Eliezer T. Margolis, PhD, ABPP

Assistant Clinical Professor (retired)
Departments of Psychiatry & Behavioral Sciences,
and Physical Medicine & Rehabilitation
Feinberg School of Medicine, Northwestern University

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Note about the text: This manuscript essentially appears in published form at Brain Injury Source, Vol. 2 No. 1, Winter 1998, pp. 24-28, 50.  However, the published version contains many textual errors, including some substantive elisions.  Cited references appear at the end of the full text.

I. Psychical Trauma Concomitant With Brain Injury

In the search for effective psychological treatments, it is widely assumed that, in order to convincingly demonstrate the therapeutic value of a given proce­dure, one should, at minimum, be able to posit a rationale for the procedure which is framed in terms of its specificity. In this essay, I will attempt to show that an exis­tentially oriented approach–of a very specific kind–to psychotherapeutic work with individuals who have suffered brain injuries is a treatment procedure which specifi­cally addresses the need for psychicalal vs. tissue healing following brain injury.

For some time now, I have had a great interest in the application of individual psychotherapeutic procedures to the variety of problems experienced by people with brain injuries. I have noted, from personal observation and from published reports, that there is a somewhat chaotic array of clinical methods which are employed in this work, along with a tangled mix of philosophical commitments and notions of­fered in support of them. In spite of the confusion, the various approaches can be usefully sorted out according to the central therapeutic purpose that motivates each. Roughly gauged, I would characterize those defining purposes as including the fol­lowing: behavioral management (including social skills); cognitive remediation (or, cognitive rehabilitation); medical management (including management of medica­tions, risk factors of disease, symptoms of chronic illness, sexuality issues); problem solving; support; and, adjustment (or, “re”adjustment) in relation to one or more sys­tems, e.g., community, family, educational, vocational, disability care, etc. Oddly enough, none of the existing varieties of individual psychotherapeutic work, to my knowledge, have as their express purpose the healing of the psyche of the person who sustained a brain injury.

In contrast, the objective of the approach to individual psychotherapeutic work presented here is specifically defined in terms of promoting psychical healing. What is more, the specificity of the psychotherapeutic project is expanded by virtue of the fact that its objective of promoting psychical healing is framed within an appre­ciation of the distinctive and compound trauma to the psyche which is peculiar to brain injury. It should be clarified that this existentially-oriented individual psy­chotherapeutic approach is wholly unrelated to any claim of exclusivity, and does not demand rejection or devaluation of any other psychotherapeutic approach. In fact, over the course of time, through a passing incorporation of some of the central therapeutic purposes (listed above) associated with other approaches, this existen­tially-oriented approach may incidentally result in attaining the kinds of goals con­nected with each of those other approaches. Again, the point of differentiation is that the approach to the psychotherapeutic project after brain injury being advanced here has as its central purpose and critical focus the healing of the psyche.

This critical focus proceeds from the important assumption that healing is not only desirable but necessary and possible even where cure is not. So that, even when the restoration of some premorbid/preinjury condition of constitutional physi­ological integrity–whether measured in terms of isolated tissue states or more global health/wellness status–is not medically attainable because of ablation, infarction or entrenched disease process, a healing of the organism, a coming to wholeness, is still possible. Some writers on healing, such as Stephen Levine (1987) and Rachel Naomi Remen (see Moyers, 1993), have cast this idea in its ultimate form in the proposition that one might even succumb to death but be healed as persons in and through that terminal process. When applied to the field of brain injury rehabilita­tion, this superficially paradoxical way of thinking about healing vs. curing dictates that even though individuals may sustain permanent (“incurable”, irreversible, or “unfixable”) and severe insults to the central neural substrate, with correlative de­rangement of brain function, overall healing from such insults is, nevertheless, possible.

Before moving on, it should be noted that arguments for the primacy of heal­ing vs. curing are founded on the tacit premise that mind and body (i.e., brain) are completely and bidirectionally integrated in a manner which gives rise to a unified, seamless and irreducible field of bioactivity equivalent to the person. Hence, healing is understood to be pervasive, or organismic, in its effects. A corollary of this premise, therefore, of especial significance for the ideas presented here, is that working to achieve psychicalal healing is identical with achieving healing, understood as a global or organismic phenomenon.

As a rehabilitation psychologist, I have come to strongly believe that the most essential need to be addressed in the clinical situation is that of psychicalal heal­ing. All else appears to flow from that. In other words, the fullness and the extent of the trajectory of recovery following brain injury, measured in terms of concretely adaptive or functional gains, can be directly related to and is limited by the extent of psychicalal healing which takes place.

My clinical experience with individuals who have survived catastrophic brain injury has taught me that the distinctive character of brain injury springs from its multiply traumatic nature. The first traumatic dimension is primal, affecting the or­ganism as a whole. This first type of traumatic impact results from violent upheaval in biological homeostasis and assault on tissue integrity. Because central nervous system insults so often induce unconsciousness, in which increasing degrees of in­sult severity tend to produce more persistent states of unconsciousness, this level of trauma is not directly experienced in consciousness. Due to the exquisite interrela­tion of mind and body, however, this first level of trauma is registered psychically. Moreover, the fact that the trauma brands the psyche at such primal, inaccessible depth is what typically engenders such a profoundly disturbing psychological effect in the person whose mind will posttraumatically regain consciousness. This kind of psychical disturbance I have clinically observed to be particularly associated with in­stances in which there is a very dense, if circumscribed, period of peritraumatic am­nesia is seen with catastrophic cerebrovascular injuries such as spontaneous hemor­rhages of varying etiology.

A second dimension of the psychical trauma concomitant with brain injury de­rives directly from the first level of trauma except that it takes place at a basic but conscious level. Some of the primal property of the first level of trauma is pre­served, however, in the inchoate quality of the apprehension of the onslaught on the organism which has occurred. The traumatic reaction associated with this dimen­sion of psychological trauma arises in a level of experience which, while not concep­tually mediated, is clearly and dramatically manifest in the signs of shock. The per­son is not yet verbally reflecting on their experience in a cogent fashion, but is still immersed in and reeling from the devastating blows of it. In addition to being shaken, the individual often feels an intensely sharp sense of dislocation. Persons newly traumatized by severe brain injury find themselves pressed up against an in­stinctive knowledge of the monstrously destructive force that almost took their lives, and have yet to commence the inevitable stock taking of the calamitous damage done to them. In my experience, there is a great potential for this dimension of trauma to resolve naturally with the passage of time unless there is a retraumatizing event or there is unabated aggravation in one or more of the many aspects of a third dimension of trauma.

The third dimension of psychological traumatization is more consciously real­ized than the previous two; in many ways, it forms the complex, problematic residue from brain injury. This is the dimension of trauma which is expressed through a va­riety of states of distress in the phenomenology of the self. In other words, this is the trauma that comes into being through the individual’s implicit construction of the experience of their brain injury as an injury to their psychological self.

This psychological, or experienced, self has a dual nature. It is predominantly the self which is the main character—one hopes, the hero/ine—of the life story. And it is, of course, within this narrative sense of self that the meanings and consequences of the brain injury redound upon the unresolved conflicts and psychological concerns of the pre-injury self. There is another experienced self which is more the cyber­netic, or cognizing, self; it plays a less dominant role in the personality. Less affec­tively-valenced, this mode of self is identified with what it feels like to a person when their mind is intensively and narrowly focused on guiding some complex motor sequence or carrying out some information processing or problem-solving task. The cognizing self experiences what might be considered, roughly speaking, as proprio­ception of the brain engaged in conscious mental activity.

In all, this third dimension of trauma encompasses: the organization of self experience, the contents of self experience, and the very feel of being, with its al­lied, sense of reality. It seems that within the world of the conscious and psycho­logically intricate self, penetrating, pervading, and unrelenting awareness of loss, more than any other factor, constitutes the wounded, reactive sensitivity that drives this third traumatic dimension of brain injury. It applies to losses in every conceiv­able domain of human activity and being, but is singularly tied to disruptive alter­ations in the foundational, frame-of-reference functions attended to by the narrative self, such as identity, lovability, value, social status, sense of normalcy, and cos­mological, or theological, view.

Furthermore, the computer-like, cognizing self appears to have its own spe­cialized attunement to loss experienced as deficit state. There appears to be a highly specific dysphoria that stems from an immediate and direct experiencing of the fragmented, slowed, distractible and/or otherwise balky mind which often emerges in the aftermath of brain injury.

While these three genres of psychical trauma are identifiably different, they have been rendered here, with heuristic intent, as more separable than they are. In actuality, the trauma dimensions resonate with one another, painfully amplifying each others’ effects and contributing to the formation of a uniquely nuanced elabora­tion of an individual post-injury profile of psychical traumatization.

II. Psychical Healing, The Experience of Relationship

Within the past 15 years or so, a new, relational paradigm of human psychol­ogy has begun to more confidently occupy its place among competing ideologies of human nature. The relational paradigm has been advanced by field research findings in evolutionary biology but it has been expressly codified in a gathering body of feminist-leaning writing on human development, personality, and social psychology which has incorporated a critique of the heretofore dominant paradigm in psychology (Jordan, Kaplan, Miller, Stiver & Surrey, 1991). In its simplest form, the new paradigm posits that the motive for humans to be well related to meaningful others is more contributory to evolutionary success on a species level, and to maturation and psychological health on an individual level, than the societally prized motive of the historically dominant paradigm of being independent, separate, and personally sovereign (e.g., Guisinger & Blatt, 1994). In sum, the relational paradigm asserts the primacy of relational connectedness, among all other variables, to inform and de­termine the quality of human existence.

The approach to psychotherapy with people who have suffered brain injuries, being offered here, proceeds from an unqualified endorsement of the relational paradigm. As such, the approach arises from a corollary of the paradigm that the most profound source of human tragedy and psychical traumatization is loss of rela­tionship. The often unfathomable suffering which accompanies brain injury is no ex­ception.

The overwhelming proportion of the most conscious and most lingering kind of psychical traumatization that follows in the wake of brain injury organizes itself around deep and forceful concerns about the ultimate and most momentous conse­quences of injury: the loss of relationship. In my experience, individuals are pos­sessed by two interrelated types of feelings about the personal cost of their injuries.

Individuals with acquired brain injuries quickly discover that one of the less visible but no less rigid and cruel status hierarchies which context our lives in North America is cognitive. So, the first penetrating terror about portended loss of rela­tionship is that because their brain injury so drastically reduced their social value, they fear they are left without enough social capital to draw others, of almost any status, into relationship with them, let alone individuals of perceived high status. This can stir primitive, unabating fears of being shunned; fears which negatively in­cline some towards a very refractory, depressive syndrome of apathetic social with­drawal which is different from the adynamic presentation following some frontal lobe injuries.

The second type of searing feeling connected with threatened loss of rela­tionship stems from a naive appraisal that, because of neural tissue damage in the brain, the complement of subtle neuropsychological competencies which support the capacity to come into meaningful, soulful relationship are now irretrievably lost. To the person with a brain injury, this looms as something far greater than a possible adjustment to newly degraded social skills or social judgment. It is, rather, a dread fixed on the experience of connectedness itself. Relationship is construed from con­nection; internally, with the self, and externally, with others and the world. With­out the neuropsychological integrity to experience connectedness, to actively assist in its creation, all but the most mechanistic kind of relationship is lost.

As the foregoing makes clear, in order for healing of the psychical trauma con­comitant with brain injury to take place, catastrophic feelings about loss of relation­ship must be addressed. And this is precisely the essence of the method of psy­chotherapy being put forth here. More pointedly, this approach to psychotherapy derives its ability to heal the psychical trauma peculiar to brain injury because of an experience of relationship that the psychotherapy purposefully fosters owing to its grounding in existential constructs of relatedness. Specifically, an existentially con­ditioned psychotherapy yields an experience in relationship that is a) affirmational concerning the prospect of continued relational appeal, addressing the first type of fear of loss of relationship due to ostracism of the mentally defective, and that is b) confirmational of preserved capacity of relationship, addressing the second type of feared loss of relationship.

At this juncture, it will be most helpful to clarify, in substance, in what re­spect the proposed psychotherapeutic approach is existentially conditioned. When the terms existential and psychotherapy are conjoined, it is often supposed—in particular, by North American audiences familiar with Yalom’s landmark book on the subject (1980)—that it signifies a psychotherapeutic endeavor that is occupied with themes such as meaning, choice, responsibility, authenticity, and an unsparing con­frontation with death. In other words, the conjunction chiefly signifies a special in­tensity of interest with respect to the content, or issues, around which the psy­chotherapeutic relationship is engaged. (For an example of this kind of infusion of psychotherapy with traditionally existential themes, specifically applied to a brain injury case, see Nadell, 1991.) This is not at all what is intended in my conjoining of the two terms, however.

In appropriating the term existential, the intent here is, first and foremost, to signify a highly distinctive envisioning of what inheres in the face-to-face human en­counter of true dialogue, what the 20th Century philosopher Martin Buber called “meeting”. In fact, a little over 40 years ago, Buber described an approach to psy­chotherapy elegantly concentrated on the healing which comes just from the ar­rangement of a meeting of this order (1957/1963).

Because the proposed existential psychotherapy relationship is so decidedly defined by the mode in which the partners to its engendered dialogue are related to one another, it prominently diverges from a broad range of verbal psychotherapies which are geared toward the generation of problem solutions and/or insight. With its marked shift away from the achievement of impressive solutions or insights, the psychotherapy relationship which is approached from an existential commitment to meeting implies just as marked a shift away from the psychotherapist’s cleverness at making interpretations or devising impressive solutions. In contrast, the shift is towards the psychotherapist’s capacity for and readiness to meet, that is, to make genuine relationship through rendering him/herself fully present, in openness, to the individual who is her/his patient.

In an existentially conditioned psychotherapy relationship, the psychothera­pist must be not only capable of but eager for and adept at several different kinds of readiness, all of which attend the general readiness to meet and are associated with different aspects of openness and giving up. First—because it so radically de­parts from expected role behavior—to be ready to meet, the existentially condi­tioned psychotherapist must give up his/her position of authority, meaning their claim to a hierarchical superiority in the relationship. This giving up is in favor of acknowledgment of absolute parity with the patient in terms of human worth, and a commitment to be wholly unconcealed, or guilelessly present, in the meeting, just as the patient is. Both of these, the acknowledgment and the commitment, are prereq­uisite to a mutuality of relationship that is foundational to genuine dialogue (Jordan, 1991). And, this readiness to come nakedly into dialogical relationship can not be achieved by declaration but only through deed, for our patients—even with their residual brain dysfunctions—know whether we are experiencing our life unfold with them as theirs unfolds with us, or whether we are hiding and watching them from the midst of a self-protective professionalism, with its conceit of objective neutrality.

Second, to be ready to meet, the existentially conditioned psychotherapist must give up her/his internal need for mastery and control of the psychotherapeutic situation. The psychotherapist comes to the meeting with a total commitment to existing, together with the patient, in the openness of the moment of dialogue. It is a commitment which, if authentically undertaken, leaves no room for the customary preoccupation with technical management of the encounter. This aspect of the psy­chotherapist’s commitment is a wide opening into the readiness for something en­tirely new, uncontrolled, presupposed or preconceived to happen, within each part­ner to the dialogue, and in the between of the dialogic relationship.

In keeping with the above, the existentially conditioned psychotherapist’s readiness to meet represents a giving up of the comforts, habits and subterfuge that were relied upon to shape the more accustomed manner of making psychother­apeutic relationship. In consequence of this ‘giving up’, however, the psychothera­pist is free and ready to enact a commitment that constitutes nothing less than a wholly being for the patient, in the dialogic encounter.

Special care needs to be taken to understand that the psychotherapist’s com­plete giving over to the openness of meeting is most emphatically not a surrender of masochistic submission, i.e. a neurotically gratifying deliverance to the patient’s motive, conscious or otherwise, to have power over the therapist, but a surrender to the moment of dialogue. Furthermore, despite the psychotherapist’s abandonment of control (and certainly, the motive to have power over the patient), her/his ‘being for’ the patient is the consummate expression of what is, simultaneously, interper­sonal accountability and therapeutic responsibility to—versus the responsibility for which is associated with management of the psychotherapeutic relationship.

Now that we have examined the first two kinds of readiness in which the existentially conditioned psychotherapist arranges her/his person for “meeting”, we come to the third and culminating readiness. From the standpoint of more conven­tionally conceived psychotherapeutics, this readiness is the most methodologically, or technically, critical to the efficacy of the relationship as a means of promoting healing from the psychical traumatization which is concomitant with brain injury. This is the readiness to respond, in relationship, which is the fullest embodiment of the responsibility ‘to’ the patient. This specifically psychotherapeutic readiness to re­spond importantly assumes a preceding empathic accuracy in the therapist that will assure the attunement of the response. It should now be evident that the initial kinds of the psychotherapist’s readiness to meet made way for him/her to arrive at such empathic accuracy. Namely, it is through a heightened, exclusive attentiveness to the patient, or a being fully present to the patient, that the psychotherapist is able to respond with unerring or uncontrived attunement. (For an extremely helpful discussion of the elusive term presence, see May, 1983, pp. 158-162).

When there is this kind of psychotherapist readiness to respond, it is made vibrantly real through dialogic responses that are so accurately attuned to the pa­tient’s very experience of coming into being that the patient knows an unmistakable being with in the relationship. The patient’s experience of the psychotherapist’s presence in meeting, with all of its implicit openness, radical acceptance and commitment, is power­fully condensed in the being with experience. The affirmation of the patient’s es­sential worth, with its unstated but unconditional acceptance, is so powerfully im­mediate for the patient, so affectively overtaking of his/her lived experience, that it requires no commentary, in thought or speech, to validate or commemorate it.

It is well beyond the scope of this essay to systematically highlight corre­spondences with other psychotherapeutic approaches (for a comprehensive treatment of such correspondences, see Friedman, 1985), however, it will be useful to simply point out that, phenomenologically speaking, the affectively charged being with experience de­scribed here is parallel with Heinz Kohut’s self psychological construct of “mirroring” (1977). In a similar vein, it is important to glancingly note that, despite the fact that it was not conceived of as a psy­chotherapy per se, A. R. Luria’s monumental 25-year treatment relation­ship with a man with massive brain damage from war wounds, described in The Man With A Shattered World (1987), exem­plified some of the cardinal attributes of the psychotherapeutic approach suggested here.

In review, then, we see that the patient’s non-intellective, or visceral, experi­ence of the psychotherapist’s presence in meeting provides the patient with un­questionable affirmation of his or her unique humanness and unconditional worth. And it is this affirmational aspect of the relationship that promotes psychical healing in regard to catastrophic concerns about relationship loss due to decimated personal value following brain injury. As was set forth above, there is also a confirmational aspect of meeting, and we will turn to examine that by way of concluding.

The confirmational aspect of meeting is really secondary to the affirmational aspect because a) it is augmentive of but not necessary to psychical healing, and b) it is less experientially immediate as the reflected upon derivative of the being with experience. To the extent that what is generally regarded as insight does play a role in the existential approach to psychotherapy following brain injury presented here, it resides in the generated awareness that relationship capacity re­mains meaningfully intact.

In this latter case, psychical healing occurs because the meeting in psy­chotherapy establishes a fact of meeting, a fact of created relationship that plainly attests to and confirms a preserved capacity for relationship. Further, the capacity for relationship has been demonstrated to be preserved at a level “good enough” to produce vivifying feelings of affirmative connection. Reassuringly, the observed fact of meeting bears the promise of future connectedness; because it can be, the ex­perience of dialogic relationship will be replicated elsewhere, in other contexts, with other persons.

In all, I have sought to describe here the psychotherapeutic arrangement of an experience of dialogic relationship for the purpose of promoting psychical healing in the aftermath of brain injury. Unstated but coinciding in this purpose is the hope of facilitating a radical evaluative shift in patients’ experience of their traumatized selves in relation to their appraisals of existence. In developing a specific psy­chotherapeutic approach to healing following brain injury, existential methods have been appropriated in order to serve the hope that through meeting—and its experi­ence of embracing, interpersonal acceptance—persons who suffer brain injury are able to come into the worthwhileness of living not by dint of recruitment to the philosophic proposition that ‘life is good’ but through direct knowledge of the good­ness of living that is immediately experienced in relational connectedness.

References

Buber, M. (1957/1963). Healing through meeting. In M. Friedman (Ed. and trans.), Pointing the way (pp. 93-97). New York: Harper and Row. (Original work published 1951)

Friedman, M. (1985). The healing dialogue in psychotherapy. Northvale, NJ: Jason Aronson.

Guisinger, S., & Blatt, S. J. (1994). Individuality and relatedness: evolution of a fundamental di­alectic. American Psychologist, 49, 104-111.

Jordan, J. V. (1991). Empathy, mutuality and therapeutic change: Clinical implications of a relational model. In J. V. Jordan, A. G. Kaplan, J. B. Miller, I. P. Stiver, & J. L. Surrey (Eds.),Women’s growth in connection: Writings from the stone center (pp. 283-289). New York: Guilford Press.

Jordan, J. V., Kaplan, A. G., Miller, J. B., Stiver, I. P., & Surrey, J. L. (1991). Introduction. In J. V. Jordan, A. G. Ka­plan, J. B. Miller, I. P. Stiver, & J. L. Surrey (Eds.), Women’s growth in connection: Writings from the stone center (pp. 1-7). New York: Guilford Press.

Kohut, H. (1977). The restoration of the self. New York: International Universities Press.

Levine, S. (1987). Healing into life and death. Garden City, NY: Anchor Press/Doubleday.

Luria, A. R. (1987). The man with a shattered world: The his­tory of a brain wound (L. Solotaroff, Trans.). Cambridge, Mass.: Harvard Univ. Press. (Original work published 1972)

May, R. (1983). Concerning therapeutic technique. In R. May, The discovery of being: Writings in existential psychology (pp. 151-171). New York: W. W. Norton.

Moyers, B. (1993). Wholeness: Rachel Naomi Remen, M.D., Commonweal, Bolinas, California [V. Wounded Healers]. In B. S. Flowers (Ed.), Healing and the mind (pp. 343-364). New York: Doubleday.

Nadell, J. (1991). Towards an existential psychotherapy with the traumatically brain injured patient. Journal of Cognitive Rehabilitation, 9 (6), 8-13.

Yalom, I. (1980). Existential psychotherapy. New York: Basic Books.