Neuropsychoanalysis

An Interdisciplinary Journal for Psychoanalysis and the Neurosciences

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Implications of a neuropsychoanalytic formulation

in the psychodynamically-oriented psychotherapy
of a non-neurological patient

Hadas Mor-Ofek

To cite this article: Hadas Mor-Ofek (2022) Implications of a neuropsychoanalytic

formulation in the psychodynamically-oriented psychotherapy of a non-neurological patient,
Neuropsychoanalysis, 24:2, 159-170, DOI: 10.1080/15294145.2022.2127856

To link to this article: https://doi.org/10.1080/15294145.2022.2127856

Published online: 17 Oct 2022.

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NEUROPSYCHOANALYSIS
2022, VOL. 24, NO. 2, 159–170
https://doi.org/10.1080/15294145.2022.2127856

CLINICAL REPORT

Implications of a neuropsychoanalytic formulation in the psychodynamically-

oriented psychotherapy of a non-neurological patient
Hadas Mor-Ofek
Private practice, Jerusalem, Israel

ABSTRACT ARTICLE HISTORY

Neuropsychoanalysis is an interdisciplinary field that integrates neuroscience and psychoanalysis. Received 20 May 2021
Recently, a neuropsychoanalytic approach to clinical practice has been introduced by Mark Solms. Accepted 16 May 2022
The neuropsychoanalytic clinical formulation is based on identifying the main unmet basic
KEYWORDS
emotional needs throughout the patient’s life, the predictions that have been generated in an Neuropsychoanalysis;
attempt to meet those needs, and the defenses that have developed to deal with the sufferings psychotherapy; affective
resulting from these faulty predictions. The psychotherapeutic process is aimed to modify neuroscience; prediction;
inefficient predictions via working through various manifestations of these predictions. The PLAY; free energy principle
current clinical report presents implications of a neuropsychoanalytic formulation in the
psychotherapy of a non-neurological patient in his late thirties. The patient’s background, as
well as the treatment process and the transferential and counter-transferential dynamics, led to
identifying PLAY as the main unsatisfied emotional need. Lack of PLAY compromised the
patient’s ability to handle other emotional needs, especially PANIC/GRIEF. Manipulation,
emotional pressure, and blurring the other’s needs were the themes that characterized the
predictions the patient used in handling the unmet need. These faulty predictions resulted in
suffering and frustration. Interpretations derived from that conceptualization and their influence
on the patient and the treatment process are reported in this paper.

Since its foundation, the Neuropsychoanalytic Associ- perspective on the transference and countertransfer-
ation has aimed at updating psychoanalytic theory in ence is also presented. The feasibility and benefits of
dialogue with accumulated findings in neuroscience, the neuropsychoanalytic clinical approach are discussed.
and vice versa (Balchin et al., 2019). This objective is in
line with Freud’s intention to establish a scientific
inquiry of the human mind. Even though he abandoned The neuropsychoanalytic clinical approach
his efforts to associate his ideas with empirical findings,
The neuropsychoanalytic premises
due to a lack of scientific methods, Freud kept believing
that physiological substrates that underlie mental pro- The neuropsychoanalytic perspective of the human mind
cesses would be identified one day (Freud, 1920). integrates psychoanalysis with neuroscientific domains
Post-Freudian psychoanalysis has proliferated in such as affective neuroscience (Panksepp & Biven,
various directions, leading to dialectical tensions 2012a, 2012b) and computational neuroscience (Friston,
between those who see psychoanalysis as an empiri- 2010). Neuropsychoanalysis, similar to psychoanalysis,
cal-scientific discipline on the one hand, and a herme- recognizes survival, reproduction, and well-being as
neutic-intellectual discipline on the other (Mitchell & core objectives of the human mind (Solms, 2019).
Black, 1995). However, one way or the other, clinical The human infant is born with a set of innate needs
implementation has always kept a dialogue going with and corresponding affects. These needs and affects
available knowledge in a variety of fields, and integrat- include bodily (interoceptive-homeostatic), sensory
ing neuroscientific advances into psychoanalytic clinical (exteroceptive-pleasure/unpleasure) and emotional
practice continues to be important to many clinicians. urges that correspond to “drives,” “reflexes” and
In this paper, I aim to suggest an application of a neu- “instincts” in the Freudian terminology (Panksepp,
ropsychoanalytic clinical approach and to present a case 1998; Solms, 2019). These innate needs and affects are
report that illustrates it. A neuropsychoanalytic in fact our “tools for living,” since they reflect the

CONTACT Hadas Mor-Ofek [email protected] Nes Harim, Israel, 9988500

This article has been corrected with minor changes. These changes do not impact the academic content of the article.
© 2022 International Neuropsychoanalysis Society
160 H. MOR-OFEK

individual’s internal and external state, and accordingly, integrating ideas regarding the free energy principle
direct her/him to implement action plans. (FEP), a branch in computational neuroscience that has
Following Panksepp’s seminal work, neuropsychoana- been used in comprehending the generation and oper-
lysis identifies seven innate emotional systems: SEEKING, ation of secondary and tertiary processes. The FEP has
RAGE, FEAR, LUST, CARE/NURTURANCE, PANIC/GRIEF, been suggested to play a key role the brain’s function-
and PLAY (for a brief description, see Table 1). The basic ing, based on Helmholtzian ideas concerning the brain
emotions are anatomically and functionally hard-wired as an inference machine (Friston, 2010; 1866, in Friston
systems in the mammalian brain. Each basic emotion et al., 2006). The brain generates and uses internal stat-
has a distinct subjective quality as well as a set of istical hierarchically organized models to infer the causes
typical behaviors. This taxonomy includes some for its sensory input in the service of survival and well-
emotional systems (SEEKING, LUST, CARE/NURTURANCE, being. The models (i.e. predictions) are formed by
PLAY) that fine-tune the all-purpose appetitive drive, the extracting regularities from the environment, to orient
libido, by dividing it into different sorts of gratifications, the subject and drive her/him to satisfy their needs
whereas other emotional systems (FEAR, RAGE, PANIC/ and guide the choice of suitable actions.
GRIEF) support life without an attached pleasure- Solms suggests that successful predictions enable
seeking quality (Solms & Zellner, 2012). “good enough” needs satisfaction and affect regulation;
The basic emotions are rarely experienced by adults they are automatized and become preconscious (Solms
in their raw manner, even though physiological-auto- uses both the terms preconscious and unconscious in
nomic aspects and hue of subjective feeling preserve reference to this state), thus freeing working memory
the basic quality in mature emotional experiences. resources (Solms, 2018a, 2018b, 2019). In the free
During mental development, emotions are embedded energy model, inevitable mismatches between the
in secondary processes, which include learning from expected and the actual situation lead to the generation
experience how to meet needs (i.e. with what objects, of prediction error, which also corresponds to a release
by what means, and under what circumstances of free energy (i.e. energy that is not bound). In the par-
emotional gratification is possible) (Solms, 2019, 2020). ticular case of unmet emotional needs, which corre-
Emotions become further embedded in tertiary pro- sponds to a challenge to the maintenance of
cesses, which include cognitions and artifacts of societal homeostasis, the prediction error is broadcasted
and cultural influences that enable noetic and conscious through negative affective arousal. Thus, at this level
reflections upon the self and the environment. The com- predictive errors signal an increase in free energy that
bination of the three emotional levels creates the indi- is not bound to action in the service of life conservation.
vidual’s mental landscape (Panksepp & Biven, 2012b). This state of affairs reactivates the preconscious predic-
In addition to the affective neuroscience model tion back to consciousness and may lead to reconsolida-
described above, neuropsychoanalysis has also been tion processes in the working memory (Exton-
McGuinness et al., 2015; Schwabe et al., 2014), in order
to generate a better prediction. This is the “reality prin-
Table 1. Definitions of the seven basic emotions.
Basic
ciple” in progress (Smith & Solms, 2018). Afterward, the
emotion Definition (Panksepp & Biven, 2012a; Solms, 2020) new prediction is automatized, leaving space for new
SEEKING Enthused, expectant engagement with the environment, learnings in the working memory. Situations in which
accompanied by an empowered sense of self. It triggers basic needs conflict one with the other necessitate
“foraging” behavior, which promotes learning from
experience. regeneration of prediction as well, in order to prioritize
RAGE Arousal response to frustration and competition for emotional demands.
resources. The associated innate behavior is “affective
attack.” The aforementioned predictive process forms one of
FEAR Avoidance of physical danger and death. The associated the ego’s central tasks. They are mainly not conscious.
instinctual behaviors are freezing and fleeing.
LUST Sexual urges that facilitate reproductive success and Some predictions are not preconscious, but rather
demand the release of erotic tension. stored in implicit memory systems (procedural,
CARE Nurturing urges that facilitate the wellbeing of our offspring
and their equivalents.
emotional) that bypass thinking. Solms (2019) claims
PANIC/ The response to a threat or a loss of attachment objects. that repression is based on a similar mechanism that
GRIEF Protest and despair behaviors (panic and sadness, comes into action during childhood, when the ego is
respectively) are the instinctual responses.
PLAY Joyful, rough-and-tumble social interactions provide a overwhelmed by unsolvable emotional situations and
fundamental substrate for social learning, hypothesized to cannot form realistic predictions. Under these circum-
be governed by innate rules concerning fairness and
boundaries, and facilitate reciprocity. These joyful stances, immature or unrealistic predictions are gener-
interactions serve as a mean to negotiate the other basic ated and automatized, although they have not
emotional needs.
managed to meet needs successfully. The automatized
 NEUROPSYCHOANALYSIS 161

“illegitimate” predictions are repressed in a nondeclara- Clinical implications of neuropsychoanalysis

tive manner, and thus cannot be updated, despite inevi-
After sketching the main ideas of this neuropsychoana-
tably generating prediction errors.
lytic approach, I now will describe the formulation of
According to Solms (2013), these processes and con-
the treatment process (Solms, 2018a; Smith & Solms,
tents constitute the psychodynamic unconscious. This
2018b) as I understand it. The first step in the neuropsy-
view proposes to update Freudian metapsychology,
choanalytic formulation is to identify the patient’s
which associates the unconscious with the id. Solms
unmet basic emotion. The affects and symptoms that
turns the tables by suggesting, on the grounds of neu-
the patient presents with are the main clues.
roscientific findings, that the id is conscious, while the
Since the primary faulty predictions remain repressed,
ego is mainly preconscious or unconscious. Neverthe-
the next step is to infer them. These illegitimate automa-
less, due to repression, the pathogenic predictions
tized predictions create erroneous action plans that do
cannot be remembered directly, only through emerging
not gratify the emotional need. Identification of these
symptoms and derived behavioral patterns, “the return
predictions is based on analyzing transferential episodes
of the repressed,” in Freud’s words (Freud, 1915, p. 154).
that resemble the context in which the erroneous pre-
At this stage, secondary predictions are generated for
dictions were generated. During this stage, secondary
explaining away the remaining negative affect. These
predictions and defenses that deal with the remaining
secondary predictions constitute the defense mechan-
unmet emotions are brought to attention. By working
isms (Smith & Solms, 2018). The defenses/secondary pre-
through various contexts, these secondary predictions
dictions range in their efficiency and reality testing, and
are replaced by more adaptive reality-based predictions.
span from primitive, psychotic predictions to narcissistic
Neuropsychoanalysis, as an innovative approach that
and neurotic ones.
has been accused of being clinically irrelevant (Talvitie &
Neuropsychoanalytically-informed psychotherapy
Ihanus, 2011) or even harmful (Blass & Carmeli, 2015),
aims to update secondary predictions into better ones.
calls for a close look at whether it offers added value
This can be achieved by attending to repetitions of the
to the psychotherapeutic process. In the following
predictions in the patient’s life and symptoms. The
section, I present a case report in which a neuropsychoa-
patient’s repressed predictions are manifested in enact-
nalytic formulation was implemented and found to be of
ments and transference in its broad meaning – various
significant value in the clinical process.
episodes throughout the patient’s life, including the
therapeutic relationship. As in the traditional psychoana-
lytic treatment, transference is still central in the neurop-
sychoanalytic work (Solms, 2018a). The psychotherapy of Alex – A clinical report
According to neuropsychoanalysis, the therapeutic
Background details
change depends, in part, on the mechanism of sal-
ience. Paying attention to preconscious automatized Alex is an Israeli man in his late thirties. He is married and
secondary predictions brings them back to working a father to seven children. He is an ultra-orthodox reli-
memory, i.e. consciousness. This process involves gious man and spends his mornings in religious obser-
experiencing the pain of the unmet emotional need vances. In the afternoons, he works as a counselor. His
and tolerating the inconvenience of uncertainty, relationship with his wife is tense. He appreciates her
which arises until new predictions can be generated. wisdom but finds her critical towards him. Alex feels
In this regard, the therapist’s capacity to tolerate uncer- attached to his children.
tainty is essential (Solms, 2019). The therapist’s toler- Alex is the second of six children. His father is a rabbi.
ance can assist the patient to lessen the risk of His mother passed away a few years prior to therapy.
overwhelming the ego and triggering the regeneration Alex’s relationship with his father as well as with his sib-
of faulty predictions. lings are good. The relationship with his mother was
The neuropsychoanalytic clinical approach is at the complicated. She was somewhat distant towards her
beginning of its journey. The centrality of Panksepp’s older children. He remembered that physical connected-
ideas concerning the mammalian basic emotions calls ness was rare. She appreciated him for his high intelli-
for the exploration of transformations of these emotions gence and called him “smart Alex.” He was not
into the subtle feelings that characterize the human encouraged to express any signs of naughtiness. He
mind (Kernberg, 2000). However, the FEP ideas about remembered that around the age of 12, while being fru-
the generation of predictions and their refinement strated, he reacted unusually by being cheeky and
bridge the global concepts of affective neuroscience rejecting her efforts to reconcile with him. She did not
and the subtle dynamics of the human mind. accept that and manipulated him into talking to her
162 H. MOR-OFEK

by threatening that she wouldn’t join him for a party she During the first months of therapy, Alex was occupied
had promised to attend. He eventually agreed to allow with his vulnerabilities. He described everyday episodes
her near him again, but after then, he reacted in tense at work and with his wife, in which he felt criticized. It
obedience to her. was apparent that Alex had difficulties in expressing
Around the age of twenty, like other youngsters in his needs and that led to situations that often ended in
community, he started a matchmaking period in order to arguments and criticism. In the therapy sessions, Alex
get married. After meeting his wife, the mother subtly was open-minded and introspective.
didn’t approve of his choice. After getting married, he Around then, Alex decided to make some changes in
felt he had to present a perfect marriage to her. He his daily routine; he had become more aware of his
was left with no one to talk to about the difficulties of needs, and that encouraged him to put an end to
the first stages of marriage. That had special meaning some uncomfortable arrangements. He was satisfied
because, in the ultraorthodox community, the spouses and trustful in the therapeutic process. He was less
barely know each other before the wedding. distant and less restrained and talked more freely
From the beginning, the couple had difficulties in about longing for my closeness. It was difficult for him
marital life. Alex admired his wife’s intellectual virtues, to bear the breaks between the sessions. He was fru-
but was frustrated by her self-centeredness and impa- strated that he was not part of my life. He also men-
tience. It was difficult to emotionally communicate tioned difficulties in remembering the contents of the
with her. Their efforts to resolve these tensions meetings. I invited him to explore that. He was con-
through conversations often ended up in arguments cerned it reflected a degenerative process. However,
and distancing. Surprisingly, he said that their sex life his frustration got intense. He lost interest in these
was extremely satisfying. This was an escape from every- explorations and put pressure on me to let him record
day tensions. the meetings. I was uncertain about that request, but
After a few years, Alex felt more reassured of his he seemed quite distressed, so eventually, I agreed. I
abilities as the head of his family and got closer to thought that the recordings might serve as a transitional
his mother. He noticed she was warmer with her object (Winnicott, 1971) that would lessen his distress.
grandchildren than she had been with him. Around Alex became occupied with his marriage. His wife
that time, his mother seemed unwell, weak, and less wanted him to be more present and sharing, but it
focused. He was worried and shared it with his broth- never happened. He felt her wishes were not genuine
ers and sisters. They were all troubled, but the parents because they were, in general, not honest with one
calmed them down by connecting it to her retirement. another. This situation influenced their sex life. It was
Although her state worsened, the parents insisted less satisfactory than it used to be.
everything was fine. This time it did not reassure the He became increasingly demanding during his ses-
children, but they could do nothing. Shortly after, the sions. Alex was distressed and wanted my support and
father asked them to come to the hospital. The understanding. I tried to be super-attuned to him, but
mother was unconscious. She passed away the day whenever I failed to understand him, he felt desperate
after. Alex didn’t have the chance to say goodbye. and angry. Other times, he wanted me to be more affec-
During the “Shivah” (gathering together throughout tionate. He revealed a fantasy of becoming my child. I
the first week of mourning according to Jewish tra- was empathic to his wishes and tried to find the right
dition), Alex was self-controlled and supported his stance that would validate his needs but not confuse
wife and children, who had been very attached to his or seduce him. Towards the end of the sessions, I often
mother and fell apart after her death. thought we succeeded in managing things and felt
satisfied, although completely exhausted. However, in
the coming session, it started all over again.
The treatment process
At that stage, Alex said he wanted to tell me some-
Alex contacted me in 2017. He mentioned low tolerance thing that might make me angry. Whenever he felt
to criticism and marital conflicts as reasons for referral. lonely, he Googled me, and lately, he also Googled my
We started to meet on a weekly basis. husband. At first, I was interested in his motives. He
In the first session, Alex seemed tense, and his look said that by watching my pictures and getting to know
was somewhat taut. It was not a conventional choice other parts of my life, he felt less abandoned. I under-
for an ultraorthodox religious man to choose a female stood it as a desperate act to keep me close. Later, I
therapist. When I asked him about that, he said he started to feel intruded upon. I asked him to stop it
would feel less restricted this way. However, for a long and interpreted it as the result of giving up hope to
period, he seemed distant. get closer directly, with my consent. I offered him to
 NEUROPSYCHOANALYSIS 163

meet twice a week, hoping it would alleviate his need. debt right away. I asked him to wait before deciding
Alex agreed reluctantly, since he couldn’t afford it for what to do and invited him to observe this crisis. He
long. I insisted, thinking this arrangement reflected a wanted to keep the recordings, but I couldn’t bear it
better understanding of his needs and my boundaries. and I asked him not to. The intensive emotional experi-
In the following sessions, Alex seemed calmer. ence during this time challenged my capacity to think. It
However, a few weeks later, the previous pattern was clear that this chain of events reflected a massive
returned. Alex was still demanding and unsatisfied, collapse in the already fragile psychotherapeutic space.
and I was frustrated. Nothing was enough. During the first stages of therapy, I noted a delicate
In 2020, the Coronavirus pandemic rocked our lives. A tension between the schizo-paranoid position, which
long period of lockdowns had started. Alex didn’t want was manifested through Alex’s use of splitting during
to miss a single session, and we met on Zoom. He disagreements, and the depressive position that was
asked my permission to record the meetings so he reflected in Alex’s capacity for introspection (Klein,
could watch them again in case he missed some of my 1946; Ogden, 1986). My therapeutic position oscillated
utterances whenever the internet bandwidth was between exploration and interpretation of Alex’s experi-
unstable. Within the confusion of those days, I agreed ences and between attunement and responding to
without a second thought. emotional needs. For example, I interpreted Alex’s
Two months later, he was gloomy. Due to their demands as expressions of longings for parental
financial status, he could not afford to meet twice a figures, and at the same time, I tried to be more
week, although he needed that very much. I weighed present and available. From time to time, the dialectic
the possibilities and offered reduced payment. He space collapsed, especially in reaction to breaks in the
refused, but said that he was about to start a new treatment routine. I understood his extreme distress as
project that might change the picture. I then offered an expression of a disruption in life continuity, resulting
that he could pay only for weekly sessions and to from prolonged absences, like in Winnicott’s (1970)
leave the rest for better times. He asked what would formula “x + y + z.” This formula describes the length of
happen if he wasn’t able to pay later. I said we would time in which the mother’s absence becomes traumatic.
have to find a solution if we got there. We continued X represents the infant’s feeling that mother is emotion-
to meet twice a week. ally present even though she is absent, y represents a
Towards the end of 2020, while summarizing the tax longer absence, in which the infant is distressed, but
year, I realized Alex’s debt grew significantly. I was not traumatized, and z represent an extra time in
embarrassed to realize I had never mentioned it. When- which the mother’s absence traumatizes the infant and
ever it crossed my mind, it wasn’t “the right time.” At creates a break in the going-on-being.
that point, it was clear I had to bring it up, and so I However, as the therapy continued, and the thera-
did. He was surprised and said he thought he wouldn’t peutic relationship became more intense, the dialectic
have to pay for the extra sessions if he wasn’t able to. I space collapsed more often. The aforementioned trans-
was extremely surprised. I tried to recall what I had ferential and counter-transferential dynamics resembled
said exactly months before, wondering if I gave a confus- transitions from depressive-interpretive-symbolic space
ing message. I was furious at myself for blurring it and into schizo-paranoid concrete enactments and reifica-
felt abused and guilty. Alex looked defeated. He said tions. As a result, experiences of aliveness and
that whenever he doubted my caring, he reminded meaning were replaced by futile substitutes. This situ-
himself of the extra sessions and that reassured him. I ation worsened during the outbreak of the pandemic
told Alex I believed he sensed my concern and caring that probably intensified the anxiety and, as a result,
through my presence. the schizo-paranoid tendencies.
I also said it was unlike me to make such financial This process exploded in the “recording crisis,” which
offers. He replied by saying he had saved a recording may represent a perverse collapse of the therapeutic
of the Zoom session in which I offered him that. I was intersubjectivity (Ogden, 1996). The emotional abuse I
astounded. I was sure that after listening, he deleted felt because of Alex’s use of my emotional responsive-
them. He said he was sure I had given my permission ness as a concrete object seemed like a withdrawal
for him to keep the recordings, and that they were his into a realm of part-objects (Bach, 1994). I participated
assets. Whenever he felt empty or lonely, he watched in this process by gradually blurring the emptiness and
them. I was devastated and doubted whether I would futileness I felt for a long time. Instead of recognizing
ever like to see Alex again. these experiences, I offered Alex substitutions that par-
In the following meetings, we were both upset and tially disguised the absence of his sense of being alive
cautious. Alex felt abandoned. He wanted to pay his and loved (Khan, 1979).
164 H. MOR-OFEK

Considering these understandings, I tried to rehabili- might not be fully met throughout the patient’s life,
tate the therapeutic space. I offered Alex interpretations the main unmet emotional need that currently anchors
suggesting that whenever he was at risk of losing the patient’s suffering and symptoms should be ident-
emotional contact, he transformed the lively experi- ified. Table 2 presents hypothesized expressions of the
ences into lifeless objects he could control. Alex’s reac- basic emotions, embedded in secondary and tertiary
tions moved between pain and insult, and efforts to processes, as observed in Alex’s case.
understand and reflect. However, I still needed help in I realized my initial interventions were based on
bringing back my ability to think. It seemed to me that PANIC/GRIEF as Alex’s central unmet emotion.
I navigated in quicksand, and even though I understood However, in supervision, PLAY was identified as the
the mental dynamics, it was difficult for me to manage it main unmet emotional need. Pointing at PLAY was
in real-time. derived from recognizing that although PANIC/GRIEF
seemed central, its characteristic affective tone
(depression, panic) was probably not dominant;
Neuropsychoanalysis in action instead, power struggles that may relate to unsatisfied
The neuropsychoanalytic formulation PLAY needs appeared to have been prominent, at least
in retrospect. Many of Alex’s interpersonal interactions
A neuropsychoanalytic formulation was addressed fol-
reflected dominance/subjugation themes, even when
lowing a supervision session with Prof. Solms, two
they were associated with abandonment or longing.
years into the therapy.
Alex’s relationship with his mother, which probably left
The first stage in Solms’ neuropsychoanalytic formu-
him with unsatisfied attachment needs, may have
lation is to identify the central unmet emotional need
reflected a lack of PLAY satisfaction as well. His role as
in the patient’s life. Although all the basic emotions
“smart Alex” narrowed his ability to negotiate mutuality
with his mother, and later on with others, since he was
Table 2. Hypothesized expressions of the seven basic emotions obliged to stay in a mature, responsible and serious pos-
following Panksepp (1998) as observed in Alex’s case, ition, and unable to be in the subordinate position.
embedded in secondary and tertiary levels. It is noteworthy that, although the instinctual context
Basic
emotion Clinical expression
of PLAY should happen with peers, it is hypothesized
SEEKING Towards initiation of a new project with at-risk youngsters,
that it can occur in other interpersonal contexts as
Alex was excited. He was looking for relevant professional well. For instance, even though the common emotional
literature and took courses on the subject. He shared his system that characterizes child–parent relations is CARE/
insights with me with great enthusiasm.
RAGE Alex expressed anger and frustration in a transparent, NURTURANCE, PLAY may also be present. The subjective
although restrained, way. It was expressed through a quality of PLAY and its characteristic behaviors (as well
hostile look, restlessness, and thunderous silence.
For example: as the physiological-neurological substrates) point to
A: I hesitated before talking about the argument with my different emotional systems that are active in a current
wife.
H: Why? situation. Thus, Alex’s childhood memories concerning
A: I remembered you seemed empathic towards her when I his relationship with his mother (like in a memory from
told you about our debts. You were surprised to hear that
because my wife is the breadwinner; she takes care of the
age of 12, where he felt manipulated by her), may
financial issues. have expressed a lack of PLAY in the parental context.
H: I was truly surprised when I realized you don’t share this The usage of manipulation in any interpersonal relation-
responsibility.
A: It doesn’t matter. ship, including parent–child relations, compromises the
Alex remained silent and tense and stared at me angrily for a possibility for mutual recognition of one the other’s
long time.
FEAR When Alex got blood tests and received worrisome results, will, and thus may create or reflect a lack of PLAY
he was afraid he might be ill. He was unable to sleep at satisfaction.
night and could not concentrate until the medical worries
were refuted. Secondary predictions concerning Alex’s possible
LUST Satisfying sexual relations with his wife, even though they unsatisfied PLAY needs may have attempted to deal
followed the Jewish restrictions concerning sexuality.
CARE Alex is a caring father and devoted son. He visits his father
with his need for mutuality and sharing through efforts
often and studies the Torah with him, knowing it enlivens to make others do things his way. Thus, his secondary
his father. process predictions related to using emotional pressure
PANIC/GRIEF Alex’s grief for his mother’s passing emerged during the
second year of therapy. He expressed longings and once or blurring the other’s needs. Paradoxically, these predic-
showed me a picture in which she held him as a baby. He tions compromised his ability to create reciprocal con-
carried it in his wallet.
PLAY Alex described a cherished childhood memory in which he nections, and often ended in overt or implicit power
played soccer with other children during summer struggles. That way, even when he got what he wanted,
afternoons.
he was unsatisfied, being left with no one to share.
 NEUROPSYCHOANALYSIS 165

One of PLAY’s suggested derivatives is an enhance- variations, unlike serious behaviors … ” (Burghardt,
ment of a better negotiation of other emotions, thanks 2005, in Panksepp & Biven, 2012b, p. 352). These criteria
to its function as a tool to test solutions to complex make PLAY a medium in which a wide range of
real-life situations (Panksepp & Biven, 2012b). Various emotional scenarios may be triggered and experienced
episodes in Alex’s life reflected the lack of this at a moderate level, and in a shared state, in which
influence, as seen in the following vignette. none of the participants consistently dominates or is
Toward the end of a session in which we discussed his subjugated, thereby allowing new predictions to
fear of missing mutual and close experiences, I noticed emerge. Since Alex’s predictions often led to power
he looked at the clock and seemed lifeless. struggles, he lacked opportunities to create moderate
shared states, which compromised his ability to gener-
H: What happened? ate efficient predictions that would result in the full
A: What? expression and satisfaction of other emotional needs.
H: Something has changed. You look different.
A: I’m just thinking I didn’t use this meeting (the
For example, the lack of PLAY impacted Alex’s LUST as
Hebrew word for “use” means also “to exploit”). well. When the power struggle between him and his
H: Look at what has just happened. wife became more apparent, their sex life was affected.
A: What? Instead of mutual satisfaction of sexual needs, they
H: After I mentioned the disappearance of precious “settled accounts” in bed.
mutual experiences, your face seemed lively. We
In my opinion, my countertransference indicated the
were close; you felt understood. And right then,
you’ve noticed we haven’t got much time. You influence of the lack of PLAY on the possibility of nego-
said, “I didn’t use = exploit the meeting.” tiating attachment needs in Alex’s case. I felt I had to
A: I don’t really understand. please Alex, but my efforts and attunement, that
H: I think you didn’t want the precious connectedness reflected the recognition of Alex’s attachment needs
to disappear when the meeting ends, so you said (PANIC/GRIEF), never seemed enough. I felt forced to
something upsetting like “I want to “squeeze”
more from this meeting.” At this exact moment,
try harder, only to find out later that he remained unsa-
you became lifeless. tisfied. I was imprisoned in this exhausting cycle and felt
coerced and even abused. These emotions may serve as
This vignette shows the threat of abandonment, which identification marks of lack of PLAY influences, which in
may be connected to PANIC/GRIEF feelings that Alex turn resulted in a somewhat not-wholehearted presence
often felt when realizing the meeting was about to that became more prominent after the recording crisis. I
end; I hypothesize that the latter could not be nego- didn’t want to be Alex’s “playmate” anymore, and from
tiated due to a lack of PLAY/mutuality. The psychother- that perspective, both his attachment needs and PLAY
apeutic setting may provide a certain frame for a needs were compromised.
genuine expression of the need for connectedness.
However, in the vignette, instead of a direct PANIC/
Implications of a neuropsychoanalytic
GRIEF expression, which could lead to a shared sorrow
formulation
about the coming end of a precious time, Alex “quit
the game,” by dismissing the shared meaningful experi- I had a session with Alex right after the supervision. I
ence. By doing that, the pain of separation was replaced intended to connect the lack of PLAY and its secondary
by a more domineering tone – which may reflect a lack predictions to the current crisis. I conceptualized keeping
of PLAY – that sabotaged the opportunity to feel close. the recordings without my explicit permission as a predic-
Because PLAY can provide opportunities to negotiate tion in which, in order to get something he needed, Alex
other emotional needs, it, therefore, has a central role in blurred the mutuality that was related to the recordings:
the possibility of generating better predictions, via the Alex sat tensely. His eyes were hostile.
exploratory and testing nature of PLAY interactions.
H: It was a long and painful week for both of us, I
PLAY, as was suggested by Panksepp and Biven
guess.
(2012b), may serve the learning process in ways that A: Yes. I still don’t understand what happened. In the
are complementary to dreaming. They both may help past week, I could not listen to the meeting
to organize information in the brain, in ways that because you didn’t allow me to record it. Whenever
promote higher-order affective responses to life I thought about your demand to delete the record-
ings, I thought you’re unfair. You allowed me to
events. The authors cite two suggested criteria for a
record it.
behavior to be considered as play – “play is an exagger- H: I’m sorry you feel this way, but I didn’t mean you
ated and incomplete form of adult activities” and “play can keep them.
exhibits many repetitive activities done with abundant A: Fine (angrily).
166 H. MOR-OFEK

H: I want to share some ideas. I understand you need processing the intense feelings I experienced. Later, I
something from me, but when you take it against considered publishing the clinical materials that illus-
my true will, it can’t satisfy you. Moreover, instead trated Solms’ proposed method of a neuropsychoanaly-
of exploring your fear of forgetting, I allowed you tic clinical application. After consultation, I decided not
to record the meeting, and we’ve lost the opportu- to ask for Alex’s permission, but rather to change his per-
nity to touch one of your deepest worries.
sonal details according to the ethical code for publishing
A: I understand what you’re saying, but I’m really
afraid I won’t remember. clinical cases (Gabbard, 2000). I imagined that sharing it
H: I understand. But you know, you’re not alone here. with him would burden him unnecessarily. With my eyes
We can remember together. wide shut, I blurred any impact of my writing over the
psychotherapeutic process.
In the above vignette, I tried to point out the price Alex
In the fall of 2021, the Covid-19 risk decreased. I had
paid when using pressure for getting an emotional pres-
decided to give up wearing a facial mask during sessions.
ence. The longed-for connectedness couldn’t be forced.
I thought Alex would be glad, but he seemed puzzled and
A few weeks later, I reminded Alex of a dream he had
uneasy when I announced it. He kept his mask on for a
two years before. He was listening carefully and seemed
while and then said that again, this was a “fixed game.”
excited and peaceful at the same time. I asked him about
He always had to accept my rules because I had power
that. He said that I gave him something he could hold on
over him. I responded by talking about risk-taking, but
to. I asked him what he meant, and he said that remem-
immediately I realized I missed the point. I understood
bering his dream was something I did wholeheartedly,
his remark was probably a manifestation of his unwilling-
and that could stay within.
ness to accept the fact that in the therapy setting we were
not in the same position, e.g. lack of PLAY, but it seemed
Working through: identification and negotiation more than that. He was sensing a lack of fairness between
of predictions us, but it was unclear to me what it was. Then something
clicked. I figured out I prevented mutuality by not sharing
During the following months, Alex was mainly con- my writing about the therapy. That understanding left me
cerned with his marital relationship and our relationship. extremely anxious, realizing I had to tell him about it and
In both, he made fruitful efforts to form mutuality and ask for his permission; otherwise, it would become abuse.
cooperation by identifying the various ways in which Thus, for the first time in our relationship, I felt he had
he used to force the others in order to get what he power over me. He became someone who could give
needed. This raised his hope and wellness. However, in me or deny me something that I really wanted.
situations in which he was frustrated, he eventually felt I said, “Alex, you’re right. Something between us is
desperate. After these episodes, he was needy and unfair. It’s not the masks. There is something that I didn’t
demanding again, but in a more refined manner. tell you, and by that, I didn’t play a fair game.” He
It seemed that the “recording crisis” gradually became curious. I told him about the case report. I immedi-
receded to the background. When he mentioned it, he ately added that I changed his personal details, although I
was still deeply hurt, since he knew that I didn’t assumed it wasn’t the issue. I explained that writing was
believe that the whole thing was done in good faith. partially an effort to deal with my emotional reactions to
By that, he felt invalidated by me. He understood that I the recording crisis and also the result of the positive
felt exploited, but could not empathize with me and impact I attributed to the neuropsychoanalytic formu-
thought I was unfair. He was frustrated since his depen- lation. Alex was shocked and didn’t say much. On the door-
dence on me forced him to obey my decision to delete step, he said it was fine that I published a case report about
the recordings against his will. him. I replied by saying we should give it more time.
We went back and forth in negotiating the predictions In the next sessions, Alex and I negotiated the mean-
that possibly dealt with his PLAY system needs, for ings of that event, especially considering the recording
example, in regard to Covid-19 directives. I insisted on crisis. That stage of therapy resembled working
wearing a facial mask during meetings while Alex was through secondary predictions concerning mutuality
unhappy with that and complained I was dominating him. and possibly PLAY in the transference and countertrans-
ference through recurrent negotiating episodes that
were concerned with the recognition of the other’s will.
Neuropsychoanalytic perspective on
After that session, I was shaken. On the one hand, I
countertransference
felt that I did the right thing. I realized that I prevented
A few months after the “recording crisis,” I started to Alex from expressing his wishes concerning publishing
write the current case report. At first, it was my way of his own experiences and that asking for his permission
 NEUROPSYCHOANALYSIS 167

gave us a true chance for mutuality. On the other hand, I Interpreting Alex’s dream could have been done in
was flooded by the fear that I would lose something different ways, such as attending to expressions of sexu-
meaningful. Feeling so dependent on his will showed ality or abuse on my behalf. However, the offered
me, by projective identification processes, what kind of interpretation was based on my hypothesis that Alex’s
feelings Alex probably felt when I asked him to delete fear of retaliation reflected the impact of distortion in
the recordings he cherished, and at the same time, the PLAY emotional system. This hypothesis was based
how easily the other’s wishes can be blurred. on Alex’s utterances related to his concerns that even
When we met, Alex told me it was one of the hardest though I said he had the right to refuse the publication,
weeks of his life. He wanted to take a break from the I was not honest. He was worried I might hide my true
therapy, but felt he couldn’t. He mentioned a dream feelings and eventually that would impact his ability to
from the night before: express his will. The above dialogue presents nego-
tiation and a slight change of the secondary prediction
A: You are giving a talk about my therapy. You ask me
concerning the fear of being subjugated to the other’s
to add my perspective on the process. I don’t want
to, but I say nothing. You start to project some will/power by blurring/ignoring the other’s right to
slides, and I don’t understand what’s the connec- agree or object. Countertransferential processes, in
tion and what I’m supposed to say, so I say which the unmet emotional need is evoked in the thera-
nothing. The talk ends quickly. You collect your pist and necessitates the therapist to generate relevant
things and look angrily at me. You say “I didn’t predictions, are also illustrated. During Alex’s psy-
know you don’t know how to speak.” When we
get out, I can see that your chest is exposed.
chotherapy, I was “infected” by the lack of PLAY and
H: What a dream … Do you have any thoughts or its direct outcome, mutuality. I developed my own sec-
associations? Any feelings? ondary prediction that dealt with the wish to get what
A: It reflects my fear you’d be angry at me. You’re I wanted without the risk of refusal. In the above vign-
human. Even though you said I don’t have to ette, handling the consequences of our predictions pro-
give you permission to publish, I’m sure you’ll be
moted reciprocity.
disappointed and angry.
H: I understand. But it’s the last part of your dream
that resembles my feelings. I was anxious that I
Prediction, creativity and mutuality
might lose something very important to me. I felt
vulnerable, exposed in my entitlement and needs. During the weeks Alex and I dealt with the crisis, he also
In the past week, I thought a lot about that. I rea- revealed feelings of being intruded upon by my willing-
lized it uncovered something private about me –
my ambitions and the steps I dared to take in
ness to let others enter his private place. He said that
order to achieve them. I also guess this is not far confidentiality allowed him to express neediness. He
from how you felt last year when I asked you to was worried it might disappear if he agreed to the pub-
delete the recordings. lication of the case report. I asked him why he didn’t say
no. Was it because he worried I might be angry? He
Alex listened carefully.
replied that it wasn’t that. He felt publishing might be
A: Why did we have to go through all of this then and meaningful to him, but he needed more time.
now? In the meantime, some changes in his everyday life
H: Maybe it’s the core of your pain. The “recordings occurred. He consulted a friend about the publishing.
crisis” and what happened just now are kind of
It was the first time he was vulnerable in front of a
complementary perspectives, from your side and
mine, on a similar issue. You needed my presence friend, not the regular “smart Alex.” During a fight with
desperately, so you blurred the need to get my per- his wife, he needed her support but acted ungently as
mission to keep the recordings or to check whether usual. She backed off. Then, instead of moving farther,
I indeed meant not to charge you for the extra he asked her to stay close and said he needed her. He
meetings. This blur of my will allegedly enabled felt vulnerable, but they kept talking and felt closer.
you to get what you needed, but you still felt unsa-
He became interested in the content of the report. He
tisfied. When I think about what happened
between us now, I think that my wish to publish wanted to know what I had written about him and how I
the clinical materials blurred the need to ask for understood his situation. I shared the neuropsychoana-
your permission. In retrospect, I realize that when- lytic understandings with him. He was enthusiastic. It
ever I thought about publishing, even though I shed light on various aspects of his life, and on psy-
completely hid your personal details, I wasn’t at
chotherapy. “A few months ago, I’ve noticed something
peace. Whenever I imagined you reading it
someday, I felt restless, but I ignored it. was favorably changed, but I couldn’t understand what
A: I understand. Now I can realize why you felt so bad exactly it was. I guess it has something to do with that
then. PLAY you are talking about,” he said. I presume that
168 H. MOR-OFEK

Alex’s remark reflected the gradual changes in the sec- In my opinion, the added value of using Solms’s neu-
ondary predictions concerning mutuality, that led to ropsychoanalytic formulation, in this case, is its clarity.
better recognition of the other’s will and thus to a The neuropsychoanalytic perspective suggested for
more genuine connectedness between us. During that this case is compatible with some psychoanalytic con-
meeting, Alex was lively. We were playing with ideas in ceptualizations: for example, the schizo-paranoid inter-
mutual and creative manners. personal dynamic (Klein, 1946; Ogden, 1986) and the
A week later, Alex started the meeting by saying he perverse collapse of intersubjectivity (Ogden, 1996),
wanted me to publish the clinical report. which seem in congruence with the proposed dynamics
of a lack of PLAY. The prominent themes of manipulation
It gives me the feeling that I’m part of a creation. I don’t
think I would ever write something by myself, but
and coercion in the case reflect the aforementioned psy-
through your writing about my therapy, I’m part of it. I choanalytic as well as PLAY dynamics. However, thinking
don’t feel intruded anymore, but that the two of us of PLAY, its interactions with other emotional systems,
choose what we share with others. and the derived secondary predictions offered the thera-
pist a clearer map for navigating these intensive
emotional situations and enabled her to enhance
Discussion and closing remarks
mutuality. The patient’s utterance that “something in
This clinical report is one of the first efforts to illustrate the therapy was favorably changed” echoes that impact.
the clinical implications of neuropsychoanalysis, as pro- Since the beginning of the treatment, it was clear that
posed by Solms. Examining the feasibility of neuropsy- the patient was struggling with painful attachment
choanalytic formulations in clinical practice requires needs. This understanding was central in the therapist’s
considering their benefits, and clarifying whether it pro- initial therapeutic position. The neuropsychoanalytic
vides value from the “benchmark” of psychoanalytic contribution to this case lies in its emphasis on the inter-
psychotherapy. action between attachment needs (PANIC/GRIEF system)
The psychoanalytic perspective that served the and the PLAY system. I would like to discuss this idea
process well during the initial stages of therapy was con- from two perspectives.
cerned with efforts to establish and maintain intersub- Beginning with the relations between attachment
jective dialectical space, in which Alex’s needs/ needs and play/PLAY, it is worth mentioning that
experiences were recognized, contained, and trans- under a threat of separation, the ability to play, in the
formed into more reflexive and lively experiences. The Winnicottian as well as the Pankseppian senses (Pank-
therapist identified attachment needs as prominent in sepp & Biven, 2012b; Winnicott, 1970), is compromised.
the patient’s symptomatology and struggled to find a This might lead to the hypothesis that Alex’s excessive
dialectical position between interpretation and attune- longing for the therapist’s presence and affection prob-
ment to these needs. However, due to the intensification ably reflected his unmet attachment needs and affected
of the transference/countertransference emotional his ability to be playful. However, Panksepp’s research
experiences, this dialectical space collapsed. That led on PLAY does not directly relate to the Winnicottian
to a partial loss in the therapist’s ability to reflect and concept that sees play as a mental (and not necessarily
to a threat to the therapeutic process. interpersonal) transitional phenomenon. Prominent
Applying Solms’s neuropsychoanalytic approach, I neuropsychoanalytic theorists such as Panksepp and
hypothesized that PLAY was a central emotional factor Solms (Panksepp & Biven, 2012a, 2012b; Solms, 2018b,
in the patient’s symptomatology and in the therapeutic 2019, 2020) view PLAY as a tool to manage social
process; during that time, this perspective enabled the states via rough and tumble interactions that exercise
therapist to reconceptualize the recurrent crises as a the participants’ ability for reciprocity. This reciprocity,
reflection of the lack of PLAY and the activation of sec- first and foremost, is essential for creating and preser-
ondary predictions that replaced mutuality with force/ ving a social structure. However, reciprocal interactions
manipulation. The latter helped the therapist to restore with others create joy, connectedness and sharing, and
her ability to mentalize during crucial events and, they might also serve as opportunities to improve the
through that, to be able to decrease the activation of organization of affective information in the brain (Pank-
faulty predictions that ended up in frustration and a sepp & Biven, 2012b). These outcomes facilitate the
sense of abuse. Identification of the predictions and ability to handle other emotional needs, including
their price throughout the patient’s life and in therapy PANIC/GRIEF. In my opinion, the Pankseppian PLAY is
raised the possibility to generate other predictions, not far from the Winnicottian concept. I suggest that
resulting in mutuality that resembled more PLAYful the overlap between the two concepts is reflected
relations. during the session in which gaining mutuality between
 NEUROPSYCHOANALYSIS 169

the patient and the therapist was accompanied by the mental states. This odyssey leads the therapeutic
patient joining the therapist in the creative act of couple to a dialectic movement between uncertainty
writing, a typical mark of the Winnicottian playfulness. and understanding. Solms’ neuropsychoanalytic propo-
Therefore, it is suggested that if the Pankseppian sal may serve as an anchor to that journey, by offering
PLAY widens the options to handle other emotional a map that is based on both scientific-based and subjec-
systems, the relation between PLAY/play and PANIC/ tive grounds.
GRIEF can be found not only in the impact of separation
on playfulness but also in a reverse manner in which a
lack of PLAY impacts the ability to handle separation, Disclosure statement
e.g. PANIC/GRIEF, as was illustrated in the clinical
No potential conflict of interest was reported by the author(s).
material. As basic emotional systems, PLAY and PANIC/
GRIEF exist concurrently and interact in both directions.
Another perspective on the relation between attach-
ment needs and PLAY lies in the hypothesis that the
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