JL - Case (11/10/25)

ORIGINAL RESEARCH

  • Published: 25 August 2017

  • DOI: 10.3389/fpsyg.2017.01418

  • Edited by: Antonella Granieri, University of Turin, Italy

  • Reviewed by: Silvio Arrigo Merciai, Independent Researcher, Turin, Italy; Adriano Schimmenti, Kore University of Enna, Italy

  • Correspondence: Paul A. Moore moorep1@tcd.ie

  • Specialty section: This article was submitted to Psychoanalysis and Neuropsychoanalysis, a section of the journal Frontiers in Psychology

  • Received: 23 June 2017

  • Accepted: 04 August 2017

  • Published: 25 August 2017

Citation

Moore PA, Salas CE, Dockree S and Turnbull OH (2017). Observations on Working Psychoanalytically with a Profoundly Amnesic Patient. Front. Psychol. 8:1418. doi: 10.3389/fpsyg.2017.01418

Authors and Affiliations

  1. Paul A. Moore - Department of Psychiatry, School of Medicine, Trinity College, Dublin, Ireland

  2. Christian E. Salas - Laboratory of Cognitive and Social Neuroscience, Faculty of Psychology, Diego Portales University, Santiago, Chile

  3. Suvi Dockree - National Rehabilitation Hospital, Dublin, Ireland

  4. Oliver H. Turnbull - School of Psychology, Bangor University, Bangor, United Kingdom

Abstract

  • Individuals with profound amnesia experience significant impairment in explicitly recalling new episodic events.

  • However, they seem to retain the ability to utilize information from other cognitive sources, particularly emotional ones, which are critical for forming and maintaining interpersonal relationships.

  • Psychoanalytic study in the context of profound amnesia is suggested to help understand the relevance of different memory systems, particularly how they affect processes like transference and countertransference in therapy.

  • The paper describes psychoanalytic work (72 sessions) with JL, a patient suffering from profound amnesia post-anoxic episode.

  • The therapy was modified due to JL's struggle to connect elements of his therapeutic process but did document areas of preservation, particularly a functioning therapeutic alliance that allows for transference.

  • JL’s transference evolves through three phases:

    1. Rejecting

    2. Starting to take in

    3. Full use of the analytic space

  • Each phase displays different levels of interaction between JL and the analyst, having significant theoretical implications for psychoanalytic practice.

Keywords

  • amnesia, brain injury, emotion, memory, psychoanalysis, psychotherapy, transference

Introduction

  • Profound amnesia due to acquired brain damage has provided insights into the neurological and neuropsychological mechanisms of memory and learning.

  • Key findings include the identification of multiple independent memory systems.

  • Individuals with profound amnesia, especially post-hippocampal damage, can experience emotions and learn the emotional significance of experiences, influencing their decision-making process.

  • Such findings align with psychoanalytic theories regarding explicit and implicit domains' roles in personal change.

  • Notably, existing literature discussing psychoanalytic treatments for individuals with profound amnesia is scarce, with only one previous case focused on emotional learning in an amnesic patient.

Case Description

Biographical Information

  • JL, a 38-year-old single man, experienced an anoxic brain injury 3 years prior to treatment due to complications from diabetes and subsequent cardiac arrests.

  • He suffers from marked anterograde amnesia, affecting his ability to create new episodic memories, with preserved retrograde memories.

  • Premorbid issues included significant family disruptions, early alcohol abuse, and dependency issues exacerbated by his parent’s deaths, leading to a deterioration in personal health.

  • Post-injury, JL has lived in a structured rehabilitation environment but expressed frustration over the lack of autonomy.

Clinical Presentation

  • During the initial consultation, JL was reasonably friendly and engaged yet quickly showcased significant memory impairments.

  • Vignettes from sessions illustrate JL’s repetitive dialogue and inability to retain information, highlighting the profound nature of his deficits.

Neuropsychological Presentation

  • His pre-injury intelligence was average; post-injury functioning dropped to low average with a notable gap in processing speed.

  • Memory assessment confirmed profound anterograde amnesia. Immediate and delayed recall tests were markedly impaired.

  • Executive functioning appeared to remain intact.

Psychotherapeutic Process

  • JL underwent 72 weekly sessions of psychoanalytic psychotherapy, guided by Paul Moore, specifically adjusted to his cognitive limitations.

  • Treatment objectives focused on addressing emotional adjustments and how process modifications were necessary due to JL's pronounced cognitive challenges.

  • The therapeutic relationship dynamically evolved through various transference phases

Transference Phases

1. Rejecting Phase

  • A pivotal episode occurred in session 6 regarding a disagreement about a local bridge, revealing JL's strong defense mechanisms related to his cognitive dislocation and narcissistic structures.

  • The clash highlighted JL’s refusal to accept external reality and the consequent defensive issues, revealing deeper narcissistic rage.

2. Starting to Take In

  • Eventually, JL showed signs of engaging with the analyst’s interventions and beginning to process feedback, although he still displayed resistance.

  • An illustrative vignette showed JL discussing his frustrations regarding a non-functional television, symbolizing his broader interpersonal interactions and relational dynamics.

3. Full Use of the Analytic Space

  • Toward the treatment's conclusion, JL became more receptive to exploring and processing his past and current realities, reflecting on his emotional issues in a more nuanced light.

Countertransference Experiences

  • The analyst noted various countertransferential challenges, such as confusion, hopelessness, and sometimes physical responses linked to hypoglycemic events, reflecting the complex interplay between JL’s cognitive deficits and the analyst’s emotional responses.

Ethical Considerations

  • Conducted in compliance with Headway Ireland’s guidelines, ensuring thoughtful examination of the impacts of treatment termination on both JL and the analyst.

Discussion

  • Overall, the findings support previous claims about the capacity for emotional learning in profoundly amnesic patients and critique standard models of therapy emphasizing episodic memory as a prerequisite for therapeutic changes.

  • This study augurs critical exploration of therapy modalities better aligned with emotional learning and implicit memory systems rather than traditional frameworks focused predominantly on explicit memory.

  • Ongoing research proposals were made to expand the breadth of studies in this domain to deepen understanding of treatment processes in neuropsychological contexts.

Analysis: Panksepp's Emotional Systems

  • The observed therapeutic dynamics with JL can be fruitfully analyzed through Jaak Panksepp's framework of primary emotional systems, which are subcortical affective circuits that drive fundamental behaviors and emotional experiences:

    • RAGE System: JL's experiences often trigger the RAGE system, resulting in heightened states of agitation and frustration. This response aligns with Panksepp's assertion that the RAGE system is crucial for self-assertion and can manifest in aggressive behaviors when individuals feel constrained or threatened. The impact of these triggers on JL's therapeutic progress highlights the need for interventions that can effectively modulate these emotional responses.

    • FEAR System: In addition to RAGE, JL also exhibits pronounced reactions from the FEAR system, which can lead to withdrawal and avoidance behaviors. This system underscores Panksepp's view that fear-related emotions play a vital role in survival, yet excessive activation can hinder therapeutic engagement. It is essential to develop strategies that foster a sense of safety and security for JL to enhance participation in therapy.

References

  • Cited works across neuropsychology, psychoanalysis, and rehabilitation, examining various relevant psychological frameworks, emotional constructs, and memory theories, and continuing to explore the intersection of memory, identity, and therapy within profound cognitive impairments.