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.

[Supporting perinatal professionals]. / L'accompagnement des professionnels en périnatalité.

No professional, no team can be a caregiver if they themselves are not well supported, well "cared for", i.e. if they are not well looked after. Professional support is therefore not a luxury, but a sine qua non of quality care and psychological care. After a few reminders about practice analysis and supervision, the impact of the baby's functioning on that of professionals (an impact to be taken into account in terms of their support) is considered, before tackling the concept of intransitive demand, which is also to be considered in the work of supervision.

RELATIONAL DIMENSION VERSUS ARTIFICIAL INTELLIGENCE.

Thirty years ago, we proposed the similarity between the functioning of artificial intelligence and the human psyche, suggesting multiple parallels between the Freudian model proposed in the "Project for Psychology for Neurologists" and the connectionist theories applied in the generation of parallel distributed processing systems (PDP), also known as connectionist models. These models have been and continue to be the foundation of general artificial intelligences like ChatGPT, evolving and gaining prominence in everyday life. From the earliest applications in psychiatry, recreating computationally simulated modes of illnesses, to the use of deep learning models, especially in the field of computer vision for tasks such as image recognition, segmentation, and classification. Recurrent Neural Networks (RNN) and Long Short-Term Memory (LSTM) are employed for tasks involving sequences of data, such as natural language processing, or models based on the Transformer architecture, like BERT and GPT (Generative Pre-trained Transformer), which have revolutionized natural language processing. In this present work, we analyze the significance of the emergence and exponential growth of these types of tools in the field of healthcare, from medical diagnosis and patient care to psychological attention and psychotherapeutic treatment, exploring the changes and transformations in the forms of subjective expression that are arising. We also examine and argue for the importance and validity of the relational dimension proposed by our psychoanalytic approach in contrast to the potential use of these tools as treatment models.

Ethical Dilemmas and Countertransference in Legally Mandated Reporting of Fatal Child Neglect.

In the fall of 2019, a much-publicized court case brought to national attention the issues of patient-doctor confidentiality when it comes to reporting the deaths of newborns in the United States. It is unclear whether the recent overturning of Roe v. Wade will lead to more cases like this. This article discusses issues of countertransference, as well as the ethical and legal implications were it to be a psychiatrist, in active treatment of such a patient, who would be required to make such a report. More specifically, as in the publicized court case, the patient could be a minor at the time, receiving treatment from a child psychiatrist. The implications of such a case include how countertransference affects the perception of fatal child neglect compared to intentional neonaticide; the ethical dilemma of generating a mandated report with the goal of child safety when such a report could lead to real legal consequences for a minor child; and considerations regarding continued treatment of a patient after such a report is made. It is likely that countertransference, shaped by attitudes toward mothers and idealized views on mothering, may play a large role in all these circumstances.

COVID-19: When It Leaves Us Voiceless and Powerless.

Conversion disorder-called functional neurological symptom disorder in the DSM-5-has roots that trace back to antiquity. The term conversion, originating from psychoanalysis, signifies the appearance of physical symptoms as an effort to resolve or convey unconscious and distressing intrapsychic conflicts- "converting" them from manifesting in the mind to manifesting in the body. Despite efforts made in elucidating the neurobiological etiologies of functional neurological symptom disorder, a psychodynamic lens remains indispensable in understanding the patient. This article presents two patients who developed functional neurological symptom disorder, one after a COVID-19 vaccination and one in the context of long COVID. A discussion follows on the intrapersonal, interpersonal, and systemic etiological factors that predispose, precipitate, and perpetuate COVID-related functional neurological symptom disorder. We elaborate on psychodynamic psychological processes and conflicts that may unfold between patients with COVID-related functional neurological symptom disorder and their health care providers. We also share suggestions on how a consultation-liaison psychiatry team may offer support to the primary treating team to facilitate a therapeutic space within which patients with COVID-related functional neurological symptom disorder may recover.

The Oedipal Virtual Citadel: Varieties of Isolation, Oedipal Conflict, and Cover-Up.

The author elaborates some of the fantasies and defenses that protect some patients in their oedipal fixations, particularly those related to forms of personal isolation. To some extent, cover-up is intrinsic to oedipal conflict and fantasy, but what is covered up is quite variable. In this paper, the author highlights elements of personal isolation that the patient cultivates in order to protect love for a desired oedipal parent and the conscious and unconscious fantasies associated with this love. The patients described here use forms of personal isolation to cover up and secure the gratification of oedipal fantasies. Their isolation also serves to protect them from fantasies of unique forms of destructiveness in relation to self and the desired other. The citadel, a concept from Guntrip's description of defenses protecting the schizoid patient's fear of destructive love, is characterized here for the neurotic patient as virtual because in some ways, each of the participants in oedipal conflict turn a "blind eye" to a staged cover-up. Clinical illustrations examine the transference-countertransference process of shifts from turning a blind eye to sustaining a process of seeing what is being covered up but has already been seen.

The Columbia Academy for Psychoanalytic Educators: A Pilot Program for Developing Analysts and Supervisors of Analytic Candidates.

The Columbia Academy for Psychoanalytic Educators supports graduate analysts' professional development at the Columbia University Center for Psychoanalytic Training and Research. In 2018, a pilot program was launched for faculty interested in analyzing and supervising candidates, whose aim is to support and educate those interested in taking on these essential training functions. The focus is on educating the educators, which is a significant departure from the historical focus on evaluation, vetting, and faculty hierarchies. In the process of developing and piloting the program, complex and long debated issues in psychoanalytic education and development were considered that are relevant to many institutes, including training of supervisors and analysts of candidates, addressing problematic faculty hierarchies, creating safety for those presenting clinical work to colleagues, building professional peer relationships, and engagement of faculty in time consuming and nonremunerative activities. The authors report on their experience developing and evaluating this pilot program.

Working through multiple crises: the experience of psychotherapists and psychoanalysts in Lebanon.

INTRODUCTION: This research explores the impact of the COVID-19 pandemic on psychotherapists' practices and their ability to maintain a framework despite a shared reality with their patients. The specific focus in this article is on the Lebanese context, which is characterized by a series of crises including economic collapse, the COVID-19 pandemic, and the Beirut blast. The objective of this study was to examine how the destabilization of the meta-frame due to crises necessitates adaptations in theoretical knowledge, practice, and setting. METHODS: We conducted a qualitative study among a population consisting of mental health professionals, which were recruited in Lebanon through associations and societies of psychologists, psychotherapists, and psychoanalysts. Data was collected using semi-structured individual interviews. The interviews were analyzed using interpretative phenomenological analysis (IPA), which allowed for a dynamic exploration of the participants' experiences. RESULTS: Our study revealed four superordinate themes: (1) The strained frontiers; (2) The cumulative traumatic reality and its impact; (3) A challenged professional identity; (4) The creativity stemming from collective trauma. CONCLUSIONS: Our results highlight the insecurity caused by external reality infiltrating the therapeutic setting. Online therapy allowed for continued work, but uncertainty about the online environment's impact on therapeutic relationships was observed. The study underscores the importance of adaptability, containment, and support for therapists navigating crises, particularly in the online setting.

The Process of Case Writing: A Fourth Pillar of Analytic Training.

The educational and clinical effects of the process of case writing during analytic training have not been extensively studied, even though the case report, as a product, has prompted attempts to make it a more revealing and accurate document. Countertransference experiences during an analysis can constrain both the candidate's writing and the analytic work, while examining them during the writing process can deepen the candidate's analytic work. Three overlapping resistances to the writing, and their underlying anxieties, are described. These are publication resistances: concerns about the anticipated reception of the candidate's work by potentially critical readers; transference resistances: feelings toward the analytic institute that requires the writing; and countertransference or reimmersion resistances: fears of reawakening reactions from the analysis. These can interfere with finding a safe internal space in which to write. Examples are given of writing through of these resistances during case supervision, resulting in more open writing and in a deepening of the analytic work. As the case writing process can have direct and potentially profound effects on the candidate's current and future analytic work, it is proposed that the process of case writing is a fourth pillar of analytic training, in addition to the candidate's personal analysis, case supervision, and didactic seminars.

Does a lack of emotions make chatbots unfit to be psychotherapists?

Mental health chatbots (MHCBs) designed to support individuals in coping with mental health issues are rapidly advancing. Currently, these MHCBs are predominantly used in commercial rather than clinical contexts, but this might change soon. The question is whether this use is ethically desirable. This paper addresses a critical yet understudied concern: assuming that MHCBs cannot have genuine emotions, how this assumption may affect psychotherapy, and consequently the quality of treatment outcomes. We argue that if MHCBs lack emotions, they cannot have genuine (affective) empathy or utilise countertransference. Consequently, this gives reason to worry that MHCBs are (a) more liable to harm and (b) less likely to benefit patients than human therapists. We discuss some responses to this worry and conclude that further empirical research is necessary to determine whether these worries are valid. We conclude that, even if these worries are valid, it does not mean that we should never use MHCBs. By discussing the broader ethical debate on the clinical use of chatbots, we point towards how further research can help us establish ethical boundaries for how we should use mental health chatbots.

Entrenched grievance as a harbour for the unmourned.

This paper hopes to enhance understanding about entrenched grievance in a couple of ways: (a) Initially, the paper reviews how entrenched grievance reflects melancholic states of mind in terms of its avoidance of the pain of loss and change. But the main contribution of the paper is likely to be found in (b), that is, via detailed clinical material, the paper illustrates how earnest efforts on the part of the analyst to bring understanding may lead to cognitive entrapments such as the convictions incumbent in the "knowing" analyst. Further, that this knowing analyst may need to become aggrieved, that is, narrow, impatient and concrete towards her patient's entrenchment, and then to recogize this plight in herself before she can genuinely hear her patient's grievance about her from a wider view, that is as a complaint from the "lively self", deserving recognition. The clinical detail demonstrates that such recognition softened the patient's grievance, allowing both members of the dyad to become more collaborative and open to the pains and growth available from mourning states of mind.

Aggression in Psychodynamic Psychotherapy and Supervision: Becoming a More Effective Therapist.

Access to one's healthy aggression is critical for both patient and therapist. On the patient's end, the ability to access and modulate aggression is fundamental to the establishment of healthy self-esteem and the capacity to sustain relationships and pursue life goals. On the therapist's end, access to aggression allows for the setting of a secure therapeutic frame and the subsequent conduct of the deep work of therapy. Conversely, lack of access to aggression creates burdensome and problematic situations that may subvert the treatment. Beginning therapists have a particular susceptibility to minimize their own aggression given certain factors in their choice of profession. Supervisors' modeling of the experience of aggression, as well as the provision of a safe atmosphere in which new clinicians become comfortably aware of their own and their patients' aggression, will help fortify beginning therapists' capacity to harness their aggression in the service of the work.

Oncology clinicians' feelings towards patients presented in supervision: A pre-post assessment using the feeling word checklist.

OBJECTIVE: Clinical supervision of oncology clinicians by psycho-oncologists is an important means of psychosocial competence transfer and support. Research on this essential liaison activity remains scarce. The aim of this study was to assess the impact of supervision on oncology clinicians' feelings towards patients presented in supervision. METHODS: Oncology clinicians' (n = 23) feelings towards patients presented in supervision were assessed with the Feeling Word Checklist (FWC). The FWC was filled in by supervisees prior and after their supervision sessions (n = 91), which were conducted by experienced supervisors (n = 6). Pre- post-modification of feelings was evaluated based on a selection of FWC items, which were beforehand considered as likely to change in a beneficial supervision. Items were evaluated on session level using t-tests for dependent groups. Composite scores were calculated for feelings expected to raise and feelings expected to decrease and analysed on the level of supervisees. RESULTS: Feelings related to threats, loss of orientation or hostility such as "anxious", "overwhelmed", "impotent", "confused", "angry", "depreciated" and "guilty" decreased significantly after supervision, while feelings related to the resume of the relationship ("attentive", "happy"), a better understanding of the patient ("empathic"), a regain of control ("confident") and being "useful" significantly increased. Feeling "interested" and "calm" remained unchanged. Significant increase or decrease in the composite scores for supervisees confirmed these results. CONCLUSIONS: This study demonstrates modification of feelings towards patients presented in supervision. This modification corresponds to the normative, formative, and especially restorative function (support of the clinician) of supervision.

Top Ten Tips Palliative Care Clinicians Should Know About the Psychological Aspects of Palliative Care Encounters.

Palliative care clinicians enhance the illness experiences of patients and their families through building therapeutic relationships. Many psychological concepts underlie a clinician's approach to a specific patient. Through high-yield tips, this article highlights ten selected psychological elements that palliative care clinicians often use to support patients. As we all (both clinicians and patients) bring our own histories and unique biographies to the work of palliative care, a more explicit focus on the psychological aspects of this work can enhance our own experience and efficacy as providers. With a thoughtful focus on the psychological aspects of how we engage with patients, palliative care clinicians can offer a more meaningful therapeutic encounter.

Identifying the origins of countertransference using the Core Conflictual Relationship Theme method: A multiple case study approach.

OBJECTIVE: Measurement of countertransference (CT) has proven challenging throughout the history of studying this construct. We sought to determine the potential value of using a common measure of transference, the Core Conflictual Relationship Theme (CCRT) method, as a means of studying CT. METHOD: The Relationship Anecdote Paradigm and the CCRT method were used to examine CT in two studies. In Study 1, we examined the correspondence between a therapist's wishes with significant people in her life (i.e., her parents and husband) and three long-term patients. In Study 2, we identified the interpersonal wishes of a different therapist and examined 14 of her sessions with 3 patients for evidence of how these wishes and needs were displayed in her clinical work. RESULTS: Analyses revealed that specific wishes in therapists' personal lives could be detected from projective interviews and these wishes were similar, but not necessarily identical, to wishes in therapists' descriptions of, and actual work with, their patients. Evidence of both chronic wishes and patient-specific wishes was revealed. CONCLUSIONS: These findings support the idea that the origins of CT reside in therapists' interpersonal wishes and that the CCRT may be a promising means of identifying CT in research, practice, and supervision.

Institutional Transference in Serious Illness Care.

Institutional transference is a phenomenon describing patients' attitudes toward the institutions where they receive mental health or medical care. While transference toward individual clinicians in palliative care has been described, attitudes of patients with serious illness toward the institutions where they receive specialized care have not been described. Here, we present three cases which demonstrate the phenomenon of institutional transference in patients with serious illness and the resulting clinical implications, which include countertransferential responses of clinicians caring for them. We consider three conditions: (1) the idealized reputation of the academic cancer center, often a tertiary referral center; (2) loss of an institutional connection during care transitions; and (3) countertransferential reactions to institutional transference. We highlight characteristics and personality styles of individuals with cancer that may complicate and intensify institutional transference and identify potential interventions to address common challenges associated with institutional transference.

Transferência e contratransferência: os efeitos clínicos do observador no trabalho em grupos terapêuticos / Transference and countertransference: the observer's clinical effects in therapeutic groups / Transfert et contre-transfert: les effets cliniques de l'observateur dans les groupes thérapeutiques / Transferencia y contratransferencia: los efectos clínicos del observador en el trabajo con grupos terapéuticos

O propósito deste artigo é refletir sobre os conceitos de transferência e contratransferência, articulando-os com a dimensão clínica do lugar do observador no trabalho em grupos terapêuticos. Inicialmente, será feito um percurso histórico sobre tais conceitos na psicanálise. Posteriormente, a noção de transferência será discutida como um vínculo que pode se manifestar pela via da expressão corporal e sensorialidade, enquanto a contratransferência será analisada a partir do campo da intersubjetividade. Esses aspectos serão ilustrados por duas vinhetas clínicas

This paper reflects on the concepts of transference and countertransference in articulation with the clinical dimension of the observer's place in therapeutic groups. After a brief historical overview of these concepts in psychoanalysis, the notion of transference is discussed as a link that can manifest itself via bodily and sensorially. Countertransference, in turn, will be analyzed based on intersubjectivity. These aspects will be illustrated by two clinical vignettes

Cet article reflète aux concepts de transfert et de contre-transfert en articulation avec la dimension clinique de la place de l'observateur dans les groupes thérapeutiques. D'après un aperçu historique de ces concepts en psychanalyse, on discute la notion de transfert en tant que lien qui peut se manifester par l'expression corporelle et la sensorialité. Le contre-transfert, à son tour, sera analysé à partir du domaine de l'intersubjectivité. Ces aspects seront illustrés par deux vignettes cliniques

El propósito de este artículo es reflexionar sobre los conceptos de transferencia y contratransferencia articulándolos con la dimensión clínica del lugar del observador en el trabajo con grupos terapéuticos. Inicialmente, se hará un recorrido histórico sobre tales conceptos en el psicoanálisis. Posteriormente, la noción de transferencia será discutida como vínculo que puede manifestarse por la expresión corporal y la sensorialidad, mientras que la contratransferencia será analizada a partir del campo de la intersubjetividad. Estos aspectos serán ilustrados por dos viñetas clínicas

Shared Fragility-Contemplating the Impact of Patients' Suicides on Clinicians.

The experience of patient suicide can have a profound impact on clinicians, yet there are limited opportunities for them to express and process their emotional responses. We organized a reflective group session for psychiatrists in Singapore who had encountered patient suicides. Ten psychiatrists participated, with five in the "inner" group (those who had experienced patient suicide) and the remaining five forming the "outer" group. Led by a senior psychiatrist trained in psychodynamic psychotherapy, the inner group shared their reflections on patient suicides, while the outer group provided their insights thereafter. Participants provided written feedback about their session experiences. The session was recorded, transcribed, and analyzed to identify key themes. Three main narrative themes emerged from the analysis. Firstly, there was the acute response to the suicide, involving intense emotional reactions. Secondly, the relationship between clinicians and patients with suicidal thoughts was explored, encompassing countertransferential responses, superego defenses, and resulting anxiety. Lastly, the study examined how clinicians feel about suicidality itself, shedding light on complex attitudes and perceptions. Our findings confirm previous research, indicating that the response to patient suicide is stressful and traumatic for clinicians, who grapple with emotions such as grief, guilt, incompetence, and fear. Moreover, we delve into the intricate connections clinicians have with the concept of suicidality, shaped not only by their own experiences but also by the insights of those who have yet to confront patient suicide. The reflections shared by the participants emphasize the significance of establishing therapeutic spaces for clinicians to process these complex emotions effectively.

The Impact of Patient Suicide on Clinicians.

The experience of patient suicide on clinicians is associated with complex affective states that include grief, guilt, shame, and fear and distressing subjective experiences of incompetence and helplessness. The authors review the literature of the subject and highlight the work of Rajagopalan and colleagues in Singapore, who implemented a one-time reflective group session to help clinicians process the experience of patient suicide to reduce psychological distress and prevent burnout and moral injury.