Defining psychosis as a process reversal and as an unusual or extreme state implies that the client’s ability to exist in a given environment is disturbed. This means that the psychiatrist has to be acutely aware of her client’s resistances to the world and also of her own resistances to the client, for process reversal polarizes the environment. The world around an individual in the midst of a process reversal always becomes her opposite, just as the client becomes the secondary process for the world. Without understanding what is happening, a therapist usually finds herself acting out the opposite part of a client’s pattern, the cop to the robber, the optimist to the depressive and so on, instead of making both processes more accessible to the client.
If the therapist becomes antagonistic to the patient s state, both are in for trouble. Creative work with an extreme state requires you to be outside the state and outside of its polar opposite, while simultaneously getting inside and fully empathizing and appreciating it. But the latter is only possible when you are not caught in it.
The psychiatrist is faced with many unanswered questions. Why is one client susceptible to one type of process reversal rather than another? Our knowledge at present indicates only how patients become psychotic and how to deal with them. We know that individuals with weak primary processes become schizophrenic under stress, in contrast to becoming physically ill. Individuals with strong primary processes, on the other hand, become psychosomatically ill and experience process reversal as a temporary fever or debilitating handicap. Where there is an edge against violence, epilepsy is common. The following hypothesis needs testing as well; people attached to a primary process of peace become addicted to drugs or endorphine effects such as those produced by physical exercise. What kinds of belief systems are present before the onset of catatonic states? Can retardation be altered through processing?


In a larger scheme of things, the notion of the culturally molded mind, introduced by Vygotsky and Luria, leads to a very important corollary for our understanding of the biological machinery of the mind: The brain comes pre-wired for certain kinds of pattern recognition but not for others. This means that the brain must have some capacity, in fact huge capacity, to store information about various facts and rules, whose nature is not known in advance but is acquired by learning through personal experience or derived from culture. How can this be done?
Evolution solved the problem through the judicious application of the principle that “less is more.” The “old” subcortical structures are preloaded with hardwired information representing the “wisdom of the phylum,” and so are the cortical regions directly involved in processing sensory inputs: vision, hearing, touch. Motor cortex is also to a large degree “pre-wired.”
But the more complex cortical regions, the so-called association cortex, have relatively little pre-wired knowledge. It has, instead, a great capacity to process any kind of information, to deal in an open-ended way with any curve ball the circumstances may throw at the organism. In a seemingly paradoxical way, the more advanced certain cortical regions are and the more recently they developed in evolution, the less “preloaded with software” they are. Instead, their processing power is accomplished increasingly by the ability to forge their own “software” as required by their survival needs in an increasingly complex and unpredictable outside world. This ability to forge “software” in the form of increasingly complex attractors is in turn accomplished by endowing these new brain regions with an open-ended capacity to deal with complexity of any nature. In contrast to the inborn, pre-wired processors, like the angle-specific neurons of the visual cortex, the pattern-recognition capability of these most advanced regions of the cortex is called “emergent,” because it truly emerges in the brain, which is very complex but also very “open-minded.”
This leads to a conclusion that is quite profound: The evolution of the brain is dominated by one grand theme, a gradual transition from a “hardwired” to an “open-ended-open-minded” design. As a result, the functional organization of the most advanced heteromodal association cortex does not resemble a quilt consisting of little regions each in charge of its own narrow function. To use the technical parlance of neuroscience, it is not modular. Rather, it is highly interactive and distributed. The heteromodal association cortex develops along the continuous distributions, called gradients, that emerge spontaneously, as dictated by brain geometry and neural network economy, and not by some preordained, genetically or otherwise, content-specific order. In the association cortex, functionally close aspects of cognition are represented in neuroanatomically close cortical regions. This congruence between cognitive metric and brain metric is exactly what one would expect as an “emergent property” in a self-organizing brain. I term this emergent principle of neo-cortical organization the gradiental principle. By contrast, attaining such congruence between cognitive metric and brain metric through genetic programming would have amounted to a tremendous, and unnecessary, waste of genetic information. Mercifully, this wasteful approach was rejected by evolution. Instead, evolution carved out in the brain design a space for a tabula rasa, but one powered by an exquisite neural capacity for processing complexity of any kind and filling itself with any content.

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