Mourning, melancholia and machines: An applied psychoanalytic investigation of mourning in the age of griefbots.

Death and mourning are being shaped by posthumous opportunities for the dead to affect current life in ways not possible in pre-digital generations. The psychological and sociological impact of the dead "online" and of "grief tech" is only beginning to be understood. It has not yet been explored psychoanalytically until this paper that examines one type of grief tech, namely the griefbot. This development is critically explored through a psychoanalytic reading of an episode of Black Mirror. I suggest that a psychoanalytic model of mourning provides an invaluable perspective to help us to think about this technology's potential as well as the psychological and ethical risks it poses. I argue that the immortalization of the dead through digital permanence works against facing the painful reality of loss and the recognition of otherness, which is fundamental to psychic growth and to the integrity of our relationships with others. Drawing on Derrida's conceptualization of "originary mourning", I suggest that mourning is an interminable process that challenges us to preserve within the self the otherness of the lost object. The tools we use for mourning need to be assessed first and foremost against this psychological and fundamentally ethical process.

The Seductions of Identity: Thinking About Identity and Transgender.

In this paper I first outline a conceptual compass to think about identity generally before addressing more specifically the question of transgender identity. To this end, I draw on Gilles Deleuze's (1993) related concepts of the rhizome and of the fold. I then argue that the body has always been and is ever-more-so the place for figurating the self, for finding and substantiating identity-hence, the unconscious psychic investments that we have in our bodies are key to our theorizing about any kind of identity. I propose that this focus provides a more productive, generative starting point for thinking about transgender identity specifically than any individual developmental theory because it accommodates the heterogeneity subsumed under the umbrella term transgender.

The missing: Exploring the use of photographs in "working through" the natal body with transgender youth.

This paper focuses on how for some young people who identify as transgender, the anticipation, and/or the actual process, of transitioning represents a movement away from something in themselves that feels wrong, painful, or traumatic and that has not yet been consciously recognised as such. This becomes a 'missing' part of the self's experience, locked into the body. I suggest that the process of identifying and restitution of 'the missing' part requires working through the natal body in its metaphorical and literal senses, in the service of expanding autonomous choice about how to find a hospitable home in the body. Building on Money-Kyrle's three 'facts of life', I propose a fourth one, namely the inescapable fact of our embodied nature, to underscore that our personal history always includes our embodied history, hence the importance of working through what the natal body unconsciously represents. I describe the use of photographs during psychoanalytic psychotherapy with young people who have commenced social transitioning, to work through visual representations of the natal body in the service of facilitating the working through, in its psychoanalytic sense, of the natal body's unconscious narrative. I suggest that deploying this visual mode may be especially helpful in engaging young people on the autistic spectrum who nowadays comprise a significant minority of transgender young people.

Efficacy and moderators of short-term psychodynamic psychotherapy for depression: A systematic review and meta-analysis of individual participant data.

BACKGROUND: Short-term psychodynamic psychotherapy (STPP) is frequently used to treat depression, but it is unclear which patients might benefit specifically. Individual participant data (IPD) meta-analyses can provide more precise effect estimates than conventional meta-analyses and identify patient-level moderators. This IPD meta-analysis examined the efficacy and moderators of STPP for depression compared to control conditions. METHODS: PubMed, PsycInfo, Embase, and Cochrane Library were searched September 1st, 2022, to identify randomized trials comparing STPP to control conditions for adults with depression. IPD were requested and analyzed using mixed-effects models. RESULTS: IPD were obtained from 11 of the 13 (84.6%) studies identified (n = 771/837, 92.1%; mean age = 40.8, SD = 13.3; 79.3% female). STPP resulted in significantly lower depressive symptom levels than control conditions at post-treatment (d = -0.62, 95%CI [-0.76, -0.47], p < .001). At post-treatment, STPP was more efficacious for participants with longer rather than shorter current depressive episode durations. CONCLUSIONS: These results support the evidence base of STPP for depression and indicate episode duration as an effect modifier. This moderator finding, however, is observational and requires prospective validation in future large-scale trials.

Identifying with the beautiful: Facial attractiveness effects on unisensory and multisensory self-other distinction.

People tend to evaluate their own traits and abilities favourably and such favourable self-perceptions extend to attractiveness. However, the exact mechanism underlying this self-enhancement bias remains unclear. One possibility could be the identification with attractive others through blurring of self-other boundaries. Across two experiments, we used the enfacement illusion to investigate the effect of others' attractiveness in the multisensory perception of the self. In Experiment 1 (N = 35), participants received synchronous or asynchronous interpersonal visuo-tactile stimulation with an attractive and non-attractive face. In Experiment 2 (N = 35), two new faces were used and spatial incongruency was introduced as a control condition. The results showed that increased ratings of attractiveness of an unfamiliar face lead to blurring of self-other boundaries, allowing the identification of our psychological self with another's physical self and specifically their face, and this seems to be unrelated to perceived own attractiveness. The effect of facial attractiveness on face ownership showed dissociable mechanisms, with multisensory integration modulating the effect on similarity but not identification, an effect that may be purely based on vision. Overall, our findings suggest that others' attractiveness may lead to positive distortions of the self. This research provides a psychophysical starting point for studying the impact of others' attractiveness on self-face recognition, which can be particularly important for individuals with malleable, embodied self-other boundaries and body image disturbances.

To be, or not to be? The role of the unconscious in transgender transitioning: identity, autonomy and well-being.

The exponential rise in transgender self-identification invites consideration of what constitutes an ethical response to transgender individuals' claims about how best to promote their well-being. In this paper, we argue that 'accepting' a claim to medical transitioning in order to promote well-being would be in the person's best interests iff at the point of request the individual is correct in their self-diagnosis as transgender (i.e., the distress felt to reside in the body does not result from another psychological and/or societal problem) such that the medical interventions they are seeking will help them to realise their preferences. If we cannot assume this-and we suggest that we have reasonable grounds to question an unqualified acceptance in some cases-then 'acceptance' potentially works against best interests. We propose a distinction between 'acceptance' and respectful, in-depth exploration of an individual's claims about what promotes their well-being. We discuss the ethical relevance of the unconscious mind to considerations of autonomy and consent in working with transgender individuals. An inquisitive stance, we suggest, supports autonomous choice about how to realise an embodied form that sustains well-being by allowing the individual to consider both conscious and unconscious factors shaping wishes and values, hence choices.

Dynamic interpersonal therapy for moderate to severe depression: a pilot randomized controlled and feasibility trial.

BACKGROUND: Improving Access to Psychological Therapies (IAPT) services treat most patients in England who present to primary care with major depression. Psychodynamic psychotherapy is one of the psychotherapies offered. Dynamic Interpersonal Therapy (DIT) is a psychodynamic and mentalization-based treatment for depression. 16 sessions are delivered over approximately 5 months. Neither DIT's effectiveness relative to low-intensity treatment (LIT), nor the feasibility of randomizing patients to psychodynamic or cognitive-behavioural treatments (CBT) in an IAPT setting has been demonstrated. METHODS: 147 patients were randomized in a 3:2:1 ratio to DIT (n = 73), LIT (control intervention; n = 54) or CBT (n = 20) in four IAPT treatment services in a combined superiority and feasibility design. Patients meeting criteria for major depressive disorder were assessed at baseline, mid-treatment (3 months) and post-treatment (6 months) using the Hamilton Rating Scale for Depression (HRSD-17), Beck Depression Inventory-II (BDI-II) and other self-rated questionnaire measures. Patients receiving DIT were also followed up 6 months post-completion. RESULTS: The DIT arm showed significantly lower HRSD-17 scores at the 6-month primary end-point compared with LIT (d = 0.70). Significantly more DIT patients (51%) showed clinically significant change on the HRSD-17 compared with LIT (9%). The DIT and CBT arms showed equivalence on most outcomes. Results were similar with the BDI-II. DIT showed benefit across a range of secondary outcomes. CONCLUSIONS: DIT delivered in a primary care setting is superior to LIT and can be appropriately compared with CBT in future RCTs.

Stepped approach to improving sexual function after gynaecological cancer: the SAFFRON feasibility RCT.

BACKGROUND: Women affected by gynaecological cancer are often unaware of the sexual consequences of both the cancer and its treatment. Most do not receive appropriate advice or help to recover sexual function, and the effect on their sexuality may be profound, both physically and emotionally. However, several potential therapies can be effective in helping recover some sexual engagement and change self-perception around sex. A major initial challenge is informing and involving patients in an appropriate and sensitive manner, and a further issue is delivering therapies in busy gynaelogical oncology clinics. This study was conceived in response to a National Institute for Health Research (NIHR) Health Technology Assessment (HTA) call asking for proposals to improve sexual functioning in women treated for gynaecological cancer while taking into account associated issues of mood. Existing evidence-based therapies for improving sexual function after cancer treatment were adapted and placed within a 'stepped care' model for delivering these in the NHS setting. An assessment and treatment stepping algorithm was developed in parallel, both to assign women to a treatment level at assessment and to follow their progress session by session to advise on changing intervention level. The assessment tool was applied to all participants on the principle that the problem was sexual difficulty, not the cancer of origin. PARTICIPANTS: Women aged > 18 years (with partners at their choice) treated for any gynaecological malignancy with surgery and/or chemotherapy and/or radiation at University College London Hospital or Bristol Gynaecological cancer centres, minimally 3 months post end of treatment, of any sexual orientation, with sexual function difficulties identified by three initial screening questions. DESIGN: A feasibility two-arm, parallel-group randomised controlled pilot trial. SETTING: Two NHS gynaecological cancer centres, one in London and one in Bristol. INTERVENTIONS: A three-level stepped care intervention. OBJECTIVE: To assess the feasibility of conducting a full-scale investigation of stepped therapy and indicate the potential benefits to patients and to the NHS generally. PRIMARY OUTCOME MEASURES: Recruitment to study, proportion of women stepping up, number of usable data points of all measures and time points over length of trial, and retention of participants to end of trial. RESULTS: Development of the intervention and accompanying algorithm was completed. The study was stopped before the recruitment stage and, hence, no randomisation, recruitment, numbers analysed, outcomes or harms were recorded. LIMITATIONS: As the study did not proceed, the intervention and its accompanying algorithm have not been evaluated in practice, and the capacity of the NHS system to deliver it has not been examined. CONCLUSIONS: None, as the study was halted. FUTURE WORK: The intervention could be studied within a clinical setting; however, the experience of the study group points to the need for psychosocial studies in medical settings to establish pragmatic and innovative mechanisms to ensure adequate resource when extending staff clinical skills and time to deliver any new intervention for the duration of the trial. TRIAL REGISTRATION: Current Controlled Trials ISRCTN12010952 and ClinicalTrials.gov NCT02458001. FUNDING: This project was funded by the NIHR HTA programme and will be published in full in Health Technology Assessment; Vol. 23, No. 5. See the NIHR Journals Library website for further project information.

Women affected by gynaecological cancer are often unaware of the sexual consequences of the cancer and its treatment. Most do not receive appropriate help to recover sexual function, and the physical and mental impact on their sexuality may be profound. However, several therapies could be effective in helping recovery. A major initial challenge is informing and involving patients appropriately and sensitively, and a further challenge is delivering therapies in busy cancer clinics. This study was conceived in response to the funder's call asking for proposals to improve sexual functioning in women treated for gynaecological cancer while taking into account associated issues of mood. Existing evidence-based therapies for improving sexual function after gynaecological cancer treatment were adapted and a new therapy for complex difficulties was devised. Three levels of intervention were developed and placed into a 'stepped care' model: a self-help intervention, a clinical nurse specialist-delivered intervention and a clinical psychologist high-level intervention for problems not responding to levels 1 and 2. In parallel, an assessment and treatment algorithm was developed to assess women and follow their progress closely to inform whether or not their intervention level should be changed. However, major difficulties were encountered: procedural and logistical delays in setting up the study, both at the beginning across a range of hospitals and, later, at the point of training staff within the NHS to deliver the interventions within their clinical workload. Issues such as maternity leave with untrained locum cover led to nursing staff being unable to free up qualified staff to be part of the study. It is hoped that the existing developments can be tested in a future study to determine (1) if they are effective and (2) whether or not they can be delivered within the NHS.

Trans-itory identities: some psychoanalytic reflections on transgender identities.

The capacity of transgender to incorporate all gender variance and sexual preferences has become a powerful tool of activism and personal identification. Rather than being an index of marginality "trans" has become a central cultural site. In this paper, I will argue that this identity label encompasses a complex range of internal psychic positions in relation to consciously stated sexual preferences and gender identifications. My aim is to explore what can appear to be in some cases a premature embracement of the empowering potential of the transgender identification through my work with under 18-year-olds who are seeking medical intervention for gender dysphoria. This can undermine the painful psychic work required to establish what transgender means for any given young person. In an external culture where to ask "why transgender" (as opposed to "how transgender") is felt to be pathologising, working with these young people can prove difficult for the analyst. The challenge is to tread the fine line between a dialogue based on an equidistant curiosity about meaning and function that is core to an analytic approach, and a posture of implicit skepticism.

A psicanálise em tempos de tecnocultura: algumas reflexões sobre o destino do corpo no espaço virtual / Psychoanalysis in times of technoculture: some reflections on the fate of the body in virtual space / El psicoanálisis en tiempos de tecnocultura: algunas reflexiones sobre el destino del cuerpo en el espacio virtual

Neste trabalho, a autora oferece uma visão geral de alguns desafios que os psicanalistas encontram em tempos de tecnocultura. Sustenta mais especificamente que, em nosso trabalho clínico, podemos observar como os avanços tecnológicos e os valores predominantes da cultura contemporânea tornam possíveis e aceitáveis a alteração e ampliação do corpo e suas funções na realidade e no espaço virtual. Isso pode contribuir para um split entre o corpo e o self, levando a uma versão século XXI muito particular da subjetividade incorporada, que estimula uma negligência em relação ao significado inconsciente do corpo. Os problemas surgem quando, de um ponto de vista psicológico, não estamos mais pensando o virtual como sendo uma ampliação do assim chamado real, e sim como sendo uma alternativa ao real. Contudo, a autora também discute um caso clínico que ilustra como a utilização do ciberespaço pode promover o “desenvolvimento” psíquico e como pode ser usado para evitar a experiência (psíquica). Isso tem implicações técnicas em termos de como abordamos em nossas interpretações o uso que o paciente faz das novas tecnologias para atender às prerrogativas do mundo interno em relação ao contexto externo contemporâneo.

In this paper the author gives an overview of some of the challenges facing psychoanalytic clinicians working in times of technoculture. More specifically she argues that in our clinical work we can observe how technological advances and the dominant values of contemporary culture make it possible and acceptable to alter and extend the body and its functions in actuality and in virtual space. This can contribute to a split between the body and the self, leading to a very particular twenty-first century version of embodied subjectivity that encourages a neglect of the body's unconscious meaning for the individual. Problems arise, from a psychological point of view, when we are no longer thinking in terms of the virtual as augmentation to the so-called real but more along the lines of the virtual as alternative to the real. However the author also discusses a clinical case to illustrate how the use of cyberspace can also be used to support psychic “development” as much as it can be used to foreclose experience. This has technical implications in terms of how the analyst interprets the patient's use of new technologies to meet the prerogatives of the internal world and of development.

En este trabajo, la autora ofrece una visión general de algunos desafíos que los psicoanalistas encuentran en los tiempos de tecnocultura. Sostiene, específicamente, que en nuestro trabajo clínico podemos observar cómo los avances tecnológicos y los valores predominantes de la cultura contemporánea hacen posibles y aceptables la alteración y ampliación del cuerpo y sus funciones en la realidad y en el espacio virtual. Esto puede contribuir con un split entre el cuerpo y el self, llevando a una versión siglo XXI, muy particular, de la subjetividad incorporada que estimula una negligencia en relación al significado inconsciente del cuerpo. Los problemas surgen cuando, desde un punto de vista psicológico, no estamos pensando más en lo virtual como una ampliación de lo llamado real. Sin embargo, la autora también discute un caso clínico para ilustrar cómo la utilización del ciberespacio puede promover el “desarrollo” psíquico, así como también puede ser usado para evitar la experiencia (psíquica). Esto tiene implicaciones técnicas en términos de cómo abordamos, en nuestras interpretaciones, el uso que el paciente hace de las nuevas tecnologías para atender a las prerrogativas del mundo interno en relación al contexto externo contemporáneo.

El psicoanálisis en tiempos de la tecnocultura: algunas reflexiones sobre el destino del cuerpo en el espacio virtual / Psychoanalysis in times of technoculture: some reflections on the fate of the body in virtual space

La autora constata la creciente presencia en la vida contemporánea de la tecnocultura y el ciberespacio. Partiendo de la ya polémica contraposición freudiana entre la realidad fáctica y la realidad psíquica (con elementos virtuales por definición), se pregunta por la influencia psíquica de los mundos virtuales que ofrecen internet y el ciberespacio. Se adentra en la complejidad de algunos de ellos, como Second Life o diferentes programas de investigación en que el protagonista puede habitar diferentes cuerpos o avatares en el mundo virtual. Presenta la experiencia de un proceso analítico con un paciente que motu proprio hace uso primero de vídeos y chats que va llevando como material a su analista, para más adelante pasar a experiencias virtuales con contacto visual con otros, y finalmente a contactos en la realidad fáctica. Analiza la trascendencia para el paciente de estos intercambios progresivos para asumir y desarrollar aspectos de su imagen corporal e identidad sexual. La autora propone el mundo del ciberespacio como un espacio potencial para la experimentación y progresiva elaboración psíquica y que podría ser considerado en los procesos psicoanalíticos como material de utilidad para el crecimiento y la maduración psíquica (AU)

The author notes the increasing presence of techno-culture an cyberspace in contemporary life. Starting from the already controversial Freudian opposition between factual reality and psychic reality (with virtual elements by definition), she questions the psychic influence of the virtual worlds offered by the internet and cyberspace. She explores the complexity of some of these, such as Second Life and various other programs for experimentation in which the protagonist may inhabit different bodies or avatars in the virtual world. She presents the experience of an analytic process with a patient who, of his own accord, first makes use of videos and chat rooms, which he brings to his analyst as material, to later move on to virtual experiences with visual contact with others, and finally to contact in factual reality. She analyzes the significance for the patient of these progressive exchanges in coming to terms with and developing aspects of his body image and sexual identity. The author puts forward the world of cyberspace as a potential space for experimentation and progressive psychic elaboration and suggests that it might be considered in psychoanalytic processes as useful material for psychic growth and maturation (AU)

Off the couch, into the toilet: exploring the psychic uses of the analyst's toilet.

The analyst's consulting room toilet lends itself to myriad uses in the context of the analytic relationship. It is a place where "dirty" secrets may be excitedly deposited and where perverse fantasies can be fueled and acted out, as illustrated in the analysis of Mr. D. This perverse use of the analyst's toilet is contrasted with the case of Ms. C., whose anxieties about the destructiveness of her aggression led initially to a phobic avoidance of the toilet and then evolved toward its use as a container for parts of herself she felt were bad and unacceptable, thereby protecting the relationship with the analyst, who could not yet be trusted to receive and survive her projections. In these cases the toilet becomes quite concretely the location of the "toilet-breast" (Meltzer 1967), a means of preserving a more idealized relationship with the analyst.

The body of the analyst and the analytic setting: reflections on the embodied setting and the symbiotic transference.

In this paper the author questions whether the body of the analyst may be helpfully conceptualized as an embodied feature of the setting and suggests that this may be especially helpful for understanding patients who develop a symbiotic transference and for whom any variance in the analyst's body is felt to be profoundly destabilizing. In such cases the patient needs to relate to the body of the analyst concretely and exclusively as a setting 'constant' and its meaning for the patient may thus remain inaccessible to analysis for a long time. When the separateness of the body of the analyst reaches the patient's awareness because of changes in the analyst's appearance or bodily state, it then mobilizes primitive anxieties in the patient. It is only when the body of the analyst can become a dynamic variable between them (i.e., part of the process) that it can be used by the patient to further the exploration of their own mind.

The body one has and the body one is: understanding the transsexual's need to be seen.

The transsexual individual confronts the analyst with a disturbing otherness. How this otherness is understood, that is, how the analyst 'looks' at the patient through her distinctive theoretical lens impacts, in turn, on the patient's experience and what transpires between them. In this paper the author outlines a developmental model rooted in attachment and object relations theory to provide one alternative way of 'looking' at some of these patients' experiences in the clinical setting. It is suggested that in some cases of transsexuality the primary object(s) did not mirror and contain an early experience of incongruity between the given body and the subjective experience of gender: it remains unmentalized and disrupts self-coherence leading to the pursuit of surgery that is anticipated to 'guarantee' relief from the incongruity. Through an account of work with a male to female (MtF) transsexual who underwent surgery during her five years of psychotherapy, the author explores how a focus on the transsexual's experience of 'being seen', that is, of being taken in (or not) visually and mentally by the object in their state of incongruity, affords another window through which to approach the transsexual's experience in the transference-countertransference dynamics.