Neuropsychoanalysis

1. Introduction

Version followed: Kaplan-Solms & Solms, Clinical Studies in Neuro-Psychoanalysis (2000; 2nd ed. 2002) for the clinical method with neurological patients; Solms's affect-centred revision of psychoanalytic theory as set out in The Hidden Spring (2021), "The Neurobiological Underpinnings of Psychoanalytic Theory and Therapy" (Solms 2018), the drive-theory revision (Solms 2021/2022) and Lee & Solms (2023/2024); Panksepp's seven primary-process emotional systems (SEEKING, LUST, CARE, PANIC/GRIEF, PLAY, RAGE, FEAR) as the taxonomy of emotional needs. [source: Solms 2018; Lee & Solms 2024; Routledge book page]

Say it plainly first: neuropsychoanalysis is a framework, not a manualised therapy. It has no treatment manual, no fixed number of sessions and no institute protocol. It is a way of grounding psychoanalytic theory and technique in affective neuroscience. In practice the treatment is ordinary psychoanalysis or psychoanalytic psychotherapy, re-oriented by a revised theory. Its distinctive clinical contributions are (a) a method for psychoanalytically studying and treating patients with focal brain lesions ("dynamic localisation", after Luria), and (b) an affect-first way of formulating and interpreting: start from the feeling, name the emotional need it signals, find the automatised prediction that fails to meet it, and revise that prediction through transference work and working through. [source: Solms 2018; Kaplan-Solms & Solms 2000; NPSA workshop pages]

How change happens (Solms's model): Feelings are conscious signals of unmet needs. Development means learning, on top of innate instinctual predictions, how to meet needs in the world. Mental disorder comes from failures of that learning. Where a problem was insoluble in childhood, a poor solution was automatised prematurely (Solms's reconception of repression). It now runs non-declaratively, outside working memory, and does not update even though it keeps producing prediction error, which is felt as distressing affect. Therapy makes the present-day enactments of those predictions (above all in the transference) conscious, so they can be "re-problematized in working memory" (Solms 2018) and reconsolidated. Through many repetitions (working through), better predictions are consolidated alongside the old ones. Solms describes the aim as helping patients learn better ways of meeting their emotional needs, as opposed to suppressing the feelings. [source: Solms 2018]

Where this guide synthesises: The founders give principles and a technical sequence but not session-level procedures. Every step-by-step procedure below that goes beyond what the sources state is marked [synthesis]. Points not verified in a primary text are marked [uncertain].

2. Framework

The sources give no formal phases. Solms (2018) does describe a technical sequence: identify the dominant emotions → use them to find the meaning of the symptom and the predictions behind it → infer the predictions from repetitive patterns → interpret their here-and-now (transference) derivatives → work through over numerous, frequent sessions. The phases below organise that sequence. The phase labels, goals and transition criteria are [synthesis]. [source: Solms 2018]

Format. Individual psychoanalysis or psychoanalytic psychotherapy, open-ended, with frequent sessions. Solms (2018) says psychoanalytic treatment "takes time" and that working through needs numerous repetitions. No session count is specified in the sources [uncertain]. Lee & Solms (2024) say change will not occur quickly and that deep change is the work of long-term psychotherapy. In the neurological-patient studies, patients with focal lesions had a neuropsychological assessment and then psychoanalysis or psychoanalytic psychotherapy. In one Korsakoff case Solms saw the patient daily for about two weeks before recording sessions. [source: Solms 2002 JEP; Coelho review of Kaplan-Solms & Solms]

Phase 0 (neurological patients only): Neuropsychological syndrome analysis

Goal: Know which functional component of which functional system the lesion has disrupted (Luria's qualitative syndrome analysis) before interpreting psychologically. [source: Kaplan-Solms & Solms 2000, via Coelho review]
Format: Standard neurological and neuropsychological assessment, with lesion site from imaging. Typically done by the neuropsychologist-analyst or a colleague.
Move on when: You can state which deficits are "hardware" and which behaviours remain to be understood psychodynamically. [synthesis]

Phase 1: Engagement and affect-first formulation

Goals: Build trust; identify the dominant, specific affect; map it to the emotional need it signals (one or more of the seven systems); generate a first hypothesis about the failing prediction ("what the patient keeps doing to meet this need, and why it does not work"). [source: Solms 2018; Lee & Solms 2024]
Typical length: First few sessions [synthesis/uncertain]. With in-patient neurological cases, daily sessions. [source: Solms 2002]
Move on when: You and the patient can name the main feeling(s) precisely, the patient has begun to treat feelings as meaningful instead of only wanting them removed, and a repetitive pattern is visible. [synthesis]

Phase 2: Transference and pattern interpretation

Goals: Make the automatised predictions conscious through their present-day enactments, especially with the therapist. Link those enactments to other relationships and to the past. Draw attention to feelings the patient finds unacceptable, and to how the patient avoids them. [source: Solms 2018]
Move on when: The patient can recognise the pattern in the moment (sometimes before acting on it) and can tolerate the affect it was protecting against. [synthesis]

Phase 3: Working through and building new solutions

Goals: Repeated interpretation of the same prediction across many contexts. Re-problematise the old insoluble problem with adult resources. Find and practise new ways of meeting the need, and harmonise competing needs. [source: Solms 2018; Solms 2021/22 drive-theory abstract; Lee & Solms 2024]
Move on when: New responses happen spontaneously outside sessions, distressing affect has fallen in frequency and intensity because the need is being met (not because feeling is being avoided), and setbacks are recognised quickly. [synthesis]

Phase 4: Ending and consolidation

Goals: Consolidate. Solms reports a "sleeper effect": gains in psychoanalytic therapy keep growing after treatment ends, which he explains as new predictions consolidating further through use. [source: Solms 2018]
Practical: Plan the ending in advance; treat separation affect (PANIC/GRIEF) arising around ending as live material. [synthesis]

3. Guiding principles

Brain and mind are one thing seen from two observational perspectives (dual-aspect monism). → Use neuroscience to constrain and sharpen your clinical theory, never to replace the subjective, first-person data of the session. [source: NPSA 2018 workshop page; Solms 2018]
Affect is the foundation of consciousness; "the id is conscious". → Do not assume the patient's feelings are unconscious and need "uncovering". The feeling is usually already felt. What is unconscious is its meaning: which need it signals and which prediction is failing. [source: Solms 2018; NPSA 2019/2020 workshop pages; The Hidden Spring]
Patients "suffer mainly from feelings". → Start every formulation from the dominant feeling, not the diagnosis or the cognition. [source: Solms 2018]
Feelings represent unmet needs (homeostatic error signals). → Treat feelings as information about what is wrong, not as noise to eliminate. Lee & Solms say affect "is here to stay". [source: Solms 2018; Lee & Solms 2024]
There are many drives, not two. Seven are emotional (Panksepp's systems), the rest bodily. → Specify which need: separation distress (PANIC/GRIEF) is not fear, frustration-rage is not anxiety. Precise naming is a clinical intervention in itself. [source: Solms 2021/22 abstract; Lee & Solms 2024]
There is no death drive; all drives are homeostatic and self- or species-preserving. → Read self-destructive patterns as failed attempts to meet a need, and look for the need. [source: Solms 2018; Solms 2021/22 abstract]
The main developmental task is to supplement innate predictions with learned ones, so needs are met and harmonised. → Ask "what has this person not yet learned how to do in order to get this need met?" [source: Solms 2018; Solms 2021/22]
Repression is premature (illegitimate) automatisation of a solution to an insoluble problem. → Look for the childhood dilemma that had no good solution, and for the "childish prediction" still running. [source: Solms 2018; NPSA slide deck "Repression, Defence and the Cognitive Unconscious"]
Conflict is another word for an insoluble problem. → Formulate conflicts as two needs that the patient's current predictions cannot satisfy together. [source: Solms 2018]
Non-declarative predictions cannot be retrieved into working memory; only their derivatives and affects return. → Do not hunt for buried memories. Work with what is enacted now, especially in the transference. [source: Solms 2018]
Change means reconsolidation, and reconsolidation is resisted. → Expect resistance as a lawful feature, not a failing. Interpret it, and do not argue with it. [source: Solms 2018]
Working through needs many repetitions; treatment takes time. → Repeat the same interpretation in new contexts without impatience. Set realistic short-term goals. [source: Solms 2018; Lee & Solms 2024]
Treat causes, not just symptoms; medication suppresses feelings and is symptomatic. → Keep medication in a supportive role and do not let it substitute for learning. Notice your own pressure to "do something". [source: Solms 2018; Lee & Solms 2024]
Recognise the common factors that predict good outcomes: open-ended dialogue, recurring themes, past–present links, unacceptable feelings, avoidance, here-and-now relationship, links between the therapy relationship and others. → These are the core technical moves (see Section 4). [source: Solms 2018, citing process research]
(Neurological work) Functions are dynamic systems, not centres (Luria). → A lesion changes how the whole mental apparatus is organised. Do not read every behaviour as a direct deficit, and do not read every deficit as defence. [source: Kaplan-Solms & Solms 2000, via Coelho review and Routledge contents]
(Neurological work) Psychoanalytic observation is a legitimate clinical instrument. → Psychometrics alone "is not adequate" for capturing subjective life. Get to know the patient as a person. [source: Solms 2002 JEP]
Theory is provisional and falsifiable. → Hold neuroscientific formulations as hypotheses to test against the patient's responses, not as truths to impose. [source: Solms 2018]

4. Complete intervention inventory

Neuropsychoanalysis adds no new "exercises". What it contributes is (A) a method for neurological patients and (B) an affect-first reorientation of standard psychoanalytic interventions. Below are all the clinical moves named in the accessible primary sources, plus two secondary-source proposals that are labelled as such. All therapist wording is mine and labelled (illustrative). Step-by-step breakdowns are [synthesis] unless tagged otherwise.

A. Work with neurological (focal-lesion) patients

A1. Neuropsychological syndrome analysis (Luria) before analytic work

Purpose / when: With any patient who has a known or suspected brain lesion, establish which functional component is disrupted, so that deficit and defence are not confused. The first step of the Kaplan-Solms & Solms method. [source: Kaplan-Solms & Solms 2000, via Coelho review; Routledge contents "the work of Luria"]
Steps: (1) Obtain the lesion site from imaging and neurology. (2) Get or carry out a qualitative neuropsychological assessment: what kind of error the patient makes, not just scores. (3) List the deficits (e.g., aphasia type, neglect, memory, executive). (4) Write down, separately, the behaviours and attitudes that these deficits do not explain. Those are your psychodynamic questions. [steps 3–4 synthesis]
Example language (illustrative): "Before we start talking regularly, I'd like to understand exactly what the stroke has changed for you, and what it hasn't."
Watch for / working when: You can tell the patient (and colleagues) clearly which difficulties are neurological. Interpretations that follow do not ask the patient to do something their brain cannot do.

A2. Psychoanalytic observation and treatment of the lesion patient (dynamic localisation)

Purpose / when: To understand, and treat, how a lesion has reorganised personality, emotion and motivation. Also used as a research method: comparing psychoanalytically described changes across lesion sites to locate the functional systems behind mental faculties. [source: Solms 2002 JEP; Coelho review; Routledge contents]
Steps: (1) Offer psychoanalysis or psychoanalytic psychotherapy after the assessment in A1. (2) See the patient often enough to build an alliance. Solms describes daily sessions for about two weeks with one in-patient. [source: Solms 2002] (3) Listen with evenly suspended attention, including to bizarre or fragmentary speech. (4) Form hypotheses about unconscious factors, test them by interpretation, and revise them according to the response. [source: Coelho review] (5) Record your understanding live. Solms notes transcripts are a poor substitute for in-session experience. [source: Solms 2002] (6) Compare the picture with other patients who have similar and different lesions (the research arm). [source: Kaplan-Solms & Solms 2000]
Example language (illustrative): "You've told me twice that your left arm is fine 'just resting'. I wonder if it's very hard to let yourself feel what has happened to it."
Watch for / working when: Interpretations produce meaningful changes (new material, affect, temporary insight) rather than none. Lack of change may mean the target function is neurologically unavailable, so return to A1.
Lesion-site observations [source: Routledge chapter titles; Coelho review; Röckerath 2002]: left perisylvian cases (Broca's: "normal mourning"; Wernicke's: "perforated consciousness"); left parietal ("a man with a shattered world"); right perisylvian ("failure of mourning"); ventromesial frontal ("the end of the world"). [uncertain] Only the chapter titles and reviews are drawn on, not the case material, so the specific technical adaptations per site are not reproduced here.

A3. Treating confabulation and "bizarre" speech as meaningful (e.g., Korsakoff)

Purpose / when: With confabulating or disinhibited patients, where the reality-oriented secondary process is weakened. [source: Solms 2002 JEP]
Steps: (1) Listen for wishful and emotional content in confabulations, instead of only correcting facts. Solms found that they showed primary-process features: psychical reality replacing external reality, no contradiction, timelessness, mobile cathexis. (2) Notice which wish or worry the confabulation resolves. (3) Make simple interpretations that link the confabulation to the emotional situation and bring the patient back "on track". [source: Solms 2002] (4) Keep interpretations short and concrete, in keeping with the memory limits. [synthesis]
Example language (illustrative): "You've just told me you're at work and the boss is pleased with you. I think being here in hospital is frightening, and it feels better to be somewhere you're in charge."
Watch for / working when: The patient briefly re-orients, or the anxiety behind the confabulation becomes speakable. Expect the effect to be transient.

A4. Working with neglect and anosognosia (right-hemisphere damage)

Purpose / when: With patients who deny or ignore their deficit after right-hemisphere damage. [source: Röckerath 2002 abstract]
What the sources report: In psychotherapeutic interviews, Kaplan-Solms & Solms observed that patients could become temporarily aware of the deficit they had denied. They read the neglect syndrome partly as defensive, in the sense of a failure of mourning: the loss is not worked through. [source: Röckerath 2002 summarising Kaplan-Solms & Solms; Routledge chapter title] The Frankfurt/Cologne group's 4-year treatment series suggested that defence against depression is not the whole story: a failure to build a body schema for the paralysed side also contributes. [source: Röckerath 2002]
Steps [synthesis]: (1) Do A1 so you know the extent of the deficit. (2) Approach the loss gently and repeatedly, through the patient's affect (irritation, flatness, sudden sadness) rather than through confrontation with facts. (3) When momentary awareness appears, stay with the feeling (PANIC/GRIEF, despair) and name the loss. (4) Support mourning over many sessions. Accept that some lack of awareness is neurological (body-schema loss) and will not yield to interpretation.
Example language (illustrative): "Just now you looked at your hand and went quiet. It's as if, for a moment, you could see what you've lost."
Watch for / working when: Moments of awareness last longer, grief can be spoken about, and the patient joins in rehabilitation. Warning sign: catastrophic distress after confrontation. Slow down.

B. Affect-focused psychoanalytic technique (any patient)

B1. Identify and specify the dominant affect

Purpose / when: The first move with every presentation and in every session. The dominant emotions "reveal the meaning of the symptom" (Solms 2018). [source: Solms 2018; Lee & Solms 2024]
Steps: (1) Ask what the patient feels, and track the strongest feeling in the session, including your own countertransference. (2) Don't accept loose terms ("stressed", "down", "anxious"). Differentiate depression, anxiety and anger. [source: Lee & Solms 2024] (3) Map the affect to a system: fear of danger (FEAR), panic or despair at separation and loss (PANIC/GRIEF), frustration (RAGE), loss of interest (SEEKING down), sexual longing (LUST), urge to look after (CARE), playful or competitive pull (PLAY). Bodily affects (hunger, pain, fatigue) and sensory ones (disgust) may also be involved. [source: Solms 2018] (4) Check that the affect fits its trigger. A proportionate unpleasant feeling counts as regulated. [source: Flores Mosri 2021 — secondary]
Example language (illustrative): "When you say 'anxious', is it more like being in danger, or more like being left alone?" · "You smiled, but I felt a flash of irritation in the room. Was there something frustrating in what I said?"
Watch for / working when: The patient starts naming feelings more precisely themselves. A panic presentation turns out to be about losing someone, as in Solms's example that panic means being afraid of losing something. [source: Solms 2018]

B2. Formulate the need behind the feeling (drive → affect → behaviour)

Purpose / when: After B1, to turn the symptom into a statement about an unmet need and a failing strategy. [source: Lee & Solms 2024; Solms 2018]
Steps: (1) Name the need (B1 mapping). (2) Describe what the patient habitually does to meet it. (3) Explain why that does not work: what prediction it rests on. (4) Look for competing needs (e.g., CARE vs RAGE, PANIC/GRIEF vs FEAR of intimacy). Conflict is an insoluble problem. [source: Solms 2018; Lee & Solms 2024] (5) Write a one-line formulation: "Need X → felt as Y → met by doing Z, which predicts W, which keeps failing because…" [step 5 synthesis]
Example language (illustrative): "It sounds as if starting a new relationship quickly is your way of making sure you're never left. And yet every time it happens fast, it ends, and you're left again."
Watch for / working when: The patient finds the behaviour "problematic but understandable" (Lee & Solms vignette, paraphrased) rather than shameful or random.

B3. Re-frame "take this feeling away"

Purpose / when: When the patient's goal is to get rid of a feeling, often with medication or substances. [source: Lee & Solms 2024 (Nina vignette); Solms 2018]
Steps: (1) Acknowledge the suffering. (2) Explain that the feeling is a signal of a need, and that removing it without meeting the need doesn't solve the problem. (3) Invite curiosity about what the feeling is asking for. (4) Keep medication supportive and discourage drug use that blunts feelings and healthy SEEKING. [source: Lee & Solms 2024]
Example language (illustrative): "I can see how much you want this feeling gone. I think it's telling us something you need and aren't getting. If we understand what, it has a chance of settling for good."
Watch for / working when: The patient brings feelings as material ("I noticed it again when…") rather than as complaints.

B4. Identify recurring themes and repetitive patterns

Purpose / when: Non-declarative predictions cannot be recalled. They can only be inferred from what the patient repeatedly does and achieves. [source: Solms 2018; Lee & Solms 2024]
Steps: (1) Collect episodes in which the same affect peaks. (2) Look for the shared sequence: trigger → feeling → action → outcome. (3) Infer the prediction from the outcome the patient repeatedly brings about. (4) Show the pattern with 2–3 concrete examples, not abstractions. [steps 2–4 synthesis]
Example language (illustrative): "With your manager, your sister and now with your partner, the moment someone seems displeased you go silent and pull away. Then you feel completely alone."
Watch for / working when: The patient adds examples of their own and starts spotting the pattern between sessions.

B5. Draw attention to feelings the patient finds unacceptable

Purpose / when: When an affect is felt but disowned, minimised or immediately replaced by another (e.g., rage turned into guilt). [source: Solms 2018, listing outcome-predicting techniques]
Steps: (1) Notice the affect in voice, body or countertransference. (2) Name it tentatively. (3) Explore what makes it unacceptable: which other need it seems to threaten. [step 3 synthesis]
Example language (illustrative): "When you talk about your father cancelling, your jaw tightens, but you say you're 'fine with it'. I wonder if being angry with him feels dangerous."
Watch for / working when: The feeling can be held in the room without collapse or retaliation.

B6. Point out how the patient avoids feelings (defence interpretation)

Purpose / when: When the patient changes topic, intellectualises, jokes, acts out or numbs (including with substances) at the moment an affect rises. [source: Solms 2018]
Steps: (1) Notice the moment of avoidance. (2) Describe the sequence (feeling rises → shift). (3) Wonder with the patient what the avoidance protects against. Solms frames repression as reducing the weight (precision) given to prediction-error signals. [source: Solms 2018]
Example language (illustrative): "Just as you got to the part about the funeral, you started telling me about the traffic. It seemed to happen just as it got sad."
Watch for / working when: The patient catches the shift themselves. Increased affect in session with less acting out outside.

B7. Here-and-now transference interpretation

Purpose / when: The central lever of change. Transference is the automatised enactment, in current relationships, of non-declarative predictions formed in childhood. Interpreting it allows the prediction to be thought about and re-problematised in working memory. [source: Solms 2018; Lee & Solms 2024]
Steps: (1) Track how the patient's dominant need and prediction show up with you (lateness, compliance, testing, idealisation, anger at breaks). (2) Use your countertransference as data. (3) Interpret the enactment as it happens: what the patient expects of you, the feeling, and the strategy. (4) Link to the need (B2).
Example language (illustrative): "You've apologised three times today for 'taking up time'. I think you're expecting me to get fed up and want you gone, the way you've always felt you had to keep your needs small."
Watch for / working when: The patient can feel the expectation and notice it isn't confirmed. Prediction error, felt and thought about.

B8. Link the therapy relationship to other relationships and to the past

Purpose / when: After a here-and-now interpretation has been taken in, to generalise it and to locate the original insoluble problem. [source: Solms 2018]
Steps: (1) Link the transference pattern to current relationships. (2) Link it to the childhood situation in which the prediction was a reasonable or only solution. (3) Frame the past solution as understandable then and outdated now. [step 3 synthesis, consistent with Solms's "premature automatisation"]
Example language (illustrative): "As a child, with a mother who was so often ill, keeping quiet about what you needed may have been the only way to keep her. You're still doing it with me and with your partner, where it isn't needed in the same way."
Watch for / working when: Grief or anger about the original situation appears, and the patient begins to think about the old problem with adult resources.

B9. Re-problematise the insoluble problem (conflict work)

Purpose / when: When the formulation shows two needs that the patient's predictions set against each other (e.g., closeness vs autonomy, CARE vs RAGE). [source: Solms 2018; Solms 2021/22; Lee & Solms 2024]
Steps: (1) Name both needs as legitimate. (2) Show that the old solution sacrifices one need. (3) Explore new options that might satisfy both now ("harmonising" needs). Lee & Solms say conflicting drives need cognitive problem-solving. [source: Lee & Solms 2024] (4) Where the problem truly has no solution (an irreversible loss), turn to mourning (B12). [step 4 synthesis]
Example language (illustrative): "You need to be close to people, and you need not to be controlled. So far it has felt like you can only have one. Let's think about whether that's still true."
Watch for / working when: The patient tries new behaviour in which both needs get some satisfaction.

B10. Clarify the need behind a defensive wish

Purpose / when: When the patient asks for help with a wish that would deepen the problem, e.g. "I just want no relationships". [source: Lee & Solms 2024]
Steps: (1) Don't endorse or argue with the wish. (2) Clarify the need it protects (e.g., avoiding PANIC/GRIEF). (3) Remember that most emotional needs can only be met through other people. [source: Lee & Solms 2024]
Example language (illustrative): "Having no one would mean no one could leave you. I wonder if that's what you most want to be protected from."
Watch for / working when: The wish softens into a statement of the need and of the fear.

B11. Working through

Purpose / when: After transference interpretation "comes the harder work" (Solms 2018): repeated interpretation of the same prediction until new predictions are consolidated alongside the old. [source: Solms 2018; Lee & Solms 2024]
Steps: (1) Interpret the same core pattern again, each time it appears in a new context. (2) Notice and support each instance of a new response, and review its consequences. (3) Expect relapse into old predictions under stress. Interpret it, without treating it as failure. (4) Keep frequency high enough for continuity. [steps 2–4 synthesis]
Example language (illustrative): "This is the same old fear in a new place: that if you want something, you'll be punished for it. But this time you asked anyway. What happened?"
Watch for / working when: The time between the trigger and the patient's recognition shortens. New responses become automatic. Gains continue after ending (sleeper effect). [source: Solms 2018]

B12. Supporting mourning for problems that cannot be solved

Purpose / when: When the need can no longer be met in its original form (death, irreversible disability, lost childhood), or in chronic separation distress or depression. [source: Flores Mosri 2021 — secondary. "Normal mourning" and "failure of mourning" are Kaplan-Solms & Solms chapter themes.]
Steps [synthesis]: (1) Name the loss and the PANIC/GRIEF affect. (2) Allow despair without hurrying to repair. (3) Help the patient find whether some part of the need can be met elsewhere now.
Example language (illustrative): "Some of what you needed from her you'll never get now. It makes sense that this hurts so much."
Watch for / working when: Grief moves from protest to sadness, and interest (SEEKING) returns.

B13. Reading depression as shutdown and rekindling SEEKING

Purpose / when: Depressive states, anhedonia, hopelessness. [uncertain] In The Hidden Spring and in Panksepp-tradition papers (e.g., Watt & Panksepp 2009), Solms is generally understood to frame depression as a shutdown that ends prolonged separation distress and suppresses SEEKING. Flores Mosri (secondary) also suggests that prolonged rage may shut SEEKING down.
Steps [synthesis]: (1) Look for the loss or separation behind the depression (B1, B2). (2) Work with the grief (B12) rather than only with activation. (3) Notice and gently encourage any return of curiosity or interest.
Example language (illustrative): "You lit up for a moment talking about the garden. That's the first time you've sounded curious in weeks."
Watch for / working when: The return of interest, anticipation and exploratory talk.

B14. Countertransference monitoring and realistic goal-setting

Purpose / when: Throughout, especially when frustrated, impatient or pressed to "do something" (e.g., to prescribe more). [source: Lee & Solms 2024]
Steps: (1) Notice frustration and impatience as data on the patient's affects and as a sign that goals may be too ambitious. (2) Reset to realistic short-term goals. (3) Provide continuity, stability and structure as interventions in their own right. [source: Lee & Solms 2024]
Example language (illustrative, to self or team): "The urge to change the plan again is our own frustration. What need of the patient's is not being met here?"
Watch for / working when: Fewer reactive changes of plan. A steadier frame.

B15. (Secondary proposals) Four-dimension affect assessment and resting-thought reports

Source: Flores Mosri (2021), a hypothesis paper, not a Solms technique. Assess affect via (1) its subjective quality through transference–countertransference, (2) behaviour (nonverbal and instinctual patterns), (3) the patient's ideas about their feelings, (4) hypothesised neural correlates. Ask about spontaneous resting-state thoughts (e.g., at night when unable to sleep) to reveal pending needs. Prefer face-to-face work to see nonverbal affect.
Example language (illustrative): "When you're lying awake at night, where does your mind go?"
Watch for: Treat neural-correlate hypotheses as speculative. Do not offer them to patients as explanations.

5. Handling problems

The sources state only the principles behind most of these responses: resistance to reconsolidation is lawful, change is slow, feelings are signals, and countertransference pressure is real. The concrete responses are mostly [synthesis] and are marked where they go beyond the sources.

Resistance

Source position: Reconsolidation "is generally resisted", and repression involves intense resistance to reactivating insoluble problems. Resistance follows from the limits of working memory and is to be expected. [source: Solms 2018] Kaplan-Solms & Solms also name defensive resistance as a main obstacle in the lesion studies. [source: Coelho review]
Response: Interpret the resistance as protection against re-living an insoluble problem (B6). Name the feeling it avoids, and do not push content. [source-consistent synthesis]
Illustrative: "Each time we get close to how lonely it was, something takes us somewhere else. Maybe it's too much to have to feel that again without knowing it can turn out differently."

Stuck clients (no movement despite insight)

Source position: Insight is not enough. Old predictions are non-declarative and persist, and new ones must be consolidated through repetition. [source: Solms 2018; Lee & Solms 2024]
Responses [synthesis]: (1) Check whether you've named the right need. Re-do B1/B2, since a FEAR formulation may really be PANIC/GRIEF. (2) Move from talk about the past to the here-and-now enactment (B7). (3) Check whether the problem is in fact insoluble and needs mourning, not solving (B12). (4) Consider whether frequency is too low for working through. (5) Reset goals to realistic short-term ones (B14).

Overwhelm (affect flooding)

Source position: Not addressed directly. [synthesis]
Responses [synthesis]: Slow down; reduce interpretive depth. Name the affect simply and specifically (naming is regulating). Strengthen the frame (continuity, structure). Lee & Solms treat stability and structure as interventions. Return to the material later. In neurological patients, rule out catastrophic reactions to confrontation with a deficit (A4).
Illustrative: "This is a lot right now. Let's stay with just one thing: you're frightened. We don't have to go further today."

Non-adherence (missed sessions, lateness, drop-out risk)

Source position: Not addressed as such. [synthesis]
Responses [synthesis]: Treat absences as enactments of the core prediction and interpret them in the transference (B7), especially around breaks (PANIC/GRIEF) or after anger (RAGE). Keep the frame consistent. Raise it early and without reproach.
Illustrative: "You missed the session right after I told you about my holiday. I wonder if it felt safer to leave before being left."

Ruptures

Source position: Not addressed directly. The here-and-now relationship is one of the outcome-predicting factors Solms cites. [source: Solms 2018]
Responses [synthesis]: Treat a rupture as the core prediction becoming live: the patient expects harm, rejection or control and reacts. Acknowledge your contribution. Name the need that was frustrated, and the feeling (often RAGE or PANIC/GRIEF). Let the experience of repair stand as prediction error: the expected outcome did not happen.
Illustrative: "I think I got it wrong last week, and you felt I wasn't listening, just like at home. I'm glad you told me."

Modality-specific difficulties

Over-biologising. Using neuroscience words with patients ("your amygdala", "your PAG") can intellectualise and become a defence. Keep neuroscience for your formulation and speak with the patient in terms of feelings and needs. [synthesis; Flores Mosri also notes neural correlates are only hypotheses]
Assuming feelings are unconscious. Solms argues affect is conscious. If you keep "searching for the hidden feeling", you may miss the felt one that is in plain view. Ask what the obvious feeling means. [source: Solms 2018; Flores Mosri 2021]
Mis-mapping systems. The seven-system labels are coarse, and real states are often blends. Hold the mapping loosely and revise it as the patient responds. [synthesis]
The patient who wants the feeling removed / pressure to medicate. See B3 and B14. Medication can be supportive but is symptomatic. [source: Solms 2018; Lee & Solms 2024]
Deficit vs defence in neurological patients. Interpreting a true deficit as defence is harmful, and so is attributing all denial to the lesion. Use A1 first, test interpretations, and accept that some features (e.g., body-schema loss in neglect) are not defensive. [source: Röckerath 2002; Kaplan-Solms & Solms 2000 via review; synthesis]
Memory-impaired or confabulating patients. Keep sessions frequent, interpretations short, and expect gains to be transient. [source: Solms 2002 for frequency; rest synthesis]
Patients who never become accessible. Solms acknowledges that some patients do not become accessible to psychotherapy. Consider supportive or structured approaches and continuity of care. [source: Solms 2018; specific alternatives are synthesis]
No manual or fidelity standard. There is no adherence measure. Use case discussion or supervision in neuropsychoanalytic study groups (e.g., NPSA-affiliated groups, in the format of the Tavistock/BNG Solms case workshops) as your quality check. [source: NPSA workshop pages; recommendation is synthesis]

Sources

Sources:

Books cited:

Kaplan-Solms, K. & Solms, M. (2000; 2nd ed. 2002). Clinical Studies in Neuro-Psychoanalysis: Introduction to a Depth Neuropsychology. Karnac/Routledge.
Solms, M. (2021). The Hidden Spring: A Journey to the Source of Consciousness. Profile/Norton.
Panksepp, J. (1998). Affective Neuroscience: The Foundations of Human and Animal Emotions. Oxford UP; Panksepp, J. & Biven, L. (2012). The Archaeology of Mind. Norton. (Source of the seven-system taxonomy.)

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