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Neuropsychoanalysis, 2011, 13 (1




C. Bowen, G. Yeates, & S. Palmer: A Relational Approach to Rehabilitation: Thinking about Relationships after Brain Injury. London: Karnac, 2010. ISBN: 978–1–85575–748–6, 376pp., £26.99 (pbk.).

.In the history of neuropsychological rehabilitation there have been books that promote a change of paradigm. These books possess a peculiar transitional quality. They are rooted in old theories and concepts but, at the same time, try to break free from them, in an attempt to build up something new. Rather than systematizing what we already know, they point in novel directions, providing possibilities and inspiration. This book is one of those books. I will try to justify such a statement. But in order to do so, I will have to put this book in the context of how the field of neuropsychological rehabilitation has evolved. Much of the early work with people who suffered a brain injury was devoted to the comprehension of the “disordered mind” (Prigatano, 1991) and the mechanisms by which these altered cognitive functions could be restored (Goldstein, 1942; Luria, 1973). Although this first era offered a priceless understanding on the relationship between brain and psychological processes, it was not until the 1990s, with Principles of Neuropsychological Rehabilitation (Prigatano, 1999), that the “wounded soul” (Prigatano, 1991) of brain-injured patients was systematically introduced as a focus of rehabilitation. This new emphasis on the patient’s experience of the injury, and on the mechanisms by which personality and injury dynamically interacted, was a groundbreaking proposition. In the same year, another book redefined one of the most emblematic components of the field, cognitive rehabilitation. In Case Studies in Neuropsychological Rehabilitation, Barbara Wilson (1999) offered a detailed description of patients with diverse neuropsychological impairments, and the strategies used to help them restore and compensate their deficits. The most powerful message of this book was that cognitive rehabilitation (and its tools) was, in essence, a means for returning to emotionally meaningful activities. Thus, the main goal of cognitive rehabilitation was not restoring a previous level of cognitive functioning, especially considering that many patients never accomplish that, but returning to satisfying levels of social participation by recovering those important roles that define us. Finally, Collaborative Brain Injury Interventions: Positive
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Everyday Routines, by Mark Ylvisaker and Timothy Feeney (1998), generated a third paradigm shift. This time, two propositions were drawn from a sociohistorical background. First, if we are interested in helping patients to reconstruct their identity after brain injury, by generating positive daily routines, rehabilitation must occur in the real world, outside testing rooms or rehabilitation centers. Second, if we want to generate effective interventions, we have to successfully manipulate the social environment by recruiting relatives and co-workers as active sources of external cognitive compensation and behavior regulation. Although others before have insinuated these two ideas, it was not until Ylvisaker and Feeney’s work that they acquired a radical character. I have taken this detour to place A Relational Approach to Rehabilitation in its historical context, as a way of mapping its theoretical debts and bringing out its contribution. In some way, A Relational Approach embraces all the above-mentioned principles: an interest for the patient’s phenomenological experience, the use of cognitive rehabilitation to increase levels of participation, and the recruitment of significant others to regulate behaviour. However, it moves beyond, by addressing the shared emotional experience between patient and relative after the injury, the use of strategies to lessen the impact of cognitive impairment on intimate relationships, and the collaboration of significant ones in compensating for deficits during interpersonal exchanges. But what is the paradigm shift that A Relational Approach puts forward? The main proposition is that a brain does not exist in isolation. This principle seems supported by a broad spectrum of evidence that suggests that immature brains develop during interaction with other brains (Siegel, 1999), or that certain complex socioemotional processes require brainto-brain interactions (Anders, Heinzle, Weiskopf, Ethofer, & Haynes, 2010; Gallese, 2003). A radical consequence of this working hypothesis is that after the injury, patients’ brains remain interacting with other’s brains, in spite of their difficulties in doing so. And I would even dare to say; they actively seek for others after the injury, as a source of cognitive restoration and emotional compensation (Freed, 2002). This turn towards the virtual space between brains and the neuropsychological system that two brains co-create is perhaps Bowen, Yeates, and Palmer’s main contribution. The consequences of such an approach are vast, theoretically and clinically speaking. If the focus of attention is not the separated brain, or the isolated experience of the survivor, then it is this betweenness that needs to be systematically explored. And the authors draw on several working

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2 hypotheses regarding how this relational space can disrupt or facilitate adaptation to injury. For example, the appraisal that a survivor may have of his executive impairment may not be determined exclusively by the impairment itself but, rather, by how the impairment is managed and signified during interaction with others, or even during internal interactions between parts of his own self. As the authors suggest, a shared experience of mind emerges from personal interactions, and it is this shared experience that can generate coherence or disorganization in the survivor after the injury. Another clinical observation that supports this relational approach is the fact that cognitive deficits are not static, but dynamic and context-dependent. Cognitive deficits are usually more obvious during interpersonal interactions compared to when survivors are alone. And even during interpersonal interactions, they may vary according to the number of people around, or the level of confidence that the survivor may have regarding the availability of help and support. Although it might seem obvious, it is important not to forget that changing the focus of neuropsychological rehabilitation from the isolated subject to the relational space is a crucial turn, considering that brain injury often compromises the capacity to regain intimacy between survivor and relatives, eroding the same bonds that are needed to cope with physical, cognitive, and emotional changes. I suggested before that one of the main characteristics of paradigmatic books is their transitional quality. That feature is quite pervasive throughout this book and is especially observable in the authors’ attempt to link neurological, theoretical, and clinical evidence under an overarching relational proposition. Of special interest for the reader might be an unprecedented review chapter on relational neuropsychology (chapter 3), where they summarize evidence to support a claim for the relational nature of cognitive and affective processes. Two more chapters are of outstanding relevance by exploring the depth impact of brain injury on people’s capacity to connect and experience intimacy (chapters 4 and 5). Finally, in two interesting chapters (chapters 8 and 10) the authors describe the possible modification of psychotherapy tools to properly address the impact of cognitive and emotional impairments on relationships. In my opinion, this is perhaps the most promising idea of the book, where “hard” neuropsychological knowledge is used to address complex interpersonal issues such as identity reconstruction and bereavement. A final word on the relevance of this book for neuropsychoanalytic thought. Although this book comes from a systemic tradition, many of its propositions might make sense to the psychoanalytically oriented mind. In fact, the authors use psychoanalytic concepts, such as projection, to explain complex emotional aspects of interpersonal life. Even more, anyone familiar with the evolution of psychoanalytic thought

Book Reviews might perceive similarities between the authors’ ideas and those put forward by the so-called relational turn (Beebe & Lachman, 2003; Stolorow & Atwood, 1992) in psychoanalysis, where the basic unit of analysis is the relational space between subjects. I believe that the relevance of this book for neuropsychoanalysis is that it offers enough evidence to make a case for a relational perspective in neuropsychoanalysis, a line of research that has been shadowed by a strong metapsychological Freudian trend. A relational psychoanalysis seems conceptually more fitted to understanding the interpersonal dimension of brain injury and the mechanisms by which people influence and regulate each other.

Anders, S., Heinzle, J., Weiskopf, N., Ethofer, T., & Haynes, J. (2010). Flow of affective information between communicating brains. NeuroImage, 54 (1): 439–446. Beebe, B., & Lachmann, F. (2003). The relational turn in psychoanalysis: A dyadic systems view from infant research. Contemporary Psychoanalysis, 39 (3): 379–409. Freed, P. (2002). Meeting of the minds: Ego reintegration after traumatic brain injury. Bulletin of the Menninger Clinic, 66 (1): 61–78. Gallese, V. (2003). The manifold nature of interpersonal relations: The quest for a common mechanism. Philosophical Transactions of the Royal Society London, B, 358: 517– 528. Goldstein, K. (1942). Aftereffects of Brain Injury in War. New York: Grune & Stratton. Luria, A. (1973). The Working Brain: An Introduction to Neuropsychology. New York: Basic Books. Prigatano, G. (1991). Disordered mind, wounded soul: The emerging role of psychotherapy in rehabilitation after brain injury. Journal of Head and Trauma Rehabilitation, 6 (4): 1–10. Prigatano, G. (1999). Principles of Neuropsychological Rehabilitation. New York: Oxford University Press. Siegel, D. (1999). The Developing Mind: How Relationships and the Brain Interact to Shape Who We Are. New York: Guilford Press. Stolorow, R., & Atwood, G. (1992). Contexts of Being: The Intersubjective Foundations of Psychological Life. Hillsdale, NJ: Analytic Press. Wilson, B. (1999). Case Studies in Neuropsychological Rehabilitation. New York: Oxford University Press. Ylvisaker, M., & Feeney, T. (1998). Collaborative Brain Injury Interventions: Positive Everyday Routines. San Diego: Singular Publishing Group.

Christian E. Salas