Mind Body Interaction GA

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Group Analysis
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DOI: 10.1177/053331648301600203
1983 16: 95 Group Analysis
Heinz Wolff
Mind-Body Interaction and the Psychotherapeutic Process
 
 
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by Terry Birchmore on July 30, 2010 gaq.sagepub.com Downloaded from
7th S. H. Foulkes Annual Lecture
MIND-BODY INTERACTION AND THE
PSYCHOTHERAPEUTIC PROCESS
By Heinz Wolff
I WISH first of all to thank the Group-Analytic Society for having done me
the honour of asking me to give the 7th Foulkes Lecture today. Although I
have not had the advantage of having been in one of Michael Foulkes’ groups
as a group member or observer, I have benefited a great deal from his writings
and from hearing him talk and lecture on group analysis, that particular form
of group psychotherapy of which he was the originator.
As the name group analysis indicates, its origin lies in the concepts and
practice of psychoanalysis which laid the foundations for Michael Foulkes’
own training as a psychoanalyst and psychotherapist, and thus ultimately for
the creation by him of Foulkesian group analysis, based on his special interest
and discoveries in group phenomena and processes of social interaction.
Hence the GroupAnalytic Society, founded by him in 1952, and the Institute
of Group Analysis, which emerged from it as the centre for education in group
analysis in London, have common roots in the principles of psychoanalysis,
dynamic psychotherapy and social interaction.
When I was confronted with the task of choosing a suitable topic for this
lecture I therefore decided to try and make use of some psychoanalytic,
groupanalytic and psychotherapeutic concepts in order to throw further light
on the relationship between mental and physical phenomena, or between mind
and body in health and illness, an area which has always been of special
interest to me in my clinical work, first as a physician and later as
psychotherapist and psychiatrist.
This lecture was delivered at the Royal College of Physicians, London, on May 23,
1983.
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The mind-body relationship is of interest for two main reasons. Firstly,
because of its clinical relevance in terms of the influence of life events and
personal experience on bodily function in health and disease. And secondly,
because of its philosophical and theoretical implications which have been a
challenge to man’s understanding of himself at least since the days of the
ancient Greek philosophers.
Originally the heart or the diaphragm was considered by the philosophers
to be the part of the body in which the mind or the soul was located. Even
after the brain was recognised as the bodily organ on which mental activity
was based, so that the question of the relationship between mind and body
became a question of the relationship between mind and brain, this remained
essentially a philosophical issue. The application of the methods of the natural
sciences to the investigation of cerebral structure and function took a long
time to develop, but in the present century clinical observations and the neuro-
sciences have made and are continuing to make rapid advances, so that a
great deal is now known about the influence of the brain and cerebral activity
on mental functioning. Similarly. clinical and experimental psychologists,
working either on their own or together with clinicians and neuro-scientists,
are studying those aspects of mental processes which are amenable to
objective observation and to experimentation and measurement. These
disciplines have thus provided us with increasing knowledge of such
phenomena as behaviour, cognition. language, memory and perception and
their relation to cerebral function. On the other hand they have thrown little if
any light on subjective mental phenomena, by which I mean all those inner
experiences like love, hate, hope, faith, sadness, despair, imagination, play,
artistic appreciation, religious experience, creativity and so on, in fact all those
subjective experiences which give meaning to what we perceive, phantasize
about, do and remember every day of our lives.
Psychoanalysts, psychoanalytic psychotherapists and group analysts have
speciai interest and knowledge of exactly these inner, subjective aspects of
mental functioning. This is why I want to share with you some thoughts on
what I believe the discipline of dynamic psychotherapy can contribute to our
understanding of the mind and its relationship to the body alongside the
neuro-sciences and experimental psychology.
Phflosophical Conslderations
I will not spend much time recapitulating all the philosophical arguments
concerned with the age-old controversy between so-called mind-brain dualism
and mind-brain monism. For a detailed account I refer you to Popper in ‘The
Self and its Brain’ ( 3 977). Briefly, according to the dualist concept, mind and
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brain are different in nature. I f’this were the case they could either be
independent of and unable to influence each other; or one could influence the
other; or they could interact. According to the theory of mind-brain monism,
mind and brdn are identical, in which case the hope of most, though not all
modern neuro-scientists would be that ultimately all mental phenomena could
be reduced to, explained and expressed in terms of cerebral function. This
view is nowadays usually referred to as radical or reductive materialism. I n its
extreme form all mental function would then be thought of as identical with
cerebral function, so that the mind and what we consciously experience would
be nothing more than a by-product of cerebral function or an
‘epiphenomenon’ which could have no influence or function of its own.
Thinking, feeling, wanting. as well as conscious awareness of oneself and
others, would thus become irrelevant to what happens to us in our lives and to
our behaviour.
In order to avoid this extreme and clearly unacceptable form of mind-brain
monism an alternative view has been put forward, namely that of psycho-
physical parallelism. According to this, mind and brain are considered to be
one and the same entity; but this could either be studied objectively from
outside, as it were, in terms of brain function, and be described in
physiological, mainly electrical and biochemical language, or it could be
looked at from the point of view of the mind from inside, as it were, and be
expressed in psychological language and in terms of our inner subjective
experience. This view side-steps the possibility of interaction between cerebral
and mental phenomena from the very outset.
There has been and to a certain extent still is considerable opposition to the
possibility that mental and cerebral function could in some way be different
from each other and yet capable of interacting. The historical reason for this
goes back to the 17th century when Descartes introduced the dualist concept,
since known as Cartesian dualism. The reason for the present-day opposition
to any kind of dualistic and interactional concept of the mind-brain
relationship stems from the fact that Descartes, like many of his
contemporaries, postulated an immaterial soul which because of its
immaterial, divine quality could not be conceived of as being able to interact
with the obviously material, physical brain. Descartes believed that the soul
was located in the pineal gland, a small body in the centre of the brain. He
considered that everything we perceived ultimately reached the pineal gland
and was there recognised and experienced by the soul. However, because of
its immaterial nature the soul could not, he thought, be responsible for action
and voluntary movements. He therefore postulated that there also existed in
the ventricles of the brain small material substances which he thought were
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responsible for movements carried out by muscles.
contemporary of Descartes, in ‘The Anatomy of Melancholy’ (1 62 1):
Similar views were expressed by the English author Robert Burton, a
‘In the upper region (of the body) serving the animal faculties, the chief
organ is the brain, which is a soft, marrowish, and white substance,
engendered of the purest part of seed and spirits, included by many
skins, and seated within the skull or brain-pan: and it is the most noble
organ under heaven. the dwelling-house and seat of the soul, the
habitation of wisdom. memory. judgement. reason, and in which man is
most like unto God: and therefore nature hath covered it with a skull of
hard bone and two skins or membranes, whereof the one is called diira
muter, or i nei i i i i x, the other pia inater . . . this fore part (of the brain)
hath many concavities distinguished by certain ventricles,which are the
receptacles of the spirit brought hither by the arteries from the heart,
and there refined to a more heavenly nature, to perform the actions of
the soul’.
Nowadays the relationship between mind and brain is no longer a religious but
a human and scientific issue. The Cartesian concept of soul-brain dualism
which in Descartes’ days appeared incompatible with soul-brain interaction
has long since been superseded by the problem of how the mind, not the soul,
relates to and possibly interacts with the brain. No-one would doubt
nowadays that mental function is dependent on brain function. At the same
time every individual person knows that what he feels, thinks, wants, decides
to do, does or phantasizes about, that is, the whole of his experience of himself
and others, has a reality of its own, a psychic reality which we call our mental
experience or briefly our mind. not our soul. It is the relationship of the mind,
in this sense of the word, to the brain and body which I am concerned with.
The Present Scientific Position
This is not the place to describe in detail what is now known about the
functions of different regions or systems of the brain and about the
biochemical processes governing cerebral function, and how all this relates to
mental functioning. For an up-to-date account see Eccles in ‘The Self and its
Brain’ referred to earlier; the Ciba symposium on ‘Brain and Mind’ (1979)
and Lishman on ‘Organic Psychiatry’ (1978).
We now know that such highly developed mental functions as language,
speech, ideational and mathematical ability depend on certain specific areas
located in the dominant, in the majority of people the left, cerebral
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hemisphere. The results of surgery on a few patients in whom the connecting
fibres between the right and left cerebral hemispheres have been divided for
treatment of severe epilepsy by cutting the connecting structure, the c or ps
calloswn. have thrown a great deal of new light on the different functions and
interactions between the two hemispheres (Sperry, 1974). Observations on
these split-brain patients have shown that not only language but also self-
conscious awareness and symbolic functioning are largely dependent on the
dominant hemisphere. The minor or right hemisphere, on the other hand, is
particularly concerned with spatial and pictorial ability and with non-verbal
emotional experience.
Our knowledge of the cerebral basis for memory has also advanced
considerably: it is now recognised that certain basal parts of the brain, the sc-
called hypothalamic and hippocampal areas and their connections, as well as
the neocortex, play an important r6le in memory storage. It is also now
known that structural growth in neuronal cells, esQecially at the synapses, - -
occurs as the result of learning and memorising, and opposite changes of
atrophy are associated with disuse due to lack of stimulation; there is also
evidence that learning processes depend on protein synthesis in these
neurones. Knowledge is also rapidly accumulating on the function of various
transmitter substances at neuronal synapses, for example in relation to
changes in affect, as in depression.
These few comments have to suftice to remove any doubts, if they were still
to exist, that brain function provides the necessary physical basis for mental
functioning and vice versa, that mental experience influences cerebral
structure and function. We may note in passing that already in 1895 Freud
attempted to correlate cerebral function and especially the function of
neurones with his early psychological discoveries by trying to write a
‘Psychology for Neurologists’ or. as it was later to be called, a ‘Project for a
Scientific Psychology’. He ultimately abandoned this attempt and the ‘Project’
was not published until 1950, several years after his death.
I want to stress at this point that the upto-date neuro-psychological
findings ofthe kind briefly referred to have made it clear that to speak of either
the brain or the mind is a gross over-simplification. The brain, although one
organ anatomically speaking, consists of many different parts, systems and
connecting fibres, of millions of neurones, synapses and collections of
ncurones. We have learned to think of many different cerebral functions and
physiological processes each of which needs to be studied in its own right.
Similarly, the concept of the mind as an entity needs to be revised. The
‘mind’ is in fact not a thing or object located somewhere in the body or in
space but a word used to embrace a multitude of different, though often
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interrelated, psychological processes and mental phenomena and personal
experiences. This fact is well known not only to psychologists but especially to
psychoanalysts, who are used to thinking in terms of multiple internal object
relationships, mental representations, thoughts and phantasies, conscious,
preconscious and unconscious mental processes, wishes, feelings, defence
mechanisms and so on. The days when one could speak of rhe mind or the
brain and their inter-relationship are over: instead we are now concerned with
a multiplicity of cerebral and mental phenomena and their relationships.
I want here to refer particularly to man’s ability to be consciously aware of
himself and others, that is. to the phenomenon of consciousness in general and
of self-conscious awareness in particular. We are all able to reflect on
ourselves, to observe our own feelings. thoughts and actions, or to be
introspective. I n fact it is one of the tasks of psychoanalysis, psychotherapy
and group analysis to increase and refine our patients’ knowledge of
themselves, as well as our own understanding of ourselves. The cerebral basis
of consciousness and self-awareness is still far from being understood but as
conscious experience is closely related to our ability to think and to express
our thoughts through language. that is. in symbolic form, there is reason to
believe that the speech area in the dominant hemisphere on which symbolic
function and language depend may also be connected with our capacity for
self-awareness (Popper and Eccles. 1977).
Although conscious awareness of the environment and of others and
possibly to a limited degree even of the Self may occur in the case of some
higher mammals, it is clear that man’s ability to think, to express himself and
to communicate with others in symbolic terms, that is through language and
speech, and to be aware of himself as a unique individual are among the most
characteristic and highly developed features of the human species. If we
accept the concept of Darwinian evolution and recognise that the human
species has evolved through natural selection, it follows that the highly
complex human brain is the result of such an evolutionary process. The
evolution of the human brain has made it possible for mankind to develop its
characteristic mental functions. including those of self-awareness, symbolism
and language, and thus to our ability to relate to and to understand others, to
exist as unique individuals in social organisations and to control society and
our physical environment to an extent which vastly exceeds that of any other
animal species. In this sense the evolution of the brain and hence of mental
processes and social functioning has given the human species an advantage
over all other species in existence so far.
I must, however, remind you of the fact that these physical evolutionary
processes and resulting social developments are by no means all of advantage
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to our species. Freud (1929) already drew attention to the fact that some of
these highly developed human functions could under certain circumstances be
used to our disadvantage and even to self-destruction. The concluding
paragraph of ‘Civilization and its Discontents’, reads as follows:-
‘The fateful question for the human species seems to me to be whether
and to what extent their cultural development will succeed in mastering
the disturbance of their communal life by the human instinct of
aggression and self-destruction. It may be that in this respect precisely
the present time deserves a special interest. Men have gained control
over the forces of nature to such an extent that with their help they
would have no difficulty in exterminating one another to the last man.
They know this, and hence comes a large part of their current unrest,
their unhappiness and their mood of anxiety. And now it is to be
expected that the other of the two ‘Heavenly Powers’, eternal Eros, will
make an effort to assert himself in the struggle with his equally immortal
adversary. But who can foresee with what success and with what .result?’
Today this danger is vastly greater even than it was when Freud wrote this
paragraph in 1929. Mankind is now facing the threat of destroying itself as
the result of the discovery of nuclear weapons, through nuclear war. Scientific
discoveries and social developments which have followed the physical
evolution of the human brain have left mankind with this most serious conflict
between survival and self-destruction, between love and hate. Conflicts
between these two opposites are characteristic of every human individual and
they make their appearance in every social organisation, including the
therapeutic group. I n all individual and group psychotherapy, therefore, we
have to deal with this basic human issue of how to contain aggressive and
destructive impulses, and how to foster the capacity for human concern as a
balancing force to counter aggressive behaviour. However, these remarks
anticipate the next part of this lecture, namely, further consideration of the
structure and function of the mind.
The Mind as t he Hlghest Level of Biological Organization
I hope I have made it evident by now that cerebral processes provide the
essential physical basis on which the occurrence of mental processes depends.
Mental processes, however, differ from cerebral processes in as far as they
take place at an even higher level of biological organisation than the physical
processes within the brain. The concept of levels of biological organisation is
fundamental to our present-day understanding of the mind-brain and mind-
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body relationship. At each level of biological organisation the principle applies
that the ‘whole is greater than its parts’. A single cell or a unicellular organism
like an amoeba, although it is composed of atoms, molecules, and chemical
substances which interact with each other, has a structure and function of its
own, and as such it relates to and interacts with its environment. This principle
applies at every higher level of organisation. so that each organ, which
consists of a multitude of cells. has its own structure and functions, dependent,
of course, on its component cells. The human organism as a whole similarly
has its own characteristics and functions: these, in turn, depend on all the
component organs which make up the body, and on their interaction.
Moreover, the behaviour of the organism as a whole influences its various
organs and its component cells by as it were a feed-back process, or so-called
downward causation.
If we apply this principle to the mind-brain relationship it follows that while
mental processes depend on individual cerebral structures and functions, the
multiplicity of mental processes, commonly referred to as the mind, functions
at a higher level of biological organisation than the brain. The mind has its
own structure and function and as such it has to be studied and described at
its own level of organisation, that is in psychological and experiential terms. I t
cannot be described in or reduced to the terms governing cerebral function,
which belong to a lower level of biological organisation.
The following analogy, taken from group analysis, may help to clarify this
further. One of the most important concepts underlying group psychotherapy,
and Foulkesian group analysis in particular, is that the therapeutic group,
while it consists of its individual members and the group conductor, functions
as a whole. Each member of the group, through what he says, through his
behaviour and interactions with other members, or just by his silent presence
contributes to the atmosphere or, as Foulkes called it, the matrix of the group
as-a-whole. Foulkes’ ideas concerning the group matrix have recently been
reviewed by Roberts (1982). The group evolves or emerges from its
component members but it functions as a whole at a higher level of, in this
case, social organisation. I t has its own structure and function which goes
beyond the sum of its parts, that is. beyond the sum of its individual members.
Foulkes (1964) says: ‘It becomes easier to understand our ciaims that the group
associates, responds and reacts as a whole. . . In this sense we can postulate the
existence of a group mind in the same way as we postulate the existence of an
individual mind’. Equally important is the fact that the group in turn affects its
individual members and the conductor. Each member’s feelings, thoughts,
phantasies and behaviour are constantly being influenced by what is going on in
the group as a whole. We are thus confronted in the grouptherapeutic process
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with constant interaction between the individuals in the group and the group as
a whole. The group affects and influences each member, just as each member
contributes to the structure and function of the whole group. We have here a
perfect example of upward and downward causation, or of a feed-back system
between two levels of organisation.
This analogy may help us understand better how all the separate structures
and functions of the brain similarly make up the totality of our mind, which
functions as a whole but is more than the sum of all the component brain
functions. The mind or what we experience in turn affects our brain and its
functions by what I have already referred to as downward causation. J ust as
the individual group members and the group as a whole are in a constant state
of interaction, so are cerebral and mental functions, or brain and mind,
interacting with each other. The mind cannot exist without the brain, just as
the group cannot exist without its individual members. The brain by upward
causation influences the mind, and the mind by downward causation in turn
influences the brain and through the brain other parts of the body, just as the
group affects its members and their behaviour in the group, through a
constant process of interaction.
The Mind and its Functlons
Having thus established that the mind emerges from the brain, or to put it in
terms of function, that mental function emerges at the next higher level of
biological organisation from cerebral function and that mental and cerebral
functions interact with and influence each other, we are ready to consider
what determines the development of each individual person’s mind, its
content, its functions, and the nature of that individual’s experience. It is at
this point that we need to give full recognition to the influence of the personal,
social and cultural environment on mental development and conscious
experience (Crook, 1980).
To an audience largely composed of psychotherapists, group
therapists, psychoanalysts, psychologists and sociologists it may appear self-
evident that it is the influence of the outside world and of our relationships to
objects and people with whom we interact from infancy onwards, and later
with society at large, which determines the development, content, structure
and function of the mind. While the brain provides the necessary physical
basis for mental functioning, it is the social and cultural environment which is
responsible for its content and meaning. The outstanding contribution which
the individual’s experience in infancy and childhood makes to the development
of mental functioning, of personal attitudes and the meaning of experience
has, of course, been studied in great detail by psychoanalysts and dynamic
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psychotherapists, and more recently also by psychologists (Trevarthen, 1977;
Schaffer, 1977).
I n this context I would also like to draw your attention to the important
distinction between mechanism and meaning made by Denis Hill in his Ernest
J ones lecture given in 1970. Mechanisms belong to the level of cerebral
function; meanings belong to the level of mental function. I t is psychoanalysis
which has made such an important contribution to our understanding of how
human development from birth onwards and throughout childhood,
adolescence and adulthood shapes the meaning and nature of our experience
and the functions of the mind. These mental functions need to be studied,
understood and described in psychological, psychodynamic and psycho-social
terms. They require full recognition of the individual’s subjective experience as
well as of inter-subjective experience between persons and groups of people.
Objective observations of cerebral mechanisms and of human behaviour,
however important they are as instruments of research, have to be integrated
with the study and description of subjective experience, of phantasy and of
intrapsychic processes if we are to increase our understanding of individuals,
groups and social organisations. The contributions made by Foulkes and
group analysis in some of these respects speak for themselves.
Out of the many mental functions which constitute the essence of being
human I will refer to only a few which are of special concern to us. These
include the meaning we attach to our experience; our capacity for
symbolisation and hence to use language and other symbols for
communication; our ability through empathy, projection and identification to
understand other people and to relate to them, and our highly developed
ability to be conscious of ourselves, and of our subjective experience; as well
as its opposite, so well known in the psychotherapeutic process, namely to
split off, project, make unconscious through repression, or to deny those
aspects of ourselves and of our experience which we want to disown.
I t is not possible to say exactly when an infant can first be said to
attach meaning to what it perceives from within itself or from without, to
what is happening to it in relation to its own body or to its environment,
represented by its mother, and to its own actions or movements. All we can
say is that a mother who, to use Winnicott’s expression (1965), relates to her
baby in a state of primary maternal preoccupation can very early on recognise
the meaning of her baby’s behaviour and respond to it appropriately, through
her capacity to be a good-enough mother. At this earliest stage of
development when mother and baby are still in a state of fusion it is thus the
mother who carries the function of giving meaningfulness to the shared
experience of the infant-mother couple. Soon, perhaps within a few days after
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birth, the situation begins to change, so that the infant itself m&y have the first
inkling of what we call meaningful experience. At this earliest stage
meaningfulness from the infant’s point of view is, of course, entirely non-
verbal or pre-verbal; it has to do with feeling, not yet with thinking. We could
speak of the infant beginning to learn from and in its relationship to its
mother, that experience is associated with meaningful feelings.
How do we know and recognise that this is happening? I would suggest
that the best evidence comes from the mother herself, and from those other
significant adults, the father included. who are in close relation to the baby.
Infant observation by psychologists. psychoanalysts and dynamic
psychotherapists has contributed to our growing knowledge in this field.
Equally important is what we have learned from child psychotherapists and
child analysts, especially Anna Freud, Melanie Klein, Winnicott and others.
Another vital contribution comes from therapists and analysts who have
worked with adult patients passing through periods of regression. At such
times the regressed patient has sensations, feelings, phantasies, thoughts and
bodily experiences often associated with great anxiety, intense frustration, fear
and hopelessness, or at other times of rest and contentment in his or her
transference relationship. But the meaning of these experiences is usually
unknown to the patient while in a state of regression. Instead it is what the
therapist experiences in his counter-transference which combined with his
training helps him to understand at a thinking and knowing level what the
meaning of his regressed patient’s experience might be. It could be said that
the function of attaching meaning to experience is for the time being posited in
the analyst or group analyst, ‘just as it was once posited in the mother in
relation to her infant.
As the infant develops further. its own separate ability to attach meaning to
experience increases and is certainly very obvious when the infant reaches the
age of a few weeks to two months. During these first few weeks of life we can
observe the gradual emergence and development of the infant’s mental
function. The cerebral mechanisms available at and developing further after
birth provide the essential physical basis for this early development but it is the
facilitating environment provided by the mother and soon also by others in the
infant’s environment on which the emergence of meaningful mental function is
so utterly dependent. I t is of interest to note that while it was Winnicott (1965)
who stressed the importance of the facilitating environment for maturation to
take place, Trevarthen (1979), a neurepsychologist, also speaks of
consciousness requiring ‘a facilitating environment’. He goes on to say that:
‘consciousness depends upon and is developed by an environment of objects
and meanings which is inevitably altered by consciousness’. I find it
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encouraging to see that from these different fields of psychoanalysis,
psychology, sociology and the neuro-sciences an integrated view of the nature
and function of the mind is thus beginning to emerge.
Next, the capacity to make use of symbols arises out of our ability to
endow objects and persons with meaning. I n infancy this can, of course, be
seen in the use infants make of transitional objects, of toys and of play
(Winnicott, 1971). This is accompanied by the development of phantasy and
the use of baby language, leading ultimately to the specifically human capacity
to use words and language for communication. I have earlier referred to the
fact that the use of language is dependent on the development and function of
the speech area in the dominant hemisphere of the human brain but we can
now recognise clearly how the actual development of linguistic function is
determined by the relationship of the child to significant others and to its
social environment, and by the growing ability to use words as symbols.
Language, speech, writing. reading and related forms of communication in
turn make it possible for information and creative work to be passed on from
generation to generation. This leads to the evolution of culture which includes
literary, artistic, scientific. social. spiritual, religious and many other forms of
specifically human concepts and activities. Each individual human being’s
mind is therefore constantly being influenced by the social and cultural
environment in which he develops and exists. Psychotherapy, both of
individuals and in groups. provides us with a unique opportunity of studying
this constant interaction between the inner and outer world through such
processes as introjection. identification. projection, projective identification
and so on. It is, I submit, the psycho-therapeutic process based on
psychoanalytic and groupanalytic concepts which has contributed so much
and will, I am sure. continue to provide further knowledge and understanding
of these many different functions of the mind.
I have left further consideration of the phenomenon of consciousness,
including conscious awareness of the self and of others to the end of this part
of my lecture. I n this area there is still a great deal of uncertainty, in terms of
understanding . of the underlying cerebral mechanisms, although much
progress is now being made (Creutzfeld, 1979). But the following comments,
based on knowledge derived from the psychotherapeutic process, will I hope
be helpful at the level of mental functioning.
When we speak of being conscious we always mean that we are being
conscious of something: that is. the concepts of object-relations theory help us
to recognise that consciousness is always object-related. The object may be
some aspect of our environment. a person, part of a person, a group of people,
or a material object of some kind. I n early childhood the infant is probably
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first conscious of sensations arising from its own body, then of some aspect of
its mother, and later of the mother as a whole person. As a sense of an
autonomous self, the awareness of ‘I-am-I’ develops, we learn also to become
conscious of our identity, our personal attitudes and beliefs, and ultimately of
many other aspects of our own inner world. These include internalised objects
and associated memories, feelings. thoughts, wishes, phantasies and so on.
Our mind is capable of turning conscious attention to one or more of these
outer or inner objects at any one time. It is during the psychotherapeutic
process that we are constantly concerned with these aspects of mental
function. We are also particularly concerned with the fact that we are so often
unaware, that is unconscious. of the reasons for our attitudes, beliefs and
behaviour, and much of analytical psychotherapy is, of course, directed
towards bringing these unconscious aspects into consciousness. Even when
asleep, conscious awareness returns to us in the shape of dreams which reveal,
usually by means of symbolism. some of these unconscious mental
phenomena. My central conclusion in these respects is that we need to
abandon the belief that consciousness is a wholesale phenomenon capable of a
single explanation. There are different degrees of consciousness and
unconsciousness, and in either case we have to study what determines
conscious awareness, or the lack of it, in terms of cerebral function, and in
terms of specific objects and functions of the mind and of our environment.
Psychosomadc Concepts
The previous considerations. which have led us to think in terms of brain-mind
interaction, upward and downward causation between the two, and the
dependence of mental function on the personal and social environment, should
help us clear up some of the misconceptions and difficulties relating to so-
called psychosomatic illness, psychosomatic medicine or, as I prefer to call it,
the psychosomatic approach. I will restrict myself to only a few comments.
The first of these is that the term ‘mysterious leap from mind to body’
coined by Freud, later discussed by Deutsch (1959) can now finally be
dispensed with, as has been argued by Murray J ackson (1979) and others. I n
fact from all that I have discussed and summarised it follows that on the
contrary it would be most surprising if life events and personal experience,
which affect our mind and brain, in their constant state of interaction, and all
we now know about the influence of the brain on the body through the
endocrine and. autonomic nervous system, did not influence our state of
physical health or ill-health.
The next important point is that in the field of medicine as a whole it is
gradually being recognised that in many diseases it is necessary to think in
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terms of multifactorial aetiology. several biological, psychological and social
factors and their interaction having, to be considered rather than one single
biological or psychological cause. The belief, for example, that some physical
disorder, say, duodenal ulcer. could be either entirely of organic origin or
entirely psychogenic is being replaced by recognising that genetic,
constitutional and acquired physical factors, as well as psychological ‘and
social stresses need all to be taken into account in deciding why a particular
person has developed a particular illness, o? has suffered a relapse at a
particular time in his life. The belief that there is a limited number of structural
diseases which are ‘psychogenic’ has been replaced by this multifactorial or
bio-psycho-social approach to patients and their symptoms or illnesses in
general. In the psychosomatic approach the concept of physical vulnerability
to stress of one or other target organ, say, the colon in ulcerative colitis, the
duodenum in duodenal ulcers, or the brain in schizophrenia, pays the
necessary attention to organic or bodily aspects on the one hand and to social
stresses and psychodynamic factors on the other.
I next want to emphasise that the time has come also to avoid the over-
simplified view that one or other par$ular psychc-analytic explanation could
account for the development of all structural or physiologically determined
psychosomatic symptoms and disorders. For example, most- workers in this
field have abandoned the view that specific personality types or specific
conscious or unconscious conflicts (Alexander, 1950) can necessarily be
correlated with specific structural diseases. This view has to some extent been
replaced by a hypothesis based on object-relations theory (McDougall, 1974).
This hypothesis suggests that individuals who have at an early stage of their
development failed to internalise from a containing mother or mother-figure
the capacity to use symbolisation and phantasy formation to contain psychic
pain due to, say, separation or losses, may be especially prone to develop
psychosomatic symptomatology. Or, to put it the other way round, that
individuals who have developed the capacity to deal with psychic pain through
symbolisation, phantasy formation and emotional self-expression might be
better protected against the development of psychosomatic bodily disorders.
The problem here is that psychosomatic symptoms of one kind or another
are almost universal; they occur in patients with a wide variety of personality
types and internal psychic structure and function. Moreover, the same patient
may have a psychoneurotic symptom,’ say I conversion hysteria br anxiety
neurosis in which symbolization and phantasy are of paramount importance,
at one time, and a psychosomatic symptom at some other time, or even
simultaneously.
It is also important to note that an impoverishment of phantasy life, of
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symbolic functioning and of emotional self-expression thought of as
characteristic of patients with psychosomatic symptoms, and described as
alexithymia by Sifneos (1973) and as pensee opirutoire' by Marty and de
Muzan ( 1963), whilst common in patients with psychosomatic symptoms,
also occurs in patients with psychoneurotic symptoms and in normal people.
I would, therefore, like to suggest that while these and other formulations
may indeed be applicable in particular patients, it is not appropriate at present
to try and explain all psychosomatic symptomatology, be it due to structural
disease or physiological dysfunction, on the basis of a single psychodynamic
hypothesis. Instead we need further detailed studies of individual patients, and
research at a variety of levels, that is,,at the level of bodily and cerebral
function, at the level of psychodynamic structure and functioning, and at the
level of social functioning. with special emphasis on the interactions that take
place between body, brain, mind and the social environment.
The Psychotherapeutic Process
Although I have based much of what I have said so far on what we have
learned from psychoanalysis, group analysis and dynamic psychotherapy in
general I want to conclude by briefly looking at a few of the impliiations of
the concept of mind-body interaction for dynamic psychotherapy itself. This I
would like to do under two closely related headings: the attitude of
psychotherapists, and the work they do with their patients. For the sake of
brevity I shall here use the words psychotherapy or psychotherapist, for all
forms of dynamic psychotherapy, including psychoanalysis, group analysis
and the various forms of analytically oriented individual, group and family
therapy.
Taking the psychotherapeutic attitude first: the therapist by the very nature
of his professional work and training needs to keep the focus of his attention,
centred on his patient's mind with its psychic reality. It is what the patient
experiences and conveys to his therapist that he is concerned with, and with
the attempt to understand its meaning. Whilst as therapists we therefore fully
acknowledge the reality of mental phenomena and hence of our patients'
subjective as well as objective experiences, we need at the same time to remain
aware of the reality of the body and its relation to mental phenomena. This
implies an attitude on the part of the therapist which acknowledges the
profound impact which emotional experience, including experience in the
transference and in the patient-therapist relationship in general, has on bodily
function. And conversely, of course, that bodily processes, our instinctual
needs and the various bodily functions affect our phantasy life and personal
development and thus our mental functioning both in health and in illness. The
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inescapable fact that the body in its own right is prone to illness and ultimately
cannot escape death needs to be sipilarly acknowledged. Physical illness can
affect mental function not only directly but also indirectly because it can lead
to phantasies which are often secondary to physical symptoms, to severe
anxiety, fear of loss, actual loss and other forms of psychic pain.
Freud was of course profoundly aware of the intimate relation between
mental phenomena and bodily functions andsexpressed this in ‘The Ego and
the Id’ (1923) where he says: ‘The Ego is first and foremost a bodily Ego’.
I n the light of what I have discussed in this lecture I would like to interpret this
statement of his as indicating not identity of body and mind but the fact that
mind and body are in a constant state of mutual dependence and interaction.
To be aware of this is one of the essential attitudes required of all
psychotherapists.
How then does this affect the actual psychotherapeutic work? Firstly, I
want to stress how much of what the patient communicates to his analyst or
therapist and in groups to the group leader and the other group members is
in fact conveyed non-verbally through bodily behaviour. Although this is of
course a well-known and widely recognised fact I believe that in the actual
practice of individual and group therapy more systematic attention needs to be
paid to this than is usual. The facial expression; restless movements of arms or
legs or of the whole body: repetitive gestures, lying on the couch, or sitting up,
in a state of tension and immobility, or being silently relaxed or even falling
asleep; the nature of the patient’s breathing, all these and other easily
observable physical phenomena need to be recognised as having meaning of
which the patient is often quite unaware. The therapist can use these bodily
expressions of mental processes to understand what may be going on at the
time and, when appropriate. draw the patient’s attention to them, and use
them as a basis for interpretation.
The other point concerning the work that is being done in therapy is
connected with the counter-transference. I ts central importance is, of course,
acknowledged by all dynamic psychotherapists but I want to draw attention
to the fact that the therapist may not only have thoughts, feelings and
phantasies but also bodily sensations which arise in him during the sessions
which may reflect his response to what is being conveyed to or projected into
him unconsciously by the patient. Feeling tense, being restless, making
movements like shifting one’s position in the chair, actual physical discomfort,
like a sudden headache, or the opposite, feeling very relaxed and at ease,
almost to the point of falling asleep. should be noted and an attempt be made
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to understand their meaning in terms of what the patient may be projecting
into the therapist. Hopefully, as therapy progresses patients will as a result
themselves become increasingly aware of the close connection between their
emotional experiences and their physical sensations, symptoms and
behaviour. These few remarks on the actual process of psychotherapy will
have to suffce in the context of today’s lecture.
Conclusion
I would like to end by sharing with you my main conclusions, if you like, my
personal view, which follows from the thesis of mind-body interaction in the
form in which I have put it forward.
The human mind occupies a very special position in our world. It provides
meaning - and at times non-meaning - of each individual for himself and
for others. The mind stands at the very centre of all that man has created in
terms of thought, play, imagination, culture, art, science, social organisations,
religious and spiritual experience and so on. It provides the basis in each of us
for the capacity not only to act and to do, but also to exist and to be.
More specifically, in the context of today’s lecture, it is the human mind
that has created the fields of psychoanalysis, group analysis and
psychotherapy in its various forms. The essence of each of these is that the
mind observes and studies itself. Similarly. it is the human mind that has
created the scientific knowledge now available in the neuro-sciences which
have thrown so much light on the brain and in turn, through the brain, on the
mind itself and on their inter-relationship.
By thus giving the mind its proper place at its own level of biological
organisation, whilst never ignoring its physical dependence on and interaction
with the brain, as well as with the world around us, we can, I hope, avoid the
pitfall of attempting to reduce mental to physical or behavioural processes.
The human mind deserves respect in its own right. With that thought may I
now leave it to the minds of each of you to consider further the meaning of
what I have tried to share with you.
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