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.

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.

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.

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

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

Institutional Transference in Serious Illness Care.

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

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

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

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

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

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

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

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

The Impact of Patient Suicide on Clinicians.

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

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."

Illusion, musicality, and evanescence.

I explore some similarities between experiences of music and of analytic sessions. I focus on qualities of evanescence, the way that music - in contrast to many other arts - in one perspective only lasts as long as it is actually being played. Then it's over. The analyst-patient discussion in a session is similar. Yet the psychic reverberations of some transient, fugitive moments may last a lifetime. And even when no verbally profound understanding is occurring, nevertheless the patient-analyst encounter is emotionally significant. I illustrate this with a clinical example. I explore transference as illusion, and the relationship between truth and illusion in terms of Bion's O. I end with thoughts about the paradoxical value of the illusoriness of aesthetics and nature as considered by Freud in his short paper "On Transience" (1916), and the grin of Lewis Carol's Cheshire Cat, left hanging in the air.

Countertransference in the treatment of patients with personality disorders: A longitudinal study.

OBJECTIVE: This study examines how therapist emotional response/countertransference (CT) develops during treatment for patients with personality disorders (PDs) and how pre-treatment patient factors (severity of personality pathology, PD category, level of symptom distress) predict CT responses. Secondly, we explored associations between patient clinical outcome and CT. METHOD: A longitudinal, observational study including 1956 patients with personality pathology treated at psychotherapy units within specialist mental health services. Therapists' emotional response was repeatedly assessed by the Feeling Word Checklist-Brief Version (FWC-BV) with three subscales-Inadequate, Confident, and Idealized. RESULTS: Levels of Inadequate CT were lowest and stable over time while Confident and Idealized increased over time. Greater severity of personality pathology and borderline PD predicted higher initial Inadequate, lower initial Confident and decreasing Inadequate over time. Antisocial PD predicted decreasing Confident. Number of PD criteria had higher impact on therapist CT than level of symptom distress. Clinical improvement was associated with decreasing Inadequate. CONCLUSION: Therapists reported predominantly Confident CT when working with PD patients. More severe personality pathology, and borderline PD, specifically, predicted more negative CT initially, but the negative CT decreased over time. Patients who did not improve were associated with increasing Inadequate.

Navigating Countertransference in Inpatient Settings: Optimizing Interventions for Patients with Borderline Personality Disorder and Repeated Acute Hospitalizations.

Over the years, the psychiatric inpatient treatment paradigm has shifted to more brief stays focused on acute stabilization and psychopharmacologic-focused interventions, rather than individual psychotherapeutic engagement. Unfortunately, this has allowed patients with complex interpersonal dynamics, particularly borderline personality disorder, to slip through the cracks of effective treatment. This can contribute to repeated inpatient admissions, where both patients and clinicians feel trapped in a maladaptive, unhelpful cycle. In this article, we examine the evolution of inpatient treatment with de-emphasized psychotherapy practices, review the particular dynamics that patients with borderline personality disorder may evoke within an interdisciplinary treatment team, and provide a framework of clinically based vignettes for scenarios that may arise within inpatient treatment of this patient population. With attention to countertransference patterns and common pitfalls of communication, we offer alternative approaches and conversations with the hopes of improving outcomes and alliances in a new landscape of psychiatric practice.

On the analytic transference.

This paper is a presentation of the concept "transference" in psycho-analysis. In Freud's thought, transference movements are new editions, copies of tendencies or phantasies that are the repetition of infantile prototypes, relived with a lively feeling of actuality. The text shows Freud's reflection on transference, and the importance of the countertransference which has been much developed by the post-freudians authors. Then, the principal forms of transference are presented, for example passionate transference, or transference by reversal. The psychoanalytic reflection about transference leads to study the analyst's neutrality, and to pay attention to the setting of the sessions. André Green emphasizes that the transference that is addressed to the analyst is at the same time a transference on the setting and on to speech. In the complexity of the "analytic situation" (Donnet), speech is transformed under the effect of the transference address (Rolland).

Field theory: The transference-countertransference relationship and second look.

This paper examines the characteristics and clinical utility of the psychoanalytic field theory proposed by M. and W. Baranger, with particular emphasis on the issues of the transferential-counter transferential relationship and the 'second look'. The role of central key metaphors embodied in the experience of both patient and analyst is illustrated through the author's personal experience and participation in Three Level Model (3LM) work groups. The risk of moments of intense communication between patient and analyst has the possibility for the analyst to lose distance, making it necessary to go beyond moments of emotional resonance and reverie and to take a "second look" to understand the analyst's involvement in the interactional process in order to prevent the constitution of bastions of the field. The 3LM work groups extend the temporal context to include longer periods of time and a "third group look" that triangulates perspectives through group discussions, allowing for the exploration of transformations that have occurred in the analysis. The field perspective contributes to a deeper understanding of the transference-countertransference relationship. The "second" and the "third look" broadens the analyst's insights and enriches the understanding of the psychoanalytic process and its multifaceted dynamics.

The enigma of transference. Freud's discovery and its repercussions.

This brief introduction gives an historical outline of the development of the concept of transference in the different psychoanalytic traditions. It goes back to the various meanings of the German term "Übertragung" - transference, transcription, transmission, transposition and assignment - and how they were accentuated by the different psychoanalytic schools. The paper depicts the transition from a mainly intrapsychic understanding of transference as repetition to a more bipersonal and intersubjective approach exploring the different meanings of "intersubjectivity" and the forces that operate within the analytic field. Major developments arose from a new understanding of the role of the analyst's countertransference and the detection of transference mechanisms in narcissistic, borderline and psychotic states. The exploration of different forms of splitting and projective and introjective identification deepened the understanding of the analytic communication and led to concepts like "acting in", role-responsiveness, "actualization" and "enactment". As the author tries to show, all these approaches can find a legitimization in Freud's original writings, but the main differences concern technical issues, i.e. the interpretation of transference.

Forensic Mental Health Evaluators' Unprocessed Emotions as an Often-Overlooked Form of Bias.

There has been robust interest in the influence of cognitive and implicit biases that can hamper a forensic mental health evaluator's ability to provide objective opinion evidence. By contrast, literature exploring the biasing effects of the examiner's unacknowledged and unprocessed emotions has been scanty. Borrowing from concepts originating from psychodynamic treatment literature, this article explores how a forensic mental health evaluator's emotional and transferential reactions can affect the assessment process and formulation of findings. We make the case that forensic mental health evaluators are not impervious to their own mental health concerns, including vicarious trauma. We ultimately argue for a cultural shift in forensic practice that acknowledges the unavoidable existence and influence of a forensic evaluator's human emotions, personal reactions, and conflicts, so that strategies can be developed for compassionate but careful management in training programs, supervision, and beyond. We suggest that self-reflection, sometimes with the aid of consultation and psychotherapeutic support, is not only important for clinical trainees but also could serve forensic practitioners throughout their careers, especially during challenging junctures in their personal and professional lives.

Melville's "Bartleby, the Scrivener: A Story of Wall-Street": The Vicissitudes of Treating a Difficult Patient.

Taking the liberty of imagining the lawyer in Melville's "Bartleby, the Scrivener" as narrator/therapist and Bartleby as patient, this article, written with the therapist/reader in mind, traces the vicissitudes of countertransference and speculates on what constitutes a "good enough" therapeutic effort.

Stigma and Countertransference in Resident Attitudes toward Patients with Substance Use Disorders.

Apprehending the full range of one's countertransference presents a challenge for the new therapist and psychiatry resident. Experiencing negative or aggressive feelings while also striving to consolidate one's professional identity and self-experience as a good, helpful, and competent doctor feels dissonant and contradictory. Developing and practicing the skills of countertransference awareness and analysis are crucial aspects of psychiatry and psychotherapy training. These skills can help the trainee navigate difficult clinical interactions through reflection on their own anxieties, as well as the unconscious social and personal biases and motivations that shape their countertransferences. This article examines some of the countertransference reactions that may be colored by social and personal stigma toward patients with substance use disorders. Acknowledging and exploring such countertransference reactions in training not only can provide valuable insights into the psychodynamic experiences of the patient and the treatment dyad, but also can sharpen a lifelong tool, helping the trainees weather powerful and disorienting countertransference currents, untangle their personal motivations and prejudices, and recognize the times when supervision may help to provide containment and clarity throughout their careers.

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.