Book Review

A Map of the Mind: Toward a science of psychotherapy

N Engl J Med 1999; 340:1219April 15, 1999

Article

A Map of the Mind: Toward a science of psychotherapy
By Richard Brockman. 297 pp. Madison, Conn., Psychosocial Press, 1998. $37.95. ISBN: 1-887841-14-8

In A Map of the Mind: Toward a Science of Psychotherapy, Brockman proposes that psychotherapy be established as a prospective science practiced “in accordance with scientific procedure.” He presents a systematic therapeutic approach that draws on psychoanalytic understanding, current developmental theory, behavioral psychology, neurobiology, the classification of diagnoses in the fourth edition of the Diagnostic and Statistical Manual of Mental Disorders, and psychopharmacology. His approach requires the continuous generation and testing of hypotheses that are based on the “centrality of affect” in early attachments, which determine patterns of relating to others, and on the brain's dual system for processing memory and emotion.

Brockman starts from the “brilliant and wrong” psychoanalytic perspective of Freud and traces our knowledge of human development to Darwin, on facial expressions, and to Bowlby and others, on infant attachment. He emphasizes an active interviewing process to obtain all the data from the many sources of information that psychotherapy has at its disposal: the mental-status examination, history, psychodynamics, behavior, and so forth. He builds the case that the hypotheses generated from these data and then tested in psychodynamic psychotherapy make it a unique setting for the study of relationships. The fluctuating sense of interpersonal safety that patients experience during the process, reflected by their behavior and responses, reveals other remembered histories that sometimes differ from the patients' accounts of their stories. From the standpoint of current neurobiologic theory, which Brockman summarizes, the emotional tone of these memories at the time they were stored is central in determining the quality and freedom of responses triggered by present-day events or perceptions. The responses are automatic, reflexive, and constrained when the memories are associated with danger. They are more discriminating, under conscious control, and freer when the memories are associated with safety. The predictable interpersonal behavior that develops from these learned responses is the underpinning of our patterns of relating to others.

Using clinical examples, Brockman takes the reader step by step through therapeutic dialogues that demonstrate how patients' past attachments, revealed through their responses and behavior in the relationship with the therapist (i.e., transference), can be used in building clinical formulations about the patient that evolve into “maps of the mind.” These maps are then used to orient decisions at every stage of the therapy and to guide the therapist toward the goal of providing safe passage for patients as they seek greater freedom of affect and thus greater choice of behavior, response, and thought. The more difficult, even traumatic, the patient's past attachments have been, the more urgent the need for a therapeutic framework that spans and differentiates among the biologic, interpersonal, and psychological realms.

Although the book is intended for psychotherapists, readers with a more traditionally scientific background may find the biologic substrate of Brockman's arguments for establishing psychotherapy as a science more thought-provoking than impressionistic or anecdotal expositions. Such readers may also appreciate Brockman's emphasis that therapeutic hypotheses be kept tentative in serving the data-collection process. Psychotherapists who are unschooled in current neurobiologic concepts will find Brockman's book understandable and user-friendly. They may also appreciate his cautious tone in “respecting the complexity of human behavior.” For although it is difficult to disagree with the value of a systematic therapeutic direction, any assumption of clinical objectivity in the relative reality of the therapeutic dyad carries risks. First, there is the tendency for any model to lead us to see only what we already think we know. Second, judgments of a “theoretical” therapeutic authority may themselves one day be judged “brilliant and wrong.”

Brockman's book provides an elegant integration of traditional psychotherapeutic thinking and modern neuroscience. His clinical examples are compelling, and they help make a complex subject clear. His discussions are emotionally open, including the difficult feelings he experiences as a therapist and the mistakes we have all made. This style gives us rare access to the integrative mind of a modern-day psychoanalyst. The book is filled with clinical wisdom, is enjoyable to read, and has much to offer. I recommend it to anyone who is learning, practicing, or teaching psychotherapy.

Jonathan Schindelheim, M.D.
New England Medical Center, Boston, MA 02111