Biology and the Future of Psychoanalysis: A New Intellectual Framework for Psychiatry Revisited
1999; American Psychiatric Association; Volume: 156; Issue: 4 Linguagem: Inglês
10.1176/ajp.156.4.505
ISSN1535-7228
Autores Tópico(s)Mental Health and Psychiatry
ResumoBack to table of contents Previous article Next article Special ArticleFull AccessBiology and the Future of Psychoanalysis: A New Intellectual Framework for Psychiatry RevisitedEric R. Kandel, M.D.Eric R. KandelSearch for more papers by this author, M.D.Published Online:1 Apr 1999https://doi.org/10.1176/ajp.156.4.505AboutSectionsView articleAbstractPDF/EPUB ToolsAdd to favoritesDownload CitationsTrack Citations ShareShare onFacebookTwitterLinked InEmail View articleAbstractThe American Journal of Psychiatry has received a number of letters in response to my earlier “Framework” article (1). Some of these are reprinted elsewhere in this issue, and I have answered them briefly there. However, one issue raised by some letters deserves a more detailed answer, and that relates to whether biology is at all relevant to psychoanalysis. To my mind, this issue is so central to the future of psychoanalysis that it cannot be addressed with a brief comment. I therefore have written this article in an attempt to outline the importance of biology for the future of psychoanalysis. We must recollect that all of our provisional ideas in psychology will presumably one day be based on an organic substructure.— Sigmund Freud, “On Narcissism” (2)The deficiencies in our description would probably vanish if we were already in a position to replace the psychological terms with physiological or chemical ones.…We may expect [physiology and chemistry] to give the most surprising information and we cannot guess what answers it will return in a few dozen years of questions we have put to it. They may be of a kind that will blow away the whole of our artificial structure of hypothesis.— Sigmund Freud, “Beyond the Pleasure Principle” (3)During the first half of the twentieth century, psychoanalysis revolutionized our understanding of mental life. It provided a remarkable set of new insights about unconscious mental processes, psychic determinism, infantile sexuality, and, perhaps most important of all, about the irrationality of human motivation. In contrast to these advances, the achievements of psychoanalysis during the second half of this century have been less impressive. Although psychoanalytic thinking has continued to progress, there have been relatively few brilliant new insights, with the possible exception of certain advances in child development (for a review of recent progress, see references 4–7). Most important, and most disappointing, psychoanalysis has not evolved scientifically. Specifically, it has not developed objective methods for testing the exciting ideas it had formulated earlier. As a result, psychoanalysis enters the twenty-first century with its influence in decline.This decline is regrettable, since psychoanalysis still represents the most coherent and intellectually satisfying view of the mind. If psychoanalysis is to regain its intellectual power and influence, it will need more than the stimulus that comes from responding to its hostile critics. It will need to be engaged constructively by those who care for it and who care for a sophisticated and realistic theory of human motivation. My purpose in this article is to suggest one way that psychoanalysis might re-energize itself, and that is by developing a closer relationship with biology in general and with cognitive neuroscience in particular.A closer relationship between psychoanalysis and cognitive neuroscience would accomplish two goals for psychoanalysis, one conceptual and the other experimental. From a conceptual point of view, cognitive neuroscience could provide a new foundation for the future growth of psychoanalysis, a foundation that is perhaps more satisfactory than metapsychology. David Olds has referred to this potential contribution of biology as “rewriting metapsychology on a scientific foundation.” From an experimental point of view, biological insights could serve as a stimulus for research, for testing specific ideas about how the mind works.Others have argued that psychoanalysis should be satisfied with more modest goals; it should be satisfied to strive for a closer interaction with cognitive psychology, a discipline that is more immediately related to psychoanalysis and more directly relevant to clinical practice. I have no quarrel with this argument. It seems to me, however, that what is most exciting in cognitive psychology today and what will be even more exciting tomorrow is the merger of cognitive psychology and neuroscience into one unified discipline, which we now call cognitive neuroscience (for one example of this merger see reference 8). It is my hope that by joining with cognitive neuroscience in developing a new and compelling perspective on the mind and its disorders, psychoanalysis will regain its intellectual energy.Meaningful scientific interaction between psychoanalysis and cognitive neuroscience of the sort that I outline here will require new directions for psychoanalysis and new institutional structures for carrying them out. My purpose in this article, therefore, is to describe points of intersection between psychoanalysis and biology and to outline how those intersections might be investigated fruitfully.THE PSYCHOANALYTIC METHOD AND THE PSYCHOANALYTIC VIEW OF THE MINDBefore I outline the points of congruence between psychoanalysis and biology, it is useful to review some of the factors that have led to the current crisis in psychoanalysis, a crisis that has resulted in good part from a restricted methodology. Three points are relevant here.First, at the beginning of the twentieth century, psychoanalysis introduced a new method of psychological investigation, a method based on free association and interpretation. Freud taught us to listen carefully to patients and in new ways, ways that no one had used before. Freud also outlined a provisional schema for interpretation, for making sense out of what otherwise seemed to be unrelated and incoherent associations of patients. This approach was so novel and powerful that for many years, not only Freud but also other intelligent and creative psychoanalysts could argue that psychotherapeutic encounters between patient and analyst provided the best context for scientific inquiry. In fact, in the early years, psychoanalysts could and did make many useful and original contributions to our understanding of the mind simply by listening to patients, or by testing ideas from the analytic situation in observational studies, a method that has proved particularly useful for studying child development. This approach may still be useful clinically because, as Anton Kris has emphasized, one listens differently now. Nevertheless, it is clear that as a research tool this particular method has exhausted much of its novel investigative power. One hundred years after its introduction, there is little new in the way of theory that can be learned by merely listening carefully to individual patients. We must, at last, acknowledge that at this point in the modern study of mind, clinical observation of individual patients, in a context like the psychoanalytic situation that is so susceptible to observer bias, is not a sufficient basis for a science of mind.This view is shared even by senior people within the psychoanalytic community. Thus, Kurt Eissler (9) wrote, “The decrease in momentum of psychoanalytic research is due not to subjective factors among the analysts, but rather to historical facts of wider significance: the psychoanalytic situation has already given forth everything it contains. It is depleted with regard to research possibilities, at least as far as the possibility of new paradigms is concerned.”Second, as these arguments make clear, although psychoanalysis has historically been scientific in its aim, it has rarely been scientific in its methods; it has failed over the years to submit its assumptions to testable experimentation. Indeed, psychoanalysis has traditionally been far better at generating ideas than at testing them. As a result of this failure, it has not been able to progress as have other areas of psychology and medicine.The concerns of modern behavioral science for controlling experimenter bias by means of blind experiments has largely escaped the concern of psychoanalysts (for important exceptions, see references 10–12). With rare exception, the data gathered in psychoanalytic sessions are private: the patient’s comments, associations, silences, postures, movements, and other behaviors are privileged. In fact, the privacy of communication is central to the basic trust engendered by the psychoanalytic situation. Here is the rub. In almost all cases, we have only the analysts’ subjective accounts of what they believe has happened. As the research psychoanalyst Hartvig Dahl (11) has long argued, hearsay evidence of this sort is not accepted as data in most scientific contexts. Psychoanalysts, however, are rarely concerned that their account of what happened in a therapy session is bound to be subjective and biased.As a result, what Boring (13) wrote, nearly 50 years ago, still stands: “We can say, without any lack of appreciation for what has been accomplished, that psychoanalysis has been prescientific. It has lacked experiments, having developed no techniques for control. In the refinement of description without control it is impossible to distinguish semantic specification from fact.”Thus, in the future, psychoanalytic institutes should strive to have at least a fraction of all supervised analyses be accessible to this sort of scrutiny. This is important not only for the psychoanalytic situation but also for other areas of investigation. Insights gained in therapy sessions have importantly inspired other modes of investigation outside the psychoanalytic situation. A successful example is the direct observation of children and the experimental analysis of attachment and parent-child interaction. Basing future experimental analyses on insights gained from the psychoanalytic situation makes it all the more important that the scientific reliability of these situations be optimized.Third, unlike other areas of academic medicine, psychoanalysis has a serious institutional problem. The autonomous psychoanalytic institutes that have persisted and proliferated over the last century have developed their own unique approaches to research and training, approaches that have become insulated from other forms of research. With some notable exceptions, the psychoanalytic institutes have not provided their students or faculty with appropriately academic settings for questioning scholarship and empirical research.To survive as an intellectual force in medicine and in cognitive neuroscience, and indeed in society as a whole, psychoanalysis will need to adopt new intellectual resources, new methodologies, and new institutional arrangements for carrying out its research. Several medical disciplines have grown by incorporating the methodologies and concepts of other disciplines. By and large, psychoanalysis has failed to do so. Because psychoanalysis has not yet recognized itself as a branch of biology, it has not incorporated into the psychoanalytic view of the mind the rich harvest of knowledge about the biology of the brain and its control of behavior that has emerged in the last 50 years. This, of course, raises the question, Why has psychoanalysis not been more welcoming of biology?THE CURRENT GENERATION OF PSYCHOANALYSTS HAVE RAISED ARGUMENTS FOR AND AGAINST A BIOLOGY OF MINDIn 1894 Freud argued that biology had not advanced enough to be helpful to psychoanalysis. It was premature, he thought, to bring the two together. One century later, a number of psychoanalysts have a far more radical view. Biology, they argue, is irrelevant to psychoanalysis. To give an example, Marshall Edelson (14) in his book Hypothesis and Evidence in Psychoanalysis, wrote:Efforts to tie psychoanalytic theory to a neurobiological foundation, or to mix hypotheses about mind and hypotheses about brain in one theory, should be resisted as expressions of logical confusion.I see no reason to abandon the position Reiser takes despite his avowed belief in the “functional unity” of mind and body, when he considers the mind-body relation:“The science of the mind and the science of the body utilize different languages, different concepts (with differing levels of abstraction and complexity), and different sets of tools and techniques. Simultaneous and parallel psychological and physiological study of a patient in an intense anxiety state produces of necessity two separate and distinct sets of descriptive data, measurements, and formulations. There is no way to unify the two by translation into a common language, or by reference to a shared conceptual framework, nor are there as yet bridging concepts that could serve…as intermediate templates, isomorphic with both realms. For all practical purposes, then, we deal with mind and body as separate realms; virtually, all of our psychophysiological and psychosomatic data consist in essence of covariance data, demonstrating coincidence of events occurring in the two realms within specified time intervals at a frequency beyond chance.” [15, p. 479]I think it is at least possible that scientists may eventually conclude that what Reiser describes does not simply reflect the current state of the art, methodologically, or the inadequacy of our thought but represents, rather, something that is logically or conceptually necessary, something that no practical or conceptual developments will ever be able to mitigate.In my own numerous interactions with Reiser I have never sensed him to have difficulty relating brain to mind. Nevertheless, I have quoted Edelson at length because his view is representative of that shared by a surprisingly large number of psychoanalysts, and even by Freud in some of his later writings. This view, often referred to as the hermeneutic as opposed to the scientific view of psychoanalysis, reflects a position that has hindered psychoanalysis from continuing to grow intellectually (16, 17).Now, psychoanalysis could, if it wanted to do so, easily rest on its hermeneutic laurels. It could continue to expound on the remarkable contributions of Freud and his students, on the insights into the unconscious mental processes and motivations that make us the complex, psychologically nuanced individuals we are (18–26). Indeed, in the context of these contributions, few would challenge Freud’s position as the great modern thinker on human motivation or would deny that our century has been permanently marked by Freud’s deep understanding of the psychological issues that historically have occupied the Western mind from Sophocles to Schnitzer.But if psychoanalysis is to rest on its past accomplishments, it must remain, as Jonathan Lear (27) and others have argued, a philosophy of mind, and the psychoanalytic literature—from Freud to Hartmann to Erickson to Winnicott—must be read as a modern philosophical or poetic text alongside Plato, Shakespeare, Kant, Schopenhauer, Nietzsche, and Proust. On the other hand, if the field aspires, as I believe most psychoanalysts do aspire, to be an evolving, active contributor to an emerging science of the mind, then psychoanalysis is falling behind.I therefore agree with the sentiment expressed by Lear (27): “Freud is dead. He died in 1939, after an extraordinary productive and creative life…it is important not to get stuck on him, like some rigid symptom, either to idolize him or to denigrate him.”BIOLOGY IN THE SERVICE OF PSYCHOANALYSISMy focus in this article is on ways that biology might reinvigorate the psychoanalytic exploration of mind. I should say at the outset that although we have the outlines of what could evolve into a meaningful biological foundation for psychoanalysis, we are very much at the beginning. We do not yet have an intellectually satisfactory biological understanding of any complex mental processes. Nevertheless, biology has made remarkable progress in the last 50 years, and the pace is not slacking. As biologists come to focus more of their efforts on the brain-mind, most of them have become convinced that the mind will be to the biology of the twenty-first century what the gene has been to the biology of the twentieth century. Thus, Francois Jacob (28) writes, “The century that is ending has been preoccupied with nucleic acids and proteins. The next one will concentrate on memory and desire. Will it be able to answer the questions they pose?”My key argument is that the biology of the next century is, in fact, in a good position to answer some of the questions about memory and desire, that these answers will be all the richer and more meaningful if they are forged by a synergistic effort of biology and psychoanalysis. In turn, answers to these questions, and the very effort of providing them in conjunction with biology, will provide a more scientific foundation for psychoanalysis.In the next century, biology is likely to make deep contributions to the understanding of mental processes by delineating the biological basis for the various unconscious mental processes, for psychic determinism, for the role of unconscious mental processes in psychopathology, and for the therapeutic effect of psychoanalysis. Now, biology will not immediately enlighten these deep mysteries at their core. These issues represent, together with the nature of consciousness, the most difficult problems confronting all of biology—in fact, all of science. Nevertheless, one can begin to outline how biology might at least clarify some central psychoanalytic issues, at least at their margins. Here I outline eight areas in which biology could join with psychoanalysis to make important contributions: 1) the nature of unconscious mental processes, 2) the nature of psychological causality, 3) psychological causality and psychopathology, 4) early experience and the predisposition to mental illness, 5) the preconscious, the unconscious, and the prefrontal cortex, 6) sexual orientation, 7) psychotherapy and structural changes in the brain, and 8) psychopharmacology as an adjunct to psychoanalysis.1. Unconscious Mental ProcessesCentral to psychoanalysis is the idea that we are unaware of much of our mental life. A great deal of what we experience—what we perceive, think, dream, fantasize—cannot be directly accessed by conscious thought. Nor can we explain what often motivates our actions. The idea of unconscious mental processes is not only important in its own right, but it is critical for understanding the nature of psychic determinism. Given the centrality of unconscious psychic processes, what can biology teach us about them?In 1954 Brenda Milner (29) made the remarkable discovery, based on studies of the amnestic patient H.M., that the medial temporal lobe and the hippocampus mediate what we now call declarative (explicit) memory storage, a conscious memory for people, objects, and places. In 1962 she made the further discovery that even though H.M. had no conscious recall of new memories about people, places, and objects, he was nonetheless fully capable of learning new perceptual and motor skills (for a recent review see reference 8). These memories—what we now call procedural or implicit memory—are completely unconscious and are evident only in performance rather than in conscious recall.Using the two memory systems together is the rule rather than the exception. These two memory systems overlap and are commonly used together so that many learning experiences recruit both of them. Indeed, constant repetition can transform declarative memory into a procedural type. For example, learning to drive an automobile at first involves conscious recollection, but eventually driving becomes an automatic and nonconscious motor activity. Procedural memory is itself a collection of processes involving several different brain systems: priming, or recognition of recently encountered stimuli, is a function of sensory cortices; the acquisition of various cued feeling states involves the amygdala; formation of new motor (and perhaps cognitive) habits requires the neostriatum; learning new motor behavior or coordinated activities depends on the cerebellum. Different situations and learning experiences recruit different subsets of these and other procedural memory systems, in variable combination with the explicit memory system of the hippocampus and related structures (30, 31) (figure 1).In procedural memory, then, we have a biological example of one component of unconscious mental life. How does this biologically delineated unconscious relate to Freud’s unconscious? In his later writings Freud used the concept of the unconscious in three different ways (for a review of Freud’s ideas on consciousness see reference 32). First, he used the term in a strict or structural way to refer to the repressed or dynamic unconscious. This unconscious is what the classical psychoanalytic literature refers to as the unconscious. It includes not only the id but also that part of the ego which contains unconscious impulses, defenses, and conflicts and therefore is similar to the dynamic unconscious of the id. In this dynamic unconscious, information about conflict and drive is prevented from reaching consciousness by powerful defensive mechanisms such as repression.Second, in addition to the repressed parts of the ego, Freud proposed that still another part of the ego is unconscious. Unlike the unconscious parts of the ego that are repressed and therefore resemble the dynamic unconscious, the unconscious part of the ego that is not repressed is not concerned with unconscious drives or conflicts. Moreover, unlike the preconscious unconscious, this unconscious part of the ego is never accessible to consciousness even though it is not repressed. Since this unconscious is concerned with habits and perceptual and motor skills, it maps onto procedural memory. I shall therefore refer to it as the procedural unconscious.Finally, Freud used the term descriptively, in a broader sense—the preconscious unconscious—to refer to almost all mental activities, to most thoughts and all memories that enter consciousness. According to Freud, an individual is not aware of almost all of the mental processing events themselves yet can have ready conscious access to many of them by an effort of attention. From this perspective, most of mental life is unconscious much of the time and becomes conscious only as sensory percepts: as words and images.Of these three unconscious mental processes, only the procedural unconscious, the unconscious part of the ego that is not conflicted or repressed, appears to map onto what neuroscientists call procedural memory (for a similar argument see also reference 33). This important correspondence between cognitive neuroscience and psychoanalysis was first recognized in a thoughtful article by Robert Clyman (34), who considered procedural memory in the context of emotion and its relevance for transference and for treatment. This idea has been developed further by Louis Sanders, Daniel Stern, and their colleagues in the Boston Process of Change Study Group (35), who have emphasized that many of the changes that advance the therapeutic process during an analysis are not in the domain of conscious insight but rather in the domain of unconscious procedural (nonverbal) knowledge and behavior. To encompass this idea, Sanders (36), Stern (37), and their colleagues have developed the idea that there are moments of meaning—moments in the interaction between patient and therapist—which represent the achievement of a new set of implicit memories that permits the therapeutic relationship to progress to a new level. This progression does not depend on conscious insights; it does not require, so to speak, the unconscious becoming conscious. Rather, moments of meaning are thought to lead to changes in behavior that increase the patient’s range of procedural strategies for doing and being. Growth in these categories of knowledge leads to strategies for action that are reflected in the ways in one person interacts with another, including ways that contribute to transference.Marianne Goldberger (38) has extended this line of thought by emphasizing that moral development also is advanced by procedural means. She points out that people do not generally remember, in any conscious way, the circumstances under which they assimilated the moral rules that govern their behavior; these rules are acquired almost automatically, like the rules of grammar that govern our native language.I illustrate this distinction between procedural and declarative memory that comes from cognitive neuroscience to emphasize the utility for psychoanalytic thought of a fundamentally neurobiological insight. But in addition, I would suggest that as applied to psychoanalysis, these biological ideas are still only ideas. What biology offers is the opportunity to carry these ideas one important step further. We now know a fair bit about the biology of this procedural knowledge, including some of its molecular underpinnings (8).The interesting convergence of psychoanalysis and biology on the problem of procedural memory confronts us with the task of testing these ideas in a systematic way. We will need to examine, from both a psychoanalytic and a biological perspective, the range of phenomena we have subsumed under the term “procedural memory” and see how they map onto different neural systems. In so doing we will want to examine, in behavioral, observational, and imaging studies, to what degree different components of a given moment of meaning or different moments of this sort recruit one or another anatomical subsystem of procedural memory.As these arguments make clear, one of the earlier limitations to the study of unconscious psychic processes was that no method existed for directly observing them. All methods for studying unconscious processes were indirect. Thus, a key contribution that biology can now make—with its ability to image mental processes and its ability to study patients with lesions in different components of procedural memory—is to change the basis of the study of unconscious mental processes from indirect inference to direct observation. By these means we might be able to determine which aspects of psychoanalytically relevant procedural memory are mediated by which of the subcortical systems concerned. In addition, imaging methods may also allow us to discern which brain systems mediate the two other forms of unconscious memory, the dynamic unconscious and the preconscious unconscious.Before I turn to the preconscious unconscious and its possible relation to the prefrontal cortex, I first want to consider three other features related to the procedural unconscious: its relation to psychic determinism, to conscious mental processes, and to early experience.2. The Nature of Psychological Determinacy: How Do Two Events Become Associated in the Mind?In Freud’s mind, unconscious mental processes provided an explanatory mechanism for psychic determinism. The fundamental idea of psychic determinism is that little, if anything, in one’s psychic life occurs by chance. Every psychic event, whether procedural or declarative, is determined by an event that precedes it. Slips of the tongue, apparently unrelated thoughts, jokes, dreams, and all images within each dream are related to preceding psychological events and have a coherent and meaningful relationship to the rest of one’s psychic life. Psychological determinacy is similarly important in psychopathology. Every neurotic symptom, no matter how strange it may seem to the patient, is not strange in the unconscious mind but is related to preceding mental processes. The connections between symptoms and causative mental processes or between the images of a dream and their preceding psychically related events are obscured by the operation of ubiquitous and dynamic unconscious processes.The development of many ideas within psychoanalytic thought and its core methodology, free association, derives from the concept of psychic determinism (39). The purpose of free association is to have the patient report to the psychoanalyst all thoughts that come to mind and to refrain from exercising over them any degree of censorship or direction (39, 40). The key idea of psychic determinism is that any mental event is causally related to its preceding mental event. Thus, Brenner (40) wrote, “In the mind, as in physical nature about us, nothing happens by chance, or in a random way. Each psychic event is determined by the ones which precede it.”Although we do not have a rich biological model of psychic declarative explicit knowledge, we have in biology a good beginning of an understanding of how associations develop in procedural memory (for a review see reference 31). Insofar as aspects of procedural knowledge are relevant to moments of meaning, these biological insights should prove useful for understanding the procedural unconscious.In the last decade of the nineteenth century, at the time that Freud was working on his theory of psychological determinacy, Ivan Pavlov was developing an empirical approach to a particular instance of psychic determinism at the level of what we now call procedural knowledge: learning by association. Pavlov sought to elucidate an essential feature of learning that had been known since antiquity. Western thinkers since Aristotle had appreciated that memory storage requires the temporal association of contiguous thoughts, a concept later developed systematically by John Locke and the British empiricist philosophers. Pavlov’s brilliant achievement was to develop an animal model of learning by association that could be studied rigorously in the laboratory. By changing the timing of two sensory stimuli and observing changes in simple reflex behavior, Pavlov (4
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