Blog: Reflecting on Traumatic Brain Injury Month

Kurt Goldstein and Frieda Fromm-Reichmann on Traumatic Brain Injury
Symptoms are an amalgam of neurological injuries and the survivor’s individual physical and psychological efforts to adapt to those injuries
By Harold Kudler, MD
March is National Brain Injury Awareness Month. Traumatic Brain Injury (TBI) has been dubbed “the signature injury” of our recent wars in Iraq and Afghanistan and affects an estimated 20% or the 2+ million American Service Members who have deployed.  What do psychoanalysts have to say about TBI?
It is beyond the scope of this brief communication to fully engage psychoanalytic questions of mind and brain--this would take us back at least to Freud’s 1895 Project for a Scientific Psychology. Instead, I will observe National Brain Injury Awareness Month by focusing on a little known episode in the history of Psychoanalysis: the interaction between neurologist/psychiatrist Kurt Goldstein (1878 – 1965) and psychoanalyst, Frieda Fromm-Reichmann (1989-1957).
Much of what follows can be traced to Gail Hornstein’s 2000 biography, To Redeem One Person is to Redeem the World: The Life of Frieda Fromm-Reichmann (published by the Free Press, New York) and the reader is referred to this valuable work for further details. 
Fromm-Reichmann had been a medical student under Goldstein, who supervised her doctoral thesis. She worked with him on specialty wards for WWI neurological casualties.  From 1914-1920, they produced numerous joint publications on the brain injuries of war.
As Hornstein states, “The ‘irrationality’ of brain injury had always baffled physicians… Casualties of war were even more puzzling, because the speed and trajectory of a bullet or a piece of shrapnel were completely unpredictable, creating what appeared to be a pattern of symptoms unique to each patient.” 
Goldstein’s observations of patients with brain injury led him to understand these “unpredictable” symptoms as a complex amalgam of neurological injuries and the survivor’s highly individualized physical and psychological efforts to adapt to those injuries.  In other words, the “irrational” symptoms of brain injured war casualties could be understood as adaptive compromises between brain and psyche in a manner consistent with what Psychoanalysis had only recently recognized as the underpinnings of dreams and hysteria.  Goldstein’s “holistic” perspective was laid out in his seminal work, The Organism (1939).  He coined the term “self-actualization” to describe this adaptive process. 
The neurologist, Oliver Sacks, said the following of Goldstein in his foreword to the revised English edition (1995) of The Organism:  “… from the start, the physician in him found the classical methods - delineating a number of isolated "deficits" - inadequate. Whatever particular deficits there might be, he felt, there was always a general reaction or change in the individual as well, sometimes farther-reaching than the deficit itself. There grew on him the sense of the patient reacting as a whole, as an organism, developing altered orientations and behaviors in response to injury or illness.”
According to Hornstein, Fromm-Reichmann’s “… whole approach to treatment emerged from her research with Goldstein, and it is impossible to understand her later work with psychotics without appreciating this fact.  Years of daily contact with brain-injured patients accustomed her to so wide a range of symptoms that schizophrenia never seemed especially bizarre to her (as it did to most analysts, trained solely in work with outpatient neurotics)…  And because the patients in Goldstein’s clinic had experienced [brain] traumas about which there was no ambiguity- unlike the many shell-shock victims being treated elsewhere, the “reality” of whose symptoms was contested both by physicians and military authorities- she never doubted that even the most mysterious behaviors had identifiable causes.”
Through her work with Goldstein, Fromm-Reichmann came to understand the importance of helping each patient build upon personal strengths in order to adapt to otherwise overwhelming problems.  She learned from his empathic, highly individualized approach.  This work was redemptive for the patient but it demanded that the clinician maintain faith in the patient’s ability to make meaning, adapt and overcome despite profound trauma, biological and psychological.  She came to realize that, ultimately, the clinician could not accomplish this for the patient: rather, the clinician’s role was to assist the patient in the struggle to achieve a new balance in his/her own life.
These insights, learned at the bedside with brain-injured patients, shaped Frieda Fromm-Reichmann’s fundamental approach to her patients and, through her, they helped frame the precepts of American Psychoanalysis and Psychiatry in the decades to come.  A shining example of her influence can be found in Hilde Bruch’s  1974 book,  Learning Psychotherapy, in which Bruch, a trainee and analysand of Fromm-Reichmann) explains:
 “To describe the task of therapy in general terms, it is to assist a patient in the development of a center of gravity so that he experiences himself as self-directed and takes pride in being the person he is, free to assert himself and to pursue satisfaction in terms of his own goals of living ... every small step in the right direction needs to be acknowledged. ... Successful psychotherapy does not do away with problems of living, but it renders an individual more competent in dealing with them.”
The Service Members and Veterans Initiative has a hundred years of psychoanalytic history to reflect upon during National Brain Injury Awareness Month- and we have much more work to do in sharing these hard won principles with colleagues, with the general public and, most importantly, with our patients and their families.