Changing Habits of Mind

Front matter

CHANGING HABITS OF MIND

A BRAIN-BASED THEORY OF PSYCHOTHERAPY

Changing Habits of Mind

Contents

Preface vi Acknowledgments vill 1 The Dyad: Adventures in Psychotherapy’s Wonderland 1 2 The Paradigmatic Shift: The Tyranny of Habits of Mind 26 3 A Theory of the Mind 44 4 The Ghost in the Machine 75

5 The “I” and Its Psychological Selves: Without Our

Navigator We Can’t Be Sure of Where We Are Going 93 6 What Emotions and Feelings Really Are! 116 7 Emotions and Feelings 129 8 A Portrait of the Person 159 9 The Art of Psychotherapy 180 Appendix 210 Bibliography 212

Preface

This book has been inspired by two major events in my professional life. First, my mind was primed with information about the brain in my doctoral dissertation on the effects of the lobotomy operation on learning. While I was intrigued by the results of the experiment and their implications for neuroscience, I remained dedicated to becoming a psychotherapist.

Second, in the early phase of my psychotherapy practice, I consulted with Hellmuth Kaiser, a member of the International Psychoanalytic Association, who called my attention to the clinical significance of the text and subtext of conversation that happens in conventional conversations, including psychotherapy ones. Hellmuth showed me how to use the subtext of psychotherapeutic dialogue to improve my therapeutic skills. His consultation was personally and professionally life altering.

It turned me into a relational therapist. It was, also, theoretically enticing. The duality of therapeutic dialogue drew my attention to the left-right duality of the brain’s hemispheres. As I became more comfortable in my practice, I began asking questions about subtext and what made it so emotional. I have spent the rest of my life pursuing this question, both in my practice and my ways of thinking about the relationships between the brain, personality, and psychotherapy.

My dissertation encouraged me to learn more about the brain, which resulted in the theory explained in this book. Like all good theories, it asks more questions than it answers. In addition to addressing the complexity of the brain, I found myself wandering through epistemological issues, evolutionary, cultural, and, of course, psychological ways of thinking before I could theoretically integrate the mind with its body into a coherent functional relationship. It has been a compelling and exciting adventure.

The practices of psychotherapy and psychotherapy research have suffered from the absence of a theory of personality. Psychotherapists and psychotherapy researchers speak different theoretical languages and confuse themselves and their colleagues in the other camp by using the same words to describe different phenomena. My book opens a way to overcome this source of confusion.

Preface vii

The book, in the first chapter, begins with my recognition that by integrating brain dynamics with personality, I needed to make a paradigmatic shift in the way I would be describing the personality with the brain dynamics. The paradigmatic shift is described in the second chapter by describing cognition as being organized with linear/nonlinear and sensory/non-sensory formats. This called for a theory of the mind. In the third chapter the mind is described as emerging from the interaction of three biological functions of the brain: orientation (self-process), simplification (cognition), and display (consciousness). The fourth chapter explores the neurological literature where the biological functions of the mind are located in the brain.

The first half of the book, which is theoretical description of the mind/ brain relationship, helped me write the second half, that describes how the mind—a process that evolved to stabilize the brain’s growing complexity— creates a personality with an “I” and its selves (Chapter 5), emotion, and feelings (Chapters 6 and 7). Chapter 8 integrates all of them to describe the person, which is shaped by homeostasis, developmental family dynamics, and culture.

My theoretical descriptions of psychological variables are exemplified with clinical vignettes: stories. I have taken care to conceal the identities of clients whose personalities illustrated the dynamics I describe. None of their names are true and for some I’ve changed their gender because it was irrelevant to the clinical issue I was describing.

Finally, in Chapter 9, I discuss the art of psychotherapy. In it, I describe how and why the therapist’s person is of prime importance in the therapeutic process since so much psychotherapeutic work can and should be done in the here-and-now interplay of the session. From the early beginnings of psychotherapy in the nineteenth century, therapists have been encouraged to avoid emotional contact with the people they serve—an impossible demand. Therefore, it is important for therapists to learn how to use their feelings therapeutically. Intensive long-term psychotherapy is an emotionally difficult but loving process.

Over the years, I have made presentations at conferences of the Society for the Exploration of Psychotherapy Integration that focused on the importance of integrating different psychotherapies. At some of their annual meetings, therapists have asked to see videos of my work with clients. You may be interested in seeing how I work. From time to time, samples will be added to my website: https://zoltangross.com.

Acknowledgments

This book could not have been written without my psychotherapy practice, which showed me a way to escape many of the common-sense falsehoods that exist about human nature. It has been a wonderful love affair. My childhood friend, Fred Nicholas, has always been a source of encouragement and warmth. I also cherish the encouragement of David Kudrow, M.D., a distinguished neurologist. I am indebted to George Stricker, Ph.D., Marvin Goldfried, Ph.D., and Paul Wachtel, Ph.D., cofounders of the Society for the Exploration of Psychotherapy Integration (SEPI), for creating an intellectual home for a lonely, private practicing psychotherapist and for encouraging my devotion to integrating homeostasis with personality dynamics. Nuno Conceição, Ph.D., Shigeru Iwakabe, Ph.D., two of my SEPI colleagues greatly helped with encouragement and enthusiasm. Helpful edits were suggested by Susan Harris, Ph.D., Jeff Bortz, Ph.D., Jeanne Robson, Ph.D., and three friends who are no longer with us, Michael Mahoney, Ph.D., James Rosenau, Ph.D., and Herb Turman. I am most deeply indebted to Peter Gelfan, who was the editor who taught me how to escape from writing ideas to myself to writing to my readers and to think in an orderly way. Those were important pieces of learning for me. And Jane Ryder, who is my guide, consultant, and emotional support as I have been learning how to get this book published. Susan Hoyt, an eagle-eyed copy editor, cleaned the copy of this book. And Fidelia Sillas, whose keen intellect and computer skills taught me much about that strange tool. She also relieved me of much detailed, but necessary, work which I abhor.

My sons, Jonathan, Richard, and Andrew, have for years read drafts of chapters, discussed the theory, and encouraged me to pursue this adventure. And finally, I love my wife, Pat, whose love, understanding, and grammatical excellence helped me through my most difficult confusions.

Chapter 1 Adventures in Psychotherapy’s Wonderland

The Whole Is More Than the Sum of Its Parts

About a year after my resignation from the United States Army Air Corps, where I served as a celestial navigator in the Air Transport Command during World War II, I fell in love with psychotherapy. That startling moment happened when I was a student in Grace Fernald’s Reading Clinic at UCLA. I was interviewing the mother of a six-year-old boy with whom I worked at the clinic. It was my first professional interview. We talked about her son, who was having difficulty learning to read, and about her worries about his future well-being. She left the interview relieved and I felt wonderful. I knew where I was headed in life.

When the war ended, I returned to UCLA to finish the doctoral program I interrupted to enlist in the Army Air Corps. In my doctoral dissertation, I hypothesized that lobotomized patients would suffer a learning deficit (Gross, 1952). At that time, there were no psychological tests that showed psychological impairment resulting from the lobotomy operation. My dissertation clearly showed that lobotomized patients had been seriously impaired by the operation. The research primed my mind to think about brain dynamics. I could have used my dissertation as a way of becoming a research neuropsychologist, but by that time I was hooked on becoming a psychotherapist where for over the past 60 years I have been enriched by that devotion.

At the beginning of my private practice, I went into my own psychoanalysis, which was then regarded as the most effective psychotherapy in the marketplace. Times have changed. Psychoanalysis has lost much of its almost religious beliefs. I went into it to resolve my own emotional difficulties and to learn more about psychotherapy by being in it myself. Early in my practice, patients would lie on my couch and free associate. I would interpret their associations and dreams and try to be a blank screen. I wasn’t too successful at that. My patients teased me about being the great stone face. Try as I might, I was unable to totally keep my person out of my psychotherapeutic work with patients. I am now convinced that it is impossible for any therapist, of any stripe, to keep his or her person out of the therapeutic relationship. Nor do I believe that it is therapeutically desirable to do so.

In pursuit of my efforts to unravel the mysterious emotionality of my practice, I turned to Josef Breuer’s' report of his work with Anna O.: the first psychoanalytic case study. To my great surprise, I discovered that it was not the talking cure it was reputed to be. This study triggered the birth of psychoanalysis. And it is the source of the many misunderstandings about the nature of cure, the nature of the therapeutic relationship, and the nature of what is meaningful in that relationship.

As I pursued my interest in the Breuer/Anna O. relationship, I found that there are two very different literatures about it (Jones, 1953; Gay, 1988; Breger, 2009; Skues, 2006). The conventional one describes it as the inspiration of psychoanalysis. The other one, more recently published, disputes the claim that it was a talking cure. The Breuer/Anna O. relationship is a sadly misunderstood infatuation that dramatically affected both of their lives and shaped the course of psychoanalytic thinking.

In this chapter we will see that the curing of Anna O’s symptoms, which were celebrated as the effects of the talking cure, arising from her enchanted relationship with Dr. Josef Breuer. Reading Breuer’s report of his treatment of Anna O. confirmed my belief that the personality changing power of their psychotherapeutic relationship happened within the therapeutic relationship itself instead of Anna O./Breuer’s and Freud’s explanations of it.

I will describe the reasons for my conclusions as I present evidence for them in the following discussion. We will also see how difficult it was for them to acknowledge the therapeutic meaningfulness of the relationship that enthralled them.

They had a truly playful collaborative relationship. With much pleasure, they came up with explanations of what caused her personality changes. Not only were their explanations fun, they enabled Anna O. and Breuer to be blind to the infatuation that magically dispelled her grief and madness.

Many of Breuer’s explanations are still thought to be meaningful in psychotherapeutic thinking. Understanding, catharsis, interpretation, and insight are still strongly held beliefs about the nature of what Anna O. called her talking cure. My re-examination of Breuer’s case study validated the misgivings I had at the beginning of my practice about the therapeutic meaningfulness of these explanations.

Many years ago, I had the good fortune to have dinner with Rollo May, with whom I shared my theoretical misgivings about psychoanalytic personality theory. He agreed, saying that “Freud was a genius in asking all the right questions. Unfortunately, he came up with the wrong answers.” At that time, I didn’t know enough to understand this paradoxical agreement. Now I understand that Freud did ask brilliant questions and because of the limitations of understanding about personality and neurology 130 years ago, he could not come up with the right answers. His answers may have been wrong, but by applying a Darwinian metatheory to what he saw clinically, he made profound contributions to the creation of psychotherapy and he opened up new ways of thinking about human nature.

Looking at the Breuer/Anna O. relationship from today’s perspective we can see the power of their emotional relationship in what they called a cure. A re-examination of their relationship sets the stage for a contemporary description of interpersonal relationships which is paradigmatically different from those currently used to describe the therapeutic relationship.

The Breuer/Anna O. Relationship Revisited

In 1880, on nightlong vigils, Anna O. cared for her dearly loved dying father. Finally, exhausted with excruciating grief, she developed a variety of hysterical symptoms, which prompted her mother to call Dr. Josef Breuer, a highly regarded Viennese physician. In the course of his treatment of Anna O., Dr. Breuer generated concepts about catharsis/abreaction, repression, and interpretation that inspired Freud to give birth to psychoanalysis. For many therapists they are still thought to be meaningful explanations about the nature of cure (symptom removal): which was the goal of his medical treatment. It was not psychotherapy as we know it these days.

Looking back at it from today’s perspective will give us a better understanding of the nature of intimate relationships; especially the relationship that occurs in intensive emotionally oriented psychotherapy. We will see that their relationship ameliorated her suffering and the symptoms that plagued her. It also illuminates our human devotion to explanation and why we have overvalued it as a psychological change technique.

And, finally, it raised questions about the nature of and duration of personality change. The Breuer/Anna O. relationship vividly highlights the difference between psychotherapies that help people feel better and psychotherapies that help people escape from the characterological prisons of their childhoods. It is the difference between relieving the ache of loneliness by making emotional contact and the painful work of changing habituated character structures and creating more stable age-appropriate ones.

On hot summer nights, Breuer described his treatment of Anna O. to his dear friend, Freud, who was fascinated by Breuer’s account of Anna O's cure from her painful illness. He told Freud that, when Anna recalled repressed painful or disagreeable emotional experiences, which, he believed, caused her symptoms, the symptom was either alleviated or it disappeared. Within the tradition of the time, if the doctor relieved a patient of a symptom, he believed she had been cured.

This was the beginning of the belief that returning the repressed to consciousness was curative. Fifteen years after treatment was terminated, Freud persuaded Breuer to publish his case study of Anna O.; Breuer did so with some reluctance. Here, I will present parts of Breuer’s account of his relationship with Anna O., which reveal the close loving relationship they had with one another. I will conclude my description of their relationship by showing how the denial of their love led them to change the ways they lived the rest of their lives.

From my reading of Breuer’s description of her condition and his treatment of her, it was clear that he and his patient had different unacknowledged and nonconscious personal agendas about the purposes of their relationship. The following quotations from Breuer’s report highlight the emotionality of their relationship.

On December 11, [1880] the patient took to her bed and remained there until April 1... . There developed in rapid succession a series of severe disturbances which were apparently quite new.

It was while the patient was in this condition that I undertook her treatment, and I at once recognized the seriousness of the psychical disturbance with which I had to deal. . . . For two weeks she became completely dumb and in spite of making great and continuous efforts to speak she was unable to say a syllable. And for the first time the psychical mechanism of the disorder became clear. As I knew, she had felt very much offended over something and had determined not to speak about it. When I guessed this and obliged her to speak about it, the inhibition, which had made any other kind of utterance as well, disappeared. . . . thenceforward she spoke only in English. . . . At times when she was at her best and most free, she talked French and Italian. There was complete amnesia between these times and those at which she talked English.

Shortly after she left her sick bed, her father died. About his death, Breuer said,

This was the most severe psychical trauma that she could possibly have experienced. A violent outburst of excitement was succeeded by profound stupor which lasted about two days and she emerged in a greatly changed state.

When she recovered from the trauma of her father’s death, her physical symptoms improved. However, her relations with others changed dramatically. She could or would not recognize people who displeased her and her tolerance for people, even those she liked, were short lived. Breuer went on to say,

I was the only one whom she always recognized when I came in; so long as I was talking to her she was always in contact with things and lively, . . . She had eaten extremely little previously, but now she refused nourishment all together. However, she allowed me to feed her.

During this period, he introduced her to another physician to care for her while he would be gone for a short period of time, “whom like all strangers, she completely ignored while I demonstrated all her peculiarities to him” (p. 27). The cigar-smoking visiting physician tried to get her attention but to no avail.

[Until] he succeeded in breaking through [her dismissal of him] by blowing smoke in her face. Suddenly she saw a stranger before her . . . and fell unconscious to the ground. There followed a short fit of anger and then a severe attack of anxiety. . . . Unluckily I had to leave Vienna... when I came back several days later, I found the patient much worse. She had gone entirely without food . . . and her hallucinatory absences [psychotic episodes] were filled with terrifying figures, death’s heads and skeletons.

I have been quoting these sections of Breuer’s case study to call attention to four aspects of his report; his presence was the most reliable condition that led to symptom removal. In essence, the warmth of their relationship was disregarded by Breuer. It was their warmth with one another that probably had its beginnings when he unsuccessfully tried to hypnotize her in an effort to reduce her anguish by suggesting it out of existence. Despite his failure to hypnotize her, the gentleness of the hypnosis induction procedure likely eased the pain of her grief and was the beginning of a loving relationship that created difficulties for both Anna O. and Dr. Breuer.

He describes her hostile and distant emotionality toward others, but he does not discuss the emotionality of their relationship, which is evident in her positive feelings toward him and the nightly devoted attention he gave to her.

His caring for Anna eventually caused his wife to complain about the amount of time he was away from home attending to Anna O. Breuer calms Anna O's anxiety. She lets him feed her. And she is “in contact and lively” when he talks to her. As treatment progressed, she calmed herself by insisting on telling him “stories.” In the following quote, he says:

The stories were always sad and some of them very charming, in the style of Hans Andersen’s Picture-book without Pictures. . . . If for any reason she was unable to tell me the story during the evening hypnosis” she failed to calm down afterwards, and on the following day she had to tell me two stories in order for this to happen. . . . I used to visit her in the evening, when I knew I should find her in her hypnosis, and I then relieved her of the whole stock of imaginative products which she had accumulated since my last visit. It was essential that this should be affected completely if good results were to follow. . . . She aptly described this procedure, speaking seriously, as a “talking cure,’ which she referred to it jokingly as “chimney sweeping”. . . she would never begin to talk until she had satisfied herself of my identity by carefully feeling my hands. . . . When I was present this state [her emotional condition] was euphoric, but in my absence, it was highly disagreeable and characterized by anxiety as well as excitement.

Breuer vacationed for several weeks and returned to find the most convincing evidence of the pathogenic and exciting effect brought about by the ideational complexes [in Anna while he was on vacation] . . . During this interval no “talking cure” had been carried out, for it was impossible to persuade her to confide what she had to say to anyone but me—not even to Dr. B. to whom she had in other respects become devoted. . . . The situation only became tolerable [when] . . . evening after evening [I] made her tell me three to five stories. When I had accomplished this, everything that had accumulated during the weeks of my absence had been worked off.

After a time, her “stories” were added to the talking cure which removed the symptoms from which she was suffering. Breuer describes this as follows:

Each individual symptom . . . was taken separately in hand; all the occasions on which it appeared were described in reverse order, starting before the time when the patient became bed-ridden and going back to the event which had led to its first appearance. When this had been described the symptom was permanently removed. In this way her paralytic contractures and anaesthesias, disorders of vision and hearing of every sort, neuralgias, coughing, tremors, etc., and finally her disturbances of speech were “talked away.”

It appeared to Anna O. and Dr. Breuer that when she repressed her emotional reactions to external events, the repressed emotional reactions were transformed into physical or psychological symptoms. They also believed that when the repressed emotional experiences were restored to consciousness by recalling them, the symptoms disappeared. For example, Breuer recorded over 300 hearing disturbances that were talked away.

In the course of their work, she would also experience delusions or hallucinations.

Finally, in June 1882, Anna O. brought treatment to a close. Breuer was satisfied with her recovery.

Unfortunately, treatment did not end as simply or positively as he stated it. There are two dramatically different versions of what happened when treatment ended. The classic version is the one told to Ernest Jones by Freud, a very close colleague. Lucy Freeman describes his final encounter with Anna in the following fictionalized paragraph.

On the evening, after what he thought was his last visit with Anna O., she fell into such great distress that her mother summoned him to her side again. As he entered her bedroom... .

Suddenly she started to thrash about on the bed, seemingly gripped by acute pain. And out of her lips came the words, “Now Dr. Breuer’s baby is coming! It is coming!” writhing all the while as though giving birth. This account is consistent with Jones’ (1953) and Gay’s (1988) description of that fateful evening in their biographies of Freud. Jones describes Breuer’s reaction to Anna’s pseudocyesis in the following quote.

Though profoundly shocked, he managed to calm her down by hypnotizing her, and then fled the house in a cold sweat. The next day he and his wife left for Venice to spend a second honeymoon, which resulted in the conception of a daughter.

Other versions (Skues, 2006; Breger, 2009) tell of Dr. Breuer returning to his practice where he treated some patients with his cathartic method. They dispute the story of the false pregnancy and suggest that Freud told Jones about it. By that time, Freud had vigorously rejected Breuer. There is an implication that Freud’s story resulted from his everlasting anger toward Breuer. After spending some six years in a Swiss sanitarium, Anna O. moved to Frankfurt with her mother and embarked upon a brilliant and renowned career as one of the founders of Jewish social welfare in Europe.

Another View from the Bridge

There is another explanation about Anna’s recovery from her symptoms. I will briefly describe it here using a theory about the equilibratory (stabilizing) nature of emotionality to describe the here-and-now dynamics of the Breuer/Anna O. relationship. From the beginning of their relationship it was clear they were attracted to one another. They were in the confusing condition of infatuation when its sexuality was denied. Although the questionable pseudocyesis, at the end of her treatment, was seen as an oedipal transference phenomenon, it can also be seen as a way of accommodating the sexual arousal she experienced in an intimate, but very unconventional relationship. Vienna, at that time, was a sexually active community (Skues, 2006). And upper-class Jewish women, Anna Os age, were discouraged from pursuing any venture outside of marriage and motherhood. As a result, it is likely that they were sexually, impatiently waiting for their fathers to marry them off to suitable Jewish bachelors. I suspect that this was not true of Anna O. There is no evidence that she was sexually interested or active. She was, however, vigorously antagonistic to the Jewish chauvinism that discouraged her intellectual pursuits.

The emotional contact she had with Dr. Breuer relieved her grief about the death of her father and the loneliness of her life. Loneliness was a constant presence throughout Anna O’s life. Being in the presence of a warm interested man, Dr. Breuer, who wanted to help her and who clearly enjoyed being with her gave her great comfort. But the relationship he offered was unusual and unfamiliar. There was nothing familial in it. Unlike the familial Jewish tradition, Breuer respected and encouraged the participation of her brilliant intellect. Nor was it professional in the ordinary sense of medical treatment. She was not the passive recipient of medical or physical treatments. She actively contributed to the theory that recovering repressed feelings led to the cure of distressing symptoms. The phrase talking cure was her description of their treatment. She felt free to discuss her feelings with Dr. Breuer, which he treated with unaccustomed interest, respect, and appreciation. In some ways, they had a conversation that resembled Martin Buber’s (1958) “I-Thou” dialogue.* Aside from Buber’s description of it, there is experimental evidence that I-Thou dialogue is emotionally arousing. I-Thou dialogue occurs when the primary topic of conversation is about the feelings that the conversants have about one another.

She and her symptoms were the primary subjects of their dialogue. Aside from that, they also enjoyed one another when they were talking about other things. When Anna O. told Breuer “Andersen-like” stories, he was pleased, and his pleasure with her assuaged her grief and anxiety. He partially replaced the love and affection she lost when her father became ill and died.

However, neither Breuer nor Anna O. were able to directly talk about their affection for one another, which probably was tinged with a sexuality which neither of them could admit. They could only enjoy the cause and effect explanations that to them looked like the cathartic effects of symptom cure. It can also be argued that her false pregnancy, if it actually happened, was a way of expressing the love and affection she felt for him but could not declare.

The rules of the psychotherapeutic relationship are so different from ordinary intimate relationships that not infrequently sexuality is sometimes simplistically and erroneously used to accommodate the complexity of the loving experience that exists between adults in a productive psychotherapeutic relationship or any creative activity, like football. I will discuss this more fully in Chapter 9.

This way of thinking about the emotionality of the therapeutic relationship is a way of integrating transferential process with the here-and-now effects of their relationship. There is no doubt Anna O. loved her father and his death was a painful loss. It is also true that her infatuation with Breuer was a tension-reducing outlet for the repression of her sexuality which existed prior to the onset of her breakdown. At the beginning of his treatment of Anna O., Breuer (while they were friends) remarked to Freud, with some surprise and relief, about the unusual absence of sexuality in her presentation or discussion. As a dedicated family man, he had the freedom of enjoying her without being burdened by the guilt-producing experience of sexuality between them. He was also uncomfortable with discussing sex openly and disagreed with Freud’s theory that repressed sexuality was the cause of emotional disturbance. This led to Freud’s unending rejection of him. I believe that Breuer and Anna O's repressed sexuality made their collaboration much easier for them. She was a very bright, attractive young woman. She spoke German, English, French, and Italian. It is interesting to note that most of her discussion with Breuer was in English. In this way her conversations with him could be private in her German-speaking home, where treatment occurred.

His attention and admiration fed her need for relief from the loneliness of her existence in Vienna. Her relationship with her mother was conflicted. Her brother was of small comfort to her. As a young woman in a wealthy, orthodox Jewish family, she was denied the ability go to the university and enrich her intelligence and find a professional occupation. Furthermore, she had little or no control over who would be chosen to be her husband. She was socially at ease with her female contemporaries. Freud’s fiancée, Martha, was one of her friends. But her active and socially conventional life did not assuage the loneliness caused by the absence of a loving relationship with a sexual partner or the estrangement that existed in her family. It is easy to understand that Breuer’s kind caring presence was a relief from the grief laden, emotionally impoverished and frustrating life she was living.