When Freud invented/discovered psychoanalysis, he devised not just a theory of mind but also a tool that enabled him to observe the "mind." And with the tool of psychoanalysis, he was able to observe the workings of the default mode network (DMN) some hundred years before anyone knew of its existence. Since then, various operations of the DMN have been identified. One is the integration of perception into memory through the process of functional connectivity. In posttraumatic stress disorder (PTSD) there is significant pathology in functional connectivity involving multiple brain networks-especially the DMN and the intrinsic alarm system. This article addresses the causes and consequences of this pathophysiology as it relates to the sense of time, safety, and story in PTSD.
Recent clinical trials have suggested the safety and efficacy of psychedelic therapy for treatment-resistant depression, posttraumatic stress disorder, addiction, and end-of-life distress. While neurobiological mechanisms such as 5-HT2A receptor activation, increased neural entropy, and default mode network modulation have been well-characterized, significantly less attention has been given to the emergence of unconscious material within psychedelic states. This article introduces a psychodynamically informed framework for understanding and working with such material in clinical contexts. Drawing on psychoanalytic theory, we explore how psychedelic compounds may facilitate access to preverbal, dissociated, and developmentally embedded psychic content, often expressed through somatic experience, symbolic imagery, and unconstrained affect. Using the four standard phases of psychedelic screening, preparation, psychedelic treatment session, and follow-up or integration, we present a structured psychodynamic lens, integrating conceptual theory with illustrative clinical vignettes. These fictional composites, informed by publicly funded clinical research programs, highlight how unspoken experience, affective intensity, and shifts in psychic structure may unfold within the psychedelic experience. We argue that consideration of unconscious communication, symbolic processes, and defensive functioning can foster greater clinical depth. This article advances the position that psychoanalytic models, though underrepresented in current psychedelic research, offer valuable tools for conceptualizing mechanisms of change beyond symptom reduction. As psychedelic treatments approach regulatory approval and broader clinical use, such perspectives may play an important role in future research, training, supervision, and individualized care models.
Maternal-infant early bonding, a robust precursor for later healthy infant development, may be jeopardized by maternal early exposures to adverse experiences (ACEs). Both psychological and biological aspects of maternal functioning have been identified as potential putative mechanisms for the deleterious effects of ACEs on maternal-infant bonding, but research has rarely included both in mediation testing, limiting our understanding of the relative contributions of each. We prospectively evaluated the direct and indirect effects of maternal report of ACEs on mother-infant bonding using pregnancy maternal mental health (depression, anxiety, and posttraumatic stress symptoms) and cortisol levels, a marker of HPA-axis functioning. Participants were 446 women recruited from the community; poverty and intimate partner violence (IPV) were overrepresented in our sample. Women completed self-report surveys during their pregnancy and at 1 month postpartum. Baseline cortisol levels were assessed in the laboratory during late pregnancy. A structural equation model to test sequential mediation was estimated and included relevant covariates (race, IPV, traumatic birth). There was a significant indirect effect of ACEs on maternal-infant postpartum bonding via late-pregnancy mental health, but not through maternal late-pregnancy baseline cortisol levels. Our findings underscore the potential for screening and therapeutic intervention addressing depression, anxiety, and PTSD symptoms during pregnancy among women with ACEs history, with benefits that may span two generations and set the stage for a healthy mother-child relationship.
Much has been elucidated about the neurobiological effects of early childhood trauma and its transgenerational transmission, although its integration into psychodynamic therapy has been challenging. Here we focus on a common area of interest to both areas-emotion and cognition rooted in past trauma experiences and how these experiences produce maladaptive behaviors transmitted to the next generation through parenting behaviors. We explore two mammalian research paradigms of early-life trauma explicitly within attachment, and transmission of transgenerational pathology through the caregiver to the offspring. We suggest that understanding the neurobiology through this mammalian nonhuman research can provide, in part, an understanding for the complex psychodynamic thought processes seen in adulthood, particularly as the mother begins to raise her own child. Specifically, while cognition and complex conscious and unconscious thoughts are characteristic of the human condition following early-life trauma, the mother-infant attachment system is a phylogenetically preserved system with some basic characteristics seen across species. We outline how embracing both the cognition and preserved trauma neural programing within attachment may provide some insight into cases, especially for the parent-child social interactions well documented to program the brain. Using mother-infant attachment, we suggest there is an area of convergence between clinical psychodynamic focus and basic research in brain function and mechanisms. Focusing on this convergence may provide a unique viewpoint to psychodynamics to supplement diagnosis and treatment.
Neuroscience continues to uncover anatomical, mechanistic, and etiological linkages between mental illness and addiction. The neurodevelopmental pathogenesis of these often intertwined brain disorders is contributed to by both genetic and experiential-causal events. This article introduces the term ecocausatypes to describe traumatically adverse experiences and attachment disruptions that are biologically potent on par with genes, and highly interactive with genetics in causing psychiatric and addiction phenotypes. Neural network theory explains how genotypes and ecocausatypes are biologically integrated, leading to pathological patterns of social-emotional function and motivation in adulthood. At the heart of this pathogenesis, impulsivity is a behavioral feature of motivational neural network dysfunction that is associated with and interlinks disturbances in attachment, trauma-spectrum psychiatric disorders, and addiction vulnerability. On the neural network level, impulsivity is a product of neural wiring and information processing that involves connectivity between the prefrontal cortex, the amygdala, hippocampal formation, and the nucleus accumbens-the primary motivational neural network that is pathologically altered by addictive drugs. Recognizing the effects of ecocausatypes on the development of these frontal cortical-striatal-temporal limbic networks provides a clear understanding of how disordered attachment, trauma-spectrum mental illness, and addiction pathogenesis are biologically and clinically interlinked. This neuroscience has significant implications for training, clinical practice, and research in psychiatry, in which adverse childhood experiences and attachment disruptions are understood as being just as biologically important as genetics, and where medication management and attachment-based psychotherapies are routinely integrated.
This article proposes an updated conceptualization of the psychotherapeutic frame, emphasizing its adaptive functions, particularly in the treatment of patients with complex trauma histories or disrupted early attachment relationships. Although conventional views emphasizing the frame's static elements need to be considered, they are insufficient for managing complex relational dynamics, frame departures, impasses, and enactments that commonly arise in treatment with patients who have experienced significant trauma. Integrating insights from attachment theory and the neuroscience of memory systems, this article argues that the frame's interaction with implicit memory systems, especially procedural memory, underlies the frame's therapeutic significance. Departures from the frame are conceptualized primarily as activations of these procedural scripts, often reflecting attempts to navigate relational distress based on past experiences. A systematic, "frame-in" approach treatment is proposed, involving monitoring of six core frame constituents-roles, logistics, tasks/boundaries, goals, abstinence from maladaptive behaviors, and safety. This approach facilitates early detection and management of potentially disruptive enactments, protects the therapeutic alliance, helps regulate overwhelming affect, and promotes therapeutic implicit/procedural learning by modifying maladaptive relational patterns within a secure therapeutic framework. The frame-in approach is presented as a specific set of techniques for actively managing the therapeutic alliance, rather than viewing the alliance as a separate construct.
The articles included in this Special Issue of Psychodynamic Psychiatry focus on the neuroscience of intrapsychic trauma. Understanding the brain basis of trauma allows for more informed therapeutic decisions-both biological and psychodynamic. Just as there is no one cause of mental disorders, there is no one treatment. Furthermore, the neuroscience of trauma is early in its development as a discipline. This editorial highlights important aspects of trauma and current knowledge in relationship to the brain and behavior. A variety of approaches to this topic may be found in the articles included in this Special Issue.
There has been an increasing interest in the use of classic psychedelics (such as psilocybin) and 3,4-methylenedioxymethamphetamine (MDMA) for treating mental health conditions. Individuals often describe psychedelic sessions as among the most significant experiences in their lives, emphasizing the sense of awe, connectedness, and spiritual transformation taking place. While the psychedelic literature from the past two decades has mostly focused on using these drugs in the treatment of major depressive, anxiety, and substance use disorders, researchers have also investigated the utility of classic psychedelics and MDMA for other conditions, including trauma- and stressor-related disorders. Trauma can profoundly affect biological systems, including stress hormone pathways and neural circuitry, often leading to hyperarousal and rigid cognitions. In this article, we discuss how some of the concepts posited by Wilfred Bion can be applied to neurobiological models of the mind and to the effects of these drugs. Relevant concepts from neurodevelopment are presented first, including how key areas can be significantly affected by early adversity. This is followed by a discussion of Bion's theory of containment and of how the K link (K denoting knowledge) is developed or disrupted, depending on one's experience. Finally, we present extant literature on the use of MDMA and classic psychedelics in trauma disorders, reflecting on how a Bionian lens can enrich our understanding of their therapeutic action.
This article aims to give the reader an overview of the concept of omnipotent responsibility guilt, which, according to control-mastery theory (CMT), is the emotional manifestation of a set of pathogenic beliefs that make people believe that if they put their needs in the foreground and do not try to satisfy the needs of their important others, their significant others will suffer. These pathogenic beliefs were generally developed to adapt to early traumatic and adverse experiences, that is, experiences that disrupted the patient's sense of safety in acute, systematic, or chronic ways. In the case of people with omnipotent-responsibility-related pathogenic beliefs, among these experiences, we find parents with physical or psychological problems, parents who were victims of accidents, parents who were separated or were mourning some loss and wanted their children to take care of them, and situations where parents reversed their roles with their children. Omnipotent responsibility guilt correlates with different forms of psychopathology, such as depression, obsessive-compulsive disorders, and anxiety disorders, and with several transdiagnostic features, such as worry and low self-esteem. We describe some clinical exemplifications to show how, according to the CMT, patients with pathogenic beliefs supporting omnipotent responsibility guilt can try to become aware and disprove these pathogenic beliefs and master their traumas in psychotherapy, and how therapists can help them have the corrective emotional experiences they need to get better.
Introduction: Intensive short-term dynamic psychotherapy (ISTDP) focuses on emotional processing and the resolution of internal conflicts. This randomized pilot and feasibility study evaluated the implementation of a novel 12-week group program based on ISTDP model, and compared clinical outcomes in reducing symptoms associated with personality vulnerabilities (e.g., emotion regulation, self-harm). The setting of the study was an Australian Public Hospital Service. Methods: Participants were referred to a brief intervention service for personality disorders and were randomly assigned to either the ISTDP group or the dialectical behavior therapy (DBT) group. Outcome measures included questionnaires assessing mood and distress, emotion dysregulation, disassociation, and DBT skill use. Feasibility outcomes, such as recruitment, attrition, and potential participants' experiences of the therapy, were also evaluated. Results: A total of 15 participants were recruited, with nine randomly allocated to the ISTDP group and six to the DBT group. Both groups showed improvements in clinical symptoms, including reductions in depression, emotion dysregulation, and dissociation. The ISTDP group also demonstrated a reduction in anxiety and stress. Follow-up surveys indicated that participants found both group interventions relevant, useful, and beneficial for managing their thoughts and emotions. Conclusion: Both the ISTDP and DBT interventions were well received by participants, and no adverse events were reported, further supporting their potential for implementation in public hospital settings and feasibility.
Some patients, especially those encountered early in one's career, become emblazoned in memory. Such was the case for this author with Rudy. His is a moving story by virtue of who he was and what happened to him. From him, I learned of the potential for deeply mutative work with medically ill patients, even in the context of infrequent meetings. I learned how and why in supportive, dynamically oriented therapy, there are times when bending the frame is essential. Rudy taught me-and my students-how important the "art" of medicine is and about the potential for "healing" even in the absence of cure. His story conveys the deep psychological impact of childhood illness and demonstrates the potential to reverse some of that impact when illness is encountered once again in adulthood. The theme of the "music" of the consulting room provides an organizing metaphor for the dialectic of spontaneous, emotionally engaged responsiveness and disciplined restraint that optimally characterizes dynamic psychotherapeutic work.
This year marks 50 years since John Gunderson and Margaret Singer identified borderline personality disorder as a distinct psychiatric disorder, yet the history of the syndrome predates this pioneering work by several decades. Undoubtedly, the evolution of the borderline personality disorder construct occupies a position of great importance in the history of psychiatry; debates surrounding its nature, etiology, and diagnosis continue to fill the pages of psychiatric and psychotherapy journals around the world. This article seeks to provide a brief overview of the history of borderline psychopathology, from early descriptions of "borderline schizophrenia" to Gunderson's identification of borderline personality disorder and beyond. It focuses mainly on the evolution of psychoanalytic models of borderline personality disorder, including work by theorists such as Kernberg, Masterson, and Adler, but also covers Linehan's development of dialectical behavior therapy and more recent discussions regarding the relationship between borderline personality disorder and complex trauma. We argue that understanding the history of borderline personality disorder can enrich contemporary practice and inform current discussions regarding the disorder's nosological status.
Traumatic shame is a source of deep psychological suffering and can become so pervasive that it hinders the possibility of a life worth living. Furthermore, it represents a complex treatment challenge in psychotherapy. Drawing from the perspective of control-mastery theory (CMT), we elucidate how traumatic shame can stem from processes of compliance with negative parental messages or identification with traumatizing caregivers. Additionally, traumatic shame can manifest as self-punishment motivated by guilt. In the first part of the article, we focus on the main features of traumatic shame and describe its origins, pathogenesis, and psychopathology manifestations through recent empirical research studies. In the second part, we explore how CMT offers a comprehensive framework for understanding and treating traumatic shame, particularly in severely traumatized patients. Finally, a clinical vignette illustrates the application of CMT in psychotherapy, showing how therapists can navigate the complexities of traumatic shame and promote the achievement of a more fulfilling life.
For decades, diplomats and psychoanalysts have applied psychoanalytic theories to international relations. Their collaborations have led to the creation of Track II diplomacy, defined as unofficial meetings among people with access to policymakers. Track II diplomacy illuminates psychological barriers to negotiations by clarifying negotiators' defense mechanisms and communication styles. Track II diplomacy assumes a desire to negotiate, but differences in expectations among negotiating parties can interrupt negotiations. This Perspective suggests that conceptualizing interruptions through the psychoanalytic impasse can introduce novel ways to resume negotiations. I draw on experiences with India-Pakistan Track II diplomacy.
The meaning of being adopted is a process that needs to be reworked throughout the life cycle. Therapists ought to be familiar with the concerns that are pertinent to patients who are adopted but must be careful not to place adoption at the center of the therapy if this is not why patients are seeking help. The object relations of the adopted person will play an important role in therapy, given that the person has two sets of parents, one real and another that may exist only in fantasy. The most commonly reported negative self-representations of patients in treatment who are adopted include feelings of being unwanted and therefore undesirable. In patients in which adoption plays a central role, there are seven core issues that can be used as a guideline in psychotherapy with an individual affected by adoption: loss, rejection, guilt and shame, grief, identity, intimacy, and control. It is very difficult to predict the risk for psychopathology and long-term outcomes of adoptees because of the many variables and their complex interplay, yet research findings reveal that the majority of adoptees are functioning well. Research studies support the advantage of adoption over placement in foster care, in institutions, or with uncaring, abusive, or neglectful biological parents.
In 2021, in the wake of rising anti-Asian violence in the United States and abroad, we piloted a group psychotherapy intervention for Asian American and Pacific Islander (AAPI) patients in the outpatient services department of McLean Hospital. The group, which lasted 12 weeks and took place virtually, included five group members and combined an interpersonal process group psychotherapy approach with the multicultural orientation framework. In this article, we discuss the intervention design as well as three key clinical vignettes from the group that challenged fundamental assumptions about ourselves as Asian American therapists and about the creation of a group that centers race, culture, and mental health. In particular, through discussion of the vignettes, we explore three scenarios that group therapists may face when facilitating similar multicultural groups: (1) drawing on notions of racial melancholia and racial dissociation, how to manage intragroup conflict between individuals with starkly different relationships to race and racial identity; (2) how to respond to intersectional microaggressions occurring between group members within a multicultural framework; and (3) where to draw the limits of psychodynamic approaches to psychotherapy in multicultural settings. Ultimately, we find that clinical encounters cannot be divorced from the histories and institutions that frame those encounters. Failure to recognize the impacts of such historical and institutional forces on clinical work risks perpetuating the inequities seen in mental health outcomes for AAPI individuals and communities.
This invited Editorial provides a commentary on Jenifer Nields's article published in the Narrative Medicine section of this issue of Psychodynamic Psychiatry. The author, who is familiar with Nields's clinical work and pedagogical skills, reflects on countertransference awareness and harmonious alignment of psychotherapeutic technique oscillating along the supportive and psychodynamic spectrum to better serve the needs of complex and challenging patients. He further emphasizes the importance of exploring spiritual and religious dimensions when relevant in therapeutic encounters.
Transcranial magnetic stimulation (TMS) is an established treatment for mood disorders, yet its relevance to psychodynamic psychotherapy remains underexplored. This conceptual article integrates neuroscience and psychoanalytic theory to examine how TMS may influence insight and affect regulation and the therapeutic relationship. By enhancing neuroplasticity, TMS may reduce resistance and support deeper emotional processing, potentially increasing receptivity to psychodynamic work. At the same time, neuromodulation may alter transference dynamics and perceptions of the therapeutic alliance. The article also explores how the treatment environment, including sensory input, relational context, and the symbolic role of the TMS provider, shapes psychodynamic engagement. A dedicated section outlines what a psychodynamically informed TMS setting may look like. Rather than viewing TMS as solely biological, the article proposes an integrative model in which neuromodulation and psychodynamic therapy are mutually reinforcing, emphasizing the importance of setting, psychoeducation, and relational attunement in maximizing therapeutic impact.
Mentalization-based therapy (MBT) formulates eating disorders as disorders of the self. This article examines the meaning of self-hatred and self-directed negativity as manifestations of self-alienation and vulnerable mentalizing. Relevant concepts are examined to substantiate MBT as a clinical approach to negative self-representations and epistemic mistrust. In this context, MBT states that a clinician's not-knowing stance is crucial to help elucidate underlying states of mind. Additionally, representing the patient as possessing an agentic-self is seen as crucial to the generation of curiosity about rigidified definitions of the self. Clinical vignettes are provided, and guidelines relevant to clinical practice are proposed.
