Implications for Psychoanalysis Concluding Remarks

Psychoanalysis emphasizes that painful and conflicted aspects of childhood can be unconsciously repeated in current relationships, in ways that are maladaptive for current functioning. Psychoanalytic treatment involves examining this unconscious repetition within the transference relationship. Psychoanalysts are often criticized for being too preoccupied with a patient's childhood. These skeptics have difficulty in accepting that an emotionally distressing problem with a parent that happened "so long ago," in childhood, can still affect the person as an adult. Yet by contrast these same skeptics often have no difficulty accepting the many everyday ways in which childhood relationships with parents can lead to permanent changes in the way a person lives their life. Parents teach children how to tie their shoes, brush their teeth, cultural values, morals, and social rules such as waiting one's turn to speak, or saying please and thank you. Such teaching often lasts a person's lifetime.

The neuroscience of prediction indicates that, in a similar way, what is learned with parents emotionally, in terms of being rejected, disappointed, shamed, or being made to feel inadequate, can also influence the individual for a lifetime. As a result of how the brain is organized, we predict from our experiences in early childhood (with important care-givers) what to expect from people in general. This biases us to experience current relationships as similar to past ones. It is not that current relationships are in fact identical to past ones, but that we subjectively experience them in this way.

The link between past and present is often difficult to recognize. For one thing, the brain disconnects repeated learning, from the specifics of person, place and time in which it was learned. I ride a bicycle, but have no memory recall of who taught me. Secondly, as a coping device, a child often disconnects conscious awareness from the painful emotions they experienced when little and vulnerable. For example, Jane reports that her mother frequently threatened to "leave" when she and her two siblings acted up. Her father loved her but berated and devalued her mother. Jane denies having any emotional feelings about either of these. At the same time, however, she despises her dependency needs, avoids commitment with men, and goes into "attack mode" at any indication that a man is critical of her. In the course of treatment as she emotionally connects to the childhood emotions, she is better able to realize how they in fact, do affect her in her current relationships. In the course of treatment Jane is finally able to marry a loving man and have children. However, she remains susceptible to her defense of not feeling painful emotions. She still has the tendency to go on "attack" with hostile criticism of her husband, rather than reveal feelings of hurt or vulnerability. In the treatment I continually point out the difference between what she expects and how her husband actually feels and treats her (He adores her, saying "she is my dream woman.") I help her to feel less ashamed about vulnerability, and to express hurt feelings without resorting to maladaptive "attack" defenses.

In the case of Julian, despite the fact that he recognizes that his therapist, over 2 years of treatment, has always treated him with the utmost care and kindness, remains suspicious and on guard. He remains reluctant to share his innermost vulnerable feelings, for fear of how the therapist will react. Martha, who was raped in the parking lot after work by a man with a beard, has no conscious recollection of the beard, having focused all conscious attention on the knife he held in her back. For months, not only does she avoid parking lots, as would be expected, but she is fearful of men with beards, even her kindly husband. Only when she reads the police report describing her attacker's appearance does she understand her fear. Nora grew up in a family in which she felt she had to be compliant in order to keep her parents' love and attention. As she matured, automatic compliance became a part of her personality structure, despite the fact that other people are quite willing to love her, even if she disagrees or argues. Patricia, whose parents were too preoccupied with their own lives to pay much attention to her, grew up expecting people to neglect her and not want to be with her. Even now, as an adult, when she goes out with friends, she experiences that people leave her out of the conversation, avoid her, or seem impatient to get away. It is not that her friends do this in fact, but this is her subjective perception of what is happening and she reacts accordingly. In this case, she always tries to please others, conforms to opinions, doesn't join in to the conversation much, and tends to leave social events early, to avoid the feeling of them leaving her. Unfortunately not only do her perceptions confirm her predicted expectations, but her own automatic behavior of isolating herself serves to reinforce her assumptions of being left out and unwanted by others.A type of projective identification can occur, when others do become angry and impatient, as people like Patricia stubbornly hold onto their old and threatened experience, despite the other's current well-intentioned efforts.

In the treatment situation, whether it is psychoanalysis or psychoana-lytically oriented psychotherapy, initially it is the analyst or therapist who draws the patient's attention to how the patient tends to feel and behave with people, and inquires as to any automatic assumptions and beliefs which may underlie these. Eventually, particularly in psychoanalysis, greater emphasis is given to examining the nature and quality of the transference relationship. In this way maladaptive patterns of relating can be revealed and evaluated in terms of whether they may be derived from similar patterns developed during early relationships. For the patient to change, they must be aware that the therapist does not currently react in the expected way. For example, the therapist is interested in the patient's stories and feelings, not disinterested as expected. The therapist is supportive and nonjudgmental of the patient, not critical or humiliating as expected. For example with Roger, after many sessions in which he describes his interactions with his wife, his children and his colleagues, I point out that there seems to be no difference for him between what he anticipates regarding how a person feels toward him, and what he believes they actually feel. This helps Roger to notice the ways in which people feel differently from what he expects.

Recognizing the difference between past and present, while providing insight, is often only the first step. It is generally not sufficient for change to occur. The patient must also be able to inhibit the old response and shift to a new one. The patient becomes consciously aware of their "mal-adaptive tendency" and then must voluntarily choose to respond differently. For many people this second step takes a lot of conscious effort and time. For example Ella's mother tended to belittle her and compete with her for who was smarter and more talented. Similarly Ella tends to experience people, including me, as either criticizing her, devaluing her, or jealously trying to be "one up" on her. In response she is constantly on the defensive. Within the treatment it requires that she make a lot of effort to notice that I am quite sensitive and concerned about her feelings, and that I admire her a great deal. It took quite a while for her to modify her defensive behavior. However even after a great deal of change occurred, she still sometimes would first act defensively and then afterwards say, "I know you were being supportive, but sometimes I just can't stop myself from sniping at you." Often she complains,"It takes too much work! Sometimes it is just easier to either withdraw or get angry."

There are many cases in which patients feel ashamed that "events that happened so long ago" can still affect them. For this reason I often explain to the patient that to a large extent, repeating the past is embedded in the very nature of how the brain operates. This can also help patients deal better with the idea that a full "cure" may not be possible. The old tendencies may still continue to emerge, because that is how the brain tends to work. The patient may still have the old feelings of hurt or humiliation, the old tendencies to want to shut down or strike back, like Ella. But much can still be done to counteract these tendencies, and help the patient function more adaptively. The patient can use the "consciousness" system, to pay attention, and make voluntary efforts to regulate emotion, inhibit mal-adaptive behaviors, and select more adaptive ones. The therapist who recognizes the biology of the brain will be in a better position to empathize with the lifelong challenge the patient must face in this struggle, and will be less likely to feel discouraged themselves as to their therapeutic effectiveness [65].

There are so many ways that patients suffer. They don't cope well with life. They don't like themselves. They have feelings such as emptiness, despair, shame, and guilt. They are self-defeating in their jobs and their relationships. The neuroscience of prediction adds to current psychoanalytic theory and technique. Perhaps most controversial is the implication that the analyst should be more active in helping the patient to focus their attention on the nature of the problematic repetitive pattern and to encourage them to "problem-solve," so to speak, in order to develop ways of consciously inhibiting old patterns and voluntarily initiating new more adaptive ones. By understanding the biology of predictive brain mechanisms, analysts may be less "resistant" to the use of active approaches to treating long-standing maladaptive interpersonal response styles.

The neuroscience of prediction suggests changes for the society at large as well. The lifelong consequences of prediction indicate just why it is so important to provide services to help children and families. The tenacious nature of maladaptive repetitions in social relationships, and the role that interpersonal forms of treatment specifically can play, may encourage greater emphasis on long-term, non-pharmacologic forms of treatment.

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