The marriage between psychiatry and psychoanalysis has been increasingly strained during the past few decades, as psychiatry has become more and more biologically oriented and psychoanalytic treatment is seen as incompatible with the "hurry up" emphasis of managed care. Although threatened, the marriage has survived because patients treated with medicines still need to talk to someone. Psychiatrists today must rely on the language of psychoanalysis to have conversations with and about patients, to roughly estimate the extent of clinical change whatever its cause, and to understand what is going on in their patients’ minds. Psychiatrist readers of the Journal who are devoted to the third of these concerns—understanding—will find this book stimulating and valuable. It is not easy reading but contains many vivid case illustrations of treatments that were failing for no obvious reason, a dismaying situation all too familiar to all of us. Readers from all perspectives will appreciate the clarity with which Goldberg depicts the unexpected treatment twists and turns demonstrating remedies for a variety of clinical impasses.

Starting from the perspective of the patient, the author critically reviews both new and old conceptual psychoanalytic models with which therapists buttress therapeutic interventions designed to help the patient attain the kind of understanding that fosters emotional growth and diminishes neurotic suffering. Most of these he finds seriously flawed; for example, he warns against a too-ready adoption of the many familiar mind models that split mental phenomena into two realms—dualisms like self versus object, unconscious versus conscious, cognition versus emotion, body and mind, or acting versus thinking.

Supported by his many years of clinical experience and his lucid understanding of previous mental models that depend on evidence, validity, or explanatory power, Goldberg proceeds to identify in detail the therapeutic stance he finds most rationally justified. I will try to convey his approach through a brief discussion of one dualism that he decries, the split between the domains of self and object, which influences the ways therapeutic interventions are conceptualized and used during psychoanalysis and psychotherapy.

When we think about our minds, we do so in images that have spatial dimensions. For instance, there is the image of the iceberg, whose part above the water line represents the area of consciousness and whose large invisible portion hidden below represents the unconscious. Or there is the image depicting the relationship of ego to id as that of a rider (ego) attempting to dominate a strong wild horse (the unconscious id). The mind is conceptualized as a sort of encapsulated bag with the subjective portion inside and the external objective world outside. The upper region in the bag is the realm of consciousness and is split off from the lower region, the world of the unconscious. Or if we imagine one bag to represent myself as the subject, we can imagine that you (the nonself other) is a different bag designated as an object. When Goldberg inspects the model of child development of the object relations school, he notes that for them, the subject’s bag contains a psychological world of representations that is distinct and different from the real external perceptual world. According to that theory, the universe of perceptions and people in the object bag can be taken into the subject bag (internalized) throughout a person’s lifetime.

Goldberg argues that a quite different concept of the mind emerges if the mind is thought of more as a psychological activity than an interaction of spatially located containers. The idea of the mind as activity almost completely dissolves the polarizing split between the self and the object that persists in object relations theory and is fully compatible with the analytic findings of Heinz Kohut, the philosophical position of Martin Heidegger (1), as described in an appendix of the book, and most major philosophers today (e.g., John Searle [2]).

In this line of thinking, the developing child’s relations with the mother and father can be viewed as a series of influential meaning-making emotional transactions or enactments (conscious and unconscious), all of which will determine the coloration of the adult personality and its vicissitudes. Such a perspective does not see maturation as a progressive series of internalizations during which the real perceptual and emotional world of significant people set up camp in the subject’s mind but, rather, as the growth of the child’s mind-body-self that can never be separated from its sustaining love objects. Goldberg writes that "a self extends beyond an individual’s skin, and the mind extends beyond an individual’s skull" (p. 124).

Interpretation during analysis and psychodynamic therapy now becomes primarily a means to detect, review, and modify meanings. "Meaning" refers to the myriad back-and-forth emotional and verbal transactions between patient and therapist that have relevance for symptoms, maladaptive defenses, and behaviors, as well as for personality strengths. However, Goldberg maintains—contrary to the late Stephen Mitchell (3)—that the analyst is in a privileged, usually optimal position to identify meaning and to recognize reality distortions. "All patients need both to be understood…but they need to have such understanding explained to them" (p. 194). The therapist, too, may never be sure of the truth, while mired in profound misunderstanding of the patient’s communications for sustained time periods. Therefore, the therapist must continue to "persistently puzzle" with the patient searching for new comprehension of both past and present sources of patients’ suffering. Derrida, the enemy of finality in attributing meaning, while not cited in the book, would approve of this stance were he still alive.

To act according to the precept of placing the welfare of the patient above their own self-interest, therapists may temporarily have to break rules promulgated by followers of doctrinaire schools of psychological theory. The therapeutic space must not be one where "anything goes," but one in which "everything matters," because the therapist’s activity must always have the goal of detecting meaning and enhancing understanding. (Exploitation of the patient is of course always unethical.)

Viewed from this perspective, the mind is not identical with the brain because activities of the brain or its organic deficits only rarely correspond at all with the mind’s activities or with its aberrations that characterize psychopathology. (An exception may be seen, the author indicates, in cases of antisocial personality disorder, which may have an association with reduced prefrontal gray matter of the brain. Such rare patients cannot profit from "talking therapies.") Goldberg opposes any "hybrid mixture of brain and person" that we try to cure. This therapeutic posture might support some brain-mind dualism, in disagreement with Kandel’s conclusion ("Psychoanalysis is, in the best sense, a part of biology"), which appeared in the Journal as a response to the fractious debate (4) regarding his theories (5).

Freud used the interpretive method to lift repressions or to move emotional content out from the dark unconscious regions of the mind across the repression barrier to the bright conscious world where rational decisions could be made. Most of us, however, have long suspected that the idea of "where Id was let Ego be" is not a good explanation of why and how Freud’s "talking cure" works. Goldberg finds Freud’s treatment approach often inadequate and feels it produces inevitable misunderstanding, a term that is found in the title of the book. Interpretation leading to insight by patients into childhood sources of their psychopathology used to be considered the single most important curative factor in psychoanalytic treatment. This may still be so, but only if the concept is updated and clarified in Goldberg’s manner.

The author’s conceptualization of interpretation leading to insight uses the image of a "hermeneutic circle," the repeated cycle of understanding-misunderstanding-understanding, kept in motion by new reality developments or frustrations that challenge the most recent understandings. It begins with the therapist’s initial understanding of the patient’s symptoms and neurotic suffering and proceeds with both of them beginning to recognize remaining misunderstandings. Through interpretation, a new understanding may occur with some insight into the previous defective psychological configurations, which then leads to recognition of remaining or novel misunderstandings. The cycle may have to continue even after the ending of treatment through mobilization of the patient’s autoanalytic function or further treatment. During almost all therapy outside of formal analysis, interpretation must be liberally melded with other therapeutic activities (i.e., soothing, clarification, abreaction, suggestion, and self-esteem maintenance) described by the author in his first major book, Models of the Mind(6), written with John Gedo.

This last and I think best of the 26 books with which Goldberg has been associated illustrates the many difficulties and dead ends that analytic therapists and their patients must surmount while traveling around segments of the "hermeneutic circle." The book’s mustering of evidence is always firmly rooted in the author’s lifetime of listening to many, many patients with empathy. He seems to retain a remarkable objectivity, but he often expresses his ideas with a self-deprecatory, ironic humor. I had a few uproarious laughs while reading chapter 12, "Me and Max," which is a terrific introduction for students seeking to master the most critical elements of doing competent psychotherapy.

Psychiatrists who only write medicine prescriptions and have little or no interest in talking with patients should ignore this book. Those of us who continue to believe that sensitive emotional communication is crucial for understanding and facilitating clinical change (with or without the use of psychoactive agents) must give this book considerable careful attention. In grappling with these matters Goldberg defines the process of insight more extensively than any writer since Freud. In doing so he is no longer fulfilling the mandate to apply and amplify the brilliant discoveries of Heinz Kohut but truly becomes "his own man," capable of fundamental original contributions to depth psychology.