Intersession fantasies about the therapist are common but rarely examined clinically. Often understood as adaptive internalisation of a benevolent object, they may also express compulsive absorption, dissociative retreat, or conflicted dependence. This paper examines therapist-focused imagined encounters in maladaptive daydreaming (MD), defined by extensive immersive fantasy associated with distress and functional impairment. Using an object relations framework, I present three de-identified adult case vignettes in which recurrent imagined interactions with the therapist became a salient between-session process. The cases illustrate distinct functions and risks: an anxiety-driven "inner session" that supported behavioural change and reduced reassurance seeking; reparative kinship and romantic scenarios that countered longstanding humiliation and deprivation while encouraging retreat from external life; and trauma-linked immersive scenes in dissociative identity disorder that aided containment and parts communication yet sometimes triggered dysregulated somatic states and sexualised self-harm urges. Across cases, therapist-centred daydreaming was clinically heterogeneous. Its meaning depended on phenomenology, consequences, and the treatment frame, including boundaries around between-session contact and the handling of shame. I propose distinctions between transitional internal use of the therapist and maladaptive absorption, with implications for assessment, pacing, containment, and endings.
In societies organised around an imperative of suicide prevention, the expansion of assisted-dying legislation presents a clinical and ethical paradox: on what basis is a wish for death considered pathological in one context and reasonable in another? This paper argues that assisted dying and suicide, though often treated as psychologically equivalent, represent fundamentally different psychic configurations. Psychological processes matter because misunderstanding them, and mistaking a suicidal act for an assisted death, may lead to serious harm to patients, families, clinicians, and the integrity of clinical safeguards. Drawing on psychoanalytic theory, suicide research, bereavement studies, and international evidence, the paper proposes that the key distinction lies in the work of mourning. Suicide is conceptualised as a pre-mourning state in which unbearable affect is evacuated through acting out, often with traumatic consequences for survivors. Assisted dying, by contrast, may represent the culmination of a process in which mortality has been acknowledged, symbolised, and shared. Through clinical vignettes, bereavement outcomes, fluctuating desire for hastened death, and the physician's symbolic and countertransferential role, the paper shows how these configurations may diverge and overlap. It concludes by proposing a mourning-informed clinical framework and outlining implications for supervision, multidisciplinary practice, safeguards, and future research.
Working in forensic psychiatry can lead to complex feelings, including countertransference reactions, in professionals who are attempting to provide care and containment for offenders. If these feelings go unrecognised and unexplored, then they may interfere with therapeutic care. In this paper, we describe case reflections which could be discussed in a Balint style reflective practice group, for clinicians caring for people within the forensic psychiatry system. Group processes are described, to demonstrate the essence of the work that occurred, via case vignettes. We describe seven fictionalised cases, considering a selection of factors that may be reflected on, demonstrating the process of the group. We highlight a general theme of each group, including intense feelings of loss and grief, contrary views leading to chaos, denial of reality, loss in suicidal ideation, psychosis as an escape from reality, therapeutic nihilism and complex moral dilemmas. In forensic psychiatry, professionals are dealing with some of the most traumatised people in society, which can be very emotionally triggering. Use of Balint groups and other forms of reflective practice invite clinicians to process such trauma and avoid burnout.
The author describes his experiences of the development of Transference-Focused Psychotherapy for Groups (TFP-G) for the treatment of personality disorders. TFP-G derives from object relations theory, which is a theory of psychic presences. However, the author reports his observation of psychic absences and draws on field theory to describe these experiences of non-representation which are not typically associated with the more extreme alterations of split self and object representations characterising borderline conditions. He proposes broadening the scope of the therapist's observations to take into account the work of the negative so as not to go undetected or be confused as a form of Basic Assumption. TFP-G places an emphasis on the therapist's use of countertransference, but this is insufficient for non-represented states. The author discusses the application of the concepts of the field and alpha function for dealing with these phenomena whilst remaining faithful to the TFP-G model.
Complex trauma or adverse childhood experiences are known to have detrimental, long-lasting consequences for both the child's development and the caregiving environment. In recent decades, advances have been made in developing effective interventions for this vulnerable group of families. The present study reports on features of feasibility and preliminary effectiveness of a contemporary three-track psychoanalytic approach for complex trauma and explores patterns of symptomatic change pre- to post-treatment. Results suggest that real-world needs for a specialized approach are high and that primary caregivers find the approach highly credible and satisfactory. Moreover, findings indicate that the intervention was mode-rately effective, with just over half of the children exhibiting Clinically Significant Improvement (CSI) in socio-emotional and behavioral symptoms. The other children were mostly assessed by the therapists and primary caregivers to be in need of longer-term treatment and/or (semi-)residential care. Interestingly, regardless of CSI, exploration of symptom trajectories revealed two distinct patterns of change (with large or small fluctuations), evidencing non-linear and variable change across treatment. In sum, this feasibility and pilot trial provides preliminary support for the feasibility of implementing and further investigating contemporary psychoanalytic approaches to complex trauma that integrate traditional play-based methods with mentalizing- and trauma-informed frameworks.
This paper asks what Lacanian psychoanalytic theory might offer a general practitioner working over many years with highly complex patients. I reflect on 25 years of practice with patients who attend frequently, suffer significantly and are difficult to help by conventional medical means. Many of these patients are diagnosed with borderline or emotionally unstable personality disorder and treated with antipsychotic medications. Drawing on Darian Leaders discussion of Lacan's Concept of the analyst as 'secretary of the alienated subject' and related writings on 'ordinary psychosis', I explore how psychoanalytic ideas may illuminate aspects of clinical work in primary care that might otherwise seem futile or menial. The idea of 'secretarial duties', such as writing letters, documenting details and providing punctuation through regular short appointments are elaborated with clinical examples. This reflective paper suggests that Lacanian theory may offer a way to conceptualize and articulate the delicate nature of this work so often undertaken in primary care with patients the system has largely abandoned.
In this paper, I explore a clinical case through the lens of psychoanalytic theory, drawing on the works of Anzieu, Bick, and Kernberg. By integrating theoretical insights with clinical observations, I aim to illustrate my patient's struggle with the sensation of having thin, wounded skin-lacking its protective upper layer-a 'skinless self' marked by profound vulnerability and self-injury as a means of regaining control and establishing a sense of grounding. Furthermore, I examine the therapeutic process, emphasizing the roles of transference, countertransference, and the creation of a holding environment in reconstructing the Skin Ego. This paper highlights the necessity of establishing a containing environment before engaging in deeper interpretations, demonstrating how psychoanalytic psychotherapy can help stabilize a fragmented self. Ultimately, this case underscores the importance of addressing fundamental deficiencies in self-containment when working with patients experiencing severe personality pathology.
This systematic single-case study aims to articulate the gestural-affective interaction and verbal exchange between patient and therapist during episodes of representational change in a depressed young adult consulting at a university health service. Dynamic Interpersonal Therapy sessions conducted in a virtual setting were coded with the Generic Change Indicators System to identify Change Episodes, which were later processed with the Face Reader Recognition Software to observe their gestural-affective correlates. The data was analyzed under an emergent Thematic Analysis. Four implicit relational transactions were identified as relevant milestones to account for the patient process of affect/discourse integration: Balance, Discernment, Marking and Synchrony. The results show the ability of the therapeutic relationship to act as a resonant affective device, enabling the connection of discourse with the emotional domain, contributing with the elaboration of the Interpersonal Affective Focus and increasing the patient's affective flexibility. The gestural-affective therapeutic interaction works as a relational context that enables the co-construction of what is traditionally understood as insight.
The potential value of mentalizing to leadership has been previously described and the purpose of this paper is to consider how this may work in practice. The authors have provided mentalization based leadership for over ten years in different teams and this paper shares our learning about mentalization based methods that have proved useful for this purpose. The intention is to illustrate that a mentalizing approach to leadership is not just about being a sensitive manager but involves specific ways of attending to mental states that support effective team practice. This approach makes explicit mentalizing a core aspect of all aspects of team functioning so that it is integrated into team meetings, case discussion, supervision and professional meetings with other teams. Examples are provided as to how to hold a clear boundary between mentalizing as a treatment and mentalizing as a way of supporting work interactions. Providing mentalization informed leadership is considered with respect to organisational power, professional inclusion, the need for safe practice and other core dilemmas of clinical team practice.
An abridged version of this paper was presented at the International Association for Suicide Prevention's 33rd World Congress (Austria, June 2025). In this paper, I pose and respond from several angles to the following question: Is it possible to kill oneself? The purpose is twofold: first, to elaborate on psychoanalytic theory pertaining to suicide; second, albeit a primary concern, to promote interdisciplinary dialogue with wider suicide prevention research and practice. The question is used to orient a critique of the current mainstream suicide prevention paradigm that is dominated by positivist, risk-based models. I address the difficulties this presents for both patient and clinician and plea for a deeper theoretical engagement with the clinical phenomenon of suicide, one that resists reducing the act to a symptom of mental illness. I use the question to offer a clinical contribution to working in the aftermath of a non-fatal suicide attempt; specifically, using a Freudian and Lacanian framework, I examine the disjunction between the individual's act and her purported intent (or lack thereof), arguing that psychoanalysis is in a unique position to engage with such instances.
Severe Somatic Symptom Disorder (SSD) are prevalent and burdensome. Dynamic Interpersonal Therapy (DIT) has shown promise for treating SSD, but its mechanisms remain unclear. This study explored both patients' perceived outcomes of a multidisciplinary DIT program and their perspectives on its working mechanisms by semi-structured interviews with 13 patients who completed a six-month multidisciplinary DIT program. Thematic analysis was used to examine these experiences and perceived working mechanisms. Participants reported improvements in physical symptoms, mental health and daily and interpersonal functioning. Furthermore, five perceived working mechanisms were identified: (1) Facilitating conditions and environment - the importance of a balanced group composition and a healing environment; (2) Synergy of the multidisciplinary approach - how different therapeutic components reinforced each other; (3) The group works - benefits of group cohesion, altruism, and interpersonal learning; (4) Exploring patterns - recognizing and changing maladaptive interpersonal behaviour; (5) Being seen and heard - the centrality of feeling recognized and understood in fostering epistemic trust. These patients' accounts suggest that the perceived benefits of this program may stem from its capacity to foster epistemic trust, enhance mentalization, and address maladaptive interpersonal patterns. The multidisciplinary approach enhances these therapeutic effects. However, further research is needed to gain deeper insights into potential working mechanisms.
This single-case longitudinal study examined changes in therapist and patient mentalization over five video-feedback sessions with a mother experiencing postpartum depression. Using qualitative and observational coding, the study analyzed the moment-to-moment evolution of mentalization within therapeutic interactions. The intervention assessed both therapist and patient mentalization, identifying three core themes related to the therapeutic process. Video-feedback contributed to increased maternal mentalization, fostering a more accurate perception of the infant's needs and emotional states. Improvements in maternal mentalization were associated with reduced anxiety and self-doubt, greater sensitivity, and enhanced attachment behaviors. The participant also reported decreased depressive symptoms and greater confidence in interacting with her infant. Findings indicate that video-feedback provides a structured and reflective space for mothers to observe, interpret, and regulate their caregiving behaviors through guided self-observation and therapeutic scaffolding. These results underscore the role of video-feedback in enhancing mentalization within mother-infant psychotherapy, offering a promising intervention for addressing postpartum depression-related caregiving difficulties. While findings highlight its potential to bridge the gap between perceived and actual caregiving behaviors, further research is needed to examine its mechanisms of change, long-term impact, and clinical applicability.
Pathological narcissism is organized by a pathological grandiose self, a compensatory, defensive structure in which the individual's experience of self and others is overshadowed by an idealized version of the self (perceived as superior) that replaces a more realistic self-representation that integrates both strengths and vulnerabilities. Narcissistic personality disorder (NPD) is a complex psychological condition that involves a consistent pattern of behaviors lasting over time and occurring in various social contexts, which can lead to significant impairments in social relationships and occupational functioning. A contemporary object relations model approach provides a theoretical framework for understanding the distorted and often contradictory representations of self and others that underlie the fluctuating mental states of those with pathological narcissism. In transference-focused psychotherapy (TFP) for narcissistic pathology, or TFP-N, the strategies, tactics, and techniques of TFP are adapted and extended with specific modifications to address the special clinical challenges posed by patients with this condition. TFP training serves as a useful, integrative, and dimensional model, which is well-suited for residency programs, allowing residents to gain experience in intensive psychodynamic treatment for personality disorders (PDs). This paper presents a case study of a patient with severe NPD treated in a psychiatry residency program using TFP.
