Meissner Mind-body 2002

Psychoanalytic Psychology 2007, Vol. 24, No. 2, 333–354

Copyright 2007 by the American Psychological Association 0736-9735/07/$12.00 DOI: 10.1037/0736-9735.24.2.333

MIND, BRAIN, AND SELF IN PSYCHOANALYSIS Therapeutic Implications of the Mind-Body Relation W. W. Meissner, SJ, MD Boston College

Theoretical and empirical findings regarding the mind-body relation and its integration within a concept of the self-as-person lead to certain therapeutic implications and applications. The mind-set of the analyst or psychotherapist regarding the integration of mind-body can have important reverberations, which can dictate decisions for therapeutic intervention and management. Implications for conceptualizing technical modifications in analytic therapy are suggested. Conceptualization of mind and brain operating as an integrated and functional unity contribute to better understanding aspects of mental functioning that remain beyond the reach of conscious awareness and direct therapeutic processing. Particular attention is paid to the issue of combining medications clinically with psychotherapy and psychoanalysis. Future integration of psychoanalysis with advancing trends in therapeutic intervention and with rapidly expanding neurobiological understanding of mental actions as related to brain activity may require a deepening awareness of complexities of the mind-body relation and a more analytically meaningful resolution of the problem. Keywords: mind-brain relation, dual-track approach, self, medication, therapeutic alliance

Mind-Brain in Treatment The implications of a functionally unified view of mind-body integration are multiple. They range from analytic perspectives on forms of psychopathology that implicate bodily dispositions and dysfunctions in varying degrees and their influence on the course of therapeutic interaction and the difficulties they create in negotiating the therapeutic terrain to more pragmatic issues concerning certain options for therapeutic intervention. In the current climate of burgeoning research and discovery of the active role of the brain in healthy and adaptive functioning and in pathological dysfunctioning, the borders sepa-

Correspondence concerning this article should be addressed to W. W. Meissner, SJ, MD, St. Mary’s Hall, Boston College, 140 Commonwealth Avenue, Chestnut Hill, MA 02467. E-mail: [email protected]

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rating scientific disciplines studying human behavior and experience are becoming less exact and increasingly permeable. As Martin (2002) put the matter in regard to psychiatry: Neurology and psychiatry have, for much of the past century, been separated by an artificial wall created by the divergence of their philosophical approaches and research and treatment methods. Scientific advances in recent decades have made it clear that this separation is arbitrary and counterproductive. Neurologic and psychiatric research are moving closer together in the tools they use, the questions they ask, and the theoretical frameworks they employ. (p. 695)

I would apply this comment with equal emphasis to psychoanalysis as well as psychiatry. When Martin further comments: “Clearly a conjoined effort of neurologists and psychiatrists is necessary to understand how a disease of the brain results in an illness of the mind. Clinical attempts to categorize diseases as ‘organic’ or ‘functional’ become somewhat arbitrary” (p. 698), analysts can take this to imply that psychoanalytic efforts to envision pathogenic processes as exclusively mental and not simultaneously neurobiological are not only arbitrary but increasingly obsolete, and this is not merely in areas of research and theory, but in the clinical work with patients as well. We can pursue this discussion against a background of controversy concerning the relative dichotomy between analytic theory and cognitive neuroscience versus their potential complementation and integration. Weinberger, Siegel, and Decamello (2000) argued that the prevailing emphasis on thought and rationality of cognitive sciences prevented their integration with analytic approaches that focused on the primacy of irrationality, intuition, and affect. Freud’s limited effort to provide a biology of the mind affected the divergent courses of analytic theory, emphasizing affect and psychopathology, and cognitive science focused on aspects of thought and cognitive competence (Fonagy, 2003). However, in the face of the advances in neuroscience (Meissner, 2006a, 2006b, and 2006c), these barriers are rapidly eroding. Barratt (1996) added that neuroscientific findings effectively undermine any accurate recollection or reconstruction of the patient’s history, so that “Accordingly, much of psychoanalytic ‘metapsychology’ must be entirely reconsidered to realign it with contemporary neuroscientific evidence concerning the conditions of neural functioning and the emergence of reflective consciousness” (p. 402). My focus in this present discussion centers on implications of an integrated understanding of the mind-body relation for the analytic relation and for the general aspects of analytic therapeutic interaction rather than on specific technical interventions. A first-order question concerns what and how neurobiological knowledge comes to bear on psychotherapeutic and analytic work with patients. This point has more recently been argued by Pulver (2003), emphasizing the difference between analytic technique, narrowly conceived, and analytic theory or metapsychology. Although neuroscientific advances may come to play a role in modifying or achieving greater integration with the metapsychology, the same claim, he opines, cannot be made for technique as such. This argument can find much to recommend it in de facto terms, that is, neurobehavioral or neuropsychological discoveries have in fact little direct impact on technique; I will argue much the same point later in this article, but it seems to me imprudent and unwise to ignore potential areas of future integration and modification of analytic techniques resulting from neuroscientific research. I would hesitate to close that door, and I certainly would not lock it. Pulver’s viewpoint seems to me to echo earlier dualistic persuasions, drawing a line—not unlike Freud— between analytic understanding, focusing on meaning

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and mental processes, and neuroscience dealing with neuronal mechanisms and computational processes. While rejecting reductionism, consilience, and dualism, Pulver opts for congruence, meaning that psychoanalytic propositions must at least be congruent with neuroscientific explanations. Congruence, I would see it, is merely another variant of dualism (Meissner, 2003b). The opposite side of this coin was argued by Beutel, Stern, and Silbersweig (2003). Their conclusions are well summarized: Based on the studies reviewed here and in the context of an emerging view of brain plasticity, the distinction between somatic therapies that impact on the brain and psychological therapies, with elusive, purely subjective effects is no longer tenable. It must rather be assumed that psychotherapies that successfully ameliorate symptoms and complaints (or more profoundly change object relationship patterns, affect regulation capacities, and the like) are likely to have a measurable impact on the brain, even though we know little about the mechanisms involved. (p. 794)

Although this way of approaching the problem resonates more directly with the integrative view of the mind-body relation I have been supporting, we all know that the jury is still out. How, in what ways, and in what directions these developments evolve, if ever they do, remains unknown and as yet to be discovered, but my emphasis here is that more is to be gained by a unified and integrated view of the mind-body relation than otherwise. In any case, it seems clear that psychotherapists work on one side of the mind-body equation and they do so with a certain blindness to the specifics and details of the biological processes underlying and synchronous with the mental and behavioral processes they deal with. It is this unequivocal fact that led Reiser (1984, 1994) and other dual-track theorists to entertain a dualistic resolution of the mind-body problem. Thus, although it serves little clinical utility for me as analyst to understand the complex neurophysiological and psychosomatic processes producing anxiety reactions in my patient, it is of vital importance and central to my therapeutic effort to know that there are such mechanisms and processes at work and that they underlie and explain aspects of the patient’s anxiety experience. In other words, if it is not my knowledge of the neural circuitry activated in a panic attack that guides my therapeutic approach, it is nonetheless my understanding of the nature of the mind-body relation that will go a long way in determining the therapeutic approach I take and the manner and tools of intervention I decide upon—whether psychological or physical or both. In this light, the research strategy of the dual-track approach remains both necessary and pragmatic—psychoanalysts are not schooled in the use of neuroscientific technologies nor are they equipped to study the intricacies of brain functioning as such. Their business is the study of human behavior, motivation, and meaning of mental life, and more unconscious than conscious. They make their contribution in careful study and understanding of psychological processes and how they find expression in human behavior and relationships. By the same token, neuroscientists are not equipped to study the complexities of human motivation, cognition, and behavior; theirs is the business of exploring the mechanisms and processes of brain activation and functioning generating specific behaviors and mental phenomena. Thus, the study of behavior and the study of brain mechanisms can meet on the common ground of the more complete understanding of the human person and his behavior. Needless to say, there comes a point at which neuroscientific research is able to provide physical agents or processes that can have meaningful therapeutic effects on the

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mind-body. The advent of psychopharmacological agents is a case in point. The potential for development of increasingly useful and effective therapeutic medications is immense. But even in this case, psychoanalysts and psychotherapists are not concerned with how the medication concerned does its job, but with what effect it has on the patient’s behavior and mental processes. Yet the integrated perspective on the mind-body relation offers a common frame of reference from within which our understanding of the effectiveness of such medications and their integration in the course of analytic therapy can be facilitated. Progress in neurobiological understanding of the bases of emotion, for example, may have important implications for the analytic therapeutic approach to treatment of different emotional states, for our understanding of what conditions contribute to and reinforce anxiety reactions rather than depressive, shame rather than guilt, and what differences in therapeutic approach may be more appropriate or effective for each. The fact that analysts already understand a good deal about such affective states should not lead us to feel that there is nothing more to learn about them or that the careful dissection and detailed study of aspects of such states from the neurobiological perspective will not have something important to add to our knowledge. That potentiality remains as yet a promise, but the pace of discovery and advancing knowledge may change that promise into reality any day. Arguing along similar lines for a more meaningful integration of mind and brain, Peskin (2001) concluded: “Furthermore, it is not necessary for a theory of motivation (i.e., a psychological theory) to postulate how the mental ‘emerges’ from the neurophysiological, a process misconceived in the first place. There are neurophysiological correlates of mental phenomena, or a little more precisely, there are molecular genetic, neurochemical, neuroelectrical, neuroanatomical correlates (which I will call physiology) of mental phenomena. However, both neurophysiology and psychology are aspects of neurobiology” (pp. 660 – 661, italics in original). My argument, however, takes a further step—the neurophysiological events are more than merely correlates of mental events; the mental events are what the neurophysiological events are doing, that is, the mental events are equivalently actions of the neurophysiological processes. Suggestions regarding the impact of therapeutic techniques on brain function have come from diverse sources. Erdelyi (1985) drew an analogy between psychoanalysis and systematic desensitization, and LeDoux (1996) described the effects of psychotherapy as “helping the cortex gain control over the amygdala” (p. 265). Psychoanalysis, he suggested, “with emphasis on conscious insight and conscious appraisals, may involve the control of the amydala by explicit knowledge through the temporal lobe memory system and other cortical areas involved in conscious awareness” (p. 265). The problem is that amgydalo-cortical traffic is heavier than cortico-amygdalar, so that the influence of emotions on thought is greater than that of thought on emotions. The basic problem, then, is how analysis or therapy using the tools of the mind can exercise causal effects on the brain.

The Body on the Couch In a previous analysis of the impact of body and body-related phenomena on the analytic process (Meissner, 1998) I drew a series of conclusions that are congruous with the implications of the mind-body perspective in this present study. I argued that participation of both analyst and analysand are inherently bodily: not only is the presence of the patient on the couch physical, but verbal behavior is itself also physical; even empathy is dependent on affective attunements that are themselves bodily and are conjoined with

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other bodily mediated observational data (Meissner, 2003a). Other bodily expressions involve off- and on-couch enactments. Body characteristics of both participants shape aspects of the analytic relation, affecting both transference, alliance, and real relation. Regressive experiences and arousal of anxiety on the couch are related to issues of body image and body boundaries.1 Body-related, including psychosomatic, symptoms, can arise in analysis, the nature and degree of disturbance reflecting aspects of body image and the experienced integrity or vulnerability of the body self. In addition, other bodily aspects, extrinsic to the analytic setting, can influence the analytic interaction: sex and gender, death or illness, age and aging, physical size, among others (Meissner, 1996). This perspective was echoed in McDougall’s (1995) observation: The concept of mind-body duality, a legacy of Cartesian philosophy, can cloud our perception, skew our theoretical conceptualization, and even distort our clinical work. Likewise, the assumption that the body has no ‘language,’ as some theoreticians claim, is also dangerously biasing for a psychoanalyst. Perhaps body-language is the only language that cannot lie! (p. 157)

To which I would append that the language of the body is, from the perspective of the self-as-person (Meissner, 2001) synonymously the language of the self. Or, as Lombardi (2002) puts it: “. . . the psychoanalytic experience becomes an opportunity for working through conflicts inherent in the mind-body relationship, whereby both the physical and mental manifestations of the individual are joined in a single context—‘attempting to overcome any dualism by proposing a unitary picture of the human being in which all functions are complementary’ (Mancia, 1994, p. 1284)” (p. 369). Arguing in similar terms from the perspective of the integration of mind and brain, Brenner (2000) puts the case for the impact of psychoanalysis on the brain forthrightly: “One frequently hears the ‘organic’ or physicochemical contrasted with the psychological or psychoanalytic as though the two approaches were conflicting opposites. Exactly the reverse is the case. When an analyst speaks to an analysand, physicochemical events are initiated in the analysand’s brain: in the cochlea, in the geniculate bodies, in the temporal cortex, and elsewhere. One can say of psychoanalysis, just as one does of the administration of psychotropic drugs, that it affects the functioning of the brain” (pp. 626 – 627).2 The emphasis on the fact of language as a medium of neural change is central. In a more integrated view of the mind-body relation, the mystery of how mind influences body is replaced by the question of how that part of the brain producing language influences the body—there is no mysterious leap.

1 Lombardi (2003) describes the splitting of mind and body in the fantasy system of his psychotic patient Matteo. The disturbances in an integrated self-experience and of the patient’s body image resulted in divided self-images deeply invested with oral aggressive and destructive motives and fantasies. Lombardi cites Tausk’s (1933) “influencing machine” as an example of similar splitting; see also Laing (1959/1969). I would emphasize that cases like this speak to fantasies of separation of mind and body and even of disembodiment, but they do not affect the real ontological integration and unity of mind-body. 2 The impact of words on the integrated psyche-soma was similarly argued by Shapiro (2004), who concluded: “In summary, recent neuroscientific advances permit analysis to again consider the body as a substrate for the generation of wishes and drive derivatives, and the work it causes the mind to do. Moreover, we have new evidence to assert that there are structural parallels between psychic constellations in memory and language and complementary neural circuits. Top-down modulation of relatively fixed brain circuitry is possible. Verbal instruction has now been shown to penetrate the mental apparatus to the brain, and to change physiology” (p. 341).

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Writing more recently about affect and the therapeutic action of analysis, Andrade (2005) makes the same point: From the evidence brought to us by neuroscience that the mind is the operational manifestation of the brain, we can conclude that when we talk of psychic change we are also referring to a corresponding somatic change. . . . When we say that the introjection of the analyst modifies the patient’s ego, discoveries in neuroscience let us assume that when he becomes a good object affective interaction can promote the development of new neural circuits which in turn—although they spring from a neurotransmitters secreted as a result of emotional responses— develop cognition and regulate emotions. If we consider what happens in the brain during affective interactions, it is not unreasonable to presume that the psychoanalytic method can act upon the cerebral tissue associated with failures of development. When we talk of introjection and psychic change we are simply describing in metapsychological terms what is taking place neurochemically. It is appropriate to reason in this way if you believe in a brain-mind continuum, where the existence of psychic phenomena which are not an expression of some activity in the brain is inconceivable. (pp. 685, italics in original)3

In this regard, these comments all echo Kandel: “Insofar as psychotherapy is successful in bringing about long-term changes in behavior, it does so by producing alterations in gene expression that produce new structural changes in the brain” (1998, pp. 465– 466). From a psychiatric perspective, Andreasen (2001) also addresses this issue: Psychotherapy acts on both the mind and the brain. In fact, as we understand more and more about how the brain works and how it changes in response to experience, we are steadily recognizing that the effectiveness of psychotherapy is a consequence of the ability to affect “mind functions” such as emotion and memory by affecting “brain functions” such as the connection and communication between brain cells. . . . Psychotherapy affects specific mind/ brain systems, such as learning, memory, and emotion. . . . But to the extent that these [psychotherapeutic] techniques are effective, they lead to changes in a ‘plastic brain,’ which learns new ways to respond and adapt that are then translated into changes in how the person feels, thinks, and behaves. Psychotherapy. . . is in its own way as “biological” as the use of drugs. (p. 31)

Beitman (1996) even charged that the practice of psychotherapy has been too long brainless and suggested that future theories of psychic functioning should be constrained by knowledge of brain functions. He uses the example of self-observation, a higher brain function depending to some extent on prefrontal cortex. In introspecting and reporting feelings, the patient opens a pathway between prefrontal cortex and cingulate gyrus, where in close connection with the limbic system emotional components are added to the mix and transferred back to prefrontal cortex, hence to Broca’s speech area, and finally through motor connections finds expression in speech. He suggests that psychotherapeutic efficiency might be improved by precisely targeting brain structures involved and devising psychological techniques for influencing them. The idea has appeal, but we also know that

3 Andrade (2005) also notes the limits within which the results of analytic verbal and affective methods are constrained. As he explains: “Thus, when we develop the ego we can only partially correct those flaws resulting from very serious errors in the behaviour of primary objects that occurred during a period of maturation and structuring, just as the possible recomposition of cerebral tissue as described by neuroscientists is itself only ever partial. With this in mind, we cannot maintain great therapeutic ambitions, since our regressive method is a virtual one— old relations are not revived in any real sense, as the reconstitution of the original environment is now dealing with an adult psyche and brain” (p. 694).

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the processes in the brain are complex and problematic in their own right. Although it seems reasonable to entertain the possibility of increasingly effective influence on the operation and integration of brain functions in and through psychotherapy, at this point the suggested precision may be more a wishful fantasy than a realizable possibility. Our ideas in the present state of knowledge are largely generic, but as our understanding of the specificity of brain action in relation to mental or behavioral manifestations improves, the potentiality for more detailed and effective interventions lies before us. Arguing from the perspective of somatically encoded and unmentalized experience and related unconscious fantasies, Mitrani (1995) suggested that “The introduction of unmentalized experience implies an approach in which the analyst attempts to shift somato-sensory or body memories and protofantasies from the body into the mind—from the realm of action and bodily events to that of logical verbal expression—where these may be represented symbolically for the first time, finally to be introduced into the orbit of self-reflection” (pp. 81– 82). The operative question is how this transition can be accomplished. Are there alternatives, given a degree of modification of what goes on in the patient’s brain by analytic or therapeutic interactions? On the most superficial level, analysts have come to recognize the expressive quality of bodily posture, gesture, and motility and the role they can play in the analytic situation (Pally, 2001). Freud (1905/1957) had early on recognized the significance of Dora’s reticule play, and more recently the role of nonverbal motoric behavior has been developed by McLaughlin (1992) among others. A bodily fantasy may open the way to significant conflicts, or the meaning of a gesture may unveil the feeling that gave rise to it and the associated emotional context of implication (Quinodoz, 2001). On these terms, emotional nonverbal communication often does, and, more than we think, may have as much to do with how the analytic process develops as verbal interchange. As Pally (1998) observed: “Analysts and patients may influence one another’s body sensations, imagery, thoughts, behaviors and even words by unconscious processes, nonverbal cues of emotion, such as autonomic changes (i.e., flushing, dry mouth) and behaviors (i.e., facial expression, posture, gesture). These cues are vital data from the analyst as well as from the patient. How the analyst feels, both ‘in the body’ and ‘in the mind,’ may be as important an indicator of what is going on in the patient as whatever the analyst is thinking. How the analyst communicates may be as important as what the analyst says (Pally, 1996)” (p. 360, italics in original). These aspects of analyst behavior seem to reflect involvement of right hemisphere activity (Pally, 2001) as opposed to dominant or left-hemisphere-dependent verbal and interpretive activity. Gedo (1995, 1997) attempted to integrate mind and brain by advancing the notion that the process of working-through could be conceptualized in terms of effects of the therapeutic process on neurophysiological mechanisms resulting in reorganization of neural networks.4 This would call in his view for an analytic technique beyond mere interpretation. He (1991) conjectured at one point that the analysand’s potential for identifying with the analyst’s methods of data gathering, evaluation, and inference was central to the success of the analytic process.5 Regression allowing access to the most relevant data may facilitate mobilization of cerebellar models of self, which under optimal conditions are amenable to exploration and interpretation. But such secondary process

4 Gedo’s view did not go unchallenged—see the discussion in Boesky (1995) and Smith (1997). 5 This is a perspective consistent with my view of the therapeutic alliance and its role in therapeutic interaction. See Meissner (1996).

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discursive methods, he argues, may fall short of affecting more archaic levels of self-schemata and require other nonverbal media of intervention or even enactment. Levin (1991) tried to meet this contingency by the use of metaphors that tend to maximize effective communication with levels of experience encoded in concrete, sensorimotor, and presentational signs and symbols. These models, reflecting the relative influence of one or other hemisphere, may play themselves out in the transference paradigm as well. The analyst’s therapeutic choices in such cases evolve around the issue of which hemisphere can be engaged most effectively at any given moment in the therapeutic process. Another perspective on the integration of mind and body in therapy pertains to the affective construction of memories. Reiser (1997) pointed to the affective organization of memories as a linking principle between brain organization and psychic functioning. As he put it, “Both psychoanalysis and cognitive neuroscience inform us that meaningful life experiences are encoded in mind/brain by perceptual images registered during the experience. Both disciplines indicate further that these stored encoding images are arranged in nodal memory networks organized by affect” (pp. 899 –900, italics in original). The associative connections between these stored perceptual images are mediated by corticolimbic networks that bind images to the affect that accompanies registration. The aim of analysis is to reactivate these repressed conflictual memory complexes, frequently revealed in dreams, bringing them to conscious awareness, and subjecting them to reprocessing to achieve better understanding from the perspective of mature and reasonable capacities and in the context of a constructive and productive analytic relation. Along similar lines, Pugh (2002) pointed out that memory systems vary in durability and reliability, some forms of explicit memory, for example, semantic memory, are well-nigh indestructible because of cortical consolidation, whereas episodic or declarative memory is more fragile because of vulnerability of the hippocampus to stress hormones largely related to trauma. But episodic memory is of far greater interest in the consulting room than semantic memory, albeit more subject to forgetting or reshaping. In addition, implicit or procedural memories encoded in the amygdala play an important role but take the form of unrepresentable and nonsymbolic affect states (Mitrani, 1995; Ross, 2003). Accordingly, as Gabbard and Westen (2003) note: Many defenses. . . likely become routinized, like much of procedural knowledge (‘how-to’ knowledge, or skills—in this case, procedures for regulating affect unconsciously), at the level of the basal ganglia (subcortical structures increasingly implicated in procedural knowledge) as well as in inhibitory circuits in the ventromedial prefrontal cortex. In contrast, conscious affect regulation strategies that are most likely to produce changes (often called coping strategies), such as self-distraction, involve executive functions associated with working memory (momentary memory available for conscious manipulation), which is under control of circuits in the dorsolateral prefrontal cortex as well. The technical strategies that are most likely to produce changes in conscious and unconscious affect regulation strategies may thus at times be different, because they are directed at changing structures that are not only functionally but neuroanatomically distinct. (p. 829, italics in original)

Another vantage point for integrating mind and body in psychotherapy or psychoanalysis is that provided by the body image. Pankow (1981) reflected on the phenomena of loss or abandonment of the body in schizophrenic and borderline patients, a phenomenon that has been discussed in some detail by Green (2001), and the role of fantasy and psychodynamic influence in structuring of the body image. The treatment implications for such conditions were discussed by both Pankow and Green.

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Related to the question of body posture is the often debated question of whether the use of the couch is essential for psychoanalysis.6 From the perspective of the mind-body relation, this may be a more complex question than is often assumed. Whatever other reasons there may be for using or for abandoning or minimizing use of the couch, the question of whether or to what extent the usual supine posture of lying on the couch may induce a mental state conducive to associative reflection or to mobilizing aspects of implicit memory or correspondingly modifying or softening defensive or repressive barriers to unconscious or conflict-related material buried in the patient’s memory systems, is worthy of discussion and exploration. Certain patients, under conditions that I would consider optimal for analytic reflection, seem to relax on the couch and at times to gradually drift into an intermediate state of altered consciousness akin to what Bion (1962) and Ogden (1997) have described as “reverie.” In this state, the sense of defensive tension, guardedness, and secondary process structure seem to relax and soften into a more fluid, at times illogical, often dream-like mental process that may last for varying periods of time, but seem to suggest a momentary abandonment of the usual conscious focusing of attention, intention, and effort. Does this reflect the influence of the body on the mind, in the sense that the relaxed and muscularly and posturally disengaged position of the body might serve to induce a shift in mental focus and processing akin to what we recognize as primary process, or something like it? I can only pose the question here, but taken in the context of the mind-body relation and its engagement in the therapeutic process, the use of the couch may take on another dimension of significance not usually considered. As a final comment on this subject, a unified perspective on the mind-body relation predicates that the full spectrum of therapeutic interventions that can affect the mind-body have a place in the treatment process. In this sense, we cannot rely on or resort to circumscribed techniques that would seem to be limited in their impact of the mind-body, as I think was the case in earlier days of psychoanalysis when emphasis on interpretation was so central and monolithic. We know now that more is involved, even when the utility and importance of interpretation is recognized and utilized. We know that affective conditions play a vital role in how interpretations are received, that the relation with the analyst or therapist is pivotal in the therapeutic process, not only in transference terms, but I would add in terms of the therapeutic alliance and the real relation as well (Meissner, 1996). In this connection, the distinction between episodic and implicit memory maybe pivotal. Study of memory systems suggests that the complex forms of memory— procedural, episodic, declarative, autobiographical, implicit—are relatively independent and mediated by separate neural processes. This might mean that early formative experiences, stored in implicit procedural memory, cannot be integrated with episodic or autobiographical memories developed later after the third or fourth year. This raises the question whether the usual analytic approaches to recovery of episodic and autobiographical memories are the best avenues to meaningful psychic change. Proposing that the more meaningful basis for authentic change is found in transformations affecting implicit memory, Fonagy and Target (1997) concluded: Unconscious memory is implicit memory. The psychotherapist or psychoanalyst’s pressure on the patient to find the episodic roots of these memory traces is doomed to failure, as episodic

6 See my discussion of the technical issues related to the use or nonuse of the couch in Meissner (2005).

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experience is stored separately without the significance for the determination of behavior, expectation, and belief that common-sense psychology attributes to it. The recovery of the episodic roots of implicit memories leads to illusory experience, not to psychic change. Change will occur through the reevaluation of mental models, or the understanding of self-other representations implicitly encoded as procedures in the human mind. Change is a change of form more than of content: therapy modifies procedures, ways of thinking, not thoughts. Insight or new ideas, by themselves, cannot sustain change. The internalization of this therapeutic process as an indication for appropriate termination of therapy implies a change in mental models, in alteration of the hierarchical organization of implicit memory procedures. It is not necessarily associated with increased self-awareness as a specific self-conscious activity. (p. 215, cited in Leuzinger-Bohleder and Pfeifer, 2002, p. 16)

In this respect, Schore (2002) also commented “that the coconstructed therapeutic alliance can act as a growth facilitating environment for the experience-dependent maturation of . . . regulatory systems” (pp. 470 – 471). Only in this amplified frame of consideration and interaction does the combination of security, trust, safety, maintenance of boundaries, and the respective therapeutic roles that set the stage for therapeutic efficacy offer promise of influencing aspects of brain functioning that are involved in neurotic and personality dysfunction. In all of this, we are in a position analogous to the chess analyst. It would do us little good to have a detailed analysis of the neuronal activation and network connections being activated in any segment of the patient’s behavior. Like the chess analyst who analyses the chess moves and strategy, the focus of our interest and effort to understand in therapy or analysis falls on the patient’s mental processes, both those he is conscious of and those he is not, and on the full spectrum of his other behaviors. This is our handle on the mind-brain relation, the only handle we have. In this sense, the dual-track model is the approach that at this stage of methodological development serves our therapeutic purposes best. But we should not, in my view, allow the limitations imposed on our thinking by this necessary methodological and conceptual dualism to substitute for the understanding of the ontological unity and integration of the mind-body complex in the organization and functioning of the integrated self. But we also know that behind the array of behaviors we experience with the patient there is a unified and integrated source whose actions constitute the patient’s mental behaviors and produce his physical behaviors, but to whose action we have no direct access. Access to the actions of the brain requires the methods and concepts of neurobiology.

Combining Drugs and Psychotherapy One of the central areas in which the implications of the mind-body problem assume importance is the question of when and how the use of pharmacological agents can and should be implemented in the course of psychotherapy or psychoanalysis. The technical aspects of this question are complex and deserve separate consideration in their own right, especially from the perspective of mind-body integration. Freud (1940/1964) himself, following the convictions regarding mind-body interactions he had constructed in the Project (1895/1950/1966), had envisioned the use of somatic therapies in the treatment of mental disorders: “The future may teach us how to exercise a direct influence by means of particular substances, upon the amounts of energy and their distribution in the apparatus of the mind. It may be that there are other undreamed of possibilities of therapy. But for the moment, we have nothing better at our disposal than the technique of psychoanalysis” (p. 182).

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The mind-body problem confronts us directly when we treat a patient’s mood disorder, anxiety, or psychosis with medication. The basic question current advances psychopharmacology pose is: How does a chemical substance bring about change in the mental state of the patient? The mental phenomena of self-esteem, self-confidence, alertness, feelings of alienation, and other personality variables seem changed by the drug, but we also know that the same phenomena can be modified by talking with the patient. For the most part, doctors who combine medication with psychotherapy in the treatment of mental disorders do so with a dualistic rationale based on a concept of dual causality, physical and mental. For many, if not most, psychiatrists, the prevailing assumption is that analysis or psychotherapy treat the mind and medications treat the body, a view that ignores that drugs also affect the mind and psychotherapy affects the brain. Some practitioners appeal to a dualistic bimodal model, integrating psychodynamic and psychopharmacological models in combination to explain respective aspects of the patient’s problem (Cabaniss, 1998; Sandberg, 1998; Swoiskin, 2001).7 But as Andreasen (2001) recently commented, the mind versus body dichotomy is relatively so entrenched that simply describing it as a false dichotomy does not help much “to dissuade people from the foolishness of the drugs versus psychotherapy distinction” (p. 29). The “false dichotomy” also brings an unfortunate simplification into treatment of mental disorders in the form of an either-or approach, either psychotherapy or drugs. Andreasen then adds: “When medications and psychotherapy are polarized and pitted against one another, unfortunate consequences result. Patients are confronted with conflicting advice and left in a state of confusion and doubt. They may be given only medications when they also need psychotherapy. They may be denied medications and given only psychotherapy. The best advice is not ‘either-or,’ but ‘either-or-both, as needed.’ Whatever the treatment, the most basic mechanisms are the same. Both affect mind functions by changing brain functions” (p. 32). In terms of the present analysis, drugs exercise an effect on the brain mechanisms in question, psychosocial techniques have their effect on the mental actions effected by brain activity. Both have their impact on the same basic process, but from different perspectives.8 Regarding the question of combining psychotherapy and medication, psychoanalysis and psychopharmacology often take radically different views of the pathology under treatment, one dealing with the mind to the exclusion of the body, the other treating the body with little concern or interest in the mind. The pharmacologist, for example, sees depression as a disorder of neurotransmitter metabolism; the analyst sees it as the product of dynamic psychic processes involving loss, narcissism, and the vicissitudes of aggression. The pharmacologist decries the analyst’s use of terms referring to hypothetical entities that defy operational definition and to narrative reconstructions that elude falsifiability by any kind of observable prediction. In turn, the analyst complains of the pharmacologist’s tendency to oversimplify psychic disorders, reducing individual variations to general typologies, and being willing to treat symptoms while ignoring the

7

Willick (1993) has suggested that the decision to medicate should be guided by empirical clinical evidence rather than by etiological convictions. Analysts often withhold medications, he observed, when dynamic conflicts also seem to be operative. Conversely, my argument here, based on an integrated view of mind-body, would theoretically endorse use of medication in combination with analytic or psychotherapeutic interventions when clinically indicated. 8 See Ledoux’s (2002) discussion of combining drugs and therapy in various forms of psychopathology.

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underlying disease process. There is often a standoff between the advocate of the mind and the proponent of the brain. As a case in point, the relevance of these concepts in the treatment of schizophrenia surfaced in the discussion triggered by Willick (2001) in arguing that the weight of empirical evidence supported the conclusion that schizophrenia was a biological and not a psychogenic disorder, and, therefore, was not an appropriate condition for psychoanalytic treatment. This view was challenged by Fratarolli (2002), who argued for a more classically oriented model based on the combination of drive, conflict, and defense as the basic etiology, to which biological factors might contribute but did not play a causal role. Alternatively, Robbins (2002) argued for a more interactive and multisystemic model of the disease process in which psychic and somatic were mutually interactive. In each of these contributions, the dualistic perspective prevails— blatantly in Willick, more subtly in Fratarolli and Robbins. However, in all including Willick (2002), the utility of antipsychotic medications is acknowledged and taken advantage of. Does this reflect a degree of tension between practical clinical application and theoretical perspectives? Despite these discipline-related contrasts, Wallace (1988) made the point in comparing verbal and pharmacological interventions that: “Each of these interventions—and its effects—is no more or less material and somatic or meaningful and psychic than the other. Words are meaningfully patterned sound waves intercepted and processed by sensory organs, a peripheral nervous system and ultimately, by those dual aspect activities known as mind. Medications are physiologically active substances dispensed within the context of the historically situationally determined meanings of a doctor-patient relationship. Alterations in states of mind effected by either modality include changes in both psychological and neurophysiological-anatomic aspects of mentation” (p. 18). We need to remind ourselves that treatment decisions can reflect the tensions of the mind-body problem. When the biologically oriented psychiatrist decides to treat the brain rather than the mind, the decision presumes an assumption that symptoms are caused by neurophysiological processes calling for medication or other physical intervention. When the psychoanalyst or psychotherapist decides to treat the mind rather than the body, the opposite assumption prevails: that symptoms are attributable to unconscious meanings, motives, and affects that require being brought to conscious awareness and effective resolution. The dichotomized choice of treatment is presumptively dictated by a philosophic option rather than empirical evidence. Along this line Unger’s (1982) comment resonates: “The same set of mental experiences always presents itself to us as the result of two sets of factors: one, physical; the other, psychodynamic. Any disorder or therapy that begins with one of these factors will immediately have effects upon the other. At opposite poles of the field of mental pathology, one or the other of these elements may dwindle in importance. But in the broad middle range they coexist. If the principle of homology still applies, it must hold at a deeper level of causation, to which our current conceptions of the mental and the organic may prove equally foreign” (p. 157).

Technical Issues in Analysis Use of medications for patients in analysis has been a controversial subject.9 Following introduction of effective psychotropic medications, especially antianxiety and antidepres9 An interesting subplot in this connection was stirred up by Gottlieb (2002) in a brief note on the use of SSRI medications in analysis, advancing the hypothesis that one important effect of these

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sive agents, combination of medications with psychotherapy became more or less common usage. In contrast, the prevailing attitude among analysts was that use of such agents during the course of an analysis would diminish symptom intensity and thus possibly undermine motivation for continuing analytic work, or at least serve as a complicating parameter that would contaminate transference and possibly become a vehicle for enactment of countertransference (Ostow, 1962; Sarwer-Foner, 1960). Writing three decades ago, Ostow (1975) commented on this viewpoint as follows: Some psychoanalysts concede that these conditions are indeed proper clinical indications for administering medication but that medication nevertheless makes subsequent true analysis impossible. When he administers and monitors medication, the psychoanalyst does depart from the role of uninvolved interpreter, and he does become more personally involved in the patient’s fate. By so doing he complies with the patient’s wish that he be personally and genuinely concerned with his recovery. (p. 464)

In more contemporary terms, in which personal involvement is viewed not only as unavoidable but in some ways necessary, this seems benign enough. But Ostow goes on to warn that patients who have been depressed for long periods without drug intervention can become angry at the analyst for withholding the supposed relief, resulting in even greater disruption of the analytic process. He offers his opinion that “. . . if the entire process of administering, regulating, and withdrawing medication is evaluated, the analytic process itself does not suffer” (p. 464). Earlier views that the use of medications can interfere with the analytic process have been gradually yielding ground. In the intervening years, this early view has undergone considerable revision not only because more effective medications have found their way into the pharmacological armamentarium, but also because analysts have gained increasing experience in combining analysis or analytically oriented psychotherapy with these drugs (Esman, 1989; Roose, 1990; Wylie & Wylie, 1987). In certain cases, addition of some psychopharmacological agent has seemed not only advantageous, but necessary for effective therapeutic management (Kantor, 1989, 1993).10 For example, the American Psychiatric Association guidelines for treatment of borderline personalities (American Psychiatric Association, 2001) indicate that combined psychotherapy and psychopharmacology are optimal for treatment of this spectrum of personality disorders. Double-blind and placebo-controlled studies suggest that use of serotonin uptake inhibitors (SSRIs) can improve affect lability and management of hostile and destructive behavior. As Gabbard (2005) comments: These agents may facilitate psychotherapy by reducing ”affective noise“ – such as intense anger, hypervigilant anxiety, or dysphoria—that prevents patients from reflecting on their internal world and the inner experiences of others. . . . Use of an SSRI may help facilitate psychotherapeutic changes in the brain. The patient’s capacity to perceive the therapist as a helpful and caring figure instead of a persecuting and malevolent figure will serve to build up

drugs was their capacity to modify aggressive feelings. The note stimulated a heated debate and discussion over the role of SSRIs and their therapeutic use in analysis (Levinson et al., 2004). 10 Recent reports support the increased effectiveness of combining forms of psychotherapy with pharmacotherapy, e.g. Lenze et al. (2002).

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new neural networks of internal representations while weakening the old ones. (pp. 653– 654)11

Obviously, no drug can take the place of the search for meaning and the struggle to achieve psychic growth. Yet the therapeutic potential of combining empathic analysis with psychotropic medications offers the possibility even of anatomical if not functional repair. It may be that SSRIs can buffer the damaging effects of cortisol-mediated stress on hippocampal neurons, offering the possibility of regenerative healing in the adult hippocampus under favorable conditions. Thus, both psychotherapy and psychotropic medications can interact to facilitate healing (Ross, 2003). Along with greater openness to use of medications, analytic sophistication regarding implications of the use of medication on transference and the analytic process has grown apace. The role of pills as vehicles for transference and countertransference expression and their function as transitional objects (Adelman, 1985; Gutheil, 1982; Hausner, 1985–1986) became better understood. The prevailing view at this juncture is that use of medications is not at all incompatible with an ongoing analytic process, especially in the treatment of mood or anxiety disorders. Not only do a fair percentage of analysts use such combined therapy, but also the incidence is significant even in training cases (Roose & Stern, 1995). As I have discussed elsewhere (Meissner, 1996), I tend to regard the use of medication as one of the reality-based factors that impinges on the analytic process that can have important reverberations for the analytic relation and transference. If the analyst is persuaded that medication may serve his patient well, he needs to keep in mind implicit messages he may convey in introducing the subject. Will the patient experience it as an expression of the analyst’s disappointment in him for not being able to manage his feelings without artificial help? As Ostow (1975) observed: When a patient has undertaken psychotherapy or analysis because of his conviction that his distress can be reversed by such a procedure, a recommendation made during the course of treatment to accept chemotherapy may be interpreted as an indication that the patient’s illness is organic since he cannot be helped by purely psychological measures. In other words, the recommendation of drug therapy reinforces the usual hypochondria of depression. Under such circumstances, reassurance, explanation, and interpretation are required before treatment is actually begun. In any case, introducing drug therapy may well be regarded by the patient as an intrusion into his analysis or psychotherapy. (p. 465)

Will he take it as affirming his inferiority and weakness? Will he accept it compliantly as a magical talisman from the powerful analyst? The possibilities are multiple and can insert themselves subtly and by implication. An important factor at this juncture pertains to the analyst’s understanding of the mind-body relation, particularly as it affects his grasp of the interdigitation of the mental and the physical in the therapeutic process. If the analyst himself thinks in dichotomously dualistic terms, that is, of mind versus brain-body, the way is open to the kind of misunderstanding that can generate the above feelings. If talk and medication are viewed as alternatives in treating the patient’s disorder— either talk or drugs, or when talk fails use drugs—the way lies open for false assumptions and misinterpretations in the patient’s mind and in his participation in the therapeutic process. 11 Gabbard (2005) also reviews some of the mounting evidence documenting neurobehavioral effects of both appropriate medications and psychotherapy on the treatment of personality disorders.

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Under the best of circumstances, precisely because of the potential for such miscommunication and misunderstanding, the issue of taking medication is and should be a matter for mutual exploration and decision between analyst and analysand. Implications for the analytic work should be discussed, possible transference issues explored in detail, and reverberations for therapeutic alliance sorted out. Lurking in the background inevitably is the medical model, according to which the magician-doctor, who has the power and knowledge to heal, applies his wisdom to the ignorant, suffering, helpless, and accommodating patient. To the extent that it goes unaddressed, this model will contaminate the analytic process and lead to a potentially problematic misalliance. Introduction of medication to the therapeutic process brings with it other issues of management toward which analytic practitioners may have a wide diversity of attitudes and/or discomfort. Even when the decision-making process regarding use of medications has been adequately conducted, the ongoing technology of drug management may create additional problems. The elaborate ritual of drug taking and drug monitoring—the necessity for explaining side effects, obtaining informed consent, checking on side effects (e.g., orthostatic pressure, weight gain, impotence), checking on compliance, taking plasma-level measurements— can create myriad complications in the analytic process affecting transference, countertransference and alliance. The potential for distortion of therapeutic alliance and creation of problematic misalliances is not insignificant. When use of drugs seems advisable, the analyst has the option of turning drug management over to a colleague who is better versed and experienced in the use of psychopharmacology. It has been my experience that this by no means eliminates the issues of using drugs from analytic consideration, but it does allow for a freer and less encumbered exploration of its meaning and effectiveness (or lack thereof) in the analytic setting. This is somewhat analogous to the therapeutic/administrative split familiar in hospital and clinic settings, with similar advantages and disadvantages. Although the displacement of drug management out of the analysis resolves some of the problems it may create within the analytic relation, it does so at the cost of the complications attendant on bringing another therapeutic agent into the picture. Issues of splitting of transference and particularly of playing into the defensive needs of the patient to escape analytically relevant conflicts and to exploit the tension between taking drugs and talking about problems and issues in the interest of frustrating therapeutic objectives can come into play. In this respect, attitudes toward the mind-body relation can become pivotal, that is, pharmacology-body versus psychoanalysis/psychotherapy-mind, and can be used defensively especially to avoid meaningful exploratory effort. These therapeutic issues are compounded by widely pervasive professional commitments in the mental health community. This question and the problems related to it have become embroiled in a highly divisive controversy that is strongly determined by underlying dualistic commitments on both sides. The assumptions that operate on both sides of the mind-body division, between biological psychiatrists who maintain that only some form of physical intervention will alleviate the patient’s symptoms, and psychoanalysts or dynamically oriented psychotherapists who hold that psychological intervention is the only viable option for treatment, although both assumptions are probably both unnecessary and untrue, would both require commitment to either a monistic or dualistic perspective of some sort. These assumptions can create pressures that force the treatment process in an either-or direction, either drugs or psychotherapy, not necessarily in the best

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interest of the patient.12 The additional and not infrequent assumption that all cases of a given disorder deserve the same approach and kind of treatment also would have to be questioned. Experience tells us that in therapy of any kind and especially in treatment of mental disorders the “one size fits all” approach is doomed to failure. Treatment is always individualized. Some cases are best approached psychoanalytically, some psychotherapeutically, some pharmacologically, and some with a combination of approaches, possibly even varying over the course of a treatment. As Roose and Johannet (1998) point out, use of phenomenology to guide medication decisions would seem to support mind-body dualism. The division in Diagnostic and Statistical Manual of Mental Disorder, Fourth Edition, between Axis I disorders (biologically based, not attributable to psychic conflict, and not treatable by psychotherapy) versus Axis II disorders (resulting from psychic conflict and approachable by psychological treatment rather than medication) perpetuate a dualistic split between brain (Axis I) and mind (Axis II). The use of medication in psychoanalysis rides on this underlying split: even if the conflict is resolved in the analyst’s mind, it may not be for the patient. Patients commonly ask whether their illness is biological or not. Even an unequivocal answer that it is biological or not will not dispel the conflict of mind versus body. The question masks the fantasy that if the problem is biological, the patient cannot control it and is therefore not responsible for it. But if the patient is not responsible for his hypertension, he can still be held responsible for dealing with it. If the patient is not responsible for his depression, he remains responsible for dealing with it and helping himself to escape it (Meissner, 1996). The question remains to what extent does introduction of medication into the therapeutic situation bring with it these ambiguities. In addressing this issue, Chessick (1985) issued the complaint that: The choice of a biological paradigm in psychiatry, as is also becoming true in the general field of medicine, is an inauthentic choice. It is an act of bad faith that enables psychiatrists temporarily to avoid facing the problems that are really troubling their patients. It enables the psychiatrist to avoid a confrontation with the psychological and sociological factors from which arise the etiological power of personal and collective myths and psychic unconscious realities in the formation of a whole variety of disorders. (p. 381)

He extended this complaint more recently (2001) to the tendency to reduce obsessivecompulsive disorders to forms of brain disease. Rather, he would contend “that these conditions probably are on a complemental series, with the proportion of contribution from organic and psychogenic causes variable in each case” (p. 183). These same dualistic and divisive tendencies have become institutionalized into aspects of the health care system. Along the same line, Guze (1998) pointed out the division in care of mental patients by managed care programs along mind versus body lines. Psychological interventions are split off from use of medications and are employed by professionals belonging to different organizations and systems of care that do not interact with each other and maintain very different views of the patient and the nature of his illness. This reflects the worst aspects of Cartesian dualism and works against the best interests of the patient.

12

The prevailing dualism caused Fawcett to remark in 1997 that despite extensive research in psychopharmacology and in forms of psychotherapy, there was little study of treatment integrating both approaches.

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Gabbard (1992) stated the case for mutual interaction succinctly: “Research on both primates and humans suggests that psychological influences result in permanent alterations of a neurobiological nature. Similarly, psychological interventions in a treatment context may have a profound impact on neurophysiology. Clinical case examples demonstrate that ‘biologically based’ disorders may be rich in unconscious meaning” (p. 991). In this sense, the learning that takes place in an analytic or therapeutic process is mediated by plastic alterations of the brain (Edelman, 1989; Kandel, 1998, 1999). Schore (1997) addresses the same question: An answer to this comes from current brain research indicating that the capacity for experience-dependent plastic changes in the nervous system remains in place throughout the life span. In fact, there is now very specific evidence that the prefrontal limbic cortex, more than any other part of the cerebral cortex, retains the plastic capacities of early development. The orbitofrontal cortex, even in adulthood, continues to express anatomical and biochemical features observed in ontogeny, and this property allows for structural changes that can result from psychotherapeutic treatment. (p. 831)

Gabbard (1994, 2001) further argues the case for combining medication with psychodynamic therapy in cases of obsessive-compulsive disorder, especially in clarifying and addressing relationship difficulties, as well as in panic disorder and generalized anxiety disorder. Along the same line, Kandel (1979) made the point that “It is only insofar as our words produce changes in each other’s brains that psychotherapeutic intervention produces changes in patients’ minds. From this perspective the biological and psychological approaches are joined” (p. 1037). He (1998) also lent his support to the combined use of drugs and psychotherapy: “The joint use of pharmacological and psychotherapeutic interventions might be especially successful because of a potentially interactive and synergistic—not only additive— effect of the two interventions. Psychopharmacological treatment may help consolidate the biological changes caused by psychotherapy” (p. 466). Subsidiary to the drug-versus-talk issue is the question of placebo effects. Besides active drugs, placebos can induce subjective expectancies for beneficial change—for example, tranquilizers make you feel more relaxed. Such response expectancies tend to become self-confirming, affecting not only subjective experience but physiological parameters—a mental state seems to be producing a physiological response and vice versa (Frank, 1977). Biological psychiatrists have been slow to ask how the placebo exerts its effect, if mind states are taken to be reflections of corresponding brain states (Rose, 1984). One reasonable approach to this problem is to see the events in terms of identity or complementarity, according to which mental state and physiological process are alternate descriptions of the same underlying event. Thus, a placebo-induced increase in heart rate is not caused by the expectancy but by the physiological brain state with which it is identified (Kirsch & Hyland, 1987).

Summary and Conclusions Analysts are not accustomed to thinking of their analytic efforts as directed to modifying patterns of brain activation. Reflection on the integrative perspectives of the mind-brain relation and their institution in a unified concept of the self as synonymous with the human person place the analytic relation and its attendant patterns of interaction in a much more encompassing frame of reference in which usually verbal analytic interventions have

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direct effects on the patterns of activation in the neural net. Such interventions are not only expressions of mind-brain-body action on the part of the analyst (insofar as language and speech are constituted by patterns of activation of both language centers in his brain and motoric sequences in speech production) and are received, encoded, and understood in virtue of patterns of neural activation in the mind-brain of the patient. We must conclude that all interactions between analyst and patient—whether conceived in terms of transference-countertransference, real relation, or therapeutic alliance (Meissner, 1996, 2000)—are functions of mind-brain-body in action. Although details of the neurobiology of mental processes are of little direct concern to the practicing analyst or therapist, they are not irrelevant. It may not at this point matter that the patient’s recollections are attributable to temporo-hippocampal as opposed to fronto-temporal circuitry in the brain. What matters is that the mental recollecting is at the same time an action of the patient’s brain and reflects dynamic processes taking place in the neural net. In other words, the details of the neuroscientific approach to the brain as yet offers little directly to helping the therapist do his job, but the resolution of the mind-body relation he adopts may in contrast have considerable consequences. The view of the self as embodied and of the patient’s productions and activities in the analysis or therapy as expressions of a unified and integrated mind-body goes a long way toward more comprehensive understanding of affective processes, of psychosomatic processes, and the deeper understanding of the functioning of the patient as a human being. In an era when rapid advances are being made in devising increasingly effective somatic treatments of mental disorders, a more unified and comprehensive understanding of the mind-body relation is essential. In many of these areas, the techniques and circumstances in which somatic and psychic modalities of treatment can be implemented and combined are under discussion, but effective integration will be better served by a unified understanding of the self as encompassing the total person and by an integrated and unified perspective on the mind-body relation in the self.

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