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1. I had an appointment at the San Francisco VA at nine o’clock in the morning. I was given instructions by my neuropsychologist at the Martinez VA about how to go to a VA office in Oakland that would have a bus that would take me there. I got up at six o’clock in the morning to make sure that I would not be late for the bus. I had no trouble getting to the VA building where I was to catch the bus, but my troubles started then. I had been told that I needed to obtain a ticket for the bus that would take me to San Francisco, but when I asked several people where I should go to attain that ticket no one seemed to know. Finally I was told to go to the third floor of the building. But when I got there, once again I was told that the ticket could not be obtained there and I should go to the fourth floor. I was starting to feel frustrated and when the person on the fourth floor also did not have the ticket for me, I became angry and demanded to see the supervisor. Before I knew what had happened, there were five or six people surrounding me, one of them being a guard who was telling me that my behavior was not acceptable and I was to leave the building. At this point I felt completely overwhelmed, enraged, and filled with shame. I went outside and wandered around and finally found the place where the bus left from. The bus driver told me to go back in the building to obtain the ticket. I was totally overwhelmed and angrily told her that I had already tried that and no one knew where I should go. She also was alarmed by my tone of voice and motioned a guard to come over. Finally, the guard seemed to understand the problem and was able to obtain a ticket for me. When I arrived at the San Francisco VA, I was already very exhausted. Luckily, I was able to see the physician quickly and he was very nice and sympathetic with what I had gone through. After the examination he told me to go and get some tests done. I had another problem when I tried to do this, because one of the people told me that I could not have that test done at that time, even though I had the doctor’s prescription. That caused another upset for me and with the people there. So overall it was an extremely difficult situation and I left feeling confused, depressed, and shamed.
2. When I went to my regular weekly appointment with my neuropsychologist, there was a machine in the building that described medications and what they were used for. I wanted to look at that because I was trying to figure out how my medications were affecting me and what each one was for. But there was one medication whose name I couldn’t find, so I asked the secretary at the desk and she said she would look into it. After my appointment, I went up to her to get the information and she said that the medication I wanted to know about was not listed in the medications in the machine. I explained to her that it must be listed, possibly under a different name. She didn’t seem to understand what I was saying and became very impatient with me. When I was persistent, she again called several people to the desk and soon there was also a guard who was called. I was shocked that these people felt that I was going to become dangerously aggressive. All I wanted to know was if it there be another name to the medication. Finally, my neuropsychologist was called. He brought me to his office and I explained the problem to him. He was able to tell the other people, who in fact did find the alternative name of the medication I wanted to know about. But again I left feeling overwhelmed, confused, and very ashamed of myself.

3. The difficulties I first had with my neuropsychologist were around the fact that I felt he only wanted to give me homework and was not interested in who I was as a person nor in what I had to say about my experience. He only wanted to make sure that I did the homework. This made me feel insignificant and resistant to doing the homework. When he was finally able to let go of that goal and to listen to me talk about what was bothering me, I felt more relaxed and eventually could attempt the tasks he wanted me to try. But it was not until he told me that he was really interested in what I had to offer and would like to have me work on a poster with him in which I would talk about my experience of TBI, that I really felt trust that he valued me and what I had to say.

4. During the first period of treatment, in relationships with both friends and practitioners, the patient had many experiences of being misunderstood and therefore quickly accelerating to a state of catastrophizing and aggression. For example, the experience with his neuropsychologist was at first quite difficult for him. The neuropsychologist attempted to help the patient specifically with cognitive issues. But the patient was unable to cooperate, because he did not feel that he was being “seen” but rather that he was being treated like an “object”. The neuropsychologist eventually called me, communicating that he was having a very difficult time with the patient and asking for a consultation. In the consultation, after listening to his complaints about the patient, I told him that if he could establish a relationship with the patient in which the patient felt that he was really listening to him and was more concerned about him than about the tasks the neuropsychologist assigned to him, the patient would be more cooperative. When I returned from a break after speaking with the neuropsychologist, the first thing the patient said to me was, “What did you say to Dr. M.? He’s like a different person now.” That treatment has been proceeding more smoothly.

5. The most difficult aspect of my reentry into the world was that I was told that there was nothing more that could be done for me — that I had “done a real job on myself” and that’s what I would have to live with. No one explained to me exactly what it meant to have a traumatic brain injury or what parts of my brain exactly had been injured. There were no referrals to physical therapists, psychologists etc. I felt like I was damaged goods and no one wanted anything to do with me. That was a period of deep depression.

6. Time is a very big issue — both because of the memory difficulties so I never knew exactly what day of the week it was and had to cross off the days on the calendar — but also the understanding that it was going to take a long time but that some kind of a recovery would be possible very gradually. I felt there was very little understanding about the time that I needed to adjust and to heal.

We feel that acquiring “psychoanalytic” skills — for example, listening to the patient without preconceptions, and reflecting the patient’s experiences — would enhance the rehabilitative efforts of TBI practitioners and minimize the misunderstandings that lead to a belief that TBI patients are dangerously aggressive and willfully uncooperative.

Traumatic brain injury: the silent epidemic

Traumatic brain injury (TBI) is a complex injury with a broad spectrum of symptoms and disabilities. Depending on the nature and severity of the TBI injury, people suffer symptoms that affect every aspect of life. The signs can be very subtle, and may not be noticed by other people, and may appear days or weeks after the accident.

Some common symptoms of TBI: decreased ability to perform at work, irritability, depression, chronic headaches, frustration, changes in sexual functioning, fatigue, alienation, changes in relationships, vertigo (dizziness), changes in attention, double vision, changes in ability to plan and organize, anxiety, nervousness, increased distractibility, impulsiveness, difficulties with language production and understanding, lightheadedness, loss of balance, difficulty walking or sitting, diminished memory, changes in decision-making, muscle stiffness and or spasms, confusion, seizures, hopelessness, helplessness, sleep difficulties, apathy, slurred and or slowed speech, emotional numbness, tingling, numbness, pain, or other sensations, withdrawal, slowed speed of mental processing, weakness in one or more limbs, facial muscles, or an entire side of the body, anger, isolation

Recent data shows that, on average, approximately 1.4 million people sustain TBI each year in the United States. Of those, 50,000 die, 235,000 are hospitalized, 1.1 million are treated and released from an emergency department visit. The number of people with TBI who are not seen in an emergency department or who receive no care is unknown.

“The need for psychodynamic principles in outreach to new combat veterans and their families”: Harold Kudler, M.D.(2007) Journal of American Academy psychoanalysis, 35:39-501.

a. Their needs would be better met through a public health model that incorporates progressive outreach and engagement of all new veterans rather than a traditional medical model which focuses only on those with a biological disorder. Working with new veterans and their families requires facilitation of their own adaptive processes (psychological, social, and biological). This approach carries with it the potential to reorient and revitalize the theory and practice of psychiatry.

b. TBI mind: withdrawal , control, inappropriate aggression, hypervigilance, justified anger or detachment, guilt, aggression, catastrophizing, confusion, need to right wrongs often leading to danger, inability to separate one’s mind from another’s

c. Neurological Reset training through psychodynamic intervention

d. Readjustment issues recovery model with emphasis on readjustment, new learning, and the capacity for continued change

Psychodynamic principles

1. The concept of theory of mind

2. the primacy in treatment of an “attachment” or “containment” relationship

3. the relationship as a primary tool in activating change: the attachment relationship provides the optimal context for the capacity to mentalize

4. the crucial importance of the frame

5. Preset liabilities/ pre-existing trauma: the creation of new implicit emotional procedures and the establishment of reliable modifications to old implicit patterning

6. direct attunement

7. modulation of affects through use of the therapist’s mind

8. Poor mentalizing results in dysfunctional personality traits such as aloofness, mistrusts, egocentrism, lack of empathy, aggressiveness, anxiety, impulsivity, and rigidness, as well as behavior that appears literal, resource list, tactless, undemonstrative, unimaginative and unresponsive

9. when the behaviors are understood as arising out of the lack of theory of mind skills, professional and personal relationships will improve for the TBI patient

10. the psychological self develops through the perception of oneself in another person’s mind

11. The development of an “interpersonal interpretive mechanism”

12. four emotional processing and control mechanisms that contribute to the developmental unfolding of the interpretive function: labeling in understanding affect; arousal regulation; effortful control; and specific mentalizing capacities (Fonagy and Target, 2002).

13. Therapeutic change arises from a certain type of emotional, cognitive and corporal exchange between patient and therapist in the here and now

14. new moments arise when two people make a special kind of mental contact — namely, an intersubjective contact

15. the concept of brain plasticity: only in an intersubjective context

16. discovering a history: a narrative

17. grieving

Key psychoanalytic terms

1. Theory of mind

2. attachment relationship

3. container/contained

4. bizarre objects

5. beta elements

6. alpha elements

7. transference: analytic relationship

8. self-regulation

9. listening to the patient without preconceptions

10. reflecting the patient’s experiences

11. interpersonal interpretive mechanism (I IM)

12. projective identification

13. unrepressed unconscious

14. dream and the unconscious

15. reparation

16. change in the “here and now”

17. transformation

18. non-symbolic, nonverbal aspects of the analytic process

19. reorganization

20. shared manifold of intersubjectivity

21. we- centric space

22. embodied simulation and the mirror neuron system

23. moments of meeting

24. responding to the person rather than the pathology or

Psychoanalytic Approaches

1. Peter Fonagy

Fonagy and colleagues state; “The psychological self develops through the perception of oneself in another person’s mind as thinking and feeling” (2002, p. 28). Infants find their mind in the mind of their caregiver.

Fonagy draws upon Bowlby’s proposition that a fundamental, evolutionary neurobiological attachment relationship between the mother and the infant provides the optimal context for the infant’s capacity to mentalize (Bowlby, 1973, 1982). Fonagy emphasizes that the emotion regulation that the attachment relationship provides is the foundation for mentalizing capacities. The regulation and subsequent understanding of emotions plays a formative role in mentalizing and arises from a mirroring process in which infants’ emotional expressions elicit a high but imperfect level of caregiver responsiveness.

Fonagy asserts that it is not the attachment relationship per se but rather the capacity of the attachment relationship to promote the development of what he calls an “interpersonal interpretive mechanism (IIM)” that is essential. The IIM evaluates the social environment. The establishment of the interpretive neural mechanism is a key evolutionary function of early relationships. A major selective advantage of attachment in humans is the opportunity it affords for the development of social intelligence and meaning making by means of the IIM.

2. Wilfred Bion

Bion’s (1962) also views the capacity for thinking as arising out of the mother/infant relationship. Through the mothers containing function, pressing internal impulses (raw sensory experience) are transformed into tolerable and thinkable experiences.

According to Bion the intolerable primitive sensory experience (beta elements) of the baby are projected into the mother who, through her “alpha function” (reverie) transforms the raw sensory experience into “alpha elements” that can be used for thinking. The infant then internalizes the experience of the mother’s alpha function which becomes the incipient mind (alpha function) of the baby. In this way, the mother “regulates” the emotions of the infant and the baby then internalizes the mother’s function of regulation. The capacity for emotion regulation in the baby is established (internalizing the capacity for an “interpersonal interpretive mechanism”).

When the mother is unable to receive the beta elements, they are returned to the baby with aspects of the baby’s personality, more terrifying because of their rejection by the mother. The infant wards off these terrifying beta elements through the use of excessive projective identification. The fragmented beta elements become “bizarre objects” that cannot be metabolized. The infant who started out with a “fear of dying” is left with a “nameless dread”. In this situation, the baby’s capacity for emotion regulation is thwarted.

In other words, the failure of the container-contained (Bion) or attachment (Bowlby, Fonagy) relationship, upon which the baby’s capacity for emotional regulation depends, means that the baby cannot develop the incipient capacity to self-regulate. Without the experience of being regulated, the baby cannot develop its own capacity to regulate. With no alpha function to internalize, the baby does not begin the process of “thinking”, or in Fonagy’s terms, “mentalizing”. The infant is persecuted by bizarre objects, objects which cannot be “thought about”. This situation leaves the infant with no mechanism which can provide emotion regulation and thus the capacity for “thinking.”

Bion also states that a successful containment relationship allows a contact area to form between conscious and unconscious material (1962, p.27). He states that alpha elements — beta elements that through alpha function can now be used for thinking — form a contact barrier, separating the conscious mind from the unconscious mind. When containment is not successful, this contact barrier is not formed. In this situation, the patient cannot distinguish between reality and fantasy, somatic sensations and thoughts, one’s own sensations and what the other person might be experiencing. Patients with traumatic brain injury often present in this way.

Therapeutic change in the here and now

1. Jimenez proposes that “therapeutic change arises from a certain type of emotional, cognitive and corporal exchange between patient and therapist in the here and now” (International Journal of psychoanalysis, 2006, p. 1493). The Boston Process of Change study group has put forward a model of change which includes current knowledge of recent developments in cognitive sciences. Using studies of mother-infant interaction and the development of theory of mind, the authors assert that the therapeutic effect of the “analytic” bond lies in the intersubjective and interactive processes which give rise to what they call “implicit relational knowledge,” including theory of mind skills. They describe the non-symbolic, nonverbal aspects of the analytic process. According to this model, there are moments of intersubjective meeting between patient and therapist which are capable of creating new organizations in the relationship and thus of reorganizing the implicit unconscious.

Bion adds that both the analyst and the analysand experience reorganization in this sense. Fonagy also emphasizes this model as key to the development of mentalizing capacities. He describes how the therapeutic process replicates the attachment relationship and in this way leads to new neurological capacities. He says that the analyst uses the relationship with the patient as a vehicle for helping the patient to find a way of thinking, understanding, and coping with feelings; of recognizing the connections and differences between oneself and somebody else; and of being with another person. The analyst has to teach the patient about minds, principally by opening his mind to the patient’s explorations. (Fonagy et.al.,2002).

2. Gallese

Gallese points out that neuroscientific research has started to unveil the neural mechanisms that mediate between the multilevel personal experiential knowledge we hold of our “lived body” and the implicit certainties we simultaneously hold about others. Such personal body related experiential knowledge enables our intentional attunement with others, which in turn constitutes a “shared manifold of intersubjectivity.” This “we-centric space” allows us to directly experience the meaning of the actions performed by others, and to decode the emotions and sensations they experience. An implicit form of “experiential understanding” is achieved by modeling the behavior of other individuals as intentional experiences on the basis of the equivalence between what the others do and feel and what we do and feel. This modeling mechanism is “embodied simulation.” Mirror neurons are probably one component of the neural correlate of this mechanism (Gallese, 2006).

Fonagy conceives of embodied simulation and the mirror neuron system as one of the systems underlying mentalization. (2006) He describes a fronto-cortical system that invokes declarative representations and the mirror-neuron system, that subserves a more immediate and direct understanding of the other. He points out that Gallese and Goldman hypothesize a shared sub-personal neural mapping between what is enacted and what is perceived that can be used to predict the actions of others (Gallese, 2003; Goldman, 2006).

“This automatically established link between agent and observer may not be the only way in which the emotions of others can be understood, but the simulation of action by means of the activation of parietal and pre-motor cortical networks may constitute a basic level of experiential understanding that does not entail the explicit use of any theory or declarative representation”(Fonagy, Mentalization-Based Treatment, 2006, p.58).

3. Stern

Consistent with the mentalizing stance, Stern advocates “holding theory at a further distance during the session so that the immediate relationship can be lived more fully.” This is in line with Bion’s injunction that the analyst must work “without memory, desire or understanding” for the treatment to be called an analysis (Cogitations, p. 319).

In Daniel Stern’s terms, present moments are those that arise when two people make a special kind of mental contact — namely, an inter-subjective contact. This involves the mutual interpretation of minds that permits us to say “I know that you know that I know” or “I feel that you feel that I feel.” There is a reading of the contents of the other’s mind (refer to the work of Gallese, 2002). Such readings can be mutual. According to Fonagy, Stern is describing mentalizing at its best in characterizing the psychotherapeutic process in this way (Fonagy, 2006, p. 120).

Stern, Puget, Jimenez , Bion and others highlight present moments — these moments have special therapeutic value in being novel, engaging, and unpredictable. The potentially most mutative are “moments of meeting”, which Stern refers to as mind reading. Fonagy calls this “mentalizing interactively in the transference.” We hypothesize that implicit emotional and cognitive processes of psychoanalysis activate neurological change, and that “embodied simulation” is an essential vehicle for this change. Although the traumatic brain injury patient often cannot tell us what he or she is feeling, the intuitive, intentional attunement and simulation capacities of the analyst are an aspect of mentalizing that allows the analyst to “know.” The patient in this way begins to experience him or herself as having a mind that can be known by both the patient and the analyst.

Experiences (see section “The TBI patient speaks”)

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