Transplantation experience as a predictor for quality of life during the first 6 months after lung transplantation.

OBJECTIVE: Quality of life (QoL) is a crucial goal of post-transplant care. This study investigated predictors of QoL within the first 6 months after transplantation. METHODS: Forty patients were assessed 2 weeks (T1), 3 months (T2), and 6 months post-transplant (T3). In the quantitative part, the EuroQol questionnaire (EQ-5D) and visualization methods (Prism) were applied. In the qualitative part, interviews were analyzed. Regression analyses were used to investigate the impact of the pictorial ratings at T1 on QoL at T2 and T3. The pictorial variables were related to the interviews for an in-depth analysis. RESULTS: There was an increase in QoL between T1 and T2 that remained stable from T2 to T3. Smaller distances in the variable Prism_Lung (acceptance of the lung) and larger distances in the variable Prism_Transplantation (distance to the transplantation experience) were related to the increase in QoL between T1 and T2 and to an higher QoL at T2. High-QoL patients were able to create an equilibrium of defense and acceptance. CONCLUSION: Psychological processes early after transplant are of significance for the development of QoL within the 6 months following the surgery. These insights demonstrate that a mixed methodological approach provides a helpful understanding of post-transplant processing.

The Swiss Transplant Cohort Study's framework for assessing lifelong psychosocial factors in solid-organ transplants.

BACKGROUND: Understanding outcomes after transplant requires a biopsychosocial model that includes biomedical and psychosocial factors. The latter, to date, are assessed only in a limited way as part of transplant registries or cohort studies. The Swiss Transplant Cohort Study (STCS) is a nationwide open cohort study (starting May 2008) to systematically and prospectively assess psychosocial factors. This article describes the framework underpinning STCS's psychosocial assessment. METHODS: The STCS framework was adapted from the multidimensional conceptual perspective of Dew et al to describe transplant psychosocial domains and specific outcomes by adding a time perspective, a system perspective, and interaction among domains. RESULTS: We propose a multidimensional, multilevel biopsychosocial framework representing mutually influencing domains from before to after transplant, and exemplify each domain by factors included in STCS and their measurement. The transplant patient, centrally positioned, is described by clinical and sociodemographic characteristics (eg, socioeconomic status, educational, professional, and relationship status). The following psychosocial domains further describe the patient: (1) physical/functional (eg, perceived health status, sleep quality, daytime sleepiness), (2) psychological (eg, depression, stress), (3) behavioral (eg, medication adherence, smoking, drug use, physical activity, sun protection), (4) social (eg, work capacity/return to work), and (5) global quality of life. Factors associated with health care system level (eg, trust in transplant team) are also included in the model. CONCLUSION: The STCS's psychosocial framework provides a basis for studying the interplay of biomedical, sociodemographic, psychosocial, behavioral, and health care system factors in view of transplant outcomes and therefore has the potential to guide biopsychosocial transplant research.

The Crises of Oedipus.

This article describes the various crises of the Oedipus complex. In the beginning, I address the crisis of the first traumatic days when Oedipus was to be abandoned in the wilderness. This early breakdown takes place at what may be denoted as stage zero. During this first crisis, the defensive solution is an act of doubling, according to Quinodoz's dédoublement of the parental pair, accompanied by the defenses of splitting, foreclosure, and annihilation. Protected by these defenses, the child would be able to search for a solution to the neurotic part of the Oedipus complex. According to Freud's and Lacan's conception, these phases encompass the stages of the imaginary omnipotence, of the symbolic prohibition, and the symbolic reconciliation. The second crisis of Oedipus signifies therefore that the desire encounters the prohibition of the third (e.g., the father). I will show these stages in the 1967 film adaptation of Oedipus Rex and the life of its director, Pierre Paolo Pasolini. Against this background, the third crisis of Oedipus is considered: the impending ecological catastrophe.

Association of Fatigue Severity With Maladaptive Coping in Multiple Sclerosis: A Data-Driven Psychodynamic Perspective.

Fatigue in persons with multiple sclerosis (PwMS) is severely disabling. However, the underlying mechanisms remain incompletely understood. Recent research suggests a link to early childhood adversities and psychological trait variables. In line with these studies, this paper took a psychodynamic perspective on MS-fatigue. It was hypothesized that fatigue could represent a manifestation of maladaptive coping with intense emotions. The schema therapeutic mode model served as a theoretical and empirically validated framework, linking psychodynamic theory and empirical research methods. The study was based on a data set of N = 571 PwMS that has also served as the basis for another publication. Data was collected online. The Schema Mode Inventory was used to quantify regulatory strategies to cope with emotionally stressful experiences. In addition, depressive symptoms (Beck's Depression Inventory - FastScreen), physical disability (Patient Determined Disease Steps), alexithymia (Toronto Alexithymia Scale-26), adverse childhood experiences (Childhood Trauma Questionnaire), and self-reported fatigue (Fatigue Scale for Motor and Cognitive Functions) were assessed. Latent profile analysis revealed three distinct groups of PwMS, based on their coping mode profiles: (1) PwMS with low maladaptive coping, (2) PwMS with avoidant/submissive coping styles, and (3) PwMS with avoidant/overcompensatory coping styles. Multivariate comparisons showed no significant difference in physical disability across the three groups. However, heightened levels of self-reported fatigue and depression symptoms occurred in PwMS with maladaptive coping styles. A path model uncovered that self-reported fatigue was robustly related to physical disability (ß = 0.33) and detached/avoidant coping (Detached Protector; ß = 0.34). There was no specific relation between any of the maladaptive coping modes and depression symptoms. Detached/avoidant coping was in turn predicted by childhood emotional abuse and neglect. The results indicate that childhood adversity and detached/avoidant coping styles may be associated with variability in MS-fatigue severity: PwMS that resort to detached/avoidant coping in response to negative emotions also tend to report heightened levels of fatigue, although they do not differ in their perceived disability from PwMS with low levels of fatigue and maladaptive coping. A link between MS-fatigue and the psychodynamic traumatic conversion model is discussed. The implications of these findings for therapeutic interventions require further study.

The Actualization of the Transplantation Complex on the Axis of Psychosomatic Totality-Results of a Qualitative Study.

Although transplantation medicine is not new, there is a clinically justified gap in the existing literature with respect to the psychological processing of lung transplants. The present study aims to examine whether lung transplantation leads to an actualization of psychological, e.g., oral-sadistic fantasies. Following a qualitative approach, 38 lung transplant patients were interviewed three times within the first six months after transplantation. Data analysis focused on identifying unconscious and conscious material. The inter-rater reliability for all codes was calculated using Krippendorff's Alpha (c-α-binary = 0.94). Direct and implicit evidence of a so-called transplantation complex was detected e.g., regarding the "incorporation" of the dead donor and his lungs. These processes occur predominantly at an imaginary level and are related to the body. Our findings emphasize that such psychological aspects should be borne in mind in the psychological treatment of lung-transplant patients in order to improve the processing of lung transplants, and that this might have a positive effect on patient adherence.

[Subjective experiences following organ transplantation--a qualitative study of 120 heart, lung, liver, and kidney recipients]. / Subjektives Erleben nach einer Organtransplantation--eine qualitative Studie mit 120 Herz-, Lungen-, Leber- und Nierenempfängern.

OBJECTIVES: The communication with patients who have undergoned transplantation is greatly influenced by their subjective experience. This paper deals with this subjective transplant-specific experience six months after surgery. METHODS: Following their heart, lung, liver, or kidney transplantation, 120 patients were questioned concerning their experiences regarding the transplantation, the organ itself, and changes in their personal life. Their statements were investigated by qualitative content analysis. RESULTS: Generally, the statements concerning the transplantation were positive. Interpersonal contact with the medical staff and or family members was perceived as very helpful. Two-thirds of the patients spoke openly about their organ. For the most part, their statements about changes in their personal life were positive, expressed in the sense of personal growth. Fears and insecurities occurred as negative changes. CONCLUSIONS: On the whole, the majority of the patients expressed positive experiences regarding their transplantation. Interpersonal and supportive relationships played a significant role.

Gamma elements as protomental representations: Suggestions for expanding W. R. Bion's theory of elements.

W. R. Bion developed various models and theories to describe the formation of mental representations. This article introduces an expansion of the model of alpha and beta elements by a new category, termed "gamma elements". Despite being transformable, gamma elements are characterized by an excessive feeling of reality, such that the subject must evacuate them. We are dealing here with visions, pseudohallucinations, scenarios in nightmares that are as terrible as they are sensorily charged, flashbacks, or overwhelming physical feelings interspersed with hypochondriacal anxieties. Using the "theory of maternal semiotics" (Kristeva), the author traces how the child's projectiles, i.e. beta experiences projected into the maternal container, are transformed into alpha and gamma elements. In this respect, gamma elements are more or less precise indicators of the analytic process: they indicate the extent to which the analysand is capable of enduring and transforming frustrating experiences in the here-and-now. The expansion of Bion's model of elements, therefore, has direct clinical relevance, in that gamma elements can be understood both as imaginative creations and as indications of disorganizing processes.

Psychological processing of transplantation in lung recipients: a quantitative study of organ integration and the relationship to the donor.

OBJECTIVES: Lung recipients undergo a complex psychological process, including organ integration and processing of attitudes towards the organ donor. DESIGN: Seventy-six lung recipients were asked to participate in a cross-sectional questionnaire study on the psychological processing of lung transplants. METHODS: The questionnaire consisted of statements describing aspects of organ integration and the patient's relationship with the donor. Furthermore, chronic stress/psychological distress (Screening Scale of the Trier Inventory; Symptom Checklist SCL-K-9) and the emotional effects of transplantation/immunosuppression (Transplant Effects Questionnaire; Medication Experience Scale for Immunosuppressants) were assessed. RESULTS: In general, lung recipients perceive the transplant as part of themselves (97.4%) and not as a foreign object (90%). One-third of patients still have frequent thoughts about the donor, whilst the majority (80.3%) do not believe that they have adopted the donor's characteristic traits. Factor analysis reveals the two-dimensional structure of the questionnaire items 'organ integration' (factor 1) and 'relationship to the donor' (factor 2). Poor organ integration predicts low adherence, low disclosure and high feelings of guilt, whilst a close donor relationship predicts chronic stress and psychological distress. CONCLUSIONS: Poor organ integration and a close relationship to the donor should be borne in mind in psychosocial treatment regarding the patient's adherence behaviour and psychological distress.

The experience of transplantation as reflected in dream life: A case study illustrating the mental processing of a lung transplant.

Although it is well known that a lung transplant enhances the recipient's quality of life, our knowledge of how it is processed mentally is limited. In this study, interviews were conducted with a lung-transplant patient two weeks, three months, and six months after surgery so as to investigate the relevant unconscious processing mechanisms. A dream reported in the first interview was analysed in accordance withapplying the Zurich Dream Process Coding System. A 'transplantation complex' was reconstructed on the basis of various sources of information (the dream and the waking narratives). The principal aspects of the transplantation complex that emerged from both the dream and the waking narratives concerned the oral-sadistic phantasy that the donor had been killed and that his lung, or soul, had been violently incorporated in the patient. The main unconscious themes involved in the processing of the transplant were found to have been already laid down in the dream and to have been presented in it in the form of visual analogues. According to our interpretation of the data analysed, powerful cannibalistic phantasies and death wishes played an important part in the processing of the transplant. These archaic phantasies may have been actualized by the transplant.

Psychological response and quality of life after transplantation: a comparison between heart, lung, liver and kidney recipients.

PRINCIPLES: Various non-specific questionnaires were used to measure quality of life and psychological wellbeing of patients after organ transplantation. At present cross-organ studies dealing specifically with the psychological response to a transplanted organ are non-existent in German-speaking countries. METHODS: The Transplant Effects Questionnaire TxEQ-D and the SF-36 Quality of Life Questionnaire were used to examine the psychological response and quality of life of 370 patients after heart, lung, liver or kidney transplantation. The organ groups were compared with regard to psychosocial parameters. RESULTS: 72% of patients develop a feeling of responsibility for the received organ and its function. This feeling is even stronger towards the patient's key relationships i.e. family, friends, the treatment team and the donor. 11.6% worry about the transplanted organ. Heart and lung patients report significantly fewer concerns than liver and kidney patients. Overall, only a minority of patients report feelings of guilt towards the donor (2.7%), problems in disclosing their transplant to others (2.4%), or difficulties in complying with medical orders (3.5%). Lung transplant patients show significantly better adherence. CONCLUSIONS: A feeling of responsibility towards those one is close to and towards the donor is a common psychological phenomenon after transplantation of an organ. Conscious feelings of guilt and shame are harboured by only a minority of patients. The fact that heart and lung patients worry less about their transplant might have primarily to do with the greater medical and psychosocial support in this group.

[Questionnaire on emotional response after organ transplantation: German validation of the Transplant Effect Questionnaire (TxEQ-D)]. / Fragebogen zur psychischen Verarbeitung einer Organtransplantation: Deutsche Validierung des Transplant Effects Questionnaire (TxEQ).

OBJECTIVES: The present study investigates a) whether the German version of the Transplant Effects Questionnaire (TxEQ-D), which measures the emotional response to an organ transplantation, has the same factorial structure as the English original version and b) whether the psychometric properties as well as the correlations with the scales of the SF-36 are comparable. METHODS: The questionnaire TxEQ was translated into German and filled out by 370 heart, lunge, liver and kidney transplant patients. Subsequently, factor and item analyses were conducted. The SF-36 was used to test validity. RESULTS: The TxEQ-D has the same factorial structure as the English version as well as comparable psychometric properties. The TxEQ-D factor "worry about transplant" shows the highest correlations with the 10 scales of the SF-36, the lowest correlations with the 10 scales of the SF-36 scales are found for the factor "adherence". CONCLUSIONS: The TxEQ-D is a useful screening instrument in psychosomatic research and in the psychotherapy practice to detect patients with problematic emotional responses to an organ transplantation.

Choosing the appropriate treatment setting: which information and decision-making needs do adult inpatients with mental disorders have? A qualitative interview study.

BACKGROUND: Decisions on medical treatment setting are perceived as important but often difficult to make for patients with mental disorders. Shared decision-making as a strategy to decrease decisional conflict has been recommended, but is not yet widely implemented. This study aimed to investigate the information needs and the decision-making preferences of patients with mental disorders prior to the decision for a certain treatment setting. The results will serve as a prerequisite for the development of a high-quality patient decision aid (PtDA) regarding the treatment setting decision. METHODS: We conducted retrospective individual semi-structured interviews with n=24 patients with mental disorders in three psychotherapeutic inpatient care units. The interviews were audiotaped, transcribed, coded, and content-analyzed. RESULTS: The majority of the patients wanted to be involved in the decision-making process. They reported high information needs regarding treatment options in order to feel empowered to participate adequately in the decision for a certain treatment setting. However, some patients did not want to participate or receive information, for example, because of their high burden of mental disorder. Whereas the majority were satisfied with the extent they were involved in the decision, few participants felt sufficiently informed about treatment options. Most patients reported that a decision aid regarding an appropriate treatment setting would have been helpful for them. Important information that should be included in a PtDA was general information about mental illness, effective treatment options, specific information about the different treatment settings, and access to treatment. DISCUSSION: The identified information and decision-making needs provide a valuable basis for the development of a PtDA aiming to support patients and caregivers regarding the decision for an adequate treatment setting. As preferences for participation vary among patients and also depend on the current mental state, a flexible approach is needed to meet patients' individual wishes and needs.

Psychosocial vulnerability predicts psychosocial outcome after an organ transplant: results of a prospective study with lung, liver, and bone-marrow patients.

OBJECTIVE: The pretransplant medical evaluation of transplantation candidates includes an assessment of psychosocial data. This study investigates psychosocial vulnerability as a predictor of posttransplant outcome. METHODS: Seventy-six patients were assessed prior to lung, liver, or bone-marrow transplant. Pretransplant vulnerability markers were cognitive beliefs (sense of coherence and optimism), affect (anxiety and depression), and external resources (social support). In addition, psychosocial functioning was assessed by professionals. Quality of life, general life satisfaction, need for counseling, and survival rate were assessed 12 months after transplant. RESULTS: Pretransplant variables explain 21-40% of the variance in posttransplant psychosocial outcome variables. Cognitive beliefs predict mental quality of life; affect (depression) and social support predict life satisfaction; and expert-rated psychosocial functioning predicts life satisfaction and need for counseling. CONCLUSION: The multidimensional vulnerability model is suitable for predicting posttransplant psychosocial outcome. Patients with high pretransplant vulnerability should receive ongoing psychosocial counseling.

Quality of life and psychosocial situation before and after a lung, liver or an allogeneic bone marrow transplant. Results from a prospective study.

BACKGROUND AND OBJECTIVES: Only few comparative prospective studies have been published on psychosocial issues of organ transplant. This study investigated patient groups with various organ transplants with respect to their quality of life and psychosocial situation before and after surgery. METHODS: 76 patients receiving an organ transplant (lung n = 22, liver n = 26, allogeneic bone marrow n = 28) were investigated with regard to quality of life (SF-36), life satisfaction (FLZ), social support (F-SozU), and psychological symptoms (HADS-D) before (T0) as well as six (T1) and twelve (T2) months after transplant. RESULTS: In the pre-transplant period the values of the psychosocial variables were partly lower than those of the community normal sample. After transplant lung and bone marrow patients reported less anxiety and depression and a higher life satisfaction, and liver patients reported less depression, compared to the norms. Quality of life, life satisfaction and psychological symptoms of all patients improved significantly post-transplant, whereas the perceived social support decreased. Contrary to the other groups, the psychological well-being of liver transplant recipients was deteriorating between T1 and T2. CONCLUSIONS: An organ transplant improved the patients' quality of life and psychosocial situation to a great extent. This effect was better in lung and bone marrow than in liver transplant patients.

Quality of life and psychosocial situation before and after a lung, liver or an allogeneic bone marrow transplant.

BACKGROUND AND OBJECTIVES: Only few comparative prospective studies have been published on psychosocial issues of organ transplant. This study investigated patient groups with various organ transplants with respect to their quality of life and psychosocial situation before and after surgery. METHODS: 76 patients receiving an organ transplant (lung n = 22, liver n = 26, allogeneic bone marrow n = 28) were investigated with regard to quality of life (SF-36), life satisfaction (FLZ), social support (F-SozU), and psychological symptoms (HADS-D) before (T0) as well as six (T1) and twelve (T2) months after transplant. RESULTS: In the pre-transplant period the values of the psychosocial variables were partly lower than those of the community normal sample. After transplant lung and bone marrow patients reported less anxiety and depression and a higher life satisfaction, and liver patients reported less depression, compared to the norms. Quality of life, life satisfaction and psychological symptoms of all patients improved significantly post-transplant, whereas the perceived social support decreased. Contrary to the other groups, the psychological well-being of liver transplant recipients was deteriorating between T1 and T2. CONCLUSIONS: An organ transplant improved the patients' quality of life and psychosocial situation to a great extent. This effect was better in lung and bone marrow than in liver transplant patients.

[Psychosocial need for counselling before and after a lung, liver or allogenic bone marrow transplant--results of a prospective study]. / Psychosozialer Beratungsbedarf vor und nach einer Lungen-, Leber- oder allogenen Knochenmarkstransplantation--Ergebnisse einer prospektiven Studie.

OBJECTIVES: Transplant patients are exposed to many different types of mental and social stress. The study investigates these patients' need for psychosocial counselling. METHODS: At 6 months and again at 12 months following either a lung, liver or bone-marrow transplantation, 76 patients were questioned about their need for psychosocial counselling. The measuring instruments employed were: SF-36 (quality of life), FLZ (life satisfaction), HADS-D (anxiety/depression), and F-SoZu K-14 (social support). RESULTS: The need for psychosocial counselling in all three patient groups was at its greatest before transplantation. It amounted to 42.9 % (lung transplantation patients), 50.0 % (liver transplantation patients) and 26.7 % (bone marrow transplantation patients). Six months after transplantation, the need for counselling in all patient groups had quite clearly decreased. Among liver transplant patients, however, it increased again between the sixth and twelfth months. The need for counselling in all patient groups correlated significantly with anxiety. Moreover, at one-year follow-up, significantly negative correlations with mental health, life satisfaction and social support were observed. DISCUSSION: Especially during the evaluation phase prior to organ transplantation, transplantation patients demonstrate a considerable need for counselling. Psychosocial counselling should be an obligatory part of therapy before and after organ transplantation.

Patients' Early Post-Operative Experiences with Lung Transplantation: A Longitudinal Qualitative Study.

BACKGROUND AND OBJECTIVES: Lung transplantation is a complex medical treatment, and for patients with end-stage lung diseases it is often the last therapeutic option available for survival. However, lung transplantation poses not only a physical but also a psychological challenge for patients. The aim of this study was to gain a deeper understanding of patients' individual concerns related to their lung transplantation within the first 6 months post-transplant. METHODS: Forty lung transplant patients were interviewed at three different measurement timepoints post-transplant (T1: 2 weeks; T2: 3 months; and T3: 6 months) using semi-structured interviews to address their thoughts, feelings, and attitudes with respect to the transplantation process, their new lungs, and their medication. Interviews were analyzed by means of qualitative content analysis. RESULTS: "Physical complaints", "fear of organ rejection", "side effects of medication", and "restrictions in everyday life" were the most frequently named concerns within the first 6 months post-transplant. Most themes remained unchanged over time, whereas mentions of restrictions in everyday life increased significantly over the three assessments. CONCLUSIONS: Although the majority of the patients experienced considerable improvements in physical health after transplantation, they simultaneously reported that they were suffering from physical complaints, fear of organ rejection and infections, medication adverse effects, and restrictions in everyday life. For patients, lung transplantation therefore often means replacing one disease with another. Healthcare providers are challenged to support patients in dealing with this unresolvable dilemma.

Psychosocial situation and physical health in 50 patients > 1 year after lung transplantation.

BACKGROUND: Lung transplants have been performed worldwide since the early 1980s. While numerous studies have been published on somatic aspects after lung transplantation, there is considerably less information available on psychosocial aspects and on the correlation between the physical and the psychosocial state of health after transplantation. METHODS: Between 1992 and 2002, 125 patients underwent lung transplantation at University Hospital Zurich. To be included into the study, patients had to have received a lung transplant > 12 months previously and to have good knowledge of the German or Italian languages. With the aid of standardized questionnaires, psychosocial variables such as levels of anxiety and depression, self-esteem, and social support were determined. In addition, self-assessments of physical and psychological health were obtained. The medical data included information on FEV1, complications such as pulmonary infections, acute or chronic allograft rejection, and assessment of the patient's physical and psychological health by the treating doctors. RESULTS: The overall degree of anxiety and depression of the lung transplant recipients was comparable to standard samples of an average population. However, male lung transplant recipients were significantly more depressed than female recipients. Self-esteem was higher than in clinical comparison samples. Preceding pulmonary complications had long-lasting effects on the level of anxiety, whereas nonpulmonary complications did not have such an effect. CONCLUSIONS: Overall, the psychological well-being of patients after lung transplantation is similar to the normal population. Subgroups of patients with increased psychological distress have been identified.

Post-transplant outcome-clusters of psychological distress and health-related quality of life in lung transplant recipients.

QUESTIONS UNDER STUDY: To (1) assess distinct clusters of psychological distress and health-related quality of life during the first 6 months following lung transplantation; (2) identify patients with poor psychosocial outcomes; and (3) determine potential predictors regarding psychological distress and health-related quality (HRQoL) of life at 6 months post-transplant. METHODS: A total of 40 patients were examined for psychological distress (Symptom Checklist short version-9) and quality of life (EuroQOL five-dimension health-related quality of life questionnaire) during their first 6 months post-transplant. Hierarchical cluster analyses were performed to identify specific types of post-transplant outcomes in terms of psychological distress and HRQoL over the first six post-transplant months. Correlational analyses examined medical and psychosocial predictors of the outcome at 6 months post-transplant. RESULTS: Three distinctive clusters were identified, summarizing either groups of patients with (1) optimal (35%), (2) good (42%), and (3) poor outcome-clusters (23%). The latter tended to be older, to suffer from more severe disease, to have more co-morbidities, to have had a prolonged intensive care unit and/or hospital stay, to have more hospital admissions and were more frequently treated with antidepressants post-transplant. Disease severity, length of stay, quality of life two weeks post-transplant, hospital admissions and use of antidepressants were strong predictors of psychological distress and impaired health-related quality of life at six months of follow-up. CONCLUSION: Almost a quarter of the investigated patients suffered from elevated distress and substantially impaired HRQoL, with no improvements over time. Results underscore the psychosocial needs of patients with poor post-transplant outcomes.

Semiotic aspects of the countertransference: some observations on the concepts of the 'immediate object' and the 'interpretant' in the work of Charles S. Peirce.

The field of semiotics, established by Charles S. Peirce, is characterised by its recognition of non-linguistic signs and embedment in a communicative interaction; for this reason, it is especially well suited for a semiotic investigation of intersubjective processes. In this paper, the authors show how these intersubjective processes can be understood in semiotic terms within the transference-countertransference setting. Based on a case vignette, the relationship between the 'real object' (e.g. an unconscious fantasy) and the sign (e.g. a particular facial expression) is first demonstrated. In this mediation between sign and referent, an important role is played by the 'immediate object', by which Peirce understood the mental concept of a sign. However, a further component of the Peircian sign is responsible for the emergence of the countertransference, namely, the 'interpretant'. The core of Peircian semiotics, namely the concept of an (infinite) process of signification, sheds light in semiotic terms on the dialectical movement between transference-signs and countertransference-signs, the interpretation and encounter between two subjects. The paper concludes with a discussion of both the interdisciplinary applicability of Peircian semiotics, for example in the context of the neurosciences, and the differences between the Peircian epistemological position and psychoanalytical conceptions of the objective cognition of mental processes.