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The nature of communication in the talking cure.

Posted on January 12, 2014 at 6:36 PM Comments comments (106)

Mark Solms is the director of the Arnold Pfeffer Center for Neuro-Psychoanalysis at the New York Psychoanalytic Institute; a lecturer at the University College Londons Department of Psychology; a consultant in neuropsychology at the Anna Freud Center in London; and an honorary lecturer in the Academic Department of Neurosurgery at St. Bartholomews and the Royal London School of Medicine. Over the last 15 years, Dr. Solms has been the driving force in establishing the new field of neuro-psychoanalysis, which brings together the fields of neuroscience and psychoanalysis.

What is the nature of communication between the analyst and the patient 

Defining psychoanalysis as "the talking cure" is somewhat misleading, a misnomer. We have the mystical-sounding phrase from Freud about the communication from the unconscious of the patient to the unconscious of the analyst. We speak of empathic attunement and projective identification as a form of communication between patient and analyst, which is reflected in the countertransference. The nature of communication in the analytic room somehow fails to be conveyed in the words that are transcribed down from a recording of the analytic session. Something goes on inside of the patient and the analyst in parallel with the talking which cannot be readily captured. 

The building blocks of the meaning-making process. 

The most rudimentary form of a conscious thing that stands for something occurs within ourselves about ourselves, to ourselves. Communication is communication of meaning. The best theory that we are working with revolves around the notion that consciousness originates in structures within the very deep core of our brain stems. These structures which project very widely to the forebrain, are representing aspects of the state of ones self, the subjective state, the visceral bodily state. This state of self is meaningfully being represented as a feeling of consciousness which either feels good or bad. Action tendencies are intrinsically interwoven to these feeling states. Pleasurable feelings are associated with approach behaviours, they motivate approach behaviours. 

Negative/painful feelings are associated with avoidance behaviours. These raw feeling states originate in the periaqueductal gray (PAG). Even in such elementary forms of consciousness, something is conveyed but not necessarily intentionally. We see that in herd-contagion behaviour. 

The approach mechanism is essentially a seeking mechanism. It has to do with detecting needs that can only be met in the outside world. It is almost an implicit predictive mechanism: "Unless I go looking for food, I am not going to survive". The feeling that comes with it is mildly optimistic, mildly curious - "something good is going to happen and I want to be there kind of feeling". Freud defined emotions as "mnemic residues of biological situations of universal significance". The universality of significance makes us all know what it means when we see it. Basic emotion systems link our core consciousness to the outside world and those around us. Emotions are a perceptual modality, they are a medium of consciousness just as vision, smell, hearing are a medium of consciousness.  

When another animal (human) feels something and another sees it, hears it, smell it (there are all sorts of ways in which the state of an animal is conveyed) then one knows what the other animal is feeling. These are things which we can't afford to learn, they are "mnemic residues" - we just know what it means, although we may not be able to demonstrate. Empathic knowing When I see that experience it activates the same system in me. I know what it is because it is activated in me. Mirror-neurons allow a higher level elaboration of this basic system. Mirror-neurons were accidentally discovered in a research lab in Italy. When a monkey with a brain activity recording device on its brain observes another monkey eating a banana, the same areas in the brain of the observing monkey are activated. There is a mirroring of the motor-neuron activity in the acting monkey, which is activated in the brain of the perceiving monkey. 

The prefrontal cortex allows for a suppression of the basic emotional systems, inhibiting the action tendencies associated with them. They enable us to not have to act on the feeling, to create virtual scenarios, to represent the relation between things. A 'non-doing' kind of thinking evolves - a highly abstracted, symbolic thinking removed from the emotional core. It is our 'pride and joy' but the price is that it alienates us from our feelings. We develop this curious inability to know what is driving our own actions. 

In therapy the analyst is taught to listen with his "third ear", with an evenly suspended attention. The analyst does not listen to the words, because they only convey part of the story - she picks something up, she feel something, which is akin to a biological situation with universal significance. This way we recognise the patient's emotional configuration, and we use the words to convey our understanding. The talking cure is not about the talking - the talking is about feelings. 

Not Knowing is the Royal Road to Feeling Both a Shameful Fool and Creative Healer

Posted on July 2, 2013 at 10:26 AM Comments comments (2)
A moving article by psychiatrist and psychotherapist Robert Lewis asking:  "How does one both be the  responsible healer who maintains the frame and the wounded healer inside the frame with the wounded  patient? In some ways, one hopes to embody a presence, not unlike that of the parent who both takes responsibility for his child and yet remembers that the child (patient) knows at least as much about where  your journey together must go."

There are no things, only relationships

Posted on January 15, 2013 at 2:37 PM Comments comments (89)
Ian McGilchrist gives a lecture at Schumacher. Watch here. 

Affective neuroscience: Pro-social behaviour

Posted on January 11, 2013 at 5:07 PM Comments comments (106)
Stephen W. Porges is one of the world's leading experts in the autonomic nervous system, and author of a book titled "Polyvagal Theory - Neurophysiological foundations of emotions, attachment, communication and self-regulation". The book is basically a collection of articles published during a career spanning 40 years. 

Telluride conference on compassion 
I first learned about his work a couple of months ago when I watched the YouTube posted footage of the Compassion science conference organised by CCARE Stanford in Telluride, Colorado, in July 2012. Watching him deliver his presentation, Mr. Porges impressed me as an anxious, vulnerable man who self-admitted to feeling a bit lost as he couldn't see the faces of his audience and said he found it difficult without being able to gauge the feedback from facial expressions. The organisars duly turned on the lights and offered him a glass of water and he saluted this act of "pro-social behaviour". 

Porges' theory combines observations on comparative anatomy about the development of the nervous system from fish to reptiles to mammals, with the study of the nervous system of newborns, insights from psychiatric conditions in which pro-social behaviour is impaired (autism, depression). Porges states that his scope is both scientific and humanistic - in that he wants to promote better, more humane care practices amongst clinicians, that honour the healing power of human relationships. 

Autonomic nervous system
Porges focuses on a part of the Autonomic Nervous System - the para-sympathetic nervous system (PNS), which traditionally was believed has an antagonistic relationship with the sympathetic system (SNS). The PNS consists of cranial nerves that have efferent (taking information to the body and internal organs) and afferent branches (that bring information from the body and the internal organs). 

The vagus nerve
The thenth cranial nerve (X), also called the vagus nerve is of particular interest. This nerve has two pathways - an unmyelinated one, which originates in the dorsal motor nucleux (DMNX) and a myelinated one, which originates in the nucleus ambiguus (NA). Myelinated nerves transmit information much faster. The myelinated vagus is a mammal "invention". Reptiles do not have it. What reptiles do have, is an unmyelinated vagus. The role of this nerve is to massively slow the heart's pacemaker - an important part of death-feigning. For mammals it is extremely dangerous to resort to death-feigning as a strategy to escape danger. A massive slow-down in breathing and heart-beat can cause cause serious damage to the mammalian oxygen-hungry brain and body. So mammals also have a myelinated vagus nerve, which makes sure that the unmyelinated nerve does not stop the heart.

Myelinated vagus, a mammal invention
What is interesting about the vagus nerve is that it's branches do not only innervate the heart, but also the facial muscles, the larynx, the pharynx and the inner ear muscles. This means in effect that engaging in pro-social behaviour - communicating with our face and voice, listening also has the effect of maintaining our heart beat within the normal range and preventing us from going into a state of mobilization (sympathetic activation characterized by flight, fight or freeze behaviour) or immobilization - death feigning). Basically it's like a neural brake that stops us  from "literally bouncing off the walls" (Porges, p.31) 

Hierarchy of behavioural responses
Vagal tone is highest when we are in a non-threatening situation. If we detect danger in the environment, then vagal tone withdraws and the body is now under the influence of the sympathetic nervous system, which gears it through hormones such as norepinephrine (noradrenaline) and cortizol to send all available energy into the muscles in order to fight or freeze, or run away. A state of mobilization is incompatible with pro-social behaviour. Traumatized clients which are easily triggered to feel angry or scared may not be available to be contacted through conversation and reasoning. 

Misreading the environment
What is interesting is that not only does the environment affect our internal state, our internal state also "colours" the way we interpret our environment. Traumatized individuals who are constantly in a state of agitation, are also more likely to "misread" cues from the environment and interpret them as dangerous. This is why working with clients diagnosed with borderline personality disorder is so difficult. No matter how benign and benevolent the therapist believes she is, the client easily mis-reads and mis-interprets her actions. The transactional analysis cathexis school calls this phenomenon "re-framing" (Schiff). Reframing, far from being a conscious process seems more likely that is "wired" into bodily responses which were geared to deal with harmful, dangerous environments. 

If the situation is interpreted to be imminently life-threatening and the emotional response triggered is one of terror, then the unmyelinated vagus takes over and slows the heart right down. The result is immobilization (fainting, dissociative state). In transactional analysis language, client becoming immobilized is an indication that they are cathecting a severely traumatic Child ego-state. 

Porges basically says that in any given situation we will employ the evolutionarily newest neural systems - those involved in pro-social behaviours. If this strategy fails then the sympathetic system will activate to promote flight, fight or freezing and if that fails as well, we will go into immobilization (fainting, dissociation). 

Other important researchers
If I had a criticism of Porges is that like any researcher absorbed by his area of focus he tends to downplay the importance of other neural areas involved in the process. He barely mentions the work of Damasio, LeDeux, Richardson and Sapolsky. Damasio talks about the importance of the medial-prefrontal cortex in self-control. LeDeux talks about the way in which "news" of possible danger hit the amygdala before the prefrontal cortex through a "fast and dirty way", which means that we react before we've had time to assess what it is that we are reacting to. Richardson focuses amongst other things on the insula, involved in representing bodily states and Sapolsky is an expert in stress and the sympathetic activation and its effects on the hippocampus. 

Implications for practice
I think Porges' theory supports humanistic practices such as person centred and body-based psychotherapy as facial expressiveness, a positive warm presence and caring attitude which are valued in these types of therapies are also proven to promote states of calm and healing. I think that this theory challenges traditional psychoanalytic approaches such as neutral stance and non-disclosure which I think can trigger mobilization in already traumatized individuals. It also challenges health professionals in general - doctors and nurses, who traditionally are more concerned with performing the tasks and operations needed to maintain and promote bodily function and are less concerned with how they relate to their patients and the potentially harmful impact of their distant stance.  

Zero degrees of empathy

Posted on November 7, 2012 at 8:03 AM Comments comments (99)
Empathy. It is considered an essential skill and a core condition (Rogers) in psychotherapy and counselling. It is the ability to put oneself in another person's shoes, to experience the world as they are experiencing it. In essence when we are being empathic we are recreating in our own mind and body a map of another person's mind, we are resonating with their pain and experiencing it as our own. 

A while ago I read a book by Simon Baron-Cohen "Zero degrees of empathy". Baron-Cohen asked the question "why does evil exist?" and wanted to find a scientific answer rather than a religious one. Baron-Cohen is an expert in autism, a condition which is characterised by a person's reduced ability to pick up and interpret another person's facial and bodily expressions in order to understand what they are feeling. This causes a considerable amount of strain socially. People are unable to gauge whether what they are doing is appropriate to the situation at hand. For instance, they might tell you a story about a subject that they are passionate about and fail to notice that you are drifting off, getting bored and would like them to stop. People with autism feel lost in social situation. They find it difficult and confusing - a minefield. They notice that people frequently get irritated and fed-up and this is scary because they don't understand what they've done wrong. 

People with high-functioning autism (Asperger's) can be helped to manage social situations by being taught about non-verbal communication and the significance of social cues. It's a little bit like learning to colour by numbers. 

There is another category of individuals tthat display zero-empathy. Baron-Cohen suggests that in this category are people on the high-end of spectrum of personality disorders such as borderline personality disorder (BDP), narcissistic personality disorder and antisocial personality disorder. 

Amongst other traits, patients diagnosed with BDP show an inability to connect with the pain caused to others through their self-harming acts and suicidal threats. They do not understand or experience the turmoil and the extreme fear that the other person is overwhelmed with. 

Clients with narcissistic structures are unaware of the other having any needs. They fill up the space with their discourse and tend to put others down. 

Antisocial personality disorder (psychopathy) is a condition rarely encountered in the therapy room. Psychopaths who are also violent and break the law tend to end up in prison. Those who don't break the law may be highly successful professionals. Cambridge trained psychology researcher dr. Kevin Dutton is fascinated by psychopaths. He has interviewed many of these individuals. 

Dutton has a certain admiration for psychopaths. He has found that some psychopathic traits (charm, ruthlessness, low empathy, focus, low stress response under pressure), if  coupled in an individual with high intelligence and low predisposition to violence may be highly useful in certain professions such as surgery, law and the arm and facilitate a high degree of achievement in these areas. (Psychopath in your family is a short film uploaded on his website www.wisdomofpsychopaths.com. I also found this documentary: I am fishead that proposes the thesis that corporate leaders are psychopaths)

The psychopath can accurately create a map of another's mind. He (because it tends to be a man) is extremely good at gauging what the other may be experiencing or thinking. However, the psychopath fails to experience another person's pain and are themselves emotionally under-aroused. Functioning MRI brain scans show that in psychopaths the amygdala (the structure of the brain that gets activated when we experience negative emotion and fear) is under-activated. 

In other words psychopaths cannot display the kind of "hot" empathy that translates into compassion and moral restrain. They are very good at thinking on their feet, focused, driven and because they brain/body rarely triggers the stress response, their verbal and manual performance remains highly accurate even in the most daunting situations. 

Why is that? Stress response translates partly into the release of a steroid hormone - cortisol. This hormone triggers bodily reactions that are biased towards facilitating a motor reaction such as running really fast. Prolonged exposure to glucocorticoids however has negative effects on the hippocampus (the part of the brain involved in the retrieval of autobiographical memory). We have all experienced stressful situations in which we feel tongue tied and cannot remember facts that we do know. Cortisol is to blame. In fact, cortisol not only interferes with the functioning of the hippocampus but can also contribute to premature cell death at this site. Prof. Dr. Robert Sapolsky from Stanford University has proved that stress has a negative effect on memory and the hippocampus. (The audio of his talk Stress and memory Forget it! is uploaded on youtube. Ignore the picture of the cat.)

Psychopaths have no such concerns. They are able to withstand extremely stressful situations without their nervous system being overwhelmed and without their body swimming with adrenaline or cortisol. 

Unsurprisingly, it turns out that what all people with zero-degree of empathy have in common is that they are not so good at relationships. The inability to hold someone else's mind in your mind, to respond with compassion is not conducive to being able to form a strong bond with another human being. 

The good news is that we are getting better and better at identifying low-empathy in children and that there are ways to train people in empathy. 

And to end, I found this brilliant short animated history of empathy by Jeremy Rifkin. It is called "The empathic civilisation". Rifkin argues traces the evolution of the empathic brain and argues that our ability to extend empathy to others with whom we don't share the same culture and religion, as well as to other species is essential to our survival on this planet. 

Is psychotherapy a form of political action

Posted on November 6, 2012 at 5:20 PM Comments comments (96)
What is the project of psychotherapy? Judy Yellin, a keynote speaker at the International Relational Transactional Analysis conference understands psychotherapy as a political project of liberation from internalized coercive systems. Therapists, Yellin believes act as representatives of a new order. Successful therapy is achieving freedom from authoritarian internal working models. 

Interpolation

The therapist's discourse becomes an interpolation - an interruption of the prevailing internal injurious discourse a forceful stance against the totalitarianism of the internal structure of false beliefs and self-attributions handed down from parents. 

Interpolation comes from the latin words "inter"- between and "polare" to drive away, to bang on the door. 

The client's internal prevailing discourse is manifested at different levels of impasse. Ray Little talks about ego states (different aspects of our personality - introjected or archaic) as relational units - always active in dialogue. I think that it is this internal dialogue that we interrupt through the process of enquiry and clarification. 

Interpolation aims go one step beyond empathy. The therapist becomes an invested agent, a participant with an agenda and not simply a self-object or mirror. 

I have mixed feelings about the concept of "interpolation", partly because it can simply be understood as one person forcefully driving their speech through that of another. It is not the external speech of the client that we are looking to interrupt. If we did so, we would only succeed in silencing them and heightening the power of the internalized destructive voice that may be saying "you are stupid", "you are not worth listening to". If by interpolation we simply understand telling the client: stop that, don't say that or what you're saying is wrong, we run the risk of becoming just another persecutor. 

I think a more useful approach is to create an environment in which the client can begin to examine their internal discourse to be curious about its purpose and function and question whether it is still useful and protective in their current life. 

Part of the struggle in psychotherapy is that clients are attached to their internalized persecutory voices. We all learn about how it is OK to be in the world through values and morals handed-down from our parents and the culture in which we are born. Compliance to these norms provides safety at a time when we are too young to fend for ourselves. We are told how to think and what the Truth is. Discarding everything we were told was true and right is a painful process and which temporarily makes the world strange and our place in it rather uncertain. 

Gender identity

Another concern I had about Judy Yellin's discourse was to do with her assertion that gender identity is entirely a cultural construction, which is the feminist view.

It is not, or rather not fully. Research has shown that gender identity is very much tied up with the type of brain we develop as a result of gene expression under the influence of hormones. Simon Baron-Cohen and others have done extensive research in the area. There are structural differences. Girls for instance have a larger corpus callosum - which means that the two hemispheres are more fully integrated in women. Generally girls have a type E brain - geared towards an empathy and boys have a type S - geared towards systemising - understanding how systems work. 

Baron-Cohen has devised specific tests to test for empathic/systemising tendencies. Women overwhelmingly score better at empathy whereas men score better at creating and understanding systems. There are individuals of both sexes that show aptitude in both directions. 

I would say that cultural gender stereotypes have derived from the natural gender differences. The problem with the cultural gender discourse is that it has traditionally failed to accommodate for individual variance. Some men are better at empathising and  nurturing and some women are better at systemising. Some men are attracted to men and some women are attracted to women. 

I think Yellin as a feminist targets this type of constricting cultural/religious discourse - a discourse that fails to take into consideration individual idiosyncrasies, departures from the "average". But she is wrong to suggest that gender differences are pure constructions. Any liberal parent who has tried to offer their child as varied a choice as possible in terms of toys/colours is able to testify that more often then not the child will still make gender - specific choices. 


Who is more likely to drop out of treatment?

Posted on October 10, 2012 at 7:57 AM Comments comments (1)
Study about the factors influencing early drop-out from treatment. This research article was published in the Irish Psychologist in September 2005.

Common client concerns

Posted on October 8, 2012 at 9:56 AM Comments comments (229)
On the BACP website I found a compilation of common client concerns. Although unsettled or puzzled clients may not always have the courage to raise these issues directly with the therapist. 

  • My therapist agreed to see me on a reduced fee. She has now announced that she will be raising her fees and I can no longer afford therapy. 
  • My therapist keeps changing the time of my appointment at short notice.
  • I found out that my therapist is a trainee and I think she should have told me at the beginning. I worry about whether she is good enough.
  • My therapist often doesn’t say anything and waits for me to speak. The long silences make me feel uncomfortable.
  • My therapist used to give me a hug but now doesn’t.
  • I would feel better if my therapist would give me a hug sometimes, but she won’t my therapist often talks about herself in sessions. I feel annoyed because sometimes the session is more about her than me.
  • My therapist said I could ring her whenever I needed her but now she’s told me to stop and I don’t understand why.
  • My counsellor wants to tape some of my sessions. I don’t know if this is normal I feel very uncomfortable because my counsellor takes notes during sessions.
  • I met my therapist in a social setting and felt disturbed by some of the things she said about herself. I can’t relate to her now in the same way that I did before.
  • My therapist suddenly told me that she can’t carry on working with me because she got a full time job and next week will be my last session. I feel she’s dumping me and I’m very upset.
  • My therapist won’t give me any advice although I keep asking her what I should do. I expected to be given more help in making decisions.
  • My therapist won’t give me any advice although I keep asking her what I should do. I expected to be given more help in making decisions.
  • My therapist has suggested we meet at her home rather than my GP’s surgery where we started. 

Here is a PsychCentral article educating clients on how to get the best out of therapy.


Unfolding

Posted on September 16, 2012 at 1:01 PM Comments comments (105)
Eric Berne is not necessarily known for his relational approach to therapy. Trained as a psychiatrist, I think he was more comfortable in the role of the expert, the doctor who accurately assesses what is wrong with you and prescribes the right treatment. 

I get the sense that Berne was a man of action. He writes extensively about how he operates as a therapist, the sequencing of treatment, but reading his case studies I am often left wondering how he was impacted by his clients. Two people engaging with each-other are going to be both changed by the experience. 

Given my prejudices about Berne, I was pleasantly surprised to find the other day a few notes addressing the therapeutic relationship in Principles of Group Treatment (1966, Berne, Grove Press) 

"First, in regard to his own development, he [the therapist] should ask himself: Why am I sitting in this room?(…) What will this hour contribute to my unfolding? In  regard to his patients and their motivations, he should ask: Why are they here? (…) What will this hour contribute to their unfolding? Then in regard to his duties toward them and their expectations of him: Why did they choose to come to me rather than to some other equally qualified person?” (p.64) 

I like Berne's choice of word: "unfolding". A very poetic word. It makes me think of a fern leaf, starting out as a tightly wrapped bud, slowly unfurling, growing into its function. 

The therapeutic relationship

Posted on September 13, 2012 at 2:11 PM Comments comments (159)

Psychotherapy is a specialized type of relationship, initiated for the purpose of alleviating psychological suffering. “Relationship” comes from the Latin word (relationem –to establish a connection). When I work I aim for a contract that stipulates that we will investigate together the client’s difficulties by looking directly at the relational dynamic established in the therapy room. In accordance with the TA methodology, I do this by inviting the client to join me in analysing the communication between us, which in TA terms is formed of transactions, games and interlocking scripts.
 
I see the relationship as both an opportunity both to revisit earlier failures in relationships, to experience something different and rehabilitate neural networks that may have been damaged by early trauma, networks that are involved in affect regulation, decision making and the ability to relate to others’ experience (Cozolino, 2010).
 
The psychotherapeutic relationship is experiential and experimental. Widdowson uses the metaphor of “relationship laboratory” and emphasizes the “potential to relate from to each other from a range of ego states, from scripty positions and autonomous positions” (Widdowson, 2010, p.79). Hargaden & Sills also see the joint creative effort at the heart of this process. They define the therapeutic relationship as “the connection of the person of the therapist and of the person of the client in open empathic mutuality and through what they create together”. Therapist and client are both changed by this process of engagement.