Impasse sign in balloon mitral valvotomy.

A 33-year-old female presented to our out-patient department with worsening shortness of breath over the past 2 years.

Impasse-Driven problem solving: The multidimensional nature of feeling stuck.

This study reports findings across four preregistered experiments (total N = 856) that establish the multidimensional nature of impasse and resolve two paradoxes implicit in the problem-solving literature: how a state of impasse can be at once necessary to solve a problem with insight yet also have appear to have a catastrophic effect on solution rates, and why individuals such as problem-solving and gaming enthusiasts seem to seek out this apparently aversive state. We introduce a new way of measuring impasse based on qualitative reports and subsequently confirmed through quantitative analysis that exploits two aspects of impasse: its dynamic and unstable nature (it can be resolved or unresolved) and its multidimensionality in terms of feelings of cognitive speediness, motivation, and affect. The feeling of being stuck varies between resolved and unresolved impasse in terms of feelings of speediness and positive affect, but not motivation, which remains constant. We demonstrate that the feeling of insight can be reliably elicited by experiencing and resolving impasse but also in the absence of impasse, which suggests that there is more than one path to an insight experience. This adds depths to current proposals of the cognitive mechanisms underlying both insight problem-solving and impasse. Our findings are robust across a range of problem types. The novel conception of impasse in this paper as dynamic and multidimensional has implications for theories of insight problem solving, and also wider implications for understanding how impasse can be resolved across different domains such as education and design.

Errare Humanum Est (To Err Is Human): A Mentalizing Breakdown in the Therapeutic Work With an Adolescent.

The therapeutic stance in therapies conceptualized by the two-person psychology (Wachtel, 2010) binds the therapist to genuine self-scrutiny. The concepts of transference and countertransference are viewed as jointly constructed endeavors between therapist and client, wherein the therapist needs to be aware of her contribution to difficulties arising in the therapeutic dyad. Different conceptualizations of this therapeutic technique have been eloquently described elsewhere throughout the years in terms of intersubjectivity (Stern, 2005; Aron, 2006), mentalizing (Fonagy and Bateman, 2006), mindfulness-in-action (Safran et al., 2001), rupture and repair (Newhill et al., 2003), and epistemic trust (Fonagy and Allison, 2014). These concepts will be presented interchangeably with a clinical vignette delineating a rupture in the therapeutic work with an adolescent. Finally, the article concludes with a discussion of identifying non-mentalizing modes (Allen et al., 2008) within the therapist to get back on track and restore epistemic trust (Fonagy et al., 2014) in the therapeutic relationship.

The balloon impasse sign in percutaneous transvenous mitral valvuloplasty.

Percutaneous transvenous mitral valvuloplasty (PTMV) is an established therapy for rheumatic mitral stenosis (MS). While the Wilkins score standardizes the description of valve anatomy and predicts successful PTMV, echocardiographic assessment has some limitations. The 'balloon impasse' sign is the inability to cross a stenotic valve with a deflated Inoue balloon. This sign was described in the 1990s as an indicator of severe subvalvular thickening (regardless of the echocardiographic findings), portending an increased risk of severe mitral regurgitation (MR) post-PTMV. Despite its implications for management, it has been seldom reported. A 57-year-old woman with symptomatic, severe MS and a Wilkins score of 7 underwent PTMV. The 'balloon impasse' sign was observed when attempting to cross the stenotic valve. When the balloon was fully inflated, severe MR was noted, and the patient required mitral valve replacement. This case demonstrates the continued importance of the 'balloon impasse' sign and its implications for the therapeutic efficacy of PTMV.

Unpacking Impasse-Related Experience during Insight.

Mental impasse has long been recognized as a hallmark of creative insight, but its precise role has been unexplored. The aim of the present work, consisting of two studies, was to experimentally probe mental impasse perspective from insight experience, namely impasse-related experience during insight. In Study 1, participants were requested to complete a compound remote association task and a forced-choice subjective experience depiction task that could provide data on impasse-related experience. The results showed that reports of negative experience, such as feelings of loss (t = -5.51, p < .001, Cohen d = 1.07) and personal experience (mirrored by 'other' response; t = -2.62, p < .05, Cohen d = 0.48), were more common in the impasse condition than in the no-impasse condition; correspondingly positive affect and positive cognitive experiences such as happiness (t = 4.20, p < .001, Cohen d = 0.77), ease (t = 5.90, p < .001, Cohen d = 1.20), certainty (t = 7.46, p < .001, Cohen d = 1.36) and calmness (t = 4.42, p < .001, Cohen d = 0.81) were experienced more frequently in the no-impasse condition. These findings were replicated in Study 2, in which participants were invited to solve a set of classic insight problems and to freely report any feelings of being at an impasse. Across two studies, this work suggests that impasse-related experience during insight problem solving is multi-faceted and consists of negative affective and cognitive components. The implications of these findings are discussed.

WHAT'S NEW IN PARALLEL PROCESS? THE EVOLUTION OF SUPERVISION'S SIGNATURE PHENOMENON.

The concept of parallel process has played a central role in psychoanalytic supervision for the last 60 years, generating continuing interest in the power of the unconscious to create unexpected intersections between the analytic and supervisory relationships. I track the evolution of the concept, starting with its invention by an interpersonalist psychoanalyst, adoption by two ego psychologists, enrichment by object relations theory, and, finally, redefinition as a multi-directional dynamic by relational psychoanalysts. I then further elaborate the relational view of parallel process, illustrating its complex, multidirectional nature with an extended vignette. I discuss the relationship of enactment to parallel process and illustrate the usefulness of supervisory consultation when enactments that parallel into the supervisory relationship lead to impasse. Finally, I point to educational and neuropsychological research that suggests that working with parallel process is good pedagogy.

Aztreonam plus Clavulanate, Tazobactam, or Avibactam for Treatment of Infections Caused by Metallo-ß-Lactamase-Producing Gram-Negative Bacteria.

Metallo-ß-lactamase (MBL)-producing Gram-negative bacteria are often extremely resistant, leading to a real therapeutic dead end. Here, we evaluated the in vitro and in vivo efficacy of aztreonam in combination with ceftazidime-avibactam, ceftolozane-tazobactam, or amoxicillin-clavulanate for the treatment of infections caused by MBL-producing Enterobacteriaceae, MBL-producing Pseudomonas aeruginosa, and extremely drug-resistant Stenotrophomonas maltophilia First, we report two clinical cases, namely, a urinary tract infection caused by an NDM-5-producing Escherichia coli isolate and a pulmonary infection caused by a S. maltophilia isolate efficiently treated with the association of aztreonam-ceftazidime-avibactam and aztreonam-amoxicillin-clavulanate, respectively. Then, a total of 50 MBL-producing Enterobacteriaceae isolates, 3 MBL-producing P. aeruginosa isolates, and 5 extremely drug-resistant S. maltophilia isolates were used to test aztreonam susceptibility in combination with ceftolozane-tazobactam, ceftazidime-avibactam, or amoxicillin-clavulanate. The Etest strip superposition method was used to determine the MICs of the aztreonam/inhibitor combinations. According to CLSI breakpoints, aztreonam susceptibility was fully restored for 86%, 20%, and 50% of the MBL-producing Enterobacteriaceae isolates when combined with ceftazidime-avibactam, ceftolozane-tazobactam, and amoxicillin-clavulanate, respectively. In P. aeruginosa, the aztreonam-ceftazidime-avibactam combination was the most potent, even though the reduction in MICs was at most 2-fold. With the 5 S. maltophilia isolates, aztreonam-ceftazidime-avibactam and aztreonam-amoxicillin-clavulanate were found to be equal (100% susceptibility). Overall, aztreonam-ceftazidime-avibactam was the most potent combination to treat infections caused by MBL producers compared with aztreonam-amoxicillin-clavulanate and aztreonam-ceftolozane-tazobactam. However, in many cases aztreonam-amoxicillin-clavulanate was found to be as efficient as aztreonam-ceftazidime-avibactam, offering the main advantage to be markedly cheaper. We also confirmed the validity of Etest superpositions as a very simple method to determine MICs of aztreonam combinations.

[From impasse to alliance, a singular encounter]. / De l'impasse à l'alliance, une rencontre singulière.

The story of Amina, hospitalised at the Oasis at the Ain psychotherapy centre (CPA), illustrates how a nursing team can be mobilised to avoid the use of seclusion. Time, creativity and respect for the patient are key to the success of the care approach.

Self-analysis and the development of an interpretation.

In spite of the fact that Freud's self-analysis was at the centre of so many of his discoveries, self-analysis remains a complex, controversial and elusive exercise. While self-analysis is often seen as emerging at the end of an analysis and then used as a criteria in assessing the suitability for termination, I try to attend to the patient's resistance to self-analysis throughout an analysis. I take the view that the development of the patient's capacity for self-analysis within the analytic session contributes to the patient's growth and their creative and independent thinking during the analysis, which prepares him or her for a fuller life after the formal analysis ends. The model I will present is based on an over lapping of the patient's and the analyst's self-analysis, with recognition and use of the analyst's counter-transference. My focus is on the analyst's self-analysis that is in response to a particular crisis of not knowing, which results in feeling intellectually and emotionally stuck. This paper is not a case study, but a brief look at the process I went through to arrive at a particular interpretation with a particular patient during a particular session. I will concentrate on resistances in which both patient and analyst initially rely upon what is consciously known.

Impactos que geram impasse frente à vulnerabilidade psicossocial / Impacts that generate impasses in face of psychosocial vulnerability

O artigo utiliza o mito de Sísifo para ilustrar o trabalho que um grupo de psicanalistas da SPPA realiza desde 2006 em parceria com a SMED (Secretaria Municipal de Educação da Prefeitura Municipal de Porto Alegre) e, a partir de 2013, com o Projeto Pescar/POA. Apresenta uma contextualização e relato de ambas as experiências através de vinhetas. Salienta que este trabalho, fora dos consultórios, desperta muitas inquietações e sentimentos de impotência. Obriga-nos a sair da posição do saber até a de sentir o desamparo frente à extrema violência. A banalização da violência tenderia a prejudicar nossa escuta? Primo Levi (1988) e Boris Cyrulnik (2009), que sobreviveram aos campos de concentração, nos ensinam a importância da palavra para dar um sentido possível ao sem sentido; destacam a possibilidade de mudar o sentimento íntimo de uma pessoa a partir do relato de suas experiências. Nos grupos de adolescentes, nos encontros com as famílias do Projeto Pescar e nas rodas de conversa com educadores e assessores da SMED, tentamos criar um espaço transicional que favoreça a criação de metáforas possíveis que ampliem a capacidade dos sujeitos de dar conta de seus impasses (Botbol, 2013)(AU)

This article draws upon the myth of Sisyphus to illustrate the work that a group of psychoanalysts of the Psychoanalytic Society of Porto Alegre has been undertaking since 2006 with the City Education Department of Porto Alegre (SMED) and, from 2013 on, with Pescar Project/POA. It presents a contextualization and a report of both experiences through vignettes. This work, outside the offices, often raises feelings of restlessness and powerlessness, demanding us to leave the position of knowing to assume that of feeling the helplessness in face of extreme violence. Could the banalization of violence impair our listening? Primo Levi (1988) and Boris Cyrulnik (2009), who have survived concentration camps, teach us the importance of the word to give a possible meaning to what is meaningless, highlighting the possibility of changing a person's intimate feeling by recounting his/her experiences. In adolescent groups, in the family meetings of Pescar Project and in conversations with SMED educators and assistants, we have tried to create a transitional space that favors the creation of possible metaphors to broaden the ability of subjects to tackle their impasses (Botbol, 2013)(AU)

En este artículo, se utiliza el mito de Sísifo para ilustrar el trabajo que realiza un grupo de psicoanalistas de la SPPA desde 2006 en alianza con la Secretaría Municipal de Educación de la Alcaldía Municipal de Porto Alegre (SMED) y, a partir de 2013, con el Proyecto Pescar, también de Porto Alegre. Se presenta una contextualización y el relato de ambas experiencias por medio de viñetas. Se señala que este trabajo, fuera de los consultorios, despierta muchas inquietudes y sentimientos de impotencia, obligándonos a salir de la posición del saber para experimentar la de sentir el desamparo frente a la extrema violencia. ¿La banalización de la violencia tendería a perjudicar nuestra escucha? Primo Levi (1988) y Boris Cyrulnik (2009), que sobrevivieron a los campos de concentración, nos enseñan la importancia de la palabra para dar un sentido posible al sin sentido. Ellos resaltan la posibilidad de cambiar el sentimiento íntimo de una persona a partir del relato de sus experiencias. En los grupos de adolescentes, en los encuentros con las familias del Proyecto Pescar y en las ruedas de conversación con educadores y asesores de la SMED, intentamos crear un espacio transicional que favorezca la creación de metáforas posibles que amplíen la capacidad de los sujetos de dar cuenta de sus impasses (Botbol, 2013)(AU)

[Is therapeutic deadlock inevitable?]. / Les impasses thérapeutiques : une fatalité ?

Many long-term treatments appear to be an expression of therapeutic deadlock. The situation leads to a questioning of the concept of chronicity and the identification of the determining factors of situations which are apparently blocked, marked by the search for solutions taking a back seat to the taking of action. The interaction between patients' mental apparatus and the care apparatus lies at the heart of the question, interpreted from an institutional, collective and individual perspective, supported by the clinical and psychopathological approach, and the return to the prioritisation of the thought.

[Shared feeling of therapeutic deadlock in a psychiatric institution]. / Sentiment partagé d'impasse thérapeutique en institution psychiatrique.

Therapeutic deadlock in psychiatry is different from other medical disciplines: the feeling of deadlock is inherent to psychiatric care with chronic patients. It is present in different forms in institutional life where it is often shared. Reintroducing processes of speaking and thinking is therefore a priority to treat and relaunch a fixed psychological approach both on the part of the patient as well as the team. Reasserting the "psychoanalytical work as a group" can be a way of understanding situations of deadlock to find new ways of moving forward.

[Deadlock in a crisis unit, from helplessness to containment]. / Impasse en unité de crise, du désarroi à la contenance.

The case of a young woman hospitalised in a psychiatric unit illustrates the deadlock which invades institutional life and presents possible solutions for overcoming it. This deadlock is in fact two-fold: that of the patient and that of the team caring for her. The patient's suffering is echoed by that of the caregivers, whose attempts to re-establish a bond, to give meaning to the procedures carried out, are lost in the meanders of an instability which has been reinforced over time by the pleasure of repetition.

[Cultivating confidence: a way forward in the face of therapeutic deadlocks]. / Cultiver la confiance : une piste face aux impasses thérapeutiques.

The aftercare centre is a therapeutic tool which sometimes enables situations of therapeutic deadlock to be overcome. By focusing on the long term, the patient is able to undertake a sustainable transformation of their relationship with themselves and with others. However, this challenging work cannot be carried out without a foundation of respect for the caregiving teams with regard to their therapeutic capacity as well as trust in their partners.

[Taking the time to understand to move on from therapeutic deadlock]. / Prendre le temps de comprendre pour sortir de l'impasse thérapeutique.

Psychotic symptoms of the type elementary phenomena and hallucinations can be pacified thanks to an individualised response. Teamwork is essential for fighting against the feeling of therapeutic deadlock. This article presents the therapeutic effects of the institutional care of a child with psychosis within a day hospital.

El cuerpo en la diferencia sexual / The body in the sexual difference

El presente texto fue elaborado en calidad de introducción para un volumen titulado "Ser-para-el-sexo", que reúne la contribuciones de Alenka Zupancic, Joan Copjec y Rithée Cevasco, acerca del debate contemporáneo en torno a la diferencia sexual. En este artículo hemos procurado poner de relieve la incidencia de la noción de cuerpo en dicho debate. El cuerpo se abre, entonces, al diálogo entre la voz de la filosofía y la voz del psicoanálisis lacaniano, y una tercera voz, que es la del feminismo, defensor de las premisas y planteamientos conceptuales de la teoría de género y, en particular, la voz de su principal precursora, Judith Butler. El hilo rojo que hilvana los diversos argumentos es la noción de cuerpo sexuado, es decir, el cuerpo marcado por la diferencia sexual como punto de impasse ontológico que el psicoanálisis ha puesto en primer plano

This paper was written as an introduction to a book entitled "Being-toward-sex", which includes the contributions by Alenka Zupancic, Joan Copjec and Rithée Cevasco, about the contemporary debate concerning sexual difference. Our purpose in this paper is to emphasize the incidence of the notion of body in such debate. The body is thus opened to the dialogue between the voice of philosophy and the voice of lacanian psychoanalysis, and also a third voice, that of feminism, defending the premises and concepts of gender theory, and particularly, the voice of its main precursor, Judith Butler. The red thread that links together the various arguments is the notion of sexed body, that is, the body affected by the sexual difference as a point of ontological impasse, which has been placed in the foreground by psychoanalysis

Agreement Attraction and Impasse Aversion: Reasons for Selecting a Poor Deal Over No Deal at All.

In the present studies, we examined the positive value of agreement and the negative value of impasse. Participants chose to give up real value and sacrifice economic efficiency in order to attain an agreement outcome and avoid an impasse outcome. A personally disadvantageous option was selected significantly more often when it was labeled "Agreement" rather than "Option A," and a personally advantageous option was avoided significantly more often when it was labeled "Impasse" rather than "Option B." In a face-to-face negotiation, a substantial proportion of individuals reached an agreement that was inferior to their best alternative to agreement. We showed that the appeal of agreement and the aversion to impasse both contribute to this effect, yet the aversion to impasse is the stronger of the two motivations. These findings have important implications for negotiators.

The challenge of a ban on animal testing for the development of a regulated legal market for new psychoactive substances (NPS) ('legal highs') in New Zealand: Issues and options for resolution.

BACKGROUND: In mid-July 2013, New Zealand passed the Psychoactive Substances Act (PSA), which allowed 'low risk' psychoactive products ('legal highs') to be approved for legal sale. In early May 2014, following public protest, the Psychoactive Substances Amendment Act (PSAA) was passed banning animal testing of psychoactive products, potentially making the new regime unworkable. AIM: To investigate strategies to overcome the impasse created by the animal testing ban. METHODS: Solutions to the impasse were investigated using 'scenario' and 'stakeholder' analysis. Legislation, parliamentary debates, and regulatory statements related to the PSA and animal testing were reviewed. Strategies to resolve the impasse were discussed with stakeholders including the Psychoactive Substances Regulatory Authority (PSRA) officials, health officials, a legal high industry lawyer, and a leading legal highs manufacturer. This process generated six possible scenarios and five decision-making criteria of key importance to major stakeholders. Scenarios were then evaluated based on feedback from the industry and regulators. RESULTS: The six scenarios were: (1) pragmatic modification of the animal testing ban; (2) waiting until new non-animal test models are internationally accepted; (3) use of non-validated replacement test methods; (4) judicial challenge of the animal testing ban; (5) 'creative compliance' by only presenting human clinical trial results; and (6) philosophical re-conceptualisation of the 'benefits' from psychoactive products. Options 1 and 5 appear to be the most attractive overall solutions. However, both rely on a new political consensus and astute framing of the issues by political communicators. Political decision makers may be happy to accept Scenario 2 which would impose significant delays. CONCLUSIONS: A 'failed' pharmaceutical product with psychoactive effects may have the test data required to be approved under Scenarios 1 and 5. Ultimately, the pleasurable benefits from psychoactive products may need to be included in the debate.