Introduction to "The older analyst at work: The old man and the sea?"

This Analyst at Work section examines the work of an older psychoanalyst as he ages yet continues to work as a psychoanalyst. Eike Hinze describes his work with a disturbed young man. Decisions about starting an analysis and the struggles involved in 'reaching' this patient form part of the question of whether this is a 'quest', or another analysis, near the end of an analytic career.Of particular note is Dr. Hinze's explicit use of his own 'reverie'/ countertransference/ unconscious states to form interventions. The two discussants express their own understanding of how they might approach the problems posed. They both speak to the forms of intervening that differ from their own, and their clinical understanding of revealing one's own associations in the clinical hour. They also speak to how the process of aging might have influenced the clinical work itself.The possible shift in technique over the course of Dr. Hinze's clinical career is more difficult to assess: does it come from age, maturity, shifts in theory and technique, or an intense desire to make emotional contact within this particular patient and clinical setting? These are the "question marks" conveyed in their discussions, like the one in the title itself.

The Impact Message Inventory-Circumplex (IMI-C): Exploring the Aversiveness Component of Therapists' Covert Reactions to Patients' Interpersonal Communications.

The Impact Message Inventory-Circumplex (IMI-C) is a two-dimensional measure of patient-induced countertransference. Surprisingly, in a replication study of its circumplex structure, Hafkenscheid and Timmerman could retrieve a third dimension, in addition to the basic dimensions of Affiliation and Control. They tentatively interpreted this preliminary third dimension as representing 'reactance' (oppositional and uncooperative patient behaviours), with 'active' and 'passive' as polarities. This provisional interpretation was no more than plausible and was partly speculative. Therefore, a more systematic empirical approach to the meaning embedded in the third dimension is required. The present empirical study tests the hypothesis that the preliminary third dimension might represent aversiveness rather than reactance. A panel of IMI-C users (N = 100) independently judged all 56 items of the instrument in terms of the general (i.e., without taking a specific patient in mind) emotional undertone enclosed in the item formulations using a forced choice three point scale format: 'positive emotional undertone' (+), 'neutral' (o) and negative (aversive) undertone (-). Overall, IMI-C users appeared to evaluate the formulations of items constituting the preliminary third dimension as intrinsically more aversive (negative emotional connotation), compared to the group of IMI-C items not included in this preliminary third dimension. However, the original octants of the IMI-C could be discriminated in terms of aversiveness as well. Anyhow, clinical interpretations of IMI-C profiles may benefit from an examination of the aversiveness component, enclosed within the items and octants themselves, irrespective of the specific patients judged with the instrument.

Treatment Objectives, Memory, and Desire.

This article explores the problems of the frequent loss, in the course of treatment, of the initial goals and motivation for treatment by both patient and therapist, and the connected lack of clarity of the real initial motivation for treatment on the part of both participants. It is strongly proposed that a true coincidence of at least one important initial motivational goal of patient and therapist is essential to assure the success of psychotherapy and that particular care is required to establish such agreement. On this basis, the goals of therapy may be expanded in the course of the therapist's experience, countertransference, and the patient's changing reality during treatment, and the existential and philosophical value systems of the therapist may play an important role in such widening of the therapist's expectations for the patient.

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.

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.

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.

Changes in mentalization in patients with personality disorders during sequential brief-Adlerian psychodynamic psychotherapy: The role of therapists' technique and countertransference.

Mentalization, that is the capacity to understand our and others' behaviors in terms of intentional mental states, represents one of the core features of personality disorders (PDs) and can be related to therapists' countertransference (CT) and interventions. AIMS: The aim of the present work was to study the relationship between therapists' technique, therapists' CT, and patients' mentalization, in a sample of patients with PDs undergoing a 40-session program of sequential brief-adlerian psychodynamic psychotherapy, a psychodynamic therapeutic model specifically developed for the treatment of PDs in public mental health services. METHOD: Eighty-seven patients with PD and their therapists completed ratings of mentalization (mentalization imbalances scale and reflective functioning questionnaire), CT (therapist response questionnaire), and therapists' intervention (comparative psychotherapy process scale) at five different time points (Sessions 5, 10, 20, 30, and 40). RESULTS: Results showed that patients' mentalizing problematics decreased over time. Moreover, we found a reduction of therapists' disengaged CT, and an increase in positive CT over time. Regarding therapists' techniques, psychodynamic-interpersonal interventions were on average higher than cognitive-behavioral, but both techniques were used increasingly over time. Our results also showed significant and clinically coherent interactions between therapist's CT and techniques and between patient's mentalization imbalance and therapist's response. Our results highlighted the importance of early stages in therapy, since the most significant relationships between the various process variables (patient's mentalizing imbalances, therapist's techniques, and emotional responses) are observed between t1 and t2, corresponding to the initial phases of the treatments. Clinical implications will be discussed. (PsycInfo Database Record (c) 2024 APA, all rights reserved).

"How Can I Trust You When I Know You Can Die?" Surviving the Death of an Analyst in a Child Analysis.

This reflection on the initial stages of treatment of a latency girl whose previous analyst died offers some insights into inner workings of mourning in children. The mourning process intersects in complex ways with a developmental stage, object constancy, unconscious phantasies, and conscious ideas about life and death. Clinical material illustrates some challenges that emerge in the transference-countertransference matrix when working with a child who lost both her primary object (the mother) and her transference object (the analyst). The reality of the analyst's death emphasizes that for a child patient the analyst is always a transference object and a real object at once.

What Should Health Professions Students Know About Countertransference in Inpatient Psychiatric Environments?

Inpatient psychiatric units are heavily regulated physical environments designed around the twin aims of treatment and containment. Less formally regulated but no less important are emotional norms and tones that also contribute significantly to psychiatric care environments. Inpatient psychiatric units are co-created by patients and clinicians, but clinicians have authority that patients do not. This means that clinicians' management of their own transference and reactions is clinically and ethically important. This article defines transference reactions and draws on case examples to canvass how positive and negative transference reactions can influence inpatient care of patients who are suicidal.

A tripartite model of the psychotherapy relationship: Interrelations among its components and their unfolding across sessions.

The tripartite model of the therapy relationship, which includes the working alliance, real relationship, and transference-countertransference configuration, has been a useful way to conceptualize the complexity of the connection between a therapist and a client. However, little research has focused on the interrelationships between these three components over time. This study sought to replicate the findings of Bhatia and Gelso (2018) by examining the between-person relationships among each of the three elements averaged across all sessions. Additionally, we extended earlier work by examining the within-person relationship between the working alliance, the real relationship, and transference-countertransference with themselves as well as with each of the other elements across sessions. Using 5,931 sessions across 142 clients and 36 therapists, we examined time-ordered associations among the cocreated working alliance, cocreated real relationship, and the therapist-rated transference-countertransference configuration using latent variable dynamic structural equation modeling. Results replicated the findings of Bhatia and Gelso (2018), demonstrating that in one session, the working alliance and the real relationship were positively related, and both the working alliance and the real relationship were negatively related to the transference-countertransference configuration. Regarding the interrelations over time, the findings revealed that the working alliance in the previous session had a significant and positive relationship with real relationship in the current session, and the real relationship in the previous session was related to reduced transference-countertransference in the current session. These findings provide support for complex interrelations among the components over time. (PsycInfo Database Record (c) 2024 APA, all rights reserved).

[Loss of contact between doctor and patient: early signaling can prevent escalation]. / Verbroken arts-patiëntcontact.

A good therapeutic relationship leads to better outcomes. In the event of an imminent break in contact, discussing the alliance rupture can be helpful. Optimal use of the countertransference also contributes. Metacommunication can be useful. In this article, some cases illustrating these concepts, are being discussed.

Rorschach Human Movement and Psychotherapy: Relationship with the Therapist's Emotional Responses.

The emotional responses of psychotherapists to their patients, known as countertransference, can yield valuable insights into the patient's psychological functioning. Albeit from a different perspective, the Rorschach test also provides information about the patient's psychological processes. In particular, the Rorschach human movement response (M) has been shown to be a useful measure of higher-level psychological functioning. In an attempt to bridge these two largely different perspectives, the aim of this study was to explore the association between M responses in the Rorschach protocols of psychotherapy patients and emotional responses exhibited by their therapists. To this end, a convenience sample of 149 outpatients were administered the Rorschach according to the Comprehensive System, and their therapists completed the Therapist Response Questionnaire. Through a series of regression models, controlling for response style, response complexity, and degree of psychopathology, M demonstrated a significant association with the therapists' emotional responses. A lower number of M responses was associated with the therapists' feelings of disengagement, and a higher number of M responses was associated with the therapists' feelings of being more involved with the patient. Taken together, these results suggest a potential relationship between the number of M responses the respondent gives in the Rorschach and the subsequent development of the therapeutic alliance between the respondent and their therapist.

Structural Aspects of Synchronistic Moments in Psychotherapy-Findings of an Empirical Study of Synchronicities in Psychotherapy and Psychoanalysis1.

Synchronicity describes a meaningful coincidence of events, which is familiar to us from treatments of our patients, but unfortunately has not yet been empirically substantiated. Adding to previous findings that point out beneficial aspects of synchronicity (Marlo, 2022; Lagutina, 2021; Connolly, 2015), in this paper I will show through a series of five synchronistic moments which happened in the context of therapy and analysis and which have been documented empirically, how synchronicities occur and can be used therapeutically. In my research I found several situational factors that can be considered structural aspects of synchronistic moments. Furthermore, I will show that synchronistic phenomena can have a positive influence if certain relational and transference-countertransference referential aspects are considered by the therapist and analyst. The concept of synchronicity brings the possibility of a further therapeutical instrument for the patient-analyst-dyad.

La synchronicité décrit une coïncidence significative d'événements, qui nous est familière dans les traitements de nos patients, mais qui malheureusement n'a pas encore pu être étayée scientifiquement. Dans cet article - tout en allant dans le sens d'articles antérieurs qui montrent les aspects bénéfiques de la synchronicité (Marlo, 2022; Lagutina, 2021, Connolly, 2015) - je montrerai, à travers une série de cinq moments synchronistiques qui se produisirent dans le contexte de thérapie et d'analyse et qui ont été documentés de manière empirique, comment les synchronicités se produisent et comment elles peuvent être utilisées de manière thérapeutique. Dans ma recherche j'ai trouvé plusieurs facteurs situationnels qui peuvent être considérés comme des aspects structurels de moments synchronistiques. De plus, je montrerai que les phénomènes de synchronicité peuvent avoir une influence positive si certains aspects relationnels, et qui font référence au transfert-contretransfert, sont pris en compte par le thérapeute et l'analyste. Le concept de synchronicité offre la possibilité d'un instrument thérapeutique de plus pour la dyade patient-analyste.

La sincronicidad describe una coincidencia significativa de eventos, que nos es familiar a partir de los tratamientos de nuestros pacientes, pero que desafortunadamente aún no ha sido científicamente fundamentada. Sumándome a hallazgos previos que dan cuenta de aspectos beneficiosos de la sincronicidad (Marlo, 2022; Lagutina, 2021; Connolly, 2015), en este trabajo mostraré a través de una serie de cinco momentos sincronísticos que sucedieron en el contexto de la terapia y el análisis y que han sido documentados empíricamente, cómo suceden las sincronicidades y cómo pueden utilizarse terapéuticamente. En mi investigación encontré varios factores situacionales que pueden considerarse aspectos estructurales de los momentos sincronísticos. Además, mostraré que los fenómenos sincronísticos pueden tener una influencia positiva si ciertos aspectos relacionales y vinculados a la transferencia-contratransferencia son considerados por el analista - terapeuta. El concepto de sincronicidad brinda la posibilidad de un instrumento terapéutico más para la díada paciente-analista.

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.

The Kvetch: Assessment, Pathogenesis, and Treatment of Patients Who Are Clinically Impaired by Chronic Complaining.

ABSTRACT: Clinicians often encounter patients whose presentations are characterized by long lists of complaints about their biological, psychological, interpersonal, and social conditions. The problems on which the complaints are based are variably reality-based and variably modifiable. Some of these patients display chronic complaining as a core, distinguishing feature. Accordingly, the aims of this article are to consider excesses of chronic complaining as psychiatric phenomena, explore possible pathogenetic contributions, describe approaches for treating conditions marked by clinically pertinent chronic complaining, and suggest areas for future research. Based on clinical observations enhanced by selective narrative literature review, we delineate and differentiate four groups of patients: 1) situational complainers; 2) chronic complainers due to unidentified medical problems; 3) mood-induced chronic complainers; and 4) personality-driven pan-dimensional chronic complainers. The last-mentioned group consists of help-seeking versus help-rejecting subtypes, the latter including a subset we designate as malignant chronic complainers. Strategies for managing these patients begin with detailed assessment of all complaints, ascertaining reality-based contributions to the complaints, including those initiated by patients themselves. Management approaches use specific biopsychosocial techniques based on patient-centered particulars. Psychotherapeutic strategies center on compassionate, empathic witnessing. Specific tactics include attending to unresolved grief and trauma, behavioral activation, cognitive and narrative restructuring and reframing methods, mentalizing and imaginal approaches, and psychodynamic methods including attention to attachment issues and transference. Sources of countertransference reactions to these patients should be identified and can be addressed. The many questions raised by these patients' presentations merit further research.

Recommendations for Dynamic Treatment of Identity-Based Trauma: Opening the "I" to Reflection.

Current treatments for trauma are ineffective for many patients. For traumas involving violence that targets aspects of patients' identities, treatments that do not address systemic factors involved in the trauma (e.g., past and ongoing experiences of identity-based oppression and marginalization, developmental sequelae of invalidation or policing of identity, and identity-related patterns of transference and countertransference) may be ineffective. Psychodynamic approaches can flexibly address the identity-related dynamics between therapist and patient and incorporate patients' experiences of their various identities, in the context of trauma, into clinical formulation and treatment. The authors present concepts relevant to the dynamics of intersectional identities that may arise between therapist and patient and provide a case study illustrating how a patient's various identities affect their symptom manifestation and treatment course. The authors advocate for cultural humility and self-exploration of biases and assumptions among clinicians, because therapists do not hold expert knowledge of their patients' cultural experiences.

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.

Anxiety, Desire, and the Object a: Lacan on Lucia Tower's "Countertransference".

Lacan's seminars are a treasure trove of innovative psychoanalytic explorations. In Seminar X, Anxiety, he takes up this Freudian theme and explores a number of interrelated ideas: castration, the difference between the sexes, two different forms of acting out, and what he terms his only original theoretical contribution: the object a and its "various incidences." The object a is described here in detail, especially in relation to Lacan's argument that analysts who are women have a freer relationship to their desire and the countertransferences it spawns than do men. Lacan discussed Lucia Tower's classic paper, "Countertransference," in light of these notions. This essay is a close reading of Lacan's close reading of Tower, whose account, he says, must be approached in all its "innocence and freshness."