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1. Introduction
In this article, I
would like to discuss the difficulties facing the integration of
psychotherapy
and the theory of
psychoanalysis with neuroscience. I have already addressed this
problem
in previous
publications in Polish (Przybyła 2017a, 2017b), where I indicated
the possibility
of working
out a reasonable compromise between these knowledge orders in the form
of a
so-called explanatory
dualism. In this text, I would like to focus primarily on the
limitations
related to the methodological
and theoretical assumptions that hinder or even make
impossible the
integration of the two
fields of knowledge using the example of the best-known
version of this
integration, neuropsychoanalysis.
The tradition of combining psychotherapy
and neuroscience, as
well as attempts to give
new justification to psychotherapy thanks to
neuroscience,
already has its own rich history
and collection of cases (Ginot 2015, Schore
2003). Often, this
integration is unfortunately limited
to switching the language employed,
and to applying
metaphors from the field of neuroscience
to the definitions of psychological
problems (for
example using the concept of neural
networks).
Another common procedure is
the
use of generally-known psychological concepts, such as
memory
or attachment,
as if they
had
a clear and established neurobiological sense. At the beginning
of this discussion, it is
worth
reviewing the history of this trend in psychotherapy.
Eric Kandel in his famous text A
New Intellectual Framework for Psychiatry (Kandel
1998),
expressed his
opinion about the need to integrate the efforts of various human
sciences:
psychiatry, genetics,
neuroscience and psychotherapy. He perceived these fields of
knowledge as complementary
to each other, and saw their healing effects as a synergy effect
rather than a particular
impact on the psychic or cerebral sphere. Kandel's article, together
with its
continuation – in
another article, turned out to be a programme-setting text for
researchers who want
to combine the
psychoanalytic perspective with a neuroscience point
of view. Such a
perspective was also represented
in the work of Allan Schore (Schore 2003).
The presence
of an empirical, research and biological
perspective is in fact a more and more
visible tendency in
psychodynamic psychotherapy.
Representatives
include, among others, such clinicians and researchers as Peter Fonagy,
Otto Kernberg,
and Glen Gabbard. There have also been significant studies on the
effectiveness of psychoanalytic
therapies. Falk Leichsenring (Leichsenring & Rabung 2011)
performed a
metaanalysis of such
studies for various psychopathological units, as well as for
complex mental problems,
such as personality disorders. These studies, despite all
weaknesses related
to the methodology of
psychotherapy research in general, indicate the
effectiveness of
long-term therapies in
the psychodynamic paradigm. The aforementioned
Glen Gabbard (2000,
2005) emphasized the necessity
and value of integrating biological and
psychological
knowledge. According to this point of
view, the most important thing is
understanding the
mutual relations between different fields of knowledge
and levels of
human functioning.
Gabbard described the division into psychiatrists who deal
with the
brain or mind
therapists, as a return to a harmful Cartesian dualism. Neuroimaging
studies show in
spite of their imperfections that under the influence of psychotherapy
and
pharmacotherapy
there are changes in the functioning of the brain, sometimes different
depending on
the method of influence i.e. through drugs or through interpretations
and
contact with the therapist.
This is where the idea of combining psychotherapy and
neuroscience comes
from. However, a risk
arises here that psychotherapists will use
biological models in
their practice in the service
of resistance, without recognizing the
defense-related and
countertransference-binding efforts
that cause them.
Another avenue pointing to the sense of integrating clinical knowledge
and
psychotherapeutic
perspectives with the biological perspective are the constantly
renewed
efforts of scientists
trying to explain human behavior by entering them into the repertoire
of
other animal behavior.
Ethology, behaviorism, sociobiology, and evolutionary psychology
have all tried to do
this. There are many
indications that some basic behavioral and
biological affective
and motivational
mechanisms are shared by humans and other animals,
or at least with
other mammals (Panksepp
& Biven 2012). This suggests that the primary
emotional and
motivational processes are determined
by the action of genes and are related
to the functioning
of the human brain and its individual
subsystems. This is in accordance
with Freud's
suggestion of certain phylogenetic and biological
determinants of human
behavior and
sexuality as among the most important sources of human
motivation. Taking
into account Bowlby's
research on attachment, inspired by evolutionism and
ethology,
conclusions about
the ways of creating relationships with others (object-ralation
theory, ego
psychology, self-psychology), psychoanalysis has pointed to the basic
phenomena
in the functions
that human shares with other mammals. This includes parental care and
the
importance of separation
stress, creating fundamental bonds and relationships with objects
that mark the foundations
of social functioning, sexual function, as well as competitive and
aggressive
behaviours with
representatives of both sexes of their own species. In particular,
the issue of bonding
with caregivers,
attachment and separation is the object of attention of
both developmental
biologists and psychotherapists.
As Eric Kandel (1999) pointed out, this
is one of those
areas that combine psychoanalysis
with biology. Moreover it is worth paying
special attention to
psychoanalysis as a psychological
theory that describes the human mind
in an extremely deep
and intellectually satisfactory
way. There is no other theory of the
functioning of the
mind that would describe it in such
a multifaceted and multi-layered way
as psychoanalysis.
It captures the issues of norm and pathology,
the emergence of human
subjectivity and its
development in the life cycle, and refers to both
rational and irrational
aspects of human
behavior. The mind is perceived in a synchronous perspective,
through the
analysis of
functioning here and now, the functions of the ego, the vicissitude
of drives, and in
the diachronic
perspective through the history of the creation of the inner
world of the
human being. In this
sense, the most important and the most interesting problems
in modern
psychotherapy are delineated by two areas of knowledge: psychoanalysis
and
neuroscience. None
of the theories and methods of therapy is as rich in theory as
psychoanalysis. No
other therapeutic modality creates a full anthropological vision of
the
human being, embodying
function and development
in the life cycle. But psychoanalysis has
done so.
Therefore, it seems that the most important branch of available
therapies remains the
family of
psychoanalytic therapies. It is not a surprise that psychoanalysis is
the theoretical
background to which
brain researchers refer. Among others Allan Schore (2003), Daniel
Stern (2005) and
Mark Solms (2000),
referred to psychoanalysis (see also Salone et al. 2016).
The questions of
what status the
combination of psychoanalysis and neuroscience in the form
of
neuropsychoanalysis suggested by
Mark Solms will have. Will it be a creative perspective
as Kandel hoped –
or rather a harmful reductionism?
I will consider in the further part of
the text a few
problems related to the answer to the
question. An important issue which is
often overlooked
when discussing this topic is the internal diversity
of psychoanalysis.
Modern
psychoanalysis bases itself on Freud's research but rejects it as well.
It is difficult to
talk about
psychoanalysis today without mentioning Anna Freud, Heinz Hartmann,
Melanie
Klein, Wilfred Bion,
Donald Winnicott, Heinz Kohut, and many more. Modern Italian
psychoanalyst
Antonino Ferro even expressed the view that Freud's legacy must be
dismissed as
unnecessary and as ballast (Ferro & Nicoli 2017). Another analyst
Thomas
Ogden also proposes
to replace Freud with Bion. Neuropsychoanalysis rarely consider the
perspective of modern
psychoanalysis. This is one of the many limitations that are
associated
with this kind of combination
neuroscience and psychoanalysis. The exception is work of
Allan Schore, who
refers to a broad
psychoanalytic tradition. He refers to classic concepts of
Freud, Klein and
post Kleinian tradition (Schore
2003), self-psychology of Heinz Kohut
(Schore 2002), as
well as attachment theory
(Schore 2000, 2001).
The best known integration perspective is neuropsychoanalysis (Solms
2000). This was
presented by
Mark Solms, who together with Olivier Turnbull wrote an explanatory
article
What
Is Neuropsychoanalysis?
(Solms
& Turnbull 2011, 2015). The viewpoint they present is
very
general. They
point to several research problems which they considered important.
First
of all, it is important
to study psychic phenomena, especially those postulated by
psychoanalysis.
On the other hand, they
are interested in psychoanalytic work with
neurological
patients who have specific brain damage.
Analysis of the functioning and
psychoanalytic
understanding of such patients should allow
us to establish the relationship
between
disturbances of brain functioning and psychodynamic phenomena.
The authors of
the
article adopt a monistic vision of the human being. This means that the
brain and mind
are
two aspects of the same thing. It seems, however, that their position
is to a large extent
an
ideological declaration and requires a deeper philosophical analysis.
They do not pay
attention to the
fact that language produces a certain ontological universe. Therefore,
it is
important to
note that psychoanalysis and neuroscience use different languages and
operate
in different theoretical
and ontological fields. Both also have their own terminology and
research methods.
One can say, according to
Alfred Tarski's concept of truth, that their
integration will be
possible only when one
can find a common language ona higher level in
which both fields
could be described.
2. Critical
reflection
This part of the
article will propose critical arguments for the project of building a
new
theory for
neuroscience-based psychotherapy, as well as a critical look at the
possibility of
combining
neuroscience with psychoanalysis. I will present here the basic
philosophical and
methodological
problems in which this project is involved. I will focus here on the
criticism
of neuropsychoanalysis.
These arguments have already been presented in Polish (Przybyła
2017a, 2017b).
The
first argument, which will appear in subsequent parts of the text, has
already been
formulated during
the discussion of the article by Solms and Turnbull: authors and
researchers, connected
with neuropsychoanalysis, quite willingly and freely refer to the idea
of psychophysical monism
and claim that phenomena described by clinicians and
psychoanalysis can
be reduced to brain
phenomena. Firstly, this seems to be, above all, a
certain ideology,
and secondly, a kind of hope
associated with it, and not a current state of
knowledge.
Furthermore, it mixes together two irreducible
languages: the language of
psychoanalysis and
the language describing neuronal phenomena.
At the same time, it does
not offer a common
language in which these areas can be described
together. It is important
to emphasize the
fact that “neuropsychotherapy” very often merely
switches the language.
Instead of the
mind, one talks about the brain. Instead of emotions, one
talks about
neurobehavioral
systems or neurotransmitter secretion. In addition, neuroscientists
freely use
psychological concepts such as memory, learning, attachment, as if
they were
describing the
well-known facts of the brain's functioning in this way. They forget
that this
language describes correlates,
and not identical phenomena.
Another
argument will be illustrated by three cases from research practice.
This argument
claims that you can
not speak about psychotherapy simply based on neurobiology. One can
not change
metapsychology on this basis, because the data obtained from
neuroscience
research are far from
clear interpretation. The first example is not a case describing the
practice of neuropsychoanalysis,
but it shows a general trend which also exist in
neuropsychoanalysis.
This is the case of
research on mirror neurons. These extremely
interesting brain
cells were discovered in the
1990s by examining macaques observing the
actions of other
monkeys. The main thesis about the
role of these cells is that monkeys and
humans have a brain
system of nerve cells which "map" the
actions of other individuals in
the brain. On the
basis of data of unclear significance many different
theories about the
genesis of language,
causes of autism, social brain activity, human intersubjectivity,
learning,
empathy,
identification, etc, have been put forth. The problem is that as Gregory
Hickok
(2009) argues much
of the interpretation of the available data is incorrect. It is
worth paying
attention to how unclear data from laboratory become the basis for
formulating far-reaching-conclusions.
Other examples come from the journal Neuropsychoanalysis.
They are intended to
illustrate
how far
neuropsychoanalysis makes use of uncertain data, which, for example,
does
not prevent Solms from
proposing a revision of psychoanalytic theory on their basis.
This
problem can be clearly
seen in the discussion about Heather Berlin's article The
Neural
Basis
of the Dynamic Unconscious
(Berlin
2011). This work attracts attention due to the
richness
of data, the quoted research
procedures, and the references to unconscious
phenomena,
which met with enthusiastic reception
from, among others, Eric Fertucka
(2011).
Vaughan Bell (2011) notes that the author refers
in the text to disease entities whose
existence
is debatable (such as DID, dissociative
identity disorder).
When we examine the
brain
function of people with such a diagnosis, then what are we actually
examining?
Another
critical voice is the commentary of Morris Eagle (2011), who points out
that the
majority
of operations carried out in experiments on the functioning of
unconscious
processes examine
the descriptive form of the unconscious rather than its crucial form
for
psychoanalysis and
psychodynamic therapy. According to Eagle, these studies are therefore
characterized by low
ecological validity.
Another example taken from Neuropsychoanalysis
is
a new concept, which was formulated
by Mark Solms. This
is the theory of the conscious id (Solms & Panksepp 2012, Solms
2013).
The main
thesis is that consciousness is generated by the brainstem and is
primarily
affective. Solms takes
issue in this way with the statement that consciousness arises in
connection with the
activity of the cerebral
cortex, which would be connected with what
Freud called the
ego, not with the id, which
was seen as unconscious. One of the arguments
that Solms invokes
in his dispute with Freud's
standpoint is the presence of very fundamental
perception in people
with lesions of CNS cortical
centers, and the fact of demonstrated
emotional reactions
in cases of congenital cortical deficiency
in humans (called
hydranencephaly).
This theory for Solms means that one should think critically
about the
basics
of the psychoanalytic vision of the mind and the purpose of the
therapy that Freud
formulated,
that is, making the unconscious conscious, and - in later publications
-
replacing the id
with the ego. Solms claims that the id is conscious, and that would
make
Freud's suggestion
pointless. However the data referred to by Solms are not so
unambiguous. In her discussion
of his publication, Heather Berlin (2013) noted that the facts
about the existence
of consciousness in
animals without a cortex and after brainstem lesions
do not clearly
indicate the thesis of
Solms, that there can be consciousness without cortex,
but cannot occur
without the activity of
brainstem structures. Besides, the fundamental
problem is what
Solms understands under the
concept of consciousness. Berlin suggests that
this understanding
may be limited to certain automatisms
and reflexes. This seems far from
the common
understanding of consciousness, not only
as a state of vigilance, but as an
auto-reflective
state, which consists of various emotional and cognitive
components. Robin
Carhart-Harris
(2013) made similarly critical remarks stressing that the
relation of the ego
to
id reflects
rather the associations of the cerebral cortex with the limbic system,
and in this
sense,
Freud's description of this relationship may be quite adequate.
Another comment was
formulated
by Larry Kunstadt (2013) showing that Solms unites in a loose way different
concepts
of neuroscience and psychoanalysis, e.g. affective states and id. This
is probably
a wider problem.
However, theoretical concepts cannot be changed without consequences.
Each of them
creates an ontological universe and is therefore not reducible to any
other.
At the
end of a critical look at the relationship between neuroscience and
psychotherapy, it
is worth
considering the remarks formulated by Rachel Blass and Zvi Carmeli
(2015) in
their discussion
of the publications of Solms and his colleagues. These authors discuss
the
neuropsychoanalytical
perspective defending the idea of self-reliance of psychoanalysis and
the harmfulness
of attempts to base it on biology. They referred to Yovell, Solms and
Fotopoulou's presentation
of the main ideas of neuropsychoanalysis in The
International
Journal
of Psychoanalysis.
In Blass and Carmeli's opinion, the attempt by Solms and his
colleagues
to equate the mind
with the brain is invalid. According to the authors of this
criticism,
these two spheres: the brain
and the mental sphere, are separate and irreducible
levels
of description. In this sense, the mental
and brain orders are ontologically different,
although
it may actually describe the same thing from
different perspectives and on different
levels.
The equation of one description level to another is
also harmful because it destroys
the
uniqueness and the advantages of each discipline. Blass and Carmeli
employ the analogy
of
a song performed on a musical instrument: to analyze music, we do not
necessarily need to
know
the details of the instrument's construction and playing technique, although
it can not
be
denied that the music and the instrument on which it is played are
directly related to
each
other. Another argument of the authors is an analysis of the clinical
example
presented by Solms
and colleagues in which they had some harmful intervention. They
changed the analysis
of the subjective meanings of the patient into an analysis of his
cognitive
functioning, and thereby
referred to psychological theory, and not a neurological analysis as
they would like to present
it. By introducing an intervention based on explaining the
phenomenon of memory
function, they leave the
analytical paradigm and omit the work of
interpretation,
which is the heart of the analytical
approach. Such an intervention might
calm down or inform
the patient, but it does not have
a healing effect on his subjective world
of experiences. It
is worth emphasizing that the abandoment
of interpretative activity is
usually a
therapeutic acting-out which is often related to the involvement
of the therapist in
a
transference-countertransference process, or proof that the identification
of therapists
with the
psychoanalytic paradigm is declarative and selective rather than self-evident.
Taking into account
the above remarks, Blass and Carmeli concluded that the approach
proposed by Yovell,
Solms and Fotopoulou is detrimental to psychoanalysis itself.
3. Conclusions
I would like to
emphasize here above all the positive aspect of the inability to
integrate
neurobiology with
the language of psychoanalysis. On the one hand, this difficulty can
be
described as
philosophical or ontological. This is the discussed lack of a common
language
for both areas of knowledge
which would enable their theoretical and conceptual
integration. On the
other hand, there is
another difficulty which can be simply described as
a methodological
one. It is the inability to
operationalize clinical knowledge in the way that
would recognize the
proper sense of psychoanalytic
terms. In practice, the point is that
neurobiologists
cannot reliably and accurately examine
the processes and phenomena
observed in the
therapy process. The operations that scientists
make are a distant and
insufficient
approximation of the clinical sense of the studied phenomena.
Another difficulty
that excludes
integration is the still uncertain status of interpreting data
from
neurobiological
research, which undermines the sense of introducing changes in
metapsychology.
The
right way to procede is to use a double method of description. This is
a description
that does
not reduce one discipline of knowledge to another. Of course, it is
not known
whether the same
phenomenon can be described in two different ways. Nevertheless, one
can
generally treat human
mental activity as such, which can be in some aspects described by
neuroscience, and in
others aspectss (or the
same) by psychoanalytic theory. However, these
languages should not
be reduced to one another.
Firstly, because the restrictions and
opportunities for
translation from one conceptual
system to the other are unclear. Secondly,
because it would
probably lead to a reductionism
that loses the specificity and richness of the
theoretical and
practical proposals of both fields
of knowledge. This position is also
connected with the
proposal of the existence of neurobiologically-informed
psychotherapy
and seemingly
consistent with Kandel's proposals neuroscience
that takes into account the
results of
psychoanalytic investigation. It seems that in practice,
it is this model that is very
often present in the
approach of therapists and researchers themselves,
especially from the
neuropsychoanalysis
trend. Mark Solms argues that neuropsychoanalysis
is not
neurobiologically
informed psychoanalysis. It seems however that this is what
we are mainly
dealing with within
this trend.
In summary, we can say that differencess in perspectives is valuable
in the deliberations of
neuroscience and
psychoanalysis about the human mind. Possible dialogue should be based
on the principle
of cooperation and not incorporation. However, this dialogue will lead
to
theoretical and methodological
abuse and perhaps also in practice (in working with patients)
if it does not take
into account the
fundamental irreducibility and limited translatability of
the two orders of
knowledge. On the one
hand, one should be aware of the possible abuse of
neuroscience's
prestige in the explanation
of various phenomena (Satel & Lilienfeld 2013).
On the other hand,
the recours of practicing
psychoanalysts to neuroscience does not bring
anything new in the
understanding of the therapeutic
process. They are therefore an
additional
legitimation for analytical practice. This is precisely
the kind of use of
neuroscience
proposed by the outstanding Italian psychoanalyst Franco De Masi
(2009,
2013).
It is
worth considering what form of psychotherapy is the most compatible
with the
findings of
neuroscience. This is not question about creating a new form of
therapy based on
the results of biological
research. As I have tried to show, it is a methodologically
inappropriate
strategy. Therefore, it
is worth considering which of the forms of existing
psychotherapy is
already consistent with
certain findings of neurobiology. It is mainly a
question of
appreciating emotional experience
as a factor shaping and changing the
personality. It
seems that in this respect the most interesting
option is the the psychodynamic
psychotherapy
focused on transference (TFP) developed
by Kernberg and his team (Salone
et al. 2016) The
practical usefulness of this therapy is not
undermined by critical voices
about its coherence
and theoretical clarity (Christopher et al. 2001).
TFP pays particular
attention to the
importance of dyad self-object, and the affect that connects
them. These
dyads are activated
in a therapeutic relationship, which becomes the object of work.
This
point of view also
assumes the significance and indissolubility of the self and object
pair, which shows
that human personality from the beginning is associated with
interaction
with significant
others. This assumption is consistent with research on child
development,
research in the paradigm
of attachment, as well as with the research which has been
recently presented
in the neuropsychoanalysis
community (Fotopoulou & Tsakiris 2017).
Kernberg's
psychoanalytic approach
assumes that mature psychic structures (id / ego /
superego) are based
on an unconscious substrate
built from the relation of self-affect-object,
which are formed in
the first three years of human
life and are probably stored in implicit
memory. They also
decide the dominant attachment pattern
in affective reactions of the
patient.
Identification of these original structures becomes the basis
for interpretive work.
This work is to lead
to change a restructuring in the mind of the patient. This
applies to the
whole spectrum of
psychopathology excluding the psychotic organization. This therapy
is
therefore used in
treatment of borderline personality organization as well as neurotic
personality
disorders (Caligor et al. 2007, Yeomans et al. 2015) It seems to me
that the
example of TFP
and its juxtaposition with the results of neuroscience research
clearly show
how reasonable and methodologically
consistent relations between the various fields of
knowledge can be.
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