Psychotherapy

Tomography of the Mind

NORMAN A. CLEMENS, MD

The machine whirs and clicks from slice to slice, as the offer us. I shall illustrate the array of perspectives by technician watches through a shielded window and the introducing a hypothetical, composite patient immobile patient moves on a pallet through a series of stations. The mass of data from this exercise goes to a Alice, a 42-year-old married woman, was referred by fast computer and is integrated into detailed cross sec- her internist because of persistent anxiety and depres- tions in three dimensions. Equally, the data could be sion. She had previously made two non-lethal attempts used to construct a three-dimensional model in space. at suicide, resulting in brief hospitalizations. One of her The marvels of the CAT, MRI, SPECT scans and their children was under treatment for obsessive-compulsive enhancements never fail to astonish us. symptoms. Alice had lost 10 pounds in the past 3 Minus the whirring and clicking, a comparable event months and had difficulty falling asleep at bedtime. takes place minute-to-minute in the mind of the skilled psychotherapist. In my long career, this process and the The Descriptive Perspective therapy it enables have been the most fascinating and rewarding part of being a psychiatrist. What emerges on This is a look at the patient from the outside—the the computer screen of my mind is not just three but a appearance, behavior, affect, basic cognitive skills, plethora of dimensions of my patient’s—and my own— stream of thought, mental content, and so on, that make mental operations. Most of them were originally defined up the mental status examination and lead to a multi- by Sigmund Freud and a succession of brilliant psycho- axial DSM diagnosis. analysts who built on his work. Some have been extend- ed by the analysts who founded other forms of Alice showed depressed and anxious affect, slight psychotherapy, usually coning down on one dimension psychomotor retardation, gloomy and negativistic or another. Together they provide an array of possibili- thought content without delusions or hallucinations, ties for understanding and intervening with the patient moderate suicidal risk, and normal cognitive functions. and the illness. Because of her long history of depression, she received While the interpreters of diagnostic imaging have to the diagnoses of dysthymia and generalized anxiety look at one slice at a time, the skilled psychotherapist disorder. Elements of her history suggested a histrionic may be assessing multiple dimensions simultaneously. personality disorder, early signs of menopause, and sig- Nor are therapists limited to the four dimensions of nificant marital stress: her Global Assessment of space and time. The concept of multiple perspectives Functioning (GAF) score was 65. The treatment plan was originally formulated by Rapaport, Hartmann, and was to start a new antidepressant and psychotherapy. others1–4 in a system called metapsychology, which high- lighted five modes of organizing data about mental The Psychodynamic Perspective operations. Since then, additional perspectives have fur- ther enriched our understanding of patients and our- This perspective is the “cross-sectional view” of the selves. For instance, the developmental perspective has patient at a moment in time. Operating in the here and been made more systematic by augmenting the concept now, it considers the dynamic interplay of several of phases of development (a cross-sectional view at each phase) with a longitudinal view of lines of development NORMAN A. CLEMENS, MD, is a clinical professor at Case of various mental functions. Self psychology, object rela- Western Reserve University and training psychoanalyst in the Cleveland Psychoanalytic Institute. He was the founding chair tions theory, interpersonal and intersubjective perspec- of the APA Commission on Psychotherapy by Psychiatrists and tives, cognitive and behavioral techniques—all have is currently chair of the APA Committee on APA/Business given us new ways of interpreting the data our patients Relationships.

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important functions of the mental apparatus, described that his or her mental operations are the product of in what psychoanalysts call the “structural theory”—the long experience in which emotions have played a pow- familiar id, ego, and superego. The id is the source of erful role, even shaping the development of the brain. drive and motivational energy. The ego has a host of Psychoanalysts have defined successive phases of devel- functions that coordinate and deal with both internal opment in which all aspects of mental function unfold and external elements in a person’s life, such as sensa- in an interactive, dynamic way at each moment in time, tion, motor activity, self-control, integration of memory resulting in maturation and interaction of numerous and knowledge, decision-making and intention—the mental functions that may or not be fully achieved by basic executive functions of the mind, geared to reality. adult life. Child analysts have sketched out the usual The superego comprises both the conscience—the moral patterns of evolution of key mental functions, system- standards—and the ego ideal, which is the set of stan- atizing their observations as lines of development of dards and aspirations by which one judges one’s behav- each of these functions. The past plays an enormous ior. A major focus of psychodynamic psychotherapy role in defining how a patient functions today, and this (PDP) is to aid the patient in understanding and resolv- is what the clinician focuses on rather than simply ing internal conflict between the various parts of the intellectualizing about what happened decades before. patient’s mind. Cognitive-behavioral therapy (CBT) also Only PDP deals systematically with the developmental works in this perspective to some extent, by calling perspective. attention to dysfunctional “automatic thoughts” gener- ated by less reality-oriented parts of the mind and Alice’s sadistic conscience and her marriage to an employing learning techniques to strengthen the ego’s abusive husband had their roots in repeated beatings reality-based thought patterns, which tips the conflict in by her father as a little girl. She had also been assault- the ego’s favor. ed as a teenager. She had never developed the capacity for mature sexual expression or the self-confidence to Alice was struggling with rage at her abusive hus- assert herself effectively to change a damaging situa- band. She could barely contain her impulses to attack tion. Through repetition of past traumata she had him or to seek solace in a sexual relationship with a attempted but failed to achieve mastery. handsome, kindly co-worker. She felt guilty about her fantasies and tentative flirtations, and she was The Unconscious-Conscious Perspective ashamed of herself for violating standards (her ego ideal) of what a good wife ought to be. Her sadistic con- A vast array of thought processes take place below the science, failing in its role of preventive control before level of awareness, leaving the conscious part of the damage was done, punitively and sometimes danger- mind relatively free to focus on living in current reali- ously enlisted the ego to defensively turn rage inward ty.All id functions and a large part of ego and superego upon herself rather than attack others. Confronted by functions take place out of awareness. Access to deeper this internal conflict, her ego experienced strong anxi- layers of mental activity is a relatively dynamic, fluc- ety both from contemplating the horrifying conse- tuating attribute of the mind, regulated by what the quences of her potential behavior in external reality ego feels safe in tolerating and thereby somewhat and from sensing its own weakness to control the mael- amenable to enhancement through psychotherapy. strom within. Alice was in a state of intense, destabiliz- Psychoanalysis and its derivative, PDP, pay special ing conflict. Her therapist saw his role as helping Alice attention to this dimension of mental life, but struc- define the conflict, firm up her sense of reality, acknowl- tured therapies such as CBT and interpersonal psy- edge her contradictory wishes and their implications, chotherapy (IPT) also expand consciousness through give up more primitive defenses (denial, displacement, clarifying and defining circumscribed insights into introjection, and projection), and replace them with thought and feeling. Various mental defense mecha- more mature defenses and executive actions that would nisms, especially repression, have the effect of clouding allow her to cope more effectively with her situation. conscious awareness of past and present matters, cre- ating a dynamically unconscious realm of thought. The Developmental Perspective This especially affects explicit memories. Other domains of memory, particularly procedural memory, This is the “longitudinal” view of the patient over time. are deeply unconscious, visible only in their conse- It recognizes that the patient wasn’t born yesterday, quences such as automatic behaviors.

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Much of Alice’s awareness of her childhood abuse these issues by including all the parties in the treat- was dim, as was her ability to see the extent of her ment. Classically, psychoanalysis approaches only the rage about both past and present abuse. Repression, intrapsychic processes of the individual and does not denial, undoing, and other defenses kept the picture include family members as participants or objects of very cloudy. Psychotherapy helped her become more concern, but awareness of these relationship issues now fully aware of these issues at a pace her ego could tol- plays a large part in psychoanalysis and PDP. The rela- erate without overwhelming anxiety, which in turn tionship with the therapist is also a central focus of psy- enabled her to work out more realistic solutions to her choanalytically derived treatments, as past object life situation. relationships get re-enacted in transference and count- er-transference. The Self/Object Perspective Besides working with the intrapsychic dimensions of This perspective looks closely at the patient’s mental Alice’s self and object representations, her therapist representations of her self and of important people in addressed the day-to-day interactions between her and her life. Here the line of development of narcissism and her family members, with an eye to improving their object relations comes into play. Key issues are the abil- emotional tone and behavioral patterns. Her husband ity to distinguish oneself, one’s needs and wishes, even was included in therapy sessions from time to time. Her one’s identity from those of others; the ability to therapist was constantly attentive to Alice’s interaction empathize and take pleasure in the other’s successes; with the therapist himself, its resemblance to her past the capacity to love another as a separate person rather significant relationships, and the responses evoked in than as an extension of oneself; and a secure self-esteem the therapist’s own mind—selectively using these obser- based on a realistic view of oneself, one’s strengths, vations to enhance Alice’s understanding and mastery. needs, and human limitations. The fulfillment of this line of development according to Kohut is the achieve- The Adaptive Perspective ment of empathy, humor, creativity, and wisdom.3 Erikson’s stages of development also reflect this per- From this perspective, one considers how the dynamic spective, which includes a vision of the human life balance of the patient’s defense mechanisms, character- cycle.1 Because this perspective is closely related to the istic thought patterns and behavior, symptoms, and so developmental perspective, PDP is the treatment that on, affect her ability to function and cope with her commonly addresses it, although dialectic-behavioral world. Strategic decisions may then emerge, in which therapy (DBT) also deals with it in its approach to bor- the patient and her therapist come to terms with what derline personality disorder. works and what doesn’t. At times, they may tacitly decide, “If it ain’t broke, don’t fix it.” At other times, bla- Alice was in a constantly competitive, hostile rela- tantly maladaptive compromise-formations must be tionship with her husband, alternating between ideal- confronted. izing and devaluing his achievements and his personal engagement with the family. Her self-esteem was frag- Alice’s over-involvement with her daughter’s school ile, she was easily wounded and offended, and she often activities was clearly not something she could relin- saw others only from the standpoint of what they could quish, so she and her therapist concentrated on Alice do for her. She treated her children’s accomplishments not imposing her own preferences on her daughter’s as if they were her own and objected to interests of selection of activities and roles. theirs that did not parallel hers. The Neurodynamic Perspective The Interpersonal Perspective There is no mind without a brain, and awareness of Patients’ actual relationships with significant other per- brain functions enriches our understanding of how the sons are vital aspects of their lives that must be mind works. It is now recognized that pharmacological addressed in treatment. IPT concentrates on this modulation of various neurotransmitter systems can dimension through focusing narrowly on issues of grief potentially augment psychotherapy, so that the two and loss, role changes in work and family, and manage- modalities together produce greater benefit. There is ment of relationships. Family therapy also addresses dramatic new information about the extensive effects of

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the child’s environment on its developing brain struc- each one. Just as computerized axial tomography pres- ture and function, the damage to the hippocampus ents varying images of the same structures in differing caused by traumatic stress, the generation of new neu- dimensions, these perspectives overlap and interact in rons from stem cells in adult life, and the potential for many ways. They are hard to describe in isolation. Yet dynamic modification of brain function through experi- the skilled therapist automatically integrates them and ence. Therapy may modify functional neurophysiology shifts readily from one perspective to another as each is in the same manner as medications. useful. Openness to the various viewpoints greatly enriches what we can bring to our work with patients. An SSRI considerably improved Alice’s regulation of her affective states during the early part of her treat- ment, until she gradually matured her own ego strengths and their corresponding neural pathways. Possible hippocampal neuronal loss during her adoles- References cent traumatic experiences was likely either replaced or 1. Erikson EH. Childhood and society. New York: WW Norton; compensated for by enhancing her limbic regulatory 1950. systems in the therapeutic milieu. 2. Hartmann H, Kris E, Lowenstein R. Comments on the forma- tion of psychic structure. Psychoanal Study Child 1946;2: 11–38. Synthesizing the Tomographic Images 3. Kohut H. The analysis of the self. New York: International Universities Press; 1971:296–328. This list of perspectives is necessarily incomplete and 4. Rapaport D, Gill M. The points of view and assumptions of superficially elaborated. A large literature stands behind metapsychology. Int J Psychoanal 1959;40:153–62.

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