Psychotherapy Meets Emotional Neuroscience

The Two Minds of Cognition and Feeling

Gilbert Pugh

• Publisher: Routledge
• Year: 2019
• Print ISBN: 9780367333379
• eBook ISBN: 9781000145113
• Topic: Psychology
• Subtopic: Mental Health in Psychology
• Index: Psychology

Psychotherapy Meets Emotional Neuroscience: The Two Minds of Cognition and Feeling introduces new insights from the neurosciences into the nature of our emotions and feelings, and argues for a more empathetic approach to psychotherapy as a result.

Respectful of Freud the neurologist and explorer of the mind, the book seeks to contextualise psychoanalytic theory with recent discoveries in how emotions are generated in the brain, as well as those around memory, to clarify key psychological processes such as projection and transference. It includes sketches of a number of influential analysts whose emphasis has been on a close, affective relationship with their patients—including Ferenczi, Kohut and Winnicott—and explains why, in the light of recent research, empathy is necessary for any effective psychotherapeutic relationship. There are also chapters on the use of drugs to complement psychotherapy, and how the free energy principle can explain brain functioning.

In an era when neuroscientific research has provided far-reaching discoveries into how our brains work, this clear-sighted, accessible overview will offer psychotherapists and psychoanalysts, whether practicing or training, or indeed non-professionals seeking therapy for personal reasons, a way of incorporating new knowledge into their understanding of their patients and themselves.

1

EARLY INFLUENCES

My interest in the “Talking Cure” began several years before entering Guy’s hospital as a medical student in the early 1960s. Before I was 16, I had read Freud’s New Introductory Lectures on Psychoanalysis and some of his Studies on Hysteria and was fascinated by his accounts of traumatised patients who had paralysed limbs or areas of numbness for which there was no neurological explanation, but I still questioned whether or not these were true observations. Freud originally described these patients as having “no knowledge of their own anatomy”.

Once we had crossed the Pons asinorum, battered but unbowed by the second M.B. (the pre-clinical, purely scientific part of a medical degree), excitedly and expectantly we medical students thankfully abandoned corpses and chemistry and entered the real world of live patients and their illnesses. We spent periods of six months on medical wards, then surgical wards and spent time with other disciplines, such as skins, neurology, pharmacology, and obstetrics: then came the turn of psychology, or psychological medicine, as it was then called.

The course began with a lecture for the whole of our year given by the medical director of the psychiatric wing of Guy’s hospital, the York Clinic. The semi-circular lecture theatre, with rows of seats arching around the raised dais, had a wooden rail about 3 feet high, which separated the audience from the speaker. Gradually, the theatre filled with cheerful, chattering medical students, eager to hear something new and so different from the atmosphere of former lectures held in this theatre on regional anatomy or the biochemistry of digestion. Some minutes passed, then a gasp and absolute silence. The lecturer in a smart suit, brightly coloured shirt with socks to match, mounted the wooden rail and with arms spread wide, body rocking like a glider in flight, negotiated the whole of the semi-circular rail and nimbly jumped down onto the platform. Applause, stamping of feet and whoops of delight greeted this performance.

It was only years later that I learnt that Dr David Stafford Clark (see figure 4) amongst his other achievements had been a medical parachutist and one of the last combatants to leave the Normandy beaches in 1944.

When there was silence once more, he said in a clear clipped voice: “you see that would have been impossible for me to do two thousand feet in the air: that is the theme of my talk to you today…”

Some weeks later, we met Dr Stafford Clark again at a psychiatric outpatient clinic for senior medical students. He asked me to examine an ex-soldier who was unable to move his heavily tattooed left arm for no apparent reason and who had had every imaginable test to eliminate an organic cause for his paralysis including a routine test for syphilis, before being referred to the psychiatric department. (It was hospital policy at that time to test anyone with a tattoo for syphilis: the NHS would be bankrupt if this were the practice today!) I examined the man thoroughly and could find no cause for his paralysis, but because we were learning about differential diagnoses in medicine, my assumption was that I had missed some sign or symptom to explain his incapacity. When Dr Stafford Clark explained that this was a case of conversion hysteria as a result of traumatic stress, we were all incredulous to the point of disbelief. Now in other branches of medicine no medical student would even think of questioning a consultant’s diagnosis, so it was not surprising that he was a little irritated by our suspiciousness of his.

Without saying another word, he beckoned me, walked over to the patient again and deftly examined his cranial nerves, reflexes, muscle tone, and sensory system and, finding nothing amiss, asked us as a group to explain what anatomical lesion could explain this man’s symptoms. Some of us made clever suggestions about obscure lesions in this or that location, but each time Dr S-C countered with remarks such as: “If that were so, why is this or that reflex intact then?” We soon gave up and with smiles and shakings of the head, it dawned on us that we had witnessed an actual demonstration that parts of the mind that were not conscious did not obey the rules of anatomy and that there were more things in heaven and earth than were revealed in our dissecting room studies. My scepticism on first reading Freud had disappeared forever. Until our knowledge of the brain is more advanced, this group of patients will often find themselves regarded with suspicion by both neurology and psychiatry.

Thinking back, it was undoubtedly this episode that convinced me that it was the study of the mind and its inseparability from the brain and body where my future interest in medicine lay. What occurred a few months later confirmed the exact nature of this interest. One day after we had finished another psychiatric outpatient clinic with Dr S-C, he approached me and asked if I would be interested in taking on a patient for psychotherapy. I felt thrilled and privileged and mumbled my thanks and willingness to have a go.

Later that evening, I wondered what I had let myself in for. My only instruction was to contact Dr S-C’s secretary to find out the name of the patient and the date and time when we would meet. I had no idea whether I would be sitting in on a psychotherapy session conducted by someone else or whether, and this was a frightening thought, would I be actually responsible for conducting the sessions on my own? Surely not! Remember, I had no experience in psychotherapy at all let alone taking clinical responsibility for a patient unsupervised. In retrospect, I realised that Dr S-C’s thinking was that a concerned and keen medical student, who he knew was unlikely to say or do anything too stupid, would make up in empathy what he lacked in knowledge.

When the day came, I made my way to a small consulting room in the psychiatric wing of the hospital where there were seated not one patient but a couple, both small in build and deep in conversation. Thus began nearly 50 years ago my first psychotherapy session.

All these years later, I remember little more about the problems for which the couple had sought help; I remember the tears and the impassioned exchanges directed at one another in a guttural European language which softened when the husband re-directed them to me in broken, careful English. Little more I remember, not even how many months I spent with them. What I do remember are their beaming faces as they left after our last session and the little packet of biscuits she pressed into my hand.

Whether or not this couple had actually achieved any lasting benefit from my best efforts, I shall never know, but what has stayed with me, and is confirmed by my later experiences in clinical practice, is the strong impression that what is healing in psychotherapy is not clever interpretations, or the correct application of psychoanalytical technique, but a total commitment to forming an empathic relationship with the patient to try to understand how the past, as perceived by the patient, has formed patterns of thinking and behaving, which do not serve the patient well in the present.

Dr Stafford Clark, though I never knew him other than as a teacher, was one of the shining examples for me of a clinician who was influenced by Freud—he had after all written a book entitled What Freud Really Said—but who employed any technique available, whether it was psychotherapy, hypnotism, or drugs, to help a patient get well. He presented a series on medical hypnotism in the very early days of television, and I remember being fascinated by the case of a woman who spoke only English as an adult, but who under hypnosis, could speak only German in a charming childlike way. As a physician he would, like Freud, have been fascinated by the advances in the neurosciences which have illuminated and confirmed so many of Freud’s observations.

Dr S-C was a pioneer who followed in the footsteps of that other humane and original thinker W.H.R. Rivers, mentor of Siegfried Sassoon who worked with shell-shocked soldiers at Craiglockhart War Hospital near Edinburgh in the First World War. Dr S-C had a similar appointment as medical director of Waterbeach Bomber Command hospital near Cambridge in the Second World War Whilst there, he was responsible for removing the stigma of the pejorative discharge diagnosis lacking in moral fibre, which ruined the careers and lives of so many airmen stretched beyond endurance by the horrors of war. Many of their predecessors in River’s era lost more than their careers. Both Rivers and Stafford-Clark were trailblazers in understanding what, in the First World War, was called “shell shock” and is now called “post-traumatic stress disorder” (PTSD). The high incidence of PTSD in soldiers returning from the Afghanistan conflict suggests that the number of soldiers estimated to have suffered shell shock in the First World War was grossly underestimated, perhaps by a factor of ten. This is hardly surprising since shell shock and cowardice were at that time synonymous. Both Stafford-Clark and Rivers taught at one time at Guy’s hospital in London.

*********************

Final exams, marriage, and the requirement to complete two house jobs, one medical and the other surgical, to fulfil the registration process, for a while, diverted my attention away from matters psychological. I blotted my copybook during my first house job because my consultant, a somewhat cold individual and poor surgeon, asked me to arrange for a photographer to take pictures of cancerous lesions on a dying patient in our care for a paper he was writing. I felt strongly that he should be spared this final indignity and I politely refused. He was furious, and I told him if he really wanted photographs of a dying man, he should fix it up himself. For this and other reasons, I had as little to do with him as possible after that; my refusal to ask him for a reference could have had serious consequences for my future career were it not for a charming ENT consultant with whom I did a weekly clinic, who when I explained my dilemma, gave me a glowing reference.

My second house job was overshadowed by the fact that my new boss, a prize-winning gold medallist in medicine, was also one of the most severe alcoholics I have ever encountered. On the Sunday evening before my appointment began, as I was finding my way to my room, I came across this figure staggering down the underground corridor in full morning dress with a grey top hat perched at a jaunty angle over his right temple. He told me sometime later that his only daughter’s wedding had been a prolonged affair. I took his arm and he indicated where he would like to be directed. He took me towards his room which turned out to be exactly opposite to mine. Later I learnt that he was my boss.

Before retiring to bed, I visited one of the wards I was to look after for the next six months. I introduced myself to the three nurses who were sitting at their station in the middle of the ward chatting and reading Sunday rags. I returned to the first bed and attempted to introduce myself to an elderly lady lying motionless on her back. When I got no response, I took her pulse and realised that she was dead and had been for some time. On returning to the nurses’ station, I asked how the patient was in the first bed. “She’s just fine”, someone said. I suggested she might like to take another look.

Quite soon I got to know the daily habits of my boss. His mornings began with a visit to the local pub via the back door: his evenings ended slumped on a bar stool front of house. Amazingly, he conducted ward rounds and attended outpatient clinics in a professional way, but by five o’clock, he was indisposed, which meant he was not available for consultation in emergency cases. An incredibly competent Israeli senior registrar covered for him, but when he was off duty, the task fell to me. Looking back, this meant that I took on more responsibility than I was comfortable with, but it also meant I gained a great deal of experience in a short time.

On one occasion, I was called to casualty to see an obese middle-aged man who was in extremis. I shocked his heart several times and restarted it, but his heart tracing was erratic. I summoned the on-call anaesthetist and asked her to intubate his airway. She shamefacedly said she had never put a tube down the larynx on her own before and refused to try. She was greener than I was. Fortunately, as students at Guy’s hospital on the anaesthetic “firms”, we were taught to intubate so I took over. She competently administered oxygen, but despite our best efforts, the patient died. I don’t think others would have done any better in this case, but as a junior houseman, knowing there would be no senior colleagues to consult in an emergency, it was a lonely experience. This was 50 years ago and, despite criticisms of the NHS, these sorts of situation would never happen today in the United Kingdom.

I was fond of my boss and learnt a lot from him on ward rounds. I was fascinated by his attachment to older remedies, one of which was a treatment for asthma involving enemas of olive oil and chloroform. Any significant flatulence would have anaesthetised the whole ward.

*********************

With the junior house jobs over, I turned my mind once again to matters psychological. I took a senior house job at a local mental hospital on the Mile End road in East London. I was assigned to the locked ward and given a massive bronze key which I shouldn’t have kept as a memento of those transitional days. On either side of the heavy front door were the padded cells, the “pads”, the one on the left for male patients and on the right for the female. The male and female parts of the ward were separated by the “pads”, and my office was on the female side.

My role on this ward was to admit new patients, supervise the female side of the ward, administer electro-convulsive therapy, and assess and renew the prescriptions for the large number of psychotic patients who trooped in every morning. There was little opportunity to get to know these individuals personally; there seemed only time to repeat their prescriptions.

In those days, the late 60s, schizophrenic patients were treated with large doses of Largactil and a few derivatives, but the side effects were distressing. They included rigidity and tremor, abnormal body and face movements, and restlessness. These side effects seemed at times to define the very illness being treated.

After a while, I began to feel despondent about whether this approach to mental illness was really what I would find satisfying in the long term. There was no doubt that everyone on that ward was dedicated to doing their best to help these severely ill people, but the therapeutic tools available to them were so blunt and damaging. It has to be said, however, that ECT statistically remains one of the most effective treatments for intractable depression: I found it distasteful to administer as it involved inducing an epileptic fit and, in those days, its scientific efficacy was far from proven; nowadays the technique has been refined.

My abiding memory of that ward was the empathy and kindness and indeed bravery of one junior mental nurse. I was seeing outpatients in my office one winter afternoon when sounds of an angry disturbance came from the female side of the ward. To start with I took no notice as such upsets were commonplace. Shortly afterwards my name was called urgently, and on entering the ward, I witnessed a violent affray at the far end. Two male nurses were wrestling with a violent young man who, in a confused state, had wandered into the female ward. He was shouting and screaming and swearing and punching at everything in sight. Further help arrived, and with difficulty, we bundled him into the safety of one of the pads. I stayed with him for a short while trying to calm him down but had to return to my waiting patients.

As I worked through my clinic, from time to time I heard angry voices coming from the pad, but towards the end of the clinic the sounds had ceased. When I had finished I entered the cell. The scene resembled a battlefield after the fighting was over. There were puddles of urine and vomit on the floor and twisted clothes were strewn everywhere, and streaks of blood and faeces were smeared on the deep-buttoned leather walls. But in the far corner was a sight which instantly reminded me of my first dramatic viewing of a renaissance pieta in Bologna. The young man, quite naked, was curled up in the foetal position and sobbing quietly. The young nurse crouched beside him, stroking his vomit-matted hair and whispering in his ear. I couldn’t hear what she was saying, but whatever it was, she knew instinctively how to supply just that resonance of kindness and empathy that perhaps the child within the man had never known. Soon arm in arm she walked him unsteadily back to his ward.

Before I left for home that evening, I called in on the young man. He was smiling, sitting up in bed smoking with a mug of hot chocolate in his hand. “So sorry about that, Doc”, he said.

*********************

After six months of working in the locked ward, I decided that, despite my profound respect for all those who worked there, this highly physical approach to mental illness almost by necessity, excluded an appreciation of the complex interactions between body, mind, and brain. I felt that the awe-inspiring complexity of our biological/psychological systems warranted more than the willy-nilly administration of one drug for depression, another for schizophrenia, and yet another for anxiety states, with no real knowledge of the brain chemistry involved and of the manifold interactions. Maybe, I thought, just maybe psychoanalysis would offer me some sort of resolution. I wasn’t to know then that my decision to abandon the organic model for the equally speculative world of psychoanalysis would not be an easy transition.

My decision to leave and try a different approach was shockingly reinforced by at least two summonses in successive months to the Coroner’s court at the back of St Pancras station to attend the inquests on two schizophrenic patients who had died probably by taking the drugs that I had prescribed for them. They had taken their places in the queues at the hospital outpatient clinic for their tri-monthly repeat prescriptions and presumably between visits had become seriously depressed to the extent that they took their own lives. I appalled myself that I knew so little about the details of their lives and the chemistry of the drugs I was prescribing. Looking back, one of the most reassuring things about seeing patients regularly in psychotherapy is that you can keep a careful watch on the patterns of their daily lives and note significant changes in mood, which might foretell the onset of a more serious problem.

As I left the mental hospital for the last time, I noticed that the road I was walking down had the same name as the locked ward, which had been my workplace for the previous six months: Coburn must have been a local philanthropist. Saying goodbye to the patients had been a wrench, and I was moved by the little gifts that accompanied my farewells. In particular, I recall a little table mat that a plump long-stay patient had embroidered for me. She was completely institutionalised and had been incarcerated for 20 years with the original diagnosis of moral insanity: she had had an illegitimate child. I achieved no more with her than enabling her to walk accompanied in the hospital garden on a few occasions. As I turned the corner away from the hospital, I felt incredibly sad: it was all too easy for me just to walk away.

By this time I had worked out that my next career move had to be away from the purely organic psychiatric approach to mental illness. I considered enrolling in one of the then handful of psychotherapy training centres in London. But I had set my sights on what I then regarded as the most comprehensive training at the Institute of Psychoanalysis then situated in a beautiful building in New Cavendish Street, London. Since then the institute has moved to much less imposing premises in West London, appropriately once a dairy. This change of location reflected perhaps a change in status of psychoanalysis itself.

In those days, the transition from psychiatry to a psychotherapeutic approach to mental illness was far from easy. To become a psychiatrist, a medical qualification was re...

Table of contents

• Cover
• Half Title
• Title Page
• Copyright Page
• Dedication
• Table of Contents
• Notes
• Preface
• Picture credits
• Acknowledgements
• 1. Early Influences
• 2. Some Background
• 3. The Emotional Brain
• 4. Projection
• 5. Other Defences We Employ
• 6. Transference and Countertransference
• 7. Memory
• 8. Localisation: what goes on where in the brain?
• 9. The Aversion to Feelings
• 10. Drugs
• 11. Free Energy
• 12. The Cognitive Cortex No Longer Rules
• 13. Neuroscience: co-operation not incorporation
• Notes
• Index