Some reflections on the unique time of Nachträglichkeit in theory and clinical practice

Of the various forms that the matter of time assumes in analysis, Nachträglichkeit represents Freud’s first intuition on the subject. The focus of this article is directed toward the specific temporal dimension that the concept of Nachträglichkeit expresses, and how that dimension, which overturns linear time, is expressed in clinical work. The concept of Nachträglichkeit is approached from a theoretical point of view, tracing back the role and development that this notion has had in psychoanalytic Freudian and post‐Freudian thinking. The goal of this article is to demonstrate how Nachträglichkeit represents the unique temporal movement of the analytic session and the characteristic positioning of the mind of the analyst at work. Three clinical examples are presented. The analytic scene is formulated as occurring in two times, and through the working through that takes place, patients can recover the enigmatic ‘remainder’, which is consequently traumatic and which has compulsively accompanied them through the various times of their existence. Nachträglichkeit, as a non‐linear temporality, introduces a unique dimension into the clinical work that influences listening to and interpretation of the material. The recognition of that (trauma, infantile sexuality, non‐linear temporality) has consequences for the analyst’s way of working in session and on the interpretation of clinical material, as I will try to show through my theoretical exposition and clinical examples.     

Mental health problems and post-migration stress among multi-traumatized refugees attending outpatient clinics upon resettlement to Norway

Refugees have often been exposed to multiple traumas making them prone to mental health problems later. The aim of this study is to describe the prevalence and symptom load of psychiatric disorders in refugees admitted to psychiatric outpatient clinics and to investigate the relationship between multiple exposure to traumatic events, the severity of traumatic symptoms and post-migration stressors. A clinical sample of 61 refugee outpatients from psychiatric clinics in Southern Norway was cross-sectionally examined using three structured clinical interviews (SCID-PTSD, SIDES and MINI) and self-report psychometric instruments (HSCL-25, IES-R). Post-traumatic Stress Disorder (PTSD) was diagnosed in 82% of the patients, while Disorders of Extreme Stress Not Otherwise Specified (DESNOS) was present in 16% of them. Comorbidity was considerable; 64% of the patients had both PTSD and major depression disorder (MDD) and 80% of those who had PTSD had three or more additional diagnoses. Multi-traumatized refugees in outpatient clinics have high prevalence of PTSD, DESNOS, comorbid depression and anxiety disorders. A more severe symptomatology was found in patients diagnosed with both PTSD and DESNOS, than in those diagnosed with only PTSD. Higher rates of unemployment, weak social network and weak social integration were also prevalent in these outpatients, and related to increased psychiatric comorbidity and severity of symptoms. Further research may clarify the existence of a cumulative relationship between pre-resettlement traumas and post-resettlement stressors in the mental health of refugees, which in turn may help to improve therapeutic interventions.     

Cognitive Processing Therapy Versus Supportive Counseling for Acute Stress Disorder Following Assault: A Randomized Pilot Trial

The study tested the efficacy and tolerability of cognitive processing therapy (CPT) for survivors of assault with acute stress disorder. Participants (N = 30) were randomly allocated to CPT or supportive counseling. Therapy comprised six individual weekly sessions of 90-min duration. Independent diagnostic assessment for PTSD was conducted at posttreatment. Participants completed self-report measures of posttraumatic stress, depression, and negative trauma-related beliefs at pre-, posttreatment, and 6-month follow-up. Results indicated that both interventions were successful in reducing symptoms at posttreatment with no statistical difference between the two; within and between-group effect sizes and the proportion of participants not meeting PTSD criteria was greater in CPT. Treatment gains were maintained for both groups at 6-month follow-up.     

Research trauma in incarcerated spaces: Listening to incarcerated women's narratives

This paper discusses researcher emotional experiences evoked while conducting narrative interviews in a research project that explored the rehabilitation experiences of 18 incarcerated women. I highlight the significance of listening as a methodology in spaces of incarceration. The importance of retrospective reflexivity in locating experiences of trauma encountered during the research process is discussed. The paper also brings to the fore the transformative power of stories for listeners as I share how my prejudices and attitudes regarding incarcerated women, as people who are framed as dangerous, were challenged. Experiences with interviewing and connecting with the incarcerated women further emphasised the importance of proactive self-care for researchers, with the significance of reflexivity as a self-care tool when doing qualitative research with vulnerable populations.     

Dreaming the other's past: Why remembering may still be relevant to psychoanalytic therapy,at least in some traditions

Against the background of a reconstruction of the reasons for the vanishing role of remembering in the history of psychoanalysis, Botella's (2014, Int J Psychoanal, 95 ) arguments regarding the therapeutic significance of reconstruction and remembering and of the therapist's role are discussed. The difference between intellectual reconstruction and actual emotional remembering are underlined, the term regredience is compared to competing concepts such as equally suspended attention, countertransference and reverie. It is argued that to conceptualize the use of countertransferential associations for reconstructing past traumatic events is difficult with a monadic conception of the unconscious and problematic both in terms of truth claims and in terms of achieving a shared creative atmosphere in which therapist and patient participate alike. It is concluded that historical truth may be important for traumatic experiences, and that biographical reconstruction and change in the subjective life story help to make sense of neurotic patterns and integrate diachronic identity.     

Sexual Assault Training in the Military: Evaluating Efforts to End the “Invisible War”

Sexual assault is an insidious problem in the United States military. In 2005 the Department of Defense (DoD) created the Sexual Assault Prevention and Response Office, which centralizes responsibility for sexual assault training. However, this training initiative has undergone little evaluation by outside researchers. Addressing this need, we analyzed responses from over 24,000 active duty personnel who completed the 2010 DoD Workplace and Gender Relations Survey. We assessed whether sexual assault training exposure (None, Minimal, Partial, or Comprehensive) predicted accurate knowledge of sexual assault resources and protocols. Using a social-ecological framework, we investigated whether institutional and individual factors influenced Service members’ training exposure and judgment of training effectiveness. According to our results, exposure to comprehensive training predicted lower sexual assault incidence and superior knowledge. However, comprehensive training differed as a function of military branch, rank, gender, and sexual assault history. Judgments of training effectiveness also varied across these dimensions. Our results highlight the importance of considering context, gender, and victimization history when evaluating institutional efforts to end sexual violence. The DoD’s 2010 annual report on military sexual assault concluded that “most Active Duty members receive effective training on sexual assault” (p. 104). Our results cast doubt on that assertion.     

术后镇痛对创伤患者围术期细胞因子和胰岛素抵抗的影响研究

研究术后镇痛对创伤患者围术期细胞因子IL 6、TNFα和胰岛素抵抗(IR)的影响.选取60例患者,随机分为两组,A组患者应用一次性术后镇痛泵,加入舒芬太尼2.5μg/kg+盐酸托烷司琼4mg,用生理盐水稀释至100ml,2ml/h持续注入.B组患者为术后根据临床需要临时给予杜冷丁每次50mg～100mg肌肉注射,每日不超过3次.发现两组患者术后镇痛效果比较,A组患者舒适程度要优于B组,随访患者无与药物相关的不良反应.术后两组患者血浆IL-6、TNF-α水平均开始升高,术后12h左右达峰值,24h后开始回落,但均明显高于术前.血糖和血胰岛素值也在术后升高,术后24h左右达峰值,之后逐渐回落.ISI在术后开始降低,术后24h降到最低,之后逐渐回升,但均低于术前,说明IL-6、TNF-α水平升高与创伤后胰岛素抵抗有相关性.A组患者术后12h、24h、36h、48h的血糖、血胰岛素、IL-6、TNF-α水平与B组比较明显降低,而且术后48h基本可以恢复术前水平.应用舒芬太尼术后镇痛可以通过抑制血浆中IL-6和TNF-α水平,从而抑制围术期胰岛素抵抗,降低应激反应,从而达到减轻免疫抑制和降低或缩短IR时间的目的.     

Extreme Outcomes Sway Risky Decisions from Experience

Whether buying stocks or playing the slots, people making real‐world risky decisions often rely on their experiences with the risks and rewards. These decisions, however, do not occur in isolation but are embedded in a rich context of other decisions, outcomes, and experiences. In this paper, we systematically evaluate how the local context of other rewarding outcomes alters risk preferences. Through a series of four experiments on decisions from experience, we provide evidence for an extreme‐outcome rule, whereby people overweight the most extreme outcomes (highest and lowest) in a given context. As a result, people should be more risk seeking for gains than losses, even with equally likely outcomes. Across the experiments, the decision context was varied so that the same outcomes served as the high extreme, low extreme, or neither. As predicted, people were more risk seeking for relative gains, but only when the risky option potentially led to the high‐extreme outcome. Similarly, people were more risk averse for relative losses, but only when the risky option potentially led to the low‐extreme outcome. We conclude that in risky decisions from experience, the biggest wins and the biggest losses seem to matter more than they should. Copyright © 2013 John Wiley & Sons, Ltd.     

Psychological Consequences of Pregnancy Loss and Infant Death in a Sample of Bereaved Parents

This study aimed to explore a broad range of psychological reactions to trauma in a sample of bereaved parents in order to assess whether the traumatic framework is adequate for describing the entire range of emotional reactions to infant death. A sample of bereaved parents (N = 455) who lost their child through perinatal or postnatal loss were compared to a control group of parents (N = 110) who gave birth to a healthy child. Multivariate regression analysis clearly demonstrated that bereaved parents scored significantly higher on the Depression, Anxiety, Dissociation, Sleep Disturbances, Somatization, Interpersonal Sensitivity, and Aggression subscales of the Trauma Symptom Checklist. Consistent with previous studies, the results showed that for up to 5 years postloss bereaved parents expressed elevated levels of trauma-specific and psychological outcomes, in particular interpersonal sensitivity and aggression.