The Clinical Effectiveness of Psychoanalysis Today: Freud's Living Legacy, Neuroscience, and the Brain with Dr. Mark Solms #91

Freud, he was a kind of a kid in a toy shop because nobody had done this before. He called it dissecting the function. And he said, you know, I know that this method of dissection hasn't been used before, but I can see no harm in it. I'm literally quoting him. He said, I can see no harm in it so long as we do not confuse the scaffolding and the building.

Hello, I'm Dr. Farrah White.

And I'm Dr. Grant H Brenner.

We're psychiatrists and therapists in private practice in New York. We started this podcast in 2019 to draw attention to a phenomenon called the doorknob comment. Doorknob comments are important things we all say from time to time, just as we're leaving the office, sometimes literally hand on the doorknob.

Doorknob comments happen not only during therapy, but also in everyday life. The point is that sometimes we aren't sure how to express the deeply meaningful things we're feeling, thinking, and experiencing. Maybe we're afraid to bring certain things out into the open. Or are on the fence about wanting to discuss them. Sometimes we know we've got something we're unsure about sharing and are keeping it to ourselves. And sometimes we surprise ourselves by what comes out. 1 1, it don't make—

Welcome to the Doorknob Comments podcast. We're joined today by Professor Mark Solms, a world-renowned pioneer in mental health and neuroscience, a psychoanalyst, and a professor of neuropsychology. He holds the chair of neuropsychology at the University of Cape Town and Groote Schuur Hospital's Department of Psychology and Neurology. And is the training director of the South African Psychoanalytical Association. Professor Solms founded the International Neuropsychoanalysis Society and has published extensively in both neuroscientific and psychoanalytic journals. He's the author of 8 books including The Neuropsychology of Dreams, Clinical Studies in Neuropsychoanalysis, The Brain and the Inner World, and The Hidden Spring. Additionally, he is the editor of the revised standard edition of The Complete Psychological Works of Sigmund Freud, as well as the forthcoming Complete Neuroscientific Works of Sigmund Freud. Most recently, he is author of his newest volume, The Only Cure: Freud and the Neuroscience of Mental Health. Welcome, Professor Solms.

So could you tell us, could you start by telling us a little bit how you got the idea for The Only Cure?

Funnily enough, it was my publisher who said that the appearance of Freud's Complete Psychological Works, you know, this revised standard edition, they said it's too good an opportunity to miss. I must write something about Freud. So what they had in mind was something about translating Freud, which I thought was rather a sort of limited topic. Probably there are 5 other people in the world in addition to me who are interested in that. So I thought I would use the word translation more broadly, and I would speak about translating Freud from the language of psychoanalysis and the, you know, the early 20th century to the language of neuroscience in our own century. So that's what it is. It's an attempt to How does all of this stand up in light of how we think about the mind today from a neuroscientific point of view?

I think that's actually quite fascinating. And, you know, I had been at an analytic institute in New York for quite some time, and I think it's really, really refreshing to see someone sort of infuse the latest you know, science and research into a field like psychoanalysis.

Well, thank you. That's a polite way of putting it. Another way of thinking about it is, you know, I'm trying to bring a scientific perspective to psychoanalysis, which means necessarily a critical perspective. And that's not always welcome. And then conversely, you know, I'm trying to bring what is valuable in psychoanalysis into neuroscience, which is also not always welcome. So although I, you know, the guiding principle of my writing this book was that I want to say what I really think is true, I was mindful of the fact that I might be losing friends on both sides of my interdisciplinary working life in doing so.

It was interesting. One thing I think Farah and I agreed beforehand is not to get too much into psychoanalytic politics. Having said that, because we don't know that listeners are super interested in the internecine bizarre battles, though if you're a historian, it's very interesting, and you chronicle very well some of those travails between Carl Jung and Sigmund Freud. And some others, and you allude, I think, to others still, like Lacan. And your discussion of relational psychoanalysis made me smile, having trained in an interpersonal relational tradition. And, you know, I agree with a lot of those sort of observations that you made. I think what really comes out for me on the Freudian side, and having read Carl Jung and Sigmund Freud as a preteen, interested in becoming a psychoanalyst in the 1980s, I never really felt a strong kind of conflict. You know, you helped to clarify that. But what I think you really get at and what I want to ask about is, you know, what is the essence of what Freud said? And you go through a lot of details where he defined the neuroscience that we use today, and somehow his work, you know, has not been cited. So I think it's good that you're bringing light to that. So I wanted to ask you about that particular piece of it, like the neuroscience that Freud actually discovered that has been unsung or unrecognized.

Gosh, well, actually, that's a very big topic, so I will, I will not be able to do it justice. I'll just mention a few headlines. To begin with, something of the the history in the sense of how Freud transitioned from neuroscience to psychoanalysis. It's not that he became— it wasn't a radical shift. He was still studying the same things. He was interested in how the instrument of the mind works, you know, what makes us tick, how are we put together. Starting out as a very basic neuroscientist, he moved up the nervous system from the single cell, you know, to the cortex and uniquely human functions, particularly language. And in trying to understand how language is organized in the brain, he started to bring psychological topics, psychological concepts to bear. Because that's simply necessary. You know, if you study the aphasias, in other words, the disorders of language that arise from focal brain disease, the way that language breaks down, it can only be described in terms of linguistic concepts. So, you know, he started to use psychological theory and made a point of it, saying, you know, you can't understand mental functions without using mental theories. And mental concepts and making observations about psychological phenomena. And then around the same time, he was, as any neurologist is, he was seeing a lot of what we now call functional neurological disorders. And the observation that he made, which is kind of like obvious in retrospect, was that the paralysis of the patients with functional neurological disorders, and I'll just speak of the paralysis to keep things simple, they don't follow the rules of anatomy. So, for example, a person with a functional paralysis of the left arm, the paralysis starts at the shoulder and ends at the tip of the fingers, and it affects the whole arm equally. In other words, it's a paralysis of the idea of an arm rather than the way that the arm is actually represented in the cerebral cortex. And so he started realizing that there too, that you need psychological concepts to understand functional neurological disorders. Then came the problem that we had no methods for studying the living brain in those days. I'm talking about the 1890s. So if you're interested in what's going on in the, what I'm calling the instrument of the mind, which is a term he used, he also spoke of the apparatus of the mind, and you want to make observations and you want to test your hypotheses against further observations, the only method available was psychological. There were no neurophysiological methods. I mean, even the EEG, you know, hadn't been developed until the last years of Freud's life. So it was ironically in order to be a proper scientist that, you know, he made the shift to using psychological methods because he was now interested in studying these aspects of what could equally well be described brain function. Mental function, brain function, same thing as far as Freud was concerned. Ultimately, he wanted to discern the underlying workings, the underlying functional organization of these systems. So he then, you know, I think this was the truly pioneering step. Was to try to study and try to discern the functional organization of the mental apparatus from a subjective point of view. That is, on the one hand, you know, putting him on very shaky ground methodologically, but on the other hand, my word, that's half of what we know about the brain, you know, is what it's like to be a brain. And there are things that you can only learn about from a subjective point of view. In other words, how do you feel? You know, feelings are rather important in terms of what we do. You can't explain what we, what you do, you can't explain behavior without reference to the subjective determinants of behavior. So it really was a very important step to try to incorporate into mental science in the broadest sense, neural mental science, to try to incorporate what we can learn about this part of nature from the subjective point of view. It surely must exist for a reason. You know, why does it feel like something to be a brain? It's not just a nice-to-have sort of extra bell or whistle. You know, it surely does something. So it was really important. And then, you know, not to overegg my answer, I will just say that from then onwards, Freud, he was a kind of a kid in a toy shop because nobody had done this before. He called it dissecting the function. And he said, you know, I know that this method of dissection hasn't been used before, but I can see no harm in it. I'm literally quoting him. He said, I can see no harm in it so long as we do not confuse the scaffolding and the building. You know, so, so this, this, he introduced functionalism. The idea that what we are trying to do is understand the function, and you can study it in its psychological realization, you can study it in its neurophysiological realization, you're studying the same thing. What we nowadays call memory systems, for example, it's not a piece of tissue, nor is it a thought or a feeling, you know, it is an abstraction. And so Freud was trying to see how can we how is this thing put together? The memory systems, the drives, as he called them, in other words, the motivational systems, the executive system, what he called the ego, and so on. And so when I say he was a kid in a toy shop, I mean, he couldn't but make discoveries. Nobody had done it before. So, you know, the fact that he in broad brushstrokes ended up sketching, you know, how the thing works, I mean, very broad brushstrokes. Let's not overstate it. You know, this was 100 years ago. But, you know, he sketched the territory in a way that we then were able, from the other end of the microscope, as it were, you know, to rediscover from a neuroscientific point of view. And the fact that, to a large extent, the two sets of conclusions in broad brushstrokes coincide with each other, is not entirely surprising. I also don't think that there's a secret plot to write Freud out of history. I think we genuinely rediscovered these things, not even knowing that Freud had discovered them before. And the sorts of things I'm talking about, we can go into detail if you want me to, but I mean, you know, the embodied nature of cognition, the fact that there are these fundamental driving forces that we human beings, you know, whatever else we are, Homo sapiens is a species of animal. That was a shocking thought those days in Victorian times, But, you know, of course we are. And so, you know, this sort of thing. And Freud recognizing that a large part of our cognition is unconscious. At the time that he said that, you know, it was considered an oxymoron to speak of unconscious mental functions. Mental meant conscious. What do you mean unconscious mental? And so on. So all of these things, we've rediscovered them and critical periods, the importance of early development, etc., etc. And now we're able to add a lot more precision. And I'll end this long spiel by saying, and let us not forget, there also are many mistakes that Freud made inevitably, as any pioneer with such rough-and-ready tools is inevitably going to make. And so we mustn't overlook the mistakes too and where we have to correct him.

Very good points, I think. And are there any sort of more salient issues for you in terms of, you know, things that are easier to correct just in terms of your own research and because, you know, you're such a pioneer in the field?

There are two things that under the heading of what we've been talking about. There are two things which I think stand out in terms of what needs correcting. One of them is, I mentioned the drives, in other words, the basic biological motivating forces. Freud was very unsure as to how to classify, you know, how many are there, how many basic urges are there that we can call true natural kinds. And he came up with one theory around about 1915, he stated it in its fullest form, then he changed his mind completely. In 1920, he came up with another theory, a completely different classification, and there he said, look, you know, psychological methods are not best suited to discerning these basic biological forces. The future will, you know, doubtlessly, biology of the future will doubtlessly correct me on this score. And my word, yes, we need to correct him on that score. So the most authoritative taxonomy of the basic, what we now call the basic emotions, the natural kinds of emotional need, is Jaak Panksepp's. And if you follow him, well, there's 7, not 2. Freud thought there were 2 basic motivational forces. Panksepp says there's 7. And if you accept or even just entertain the new taxonomy, it's inevitably going to make you look at, you know, if you think about what we are talking about, the basic motivational forces in our minds, it's not a minor detail. You know, if you change the taxonomy from 2 to 7, you know, you're going to see things very, very differently. The other thing that I don't know if it'll be obvious to everyone why this is so important, they might just think, you know, this is a detail, but it's not, in my opinion, is that Freud, like everybody else, Freud was a neurologist, he learned, you know, the standard sort of things. One of the standard things is that consciousness is a cortical function. It's bound up with perception and cognition. And Freud followed that mainstream view that consciousness is a top-down function. It's a cortical function. It has to do— it is fundamentally perceptual in nature. He said all of those things. And he also said, I'm just following the mainstream view. This is what we all know. And I and a few others like Antonio Damasio and the aforementioned Jaak Panksepp and others, you know, we strongly of the view that consciousness is not a top-down cognitive high-level thing. It is a much more fundamental, basic brainstem. It's a bottom-up— consciousness bubbles up and irrigates the otherwise unconscious cognition. We sort of feel our way into our cognitions. So as I say, that may sound quite arcane, to many people, but it has all kinds of consequences. While you're saying, you know, where we need to correct him, there's one other thing I must mention, and it has to do with this taxonomy of the drives. And this part, I hope I can articulate it clearly, but it's really, really important. Freud had a completely different understanding of sexuality from everybody else, you know, Freud, Freud made this observation that we don't— that there are things that we do sexually, which don't seem to be in the service of reproduction. So the biologically speaking, you know, what's sex for? It's for reproduction. And that's why such enormous pleasure attaches to it, because it rewards you for for doing this funny thing, you know, which— because if you do this funny thing, it'll produce babies, which is rather important biologically, you know, for the future, for the survival of the species. So Freud observed, but then why do we do so many things which can't possibly result in babies, like masturbation, like foreplay, you know, like pleasure in, in, in all of these weird things that are plainly sexual, under the headings of perversions, you know, like fetishism and exhibitionism and so on. I mean, how's that going to result in a baby? So, but it's plainly sexual. So, and homosexual intercourse, it also can't produce a baby. And frankly, you know, why do we use contraception all the time? It's because we're hoping not to reproduce, you know. So his observation was that sex is not about reproduction, it's about pleasure. It's about pleasure for its own sake. And all of that sounds perfectly sensible. But then he goes further and he says, therefore, anything that is done solely for the purpose of pleasure, it must also be called sexual. And there's a logical error. I mean, maybe you should say it should all be called pleasurable, you know, what, why call it sexual? But he did. And therefore, he says, a baby suckling at the nipple, who is no longer in need of nourishment, what is motivating it now is sexuality. We would say, and this is where it goes back to the taxonomy of drives, no, what's motivating it is attachment. You know, that is rewarding in its own right, being close to your caregiver. And it has all sorts of good biological reasons. But for Freud, it was sexual. For Freud, eating chocolate because you like it, you like the taste, you know, rather than the glucose that it gives you, that means eating chocolate for pleasure is sexual. Kids are squealing with delight on swings and roundabouts, that's sexual. And so that is a whopping great confusing mistake, which I think brought Freud unbelievable problems, which were totally unnecessary. And so I'll just say, and this overlaps with my point about the classification of the drives, there are many different pleasures in the brain. One of them is sexual. And then there, when it comes to emotional drives, at least 6 other forms of pleasure. And there's no scientific reason to, to conflate those other pleasures. With sexual pleasures. They have different— those other pleasures have their own chemistries, their own circuitries, you know, they, they, they, they best seen. But Freud's point that we need to take note of the emotional motivations of behavior, in other words, that what drives the subject is feelings, You know, you want to do things that feel good and you want to avoid things that feel bad, not because of any underlying biological evolutionary determinant. All that motivates us is the feelings. And that is the kind of the dividing line between biology and psychology is the recognition, as I said at the very beginning, that subjectivity matters. You know, feelings do something. And my word, anybody who works with emotional disorders knows that people are driven by feelings and not always in their own best interests. And it's very hard to understand psychopathology without understanding that. So there you have it. Very long answer.

Sorry.

No, that's—

It's important. I think to the point of subjectivity and studying subjectivity, and I've been giving this a lot of thought for A few different reasons. One is I, I do mainly psychoanalytic work versus medication management. I have a very small medication practice. I do a fair amount of interventional psychiatry with transcranial magnetic stimulation, um, and consequently have like a different view of neuroscience than, than I, than I had, as we do, uh, advanced techniques using functional MRI and specific patient-specific targeting and, and then working with people and seeing how someone who's done pretty well in psychoanalysis for several years, within a few days of getting accelerated protocols with TMS, completely changes their subjective inner world. And so I've been thinking a lot about how do we operationalize, you know, one's own experience. I think of it almost— and I'm curious what you think about this— in light of where consciousness comes from and to Freud's point about an apparatus, that the inner landscape is very much something we can understand through introspection. And psychoanalysis is a powerful tool for doing that. And particularly that we can do things internally when we have more choices. And toward the end of your book, you say, "In the end, only consciousness can free us from the hold of unconscious compulsions.". It takes time and patience. Now, I've worked with people who have very strong complexes that are compulsive, you know, for example, feeling like there's a powerful inner critic who's been driving them to work hard since a young age with a very strong survival flavor. And then after a couple of days of TMS, this personification of an inner bully or critic virtually dissolves overnight, and they're left with sort of more normal-seeming anxious thoughts. And it's quite jarring. I would think of it almost as psychological whiplash, that something that appeared to be an invariant fixture of the inner world can disappear so, so quickly and so thoroughly. Definitely, um, curious what you think from a neuropsychoanalytic point of view because you also have worked a lot and taught and discovered and developed ways of working with people with neurological problems. You talk about a number of interesting cases in The Only Cure. I think of these TMS responses as almost being like anti-lesions. And so, all of a sudden, what is almost like a neurological obsession, that's something that is like a fixture of the inner world, and really problematic and taken to be part of one's identity is gone very quickly. I'm curious what your thoughts are on, number one, the general idea of learning to use what I kind of weirdly call our inner appendages and the motor aspects of that with where we pay attention with our consciousness. And then, what you would think about something that seems so fixed vanishing, you know. And I know that Freud wrote about this quite a bit. You alluded to it, um, and also in Analysis Terminable and Interminable, he talks about some people being like soft clay and others being like hard stone. But people can work in analysis, and he says some people appear to have like a deficiency of entropy even though they're younger. So I'm curious what you think about this plasticity and how people can best navigate the subjective space, having, you know, studied Freud better than anyone practically?

Well, let me say two things to this. The first is that you don't need to persuade me of the truth of what you've just said. In other words, you know, that something that seems so ossified and rigid and immovable, and it's lasted decades, can be so dramatically changed by way of a physiological intervention. Why I say you don't need to persuade me is because I have worked, I have been fortunate enough to work with Helen Mayberg in both Canada and the United States and with Volker Körnen in Germany. Helen Mayberg is a neurologist. Volker Körnen is a neurosurgeon. And what both of them have done is deep brain stimulation in the treatment of chronic depression. And these are patients who have been through everything. You know, they've had ECT, they've had every kind of antidepressant medication under the sun, they've had psychotherapy, etc. And then in seconds, you know, you insert an electrode in an appropriate position. Helen Mayberg, it's in the subgenual anterior cingulate gyrus, and Volker Koerning puts it into the medial forebrain bundle. So she is getting at those opiodergic sort of panic, separation distress circuits, and he's getting at what's called the brain reward system, or it's better named a seeking system or a wanting system. And, you know, the patient, remember, we're talking about burnt out, you know, really, really bad depression. The patient suddenly says, Volker Kernan's patient says, I think I might go on vacation this summer, you know, suddenly they've got a forward-looking mind with some optimism and hope and interest in the future. And Helen Mayberg's patients, it's like, gosh, I suddenly realized how much You know, you care for me. Thank you so much. I'm so grateful. You know, and they just suddenly feel loved and connected and so on. So these things happen. Now, what's important? And so that's the first thing I wanted to say, you know, that what you're telling us about TMS, I've seen even more dramatic versions of it. And, you know, so this is just a fact that these things happen. And remember, I'm agreeing with you that these are things that have been there for decades. And you change them in seconds. So now's the second thing I wanted to say. It is absolutely essential that we have one psychiatry which can incorporate these sorts of facts, you know, that you can change somebody's mind literally, you know, with, with TMS or DBS or whatever. And you can also change somebody's mind through psychotherapy with nothing other than talking to them. You know, and this is the same mind, you know, how things have been in the past. And this is really pretty much what my working life has been about, is trying to get away from this past where it's like, you know, which football team do you support? Are you on the side of organic psychiatry or psychoanalysis? You know, and our patients are not, you know, it's not doing the right it's not doing what's best for the patient. We need to understand this territory in an integrated way where both sets of observations align in us elucidating the one and only mind. You know, in other words, how does this thing work? And it's, again, it cries out for a functionalist model, you know, that if you're going to integrate physiological observations and psychological observations, you can't use either language. You need some sort of, some sort of common currency. And I think that common currency is the language of function. So we need to understand what are we doing to the underlying functional organization of the human mind when we do these physiological and these psychological interventions. And it has to be one seamless understanding. And I think that what's been sorely lacking in psychiatry, and I mean now in what is sort of stupidly called biological psychiatry, as if there's a psychiatry that—

By the way, I completely agree with what you're saying.

Yeah. What's been lacking is any kind of theoretical understanding of how the mind works, you know, to just intervene at the level of molecules or receptors. Without any understanding of what you're doing in terms of the full rich complexity of the mind and its development, I think, is to do no justice to our field. And the same applies to psychoanalysts. If all that they're ever going to know and understand, you know, is what they hear sitting behind the couch of somebody saying everything that comes into their head and don't use all the other knowledge that we've got, in order to help us to understand, well, what does this all tell us? How does this thing work? I think that that's the main— for me, what you're saying, it points to the need for an integrated psychological and physiological psychiatry where we are all working on the same side in order to advance the interests of mental health care. In other words, of our patients. And it's just so much more interesting I don't know why anybody does anything else. It's fascinating. And we're making really great progress because we're doing what we should have been doing all along, at least since the methods became available. I forgive Freud for using only psychological methods because it's all he had. But I don't think it's forgivable anymore. And I mean, since the '50s. It's, it's become increasingly unforgivable to stay on only one or the other side of the fence.

Yeah, I find it, uh, confusing, to put it politely. And, and the types of things I've seen in patients over the years, and even people telling me, I wish I had known about this, I've been suffering for 10 years— they're recovered in 2 days, no wires, no brain surgery required. But understanding that over time is really what I'm interested in. And I wanted to come to the other part of what I asked is, how do you think about people kind of functionalizing or operationalizing their inner subjective world? And how do you tie that to these objective things? We can see in studies of psychoanalytic therapy that motor changes, the people's behavior seems to be influenced through changes in the putamen. With TMS, it seems to be related to the anterior medial cingulate cortex. There are these kind of networks of the brain that we can start to understand, but this subjectivity of kind of being in the cockpit of a human mind and body, I'm curious how you speak to that very abstract question.

Well, you said earlier, Grant H Brenner, you know, that we can gain access to what makes us tick through introspection. And that's a very generous statement to me as a psychoanalyst, because sadly, there are enormous limits to introspection. You know, so you can look inwards. It's a jolly good thing. I recommend it. Know thyself. You know, it's good advice to follow, advice given thousands of years ago. But, you know, there's a limit to how well you can know yourself. And this is when I said earlier, Freud said there's a lot of mental functions that are unconscious. Well, here's the, here's the point, you know, that there are things that motivate you that you don't know what they are. They're not accessible to introspection. And so, so as much as I'm all for us taking a subjective perspective, I also think we need to recognize the limits. And then you start making guesses about what lies beyond, you know, what lies behind. And that's where Freud hit that methodological, you know, wall. So from the point of view of physiological methods, you mentioned fMRI fleetingly, you know, positron emission tomography, all of these wonderful EEG technologies we have today, EMG, blah, blah, blah, all this stuff, you know, you can observe with no resistance, there's nothing opposing you seeing what's there, you know, so you can see the whole kaboodle, the physiological correlates of what is consciously accessible to the patient and the physiological correlates of what's not consciously accessible to the patient. And so you mentioned the putamen. I mean, that's just one instance. The things that we learn, and when I say what we learn, I mean, you know, the things that have influenced us over a lifetime. I don't want to be too cognitive about it. I mean, the things that have happened to us, the problems we've had to resolve, the solutions we've come up with in the process. They may have been ever so conscious at the time when we were little grappling with these things. And, you know, when we have traumatic experiences, they're ever so conscious at the time. But eventually, you know, the way in which we settle these these troubles, the way in which we resolve these problems, they become automatized. In other words, it's the best I can come up with. There's no point in thinking about this anymore. Let me just put this out of mind. That's what we do. And this is not me sucking something out of my thumb. I mean, it's the basic, you know, it's called consolidation, systems consolidation. It goes from short-term memory into declarative long-term memory and from declarative long-term memory into non-declarative. In other words, can't be thought anymore. That's what Freud called the unconscious. We now call it non-declarative long-term memory. And so there are things that we've learned, there are ways, there are solutions we've come up with in life, which are automatized, and they're automatized in these structures that we are talking about, these subcortical memory systems, the basal ganglia of which the putamen is a part, the amygdala, which is a big-ticket item, but it's a subcortical memory structure, the cerebellum, which the psychological functions of which, you know, are only now coming properly into view. All of these structures, we have no introspective access to what they're doing, but they're doing a lot. And we can access those structures, not only, as I was saying, physiologically with these methods, we can visualize what's going on,. But we can intervene in these structures, and that's what you're talking about. You know, you can directly intervene in— you mentioned, I think you mentioned medial prefrontal cortex. But I mean, TMS sadly has its limits in terms of what it can't get to. But, you know, now with this new coil, you know, there's more that can be done. I think that there's going to be really big advances in, in that field. I think you're in the right place at the right time.

So I mean, with TMS, for listeners, we can reach the surface of the brain, but what you can see is that deeper structures are activated through circuits and network changes. And so that area you described, SGACC, SG25, Helen Mayberg's area, is hyperconnected, and TMS When we use targeting, we treat an area of the cortex in the left dorsolateral prefrontal cortex, which has an anti-correlation with it. But, a lot of these areas, they're not super deep, but you can't quite reach them with a magnet. There are things like transcranial focal ultrasound where you can stimulate deeper brain areas with ultrasound, which you can focus it like the sun with a magnifying glass. But that subjective experience of having, you know, it's interesting, someone sees a dramatic change in themselves over the course of a few days. The understanding of that takes place over months. And it's almost an existential experience for people. Because I think what you're talking about in a way is the, the material reality of the brain as an organ becomes evident in a very positive way. Very different from, you know, if someone has a stroke and they lose function, and very different from what you're describing if they have a functional neurologic disorder like the, the stocking and glove, you know, paralysis, which doesn't follow the, the way the nerve anatomy is. And you, you do describe some very interesting experiments in the book around those types of phenomena. They used to be called conversion disorders, um, or somatoform dissociation, where the lack of awareness can be reversed with quite simple things like putting cold water in someone's ear. But I'm afraid we're getting too far into the stratosphere with my own kind of desire—

Before you move on, Grant H Brenner, I know that, I mean, sadly this field is so rich, we could carry on talking about any one bit of this for many hours. But you said something there that I don't want to just skip over, which is that the— and this speaks to the integration again, you know, that it's not a matter— it's why should it be that our patients only get the one or the other treatment? So, you know, you're speaking about interventions which open windows of opportunity. TMS is one. Deep brain stimulation, which is a radical intervention. I'm not saying everybody should be running off with deep brain stimulation. It's more proof of concept, you know. Than a scalable treatment in terms of real general public healthcare. But even Helen Mayberg, who's got no axe to grind, she's a neurologist, she discovered, she realized, she learned that her patients after DBS, they need psychotherapy because you've opened a window of opportunity that you then need to capitalize on. And the same applies to psychedelic-assisted psychotherapy. I really worry about those who think that the future of this is just the psychedelics and skip out the psychotherapy. I think, frankly, in some people's cases, it's dangerous to take psychedelics and not have somebody there to help you integrate what you became aware of, what you gained access to that had previously not been available. So I think that we— again, it's not a matter of supporting football teams. We must work together. And this is just obviously the way forwards. Sorry, I just needed to say that.

I completely agree. And that's part of what I'm working on in my practice is to put together these frameworks that really serve the patient. I think of it developmentally. It's a developmentally oriented treatment. And within each patient's sort of optimal developmental trajectory, there's all these different things you can do at different times. And, you know, we just don't understand exactly how to sequence it on a personalized basis, right? It's hard to get an fMRI. You can do an EEG in the office, but the EEG data is hard to understand yet. And then we have things like functional near-infrared spectroscopy, which we can do in the office and see cortical activity. It's really— it's a great time to be in the field in terms of what is available to help people. And there's all kinds of terrible economic forces that you mentioned the word scalable. And it is interesting that these neurologically-based interventions have virtually no data for longer-term therapy. It's only been studied in relation to short-term therapies and plasticity windows. The cultural piece I want to say before we shift gears with psychedelics, I think, is to me a source of consternation. Because people really confuse the trip with the biological effect. And, it's so overdetermined culturally because of the 1960s and LSD, but there's research on molecules that are 1 or 2 atoms different from LSD in animals that don't cause them to have a psychedelic experience but still have what appear to be analogs of antidepressant effects. And, Certainly the commercial, what I will often call the ketamine gold rush, further confuses things and doesn't really serve people.

Beware magic bullets in general.

Yeah, I agree with that. And I think what's interesting, as I was training, a supervisor once said that people sometimes can come to the right treatment at the right time. Um, and I found, let's say, in my brief clinical experience so far, that that happens to be true a lot of the time. And if there's anything that we can do as clinicians, it's to partner with our patients and support that, um, so they can be quite happy with psychotherapy and their results. Or they can be quite unhappy but attached to their therapist. And it's our job to help them distinguish. Yeah, if you want to keep doing this because it feels good, that's fine. If you want to target certain symptoms, then maybe we take a different path.

I'm, I'm, I'm very much aligned with what you're saying.

Yeah, so shifting gears a little, one of the things I really loved about The Only Cure, and you know, it's rare that I read an entire book nowadays, and I highly recommend it because it, it really goes beyond, uh, what you're describing about talking about who Freud was. You, you really get even more than I think in some of your earlier writings that I've read anyway. It would be hard to read all of your writings, of course. Let alone write them. You talk about your own experience, and I was just blown away by your, by your description of free association with Clifford York at the Anna Freud Center. And I love the idea of free association. I think it's a very compact algorithm. It's such a simple recipe for psychotherapy and so elegant. And I'm wondering if you could speak to that fundamental rule of psychoanalysis a bit.

So just to explain, what Grant is talking about is my own analysis, which I wrote about in this book with my analyst's name was Clifford York. So that's who he is. Interestingly, so, you know, Sigmund Freud's daughter, Anna Freud, set up this place called the Hampstead Clinic. And when she retired, my analyst took over from her. So I like to say, you see, there's only these 3 degrees of separation between Freud and me. So he analyzed me. He was a very old school classical analyst. And so I had that kind of analysis where I lay on the couch 5 times a week and was required, I mean, like absolutely required to say every single thing that came into my head. That's the method. Method of free association. You don't select, you don't think what's relevant, you don't try and make connecting links that are logical or, you know, following a particular theme, and you also don't exclude thoughts which are impolite, you know, and the sorts of things you wouldn't normally say out loud. You're absolutely obliged in psychoanalysis of the classical sort to say literally everything. Freud said it must be, you know, like if you're in a train and you're looking out the window, you just describe everything that passes as you look. So that's what you do. You look inwards and you just describe everything that comes into your head. The rationale behind that is that, well, first of all, obviously, you're going to reveal more than you would if you were selecting, you know, so you're giving an unselected, you know, true cross-section of what's really on your mind. But also because it's unselected, the underlying structure, the implicit structure that's organizing this explicit surface slowly emerges. So that's the idea, because we don't have access to those underlying organizing principles that I was speaking about earlier, The things that, you know, the limits of introspection. You just give this random sample of what's on your mind, unselected, uncensored, uninhibited, as far as you can bring yourself to do it. And then the analyst's job is to say to you, well, it seems as if these things connect in this way, you know, that yeah, we seem to have an underlying theme. This seems to be a recurring underlying theme in your thoughts. You know, it seems this thing seems to be a major principle in what puts you, you know, what joins the dots for you. In other words, how you've been put together. And it's an extraordinary, extraordinary revelation. You know, I must say, I was not particularly mentally unwell. It's a very, you know, it's a method that I think has its limits, you know, as a therapy, You know, it's certainly educational. You learn a darn sight more about yourself than you might want to. You know, so I really— it's an education that I greatly value, the fact that I was able to literally unpick, you know, the kind of tapestry of how I'm put together and then slowly put it together again with fewer knots and, you know, and and so on. So that's what I did. But, you know, I don't know what else you're wanting me to say, Grant. I'll just say this, that the fact that it is so very difficult to actually— I mean, even as I was writing the book, I thought, gosh, you know, I'm not sure I want to tell these readers what came out in my analysis. And that says a lot. You know, it's like one of the basic things about the nature of the mind is that there are things that we don't want to know and we don't want others to know about what really goes on inside of us. And so, you know, these are basic, basic Freudian discoveries about things that he called resistance and defense and, you know, and the way we disguise things and censor things even to ourselves. So to have as best a picture of what it is, as I said, know thyself is a very valuable piece of advice. And it was a little— but it's not for everyone. You know, that's why I'm saying I wasn't particularly unwell. I think that if I was in dire straits, I don't think I would be able to use that method. And I don't think I'd be able to wait for so long. I would need a more urgent and symptomatic sort of intervention.

And, uh, you know, go ahead. Sorry. Well, I think it's a bit psychedelic also. Free association is a little bit trippy in a way, right? It's a high entropy thing, and it's not for everyone. And, you know, certainly some people will discover things about themselves that are destabilizing. They're not ready to know, right? There's the idea of the premature interpretation. Um, I found it I found it some sympathetic cringe kind of reading some of what you wrote, which I think should make people want to preorder the book also. I thought of my own analysis on the couch, and I've got 5 generations down from Freud, so I can relate with that feeling. I find myself wanting to hear what Farah thinks and what you're wanting to learn about, while also wanting to ask who your favorite cases were because the book is written—

Well, just reassociate for us, Farrah, and go.

I don't know. I want that on tape. But I do— Yeah, it's— You know what's interesting and what you didn't mention is that it's a really challenging thing to do. And I think that unless people try to do it, they really don't know how difficult it can be. Whether it— to me, it doesn't matter how much or how little they trust themselves or the other person, their analyst. There are, you know, so many barriers, I think, to freely associating.

So it's not very free. They talk— we talk about it as an accomplishment, not a given. And I don't really— you may know this, um, Are there any studies of the neuroscience of free association over time, the way people have studied meditation and stuff? Because I think that would be worth doing.

You know, unfortunately, this is a sign of my age. There is a colleague who's busy studying it right now, an fMRI studies of free association as opposed to just mind wandering in general. And whether it's in a clinical context or not in a clinical— I can't remember his name, but, but, you know, there's so much low-hanging fruit. It's kind of extraordinary that, that only now is anybody doing proper neurophysiological studies of reassociation.

Psychoanalysis in general. I mean, I was actually shocked. There aren't many interventional psychoanalysts, interventional psychiatrists who are psychoanalysts. I might I'm sure I'm not the only one, but what I found speaking at conferences to technologically-oriented people is they are fascinated by the psychoanalytic aspect of it and the idea of studying things like reflective function after interventions. But again, I'm conscious of the time and I kind of desperately want to know about Prince Friedrich III of Solms-Barreuth. You talk about him quite a bit in the book, and I'm wondering how he plays in.

Yes. So what this refers to, in the book, I go through various different topics. And right at the end, I look at the question of, what are the implications, given what we've gotten to know about And let us be aware of the arrogance of the present. I don't think we now know how it works. You know, I think that we know a hell of a lot more than we did before. So at the end of the book, I said, okay, so if this is how it works, this is how our current best understanding, you know, of how the human mind is put together in health and disease, you know, then what are the implications for society, for culture, for, you know, on the larger scale? So it's in that chapter that I mention this distinguished relative of mine. He was a very privileged chap in Germany, and with the rise of Hitler, he thought that he could say what he thought, and he was like the equivalent of a modern oligarch. He could get away with with murder. What is it that Trump literally said, that he could stand and shoot somebody in Fifth Avenue and he'd get away with it? I think this relative of mine probably felt like that, you know, he was so immune because of his status. But, you know, the world of Germany was rapidly changing. And so eventually a number of colleagues of his, senior military people, They got together in his home and plotted to assassinate Hitler. And I'm sure many people, because there was a film about it, you know, the Valkyrie plot, I'm sure many people know it ended up not working. They didn't manage to kill Hitler. And in fact, most of them ended up being hanged or forced to shoot themselves and so on. So this relative of mine was a central member of that plot. And so why I write about him is to, I mean, amongst other things, it is to use him as a kind of a point of entry into questions like, why do people, if we are animals, species of animal, which ultimately, you know, what's designed us is natural selection and, you know, whatever is necessary for survival and so on. Why do people do things like that? You know, take such a risk, you know, to do this noble thing of trying to assassinate Hitler, putting themselves literally in the, you know, it was called the wolf's lair. Was Hitler's headquarters, going into the lion's den in order to do this thing which was for the greater good. And then the other way in which I used that story was to think about what happened afterwards, because most of his friends were hanged or forced to shoot themselves. He, because he had such valuable property, the, the Himmler, the head of the SS, said if he signs over his properties to Himmler, you know, then he will let him go as long as he leaves Germany in 24 hours, which he did, signed over his property and left within 24 hours and came here to South Africa where I'm speaking to you from. And then he developed prostate cancer and he refused treatment and he was dead within 18 months. And so it's about survivor's guilt and all of that. You know, I was also wanting to, you know, why do people take these, do these altruistic things? Why, if we are biologically motivated animals, you know, why do we do things like kill ourselves. In effect, that's what he did, out of guilt and shame of having survived when all of his friends didn't. So these are the kinds of things that I deal with right at the end of the book. And again, you can see why we need a psychological psychiatry alongside a biological one. I mean, you know, how does one begin to approach these things without psychological concepts? And so there you have it.

Wow. I mean, such a fascinating story. And I think this book is a huge contribution to the field as it stands now and also to the future. It really hopefully will forge a new path for people in training. And I know for a fact that it's available because I just pre-ordered 2 copies. This morning before we got on to the call. So yeah, any sort of final thoughts from either of you?

Well, I would like to mention a part around the middle of the book where I look into the evidence for the efficacy of psychotherapies in general and psychoanalytical psychotherapies in particular, because I need to just restate you know, we need to integrate all of these. We're all in the same boat, you know. So I don't think only one form of psychotherapy works. We have to understand how do they— so many different forms work and what works for whom and why and so on. But leaving aside all of those complexities for now, I just want to make known that a central part of the book is going through the randomized, controlled, double-blind trials, rigorous tests of the effectiveness and efficacy of these treatments. And they, they really do a hell of a lot better than most people will imagine. You know, psychotherapy is an extremely effective form of treatment. And then it's also a matter of, you know, what is symptomatic treatment as opposed to what is causal treatment. I mean, symptomatic relief Anybody who suffers knows symptom relief is great. You know, let's not, let's not underestimate the value of symptomatic treatments. And sometimes they're lifesaving, even in psychiatry. You know, so, so it's terribly important that we have a full armamentarium of treatments. But psychotherapy, in follow-up studies, so after the treatment is finished, You know, the fact that especially in psychoanalytical psychotherapies, we have this thing called the sleeper effect, where the patient not only maintains their symptomatic gain, but they actually get more better after the treatment, which shows that something has been triggered in the— by the process of the treatment, which carries on being efficacious after the end of the treatment. And I really, I think it's one of the best kept secrets in public healthcare, you know, that psychotherapy is a very effective form of treatment. Treatment. Now it's time-consuming and it's expensive. So, you know, this is— these are strokes against it. I don't think that we can deny that a treatment that is shorter and cheaper has a certain appeal, as opposed to a treatment that's longer and more expensive. But I don't think that we should conflate the two issues, you know, in terms of what is the most cost-effective is not the same question as what is the most effective. And I think even from a purely scientific point of view, leaving aside the public health aspects, we really do need to know what is most effective and why. Then we can start looking at, well, how can we deliver that particular ingredient in a more scalable fashion. So the results of And while I'm on this particular hobbyhorse, I need to also say, let us not forget that psychoanalysts resisted measuring the effectiveness of their treatment for years. They said, you can't measure these things and blah, blah, blah, you know, and they got egg on their faces because then the word evidence-based meant not psychoanalysis, you know. But finally, we have an evidence base for psychoanalytical therapies. And it's really something to be pretty darn proud of. So I want to draw attention to that part of the book too. Thank you.

Yeah, the research review is really good. Fer, I know you're pressed for time a little bit. The effect of longer-term therapy, psychodynamic and psychoanalytic, carries on after the therapy ends, which leads me to believe that it is a developmental experience, right? It alters developmental trajectory. It's not just sort of therapy it's almost like a different class of experience because it has a developmental impact. And the economics, by the way, and everyone I think can, can look at this data, is actually more favorable for longer-term therapies because they save vast amounts of money in the future because there's reduced psychological and medical morbidity. And so there was a study in Lancet, I think in even 2016, I want to say, where they found for every dollar spent on mental healthcare, it saved $3 to $6 down the road. But, you know, people think about the next quarter profit margins only, which, you know, maybe for another time. I don't know if Freud had much to say about the short-term versus long-term thinking, except that we all seem to be perpetually stuck in survival mode.

Very good.

Yeah, such a wonderful conversation. And again, thank you so much. It's always delightful to talk with you. Where can people find you? What's the best way for them to learn about your work?

And so, well, you can find me personally. I don't have a website, but I am on X, Twitter. @mark_solms. And the, the, the Neuropsychoanalysis Association has a website where all of the, you know, latest events and educational things that are available are accessible there. But if anybody wants to get in touch with me directly, either follow me on Twitter, on X, Twitter, or, you know, these days I've discovered you can get email addresses at the push of a button. So I don't mind being emailed.

Great. Well, that's very good.

Thank you, Professor.

Thank you so much.

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