ESSENTIAL PSYCHODYNAMIC PSYCHOTHERAPY
An Acquired Art

Teri Quatman

CONTENTS

List of figures
Preface
Acknowledgments
1 An Acquired Art
2 The Art and Power of Listening-Deeply
3 The Science of It
4 The Chain of Emotion
5 The Art of Listening Deeply: In the Room
6 Creating Space
7 Understanding, the Bass Clef, and Intersubjectivity
8 The Silent Patient
9 Object Relations
10 Transference
11 Countertransference
12 Defenses and Anxieties
13 Endgame
References
Index

FIGURES

3.1 The Brain
3.2 Brainstem Structures
3.3 Subcortical Limbic Structures
3.4 The Cerebral Cortex: Hemispheres
3.5 The Cerebral Cortex: Lobes

上を逐語的に正確に省略しないで日本語に翻訳してください。
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PREFACE

I dedicate this book to my students. It is they who have inspired my thoughts; it is they who have, without their direct
knowledge, co-created this work. I think of the two thousand plus masters’ students I’ve encountered in classrooms over
time, students embarking upon their program of study in Counseling Psychology, students whose goal it was simply to
become the best clinician/therapist they could be. I think of myself as I started the same trek in the late 1970s. Naïve to the
field in every possible way, I stepped forward with a desire that I might one day grow to be an effective psychotherapist.
As I pursued my education in the late 1970s and throughout the 1980s-one degree followed by the next, and then the
next, and the next-I kept having the nagging feeling that while I was piling up degrees, I felt in no way ready to be a
therapist. I didn’t feel that I had the wisdom, the life experience, the-I didn’t know what it was, the, the way of being-to be
the kind of therapist I’d wanted to become. Over time, and given the training I had received, I felt that I had to redefine my
vision of what being a therapist might be in the direction of brief and targeted inventions. These were the halcyon days of
the behavioral and cognitive therapies. I had, after all, learned how to de-condition phobic disorders, to reframe depressive
disorders, to structure behavioral interventions for acting-out teens. But for all I knew how to do, I still didn’t feel like a
therapist.
What I did not know, and what very often my students do not know, was that becoming the kind of therapist I wanted to
be would require a personal transformation. It would require that I jettison my certainties, re-visit my biases, retract many
of my tightly-held beliefs, and walk forward into a great deal of darkness at first. It would also mean (as a prerequisite) that
I engage in the process of therapy for myself. This came as a surprise and shock to me, as I had cultivated the self-perception
of being a together and well-integrated human being, having come from a stable and loving-enough family, and having felt
no need for personal therapy. What I could not know as a beginner was that these self-perceptions themselves created a kind
of psychic impermeability that would stand in the way of my becoming the kind of therapist I truly wanted to be.
One evening as I was teaching a class on theories of psychotherapy, a student came to me at break. She said, “You like this
stuff!” (referring to my lecture on behavioral interventions). “Yes!” I said, with enthusiasm, “I like this stuff!” She went fur-
ther, “Can I ask why?” “Sure,” I said, “because it works!” She replied thoughtfully, “That’s strange, because the person I have
come to know as my instructor in this class would need more than that.” With that rather cryptic comment the student left,
but her comment stayed. It would stay and stay, confronting me with my own well-buried misgivings, and reminding me
of my original motivation for wanting to be a therapist. I had wanted to develop a deep understanding of other humans and
myself; I had wanted to be able to help others see what was underneath their stuckness, their self-sabotages, their inability
to live their lives fully.
Thus began my journey into psychodynamic psychotherapy. Piqued by my student’s comment, and placed in my in-
ternship under the supervision of a highly intuitive psychodynamic supervisor, I began what has become a very long and
arduous trek. I was handed Althea Horner’s (1984) Object Relations and the Developing Ego in Therapy. I found it both intri-
guing and inscrutable. The next months and years were to take me onto the formerly vilified territory of Freud (whom I
had dismissed without ever having really read) and his past and present-day successors. They were known to me initially
as Object Relations therapists, but soon broadened to include the multiple worlds of Psychoanalytic and Psychodynamic
Psychotherapies. The ensuing time would also include multiple therapies for myself. It would include months stretching

I sit at my computer this morning not because of the length of my journey but because of its lighting. I write because of
my commitment to education and to the quest to make the first steps of the psychodynamic journey less elusive and less
inscrutable to my students than they were to me. I write with a particular gratitude to Tom Ogden, who, through the gener-
osity of his mentoring, the clarity of his thinking and painstakingness of his writing, has deepened my work and brightened
my path considerably.
In the following pages, I explain some of the basics of the practice of psychodynamic psychotherapy (a term which will
proxy for Object Relations, Psychoanalysis, and Psychoanalytic Psychotherapies). Our field is theory-intense, but few au-
thors attempt to explain the basics of practice to the beginning/progressing therapist. I dedicate this work to the now thou-
sands of students who have entered my classroom quarter by quarter, wanting to have the tools of insight and effectiveness
without knowing how to name their quest. I write because of the terribly long uptime it took to decipher the beginners’
materials of the psychodynamic trade. I write to and for my students. I hope this work serves to make the journey brighter
for them, as their questions and queries along the way have made my life brighter for me.

into years of practicing a therapy that I couldn’t quite visualize and had no way to judge the effectiveness of. It was, for a very
long time, a dimly-lit journey.

1 AN ACQUIRED ART

When I was assigned my first client in graduate school-my first adult client who had made an appointment and was going
to meet with me for an hour of psychotherapy-I was excited. This would be real therapy; not the ad hoc school counseling
kind I had done along the way as a high school teacher or middle school/high school counselor, not the kind I had done in
graduate school classes when I’d paired up and practiced a counseling skill with a classmate. This was the real deal. I was in-
deed excited.
But as the idea of it crept inexorably toward the reality of it, I began to have uncertain feelings in my gut. By the time I had
one more hour before our therapy meeting, I was beside myself with anxiety. I remember I was sitting in a graduate Career
Development seminar and shot a note to my friend Pat, who was sitting next to me. Pat had been an experienced clinical
social worker before he joined our doctoral program. “What do I do?” was my anxious question. In that moment I really had
no idea, despite having sat with scores of students one-on-one as a counselor-in-training, and having conducted dozens of
structured interviews for those seeking to qualify for an anxiety disorders study across campus. My program had somehow
certified me at this point as being ready to see this real client for just plain therapy-the 50-minute kind. Pat leaned in and
whispered, “You listen to him … Just listen to him. And at the end tell him, ‘I think I can help you.’ He’ll be more nervous than
you are.” Not possible, I thought privately.
Of course, I did meet with that first client. I did listen to his story about a failed marriage in the distant past and its impact
on his current relationship. I did tell him I thought I could help him. I do even think I remember meeting with him for a
second appointment. Beyond that, my memory fades, or was it that he did not return? The anxious feelings return as I write
the story.
Acquiring the art of psychodynamic therapy is a long, arduous process fraught with scary moments: first times, inde-
cipherable concepts, people who can’t seem to change, the gap between how we interact with a client or patient and the way
we imagine a more mature therapist would, the wish to steer it down a more meaningful track, the wondering where that
would be and how we might get there.
We are certified as ready to start practicing at some point, and most of us hope we’ll be good at it because we thought we
would be, or we hoped we would-that’s why we went through all the trouble and training in the first place. But then, we
get in the room with the patient and it seems at times that everything we think we have studied or known exits out the door.
In this book I will be attempting to speak about an acquired art. Acquired, because it’s something more than studied or
even practiced. It comes upon you gradually as you position yourself to take it in and practice what you know to practice.
And then there is the inexorable element of time. An acquired art takes a long time, because the various complexities of it re-
quire a readiness within us even to identify them as desired elements.
Rather than a practiced art, an acquired art is more like an internalized state. We are taught, we read, we think, we hear
our colleagues present, we identify supervisors who do the thing we want to be able to do, we try to copy them. But until a
certain readiness is born within us, all the copying in the world does not seem to budge us forward one bit. It truly takes an
act of faith to keep going in the pursuit of an acquired art.

This book addresses itself to the very elusive and hard-to-acquire art called psychodynamic psychotherapy. It especially
attempts to address the front end of this acquisition process, because this is the time when we feel most lost, most fraudu-
lent, most discouraged, and most seemingly unable to benefit from anything we hear or read about along the way. We keep
going, but if we’re honest with ourselves, for most of us, it is with a deep sense of doubt that we will ever become the kind of
therapist we see (or can’t even imagine) in our mind’s eye.
I suppose it is not unlike acquiring a truly fine touch as a musician. The beauty will ultimately reside in the nuance, but
one has to live for a long time with garish approximations of that nuance, and keep pressing with what one author called
“a long obedience in the same direction” (Peterson, 1980). Our mentors, our fellow students, and ultimately our patients
give us just enough encouragement along the way for us to bear with our own not-knowings, and to keep on keeping on.
For my part, I have only ever observed my own growth as a therapist in retrospect, and that, probably in five-year chunks.
Furthermore, I didn’t start to make sense to myself as a therapist for the first ten years. It’s a long time to stay at something
(and even to be paid for doing something) that one doesn’t truly understand. But that is our path.
So I will start as close to the beginning as I possibly can, and move forward only when I feel I’ve said something clearly.
This may mean that I give you some of the dryer stuff first, but do try to stay with it. Foundations are never sexy, but the
whole rest of the house depends on them. So let’s start at the beginning.

The Art of What?
The art of what? What are we supposed to be attempting to do or have happen when we “sit with” or “listen to” a client or
patient? In this moment, with this person, in this room, what? What is the goal? What is the process? And most import-
antly, what is the point?
The answer is: it depends. That’s a really unsatisfying answer, but it actually does depend. It depends on where we’re
headed. While it may be true that as psychotherapists our main tool is to listen to the other, absent some orienting compass
to tell us where we’re going and what our listening might be accomplishing, it can feel like bobbing in an inner tube in the
middle of the ocean: too cold, too directionless, ultimately not getting us anywhere, and most certainly not worth being paid
to do!
So for a few minutes, let’s stand back and consider what is, or might be, the intended goal of our listening, then we can talk
about the process of it (and the point of it).

What’s the Goal?
The goal of psychotherapy can be thought about in its broadest terms as being oriented toward one of two outcomes: either
toward alleviating human suffering or toward promoting human growth (although most therapies do some of both). In
general, it is the first-the suffering part-that brings people to a therapist to begin with. And this-suffering part-comes
as a surprise and a shock to many new therapists. It’s different from what we may have envisioned when we came to the
field.
Perhaps we were the confidants of our friends or mothers or fathers as younger people. People came to us with their
problems, with their secrets. We learned that we were good listeners, and that they felt safe with us. They opened up to us.
That felt good. We found ourselves giving what we thought was wise advice. That felt good. We were valued for our skill, and
enjoyed doing it. We decided we wanted to be paid for this thing we did with such success. Good plan.

But when we begin the professional practice of psychotherapy, most of us encounter human suffering well beyond the
scope or severity of our experience with friends and relatives. The range of suffering that presents in a therapist’s office is
enormous; to a new therapist (and sometimes to an old therapist) it is overwhelming. The suffering has many stripes. It can
be circumscribed, such as the inability to finish a school degree or the desire to lose weight. It can be global (“I just feel lost
in my life”). It can focus on emotions like sadness, guilt, anger, disgust, fear, shame, grief, etc .; or even positive ones (“I get
so full of joy and excitement that I spend piles of money all at once”), or dysregulated ones (“I get set off, and then I have to
cut myself in order to feel better”). The suffering can focus on behaviors (“I have to check the locks on my house seven times
before I can leave” or “I find myself raging at my second child”). It can be intrapersonal (“I’m depressed,” “I’m anxious”) or
interpersonal (“I’ve never really trusted anyone” or “I feel hated at work”). It can focus on the past (for example, having lived
through traumatizing events) or the present (“My marriage is falling apart”) or the future (“I have no hope for my life”). The
list is endless.
And the examples I’ve given here, as you may well know by now, are quite sanitized. Some of what we see and listen to
is beyond heartbreaking-young adolescents beginning to devolve into psychoticism-hearing voices and sealing off their
bedrooms with layers of tin foil; children whose parent has punished them by killing their beloved pet. If we stop to think
about it, the suffering that people bring into our counseling room is far more than we bargained for, and is often deeply trau-
matizing to us. The expectation that we might be able to help in many moments exceeds our bandwidth entirely.
Some therapies focus exclusively on the alleviation of such suffering. This would certainly seem to be a big enough task!
But other therapies (i.e., the psychodynamic spectrum) go a step beyond that goal and focus on the life potential inherent
in people beyond and underlying their points of suffering. This focus tends to be shifted slightly toward the person carrying
the symptom rather than the symptom itself. This is not to say that the point of suffering is ignored, but it is contextualized
within the personality and history of the person expressing this hurt in this particular way.
Let me give you an example of how this might look. A young man came to me some years back because of his wife’s
concern that he was “losing it” with his children. While he did not feel that he was “suffering” from this, the rest of the
family was. And he was at risk of experiencing the loss of his marriage and family over this issue. My task as therapist was
to help alleviate the suffering in the system.
But as I listened to this young man for several sessions, what struck me about him was his lostness in general. He not only
“lost it” in particular moments with his children, he seemed to have “lost it” in his life in general. He seemed mechanized
with me-dutiful, pasty, routinized, monotonic, depressed-missing the warm glow of interpersonal spontaneity and vital-
ity that makes us most human.
As I experienced this man’s absence, the focus of the therapy shifted from the circumscribed symptom of his “losing it”
with his children to the more general goal of his more fully inhabiting his own life as a human being. The work included the
effort to understand his absence: how and why it came to be, what it felt like (physically and emotionally) to be absent with
his children, with his wife, with himself, and in his time with me; what it stirred in him to talk about these things with me,
and so on.
Over time, the “losing it” with his children subsided. But, as important as this was, the therapy was about much more
than this “presenting” symptom. By the end of it, this young man had became much more able to be present in all these
contexts, and to understand the forces that had driven him so far from himself that he had gone missing from his own life.
(We will get to the hows and whats of such a therapy in the upcoming chapters.)

Different Goals: Different Looks
To be clear, the range of therapies we learn about in school-behavioral through psychodynamic-do share one theme com-
mon to all: the effort to change something about a person. And it’s worth noting at this point that whatever your theoretical
orientation, changing something about a human is, in and of itself, a rather lofty aspiration. We humans are junkies for the
emotionally familiar. While in a constant change trajectory related to our own physical growth and aging process, we are
profoundly wedded to and soothed by the power of the familiar. So without our willing it, we often resist change (even for
the better) with a resoluteness that borders on fanaticism (and wanders into the unconscious).
But beyond what the various therapies share in common, they differ substantially in their look and feel. Some are more
oriented toward the symptom, are time-limited and focused, and usually feature a rather active stance on the part of the
therapist (think behavioral and cognitive behavioral therapies here). Some therapies are more oriented toward the patient
or client’s more global personal growth, tend to be longer-term and more multi-focal, and usually feature a more non-
directive style from the therapist (think psychodynamic psychotherapies here, as well as Rogerian, Gestalt, Jungian, and Ex-
istential, among others).
The process of therapy, at least theoretically, should follow from the goal. This is precisely why we study different
“schools” of therapy-because there are legitimately different ways to a) define the problem and b) go about its solution in
psychotherapy. (This, of course, presents a problem to the naïve seeker of psychotherapy who just wants to see a therapist.
These various theoretical nuances make no difference to and indeed are invisible to someone who is seeking a therapist
because they have lost a loved one or find themselves overwhelmed with anxiety or have decided they need help with their
obesity or are alarmed with how they find themselves treating their children, or … ). But that very obvious flaw in the user-
end of clinical practice aside, how we as practitioners orient ourselves theoretically will determine where we swim in our
inner tube, at what pace, and toward what shore.
Ultimately, since this is a book about psychodynamic process and technique, we will focus there in the remaining
chapters. But understanding the legitimacy of other therapeutic approaches helps us to respect rather than to dismiss other
therapies, and to know what might be appropriate for a particular client or patient. So let me talk for just a few minutes
about several main points along the spectrum of psychotherapies, because where we position on this spectrum determines
what we’ll be aiming at and doing as a psychotherapist.

Symptom-Focused Therapies
On one end of the spectrum of therapies are the behavioral therapies. If you’ve potty trained an infant or rewarded a puppy
for the “right” behavior, you’ve no doubt employed the techniques of behavioral therapy-perhaps unawares. Behavioral
therapies aim to change a targeted behavior, such as stopping smoking or increasing behavioral compliance in some way.
Virtually anything visible about a human-or mammals in general (animal lovers do this intuitively)-can be subdivided
into discrete behavioral entities. So the art and genius of the behavioral therapies lies in this subdividing and conquering
analysis. Necessarily, the more amorphous the complaint, the more a behavioral therapist must use a contraction of the tar-
get as a proxy for the larger or more amorphous target.
Behavioral therapies are powerful for what they aim at: discrete behavior change. We experienced their power in a group
program we set up in the schools for bullying and picked-on middle-schoolers in Southern California. We gathered the
teacher-identified twenty-five “worst” kids in the school for one hour per week. We sat them in a large circle and used

a curriculum to teach them about assertive, aggressive (bullying), and passive (doormat) behaviors, with much student
participation. We observed the kids during the group time, and circulated among them dispensing white (appropriate), red
(aggressive), and blue (passive) poker chips, in response to their identifiable behaviors in the group. The chips had positive
and negative values, respectively. We also gave teachers a limited number of white chips (only) with instructions on their
use. The chips would be reconciled at each session’s end, and could be “cashed in” during the school week for certain valued
targets, like being able to cut to the front of the food line at lunch (“butt passes”), or being able to be exchanged for ice creams
at the cafeteria. Pretty soon, the teens caught onto the game and began to adopt appropriately assertive behaviors inside and
outside the group. By the end of the year, the “Social Behavior Group” had become quite high-status among students, and
teachers were blown away at the positive changes wrought in members of the group.
Let me offer a quick digression here on a common misapprehension of behaviorism. It is not about punishment. There
was a reason we only gave white (reward) chips to teachers. Parents and teachers often naïvely orient themselves toward
meting out punishments for the crimes of children. Time outs, grounding, loss of internet privileges, loss of dessert, change
in curfew, canceling the field trip. It’s endless, and all well intentioned. What gets lost in the shuffle is the relative power of
positive reinforcement (think white chips and butt passes) versus the relative impotence of narrow and stimulus-depend-
ent punishment.
Example: when did you last speed on the freeway? When there was no policeman visible, right? So the threat of getting a
ticket didn’t really extinguish your speeding behavior. The threat of punishment (police car on the side of the road) had to
be present and proximate to get its desired effect. Absent constant monitoring, we all game the system. Even when we are
ticketed, we go back to our former-surveillance-driven speeding behaviors quite soon. Why? Because punishment requires
that the punisher catch the behavior. So get this! All the moments of not being caught function to reinforce positively (with
the feeling of freedom, our need for speed, and our getting away with it) our entrenched speeding behaviors. That’s why we
all-well, most of us-speed. The system has taught us to.
Now, consider the power of a positive reinforcer. Suppose your insurance company were to devise a (not yet invented) GPS
speed monitor in your car, and to rebate a direct percentage of your car insurance per month based upon the percentage of
time you drove at or below the speed limit. Different motivational system entirely. Staying at the speed limit would earn
something valuable to you. The research is robust and unequivocal on this point. Rewards change behavior; punishments
create surveillance behavior. End of digression.

CBT
OK. One step over from the purely behavioral therapies are the cognitive-behavioral approaches (CBT). These have become
the genre of choice in the current managed-care environment. The CBT schools differ from the purely behavioral therapies
in that its practitioners marshal the substantial role of the thinking process as their aid in achieving behavioral change. Let’s
take, for instance, someone who has become phobic and panicky in public places in general, or on bridges or in stadiums
or restaurants or airplanes in particular. Isolated instances of panic in these places can and do lead to more generalized and
life-constraining avoidance of them, sometimes building to what we call “agoraphobia.” This range of anxiety-based dis-
orders can wreak havoc in families, careers, and life pursuits. I once interviewed a very well-heeled and well-spoken woman
who had not been out of her own bedroom in eight years (except under the influence of the drugs she took to get to our
clinic).

Via cognitive behavioral therapy (CBT), the sufferer/client can be helped by a therapist to gradually engage in the feared
behavior by simultaneously moving toward the feared entity (behavior) and attending to the thoughts and feelings gener-
ated in their mind and body (cognition). With the support of the therapist, the client can be helped to use their mind to
understand and challenge the edifice of thoughts underlying and maintaining the target behavior.
We used this powerful set of techniques in the Stanford Anxiety Disorders Clinic to help formerly house-bound or
similarly constrained clients to move gradually, step by step, toward the freedom (quite literally) to walk around inside
Nordstrom’s without having to flee due to overwhelming anxiety (our clinic abutted the Nordstrom parking lot). It was an
incredibly effective therapy, and those patients who were able to gradually reclaim their lost freedom of movement in life
found the techniques of cognitive behavioral therapy an inestimable gift to them and their families.
This therapy is very often criticized by practitioners of the more psychodynamic psychotherapies as too short-term and
too symptom-focused to do any real good. However, those who have been released from the terrible grip of a particular
disorder via CBT techniques are not part of this chorus. What’s important to keep in mind is that the goal determines the
process. If release from a particular symptom (the alleviating of suffering) is the focal goal, then behavioral and cognitive
behavioral therapies can be powerful tools. This is why CBT has enjoyed such popularity with managed care companies: it
tends to be symptom-focused, it is short-term, it works, and it can be expressed in terms of therapeutic goals and progress
reports that non-professionals can read and understand.

Personal Growth/”Beyond-the-symptom”/ Psychodynamic Therapies
But many people are not particularly symptom-focused when they come to see us as therapists. Their discontents are more
diffuse. They seek therapy because, more generally, they have the sense that in some way their lives are not working for
them or are certainly not optimized. Or some come with a specific complaint but it is imbedded in a much larger matrix
of dissatisfaction and dysfunction. Some have experienced one or more shorter-term therapies but have found themselves
wanting and needing something more.
It has been my experience that many people come to the first session of therapy with something specific to start-“I don’t
know how to handle my teenage daughter,” “I am having a lot of conflict with my partner and am not sure whether to stay
in the marriage,” “I can’t seem to have any kind of life worth living beyond the death of my son.” But at some level, they are
seeking therapy because they have come to the realization that rather than having a symptom, or even being had by a symp-
tom, they themselves are the locus of their concern. They want more for themselves and of themselves in their lives.
This is the province of the psychodynamic or depth-oriented psychotherapies. It is lofty, exciting, and very human. But
this territory comes with many more practical and existential questions than its more behavioral “cousins.” For instance,
how do we as therapists even begin to put our arms around a target that is so broad, so undefined, and in many cases, so
deeply imbedded in personality, personal history and interpersonal style? And what does therapeutic success look like? And
who defines what is healthy or optimum for this particular human being at this particular time in their life? And what gives
us the warrant to believe that we can or should pursue such a lofty goal as human optimization? Is our art and our practice
up to the task of profound human change?
It is not uncommon to hear students share with me that they have worked with a therapist for a number of years, but
see no appreciable difference in how they feel within themselves or in how they live their lives. They enjoy having a person
(a therapist) to talk to for personal support and as an emotional backstop, but they do not feel real shifts in how they ex-

perience themselves or their relationships. So beyond these other concerns, what makes the difference between a long-term
therapy that effects deep psychological growth and one that does not?
These are huge questions, whose presuppositions and orienting axes are often poorly articulated in the training of
therapists, even for those purporting to work in psychodynamic genres. We, on the educational side, often step right into
therapeutic technique before considering the what of what it is we’re trying to do-what are we really up to?
Carl Jung was uncommonly straightforward about these huge questions. Jung saw the evolution of the soul as the
ultimate goal of therapy-a decidedly larger target than symptom relief. To Jung, this meant the full realization of the po-
tentialities of the human person, with attention to those aspects, conscious and unconscious (or “shadow” sides in Jung’s
lexicon) that get in the way of that progression. Jung further believed that each person had a pull toward personal growth
within him or her, and that it was the therapist’s job to follow the lead of that inclination in the patient (Jung, 1955).
Jung is certainly not the only clinical writer to hold these views about the locus of long-term therapeutic work, but he
does so with a certain clarity of language that is unflinching, and so enormously helpful. As purveyors of long-term, depth-
oriented psychotherapy, we commonly hold certain “truths” to be self-evident. But doing long-term work requires a num-
ber of presuppositions that can and should be named.
They are, for starters, that human beings can indeed change, that one person can help another more fully realize his/her
potential as a human being, that the medium of “the talking cure” can be instrumental in this pursuit, and that human
beings contain a gradient of growth within them that can successfully guide the discourse in psychotherapy. The process
that is elegantly elaborated by the stream of writers and thinkers within psychodynamic and related disciplines leans heav-
ily on these presuppositions. In their absence, a psychotherapist, no matter how well intentioned, can drift directionless in
a sea of possible “helpful” interventions, and cover very little distance in terms of meaningful psychological change in very
much time.

Where We’re Headed
Our journey together in the pages to follow will lean on these same presuppositions, but will be explicit about such leanings,
and will attempt to make sense of how they facilitate a process that can profoundly re-sculpt-from within-the people who
engage in it. Just as the short-term therapies, done properly, can and do work, the long-term therapies, done with proper
training, discipline and spirit, can bring change and new life at the deepest levels of the human “psyche” (Greek for the word
“soul”). In the pages to follow, it will be my joy and privilege to lead us together on the beginnings of that journey, whose
pursuit, if you choose it, will extend for years in front of you. I hope to illuminate the first steps for us, which will start in the
next chapters with a renovation of what it means to listen. Here we go.
But just a brief clarification of terms before we launch. I’ll use the term “psychodynamic” throughout this book. This
is meant as the largest umbrella term available to designate the range of therapies-Object Relations, Psychoanalysis, and
Psychodynamic therapy-that take as their starting point the existence of the unconscious and the primacy of transference
(and resistance) in the work of therapy. Questions such as the frequency of sessions, the length of the therapy, the use of a
couch, degrees of “relational-ness” and the requirement of formal institute-based training, etc., are particular aspects of the
work that are sometimes used to define the boundaries of these subsets of psychodynamic work. But within this work, the
word “psychodynamic” will be inclusive of all of these variants.

2 THE ART AND POWER OF LISTENING-DEEPLY

DOI: 10.4324/9781315750095-2

What is it like to listen to another human being? To really listen? This is an oddly emotional question. Humans talk and
listen to one another constantly. We are involved in human commerce all the time. At the store, at the ball game, over the
dinner table, in the classroom. We’re doing it all the time.
But what is it like to listen deeply? What comes to mind is a scene from my friend Gena’s funeral. She was a small, beau-
tiful, dark-haired woman, whose deep brown eyes somehow beckoned you toward an honesty and depth in yourself in her
presence. We, her friends, stood together around the grave that was to hold her ashes. We breathed silently together with
hearts that all hurt in the same way from the ache of having her leave us so quickly. A brain aneurysm. Here, hospitalized,
getting better, and then gone. What strikes me was that when we spoke that day, what little we spoke, we seemed to listen to
one another as Gena did, with eyes and soul that were open, that could feel the hurt-even physically-that said “Your hurt
is welcome here. It can put down its bags and stay awhile. It won’t be jostled. It won’t be rushed. It won’t be asked to hurt
less, or to hurt differently, or to distract itself. It won’t even be asked to word itself. It can just be. And we can just be together
-you, me, the hurt.”
The art of listening deeply. I often pass by classrooms in Loyola Hall with beginning counseling students starting to
practice listening to another in the new way a counselor should listen to a client or patient. The students sit in dyads at
the tables, attempting to hear someone’s story above the din of the rest of their classmates doing the same exercise. They
practice reflective listening, which means that they listen to a sentence or two then try to say back to the person something
of what they have just heard: “So you really wanted to get to the 10K event on time.” “So you’re starting to get concerned that
you won’t have the money to register for courses next quarter.” I often think to myself that it’s a strange exercise for adults to
do with one another; that our cultural orientation toward listening has become so thin that we have to be taught to track on
even the most accessible layers of content that one person is trying to convey to another. It’s troubling just to think about it.
What made Gena’s eyes and her being a vehicle of listening deeply? This is very close to the heart of the matter in acquir-
ing the art of it, so we’ll slow down a bit here.

Attuning
Listening in psychodynamic therapy is a part of a process we call attunement. This is a concept used with most precision
in the study of babies and their mothers/ caregivers. In the process of attunement, one person (baby) attempts to express
something, at first entirely non-verbally, to another. When it goes well, the other picks up the signals and responds in a
way that is accurate, or is at least progressively accurate, and the baby feels understood, soothed or met in some way that’s
congruent with the need/signal sent. Attunement is a three-step process: signal-sending, signal-receiving/deciphering, and
signal response. The receiving person must necessarily use him/herself as reference, must scan inside him/herself to make
sense of what the signal might be saying, then must respond on that basis. Because of this, the response carries a piece of the
responder with it. It’s signed. It’s personal.

This is a different kind of listening from the listening we do in normal social intercourse. It’s where just being a “good
listener” to the story another is telling differs from the art of listening deeply. Attuned listening takes place outside of the
medium of words. It is centered around the wordless communication of an emotion, or a need state, or a state of being from
one person to another, often underneath and even apart from the language they are using. It is most identifiable, of course,
with mothers and their babies, but some-like Gena, routinely listen at this different level.
Attuned listening is one of the centerpieces of psychodynamic psychotherapy, so let’s look closely at what is involved. I’ll
start in this chapter with the art of it, then move in the next chapter to the science of it.

Preliminaries
To become a psychodynamic psychotherapist is to slowly master the art of listening in an entirely different way. It involves
accessing parts and pieces of our human repertoire that we may not fully know are there. In this way, it is perhaps like the
process of mastering a musical instrument. It takes time, patience, practice that seems tedious and endless, but over time, at
what seem ineffably magical moments, new vistas begin to open to us. We begin to feel the feel of it. We sink down into the
soul of it. It begins to be in us, to guide us, to move us, to surprise us, to mystify us. It’s no longer something we think about
doing; it’s something that happens through us.
Listening deeply-with the entire “satellite dish” of our minds and bodies-this is an acquired art. But it’s built on count-
less hours of practicing the basics; the chords and scales. It moves, over time, from simple (and awkward) to complex (and
overwhelming), and finally, in moments, back to simple (and sometimes elegant).
But, it’s delicate, and many things have to be in place in us for it to be fully operational. So my task, as I’m writing, is to
parse this art. I’ll be as honest as I can along the way. Many days still, I hit the wrong keys or can’t feel the rhythm of it. Some-
times the tune sounds way out of tune. Thankfully, my patients are patient with me.

Quieting Down
So, some preliminaries. First and most fundamentally, in order to listen deeply to another in the attuned way a psycho-
dynamic therapist needs to listen, we have to quiet ourselves down inside. It takes practice to learn how to calm ourselves
from the anxiety of what it’s like to sit with this person, this day, with the expectation that we will be of help to them.
For a novice therapist or a therapist in training, this is-let’s be honest-an impossible task. There is no way to quickly get
over the anxiety of occupying the role of therapist. It takes “time in the chair”-lots and lots of it. Because at the beginning,
we watch ourselves. We wonder whether we’re really cut out for it. We wonder whether we’re really as good at it as our
friends and family members have said. We hear ourselves talking in a session. We watch its impact. We wonder what our
supervisor would have said, would have thought about, would have picked up on. We see this session going well (yah!), this
one going nowhere (huh?), this one completely tanking (uh-oh … ). We judge ourselves, moment by moment, session by ses-
sion. It’s a torturous developmental step, and it can’t be avoided.
But, given that we are pain-avoidant by nature, it’s natural to try to get around this part. Our job is to listen-first and
foremost-to sit with the feelings being expressed. The why of why listening is so powerful is something I’ll address as we
move forward. But for now, we’re talking preliminaries: how to settle into the “role” of therapist, and listen. Just listen. As
beginners, we are often hungry for something more than just listening. New therapists tend to look for scripted language
and sure-fire techniques so they can be sure to “do” something that will be helpful.

Even mature therapists at times use “doing” something as a way to stave off the anxiety (and often helplessness) of
“merely” listening to the other, merely being with. This anxiety has many faces. It can take the form of asking a question
when the emotion in the room just needs time to sit there for a while. It can be making a valuable suggestion: “Have you
ever thought about trying this, or that?” It can be the irrepressible urge to point out the bright side, or the humorous side,
when things in the room have gotten heavy and hopeless-a commonplace strategy in American culture. But lightening the
moment, or problem-solving, or attempting to fix something, or make it better, can effectively drop the patient at their point
of greatest despair, leaving them utterly alone in the darkness of it. The capacity to listen and to follow the path of pain with
the other is a tolerance and a muscle that must be developed over time.
So, first things first. We have to quiet down inside-as new therapists and veterans-in order to listen. No easy task.

Getting Present
Then, we have to get present for this particular person. This entails being in a receptive state of mind, perhaps having
shaken off the assaults of the day that have squeezed our own emotional being en route to this moment. We come from the
stresses and hurts of our own lives, of course, before we sit down to be with another. Sometimes, paradoxically, these make
us more tender, more accessible inside. I’ve found in my own experience that at the times of greatest loss in my life, I have
been my widest open inside; most able to be with the pain of the other.
But of course, sometimes, our stuff inevitably gets in the way. Some hurts are too tragic to allow us to function. These
are times when we need and have to step back for a while. Then there are the other times when we hurt deeply, but are ok
enough to be present with the other.
The next scene only works for cat-lovers, but I’ll risk it. I remember in particular doing therapy the day after I had to
put down my treasured 17-year-old cat, Bear. The searing hurt of it was everywhere in me. In many ways it made me more
deeply present with each of my patients, throughout the day, throughout the whole week following. Then without warning
inside, I found myself in the presence of one of the people in my practice who herself had a particularly special affinity
for animals, and had also lost her cat a month earlier. That day, in the moments when we sat together, the hurt of it came
pounding back at me, disorganizing me inside. I did my best to straddle my world and hers simultaneously, but ultimately
was losing the battle, so I decided I needed to tell her what was so heavy in the air between us, something I virtually never
do. She said she knew … (how could she know?). It settled both of us.

Listening-A Point of Departure
OK. So, after having settled ourselves with the assignment of being a therapist, and with the job of being present in spite of,
or in the midst of, our own emotion, we move on to the complex business of listening to this other person. We’re there to lis-
ten, after all.
We are taught by life experience and professional training to pay close attention to the content of what our clients/
patients are saying. It’s our job to be alert, present, engaged. To remember things. To develop an organized view of their life,
their concerns, their significant others, all of it. With some people, because of how they engage with us, this is easy; with
some, it’s really not. But this is a part we’re relatively trained in through our normal non-therapist interactions. Usually,
people are drawn to the field precisely because they are good listeners.
But now I want to introduce a point of departure-where ordinary listening becomes attuned listening-and where the
satellite dish comes in. Here it is. While we’re listening to what the other person is saying to us, an attuned listener is simul-

taneously listening on an entirely different channel. Two channels at once. The one our patient is talking to us about, and
the one being broadcast apart from the language they’re using-the one coming to us literally from their emotional brain to
ours.
Attuned listening requires that we listen to the story line, and at the same time (often preferentially) to what we’re
experiencing while we’re in this person’s presence. So, even while we’re paying close attention to what the other is saying to
us, we also need to pay close attention to ourselves, to what’s happening inside us in their presence. “Are my muscles tight?
Everywhere? Is it just in my arms? Hmmm. Am I anxious? (Did I come in anxious today, related to events in my own life? So
is the tightness mine?) Is my stomach a little whirly? Does my heart hurt, or race, or bound? How is my breathing? Normal?
Constricted? Constricted, how? Do I feel suffocated? How is it changing as they continue to talk to me? How is it different
this hour from the feelings in the room last hour?”
Yesterday, as someone presented a case in consultation group, we took a moment to ask the group members what they
were experiencing in their bodies and emotions as the presenter talked about the case. In other words, for the moment we
were not tracking on the content of the case, but on the experience of the listeners. One member said “stifling, like I can’t get
enough air to breathe.” One said “disequilibrating, like I’m in Pigpen’s dust cloud.” Two others said “shut out, like something
feels impenetrable.” The therapist presenting the case revealed to us that she had felt all these ways in the presence of this
patient and again as she relayed the session’s highlights to the group. She had made no mention of these feelings to us, but
the group had picked up her un-worded emotional experience as she relived with us what the session had felt like to her.

Stereo
In essence, this kind of listening to our own body and emotions amounts to opening up a “stereo” track inside ourselves with
which we scan our own experience as we simultaneously listen to the experience of the other. This is, of course, impossible
if our attention is pulled or focused too narrowly toward the verbal (our culturally preferred channel). It’s even more impos-
sible if we’re busy cueing up our next incredibly wise observation or intervention.
So, how do we go about listening to two things at once? Not an easy job, of course. We’re actually not built to multi-task.
What’s required in these moments is that we loosen up a bit as listeners; that we listen less attentively to the words someone
is saying or the story they are telling. Not entirely, of course. But we can switch back and forth inside. Story. Internal check.
Story. Internal check. How am I doing as I’m with this person, this day? What does it feel like?
It requires that we let go of trying to formulate our next response (in Winnicott’s words, that we let go of trying to be too
“clever” (Winnicott, 1968)). It means that we widen our aperture in order to take in this other part of the scene-the part
where their emotional psyche-soma (as Winnicott (1949) named it) is communicating to our emotional psyche-soma, tell-
ing us the non-verbal story of what it feels like to be with them, and, as we will explore later, to be them in this moment.
This may be new to you, or it may be how you’ve come to listen without even thinking about it. But attending to yourself
in the presence of the other, as counterintuitive as this may seem, is a critical part of the acquired art of listening deeply. We
human monkeys are elegantly equipped to be able to read the experience of the other monkeys in the troop. Our survival de-
pends on it, and as therapists, our attunement depends on it.

Stereo Equipment
One of the ways that I help students get a feel for this kind of listening in our advanced psychodynamic psychotherapy
seminar is an exercise that always requires some risk-tolerance from me as instructor. In the class, I ask students to pair up

fought-in World War II, my parents’ war-and that he had really engaged in the terror and violence of war, close up. I
couldn’t finish the sing-along, because my throat ached with the emotion of the moment. I was touched by their service,
their pride, and the invisible personal cost of it to each of these men, then, and even now. I teared, but didn’t let the tears
stream down my face that night.
We learn this skill along the way-the where, when and how to not let ourselves feel. The when, where and how to close
ourselves to what might be erupting from within us. To listen deeply is to open ourselves from the inside to the emotion of
the moment. We learn from the time we’re little how to close to it. We learn that growing up means getting tough enough
inside not to fall into tears when we get overwhelmed. It means finding the pathway out of our emotional selves-the prac-
ticed discipline of disattending to what hurts.

Our Experience-Dependent Emotional Repertoires
Some of this is inherent in the process of growing up; gaining more and more capacity to regulate our own emotional
states, as we are regulated from the outside by attuned and caring parents. But sadly, much of it-for many-comes of being
disattended to along the way-having our own emotional states ignored, overridden, unrecognized by the people in charge:
our parents or caregivers. If our emotions are disattended to, we learn at a neurological level-in a way that is experience-
dependent-to disattend. It’s that simple. We learn to be open to and comfortable with a full range of emotions in ourselves
and in the other, or not. We learn to be alert to and curious about emotions, and to know how to follow their trail, or not.
We learn-often very early on-that some emotions are ok; some are not. We learn that some emotions or internal states get
us left alone, dropped, even attacked; that some are dangerous. We perhaps learn that emotions or internal experiences are
safer when they’re held in, and perhaps even safer if they are obliterated entirely. We also learn within families that some
people’s emotions are ok and are allowed to be expressed, and some are not.
Developmentalist Stanley Greenspan (1989) has observed that by eight months of age, some infants already exhibit a
truncated emotional repertoire. That early, they have already learned what parts of them their parents can bear, and what
parts make their caregivers nervous, overwhelmed, angry, or just somehow absent. Some of these little ones flatten out their
emotionality, engage in dissociative behaviors, become less interactive, less demanding, less playful, less needy, less angry.
By eight months!
University of Massachusetts-Boston researcher Ed Tronick (Tronick et al., 1975) presented a microscopic view of how this
process of emotional flattening might happen in a child over time through a series of experiments he called the “Still Face”
experiments. In these, he invited a sample of mother-infant pairs into the lab, and asked the moms to play with their six-
month-old child in their carrier for a while. Tronick’s cameras recorded the interactions, one of which I’ll describe here.
We, as observers, beheld what amounted to a perfectly choreographed dance between infant and mother: mother coming
in with her face to tickle the infant; infant squealing with glee. Mother pausing to let the infant catch his breath; infant
smiling broadly with his mouth and eyes to re-invite her into the game. Tronick’s experimenters then instructed the mom
simply to discontinue the game by putting on a still face-not an angry face, not a depressed face, just a still face. What
happened next was remarkable. The baby noticed her expression, was visibly disturbed by it, tried to calm himself for a few
seconds by fixing his gaze on his own hands, and then made a concerted foray to get her to re-engage. If she continued to
present a still face, the baby, seemingly unable to bear the disconnection, began progressively to fall apart-first with small
signs of facial bewilderment and physical dysregulation-tonguing, drooling, hiccupping; next with full body dysregula-
tion; agitation across his entire body; and finally with hard, expressive crying.

What we have come to know observationally and experimentally is that parents’ own repeated emotional responses to
their babies’ and little ones’ emotions can selectively preserve parts of that child’s emotional repertoire and can make other
emotions inaccessible or scary. The development of our emotional capacities-even down to our brainstems-is experi-
ence-dependent (Panksepp & Biven, 2012). Moreover, decades of attachment research have helped us to understand that
a parent’s pattern of attunement to the physical and emotional needs of a child sets up predictable emotional response
patterns in their babies-“secure,” “avoidant,” “ambivalent,” “disorganized” attachment styles-which carry forward with
great consistency into childhood and beyond (Waters et al., 2000). If a parent disattends to, or is toxically reactive to the
emotional signals of a child, the child’s very pliable mind/brain learns about the results of his/her own emotional expres-
sion in relation to its caregivers, and makes the needed adjustments. These then become the template a child carries forward
into subsequent relationships.
Of course, we grow up generally unaware that this process has happened to and in us, and have a tendency to think of
ourselves as always having been “this” way or “that” way; whatever this or that way is. I have, on occasion, asked a class of
graduate students how many have had the experience of anger as adults. Of perhaps twenty-five mostly female students,
ten or so will raise their hands. When I ask how many think they got angry as an infant or toddler, twenty-five hands go up.
The next question-an easy step-stumps the group: “What do you think happened to your anger?”

The Point
Here’s the point. Many things can get in the way of our capacity to listen deeply to the emotions of another as therapists.
We ourselves can have truncated emotional repertoires. We might have had one or both of our own parents unable to be
present with some of our emotions because of their own emotional histories. We may find ourselves strangely unable to
be with certain states in our patients. Some states might cause us to freeze inside, momentarily emotionally leaving the
patient, as the still-faced mother left her infant. Some states may catapult us into problem-solving mode, such that we leave
the feelings of the patient and transit stealthfully into a “why don’t you try this?” stance. Some things may trigger a cascade
of (what we don’t recognize as) anxious questioning from us. It’s tricky, because we don’t necessarily see in ourselves what
we’ve muted over time, so we can’t necessarily know where we are emotionally underdeveloped, and therefore under-at-
tuned to our patients.
I picture our built-in emotional repertoire as a piano keyboard. Certain keys can become taped down within us. Whole
octaves can be missing. But we get used to the sound of the music within ourselves and don’t even know what the song
would sound like (and how beautiful it might be) if, for instance, the base notes were added in.

Expanding the Repertoire
This is why those of us who want to acquire the art of listening deeply as psychotherapists need to have the experience
of receiving attuned therapy for ourselves. It is in this setting where another human being can listen for the music within
us, and can help us slowly and carefully to untape the muted keys of our own emotional keyboard. This is often a painful
process. It hurts to understand that we’ve lost parts of our emotional birthright (and how this came to be); it hurts to realize
how thin our music has sounded all along, to others and to ourselves; it hurts to practice awkwardly as an adult what we
might easily have mastered as a child. But we simply can’t attune to another in ways that no one has attuned to us. We can’t
open in another what is closed in ourselves.

Listening deeply. The art of it. Let me take a moment to re-gather us now. In this chapter we’ve begun to talk about using
the registrations in our whole body as resonators to help catch the proto-emotional pieces of emotional and bodily experi-
ence in the other. We’ll talk more about this later. We’ve talked about what sets us up to do this piece: calming ourselves from
the anxiety of listening, getting present in, and in spite of our own emotional world. We’ve talked about listening in stereo,
scanning our own experience as we simultaneously listen to the experience of the other. And we’ve touched on the painful
reality that we are limited as therapists by our own experience-dependent emotional development, and that we cannot at-
tune to another in ways that no one has attuned to us.
Now as I wind down this chapter, I find myself where I started some pages ago, with my friend Gena in my mind. She
listened deeply and unflinchingly to the emotion in others. It was something she was able to do and be precisely because she
had done the work of opening to her own emotion over time. The art of listening deeply. Gena had it. In the following chap-
ters I’ll try to walk us slowly and clearly into what this looks like in practice, and what it requires.
But as a prelude-I will move us forward into the science of it-the neuroscience of what we’re doing as psychodynamic
psychotherapists, to be precise. This will be exciting to some; it is to me! For me, it adds legitimacy to things in psycho-
dynamic practice that might otherwise seem, at some level, ethereal and inexplicable.

3 THE SCIENCE OF IT

DOI: 10.4324/9781315750095-3

We know from multiple sources, initially from psychodynamic theorists such as Freud and Winnicott, but more recently
from interpersonal neuroscientists such as Siegel, Schore, Damasio, Panksepp and others, that the process of attuned lis-
tening involves much more than our ears and our left brain’s language decoding mechanisms. Listening deeply goes well
beyond the words spoken. It would have to. The words we speak to one another account for only about a third of the mean-
ing in any communicative exchange (Hogan & Stubbs, 2003). Then there is the other, bigger part, which often freights the
much more important load of it. How do we go about listening for that?
Particularly as psychotherapists, it’s important to know how we might go about “tuning into” the part not spoken-or
sometimes not even really felt by the other. How do we access the sometimes deeply buried affective emanations that lie
within, behind, or well beneath the explicit verbal exchanges in psychotherapy? This may seem an elusive pursuit, and it
is. But it is a crucial one, because if we don’t get this, we can miss the emotional truth that is the real target of our work as
psychotherapists.
In this recent era of burgeoning brain science, we are coming to understand some of the mechanisms underlying this
rather ethereal “tuning in” process. This is important because the science of it can help to demystify the art of it. (Never
entirely, of course.) The scientific picture is just emerging and is far from complete. But neurobiological research and ad-
vanced imaging techniques during the past decade or so have exponentiated our understandings of the mind’s emotional
underpinnings. And what we do know at this point can help ground us as we go forward in the clinical conversation about
listening deeply. So, in this chapter, we will do a brief tour of our neurological equipment for the job of listening deeply. First
a quick fly-over, and then we’ll move in closer for a better look.


From bottom to top, inside to outside, most primitive to most evolutionarily-advanced, we have three major brain regions.
The bottom-most is the brainstem-pons, medulla, and midbrain-which control the basic functions that keep us alive:
consciousness, respiration, heartbeat, blood pressure, etc. Also categorized with the brainstem is our cerebellum, in charge
of balance, coordination, and learned movements. The second major region built atop and around the brainstem and
middlemost in the brain is the vast sub-cortical area that includes the limbic system (hippocampus, amygdala, cingulate
gyrus, and dentate gyrus), the diencephalon (thalamus and hypothalamus), the basal ganglia (caudate, putamen, globus
pallidus, and substantia nigra), and the fluid-filled, shock-absorbing ventricles. This middle region is commonly associated
with emotion, learning, memory, and voluntary movement. Third and top-most (and outermost), we have the “thinking
brain”: the cerebral cortex, with its myelinated white matter underneath and its convoluted gray matter on top. We divide
the cortex into two hemispheres (left and right, with their respective verbal and non-verbal functions) and four lobes:
frontal (pre-frontal, pre-motor and motor subdivisions), parietal (in charge of primary sensory functions), temporal (audi-
tory processing and memory), and occipital (visual processing).

A Closer Look
Now, let’s look more closely at the neural territory responsible for us as emotional beings. While it is correct to associate
emotion with our (cortical-level) right brain and with sub-cortical structures such as the limbic system and hypothalamus,
our emotional architecture actually reaches even farther down into the deepest centers of our brains, all the way down into
our brainstems. Yes, the parts of our mind that are most fundamental in the genesis of our emotional experience lie at the
very deepest level of our brains, well below our conscious, thinking, intentional selves.


From bottom to top, inside to outside, most primitive to most evolutionarily-advanced, we have three major brain regions.
The bottom-most is the brainstem-pons, medulla, and midbrain-which control the basic functions that keep us alive:
consciousness, respiration, heartbeat, blood pressure, etc. Also categorized with the brainstem is our cerebellum, in charge
of balance, coordination, and learned movements. The second major region built atop and around the brainstem and
middlemost in the brain is the vast sub-cortical area that includes the limbic system (hippocampus, amygdala, cingulate
gyrus, and dentate gyrus), the diencephalon (thalamus and hypothalamus), the basal ganglia (caudate, putamen, globus
pallidus, and substantia nigra), and the fluid-filled, shock-absorbing ventricles. This middle region is commonly associated
with emotion, learning, memory, and voluntary movement. Third and top-most (and outermost), we have the “thinking
brain”: the cerebral cortex, with its myelinated white matter underneath and its convoluted gray matter on top. We divide
the cortex into two hemispheres (left and right, with their respective verbal and non-verbal functions) and four lobes:
frontal (pre-frontal, pre-motor and motor subdivisions), parietal (in charge of primary sensory functions), temporal (audi-
tory processing and memory), and occipital (visual processing).