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Running Head: ON EFFORTS TO LINK PSYCHOANALYSIS AND NEUROSCIENCE 1

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

Neuroscience

John M. Watkins

Institute of Contemporary Psychoanalysis

Author Note

John M. Watkins, Institute of Contemporary Psychoanalysis, Los Angeles, CA

This manuscript is based on an earlier unpublished version that was awarded the Daphne

S. Stolorow Memorial Essay Prize.

Correspondence: John M. Watkins, 429 Santa Monica Blvd, Suite 200, Santa Monica,

CA 90401. E-Mail: [email protected]

ON EFFORTS TO LINK PSYCHOANALYSIS AND NEUROSCIENCE 2

Abstract

Recent scientific advances are leading to renewed efforts to integrate psychoanalysis and

neuroscience, despite earlier attempts and failures by Freud and others. 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. Freud’s abandonment of neuropsychological work represented a

dramatic shift in his focus of inquiry away from studies of focal cortical lesions and toward a

more expansive general theory of mental life and psychopathology. 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.

Keywords: psychoanalytic therapy, neuroscience, intersubjectivity, trauma,

psychoanalytic theory


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

Neuroscience

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 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 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. 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 paper 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 developed 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 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.

The Case of P: Phase 1 of Treatment

P is 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 physical 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 universities and his sister was living at home and in her last year of high school. P’s

father was a physician 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.

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 on his left side. 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 parent’s 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.

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 physician 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 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 program more than a thousand miles from his home. He describes

this as the happiest year in his life. After this program, P enrolled in college where he studied

engineering. After only a year away at college, P was failing in his 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 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 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 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 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?

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, 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.

Phase 2 of Treatment: 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 outset 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 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 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 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 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

P’s 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 to disrupt his

everyday functioning. After only a few months away at college, P was failing both in his

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 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 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.


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 P’s 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 psychlogical 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 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 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. This questioning and increased autonomy

was accompanied by waves of guilt. 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

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 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 re-traumatization 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?

Phase 3 of Treatment: 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 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 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. 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 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 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, 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.

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

don’t 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 you’re 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 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.

Reductionism as a Danger Situation: 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.

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 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 has one child. He continues in treatment, two times per week. He lives near his

family of origin 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 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).

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.


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