Abstract
In rehabilitation literature, clinical psychologists are most often seen as specialists whose diagnostic mission is the assessment of psychical deficiencies caused directly or indirectly by the brain lesion, and whose therapeutic mission consists of teaching the patients how to cope with them. A psychoanalytically inspired psychotherapy is rather based on the idea that patients themselves, whether brain injured or not, and most likely unbeknownst to themselves (and a fortiori to their therapists), may well carry the inner keys to understanding their reactions to an acquired disabling injury. In this paper, we shall attempt to determine the specificities of a psychoanalyst’s work with a recently brain-injured patient. We analyze the case of a patient, particularly apt for illustrating our hypothesis, attending the rehabilitation department of a single center. We describe and analyze the content of psychotherapeutic sessions as well as the medical and rehabilitative data in the patient's medical file. The patient’s narrative of his post-traumatic amnesia confabulations provided some insight into the patient's subjectivity. The psychotherapeutic sessions made it clear that revisiting his neurotic familial relationships helped the patient to acquire some degree of “independence”, a classical rehabilitative goal. The articulation between the actual dependency directly caused by the brain lesion on the one hand, and the neurotic patient’s passivity and aggressiveness, on the other, is discussed. Exchanges between the psychoanalyst and the rehabilitation therapists helped the latter to take the patient's subjectivity into account. The specific role of a psychoanalyst in a rehabilitation department is to consider each patient as a thinking and speaking subject and not just a person with a disabled brain (even though brain injuries may cause organic psychical disorders). Developing awareness of this complexity in members of the rehabilitation team contributes to their effectiveness.
This is a preview of subscription content, log in via an institution to check access.
Similar content being viewed by others
Notes
We present this case in accordance with French bio-ethical principles for medical research involving human subjects. We have taken all reasonable steps to disguise the patient we present here. Factual elements of the case description have been changed; it has now become strictly impossible for the patient to be recognized, even by him/herself. So, indeed, names, characters, businesses, places, events, locales, and incidents are used in a fictitious manner. Any resemblance to actual persons, living or dead, or actual events is purely coincidental.
Some of these symptoms are to be seen in the clinical vignettes provided in Annex A.
BDA is the French acronym for “bouffée délirante aiguë”- literally acute delusional episode usually called “acute schizophrenia” in the English-speaking psychiatric world.
Interestingly, the mission of a clinical psychologist in the rehabilitation team is often referred to as “psychological treatment” (see Robertson, 2010), while the term psychotherapy is used to designate cognitive psychotherapy.
The interesting paradox here is that in order to comply (an implicitly passive mode of behavior)—he must be active!.
“Méconnaissance” refers to the failure to recognize conflicts, suffering or deficiencies, due to neurotic repression.
See (Annex A) what Matt answers when asked “Why a sumo?”.
References
Ben Yishay Y, Diller L. Turning points. Positive outcomes of intensive psychotherapeutic interventions in holistic neuropsychological rehabilitation settings. New York: Oxford; 2016.
Bowen C, Yeates G, Palmer S. A relational approach to rehabilitation: thinking about Relationships after Brain Injury. New York: Routledge; 2010. p. 2018.
Bruguière P. Le travail clinique en service spécialisé. Le Journal Des Psychologues. 2012;9:41–5.
Coetzer BR. Grief, self-awareness, and psychotherapy following brain injury. Illn Crisis Loss. 2004;12:171–86.
Darbyshire J, Greig PR, Vollam S, Duncan Young J, Hinton H. “I Can Remember Sort of Vivid People… but to Me They were Plasticine”. Delusions on the intensive care unit: what do patients think is going on? PLoS ONE. 2016;11(7):e0160296.
Del Grosso Destreri N, Farina E, Calabrese E, Pinardi G, Imbornone E, Mariani C. Frontal impairment and confabulation after herpes simplex encephalitis: a case report. Arch Phys Med Rehabil. 2002;83:423–6.
Freud S. Family romances, vol. 9. London: Hogarth Press; 1909. p. 235–42.
Freud S. On narcissism, vol. 14. London: Hogarth Press; 1914. p. 67–102.
Green A. Passivité-passivation: jouissance et détresse. Rev Fr Psychanal. 1999;6:1587–600.
Grosclaude, M. Le corps réanimé: un Sujet Extrême. In: Vulnérabilité psychique et clinique de l’extrême en réanimation, pp 82–89; 2015. Dunod.
Kaplan-Solms K, Solms M. Clinical studies in neuro-psychoanalysis. Introduction to a depth neuropsychology. New York: Routledge; 2000.
Klonoff PS. Psychotherapy after brain injury: principles and techniques. Guilford Press; 2010.
Kopelman MD. Varieties of confabulation and delusion. Cogn Neuropsychiatry. 2010;15:13–45.
Kovacs Z, Stock D, Bernert G. “You Are a Cannibal”- A Case Report: Psychoanalysis of an Adolescent Boy with Bifrontal Lesions (Part 1: The First Year). Neuropsychoanalysis. 2014;13:73–89.
Lacan, J. The mirror stage as formative of the I function as revealed in psychoanalytic experience. In Ecrits, 2006; pp 75–81. Norton.
Maddux B. Les troubles à expression comportementale chez le traumatisé crânien: point de vue d’une psychanalyste. Résurgences. 2014;9:18–23.
Morin C. Stroke, body image and self-representation. A neurological and psychoanalytical perspective. New York: Routledge; 2018.
Oppenheim-Gluckman H. Mémoire de l’absence. Clinique psychanalytique des réveils de coma. Issy-les-Moulineaux: Masson; 1996.
Perna R, Harik L. The role of rehabilitation psychology in stroke care described through case examples. NeuroRehabilitation. 2020;46:195–204. https://doi.org/10.3233/NRE-192970.
Peskine A, Bruguière P, Picq C, Pradat-Diehl P. Confabulations fantastiques ou délire? Ann Readapt Med Phys. 2008;51:501–5. https://doi.org/10.1016/j.annrmp.2008.05.005.
Robertson, J. Needs following Stroke. NHSGGC, 2010. Retrieved July 2 from http://library.nhsggc.org.uk/mediaAssets/CHP%20Inverclyde/Psychological_Needs_following_Stroke_Inverclyde_Protected_Learning_Event_10th_March_2010.pdf.
Sherer M, Katz D, Bodien HG, Arciniegas DB, Block C, Blum S, Doiron M, Frey K, Giacino JT, Graf MJP, Greenwald B, Hammond FM, Kalmar K, Kean J, Kraus MF, Nakase-Richardson R, Pavawalla S, Rosenbaum A, Stuss DT, Yablon SA. Post-traumatic confusional state: a case definition and diagnostic criteria. Arch Phys Med Rehabil. 2020;101:2041–50.
Thibierge S, Morin C. The self and the subject: a psychoanalytical perspective. Neuropsychoanalysis. 2010;12:63–75.
Waldon B, Casserly LM, O’Sullivan C. Cognitive behavioural therapy for depression and anxiety in adults with acquired brain injury. Neuropsychol Rehabil. 2013;23:64–101. https://doi.org/10.1080/09602011.2012.724196.
Weinstein EA. Symbolic aspects of confabulation following brain injury: influence of premorbid personality. Bull Menninger Clin. 1996;60:331–50.
Winnicott DW. Primary maternal preoccupation. In: Caldwell, L., Robinson, H.T. (eds.), The Collected Works of D. W. Winnicott, Vol 5, 1955–1959, 183–188; 2016. Oxford University Press.
Acknowledgements
Our thanks go to Christine Picq, Anne Peskine, Vanessa Ramel, Laurence Lescène, Nicole Helsly, Stéphane Vincent who vividly spoke with us of their patients. Our thanks and thoughts also go to the late Rose Katz for her unfailing support.
Author information
Authors and Affiliations
Contributions
All the authors made significant contribution to this paper. All authors read and approved the final version of the manuscript.
Corresponding author
Ethics declarations
Conflict of interest
On behalf of all authors, the corresponding author states that there is no conflict of interest.
Additional information
Publisher's Note
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
Annex A
Annex A
Session 1: 15 weeks after ABI
PB: I don't know anything about you. Could you tell me something about yourself?
Matt: I had an accident, I don't remember but I was told about it. I was in a friend’s loft with some friends and I was trying to stop a cat from falling through the window and I fell off.
PB: How long ago was your accident?
Matt: More than a year ago.
PB: You fell off?
Matt: I fell on my head. I'm in a wheelchair and I have left hemiplegia. I'm left-handed, so it's a big problem. I'm left-handed, so it's not necessarily… I'm a bit ambidextrous. Not very handy for writing a CV and I can't draw with my right hand… I arrived here on [–] but I don't know if I was in an intensive care unit before. I know I'm making a lot of progress and that's motivating. I arrived more than a year ago. I'm 23 years old, I'm going to be 24 if I make it to my birthday date.
PB: If you make it to your birthday date?
Matt: I am very optimistic. [Speaks about the occupation of his parents]. I'm looking forward to building up my own business, I'm very active [–] I'm looking forward to being autonomous and getting back to my business. As a left-handed person and a great sportsman, I can't wait to get back to an activity… I've put on a lot of weight in a few weeks, I've gained 2 kgs, I'm going to the dining room. I am very creative, independent, I need time to do things, I don't have time enough to go on the internet between visits and sessions. I'd like to be able to clear my head, go to the cinema [–] My mother told me that I had an accident trying to save cat.
PB: Had you got any strange ideas?
Matt: I knew I had been convinced to be a sumo champion [–] my parents persuaded me I had not. I trust my parents, but I know my memory is not good and the accident damaged me a bit.
PB: Why a sumo champion?
Matt: As I have a lot of imagination, maybe it comes from a film. Fighting every day… but sumo on public transport, that can't be easy. I've always been a fan of Japan and in my memory, I had to eat a lot of hamburgers and I gained a lot of weight. I like martial arts. Friends have seen me as a sumo on the Internet, but I trust my parents.
PB: What do you think?
Matt: I have not lost my personality, I have not forgotten my past. My memory has been challenged. I remember everything…
PB: Being a sumo champion?
Matt: Yes…
PB: what kind of feelings do you have?
Matt: I know for sure, but my memory has been shaken, my parents' answer is definite…
Session 27: 48 weeks after ABI
Matt: I am running away from reality through dreaming. I am a great idealist. In the dream, I let my ideal breathe…. The absence of boundaries between the possible and the impossible. I can create a fiction, a novel, a fairy tale… I realize that I am not yet put back together again. My parents reproach me with having an ill-adapted behavior at times (Matt alludes to having embarrassed everyone by stopping while the congregation was leaving the church after the mass and suddenly giving a hug to his sister).
PB: Do you find reality difficult to live with?
Matt: Yes. I was convinced that I had become a sumo champion and that allowed me to escape this painful reality… where I feel lessened and lost, deprived of the capacity to walk and if a car emerges from the left, there is the amputation of the left visual field. I also learned that I am tired for my whole life… I am deprived of freedom, of autonomy…
PB: Dreaming to be free?
Matt: I feel very scattered… I lack challenges, I'm not decision making… I'm fed up being scolded by my dad who tells me to brush my teeth…I'm kind of a bag that my parents and therapists pass around… Hard to trust others when they don't trust you…
PB: Trust you? Trust yourself?
Matt: I take public transport alone, the only hyphen to reconcile the different worlds in which I live.
PB: Reconcile dream and reality?
Matt: Regaining initiative, I miss feeling proud of myself… Between dream and reality, the relationship is conflicting. Sometimes I get annoyed when I'm inconsistent in my behavior, as when taking the wrong exit… (Matt took the wrong exit to get out of the hospital a few days before.)
PB: Regaining initiative and having the right to be wrong?
Matt: I expected to be praised and I was scolded….
PB: Like a child?
Matt: Yes, and those who force me annoy me.
We’ve reported here the first minutes of the first and the 27th session of Matt’s psychotherapy.
Only a few passages with personal details have been skipped.
Executive symptoms may be observed. Besides the sumo confabulation, they mainly concern language (e.g., “decision making” instead of “decision maker”), and evaluation of the time since the accident. Matt says he fell more than a year ago instead of 15 weeks ago. He says he’s 23 instead of 25 years old. This latter error might also have some subjective signification, suggesting that Matt’s psyche might have remained fixated at the time of the traumatic event.
Rights and permissions
Springer Nature or its licensor holds exclusive rights to this article under a publishing agreement with the author(s) or other rightsholder(s); author self-archiving of the accepted manuscript version of this article is solely governed by the terms of such publishing agreement and applicable law.
About this article
Cite this article
Bruguière, P., Morin, C., Maddux, B. et al. Contribution of Psychoanalytical Psychotherapy to the Rehabilitation Setting for a Patient with Acquired Brain Injury. J. Psychosoc. Rehabil. Ment. Health 10, 107–117 (2023). https://doi.org/10.1007/s40737-022-00299-z
Received:
Accepted:
Published:
Issue Date:
DOI: https://doi.org/10.1007/s40737-022-00299-z