On holding and containing, being and dreaming

But it's against the rules!! Structured competitive games as a neglected resource in child psychodynamic psychotherapy

In the field of child psychoanalytic psychotherapy, structured competitive games such as Monopoly, UNO or football have traditionally been regarded as less conducive to deep psychodynamically oriented work. By contrast, some contemporary authors have pointed out that in middle childhood it is often precisely in play with structured games - game-play - that spontaneity and strong emotions come to the fore. These authors suggest that game-play constitutes a potentially powerful therapeutic tool for access to, and communication with, the older child's inner world. In this paper, clinical theoretical arguments are presented alongside clinical examples in support of this view and a variety of forms of game-play encountered in the analytic playroom are discussed and analysed. The paper examines how the rules and partially predetermined content of these games act as a framing structure in which the analytic work can take place safely and spontaneously, and how the model of the container ↔ contained can be usefully applied to game-play in the child therapy room. Emphasis is placed throughout on the therapeutic role of a flexible and carefully calibrated approach to the game's rules and structure and the child's cheating.

Conversation: Bion and Winnicott

In 2023, THE A-SANTAMARIA PSICOANALISIS MEXICO ASSOCIATION planned the Online Conversations of W. Bion to generate dialogues with outstanding colleagues about the divergences and convergences of Bion with the work of André Green, Jean Laplanche, Ignacio Matte Blanco and D.W. Winnicott. The need to share thoughts about these authors' works and their links with others, facilitated widespread international dialogues about these authors and placed them all in a field of exchange, debate and challenge. The Online Conversations underlined the new dimensions in which Bion and Winnicott placed psychoanalytic theory and technique. Five outstanding presentations illustrate their understanding and grasping of these dimensions, each followed by an author exchange. These authors provide an in-depth inquiry into a wide range of topics: Angela Joyce looks at object constancy and absence through the lens of Winnicott's (1977) The Piggle; Dominque Scarfone examines the concept of contact barriers among Freud, Bion and Winnicott; Howard B. Levine discusses absence, failure and the negative in the work of Bion, Winnicott and Green; Lesley Caldwell links the works of Bion and Winnicott in addressing being alone and with others, and communicating and not communicating; finally, Rudi Vermote shows how Bion's and Winnicott's views on regression and formlessness complement each other.

The affective grounds of the mind. The Affective Pertinentization (APER) model

The paper presents the Affective Pertinentization model (APER), a theory of the affect and its role it plays in meaning-making. APER views the affect as the basic form of making sense of reality. It consists of a global, bipolar pattern of neurophysiological activity through which the organism maps the instant-by-instant variation of its environment. Such a pattern of neuropsychological activity is constituted by a plurality of bipolar affective dimensions, each of which maps a component of the environmental variability. The affect has a pluri-componential structure defining a multidimensional affective landscape that foregrounds (i.e., makes pertinent) a certain pattern of facets of the environment (e.g., its pleasantness/unpleasantness) relevant to survival, while backgrounding the others. Doing so, the affect grounds the following cognitive processes. Accordingly, meaning-making can be modeled as a function of the dimensionality of the affective landscape. The greater the dimensionality of the affective landscape, the more differentiated the system of meaning is. Following a brief review of current theories pertaining to the affect, the paper proceeds discussing the APER's core tenets - the multidimensional view of the affect, its semiotic function, and the concepts of Affective Landscape and Phase Space of Meaning. The paper then proceeds deepening the relationship between the APER model and other theories, highlighting how the APER succeeds in framing original conceptualizations of several challenging issues - the intertwinement between affect and sensory modalities, the manner in which the mind constitutes the content of the experience, the determinants of psychopathology, the intertwinement of mind and culture, and the spreading of affective forms of thinking and behaving in society. Finally, the unsolved issues and future developments of the model are briefly envisaged.

Processes of change in family therapies for anorexia nervosa: a systematic review and meta-synthesis of qualitative data

OBJECTIVE

To synthesise young person and family member perspectives on processes of change in family therapy for anorexia nervosa (AN), including systemic family therapy and manualised family-based treatments, to obtain an understanding of what helps and hinders positive change.

METHOD

A systematic search of the literature was conducted to identify qualitative studies focussing on experiences of therapeutic change within family therapies for AN from the perspectives of young people and their families. Fifteen studies met inclusion criteria and underwent quality appraisal following which they were synthesised using a meta-synthesis approach.

RESULTS

Six overarching themes were generated: "A holistic focus on the young person's overall development"; "The therapeutic relationship as a vehicle for change"; "The therapist's confinement to a script and its impact on emotional attunement"; "A disempowering therapeutic context"; "Externalisation of the eating disorder (ED)"; and "The importance of family involvement". Positive change was helped by understanding and support given to the young person's overall development including their psychological, emotional, social and physical wellbeing, positive therapeutic relationships, relational containment within the family system and externalising conversations in which young people felt seen and heard. Positive change was hindered by inflexibility in the treatment approach, counter-effects of externalisation, negative experiences of the therapist, a narrow focus on food-intake and weight, as well as the neglect of family difficulties, emotional experiences, and psychological factors.

CONCLUSIONS

Positive change regarding the young person's eating-related difficulties ensued in the context of positive relational changes between the young person, their family members, the therapist and treatment team, highlighting the significance of secure and trusting relationships. The findings of this review can be utilised by ED services to consider how they may adapt to the needs of young people and their families in order to improve treatment satisfaction, treatment outcomes, and in turn reduce risk for chronicity in AN.

Working alongside next of kin to enhance discharge: A quality improvement collaboration to co-design discharge for mental health patients

OBJECTIVES

Mental health (MH) patients seen in the emergency department (ED) setting are often viewed in isolation, outside of the context of their loved ones, the next of kin (NOK). This is especially problematic when a patient is detained under the mental health act. This project aimed to improve this engagement.

METHODS

A sense of urgency was created from a guiding coalition of the local MH and ED executive of a rural hospital. The vision was communicated to the team for action. This was then institutionally incorporated as best practice during a 3 month trial.

RESULTS

NOK were engaged more frequently as a result of this quality improvement strategy, rising to 90.8% (2021) from 63.2% (2020) compared to the previous year χ2 (1, N=166) =18.75, p = .000015. Admissions for all MH patients from the emergency department fell to 28.3% (2021) from 39% (2020) χ2 (1, N=652) =8.32, p = .0039.

CONCLUSIONS

Working with NOK is a best practice strategy that was embraced by clinicians when highlighted. This resulted in less restrictive practice and more community treatment. Creating a frame for the patient that is standardised, provides containment and co-designs future health care is beneficial.

Like the belly of a bird breathing: On Winnicott's "Mind and its Relation to the Psyche-soma"

In "Mind and its relation to the psyche-soma," Winnicott reinvents the concept of psyche-soma by viewing it as a set of experiences located neither in the body nor in the brain, and in fact, not located anywhere. Psyche, in health, is understood to be the imaginative functioning of mental processes, and soma is understood to be the experience of physical realness and aliveness. Winnicott offers a clinical illustration of work with a patient who feels unreal to herself. He describes a juncture in the analysis in which the patient's somatic functioning is everything, while Winnicott, by feeling his own breathing and watching the patient breathe, knows that she is alive. This is the beginning of her becoming able to experience her breathing (soma) and imagining (psyche) as real, alive, and her own.Among the concepts Winnicott alludes to, and that I develop, are (1) the idea that in his clinical work Winnicott not only lives an experience with the patient, he also brings an unspoken structure of meaning to the experience, and the two are inseparable; and (2) the idea that Winnicott introduces a set of terms and a way of thinking that is independent of the differentiation of conscious and unconscious mind (Freud's topographic model). These ideas include aliveness and deadness, realness and unrealness, being and disruption of being.

Back to the future: when children and adolescents return to office sessions following episodes of teletherapy

Analysts and psychotherapists are beginning to have more thorough and probing discussions about how the COVID-19 pandemic has affected their work. Shifting to online teletherapy has been necessary due to the public health measures put in place to curtail the spread of the virus. Much of the existing literature addresses how using online platforms for teletherapy works for adults. This paper instead looks at its effects on working with children and adolescents. A contrast between Winnicott's notion of holding and Bion's concept of container-contained is reviewed through a summary of a paper by Ogden. This author finds that holding might be more applicable to online work during a pandemic when the collective relationship to time and its usual parameters is severely upended. Containing could be more arduous and challenging online due to the lack of embodied presence to communicate and detect tiny nonverbal cues. A short questionnaire affirms that child analysts and psychotherapists have struggled with dimensions of online work that are particular to the developmental levels of their patients. Further, teletherapy may often not be a good fit for someone with learning differences.

Subjective Experiences of At-Risk Children Living in a Foster-Care Village Who Participated in an Open Studio

The open studio art therapy model offers a space for free creation; in this space, the art therapist supports the participants’ art process. According to this model, the creative process is the central component of the therapeutic work. This qualitative study seeks to learn, through an analysis of interviews and artwork, about the subjective experiences of at-risk children living in a foster-care village who participated in an open studio. In addition, it seeks to identify changes in the artwork over time. This study involves a qualitative thematic analysis, while the analysis of visual data is based on the phenomenological approach to art therapy. The data include interviews and 82 artworks of five participants, aged 7–10 years. Five main themes emerged from the analysis of the visual and verbal data: (a) engaging in relationships; (b) moving along the continuum from basic, primary, art expressions (e.g., smearing, scribbling, etc.) to controlled expressions; (c) visibility, on a range between disclosure and concealment; (d) holding versus falling/instability; and (e) experiencing and expressions of change. The discussion expands on the themes in relation to key concepts in the field of psychodynamic psychotherapy and art therapy. It also examines the unique characteristics of this population in reference to empirical studies on developmental trauma and challenges of out-of-home placement. Finally, it discusses the study’s limitations and presents recommendations for further research.

"Day's Residues": One Vertex Among Many

The post-Bionian paradigm in psychoanalysis invites us to listen to the session as a waking-dream-thought where unconscious-thinking-in progress is continuous. The hypothesis put forward here and illustrated using clinical material is that we can use the notion of day's residues as a metaphor to refer to the incoming narrative of the patient. Whatever the patient brings to the session can be conceived as "day's residues" in that they are potential instigators of waking-dream-thought in the session. This metaphor helps the analyst place brackets around the outside of the session, deconcretizing what apparently are hard facts, so that immediate contact is made to create a shared perspective, possibly producing in this session "food" for the mind. To create the waking-dream-thought of the session, the analyst may consider listening to the incoming narrative as a metaphor. This is not a new or different concept but a particular kind of elaboration on the metaphoric stance taken by psychoanalysts of all stripes; it is an elaboration that expands the ways we can describe the session and narrow the gap between talking about the session and the experience of the session itself.

Fostering Emotional Availability in Mother-Child-Dyads With an Immigrant Background: A Randomized-Controlled-Trial on the Effects of the Early Prevention Program First Steps

Background

In many Western countries like Germany, the social integration of children with an immigrant background has become an urgent social tasks. The probability of them living in high-risk environments and being disadvantaged regarding health and education-related variables is still relatively higher. Yet, promoting language acquisition is not the only relevant factor for their social integration, but also the support of earlier developmental processes associated with adequate early parenting in their first months of life. The Emotional Availability Scales (EAS) measure the quality of caregiver-child-interactions as an indicator of the quality of their relationship and thus of such early parenting, focusing on mutual and emotional aspects of their interaction.

Method

This pilot study examined in a randomized controlled trial the effects of the prevention project First Steps regarding the hypothesis that the Emotional Availability (EA) improved to a greater extent in "difficult-to-reach" immigrant mother-child dyads in a psychoanalytically oriented early intervention (A, FIRST STEPS) compared to a usual care intervention (B) offered by paraprofessionals with an immigrant background. A sample of N = 118 immigrant women in Germany from 37 different countries and their children was compared with regard to the parental EA-dimensions sensitivity, structuring, non-intrusiveness and non-hostility and the child dimensions responsiveness to and involvement of the caregiver in the pre-post RCT design.

Results and Conclusion

Different from what was expected, repeated ANOVAs revealed no significant pre-post group differences for the parental dimensions. For the child dimensions the effect of time of measurement was highly significant, which can be interpreted as mostly natural developmental effects. Still, on the level of simple main effects for each intervention, only in the FIRST STEPS groups child responsiveness significantly improved. When controlled for confounding variables, a significant interaction effect for maternal sensitivity in favor of the FIRST STEPS intervention was found. The systematic group differences indicate that the more extensive and professional intervention, focusing on the individual needs of the participants, is more suitable to support the quality of the mother-child-relationship amongst immigrant mother-child dyads than usual care. The results are discussed taking into account the context of the maternal migration process and potential maternal traumatization.

Clinical Trial Registration

[https://clinicaltrials.gov], identifier [DRKS00004632].

The Limit of Intimacy and the Intimacy of Limit: Play and its Relation to the Bad Object

Attachment to the bad object has remained a durable, undertheorized clinical problem. With an extended clinical example, the experience of limit, in both patient and analyst, is examined as part of a dense undercurrent in the relationship, including transference, that gives rise to shifts in understanding the attachment to an unsatisfying internal object. Importantly, the patient's and the analyst's experiences of limit are "in play" during the process of changes in the patient's attachment to the bad object. The relation of patient and analyst to the patient's internal objects, including bad and unsatisfying objects, is where play itself begins. Limit itself is constitutive of play. The analyst's attempt to analyze his own thoughts and experience regarding limits in maintaining an empathic connection to the patient's psychic reality influences the patient's capacity to take in a new part of his or her experience.

Babies in therapy, psychoanalytic interventions for infants and their parents

Babies in therapy: The study "Psychoanalytic interventions for infants and their parents" conducted on infants through the lens of psychoanalysis and clinical work with both parents and infants all contribute to our knowledge of the nature of early relationship disorders. Psychoanalytic theory's concepts of the depressive position, early defense mechanisms, transference, and psychosomatic reactions to depressive emotions are shown to be crucial in clinical cases, giving therapists new tools for intervention and increasing efficiency. Psychoanalysts have researched the long-lasting effects of early disappointments and the sense of being helplessly abandoned; they emphasize that a disruption in the relationship with the caregiver can produce a psychic economy oriented on the avoidance of anxiety, leaving less energy for development. New parents and their sick infants can benefit from early therapies with therapeutic potential and the possibility of preventing future narcissistic pain issues if they are based on psychoanalytic thinking and knowledge of early symptoms.

Psychosocial curating: a theory and practice of exhibition-making at the intersection between health and aesthetics

A recent Manifesto for a Visual Medical Humanities suggested that more in-depth analysis of the contribution of visual art to medical humanities is urgently required. This need perhaps arises because artists and curators experience conflict between the experimental approaches and tacit knowledge that drive their practice and existing audience research methods used in visitor studies or arts marketing. In this paper, I adopt an innovative psychosocial method-uniquely suited to evidencing aesthetic experiences-to examine how an exhibition of my own curation facilitated audiences to undertake psychological processing of complex ideas about mental distress. I consider the curator working in a health context as a creator of care-driven environments where complex affects prompted by aesthetic approaches to illness can be digested and processed. My definition of care is informed by psychosocial studies and object relations psychoanalysis, which allows me to approach my exhibitions as supportive structures that enable a spectrum of affects and emotions to be encountered. The key argument of the paper is that concepts from object relations psychoanalysis can help to rethink the point of entanglement between curating and health as a process of preparing the ground for audiences to do generative psychological work with images and affects. The case study is Group Therapy: Mental Distress in a Digital Age, an exhibition that was iterated at FACT (Foundation for Art and Creative Technology), UK and University of New South Wales Galleries Sydney, with an emphasis on audience response to key artworks such as Madlove-A Designer Asylum (2015) by the vacuum cleaner and Hannah Hull. It is hoped that this paper will help to reaffirm the significance of curating as a cultural platform that supports communities to live with the anxieties prompted by society's most complex medical and social issues.

Young adults' transition to a plant-based diet as a psychosomatic process: A psychoanalytically informed perspective

This study examined transition to a plant-based diet by young adults and the challenges and conflicts this brings. Interviews were conducted with nine young adults in Sweden and the answers were analysed guided by a psychological method from descriptive phenomenology. The results indicate that the transition to a plant-based diet is a process comprising five dimensions: 1) Exploring new ways of living based on health anxieties, 2) regulating conflicting emotions through differentiation, 3) transforming traditional models into new alternatives, 4) confirming new skills and abilities and 5) integrating experiences and emotions into a whole. These five dimensions reflect how transition to a plant-based diet is experienced physically and emotionally. The results also indicate that plant-based meals and ingredients used in the new diet are loaded with symbols and conflicting emotions. Psychoanalytically informed theory, especially object relation theory, was used in discussing what can happen to the mind during the transition. In a wider perspective, this study provides insights into how a dietary transition can bring stability to the life of young adults and help them endure and master their situation. More research is needed to assess the role of mental health in transitioning to a plant-based diet and to draw more general conclusions, an area where psychodynamic theory can provide insights.

A Case of a Survivor of a Suicide Bomb Attack and Winnicott's "Survival of Destruction"

The author discusses Winnicott's concept of the use of an object, illustrating how it was used in the case of a woman who survived a suicide bomb attack that killed four people. The author as analyst extends Winnicott's and Ogden's ideas by demonstrating in his clinical work that the therapist must survive the patient's unconscious omnipotent belief that her love kills and must maintain his capacity for reverie. The therapist not only has to recover from the pain inflicted by the patient's demand for love, he must also change in response to the feeling of having been destroyed. In the case presented, in order for the process of survival to become real for the patient, the therapist had to discover about himself that he unconsciously shared a common reality with the patient-he, too, was experiencing features of a silenced survivor and experienced an identification with the oppressor.

(Inter)subjectivity in the research pair: Countertransference and radical reflexivity in organizational research

Destabilizing what we know, a central tenet of critical reflexive research, is difficult without making unconscious assumptions, beliefs, and emotions available for thought, articulation, and questioning. Articulating countertransference, a technique borrowed from psychoanalysis, informs our efforts to raise awareness of the unconscious dimensions of field experiences and thus foster radical reflexivity. Bridging the literatures on reflexivity and relational psychoanalysis, we develop a new four-dimension method of writing and analyzing fieldnotes— observing, capturing the story, articulating countertransference, and developing interpretations—that foregrounds unconscious dimensions of experience. We make visible the fieldnotes we generated during an organizational study. In doing so, we demonstrate how a research pair working together in real time can become aware of their intersubjective processes, fold together multiple dimensions of experience (conscious and unconscious), and co-construct a shared understanding of organizational dynamics. This article is valuable because it demonstrates how psychoanalytic concepts can be mobilized by psychoanalytically informed, but not formally trained, organizational researchers.

"Sparks that became a little light over time": A qualitative investigation of musicking as a means of coping in adults with PTSD

This article investigates the experience of musicking (the performance of musical activity) among people coping with post-traumatic stress disorder (PTSD). Using qualitative research methods, we conducted semi-structured in-depth interviews with 10 male participants in a music project for people coping with PTSD induced by war and terrorism. The project consists of individual music lessons once a week and a musical enrichment group that meets once a month. Group meetings include workshops and lectures by music professionals and artists, during which participants are exposed to diverse musical content. Following an interpretive phenomenological content analysis, we were able to identify two central themes arising from the interviews: musicking as an intra-subjective experience and musicking as mediator of inter-subjective relationships. A further analysis revealed three superordinate themes: musicking as a secure place, musicking as a dialectic experience, and musicking as a means for identity reconstruction (bridging between past, present, and future). From this we concluded that for our interviewees musicking is a secure place for their wounded self, which allows the reconstruction of a coherent personal narrative while conducting a dialectic encounter with the trauma and its symptoms via nonverbal language. Consequently, we recommend musicking as a therapeutic tool for people coping with war-induced PTSD from both intrapersonal and interpersonal perspectives.

A theory of the setting: The transformation of unrepresented experience and play

The psychoanalytic setting can be defined in part by its functions. The setting operates as an auxiliary function for the analyst's capacities, which include containment, interpretation, as a participant in play, and supervisor of the setting. The setting houses the transition from unrepresented to represented experience. The setting is a location for the dynamic transit between vital, interactive elements of both containment and interpretation of the patient's unconscious and conscious experience. Process and non-process elements of the setting are always interacting with one another because the objects' internal fantasies of the setting are always juxtaposed with the constant, structural elements of the setting. The author attempts to further elaborate the relationship of play to understanding unrepresented experience.

In the shadow of Apartheid: intergenerational transmission of Black parental trauma as it emerges in the analytical space of inter-racial subjectivities

Using the construct of projective identification and integrating it with the body of literature on intergenerational transmission of unsymbolized parental trauma, I describe the case of an adult black South African woman called Sibulelo. It is suggested that Sibulelo has unconsciously identified with the disavowed parents and grandparents trauma that they suffered as a result of the system of Apartheid. Such trauma is expressed through her feelings of being dis-located in time and space, as if she is living outside of herself, unplugged from life, and living someone else’s life. The paper details the unfolding therapeutic process in relation to my whiteness in the context of her blackness. This brings into sharp focus an exploration of black-white racialized transference-counter-transference matrix in the context of intergenerational trauma. It is a reflective paper and opens up my own counter-transference, thus foregrounding the notion of therapeutic inter-subjectivity. A further contribution to psychoanalytic theory concerns the role of recognition and being seen as a powerful process in facilitating the symbolization of trauma. In addition, if there is no interruption of the cycles of intergenerational trauma, and therefore no symbolization, it becomes an unconscious familial compulsion to repeat. Moreover, this therapy case highlights the idea that as a traumatised family living within a bruised culture of intergenerational transmission of trauma, such repetition of trauma becomes a cultural compulsion to repeat what has not been spoken or named.

Playing in the Darkness: Use of the Object and Use of the Subject

Play in the context of the patient's sense of absence, loss, and compromised capacities for symbolization can be a link between unsymbolized experience and greater capacities for representation. Winnicott's concepts of play evolved as one of the ways that analysts translate unconscious and unrepresented experience. For many patients who have experienced absence, the analyst and the analytic setting are subjected to the patient's unconscious efforts to destroy and negate meaning and relatedness. For the analyst to be "used" as an object to be destroyed and to survive destruction, he must become a subject in the mind of the patient and in his own mind as analyst within the intersubjective field. The analyst's work with his own resistance is vital to becoming a changing subject and an object available for play in the psychoanalytic process.

COUNTERTRANSFERENCE DREAMING: LIFE IN THE INTERSUBJECTIVE THIRD

In this paper the author asks, "How long is the life of an intersubjective field?" She proposes that it is possible for the field to remain active and instructive even after formal sessions have ended: This occurs in her case of Carla, a young woman who terminates prematurely. Carla enters treatment in a downward spiral of severe trauma symptoms that began subsequent to her rape, a decade earlier. Although Carla's symptoms diminish and the analysis continues to be productive, it suddenly ends in an impasse, leaving the analyst perplexed and feeling professionally insufficient. Months later, she has three dreams pertaining to Carla and her rape. Largely employing Jessica Benjamin's recognition theory and her representation of the intersubjective third, as well as contemporary Bionian thinking, the paper depicts how countertransference dreaming is one example of how the intersubjective field can carry on the psychoanalytic function-even outside of formal treatment.

Reading Harold Searles

Through a close reading of two of Searles's papers, the author explores not only what Searles thinks, but the way he thinks and how he works with patients. Searles makes use of a form of emotional responsiveness to the transference-countertransference that entails a seamless continuity of conscious and unconscious receptivity and thought. His unflinchingly honest descriptions of what is occurring in the transference-countertransference seem, as if of their own accord, to generate original clinical theory, for example, a reconceptualization of what is entailed in the successful analysis of the Oedipus complex. He demonstrates his own distinctive form of analytic thinking and interpreting, which the author describes as 'turning experience inside out'. Searles, in clinical example after clinical example, transforms what had been the invisible, unnameable emotional context of the patient's experience into verbally symbolized psychological content that is thinkable and speakable. In the final section of the paper, the author discusses an important (and unexpected) complementarity of the work of Searles and Bion. Searles's work provides clinical shape and vitality for Bion's often abstract theoretical constructions, such as the concept of the container-contained, the human need for truth, and the relationship of conscious and unconscious experience. At the same time, Bion's work provides a broader theoretical context for Searles's work.

THERAPISTS' EXPERIENCES OF MOTHER-INFANT PSYCHOANALYTIC TREATMENT: A QUALITATIVE STUDY

As part of a larger research project in Sweden, a qualitative study investigated psychotherapists' experiences of mother-infant psychoanalysis (MIP). A randomized controlled trial compared two groups of mother-infant dyads with psychological problems. One had received Child Health Center care, and the other received MIP. Previous articles on long-term effects have found that mothers who had received MIP were less depressed throughout a posttreatment period of 3½ years, and their children showed better global functioning and psychological well-being. The present study's objectives were to describe the therapist's experiences of MIP and deepen the understanding of the MIP process. Six months after treatment began, all therapists were interviewed. Transcribed interviews with therapists from 10 (of 33 total) MIP treatments were randomly selected and analyzed in detail by thematic analysis. Therapists worked successfully with mother and infant together and found different ways of cooperation during MIP sessions. Therapists reported overall positive experiences; however, in cases where mothers needed more personal attention, it would be important to adapt the method to them.

Addressing Structural Barriers to HIV Care among Triply Diagnosed Adults: Project Bridge Oakland

People who are "triply diagnosed" with HIV, mental health issues, and substance-related disorders face tremendous barriers connecting to and remaining in HIV care. Authors of this article implemented Project Bridge Oakland (PBO), an intervention based on harm reduction and trauma-informed care, to help maintain continuity of care for triply diagnosed adults through cycles of criminal justice involvement. From August 2011 to December 2014, a clinical social worker and an HIV physician provided intensive case management for 19 clients living in Oakland, California. By working with clients across a multitude of community, clinic, and correctional spaces while maintaining a low threshold for services, the social worker was able to engage a severely marginalized population in HIV care. This article details the PBO strategies for assisting with a wide range of services needed for community stabilization, navigating criminal justice involvement, and establishing a therapeutic relationship through mundane practices such as eating and waiting for appointments. This article illustrates how programs aimed at stabilizing triply diagnosed clients in the community and connecting them to HIV care require coordination among providers, outreach to engage clients, ample time to work with them, and flexibility to account for the complexities of their day-to-day lives and experiences.

DREAMING THE ANALYTIC SESSION: A CLINICAL ESSAY

This is a clinical paper in which the author describes analytic work in which he dreams the analytic session with three of his patients. He begins with a brief discussion of aspects of analytic theory that make up a good deal of the context for his clinical work. Central among these concepts are (1) the idea that the role of the analyst is to help the patient dream his previously "undreamt" and "interrupted" dreams; and (2) dreaming the analytic session involves engaging in the experience of dreaming the session with the patient and, at the same time, unconsciously (and at times consciously) understanding the dream. The author offers no "technique" for dreaming the analytic session. Each analyst must find his or her own way of dreaming each session with each patient. Dreaming the session is not something one works at; rather, one tries not to get in its way.