Use of Countertransference to Advance Therapeutic Efficacy.

Countertransference is a basic tenet of psychodynamic theory. Although it was initially considered an unwelcome phenomenon in psychiatry, attitudes have shifted, and many mental health professionals now consider it to be a useful therapeutic tool. In this article, the author discusses countertransference as defined by the International Psychoanalytical Association's Inter-Regional Encyclopedic Dictionary of Psychoanalysis (IRED) and examines its clinical impact by using constructed vignettes of psychodynamic psychotherapies to illustrate theoretical points. As IRED delineates, countertransferences may exist at the conscious or unconscious level. In addition, the author suggests that countertransference may also exist at the preconscious level. Clinicians' examination of all levels of countertransference has the potential to be revelatory and facilitate therapeutic action, whereas unexamined countertransference can interfere with effective treatment. For this reason, self-reflection on the part of psychiatrists is essential.

Fast and friendly: The role of vocal cues in adolescents' responses to and perceptions of peer provocation.

Adolescents self-report using different strategies to respond to peer provocation. However, we have a limited understanding of how these responses are behaviorally enacted and perceived by peers. This study examined the extent to which adolescents' self-reported responses to peer provocation (i.e., aggressive, assertive, and withdrawn) predicted how their vocal enactments of standardized responses to peer provocation were perceived by other adolescents. Three vocal cues relevant to the communication of emotional intent-average pitch, average intensity, and speech rate-were explored as moderators of these associations. Adolescent speakers (n = 39; Mage = 12.67; 66.7% girls) completed a self-report measure of how they would choose to respond to scenarios involving peer provocation; they also enacted standardized vocal responses to hypothetical peer provocation scenarios. Recordings of speakers' vocal responses were presented to a separate sample of adolescent listeners (n = 129; Mage = 12.12; 52.7% girls) in an online listening task. Speakers who self-reported greater use of assertive response strategies enacted standardized vocal responses that were rated as significantly friendlier by listeners. Vocal responses enacted with faster speech rates were also rated as significantly friendlier by listeners. Speakers' self-reported use of aggression and withdrawal was not significantly related to listeners' ratings of their standardized vocal responses. These findings suggest that adolescents may be perceived differently by their peers depending on the way in which their response is enacted; specifically, faster speech rate may be perceived as friendlier and thus de-escalate peer conflict. Future studies should consider not only what youth say and/or do when responding to peer provocation but also how they say it.

Practice is the best of all instructors-Effects of enactment encoding and episodic future thinking on prospective memory performance in high-functioning adults with autism spectrum disorder.

Prospective memory (PM) is the ability to remember to carry out intended actions in the future. The present study investigated the effects of episodic future thinking (EFT) and enactment encoding (EE) on PM performance in autistic adults (ASD). A total of 72 autistic individuals and 70 controls matched for age, gender, and cognitive abilities completed a computerized version of the Dresden breakfast Task, which required participants to prepare breakfast following a set of rules and time restrictions. A two (group: ASD vs. controls) by three (encoding condition: EFT vs. EE vs. standard) between-subjects design was applied. Participants were either instructed to engage in EFT or EE to prepare to the different tasks prior to performing the Dresden breakfast or received standard instructions. Analyses of variance were conducted. Autism-spectrum-disorders (ASD) participants did not differ from control participants in their PM performance, regardless of which strategy they used. Compared to the standard condition, EE but not EFT improved time-based PM performance in all participants. This is the first study to find spared time-based PM performance in autistic individuals. The results confirm earlier results of beneficial effects of EE on PM performance. Findings are discussed with regards to the methodology used, sample composition as well as autistic characteristics.

Mocking enactments: a case study of multimodal stance-stacking.

Although research into multimodal stance-taking has gained momentum over the past years, the multimodal construction of so-called stacked stances has not yet received systematic attention in the literature. Mocking enactments are a prime example of such complex social actions as they are layered both interactionally and stance-related, and they rely significantly on the use of bodily visual resources, depicting rather than describing events and stances. Using Du Bois' Stance Triangle as a framework, this study investigates mocking enactments as a case study to unravel the multimodal aspects of layered stance expressions. Drawing on three data sets-music instruction in Dutch, German, and English, spontaneous face-to-face interactions among friends in Dutch, and narrations on past events in Flemish Sign Language (VGT)-this study provides a qualitative exploration of mocking enactments across different communicative settings, languages, and modalities. The study achieves three main objectives: (1) illuminating how enactments are used for mocking, (2) identifying the layers of stance-taking at play, and (3) examining the multimodal construction of mocking enactments. Our analysis reveals various different uses of enactments for mocking. Aside from enacting the target of the mockery, participants can include other characters and viewpoints, highlighting the breadth of the phenomenon under scrutiny. Second, we uncover the layered construction of stance on all axes of the Stance Triangle (evaluation, positioning, and alignment). Third, we find that mocking enactments are embedded in highly evaluative contexts, indexed by the use of bodily visual resources. Interestingly, not all mocking enactments include a multimodally exaggerated depiction, but instead, some merely allude to an absurd hypothetical scenario. Our findings contribute to the growing body of literature on multimodal stance-taking, by showing how a nuanced interpretation of the Stance Triangle can offer a useful framework for analyzing layered stance acts.

The self-reference effect in attention deficit hyperactivity disorder.

The self-memory system depends on the prioritization and capture of self-relevant information, so may be disrupted by difficulties in attending to, encoding and retrieving self-relevant information. The current study compares memory for self-referenced and other-referenced items in children with ADHD and typically developing comparison groups matched for verbal and chronological age. Children aged 5-14 (N = 90) were presented with everyday objects alongside an own-face image (self-reference trials) or an unknown child's image (other-referenced trials). They were asked whether the child shown would like the object, before completing a surprise source memory test. In a second task, children performed, and watched another person perform, a series of actions before their memory for the actions was tested. A significant self-reference effect (SRE) was found in the typically developing children (i.e. both verbal and chronological age-matched comparison groups) for the first task, with significantly better memory for self-referenced than other-referenced objects. However, children with ADHD showed no SRE, suggesting a compromised ability to bind information with the cognitive self-concept. In the second task, all groups showed superior memory for actions carried out by the self, suggesting a preserved enactment effect in ADHD. Implications and applications for the self-memory system in ADHD are discussed.

On the Belatedness of Psychoanalytic Clinical Writing.

The belatedness of analytic writing and its effects on analytic processes are explored through the concepts of nachträglichkeit and thirdness. The temporal gap between being with and writing about functions as a meaningful pause filled with opportunities for investigating unconscious pathways to the analyst's countertransference. The significance of analytic narration in affecting specific psychoanalytic developments is explored. The theoretical framework utilizes the concept of après coup, which brings to light new meanings in an afterwardness of time. Aspects of analytical writing dynamics are discussed as equivalent to those of nachträglichkeit. Analysts also deploy thirdness in constructing presentations of clinical material. This could be an intrapsychic third or an external figure representing an internal introjected third. A clinical vignette demonstrates the enhanced understanding achieved by writing. It specifically assisted in exploring the analyst's enactment relating to change in the setting, the background for which was a move to online analysis. This evoked infantile anxieties and painful confusions about loss. Historically, the patient had to navigate a path through miasmic ambiguities between reality and phantasy, truths and lies. A conclusion is reached, arguing that analytic processes extend beyond the duration of sessions, and that the processes of clinical writing can provide a significant contribution.

Redundancy effect of initial enactment encoding and subsequent testing on memory enhancement: Insights from an electrophysiological study.

Testing is more beneficial for memory retention than restudying the same content. However, the effect of the initial encoding method on the testing effect remains unclear. In this study, a classical testing effect paradigm was employed, along with event-related potentials (ERP), to investigate the electrophysiological processes underlying the effect of enactment encoding on the testing effect. Participants were randomly assigned to the Self-Performed Test (SPT) or Verbalized Test (VT) groups. Both groups underwent three stages: an initial encoding phase, an initial test phase (comprising a source memory task and a restudy task), and a final test phase. During the initial encoding phase, the SPT group encoded action phrases through enactment, while the VT group encoded information through reading. During the initial test phase, the SPT group exhibited superior recognition performance in item memory compared with the VT group. Both groups exhibited significant parietal old/new effects in the source memory task, with only the SPT group displaying parietal positivity during the restudy task. During the final test phase, the behavioral testing effect was exclusively observed in the VT group. Furthermore, the VT group displayed a more pronounced parietal positivity in the test condition compared to the restudy condition, while the parietal positivity between the two conditions was comparable in the SPT group. In summary, the absence of a final behavioral testing effect in the SPT group may be attributed to both enactment and testing primarily enhancing memory performance through recollection-based retrieval, as indicated by the parietal positivity. Consequently, the initial enactment encoding method leaves limited scope for further improvements through subsequent testing. These findings suggest that initial enactment encoding, and subsequent testing may be redundant in improving episodic memory performance.

A RCT to explore the effectiveness of supporting adherence to nebuliser medication in adults with cystic fibrosis: fidelity assessment of study interventions.

BACKGROUND: A multi-component self-management intervention 'CFHealthHub' was developed to reduce pulmonary exacerbations in adults with Cystic Fibrosis (CF) by supporting adherence to nebuliser medication. It was evaluated in a randomized controlled trial (RCT) involving 19 CF centres, with 32 interventionists, 305 participants in the intervention group, and 303 participants in the standard care arm. Ensuring treatment fidelity of intervention delivery was crucial to ensure that the intervention produced the expected outcomes. METHODS: Fidelity of the CFHealthHub intervention and standard care was assessed using different methods for each of the five fidelity domains defined by the Borrelli framework: study design, training, treatment delivery, receipt, and enactment. Study design ensured that the groups received the intended intervention or standard care. Interventionists underwent training and competency assessments to be deemed certified to deliver the intervention. Audio-recorded intervention sessions were assessed for fidelity drift. Receipt was assessed by identifying whether participants set Action and Coping Plans, while enactment was assessed using click analytics on the CFHealthHub digital platform. RESULTS: Design: There was reasonable agreement (74%, 226/305) between the expected versus actual intervention dose received by participants in the CFHealthHub intervention group. The standard care group did not include focused adherence support for most centres and participants. Training: All interventionists were trained. Treatment delivery: The trial demonstrated good fidelity (overall fidelity by centre ranged from 79 to 97%), with only one centre falling below the mean threshold (> 80%) on fidelity drift assessments. Receipt: Among participants who completed the 12-month intervention, 77% (205/265) completed at least one action plan, and 60% (160/265) completed at least one coping plan. Enactment: 88% (268/305) of participants used web/app click analytics outside the intervention sessions. The mean (SD) number of web/app click analytics per participant was 31.2 (58.9). Additionally, 64% (195/305) of participants agreed to receive notifications via the mobile application, with an average of 53.6 (14.9) notifications per participant. CONCLUSIONS: The study demonstrates high fidelity throughout the RCT, and the CFHealthHub intervention was delivered as intended. This provides confidence that the results of the RCT are a valid reflection of the effectiveness of the CFHealthHub intervention compared to standard care. TRIAL REGISTRATION: ISRCTN registry: ISRCTN55504164 (date of registration: 12/10/2017).

Educational Resources to Support Patients with Parasomnias.

This article serves to help reduce patient burden in searching for credible information about parasomnias-abnormal behaviors during sleep-including sleepwalking, night terrors, and rapid eye movement sleep behavior disorder. It exhibits a compiled list of accessible online resources about parasomnias as well as detailed descriptions about each resource. By increasing patient accessibility to clinically validated resources, patients are more empowered to take an active role in managing their conditions, collaborating with their health-care practitioners in clinical management, enrolling in registries, and joining newsletters sponsored by these resources.

Characterising the declarative-procedural transformation in instruction-based learning.

Many accounts of instruction-based learning assume that initial declarative representations are transformed into executable procedural ones, so as to enable instruction implementation. We tested the hypothesis that declarative-procedural transformation should be bound to a specific response modality and not transferable across different modalities. In Experiment 1, novel stimulus-response instructions had to be implemented either verbally or manually either once or three times. Modality-specific procedural encoding was probed via a subsequent implicit priming test. This involved the same stimuli but required a response that could be either compatible or incompatible with the originally instructed response using either the same or a different response modality. We found that procedural encoding was modality-specific as indicated by a stronger repetition-dependent increase of the compatibility effect when response modality was unchanged. Explicit test performance, serving as a marker of declarative encoding, was independent of modality transition and it was uncorrelated with implicit test performance. Unexpectedly, the implicit priming test also revealed a small yet significant transfer to the response modality that was previously not overtly implemented, likely reflecting covert response "simulation". To examine if covertly simulated responding occurs even when instruction implementation is omitted altogether, we conducted Experiment 2. Subjects merely viewed novel stimulus-response instructions prior to testing. Again, we found evidence for procedural encoding of the non-implemented instructions. Moreover, a direct comparison of both experiments revealed higher test scores (both implicit and explicit) for previously non-implemented instructions than for previously implemented instructions. This calls for theoretical reconciliation with diverging previous study results.

A case of prazosin in treatment of rapid eye movement sleep behavior disorder.

Rapid eye movement (REM) sleep behavior disorder (RBD) is characterized by dream-enactment behaviors that emerge during a loss of REM sleep atonia. Untreated RBD carries risks for physical injury from falls or other traumatic events during dream enactment as well as risk of injury to the bed partner. Currently, melatonin and clonazepam are the mainstay pharmacological therapies for RBD. However, therapeutic response to these medications is variable. While older adults are most vulnerable to RBD, they are also particularly vulnerable to the adverse effects of benzodiazepines, including increased risk of falls, cognitive impairment, and increased risk of Alzheimer disease. Prazosin is a centrally active alpha-1 adrenergic receptor antagonist often prescribed for trauma nightmares characterized by REM sleep without atonia in patients with posttraumatic stress disorder. We report a case of successful RBD management with prazosin in a patient in whom high-dose melatonin was ineffective. Although there was no observable reduction in dream-enactment behaviors with high-dose melatonin, the possibility of a synergistic effect of prazosin combined with melatonin cannot be ruled out. This case report supports further evaluation of prazosin as a potential therapeutic for RBD. CITATION: Cho Y, Iliff JJ, Lim MM, Raskind M, Peskind E. A case of prazosin in treatment of rapid eye movement sleep behavior disorder. J Clin Sleep Med. 2024;20(2):319-321.

Exploring techniques for encoding spoken instructions in working memory: a comparison of verbal rehearsal, motor imagery, self-enactment and action observation.

Encoding and recalling spoken instructions is subject to working memory capacity limits. Previous research suggests action-based encoding facilitates instruction recall, but has not directly compared benefits across different types of action-based techniques. The current study addressed this in two experiments with young adults. In Experiment 1, participants listened to instructional sequences containing four action-object pairs, and encoded these instructions using either a motor imagery or verbal rehearsal technique, followed by recall via oral repetition or enactment. Memory for instructions was better when participants used a motor imagery technique during encoding, and when recalling the instructions by enactment. The advantage of using a motor imagery technique was present in both verbal and enacted recall. In Experiment 2, participants encoded spoken instructions whilst implementing one of four techniques (verbal rehearsal, motor imagery, observation of others' actions or self-enactment), and then recalled the instructions by oral repetition or enactment. For both verbal and enacted recall, memory for instructions was least accurate in the rehearsal condition, while the other encoding conditions did not differ from each other. These novel findings indicate similar benefits of imagining, observation and execution of actions in encoding spoken instructions, and enrich current understanding of action-based benefits in working memory.

Development of fidelity of delivery and enactment measures for interventions in communication disorders.

OBJECTIVES: This study was part of a process evaluation for a single-blind, randomized controlled pilot study comparing Better Conversations with Primary Progressive Aphasia (BCPPA), an approach to communication partner training, with no speech and language therapy treatment. It was necessary to explore fidelity of delivery (delivery of intervention components) and intervention enactment (participants' use of intervention skills in the form of conversation behaviours comprising facilitators, that enhance the conversational flow, and barriers, that impeded the flow of conversation). This study aimed to: (1) Outline an adapted methodological process that uses video observation, to measure both fidelity of delivery and enactment. (2) Measure the extent to which the BCPPA pilot study was delivered as planned, and enacted. DESIGN: Observational methods were used alongside statistical analysis to explore the fidelity of intervention and enactment using video recordings obtained from the BCPPA pilot study. METHODS: A 5-step methodology, was developed to measure fidelity of delivery and enactment for the BCPPA study using video-recorded data. To identify delivery of intervention components, a random sample of eight video recorded and transcribed BCPPA intervention sessions was coded. To examine the enactment of conversation behaviours, 108 transcribed 10 -min-video recorded conversations were coded from 18 participants across the control and intervention group. RESULTS: Checklists and guidelines for measurement of fidelity of treatment delivery and coding spreadsheets and guidelines for measurement of enactment are presented. Local collaborators demonstrated 87.2% fidelity to the BCPPA protocol. Participants in the BCPPA treatment group increased their use of facilitator behaviours enacted in conversation from a mean of 13.5 pre-intervention to 14.2 post-intervention, whilst control group facilitators decreased from a mean of 15.5 to 14.4, over the same timescale. CONCLUSIONS: This study proposes a novel and robust methods, using video recorded intervention sessions and conversation samples, to measure both fidelity of intervention delivery and enactment. The learnings from this intervention are transferable to other communication interventions.

Effects of strain on boundary management: findings from a daily diary study and an experimental vignette study.

Introduction: Transformations in the work-nonwork interface highlight the importance of effectively managing the boundaries between life domains. However, do the ways individuals manage the boundaries between work and nonwork life change from one day to the next? If so, which antecedents may explain these intra-individual fluctuations in boundary management? Drawing on boundary management, spillover, and resource theories, we investigate daily changes in segmentation preferences and integration enactments as a function of experiencing strain in work and nonwork life. Assuming that changes in segmentation preferences reflect an individual's strategy to regulate negative cross-role spillover, we suppose that strain increases individuals' segmentation preferences; at the same time, however, it could force individuals to enact more integration. Methods: We test our assumptions with data from two studies with different methodological approaches. The first study uses a daily diary research design (Study 1, 425 participants with 3,238 daily observations) in which full-time professionals rated strain in work and nonwork life, segmentation preferences, and integration enactments every evening for 10 workdays. The second study uses an experimental vignette research design (Study 2, 181 participants), where we experimentally manipulated strain in work and nonwork life and investigated causal effects on participants' hypothetical segmentation preferences. Results: The results of multilevel modeling analyses in Study 1 show that segmentation preferences and integration enactments fluctuate from day to day as a function of strain. More specifically, strain is related to preferring more segmentation but enacting more integration. Study 2 replicates the results of Study 1, showing that strain causally affects segmentation preferences. Discussion: This two-study paper is one of the first to address daily fluctuations in segmentation preferences and integration enactments, extending our knowledge of temporal dynamics in boundary management. Furthermore, it demonstrates that strain is an antecedent of these daily fluctuations, offering starting points for practical interventions.

Cultural poetics of illness and healing.

This issue of Transcultural Psychiatry presents selected papers from the McGill Advanced Study Institute on "Cultural Poetics of Illness and Healing." The meeting addressed the cognitive science of language, metaphor, and poiesis from embodied and enactivist perspectives; how cultural affordances, background knowledge, discourse, and practices enable and constrain poiesis; the cognitive and social poetics of symptom and illness experience; and the politics and practice of poetics in healing ritual, psychotherapy, and recovery. This introductory essay outlines an approach to illness experience and its transformation in healing practices that emphasizes embodied processes of metaphor as well as the social processes of self-construal and positioning through material and discursive engagements with the cultural affordances that constitute our local worlds. The approach has implications for theory building, training, and clinical practice in psychiatry.

Legal effectiveness in promoting development policies: A case study of North Aceh Indonesia.

This research evaluated the effectiveness of the Law on the Governing of Aceh (LoGA) as the legal basis for regional development policies in the North Aceh District, Indonesia. Despite its enactment in 2006, the district has faced persistent challenges, including high poverty rates and poor economic growth. The LoGA was intended to accelerate development in Aceh after the conflict and tsunami, reflecting the legal aspirations of the region (reconsidered). Therefore, using a qualitative approach, including interviews, observations, and analysis of secondary data, this research evaluated the effectiveness of the LoGA based on its provisions, enforcement, infrastructure and facilities, political landscape, cultural factors, and societal impacts. The result showed significant substantive, institutional, and societal challenges, which led to legal uncertainty, ineffective policy implementation, and the necessity for policy revision and community involvement.

The Role of Motor Representation in Enactment Effect of Action Memory.

Noun-verb phrases are more efficiently remembered when they are enacted during learning than when they are only verbally studied, a phenomenon known as the enactment effect. While studies have debated whether motor information is key to this effect, our study explores whether the organization of motor information can support the enactment effect. We used the retrieval-practice paradigm to induce retrieval-induced forgetting (RIF). In Experiment 1, we found an RIF effect of categorization into physical motor properties (e.g., rotation-motor category), which was significantly stronger during enactment learning. In Experiment 2, we also found an RIF effect of categorization into physical motor properties with additional imagery features (e.g., the hand-physical and round-object category), but there was no significant difference between enactment learning and verbal learning. These findings suggest that motor information is fundamental to the enactment effect, but it is not primarily assimilated, even in the presence of various types of information, in the processing of action memory. We discuss these findings in the context of multimodal theory and episodic integration theory.

Distance And Relation: Emerging From Embeddedness In The Other.

Inspired by an essay by Martin Buber (1950), and then by the work of Ernest Schachtel (1959) on the idea of "embeddedness" and emergence from it, this essay is an account of the role of "distance" or "separateness" in clinical psychoanalytic work. We tend to assume that the capacity to appreciate otherness is always already present. We often lose track of the necessity to "set the other at a distance" (Buber), the prerequisite for emergence from embeddedness in the other. The entire process-i.e., setting the other at a distance and then emerging from embeddedness in the other-must take place over and over again in any treatment, and in both directions: patients must disembed from analysts, but it is just as necessary for analysts to disembed from patients. It is the emergence from embeddedness that allows the analyst's appreciation of the patient's otherness. Embeddedness in the other is discussed as mutual enactment. This use of these phenomena in treatment is articulated in the theory of witnessing presented elsewhere in recent years (Stern 2009, 2012, 2022b, in press). A detailed clinical illustration is presented.

Sleep disorders after COVID-19 in Czech population: Post-lockdown national online survey.

Objective: This study aimed to determine the frequency, type, and correlates of a broad spectrum of sleep disorders in adults with COVID-19 up to 32 months after infection. Methods: We conducted a national online survey (Jun 2021-Dec 2022), gathering information on COVID-19 diagnosis, acute disease course, and the subsequent development of sleep disorders from 1507 respondents (mean age 44.5 ± 13.1 years, 64.1% women). Results: 81.3% (1223) reported at least one sleep difficulty that either worsened or first appeared with COVID-19. Females reported a higher number of symptoms (2.03 ± 1.44 versus 1.72 ± 1.43 in men, p < 0.0001). Most common were insomnia symptoms (59.4%), followed by night sweats (38.4%), hypersomnolence (33.3%), vivid dreams or nightmares (26.4%), restless leg syndrome (RLS) (22.8%), and sleep-related breathing disorders (11.1%). All symptoms were associated with a more severe acute disease. A mild decreasing trend in the persistence of sleep symptoms with a longer latency since infection was observed, with 66.7% reporting at least half of their symptoms present at 3-5 months after acute infection, compared to 64.9% at 6-8 months, and 62.4% at 9-11 months (p = 0.0427). However, among those after 12 or more months, over half of the symptoms persisted in 69.5%. The frequency of vivid dreams and nightmares increased in association with COVID-19 in 32.9% (p < 0.001). 9.4% (141) reported new-onset or increased parasomnic manifestations after the infection. Conclusions: Our research shows that sleep disturbances are a common and persistent manifestation of COVID-19 that affects a large proportion of the population and deserves careful monitoring.