Friston, Free Energy, and Psychoanalytic Psychotherapy.

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

Friston's free energy principle: new life for psychoanalysis?

The free energy principle (FEP) is a new paradigm that has gain widespread interest in the neuroscience community. Although its principal architect, Karl Friston, is a psychiatrist, it has thus far had little impact within psychiatry. This article introduces readers to the FEP, points out its consilience with Freud's neuroscientific ideas and with psychodynamic practice, and suggests ways in which the FEP can help explain the mechanisms of action of the psychotherapies.

The neuroscience of attachment: implications for psychological therapies.

Recent advances in attachment-informed relational neuroscience point to possible mechanisms of action of psychological therapies, with implications for effective practice.Declaration of interestNone.

"Surprise" and the Bayesian Brain: Implications for Psychotherapy Theory and Practice.

The free energy principle (FEP) has gained widespread interest and growing acceptance as a new paradigm of brain function, but has had little impact on the theory and practice of psychotherapy. The aim of this paper is to redress this. Brains rely on Bayesian inference during which "bottom-up" sensations are matched with "top-down" predictions. Discrepancies result in "prediction error." The brain abhors informational "surprise," which is minimized by (1) action enhancing the statistical likelihood of sensory samples, (2) revising inferences in the light of experience, updating "priors" to reality-aligned "posteriors," and (3) optimizing the complexity of our generative models of a capricious world. In all three, free energy is converted to bound energy. In psychopathology energy either remains unbound, as in trauma and inhibition of agency, or manifests restricted, anachronistic "top-down" narratives. Psychotherapy fosters client agency, linguistic and practical. Temporary uncoupling bottom-up from top-down automatism and fostering scrutinized simulations sets a number of salutary processes in train. Mentalising enriches Bayesian inference, enabling experience and feeling states to be "metabolized" and assimilated. "Free association" enhances more inclusive sensory sampling, while dream analysis foregrounds salient emotional themes as "attractors." FEP parallels with psychoanalytic theory are outlined, including Freud's unpublished project, Bion's "contact barrier" concept, the Fonagy/Target model of sexuality, Laplanche's therapist as "enigmatic signifier," and the role of projective identification. The therapy stimulates patients to become aware of and revise the priors' they bring to interpersonal experience. In the therapeutic "duet for one," the energy binding skills and non-partisan stance of the analyst help sufferers face trauma without being overwhelmed by psychic entropy. Overall, the FEP provides a sound theoretical basis for psychotherapy practice, training, and research.

Attachment and psychotherapy.

Attachment theory provides a model for understanding (1) development within the context of the child's primary, and formative relationships, and (2) an adult's orientation toward lifelong intimate connections, social relationships, and autonomous exploration. Psychotherapy researchers have linked measures of patient attachment with therapeutic alliance, process, and outcomes. Studies of ruptures and discourse analysis distinguish in-session behaviors associated with different patterns of insecure attachments, and identify distinct ways of working with them. The therapist's own attachment organization and mentalizing capacity also play a significant role in therapeutic success. The key tenets of attachment-informed psychotherapy are: (1) the therapist-patient attachment relationship is central to promoting change, (2) the in vivo recognition of attachment dynamics during therapy guides formulation and intervention, and (3) therapy can reshape attachment dynamics.

Roots and routes to resilience and its role in psychotherapy: a selective, attachment-informed review.

Developmental research on resilience is summarised and illustrated with a case example. Self-reflection, positive relationships, and agency foster resilience in the face of adversity. Attachment and resilience are related categories. The different patterns of attachment - secure, insecure-organised and insecure-disorganised - are manifest in different patterns of resilience, depending on prevailing environmental conditions. However, the greater the environmental adversity, the less will the resilience factors emerge. Clients tend to present for psychotherapy when resilience strategies have failed. The therapeutic relationship has neurochemical and relational characteristic mirroring the secure mother-infant bond. These foster mentalising, stress innoculation, affect co-regulation, self-esteem, and agency, forming the basis for enduring and more flexible resilience strategies.

Personal experience: Suicide and psychiatric care - a lament.

A personal bereavement from suicide prompts a critique of current mental healthcare. Fragmentation, lack of long-term attachment to a tenured professional, the dearth of family therapy, and professional ambivalence are identified as weaknesses in current provision. Implicit is the case for change in UK psychiatric services, both structural (need for long-term therapies) and cultural (need for a mentalising rather than protocol-driven, 'choice'-led ethos).

An attachment model of depression: integrating findings from the mood disorder laboratory.

This paper is written from a psychodynamic clinician's perspective, juxtaposing a psychoanalytic-attachment model of depression with recent developments in neuroscience. Three main components of the attachment approach are described: the role of loss, of childhood trauma predisposing to depression in later life, and failure of co-regulation of role of primitive emotions, such as fear, despair, and helplessness. Blatt's distinction between anaclitic and introjective depression is delineated and related to hyper- and de-activation of the attachment dynamic. Recent advances in evolutionary, sociological, epigenetic, biochemical, and neuro-imaging studies of depression are reviewed. A dynamic model of depression is proposed, linking interpersonal and intra-psychic perspectives with neuro-anatomical models. The final section of the paper considers the specific role of psychodynamic approaches to the treatment of refractory depression. These include length of treatment, capacity to rework implicit memories, and focus on transference and counter-transference.

Psychodynamic psychiatry's green shoots.

Psychodynamic psychiatry makes a significant educational, scientific and therapeutic contribution to contemporary psychiatry. Recent developments in gene-environment interaction, neuropsychoanalysis and the accumulating evidence base for psychoanalytic therapies and their implications for practice are reviewed.