Rethinking treatment failures. Research on a group of Italian psychotherapists.

Introduction: Psychotherapeutic failures involve situational, relational, and personal factors. Dropout refers to a patient's unilateral termination of treatment without the therapist's knowledge or approval. Premature termination occurs when therapy is discontinued before achieving a sufficient reduction in initial problems. Objective: This study explores the role of therapist's emotional response (countertransference), gender, psychotherapeutic orientation, and patient diagnosis in the context of psychotherapeutic failures. Method: A mixed-method approach was used. Fifty-nine Italian psychotherapists, practicing mostly privately with at least 5 years of experience, were recruited through Italian professional internet websites. The Therapist Response Questionnaire and the Impasse Interview were administered to each psychotherapist. Each therapist was asked to reflect on their last dropout patient. Quantitative (MANOVA) and qualitative analyses (textual content analysis) were conducted with SPSS and T-LAB, respectively. Results: The quantitative analyses revealed that the most frequent countertransference response was Helpless/Inadequate, with female therapists experiencing this more frequently than male therapists. The qualitative analyses identified two main factors explaining most of the variance in countertransference responses: Parental/Protective versus Hostile/Angry, and Positive/Satisfying versus Helpless/Inadequate, with Helpless/Inadequate central. Additionally, the qualitative analysis of treatment interruption methods revealed two factors explaining over 50% of the variance. Lack of communication was linked to negative themes, while mediated and direct communication were associated with positive terms. Direct communication was characterized as useful, while mediated communication was linked to dropout and attachment figures. Conclusion: Under pressure, psychotherapists' anxiety levels increase, often managed ambivalently or avoidantly. These results suggest that awareness of psychotherapist emotional responses is important to limit psychotherapeutic failures. These findings offer valuable insights for clinical practice.

Playing, Paradox, and Analytic Activity Between Knowing and Being.

The author explores some ways that we help patients to hold paradoxical realities intrinsic to transference and play in analytic work. He suggests that Winnicott's guardianship of the setting for the emergence of playing raises questions about the role of neutrality in an ontological analysis. The author tries to demonstrate some ways that the work of helping patients to hold paradox in play overlaps with a concept that he has earlier referred to as an activity of neutrality. He explores how in the analytic process, understanding and being are two dimensions of the analytic process that work in concert with each other. Often the analyst works quietly in spaces between epistemological and ontological approaches in the holding of paradox.

Bion's Transformations and Clinical Practice.

Wilfred Bion's contributions to psychoanalysis are numerous: his early work on the psychology of groups that grew out of his experiences in the first World War; theories and work on the treatment of psychosis with Melanie Klein and later psychoanalysis with her; and the beginning of his own theoretical and clinical ideas, which nurtured analytic thinking and treatment approaches beginning in the mid-1960's followed by his relocation to the United States (1967). Bion's thinking can be deceptively simple, such as his statement that his third book, Transformations (1965), considered by many as exceptionally dense, is about "the communication of both patient and analyst about an emotional experience" (p. 29).

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.

The Affective Charge of Sulphur and Salt in Working with Compulsion.

The author presents a long analysis of a patient, Giulia, whose obstinate will to achieve evokes the workings of alchemical sulphur at its fieriest and a dread of its coniunctio with alchemical salt. Jung's description of these symbols in Mysterium Coniunctionis offers a useful imaginal perspective to clinical work in the area of compulsion and its possible transformations. Right from the start, the analytic relationship appeared to be mirrored and affected by this alchemical perspective. However, it was only after much time, uncertainty and emotional endurance that a fuller psychological experience of sulphur and salt could be accessed, allowing the analysis to take a more imaginative and mercurial turn. In the course of his work with Giulia the author has witnessed and experienced a range of intense affects-the many colours that the combustion of sulphur can generate-whether on the verge of unstoppable creation or ruthless destruction, often of archetypal intensity. This experience has been lived through and has undergone a transformative relation with salt, which until then had lived a dissociated existence in the fixed trauma of the compulsion and in a nocturnal underworld of tears.

L'auteur présente la longue analyse d'une patiente, Giulia, dont la volonté obstinée de réussir fait penser à l'activité du soufre alchimique à son point le plus ardent et à la crainte terrible de son coniunctio avec le sel alchimique. La description que fait Jung de ces symboles dans Mysterium Coniunctionis fournit une perspective imaginale qui est utile pour le travail clinique dans le domaine de la compulsion et de ses transformations possibles. Dès le début, la relation analytique semblait être reflétée et affectée par cette perspective alchimique. Cependant, ce fut seulement après beaucoup de temps, d'incertitude et d'endurance émotionnelle qu'une expérience psychologique plus complète du soufre et du sel a pu être atteinte, ce qui a permis à l'analyse de prendre une tournure plus imaginative et plus mercurienne. Durant son travail avec Giulia l'auteur a été témoin et a éprouvé un éventail d'affects intenses ­ les multiples couleurs que la combustion du souffre peut générer ­ que ce soit au bord d'une création irrésistible ou d'une destruction impitoyable, souvent d'une intensité archétypale. Cette expérience a été traversée et a subi une relation transformative avec le sel, qui jusqu'alors avait vécu une existence dissociée dans le traumatisme figé de la compulsion et dans les enfers nocturnes des larmes.

El autor presenta un largo análisis de una paciente, Giulia, cuya obstinada voluntad de logro evoca el funcionamiento del azufre alquímico en su forma más ardiente y el temor a su coniunctio con la sal alquímica. La descripción que Jung hace de estos símbolos en Mysterium Coniunctionis ofrece una perspectiva imaginal útil para el trabajo clínico en el ámbito de la compulsión y sus posibles transformaciones. Desde el principio, la relación analítica pareció reflejarse y verse afectada por esta perspectiva alquímica. Sin embargo, fue sólo después de mucho tiempo, incertidumbre y resistencia emocional que pudo accederse a una más plena experiencia psicológica de azufre y sal, lo cual permitió que el análisis tomara un giro más imaginativo y mercurial. En el transcurso de su trabajo con Giulia, el autor ha sido testigo y ha experimentado una gama de intensas emociones ­los múltiples colores que puede generar la combustión del azufre­, ya sea al borde de una creación imparable o de una destrucción despiadada, a menudo de intensidad arquetípica. Esta experiencia pudo ser atravesada y ha experimentado una relación transformadora con la sal, la cual hasta entonces había vivido una existencia disociada en la fijeza compulsiva del trauma y en un submundo nocturno de lágrimas.

Teleanalysis Does Not Have to be "Muted": On the Crucial Role of the Analyst's Internal Frame in any Setting.

Given that practicing teleanalytically is relatively new and more widespread than ever, questions about how to practice and teach it effectively have increased and are more pressing than ever. To contribute answers to these questions, this paper addresses long-standing and persisting negative views of teleanalysis as an inherently muted, remote, and pale experience with reduced therapeutic effectiveness. I propose that this view of teleanalysis as inherently inferior to in-office analysis limits or even precludes its therapeutic usefulness because it allows analysts to avoid making analytic use of the disturbing feelings hiding within the experience of practicing teleanalysis. Through case examples, I suggest that when analysts do not take our negative views of teleanalysis at face value but instead consider them as symbolic expressions of our and our patients' anxieties, we can improve our understanding of our analytic functioning within the tele-setting and enhance our capacity to think and engage analytically effectively in any setting. I maintain that these considerations have important implications, not only for how experienced analysts practice, but also for how we treat and teach future analysts.

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.

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.

[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.

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.

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 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.

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.

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.

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.

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.