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Chapter One
A Broken Brain, a Lost Soul
The Triangle of Well-Being
Barbara's family might never have come for therapy if seven-year-old Leanne hadn't stopped talking in school. Leanne was Barbara's middle child, between Amy, who was fourteen, and Tommy, who was three. They had all taken it hard when their mother was in a near-fatal car accident. But it wasn't until Barbara returned home from the hospital and rehabilitation center that Leanne became "selectively mute." Now she refused to speak with anyone outside the family-including me.
In our first weekly therapy sessions, we spent our time in silence, playing some games, doing pantomimes with puppets, drawing, and just being together. Leanne wore her dark hair in a single jumbled ponytail, and her sad brown eyes would quickly dart away whenever I looked directly at her. Our sessions felt stuck, her sadness unchanging, the games we played repetitive. But then one day when we were playing catch, the ball rolled to the side of the couch and Leanne discovered my video player and screen. She said nothing, but the sudden alertness of her expression told me her mind had clicked on to something.
The following week Leanne brought in a videotape, walked over to the video machine, and put it into the slot. I turned on the player and her smile lit up the room as we watched her mother gently lift a younger Leanne up into the air, again and again, and then pull her into a huge, enfolding hug, the two of them shaking with laughter from head to toe. Leanne's father, Ben, had captured on film the dance of communication between parent and child that is the hallmark of love: We connect with each other through a give-and-take of signals that link us from the inside out. This is the joy-filled way in which we come to share each other's minds.
Next the pair swirled around on the lawn, kicking the brilliant yellow and burnt-orange leaves of autumn. The mother-daughter duet approached the camera, pursed lips blowing kisses into the lens, and then burst out in laughter. Five-year-old Leanne shouted, "Happy birthday, Daddy!" at the top of her lungs, and you could see the camera shake as her father laughed along with the ladies in his life. In the background Leanne's baby brother, Tommy, was napping in his stroller, snuggled under a blanket and surrounded by plush toys. Leanne's older sister, Amy, was off to the side engrossed in a book.
"That's how my mom used to be when we lived in Boston," Leanne said suddenly, the smile dropping from her face. It was the first time she had spoken directly to me, but it felt more like I was overhearing her talk to herself. Why had Leanne stopped talking?
It had been two years since that birthday celebration, eighteen months since the family moved to Los Angeles, and twelve months since Barbara suffered a severe brain injury in her accident-a head-on collision. Barbara had not been wearing her seat belt that evening as she drove their old Mustang to the local store to get some milk for the kids. When the drunk driver plowed into her, her forehead was forced into the steering wheel. She had been in a coma for weeks following the accident.
After she came out of the coma, Barbara had changed in dramatic ways. On the videotape I saw the warm, connected, and caring person that Barbara had been. But now, Ben told me, she "was just not the same Barbara anymore." Her physical body had come home, but Barbara herself, as they had known her, was gone.
During Leanne's next visit I asked for some time alone with her parents. It was clear that what had been a close relationship between Barbara and Ben was now profoundly stressed and distant. Ben was patient and kind with Barbara and seemed to care for her deeply, but I could sense his despair. Barbara just stared off as we talked, made little eye contact with either of us, and seemed to lack interest in the conversation. The damage to her forehead had been repaired by plastic surgery, and although she had been left with motor skills that were somewhat slow and clumsy, she actually looked quite similar, in outward appearance, to her image on the videotape. Yet something huge had changed inside.
Wondering how she experienced her new way of being, I asked Barbara what she thought the difference was. I will never forget her reply: "Well, I guess if you had to put it into words, I suppose I'd say that I've lost my soul."
Ben and I sat there, stunned. After a while, I gathered myself enough to ask Barbara what losing her soul felt like.
"I don't know if I can say any more than that," she said flatly. "It feels fine, I guess. No different. I mean, just the way things are. Just empty. Things are fine."
We moved on to practical issues about care for the children, and the session ended.
A Damaged Brain
It wasn't clear yet how much Barbara could or would recover. Given that only a year had passed since the accident, much neural repair was still possible. After an injury, the brain can regain some of its function and even grow new neurons and create new neural connections, but with extensive damage it may be difficult to retrieve the complex abilities and personality traits that were dependent on the now destroyed neural structures.
Neuroplasticity is the term used to describe this capacity for creating new neural connections and growing new neurons in response to experience. Neuroplasticity is not just available to us in youth: We now know that it can occur throughout the lifespan. Efforts at rehabilitation for Barbara would need to harness the power of neuroplasticity to grow the new connections that might be able to reestablish old mental functions. But we'd have to wait awhile for the healing effects of time and rehabilitation to see how much neurological recovery would be possible.
My immediate task was to help Leanne and her family understand how someone could be alive and look the same yet have become so radically different in the way her mind functioned. Ben had told me earlier that he did not know how to help the children deal with how Barbara had changed; he said that he could barely understand it himself. He was on double duty, working, managing the kids' schedules, and making up for what Barbara could no longer do. This was a mother who had delighted in making homemade Halloween costumes and Valentine's Day cupcakes. Now she spent most of the day watching TV or wandering around the neighborhood. She could walk to the grocery store, but even with a list she would often come home empty-handed. Amy and Leanne didn't mind so much that she cooked a few simple meals over and over again. But they were upset when she forgot their special requests, things they'd told her they liked or needed for school. It was as if nothing they said to her really registered.
As our therapy sessions continued, Barbara usually sat quietly, even when she was alone with me, although her speech was intact. Occasionally she'd suddenly become agitated at an innocent comment from Ben, or yell if Tommy fidgeted or Leanne twirled her ponytail around her finger. She might even erupt after a silence, as if some internal process was driving her. But most of the time her expression seemed frozen, more like emptiness than depression, more vacuous than sad. She seemed aloof and unconcerned, and I noticed that she never spontaneously touched either her husband or her children. Once, when three-year-old Tommy climbed onto her lap, she briefly put her hand on his leg as if repeating some earlier pattern of behavior, but the warmth had gone out of the gesture.
When I saw the children without their mother, they let me know how they felt. "She just doesn't care about us like she used to," Leanne said. "And she doesn't ever ask us anything about ourselves," Amy added with sadness and irritation. "She's just plain selfish. She doesn't want to talk to anyone anymore." Tommy remained silent. He sat close to his father with a drawn look on his face.
Loss of someone we love cannot be adequately expressed with words. Grappling with loss, struggling with disconnection and despair, fills us with a sense of anguish and actual pain. Indeed, the parts of our brain that process physical pain overlap with the neural centers that record social ruptures and rejection. Loss rips us apart.
Grief allows you to let go of something you've lost only when you begin to accept what you now have in its place. As our mind clings to the familiar, to our established expectations, we can become trapped in feelings of disappointment, confusion, and anger that create our own internal worlds of suffering. But what were Ben and the kids actually letting go of? Could Barbara regain her connected way of being? How could the family learn to live with a person whose body was still alive, but whose personality and "soul"-at least as they had known her-were gone?
"You-Maps" and "Me-Maps"
Nothing in my formal training-whether in medical school, pediatrics, or psychiatry-had prepared me for the situation I now faced in my treatment room. I'd had courses on brain anatomy and on brain and behavior, but when I was seeing Barbara's family, in the early 1990s, relatively little was known about how to bring our knowledge of such subjects into the clinical practice of psychotherapy. Looking for some way to explain Barbara to her family, I trekked to the medical library and reviewed the recent clinical and scientific literature that dealt with the regions of the brain damaged by her accident.
Scans of Barbara's brain revealed substantial trauma to the area just behind her forehead; the lesions followed the upper curve of the steering wheel. This area, I discovered, facilitates very important functions of our personality. It also links widely separated brain regions to one another-it is a profoundly integrative region of the brain.
The area behind the forehead is a part of the frontal lobe of the cerebral cortex, the outermost section of the brain. The frontal lobe is associated with most of our complex thinking and planning. Activity in this part of the brain fires neurons in patterns that enable us to form neural representations-"maps" of various aspects of our world. The maps resulting from these clusters of neuronal activity serve to create an image in our minds. For example, when we take in the light reflected from a bird sitting in a tree, our eyes send signals back into our brain, and the neurons there fire in certain patterns that permit us to have the visual picture of the bird.
Somehow, in ways still to be discovered, the physical property
of neurons firing helps to create our subjective experience-the thoughts, feelings, and associations evoked by seeing that bird, for example. The sight of the bird may cause us to feel certain emotions, to hear or remember its song, and even to associate that song with ideas such as nature, hope, freedom, and peace. The more abstract and symbolic the representation, the higher in the nervous system it is created, and the more forward in the cortex.
The prefrontal cortex-the most damaged part of the frontal lobe of Barbara's brain-makes complex representations that permit us to create concepts in the present, think of experiences in the past, and plan and make images about the future. The prefrontal cortex is also responsible for the neural representations that enable us to make images of the mind itself. I call these representations of our mental world "mindsight maps." And I have identified several kinds of mindsight maps made by our brains.
The brain makes what I call a "me-map" that gives us insight into ourselves, and a "you-map" for insight into others. We also seem to create "we-maps," representations of our relationships. Without such maps, we are unable to perceive the mind within ourselves or others. Without a me-map, for example, we can become swept up in our thoughts or flooded by our feelings. Without a you-map, we see only others' behaviors, the physical aspect of reality, without sensing the subjective core, the inner mental sea of others. It is the you-map that permits us to have empathy. In essence, the injury to Barbara's brain had created a world without mindsight. She had feelings and thoughts, but she could not represent them to herself as activities of her mind. Even when she said she'd "lost her soul," her statement had a bland, factual quality, more like a scientific observation than a deeply felt expression of personal identity. (I was puzzled by that disconnect between observation and emotion until I learned from later studies that the parts of our brain that create maps of the mind are distinct from those that enable us to observe and comment on self- traits such as shyness or anxiety-or, in Barbara's case, the lack of a quality she called "soul.")
In the years since I took Barbara's brain scans to the library, much more has been discovered about the interlinked functions of the prefrontal cortex. For example, the side of this region is crucial for how we pay attention; it enables us to put things in the "front of our mind" and hold them in awareness. The middle portion of the prefrontal area, the part damaged in Barbara, coordinates an astonishing number of essential skills, including regulating the body, attuning to others, balancing emotions, being flexible in our responses, soothing fear, and creating empathy, insight, moral awareness, and intuition. These were the skills Barbara was no longer able to recruit in her interactions with her family.
I will be referring to-and expanding on-this list of nine middle prefrontal functions throughout our discussion of mindsight. But even at first glance, you can see that these functions are essential ingredients for well-being, ranging from bodily processes such as regulating our hearts to social functions such as empathy and moral reasoning.
After Barbara emerged from her coma, her impairments had seemed to settle into a new personality. Some of her habits, such as what she liked to eat and how she brushed her teeth, remained the same. There was nothing significantly changed in how her brain mapped out these basic behavioral functions. But the ways in which she thought, felt, behaved, and interacted with others were profoundly altered. This affected every detail of daily life-right down to Leanne's crooked ponytail. Barbara still had the behavioral moves necessary to fix her daughter's hair, but she no longer cared enough to get it right.
