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Neuropsychoanalysis, 2011, 13 (1) 1

BOOK REVIEWS

C. Bowen, G. Yeates, & S. Palmer: A Relational Approach to Everyday Routines, by Mark Ylvisaker and Timothy Feeney
Rehabilitation: Thinking about Relationships after Brain (1998), generated a third paradigm shift. This time, two
Injury. London: Karnac, 2010. ISBN: 978–1–85575–748–6, propositions were drawn from a sociohistorical background.
376pp., £26.99 (pbk.). First, if we are interested in helping patients to reconstruct
their identity after brain injury, by generating positive daily
.In the history of neuropsychological rehabilitation there routines, rehabilitation must occur in the real world, outside
have been books that promote a change of paradigm. These testing rooms or rehabilitation centers. Second, if we want
books possess a peculiar transitional quality. They are rooted to generate effective interventions, we have to successfully
in old theories and concepts but, at the same time, try to break manipulate the social environment by recruiting relatives and
free from them, in an attempt to build up something new. co-workers as active sources of external cognitive compen-
Rather than systematizing what we already know, they point sation and behavior regulation. Although others before have
in novel directions, providing possibilities and inspiration. insinuated these two ideas, it was not until Ylvisaker and
This book is one of those books. Feeney’s work that they acquired a radical character.
I will try to justify such a statement. But in order to do I have taken this detour to place A Relational Approach to
so, I will have to put this book in the context of how the Rehabilitation in its historical context, as a way of mapping
field of neuropsychological rehabilitation has evolved. Much its theoretical debts and bringing out its contribution. In some
of the early work with people who suffered a brain injury way, A Relational Approach embraces all the above-men-
was devoted to the comprehension of the “disordered mind” tioned principles: an interest for the patient’s phenomenolog-
(Prigatano, 1991) and the mechanisms by which these al- ical experience, the use of cognitive rehabilitation to increase
tered cognitive functions could be restored (Goldstein, 1942; levels of participation, and the recruitment of significant
Luria, 1973). Although this first era offered a priceless under- others to regulate behaviour. However, it moves beyond, by
standing on the relationship between brain and psychological addressing the shared emotional experience between patient
processes, it was not until the 1990s, with Principles of Neu- and relative after the injury, the use of strategies to lessen the
ropsychological Rehabilitation (Prigatano, 1999), that the impact of cognitive impairment on intimate relationships,
“wounded soul” (Prigatano, 1991) of brain-injured patients and the collaboration of significant ones in compensating for
was systematically introduced as a focus of rehabilitation. deficits during interpersonal exchanges.
This new emphasis on the patient’s experience of the injury, But what is the paradigm shift that A Relational Approach
and on the mechanisms by which personality and injury dy- puts forward? The main proposition is that a brain does not
namically interacted, was a groundbreaking proposition. exist in isolation. This principle seems supported by a broad
In the same year, another book redefined one of the most spectrum of evidence that suggests that immature brains de-
emblematic components of the field, cognitive rehabilitation. velop during interaction with other brains (Siegel, 1999), or
In Case Studies in Neuropsychological Rehabilitation, Bar- that certain complex socioemotional processes require brain-
bara Wilson (1999) offered a detailed description of patients to-brain interactions (Anders, Heinzle, Weiskopf, Ethofer,
with diverse neuropsychological impairments, and the strate- & Haynes, 2010; Gallese, 2003). A radical consequence
gies used to help them restore and compensate their deficits. of this working hypothesis is that after the injury, patients’
The most powerful message of this book was that cognitive brains remain interacting with other’s brains, in spite of their
rehabilitation (and its tools) was, in essence, a means for difficulties in doing so. And I would even dare to say; they
returning to emotionally meaningful activities. Thus, the actively seek for others after the injury, as a source of cogni-
main goal of cognitive rehabilitation was not restoring a pre- tive restoration and emotional compensation (Freed, 2002).
vious level of cognitive functioning, especially considering This turn towards the virtual space between brains and the
that many patients never accomplish that, but returning to neuropsychological system that two brains co-create is per-
satisfying levels of social participation by recovering those haps Bowen, Yeates, and Palmer’s main contribution.
important roles that define us. The consequences of such an approach are vast, theo-
Finally, Collaborative Brain Injury Interventions: Positive retically and clinically speaking. If the focus of attention
is not the separated brain, or the isolated experience of the
Submit books for review to: Book Reviews, Neuropsychoanalysis, 13 survivor, then it is this betweenness that needs to be system-
Prowse Place, London, NW1 9PN, U.K. atically explored. And the authors draw on several working

© 2011 The International Neuropsychoanalysis Society • http://www.neuropsa.org


2 Book Reviews

hypotheses regarding how this relational space can disrupt or might perceive similarities between the authors’ ideas and
facilitate adaptation to injury. For example, the appraisal that those put forward by the so-called relational turn (Beebe &
a survivor may have of his executive impairment may not be Lachman, 2003; Stolorow & Atwood, 1992) in psychoanaly-
determined exclusively by the impairment itself but, rather, sis, where the basic unit of analysis is the relational space
by how the impairment is managed and signified during in- between subjects. I believe that the relevance of this book
teraction with others, or even during internal interactions be- for neuropsychoanalysis is that it offers enough evidence to
tween parts of his own self. As the authors suggest, a shared make a case for a relational perspective in neuropsychoanal-
experience of mind emerges from personal interactions, and ysis, a line of research that has been shadowed by a strong
it is this shared experience that can generate coherence or metapsychological Freudian trend. A relational psychoanaly-
disorganization in the survivor after the injury. sis seems conceptually more fitted to understanding the inter-
Another clinical observation that supports this relational personal dimension of brain injury and the mechanisms by
approach is the fact that cognitive deficits are not static, which people influence and regulate each other.
but dynamic and context-dependent. Cognitive deficits are
usually more obvious during interpersonal interactions com-
pared to when survivors are alone. And even during interper- REFERENCES
sonal interactions, they may vary according to the number of
people around, or the level of confidence that the survivor Anders, S., Heinzle, J., Weiskopf, N., Ethofer, T., & Haynes, J.
may have regarding the availability of help and support. (2010). Flow of affective information between communicat-
Although it might seem obvious, it is important not to ing brains. NeuroImage, 54 (1): 439–446.
forget that changing the focus of neuropsychological reha- Beebe, B., & Lachmann, F. (2003). The relational turn in psy-
bilitation from the isolated subject to the relational space is a choanalysis: A dyadic systems view from infant research.
crucial turn, considering that brain injury often compromises Contemporary Psychoanalysis, 39 (3): 379–409.
the capacity to regain intimacy between survivor and rela- Freed, P. (2002). Meeting of the minds: Ego reintegration after
tives, eroding the same bonds that are needed to cope with traumatic brain injury. Bulletin of the Menninger Clinic, 66
physical, cognitive, and emotional changes. (1): 61–78.
I suggested before that one of the main characteristics of Gallese, V. (2003). The manifold nature of interpersonal rela-
paradigmatic books is their transitional quality. That feature tions: The quest for a common mechanism. Philosophical
is quite pervasive throughout this book and is especially Transactions of the Royal Society London, B, 358: 517–
observable in the authors’ attempt to link neurological, theo- 528.
retical, and clinical evidence under an overarching relational Goldstein, K. (1942). Aftereffects of Brain Injury in War. New
proposition. Of special interest for the reader might be an York: Grune & Stratton.
Luria, A. (1973). The Working Brain: An Introduction to Neuro-
unprecedented review chapter on relational neuropsychol-
psychology. New York: Basic Books.
ogy (chapter 3), where they summarize evidence to support Prigatano, G. (1991). Disordered mind, wounded soul: The
a claim for the relational nature of cognitive and affective emerging role of psychotherapy in rehabilitation after brain
processes. Two more chapters are of outstanding relevance injury. Journal of Head and Trauma Rehabilitation, 6 (4):
by exploring the depth impact of brain injury on people’s 1–10.
capacity to connect and experience intimacy (chapters 4 Prigatano, G. (1999). Principles of Neuropsychological Reha-
and 5). Finally, in two interesting chapters (chapters 8 and bilitation. New York: Oxford University Press.
10) the authors describe the possible modification of psy- Siegel, D. (1999). The Developing Mind: How Relationships
chotherapy tools to properly address the impact of cognitive and the Brain Interact to Shape Who We Are. New York:
and emotional impairments on relationships. In my opinion, Guilford Press.
this is perhaps the most promising idea of the book, where Stolorow, R., & Atwood, G. (1992). Contexts of Being: The
“hard” neuropsychological knowledge is used to address Intersubjective Foundations of Psychological Life. Hillsdale,
complex interpersonal issues such as identity reconstruction NJ: Analytic Press.
and bereavement. Wilson, B. (1999). Case Studies in Neuropsychological Reha-
A final word on the relevance of this book for neuropsy- bilitation. New York: Oxford University Press.
choanalytic thought. Although this book comes from a sys- Ylvisaker, M., & Feeney, T. (1998). Collaborative Brain Injury
temic tradition, many of its propositions might make sense Interventions: Positive Everyday Routines. San Diego: Sin-
to the psychoanalytically oriented mind. In fact, the authors gular Publishing Group.
use psychoanalytic concepts, such as projection, to explain
complex emotional aspects of interpersonal life. Even more, Christian E. Salas
anyone familiar with the evolution of psychoanalytic thought cesalas@puc.cl

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