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The Dialogue between Psychoanalysis andNeuroscience: Alienation and ReparationDouglas Watt Ph.D.a

a Director of Neuropsychology, Quincy Medical Center, 114 Whitwell Street, Quincy, MA02169Published online: 09 Jan 2014.

To cite this article: Douglas Watt Ph.D. (2000) The Dialogue between Psychoanalysis and Neuroscience: Alienation andReparation, Neuropsychoanalysis: An Interdisciplinary Journal for Psychoanalysis and the Neurosciences, 2:2, 183-192,DOI: 10.1080/15294145.2000.10773304

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The Dialogue between Psychoanalysis andNeuroscience: Alienation and Reparation

Douglas Watt (Boston)

The irony regarding the historical alienation of psy­choanalysis and neuroscience, of which virtually ev­eryone is aware, is that Freud started out as a verycompetent neurologist who made several importantcontributions to the neurological literature of his time,including work on aphasia. His "Project for a Scien­tific Psychology" (1895) was his attempt to give psy­choanalytic metapsychology the firm grounding inneuroscience that Freud thought critical to its scientificvalidity. Virtually everyone is also aware that the Proj­ect failed simply because the neuroscience of Freud'sday did not have the concepts to provide any suchgrounding. The Project ended up being a kind of back­wards construction, speculating about largely undis­covered brain processes that would be isomorphic withthe psychological principles of consciousness and un­consciousness that Freud was intuitively developing.

Despite this important starting point, psychoanal­ysis and neuroscience gradually became virtual adver­saries during the second half of the twentieth century.This happened after decades of hegemony of psycho­analysis in American psychiatry departments, in thecontext of a fundamental conceptual split betweenpsychiatry and neurology mostly organized around thenow fortunately outdated distinction between "func­tional" and' 'organic." Although psychiatry and neu­rology have finally moved into an increasinglyproductive dialogue over the last two decades, therehas been a much more limited movement toward re­spectful dialogue between psychoanalysis and neuro­science, and precious few of those limited initiativeshave come from the neuroscience side of the fence.Only very recently have such notables as Kandel

Douglas Watt is Director of Neuropsychology, Quincy Medical Cen­ter; Instructor in Neurology/Psychiatry, Boston University School of Med­icine.

I This paper was presented as the closing address to the First Interna­tional Neuro-Psychoanalysis Congress (London, July 2000).

(1999) suggested that perhaps neuroscience could nowreach a new kind of accommodation with psychoanal­ysis. However, the attitude of many in clinical neuro­science is that psychoanalysis is irrelevant, if it is notjust plain wrong, while experimental neuroscience(still more allied with behavioral principles) perhapssees psychoanalysis as both dead and discredited, withbridging not only irrelevant but distasteful. Many inclinical neuroscience and neuropsychiatry still believedeeply in core psychodynamic ideas, but public state­ments to that effect are often deemed risky, and partic­ularly inadvisable when dealing with nonclinicalneuroscientists, who quickly move away, and stayaway. Representatives of the view that psychoanalysisis totally outdated bunk include Paul Churchland (neu­rophilosopher and author of the well-regarded connec­tionist manifesto, The Engine of Reason, the Seat ofthe Soul, 1996) and Michael Alan Taylor (editor-in­chief of the excellent clinical neuroscience journalNeuropsychiatry, Neuropsychology and BehavioralNeurology). "Freud bashing" has become as fashion­able as the early, grandiose visions of psychoanalysisonce were, and the pendulum has not swung back to­ward the reasonable middle in any meaningful sense.

More troublesome is the fact that few outsidepsychoanalysis seem to understand that psychoanaly­sis is a sprawling and heterogeneous discipline, hardlythe monolithic and rigid set of doctrines that are sooften presented in the media as "Freudian psychoanal­ysis." As a body of thought and practice psychoanaly­sis contains nearly every position one could possiblyembrace on many technical and metapsychological is­sues, and somewhere else in the literature the oppositeof that position as well. Thus, any neuroscientist paint­ing a broad brushstroke image of psychoanalysis, char­acterizing it in terms of consistent and rigid doctrines,would reveal a fundamental ignorance about psycho­analysis, its history, literature, and technical practice.

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As a measure of the dynamic nature of the evolutionof psychoanalysis from the beginning, Freud's think­ing was constantly evolving and developing. Contin­ued conflict and heterogeneity have defined the fruitfulexpansion of Freud's original ideas through concertedefforts on the part of decades of clinicians and theo­rists working to redress errors and conceptual holesin Freud's thinking.

Since alienations typically have two sides, wemight look at this the way a couple's therapist mightexamine a failed relationship, as an interactive processwith contributions from both parties. From one sideof the border psychoanalysis was guilty of abandoningthe constructive intent in Freud's Project, while neuro­science contributed to the failure by publicly ignoringand often privately caricaturing the insights containedin key psychoanalytic concepts such as transferenceand the repetition compulsion (Freud, 1914). Wherethese omissions were not in evidence, there was aneven more basic avoidance of topics relating to emo­tion and consciousness/unconsciousness altogether.Psychoanalysis, following Freud's lead of disowninghis original efforts to ground metapsychology in neu­roscience, then retreated into "splendid" isolation,with little investment in empirical research or bridgebuilding to disciplines at its borders. Instead, there wasa reification of metapsychology that in my judgmenthas cost psychoanalysis dearly, in terms of its scien­tific credibility and in terms of its potential growth.Although there were important revisions to the classi­cal core Freudian doctrine (e.g., in object relationstheory and ego psychology, self and relational theo­ries) psychoanalytic metapsychology still lacks theneuroscientific foundation and cross-validation thatFreud had originally intended. Along with the disci­plinary isolation and the defensive management of itsborders, these trends set the stage for the profounddiscrediting and isolation that psychoanalysis enduredin the context of "biological revolution" in psychia­try, particularly in the United States.

Together, these mutually defensive postures bypsychoanalysis and neuroscience-of discrediting, de­valuing, and mutual avoidance-guaranteed that fewsynthetic conceptualizations had any chance of flow­ering in the arid desert between these two disciplines.A landmark article that marked a potential for move­ment toward consilience, and a potential softening ofdecades of formal hostilities, was David Galin's(1974) article linking topographical concepts of re­pression (and other metapsychological notions) withcortical lateralization. Sadly, this article, althoughopening up numerous avenues for synthesis, generated

Douglas Watt

no upsurge in fundamental research on the borders ofpsychoanalysis and neuroscience, that a number of usmight have hoped for. The mantle was not taken upby the broader psychoanalytic community, and psychi­atry wanted a divorce; it had no need for psychody­namics anymore anyway, as it had discovered"monoamaine tweaking" and it liked its new toys,and the increased esteem associated with its' 'remedi­calization." There have been a few notable but lonelyexceptions, such as the work of Howard Shevrin(1996) and several others who have been quietly pur­suing questions empirically for many years, often withfaint-hearted support from the analytic community,and at best a bemused tolerance (if that) from neuro­science colleagues.

A stubborn positivism in much of neurosciencehas prevented questions such as emotion and con­sciousness from being viewed as neuroscientificallyrespectable until quite recently. In this context, wehave seen a renaissance of neuroscientific interest inboth consciousness and emotion, with two major con­tributors to those subjects being Antonio Damasio(1999) and Jaak Panksepp (1998). However, as Pank­sepp has pointed out, behaviorism didn't die, it simplywent into behavioral neuroscience, where the focus islargely on the ultra-fine-grained level of analysis, witha fundamental neglect of large-scale-system propertiessuch as emotion. This neglect has been informed byfour basic assumptions:

1. There is a certain kind of left-hemisphere bias inwhich large-scale system properties are not as at­tractive as the minutiae of fine-grained detail.

2. There is the belief that animals are probably notsentient creatures and therefore that they do nothave emotions in the sense of feelings (as opposedto emotional behaviors).

3. Likewise, there is the belief that consciousness ismost certainly not a neuroscientifically meaningfuldomain of study in animals, in agreement withThomas Nagel's supposition that one can neverknow at all what it feels like to be a bat (althoughonly a few neuroscientists would even know whoNagel was or what he thought).

4. There is the assumption that fundamental relation­ships between emotion and consciousness do notexist, because these are orthogonal processes.

Clearly, these four assumptions are not sharedby all in neuroscience, particularly those coming fromclinical neuroscience, who by and large would dis­agree with most if not all four of these assumptions.

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Most encouraging over the past five years or sohas been increasing interest in a neuroscience of emo­tion ("affective neuroscience"). Concurrent with thisthere has been a strong suggestion (generated notablyby Panksepp and Damasio) for the central heuristicthat a neuroscience of emotion has to be one of thekeystones in the arch for a neuroscience of conscious­ness-a proposition that, of course, Freud himselfstrongly endorsed. Unfortunately, psychoanalysis hasbeen virtually alone and quite isolated in its interestin the fundamental connections between conscious­ness and emotion, so that there has been precious littlescientific traffic at the intersection of these topics untilrecently. But in just the last two years, we have seenthe publication of two landmark works on conscious­ness and emotion, one of them from Antonio Damasio(1999) and the other from Jaak Panksepp (1998). Da­masio's theoretical synthesis, in which core conscious­ness arises from the correlation of body (protoself) andworld mappings, in second order mapping structures,under the constant guidance of emotion (see Watt,2000, for extensive review) is fundamentally congru­ent with basic conceptions concerning the ego in psy­choanalysis. I Jaak Panksepp' s careful study in animalsof the chemoarchitectures and distributed networks in­volved in the prototype affective states gives us anempirical grounding for a science of emotional mean­ing (see Watt, 1999, for extended review). Jaak's workgives us a general roadmap for investigating how cor­tical encodings might link to the prototype states, togenerate the vast panoply of emotional meaning andemotional associations.

It seems clear to me that these two major worksat the intersection of affective neuroscience and con­sciousness studies are also intrinsically bridge buildingbetween psychoanalysis and neuroscience, eventhough that was not a primary intent of either author.Mark Solms's work has been instrumental in buildingmomentum toward a more respectful dialogue betweenneuroscience and psychoanalysis, and his summary ofclassical psychoanalytic conceptions of affect in thisjournal have given neuroscientists a concise and easilydigested text from which they can make judgmentsabout the potential congruence between psychoana­lytic concepts and emerging affective neuroscience

I However, the concept of the ego in psychoanalysis is unfortunatelyso multidimensional as to elude any simple definition-this itself being apotential topic for a whole essay. Blanck and Blanck (1979) have suggestedthat careful review of the multiple meanings of "ego" reveals that thisconcept subsumes many functions under the rubric of a global organizingor meaning-making process, rendering it broadly synonymous with almostall psychical (or higher neurological) activity. This may be a very helpful,or quite trivial, clarification, depending on one's predilections.

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concepts (see also Neuro-Psychoanalysis, Vol. 1, No.1). Solms (1997) has also opened up wide avenues fordiscussion between the neuroscience of dreaming andREM sleep and psychoanalytic theories of dreaming(see Neuro-Psychoanalysis, Vol. 1, No.2, and the on­going discussion in this issue).

My hope would be that these landmark worksby Damasio and Panksepp signal that neuroscience isinching away from the myopic focus on an isolatedcortex and moving (albeit ambivalently) toward a fu­ture neuroscience of the whole person. Such a neuro­science must have rich interdigitation with the scienceof personal meanings that psychoanalysis has at­tempted to be, for better or worse, for so many de­cades. Although Damasio, (1999) expresses optimismthat we are seeing the beginning of a true paradigmshift, we shall have to wait and see whether or notthese important theoretical contributions trickle downto influence basic neuroscience research. Without suchfundamental influence on the course of empirical neu­roscientific work, including most particularly the re­framing of fundamental hypotheses for experimentalinvestigation, it is hard to see how any of these seminalideas are likely to substantially change the still positiv­istic and behavioristic climate in much of modern neu­roscience. If such paradigm-shifting influence cannotbe more widely disseminated, it is difficult to see howneuroscience could ever hope to do much justice to thewisdom of the ages (which is largely about emotion'sprimary role in sentience), or ever truly expose thecomplex neural foundations for our "ground of be­ing" as sentient creatures. Until both sentience andemotion are much more fully investigated in this light,it is hard to imagine how we will ever come to fullyunderstand these scientific "Holy Grails."

How can one conceptualize both the currentstate-of-the-art with respect to our fragile bridges be­tween the disciplines, possible lines of theoretical ex­trapolation' and future clinical and research directionsthat would develop those bridges and deepen the dia­logue? To return to the couples therapy metaphor, thisbridge building cannot take place in a climate wherethe dialogue is dominated by the question of whetherFreud was right or wrong. Bridge building requiresboth sides to give up their old defensive (and offen­sive) behaviors. Also by definition, bridge buildingmust eventually lead to some degree of fundamentalconceptual change for both disciplines. The disciplineshave to move toward a middle ground. It is not ade­quate for psychoanalysis simply to find support for itsmetapsychology in the discoveries of neuroscience.This is still a fundamentally defensive retrenching, and

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not adequate to the task that psychoanalysis has toaccept, namely the slow and painful overhaul of a doc­trine-based metapsychology and its evolution into anempirically grounded, neuroscientifically valid, meta­psychology. To balance the scales, neuroscience mustaccept not just the existence but the primacy of theprocesses that psychoanalysis has been studying fordecades.

This "prescription for treatment" may be offen­sive to some mainstream analysts, but it is the stiffprice of progress for a discipline that has in the pastsacrificed bridge building and ongoing empirical test­ing of concepts for preservation of its internal author­ity structures. Neuroscience has its own growth painsin terms of the need to accept that there truly are suchthings as, for example, defenses against anxiety andpainful affect (there has been some progress, albeitslow, on those fronts recently). Perhaps even moredifficult, neuroscience will have to find a way to acceptthe validity of fundamental process concepts from psy­choanalysis, particularly what I would take as the clin­ical core of psychoanalytic insight, in the intrinsicallyrelated concepts of transference and the repetitioncompulsion.

Caveats and Obstacles in the Dialogue betweenTwo Traditional Adversaries

Psychoanalysis must redress lingering confusion aboutthe role of insight and what are essentially higher cog­nitive factors versus the primary role of more affect­ive-interpersonal and attachment-related processes inthe resolution of long-standing characterological struc­tures. Insight alone is not sufficient as an agent ofchange, and nor in a strict sense is insight the real goalof life. The goal instead is a fundamentally euthymicaffective balance in which we have stable, enduring,and even deepening connections to loved and valuedpeople, places, and endeavors, with well-modulated,contained, and context specific activations of the de­fensive prototype systems of fear and anger that suc­cessfully remove or resolve threats, and that do notdig us in deeper and destroy relationships. Similarly,insight is either impossible to achieve or it is emptyintellectualization in the context of a primary thera­peutic relationship in which the recapitulation of oldhistorical traumas is not just a negative component ofthe transference but a reality, in the absence or failureof a stable empathic "hold" offered by the analyst­therapist. This view may be rejected by some as anattempt to smuggle the concept of corrective emo-

Douglas Watt

tional experience through the back door. I would wantto reassure everyone that I do not want to smuggle itin the back door, I want to widen the front door andbring it right into the foyer. To avoid misunder­standing; I am not suggesting that insight is not im­portant, rather that separation between concepts aboutthe therapeutic alliance, corrective emotional experi­ence, and empathic holding, on the one hand, and thetraditional emphasis on insight on the other hand, needto be reconceptualized as complementary outlines ofmore affective versus more cognitive processes pro­moting characterological change, and not competingconceptions about change agents in the process ofanalysis and psychotherapy. However, almost any ver­sion of an evolutionarily sophisticated perspectivesuggests that we must consider the affective factors asa primary base on which the cognitive factors canpotentially operate. From the perspective of the twoclusters of affective systems (see table below), realeffective-behavioral change (what analysts havecalled structural change) must stem from the experi­ence of emotional safety lessening the activation ofthe "organism defensive states" of fear and rage, andthe lessening of separation distress. We do need in­sight to see what we are doing, where we have been,and why, but without the safety of an empathic ac­cepting connection where trauma is not happening wewill not be able to take off the character armor nomatter what cognitive working memories we can en­tertain about our own internal operations.

The following table outlines what is currently un­derstood about the prototypic affective states from ani­mal research, and might well form the foundation fora reworked and modern psychoanalytic theory ofdrives and affects. It is worth emphasizing that thetable suggests that Freud was partially right: there aretwo large groupings of primary affective states, butnot in terms of a simplistic' 'sex versus aggression"typology, more along the lines of an "organismic de­fense system" that would subsume fear and rage, andan "attachment to conspecifics" system, that wouldinclude play, sexual bonds, attachment, separation dis­tress, and nurturance. There is a third, nonspecific sys­tem that Panksepp calls the "seeking" system thatappears to function as a kind of master "gain control"for virtually all of the other affective states (Pank­sepp, 1998).

Clearly these important questions and controver­sies about curative factors in psychotherapy and psy­choanalysis have already been discussed in manyplaces in the psychoanalytic literature (and in themany psychotherapy literatures). Considerations from

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TABLE 1Distributed Midbrain-Diencephalic-Basal Forebrain Chemoarchitectures for Prototype Emotions.

(From Watt, 1999, extracted from Panksepp, 1998)

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Affective Behavior

Nonspecific Motivational Arousal­Seeking & ExploratoryBehavior

Rage/Anger ("Affective Attack")

Fear

Sexuality

Nurturance/Maternal Care

Separation Distress/Social Bonding

Play/Joy/Social Affection

?Social Dominance

Structures/Neural Networks

Ventral Tegmental Area (VTA) to moredorsolateral hypothalamic to PAG, withdiffuse mesolimbic and mesocortical"extensions' ': nucleus accumbens ascrucial basal ganglia processor foremotional "habit" systems

Medial amygdala to bed nucleus of striaterminalis (BNST) to anterior andventromedial and perifornicalhypothalamic to more dorsal PAG

Lateral and central amygdala to medial andanterior hypothalamic to more dorsalPAG to nucleus reticularis pontinecaudalis

BNST and corticomedial amygdala topreoptic and ventromedial hypothalamusto ventral PAG

Anterior cingulate to bed nucleus of striaterminals (BNST) to preoptichypothalamic to VTA to ventral PAG

Anterior cingulate/anterior thalamus toBNST/ventral septum to midline anddorsomedial thalamus to dorsal preoptichypothalamic to dorsal PAG (close tocircuits for physical pain)

Parafascicular/centromedian thalamus,dorsomedial thalamus, posteriorthalamus, to more dorsal PAG (septuminhibitory re: play)

Not clear if separate from activation of playsystems and inhibition of fear systems?

Neuromodulators

DA (+), glutamate (+), manyneuropeptides including opioids,neurotensin, CCK

Substance P (+) (ACh, glutamate[+] as nonspecific modulators?)

Glutamate (+), ACTH,neuropeptides including DBI,CRF, CCK, alpha MSH, NPY

Steroids (+), vasopressin andoxytocin, LH-RH, CCK

Oxytocin (+), prolactin (+),dopamine, opioids both (+) inmoderate amounts

Opioids (- / +) oxytocin (- / + ),prolactin (- / +) CRF (+) forseparation distress

Glutamate (+), Opiods (+ in smallamounts, - in larger amounts),muscarine (+), nicotine (+).Monoamines all appear to belargely (-) (!?)

Note: This table omits biogenic amines, which are much more nonspecific, and the higher cortical areas in mostly temporal and frontalregions deeply involved in the further elaborations of emotional processing and emotional meaning, particularly in animals with consider­able cortical evolution.

Keys [( -) inhibits prototype, (+) activates prototype] [CCK = choleocystokinin, CRF = corticotrophin releasing factor, ACTH =adrenocorticotropic hormone, OBI = diazepam binding inhibitor, ACh = acetylcholine, DA = dopamine, MSH = melanocyte stimulatinghormone, NPY = neuropeptide Y]

neurodevelopment (and any version of an evolution­ary perspective) suggest that cognitive processes arean extension of emotional processes just as emotionalprocesses are an extension of homeostasis and moreprimitive foundations for organismic pain and plea­sure. Although the constancy and empathic at­tunement of a competent analyst-therapist mayinitially seem a poor second cousin of whatever love

and gratification were missed in the childhood of thepatient, we learn that such empathic attunement is pre­cisely what was absent in our pathogenic traumas, thatsuch gifts of basic decency and attunement are notbought, and that instead they constitute the essentialfoundations for all competent and good relationshipsbetween conscious creatures. Psychoanalysis offers aframework in which we reexperience our deepest fears

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and wishes in the transference, appreciate them withcomplex working memory and cognitive operators (in­sight), and lessen the activation of pathologic defensesthat intrinsically limit our empathy for others via dis­tortions of their internal states. Most importantly, psy­choanalysis or psychotherapy opens up wide avenuesfor creative adaptation previously unavailable in thecontext of pathologic defense, because the traumadoes not really happen (of course, these avenues inturn depend deeply on an identification with the ana­lyst's empathy and attunement). We are unconsciouslyconvinced that the traumatic repetition will happen,we do our utmost to make it happen (what Freud calledthe "uncanny" nature of the repetition compulsion),but it doesn't bloom into an emotional reality (a trulyrepeated trauma), because the analyst-therapist (wehope) doesn't do anything traumatic. However, to theextent that the analyst-therapist is recruited by virtueof his or her countertransferences to act in the patient'sdrama, we have to talk about a partial or completefailure of the therapy or analysis. This basic perspec­tive, of an alliance characterized by neutrality andboundaries, nonjudgmental acceptance, low-keywarmth, and deep (not superficial) empathy, is ulti­mately what enables the consistent focus on funda­mental affective issues. These concepts, along withthe process concepts of transference and the repetitioncompulsion, constitute an explanatory and treatmentframewor k of unequalled power that neuroscienceneeds to build a bridge to. As I said in an earlier paper(Watt, 1990), if psychoanalysis, despite all its meta­psychological convolutions and problems, has pro­vided countless therapists with an explanatoryframework for understanding the complex relation­ships between affects, cognitions, previous experi­ence, current behavior, and current context, thenpsychoanalysis contains vital insights about how thebrain works as a whole that neuroscience badly needsto appreciate better.

Psychoanalysis must supplement a scientificallydated metapsychology with concepts from affectiveand cognitive neuroscience, and its traditional histori­cal reliance on metapsychological infighting betweendifferent schools and camps must be replaced by anew reliance on empirical validation of its primaryconcepts. Psychoanalysis can no longer afford a defen­sive posture in which its primary exchange with otherdisciplines runs along the lines of attempting to vali­date Freudian doctrine, as opposed to admitting thatperhaps some of Freud's ideas were simply wrong,less than optimally framed, or in need of radical over­haul. An authority-driven conservativism must be re-

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placed by a scientific conservatlvlsm driven byprimary research. This may be hard for some in psy­choanalysis to swallow, but psychoanalysis has beenperceived by many in neuroscience (and by those inother sciences as well) as ideological and either non­empirical or even antiempirical. This perception hascertainly been reinforced by its reliance on a specialjargon that, when abused (due to its high levels ofabstraction and some intrinsic vagueness) seems toproduce mystification and obfuscation of subjectiveexperience rather than deepening appreciation.

For sure, there are difficulties in advocating anew empiricism for psychoanalysis. At the very topof the short list of these would be the manner in whichany technology introduced into the therapeutic situa­tion (in order to monitor the neural systems of thepatient) becomes a fundamental distortion of the ana­lytic framework. Clearly, the mandate to preserve theframework has been perhaps the strictest of all psy­choanalytic mandates, one that we are taught never totrifle with.2 However, in an age of increasingly sophis­ticated noninvasive technologies such as MEG andfunctional MRI, psychoanalysis may have to makesome modest concessions on this point in order to getessential data. Such a new empiricism within psycho­analysis would supply the critical passport of admis­sion to the circle of scientific credibility. Just onepossibility: noninvasive functional monitoring of neu­ral systems in an analytic patient would give us im­portant insights into the long hypothesized lateralityaspects of psychodynamic processes, along with in­sights into the poorly appreciated vertical integrationof brain systems vis-a-vis psychodynamic variables(and further insights into the anterior-posterior inte­gration of brain systems).

Although psychoanalysts will rightly wonder ifall of a sudden they are being expected to becomeneuroscientists, that is not the prescription here at all.In fact, the most immediately available avenue forbridging between the disciplines lies in the clinicaldomain in which psychoanalysts spend most of theirprofessional lives. Simply put, clinical syndromesmight be more fruitfully studied if we adopted a con­joint psychodynamic/developmental and neurobiolog­ical point of view (see below, "Bridging Heuristic No.

2 Psychoanalysts have long been taught to resist' 'parameters of tech­nique," and this has at times resulted in a certain inflexibility about theframework, rather than the principle that the treatment frame has to reflecttitration of the level of negative transference that the patient is exposedto, to ensure the alliance is not swamped by intolerable ambivalence andanger (worse case scenarios refer to "psychotic transferences"). Again,these are complex issues with a rich albeit conflicted representation in theanalytic literature.

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6"). There is increasing evidence that current DSM­IV categories are wastebaskets reflecting the clumpingof similar but probably somewhat different disordersthat need to be further unpacked. The variables affect­ing this heterogeneity probably include significantvariability in the genome among sufferers of a particu­lar disorder, possibly predisposing them to somewhatdifferent neurobiological derailments under stress. Aswe have seen from the experience of dozens of syn­dromes in neuropsychiatry and neuropsychology,there are many ways to "crash" a higher brain func­tion, given that these functions depend not on a singlestructure or brain region, but on complex distributednetworks. Thus many different lesion locations cangenerate very much the same syndrome. This shouldbe instructive for those in biological psychiatry stilltrying to chase down a specific neuroanatomical "le­sion," even if only in a functional sense, or any' 'phre­nology of neuromodulators" (the notion thatdisruption of a specific neuromodulatory system couldprovide an adequate explanation for the syndromesof DSM-IV). The current heterogeneity (wastebasketnature) of virtually every syndrome in DSM-IV willhave to be supplanted by a more differentiated nomen­clature (derived from much further empirical work)before we can expect the kind of predictive and treat­ment successes that we are looking for.

A second crucial variable beyond genotypic vari­ability likely to contribute to the heterogeneity of cur­rent DSM-IV categories may be crucial life historyand psychodynamic variables. Clearly genotype, earlyhistory, personality, and characterological issues, pre­cipitating psychological and biological stressors, andneurobiological derailments are all somehow interdig­itated in the epigenetic landscape that generates clini­cal syndromes. Thus, we probably have a long way togo to truly understand the interactions of nature andnurture. But we shall never understand them if wepersist in experimental methodologies that leave outpsychodynamic and early developmental variables andthat therefore are swimming against the current ofmodern concepts about development and epigeneticlandscapes. These reductionist research methodolo­gies reflect a lingering separation of mind and body,of present and past, of nature and nurture. So, psycho­analysis has an opportunity, by virtue of its being aprofoundly developmental clinical discipline, in con­cert with its neuropsychiatric and neurological andneuropsychological colleagues, to reexamine the clini­cal syndromes in DSM-IV. Such research designshave, to my knowledge, never been implemented, andthey do not require that patients in a prospective re-

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search study receive a full analysis. However, theywould instead be informed by careful thinking aboutways in which the psychodynamic and life historyvariables could be profitably operationalized and as­sessed in a consistent fashion (with decent interraterreliability). Additionally, and just as crucially from thestandpoint of the "couples therapy" metaphor, suchbridging work with clinical neuroscience colleagueswould stop the slow but steady marginalizing of psy­choanalytic thought within the medical community,and would reinvigorate psychiatry.

These powerful concepts (the repetition compul­sion and transference) informing an epigenetic per­spective on the gradual accretion of human emotionalmeanings constitute a very sturdy pillar for bridgebuilding from the psychoanalytic side of the divide.One should lead from strength.

Bridging Topics for the ComingDecade-Initial Heuristic Clusters3

Topics

Group 1: Lateralization, Emotion, and the Na­ture of the Dynamic Unconscious. There have beenseveral heuristic lines of speculation about the invest­ment of lateralized right hemisphere processes in thefundamental phenomena that psychoanalysis has beenconcerned with for decades, particularly in terms ofhow these processes help us understand the core con­cept of transference. In two papers (Watt, 1986, 1990),I reviewed an extensive body of clinical and neuro­scientific material suggesting that transference is me­diated by right hemisphere processes. We have a longand well-established empirical tradition documentingdifferences in the affective valence of the hemispheres,in terms of a relatively more dysphoric right hemi­sphere versus a relatively more euthymic left hemi­sphere; but this description may not fully characterizethe issue of lateralization with respect to affective va­lence. I suspect that a better characterization would bethat the right hemisphere may possess our full ambiva­lence as it were, while the left hemisphere has a kindof benign, day-to-day, routinized, and more delimitedset of affective representations, yielding a weakly pos­itive (if somewhat superficial) kind of affective va­lence. Lesions to either system disturb the balance

3 I am referring to these as groups or clusters, as they obviously loadon more than one concept or question, and are an effort to get at severalintrinsically related questions.

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between the two, with the left having crucial inhibitoryfunctions vis-a-vis the right, while the right hemi­sphere-as the cortical system in the brain most con­cerned with the big picture and with global statefunctions like emotional, attentional, and executivefunctions-is obviously crucial to all of the corticalelaborations of affect. Although there is talk in somequarters of a left hemisphere' 'Interpreter" being es­sential to consciousness, the literature on right hemi­sphere damage suggests that it might be better termeda left hemisphere Confabulator.

Lateralization itself is still a perplexing topic,without an overarching integrative theory, but we dohave tantalizing clues in terms of important neuro­modulatory, structural, and even (now) neurodynamicdifferences between the hemispheres. There is a largebody of work suggesting that the hemispheres cannotbe characterized simply in terms of verbal versus spa­tial functions, but rather must be characterized interms of a more fundamental "processing style" dis­tinction. Hemispheric relations, both conjunctive anddisjunctive, thus may be a basic ground for mappingpsychoanalytic concepts about the dynamic affectiveunconscious onto neural substrates-as David Galin(1974) argued more than two decades ago. The poten­tials for bridging in this basic initiative are still largelyunrealized, although many of us who believe in thefundamental truths of psychodynamics, myself in­cluded, have pursued bridging via this particular chan­nel. In any case, the established primacy of the righthemisphere in generating higher encodings with regardto both expressive and receptive processing of affect,interdigitates richly with preliminary formulationscoming from psychoanalytic theorists about transfer­ence, other kinds of conscious emotional processing,and laterality.

Group 2: Transference, Countertransference,the Repetition Compulsion, Intersubjectivity, and Dy­namical Systems Theory. There are unappreciatedcongruencies between notions of chaotic attractors indynamical systems, the process of intersubjectivity,and the manner in which people "get to know eachother." Recently, chaos theory has emphasized the no­tion that ultracomplex systems can have "strange at­tractors" which cycle the systems into repetitivestates. They have also emphasized that systems haveattractor "basins," and that interacting ultracomplexsystems (any human dyad) are going to find certainattractor basins in the overall attractor landscape thatboth systems move toward repetitively. These cyclebetween a relatively limited set of affective states,

Douglas Watt

having an epigenetic landscape that evolves, de­pending upon the nature of the positive and negativestates activated. As I become a player in your script, insome way that allows your right hemisphere to defineaffectively who I am in relation to you, my own inter­nal set of interactive social-emotional categories foryou also "shakes down," and you find a place in mydrama too. This mutual "shaking down" and activa­tion of emotional categories is what we conventionallyterm "getting to know someone"; but we mostly getto know what each of us "primes out" from the other.However, there is really no clear leader or follower,just a kind of curious circular causality, sculptingsemistable attractor states. To the extent that thesescripts repeat old injuries for both of us, cycles ofidealization and traumatic disappointment, we can talkabout transference and countertransference and (onceagain) the uncanny nature of the "repetition compul­sion." To the extent that we forge an avoidance ofthose cycles, and there is mutual empathy, affection,and support, we can talk about a successful "real"relationship. But even those, as it turns out, are repeti­tive of early successes in attachment, recapitulationsof loving and gratifying connections from early in life.Emotional meaning is thus an intimately personal-his­torical accretion, as psychoanalysis has rightly empha­sized for many decades.

Group 3. The Potential Intersections betweenPsychotherapeutic Process, Attachment, Positive Af-fective States, and the Monoaminergic Therapies: TheLikely Role of Love and Affective Safety in Balancingthe "Symphony of Neuromodulators." It is clearfrom Jaak Panksepp's work that neuropeptides andnot the monoamines are probably the great frontier inpsychopharmacology. Neuropeptides have much morebehavioral specificity than classical neuromodulators,although the evidence also suggests that we will neverfind the kind of neat phrenology of neuromodulatorsthat American psychiatry was looking for in the 1960sand 1970s, in which a single neuromodulator performsa single function and yields a single behavior, the dis­ease of which yields a single disorder. We know nextto nothing about the (likely essential) role that goodattachments and positive affective states play in har­monizing what is understood only in the most globaland vague terms as the "symphony of neuromodula­tors." It is hard to believe that these positive affectivestates, activated in good attachments, have anythingbut the most central of roles in achieving such a globaland very poorly mapped balance.

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Alienation and Reparation

Group 4: The Nature and Functions of Dream­ing. The controversies and complexities of this sub­ject have been the focus of an excellent recent issueof Neuro-Psychoanalysis (Vol. 1, No.2) and will alsobe the focus of an upcoming issue of Behavioral andBrain Sciences (Vol. 56, No.6). This is obviously stilla deeply controversial and incompletely understoodprocess, with the spectrum of current positions rangingfrom the notion that dreaming is epiphenomenal toclassical psychoanalytic positions on dream interpre­tation. I would agree with Mark Solms's basic pointthat we know much more about the neural substratesof REM sleep than we do about dreaming (Solms,1999,2000).

Group 5: The Nature of (Neuro) Develop­ment. In many ways, this is the great frontier in neu­roscience where all of our theories will be subject tothe most acid of acid tests, and many of them I suspectwill be found wanting. Molecular genetics, neurode­velopment, and neurodynamics are three great fron­tiers in neuroscience, and their potential interdigitationis largely uncharted. Clearly, affective processes, andspecifically the vicissitudes of attachment, are primarydrivers in neurodevelopment (the very milieu in whichdevelopment takes place, without which the systemcannot develop). Psychoanalysis has been one of thevery few disciplines that has understood this and at­tempted to pursue this line of inquiry systematically.However, from a neuroscientific perspective, we knownext to nothing about such profound and foundationalevents as the infant's first smiling at mother, or theinfant's first separation cry. These are topics that manyneuroscientists consider not particularly important. In­stead, we see legions of researchers chasing down thesubtleties of visual awareness. This may be tantamountto attempting to learn the complexities of calculus be­fore we have learned how to count on our fingers.

Group 6: The Basic Psychobiological Nature ofClinical Syndromes, Particularly Depression, AnxietyDisorders, oCD, Bipolar Disorder, Schizophrenia,Sociopathy, PTSD and the Dissociative Disorders, andeven the Personality Disorders. We have sufferedtoo long from thinking that was "either psychody­namic or neuroscientific." This distinction should fi­nally be seen as scientifically unacceptable, and weshould frankly have less tolerance for these kinds ofsimplistic and polarizing notions. There is overwhelm­ing evidence that life experience plays a role in OCD,anxiety, depression, and probably most forms of bipo­lar disorder. While its role in schizophrenia is less

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certain, the roughly 50% concordance for monozy­gotic twins argues that even in this heyday of geneticexplanations, we need deeper scientific investigationof the interactions between experience and geneticpredispositions.

Finally, turning once more to the theme that per­vades almost every effort to build bridges between ourdisciplines, both sides have to move beyond the issueof whether Freud was "right" or "wrong." This is­sue, as a primary focus, is just not constructive. Forthe record, at least in terms of my own assessment,Freud was hardly right about everything; in fact, hewas tragically wrong about some important things. Buthe did leave an important legacy through trying tomap the rich vicissitudes of human ambivalence. Thefertility of many different clinical and therapeuticschools of thought owe much to Freud's view thata deeper appreciation of human "drives" and theirambivalent nature might be a good starting point fora fundamental emotional wisdom. In teaching us tocontinually appreciate the shades of gray in ourselvesand each other, I would argue that this legacy is thebest way of balancing both the earlier Ernest Jonesstyle of idealizing Freud and the now popular Freud­bashing. It is a pity that Freud himself seems to under­stand in terms of the more empathic shades of graythat his work taught us to respect more deeply. I cannotimagine that our current range of concepts concerningemotional interaction and internal psychological pro­cesses would have anything resembling their presentdepth without Freud, even though some of that depthmay have come from those of Freud's followers whostruggled with the many limitations in his original for­mulations. But isn't that how we make progress any­way? We still have to admit that science (and culture)exists and advances only because we stand on the shoul­ders of giants.

References

Blanck, G., & Blanck, R. (1979), Ego Psychology, Vol. 2.New York: Columbia University Press.

Churchland, P. (1996), The Engine of Reason, the Seat ofthe Soul. Cambridge, MA: MIT Press.

Damasio, A. (1999), The Feeling of What Happens. Bodyand Emotion in the Making of Consciousness. NewYork: Harcourt Brace.

Freud, S. (1895), Project for a scientific psychology. Stan­dard Edition, 1:281-391. London: Hogarth Press, 1966.

--- (1914), Remembering, repeating and workingthrough. Standard Edition, 12:145-156. London: Ho­garth Press, 1958.

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Galin, D. (1974), Implications for psychiatry of left andright cerebral specialization. Arch. Gen. Psychiatry,31 :572-583.

Kandel, E. R. (1999), Biology and the future of psychoanal­ysis: A new intellectual framework for psychiatry revis­ited. Amer. J. Psychiatry, 156(4):505-524.

LeDoux, J. (1996), The Emotional Brain. The MysteriousUnderpinnings of Emotional Life. New York: Simon &Schuster.

Panksepp, J. (1998), Affective Neuroscience. New York:Oxford University Press.

Shervin, H., Ed. (1996), Conscious and Unconscious Pro­cesses: Psychodynamic, Cognitive, and Neurophysiolog­ical Convergence. New York: Guilford Press.

Solms, M. (1997), The Neuropsychology ofDreams: A Clin­ico-Anatomical Study. Mahwah, NJ: Lawrence Erlbaum.

--- (1999), Commentary on Allan Hobson: The newneuropsychology of sleep: Implications for psychoanaly­sis. Neuro-Psychoanal., 1(2): 183-195.

--- (in press), Dreaming and REM sleep are controlledby different brain mechanisms. Behav. & Brain Sci.

Douglas Watt

Watt, D. F. (1986), Transference: A right hemisphereevent? An inquiry into the boundary between psychoana­lytic metapsychology and neuropsychology. Psy­choanaI. & Contemp. Thought, 9(1):43-77.

--- (1990), Higher cortical functions and the ego: Theboundary between psychoanalysis, behavioral neurologyand neuropsychology. Psychoanal. Psycho1. , 7(4):487­527.

--- (1999), Emotion and consciousness. Part I. A re­view of Jaak Panksepp's Affective Neuroscience. J. Con­sciousness Studies, 6(7): 191-200.

--- (2000), Emotion and consciousness. Part II. A re­view of Antonio Damasio's The Feeling of What Hap­pens. J. Consciousness Studies, 7(3):52-73.

Douglas F. Watt, Ph.D.Director of NeuropsychologyQuincy Medical Center114 Whitwell StreetQuincy, MA 02169

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