The field of psychiatry has been witnessing a growing trend of biogenetic reductionism which has captured the imagination of the public and other mental health practioners as well with its dazzling images of fMRI and PET scans, sophisticated second generation neuropsychopharmacological agents which have, at time, promised more than they actually delivered. The classical approach to genetics, in this case, the search for candidate genes which code for abnormal proteins, in effect making the DSM categories forms of proteinopathies, and the tendency to reduce mind and culture to molecular events occurring within the CNS of the experiencing individual, has resulted in a one-dimensional, monolingual approach to the complexities of human suffering. One of the principles of the therapeutic community is for the hospital, institution and/or community, and in this case, the field of mental health, to examine and treat itself. Some concerned voices, such as Timothy Calton and colleagues in the UK, have emerged calling more for a “patient-centred model,” i.e., a model which gives equal weight to the objective theories of disease and the subjective experiences of the patient.

After the advent of what has come to be called “biological or molecular psychiatry,” there have been some lone voices within the field of psychiatry itself, who have called our attention back to the importance of subjective experience, identity and personhood. Kendler (2005), a psychiatric-geneticist who espouses a non-reductionistic approach to mental disorders, in delineating a philosophical structure for psychiatry, underscored the importance of attending to subjective, first-person experiences. He noted:

“Our central goal as a medical discipline is the alleviation of the human suffering that results from dysfunctional alterations in certain domains of first-person, subjective experience...The clinical work of psychiatry constantly requires us to assess and interpret the first-person reports of our patients...While we want to take advantage of the many advances in the neurosciences and molecular biology, this cannot be done at the expense of abandoning our grounding in the world of human mental suffering” (pp.433-434).

The principle of giving equal weighting to subjective experience and objective neuroscience research has a long history in psychiatry: I think of George Engel’s biopsychosocial model, Leon Eisenberg’s caution to steer between a mindless and brainless psychiatry and his quip that the human brain is all biological and all social, Eric Kandel’s point that in the brain genes are the servants of the environment, John Strauss and Larry Davidson’s emphasis on the interaction between person/identity processes and disorder, Yrjö Alanen’s pointing out that an important starting point for all integrated psychobiological psychiatry is the insight that interactionality with other people is part of human biology, Daniel Weinberger’s point that the brain is the social organ of the body which translates life experience into neurochemistry, etc. Within the field of neuroscience, Jaak Panksepp (2004) recently noted in his recent edited volume "Textbook of Biological Psychiatry":

"A fuller recognition of basic emotional imbalances of many psychiatric disorders may also help reverse a growing problem of modern psychiatry-the marginalization of patients by making them mere consumers of pills rather than agents in reconstructing meaningful human relationships and life insights...perhaps through some type of Meyerian 'sociopsychobiological' synthesis..." (pp. 18-19).

Erwin Straus MD (1891-1975), phenomenologist and neurologist, was a leader in the anthropological medicine and psychiatry movement in Europe (a tradition which includes such persons as Martti Siirala, Medard Boss, von Weizäcker,Kütemeyer, etc.). This group was influential in combating mechanistic-reductionistic and physicalistic approaches to psychiatry as well as neurology (perhaps Oliver Sacks could be considered a modern representative of this perspective with his neuroanthroplogical and subjective viewpoint) as well as establishing a broad philosophical and ethical conception of human existence. My analyst further introduced me to the work of Straus, particularly his capacity to see meaning in symptoms, character, etc. I was particularly impressed by Straus’s phenomenological rendering and grasp of auditory hallucinations (which I quoted at length in a paper I gave in Norway at ISPS “Auditory Hallucinations: Speaking One’s Dissociated Mind”) presented in his paper “Aesthesiology and Hallucinations” (contained in “Existence: A New Dimension in Psychiatry and Psychology” edited by Rollo May et al in 1958).

Straus noted that there were many scientists who expected that human behavior could be totally accounted for by objective study of the brain at a molecular level of analysis. Part of the problem, Straus believed, is that we overlook the complex structure of apparently simple experiences. Straus (1982), years ahead of his time, wisely noted:

“The physiologist, who in the everyday world relates behavior and brain, actually makes three kinds of things into objects of his reflection: behavior, the brain as macroscopic formation, and the brain in its microscopic structure and biophysical processes. From the whole-the living organism-the inquiry descends to the parts: first of all to an organ-the brain-and finally to its histological elements. Statements concerning the elementary processes acquire their proper sense only in reference back to the original whole” (p.145 in “Man, Time, and World: Two Contributions to Anthropological Psychology” by Erwin Straus in 1982 for Duquesne University Press).

Straus noted: “Behavior and experience are constantly my, your, or his [her] behavior and experience; and they stand as such in relation to my, your, or his [her] brain” (p. 147). Straus strongly objects to splitting off neurophysiological processes from the context of the living, experiencing human subject, i.e., reductionistic analysis must be eventually related to the superordinate whole, experiencing organism.

Straus noted:

“The physiology of the brain...ignores the possessive-relationship; it replaces-generally without giving an account of it-my, your, or his [her] brain with a or with the brain...the reference to the possessive relationship may not be dismissed as a sentimental claim...the elimination of the possessive relationship distorts the phenomena, narrows down the problem area, and thus tacitly anticipates a theoretical judgment. If my, your, or his [her] brain is replaced by the brain, then the brain is generally viewed not as an organ of an experiencing being, but rather as a steering apparatus of a movable body...In every anatomical and physiological observation of the brain, two brains are involved: the brain of the observer and the observed brain. The elimination of the possessive relationship compels one to ignore this fundamental fact...The violence in the way behavior has been treated finds a necessary compensation in an anthropomorphic interpretation of the brain [e.g., the unacceptable term “the schizophrenic brain” is surely a scientific category error with consequences involving imprecise, reductionistic trends]. One grants less to behavior than is due to it, and gives the brain more than belongs to it” (pp. 147-148).

There is a tendency in our field to use the terms “the brain,” or “schizophrenia brain,” or the “bipolar brain.” The former neglecting that a brain is always “her” brain or “his” brain, a depersonalized brain only exists after death. This may seem like a minor point, but it draws attention to the need to understand the brain not as a machine, computer, or quantum reality, rather it is thoroughly organic and personalized: no two brains are alike, even in monozygotic twins, each brain is custom-made for its user, so to speak. The terms “schizophrenic” or “bipolar” brain is a category error. We do not diagnose someone by brain scans, but rather by phenotypic expression and self-reported symptomatology; these terms are collapsing different levels of organization, another example of the trivializing of the effects of behavior/phenotype on brain/genotype. Likewise the conflation of correlation into causation, frequently seen in the popular press when neuroimaging scans are paraded before us as evidence of biogenetic etiology. Downward causation, e.g., the effects of social experience on neural gene expression, is marginalized, and upward causation, i.e., the impact of brain on mind, is erroneously seen to be the whole story.

It is of great interest to me that in certain fields of medicine (Sarno, 2006), there is a growing recognition of the effects of such qualia as attitude, unconscious conflicts, even behavior and life-style, on medical disorders, whereas in psychiatry and clinical psychology, there seems to be a retreat from such difficult to quantify factors. In a field which ostensibly adheres to the importance of the biopsychosocial model of George Engel, or from my perspective, the psycho-socio-biological model, we are seeing more adherence to a bio-bio-bio model of human emotional disorders. Our language gets tricky here, personally, I see all of these disorders, to paraphrase Harvard social psychiatrist, Leon Eisenberg, as all biogenetic and, all psychosocial.

We are continuously learning about the impact relational and social experience has on the developing person, including the CNS. There is research emerging demonstrating that fetal cells in the rat could transform into neurons, astrocytes, oligodendrocytes, and macrophages, crossing the maternal blood brain barrier and responding to molecular distress signals if the mother's brain is injured (Choi 2005). The human mother's brain regulates to a significant degree, e.g., through the maternal- placental-fetal neuroendocrine system, the developing fetal brain, creating long-term predispositions towards stress reactivity, e.g., placental corticotropin releasing hormone/factor (Wadhwa 2005). Social pain, e.g., social exclusion, is equivalent neurobiologically, i.e., through activation of the dorsal anterior cingulate cortex (dACC), to actual physical pain-words and social isolation are painful. Social status influences the actual structure of certain neural regions, e.g., “high-status” animals actually have greater degrees of neurogenesis, and more neurons, in the hippocampus, a neural region important in learning and memory. Mirror neurons help us to replicate within our own brains and minds the experience, goals and motivations of the other.

We have about 100 years behind us of psychosis psychotherapy. There is still much to glean from such psychoanalytic clinicians as Karl Abraham, Paul Federn, Melanie Klein, Margaret Mahler, HS Sullivan, Frieda Fromm-Reichmann, Silvano Arieti, Wilfred Bion, Elvin Semrad, Max Day, DW Winnicott, HS Guntrip, Harold Searles, Otto Will, Heinrich Racker, Gisela Pankow, Ronnie Laing, Hanna Segal, Herbert Rosenfeld, Barbro Sandin, Gaetano Benedetti, Maurizio Peciccia, Michael Conran, Joe Abrahams, Henri Rey, Murray Jackson, RD Hinshelwood, David Feinsilver, Eric Marcus, Michael Robbins, Francoise Davoine & Jean-Max Gaudilliere, Ann-Louise Silver, Bert Karon, David Garfield, Ira Steinman, Wilfred ver Eecke, (apologies to my many colleagues and friends whose work I have temporarily omitted) etc.

History is important-much of it remains relatively unknown. However, we need to realize that there is a strong need to reach beyond, standing on their shoulders, what has already been understood. There are many good models of relational approaches to psychosis (e.g., Rosenfeld and Searles focused on the impact of countertransferences on psychotic symptomatology, Searles bravely pointed to the emotional dependence of the analyst on the "patient," Benedetti uses his dreams and transforming therapeutic images from his unconscious creating "transitional subjects" with his therapeutic partner, Sandin sees the patient in herself and herself in the patient, etc.) in our recent history. I have felt that my psychopathology interacts with my partners in both positive and negative ways-at time increasing emotional closeness and awareness and at times, foreclosing both. Searles once told me that he was very interested in how we analysts keep our patients sick. Over the years, I have grown to see this as a collusion with my partner in avoiding and suppressing the emergence of the so-called negative transference (which as Leon Grinberg points out, is a positive development-I highly recommend his insightful paper "Is the Transference Feared by the Psychoanalyst?" published in IJP). I am increasingly interested in the area that Winnicott identified as the "use of the object," i.e., surviving maximum destructiveness in order to establish relational externality and transform omnipotence into self-efficacy and autonmy. As a neuroscientist (I still consider myself one) and psychoanalyst, I am increasingly interested in the intersection of fear/hate with the capacity to love (e.g., the effects of compassion on the CNS and its relationship to states of annihilation terror)) and feel compassion for others and oneself and how this emerges in the transference/countertransference fields.

Contacting our therapeutic partners, who often feel excessively permeable, invaded, colonized, controlled and threatened by emotional closeness, as we sometimes do, in order to decrease the terrible loneliness and isolation of the psychotic state, is no small task. It is both our science and our art which will help us help the patient not disappear too readily and for too long periods of time (chronicity), or, in the words of Gaetano Benedetti, to "positivize" the patient as person.

Brian Koehler
New York University
80 East 11th Street #339
New York NY 10003
212.533.5687
brian_koehler@psychoanalysis.net