We met on a bright December morning in the well-worn comfort of the Yale Club in Manhattan. We talked while Dr. Reiser beamed happily over a festive holiday breakfast of perfectly broiled kippers.
Dr. Reiser, the Albert E. Kent Professor Emeritus of Psychiatry at Yale University School of Medicine, is a Training and Supervising Psychoanalyst at the Western New England Institute for Psychoanalysis. He is a past president of the American Psychoanalytic Association and currently is Chairman of the Committee on Psychoanalytic Education (COPE) of the Board on Professional Standards.
Miller: Dr. Reiser, as both a biological psychiatrist and a psychoanalyst, you stand as an example of the rare clinician-scientist who keeps a foot in each of two different but related disciplines, contributing to advances in each by working toward their conceptual synthesis or at least their rapprochement. Today, given the exponential rate of discovery in the neurosciences, many scientists and clinicians have come to view psychoanalysis as irrelevant and outmoded. At the same time, many analysts, even those who regard brain science as intrinsically interesting, do not see it as having immediate relevance or direct application to their clinical work.
Reiser: That last part, of course, is quite true. I agree with the view that clinical psychoanalysis centers on work with language, feelings, meanings, and motives, and that empathy plays a major role in helping the analyst understand what is in the patient's mind—how it developed, and how it affects thinking, feeling, and behavior both in the transference and in extraanalytic relationships. The analyst's clinical technical skills depend heavily on tuning into language with great precision; on identifying subtleties of meaning; and in using words with precise accuracy and timing in communicating his or her understanding to the patient. Certainly when I am working with patients in the office I am not thinking about brain circuits, synapses, neuronal membrane receptors, second messengers, or the like. I am thinking about meanings, affects, and memories—how they're organized and how they relate to present and previous—(developmental)—experience. All of which is a roundabout way of saying that in the day-to-day practice of analysis, all of the exciting findings in neurosciences are not of immediate direct use.
Miller: Why, then, do you think (as I assume you do) that psychoanalysts should be interested in these discoveries? Perhaps your answer might come from tracing the development of your own interest in neuroscience, and your personal conviction of its relevance for psychoanalysis.
Reiser: In becoming a physician, I had from the very start two inseparable sets of curiosities and interests. One set pertains to physiology, the other to psychology. These converge quite naturally on mind/brain issues in health and disease: for example, how the brain enables the mind to do what it does; how mental contents influence behavior; how mental mechanisms negotiate transactions with the interpersonal and social environment; and, finally, how mental contents and functions are influenced by, and in turn themselves influence, bodily functions.
I did my residency in internal medicine in Cincinnati, at a time when psychoanalysis dominated, and was the most exciting part of psychiatry. The Departments of Medicine and Psychiatry, strongly influenced by the ideas being developed by Franz Alexander and the field of psychosomatic medicine, worked together closely in teaching and in research. Senior faculty—including Maurice Levine, Milton Rosenbaum, Charles Aring, George Engel, John Romano, Eugene Ferris, Gustav Eckstein, and Arthur Mirsky—were each actively involved in at least two of the following disciplines: internal medicine, neurology, biochemistry, physiology, psychiatry, and psychoanalysis.
My first clinical research project after finishing my residency was on essential hypertension, a study that revealed the exquisite sensitivity of blood pressure level, response to medication, and clinical course of disease in reaction to emotional influences—particularly to influences in the doctor-patient relationship. These observations highlighted the challenge presented by mind/brain-body, and it was not long before I realized that I would have to acquire training in psychiatry and psychoanalysis to pursue these matters in depth. In the atmosphere that prevailed then in the College of Medicine in Cincinnati it was possible, by extending the program in time, to undertake residency training in clinical psychiatry while continuing to teach and to do laboratory and clinical research in psychophysiology on patients with psychosomatic disorders. I mention the issue of institutional ambiance here because it is so important in training for cross-disciplinary research—a topic of current importance for psychoanalysis, as we will discuss shortly.
But you'll remember that the psychosomatic formulations of that time, while they were very exciting, were in many ways incomplete and frustrating. One of the problems, I think we can see now in retrospect, was that while the brain is part of the body, early psychosomatic research couldn't deal with the brain mechanisms that mediate cognitive/emotional functions and their influence on the physiology of the rest of the body. Very fortunately, after leaving Cincinnati I had an opportunity to learn about the brain from daily working contact with neuroscientists in the vanguard of the field as it was gaining momentum—first while working in David Rioch's laboratory at Walter Reed Army Institute of Research, and later in a major interdisciplinary program on The Nervous System and Behavior at Albert Einstein College of Medicine. The latter overlapped the period of my training at the New York Psychoanalytic Institute.
Miller: You were extremely fortunate to be met by a receptive environment filled with mentors who took your interests seriously, provided role models, and encouraged you to study more than one discipline as you approached the mind/body problem. That's very different from what obtains today, where one most likely would be discouraged from planning a career that involved combined training in, say, neuroscience and psychoanalysis.
Reiser: Exactly, but at that earlier time more neuroscientific and psychoanalytic leaders than at present were interested in exploring the interface between the two areas. And, most important, there were resources available to support extended training for qualified individuals who were seriously motivated to do so. Of course, not all would (or should) be that seriously interested in it. But those who might be are finding it virtually impossible to do, because of the time and expense, and even inadvisable with respect to career opportunities, because of the intellectual distance which has developed between neurobiology and psychoanalytic psychology, with many influential
and serious workers on both sides questioning the mutual relevance of the two fields.
Miller: But your own work provides as clear and impressive a demonstration of their mutual relevance as I can think of. For example, your selection of the dream as a vehicle to explore the manner in which psychological and biological mechanisms conspire to shape a uniquely subjective human phenomenon accessible to scientific scrutiny was a brilliant tactical decision. In Memory in Mind and Brain: What Dream Imagery Reveals (Basic Books, 1990), you eloquently illustrate how recent findings regarding the function of cortico-limbic mechanisms in perception, imagery, affect, memory, and sleep can enrich and complement the clinical psychoanalytic data and formulations that emerge in the consulting room.
Reiser: Viewed in this perspective, neuroscience can have a salutary impact by stimulating us to ask fresh new questions of our data and even, ultimately, to rethink central psychoanalytic ideas: e.g., the nature of consciousness and the presumed psychobiological mechanisms involved in making use of “the mutative interpretation” in the course of working through. These certainly must involve the same (or related) cognitive-affective mechanisms.
Miller: Vice versa, you've provided neuroscientists a unique view of the way analysts work to derepress and unpack nodal memory networks, or, for example, of the manner in which the use of free association reveals the underlying affective linkages that connect associated perceptual memory traces. Your clinical vignettes can acquaint neuroscientists with the repetitive patterns of conflictual cognitive-affective data that characterize the psychoanalytic process, these furnish the “what and why” of the very phenomena the neuroscientist is trying to determine the “how and where” of. While both sides are working on many of the same large questions, they are hindered by not having a good intermediate language with which to converse. Yet much that you describe reveals the complementarity of the two sets of data.
Reiser: The problem, in a way, is what I call the asymmetry of the data on the two sides of the mind/brain divide. The kinds of observations that psychoanalytic process uniquely makes accessible are very different qualitatively, and in terms of quantitative potentialities, than the elegantly reductionistic data of neuroscience. There simply is no way at the moment to imagine how you could relate a molecular change within the cell—within a neuron or even a group of neurons—to a wish, or to an elaborate memory, or to a fantasy or to the creation of a work of art. These complex psychological productions all have to do with the function of the whole person, who is both a mind and a body. We live in our bodies, and our minds function by virtue of our brains. Likewise, our minds are influenced by what's happening in our bodies. In other words, we are our bodies; we don't just live in them.
In principle we are all studying the same thing, but we're talking different languages and we're looking at different aspects of phenomena; as you said, we don't have a Rosetta stone to translate from one domain to the other. However, it has been my conviction that if one follows the actual clinical psychoanalytic observations in detail, there are important inferences that can be drawn that permit formulation of functional principles and fruitful hypotheses.
For example, detailed psychoanalytic observations—particularly of dream imagery—demonstrate that memories are organized and arranged in “nodal memory networks” according to affect, a psychoanalytically derived principle that I propose to call “The Affective Organization of Memory” (AOM). If then you look at the neurobiology of memory—at laboratory studies that were done with very different techniques, you find the principle of the limbic organization of memory. It is important to note that the very same structures of the brain (cortico-limbic circuits and structures) organize perceptual information both for conscious registration and for memory. In other words, the brain structures that generate and govern affect are the very same ones that arrange perceptual memory in neural networks—a physiological principle of affective memory organization. If you put the physiological principle alongside the mental principle, the similarity is sufficient to generate meaningful questions that psychoanalysis can ask of neuroscience, and vice versa. The two sets of data clearly can be considered complementary rather than antithetical.
“It is even possible to envision the possibility that future research … will uncover the secret of how the talking cure works.”
Miller: So the notion of early memories being suffused by affect, and being chemically and structurally organized by intense affective experiences, might usefully augment our view of what transpires in the course of a good analysis, as repressive barriers are lifted and more archaic memories, together with their concomitant affect valences, are consciously linked and retrieved. This brings to mind the tremendously important questions Freud posed for himself, in attempting to construct a series of integrated hypotheses regarding how the subjective mind is organized, in conceptualizing the presence of a dynamic unconscious, and in hoping to determine, based on the neurology of his day, just how the brain might facilitate such functions.
Reiser: In fact Freud was, I think, quite prescient, intuitively anticipating much of what current neurobiology and neuroscience is telling us about perception and memory. It is important in this connection to remember that emotion is both a physiological and a psychological phenomenon. In addition to its subjective feeling tone, which can only be appreciated introspectively and communicated in language, it also has a physiological aspect that is driven by the autonomic and neuroendocrine systems.
Miller: So while analysts may recently have neglected what is known about the function of the limbic system, biological psychiatrists, with few exceptions, have largely overlooked the realm of subjective meanings. To ignore either side would be to miss the chance of having a truer picture of the complexity of the actual phenomenon.
Reiser: And the yield produced by the revolution in brain science, which for a time distracted attention from studies of psychosomatic phenomena, can now provide techniques that should allow us to return to questions left at the edge of technology back then, and to redirect empirical research to unresolved issues in that field. I make that point in Mind Brain Body: Toward a Convergence of Psychoanalysis and Neurobiology (Basic Books, 1984).
It is even possible to envision the possibility that future research—informed about both mind and brain aspects of these cognitive-affective systems—will uncover the secret of how the talking cure works. Knowledge of the principles and functional patterns of the brain mechanisms involved cannot help but inform our psychoanalytic inquiries, and guide them in the search for corresponding principles and patterns that must be operating in the mental domain.
Miller: In fact, though, the actual sequential or parallel steps through which analysts move, in tandem with their patients, in attempting to unlock what appear at the outset to be inaccessible—unconscious—connections among memories, cognitions, and affects, which may have been redundantly encoded in the crosswalks between limbic and higher cortical projections in the earliest epochs of life—remain to this day mysterious and largely unexplored.
Reiser: While it's too soon to hope for final answers, interesting hypotheses can be generated even now. One might suggest that the precise word at the right time, with the right tone and prosody, might untie some of these intricate inner knots that have been driving an individual's behavior, both symptomatic and characterological. Beginning with Strachey's formulation, we know that the affective mobilization at the time of the cognitive processing of the understanding seems essential, and one can't help but think that somehow the mutative interpretation could work by making it possible for the person to reprocess and reappraise both the cognitive and the emotional aspects of early experience, even as the actual affects are revived in the transference. Experimental neuroscientific techniques for
studying the cognitive and emotional impact of words on the brain are available. That they can be combined with sophisticated, psychoanalytically informed inquiry has already been demonstrated. A good example is Shevrin's “Unconscious Conflict: A Convergent Psychodynamic and Electrophysiological Approach,” in Mardi Horowitz's collection, Psychodynamics and Cognition (Chicago University Press, 1988). There is no shortage of important and exciting research challenges. But the kind of cross-disciplinary investigation we are discussing—not just between neurosciences and psychoanalysis but between psychoanalysis and the experimental behavioral and social sciences as well—will require interdisciplinary collaboration, as concepts and techniques have become so highly specialized. But at the same time, in order to conceptualize, orchestrate, and energize such inquiry, there will have to be some who speak more than one language; who understand the nature, potentialities, and limitations of the data and methods in more than one field. I'm not saying everybody has to do that, but some will have to if we are to keep up. Integration and synthesis of ideas from different fields can germinate only in prepared minds.
In a Utopian dream, one can visualize behavioral science institutes in which biologists, neuroscientists, cognitive psychologists, social scientists, and psychoanalysts would work side by side in communication with each other—each carrying out mainly his or her own work, yet at times collaborating on promising common problems selected mutually because developing concepts and methods in two fields rendered them ripe for cross-disciplinary study. Unfortunately, psychoanalysis is not keeping up in terms of producing sophisticated analysts who can generate the kind of data and methodologies that will be needed.
For example, we desperately need to work on methods for rendering clinical analytic observations suitable for study alongside observations of more experimental sciences without losing the unique richness and essence of the clinical process and data. This will involve careful systematic study of the psychoanalytic process itself. Clearly, one must be thoroughly trained and sufficiently experienced in analysis to do this, but able also to appreciate the nature of the methodologies used by more reductionistic disciplines. This is one of the reasons, I think, that we are not part of this parade of progress that's going on currently in mental science. It is up to us to correct this; to establish opportunities for the many young analysts and scientists out there who, despite their interest, have no way of getting support for the extended training required and we will have to attend also to the fact that at the moment there is precious little encouragement, either from the psychoanalytic or the academic establishment, for those who would like to follow this direction. There are no established career tracks there. To redress this is an endeavor that will occupy my energies at The American for years to come. I am determined to see if this dream can be made into some kind of reality.
Miller: Many of us hope, as do you, to see your dream realized in the coming years. Thank you, Dr. Reiser, for the opportunity to learn more about your early professional development, the scope of your present work and thought, and your wishes and goals for the future.