Clinical Studies in Neuropsychoanalysis Revisited

Christian Salas, Oliver Turnbull, Mark Solms, Christian Salas, Oliver H Turnbull, Mark Solms

• Publisher: Routledge
• Year: 2021
• ISBN:
  9781000408515
• Edition: 1
• Topic: Psychology
• Subtopic: Psychoanalysis
• Index: Psychology

In the past few decades, we have accumulated an impressive amount of knowledge regarding the neural basis of the mind. One of the most important sources of this knowledge has been the in-depth study of individuals with focal brain damage and other neurological disorders. This book offers a unique perspective, in that it uses a combination of neuropsychology and psychoanalytic knowledge from diverse schools (Freudian, Kleinian, Lacanian, Relational, etc.), to explore how damage to specific areas of the brain can change the mind.

Twenty years after the publication of Clinical Studies in Neuro-Psychoanalysis, this book continues the pioneering work of Mark Solms and Karen Kaplan-Solms, bringing together clinicians and researchers from all over the world to report key developments in the field. They present a rich set of new case studies, from a diverse range of brain injuries, neuropsychological impairments and even degenerative and paediatric pathologies.

This volume will be of immense value to those working with neurological populations that want to incorporate psychoanalytic ideas in case formulations, as well as for thosewho want to introduce themselves in the neurological basis of psychoanalytic models of the mind and the broader psychoanalytic community.

Case studies

Chapter 6

A mother and wife, after right-hemisphere stroke

A self psychological perspective

Pamela Klonoff

Psychotherapy has grown in its recognition and utilization in neurorehabilitation for people with brain injuries (Ben-Yishay & Diller, 2011; Klonoff, 2010; Langer, Laatsch & Lewis, 1999; Newby, Coetzer, Daisley & Weatherhead, 2013; Ponsford, 2004; Prigatano et al., 1986; Ruff & Chester, 2014; Wilson, Gracey, Evans & Bateman, 2011). Among these therapies, psychoanalytic approaches have imparted valuable insights into how brain injury can alter the ways in which individuals relate to themselves and others. Self psychology has particularly contributed by describing how brain damage can harm the coherence and continuity of the self. The goal of this case is to exemplify the effectiveness of self psychology concepts in comprehending psychological changes after brain injury. In order to do so, the case of a woman with a right-hemisphere stroke who underwent psychotherapy and holistic rehabilitation is presented.

1 Self psychology and selfobject relations

Self psychology, like so many other fields within psychoanalysis, developed as a clinical discipline, without any reference to neurobiology. The field is predicated on the seminal work of Heinz Kohut and explored four facets of psychoanalysis: how relational affective transactions with the social environment spur the development of the self, how experiences are internalized into maturing self-regulating structures, how early deficits in self-structure result in later self-pathologies, and how the therapeutic relationship restores the self (Schore, 2009).

The self is the essence of an individual’s psychological being, consisting of sensations, feelings, thoughts, and attitudes toward oneself and the world (Banai, Mikulincer & Shaver, 2005). Self psychology purports that healthy narcissism is a nondefective structural completeness of the self which can sustain its coherence, continuity, and self-esteem (Banai et al., 2005; Kohut, 2009). Kohut posited that the essential task of psychological development and existence is the growth and maintenance of the cohesive functioning self, also with a yearning for connection (Terman, 2014). The selfobject is the necessary precondition for development of a cohesive self (Wolfe, 1989). Selfobjects in the psychic world are objects who are experienced as part of the self, not as separate and independent (see Wolfe, 1989, for a review). Kohut posited that “parents with mature psychological organizations serve as selfobjects which perform critical regulatory functions for the infant, who has an immature, incomplete, psychological organization” (Kohut, 1977; Schore, 2009, pp. 191–192). Of note, the self needs selfobjects throughout the life span and their form changes with maturity (Kohut, 2009; Lage & Nathan, 1991). The neurobiological basis of such selfobjects has never been a reference point for the field, but there are some potential points of contact, of which the clearest might come from the themes of empathy and mirroring.

Through the reciprocal transactions with the selfobject (episodes of empathic “mirroring” or admiration of the individual’s qualities and accomplishments), the infant is able to maintain his or her internal homeostatic equilibrium, self-worth, value, and internal self-respect (Baker & Baker, 1987; Banai et al., 2005; Kohut & Wolf, 1978; Schore, 2009). Other forms of selfobjects are “idealizing,” in which an external selfobject provides calming, comforting, and protective functions through merging with idealized selfobjects (Baker & Baker, 1987; Banai et al., 2005; Brown, 2010; Kohut, 2009; Kohut & Wolf, 1978) and “twinship” or “alter ego” selfobject needs, defined as a degree of alikeness with other people and feeling bonded with the human community (Baker & Baker, 1987; Brown, 2010; Kohut, 2009). A firm self has three constituents: one pole which fundamental strivings for power and success emanate from, another pole that holds basic idealized goals, and an intermediate area of talents and skills which are activated by a tension arc between ambitions and ideals (Kohut & Wolf, 1978).

Empathic responses from critical selfobjects during formative years are necessary for the development of self-cohesion (i.e., the ability to tolerate stress) (Lage & Nathan 1991). Disorders of the self result from developmental arrests and traumatic failings resulting from parental (and/or their substitutes’ shortcomings). There is an underlying lack of self-cohesion, a dearth of confidence in dealing with life’s hardships, and vulnerable self-esteem (Baker & Baker, 1987; Banai et al., 2005). In the therapeutic process, the defective self and archaic struggles are reactivated; through the mirroring, idealizing, or twinship/alter ego transferences, the self can be reconstituted (Lage & Nathan, 1991).

2 Right hemisphere function

One further potential link between self psychological concepts and neuropsychology might come from a consideration of the functions of the right cerebral hemisphere (in those with conventional cerebral dominance). Right-hemisphere strokes naturally produce a wide range of common sequelae, often involving primarily cognitive impairment. These include hemianopia, and various forms of neglect; visuoperceptual, visuospatial, and constructional apraxia deficits; visual search difficulties; topographical orientation problems; and contralateral hemiplegia or hemiparesis, spasticity, and other motor challenges (Árnadóttir, 2011; Byars & Heilman, 2015; Capruso, Hamsher & Benton, 2006; Festa, Lazar & Marshall, 2008; Gottesman & Hillis, 2010; Matano, Iosa, Guariglia, Pizzamiglio & Paolucci, 2015; Ten Brink et al., 2016).

In addition to these, and of particular interest in the context of self psychology, right-hemisphere stroke also produces emotional processing and communication disorders: recognizing or categorizing facial emotions, as well as comprehension and expression of emotional prosody (Byars & Heilman, 2015; Festa et al., 2008). The right hemisphere is also implicated in other cognitive activities on the emotion–cognition boundary, including attending to relevant stimuli, as well as deciding when to initiate, persist, and complete actions (Byars & Heilman, 2015). Perhaps as a result of these many impairments, such neurological patients can present with a range of “psychiatric-like” symptoms. Thus, patients with right-hemisphere stroke can exhibit depression, which potentially negatively impacts attention, visual perception, working memory, episodic verbal memory and semantic memory, auditory and written language, constructional apraxia, and impairments in verbal fluency (Oliveira et al., 2015).

A related set of issues arise from the fact that damage affecting the frontal lobes have long been implicated in executive system dysfunction, producing cognitive, communication, mood, and behavioral challenges (Gottesman & Hillis, 2010; see Klonoff, 2014, for a review). Executive functions are also considered part of metacognition, defined as “thinking about thinking” (see Purdy, 2014, for a review). Metacognitive beliefs are dynamic, in that they are created and updated based on new experiences and circumstances, including consideration of patients’ own personal task failures and successes (Levine et al., 2011; Purdy, 2014). Interestingly, right hemisphere damage has also been correlated with an “updater” failure, an inability to construct, utilize, or update representational models. This translates to a reduced capacity to alter mental models through detection of novel stimuli that do not fit with the current conceptualization and subsequently shift to a new representation (Stöttinger et al., 2014). These deficits have a deleterious effect on recovery and outcomes (Gillen, 2011; Matano et al., 2015; Ownsworth & Shum, 2008) and are clearly relevant to a self psychology perspective.

How might this rather abstract list of neuropsychological impairments map onto the real-life experiences of a stroke survivor?

3 Sara’s background history

Sara was a “stay-at-home” mom who also homeschooled two of her four children, ages 2, 4, 6, and 8. Her husband, Tim, is (and was) a fire fighter. At age 29, she suffered a large right middle cerebral artery infarct including the insula. She presented with left-sided weakness, left facial droop, slurred speech, behavioral change, nausea, and vomiting. Sara was 13 weeks pregnant with her fifth child (named Amaziah: God will strengthen). A medical workup revealed a protein S deficiency. Sara was discharged to inpatient rehabilitation three days later and then home after 16 days. Upon discharge, the physician suggested to Tim that he buy a hospital bed for the downstair living room, as Sara would be unable to traverse stairs nor care for her children. Sara had limited outpatient physical, occupational, and speech therapies to address straightforward skills, such as getting in and out of bed, communicating rudimentary needs and wants, and how to walk with a walker. She existed with very low capabilities at home (e.g., “watching television and sitting in a chair”) and required 24-hour supervision. As she was totally unable to tend to her children, her 24-year-old sister-in-law, Betty, moved from Oregon to “mother” the children (and newborn son) and run the household.

In this medical and family context, it is instructive to observe the lived experience of a patient of this sort. These patients are required, of course, to navigate a range of medical challenges, physical and intellectual, often when their own intellectual and emotional capacities are restricted by the stroke itself. In addition, there are the issues surrounding rehabilitation and uncertainties about recovery and disability. And finally, and perhaps most importantly, there is the dramatically changed interpersonal world that they are forced to face – where their roles as a parent and partner can be changed beyond imagining.

3.1 Case vignette 1

Tim was distraught. Betty mustered her dwindling energies and desperately searched for neurorehabilitation for Sara. After a circuitous route, they landed at a holistic treatment program almost one year post stroke. The first step was to delineate Sara’s neurological status. Neuropsychological and speech and language testing, in conjunction with clinical observations, revealed that relative to her pre-stroke level of functioning, she demonstrated moderate-to-very severe impairments in visuoconstruction and visuoperceptual skills, and visual recall and executive functions (characterized by deficient complex attention, planning, flexible problem-solving, decision-making, judgment, time management, prioritization, organization, multitasking, “disconnection between knowing and doing,” impulsivity, not seeing the “big picture” (Gestalt), and perspective taking). Mild-to-moderate self-relative deficits were observed in her higher level inferential reasoning (written expression and writing fluency), and mild challenges were identified in her oral–motor coordination (phonation) and higher level verbal thought formulation. Retained strengths included her auditory comprehension, verbal expression, reading comprehension, sustained attention, speed of information processing, verbal learning and recall, and math. The occupational therapy evaluation revealed left-sided decreased sensory awareness, impaired visuoperceptual abilities (e.g., visual scanning, visual memory, and visual discrimination), fine and gross motor incoordination, abnormal tone, and visual neglect. The physical therapy evaluation indicated mild difficulties in her lower extremity range of motion and strength, motor timing and coordination, lack of stamina, and high-level balance (without visual input).

All too often, such patients are asked to navigate the world of neurological disability without much in the way of formal psychological support. Sara was in the more fortunate position of having access to psychotherapy, and it was instructive to see how she used this process to gradually adapt to her changed circumstances.

4 The beginning of the psychotherapy pr...

Table of contents

• Cover
• Half Title
• Series Page
• Title Page
• Copyright Page
• Dedication
• Table of Contents
• List of contributors
• Series editors’ foreword
• Introduction
• Neuropsychoanalyses
• Case studies
• Closing
• Index