On the Belatedness of Psychoanalytic Clinical Writing

The belatedness of analytic writing and its effects on analytic processes are explored through the concepts of nachträglichkeit and thirdness. The temporal gap between being with and writing about functions as a meaningful pause filled with opportunities for investigating unconscious pathways to the analyst's countertransference. The significance of analytic narration in affecting specific psychoanalytic developments is explored. The theoretical framework utilizes the concept of après coup, which brings to light new meanings in an afterwardness of time. Aspects of analytical writing dynamics are discussed as equivalent to those of nachträglichkeit. Analysts also deploy thirdness in constructing presentations of clinical material. This could be an intrapsychic third or an external figure representing an internal introjected third. A clinical vignette demonstrates the enhanced understanding achieved by writing. It specifically assisted in exploring the analyst's enactment relating to change in the setting, the background for which was a move to online analysis. This evoked infantile anxieties and painful confusions about loss. Historically, the patient had to navigate a path through miasmic ambiguities between reality and phantasy, truths and lies. A conclusion is reached, arguing that analytic processes extend beyond the duration of sessions, and that the processes of clinical writing can provide a significant contribution.

Mocking enactments: a case study of multimodal stance-stacking

Although research into multimodal stance-taking has gained momentum over the past years, the multimodal construction of so-called stacked stances has not yet received systematic attention in the literature. Mocking enactments are a prime example of such complex social actions as they are layered both interactionally and stance-related, and they rely significantly on the use of bodily visual resources, depicting rather than describing events and stances. Using Du Bois' Stance Triangle as a framework, this study investigates mocking enactments as a case study to unravel the multimodal aspects of layered stance expressions. Drawing on three data sets-music instruction in Dutch, German, and English, spontaneous face-to-face interactions among friends in Dutch, and narrations on past events in Flemish Sign Language (VGT)-this study provides a qualitative exploration of mocking enactments across different communicative settings, languages, and modalities. The study achieves three main objectives: (1) illuminating how enactments are used for mocking, (2) identifying the layers of stance-taking at play, and (3) examining the multimodal construction of mocking enactments. Our analysis reveals various different uses of enactments for mocking. Aside from enacting the target of the mockery, participants can include other characters and viewpoints, highlighting the breadth of the phenomenon under scrutiny. Second, we uncover the layered construction of stance on all axes of the Stance Triangle (evaluation, positioning, and alignment). Third, we find that mocking enactments are embedded in highly evaluative contexts, indexed by the use of bodily visual resources. Interestingly, not all mocking enactments include a multimodally exaggerated depiction, but instead, some merely allude to an absurd hypothetical scenario. Our findings contribute to the growing body of literature on multimodal stance-taking, by showing how a nuanced interpretation of the Stance Triangle can offer a useful framework for analyzing layered stance acts.

A case of prazosin in treatment of rapid eye movement sleep behavior disorder

Rapid eye movement (REM) sleep behavior disorder (RBD) is characterized by dream-enactment behaviors that emerge during a loss of REM sleep atonia. Untreated RBD carries risks for physical injury from falls or other traumatic events during dream enactment as well as risk of injury to the bed partner. Currently, melatonin and clonazepam are the mainstay pharmacological therapies for RBD. However, therapeutic response to these medications is variable. While older adults are most vulnerable to RBD, they are also particularly vulnerable to the adverse effects of benzodiazepines, including increased risk of falls, cognitive impairment, and increased risk of Alzheimer disease. Prazosin is a centrally active alpha-1 adrenergic receptor antagonist often prescribed for trauma nightmares characterized by REM sleep without atonia in patients with posttraumatic stress disorder. We report a case of successful RBD management with prazosin in a patient in whom high-dose melatonin was ineffective. Although there was no observable reduction in dream-enactment behaviors with high-dose melatonin, the possibility of a synergistic effect of prazosin combined with melatonin cannot be ruled out. This case report supports further evaluation of prazosin as a potential therapeutic for RBD.

CITATION

Cho Y, Iliff JJ, Lim MM, Raskind M, Peskind E. A case of prazosin in treatment of rapid eye movement sleep behavior disorder. J Clin Sleep Med. 2024;20(2):319-321.

Development of fidelity of delivery and enactment measures for interventions in communication disorders

OBJECTIVES

This study was part of a process evaluation for a single-blind, randomized controlled pilot study comparing Better Conversations with Primary Progressive Aphasia (BCPPA), an approach to communication partner training, with no speech and language therapy treatment. It was necessary to explore fidelity of delivery (delivery of intervention components) and intervention enactment (participants' use of intervention skills in the form of conversation behaviours comprising facilitators, that enhance the conversational flow, and barriers, that impeded the flow of conversation). This study aimed to: (1) Outline an adapted methodological process that uses video observation, to measure both fidelity of delivery and enactment. (2) Measure the extent to which the BCPPA pilot study was delivered as planned, and enacted.

DESIGN

Observational methods were used alongside statistical analysis to explore the fidelity of intervention and enactment using video recordings obtained from the BCPPA pilot study.

METHODS

A 5-step methodology, was developed to measure fidelity of delivery and enactment for the BCPPA study using video-recorded data. To identify delivery of intervention components, a random sample of eight video recorded and transcribed BCPPA intervention sessions was coded. To examine the enactment of conversation behaviours, 108 transcribed 10 -min-video recorded conversations were coded from 18 participants across the control and intervention group.

RESULTS

Checklists and guidelines for measurement of fidelity of treatment delivery and coding spreadsheets and guidelines for measurement of enactment are presented. Local collaborators demonstrated 87.2% fidelity to the BCPPA protocol. Participants in the BCPPA treatment group increased their use of facilitator behaviours enacted in conversation from a mean of 13.5 pre-intervention to 14.2 post-intervention, whilst control group facilitators decreased from a mean of 15.5 to 14.4, over the same timescale.

CONCLUSIONS

This study proposes a novel and robust methods, using video recorded intervention sessions and conversation samples, to measure both fidelity of intervention delivery and enactment. The learnings from this intervention are transferable to other communication interventions.

Exploring techniques for encoding spoken instructions in working memory: a comparison of verbal rehearsal, motor imagery, self-enactment and action observation

Encoding and recalling spoken instructions is subject to working memory capacity limits. Previous research suggests action-based encoding facilitates instruction recall, but has not directly compared benefits across different types of action-based techniques. The current study addressed this in two experiments with young adults. In Experiment 1, participants listened to instructional sequences containing four action-object pairs, and encoded these instructions using either a motor imagery or verbal rehearsal technique, followed by recall via oral repetition or enactment. Memory for instructions was better when participants used a motor imagery technique during encoding, and when recalling the instructions by enactment. The advantage of using a motor imagery technique was present in both verbal and enacted recall. In Experiment 2, participants encoded spoken instructions whilst implementing one of four techniques (verbal rehearsal, motor imagery, observation of others' actions or self-enactment), and then recalled the instructions by oral repetition or enactment. For both verbal and enacted recall, memory for instructions was least accurate in the rehearsal condition, while the other encoding conditions did not differ from each other. These novel findings indicate similar benefits of imagining, observation and execution of actions in encoding spoken instructions, and enrich current understanding of action-based benefits in working memory.

Sentence memory recall in adolescents: Effects of motor enactment, keyboarding, and handwriting during encoding

BACKGROUND

Prior research has shown that memory for action sentences is stronger when stimuli are enacted during encoding than simply listened to: the so-called enactment effect. The goal of the present study was to explore how writing during encoding-through handwriting and through keyboarding-fares compared with enacting, in supporting memory recall.

METHODS

One hundred Norwegian high school students (64 girls, 36 boys) aged 16-21 years (M = 17.1) participated in the study. Four lists of verb-noun sentences with 12 sentences in each list were presented in four encoding conditions: (i) motor enactment, (ii) verbal listening, (iii) handwriting, and (iv) keyboarding.

RESULTS

Results revealed a significant main effect of encoding condition, with the best memory gained in the enactment condition. Regarding writing, results showed that handwriting and keyboarding during encoding produced the lowest recall in comparison with the enactment and verbal listening conditions.

CONCLUSION

These results thus provide additional support for the enactment effect. While there has been much discussion on the relative benefits of handwriting versus keyboarding on student performance, both seemed to be equally poor strategies for the particular learning task explored here, potentially through increased cognitive load.

Cultural poetics of illness and healing

This issue of Transcultural Psychiatry presents selected papers from the McGill Advanced Study Institute on "Cultural Poetics of Illness and Healing." The meeting addressed the cognitive science of language, metaphor, and poiesis from embodied and enactivist perspectives; how cultural affordances, background knowledge, discourse, and practices enable and constrain poiesis; the cognitive and social poetics of symptom and illness experience; and the politics and practice of poetics in healing ritual, psychotherapy, and recovery. This introductory essay outlines an approach to illness experience and its transformation in healing practices that emphasizes embodied processes of metaphor as well as the social processes of self-construal and positioning through material and discursive engagements with the cultural affordances that constitute our local worlds. The approach has implications for theory building, training, and clinical practice in psychiatry.

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.

The effect of therapists' enactment interventions in promoting vulnerability sharing in emotion focused couple therapy

OBJECTIVE

The primary purported change process in emotion-focused therapy for couples (EFT-C) involves partners accessing and revealing their underlying vulnerable emotions and responding empathically when their partners disclose their vulnerable emotions. One main intervention to facilitate vulnerability sharing is enactment - guiding partners to interact directly with each other. The objective of the current study was to identify interventions therapists can use to help partners share vulnerability in the context of enactment. The primary hypothesis of this study was that promoting these interventions would lead to more vulnerability expressions during enactments.

METHOD

One hundred and five vulnerability enactment events were identified from videod therapy sessions of 33 couples dealing with a significant emotional injury who received 12 sessions of EFT-C. Four therapists' interventions were coded: setting a meaningful systemic context, promoting the revealing partner's emotional engagement, preparing the revealing partner for enactment, and promoting the listening partner's emotional engagement in the enactment. In addition, vulnerability expression was coded.

RESULTS

Multilevel regression models showed that two interventions were significantly associated with greater levels of expressed vulnerability: setting a meaningful systemic context, and preparing the revealing partner for enactment.

CONCLUSION

These findings suggest that therapists can facilitated vulnerability sharing using specific preparatory interventions.

Distance And Relation: Emerging From Embeddedness In The Other

Inspired by an essay by Martin Buber (1950), and then by the work of Ernest Schachtel (1959) on the idea of "embeddedness" and emergence from it, this essay is an account of the role of "distance" or "separateness" in clinical psychoanalytic work. We tend to assume that the capacity to appreciate otherness is always already present. We often lose track of the necessity to "set the other at a distance" (Buber), the prerequisite for emergence from embeddedness in the other. The entire process-i.e., setting the other at a distance and then emerging from embeddedness in the other-must take place over and over again in any treatment, and in both directions: patients must disembed from analysts, but it is just as necessary for analysts to disembed from patients. It is the emergence from embeddedness that allows the analyst's appreciation of the patient's otherness. Embeddedness in the other is discussed as mutual enactment. This use of these phenomena in treatment is articulated in the theory of witnessing presented elsewhere in recent years (Stern 2009, 2012, 2022b, in press). A detailed clinical illustration is presented.

A cultural-ecosocial systems view for psychiatry

While contemporary psychiatry seeks the mechanisms of mental disorders in neurobiology, mental health problems clearly depend on developmental processes of learning and adaptation through ongoing interactions with the social environment. Symptoms or disorders emerge in specific social contexts and involve predicaments that cannot be fully characterized in terms of brain function but require a larger social-ecological view. Causal processes that result in mental health problems can begin anywhere within the extended system of body-person-environment. In particular, individuals' narrative self-construal, culturally mediated interpretations of symptoms and coping strategies as well as the responses of others in the social world contribute to the mechanisms of mental disorders, illness experience, and recovery. In this paper, we outline the conceptual basis and practical implications of a hierarchical ecosocial systems view for an integrative approach to psychiatric theory and practice. The cultural-ecosocial systems view we propose understands mind, brain and person as situated in the social world and as constituted by cultural and self-reflexive processes. This view can be incorporated into a pragmatic approach to clinical assessment and case formulation that characterizes mechanisms of pathology and identifies targets for intervention.

The Play of Mourning

Playing is a form of responsiveness that involves a shift from more formal interpretation about defense, unconscious fantasy, or transference to one that employs humor or irony regarding the content of fantasy or poses a more direct confrontation between internal fantasy and external reality. Playing is differentiated from more formal interpretation by the analytic couple's intensity of affective expression, the idiomatic language used to express affect or ideas, or the analyst's more personally revealing reaction to the patient's recruitment of him as an internal object. Two clinical vignettes show how play emphasizes experiences of loss and waste that have been enacted in the patient's life and often in transference-countertransference engagement. Through newly discovered forms of play, these processes are occurring now in real time between patient and analyst and less through frozen memorialization of what never was.

How the Behavior Change Content of a Nationally Implemented Digital Diabetes Prevention Program Is Understood and Used by Participants: Qualitative Study of Fidelity of Receipt and Enactment

BACKGROUND

The National Health Service Digital Diabetes Prevention Programme (NHS-DDPP) is a program for adults in England at risk of developing type 2 diabetes mellitus (T2DM). It is based on NHS England specifications that stipulate specific behavior change techniques (BCTs), that is, active ingredients to produce behavior change to target diet and physical activity. Now rolled out nationally, the NHS-DDPP is being delivered by 4 independent providers as a 9-month intervention via apps, educational material, and remote health coaching. To optimize effectiveness, participants need to be able to understand and use behavior change content (eg, goal setting and problem solving) of an intervention delivered to them digitally. Previous research has shown that people benefit from support to aid the understanding and use of BCTs.

OBJECTIVE

The objectives of this qualitative study were to evaluate how participants in the NHS-DDPP understand and use BCT content, investigate how participants describe the role of health coaches in supporting their behavior change, and examine how the understanding and use of behavior change content of the NHS-DDPP varies across providers.

METHODS

In total, 45 service users were interviewed twice by telephone at 2 to 4 months into, and at the end of, the program. Topics included participants' understanding and use of key BCTs to support self-regulation (eg, goal setting) and the support they received via the program. Transcripts were analyzed thematically, informed by the framework method.

RESULTS

Participants described their understanding and use of some behavior change content of the program as straightforward: use of BCTs (eg, self-monitoring of behavior) delivered digitally via provider apps. Participants valued the role of health coaches in supporting their behavior change through the emotional support they offered and their direct role in delivery and application of some BCTs (eg, problem solving) to their specific circumstances. Participants expressed frustration over the lack of monitoring or feedback regarding their T2DM risk within the program. Variations in the understanding and use of behavior change content of the NHS-DDPP were present across provider programs.

CONCLUSIONS

Health coaches' support in delivery of key components of the program seems to be pivotal. To improve the understanding and use of BCTs in digital interventions, it is important to consider routes of delivery that offer additional interactive human support. Understanding of some self-regulatory BCTs may benefit from this support more than others; thus, identifying the optimal mode of delivery for behavior change content is a priority for future research. The NHS-DDPP could be improved by explicitly setting out the need for health coaches to support understanding of some self-regulatory BCT content such as problem solving in the service specification and amending the discharge process so that knowledge of any change in T2DM risk is available to participants.

Why art? The role of arts in arts and health

This article is an answer to a report called "What is the evidence on the role of the arts in improving health and well-being?" The authors conclude that the arts have an impact on mental and physical health. Yet, the question of the role of the arts remains unanswered. What is and what is not an art effect? Recently, embodied theory has inspired articles on the perception of art. These articles have not yet received attention in the field of Arts and Health. Scholars in psychosomatic medicine have argued for an approach based on recent work in enactive embodied theory to investigate the connection between the body and the mind. The present article examines how key concepts in this theory relate to art. This leads to a discussion of art in terms of empathy-the relation between the internal state of the artist and the internal state of the beholder. I exemplify with a conceptual framework of musical empathy. Implications for health are addressed.

On Coming Into Possession of Oneself: Witnessing and the Formulation of Experience

In this paper I use clinical theory and illustration to explore details of the formulation of experience, which depends upon the metamorphosis of experience from not-me to feels-like-me. I take the position that the movement from not-me to feels-like-me, with the accompanying possibilities for formulating new meaning that open at such moments, happens when we not only know or feel something, but also, and simultaneously, sense ourselves in the midst of this process-that is, when we know and feel that it is we who are doing the knowing and feeling. When these two events co-occur, which depends upon the process of witnessing and the breach of dissociation, we come into possession of ourselves. Witnessing of one person by another is a process of recognition, but it is also a kind of affirmation performed by "someone who is trusted and justifies the trust and meets the dependence" (Winnicott 1971, p. 60).

Afterwards-Forgetting, Remembering, Transmitting. Extreme Trauma and Culture in Post-National-Socialist Germany

Facing the rupture the Shoah marks in the history of humanity and in the life of survivors and their relatives, this article approaches long-term psychosocial consequences-after Auschwitz. The dimensions of "forgetting" in post-Nazi Germany are brought into focus by the remembering and passing on of extreme traumatic experiences of persecution. To gain insights into these processes, this article differentiates between traumatization and extreme traumatization. Survivors remember and pass on their experiences of persecution, especially through non-verbal communication and in the form of unconsciously shaped "scenes." This Scenic Memory of the Shoah is conveyed in relationships with descendants, to fellow human beings, to the environment and thus also in experiences of anti-Semitism in Germany today. The fact that extreme traumatization is expressed precisely in scenes of coexistence also means that it must be understood as an embedded factor in society, in culture-in forgetting and remembering "afterwards."

The Portal: Framing and Neutrality in the Age of Virtual Treatment

The author proposes that the concept of framing activity provides a useful approach to neutrality by synthesizing relational approaches with an extension of José Bleger's (1967, 2012) conceptualization of the frame as containing primitive aspects of the analysand. She argues that the analytic frame also serves as a depository, or bulwark, for the analyst's ideological alignments. Identifying how ongoing framing activity is in tension with this bulwark affords a means of approaching, interrogating, and "doing" neutrality that elaborates the flexibility and self-reflection that contemporary psychoanalytic thinking seeks to bring to an earlier, more rigid idea of "the frame." Clinical vignettes focus on framing and its connection to neutrality in the context of remote treatments.

The Activity of Neutrality

The author discusses the analyst's neutrality as an activity: a constantly moving position and an always-evolving process characterized by the analyst's thinking and curiosity about how to help the patient better know and become himself. The author maintains that neutrality is a cluster concept (Wittgenstein 1953) that includes a number of functions. Recent theoretical shifts regarding neutrality are briefly reviewed, and an illustrative clinical vignette is presented.

"Call Me by Your Name": The Wrong Action: From Ferenczi to Enactment as a Process

It is always hard for psychoanalysis to connect free associations and action. With Freud, action could be interpreted only when it referred to the transference; otherwise, action was a resistance to the possibility of free association. Unlike Freud, Ferenczi recognized the importance of the analyst's acting-out as the patient's unconscious request for experiences of trauma to be mobilized. By presenting a clinical case, the author offers the analyst's error as the mobilization of a traumatic block. The error activates a "Process of enactment," whereas if the error is not considered positively, it is simply a mistake, or the loss of a creative opportunity.

How do Healthcare Workers 'Do' Guidelines? Exploring How Policy Decisions Impacted UK Healthcare Workers During the First Phase of the COVID-19 Pandemic

We describe how COVID-19-related policy decisions and guidelines impacted healthcare workers (HCWs) during the UK's first COVID-19 pandemic phase. Guidelines in healthcare aim to streamline processes, improve quality and manage risk. However, we argue that during this time the guidelines we studied often fell short of these goals in practice. We analysed 74 remote interviews with 14 UK HCWs over 6 months (February-August 2020). Reframing guidelines through Mol's lens of 'enactment', we reveal embodied, relational and material impacts that some guidelines had for HCWs. Beyond guideline 'adherence', we show that enacting guidelines is an ongoing, complex process of negotiating and balancing multilevel tensions. Overall, guidelines: (1) were inconsistently communicated; (2) did not sufficiently accommodate contextual considerations; and (3) were at times in tension with HCWs' values. Healthcare policymakers should produce more agile, acceptable guidelines that frontline HCWs can enact in ways which make sense and are effective in their contexts.

Improving older adults' ability to follow instructions: benefits of actions at encoding and retrieval in working memory

The ability to follow instructions is critical for learning new skills and may support successful aging. Recent evidence indicates a close link between following instructions and working memory, and that action-based processing at encoding and retrieval can improve this ability. In this study, we examined the ability to follow instructions and the benefits of action-based processing in young and older adults. In Experiment 1, participants were presented with spoken or silent demonstrated instructions, then recalled them by oral repetition or physical enactment. Older adults produced fewer correct responses in all conditions. Both age groups were better at recalling demonstrated than spoken instructions in the verbal but not the enacted recall condition. Older adults also benefited from enacted recall relative to verbal recall, but to a smaller extent than younger adults. In Experiment 2, the additional benefit of dual modalities (spoken instructions with simultaneous demonstration) relative to single modality presentation (spoken instructions, or silent demonstration) was examined. Both age groups showed superior performance in dual modality conditions relative to spoken instructions when using verbal recall. These findings suggest that although following instruction ability appears to decline with age, older adults can still benefit from action at encoding and retrieval.

EXPRESS: Translating words into actions in working memory: the role of spatial-motoric coding

Research from a working memory perspective on the encoding and temporary maintenance of sequential instructions has established a consistent advantage for enacted over verbal recall. This is thought to reflect action planning for anticipated movements at the response phase. We describe five experiments investigating this, comparing verbal and enacted recall of a series of action–object pairings under different potentially disruptive concurrent task conditions, all requiring repetitive movements. A general advantage for enacted recall was observed across experiments, together with a tendency for concurrent action to impair sequence memory performance. The enacted recall advantage was reduced by concurrent action for both fine and gross concurrent movement with the degree of disruption influenced by both the complexity and the familiarity of the movement. The results are discussed in terms of an output buffer store of limited capacity capable of holding motoric plans for anticipated action.

The Pandemic, the Protests, the Chaos: A Destabilizing Effect on the Analyst : Analyst Involvement in Protests During the Pandemic and Its Effect on a Treatment

In May 2020, within the cultural and emotionally regressive chaos of the pandemic, the analyst witnessed a violent Black Lives Matter protest. Myriad unprocessed feelings subsequently impacted her handling the treatment of a patient who abruptly left a session to attend a protest herself. The analyst describes her own personal experience and the cascade of events that affected the treatment. She suggests that analysts can be armed with the awareness that enactments are more likely to happen when the analyst, as well the patient, are under extreme duress as is the case in the time of Covid. She describes some of the forces that were specific to this case and her own personal embroilment. She then broadens the discussion to other analysts' reports of overwhelming pandemic experiences and the corresponding effect on the work. She also elucidates the importance of the frame for therapeutic work.

Culture - Surprise and the Psychoanalyst

The author describes how an immersion experience in another culture can benefit the psychoanalyst-and the individual who is a psychoanalyst-by confronting trusted theories and challenging the analyst to create new methods for understanding basic aspects of human experience, such as the meaning of the "self."

Intersubjectivity And Analytic Field Theory

Intersubjectivity is the central concept of the relational paradigm, the most widely employed in contemporary psychoanalysis. Yet we do not have a clear definition of it. Usually it is synonymous with "the interpersonal" and thus indicates the interaction that takes place between two already constituted subjects. In this sense it has little to do with the radical social theory of subjectivation suggested by the term, at least originally, in Husserl's philosophy. In the original meaning of intersubjectivity, as handed down by Husserl and later developed by Merleau-Ponty, the binary opposition between subjectivity and intersubjectivity is dissolved and transformed into a dialectic relationship. To formulate a clear and distinct, but above all specific, definition of intersubjectivity, we need to reclaim this intuition and translate it into coherent principles of technique. It is also essential to verify whether the models of psychoanalysis proffered as intersubjective actually satisfy this parameter. On the basis of these two simple principles, the variants of psychoanalysis that are labeled intersubjective can be placed along a continuum. Examples are given of "weak" and "strong" intersubjectivity. Paradigmatic of the latter pole is the post-Bionian theory of the analytic field.

When the wheels come off: Actor-network therapy for mental health recovery in the bicycle repair workshop

Professional accounts of emotional distress originate from within mainstream mental illness discourses and are underpinned by largely conjectural biomedical, brain-based conceptions of disorder. Alternative, formulation-based approaches remain delimited by cultural norms and linguistic resources. Service users frequently declare the most ordinary aspects of therapy the most helpful: listening, understanding, and respectfulness; these are not contingent upon the presence of a mental health professional. This paper describes ameliorations in states of emotional distress amongst volunteer trainee mechanics in a bicycle workshop, which has little overtly to do with mental health. Possible explanations for these ameliorations, or 'recoveries', are presented. In an enabling setting that offers the social and material resources conducive to particular ways of being, an applied actor-network approach is introduced as a practical way to disentangle the concomitant complexities of bicycles and everyday life. This approach to analysing states of distress-introduced here as 'actor-network therapy'-combines notions of enactment and enhandedness in the appreciation of 'engrenage' - the intriguing intricacy of locally generated, provisional realities.

When the Action to Be Performed at the Stage of Retrieval Enacts Memory of Action Verbs

Abstract. According to the embodied approach of language, concepts are grounded in sensorimotor mental states, and when we process language, the brain simulates some of the perceptions and actions that are involved when interacting with real objects. Moreover, several studies have highlighted that cognitive performances are dependent on the overlap between the motor action simulated and the motor action required by the task. On the other hand, in the field of memory, the role of action is under debate. The aim of this work was to show that performing an action at the stage of retrieval influences memory performance in a recognition task (experiment 1) and a cued recall task (experiment 2), even if the participants were never instructed to consider the implied action. The results highlighted an action-based memory effect at the retrieval stage. These findings contribute to the debate about the implication of motor system in action verb processing and its role for memory.

Is the Noise the Message in Psychoanalytic Listening?

In psychoanalytic discourse, the question of meaning or lack thereof should be relegated only to the domain of the interlocutor's perception. Not every slip of the tongue or bungled action is necessarily precipitated by some unconscious motivation, although one may construct meaning for it après coup (Nachträglichkeit). What is a message versus a noise depends on the perceptual experience of the analytic couple, and a cigar, if not just a cigar, depends on the context-specific fantasy of the perceiver. The author's aim is to show the difficulty of distinguishing the noise from the message in the interactive matrix of the analytic situation. Yet what at first may seem to be a banal error such as double-booking may at times enliven a stultified course of the analytic process; it may even drag a stillborn transference out of its embalmed closet.

Case Report: When Does Puberty Become Traumatic?

Puberty provokes physiological upheaval that can be psychologically traumatic and destabilizing for the child. Before the transformations of puberty, the body is a protective vessel that acts as a stable reference for the child. A child's emotional security is derived from a sense of predictability and well-being. However, the nascent sexuality and burgeoning libido experienced during puberty can trigger unsettling changes in the psycho-affective and psycho-dynamic equilibrium of the child as he or she transforms into an adolescent. This article presents puberty as a transformative experience with traumatic impact that needs to be considered in therapy conducted with adolescents. At best, pubescent trauma can cause superficial issues in a child's adaptive abilities; at worse, it can lead to pathological symptoms. This article presents a qualitative study derived from a clinical case of an adolescent girl who expresses her pubescent suffering through social withdrawal and mutism. The study determines several symptomatic and traumatic indicators caused by the sudden physiological transformations of puberty, such as perceived breaches in a child's sense of safety and the child's ability to predict. The study also explores the feelings of helplessness, vulnerability, and aloneness that pubescent adolescents endure, which are then exacerbated by the sensed inability to turn to parents for help or peers for support.

Gesturing helps memory encoding in aMCI

Encoding in episodic memory is a step often impaired in patients with amnestic Mild Cognitive Impairment (aMCI). However, procedural memory processes are still relatively preserved. In line with previous research on the enactment effect, we investigated the potential benefit of encoding words combined with imitative gestures on episodic memory. Based on the Grober and Buschke's free/cued recall procedure, we developed the Symbiosis test in which 13 patients with aMCI and 16 healthy elderly participants learned 32 words belonging to 16 different semantic categories either in a verbal encoding (A) or a bimodal (B; verbal and motor imitation) condition, using a blocked ABBA/BAAB procedure. Overall, memory retrieval was better in healthy participants than in patients with aMCI, and better for cued retrieval in the bimodal encoding (gesture cues) than the verbal encoding (category cues) condition, but there was no interaction effect between group and encoding conditions. These results show that performing concomitant gestures can enhance cued episodic memory retrieval in patients with aMCI and in healthy elderly controls. The Symbiosis test broadens the scope of the enactment effect, from action phrases to isolated words learning in patients with aMCI. Future work should investigate how bimodal encoding provides novel perspectives for memory rehabilitation in patients with aMCI.

Age-related differences in adults' ability to follow spoken instructions

A growing body of research illustrates that working memory capacity is a crucial limiting factor in our ability to follow spoken instructions. Despite the ubiquitous nature of instruction following throughout the lifespan, how the natural ageing process affects the ability to do so is not yet fully understood. In this study, we investigated the consequences of action at encoding and recall on the ability to follow spoken instructions. Younger (< 30 y/o) and older (> 65 y/o) adults recalled sequences of spoken action commands under presentation and recall conditions that either did or did not involve their physical performance. Both groups showed an enacted-recall advantage, with superior recall by physical performance than oral repetition. When both encoding and recall were purely verbal, older adults' recall accuracy was comparable to that of their younger counterparts. When action was involved at either encoding or recall, however, the difference in performance between the two age groups became pronounced: enactment-based encoding significantly improved younger adults' ability to follow spoken instructions; there was no such advantage for older adults. These data show that spatial-motoric representations disproportionately benefit younger adults' memory performance. We discuss the practical implications of these findings in the context of lifelong learning.

Enacting objects and subjects in a children's rehabilitation clinic: Default and shifting ontological politics of muscular dystrophy care

In health care clinics, problems are constructed through interactions, a choreography of human and non-human actors together enacting matters of concern. Studying the ways in which a body, person, family, or environment is objectified for clinical purposes opens discussion about advantages and disadvantages of different objectification practices, and exploration of creative ways to handle the diversity and tensions that exist. In this analysis, we explored objectifications in a Canadian neuromuscular clinic with young people with muscular dystrophy. This involved a close examination of clinical objectification practices across a series of 27 observed appointments. We identified the routinised clinical assessments, and argue these embed a default orientation to how to intervene in people's lives. In this setting, the routine focused on meeting demands of daily activities while protecting the at-risk-body, and working toward an abstract sense of an independent future for the person/body with muscular dystrophy. But the default could be disrupted; through our analysis of the routine and disruptions, we highlight how contesting visions for the present and future were consequential in ways that might be more than what is anticipated within rehabilitation practice.

Psychic time as occasion for enactment

The author focuses on enactments in the temporality of the analytic process, taking place around analytic breaks. Being part of the rhythm of psychoanalysis, breaks can be experienced as disruptions, with increased anxiety. Threats to the integrity of the frame provide points of vulnerability and challenge to containment that may result in enactment. This is especially so when related to the patient's unique psychic time, touching on depth of disturbance that is unmetabolised and cannot find verbal expression. Enactments are discussed as representations of unconscious material, to be contained retrospectively by analytic thinking, at specific points of the patient's psychic readiness. Only after an "unthought-out action" on the part of the analyst does he/she become alive to it. Guilt and shame are often experienced following enactments. These feelings can be utilised for understanding the enactment events and their underlying affects, in the intersubjective arena, potentially furthering the analytic process. A clinical illustration is presented of a mental enactment combined with a disruption to the frame around a break, which coalesced with the patient's internal unique timing. Being an expression of the patient's unconscious readiness for transformation, the enactment is understood as occasioned in the conjunction between psychic time and analytic time frame.

Emerging From Deadness: A Microanalysis of the Analytic Relationship

Video microanalysis, a technique developed by infant researchers, is used to understand the withdrawal that developed between analyst and analysand when the latter resumed use of the couch after a period of sitting up. The case includes three excerpts of microprocess, accompanied by descriptions of content apart from explicit verbal material, content such as tone of voice, speech patterns, facial expression, and body movements, along with diagrams showing the second-by-second vocal rhythm coordination of analyst and analysand. Supervision using the video, as well as the analyst's viewing the video with the analysand in a modified use of video feedback, widened the pair's understanding of the determinants of their mutual participation in withdrawal and a feeling of deadness, thus freeing them from the repetition of an enactment. It is shown how (1) movement to the couch created an affectively heightened state that brought central psychodynamic aspects of the analysand's experience to the fore; (2) video microanalysis allowed access to previously unavailable content; and (3) understanding of unconscious, dynamically determined conflicts and defenses embedded in body movement, facial expression, speech tone, and rhythm patterns illuminated facets of the co-created relatedness between analysand and analyst.

Factors Associated with Engagement in Protective Behavioral Strategies among Adult Drinkers

Background: Protective behavioral strategies (PBSs) have been proposed as useful individual-level approaches to reducing alcohol consumption and alcohol-related harm. However, recent research suggests that few of the recommended PBSs may be effective in reducing longer-term alcohol consumption, with some appearing to result in increased intake over time. Objectives: To identify factors associated with enactment of specific PBSs to inform alcohol control efforts that aim to encourage the use of effective strategies and attenuate the effects of strategies found to be associated with increased consumption. Methods: Australian adult drinkers (n = 2,003; 50% male) completed an online survey assessing their alcohol consumption, frequency of attending drinking venues, enactment of specific PBSs, and demographic characteristics. Results: Greater enactment of the PBS that has previously been found to be associated with reduced alcohol use ('Count your drinks') was found among older respondents and those with lower levels of alcohol consumption. Older respondents were also more likely to enact two of the three PBSs that have been found to be associated with increased alcohol consumption ('Use a designated driver' and 'Leave drinking venues at a pre-determined time'). Conclusions/Importance: Results suggest that enactment of specific PBSs may differ according to the individual-level variables of gender, age, and preferred beverage type, and the environmental-level variable of attendance at licensed premises. Randomized trials investigating the effectiveness of PBS interventions among drinker subgroups are needed to determine the extent to which enactment reduces alcohol consumption and alcohol-related harm and whether effects are moderated by the variables assessed in this study.

WHAT'S NEW IN PARALLEL PROCESS? THE EVOLUTION OF SUPERVISION'S SIGNATURE PHENOMENON

The concept of parallel process has played a central role in psychoanalytic supervision for the last 60 years, generating continuing interest in the power of the unconscious to create unexpected intersections between the analytic and supervisory relationships. I track the evolution of the concept, starting with its invention by an interpersonalist psychoanalyst, adoption by two ego psychologists, enrichment by object relations theory, and, finally, redefinition as a multi-directional dynamic by relational psychoanalysts. I then further elaborate the relational view of parallel process, illustrating its complex, multidirectional nature with an extended vignette. I discuss the relationship of enactment to parallel process and illustrate the usefulness of supervisory consultation when enactments that parallel into the supervisory relationship lead to impasse. Finally, I point to educational and neuropsychological research that suggests that working with parallel process is good pedagogy.

Thinking through other minds: A variational approach to cognition and culture

The processes underwriting the acquisition of culture remain unclear. How are shared habits, norms, and expectations learned and maintained with precision and reliability across large-scale sociocultural ensembles? Is there a unifying account of the mechanisms involved in the acquisition of culture? Notions such as "shared expectations," the "selective patterning of attention and behaviour," "cultural evolution," "cultural inheritance," and "implicit learning" are the main candidates to underpin a unifying account of cognition and the acquisition of culture; however, their interactions require greater specification and clarification. In this article, we integrate these candidates using the variational (free-energy) approach to human cognition and culture in theoretical neuroscience. We describe the construction by humans of social niches that afford epistemic resources called cultural affordances. We argue that human agents learn the shared habits, norms, and expectations of their culture through immersive participation in patterned cultural practices that selectively pattern attention and behaviour. We call this process "thinking through other minds" (TTOM) - in effect, the process of inferring other agents' expectations about the world and how to behave in social context. We argue that for humans, information from and about other people's expectations constitutes the primary domain of statistical regularities that humans leverage to predict and organize behaviour. The integrative model we offer has implications that can advance theories of cognition, enculturation, adaptation, and psychopathology. Crucially, this formal (variational) treatment seeks to resolve key debates in current cognitive science, such as the distinction between internalist and externalist accounts of theory of mind abilities and the more fundamental distinction between dynamical and representational accounts of enactivism.

Virtual Enactment Effect on Memory in Young and Aged Populations: a Systematic Review

BACKGROUND

Spatial cognition is a critical aspect of episodic memory, as it provides the scaffold for events and enables successful retrieval. Virtual enactment (sensorimotor and cognitive interaction) by means of input devices within virtual environments provides an excellent opportunity to enhance encoding and to support memory retrieval with useful traces in the brain compared to passive observation.

METHODS

We conducted a systematic review with Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines concerning the virtual enactment effect on spatial and episodic memory in young and aged populations. We aim at giving guidelines for virtual enactment studies, especially in the context of aging, where spatial and episodic memory decline.

RESULTS

Our findings reveal a positive effect on spatial and episodic memory in the young population and promising outcomes in aging. Several cognitive factors (e.g., executive function, decision-making, and visual components) mediate memory performances. Findings should be taken into account for future interventions in aging.

CONCLUSIONS

The present review sheds light on the key role of the sensorimotor and cognitive systems for memory rehabilitation by means of a more ecological tool such as virtual reality and stresses the importance of the body for cognition, endorsing the view of an embodied mind.

Making the Ethnic Embryo: Enacting Race in US Embryo Adoption

How are frozen embryos donated for procreation racialized as "ethnic" subjects and what are the political implications of these enactments? Based on ethnographic research within an embryo adoption program in the United States, I examine the practices through which staff and participants produce "ethnicity" in embryos and trace its multiple permutations. Strategies used to stabilize race in embryos also disturb, fracture, and confound the bases for designating race. Analyzing race-making practices in embryo adoption reveals the interplay between practical challenges in assisted family-making practices and their wider political implications for reproductive politics.

AGGRESSIVE ENACTMENTS: CONTAINING THE "NO" IN CLINICAL WORK WITH SURVIVORS OF ABUSE

Identity development depends on the ability to say 'no.' Setting limits enables a relationship between two separate individuals to develop. Early trauma can leave the individual so vigilant to others' demands that internal prohibitions against intrusion remain silenced, which we conceptualize as a 'no' that could not be sufficiently articulated to keep the person safe. For those who have not been able to assert this fundamental limit, the consulting room provides a potential anchoring point to formulate and work through unconscious meanings. Being able to articulate and register the legitimacy of one's own no becomes an important challenge, as tensions regarding power and powerlessness, trust and distrust, are acted out within the consulting room. Case material illustrates how psychoanalytic ideas regarding transference, countertransference, and enactment help the clinician tolerate the intrusion of past into present, inviting the type of mentalization that moves towards repair rather than merely reenacting the trauma.

The Secret Life of Secrets: Deleterious Psychosomatic Effects on Patient and Analyst

The impact and complex nature of keeping secrets deserves greater scrutiny within psychoanalysis. While the capacity to keep a secret is a developmental achievement that furthers conscious choice and healthy boundary setting between self and others, an individual's need for privacy must be distinguished from untoward costs of collusion and concealment. Clinical case material shows that not all secrets are unconscious or multilayered, as assumed in most of the psychoanalytic literature. Nonetheless, in these cases deleterious effects to psyche and soma took root. These patients assumed that their secret was irreparably destructive to an essential object relationship; shame, guilt, narcissistic vulnerability, unconscious identification with an injured party, and developmental deficit were other factors found to undergird this mode of pathogenic dissembling. Two clinical examples also demonstrate that embodied countertransference reactions may herald the revelation of a secret in treatment that had been hidden, but in plain view. Secrets appear to exert their profound psychological and physical effects on patient and analyst by biological mechanisms that are as yet poorly understood but are readily observed in clinical practice. Psychoanalysts who keep in conscious awareness both the adaptive value and the potential costs of maintaining the confidences of others over the course of a career are better positioned to assist their patients and themselves in rendering essential self-care.

Patient-Targeted "Googling:" When Therapists Search for Information About Their Patients Online

The ubiquitous nature of the internet and of online social networking has created new opportunities but also challenges for the psychotherapist. Former notions of anonymity and privacy are now infeasible as a result of massive information sharing through electronic media. The clinical repercussions of these changes are being extensively debated, but issues involving patient privacy and anonymity have not been sufficiently explored. Although several aspects of the impact of the internet on therapeutic setting-such as the need for psychotherapists to exercise caution when making personal information available online-have been addressed in the literature, there has been comparatively little discussion on psychotherapists seeking information about their patients on the internet, a phenomenon known as "patient-targeted googling" (PTG).

The Direct Testing Effect Is Pervasive in Action Memory: Analyses of Recall Accuracy and Recall Speed

Successful retrieval from memory is a desirably difficult learning event that reduces the recall decrement of studied materials over longer delays more than restudying does. The present study was the first to test this direct testing effect for performed and read action events (e.g., "light a candle") in terms of both recall accuracy and recall speed. To this end, subjects initially encoded action phrases by either enacting them or reading them aloud (i.e., encoding type). After this initial study phase, they received two practice phases, in which the same number of action phrases were restudied or retrieval-practiced (Exp. 1-3), or not further processed (Exp. 3; i.e., practice type). This learning session was ensued by a final cued-recall test both after a short delay (2 min) and after a long delay (1 week: Exp. 1 and 2; 2 weeks: Exp. 3). To test the generality of the results, subjects retrieval practiced with either noun-cued recall of verbs (Exp. 1 and 3) or verb-cued recall of nouns (Exp. 2) during the intermediate and final tests (i.e., test type). We demonstrated direct benefits of testing on both recall accuracy and recall speed. Repeated retrieval practice, relative to repeated restudy and study-only practice, reduced the recall decrement over the long delay, and enhanced phrases' recall speed already after 2 min, and this independently of type of encoding and recall test. However, a benefit of testing on long-term retention only emerged (Exp. 3), when prolonging the recall delay from 1 to 2 weeks, and using different sets of phrases for the immediate and delayed final tests. Thus, the direct testing benefit appears to be highly generalizable even with more complex, action-oriented stimulus materials, and encoding manipulations. We discuss these results in terms of the distribution-based bifurcation model.

When motion improves working memory

In the present study, we used a complex span task to explore how memory traces resulting from Self-Performed Task (SPT) and Verbal Task (VT) are maintained in working memory. Participants memorised series of five sentences describing an action either through SPT or VT. Between pairs of sentences, participants performed a concurrent task that varied according to its nature and its cognitive load. The concurrent task was either a verbal task, a low cognitive load motor task or a high cognitive load motor task. A control condition served as a baseline. First, we observed that performance in SPT and VT did not decrease with verbal or motor suppression, but was lower with an increase of the cognitive load. This suggests that memory traces are maintained through attentional refreshing whatever the encoding (SPT or VT). Second, while the enactment effect was replicated in the control condition, it tended to vanish with a verbal concurrent task; moreover, it was reversed with motor concurrent tasks. Surprisingly, the latter effect resulted from an increase of VT memory performance when participants repeated the same gesture between sentences. Finally, our results provide additional evidence that the enactment effect does not rely on attention.

Exploring Narrative Structure and Hero Enactment in Brand Stories

This study examines how audiovisual brand stories both invite and enable consumers to enact heroic archetypes. Integrating research on the archetypal structure of narratives with research on the event structure of narratives, we distinguish singular plot stories (i.e., stories that show a Hero’s Journey) from embedded plot stories (i.e., stories that not only show but also tell one or more Hero’s Journeys) and develop a conceptual and narratological framework to analyze their structural elements. Application of the framework to 20 brand stories representing 8 different brands reveals meaningful variation in elements between the singular plot stories and embedded plot stories. Differences in the expression of archetypes and event structure are argued to evoke different types of Hero enactment which in turn result in different outcomes. We specifically hypothesize that the enactment of heroic archetypes in singular plot stories primarily results in catharsis (pleasure), whereas the enactment of heroic archetypes in embedded plot stories primarily results in an outcome we describe as phronesis: a form of moral sense making of the self that advances one’s practical wisdom and prudence. The final section of the paper discusses how cathartic and phronetic outcomes of hero enactment may foster the psychological bonding between brand and consumer, and invite consumers to align their moral values with the values that are reflected by heroic character traits. The central aims of the analysis presented are to provide an exploration of narrative phenomena in a reasonably broad range of brand story videos and foremost to provide a conceptual framework with an applicable instrument suited to analyze relevant categories in these brand stories. The present study is interdisciplinary in its approach to a contemporary, developing marketing phenomenon, applying psychological modeling of archetypes and heroic values with narratological insights on perspective-taking and story structure. Its contribution is to systemize, from a narratological viewpoint, how various narrative archetypes in brand video stories may contribute to the development of brand-consumer relations.

Local enactments of national health promotion policies: A Danish case

Governments of welfare states are firmly committed to public health, resulting in a substantial number of public health policies. Given the multilevel structure of most welfare systems, the influence of a public health policy is related to its ability to spread geographically and move across organisational levels. Visiting, observing, and interviewing 15 policy workers from 10 municipalities during a 2-year period, this study investigated what happened to a Danish national health promotion policy as it was put into practice and managed in the Danish municipalities. The analysis reveals that the policy was practiced in at least 5 different ways: as an ideal, a cookbook, a tangible artefact, a creative deconstruction, and a mapping. The various practices each enacted a different version of this policy, and some of these enactments brought unintended but valuable effects. Without recognising the concrete enactments and their locally experienced effects, our understanding of national public health policies risks becoming detached from praxis and unproductive. Public health policy makers must pay methodological and analytical attention to the policies' multimodality and their concrete locally experienced effects.

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.

The effects of enactment on communicative competence in aphasic casual conversation: a functional linguistic perspective

BACKGROUND

Previous research has shown that speakers with aphasia rely on enactment more often than non-brain-damaged language users. Several studies have been conducted to explain this observed increase, demonstrating that spoken language containing enactment is easier to produce and is more engaging to the conversation partner. This paper describes the effects of the occurrence of enactment in casual conversation involving individuals with aphasia on its level of conversational assertiveness.

AIMS

To evaluate whether and to what extent the occurrence of enactment in speech of individuals with aphasia contributes to its conversational assertiveness.

METHODS & PROCEDURES

Conversations between a speaker with aphasia and his wife (drawn from AphasiaBank) were analysed in several steps. First, the transcripts were divided into moves, and all moves were coded according to the systemic functional linguistics (SFL) framework. Next, all moves were labelled in terms of their level of conversational assertiveness, as defined in the previous literature. Finally, all enactments were identified and their level of conversational assertiveness was compared with that of non-enactments.

OUTCOMES & RESULTS

Throughout their conversations, the non-brain-damaged speaker was more assertive than the speaker with aphasia. However, the speaker with aphasia produced more enactments than the non-brain-damaged speaker. The moves of the speaker with aphasia containing enactment were more assertive than those without enactment.

CONCLUSIONS & IMPLICATIONS

The use of enactment in the conversations under study positively affected the level of conversational assertiveness of the speaker with aphasia, a competence that is important for speakers with aphasia because it contributes to their floor time, chances to be heard seriously and degree of control over the conversation topic.

Common sense: Its uses, misuses, and pitfalls

"Common sense" is ubiquitous in most discourse, including the psychoanalytic process. It is comprised of multiple different forms of thinking which have certain similarities of organization. Its appearance in interpersonal discourse evokes typical affects, fantasies, and intersubjective experiences, which I call "the feeling of common sense". Because of its underlying conceptual structure and its powerful affective and intersubjective components, as well as the underlying conceptual organization of the various forms of thinking associated with it, common sense can have a variety of different functions in the analytic process; some serve its forward movement, while others function, in various ways, as impediments which need to be understood and unravelled. Such understanding sheds light not only on the patient's internal dynamics, but the analyst's collusive participation in enactments at many levels. Such awareness may shape the analyst's technical decisions as much as the content of his or her interpretations. I offer clinical illustrations of a number of these phenomena.

Residues in the analyst of the patient's symbiotic connection at a somatic level: unrepresented states in the patient and analyst

This paper discusses the residues of a somatic countertransference that revealed its meaning several years after apparently successful analytic work had ended. Psychoanalytic and Jungian analytic ideas on primitive communication, dissociation and enactment are explored in the working through of a shared respiratory symptom between patient and analyst. Growth in the analyst was necessary so that the patient's communication at a somatic level could be understood. Bleger's concept that both the patient's and analyst's body are part of the setting was central in the working through.