Abstract
This ambitious paper (Solms 2021) by one of the leading psychoanalytic researchers and most prominent modern-day neuropsychoanalysts offers a heuristic opportunity to consider the relationship between neuroscience and psychoanalysis. Although focusing on the concept of drives, the paper is also a manifesto designed to demonstrate the broader psychoanalytic relevance of neuroscience. Given the vast amount of research data he brings to the task, as well as his prodigious knowledge of Freud, Solms provides a useful template to use in evaluating what neuroscience can and cannot offer psychoanalysis.
Considering what I understand to be his two aims, I will address both his ideas about the concept of drive and the broader contribution of neuroscience to psychoanalytic theory and practice. Toward those ends, it is useful to review what psychoanalysis is. After all, one finds fierce polemics, both on the APsaA Listserv and in the literature, about whether it is simply a clinical technique, many techniques, a theory, many theories, or a body of knowledge with many applications (see, e.g., Eagle 2021; Jaffe 2021; Sugarman 2021, in press). Nonetheless, many of us of a certain generation were drawn to psychoanalysis because it seemed to offer the most elegant model of human mental functioning, one that could help us understand our patients and guide us in our efforts to treat them. In short, psychoanalysis, first and foremost, consists of a model of the mind. To be sure, there are currently many competing theories of mind as psychoanalysis embraces the notion of pluralism while we work to integrate and prioritize them. Meanwhile, every school of psychoanalysis in our pluralistic world has an articulated theory of mind.
Subsumed under this model of mind are three other models: (1) a model of development; (2) a model of pathogenesis; and (3) a model of mutative action. From its beginnings, psychoanalysis has been a developmental psychology, as Freud strove to show how current mental functioning develops gradually out of an interaction between internalized childhood phenomena and external interactions with the environment. This developmental process is complex and was later elaborated by his daughter Anna and subsequent generations of child analysts and researchers. Another reason making development such a crucial element in a psychoanalytic model of the mind is the role it plays in pathogenesis. Unlike descriptive or phenomenological nosological models in psychiatry, the psychoanalytic model is holistic. Most of the psychopathology with which it concerns itself is understood as being on a continuum with everyday mental functioning. That is, we do not see our patients’ problems as discrete symptoms unrelated to the way their minds work. Rather, we believe that they involve distortions or biases in mental functioning due to various experiences and phenomena during development having impaired these functions as the developing mind struggled to manage them in ways promoting subsequent development. From an ego psychological perspective, this process promotes adaptation. Flowing from this model is the psychoanalytic model of mutative action, which prioritizes helping our patients find more successful ways to manage these developmental difficulties and their sequelae. Each psychoanalytic school emphasizes different mutative approaches based on its understanding of the developmental processes that have gone awry. But all schools, regardless of whether they emphasize the ego psychological notion of adaptation, do consider the mind’s development and its miscarriages when arriving at their mutative strategies.
The Problem with Reductionism in Solms’s Neuropsychoanalytic Approach
Unfortunately, the iteration of drive theory and neuropsychoanalysis that Solms presents in his paper says almost nothing about a model of mind or development, let alone models of pathogenesis and mutative action (which he promises will come in future papers on clinical applications). This absence of a model of mind and its development is surprising in that he seems as committed to psychoanalysis being a general psychology as were the original generation of ego psychologists (e.g., Hartmann 1964; Hartmann, Kris, and Loewenstein 1964; Rapaport 1951, 1960) and others who were quite explicit about this goal (Loewenstein et al. 1966; Rosenblatt and Thickstun 1977). His earlier discussions of neuropsychoanalysis (Solms 2000, 2014) suggest that he and his colleagues view it as a comprehensive or general psychology. Fisher and Kessler (2018), for example, are clear about neuropsychoanalysis being a basic science of psychoanalysis. They believe that neuroscience research can both demonstrate the validity of psychoanalysis and help it regain prestige and a place in academia. Many (though not all) of us aspire to the same goals and maintain the belief that psychoanalysis must become a general psychology able to integrate its unique insights with those of related sciences.
Surprisingly, however, Solms leaps over cognitive and developmental psychology as a means to this end in his emphasis on neuroscience. Much of the thinking in this paper goes from neurobiology and chemistry directly to mental experience, while bypassing all that developmental psychologists, and child analysts influenced by Anna Freud, know and are learning about the mind’s development and functioning. It is puzzling that he does so, given the criteria he insists psychoanalysis must meet if it is to be regarded as a natural science (Solms 2020). These are that it recognize (1) that the human infant is born with a set of innate needs and is not a blank slate; (2) that mental development involves creating the capacities to meet these needs in the world; and (3) that most of the ways humans learn to meet their needs are implemented unconsciously. A corollary to these criteria is that pathogenesis involves failure to find successful ways to meet these needs. My impression from his earlier papers is that Solms would agree that each of these statements can be studied and proven correct or incorrect using the natural science methodology provided by cognitive and developmental psychology. I think he would agree that both of these academic fields have already contributed much useful information to psychoanalysis. Yet they are virtually ignored in this paper.
Instead, he appears to believe, in this paper at least, that subjective, mental functioning can be comprehensively understood at the neurological level. Thus, I would argue, the model he presents here reads as reductionistic. Human functioning certainly can be studied at various levels: sociological, psychological, neurobiological, and so on. Each of these levels is important to understanding some area of human functioning. According to many philosophers of science, however, each level can be understood only with concepts and methodologies relevant to that level. To be sure, others think that a holistic causal model should not be logically foreclosed. But I do not find evidence in this paper that neuroscientific concepts can be used to explain psychological meaning or phenomena. Blass and Carmeli (2015) make the similar point that neuroscientific concepts are relevant only in explaining brain functioning, not mental functioning. “It depends,” they write, “rather on what the person who comes to understand is seeking; for instance, whether he is seeking to understand how the other is thinking or what brain functions are being activated” (p. 1563). Yet Solms leaps across levels of explanation by using terms from mathematics and physics like entropy, attractors, and Markov blankets. At best, these terms can be understood only as metaphors, but it is not clear if that is what Solms intends. They are perhaps intended to make his theory sound scientific without acknowledging that they are relevant only to phenomena other than those dealt with by psychoanalysis. It is important that he make clear whether he intends the math and physics constructs he invokes to be taken as metaphorical or not.
Certainly neuroscience can inform us on what underlying brain functions, processes, and structures allow the psychological phenomena we analysts study to occur. But it remains difficult to see how, at this stage of development in either discipline, they will ever expand our understanding of the subjective how’s and why’s of mental functioning, the so-called qualia (the “what does it feel like”). Neuroscience provides only a parallelism that demonstrates the correlation between brain functioning and subjective mental experience (Grossman and Simon 1969). But no superordinate model of human functioning has yet been discovered that can encompass and integrate the neurological and psychological spheres of human experience. Even if one agrees to define drive as arising from neurobiological sources, it “becomes motivational only when it is cognitively represented. Without such a mediating structuring process, external and internal stimulation have activating but not directional effects” (Klein 1967, p. 87). That is, drives cannot be motivating unless they are structured cognitive-affective-motor events (Klein 1976). For example, dream research finds a strong correlation between rapid eye movements and dreaming. But this correlation does not provide any understanding into the meaning of dreams (Grossman and Simon 1969).
The Absence of the Concept of Mental Representation
Interestingly, Solms’s description of emotions as elements of drives that motivate human functioning ignores the essential developmental and cognitive concept of mental representation, the likely innate capacity that allows subjective experience to be encoded so that memory and learning can occur. Everyone’s mind can make meaning because it can represent internal and external reality and amalgamate them into conscious and unconscious fantasies, which are a subset of the mental representations that constitute mind (Erreich 2015). There is a vast amount of research on the development of these representations, their developmental sequence, and their stability, as well as their impact on pathogenesis and mutative action. Developmental and cognitive research support clinical experience that emotions are common components of self- and object representations. Yet Solms writes as though representations are not part of the psychological amalgam that makes each individual’s cognitive/emotional mind unique.
The Conceptual Problem of Psychic Energy
A similar reductionism can be seen with his emphasis on psychic energy. The economic model, with its reliance on the vicissitudes of psychic energy, is possibly the most criticized metapsychological model in psychoanalysis. Most contemporary ego psychological, relational, and self psychological analysts (as well as some others) would agree that mental events cannot be explained in terms of psychic energy. Instead, such concepts as bound and unbound energy, or cathexis and countercathexis, originally served as metaphors to make our emphasis on subjective phenomena seem more scientific. “It is hard to avoid the conclusion that Freud’s theory of bound and mobile energy has little to do with a concept of energy as used by the ‘other natural sciences,’ but that it is really a theory of MEANING in disguise” (Rycroft 1968, p. 43). Yet Solms introduces the “free energy principle” to buttress his insistence that energy is required for systems to function, even psychological systems. “The revolution I am referring to is the insight that the entire nervous system functions according to a single principle, the free energy principle, derived from statistical mechanics. . . . Somatic and mental events are therefore explicable in terms of a single unifying principle” (pp. 1056–1057). There seems little difference between his concepts of free and bound energy and ego psychology’s long repudiated concepts of mobile and bound energy. In fact, he believes that his research achieves Freud’s desire (1895) to “represent psychical processes as quantitatively determinate states of specifiable material particles” (p. 295) and that “now we can measure it” (Solms, p. 1057), a claim that seems unlikely to be substantiated. These assertions appear as questionable as the similar, long repudiated ones from ego psychology (e.g., Holt 1965; Kubie 1947; Rubenstein 1965; Rosenblatt and Thickstun 1970). After all, mental events involve meaning, not energy, because they occur in the mind of an individual, not in a nervous system. A psychoanalytic model of mind should explain human subjectivity, not just redescribe it using neuroscientific terms and ideas (Sugarman 1977).
Most criticisms of the concept of psychic energy coming from ego psychology argue either that it is based on Freud’s outdated understanding of physics or that it is not necessary or adequate to explain the mental phenomena to which it has been applied (Rosenblatt and Thickstun 1970; Rubenstein 1967). Gill (1967) and Holt (1967), for example, demonstrated that it is unnecessary for explaining the phenomena of primary and secondary process, while Klein (1967) provided a conceptual model to explain the activating impact of motivation that does not need a concept of energy, particularly a theoretically inaccurate one. Likewise, concepts have been developed to explain mental/emotional intensity or quantitative variations in subjective experience without relying on an energic concept (Rosenblatt and Thickstun 1970). The same can be said for psychic structure and symbol formation (Wolff 1967), learning (Rosenblatt and Thickstun 1970), and memory (Loewald 1976; Paul 1967). Most important, these alternative formulations use data from related academic disciplines at the same level of explanation, primarily cognitive and developmental psychology. They thus allow the possibility for psychoanalysis to become the general psychology desired by Solms without using the neuroscientific concepts he espouses.
The Problem of Anthropomorphism
This current rendition of Solms’s neuropsychoanalytic revision leaves the concept of drive open to the same criticism that Schafer (1973) levied against the idea of autonomous ego functions almost half a century ago: “In being represented as self-activating and self-regulating, autonomous ego functions are being implicitly portrayed as independent, symbol-utilizing minds that can make themselves up” (p. 166). Just as ego functions could not be minds, drives cannot be either. This conceptual problem highlights the ways in which Solms’s neuropsychoanalytic model evinces many of the same problems with anthropomorphism that were noted with ego psychology’s constructs fifty years ago (see Gill and Holzman 1976; Grossman and Simon 1969; Holt 1972; Klein 1967, 1976; Mayman 1976; Rosenblatt and Thickstun 1970; Schafer 1976a,b; Sugarman 1977; Yankelovich and Barrett 1970) and even earlier by Brierley (1944, 1951). “Psycho-analytic personology is a psychology, not an anatomy or physiology, of personality; it is concerned with subjective experience and the motivation of behaviour” (Brierley 1951, p. 125). Using neuroscientific constructs to organize and explain internal human experience inevitably leads to anthropomorphism along with a mechanistic, marionette model of the person. The term marionette suggests the tendency inherent in nonpsychological models to characterize the individual as directed by forces or agencies according to principles inherent in those forces or agencies (Shapiro 1970).
Such models “become anthropomorphic by virtue of introducing into the mind different parts that have different interests, claims, and wishes, just as does the person himself” (Grossman and Simon 1969, p. 91). For example, Freud applied the notions of intention and interest to the concept of instinct despite instincts being unable to have intentions or interests; only human beings can. Solms’s model demonstrates similar tendencies. He introduces the idea of biological self-organizing systems to bridge the boundary between nonliving systems like crystals, living ones like cells, and sentient ones like the mind. He then goes a step further and asserts that all have aims and purposes (pp. 1057–1058). Finally, he suggests that all such systems form a “Markov blanket” separating the system from the nonsystem, thereby providing the origins of “selfhood” and “subjectivity.” It is as though brain cells, neuroanatomical structures, and neurochemical processes are capable of aims, purposes, subjectivity, and a sense of self. This poses the same theoretical difficulties as the anthropomorphic use by early ego psychologists of structural constructs and energic vicissitudes to explain pathogenesis and mental functioning (see, e.g., Fenichel 1945; Hartmann, Kris, and Loewenstein 1964).
The Absence of Subjective Experience and Meaning in a Neuropsychoanalytic Model
In his paper, Solms writes as though mind were a biological entity, with neurobiologically based drives and biochemically based psychic energy the phenomena that make it work. Because of Solms’s explicit commitment to Freud’s goal of a scientific psychology grounded in biology (1895), his paper and neuropsychoanalysis more generally minimize the importance of subjectivity in both theory and clinical psychoanalytic practice. Today most psychoanalytic schools emphasize the importance of subjectivity and its contribution to both everyday mental functioning and the problems for which patients seek treatment. Different schools emphasize different subjective factors involved in the mind’s continuous making of meaning out of various internal and external experiences and phenomena; but all of them emphasize the importance of the mind’s meaning-making function in contributing to symptoms, character traits, and behavioral difficulties. Clinically we work to help patients become aware of their mind—its contents and processes—and to see how it is both affected by and affects inner and outer reality. Becoming aware of one’s subjective meanings instantiated in conscious and unconscious fantasies is what helps our patients change (Erreich 2015, 2017). Such self-knowing is a psychological phenomenon and can be emphasized to place psychoanalysis well within the domain of scientific psychology.
For this reason, Pulver (2003) is adamant that neuroscience has no relevance for the practice of clinical psychoanalysis. “If there is a single overarching principle that governs our behavior in the analytic situation, it is that we attempt to understand our patient’s individual, specific motivations, particularly as they are manifested in the analytic relationship, and to help the patient understand them. We deal, that is, with the specific contents of the patient’s mind and the specific processes he or she uses to regulate them. Neuroscience clarifies the anatomical and physiological substrates from which these motivations arise. It may also say something about the general functioning of these motivations, but by its very nature it can say little about the meaning they have for an individual” (p. 762).
Blass and Carmeli (2015) use a clinical example provided by Solms and his colleagues to emphasize the seeming unawareness of the centrality of subjective experience by neuropsychoanalysis. This lack of awareness, they argue, is dangerous for psychoanalysis. The work they critique was offered by Solms and his colleagues (Yovell, Solms, and Fotopoulou 2015) to support the clinical utility of neuropsychoanalysis. Although Solms promises to demonstrate in future work the clinical implications of his neuroscientific theory of drives, the earlier paper with his colleagues seems to support the complaint that he does not emphasize the essential role of subjectivity and meaning-making in clinical psychoanalytic practice. The clinical example of Ms. A. involves a woman who reveals early in treatment the strong hope that analytic psychotherapy will allow her to regain her memory of childhood sexual abuse and so lay to rest her chronic uncertainty and ambivalent feelings about important figures who refuse to believe it occurred. From her perspective, treatment should lift repression of the abuse, presumably enveloping her memory, and prove her belief correct. If she does not regain the memory during the treatment, she will be proven wrong and to have created a false memory. After two years of failing to gain any definitive memory either way, the therapist tells her that neuroscientific research demonstrates that events occurring during great stress may not be encoded in declarative memory. That is, her failure to regain the memory of the presumed abuse would not conclusively mean that it had not occurred. Learning this data significantly attenuated her anxiety, guilt, and shame.
The fact that this information was “therapeutic” is certainly worthy of study, as one could easily imagine it making the patient even more rigidly anxious. But, as Blass and Carmeli point out, this sort of supportive intervention simply reduced the patient’s anxiety by providing external information rather than analyzing the plethora of motives, anxieties, and conflicts making the question so important to her. To use Pulver’s terms, it sidestepped the opportunity to help the patient understand the deeper, developmentally based meaning of her preoccupation. Given that Solms and his colleagues offered the vignette as an example of the role neuroscience can play in clinical technique, some might conclude instead that it illustrates the truth of Pulver’s title: “the astonishing clinical irrelevance of neuroscience.” It gives the impression that Solms and his colleagues see analytically oriented treatment as helping the patient know her historical reality using logic and manifest content. They demonstrate no attempt to understand or address the unconscious logic and meaning of the patient’s belief, particularly why knowing the “truth” was so important. Instead they conceptualized their task as helping her realize that she might never remember because of how the brain encodes traumatic memories. By not considering development or the complex ways that minds function, neuropsychoanalysis cannot make sense of the kind of beliefs/fantasies that are perfectly logical to a child who does not understand how the world works or why certain fantasies are maintained and transformed throughout the developmental process. This aspect of unconscious fantasies can be understood as involving naive misinterpretations of events due to the child’s limited knowledge of the world (Erreich 2003).
Solms’s Revision of Drive Theory
I will now turn to Solms’s concept of drives to consider whether his revision adds to our psychoanalytic theory of the mind, including its clinical utility. Despite the length of his paper, he leaves the reader unsure of the place he sees for drives in broader mental functioning. Our traditional use of the concept is to see it as a motivational construct (Klein 1976) and as playing a role in intrapsychic conflict. In the United States, most contemporary ego psychologists and conflict theorists rarely use the actual concept of drive these days; instead we use the term wish, a psychological concept that involves a mental representation. Wish is not an abstract, biological, or mechanistic concept based on dubious ideas about erogenous zones and psychic energy. This equation of drive with wish has been with us for some time (Holt 1976). “On the basis of psychoanalytic data one can say the following about the drives: They are generalizations drawn from the psychoanalytic study of wishes” (Brenner 1982, p. 38). Further, there are myriad wishes that contemporary analysts deal with and discuss in their practices, not just the limited number of drives enumerated by Solms. Contemporary analysts of many persuasions beyond ego psychology and conflict theory (e.g., relational, self psychological, intersubjective) do not limit the concept to oral, anal, phallic, or oedipal drive derivatives or any other biologically based phenomena. To restrict the concept to phenomena rising from the body (brain) leaves out psychological constructs like object relations, safety, holding, fantasy, mirroring, idealization, and so on that current models have deemed important.
In addition, the importance of internal conflict, even in theories that do not use that terminology, has been demonstrated by Smith (2003, 2005). Thus, for most analysts, the interactions among and conflicts between subjective phenomena like wishes, anxieties, ideals, prohibitions, and coping strategies are how we understand mental functioning. Wish as a concept has little use in our theory outside its interactions with the other mental constructs that we call structures or functions. Overall mental functioning involves interactions of the drive/wish with all these other mental phenomena, as well as the other mental functions traditionally subsumed under the concept of ego functions (cognition, affect tolerance and regulation, etc.).
Solms’s decision not to explain the place of drives in overall mental functioning in this paper reduces their seeming importance. David Rapaport is reported to have said that definitions are matters of strategy. From that perspective, the question of whether Solms’s concept of drives improves psychoanalytic theory rests on whether his strategy of a neuroscientific definition and understanding of drives improves our model of mental functioning. But there is nothing in the paper that demonstrates any conceptual advantage to defining drives as he does. He states that drives push the human organism (I would say human mind) to reduce uncertainty and make environmental events more predictable. There is nothing wrong with this psychological role for drives on the face of it. But what strategic advantage does it offer the psychoanalytic model of mind in understanding mental functioning? Making the environment more predictable is part of what traditional ego psychology has called adaptation (Hartmann 1958), which includes conflict, defense, and compromise solutions. And adaptation is traditionally seen as involving primarily the ego, not the drives. Conceptualizing adaptation as the province of an ego that then interacts, or conflicts, with the phenomena we usually subsume under the concept of drives has provided a psychoanalytic way to account for both interpersonal and intrapsychic functioning, development and maturation, and pathogenesis. Unless Solms can demonstrate that his neurobiological definition of drives provides broader, deeper, or more accurate elaborations of adaptation, there is no strategic reason to adopt it. His choice not to do so in this paper makes it seem prudent to wait until he does, before we consider adopting it.
Another aspect of Solms’s definition of drives that bears further examination is his emphasis on drives seeking homeostasis. This view is quite different from most contemporary psychoanalytic models of mind. Traditionally, the mind is the psychoanalytic construct usually charged with creating and maintaining homeostasis between the competing and interacting contents, functions, and structures hypothesized to constitute internal reality. In fact, it is by making meaning that the mind creates and maintains equilibrium between these facets of mental functioning. Traditional ego psychology replaced the term mind with the construct ego, while self stands in for mind in self psychology, many relational theories, and others (Klein 1976; Sugarman and Jaffe 1990). Regardless of terminology, most contemporary theories see the mind as organized hierarchically with certain psychological structures/functions regulating subordinate ones. Maintaining homeostasis between all these functions and input/output with the external world is complex and requires synthesis. Relegating the maintenance of homeostasis to a hierarchically elevated, self-regulating psychological construct makes drive a subordinate concept that contributes to the unconscious internal conflicts lying at the motivational heart of the modern theories in our field. Organizing our clinical and observational data this way has developed over many decades. Important psychological concepts like selfobjects, compromise formations, alpha and beta functions, paranoid and depressive positions, all based on a mind that seeks homeostatic equilibrium, cannot be accounted for by Solms’s proposal to make such work a drive function. Instead, Solms’s revision of the drive construct, making it a neurobiological concept, strips psychoanalysis of important conceptual moorings involving psychological, not biological, phenomena. He offers no conceptually strategic advantage to doing so at this stage of theory building.
Conclusion
In conclusion, it seems premature to turn to neuroscience to bolster the scientific status of psychoanalytic technique or theory. Trying to do so only repeats the efforts of traditional ego psychology many decades ago to make psychoanalysis a general psychology by using constructs and methodologies that were not psychological (e.g., psychic energy, cathexes, etc.). I doubt that a nonmechanistic superordinate model integrating neurobiological and psychological levels of mental functioning is possible, but it should not be ruled out. Until one is developed, however, it is important that psychoanalysis rely on data arising from psychology to claim its place in the world of science. Cognitive and developmental psychology have contributed a great deal of information directly relevant to psychoanalytic practice and theory building. And they will continue to do so.
Moreover, using neuroscience as Solms does in this paper eliminates many of the concepts that psychoanalysis has found useful in understanding mental functioning, development, pathogenesis, and mutative action. To date, neuropsychoanalysis has not offered concepts or models that will serve our field better or make it more scientific. Solms is one of many who are attempting to study psychoanalysis using various types of natural science methodologies and concepts (see, e.g., Leuzinger-Bohleber, Solms, and Arnold 2020). Such research indeed strengthens the scientific base of our field. But I do not see his neuroscientific research as one of those contributions. In saying this, it is important to differentiate the relevance of neuroscience for psychoanalysis from the ability to study psychoanalysis using natural science concepts and methodology. The latter is not a focus of this commentary. In fact, it is important to acknowledge that Solms (2020) has recently provided an example of how to use concepts from cognitive psychology (i.e., nondeclarative memory) to study the clinical phenomenon of psychoanalytic process. Others (Jiminez and Altimir 2020; Leuzinger-Bohleber, Kallenbach, and Schoett 2016) also agree that psychoanalytic process can be examined within a natural science model. And Jaffe (2021) has shown that the importance of working through in clinical analysis can be understood using the cognitive concept of procedural memory. Like these authors, I believe that clinical psychoanalytic technique can be studied from a natural science perspective, while maintaining that neuroscience is not the appropriate source of natural science data or methodology for doing so. One can respect Solms’s many contributions to psychoanalytic research while questioning whether neuroscience can help us understand or improve our clinical work.
It is interesting, of course, to know what brain structures and processes allow the subjective phenomena that concern psychoanalysis to occur. But it remains impossible to see how that knowledge will help our field understand the subjective meanings and motivations we study and treat. One can acknowledge, for example, that certain problems that we treat psychoanalytically have some basis in brain functioning (i.e., ADHD, autism) while also remaining aware that the developing mind of a patient with such a brain will always make subjective meaning of the symptoms through the development of unconscious fantasies (Sugarman 2019). New neuropsychoanalytic data about such disorders will not change our psychoanalytic emphasis on analyzing the meanings the patient’s mind has made of coping with such impairments. Ultimately, psychoanalysis as a theory of mind, development, and technique seems most likely to evolve based on psychological research, not neuroscience research. After all, meaning-making is a psychological, not a neurological phenomenon.
Footnotes
Training and Supervising Analyst and Supervising Child and Adolescent Analyst, San Diego Psychychoanalytic Center; Clinical Professor of Psychiatry, University of California, San Diego.
Submitted for publication September 8, 2021; accepted September 11, 2021.