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The Neuropsychology of the UnconsciousReview - The Neuropsychology of the Unconscious
Integrating Brain and Mind in Psychotherapy
by Efrat Ginot
W. W. Norton, 2015
Review by Roy Sugarman, Ph.D.
Jan 12th 2016 (Volume 20, Issue 2)

Before the reader gets into this book, a word perhaps on the nature of the issue. When cognitive and family forms of therapy emerged in the '50's, academics warned of the need not to neglect the subconscious aspects of therapy, after all, Freud did do dissections of the brain and published these, translated by Mark Solms. They were sheer genius, and Freud wanted to access the mind that flowed upward from these neural pathways. Arden and Linford of Kaiser fame more recently have written of brain based therapies, and other authors in journals such as Leanne Williams have developed an Integrate model, which describes the first few hundred milliseconds until the p300 signal on EEG demonstrates the updating of working memory. Emotions are thus non-conscious (perhaps a better word) and our appreciation of these emotions is what Damasio and his wife have described as feelings, the feeling of 'what happens'. Above this in the hierarchy of emotions and feelings, beyond 300-500ms, is the experience of thinking.  CBT thus focuses on a top-down use of the conscious mind to still the autonomic, blind, nervous system and regulate the homeostatic processes of the underlying neurotransmitters, including now the biome, the gut bacteria so connected to our underlying mood states, via nurotransmitters such as serotonin.

Into this arena come the modern writers such as Ginot, in the series of works that includes Siegel, Cozolino and Schore.  All of these works in the Norton series are must-haves.  Score's introduction to this book pretty much starts in the 19th century as I suggested above, and his work was focused on attachment theory, a recurrent theme in most books on psychology, and many of those reviewed on Metapsychology online, including recently books on resilience by Russell, or books on Loneliness by Cacioppo and Patrick. And to the author's merit, the introduction will acknowledge that the non-conscious mind is a field with lots of questions and no easy answers. Whilst the unconscious mind is central, the prepotent responses that occur before we know we are thinking, can dominate our habitual ways of being.  Numerous substrates of the brain, rather than a central unitary processor may play a role in our behavior as an outcome of multiple processes. The challenge as Ginot suggests is to integrate the models of psychotherapy with those of the brain, and integrate both dynamic and non-dynamic concepts. Freud's name, as I predicted above before reading the book and with Freud unable to access the still-to-be-developed science of Neuropsychology, is still relevant in such an integrative approach. As I noted above, integration of the terms affect, emotion, cognition, behaviors, all depends on what model is used, as they are not unitary phenomenon. If they were, we would not present with the untidy richness and unique personalities that we do possess, although some pathways can be illuminated which may define many of our tendencies, for instance as studies on cruelty and authority have demonstrated.

Thus this book revolves on the science of Neuropsychology and the drives of the non-conscious processes, perhaps as the first chapter suggests, an excuse or accurate state of affairs in terms of what processes are responsible for our behavior in the 'final (psycho)analysis, if you excuse the oblique reference to the book of the same name.

Freud's shorthand metaphors, of id, ego, superego, were thus the first attempts to understand this field.  The output however is that these underlying processes are much more influential than we ever thought them to be, thus more pervasive as precursors to our actions. These processes are thus not that dissociated, but rather the background noise to what is going on in the foreground of the conscious mind. Into this field is then introduced novel concepts around the sub-cortical regions.  Schore's introduction revealed a great deal of his views on the prosody of the right hemisphere, the silent side to the brain in Gazzaniga's hierarchy,  and he believes this is the seat of the non-conscious brain, although local gossip between the separated hemispheres is still possible, as Gazzaniga pointed out. The basal ganglia and the cerebellum (the largest part of the brain really) are then the focus of this chapter. We know these areas are sub servants of the skill of procedural learning, with both inhibition and stimulation of responses controlled within the loops that link these areas to the rest of the brain. Non-Conscious production of the behavior is the key task of these areas, so the central processors of the brain in Sternberg's terms is not having to provide a constant resource for actions, but rather these are done without praxis, automated in other words. Dopamine drive expectation of reward is key to these reinforced behaviors that thus have a conscious purpose driven by non-conscious biases that are reinforced by the environment, but not always useful in the long run, perhaps smoking is a good example of a simple non-consciously rewarded but useless behavior, and attachment disorders a more complex example.   What I am increasingly fond of in modern books such as these, is their increasing referral to the wisdom of the earlier psychotherapy writers, whose access to research was minor since the field was in its infancy, but whose clarity of thought and reasoning is now proving elegant and accurate enough for us to elaborate on, coming full circle to what Freud and Charcot and others were trying to do.

In the reasoning here, repeated patterns of actions are automated and perhaps done so by an unbalanced cerebellar influence set, such as old behaviors that relieved anxiety. Actions are thus directed by an internal utility alone, what one would have called an internal frame of reference in days gone by. Complex processes occur out of awareness is the Kawasaki mantra here, Out of Awareness. Elegance is thus subserved by the brain's desire or at least if it had one, hard wiring more, to favor automaticity in the service of utility. It is efficient to automate, to do without thinking, or praxis, or work, as in Zen archery. If I recall the Zen bowmen referred to the need to reduce thinking and act using non-conscious skill, doing no work in fact, something the athletes of today call the zone: a perfect balance of utility of supply versus demand in cortical and physical demand terms.  This leads to the interface of rigidity vs flexibility: these two words thus inform on how one will do therapy. Adaptation and resilience require the second in order to manage change. Perceptions here refer to such things as the fundamental attribution error or self-serving bias as an example I can think of emerging from this discussion. If that is the first continuum as the author labels it, then gradations of non-conscious processing rather than a dichotomy of non-vs-conscious is the second. They thus coexist. The conscious development of the neocortex has not supplanted the earlier reptile brain in other words. This implies an explicit and implicit set of realms in which we exist, rather like the neuropsychiatry explanation of the medial vs lateral aspects of the temporal and limbic systems mediating the internal vs external worlds as neurological substrates of perception and monitoring. This mediation is executive in nature, and thus guided by the choices we make via the prefrontal cortex as 'superego'.  As cognition develops, it fuses with emotional experience, with the more anterior regions dominating the cognitive skill sets. The self-state is thus flavored by the fusion of cognition and emotion.

No discussion of the brain or nervous mind is complete without a detailed discussion of anxiety, a state of increased arousal designed to maximize reward and minimize danger. Fear is an issue when it is a dominant part of the implicit system rather than the outside explicit immediate demands of the environment.  A great sentence here is: "This interaction between affect and defense, between the dysregulation brought about by a noxious unbearable state and the natural need to regain homeostasis, to a large degree forms many of our personality traits" kind of summarizes it all (page 36). Again, the subcortical structures such as the amygdala are the focus of the survey into what underlies much of our learned avoidance behavior.  Again the focus is on the attunement of attachment, with mirror neuron information flowing into the insula and amygdala via the interaction of parent and child. Old fears can thus be activated as adults and treated as if current, so when we think of our current situation we may use the emotionally-charged reasoning of a bygone set of experiences. This doesn't mean that the limbic system is a ghost in the machine working clandestinely, but rather, via the complex interconnections with higher order centers, many aspects of cognition are also affected, such as attention, perception, working and explicit memory.  The bottom up influence it needs to be said, are stronger and more influential than the other way round, hence the need for psychotherapy to intervene to allow the higher order to rule the roost.  This does not mean emotional conflict, but rather the emotional learning and avoidant defenses, guide our behaviors later on.  Some even question then the whole nature of the concept of 'free will'. Neverthless, these underlying processed cannot be reduced to a series of delineated events, e.g. your mother giving you ice cream after your tonsil operation, rather than hugging and comforting you, but rather to a humming along sidebar to all that is consciously going on in your world. With deference to talking cures, which may fall short in revealing the non-conscious processes, our enacted affects, thoughts and behaviors are much more revealing and reliable indicators of what lies beneath, or at least, within the universe that parallels conscious thought and words. Higher order systems can dominate, but they do so slowly, in the latter moments in time past-perception of threat.  Along the way, an occasional history of a person with conflicted behavior and emotions is given, but with little idea of the process of therapy involved in their enlightenment, although this is mentioned in terms of therapeutic significance, namely the top down process becoming weaker than the bottom up influences.  The role of chaotic attachment is again demonstrated as a source of the irrational learning taking place which is later reflected in adult behavior such as serial sexual encounters outside of marriage, outside of the awareness of the perpetrator.

As noted, up until now, there was only passing reference to therapy, but now this is made more explicit in the fourth chapter, of therapeutic enactments. The limits of the talking cure use of words is again made explicit, and enactments as communicators of the conscious-non-conscious interface are given more airtime, referring again to Schore's 'empathetic attunement'. Now the word analyst is used more frequently. Ginot is in reality a trained analytical psychologist, and so her interest in the non-conscious world is expressed in this work, and her case studies reflect her analytical approach to observing dyadic interaction.  This chapter includes a discussion of narratives, limiting this to a focus on the negative ones that cloud perception. Again, the reference points are attachment and intersubjectivity with language as the bridge between affect and cognition, and narrative related back to the areas and issues illuminated on before (such as rigidity-flexibility).  Staying in the therapeutic arena, the interrelated concepts of repetition compulsion and resistance as key elements in therapeutic discourse, reflecting on non-conscious components. The power of 'neural lessons', we only know what we learn, dominates here.  Dissociation, a particularly neuronal phenomenon, is given special mention here, as the edge of the conscious-non-conscious continuum.

As an embodiment of what the book proposes, the Narcissistic personality appears to be an attractive exemplar.  As I expected, (as a good narcissist should), Kohut gets a mention, as the painful self-state of being of the 'deflated' narcissist is explored. Kernberg is also mentioned.  As the author mentions, it is difficult to maintain empathy for the patient's hidden pain when all that is expressed is the ferocity of the defense system that helps them deal with themselves.  Insight as a concept is thus inadequate and so and expanded definition is needed. What neuroscience has to offer clinicians again returns into focus, as the author often moves away from close contact with the neuropsychological-brain-mind theme and closer to a treatise on the psychodynamic approach, transference, resistance etc, but all in the service of psychodynamic therapies. Still, this version of therapeutic encounters has some precedent: reaching back into Mauro Mancia's 'Psychoanalysis and Neuroscience' published in 2006, Kandel's 'Psychiatry, Psychoanalysis and the New Biology of Mind' in 2005, Braten's 'On being moved' in 2007 covering the mirror neurons, and Cozolino's 'Neuroscience of Human Relationships' published in 2006. Even Shalxlice's 1988 "From neuropsychology to mental structure" began this approach to some extent (many of the above works have been reviewed by Metapsychology Online).

Ginot's approach to the subject is however rather unique, as she retraces what Freud might have done if he had access to the science and the above literature and more. Her approach is colored as his was, by a psychodynamic approach to behavioral learning, but she is a keen integrationist of the Bowlby, Damasio, Kohut, Kernberg, Cozolino et al understandings of applied neuroscience and thus is more eclectic than her analytical approach would reasonably suggest. She takes on a developmental view of the human self or psyche with great success, and thus via integration provides a not novel, but certainly well-revisited and integrated reasoning to inform on her therapeutic encounters and seamlessly align this with neuroscience. With Descartes abandoned, she can apply this approach to the intergenerational pathology of trauma, as to how parents or grandparents might pass on their experience perhaps of the war, or similar experiences, and how this might impinge on generations to follow, as the Holocaust studies have shown.

Her approach is also easy enough to read, of interest only to psychologists and those working in mental health otherwise, and a good background in psychoanalytic theory is recommended, or at least reading some of the authors publications I mentioned above, and which reference her work, would be helpful.

A singular and novel work nevertheless, and as a teacher of the underlying processes behind her approach, if her writing style is anything to go by, she must be rated up at the top of that tree.  I am not sure where she will go with all this, but if there is a follow-up work, it is likely to include more of the harder neuroscience I hope, and thus take this work further. It is so refreshing in this day and age with the dominance of CBT, to see a more in depth approach to the inner world of the human self that does not neglect the role of the non-conscious, rather than the manualized and unimaginative robotic application of CBT to the human condition.


© 2016 Roy Sugarman


Roy Sugarman PhD, Director: Applied Neuroscie Roy Sugarman nce, Performance Innovation Team, EXOS USA



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