The many faces of neuropsychoanalysis – from the classic theoretical concepts of acting out and enactment to object relations and the motivational-energization aspects of brain injury

Psychoanalytic theory attempts to advance previous conceptualizations of its main ideas to improve our understanding of the human mind. By relying on clinical observations and the construction of hypotheses, crucial themes are questioned, discussed, and elaborated. Although things are changing, within psychoanalysis proper it is still relatively rare to see the inclusion of knowledge coming from fields different from psychoanalysis. Neuropsychoanalysis has always provided a space for integrating models and data from other disciplines. This issue presents several outstanding papers that take up that challenge, and cover important topics such as object relations theory, enactment and acting out, and the motivation/energization function of the mental apparatus. Our Target Article in this issue is an important paper by Otto Kernberg (2021) entitled “Some Implications of New Developments in Neurobiology for Psychoanalytic Object Relations Theory.” This integrative article by one of the most esteemed and prominent psychoanalytic theoreticians sheds new light on the subject of object relations theory and its importance in the growing integration with neuropsychoanalysis. Dr. Kernberg has made major contributions to recent object-relations models and their relationship with ego-psychology, Kleinian theory, and self-psychology. He leads the team practicing the model of transference focused psychotherapy, which is contributing to the psychotherapy of borderline syndromes. In this Target Article he summarizes his well-known model of the three-stage development of the self from infancy, to an intermediate or borderline level, to the more adult neurotic level, and here he brings in the information from neuropsychoanalysis and many aspects from brain models. He sets the stage by summarizing the recent history of the ascendance of the model of affect theory as foundational in the understanding of mind and brain processes. And he extends this to an advanced theory of object relations. In his model, divided positive and negative affects become important in the creation of the self, and the relations of the self with others. He correlates these phenomena with neuroscience findings, and develops a complex model that embraces the primary and secondary unconscious, and the experience of the various affects, all of which contribute to the functional development of the self. The process he describes is still evolving, although it now makes sense as a multi-level mental structure. And in this venture, we have invited commentaries, and they may very well contribute to this evolution. We have 13 of them and they expand, agree, and disagree with different aspects of Kernberg’s model. The authors are Simon Boag, Fredric Busch, Charles Fisher, Robert Galatzer-Levy, Leon Hoffman, Luba and Richard Kessler, Richard Lane, Nancy McWilliams, Georg Northoff, Donald Pfaff, Larry Sandberg, David Tuckett, and Yoram Yovell. Dr. Kernberg’s response to these commentaries will appear in the next issue of our journal. Although widely used in the psychoanalytic literature, acting out and enactment are poorly defined terms. In the first Original Article in this issue, Eric Bettelheim offers an extensive literature review of these two terms in his scholarly theoretical paper and speculates on the putative brain systems related to these clinical phenomena. He emphasizes the role of trauma in the generation of acting out and enactment and argues that they are related to inaccessible traumatic traces that cannot be communicated verbally and, therefore, are substituted and expressed in action. In his view, acting out is related to either patient or therapist, whereas enactment is defined as mutual acting out due to co-existing unresolved material of both the patient and the analyst. Bettelheim hypothesizes the involvement of various neurological systems and networks. He suggests that the main mediator of acting out and enactment is an imbalance between the default mode network (DMN) and the central executive network (CEN). While the DMN is devoted to imagination, and thus plays a central role in self-referential processes and introspection, the CEN is devoted to goal-directed functions. In the model presented in this paper, threatening unverbalized traumatic traces lead to hypoactivation of the DMN and hyperactivation of the CEN, resulting in a shift from self-reflection to acting out or enactment. Bettelheim’s