The Neurobiological Underpinnings of Psychoanalytic Theory and Therapy

Psychodynamically Informed Brain Stimulation: Building a Bridge from Brain to Mind

Since its inception, psychiatry has undergone several periods of radical identity transformation. Initially limited to psychotherapy alone, the advent of medications stimulated an era of biological psychiatry. For years, medications served as the mainstay of biological treatments, paralleled by a rise in treatment resistance. Brain stimulation therapies are psychiatry's newest arm of intervention and represent an area ripe for exploration. These techniques offer new hope to treatment-resistant patients, but in a manner often dissociated from psychoanalytic conceptualization and the practice of psychotherapy. There is growing interest in bridging this divide. In this article, we continue the efforts at interweaving what may seem to be disparate approaches through the topic of treatment resistance. This article aims to engage interventional psychiatrists in considering psychosocial dimensions of their treatments and to provide education for psychoanalytic clinicians on the history, mechanism of action, and applications of brain stimulation technologies.

FROM THE GATE TO THE GATEWAY: PSYCHOANALYTIC NAVIGATIONS ONLINE

The shift towards remote or online therapy was compelled by the Pandemic. Many colleagues, who neither had practice using this modality, nor had ever considered it as a possibility, ultimately adopted it. This experience brought with it a substantial expansion of online therapy beyond that moment of emergency. It opened up new prospects of intervention, but at the same time it required a greater measure of reflection in order to understand how to inhabit this new therapy space. Setting aside provisory, intermittent, or emergency situations, which temporarily transfer therapy into a "field of tents" (Bolognini, 2021), the author proposes to consider how online psychotherapy redefines an important element of the psychoanalytic setting-the issue of the space. This is no longer the therapist's place of work, envisaged and organized by him/her/them, fixed in time, and contrived only to welcome the therapeutic relationship-one of the crucial aspects of the external setting, which together with the temporal dimension, fulfills the therapy ritual. Assuming the framework to be essential to the psychoanalytic process, this paper will focus on the methodology of online therapy. The author will describe the contributions of the neurosciences, to provide a deeper understanding of the distinctive characteristics of sharing in an online vs. an offline space. Online therapy should be assessed for its distinguishing qualities within a complete theoretical, technical, and clinical reflection specific to each case. Proceeding as if it were a mere relocation of an in-person analysis would enhance the seductiveness of a therapy that is easily accessible with any laptop anywhere, anytime, and in which one could mistake an online connection for a deep connection.

Enhancing Enneagram Therapy with Contemporary Research on the Conscious and Unconscious Mind

The Enneagram is a personality framework with ancient philosophical underpinnings and cross cultural roots. It outlines nine different pathways of growth for nine different personalities. In recent years, it has started to gain traction in the peer reviewed level of research. Since the Enneagram has a conceptual versatility in addressing various levels and dimensions of the human psyche, it can both contribute and benefit from cross pollinating its insights with the latest scientific research on how the human mind works. One area of research that has the potential for this type of symbiotic partnership with the Enneagram is the study of the interaction between the conscious and unconscious mind. There is rich potential for the multi-leveled integration of contemporary findings on how the conscious and unconscious mind mutually interact with one another along with insights into personality structures from the Enneagram. These integrative insights have clinical implications and create possible directions for future research.

Friston, Free Energy, and Psychoanalytic Psychotherapy

This paper outlines the ways in which Karl Friston's work illuminates the everyday practice of psychotherapists. These include (a) how the strategic ambiguity of the therapist's stance brings, via 'transference', clients' priors to light; (b) how the unstructured and negative capability of the therapy session reduces the salience of priors, enabling new top-down models to be forged; (c) how fostering self-reflection provides an additional step in the free energy minimization hierarchy; and (d) how Friston and Frith's 'duets for one' can be conceptualized as a relational zone in which collaborative free energy minimization takes place without sacrificing complexity.

A re-introduction of the psychodynamic approach to the standard clinical psychology curriculum

OBJECTIVE

There is a strong evidence-base for a psychodynamic approach, supporting primary theoretical tenets as well as the treatment effectiveness. Additionally, there are increasing calls from the field for more individualized treatment for clients, and the lack of training in multiple orientations limits the ability of students in clinical psychology Ph.D. programs in the United States to personalize their treatments. The accumulated evidence-base for contemporary relational psychodynamic theory and therapy places it in good standing to return to the standard clinical psychology curriculum, along with other evidence-based approaches.

METHODS

We use data from the Insider's Guide (which describes clinical Ph.D. programs in the United States) from three time points over 20 years to document the waning psychodynamic approach in clinical psychology programs. We review the scientific evidence for four primary tenets of a contemporary psychodynamic approach: three related to development-from healthy to psychopathological: (1) unconscious processes; (2) internal representations of self and other; (3) dimensional model of psychopathology, and a fourth tenet that builds on these three and is the foundation for a contemporary psychodynamic approach to psychotherapy: (4) therapeutic relationship as a primary mechanism of change.

RESULTS/CONCLUSIONS

Based on the review of the evidence, we make specific recommendations for clinical psychology training programs about how to include a psychodynamic approach in the curriculum.

Converging theories on dreaming: Between Freud, predictive processing, and psychedelic research

Dreams are still an enigma of human cognition, studied extensively in psychoanalysis and neuroscience. According to the Freudian dream theory and Solms' modifications of the unconscious derived from it, the fundamental task of meeting our emotional needs is guided by the principle of homeostasis. Our innate value system generates conscious feelings of pleasure and unpleasure, resulting in the behavior of approaching or withdrawing from the world of objects. Based on these experiences, a hierarchical generative model of predictions (priors) about the world is constantly created and modified, with the aim to optimize the meeting of our needs by reducing prediction error, as described in the predictive processing model of cognition. Growing evidence from neuroimaging supports this theory. The same hierarchical functioning of the brain is in place during sleep and dreaming, with some important modifications like a lack of sensual and motor perception and action. Another characteristic of dreaming is the predominance of primary process thinking, an associative, non-rational cognitive style, which can be found in similar altered states of consciousness like the effect of psychedelics. Mental events that do not successfully fulfill an emotional need will cause a prediction error, leading to conscious attention and adaptation of the priors that incorrectly predicted the event. However, this is not the case for repressed priors (RPs), which are defined by the inability to become reconsolidated or removed, despite ongoing error signal production. We hypothesize that Solms' RPs correspond with the conflictual complexes, as described by Moser in his dream formation theory. Thus, in dreams and dream-like states, these unconscious RPs might become accessible in symbolic and non-declarative forms that the subject is able to feel and make sense of. Finally, we present the similarities between dreaming and the psychedelic state. Insights from psychedelic research could be used to inform dream research and related therapeutic interventions, and vice versa. We propose further empirical research questions and methods and finally present our ongoing trial "Biological Functions of Dreaming" to test the hypothesis that dreaming predicts intact sleep architecture and memory consolidation, via a lesion model with stroke patients who lost the ability to dream.

Neural correlates of psychodynamic and non-psychodynamic therapies in different clinical populations through fMRI: A meta-analysis and systematic review

Background

The COVID-19 pandemic has exacerbated the ongoing crisis in psychiatric and psychological care, contributing to what we have identified as a new psychological and psychiatric pandemic. Psychotherapy is an effective method for easing the psychological suffering experienced also by the various impacts of COVID-19. This treatment can be examined from a neurological perspective, through the application of brain imaging techniques. Specifically, the meta-analysis of imaging studies can aid in expanding researchers' understanding of the many beneficial applications of psychotherapy.

Objectives

We examined the functional brain changes accompanying different mental disorders with functional Magnetic Resonance Imaging (fMRI), through a meta-analysis, and systematic review in order to better understand the general neural mechanism involved in psychotherapy and the potential neural difference between psychodynamic and non-psychodynamic approaches.

Data sources

The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines were employed for our systematic review and meta-analysis. We conducted a computer-based literature search, following the Population, Intervention, Comparison and Outcomes (PICO) approach, to retrieve all published articles in English regarding the above-described topics from PubMed (MEDLINE), Scopus, and Web of Science.

Study eligibility criteria participants and interventions

We combined terms related to psychotherapy and fMRI: ("psychotherapy" [All Fields] OR "psychotherapy" [MeSH Terms] OR "psychotherapy" [All Fields] OR "psychotherapies" [All Fields] OR "psychotherapy s" [All Fields]) AND ("magnetic resonance imaging" [MeSH Terms]) OR ("magnetic"[All Fields] AND "resonance"[All Fields] AND "imaging"[All Fields]) OR ("magnetic resonance imaging"[All Fields] OR "fmri"[All Fields]). We considered (1) whole brain fMRI studies; (2) studies in which participants have been involved in a clinical trial with psychotherapy sessions, with pre/post fMRI; (3) fMRI results presented in coordinate-based (x, y, and z) in MNI or Talairach space; (4) presence of neuropsychiatric patients. The exclusion criteria were: (1) systematic review or meta-analysis; (2) behavioral study; (3) single-case MRI or fMRI study; and (4) other imaging techniques (i.e., PET, SPECT) or EEG.

Results

After duplicates removal and assessment of the content of each published study, we included 38 sources. The map including all studies that assessed longitudinal differences in brain activity showed two homogeneous clusters in the left inferior frontal gyrus, and caudally involving the anterior insular cortex (p < 0.0001, corr.). Similarly, studies that assessed psychotherapy-related longitudinal changes using emotional or cognitive tasks (TASK map) showed a left-sided homogeneity in the anterior insula (p < 0.000) extending to Broca's area of the inferior frontal gyrus (p < 0.0001) and the superior frontal gyrus (p < 0.0001). Studies that applied psychodynamic psychotherapy showed Family-Wise Error (FWE) cluster-corrected (p < 0.05) homogeneity values in the right superior and inferior frontal gyri, with a small cluster in the putamen. No FWE-corrected homogeneity foci were observed for Mindful- based and cognitive behavioral therapy psychotherapy. In both pre- and post-therapy results, studies showed two bilateral clusters in the dorsal anterior insulae (p = 0.00001 and p = 0.00003, respectively) and involvement of the medial superior frontal gyrus (p = 0.0002).

Limitations

Subjective experiences, such as an individual's response to therapy, are intrinsically challenging to quantify as objective, factual realities. Brain changes observed both pre- and post-therapy could be related to other factors, not necessary to the specific treatment received. Therapeutic modalities and study designs are generally heterogeneous. Differences exist in sample characteristics, such as the specificity of the disorder and number and duration of sessions. Moreover, the sample size is relatively small, particularly due to the paucity of studies in this field and the little contribution of PDT.

Conclusions and implications of key findings

All psychological interventions seem to influence the brain from a functional point of view, showing their efficacy from a neurological perspective. Frontal, prefrontal regions, insular cortex, superior and inferior frontal gyrus, and putamen seem involved in these neural changes, with the psychodynamic more linked to the latter three regions.

Dual-Brain Psychology: A novel theory and treatment based on cerebral laterality and psychopathology

Dual-Brain Psychology is a theory and its clinical applications that come out of the author's clinical observations and from the Split-brain Studies. The theory posits, based on decades of rigorous, peer-reviewed experiments and clinical reports, that, in most patients, one brain's cerebral hemisphere (either left or right) when stimulated by simple lateral visual field stimulation, or unilateral transcranial photobiomodulation, reveals a dramatic change in personality such that stimulating one hemisphere evokes, as a trait, a personality that is more childlike and more presently affected by childhood maltreatments that are usually not presently appreciated but are the proximal cause of the patient's symptoms. The personality associated with the other hemisphere is much more mature, less affected by the traumas, and less symptomatic. The theory can be applied to in-depth psychotherapy in which the focus is on helping the troubled side to bear and process the traumas with the help of the therapist and the healthier personality. A person's symptoms can be evoked to aid the psychotherapy with hemispheric stimulation and the relationship between the dual personalities can be transformed from conflicted and sabotaging to cooperating toward overall health. Stimulating the positive hemisphere in most therapy patients rapidly relieves symptoms such as anxiety, depression, or substance cravings. Two randomized controlled trials used unilateral transcranial photobiomodulation to the positive hemisphere as a stand-alone treatment for opioid cravings and both revealed high effect sizes. The theory is supported by brain imaging and rTMS studies. It is the first psychological theory and application that comes out of and is supported by rigorous peer-reviewed experimentation.

Neural Mechanisms and Psychology of Psychedelic Ego Dissolution

Neuroimaging studies of psychedelics have advanced our understanding of hierarchical brain organization and the mechanisms underlying their subjective and therapeutic effects. The primary mechanism of action of classic psychedelics is binding to serotonergic 5-HT2A receptors. Agonist activity at these receptors leads to neuromodulatory changes in synaptic efficacy that can have a profound effect on hierarchical message-passing in the brain. Here, we review the cognitive and neuroimaging evidence for the effects of psychedelics: in particular, their influence on selfhood and subject-object boundaries-known as ego dissolution-surmised to underwrite their subjective and therapeutic effects. Agonism of 5-HT2A receptors, located at the apex of the cortical hierarchy, may have a particularly powerful effect on sentience and consciousness. These effects can endure well after the pharmacological half-life, suggesting that psychedelics may have effects on neural plasticity that may play a role in their therapeutic efficacy. Psychologically, this may be accompanied by a disarming of ego resistance that increases the repertoire of perceptual hypotheses and affords alternate pathways for thought and behavior, including those that undergird selfhood. We consider the interaction between serotonergic neuromodulation and sentience through the lens of hierarchical predictive coding, which speaks to the value of psychedelics in understanding how we make sense of the world and specific predictions about effective connectivity in cortical hierarchies that can be tested using functional neuroimaging. SIGNIFICANCE STATEMENT: Classic psychedelics bind to serotonergic 5-HT2A receptors. Their agonist activity at these receptors leads to neuromodulatory changes in synaptic efficacy, resulting in a profound effect on information processing in the brain. Here, we synthesize an abundance of brain imaging research with pharmacological and psychological interpretations informed by the framework of predictive coding. Moreover, predictive coding is suggested to offer more sophisticated interpretations of neuroimaging findings by bridging the role between the 5-HT2A receptors and large-scale brain networks.

Drive, instinct, reflex—Applications to treatment of anxiety, depressive and addictive disorders

The neuropsychoanalytic approach solves important aspects of how to use our understanding of the brain to treat patients. We describe the neurobiology underlying motivation for healthy behaviors and psychopathology. We have updated Freud’s original concepts of drive and instinct using neuropsychoanalysis in a way that conserves his insights while adding information that is of use in clinical treatment. Drive (Trieb) is a pressure to act on an internal stimulus. It has a motivational energic source, an aim, an object, and is terminated by the satisfaction of a surge of serotonin. An instinct (Instinkt) is an inherited pattern of behavior that varies little from species to species. Drives are created by internal/ventral brain factors. Instincts require input from the outside that arrive through dorsal brain structures. In our model unpleasure is the experience of unsatisfied drives while pleasure if fueled by a propitious human environment. Motivational concepts can be used guide clinical work. Sometimes what had previously described psychoanalytically as, “Internal conflict,” can be characterized neurobiologically as conflicts between different motivational systems. These motivational systems inform treatment of anxiety and depression, addiction in general and specific problems of opioid use disorder. Our description of motivation in addictive illness shows that the term, “reward system,” is incorrect, eliminating a source of stigmatizing addiction by suggesting that it is hedonistic. Understanding that motivational systems that have both psychological and brain correlates can be a basis for treating various disorders. Over many papers the authors have described the biology of drives, instincts, unpleasure and pleasure. We will start with a summary of our work, then show its clinical application.

Una revisione della teoria delle pulsioni

Questo contributo propone profonde revisioni della teoria freudiana delle pulsioni. Le principali revisioni sono le seguenti: (1) Le pulsioni sono coscienti e sono in effetti la fonte di tutta la co-scienza. (2) L'energia pulsionale è equiparata all'energia libera variazionale (variational free energy) ed è quindi quantificabile in linea di principio. (3) Non esistono solo due pulsioni: ve ne sono tante di cui, per la precisione, sette possono essere categorizzate come pulsioni "emotive"; tutte le altre possono essere descritte come pulsioni "corporee". (4) Tutte le pulsioni sono o auto-conservative o in funzione della preservazione della specie; non esiste invece una pulsione di mor-te all'opera nella mente. Ciò significa che, dal punto di vista del meccanismo funzionale, tutte le pulsioni sono omeostatiche e anti-entropiche. (5) Il grande compito dello sviluppo mentale è quel-lo di aggiungersi alle predizioni istintuali innate, permettendo così non solo di gratificare le nostre più diverse esigenze pulsionali ma anche di armonizzarle tra loro. Questo lavoro viene svolto apprendendo dall'esperienza, principalmente attraverso un comportamento volontario, che è gover-nato da sentimenti coscienti.

Clinical wisdom, science and evidence: The neglected gifts of psychodynamic thinking

We review five key areas of contemporary psychodynamic practice and research to highlight the contributions psychodynamic concepts can make to clinical psychiatry. These areas are as follows: (1) Contributions to understanding the development of subjectivity. (2) The psychodynamic understanding of the effects of early childhood trauma and their consequences in adult life. (3) The vital importance of the psychodynamic notion of the 'holding environment' based on an understanding of the dynamics of the development of subjectivity and trauma which, if applied, might improve the quality of psychiatric care in the public mental health system and enhance both the clinical competence and morale of clinicians in the system. (4) The emerging scientific disciplines of Neuropsychoanalysis and Affective Neuroscience, which illustrate the importance of seriously studying the mind as well as the brain. (5) A brief summary of some research into the clinical effectiveness and efficacy of psychoanalysis and its related psychodynamic therapies.

A review of the treatment of functional neurological disorder with intensive short-term dynamic psychotherapy

The purpose of this article was to raise awareness of an under-recognized but well-supported treatment for Functional Neurological Disorders (FND) termed Intensive Short-term Dynamic Psychotherapy (ISTDP). There has been significant interest in the role of psychological mechanisms in FND onset and maintenance with specific evidence for maladaptive emotional processing. We outline how this supports the theoretical basis for ISTDP as an option in FND treatment and undertake a literature review of the current evidence base. We describe the application of ISTDP to FND illustrated through direct therapy transcripts. We conclude with reflections on the strengths and limitations of ISTDP as well as recommendations regarding future research.

Revision of Drive Theory

Several deep revisions of Freud's theory of the drives are proposed: (1) Drives are conscious and are in fact the source of all consciousness. (2) Drive energy is equated with variational free energy and is therefore quantifiable in principle. (3) There are not two drives but many, seven of which may be described as "emotional" as opposed to "bodily" drives. (4) All drives are self-preservative or preservative of the species; there is no death drive at work in the mind. This means, at the mechanistic level, that all drives are homeostatic and anti-entropic. (5) The great task of mental development is to supplement instinctual predictions about how our multiple drive demands may be met and reconciled with each other. This work is done by learning from experience, mainly through voluntary behavior, which is governed by conscious feelings.

Affective Neuroscience Contributions to the Treatment of Addiction: The Role of Social Instincts, Pleasure and SEEKING

Addiction is an illness prevalent in the worldwide population that entails multiple health risks. Because of the nature of addictive disorders, users of drugs seldom look for treatment and when they do, availability can be difficult to access. Permanence in treatment and its outcomes vary from case to case. Most models work from a multidisciplinary approach that tackles several dimensions of addictive disorders. However, the different etiological factors claim for a personalized treatment to enhance opportunities for better results. Problems in relationships with others play an important role in the etiology and the recovery process of addiction. This paper focuses on the social-environmental causes of addiction based on an affective neuroscience approach that attempts to integrate the interplay between social instincts, pleasure, and the SEEKING system in addiction. To advance toward better treatment strategies, it is pertinent to understand the limitations of the current multidisciplinary models. Acknowledging the social nature of the human brain may help to identify the quality of different types of traumatic early life experiences in drug users and how to address them in what may become a neuropsychoanalytic treatment of addiction.

Clinical Applications of Neuropsychoanalysis: Hypotheses Toward an Integrative Model

Neuropsychoanalysis has been established as a field based on the dialog between psychoanalysis and the neurosciences. Freud was a neurologist for 20 years and used the neuroscientific knowledge of his time as the foundation of his metapsychology. Psychoanalysis has predominantly relied on its own method to develop techniques for the different psychoanalytic treatments. It rarely uses contributions from fields outside psychoanalysis that could enrich its understanding of the mind. Neuropsychoanalysis has informed and revised several topics in psychoanalysis, for example consciousness and the unconscious, dreams, and affect amongst many others. Clear clinical applications of neuropsychoanalysis can be appreciated in the work with neurological patients. However, a constant question from clinicians is whether neuropsychoanalytic findings can contribute to psychoanalytic treatments with non-neurological patients. This paper explores clinical applications of neuropsychoanalysis mainly based on affective neuroscience to propose an analysis of emotions that may contribute to the gradual development of a neuropsychoanalytically informed psychotherapy. The task of integrating neuroscientific knowledge into psychoanalytic technique is still considered a challenge of accentuated complexity, but it is at the same time a necessary and promising endeavor that aims at improving the quality of the treatments available for human suffering and psychopathology.

The Emergence of Psychoanalytic Metaneuropsychology: A Neuropsychoanalytically Informed Reconsideration of Early Psychic Development

This paper is principally concerned with reappraising some of the major disagreements that separated the Viennese and the London Kleinians during the British Psychoanalytical Society's Controversial Discussions. Of particular focus are questions pertaining to the genesis of ego development, the beginnings of object-relating, and the role of unconscious phantasy in respect of these phenomena. The aim of the investigation is to inquire into the light that may be shed on the once intractable conflicts surrounding these questions by bringing to bear more recent developments from psychoanalysis and the neurosciences. First, various key issues from the Controversial Discussions are outlined, before the paper turns to work by Jaak Panksepp and Mark Solms that bears on these older arguments and the Freudian theories that underpinned them. With these conceptual foundations established, three questions are posed and discussed with a view to understanding the implications of recent neuropsychoanalytic thinking for some of the entrenched conflicts that divided the British Society. These questions include: (1) what does it mean for the ego if the id is conscious? (2) What does recent neuroscientific knowledge tell us about whether the ego should be thought of as present from birth? (3) How can we understand and locate unconscious phantasy if the main part of the mind that Freud thought of as unconscious is not so? Research from the arena of infant development-particularly the material and analysis of infant observation-is drawn on to illustrate various conclusions. The paper ultimately concludes that taking such an interdisciplinary approach can reveal renewed justification for aspects of the Kleinian metapsychology.

Sex and Prediction Error, Part 1: The Metapsychology of Jouissance

Jouissance is one of Jacques Lacan's most impenetrable concepts. Yet it is essential to Lacan's view of sex. The term is sometimes translated as "enjoyment," but this misses key features of the concept, notably its "traumatic," excessive character. This excess points to a structural negativity within the subject (i.e., the real), an original split that cannot be remedied. In this first of a series of three papers, it is proposed that "surplus prediction error"-as understood within contemporary neuropsychoanalysis-is a neural correlate for jouissance. In part 1, jouissance is explicated within Lacanian metapsychology, primarily in reference to Lacan's real and symbolic registers. Jouissance is an excess enjoyment, outside of the binding, representational capacities of language. The real is the negativity or antagonism within the symbolic, the limit of language and meaning, the point where jouissance emerges. To clarify the relationships among these terms, their positions are traced in some of Freud's major concepts, including drive, infantile sexuality, repetition, and the unconscious. A basic understanding of jouissance is necessary for the rest of this Lacanian neuropsychoanalytic project.

Sex and Prediction Error, Part 2: Jouissance and The Free Energy Principle in Neuropsychoanalysis

Jouissance refers to an excess enjoyment beyond (yet tied to) speech and representation. From the perspective of some Lacanian analysts, jouissance is precisely what testifies against any relationship to the brain-jouissance "slips" out of cognition. On the contrary, it is argued here that jouissance has a central place in contemporary neuropsychoanalysis. In part 1 of this series the metapsychology of jouissance was presented in relation to the real and symbolic registers. Here, in part 2, Mark Solms's neuropsychoanalytic model of Karl Friston's free energy principle is summarized. In this model, "predictions" aim to resolve prediction errors-most notably, those signaled by affective consciousness. "Surplus prediction error"-prediction error that arises at the point where the predictive model fails-is proposed to be a neural correlate of jouissance. This limit within prediction is analogous to the real as a structural negativity within the symbolic.

Sex and Prediction Error, Part 3: Provoking Prediction Error

In parts 1 and 2 of this Lacanian neuropsychoanalytic series, surplus prediction error was presented as a neural correlate of the Lacanian concept of jouissance. Affective consciousness (a key source of prediction error in the brain) impels the work of cognition, the predictive work of explaining what is foreign and surprising. Yet this arousal is the necessary bedrock of all consciousness. Although the brain's predictive model strives for homeostatic explanation of prediction error, jouissance "drives a hole" in the work of homeostasis. Some residual prediction error always remains. Lacanian clinical technique attends to this surplus and the failed predictions to which this jouissance "sticks." Rather than striving to eliminate prediction error, clinical practice seeks its metabolization. Analysis targets one's mode of jouissance to create a space for the subject to enjoy in some other way. This entails working with prediction error, not removing or tolerating it. Analysis aims to shake the very core of the subject by provoking prediction error-this drives clinical change. Brief clinical examples illustrate this view.

Drive theory, redux: a history and reconsideration of the drives

A large and significant portion of contemporary psychoanalytic theory has given up on the drives. The shift toward object relations in the 1940s and 50s, the scepticism about metapsychology in the latter half of the twentieth century, and a general confusion about the coherence of Freud's drive theory have all contributed to their slow decline in prominence. There are legitimate criticisms of the drives that deserve attention but the drives themselves require a careful examination before any successful defence of their place in the metapsychology may be mounted. The current paper provides an account of the drives informed by the intellectual history of German and English thought related to the drives and instincts as they came to Freud. This history allows us to clearly distinguish between "drive" (or Trieb) and its conceptual neighbour "instinct" (or Instinkt).

Some brief personal reflections on the 100th Anniversary Conference papers. Where are we? Where have we come from? Where might we go?

This contribution is a personal reflection on the papers presented at the New York and London anniversary conferences, in which the author takes stock to consider what they might tell us about where the discipline is now, where it has come from and where it might go. Taking the clinical contributions as evidence of the way many leading analysts in the field now proceed, it is suggested that there is an increasing and more and more subtle use of the analyst's behaviour, thoughts, fantasies, feelings and experiences, inside and outside the session, as core sources for constructing the patient's unconscious. Placing this observation in the context of issues of evidence raised in the 50th and 75th anniversary volumes, the author argues that a possible future agenda for the field may be to think more plainly about the basis of an analyst's knowledge claims, whether made implicitly or explicitly to patients in sessions. The author wonders if more disciplined understanding of transference consistent with neuroscientific findings of the last few years may be one factor that could prove useful.

Affective Features Underlying Depression in Addiction: Understanding What It Feels Like

Addiction poses a complex challenge in spite of all the progress made toward understanding and treating it. A multidisciplinary approach is needed and this paper attempts to integrate relevant neurobiological, behavioral, and subjective data under a common denominator described as a latent type of depression. It is called latent because it remains a silent syndrome due to two main reasons. The first one relates to the natural use of defenses against a predominant effect of chronic subjective pain, which arises from an ambivalent type of separation distress that compromises opioid regulation (PANIC system). Furthermore, it provokes a neurochemical cascade that impacts several neuromodulatory systems. The second reason is that such chronic subjective pain usually exhausts the natural defensive system, frequently leading the person to look for other resources such as the neurochemical manipulation of psychic pain. Thus, both the use of defenses and of psychotoxic drugs make the underlying depression hard to assess, even for the very person suffering from it. The causes, course and treatment of this type of affective configuration are discussed in this paper as an attempt to explain some of the difficulties so far encountered and to contribute to potential alternative lines of treatment.

Lessons From Astronomy and Biology for the Mind-Copernican Revolution in Neuroscience

Neuroscience made major progress in unravelling the neural basis of mental features like self, consciousness, affect, etc. However, we nevertheless lack what recently has been described as "missing ingredient" or "common currency" in the relationship between neuronal and mental activity. Rather than putting forward yet another theory of the neural basis of mental features, I here suggest a change in our methodological strategy how to approach the brain, that is, our view or vantage point of the brain. Learning from astronomy (Copernicus) and biology (Darwin), I suggest that we may want to change our currently pre-Copernican vantage point from within brain to a post-Copernican vantage point from beyond brain. Such post-Copernican vantage point from beyond brain allows us taking into view that what happens beyond the brain itself, e.g., the world, and how that shapes the brain and its neural activity, e.g., world-brain relation. We then lend empirical support to the world-brain relation by converging it with Karl Friston's free energy principle that, as we see it, provides a neuro-ecological and therefore post-Copernican view of the brain. That, in turn, allows us taking into view that mental features are shaped by both world and brain and are therefore truly neuro-ecological rather than merely neuronal. This raises the question for the link, e.g., the "missing ingredient" or "common currency" of world brain relation and mental features. Recent empirical evidence suggests that temporo-spatial dynamics may provide such link as it characterizes both the world-brain relation's free energy and mental features, e.g., their spatiotemporality as described in philosophy. Taken together, I here advocate a change in our methodological strategy on how to approach the brain, that is, a shift from a pre-Copernican vantage point from within brain to a post-Copernican vantage point from beyond brain. The latter allows us taking into view that what happens beyond the brain in the world and how that shapes the brain in such a way that it can yield mental features. This amounts to nothing less than a Copernican turn or revolution in neuroscience akin to the ones in astronomy (Copernicus) and biology (Darwin).

The Hard Problem of Consciousness and the Free Energy Principle

This article applies the free energy principle to the hard problem of consciousness. After clarifying some philosophical issues concerning functionalism, it identifies the elemental form of consciousness as affect and locates its physiological mechanism (an extended form of homeostasis) in the upper brainstem. This mechanism is then formalized in terms of free energy minimization (in unpredicted contexts) where decreases and increases in expected uncertainty are felt as pleasure and unpleasure, respectively. Emphasis is placed on the reasons why such existential imperatives feel like something to and for an organism.