post-

traumatic amnesia or cognition. Instead, attention was focused on P s motor function,

which was abnormal on the left side. He received several months of physical therapy.

There was a recovery period of uncertain length during which P s speech gradually

returned to normal.

At the time of the initial consultation, P recalled little about the accident and was

initially unaware that there might be any effects due to the accident--he knew only that he

had some upper and lower extremity weakness on his left side until high school. P was

unaware of any connection between this left sided weakness and the head injury. Instead,

P speculated that he must have fallen on his left side at some unknown time in the past.

He denied awareness of any mental changes resulting from the accident, although he

speculated that his headaches may be linked to it. The parents stated that the doctors had

assured them that P had made a complete recovery and they were unaware of any

persistent cognitive sequelae to the head injury.

Neuropsychological testing confirmed that P had exceedingly high verbal

intellectual ability. But the test scores were also remarkable for evidence of severe

impairment on tasks that involved nonverbal learning and social judgment. The nonverbal

learning impairments were detected when P performed tasks involving visual-spatial

18

construction and fine motor coordination. Difficulty was especially evident on measures

that required initiation of problem solving strategies and flexible shifting of strategies in

response to shifting task demands. In everyday situations, these areas of

neuropsychological impairment may lead to difficulty in flexibly adapting to new

situations and novel social demands.

The history of closed head injury at age six, followed by coma of about three

weeks duration is consistent with neuropsychological test results indicating residual

impairment in bilateral frontal systems function. There appeared to be relatively more

impairment of functions associated with right hemisphere frontal systems, which was also

consistent with the history of left hemiparesis following the accident. Prefrontal damage

is associated with disconnection between language regulation of behavior and ongoing

activity so that patients do not use verbal cues and subvocalization to direct and organize

ongoing behavior and problem solving (Goldstein, 1948; Luria & Homskaya, 1964).

This pattern fits with the difficulties P experienced on neuropsychological tests, including

his inability to adapt his problem solving to changing task conditions, the fragmentation

of perception evident in his inability to identify objects, and in the apparent disconnection

between his experience of emotion and his inability to label those emotions.

The Unbearable Lightness of Memories. Coupled with the cognitive changes

that accompany a brain injury, the anterograde and retrograde components of a post-

traumatic amnesia lead to the disorienting sense of a gap in lived experience; a loss of the

sense of the integrity and continuity of our existence. Without memories to anchor a

coherent sense of what took place, the task of recovery from trauma is unimaginably

complicated. The effect of these gaps in memory reverberate through relationships with

loved ones, as the loss of a sense of shared experience becomes clear when the patient

repeatedly fails to share a recollection of the traumatic event.

For psychoanalysts who regard the lifting of repression as a therapeutic victory,

P‘s case presents an interesting challenge. Here we have a severely traumatic event that

in its essential particulars appears to be ―forgotten‖, yet continues to exert a profound

influence in later life—the hallmark features of repression. Yet the effects of this

―forgotten‖ event seem far more complicated and the traces of memory more fragmented

and dispersed than our usual way of thinking about memory can accommodate. First, for

19

P, the inability to recall the events surrounding the accident was almost certainly not

because of ―repression‖ of a traumatic experience, but instead reflects a post-traumatic

amnesia due to cerebral edema and transient compromise of the memory consolidation

centers of the brain. More subtle and complicating, however, is the way the sequalea to

the head injury were declared to have no significance by neurosurgeons communicating

with the family. This is what any family would want to hear, if it was true, but did it

direct attention away from this trauma before the healing was completed? Finally, the

father‘s involvement, his own injury when hit by the car, and the painful feelings that

must have accompanied his inability to protect his son, brings a tragic and unresolved

emotional undercurrent to any efforts by the family to bring-to-mind and cope with this

trauma. Memory, in this instance, is not stored away in an individual, but instead

encoded in scattered fragments of information that tell us as much about P‘s

relationships, as about the specific event. Memory in this context is retrieved in

relationships, with pain-tinged effort, through a process of mutual reconstruction.

Memory processes undergo profound changes during the course of development,

a fact that has always presented a dilemma for psychoanalysts who rely on recounted

narratives of the past for their theories. On the development of memory, Vygotsky said,

―The young child thinks by remembering, an adolescent remembers by thinking‖ (quoted

in Luria, 1976, p. 11). This might be extended to adulthood to say, an adult remembers

by relating.

Connecting the Dots. The neuroscientist and psychiatrist Leslie Brothers (2001)

observes that descriptions of the dramatic alterations in behavior that occur in brain

injured patients, ―violate and reveal our collective concepts of personhood, our deeply

held assumptions…these stories confront us with the strangest reality of all—the reality

of our construction of human life‖ (p. 45). For Brothers, when we focus our explanations

about behavior on the mechanisms of the brain, we obscure the origins of our ideas about

personhood in collective thought. It is these social constructions that form the

fundamental dimensions of psychoanalysis.

For P, the effects of the brain injury at age six seemed barely detectable in the

years immediately following the accident. P resumed his schooling, seemingly without a

hitch, resuming his role as a top student. The shock and pain of the accident moved to

20

the background and P‘s development progressed along a path that seemed to promise a

wonderful and secure future. After graduating from high school with honors and securing

a place at a prestigious university, the unexpected and catastrophic failure in college

shattered the sense of coherence and purpose that had organized his life up to that point.

As he returned home after a lonely and agonizing last semester at college, these two

events—being hit by the car and the collapse of his college education—occupied separate

universes in his and the family‘s sense of P‘s history. In the foreground as he returned

home, was the crushing sense that his experience as the prized and accomplished person

in his family and community had been replaced by a new daily reality of chronic

unbearable pain, isolation, and shame.

Psychoanalytic work exposes the discontinuous, iterative, and context-dependent

qualities of our experience of time; requiring adjustments in our linear, practical

orientation to time even as we adhere to the boundaries of the analytic hour. Treatment

stretches out over months or years and the reporting of events that are distant in linear

time may be experienced as emotionally contiguous.

After obtaining expert medical reassurance that the effects of his head injury at

age six were minimal, P‘s family did not recognize the non-linear ripple of effects of the

brain injury on Ps development. Perhaps this reflected a disavowal of the injury as the

family came to see P‘s motor impairment and social idiosyncrasies as a part of him that

they must just accept. In his school years, P attended private, religious schools that

provided a highly structured daily routine that probably helped modify the effects of the

neuropsychological deficits, providing organizational supports that P needed to succeed

academically.

During the time he was applying for college, P began to develop occasional

headaches. This ironically coincided with a time when he was gaining increasing

recognition for his academic achievement in his community, but also as he was being

confronted with the possibility of leaving the familiar structure of his home and school

environment and losing the supports that had permitted him to function despite his

neuropsychological deficits.

As he entered the university, a continent away from his home and involving an

entirely new field of study, the headaches increased in frequency and severity and began

21

to disrupt his everyday functioning. After only a few months away at college, P was

failing both in his mechanical engineering classes and in his new relationships. As the

previously successful oldest son in a high achieving family, it was assumed without

question that he would be successful. Moreover, he felt additional pressure to find new

friendships and possibly a partner. Although he had a relationship in high school, this

ended when he went away to college and P was often preoccupied with finding a new

companion. On both counts, P returned home from college empty handed. Because he

had previously always been successful in school, his only explanation for his failure in

engineering was that he was in pain. He recalled vividly looking at problems in his

engineering laboratory and having no idea what he was looking at or what to do. P faced

the grim prospect of returning home with no coherent explanation for his failure. As these

events unfolded at college, P‘s headaches increased and he began to devote increasing

attention to seeking expert medical consultation and treatment. It is noteworthy that

despite his father‘s considerable influence in securing consultations with some of the

foremost medical experts on headache, none of the interventions was effective.

Why was P able to succeed at such a high level prior to college, only to fail during

studies at the university? P clearly had the exceptional intelligence and determination

necessary to excel in high school classes, engage in the extracurricular activities expected

by top colleges, and obtain high scores on his college entrance examinations. After

innumerable medical consultations, headaches were the only available answer to this

question. Yet the multiple diagnoses and treatment regimes did not provide dispensation

from a persistent sense of failure and shame, nor was there a response to the family‘s

expectation that P should eventually return to university studies. Explanations from

professionals indicating that the headaches must be ―psychological‖ only served to

increase P‘s sense of shame, failure, and isolation—his experience of pain, in the view of

the top medical opinion, was not real. Without mutual recognition of the experience of

pain there was no basis for ―psychological‖ treatment. P‘s increasing withdrawal, anxiety,

and sense of shame, seemed to point to a deeper story.

During sessions, P began to discuss the results of the neuropsychological testing,

particularly focusing on a series of puzzles that he found confusing. During the course of

the neuropsychological evaluation, P was not able to readily identify any the objects he

22

was asked to assemble. For example, one item required him to assemble a hand. Instead,

P persisted in the perception that the fingers must be pickets in a fence or pieces of a

house. A cow‘s udder was placed on its back and identified as ―a donkey‖. Some figures

were rotated, for example, P put an ear on a face upside down. Because P was able to

recognize real-life objects, this represented a special sub-category of agnosia that

involves recognition of an object across views or when presented from a noncanonical

viewpoint (Bauer & Demery, 2003), a kind of perceptual fragmentation is often

associated with right frontal damage (cited in Lezak et al., p. 512). As P reflected on his

experience while assembling the puzzles, he began to make connections across the years

of his development; his experience with the puzzles was the same experience he had in

engineering class at university. P reported having greatest difficulty with laboratory

classes emphasizing any type of visual-spatial construction. In retrospect, the deficits

that were evident in the pattern of neuropsychological test performance all pointed to a

stark conclusion; P could not have chosen a major with greater potential for failure than

mechanical engineering. The previously undiagnosed neuropsychological impairments

hopelessly undermined his efforts to compete in laboratory engineering courses.

P became increasingly engaged in sessions as we worked to connect his emotional

experience with the perspective emerging as we examined the historical information.

The emergence of this new narrative framework was accompanied by an increasingly

diverse set of emotions during sessions—interest, enjoyment, anger, shame, surprise,

boredom—coupled with new expressions of hope for the future. These often nonverbal

emotional expressions reflected a shift in two aspects of P‘s initial presentation. P

initially was unaware of any area of neuropsychological deficit. This gap in awareness,

termed anasognosia in neuropsychology, persisted from the time of the accident at age six

and was accompanied by two other sets of neuropsychological symptoms--alexathymia

and visual agnosia. Anasagnosia involves a lack of awareness of impairment and

neuropsychologists usually associated this with lesions to the right cerebral hemisphere.

In P s case, the lack of awareness involved two elements: a misattribution regarding the

origins of persistent left hemiparesis and a complete lack of awareness of cognitive

impairment. It is remarkable in this case that the lack of awareness of this connection to

some extent involved other family members.

23

Second, P had a long history of alexathymia, which was reported by the parents

as being present since the accident and which involved difficulty labeling and verbally

articulating feeling and emotional states. Although Ps greatest strength was found on

verbal intelligence tests, there was a significant and self-acknowledged impairment in

ability to describe emotions and feelings.

P‘s visual experience of the world was often fragmented and disconnected from

words—he had difficulty organizing complex visual information and registering the

visual information with sufficient coherence as to enable him to attach a verbal label. Yet

he was also unable to give verbal expression to the nonverbal experience of his feelings

and emotions. As he became more engaged in the analytic process and his face became

more expressive of emotion, even though he would not readily label the feelings

(although at times he painfully struggled to find words, sometimes contorting his face in

the process), I recognized and at times give words to the emotions.

The neuropsychological information provided a conceptual bridge for P and his

family to understand the link between what had previously seemed to be unconnected

issues--the early injury, the neuropsychological impairments caused by the injury, and the

failure at the university. In addition, the observation about P‘s difficulty with verbal

expression of feeling and emotional states provided a basis for the family accepting the

role of psychoanalytic intervention.

Whereas the previous understanding of P attributed his failure to headaches,

which because no physical cause had been identified was a source of shame, P now began

to envision an alternative to attributing failure to headaches. This worked to reduce the

tendency to withdraw from social involvement and daily activities because of headaches.

To help his transition to activities outside the house, P participated briefly in a day

treatment program for patients with severe psychiatric illnesses. He appreciated the

program, reluctantly participated in the group sessions, and began to spend increasing

time away from his home during the day. After a few months, he moved to a sufficient

level of independent activity to be discharged from the program.

P struggled to put words to any emotions. He also reported that he only rarely

dreamed and, until several years of analysis had elapsed, he never recalled his dreams.

The obstacles P encountered in struggling to find words to describe his emotional

24

experience was analogous to his experience in trying to label puzzles on the Object

Assembly task—is that a picket fence or the fingers of a hand, a donkey or a cow? P

might recognize the general category—animals—but the precise identification eluded

him. Similarly, P identified the valence of emotions—painful versus pleasurable for

example, but further linguistic differentiation was usually not possible.

Along with the difficulty in finding words, there was little inflection or prosody in

his voice, although more expression came through when he sang. P‘s emotional

connection with people was demonstrated through action or song, rather than through

dialogue or narrative. P was known in his family for often making up tunes and lyrics to

honor family or friends at weddings, birthdays, or other important occasions. P

sometimes practiced the songs during sessions before a family event; at other times he

sang the song at the session after the event. The songs conveyed warmth, affection, and a

witty knowledge of the person he was honoring. P also was known for his thoughtful

gifts. This was not evident during the first part of the treatment, but later P began to use

sessions to discuss gifts for family members. He frequently shopped near my office and

spent many sessions going over the possibilities for gifts. Sometimes he would come in

with a list of ideas, along with some results from searching online or in local stores. The

gifts always seemed to reflect a thoughtful insight into what might please the recipient.

P had a substantial history of psychotropic medication trials before his first

consultation with me. Previous trials with multiple medications had failed, often after

producing a short-lived ―cure‖. Quickly removing the symptoms seemed to be

experienced as a threat. Any side effects led P to feel anxious and then to abort

mediation trials. Because the pain was daily and nearly continuous, measuring the effects

of any medication was difficult in the absence of a total pain free response. During the

initial phase of treatment a simple low-dose psychopharmacologic treatment plan was

developed and remained in place, with minor variations, throughout treatment (sertraline,

100 mg. and olanzapine, 7.5 mg., q.d.). The medication served to decrease social and

generalized anxiety and to provide some ―gating‖ or easing of his feeling of being

flooded and perceptually overwhelmed.

Toward the end of one year of treatment, water intoxication ceased. P no longer

carried a bottle of water. His success at leaving the bottle behind, so to speak, was

25

marked by an outpouring of happiness. He often smiled during sessions and complaints

about pain decreased. Concurrent with this, he resumed flying and took several trips. At

the same time as his anxiety decreased and he began venturing back into the world, he

began to raise questions about the religious traditions that were so central to his family.

He began seeing women who were not religious, often without the awareness of his

family. This questioning and increased autonomy was accompanied by waves of guilt,

even as he felt pride in himself for finally resuming social contact with women. Most of

these contacts were arranged over the internet. During the next few months, P studied

intensively and passed the examination that allowed him to begin business in a new

profession. Shortly thereafter, he was hired by a firm and began taking on new

responsibilities.

Freud‘s ―Danger Situation‖: Trauma and the Loss of Love.

There is no conceptual equivalent to deficit in classical psychoanalytic theory. It

is difficult to imagine casting a neuropsychological deficit or a selfobject deficit in

classical Freudian terms. If anything, Freud proposed a theory in which excess, the

opposite of deficit, was viewed as the root of pathology. Neurotic symptoms were

viewed as reflections of an excess of unchanneled libido, certainly not as the result of a

deficit. This concept runs throughout Freud‘s major writings on neurosis (Freud, 1910,

1916-17). Moreover, Freud was at pains to assert the absence of a neurological deficit in

his case studies of hysteria, because his theory of neurosis depended on demonstrating

that the symptoms could not be explained by an organic lesion.

In his use of theoretical constructs that link pathology to excess—―libido‖,

―cathexis‖, ―anticathexis‖, ―hypercathexis‖, ―inflowing energy‖, ―binding force‖—Freud

may have erected the most daunting barrier to linking his psychoanalytic theory to

modern neurobiology. Apart from his neurological writings, I am not aware of any direct

use by Freud of a concept of deficit. The idea that pathology may result from a deficit

can be inferred in only one isolated instance in Freud‘s writings; specifically, in his

famous retraction of the theory that anxiety stems from the blockage of excess sexual

energy. Freud argued in his early writings that anxiety represented the transformation of

libido, a sexual form of psychic energy, into a symptom--anxiety. In this early theory of

sexuality, the impact of perceptions of trauma and danger in producing anxiety were

26

minimized. Anxiety was instead viewed as secondary—as a transformation product of

repressed sexual energy. Freud reversed this relationship in an extended essay,

Inhibitions, Symptoms and Anxiety, proposing that it was not repression of excess libido

that produced anxiety, but rather anxiety resulting from danger that produced repression.

This came to be termed the danger situation. In this new theory, anxiety became a signal

of danger, of helplessness, that results from separation and the loss of the mother‘s love

and which ―creates the need to be loved which will accompany the child through the rest

of its life‖ (Freud, 1926/ 1959, p. 88). The idea that anxiety results from trauma

associated with threats of loss of an attachment may represent a unique instance in

Freud‘s life and work in which he broke from earlier formulations of pathology as the

result of excess or blocked psychic energies (Breger, 2000). The danger situation

represents a singular instance in which Freud linked anxiety to a condition of deficit.

Freud faced several problems in reconciling his new ―danger situation‖ theory of

anxiety with those ―economic‖ aspects of his larger theory that posited excess psychic

energy as the basis of pathology. First, in the danger situation, the threat—the trauma--

that triggers anxiety originates on the outside. Secondly, Freud continued to retain the

idea that excess libidinal drive energies present a danger that originates from the inside.

This dualistic conceptualization envisioned a mind that was faced with threats on two

fronts—the outside threat of a loss of love object and the internal threat of unconscious

libidinal forces. So even as he advanced the revolutionary idea that anxiety emerges from

the danger situation—from the threat of a loss of love—Freud continued to cling to his

earlier drive-based model of anxiety. Because he insisted on retaining the idea of mind as

a container holding dangerous psychic energies, Freud ultimately couldn‘t extend his

model of the mind to encompass what he had explicitly placed on the outside. In essence,

Freud couldn‘t imagine a system that contained both the mother and child together.

Moreover, the task of facing simultaneous threats from both the outside and inside led

Freud to view the mind as intrinsically defective, because there was an almost impossible

task of having to continuously sort out internal and external threats, each of which

required a different defensive response.

To address this dilemma, Freud elaborated his new theory of anxiety to include

the idea of a structural defect, which he believed resulted from the conflict in responding

27

to external (danger situation) versus internal (instinctual) threats—―a defect of our mental

apparatus which has to do precisely with its differentiation into an id and an ego‖ (1926/

1959, p. 89). This defect formed the basis for several forms of neurotic anxiety,

including castration anxiety and moral anxiety. Thus, Freud did not discard his ideas

about excess psychic energy, but instead brought it back in the form of an internal

danger. This allowed Freud to reassert the libido theory and drive-based propositions

related to castration anxiety and moral anxiety, by maintaining that a ―strengthening of

the ego‖ that accompanies normal development essentially obviates the effect of this

defect (Freud, Lecture XXXII, Anxiety and Instinctual Life). The idea of a ―defect of our

mental apparatus‖ thus was the byproduct of a compromise that Freud formulated in

order to reconcile the two distinct types of threat which were thought to underlie anxiety.

Ultimately, the dialectic that emerged in Symptoms, Inhibitions, and Anxiety was

never recognized by Freud as an opportunity to extend his theory in a radically new

direction, but instead was viewed as a problem that called for a dualistic solution. Freud

virtually retraced his steps in later writings, leaving drive theory intact (Breger, 2000). In

doing so, Freud elaborated an image of human nature as isolated and embattled on two

fronts; a situation that reflected a deep and irremediable defect in the structure of the

mind. In this new view, relating to another person yields two dangers—the danger of

retraumatization and the danger of exposing deeply hidden libidinal impulses.

Freud‘s struggle with the two meanings of danger brought trauma back into his

theory, with implications for both developmental and clinical theory. Although the

danger situation had little influence on Freud‘s subsequent writings (Breger, 2000), it was

picked up later in the formulation of attachment theory (Bowlby, 1960) and in the

analysis of patient‘s fears of re-traumatization in transference experiences (Stolorow,

2006).

Freud‘s insight into the role of the danger situation in development—

forshadowing the central idea in attachment theories-- illustrates how profoundly our

understanding of a symptom shifts when trauma is traced to an early relational context.

As Stolorow (2006) points out, the danger situation also provides a conceptual

framework for examining fears of re-traumatization. Does the relational context of a fear

of re-traumatization alter our understanding of a deficit due to brain injury?

28

The Case of P: Deficits and the Danger of Re-traumatization. The initial stage of

psychoanalytic treatment with P involved the co-construction of a narrative that

increasingly included an awareness of neuropsychological deficits. In this context, P

began to experience a new capacity to name affects and to describe imagery that

conveyed emotions that for years were bound to a sense of loneliness and shame. A new

intersubjective matrix began to emerge that allowed for the beginning of mutual

recognition in the analysis and also in P‘s life outside of treatment. However, although

the emergence of a neuropsychological perspective seemed to provide an alternative

explanation to the all-purpose attribution of the crisis at college to headaches, it did not

suddenly lead to a ―cure‖ of the headaches, nor did it fully explain how a remote event,

the head injury at age six, had such a devastating impact at age 18, without having any

obvious effect in the intervening years. D. W. Winnicott (1988) said that, ―There is one

thing that must always be remembered, however, about psycho-somatic disorder, and that

is that the physical part of the illness drags the psychological illness back to the body (p.

164)‖. By this Winnicott was implying that if the clinician focuses attention on an

intellectualized explanation of the symptoms, the body will re-assert the emotional basis

with a full display of symptoms. In P‘s case, the ideas of neuropsychology were as yet

no match for the affects, which were only beginning to be explored.

P‘s initial historical narrative hued closely in its broad outlines to the account

provided by his family in presenting a sense that there had been neither a discernable

deficit, nor any measurable effect of the head injury he experienced at age six. The break

from this view occurred during the initial phase of treatment, when P complained about

feeling pressure from his parents. The pressure involved an expectation that treatment

cure the headaches and that P then return to college or, if all else failed; pursue some

form of productive employment. P‘s need for protection from these overwhelming

expectations led to a question—what is wrong with my brain?

A new picture of P‘s history began to emerge after he asked this question.

Neuropsychological deficits traceable to the accident left him unprepared to compete in a

university mechanical engineering program and the absence of any awareness of the

deficits blinded him as he struggled to make sense of his experience and spiraled toward

failure in his second year of college. As the emotional trauma was recognized and

29

understood to be linked to an earlier neurological trauma, a new relational understanding

developed and there was reduction in the ―doctor shopping‖ that had characterized his

earlier relationship to diagnosis and intervention. Although P had mentioned some

traumatic events during the initial period of treatment, a shift to four sessions was

associated with an intensification that involved a repeated recounting of key traumatic

events. The most severe symptoms of anxiety and sensory flooding, including water

intoxication and phobic avoidance of public situations, decreased dramatically.

As the debilitating anxiety receded, P began to engage in activities that reflected a

questioning and rebellion against his parent‘s values. He began dating non-religious

women, sometimes maintaining relationships for periods of months. Some conflict with

the parents emerged when they questioned him about this, although some was kept from

them. For the first time, anger emerged during sessions. As P began to enter the world

of work and to start dating, he became increasingly aware of difficulties with social skills.

He used sessions to present social dilemmas. P pursued a license in his new field of

work, passed the examinations successfully, and then began to work for a local firm. As

these successes accumulated, there was a sense of return to esteem within his family.

Still, he continued to complain of headaches, although the frequency and severity of these

complaints decreased. Travel increased and he took several business trips, as well as

trips overseas.

Socarides and Stolorow (1984-85) argued that emotional experience is

inseparable from its relational context. They hypothesized that a caregiver‘s attuned

responsiveness, conveyed through words and at times in development when the child is

capable of understanding language, allows for the integration of the child‘s bodily

emotional experience with symbolic thought, finally providing the foundation for the

child‘s capacity to name emotions. Malattunement, on the other hand, derails this

developmental process, leaving emotions as unlabeled, bodily experiences. Stolorow

(2005) elaborated this thesis further, asserting that the verbal or linguistic component of

emotional experience may be particularly sensitive to relational context: ―This context

sensitivity may account in part for ordinary, even cultural, variations in emotional

experience, but it can be seen especially clearly in the impact on emotional experience of

traumatic contexts of severe malattunement‖ (p. 105). This observation is of special

30

relevance to understanding P‘s experience. Initially, P experienced an absence of verbal

emotional expression.

P‘s subtle challenge of his parents, occurring at the same time as he was first able

to say he was angry with me, was a noteworthy development during this phase of the

treatment. Suddenly, my failure to warn P that a woman he was dating might

emotionally hurt him was enraging—an experience that in Kohut‘s (1984) view reflects

―nothing else but transference clicking into place‖, so that ―the analytic situation has

become the traumatic past and the analyst has become the traumatizing selfobject of early

life‖ (p. 178). New forms of emotional expression began to surface, together with a new

capacity to tolerate feelings that risked a negative response from his parents or me. These

developments were accompanied by a sharp drop-off of headache complaints. It

occurred only after there was a shift in his perception of the analyst and of the wider

relational surround. Rather than anticipating a potentially shaming response, P began to

anticipate that emotions could be experienced and labeled with less catastrophic

consequences than in the past.

During this phase, P began to bring coins to the sessions, then to gradually amass

a large and valuable collection of rare coins. This began after P brought a coin into a

session and, in a tentative way, presented the coin to me. Although he had mentioned an

interest in collecting coins and sports cards earlier in treatment, his mention of the coins

was generally brief and general. Over the course of several sessions, he bought several

coins online and presented them in sessions. This occurred at a time when elements of an

idealizing and mirroring transference were in the foreground of the analysis. Our

attention to the coins was often followed by P describing further details and history of the

coins during the session. The coin seemed to represent a kind of perfect reflected

cohesion and integrity. Although the first coins were ungraded, as he became more

involved in coin collection, he brought coins with high ratings that were enclosed in

special sealed plastic cases. The plastic cases were labeled with a grade by a numismatic

certifying organization—a grading whose ideal is a coin free of defects. Admiration of

the coins became a warm and positive shared experience and I came to understand a

number of details of coin collecting and the history of American coins. In the deepening

analytic relationship, the coins became a concrete medium for addressing a deeply felt

31

need for recognition, as well as a way to obtain some relief from the deep sense of shame

and defect that accompanied earlier traumas.

Psychoanalysis provides a relational framework for new organizing principles to

emerge from a new set of shared experiences and from the shared re-construction of

trauma and loss. For P, the coins represented a new way of organizing the experience of

an ideal that had been damaged, and then finally shattered by earlier traumas. The coins

came to be transitional objects to which a sense of the intact and the ideal adhered. In

this idealizing relational context, the dangers of re-traumatization began to emerge, and

the missing emotional pieces of P‘s middle years began to fall into place.

Although it apparently never came to the attention of his teachers and parents, the

idyllic quality of his later elementary school years was marred by apparently relentless

teasing that occurred on the playground, out of sight of teachers, between classes. The

teasing focused on his motor impairment. Though P came to harbor deep feelings of

anger, shame, and anxiety in response to this teasing, he never brought it to the attention

of adults, a fact later corroborated by the parents, who said they were never aware of any

teasing. Yet, even though he experienced teasing and intimidation from some peers at

school, P was able to develop a number of secure and stable friendships that have lasted

to this day. A world of painful and traumatic relationships on the playground seemed to

operate in parallel to the secure world he found in proximity to his family and teachers.

The curious absence of the protection and influence of adults in the domain of his

peers perhaps combined with P‘s difficulty communicating affect and effectively created

a dissociation in P‘s experience of these two parallel worlds. As P recalled these

experiences in our sessions, it seemed as if the memories of these daily events were

stored in two separate emotional containers that could never be accessed at the same

time. The effect was to shape a perception that emotional pain could not be

communicated in a direct way; instead it was registered and stored where it originated—

in the body.

P began to more actively re-explore several traumatic events, asking, ―Why do I

keep going back to this?‖ Shortly after beginning his studies in college, there was a fire

outside his dorm. He woke up to the sound of the fire alarm and the smell of smoke and

discovered that he was alone in his room--his suite mates had left. Feeling disoriented,

32

he ran out into the street in his bare feet. He recalls burning his feet and being laughed at

by other students as he hopped in pain as his feet hit the pavement outside of his dorm. A

stranger took him to another dorm and applied first aid to his feet until medical help

arrived.

In another event that occurred during the first semester of his second year, P

became involved with a female student who, like him, was devoutly religious. He

generally met her in the dorm common area and she always offered him coffee. P

reported an incident in which he had a severe headache. He asked her to help him to get

to his dorm. She declined, based on religions considerations. He recalled feeling

miserable as he went outside, he became confused, and was helped back to his dorm by a

stranger.

Gradually, P shifted from simply reporting the events, to a process of weaving the

episodes of recall with the emergence of more emotion during sessions. This was

illustrated in the following series of sessions. During the first session, he arrived on time,

stating that he had driven himself (an accomplishment of this phase). He mentioned that

he did not know what to do about several relationships which he was uncertain about, but

he optimistically noted that there was one woman who he might possible become more

involved with—a woman who would certainly meet the approval of his parents. In

response to his questions about what to do about this woman, Q, whom he had dated

briefly in the past few months, I clumsily suggested, ―Why dont you give her a call?‖

He shortly began to rub the bridge of his nose and to complain of a headache, and then

said, as the session was drawing to a close, ―Maybe youre pressuring me too much‖.

The following two sessions, he complained that he had difficulty getting home because of

the headache, he had gone to a coffee stand and a bookstore near my office and had two

cups of coffee, before driving home. He had not felt free of headache since and did not

know why. He at first complained that he was only aware of his headache and said very

little during the next session. During the next session, he again complained that he had

not felt good since Monday and had been driven to this session by his mother. He asked

what could account for his worsening pain over the past few days. I acknowledged the

pain he was feeling and said that I regretted making the suggestion about calling Q. He

was quiet, and then began to recall with some detail an event from his second year in

33

college. This began a series of sessions recounting these events, accompanied by the

emergence of increasing affect. Reports of headache decreased as he connected his

emotional experiences during analysis with his re-telling of these traumatic events.

During this phase, P began to observe the contrast between his parent‘s pressure and their

apparent lack of awareness of the impact of these early traumas on him.

The analytic relationship can serve as a kind of proving ground for new

organizing principles. There was a self-delineating dimension to P‘s headaches that

helped provide a buffer from the press of these family expectations. During one

springtime session, P explained his headaches this way: ―(the university) was a fear of

failure, fearing failure, thinking everyone was so smart, I asked the body to find a way

out of (the university)‖.

The episodes of shame and embarrassment that P experienced during years of

elementary school teasing—teasing that focused on neurological deficits for which P had

no words during those years—came to define the emotional experience of involvement in

the world outside his family. The teasing was a danger-situation, in which he was

separated from maternal support and without transitional words or ideas to provide

protection. P never withdrew from school or other outside efforts during those years, but

later, when the secure base of his home was much further away, the teasing and rejection

began to come back. As he faced the reality of failing completely, with nowhere to turn,

the cumulative effects of re-traumatization were overwhelming. At a deeper level, a new

organizing principle moved into the foreground—there is something about me that is

deeply flawed, a deficit, something wrong with my brain.

The neurologist Kurt Goldstein (1948) observed that emotional re-traumatization

following brain injury can occur in the most ordinary of circumstances; for example, as a

person experiencing anomia gropes to find a word while ―knowing‖ exactly what he

wants to say. For P, both the inability to convey his distress and pain, as well as pain

induced by social rejection and teasing, had re-traumatizing impacts. The repeating,

cumulative nature of these traumas is echoed in the analytic relationship, where the

expectation of re-traumatization may be experienced as a need to withdraw to safety,

even if safety means isolation.

34

Donna Orange (2003) raises some of the most troubling questions about the

application of neuroscience in psychoanalysis. Orange sees contemporary applications of

neuroscience within psychoanalysis as pernicious, including the casual and increasingly

pervasive use of neurobiological terminology to describe patients. She views this trend

as a form of reductionism that introduces a distancing and objectivist set of ―facts‖ into

the analytic relationship-- facts ―that are neither actually nor potentially experienceable

by their subject‖ (p. 476). The effect, is to ―confirm the patient‘s most shame-ridden

emotional conviction: There is something inherently defective about me‖ (p. 476).

Orange confronts us with the idea that the imposition of neurobiological jargon and

reductive explanations has the potential to lead to trauma or re-traumatization of the

patient.

If we review the experiences described above in the light of Orange‘s critique, a

pattern begins to emerge that seems to simultaneously support and refute her essential

points. On the one hand, the neurological facts, as it were, did seem to confirm P‘s sense

of being defective, a sense that was associated with shame and a catastrophic withdrawal

from the world outside his parent‘s home. On the other hand, pinpointing the effects of

the physical trauma—the brain injury—provided a sense of relief and a starting point for

the disclosure of a history of repeated emotional trauma. But it was only by returning to

the early relational context of the traumas that it became possible to understand how the

physical trauma was connected to a history of emotional re-traumatization and to begin a

process of healing. During the course of analysis, fragments of memories emerged as if

born of separate worlds. The sense of disconnection between events in P‘s history, for

example the early perception that the accident had been without consequence, was

mirrored in the disconnection between words and emotions in P‘s everyday experience.

There is a risk that the sense of disconnection that characterized P‘s early

experience might be paralleled in the analytic process by the objectifying focus on

neurological facts. This is the other side of the coin that Orange presents us—shame

inducing objectifying defect on one side, loss of attunement on the other. Kohut (1984)

was keen on emphasizing the distinction between an experience-distant view of

development and the experience-near empathic grasp of a given moment in the analysis.

In Kohut‘s view, the analyst‘s response to a patient must be to the experience-near

35

perspective; that is, to the patient‘s ―experience at a given moment‖ (p. 189). This theme

also forms the background of much of Stern‘s (2004) recent work. Yet, Kohut also

pointed out that the experience-distant principle of what is normal in development will

inevitably influence the unspoken shape of our responsiveness—our gestures, tone, and

pauses in speaking. The background is always there, so perhaps the task of the analyst is

to be open and attuned, even if the patient brings neurological facts to the analysis that

are at first difficult to grasp in the present moment.

Orange‘s (2003) perspectival realism rejects reductionism when neuroscience is

applied to psychoanalysis, but does not reject the application of empirical sciences, to the

extent that the science serves to, ―expand the contexts of understanding for the working

psychoanalyst by contributing another perspective‖ (p. 484). The task of analysis is to

provide a new relational context for development, an alternative to the cycle of alienated

parallel experiences that had been in the foreground of P‘s sense of himself since moving

away to college. Neurology was in essence the point of view that P brought to treatment.

Beginning with this point of view, it was now possible to expand that context in a way

that allowed P to experience a new organizing principle—that the events and injuries and

emotions that always seemed irreconcilable actually made sense. The neurological

perspective became a key to understanding and protecting against re-traumatization. Yet

it was not insight into these facts that led to progress. Development did not proceed until

a new sense of the analytic relationship ―clicked into place‖ and the focus on the

moments of experience in each session became the crucible for a new intersubjective

experience.

This review presents only a few examples from a long and complex analysis.

Two years of the treatment involved four sessions per week, the rest of treatment was at

two sessions per week. There was also a gap of a number of months after the first four

years of treatment, as well as tragedies that intervened in the years after the

psychoanalysis. The headache pain never completely disappeared as a complaint, but it

moved further into the background. P is currently married and financially successful. He

continues in treatment, two times per week. He lives near his family and experiences an

emotionally close and supportive relationship with them, as well as with his spouse‘s

family. He and his wife frequently entertain friends or family on the weekends and they

36

recently purchased and remodeled a house. His coin collection continues to grow and he

is active in trading at auctions and coin shows. P said recently that he learned in

treatment that what he wanted most was for his father to simply inquire about how he was

feeling, something that he felt never happened, particularly during his years of crisis.

What he needed was that response in the present moment.

Conclusion

It has become conventional wisdom that creativity and innovation emerge when

people who have expertise in two or more disciplines use the framework of one discipline

to bring a fresh perspective to the other. It might be argued that some of Freud‘s most

enduring contributions—the model of brain-behavior mapping in On Aphasia, the model

of anxiety and the danger situation in Inhibitions, Symptoms, and Anxiety—emerged from

just such a synergy.

For psychotherapy in general and psychoanalysis in particular, theoretical

coherence is a primary criterion for sorting out true from false assertions (Roth &

Fonagy, 2005). Threats to theoretical coherence are necessarily magnified when attempts

are made to bridge two fields, while keeping in mind the distinct assumptions, empirical

methods and data, and epistemological foundations of each field. A new comprehensive

theory of the person—a new metapsychology--may no longer be possible, or even

desirable, within the current framework of modern science. As Holt notes, ―As sciences

mature, schools wither‖ (p. 214). Perhaps to be both coherent and useful, theories linking

psychoanalysis and neuroscience must make sense at the level of the individual patient,

as well as at the multiple levels that define our perception of the human condition.

Theoretical coherence, then, remains an essential quality for a clinical theory of

psychoanalysis, but it not incumbent upon psychoanalysis, or any other approach to

psychological treatment, to embed its clinical theory in a new metapsychology.

For P, the neuropsychological perspective expanded the levels that could be

explored as P tried to make sense of his past and provided a strategy for connecting

isolated and overwhelming affective experiences. Perhaps this adds a dimension to

Daniel Stern‘s observation that: ―For all forms of therapy that use the past, what is most

needed are search strategies to explore the past. In good part, the treatment is the

search.‖ (Stern, 1995, p. 203).

37

Charles Tilly (2006) has examined the sociology of explanation—the social

reasons behind reason giving. Tilly points out that after a trauma, such as 9/11, early

reason giving is in the form of stories. Stories level the playing field and draw people

closer. In contrast, technical accounts imply a need for the receiver of the account to

adopt the perspective of the giver. According to Tilly, appropriate reason giving depends

on the relationship of the giver and receiver. Stories require time and intimacy: ―When

life does get complicated, stories take over the bulk of relational work‖ (p. 173). Story

telling is powerful in relationships and with issues that don‘t yield easily to technical

analysis, such as after traumatic experiences. At heart, psychoanalysis is about stories.

In the case of P, one aspect of the analysis involved the mutual crafting of stories that

included accounts of a traumatic brain injury and other traumatic events in P‘s life.

Technical accounts at a variety of medical centers and religious codes delivered with the

best of intentions had failed. Telling P that the cause of his headache pain was

psychological backfired, even though it was technically correct, because he felt ashamed

and helpless in the face of this expert explanation.

Psychoanalysis offers a perspective on human nature that has not been supplanted

by any of the speculative extrapolations of neuroscience. Psychoanalysis has persisted,

despite withering criticism and rejection by utilitarian approaches, precisely because it

offers, as Kandel points out, the only integrated view of the human mind in the context of

individual stories. Because of the intimate nature of psychotherapeutic work,

psychoanalysis has of necessity developed a language and theoretical framework for

considering the phenomenology of experience in relationships, while attempting to

simultaneously understand the influence of developmental and intersubjective dimensions

of experience on human problems and the clinical process. At its best, psychoanalysis

resists the reduction of human experience to any single objective dimension and involves

the clinician, as a person, directly in the healing process. Psychoanalysis has much to

offer neuroscience, as a framework for understanding the nature of human attachments,

and development, and as a framework for understanding the experience of a sense of

self—the emergent nature of our personal history and memories in shaping perception

and experience and the intersubjective dimension of all social experience.

38

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