Memory and Healing: Neurocognitive and Psychodynamic Perspectives on How Patients and Psychotherapists Remember

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This book addresses the current demand to apply findings in neuroscience to a broad spectrum of psychotherapy practices. It offers clear formulations for what has long been missing in how psychotherapists present their work: research-based descriptions of specific memory functions and attention to the role that synaptic plasticity and neural integration play in making lasting psychological change possible. The book provides a detailed perspective on how patients integrate into their own narratives what transpires in their treatment and how the clinician's memory guides the different phases of the process of healing.Long-neglected in psychotherapeutic formulations, findings about memory-in particular, episodic and autobiographical memory-have a direct bearing on what happens in treatments. Whether the information is about the recent past, such as what happened between sessions, or about traumatic childhood experiences, the patient's disclosures are in the service of a more complete narrative about self. At the same time, the therapist's ways of remembering what occurs in each therapeutic relationship will guide much of the healing process for the patient. Training certain memory functions is therefore critical to how therapists perform-far more significant than procedural techniques and paradigmatic formulations.

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Chapter One: Why Memory and Psychotherapy

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To begin with, I would like to describe briefly what happens to me as a therapist when I am with a patient. In this instance, the patient—I will call him Brian—enters my office for his weekly session. We exchange short greetings and sit down across from each other. He begins telling me how he is feeling, sometimes referencing our last session. Every so often, I nod. Plain red shirt, I notice. Still the same overweight frame as last week. However, Brian's facial expressions are definitely livelier today, and he appears less troubled.

As I listen to him begin the session, neither his diagnosis nor a specific treatment plan comes to mind. I remember certain details of his history, but only much later in the session and then as scenes or scripted stories. I have not memorised his treatment up to now, nor could I write a detailed history of it. I am simply responding to a relational event that has followed pretty much the same format since we first started meeting in my office. My mind is focused on the here-and-now and on cues that may tell me something about what is going on in Brian's mind. I have no conscious agenda, but I am in an entirely attentive frame of mind.

 

Chapter Two: The Nature of Subjectivity

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When a group of psychotherapists in the 1970s began discussing subjectivity, neurocognitive research had yet to be an established field of study. Their explorations of what later became a theory of intersubjectivity were instead a reaction to the impersonal and procedural way that the relationship between therapist and patient had been approached by most psychotherapists, especially in psychodynamic circles. Following the advice in Freud's technique papers, therapists, especially during the postwar period when psychoanalysis was most popular, had sought to follow a basic rule of remaining physically abstinent and emotionally neutral when working with patients. The technique of avoiding emotional responses and not volunteering any opinions or personal disclosures was supposed to ensure an objective stance and eliminate the possibility of undue influence on the patient (Freud, 1912e).

For some time, however, it had been clear to many clinicians that remaining unresponsive had a negative impact on the treatment itself and that most patients interpreted such a stance as a lack of caring. Furthermore, there was a growing awareness that therapists’ observations about the general functioning and psychopathology of their patients were far from objective; they were only one participant's version of a complex relational dynamic. The traditional view of the patient's transference as an inevitable but distorted perception of the therapist no longer seemed tenable (Lessem, 2005; Mitchell, 1988). The increasing consensus was that the therapist's perceptions of a patient's reality, accordingly, must themselves be subjective.

 

Chapter Three: Retrieving History of the Self

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If autonoetic awareness is the necessary state of mind for episodic memories to form, then, by definition, access to these memories also involves the self as an agent and as a recipient. Episodic memory is in fact uniquely concerned with what I, the rememberer, believe to have occurred in my presence at a particular time and place. The retrieval, when it involves extensive personal experiences, is therefore autobiographical knowledge and, depending on the person's capacity to maintain and continually update a narrative about this knowledge, will make available a history of his or her sense of self (Siegel, 2003).

The need for consistency, for self-cohesion, makes this retrieval particularly demanding, especially when experiences from a distant past are involved; the concern is no longer remembering a dinner date, the name of a place visited, or a concert attended. To some researchers, this means that remembering our own autobiography ought to be treated as different from episodic memory, or at least as a distinct extension of it. It appears to demand more effort and more complex cueing than retrieving some basic facts from what has been stored semantically (Gazzaniga, 2008). And for the retrieval to result in a sense of expanded self-knowledge, the rememberer at some point would have to confront the paradox that the current self may, in fact, be involved in different life circumstances and have different goals and aspirations than the self remembered (Conway, 2001). Some type of reconstruction is demanded; a unified knowledge structure has to emerge and, along with it, a narrative about a uniquely experienced history (Kihlstrom & Klein, 1997).

 

Chapter Four: Stories Told and Retold

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Based on the findings in memory research discussed in the previous two chapters, I am proposing that psychodynamic treatments, in fact all psychotherapies, have a narrative base. Only by understanding the narratives of both therapist and patient—and how they are encoded, stored, and retrieved—are we able to account for how treatments often produce coherence and integration in the lives of patients. And only by understanding the narrative base of treatment will we be able to document what actually occurs without having to rely on paradigmatic and often outdated theoretical formulations. How this documentation is done is critical to the future of psychotherapy, to its credibility with the public, and to how we educate future practitioners to develop a full narrative competence.

My proposal is by no means unique. In a symposium on narratives in 1979, Roy Schafer of Columbia University's Psychoanalytic Center made early inroads into the narrative base for psychotherapy formulations and case descriptions, especially from an analytic point of view reframing many of the original psychoanalytic formulations. According to Schafer:

 

Chapter Five: Dreams as Stories

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Reporting and interpreting dreams is another, yet different, form of storytelling in psychotherapy treatments. Patients who remember their experiences while dreaming are often eager to share these experiences with their therapist. And, if the therapist asks, a recent dream may surface even in the initial interview. Such initial dreams, or herald dreams, have a particular prognostic relevance for some therapists, for reasons yet to be established beyond the clinical experience (Kradin, 2006). Aside from their use in initial assessments, therefore, dream reports may give us important insights into how stories are constructed and how they are retained in memory and later retrieved. This, in turn, should allow us to further explore the narrative aspects of psychotherapy treatments.

Until recently, investigation of dreams was hampered by a focus on the broader function of dreaming rather than on dreams’ obvious narrative character (Domhoff, 2005, 2010). Today, beyond the important neurological function of sleep and dreaming, findings also indicate that dreams are similar to everyday stories (Hobson, 1994). Although some critical questions still remain, we are now able to compare the possible neural pathways for both (Solms & Turnbull, 2002). For instance, findings from research on cognitive image schemas signify that these schemas play a central role in how dreams are constructed. Since they develop very early in the infant's life and before the acquisition of language, they are often reflected in the metaphors common in dream reports (Mandler, 2004, 2005).

 

Chapter Six: Metaphors and Meaning

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When approaching dreams as stories in the previous chapter, we discovered that they are stories that were converted from their original image language into a wide range of verbal vehicles. In the process, dreams change from being a series of moving pictures into what we may call “eyewitness reports”—accounts of a recent event that was only experienced in private. When listening to one of these reports, we realise that the concepts and metaphors must have gone through a similar transformation. Although the primary sources are clearly the dreamer's past experiences in the form of memories, expectations, fears, and desires—dreams themselves are merely wordless.

In this respect, dreams reported in psychotherapy may feel as if they were hiding their riches. Compared to other verbal media, they appear wild and incoherent, even though the images were created without hesitation while the patient was dreaming. Dreams’ bizarre way of narrating may have some clinicians conclude that all we are doing, when trying to understand them, is making sense of something that in reality never did make any sense. However, if the images are examined more closely, we find that dreams use the same means of communication as those used about everyday experiences. What we are listening to is what Stephen LaBerge, a dream researcher at Stanford University, calls “a simulation of the world in a manner directly parallel to the process of waking perception minus sensory input” (1998, p. 495).

 

Chapter Seven: Where it Happens and How

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Most of our knowledge about what happens in psychotherapy comes from what therapists describe about treatments they participated in. Aside from taped recordings of sessions used for outcome research, this knowledge is in the form of reports, progress notes, and other documentation that was created after the fact (Messer & Wolitzky, 2007).

When considering what therapists report, we are therefore dealing with past events and how these events were remembered by one of the participants in a two-way dialogue. Even in notes taken shortly after a session or when otherwise describing the therapeutic process, therapists must use some type of narrative in order to remember and organise what they experienced. Narratives are therefore the basis for how therapists report on their work and what they remember about it. In fact, much of the ongoing communication with a patient relies on how well these narratives can hold memories for what occurred in previous interactions.

In the first part of the book, I discussed how narratives are constructed and how they tell us who we are, what we remember, even how we dream at night. In this part, I more closely examine the types of memory that therapists develop in order to serve a healing function for their patients. Using current research and material from outcome studies, I describe six particular forms of memory. Two of these relate to the therapist's episodic memory of sessions with a particular patient, two are based on what the therapist brings to each treatment, and two are of a more general nature and are based on certain learned skills and approaches. (See also Table 4.2 in Chapter Four.)

 

Chapter Eight: What there is to Tell

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Ever since Freud abandoned his attempts to anchor psychological principles in neurobiology, the psychotherapeutic field has shown an unfortunate lack of concern for the role memory plays in psychotherapy treatments. What, and how, patient and therapist remember has received little attention in spite of the rich source of data from neuroscientific research that is now available. In fact, today, in examining what can reliably be reported about a specific treatment, we must take into consideration how memory functions.

By the time Freud issued his technical recommendations on how to conduct treatments, he had abandoned his ambitious “Project for a Scientific Psychology” and was in the middle of developing his psychoanalytic methods (1885).1 He now based his formulations on what he called the case history method, a narrative rather than a neurocognitive approach (Gay, 1998; Messer & Wolitzky, 2007). His technical recommendations nevertheless give us a fairly clear picture of his own approach to remembering what is significant in each session and about each patient. The technique, he writes, “is a very simple one” and involves the following:

 

Chapter Nine: Listening in a Different State of Mind

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In answering the question “What is psychotherapy?” Jerome Frank—who for over fifty years researched the many facets of its practice—focuses on two things that psychotherapy is not (Frank & Frank, 1991).1 For one, it is not informal help that may be had from a casual acquaintance, family member, or even a stranger. Furthermore, it is not a medical or surgical procedure. In contrast to bodily intervention, psychotherapy relies on symbolic communication. It is guided by a theory that explains the sources of the patient's distress and prescribes methods for alleviating it (Frank, 2006). He explains:

An important consequence of the primacy of communication as the medium of healing is that the success of all forms of psychotherapy depends more on the personal influence of the therapist than on medical or surgical procedures. Even when the success of psychotherapeutic procedures is believed to depend solely on their objective properties, as some behaviour therapists maintain, the personal influence of the therapist determines whether the patient carries out the prescribed treatment in the first place, as well as having healing effects in itself.

 

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