PSYCHOTHERAPY

Editor: Drew Westen, PhD

Implications of Developments in Cognitive
Neuroscience for Psychoanalytic Psychotherapy
Drew Westen, PhD
Reprint requests: Drew Westen, PhD, Departments of Psychiatry and
Psychology, Emory University, 532 N. Kilgo Circle, Atlanta, GA
30322.
Harvard Rev Psychiatry 2002;10:369373.
2002 President and Fellows of Harvard College
369
During the 1960s and 1970s, psychology underwent a cog-
nitive revolution in which information-processing mod-
els based on the metaphor of mind-as-computer supplanted
the behavioral models that had dominated experimental
psychology for much of the previous century. In similar fash-
ion, we are currently witnessing what might be called a sec-
ond cognitive revolution in experimental psychology and
the neurosciences, characterized by a number of interrelated
features. In this article I describe a few of the central features
of this second cognitive revolution and then briefly outline
some of the implications and challenges for psychoanalytic
psychotherapy.*
THE SECOND COGNITIVE REVOLUTION: CENTRAL
FEATURES OF A PARADIGM SHIFT IN PROGRESS
The rst feature of this emerging paradigm shift is a change
in emphasis from serial to parallel processing models. In se-
rial processing models, units of information come into con-
sciousness one at a time (serially), then either fade away or
become stored in long-term memory. From long-term mem-
ory, they can be retrieved into short-term memory, which
holds roughly seven pieces of information (such as seven dig-
its) for about 30 seconds.
In parallel processing models, these serial, one-at-a-time
conscious processes are understood to be superimposed upon
a more pervasive parallel (many-at-a-time) architecture.
Thus, when we perceive tears in a patients eyes as he talks
about his divorce, we are processing visual information from
his face simultaneously with the sound and meaning of his
words. Together, what we see and what we hear lead to an in-
stantaneous conscious perception of tears. Had the barely
perceptible increase in the amount of liquid surrounding his
eyes not been accompanied by his words and our under-
standing of their meaning to him, we might not have noticed
it at all or might have interpreted it differently.
A second feature of the current cognitive revolution is a
conceptual shift from memory stores to memory systems. In
this view, knowledge resides not in places or engrams in
the brain, but in distributed networks of neurons whose co-
activation constitutes a representation. To put it another way,
when we perceive, say, a tear, a network of neurons is acti-
vated simultaneously. When we remember that tearful look
(and perhaps the narrative that accompanied it), enough of
the original network is reactivated to representliterally, to
re-presentthe experience in our minds. This network is dis-
tributed (that is, dispersed) over a large number of neural
units, whose simultaneous activation constitutes a memory.
Thus, in this view, a memory is not a thing that is stored
somewhere in a mental warehouse and can be pulled out
and brought to the fore. Rather, it is a potential for reactiva-
tion of a set of neurons that together constitute a particular
meaning.
Athird feature is the increasing recognition of the impor-
tance of distinguishing between explicit memory (conscious
recall or recognition, such as remembering a prior experience
or the name of a medication) and implicit memory (memory
outside of conscious awareness). Of particular relevance for
psychotherapy is the distinction between two kinds of mem-
ory that are often implicit: associative memory and proce-
dural memory. Associative memory involves the unconscious
activation of networks of associationthoughts, feelings,
wishes, fears, and perceptions that are connected, so that ac-
tivation of one node in the network leads to activation of the
others. Implicit associative memory can be seen in priming
*For a more extensive discussion of these issues, see Westen and Gab-
bard.
1,2
For examples of this second cognitive revolution in the
cognitive neuroscience literature, see Rumelhart and McClelland,
3
Schacter,
4
Smith,
5
and Squire.
6
For recent examples of integrative
efforts linking psychoanalysis and cognitive science, see Bucci,
7
Horowitz,
8
Olds,
9
Shevrin et al.,
10
and Westen.
11
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experiments. For example, presentation of the word taxi
renders an individual more likely to use the less common
spelling of the homophone fare/fair, because taxi primes the
associated word fare.
Procedural memory refers to skills that are expressed
without conscious awareness and that may even be disrupted
if the person tries to perform them using conscious control.
Skilled musicians, for example, can produce notes far faster
than they can consciously read them, just as skilled psy-
chotherapists can respond to complex, multidetermined com-
munications from their patients long before they can con-
sciously process the multiple levels of meaning. Indeed, one of
the challenges of clinical supervision is learning to verbalize
knowledge that is proceduralto make the implicit explicit.
Juxtaposed with procedural knowledge is declarative knowl-
edgeknowledge of facts (events, abstractions, details) that
can be declared.
Although researchers often use the words implicit and
explicit as synonyms for procedural and declarative knowl-
edge, the implicit/explicit distinction refers to the way in
which information is remembered (unconsciously or con-
sciously), whereas the procedural/declarative distinction in-
volves the manner in which knowledge is represented (as a
skill or as a fact encoded in a linguistic or sensory mode). De-
clarative knowledge can be implicit (such as words that are
primed and hence activated but not currently within ones
awareness, or incidents that are too painful to remember ex-
plicitly), and procedural knowledge can be explicit (such as
coping strategies, which are skills for regulating emotions).
Indeed, one of the ways in which cognitive neuroscience
might benet from greater contact with psychoanalysis is in
addressing phenomena such as implicit declarative thoughts
or memories (e.g., implicit knowledge about negative aspects
of a loved one that are kept from conscious awareness because
they would elicit unpleasant feelings).
A fourth feature of this second cognitive revolution is a
growing awareness of the role of emotion and motivation in
thought and memory and, with it, an increased focus on real-
life, meaningful memory (rather than memory stripped of
meaning in the laboratory, such as pairing of nonsense syl-
lables). Researchers are increasingly studying phenomena
ranging from traumatic memories and the impact of trauma
on the brain to more motivationally significant processes,
such as how we remember to remember to do something later
in the day.
Finally, and perhaps central to all of these features, is a
shift in metaphor, from mind-as-computer to mind-as-brain.
Whereas cognitive scientists of the 1960s drew their inspira-
tion from the high-speed computers of their day, those of the
1980s and 1990s were equally inspired by developments in
the neurosciences. Thus, the simultaneous activation of a net-
work of neurons and the transmission of neural information
at the synapse became useful metaphors for the simultane-
ous activation of information-processing units that together
could constitute a unit of meaning and for the way in which
the ring of one unit could alter the likelihood of activation
of other associated units. The shift in metaphor is of particu-
lar signicance because it brought into cognitive models three
phenomena that were shadowy figures in the cognitive sci-
ence of eras past: emotion, motivation, and consciousness.
Computers lack all three, but brains do not. For practicing
clinicians, the shift could not be more crucial, because infor-
mation-processing models that cannot address emotional
phenomena, wishes and fears, and information processed at
different levels of consciousness can be of only limited use
to them.
IMPLICATIONS FOR PSYCHOANALYTIC
PSYCHOTHERAPY
The relationship between psychoanalysis and developments
in psychology, psychiatry, and the empirical sciences more
generally has always been ambivalent. Freud usually con-
sidered psychoanalysis a science (to this day, paper presen-
tations at the meetings of the American Psychoanalytic As-
sociation are listed on the program under the heading of
scientic proceedings), but he wrestled throughout his ca-
reer with the difculties inherent in constructing a science of
meaning.
In many respects, recent developments in the cognitive
neurosciences have breathed new life into psychoanalytic
forms of psychotherapy, particularly long-term therapies, pro-
viding them an empirical grounding in basic science even if
they lack solid grounding in applied research on treatment
outcome.
A testimony to the increasing convergence of psychoana-
lytic ideas with concepts from the cognitive neurosciences is
the number of articles in the psychoanalytic literature that
reference concepts such as implicit and explicit memory and
procedural knowledge. In particular, the second cognitive rev-
olution promises to provide an empirical grounding for two
central psychoanalytic concepts: unconscious associative net-
works and unconscious procedures. A century after Freuds
pioneering clinical/theoretical efforts, a virtual explosion of
experimental research into unconscious (implicit) processes
has borne out his most fundamental assumptionnamely,
that unconscious associative networks regulate much of what
we think, feel, wish for, fear, and do.
11,12
In suggesting that
much of our mental life is organized around unconscious as-
sociational networks, Freud drew on the same British asso-
ciationist tradition employed by contemporary cognitive sci-
entists. If it is nothing else, psychoanalysis as a treatment is
a process aimed at trying to map a patients idiosyncratic as-
sociative networks, particularly those that appear relevant
to symptomatic sources of distress, in the process giving the
patient more freedom to make conscious, explicit choices.
370 Westen
Harvard Rev Psychiatry
November/December 2002
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Classic psychoanalytic models of conict and compromise
further emphasize the extent to which we carry out complex
procedures to regulate emotions (defenses) and balance com-
peting motivational and emotional pulls (compromise for-
mations). Object relations and contemporary relational
approaches to psychoanalysis emphasize implicit represen-
tations of self and relationships as well as the implicit rela-
tional procedures that guide much of the way we think, feel,
and interact in intimate relationships. Although neuro-
scientists have not yet integrated these kinds of complex af-
fective, motivational, and interpersonal/intrapsychic phe-
nomena into their models, the features of the second cognitive
revolution described above make such an integration much
more possible. Indeed, one of the major ways in which psy-
choanalysis can contribute to cognitive neuroscience, rather
than just learn from it, is to bring to bear clinical data and
conceptualizations that would probably not emerge from the
laboratory, where the focus is on nonidiosyncratic networks
that lead subjects to respond similarly to an experimental
manipulation.
Although psychoanalysts have reason to rejoice in the nd-
ings of contemporary research in cognitive neuroscience, this
research also poses some substantial challenges.
1,2,12
First
and foremost, data from the cognitive neurosciences suggest
that many unconscious processes are unconscious not by
virtue of defense but because of the construction of the hu-
man brain. People are often unaware of their implicit net-
works of association because these networks are, in Freuds
terms, descriptively but not dynamically unconscious. We
have no more access to our implicit associational networks
than we do to the perceptual processes by which we locate an
object in space. The same is true of many implicit relational
procedures that are the center of a substantial amount of clin-
ical workrelational procedures forged in a matrix of tem-
perament, experience with early attachment figures, and
evolving relationships over time.
None of this is to deny the importance of defensive
transformations of unconscious representationsmotivated
decision-making that leads people to see themselves, oth-
ers, or situations in a light that minimizes negative affect
and maximizes positive affect, or motivated failure to become
conscious of activated representations that are threatening.
The point is simply that making the unconscious conscious
is more complex than it may once have appeared, because it
entails not only helping people to see what they have been
afraid to see but also helping them to see patterns of func-
tioningways of dealing with emotions, of interacting with
other people, of viewing themselvesthat they could not
have seen even if they had wanted to.
What are the implications for psychoanalytic psycho-
therapy? Perhaps the major implication relates to free as-
sociation, the use of which constitutes a major technical
distinction between psychoanalysis and psychoanalytic psy-
chotherapy. Free association is one of the pillarsindeed, the
fundamental ruleof psychoanalysis proper as a technique,
predicated on the assumption that free association is rela-
tively free except when encumbered by defense. Acognitive-
neuroscientific account challenges the psychoanalytic view
of pristine, unfettered associations originating in the patients
childhood or even in the relational matrix of the analytic
dyad. What is on a persons (unconscious) mind at any time
is a joint function of what is chronically there (much of which
is likely, in fact, to reect concerns originally forged in child-
hood) and what has been there recently, which may or may
not be related to the concerns that brought the individual
to treatment. Recency effects include not only the events of
the analytic hour but also extraanalytic events that could be
important to explore. The particular associations that emerge
in any analytic hour may or may not be useful to examine;
with respect to core dynamics, they may represent signal or
noise. Over time one would expect important material to be
reected repeatedly in the patients associations, particularly
if the analyst makes few interpretations that shape these as-
sociations, since chronically activated networks produce de-
rivatives in both the conscious thought and the associations
of the patient. However, this is likely to be a very inefcient
process (and indeed is what drove many of the early cognitive
therapists, such as Beck and Ellis, to leave the analytic fold),
and the advantages of keeping the patients associations rel-
atively free of the analysts theories and interestseven if
doing so were possiblecome at the cost of other potentially
important interventions.
To complicate matters, patients can (consciously and un-
consciously) veer away from entire networks of association
that make them feel anxious, guilty, or ashamed, potentially
keeping central issues out of the therapeutic spotlight for
years, because doing so provides short-term relief from un-
pleasant feelings. Further, a patient who avoids feared activ-
ities (for example, an individual who avoids meaningful re-
lationships due to fear of intimacy) is unlikely to have the
relevant networks at a high enough state of activation to ex-
plore without actual exposure to the feared situation. Thus,
the analyst may need to depart from neutrality vis--vis the
patients conicts and encourage activities that both expose
the patient to what he or she has been avoiding (which has
the potential to foster the development of new networks, a
central aim of behavioral treatments) and that bring to the
fore the most important associative material. Freud was the
first analyst to practice this way, noting at one point that
people cannot free themselves of their fears unless they con-
front them. The dangers in taking sides with respect to a
patients conicts lie in making an internal conict an exter-
nal one between patient and therapist, and in the potential
for therapists or analysts to act on the basis of their own coun-
tertransferential pulls rather than in the patients best in-
terest. This paradox has no solution, of course, but good treat-
Harvard Rev Psychiatry
Volume 10, Number 6 Westen 371
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ment probably requires a balance of exploration and exhor-
tation in the service of further exploration and behavioral
change.
13,14
Although it is not free of limitations, free association is
clearly one of the most effective ways of learning about a pa-
tients associative networks. Time constraints, however, tend
to limit its use in the kinds of weekly or twice-weekly psy-
chodynamic psychotherapies widely practiced in the commu-
nity. One useful way to employ associative techniques in psy-
chodynamic psychotherapy is to use a form of directed free
association, departing at various points from the more con-
versational style of treatment and asking for the patients as-
sociations to important material or signicant memories as
a way of exploring the underlying associative networks. For
example, one patient who repeatedly dumped women as
soon as their relationship became sexual had no idea why he
was doing this, although he was always ready with an expla-
nation. On one occasion, after the pattern became clear, I
asked him to imagine as vividly as possible the events of the
prior evening, particularly the events that occurred in bed
before his latest paramour took her nal leave. I asked him to
walk me through the episode moment by moment, eliciting
associations along the way, suggesting that he report any-
thing he thought, felt, saw, tasted, smelled, or felt during the
encounter and any memories or images that emerged in re-
calling it. My aim was to activate a multimodal network and
to prime as many of its elements as possible. Doing so led to a
series of associations about his fears of his own aggression
and his tremendous guilt at these impulses and fantasies
and to several weeks in which we did virtually nothing but
associative work of this sort, after which the conict resolved
itself and never returned.
Data from the cognitive neurosciences may also help to
shed new light on classic psychoanalytic constructs such as
object representations, transference, and countertransfer-
ence. Viewing object representations (representations of the
self and others) as potentials for reactivation of previously
active neural networks that include both declarative and pro-
cedural elements may lead psychoanalytic theorists to be
more precise in their models of how representations form and
guide relational functioning. The notion that a patient can,
for example, project into the therapist a particular repre-
sentation or way of responding requires much more careful
explication than is common in psychoanalytic literature,
where too often clinically rich description alloyed with
metaphor passes for explanation (see Westen, in press
15
).
Such an explication would require theorists to be more spe-
cic about how particular representations or procedures ac-
tivated in the patient become expressed implicitly and how
they trigger particular patterns of activation in the thera-
pist that are either culturally patterned (and hence lead
to ways of responding that virtually anyone would have,
producing the kinds of repetitive interpersonal patterns
described by numerous psychoanalytic theorists) or more
idiosyncratic (the old meaning of countertransference,
as a problematic intrusion of the therapists issues into the
treatment).
Similarly, the notion of representations as potentials for
reactivation offers supportive data at the level of basic sci-
ence to the long-held psychoanalytic position that patients
are likely to express important conicts, defenses, motives,
and relational patterns in their interactions with the thera-
pist or analyst. From a cognitive point of view, the therapeu-
tic situation, to the extent that it matches prototypes from
the past, is likely to activate such responses.
16,17
Thus, it
should not come as a surprise if important relational patterns
emerge in a situation in which one person deeply self-
discloses and becomes attached in an intimate but asymmet-
rical relationship with another who is trying to be helpful,
nurturant, and attentive to that persons needs. Simply by
virtue of the way the therapeutic frame is set, the therapist is
likely to be experienced as an authority gure, an attachment
gure, an object of love, an object of desire, and so forth.
At the same time, research in cognitive neuroscience chal-
lenges a number of views of transference once taken as ax-
iomatic but increasingly challenged in the analytic literature,
such as the view that everything important about the pa-
tients psychopathology will ultimately come out in the ther-
apeutic relationship or that characteristics of the patients
internal relational paradigms are likely to express them-
selves regardless of features of the analyst such as age, gen-
der, or style. Although some relational paradigms are likely to
be so tenacious that they will ultimately turn up in virtually
every significant relationship, including a therapeutic one,
thinking about the conditions for activation of representa-
tions should lead to clearer thinking about the circumstances
in which important material is likely to emerge in the trans-
ference or will require examination of extra-transferential
relationships.
CONCLUSIONS
Data from the cognitive neurosciences are not likely to revo-
lutionize the practice of psychotherapy, but they are certainly
likely to enrich it. At minimum, these data corroborate the
importance of attending to unconscious (implicit) networks
that regulate many of the ways we think, feel, desire, fear,
and fall ill. Afundamental question at this point is how to im-
prove our technologies for changing those networks.
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Harvard Rev Psychiatry
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