On the Way to the Altar: An Illustration of Transpersonal Psychoanalytic Psychotherapy

COVID-19 Systems and Families: Acknowledging Loss, Transcending Hope.

Fantasies as imaginative activities are seen by Jung as expressions of psychic energy. In the various descriptions of active imagination the observation of the inner image and the dialogue with inner figures, if possible, are important. The model of symbol formation, as Jung describes it, can be experienced in doing active imagination. There is a correspondence between Jung's understanding of complexes and our imaginations: complexes develop a fantasy life. Complex episodes are narratives of difficult dysfunctional relationship episodes that have occurred repeatedly and are internalized with episodic memory. This means that the whole complex episode (the image for the child and the image for the aggressor, connected with emotions) is internalized and can get constellated in everyday relationship. Therefore inner dialogues do not necessarily qualify as active imaginations, often they are the expression of complex-episodes, very similar to fruitless soliloquies. If imaginations of this kind are repeated, new symbols and new possibilities of behaviour are not found. On the contrary, old patterns of behaviour and fantasies are perpetuated and become cemented. Imaginations of this kind need an intervention by the analyst. In clinical examples different kinds of imaginations are discussed.

Mentalization-based treatment (MBT), developed by Anthony Bateman and Peter Fonagy for treatment of borderline personality disorder (BPD), is explicit in seeking to establish epistemic trust in the therapeutic relationship and has as a goal its generalisation to other relationships and social connections/opportunities (Fonagy et al., 2017a, 2017b). MBT adaptations have shown some promising results with parents with histories of disrupted/disorganised attachments and abuse in childhood, and who themselves have maltreated their children (Byrne et al., 2018). These parents rarely seek referral for treatment but are coerced into the therapeutic space by a court order or child protection plan, effectively; by the threat of removal of their children from their care if they do not attend. This article outlines the research context including a summary of what we know about the childhood experiences and attachment histories of those parents with BPD who have been identified as at risk of maltreating their children and the recent research on MBT informed parenting interventions. It describes the climate of epistemic mistrust within which a specialist treatment service attempts to engage these parents and the challenges to the establishment of epistemic trust. Clinical examples are used to illustrate the journey from epistemic mistrust and hypervigilance to trust in the facilitators and the group.

Depression is the fourth leading cause of adolescent illness and disability worldwide. A growing evidence base demonstrates that Short Term Psychoanalytic Psychotherapy [STPP] is an efficacious treatment for moderate to severe adolescent depression. However, with research in its infancy, key factors contributing to efficacy are unknown. Service users' lived experiences provide valuable insight in this area. This study aimed to elucidate what adolescents value in treatment by inductively exploring lived experiences of STPP. Five adolescents with the largest reduction in depressive symptoms scores between baseline and end of treatment, who had taken part in a large-scale randomized controlled trial, were sampled. In-depth interviews carried out soon after the end of therapy were analysed using Interpretative Phenomenological Analysis. Three superordinate themes were identified: "Therapy as a Transformational Process", "Explorative and Exposing: The Therapeutic Space" and "Being Heard and Working Together: The Therapeutic Relationship". Adolescents valued a process of collaborative exploration with the therapist which when it was achieved was felt to facilitate a deep-rooted transformation in self-perception. Additionally, they described how an adjustment was needed to the particular frame of a psychoanalytic therapy. However, not all participants with a good treatment outcome experienced therapy in this way, suggesting a potential gap between the quantitative assessment of outcomes, and the way young people experience and understand the change process. Clinical implications and directions for research are discussed.

Comparing analytic activity to a spaceship launching, Laplanche (1999, pp. 231-232) suggested that there are “windows;” opportune interpretative moments. Laplanche emphasized the enduring impact of intergenerational “enigmatic messages,” such that all individuals cope with an essential “alterity” (otherness to oneself). He did not consider the countertransference implications. I propose that the analyst must also open the self-reflective window and pass through “originary situations” to prepare for intervention. In accordance with Kaes’ (2007, p. 98) formulation that “the unconscious is structured like a group,” I illustrate how unique windows of opportunity exist in psychoanalytic group treatment. Sharing and competing in a therapeutic space with “like me’s,” group members reexperience intense “horizontal” as well as “vertical” transferences, as does its leader. Clinical examples illustrate my efforts to mediate among interacting “translations” of early developmental experience—mine as well as other group members—to understand emerging psychic material.

Following some thoughts on evolutionary biology, a short historical overview and a literary example (Goethe), the author summarizes the background literature that is relevant to this topic: Freud (hypnosis), Jung (active imagination), Leuner (guided affective imagery GAI) and Reddemann/Sachsse (trauma therapy). Using clinical examples, the author shows how elements of these techniques can be integrated into psychoanalytic and analytically orientated psychotherapy. This can often lead to an intensification of affect, which can in turn have a positive influence on the development and effectivity of psychotherapy. In the author's twenty-five years of experience with this flexible and integrative technique, it has proved to be an essential enhancement to his psychoanalytic repertoire.

This paper argues that real imagination depends on the capacity to acknowledge the absence of what is imagined from the world of material actuality. This leads on to a view of symbol formation as the operation of the transcendent function between the opposites of presence and absence. 'The imaginary' is contrasted with this as a defensive misuse of imagination that attempts to deny 'negation' where negation is defined as all those aspects of the world that constitute a check to the omnipotence of fantasy--e.g., absence, loss, difference, otherness etc. Parallels are drawn with theoretical antecedents in analytical psychology and psychoanalysis, with particular attention to papers published in the Journal of Analytical Psychology (JAP) in the 1960s on the relation between active imagination, transference and ego development. A clinical example is given to show the use of the imaginary as a means of warding off the unbearable pain of Oedipal disappointment.

Jung understood dissociation as a natural state of the psyche, capable of turning defensive through development. Based on this premise, and its conception on the equivalence between psyche and matter, the present work describes the un-doing of a dissociation expressed through a chronic enterocolitis disorder. When the symbol remains closer to the body and its most instinctive manifestations, we need to descend to that level in order to let the vertical axis connection be gradually restored through the therapeutic relationship - the horizontal axis. In other words, this un-doing requires that patient and analyst follow the unconscious path proposed by symbolic expressions that gradually emerge through the patient's body and active imagination. Movement is our most primitive and fundamental experience. Many authors (Stern, Panksepp, Gallese) have agreed that, in addition to being first in terms of development, movement continues to have primacy over any other experience throughout life. This means that emotions, bodily concepts and, later, speech, evolve from a somatic basis. In the light of such neuroscientific findings, Jung's vision of the correspondence of psyche and matter will be revisited in order to portray how the analytic bond provides a context for the re-establishment of the linking/creative function of the archetype, and allows the restoring of the ego-Self axis connection by including non-verbal approaches, such as body-based active imagination, also known as Authentic Movement. Authentic Movement is an amplification of Jung's active imagination method that enables a dialogue between the ego and the diverse configurations of the unconscious. When such dialogue is grounded in the body, there is an easier access to the affective dimension stored in implicit memory. That which was relived through the body can gradually be remembered, and affects hitherto rejected, find other symbolic ways of being expressed and contained in the analytic vas.

Psychodynamic psychiatric practice during the COVID-19 pandemic has required most clinicians to conduct treatment online or by telephone. The result is a natural experiment that appears to endorse the efficacy of distance therapy. Consequently, the brick-and-mortar consulting room is no longer the presumptive therapeutic space for the conduct of psychodynamic psychiatric or other treatment approaches. The therapeutic space is reconceived as the place or medium intended for treatment and is distinguished from both the therapeutic relationship and conduct of treatment that occurs within that space. How different therapeutic spaces impact treatment is discussed with specific application to psychodynamic psychiatry and virtual venues. The "digital object" becomes a new presence; the patient's freedom to disclose mental contents is retained though empathic attunement is diminished; a shift in power dynamics may occur; timing of sessions gains greater precision in the online environment. Beyond the pandemic, practicing online is likely to become an accepted supplementary therapeutic space for evaluation and treatment by psychodynamic psychiatrists.

BackgroundA medical tests may influence the health of patients by guiding clinical decisions, such as treatment in case of a positive test result. However, a medical test can influence the health of patients through other mechanisms as well, like giving reassurance. To make a clinical recommendation about a medical test, we should be aware of the full range of effects of that test on patients. This requires an understanding of the range of effects that medical testing can have on patients. This study evaluates the mechanisms through which medical testing can influence patients’ health, other than the effect on clinical management, from a gynecologist’s perspective.MethodsA qualitative study in which explorative focus groups were conducted with gynecologists, gynecological residents and gynecological M.D. researchers (n = 43). Discussions were transcribed verbatim. Transcriptions were coded inductively and analyzed by three researchers.ResultsAll participants contributed various clinical examples in which medical testing had influenced patients’ health. Clinical examples illustrated that testing, in itself or in interaction with contextual factors, may provoke a wide range of effects on patients. Our data showed that testing can influence the doctor’s perceptions of the patients’ appraisal of their illness, their perceived control, or the doctor-patient relationship. This may lead to changes in psychological, behavioral, and/or medical outcomes, both favorably or unfavorably. The data were used to construct a conceptual framework of effects of medical testing on patients.ConclusionsBesides supporting clinical decision making, medical testing may have favorable or unfavorable effects on patients’ health though several mechanisms.

Introduction Despite the recommendations to use a bio-psycho-social framework, many physiotherapists still manage their patients mainly from a biomedical point of view. The purpose of this study is to analyze the impact of two different e-learning interventions on knowledge, attitudes, and clinical decision-making of physiotherapists managing low back pain (LBP) to increase guideline-consistent care. Methods Physiotherapists were allocated (1/1) either to an experimental or a traditional e-learning intervention. Baseline and post-intervention assessment included the Health Care Providers’ Pain and Impairment Relationship Scale (HC-PAIRS), Back Pain Attitudes Questionnaire (Back-PAQ), Neurophysiology of Pain Questionnaire (NPQ), and a clinical vignette. Participants had 2 weeks to complete the post-intervention assessment. Statistics were processed using ANCOVA and Fisher’s t-tests. Results Four hundred nineteen physiotherapists were included in the analysis. Mean scores of HC-PAIRS, Back-PAQ, and NPQ significantly improved post-intervention in both groups. There was a significant effect of the intervention type (experimental versus traditional) on the scores of HC-PAIRS (p < .001; η2 p = .243) and Back-PAQ (p < .001; η2 p = .135) but not on NPQ scores. Return to work, recommendations assessed with the clinical vignette were significantly more guideline-consistent in the experimental group (p < .001) post-intervention. Conclusion An interactive e-learning intervention which includes concrete clinical examples and focused on patient’s reassurance, self-management, and importance of screening psycho-social factors had more impact than a traditional e-learning intervention to enhance physiotherapists’ knowledge, attitudes, and clinical decision-making regarding LBP.

This insightful book offers professionals a comprehensive guide for navigating the new way of diagnosing and understanding personality difficulties and disorders introduced in the ICD-11. Through in-depth clinical examples, these experienced authors illustrate clearly how to determine severity, specify the five trait domains, and interpret aspects of personality dysfunction, including specific combinations of trait domains. The book also provides guidelines for differential diagnosis in relation to a range of other persistent mental disorders, clinical decision- making, individualized treatment planning, necessary treatment intensity, and psychotherapeutic focus. Readers will appreciate the exploration of available standardized instruments for classification, as well as the guide using the old classifications in the ICD-10 and the DSM-5 with the ICD-11 guidelines in the appendix. This book provides a roadmap for psychologists, psychiatrists, other mental health professionals, and students to use the latest advancements in classification to enhance patient care of people with personality disorders.

It is accepted that errors of misclassifications, however small, can occur in clinical decisions but it cannot be assumed that the importance associated with false positive errors is the same as that for false negatives. The relative importance of these two types of error is frequently implied by a decision maker in the different weighting factors or utilities he assigns to the alternative consequences of his decisions. Formal procedures are available by which it is possible to make explicit in numerical form the value or worth of the outcome of a decision process. The two principal methods are described for generating utilities as associated with clinical decisions. The concept and application of utility is then expanded from a unidimensional to a multidimensional problem where, for example, one variable may be state of health and another monetary assets. When combined with the principles of subjective probability and test criterion selection outlined in Parts I and II of this series, the consequent use of utilities completes the framework upon which the general Bayesian model of clinical decision making is based. The five main stages in this general decision making model are described and applications of the model are illustrated with clinical examples from the field of ophthalmology. These include examples for unidimensional and multidimensional problems which are worked through in detail to illustrate both the principles and methodology involved in a rationalized normative model of clinical decision making behaviour.

BackgroundSystems aiding in selecting the correct settings for mechanical ventilation should visualize patient information at an appropriate level of complexity, so as to reduce information overload and to make reasoning behind advice transparent. Metaphor graphics have been applied to this effect, but these have largely been used to display diagnostic and physiologic information, rather than the clinical decision at hand. This paper describes how the conflicting goals of mechanical ventilation can be visualized and applied in making decisions. Data from previous studies are analyzed to assess whether visual patterns exist which may be of use to the clinical decision maker.Materials and methodsThe structure and screen visualizations of a commercial clinical decision support system (CDSS) are described, including the visualization of the conflicting goals of mechanical ventilation represented as a hexagon. Retrospective analysis is performed on 95 patients from 2 previous clinical studies applying the CDSS, to identify repeated patterns of hexagon symbols.ResultsVisual patterns were identified describing optimal ventilation, over and under ventilation and pressure support, and over oxygenation, with these patterns identified for both control and support modes of mechanical ventilation. Numerous clinical examples are presented for these patterns illustrating their potential interpretation at the bedside.ConclusionsVisual patterns can be identified which describe the trade-offs required in mechanical ventilation. These may have potential to reduce information overload and help in simple and rapid identification of sub-optimal settings.

Depression is the fourth leading cause of adolescent illness and disability worldwide. A growing evidence base demonstrates that Short Term Psychoanalytic Psychotherapy [STPP] is an efficacious treatment for moderate to severe adolescent depression. However, with research in its infancy, key factors contributing to efficacy are unknown. Service users’ lived experiences provide valuable insight in this area. This study aimed to elucidate what adolescents value in treatment by inductively exploring lived experiences of STPP. Five adolescents with the largest reduction in depressive symptoms scores between baseline and end of treatment, who had taken part in a large-scale randomized controlled trial, were sampled. In-depth interviews carried out soon after the end of therapy were analysed using Interpretative Phenomenological Analysis. Three superordinate themes were identified: “Therapy as a Transformational Process”, “Explorative and Exposing: The Therapeutic Space” and “Being Heard and Working Together: The Therapeutic Relationship”. Adolescents valued a process of collaborative exploration with the therapist which when it was achieved was felt to facilitate a deep-rooted transformation in self-perception. Additionally, they described how an adjustment was needed to the particular frame of a psychoanalytic therapy. However, not all participants with a good treatment outcome experienced therapy in this way, suggesting a potential gap between the quantitative assessment of outcomes, and the way young people experience and understand the change process. Clinical implications and directions for research are discussed.