The Conceptualization Issue

Abstract

This article asks the question, when we sit down with our patients how do we understand why they came to see us and what do they need from us? Succinctly, what are they looking for and what are we looking for? The article then explores 3 conceptions that go beyond, and deeper, than medications or Cognitive Behavioral Therapies (CBT), in understanding and treating our patients. These 3 perspectives are the role of the preconscious-unconscious paradigm from psychoanalysis, our new understanding of the DMN from recent research in neuroscience, and revisiting William James (1890) idea that the human mind is a stream of consciousness, not just a phenomenon that focuses on the external environment when needed. Using 4 case studies, the author suggests that the most important source of our understanding of a person’s life struggles, and their healing processes lies within the preview of these 3 perspectives with the addition of the role of an unconscious stream of consciousness. The article concludes with an invitation to explore these 3+ perspectives in greater depth.

Keywords:Preconscious Unconscious Stream of Consciousness Trauma Brain Injuries Psychoanalysis Neuro-Psychoanalysis DMN

Introduction

When a patient first comes into our offices and we sit down together, how does the clinician conceptualize what the patient is there for and what they need? Further, exactly what lens/perspective are we using to answer to this question? And I will go a step further by asking: how does the clinician understand how the patient’s brain/mind works? How do our patients process their own developmental history, and the circumstances/situations that have brought them into treatment? Finally, I am asking what happens to this processing of one’s life events when the brain/mind has been traumatized (TBI, stroke, seizures, infections, brain illnesses and diseases, major mental illness, and PTSD)? How does trauma change things in the brain/mind, and how can clinicians respond effectively?

Let me begin answering these questions by suggesting an overall perspective for understanding our patients and ourselves: that our brain/minds are continuously processing our internal and external environments through a steady stream of information that never stops. (See William James 1890) This processing, and how the patient makes meaning from their internal and external environments, can lead to health, injury, illness, or disease. How then does the clinician influence this processing and move it in the direction of health? Most modern medicine attempts to influence this stream of consciousness through psychotropic medications and/or cognitive behavioral treatments. I find both solutions to be inadequate because neither is able to address what is really going on in the brain/mind. How it really works.

Below are several examples of recent interactions I have had with my patients. I am presenting these examples to explore how to better understand our patients and what they need from us. I note that I work from a neuro-psychoanalytic perspective and that the majority of my patients are struggling with brain injuries or come from highly traumatized situations. [1,2] Again, for the purpose of conceptualizing our cases, we want to know why the patient is in our office, what they need from us, and how do we as clinicians understand what they need? A hint here, author Stephen King has written in his book “On Writing” that the art and act of writing helps a person think more clearly and creatively. Writing this article has led me to think differently about my own question. As I tackled writing this article, I found myself in an entirely different place from where I thought I would be. Somewhat surprised, I ended up working to better understand that there is also an unconscious stream of consciousness “running through” the brain/mind in addition to the one we are more conscious of in our day-to-day lives. This agenda presents in the consulting room as a constant double flow, for both the clinician and the patient. In the pages ahead I will deal with my observation that our stream of consciousness runs/steams on 2 levels. (Not to make things more complicated and complex with the brain/mind than they already are!) One is more surface (is this the preconscious that Freud introduced us to?), and another running at a “deeper” level in the minds of all of us (is this just Freud’s unconscious but not necessarily seen as a streaming phenomenon?).

Moreover, that this double level stream of conscious has as its immediate and constant concern our day-to-day survival. I admit that as a result of writing this article my thinking has opened an entirely new “door” to my understanding of the brain/mind. Two streams of consciousness, one “running deeper” than the other? Really? Am I just dealing with semantics here, labels? Or is there something new to understand here? Evolution has built our brains for survival contrary to those popular ideas that our brains were built for thinking and feeling. Thinking and feeling are always there in the interest of our survival. [3] But what about this stream of consciousness “stuff?” How might this perspective apply to thinking and feeling for survival and the work and challenges of medicine? I will begin by exploring 4 cases that have shaped my thinking and feeling that a double level stream of consciousness exists within all of us, and that understanding this concept opens more effective ways to help our patients than medications or CBT. As you will see below, this is where the patient’s difficulties with injury, illnesses, disease and health really are.

Case #1

The husband described the following interaction he had with his wife following an enjoyable Saturday brunch they had at a local restaurant. He recalled that they had been holding hands and talking about their summer plans. After a pleasant and enjoyable hour together, they left the restaurant and headed home in their car. Seconds after they were seated in the car, the wife had a sudden reaction and began accusing her husband of having “changed out their car.” They used to have a brown interior, and now she was seated in a black interior. This was clearly not their car. She became enraged and told her husband that he was tricking her once again, and that this behavior simply had to stop. Unfortunately, things got worse from there and the husband ended up spending the afternoon in the county jail on charges of domestic violence (which he did not commit). My question is: where did all this rage and paranoia come from? And can we say that this incident is best understood as arising from the wife’s pre-conscious (using Freud’s terminology)? Or is this best understood/conceptualized as coming from our new understanding of the Default Mode Network in the brain? (DMN) Or is there a third possibility? Something we haven’t explored much before “the streaming of the conscious/unconscious mind” that William James wrote about back in 1890.

Case #2

This example is taken from a doctor-patient exchange I had during a session with one of my patients.
(D) “Your experience is that when you are attempting to study, there is always a scenario playing in the background of your mind. And this continues to be a very, very intrusive experience, because it is constantly interfering with your ability to live your life?”
(P) “Yes, these flashbacks are a part of everything I do all day long.”
(D) “Does this intrusive “stuff” ever go away totally?”
(P) “It will if I go to a bar, drink and play pool. Or, if I’m at home, I sometimes end up playing video games for hours to get rid of the flashbacks.”
(P) “But I can’t go to bars anymore and drink because of the medication.”
He was on Zyprexa, which did help him sleep and reduced the intensity of his flashbacks, but never totally got rid of them.
(D) “Is it like a dialogue playing in the background of your mind, all the time?” And are you a prisoner of the traumatic experiences you grew up with, that generates these flashbacks?”
(P) “I think you’re right. These flashbacks are very, very intrusive. Especially when I’m trying to organize myself to study for my classes. There are plenty of times when I just can’t study at all because I can’t focus.”
(D) “Is a piece of this your hypervigilance regarding your abusive father returning to do more harm to you? So, you constantly have to stay on hyperalert?”
(P) “Now that you asked, I do worry every day that my father will find us and come back to kill me, my mother, and my siblings.”
(D) “Does the Zyprexa help to reduce any of this hypervigilance?”
(P) “It does help me sleep at night. So that’s some relief. But overall, I am always on the alert as you said, that he might return.”
(D) “How much energy do you think it takes to maintain this kind of 24-7 surveillance?”
(P) “Well, I have been sleeping a lot lately, because I’m tired all the time.”
(D) “Exhausted?”
(P) “Yes, pretty much all the time now that you’re asking me.”

My question with this case is whether this is what long-term, chronic trauma does to people? It creates an intrusive running dialogue in the back of the mind that is always on the “lookout” for danger. And this dialogue is just below the surface of our conscious mind, always alert for danger, always a drain on one’s brain/mind energy. Then does this mean that the complex circumstances of his past (a violent, sadistic, vicious father) left him with very little room to deal with the complex circumstances of his present life? As Mr. C very insightfully pointed out: his past would literally take over his brain/mind hijacking (my word) his present circumstances. Fortunately for his treatment, he was able to articulate this theme over the course of many of our sessions, as he struggled to rid his mind of the intrusive thoughts that had become a major player in the drama of his everyday life.

Case #3

Here is another example of the doctor-patient dialogue with one of my patients that illustrates the value of understanding the patient’s stream of consciousness. I consider this a classic case of brain trauma leading to psychosis, which as the article referenced here points out is toxic to the brain. [4] And when the brain becomes toxic, what happens then? [5] What are the possibilities of cure then?

(P) “Doctor, I’m worried about my mother.”
(P) “There is too much going for me. Too much. Too much. Too much. Too much. Too much”
(D) “What concerns you most about your mother?”
(P) “When I was in law school, I think I made a lot of mistakes. I was trying to do internships all the time.”
(P) “Then there was my cousin’s wedding and the big fight that happened at the end.”
(P) “I wish it was easier for me to drive my car, but I’m having a lot of difficulty just seeing the road.”
(D) “A. are your thoughts racing right now?”
(P) “Yes, and I’m out of control right now. Because I don’t know what’s happening to me. Happening to me. Happening to me. Happening to me. Happening to me. Happening to me.”
(D) “Does it help anything, to know that I’m here to help you organize your out-of-control mind?”
(P) “Yes, but how are you going to do this. I’m really out of control right now.”

How do we work with a patient whose current psychosis was generated following childhood TBI? And is the underlying question: what happens to the brain/mind when it has been traumatized either organically, psychologically, or both (as I believe this case is)? How do we conceptualize and treat this double problem that is both organic and psychological?

The Idea of an Unconscious Stream of Consciousness

Freud wrote about the pre-conscious mind, something that was just below the surface of the conscious mind, out of awareness but easily assessable with the right events or trigger. Over the past several decades neuroscience has discovered and explored DMN (Default Mode Network) in the brain. That is, when the brain/mind is not busy with external “stuffs,” there is still an ongoing dialogue that the brain is engaged in. And William James at Harvard in the late 19th century brought our attention to the idea of a stream of consciousness that our brain/mind carries out every moment of our existence. As opposed to the idea that our brain/mind is only focused on what is external to us to ensure our survival. Is this an important idea we have lost over the past 100 plus years?

Regarding Case #1, the wife was my original patient, and then she chose to do couple’s therapy. From my original work with her I learned that she scored 10 of 10 on the ACE scale (adverse childhood experiences) although this was not something she was focused on. Although their marriage (according to both of them) had been very beautiful up until recently, the wife began serious drug use approximately 3 years ago. At one point she was heavily involved with Fentanyl (and I was asking myself, what are the consequences of long-term Fentanyl use). [4] Because of the patient’s resistances there was very little access to this extensive trauma, and so it got played out in the marriage. The husband was mean and abusive from her perspective, and that’s what the problem was. The problems in the marriage had nothing to do with her developmental history, and her paranoid ideation, it was all its fault. In her mind, the current problems in their marriage had nothing to do with her childhood trauma or extensive drug use, and everything to do with her husband being abusive to her (he was angry and frustrated with her for her drug use but not abusive).

Regarding Case #1, the wife was my original patient, and then she chose to do couple’s therapy. From my original work with her I learned that she scored 10 of 10 on the ACE scale (adverse childhood experiences) although this was not something she was focused on. Although their marriage (according to both of them) had been very beautiful up until recently, the wife began serious drug use approximately 3 years ago. At one point she was heavily involved with Fentanyl (and I was asking myself, what are the consequences of long-term Fentanyl use). [4] Because of the patient’s resistances there was very little access to this extensive trauma, and so it got played out in the marriage. The husband was mean and abusive from her perspective, and that’s what the problem was. The problems in the marriage had nothing to do with her developmental history, and her paranoid ideation, it was all its fault. In her mind, the current problems in their marriage had nothing to do with her childhood trauma or extensive drug use, and everything to do with her husband being abusive to her (he was angry and frustrated with her for her drug use but not abusive).

While she denied being on Fentanyl anymore, she was constantly paranoid about many things, and then there was the incident in the car where “You changed everything! This is not our car!” Then, do her symptoms indicate she is still using the drug? Or are these the long-term effects of Fentanyl use? And how does serious drug use (addiction) affect the person’s double stream of consciousness? These are questions I believe medicine should be pursuing as we work to better understand and work with our patients. Especially those patients whose lives are highly stressed, and for whom their life dialogue streams so deeply and damaging yet is outside their awareness.

With Case #2, Mr. C was very clear about just how much his violent home life (until after high school) was affecting his life now, especially with his current university studies. Note the following dialogue from his treatment:
(P) “I’m really upset because I got the lowest grade in the class on my final.”
(D) “What do you think happened? You always do well on tests.”
(P) “I couldn’t focus. I literally could not read the questions. And then when I found myself able to read even a little bit of what the professor was asking on the question, it literally made no sense to me.”
(D) “Definitely not your usual. Again, what do you think was going on in your mind that hijacked your ability to do well on the final?”
(P) “The medication does help stabilize me. I know I sleep much better when I’m on the medication. But my depression sometimes really, really gets me down.”
(D) “Is it the flashbacks that are sabotaging you?”
(P) “The flashbacks are with me every day.”
(D) “They are literally intrusive in your life every day?”
(P) “Yes, and they get worse when I’m stressed out.”
(D) “Was it the exam itself that was stressing you out?” (P) “Maybe a little…… But I think it was more about the conversation I had the previous night with my mother. I was telling her about my insight regarding my evil father. That I had realized that he had learned an important lesson while he was growing up in El Salvador in a gang culture. That he gained control in that violent culture by instilling fear in other people. And he brought this same lesson right here to our home. He was always instilling fear in me, all the way up until I graduated from high school and went away to college.”
(D) “How did your mother respond to your insight?”
(P) “She didn’t say anything, and then she just walked away.”

Regarding Case #3, what happens to the “stream of consciousness” when post-concussion syndrome is traumatizing to the brain? And in all the cases that current medicine deals with, does the treatment run deep enough? Deep enough to understand how our unconscious stream of consciousness influences our health, injuries, illnesses, and diseases? Day in and day out, Ms. A’s stream of consciousness was very fragmented and random. She would share random, fragmented thoughts throughout the day with family, friends, and me. Her sentence structure made sense, but not exactly where her sentences came from. During our sessions I found that I could reduce her random, fragmented thoughts through emotional communication and lots of patience. Paying less attention to her scattered thoughts and more attention to the emotional experiences that lay somewhere in her stream of consciousness. This led me to the question of what was going on in her injured brain/mind that led her stream of consciousness to be so fragmented and random?

Exploring the Questions

If we explore Freud’s idea of the preconscious mind, how does this help us understand the above 3 cases? Freud saw the conscious mind as the contents of the mind a person was aware of. The preconscious mind contains those things a person could potentially pull into conscious awareness depending on the right trigger or event. It also acts as something of a guardian controlling information that could enter consciousness. Finally, the unconscious mind contains thoughts and feelings outside of our awareness, yet they continue to exert an influence on our behavior even though we are unaware of these underling influences. This includes repressed feelings, hidden memories, habits, thoughts, desires, and reactions again outside of our immediate awareness.

The unconscious also includes those thoughts and feelings that are either too painful, embarrassing, shameful, unacceptable, unpleasant, and/or those increasing pain, anxiety, depression, conflict or distress for a person to be fully aware of. (See VeryWellMind) [5] When I review each of these cases, what “jumps out” at me is the unconscious agenda. The wife was not talking about her underlying fear and paranoid at that time. She was tensibility enjoying brunch with her husband. So where was the paranoia that so quickly came to the surface: “You changed up our car!” I am suggesting that because of her long, unexplored history of trauma (ACE rating score of 10/10), that for her to function, this had to become part of her unconscious stream of awareness (placed outside of her awareness).

More about this below. Regarding Case #2, Mr. C was very clear that flashbacks were a constant, daily intrusion in his life. And the more complex and complicated his day, the harder it was for him to function, because of all the underlying flashbacks and intrusive thoughts from his traumatic past. During his recent final exam time at the university, he was constantly plagued and interrupted by flashbacks of childhood and adolescent memories. Sadly, all these memories were of traumatic situations. During this recent final exam week, he would have to spend 6-8 hours doing something else (playing video games or taking care of his younger brother, age 4) into order to get his mind to settle down. He was acutely aware of a constant dialogue playing in the “back of his mind” that was a constant intrusion in his life. This is the kind of clinical data that indicates to me the importance of understanding an unconscious stream of consciousness, especially with highly traumatized and brain injured patients.

Finally, with Case #3, Ms. A was able to share the constant psychotic process (delusions that were absolutely real for her) that organized her life on a daily basis. In meeting with her family, it was clear that the traumatic incidents she was describing were not something they knew to be true. And here we get into very tricky territory. Are the traumatizing incidents she continued to describe actual events her family knew nothing about or was she having difficulty separating fantasy from reality. And what is psychosis, but psychosis, accounting for her delusions that she was molested during her childhood and had early sexual encounters prior to being married. Further, were all these delusions and fantasies actually coming from her original brain trauma (her original concussion at age 9-10)? And then what did her original childhood injury do to her stream of consciousness (which again flows outside her conscious awareness)? Fortunately, over time, with the opportunity to express all her delusions, fantasies, and paranoia, her family was able to share that she was consistently doing better 60% of the time.

While I was working on this article, I had the following interchange with one of my patients. In terms of understanding the role a stream of consciousness plays in health, illness and disease I found this exchange very helpful.

(P) “I lost it last night for about 50 minutes. I just couldn’t shut my brain off. It was like it was on fire!”
(D) “Are we talking panic here, as in a full-blown panic attack?”
(P) “Yes, and worse because I was totally out of control. It was so bad for me that I exactly called my ex, and he reminded me this stuff always occurs at night.”
(D) “He stayed on the phone with me to try and help?”
(P) “And it did help me because after about 50 minutes I finally started to calm down. But I don’t understand why these kinds of things keep happening to me.”
(D) “What happened during your day that might have led up to this? I’m guessing that it was something that made you feel that you couldn’t control things. Everything was getting out of control.”
(P) “Seriously, it’s that stupid county department. They continue to screw up everything and put me at risk once again.”
(D) “And perhaps a trigger from the past was also a piece of the panic attack.”
(P) “You mean, maybe my mother? When she kept telling me that I should stop complaining about stuff because no one cared what I thought?”
(D) “So, you probably ending up stuffing your thoughts and feelings for years. Because you mother told you they didn’t matter to anyone.”
(P) “Are you suggesting that this was like an after-burst from my frustrating day?”
(D) “I have been exploring the idea that there is an unconscious stream of consciousness that can contain a lot of traumatic experiences. And if this unconscious stream of consciousness gets triggered, there is an after-burst.”
(P) “Well, now that I think about this, it did feel like there was an explosion in my brain last night, for 50 damn minutes. Is that because I was taught early in my life to stuff everything I was thinking and feeling. Then finally it just blows up in my brain?”
(D) “I think this is the after-burst you were just alluding to.”
(P) “Now that I am looking back on my growing up years, I would do anything to not feel something. That’s how I survived.”
(D) “That was how you coped in childhood, adolescence and young adulthood?”
(P) “Yeah, repression and my eating disorder. I would come home from work, vomit, and then go out for a 5-mile run. Those were my coping skills in those days.”

Looking at the above 4 examples, I again find myself asking the question: why do we continually have to traumatize our children and then ignore the consequences of the damage to them? I believe this is a huge question that not enough elements in American Society are really willing to look at. So, the trauma and drama continue and continue to plague us as a society and a modern culture.

Discussion

Back with my original question: how do we understand (conceptualize) whether our patients are affected (influenced) by the preconscious, the DMN, or a continual stream of consciousness some of which we are aware of and some of which (maybe a lot of which) is unconscious. But it is a stream that is continually with us and is continually influences our lives across the board. I outlined the preconscious earlier in this article. What about DMN? What role does this play in medicine’s treatment of injury, illness and disease?

The default mode network is complicated, yet essential to human life processes. One of the best definitions I am aware of is the following from a very informative article by Vinod Menon [6]. He defines the DMN as a “collection of distributed and interconnected brain regions that are typically suppressed when an individual is focused on external stimuli; however, in the absence of attention to external stimuli the DMN switches or ‘defaults’ to internally focused thought processes, such as self-reflection, daydreaming, mind-wandering, recall of personal experiences, and envisioning the future.

The DMN is also hypothesized to be active during periods of ‘rest’ and quiet wakefulness, allowing us to reflect on our experiences, feelings, and social interactions.” [6] Research into DMN is helping us advance our understanding of how brain circuits are organized, how they contribute to cognitive and affective functioning, and how impairments in DMN can lead to psychological and organic pathology. [6] In his article, Dr. Menon argues that the DMN integrates and broadcasts memory, language, and semantic representations to create a coherent “internal narrative” that reflects an individual’s experiences. This narrative is central to the construction of our sense of self, shapes how we perceive ourselves and interact with other people, it may have ontogenetic origins in self-directed speech during childhood and is a vital component of human consciousness. [6] As I began “digging around” in the literature on the DMN (already quite extensive after only several decades) I found the correlation I was looking for that confirmed my clinical observations and experiences.

Here is what Dr. Marcus E. Raichle (the original discoverer of the DMN) wrote:

“However, regardless of the details of a particular task, the default mode network always begins from a baseline of high activity, with small changes in this activity made to accommodate the requirements of a particular task. The available evidence indicates that the functions of the default mode network are never turned off but, rather, carefully enhanced or attenuated.” [7] This statement matches my clinical findings that there is a steady stream of consciousness at an unconscious level (“the functions of the default mode network are never turned off but, rather, carefully enhanced or attenuated”). And back to my question, given trauma to the brain/mind, organic or psychological, what happens to and in the DMN? As is the case for each of the above 4 patients, there is a running dialogue, understood as the preconscious, the DMN or as an unconscious stream of consciousness dealing with their traumatic experiences. And as clinicians, how do we deal with this “background dialogue” that has affected each of the above patients in ways that are a major intrusion into their daily lives? At the same time, I can see that this background dialogue protects my patients from being overwhelmed by the traumatic experiences they have undergone.

The problem occurs when this background dialogue breaks through into consciousness and becomes intrusive in their lives through flashbacks, difficult memories, and nightmares. I will go one step further here and suggest that neither medications (that primarily treat symptoms, helpful to a degree), nor CBT (designed to change a person’s thoughts and thereby change their behavior), really address the problem of how trauma imprints itself in the brain/mind. [8] And what about the ideas Harvard Psychologist William James wrote about in his 1890 book “The Principles of Psychology,” Chapter IX, “The Stream of Thought.” James wrote, following the idea that a person can never step into the same river twice, that: “no state once gone can recur and be identical to what it was before. In talking of it hereafter, let us call it the stream of thought, of consciousness, or subjective life. Beneath this stream, sits the slit and pebbled bed of the unconscious, voluntary and involuntary memory and even alternative persona.” And further that this stream of thought “becomes a carefully chosen image for the flux of subjectivity: how ideas, feelings, and sensations, both present and past, cohere into the experience of a continuous self, that ever present “I,” which meanders through the mind from childhood until our death and possibility beyond.” What can we conclude from all of this? Again, I am not in favor of medicating away a patient’s symptoms, so they are no longer dealing with major depression, panic attacks or physical pain, consciously.

Medications can be helpful in small ways by reducing the severity and intensity of a person’s symptomatology. In the case of 2 of the above 4 patients, medication did make their lives easier. But at the same time, they were able to identify that their background dialogue was still there although less intense and severe. Which did make their lives more manageable. There is much to be thankful for regarding psychotropic medications. But only using this approach (which is so often the case) does not entirely consider the imprinting of trauma into the brain/mind and how the brain deals with all this. Nor, in my experience, do cognitive behavioral techniques address the deep problems that trauma survivors and brain injured patients are dealing with. For a short period of time, I was referring my patients for Ketamine treatments.

They did experience some changes in their depression and anxiety states, but nothing that lasted. With one exception, which I wrote about in “The Complex Architecture and Healing of Traumatic Brain Injuries,” (Cambridge Scholars Publishing 2023) the final chapter “Painting the Picture.” He had enough money to afford all the treatments he felt he needed, but by his own admission this was not the curative factor. About 9 months after he finished his treatment, his girlfriend wrote me a note stating how much our work had helped him and improved their relationship. I note that her loving support for him during his treatment was a major factor in his recovering following years of trauma coming from his family of origin and 2 major concussions. Again, this speaks to the crucial value of healthy relationships in the treatment of trauma both psychologically and physically.

Conclusion

What have I concluded from these 4 cases? Thinking about a patient’s unconscious agenda is not new for me from my modern psychoanalytic training. What is new for me is understanding that there is an unconscious stream of consciousness that is always present for all of us. And that this unconscious stream of consciousness needs to be addressed especially with highly traumatized patients and brain injured patients. I define psychoanalytic work as:

a) Addressing the fact that the unconscious “runs” all of us.
b) That the role of psychoanalytic work is working with the patient’s resistance to doing what is healthy for them, not working to change their thinking which will then change their behavior.
c) Psychoanalytic work is interesting in the patient’s psychic structure.

Exactly how do they process their worlds, internally and externally, and create meaning from this. With neuro-psychoanalytic treatment, I consider that the human mind is the subjective experience of the brain. Meaning to me that our brains create our experiences. And if the patient is coming from highly traumatizing experiences, or brain damage, their lives, their behavior, will reflect these injuries. In terms of theory and perspective, what have I concluded about the preconscious, DMN, and a stream of conscious that “runs” on 2 levels? Am I describing 3 slightly different frames of reference for the same phenomenon? Or, are these 3 slightly differing processes in the brain/mind that all add up to the complexity of human beings and their intricate struggles? Here I find myself looking back at my original question: the conceptualization issue. Exactly how do we understand what our patients are going through and why? Exactly what lens are we using to answer these questions? It finally occurred to me that one answer to these questions has to do with what our patients resonate with. How do they understand themselves? As coming from a preconscious-unconscious place, from an understanding of DMN, or from an understanding that their brain/ mind is always a stream of consciousness and an unconscious stream of consciousness.

My apologies here because I feel I have just created more complexity in our work with patients. On the other hand, it appears to me that real healing for any of our patients must go this deeply into our human nature. Nor do I believe that this is a complete enough answer to my original questions. So, stay tuned for further explorations, and I welcome all feedback. Finally, what is the importance of an unconscious stream of consciousness for our clinical work? My work with patients has taught me that this is where the real damage resides, presenting as a stream of thoughts, feelings, stressors, ideas, and complications all outside the patient’s awareness, while still having a major impact on their daily lives. And that this is best addressed through the relationship the patient has with their clinician. Within this matrix, this doctor-patient holding environment, the patient is able to verbalize, to put into words, their experiences. And through this process, through language, the patient is able to begin creating new neural pathways on the road to healing psychological and physical trauma. Is this easy work? No, it is not! But over time, with commitment from both doctor and patient, the healing process can move forward slowly but surely!

One final, final note, it is essential in this process that the clinician is also aware of their own unconscious stream of consciousness such that their resistances don’t interfere with the patient’s process. Psychoanalysis is the only disciple I am aware of that requires the clinician to be in their own treatment to understand their own brain/mind dynamics. I have found it very helpful to explore and understand my own experience with each individual patient. With this perspective as a guiding light, the challenges for both patient and clinician are difficult, but in the end, I have found these challenges workable and very gratifying to overcome when our patients get well.

Acknowledgement

No acknowledgments

Conflict of Interest

The authors declare that they have no conflict of interests.

References

1. Mark Solms, Oliver H Turnbull (2011) What is Neuro-Psychoanalysis? Neuro-Psychoanalysis 13(2): 133-145.
2. Brian Johnson, Daniela Flores Mosri (2016) The Neuro-Psychoanalytic Approach: Using Neuroscience as the Basic Science of Psychoanalysis. Frontiers in Psychology 13(7): 1459.
3. Lisa Feldman Barrett (2020) “7 1/2 Lessons About the Brain,”. Houghton Mifflin Harcourt, Boston.
4. Gerald Martone (2020) Is Psychosis Toxic to the Brain? In Current Psychiatry 19(4): 12-13.
5. Ioanna Giannopoulou (2023) Links Between Trauma and Psychosis (Review). Experimental and Therapeutic Medicine 26(2): 386.
6. Vinod Menon (2023) 20 Years of the Default Mode Network: A Review and synthesis. 111(16): 2469-2487
7. Marcus E Raichle (2015) The Brain’s Default Mode Network. Annu Rev Neuroscience 38: 437-47.
8. Leighton J Reynolds (2025) Complex-PTSD and the Imprinting Problem Part II. Clinical and Medical Research and Studies (4)(3).