Case Studies

Case 1

(This case shows how neuroscience can be applied in the therapeutic setting, as well as the connection between early childhood trauma and the later development of chronic pain)

"I didn't know what was happening here at first. I just knew I felt better when I left. Then one day I realized that it was the relationship that was making the difference in how I felt. Your brain works with my brain and the relationship changes my brain."

A patient presented with a severe traumatic brain injury and chronic pain from a severe automobile accident. She suffered pre-frontal cortex injury, hippocampal injury, axonal diffuse injury and aphasia. She also broke her neck, which had led to the chronic pain. She had complete short-term memory loss and the incapacity to organize or follow through on tasks. She had sudden outbursts of anger and also suffered from depression and anxiety. I saw her twice a week using a traditional psychoanalytic approach.

In the beginning, aphasia created a difficulty in her ability to find words with which to communicate. Her appearance was quite disheveled and her walking was difficult.

She complained bitterly about the deficits she was experiencing from the brain injury, as well as about the chronic pain. Along with the deficits in her early memory, damage to her prefrontal cortex made it difficult for her to organize and carry out tasks. She also felt that her disabilities were invisible and therefore not understood by her friends and people she encountered in her daily life. She complained about her family who she felt did not want to know how she was feeling. She often got into fights with them. She told me that she felt no one understood her despair and what a total loss of identity she was experiencing.

I felt that the most important aspect of my "listening" to her, was to be in the moment with her, without having a desire for her to "get better." I felt that I needed to not imagine a future for her that I might subtly encourage her to move toward, but rather to be with her in the present moment that was being created by both of us.

I found that, as she felt my participation with her in this way, she became more interested in herself and the story of her life began to unfold. She spoke about her life as a child, reporting that her father had left when she was three years old, and her mother paid little attention to her because she was chronically depressed and overwhelmed. My patient subsequently reported a series of catastrophic injuries that had occurred before this last one that brought her to treatment.

She told me that when she was seven years old, her father returned on her birthday and accidentally drove his car over her as he backed up in the driveway. She was rushed to the hospital with major injuries. Her father, however, left and never returned. As we uncovered these painful events, she began to realize that she had always considered herself unworthy of her father's love. She saw that she acted out the original traumatic experience through life-threatening accidents, the final one resulting in the acute traumatic brain injury and the chronic pain. She took her father's behavior to mean that she was unwanted and deserved to suffer. The accidents were also a way to stay connected to the father, despite their negative effects.

One day, she brought in a picture of herself when she was a small child. And although she had formerly complained about no longer having feelings, she cried and said that these terrible events should never have happened to this innocent child.

We continued to explore the loneliness and abandonment she experienced in her childhood, and she began to understand the connection between what she experienced as a child and the events in her life that followed. Her presentation began to change through this process. She was able to take better care of herself and she was very interested in what she was uncovering. Her speech became much more fluid and she was more able to reflect about herself and her own behavior.

We could say that the catastrophic events in this patient’s life created “a disease of plasticity.” Even before the traumatic event that created the TBI, she had been depressed, unable to marry, lonely, isolated and quick to anger. She felt lost in her life. She was always unable to manage money or to develop a satisfying career. She had, of course, in fact lost certain brain capacities, resulting from the traumatic brain injury. We can also see how, as Gabriel Burloux states in his book “The Body and Its Pain” (Link to Book Review), her chronic pain communicated the enormous deficiencies she experienced in her relationship with her mother. Many studies have shown that a large percentage of people who develop chronic pain have suffered from some form of trauma in their childhood.

The analytic relationship, however, created new neuronal pathways from which a new history evolved, a history that was continually reworked. A life that had been interrupted and created enormous discontinuity for her, began to assume a continuity as her narration in the moment revealed her story. In this way, she was able for the first time to experience herself as having a history and thus a self-identity.

In the terms of renowned psychoanalyst Wilfred Bion, the renewed plasticity that arose out of her experience of an "analytic" mother who listened "in the moment" (without memory, desire, or understanding) provided the container-contained relationship that allow beta elements of her life to become alpha elements she could use for thinking. In this way, she was able to overcome to a great extent even the actual deficits the TBI left her with.

I believe that this is what Freud meant when he said; "The desired goal would appear to be actual direct communication between one unconscious and another: the analysts unconscious has to relate to the emerging unconscious of the patient "as a telephone receiver is adjusted to the transmitting microphone."

As a colleague Jeffrey Eaton put it, “Using transformations and using the idea of an embodied mind, you move toward an organizing and embodied field of transformations that is, at bottom, a theory of how we learn from emotional experience and how that learning is instantiated in the new neuronal connections at the synaptic level. These new neuronal connections make enlarged experiences of the new present possible.”