Louis
Cozolino is professor of psychology at Pepperdine University, and a clinical
psychologist in private practice. This book is part of a series edited by Dan
Siegel, and of course is likely to create much interest in a community of
psychologists desperate perhaps to add to the arsenal of what could be
considered evidence based practice in a health science in this time of
challenge. 

From
the outset, for most, Cozolino’s book will enthral, but for some there will be
a subtle disappointment that creeps in.

Cozolino’s
approach has a narrative to it.  He
begins with a foreword by Series Editor Dan Siegel, and this is then followed
by three chapters of an overview, dissecting out the tangled shared web of
origins in neurology and psychology, a nice intro for the neophyte, but nothing
new here yet for the neuroscientist. 

His
theme of rebuilding the brain is introduced in the second chapter, and
then the heuristics of various forms of therapy, such as Gestalt,
Psychoanalytic theory and so on are used to begin production of a series of
working hypotheses at the end of the chapter, a basis for which to begin analysing
how the collection of therapies presented produces change at the neural
level.  He is setting the stage for what
is to come in section two, but that is where a feeling of disappointment comes
in, only to be inspirational again, a little further on.

Here,
in Chapter 4, a foray into the legacy provided by evolution begins with a 1998
quote from Eric Kandel (Nobel prize 2000), but that is all we will see of his
vital work.  Cozolino guides his
discussion from micro to macro worlds, from individual cells to systems of
cells in networks, passing through brain development and plasticity, to
understanding the critical periods of pruning and arborisation, as development
unfolds, in a very lightly argued chapter. 
Some of the comments, such as an inclusion of a quote on page 81, seem
to be in error, without explaining for instance how "In determining
brain-behaviour relationships, these measures (CT and MRI) need to be
evaluated on the basis of whether they are causes or correlates of the disorder
being studied".  Huh? I read back
along the pages preceding this, but no enlightenment for me.

A
comment in the summary, "The most powerful environment is the one created
within intimate relationships with caretakers" (page 82) is never
validated in the chapter body, and is of course largely untestable, and
probably wrong, but evolves from his hypotheses on page 63.  One can imagine that ADHD must emerge from
the caretaking of our parents, but of course this is not the case, or that the
most powerful influence in our lives is likely to be our caretaker, but
adolescence is also a powerful time of socialisation and neuronal activity, and
many therapeutic targets for intervention have enormous impact here, such as
the processes which lead to psychosis or mood disorder.  Such perhaps over-inclusive or convenient
statements may not be entirely true, and Scott Lilienfeld and colleagues have
noted recently that we must be careful of how we interpret hypotheses based on
untestable presumptions as if they were science (see Science and
pseudoscience in clinical psychology, Scott O Lilienfeld, Steven Jay Lynn
and Jeffrey M Lohr, Eds. 2003, The Guilford Press; New York).

The
next chapter, which begins by discriminating between the implicit and explicit
learning modes of the brain, is well done, but again superficial, with a few
case studies and some personal inputs. 
Again, for one willing to accept a superficial look into the
amygdala-hippocampal-cingulate pathways, this would prove fascinating to a
certain point.  The implications of errorless
learning (see Barbara Wilson and colleagues from the UK) and emerging work on
scaffolding by Konstantin Zakzanis and collaborators from Toronto, are not
touched on here, despite the insights they would offer for a more
neurologically sourced process of psychotherapy.  More importantly, the style followed here is to fractionate the
system of information processing into components that violate the concept of
what Flinders University Professor of Neurology William Blessing calls the
‘visceral brain’, or otherwise the fractionating of the homeostatic systems
mentioned in the first part of the book (see page 63), or fractionating of the
executive functions (see Barbara Wilson and colleagues again), or the
fractionating of the components of the executive, conscious, volitional aspects
of the brain (see the various works of Muriel D Lezak on the subject), nor the
obvious history of the Soviets, Luria and Vygotsky, all of whom inform
importantly on understanding the fascinating process which this chapter really
makes a hash of .  This is just too
short and fractionating, and while it may enable some understanding for the
novice neuroscience student, it will result in flaws that the quoted works of
Antonio Damasio have tried to address. 
In the worthwhile study of the information processing areas of the
brain, punctuation or fractionating obscures the homeostatic nature of these
systems, and the student is left, post chapter 4, without any global
understanding which would be essential to conceiving how heteromodal
information is processed.  Blessing
would say that one cannot dissect out the sensation of thirst from the act of
seeking out fluid to avoid dehydration, any more than Papez could survive
leaving the amygdala out of his formulation of the limbic cortex in 1937.  In the same way, the omission of the vital
role of the biogenic amines here suggests that structure and function are
conflated, not the least by the use of references dating from the 80’s and
90’s, many of which have been improved on since in more modern works.  Despite the promise made, Cozolino does not
satisfactorily return to the biogenic amines, nor does he address how the
expression of DNA relates to LTP, or any of the other vital aspects of neuroscience
we now know as fact, post Kandel 2000.

Many
comments, such as those about narrative on page 103 are not supported by the
work of such luminaries as Claire Penn and her associates, Paradiso and others,
where it is clear that appreciation or interpretation of narrative owes much to
right hemisphere processing in terms of its underlying algorithms and
meanings.  Again, discussions which
result in fractionating language or localising language narratives is contrary
to other themes that are true to the homeostatic hypotheses, for instance that
memory is a widespread function.

The
next chapter, on laterality, does mention who it must, namely Michael
Gazzaniga, but neglects the fascinating approach to evolution that Gazzaniga
presented in 2000, wondering as he did weather the corpus callosum actually
enables the human capacity of meta cognition (see Sugarman 2002, Revista Espanola de Neuropsicologia, Executive
functions and evolution: why our toolboxes are empty? 4(4), 351-377 for a brief
discussion.)  Again, there is just
so much more out there, I felt let down by the superficial discussion, even if
one is targeting the novice or the mildly uninformed.  The learned Louis Cozolino has such a good structure, the
skeleton could have benefited by a lot more meat, meat specifically which
addresses the various meta-cognitive abstractions which underpin our experience
of ourselves and others. 

He
does however take this further, and applies the principles of laterality that
he has elucidated to some forms of psychopathology, as he did earlier with TLE
and the amygdala, but as one can see by reading the summary at the end of the
chapter, he does not accomplish much.  I
also note the use of the royal imperative "We" in his summaries, as
in "we have moved on", but he seems to be alone on the cover, so I am
not sure why "we" are invoked, petty point, but I was left with my
cross stitch threads hanging again as on page 81, and so felt again
unfulfilled.  After all, invoking a rich
repertoire such as Mesulam and Gazzaniga, especially since publishing his
excellent and mammoth volume as editor in chief of "The new cognitive
neurosciences" in its second edition from Bradford MIT in 2000, without
making a meal of it, is saddening.  I
felt that so very often, in a book published in 2002, that much recent, most
valuable state of the art science has not been included.  I hope there is a second edition, where he
can add more substance to his considerable understanding and style in
approaching the matter.

The
book warms up in part three though, with the organisation of experience within
the healthy brain, again a superficial analysis peppered with a few case
studies, but unconvincing, even though the complex subject of executive
functioning and consciousness is tackled with aplomb in only one and a bit
pages of big typeface, and that takes some skill as a writer, which Cozolino
clearly possesses.  It is his editor I
am being unkind to, he lets the meat burn off: what a nice structure, but where
is the depth?  This is emerging as a
book written for non-neuroscientists. 
None of the facts presented is too advanced, or wrong, just right in
fact for its audience.  Even I can find
a truffle in a dark forest, when the smell is right, blind hog that I am.

Into
this arena, the discussion on the executive brain, comes a discussion of the
back-bencher of the heteromodal cortex, the parietal lobes:

"Because
behaviour is easily observable and measured, neurologists have focused
primarily on the behavioural aspects of brain injury.  However, there is more to the human experience than behaviour;
there are also the experiences of self in the world and inner subjective
space.  These more subtle and subjective
aspects of human experience have received little attention in neurological
examinations" (page 145).

Now
I have a problem with this.  Neurologists
(bless them) have paid scant attention to the behavioural aspects of brain
injury until very recently, and behavioural neurology is a relatively recent
development, as is neuropsychiatry. 
Indeed, the emergence of Kurt Goldstein, Alex Luria, Lev Vygotsky and
others following on Freud’s neurology and dissections in order to discover the
human behavioural outcomes of neurological integration or disintegration, are
acknowledged in most textbooks as the antecedents of such knowledge.  Simply put, the neurological exam is the
lower end of the neurological spectrum and in no way does the testing of
reflexes, cranial nerves, gait, eye, tongue, forearm and finger movements
constitute a neurobehavioural assessment as practiced today.  Von Bronin aside (see reference to 1963 work
on page 145), the expansion of the parietal rather than the frontal lobes in
evolution and the very superficial explanation on page 146 of what Adams &
Victor and other neurological tomes consider to be our awareness of our body and
its relation to the external world, does not constitute proof that the tertiary
association areas and Brodman’s 40 and 7 are the seat of our awareness, any
more than again, the aging references (1978 & 1987) referred to on page 147
provide any better evidence.  Localising
the function of the parietal areas with the human experience of wholeness and
position is just silly: the amygdala independently has a huge representation
from the gut, the auditory and visual areas, and Antonio Damasio’s three recent
works are anecdotally influential in making one seek awareness in the feeling,
the apperception of visceral emotion, as the seat of our knowing where and how
we exist in juxtaposition with the external and internal world, in recursive,
second order cybernetic feedback loops within a homeostatic, allostatic,
capable organism. I think line of linear reasoning won’t do, this won’t do, not
in 2003. There are many explanations out there in contemporary science, none of
which are present here.  As for the
"imaginal world", I prefer Russ Barkley’s "simulator",
which draws on more contemporary views of the brain, even if he largely ignores
Damasio too!  Other more recent
formulations demonstrate the necessary hierarchy of the executive systems in
making sense of the emotions (or our internal, visceral brain) and the feelings
of what happens (the integration of the internal with the external
extrapersonal space with the internal) that constitutes our awareness of
being.  Into this arena, surely, comes
the interceding psychotherapist, entering via the spoken word into the
mediator.  George Prigatano, the great
rehabilitation expert notes what an amazing advantage it was to primitive
hominids, to finally develop what Barkley calls a simulator, an internal
representational world that can reproduce somewhat faithfully the external
reality, and thus bind events across time and take the necessary actions to
alter behaviours that will alter the environment, to the advantage of the
simulating man.  This, I feel, missing
in Cozolino’s work, is the arena into which the therapist must walk.  All of that is known today, all of this is
accepted, supported by Gaultieri, Barkley, Gazzaniga, Damasio, Shallice, and
many others who lead the neuroscience of feeling and interacting.

The
rest of the book works on the construction of narrative, and the sculpting of
the brain and interpersonal self, and the nature of psychopathological and
traumatic brain changes.  Especially
this last part is much better in terms of research evidence and writing, such
as in PTSD and borderline personality for instance, again, too brief.  Self-injurious behaviour alone would be a
wonderful place to begin in this book to support the title, just as Damasio
introduces the effect of misplaced electrodes on an aging Parkinson’s sufferer
in his latest work.

The
fifth section, which embarks on the reorganisation of experience, refers to
psychologists in their role as clinical neuroscientists, able to create an
individually tailored enriched environment to enhance brain development (page
291). They would need to know more than he offers, and this is my gripe with
his book overall, good as it is.

That
is a noble aspiration if I ever heard such a thing, here is the value in this
otherwise vegetarian cookbook for carnivores: students of psychology in their
under- and post-graduate years need to go out and buy this book, flawed as it
may be in my eyes.  In its way, limited
though, it still is a valuable entry-level tool to introduce the unwilling
practitioner of psychodynamic thought into the real world of mind and its
antecedent brain without engendering a feeling of being overwhelmed by
neuroscience, as fascinating as that world is for such as myself. 

For
the psychologist who wishes to aspire to the role of scientist-practitioner,
this is the launch-pad, unthreatening and flawed as such a start must be, in
order to promote some motivation to continue into the vast unchartered world of
cognitive and behavioural neuroscience where there indeed be dragons, and of
course hippocampi.

Into
this arena comes Cozolino and his concept of the manageable stressor of
psychotherapy that should promote synaptic or neuronal plasticity (he doesn’t
distinguish this well enough in terms of either LTP or simulation across time
in working memory), but nevertheless I believe any follow-up work should
demonstrate with much more depth how he believes the scientist practitioner
should accomplish this, case by case, discussing it with the complexity lets
say, of the Othmers in1999.  Otherwise
we are still left at the level of treating what these latter authors called the
‘fat ankle syndrome’, and not getting to the core of brain in mind.

What
my students would be left with, after reading this work, is a fractionated
understanding of the homeostatic autopoeitic, partially open and partially
closed system, second order in its cybernetic feedback mechanisms, brain, that
we live in.  After all, light ends at
the cornea, sound at the tympanum, the outside world at the skin.  Everything after that is our imperfect recreation.  Enabled by the underpinning of working
memory, encultured by the combination of the visual and verbal variants of
this, human experience ties the cortical knots that constitute our feeling of
what happens (conflating Luria and Damasio’s terms), our awareness of being
physically present in a recreated world constitutes our humanity.  Ideational Darwinism (Barkley’s term)
implies that much of what we think we know is flawed: therapy needs to address
these flaws when they come to confound our thoughts and feelings.

Mutable
by construction and deconstruction, such a recreation allows for creativity and
error, and thus common humanity arises with all its richness.  I just wish Cozolino had done more to show
us how that all works.

 

© 2003 Roy Sugarman

 

Roy
Sugarman PhD, Clinical Lecturer in Psychiatry, Adelaide University,
Senior Cinical Neuropsychologist, Royal Adelaide Hospital Glenside Campus
Extended Care

Categories: Psychotherapy, Psychology