This is an important book. Every psychoanalyst and every psychoanalytically oriented psychotherapist has, or should have, a rationale for how he/she administers “the talking cure.” As a profession we are under increasing pressure to explicate and justify that rationale. In this exciting, well-written, and carefully thought out book, Susan Vaughan has succeeded in doing exactly that for her particular approach. We can all, young and old, learn much from it.
The author's main point of departure is Kandel's “credo”: When talk influences how another person's mind works it must do so by changing the way that person's brain works, and even how it is structured (my paraphrase). Vaughan guides us carefully through what she has been able to learn and experience, both as a scholar and as a therapist, about the transition from mind (as understood by psychoanalysis) to brain (as understood by neurobiology and cognitive neuroscience).
Each step of the way is facilitated for the reader by clear exposition of complicated scientific facts, imaginative and creative use of metaphor, and vivid clinical illustrations. These clinical examples include the author's thoughts and feelings as she worked with each patient and accounts of how they helped her to understand and to communicate that understanding to the patient in a way that would be helpful.
Each chapter begins with a clinical sample — a dream or a topic with which a patient began an hour. This is followed by a carefully researched and organized review of background information relevant to that clinical sample. This background information covers a wide variety of disciplines, ranging as the chapters progress to include neurobiology, psychophysiology of dreaming sleep, cognitive neuroscience, artificial intelligence, experimental observations on infant development (behavioral, neural, and social), psychotherapy research, and cogent segments of basic and clinical psychoanalytic theory.
In the third section of each chapter, Vaughan gives additional clinical information and shares her thinking about how to relate the clinical psychotherapeutic interactions she has described to basic biologic brain/behavior mechanisms. These are the mechanisms she postulates that could, in the clinical examples described, account for therapeutic effects of verbal and emotional interactions (including transference and countertransference) between therapist and patient. For example, in Chapter 2 after discussing computer modeling of neural network function, she writes:
So what happens once Alice's parents tell her about Max, when she is in high school, and this knowledge is added into the mix of interconnected events and ideas? This missing piece of information is the psychological key to unlocking the meaning of her mother's tears at the opening of Peter Pan or at Alice's birthday party. If Alice had understood this association earlier, her networks might have been organized in a different fashion, with a place for her brother and with associations between his death and her mother's sadness while Alice was growing up.
But Alices networks, with their built-in associations, have been organized since early childhood in the absence of this information. Once she learns about Max, it is too late for her to go back and reorganize all those interconnected themes on her own. Her networks already have evolved in a particular way. The new information gets stuck on to Alice's networks the way a wad of chewing gum is stuck to a theater seat. The gum does not fundamentally change the structure of the chair itself.
Part of our task in psychotherapy is to reach into Alice's adult networks and disconnect those neurons that link growing up with sadness. This reexamination and reshaping of networks laid down in early life is probably the neurobiological equivalent of what analysts term “working through.”
… Of course, Alice's parents were not the only ones who had conflicted feelings about Alice's growing up. Alice herself acknowledged that growing up would mean dealing with her sexuality, taking on new responsibilities, and caring for herself. But as an adult in her mid-thirties. Alice had reasons for wanting to grow up that outweigh her wish to remain a child.
… Peter Pan was known in Mrs. Darling's day because “when children died he went part of the way with them, so that they should not be frightened.” Max's short life and difficult death may have left him stranded on the shores of Neverland forever, but in a way it is a far greater tragedy that his death helped to keep his sister attached to that place, to remain behind with Peter Pan, to never grow up.
I think about how my patients, like children, help transport me back to Neverland and how much I enjoy the visit. But I wouldn't want to live there. While it is too early in therapy to know for sure, I wonder if Alice one day will want to leave Neverland forever and join me in the grown-up world that waits for her.
This excerpt serves to illustrate both the book's beauty and strength — and at the same time its main problem. Scientists working in the field of artificial intelligence (AI) are quick to point out that AI machines demonstrate how the brain could operate so as to enable the mind to do what it does — but not how it actually does it. Similarly, The Talking Cure shows us how psychoanalysis and psychoanalytically oriented psychotherapy could operate to enable patients to lead more satisfactory and comfortable lives — but not how it is actually done. Yet, as with AI, the demonstration “makes sense,” that is, it has a good deal of face validity.
Although the author recognizes and acknowledges from the start the hypothetical nature of many of her explanations, she often seems to forget that and take them quite literally, as final answers. But how could she have written such a charming, readable, effective, and reasonable argument without omitting repeated caveats that would block the smooth flow of ideas? To borrow from and extend her use of Peter Pan metaphor, how could this kind of scholarship work unless enough of us believe — when if we don't, Tinker Bell will die? The ultimate scientific value of Vaughan's book will lie in its power to stimulate continued search for new observations and to generate testable hypotheses in the minds of psychoanalysts and researchers who are qualified and supported to do the work.
This enjoyable book was written for both professional and non-professional audiences. It will be of great educational value for all who experience the talking cure as practitioners or as patients. It should be required reading for those in the earlier phases of their psychotherapeutic careers. It is full of exciting, valuable surprises for experienced clinicians — even those with primarily, but open-minded, hermeneutic orientations.
Morton F. Reiser, M.D., is Albert E. Kent Professor Emeritus of Psychiatry at the Yale University School of Medicine and a training and supervising analyst for the Western New England Institute for Psychoanalysis.