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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 sepa-

ration 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 neurobi-ological 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. Freuds limited effort to provide a biology of the mind

affected the divergent courses of analytic theory, emphasizing affect and psychopathol-

ogy, 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 patients 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 con-

sciousness (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 inter-

ventions.

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 certainlywould not lock it. Pulvers viewpoint seems to me to echo earlier dualistic persuasions,

drawing a linenot unlike Freudbetween analytic understanding, focusing on meaning

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and mental processes, and neuroscience dealing with neuronal mechanisms and compu-

tational 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 theintegrative 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 pro-

cesses 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

patients 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 uponwhether psychological or physical or both.

In this light, the research strategy of the dual-track approach remains both necessary

and pragmaticpsychoanalysts 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 under-

standing of psychological processes and how they find expression in human behavior and

relationships. By the same token, neuroscientists are not equipped to study the complex-

ities of human motivation, cognition, and behavior; theirs is the business of exploring the

mechanisms and processes of brain activation and functioning generating specific behav-

iors and mental phenomena. Thus, the study of behavior and the study of brain mecha-

nisms 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 whateffect it has on the patients 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 thepace 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 neurophysiolog-

ical, 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 neurobiol-

ogy (pp. 660 661, italics in original). My argument, however, takes a further stepthe

neurophysiological events are more than merely correlates of mental events; the mentalevents 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 sug-

gested, 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 patienton 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 McDougalls (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 contextattempting 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 psychologicalor 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 analysands 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 adminis-

tration of psychotropic drugs, that it affects the functioning of the brain (pp. 626627).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

bodythere is no mysterious leap.

1 Lombardi (2003) describes the splitting of mind and body in the fantasy system of hispsychotic patient Matteo. The disturbances in an integrated self-experience and of the patients bodyimage resulted in divided self-images deeply invested with oral aggressive and destructive motivesand fantasies. Lombardi cites Tausks (1933) influencing machine as an example of similarsplitting; see also Laing (1959/1969). I would emphasize that cases like this speak to fantasies ofseparation of mind and body and even of disembodiment, but they do not affect the real ontologicalintegration 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 thebody 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 betweenpsychic constellations in memory and language and complementary neural circuits. Top-downmodulation of relatively fixed brain circuitry is possible. Verbal instruction has now been shown topenetrate 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 manifes-

tation 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 analystmodifies the patients 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 turnalthough they spring from a neurotransmitters secreted as a result of emotional

responsesdevelop 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 expres-

sion 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 success-

ful 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. 465466).

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 mixand transferred back to prefrontal cortex, hence to Brocas speech area, and finally through

motor connections finds expression in speech. He suggests that psychotherapeutic effi-

ciency 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 affectivemethods are constrained. As he explains: Thus, when we develop the ego we can only partiallycorrect those flaws resulting from very serious errors in the behaviour of primary objects thatoccurred 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 cannotmaintain great therapeutic ambitions, since our regressive method is a virtual oneold relations arenot revived in any real sense, as the reconstitution of the original environment is now dealing withan 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 mindfrom

the realm of action and bodily events to that of logical verbal expressionwhere these

may be represented symbolically for the first time, finally to be introduced into the orbit

of self-reflection (pp. 8182). The operative question is how this transition can be

accomplished. Are there alternatives, given a degree of modification of what goes on in

the patients 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 Doras 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 anothers body sensations, imagery, thoughts, behaviors and even words byunconscious 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 thetherapeutic 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 analysands potential for

identifying with the analysts 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

Gedos view did not go unchallengedsee 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 analysts 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 expe-

rience. Both disciplines indicate further that these stored encoding images are arranged in

nodal memory networks organized by affect (pp. 899900, italics in original). Theassociative connections between these stored perceptual images are mediated by corti-

colimbic 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 reason-

able 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 largelyrelated 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). Accord-

ingly, as Gabbard and Westen (2003) note:

Many defenses. . . likely become routinized, like much of procedural knowledge (how-to

knowledge, or skillsin 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 copingstrategies), 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 psycho-

analysis 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 phenom-

enon that has been discussed in some detail by Green (2001), and the role of fantasy andpsychodynamic 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 patients memory sys-

tems, 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, inthe 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 interpretationwas 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, implicitare relatively independent

and mediated by separate neural processes. This might mean that early formative expe-

riences, 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 autobiograph-

ical 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 psychoanalysts 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, notthoughts. 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 mat-

uration 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 therapeuticefficacy 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 patients 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 patients 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 onto-

logical unity and integration of the mind-body complex in the organization and function-

ing 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 patients 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 forthe 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 patients mood disorder,

anxiety, or psychosis with medication. The basic question current advances psychophar-

macology 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 patients 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 con-

flicting 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 aggres-

sion. The pharmacologist decries the analysts use of terms referring to hypotheticalentities that defy operational definition and to narrative reconstructions that elude falsi-

fiability by any kind of observable prediction. In turn, the analyst complains of the

pharmacologists tendency to oversimplify psychic disorders, reducing individual varia-

tions 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 empiricalclinical evidence rather than by etiological convictions. Analysts often withhold medications, heobserved, 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 combinationwith analytic or psychotherapeutic interventions when clinically indicated.8 See Ledouxs (2002) discussion of combining drugs and therapy in various forms of

psychopathology.



12/22

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 psychoana-

lytic 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 prevailsblatantly 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 comparingverbal and pharmacological interventions that: Each of these interventionsand its

effectsis 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 psycho-

logical 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 brainrather 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 philo-

sophic option rather than empirical evidence. Along this line Ungers (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 antidepres-

9 An interesting subplot in this connection was stirred up by Gottlieb (2002) in a brief note onthe 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 com-

mon 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 enact-

ment 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

patients fate. By so doing he complies with the patients 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 ana-

lytic 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 wayinto the pharmacological armamentarium, but also because analysts have gained increas-

ing 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 psychopharma-

cology 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 dysphoriathat 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 patients 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 anddiscussion 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 hip-

pocampus under favorable conditions. Thus, both psychotherapy and psychotropic med-

ications 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,

19851986) 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 thetreatment 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 analysts 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 patients 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 aremultiple and can insert themselves subtly and by implication. An important factor at

this juncture pertains to the analysts 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 misunder-

standing that can generate the above feelings. If talk and medication are viewed as

alternatives in treating the patients disordereither talk or drugs, or when talk fails

use drugsthe way lies open for false assumptions and misinterpretations in the

patients mind and in his participation in the therapeutic process.

11 Gabbard (2005) also reviews some of the mounting evidence documenting neurobehavioraleffects of both appropriate medications and psychotherapy on the treatment of personality disorders.

346 MEISSNER


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Under the best of circumstances, precisely because of the potential for such miscom-

munication 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 accom-

modating 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 monitoringthe

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 splitfamiliar 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 psycho-

analysis/psychotherapy-mind, and can be used defensively especially to avoid mean-ingful exploratory effort.

These therapeutic issues are compounded by widely pervasive professional commit-

ments 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 under-

lying 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 patients 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 unneces-

sary and untrue, would both require commitment to either a monistic or dualisticperspective 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



16/22

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 psychothera-

peutically, 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 (bio-

logically based, not attributable to psychic conflict, and not treatable by psychotherapy)

versus Axis II disorders (resulting from psychic conflict and approachable by psycholog-

ical 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 analysts mind, it may not be for the patient. Patients

commonly ask whether their illness is biological or not. Even an unequivocal answer thatit 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 thera-

peutic 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 obsessive-

compulsive 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 dualisticand 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 inter-

ventions 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 inpsychopharmacology and in forms of psychotherapy, there was little study of treatment integratingboth approaches.

348 MEISSNER


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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 alter-

ations of a neurobiological nature. Similarly, psychological interventions in a treatment

context may have a profound impact on neurophysiology. Clinical case examples dem-

onstrate 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 experi-

ence-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 psy-

chodynamic 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 others 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 synergisticnot only additiveeffect of the two interventions. Psycho-pharmacological treatment may help consolidate the biological changes caused by psy-

chotherapy (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 changefor

example, tranquilizers make you feel more relaxed. Such response expectancies tend to

become self-confirming, affecting not only subjective experience but physiological pa-

rametersa 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 orcomplementarity, 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 humanperson 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



18/22

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 patientwhether conceived in terms of trans-

ference-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 patients 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 patients 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 viewof the self as embodied and of the patients 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 themind-body relation in the self.

References

Adelman, S. A. (1985). Pills as transitional objects: A dynamic understanding of the use of

medication in psychotherapy. Psychiatry, 48, 246253.

American Psychiatry Association (2001). Practice Guideline for the Treatment of Patients with

Borderline Personality Disorder. American Journal of Psychiatry, 158(October Suppl.).

Andrade, V. M. (2005). Affect and the therapeutic action of psychoanalysis. International Journal

of Psychoanalysis, 86, 677697.Andreasen, N. C. (2001). Brave new brain: Conquering mental illness in the era of the genome. New

York: Oxford University Press.

Barratt, B. B. (1996). Commentary on Wolff. Journal of the American Psychoanalytic Associa-

tion, 44, 396404.

Beitman, B. D. (1996). Integrating pharmacotherapy and psychotherapy: An emerging field of study.

Bulletin of the Menninger Clinic, 60, 160173.

Beutel, M. E., Stern, E., & Silbersweig, D. A. (2003). The emerging dialogue between psychoanal-

ysis and neuroscience: Neuroimaging perspectives. Journal of the American Psychoanalytic

Association, 51, 773801.

Bion, W. R. (1962). Learning from experience. New York: Basic Books.

Boesky, D. (1995). Commentary on Gedos Working through as metaphor and as a modality of

treatment. Journal of the American Psychoanalytic Association, 43, 356360.

Brenner, C. (2000). Observations on some aspects of current psychoanalytic theories. Psychoana-

lytic Quarterly, 69, 597632.

350 MEISSNER


19/22

Cabaniss, D. L. (1998). Shifting gears: The challenge to teach students to think psychodynamically

and psychopharmacologically at the same time. Psychoanalytic Inquiry, 18, 639656.

Chessick, R. D. (1985). The frantic retreat from the mind to the brain: American psychiatry in

mauvaise foi. Psychoanalytic Inquiry, 5, 369403.

Chessick, R. D. (2001). OCD, OCPD: Acronyms do not make a disease. Psychoanalytic Inquiry, 21,

183207.Edelman, G. (1989). The remembered present: A biological theory of consciousness. New York:

Basic Books.

Erdelyi, M. H. (1985). Psychoanalysis: Freuds cognitive psychology. New York: Freeman.

Esman, A. (1989). Psychoanalysis and general psychiatry: Obsessive compulsive disorder as

paradigm. Journal of the American Psychoanalytic Association, 37, 319336.

Fawcett, J. (1997). The mind-brain-body split resurfaces: Descartes error all over again? Psychi-

atric Annals, 27, 779780.

Fonagy, P. (2003). Genetics, developmental psychopathology, and psychoanalytic theory: The case

for ending our (not so) splendid isolation. Psychoanalytic Inquiry, 23, 218247.

Fonagy, P., & Target, M. (1997). Perspectives on the recovered memories debate (pp. 183217). In

J. Sandler and P. Fonagy (Eds.), Recovered memories of abuse. True or false? London: KarnacBooks.

Frank, J. D. (1977). Psychiatry, the healthy invalid. American Journal of Psychiatry, 134, 1349

1355.

Fratarolli, E. J. (2002). Letters: Psychoanalysis and schizophrenia: Three responses to Martin

Willick. Journal of the American Psychoanalytic Association, 50, 307316.

Freud, S. (1957). Fragment of an analysis of a case of hysteria. In J. Strachey (Ed. and Trans.), The

standard edition of the complete psychological works of Sigmund Freud (Vol. 7, pp. 1122).

London: Hogarth Press. (Original work published 1905)

Freud, S. (1964). An outline of psychoanalysis. In J. Strachey (Ed. and Trans.), The standard edition

of the complete psychological works of Sigmund Freud(Vol. 23, pp. 139207). London: Hogarth

Press. (Original work published 1940)Freud, S. (1966). Project for a scientific psychology. In J. Strachey (Ed. and Trans.), The standard

edition of the complete psychological works of Sigmund Freud (Vol. 1, pp. 281397). London:

Hogarth Press. (Original work published 1895/1950)

Gabbard, G. O. (1992). Psychodynamic psychiatry in the decade of the brain. American Journal

of Psychiatry, 149, 991998.

Gabbard, G. O. (1994). Psychodynamic psychiatry in clinical practice: The DSMIV ed.

Washington, DC: American Psychiatric Press.

Gabbard, G. O. (2001). Psychoanalytically informed approaches to the treatment of obsessive-

compulsive disorder. Psychoanalytic Inquiry, 21, 208221.

Gabbard, G. O. (2005). Mind, brain, and personality disorders. American Journal of Psychiatry, 162,

648655.

Gabbard, G. O., & Westen, D. (2003). Rethinking therapeutic action. International Journal of

Psychoanalysis, 84, 823841.

Gedo, J. E. (1991). The biology of mind: A foreword. In Levin, F. M. (Ed.), Mapping the mind(pp.

xi-xx). Hillsdale, NJ: Analytic Press.

Gedo, J. E. (1995). Working through as metaphor and as a modality of treatment. Journal of the

American Psychoanalytic Association, 43, 339356.

Gedo, J. E. (1997). Reflections on metapsychology, theoretical coherence, hermeneutics, and

biology. Journal of the American Psychoanalytic Association, 45, 779806.

Gottlieb, R. (2002). A psychoanalytic hypothesis concerning the therapeutic action of SSRI

medications. Journal of the American Psychoanalytic Association, 50, 969971.

Green, A. (2001). Life narcissism, death narcissism. London: Free Association Books.

Gutheil, T. (1982). The psychology of psychopharmacology. Bulletin of the Menninger Clinic, 41,

321330.

Guze, S. B. (1998). Psychotherapy and managed care. Archives of General Psychiatry, 55, 561562.



20/22

Hausner, R. (19851986) Medication and transitional phenomena. International Journal of Psy-

choanalytic Psychotherapy, 11, 375398.

Kandel, E. R. (1979). Psychotherapy and the single synapse: The impact of psychiatric thought on

neurobiological research. New England Journal of Medicine, 301, 10281037.

Kandel, E. R. (1998). A new intellectual framework for psychiatry. American Journal of Psychiatry,

155, 457469.Kandel, E. R. (1999). Biology and the future of psychoanalysis: A new intellectual framework for

psychiatry revisited. American Journal of Psychiatry, 156, 505524.

Kantor, S. J. (1989). Transference and the beta adrenergic receptor: A case presentation. Psychia-

try, 52, 107115.

Kantor, S. J. (1993). Analyzing a rapid cycler: Can the transference keep up? In Schachter, M. (Ed.),

Psychotherapy and medication: A dynamic integration (pp. 291311). Northvale, NJ: Aronson.

Kirsch, I., & Hyland, M. E. (1987). How thoughts affect the body: A metatheoretical framework.

Journal of Mind and Behavior, 8, 417434.

Laing, R. D. (1959/1969). The divided self. Hammondsworth, Middlesex, England: Penguin Books.

LeDoux, J. (1996). The emotional brain: The mysterious underpinnings of emotional life. New

York: Simon & Schuster.LeDoux, J. (2002). Synaptic self: How our brains become who we are. New York: Viking Penguin.

Lenze, E. J, Dew, M. A., Mazumdar, S., Begley, A. E., Cornes, C., Miller, M. D., et al. (2002).

Combined pharmacotherapy and psychotherapy as maintenance treatment for late-life depres-

sion: Effects on social adjustment. American Journal of Psychiatry, 159, 466468.

Leuzinger-Bohleber, M., & Pfeifer, R. (2002). Remembering a depressive primary object: Memory

in the dialogue between psychoanalysis and cognitive science. International Journal of Psycho-

analysis, 83, 333.

Levin, F. M. (1991). Mapping the mind. Hillsdale, NJ: Analytic Press.

Levinson, M. H., Ostow, M., Wolpert, E., Sandberg, L. S., Levine, F. J., & Gottlieb, R. M. (2004).

Letters: On the therapeutic action of SSRI medications. Journal of the American Psychoanalytic

Association, 52, 483486.Lombardi, R. (2002). Primitive mental states and the body: A personal view of Armando B. Ferraris

concrete original object. International Journal of Psychoanalysis, 83, 363381.

Lombardi, R. (2003). Catalyzing the dialogue between the body and the mind in a psychotic

analysand. Psychoanalytic Quarterly, 72, 10171041.

Mancia, M. (1994). Review of A. B. Ferrari, Leclissi del corpo. International Journal of Psycho-

analysis, 75, 12831286.

Martin, J. B. (2002). The integration of neurology, psychiatry, and neuroscience in the 21st century.

American Journal of Psychiatry, 159, 695704.

McDougall, J. (1995). The many faces of eros. London: Free Association Books.

McLaughlin, J. T. (1992). Nonverbal behavior in the analytic situation: The search for meaning in

nonverbal clues. In S. Kramer and S. Akhtar (Eds.), When the body speaks (pp. 132161).

Northvale, NJ: Aronson.

Meissner, S. J., W. W. (1996). The therapeutic alliance. New Haven, CT: Yale University Press.

Meissner, S. J., W. W. (1998). The self and the body: IV. The body on the couch. Psychoanalysis

and Contemporary Thought, 21, 277300.

Meissner, S. J., W. W. (2000). The many faces of analytic interaction. Psychoanalytic Psychol-

ogy, 17, 512546.

Meissner, S. J., W. W. (2001). The self-as-person in psychoanalysis. Psychoanalysis and Contem-

porary Thought, 23, 479523.

Meissner, S. J., W. W. (2003a). Empathy as an aspect of the therapeutic alliance. Israel Psycho-

analytic Journal, 1, 103146.

Meissner, S. J., W. W. (2003b). Mind, brain, and self in psychoanalysis: I. Problems and attempted

solutions. Psychoanalysis and Contemporary Thought, 26, 279320.

Meissner, S. J., W. W. (2005). To couch or not to couch that is the question. Gli Argonauti,

27(April, Special Issue), 2166.

352 MEISSNER


21/22

Meissner, S. J., W. W. (2006a). The mind-brain relation and neuroscientific foundations: I. The

problem and neuroscientific approaches. Bulletin of the Menninger Clinic, 70, 87101.

Meissner, S. J., W. W. (2006b). The mind-brain relation and neuroscientific foundations: II.

Neurobehavioral integrations. Bulletin of the Menninger Clinic, 70, 102124.

Meissner, S. J., W. W. (2006c). The mind-brain relation and neuroscientific foundations: III. Brain

and psychopathology, the split-brain, and dreaming. Bulletin of the Menninger Clinic, 70,179201.

Mitrani, J. L. (1995). Toward an understanding of unmentalized experience. Psychoanalytic Quar-

terly, 64, 68109.

Ogden, T. H. (1997). Reverie and interpretation. Psychoanalytic Quarterly, 66, 567595.

Ostow, M. (1962). Drugs in psychoanalysis and psychotherapy. New York: Basic Books.

Ostow, M. (1975). Psychological considerations in the chemotherapy of depression (pp. 461481).

In E. J. Anthony and T. Benedek (Eds.) Depression and Human Existence. Boston: Little,

Brown.

Pally, R. (1996). Reciprocal responsiveness in psychoanalysis. Journal of Clinical Psychoanaly-

sis, 5, 723.

Pally, R. (1998). Emotional processing: The mind-body connection. International Journal ofPsychoanalysis, 79, 349362.

Pally, R. (2001). A primary role for nonverbal communication in psychoanalysis. Psychoanalytic

Inquiry, 21, 7193.

Pankow, G. (1981). Psychotherapy: A psychoanalytic approach, an analytic approach employing the

concept of the body image. In M. Dongies & E. D. Wittkower (Eds.) Divergent views in

psychiatry (pp. 161186). New York: Harper and Row.

Peskin, M. M. (2001). Back to basics: The psychoanalytic conceptualization of motivation. Psy-

choanalytic Inquiry, 21, 658674.

Pugh, G. (2002). Freuds problem: cognitive neuroscience and psychoanalysis working together

in memory. International Journal of Psychoanalysis, 83, 13751394.

Pulver, S. E. (2003). On the astonishing clinical irrelevance of neuroscience. Journal of the American Psychoanalytic Association, 51, 755772.

Quinodoz, D. (2001). The psychoanalyst of the future: Wise enough to dare to be mad at times.

International Journal of Psychoanalysis, 82, 235248.

Reiser, M. F. (1984). Mind, brain, body: Toward a convergence of psychoanalysis and neurobiol-

ogy. New York: Basic Books.

Reiser, M. F. (1994). Memory in mind and brain: What dream imagery reveals. New Haven, CT:

Yale University Press.

Reiser, M. F. (1997). The art and science of dream interpretation: Isakower revisited. Journal of the


Robbins, M. Letters. (2002). Psychoanalysis and schizophrenia: Three responses to Martin Willick.

Journal of the American Psychoanalytic Association, 50, 307316.

Roose, S. P. (1990). The use of medication in combination with psychoanalytic psychotherapy or

psychoanalysis. In R. Michels (Ed.) Psychiatry (Vol. 1, pp. 18). Philadelphia: Lippincott.

Roose, S. P., & Johannet, C. M. (1998). Medication and psychoanalysis: Treatments in conflict.

Psychoanalytic Inquiry, 18, 606620.

Roose, S. P., & Stern, R. H. (1995). Medication use in training cases: A survey. Journal of the


Rose, S. P. R. (1984). Disordered molecules and diseased minds. Journal of Psychiatric Re-

search, 18, 351360.

Ross, J. M. (2003). Preconscious defense analysis, memory and structural change. International

Journal of Psychoanalysis, 84, 5976.

Sandberg, L. S. (1998). Analytic listening and the act of prescribing medication. Psychoanalytic

Inquiry, 18, 621638.

Sarwer-Foner, G. J. (1960). The dynamics of psychiatric drug therapy. Springfield, IL: C. C.

Thomas.



22/22

Schore, A. N. (1997). A century after Freuds Project: Is a rapprochement between psychoanalysis

and neurobiology at hand? Journal of the American Psychoanalytic Association, 45, 807840.

Schore, A. N. (2002). Advances in neuropsychoanalysis, attachment theory, and trauma research:

Implications for self psychology. Psychoanalytic Inquiry, 22, 433484.

Shapiro, T. (2004). Use your words! Journal of the American Psychoanalytic Association, 52,

331353.Smith, H. F. (1997). Creative misreading: Why we talk past each other. Journal of the American

Psychoanalytic Association, 45, 335357.

Swoiskin, M. H. (2001). Further thoughts on dualism, science, and the use of medication: In

psychoanalysis. Bulletin of the Menninger Clinic, 65, 171178.

Tausk, V. (1933). On the origin of the influencing machine in schizophrenia. Psychoanalytic

Quarterly, 2, 519556.

Unger, R. M. (1982). A program for late twentieth-century psychiatry. American Journal of

Psychiatry, 139, 155164.

Wallace, E. R. (1988). Mind-body: Monistic dual aspect interactionism. Journal of Nervous and

Mental Disease, 176, 421.

Weinberger, J., Siegel, P., & Decamello, A. (2000). On integrating psychoanalysis and cognitivescience. Psychoanalysis and Contemporary Thought, 23, 147175.

Willick, M. S. (1993). The deficit syndrome in schizophrenia: Psychoanalytic and neurobiological

perspectives. Journal of the American Psychoanalytic Association, 41, 11351157.

Willick, M. S. (2001). Psychoanalysis and schizophrenia: A cautionary tale. Journal of the American

Psychoanalytic Association, 49, 2756.

Willick, M. S. (2002). Letters: Martin S. Willick replies. Journal of the American Psychoanalytic

Association, 50, 316319.

Wylie, H. W., & Wylie, M. L. (1987). An effect of pharmacotherapy on the psychoanalytic process:

Case report of a modified analysis. American Journal of Psychiatry, 144, 489492.

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