A map of the mind: toward a science of psychotherapy

Abstract

Psychotherapy, as a field, suffers from no lack of books offering to teach the reader what it is about and how to do it. Indeed, today it is a great and exciting challenge to understand and practice psychotherapy with an eye and ear that attempt to integrate several dynamic models of mind (especially interactive/relational models) with modern cognitive neuroscience. Learning to understand and influence people through the mutative conversation we call psychotherapy requires of the modern clinician a conceptual framework that links knowledge of mind and knowledge of brain. This unique and remarkable book, one I enthusiastically recommend to students and seasoned practitioners, offers such a conceptual framework in a most elegant, engaging, informative, and well-written volume. A playwright as well as a psychiatrist and psychoanalyst, Dr. Brockman skillfully takes the reader through a step-by-step or scene-by-scene unfolding drama of the clinical interaction with an ever-increasing sense of depth, pace, understanding, growth, and change. We have the opportunity to follow several patients throughout the book and to learn not only about their histories and their problems, but also what becomes of them, their lives, and their treatments. Brockman defines affect as the central organizing principle in psychotherapy, and he uses affect to bridge his two ambitions in this book. The first is to show “how to structure one's understanding of the clinical encounter,” where I think he succeeds brilliantly. The second (a more daunting and hypothetical project) is to present psychotherapy as “a science that can and should be practiced in accordance with scientific procedure where psychological and biological data are combined in a dynamic way.” In the results of this effort he is to be congratulated for his command of both fields, and for his rigor and his creativity. The book is organized in three parts: the first, “Background,” takes us into Brockman's thinking about Freud, affect, affect theory, and attachment theory. The second part, “Data and Hypothesis,” is a truly remarkable, rich clinical narrative. The vivid dramatis personae stand before us on the stage as we hear both the external, interactive clinical process and, almost as asides to the reader, Brockman's interior conversations, his inner reflections on his experience of the therapeutic process, his questions, his hypotheses, and his emotional reactions as they serve to enrich his understanding of the clinical moment; for this alone, this book is most rewarding and unusual. Throughout this section, Brockman, as an experienced therapist and psychiatric educator, emphasizes the importance of safety as a crucial dimension of transference, resistance, and defenses. The third part of the book, “Centrality of Affect,” takes us over the conceptual mind/brain bridge. Brockman knowledgeably describes the current neurobiological, neuroscientific understanding of affect, primitive affects, trauma, and medication. This account culminates in his synthesizing formulations and his “Map of the Mind.” Reaching back to Pavlov and Freud, then on to Eric Kandel and Joseph LeDoux, Brockman creates a framework that significantly departs from the Freudian notion of unconscious conflict and repression as a major defense against conscious awareness. In Brockman's view, motivation has less to do with conflict than it has to do with how behavior and ideas are encoded—which central nervous system circuits are being activated and which are “in control.” When certain motivations are routed through sub-neocortical structures, such as the amygdala, they are unconscious in a descriptive sense and not repressed. He draws heavily on LeDoux's work in the model of fear conditioning as a model for unconscious motivation. With a significant conceptual stretch (in this reader's view), Brockman offers a localization: a region in his map of the mind where a patient's behaviors and ideas are coming from—that is to say, which areas of the brain are in control and which areas of the brain he, as a therapist, is attempting to reach in order for the psychotherapy to be effective. I believe that mind and brain disciplines have a lot to say to each other, and that the conversation has truly just begun; but the bridge hasn't been built yet to satisfactorily reduce or trace the clinical encounter to brain circuitry. Still, the ambition of a psychobiologically based psychotherapy is an admirable one and, echoing Eric Kandel's recent special article,1 one that we should eagerly pursue. Dr. Brockman has written an important book and made an invaluable contribution to our knowledge of two current forms of conversation. The first is the clinical conversation: his book is a rich clinical gem for readers at all levels who wish to learn about the process of dynamic psychotherapy. The second is the interdisciplinary conversation between psychotherapy and cognitive neuroscience: Brockman is to be congratulated for his mastery of both fields and for his efforts at necessary bridge building in our understanding of the minds and brains of ourselves and our patients.