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FOR MOST OF THE 20th century, a schism split American psychiatry right
down the middle. On one side stood the neuroscientists, who saw abnormal
brain functioning as the cause of mental illness and relied on drugs,
shock therapy, and other medical treatments. On the other side were the
practitioners of psychoanalysis, the descendants of Freud who focused on
the role played by childhood experiences and hyperactive superegos-and who
proposed talk, talk, and more talk to heal ills ranging from arachnophobia
to schizophrenia.
At the dawn of the 21st century, managed care companies seem to have
stilled the debate by anointing drugs as the treatment of choice for most
mental disorders. In her acclaimed book "Of Two Minds: The Growing
Disorder in American Psychiatry" (2000), anthropologist T.M. Luhrmann
worried that "a combination of socioeconomic forces and ideology is
driving psychotherapy out of psychiatry." Not just psychoanalysis but all
the forms of long-term talk therapy that it spawned were in danger of
extinction.
But now it seems Freud might not be relegated to a footnote in the medical
literature after all. A new approach called neuropsychoanalyis, which
integrates brain research with traditional psychoanalytic concepts such as
the unconscious and transference, has been gradually restoring some of the
luster to the 50-minute hour. Psychoanalytic therapy is becoming
fashionable once again. Even America's favorite fictional mobster, Tony
Soprano, is opting for the talking cure.
Neuropsychoanalysis traces its roots back to an early paper of Freud's
called "Project for a Scientific Psychology," in which he explored the
possible biological underpinnings of his psychological theories. Freud
abandoned this effort in the late 1890s, claiming that brain science
wasn't yet a mature enough discipline. But advances in brain imaging have
allowed researchers to look inside the brain-and some say that what they
are seeing is consistent with much of what Freud hypothesized.
Take, for example, the unconscious. Neuropsychoanalysis builds on a flurry
of studies conducted over the past 30 years that provide a scientific
basis for the existence of unconscious thoughts and motivations. Nobel
Prize-winning neuroscientist Dr. Roger Sperry, working independently of
psychoanalysts, laid the foundation in the 1970s with his studies on
so-called split-brain patients-epileptics who had had the connection
between the two brain hemispheres surgically severed. Sperry found that
the behavior of split-brain patients could be influenced without their
conscious awareness. When he exposed a patient's right hemisphere (which
regulates emotion) to a pornographic picture via her left eye, she blushed
and giggled. But asked about the source of her embarrassment, she was
unable to identify it. The part of the brain that processes emotion, the
right hemisphere, was not communicating with the part that produced
language, the left hemisphere.
Dr. Joseph LeDoux of the Center for Neural Science at New York University,
who has spearheaded a second wave of split-brain research, teases out its
implications in his 1996 book, "The Emotional Brain." "People normally do
all sorts of things for reasons they are not consciously aware of (because
the behavior is produced by brain systems that operate unconsciously)," he
writes. Likewise, neurologist Dr. Antonio Damasio of the University of
Iowa has come around to upholding Freud's basic notion of the unconscious
through studies of people who have suffered various kinds of brain damage.
In his model of the mind, Damasio draws a critical distinction between
feelings and the consciousness of feelings. According to Damasio, our
bodies often produce feelings that our minds are not aware of.
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LeDoux, Damasio and other prominent neuroscientists-including Nobel
laureate Dr. Eric Kandel and best-selling author Dr. Oliver Sacks-gave the
new field their seal of approval in 1999 when they joined the editorial
board of the flagship journal Neuro-Psychoanalysis, edited by analysts Dr.
Edward Nersessian and Dr. Mark Solms. Solms, who coined the term
neuropsychoanalysis, is also the general editor of the "Revised
Standard Edition of the Complete Psychological Works of Sigmund Freud."
Solms's first book, "The Neuropsychology of Dreams," published in 1997,
responds to the influential attack on Freud's dream theory launched by
Harvard psychiatrist Dr. J. Allan Hobson a generation ago. In the
mid-1970s, Hobson authored two famous papers that single-handedly ended
Freud's stranglehold on the subject. According to Hobson's compelling
hypothesis, dreams derive from randomly generated stimuli originating in
the brain stem, which higher parts of the brain then "interpret" by means
of bizarre imagery. The further interpretation of dreams carried out by
the waking person (and the analyst), Hobson argued, was based on the false
belief that the dreams are complex texts whose emotional significance must
be deciphered. As he writes in his new book, "Dreaming: An Introduction to
the Science of Sleep," it is "crystal clear that many aspects of dreaming
previously thought to be meaningful, privileged and interpretable
psychologically are the simple reflection of the sleep-related changes in
brain state."
But Solms claims that dreams are not as "mindless" as Hobson would have
it. In one recent paper, Solms cites a spate of neuropsychological data to
support the conclusion that the forebrain, which is directly linked to the
formation of desires and so-called higher thought processes, plays a
central role in dreaming. "New brain research shows that dreams are not
motivationally neutral," says Solms.
Neuropsychoanalysts like Solms are not trying to demonstrate that all (or
even most) of Freud's ideas were right. A dream doesn't necessarily
represent a repressed wish, and no one thinks brain imaging will find
evidence for penis envy or even the existence of an ego, id, and superego
locked in an unending tug-of-war. But neuropsychoanalysts contend that
Freud's view of the mind, despite its many flaws, remains the richest one
yet developed. And even as they welcome advances in neuroscience, they are
also wary of the field's impact. Like psychotherapists of all stripes,
Solms is worried that brain research is encouraging a biological
reductionism in which psychiatrists focus exclusively on neurotransmitters
and drugs. "The structure of the human personality has not traditionally
been on the agenda of most neuroscientists," says Solms.
Neuropsychoanalysis so far is mainly theory. But slowly, it is helping to
produce a new breed of analyst who heals both mind and brain, in an
intensive treatment that goes beyond the here and now to address issues
like early loss or trauma. Surprisingly, the public face of this
21st-century analyst is not some gray-bearded sage but the actress
Lorraine Bracco, who plays psychiatrist Dr. Jennifer Melfi on HBO's wildly
successful series "The Sopranos." In fact, Bracco is giving psychoanalysis
such a good name that in December 2001 she received a special award before
a packed house at the American Psychoanalytic Association's annual
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Many episodes of the show revolve around excerpts from Melfi's
twice-weekly sessions of psychoanalytic therapy with Mob boss Tony
Soprano. "Dr. Melfi's treatment is an excellent example of this new
integration of psychoanalysis with biology," says Dr. Glen Gabbard,
co-editor of the International Journal of Psychoanalysis and the author of
"The Psychology of the Sopranos: Love, Death, Desire, and Betrayal in
America's Favorite Gangster Family." In contrast to the many distorted
depictions of psychotherapy in movies and on TV, Gabbard praises the
unprecedented "psychiatric realism" of the show. In fact, he even uses
videotapes of it to teach medical residents at Baylor University.
Tony Soprano is drawn to therapy because he suffers from panic disorder, a
common form of anxiety. Dr. Melfi initially prescribes a drug regimen of
Prozac and lithium. "Although pills can treat Tony's biological symptoms,
they can't address the sources of conflict and suffering that trigger his
panic attacks," says Gabbard. As the couch in her office attests, Dr.
Melfi is an analyst, so she is eager to address the root of the
problem-his conflicted relationship with his manipulative mother, Livia.
As therapy proceeds, Tony begins to have flashbacks of childhood traumas,
including a disturbing scene where Livia threatens to gouge his eyes out.
Melfi's treatment plan for Tony relies heavily on another pillar of
neuropsychoanalysis, attachment research. A half-century ago, based on
observations of infants and their caregivers, psychoanalyst Dr. John
Bowlby identified early abuse and neglect as key factors in adult
psychological problems. "In Tony Soprano's case, his mother's emotional
abuse-presumably in combination with a genetic predisposition-left his
brain hardwired for a host of behavioral and interpersonal problems. But,
as research now shows, the analytic relationship itself can help to heal
the brain by establishing new neural networks, " says Gabbard.
Neuropsychoanalysis has yet to make much of a dent in mainstream
psychiatric practice. And while HBO may have embraced neuropsychoanalysis,
your HMO is still reluctant to pay for any kind of long-term talk therapy,
whatever the brain research says. But the new integrated perspective is
slowly making inroads into the psychiatric curriculum. Boston analyst Dr.
George Fishman, for example, includes it in the course on Models of the
Mind that he teaches to third-year psychiatric residents at Harvard
Medical School. "Students used to think that those of us who practice
psychoanalysis were stuck in Shangri-la. But they are now enthusiastic
about my course because they see its relevance to what they are learning
in psychopharmacology," says Fishman.
Five years ago, Fishman along with fellow analyst Dr. Toni Greatrex
cofounded a workshop at the Boston Psychoanalytic Society and Institute on
the relationship between neuroscience and psychoanalysis. These monthly
meetings have fostered a lively interdisciplinary dialogue between the
institute's analysts and area psychiatrists, psychologists, social
workers, and neurologists.
While the influence of psychoanalysis has declined steadily since its
heyday in the 1950s, many analysts think the pendulum is destined to swing
back in their direction before too long. "It's odd that just when the
theory is more powerful than ever, psychoanalysis plays such a minor role
in mental health care,'' says Dr. Allan Schore, a Los Angeles analyst who
serves on the editorial board of Neuro-Psychoanalysis.
Neuroscience, the very discipline that kicked Freud off his pedestal in
the last few decades of the 20th century, may eventually return his
brainchild, the talking cure, to prominence in the 21st. Joshua Kendall
is a writer who lives in Brookline. This story ran on page D1 of the
Boston Globe on 2/9/2003. |
