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ABSTRACTRandomized controlled trials have reported psychoanalytic psychotherapy to improve longer-term post-treatment outcomes in patients with treatment-resistant depression. In this case study, we examine the therapy process of a female trial participant diagnosed with treatment-resistant depression. Structured clinical assessments indicated that the patient's level of depression remained unchanged during and after treatment. Over the course of the therapy, she repeatedly broke away from important others and finally also from the therapy itself, which we linked to the impact of earlier experiences of abandonment on her internal world. In the discussion, we present a variety of reflections that were put forward by the authors during a series of case discussion meetings. Some of these reflections relate to how the inner world of this patient might have triggered a negative therapeutic reaction and a destructive pattern of repetition. The interpretative stance, in which the therapist interpreted this reaction as indicative of a psychic conflict and linked this conflict to the therapeutic relationship, seemed to be experienced by the patient as unhelpful and persecutory. Other elements that were brought up include basic distrust, lack of symbolization and trauma in the patient, as well as the constraints of the research context.

Depression and anxiety are increasingly prevalent in adolescents. The Brief Educational Workshops in Secondary Schools Trial investigated the effectiveness of a brief accessible stress workshop programme for 16–18-year-olds. We aimed to investigate the clinical effectiveness and cost-effectiveness of the DISCOVER cognitive behavioural therapy (CBT) workshop on symptoms of depression in 16–18-year-olds at 6 months compared with treatment-as-usual.

Mental health difficulties are common in children and young people with chronic health conditions, but many of those in need do not access evidence-based psychological treatments. The study aim was to evaluate the clinical effectiveness of integrated mental health treatment for children and young people with epilepsy, a common chronic health condition known to be associated with a particularly high rate of co-occurring mental health difficulties.

Borderline personality disorder (BPD) was introduced in the DSM‐III in 1980. From the DSM‐III to the DSM‐5, no major changes have occurred in its defining criteria. The disorder is characterized by instability of self‐image, interpersonal relationships and affects. Further symptoms include impulsivity, intense anger, feelings of emptiness, strong abandonment fears, suicidal or self‐mutilation behavior, and transient stress‐related paranoid ideation or severe dissociative symptoms. There is evidence that BPD can be reliably diagnosed and differentiated from other mental disorders by semi‐structured interviews. The disorder is associated with considerable functional impairment, intensive treatment utilization, and high societal costs. The risk of self‐mutilation and suicide is high. In the general adult population, the lifetime prevalence of BPD has been reported to be from 0.7 to 2.7%, while its prevalence is about 12% in outpatient and 22% in inpatient psychiatric services. BPD is significantly associated with other mental disorders, including depressive disorders, substance use disorders, post‐traumatic stress disorder, attention‐deficit/hyperactivity disorder, bipolar disorder, bulimia nervosa, and other personality disorders. There is convincing evidence to suggest that the interaction between genetic factors and adverse childhood experiences plays a central role in the etiology of BPD. In spite of considerable research, the neurobiological underpinnings of the disorder remain to be clarified. Psychotherapy is the treatment of choice for BPD. Various approaches have been empirically supported in randomized controlled trials, including dialectical behavior therapy, mentalization‐based therapy, transference‐focused therapy, and schema therapy. No approach has proved to be superior to others. Compared to treatment as usual, psychotherapy has proved to be more efficacious, with effect sizes between 0.50 and 0.65 with regard to core BPD symptom severity. However, almost half of the patients do not respond sufficiently to psychotherapy, and further research in this area is warranted. It is not clear whether some patients may benefit more from one psychotherapeutic approach than from others. No evidence is available consistently showing that any psychoactive medication is efficacious for the core features of BPD. For discrete and severe comorbid anxiety or depressive symptoms or psychotic‐like features, pharmacotherapy may be useful. Early diagnosis and treatment of BPD can reduce individual suffering and societal costs. However, more high‐quality studies are required, in both adolescents and adults. This review provides a comprehensive update of the BPD diagnosis and clinical characterization, risk factors, neurobiology, cognition, and management. It also discusses the current controversies concerning the disorder, and highlights the areas in which further research is needed.

Derzeit gibt es noch keine offiziellen Behandlungsrichtlinien für die komplexe posttraumatische Belastungsstörung (kPTBS). Die kPTBS unterscheidet sich von der PTBS durch die Symptomatik, Dauer oder Häufigkeit der Traumaexposition und durch eine hohe Komorbidität mit der Borderline-Persönlichkeitsstörung (BPS). Daher besteht Bedarf an der Entwicklung neuer Behandlungsmethoden, die auf diese Patient:innengruppe ausgerichtet sind. Im Folgenden wird eine neue Trauma-fokussierte Mentalisierungsbasierte Therapie, die für Patienten mit einer kPTBS entwickelt wurde und als Gruppenbehandlung konzipiert ist, beschrieben. Neben dem theoretischen Hintergrund und dem konzeptuellen Rahmen von Trauma in der mentalisierungsbasierten Therapie wird der Ablauf der Behandlung ausführlich dargestellt und anhand eines Fallbeispiels illustriert.

We explore the interpersonal origins of human culture, arguing that culture emerges as a necessary consequence of our helplessness in infancy, which in turn requires a greater degree of collaboration and social organization than is necessary for other mammals. We propose a model of cultural transmission that depends on a dyadic interpersonal process whose vicissitudes can have a lifelong impact. We explore the role played by imagining subjectively experienced psychological states and processes in others, which we have defined asmentalizing, in the process of cultural transmission, and propose that mentalizing is key to the establishment of epistemic trust—that is to say, an experience of trust that enables the individual to absorb and use the knowledge they are being offered. We suggest that psychoanalysis can be viewed as a paradigmatic example of a process of transferring knowledge from one human being (the teacher, the caregiver, the analyst) to another (the learner, the young person, the patient) and argue that the mechanisms of psychic change in analysis cannot be fully understood without appreciating this aspect of the biological/evolutionary origins of our essential humanity. Finally, we discuss the clinical implications of the model we are proposing for the psychoanalytic process.

Background The clinical concept of mentalizing has recently been extended into non-clinical contexts. In particular, the protective function of robust mentalizing as a processing capacity of interpersonal and intrapsychic events has become a focus of consideration. Theoretical approaches hypothesize that mentalizing may allow for an adequate self-awareness in the face of aversive experiences such as stress, leading to a reappraisal of these experiences and therefore enables the use of adaptive coping behaviors.Objective The study aimed to investigate the association between coping behavior, mentalizing and experiences of stress.Method 534 healthy adults completed the German-language Stress Processing Questionnaire (SVF), the Mentalization Questionnaire (MZQ), and a short scale of the Trierer Inventory of Chronic Stress (TICS) in a cross-sectional research design.Results Correlational analyses suggested associations between coping and mentalizing. Furthermore, MZQ scores predicted both positive and negative coping behavior. The relationship between stress and both negative and positive coping was mediated by mentalizing capacity.Conclusion Findings confirm the hypothesis that mentalizing may represent a coping resource within a resilience framework. An implementation of the concept in preventive mental health interventions is discussed.

Early identification of “patients at risk” for not completing regular treatment or not benefitting (sufficiently) from treatment might be among the most cost-effective strategies in mental health care. The recently introduced concept of epistemic trust (ET) may have the potential value to predict patients at risk and therefore act as a marker of treatment outcome. We argue that ET may be the final common pathway through which aversive relational experiences in the past result in interpersonal dysfunctioning, which in turn result in dysfunctional therapeutic relationships, rendering it difficult for patients to trust whatever is offered to learn in therapy. Hence, the concept of ET can play an essential role in personalized medicine, allowing for a more tailored treatment assignment to specific patients' characteristics, which may improve treatment outcomes. In this brief report, we define the clinical features of ET by describing its core domains based on consensus of expert opinion on the concept. The response rate was high, and there was a high level of agreement across experts, demonstrating a strong consensus between experts on the definition and clinical features of ET and mistrust and its significance to the understanding of personality disorders.By means of having a clear definition of the clinical features of ET, we hope to make it accessible for assessment.

This article suggests two areas of future development in the realm of personality pathology. First, a reconceptualization of personality pathology in the context of research evidence suggestive of a single model for psychopathology. Recent work on the ‘p factor’, in combination with findings from clinical research, behavior genetics, molecular biology, and neurobiological models are considered in relation to this reconceptualization of personality pathology. Second, a cultural–developmental model for personality pathology is proposed, based on Gergely and Csibra's work on natural pedagogy, Tomasello's work on joint attention and intentionality, and our recent work on epistemic trust and the social-communicative nature of psychopathology.

Attachment approaches have played a crucial role in furthering our understanding of individuals with personality disorders (PDs) and their treatment. Yet, recent years have witnessed the emergence of a number of findings that urge us to reconsider the role of attachment in PDs. Besides the overlap between conceptualizations of attachment and core features of PD, there is increasing evidence that the link between childrearing environments, including attachment contexts, and later outcomes is less substantial than often assumed. Here, we summarize these findings and propose a novel approach to the role of attachment in PDs by situating attachment within a broader sociocommunicative approach to PDs. This approach involves a reconceptualizing of attachment as an adaptation strategy to a given environment, with attachment contexts being only one, albeit important, context to learn about the social environment. Evidence for these assumptions is reviewed, and clinical implications are discussed.

The efficacy of treatment of borderline personality disorder in adolescents is an underresearched area. Although increasing research in borderline personality disorder in adolescents has emerged over the last decade there is a paucity of knowledge about how treatment is adequately designed for this group of patients. As a consequence, it is currently difficult to provide evidence-based guidelines and firm recommendations for how to design and implement borderline treatment in adolescence. In this selective review we summarize the most important research findings concerning treatment for adolescents with borderline personality disorder, including a recent mentalisation-based group treatment program. We highlight pivotal developmental obstacles for psychotherapy in adolescence and integrate these into a framework for the understanding and designing of effective treatment of borderline in adolescence.

Patients with major depressive disorder (MDD) can present with altered brain structure and deficits in cognitive function similar to aging. Yet, the interaction between age-related brain changes and brain development in MDD remains understudied. In a cohort of adolescents and adults with and without MDD, we assessed brain aging differences and associations through a newly developed tool quantifying normative neurodevelopmental trajectories.

Background:In recent years, mentalizing – the capacity to understand one’s own and others’ intentional mental states in social contexts – has been considered to be a protective capacity that enables adaptive processing of stress-related emotional arousal, benefits general well-being and underpins adaptive emotion regulation. Objective:Several studies using cross-sectional research designs have demonstrated the potential health-promoting effect of mentalizing in non-clinical samples. However, longitudinal evidence is scarce. The present study aimed to investigate whether mentalizing predicts well-being and emotion regulation strategies in a non-clinical sample of mainly young adults using a prospective longitudinal design. Methods:In a prospective research design, 135 participants completed questionnaires assessing well-being, psychological symptom severity and mentalizing capacity at baseline (T1). Twelve months later (T2), emotion regulation strategies (suppression and cognitive reappraisal), well-being and psychological symptom severity were assessed by self-report. The data were analyzed using multivariate linear regression analysis. Results:Impairments in mentalizing were a significant negative predictor of well-being 12 months later. Furthermore, impairments in mentalizing positively predicted suppression of emotional states at T2. No association was found between deficits in mentalizing and cognitive reappraisal of emotional states over the course of 1 year. Conclusion:The findings indicate that mentalizing is longitudinally associated with mental health indicators in a non-clinical adult sample. Specifically, ineffective mentalizing was associated with impaired psychological well-being and a tendency to suppress intense emotional states over a period of 1 year. Future research should replicate these findings using multiple measurement timepoints to etablish causality.

The transition from adolescence to adulthood is a period when ongoing brain development coincides with a substantially increased risk of psychiatric disorders. The developmental brain changes accounting for this emergent psychiatric symptomatology remain obscure. Capitalizing on a unique longitudinal dataset that includes in vivo myelin-sensitive magnetization transfer (MT) MRI scans, we show that this developmental period is characterized by brain-wide growth in MT trajectories within both gray matter and adjacent juxtacortical white matter. In this healthy population, the expression of common developmental traits, namely compulsivity and impulsivity, is tied to a reduced growth of these MT trajectories in frontostriatal regions. This reduction is most marked in dorsomedial and dorsolateral prefrontal regions for compulsivity and in lateral and medial prefrontal regions for impulsivity. These findings highlight that psychiatric traits of compulsivity and impulsivity are linked to regionally specific reductions in myelin-related growth in late adolescent brain development. Ziegler, Hauser et al. report brain-wide, myelin-related microstructural growth from adolescence to adulthood and show that this longitudinal growth is reduced in the presence of compulsivity and impulsivity traits.

ObjectiveWe aimed to test the feasibility of using an online parent-completed diagnostic assessment for detecting common mental health disorders in children attending neurology clinics. The assessment does not require intervention by a mental health professional or additional time in the clinic appointment.SettingTwo parallel and related screening studies were undertaken: Study 1: Tertiary paediatric neurology clinics. Study 2: Secondary and tertiary paediatric neurology clinics.PatientsStudy 1: 406 Young people aged 7–18 attending paediatric neurology clinics. Study 2: 225 Young people aged 3–18 attending paediatric epilepsy clinics.InterventionsParents completed online versions of the Strengths and Difficulties Questionnaire (SDQ) and Development and Well-being Assessment (DAWBA).Main outcome measuresWe investigated: the willingness of families to complete the measures, proportion identified as having mental health disorders, time taken to complete the measures and acceptability to families and clinicians.ResultsThe mean total difficulties score of those that had completed the SDQ fell in the ‘high’ and ‘very high’ ranges. 60% and 70% of the DAWBAS completed met criteria for at least one DSM-IV disorder in study 1 and 2 respectively. 98% of the parents reported that the screening methods used were acceptable.

Looked after children represent a vulnerable group in society, many of whom are exposed to maltreatment, particularly in the form of relational trauma, prior to placement with a foster family. Challenging behaviours can place foster placements at risk and looked after children often confront the possibility of placement breakdown. A carer’s capacity to retain a robust understanding of the children in their care as autonomous individuals with needs, feelings and thoughts can be important in enabling them to respond more effectively to the worrying or disruptive behaviour they may encounter. The Reflective Fostering Programme (RFP) is a new group-based programme aiming to support foster carers of children aged 4–11. This innovative development follows calls by the National Institute for Health and Care Excellence (NICE) and other organisations to help improve outcomes for children in care by improving resources for their carers. The RFP is rooted in evidence drawn from the field of contemporary attachment and mentalizing research, which indicates that children who have a carer high in reflective functioning tend to have more favourable outcomes in terms of social-emotional well-being. It also draws on the evidence that looking after a child who has impaired capacity to mentalize as a result of early relational trauma affects the carer’s capacity to mentalize and respond sensitively to the child (Ensink, et al., 2015). This article sets out the rationale for the RFP, outlines its key elements and concludes by indicating future service implementation and a planned feasibility study examining this approach.

•Idea of common factors supports a dimensional conceptualization of personality disorders.•Personality disorder can be considered, in part, as maladaptive communication.•Treatment needs to address interpersonal and social communication systems to establish therapeutic change.•Opening of epistemic trust via therapy allows for social learning outside treatment.

Adolescent antisocial behaviour is a major health and social problem. Studies in the USA have shown that multisystemic therapy reduces such behaviour and the number of criminal offences committed by this group. However, findings outside the USA are equivocal. We aimed to assess the effectiveness and cost-effectiveness of multisystemic therapy versus management as usual in the treatment of adolescent antisocial behaviour.

Background: Reflective Functioning (RF) is considered to play a central role in risk and resilience for psychological difficulties such as borderline personality disorder (BPD) and has become an important treatment target of transdiagnostic psychosocial interventions like Mentalization Based Therapy. However, a lack of measures to assess RF in adolescents has hampered research that can further elucidate the role of RF in different types of psychopathology. Objective: The objective of the present study was to examine the validity of the Reflective Functioning Questionnaire for Youth (RFQ-Y), examine the factor structure of the french RFQ-Y, the relationship between RFQ-Y and social cognition, psychological difficulties, BPD and narcissistic personality disorders. Method: A total of 533 adolescents and young adults (age 12 - 21) from the community completed the RFQ-Y, the Child Behaviour Checklist, the Borderline Personality Features Scale and the Pathological Narcissism Inventory. A subsample of 150 participants completed the Movie for the Assessment of Social Cognition (MASC). Results: Three factors were identified. Uncertainty/confusion was strongly positively correlated with psychological difficulties, especially symptoms of borderline personality disorder. Interest/curiosity was negatively correlated with psychopathology and Excessive Certainty was positively correlated with grandiose narcissism. RFQ-Y factors correlated more strongly with psychopathology than the MASC scales. Conclusion: This study demonstrates the validity of self-report measures like the RFQ-Y and its utility for identifying problematic styles of mentalizing associated with increased risk of psychopathology in general, as well as difficulties like narcissism in particular.

Background: Childhood maltreatment is theorized to undermine the development of mentalizing and to disrupt the consolidation of healthy narcissism and the integration of personality at the level of affect and interpersonal regulation. Consistent with this, mentalizing can be expected to mediate the relationship between childhood maltreatment and vulnerable and grandiose narcissism as well as borderline personality traits, but this has not been examined in adolescents. Objective: The aim of this study was to examine associations between childhood maltreatment and adolescent personality disorder traits and test the mediating role of mentalizing in a sample of 263 adolescents and young adults aged 12 to 21. Methods: Participants recruited from schools and a tertiary institution completed the Childhood Experiences of Care and Abuse Questionnaire (CECA-Q), the Borderline Personality Features Scale for Children (BPFS-C), the Pathological Narcissism Inventory (PNI) and the Reflective Function Questionnaire for Youth (RFQ-Y). Results: Adolescents with histories of sexual and physical abuse reported significantly more borderline personality features, as well as vulnerable and grandiose narcissism. They also reported signficantly more mentalizing difficulties including confusion regarding mental states and excessive certainty regarding mental states of others. Confusion regarding mental states partially mediated the relation between emotional abuse and borderline personality traits, as well as vulnerable and grandiose narcissism. Excessive certainty regarding the mental states of others mediated the relationship between childhood experiences of role reversal and grandiose narcissism. Conclusion: The findings are consistent with a mentalization model of adolescent personality difficulties and show that the relation between childhood maltreatment and personality disorder traits in adolescents may be in part understood in terms of the impact of such experiences on different dimensions of mentalizing.

ABSTRACTThis paper reviews recent theoretical, empirical, and clinical work related to parental reflective functioning (PRF) or parental mentalizing. PRF refers to the capacity of the parent to envision his or her child as being motivated by internal mental states such as feelings, wishes, and desires, and to be able to reflect on his or her own internal mental experiences and how they are shaped and changed by interactions with the child. This paper first briefly discusses the historical and theoretical background of this concept and its purported role in child development, with a focus on the development of child attachment, affect regulation, and mentalizing. It then reviews recent thinking and research in four areas: (1) the neurobiology underlying PRF, (2) the multidimensionality of PRF, (3) the relationship between PRF and trauma, and (4) the broader relevance of attention to internal mental states for the development of epistemic trust as the basis of an evolutionary inbuilt capacity for learning from and within social communication. It closes with a brief review of the background of, and empirical evidence supporting, interventions rooted in theoretical considerations concerning the importance of PRF, as well as suggested directions for future research and clinical practice.

Psychological treatments for adolescents with unipolar major depressive disorder are associated with diagnostic remission within 28 weeks in 65–70% of patients. We aimed to assess the medium-term effects and costs of psychological therapies on maintenance of reduced depression symptoms 12 months after treatment.

The commentary begins by briefly summarizing some of the key ideas of the target paper and locates them within the context of the theories of attachment and mentalization, emphasizing how the idea of mentalizing homeostasis adds to the richness of these theories, and counters some of their possible weaknesses by reaffirming the highly physical nature and imperatives of early relationships. The authors go on to discuss physical touch as a form of communication, and of meta-communication, and speculate that responsive physical interaction constitutes the infant’s first affirmation of their knowledge of the world as valid, and as such it indicates to the infant the value of opening epistemic trust with trusted caregivers.

Background: There are significant gaps in our understanding of vulnerable and grandiose narcissism in adolescents and whether it is associated with psychosocial difficulties as well as risk factors such as child maltreatment. Objective: The aim of this study was to examine vulnerable and grandiose narcissism in adolescents and young adults. Method: 570 participants (ages 14-21) from the community completed an online survey. Vulnerable and grandiose narcissism were assessed with the Pathological Narcissism Inventory, while psycho-social difficulties were assessed with the Child Behaviour Checklist and maltreatment with the Childhood Experiences of Care and Abuse Questionnaire. Results: Gender-specific age trends were identified, with narcissism appearing to decrease with age for females, while increasing for males into early adulthood. For females, vulnerable and grandiose narcissism was associated with maltreatment and partially mediated the relationship between abuse and neglect and internalizing and externalizing difficulties. Conclusion: These findings underscore the importance of considering the relationship between childhood maltreatment experiences and suggest that the relationship between such experiences and adolescent psychosocial difficulties may be partially accounted for by the negative impact that maltreatment has on narcissism.

Background: Childhood maltreatment represents a major and preventable risk factor for psychiatric difficulties. However, the majority of studies treat maltreatment experiences as if they occur alone, but evidence suggests co-occurrence of maltreatment is the norm rather than the exception. Little is known regarding consequences of particular types and combinations of childhood maltreatment in adolescence. Objective: To identify classes of maltreatment types and combinations using a personcentered approach (Latent Class Analysis) and then to examine whether adolescents who experienced specific types and combinations of maltreatment reported more borderline personality traits, self-injury or internalizing and externalizing difficulties. Methods: Participants included 327 adolescents and young adults aged 12 to 21 recruited from schools, colleges and a university and who completed a series of online questionnaires. Results: Four subgroups of maltreatment were identified including sexual abuse, physical abuse, neglect co-occurring with physical and sexual abuse, as well as parental antipathy cooccurring with neglect and physical abuse. With regard to personality disorder traits, adolescents who experienced sexual abuse endorsed significantly more difficulties, as did adolescents who experienced antipathy. With regard to self-injury, adolescents who experienced sexual abuse, as well as those who experienced neglect were at higher risk. With regard to internalizing and externalizing difficulties, adolescents who experienced sexual abuse reported more internalizing difficulties, whereas those who experienced antipathy and neglect reported more internalizing and externalizing difficulties. Conclusion: Awareness of specific types and co-occurring maltreatment as risk factors for personality difficulties and self-injury has implications for improving trauma informed treatment.

Eating disorders are among the most serious mental health problems affecting children and young people. There has been accumulating clinical and research evidence that early expert outpatient treatment is effective and can also significantly reduce the need for costly inpatient care, indicating that investing in community-based eating disorder services is likely to be both clinically and economically beneficial. This paper describes a large-scale service transformation programme following a major government investment (initially £30 million/year, since then increased to over £50 million/year) aimed at service level change in the provision of eating disorder services for children and adolescents in England. We describe the history, background, political context, and clinical and research evidence that contributed to the government's decision to invest in new services for eating disorders. We also provide a brief account of the implementation of an England-wide whole team training to support the creation of a network of over 70 dedicated community eating disorders services for children and young people.

The authors argue that the experienceof knowing and having the truth about oneself known in the context of therapy is not an end in itself; rather, it is important because the trust engendered by this experience (epistemic trust or trust in new knowledge) opens one up to learning about one’s social world and finding better ways to live in it. The authors consider the consequences of a lack of epistemic trust in terms of psychopathology.

The authors argue that the experienceof knowing and having the truth about oneself known in the context of therapy is not an end in itself; rather, it is important because the trust engendered by this experience (epistemic trust or trust in new knowledge) opens one up to learning about one's social world and finding better ways to live in it. The authors consider the consequences of a lack of epistemic trust in terms of psychopathology.

Translations of summaryIn this paper we make the case for a psychoanalytically informed reconsideration of the phenomena of consciousness. Classically, following Freud, who viewed consciousness as merely a reflection or perception of unconscious mental activity, psychoanalysts have tended to regard a focus on conscious experience as potentially reductionistic and at risk of overlooking the mind's deeper structures. We describe the case of Mr K, a patient who experienced disturbances of consciousness that forced us to consider the possibility that the capacity to experience ourselves as conscious, intentional agents in a coherent world of objects is not merely a modality of perception but rather a maturational and developmental achievement that to some degree depends on adequate experiences of caregiving and is vital in ensuring the possibility of human communication. As such, it is a capacity that is vulnerable to experiences of neglect and maltreatment. We suggest that as well as compromising the capacity to think about one's own and other people's feelings, such experiences may have the further adverse consequence of leading the individual to experience and risk becoming conscious of certain dangerously maladaptive, destructive states of mind which in normal development remain inaccessible to conscious experience. Phenomenologically, such states of mind are experienced as fragmentation and disturbances of consciousness. We discuss the clinical implications of these reflections and the limitations they place on psychoanalytic work in the context of their impact on the work with Mr K.

In this paper we make the case for a psychoanalytically informed reconsideration of the phenomena of consciousness. Classically, following Freud, who viewed consciousness as merely a reflection or perception of unconscious mental activity, psychoanalysts have tended to regard a focus on conscious experience as potentially reductionistic and at risk of overlooking the mind's deeper structures. We describe the case of Mr K, a patient who experienced disturbances of consciousness that forced us to consider the possibility that the capacity to experience ourselves as conscious, intentional agents in a coherent world of objects is not merely a modality of perception but rather a maturational and developmental achievement that to some degree depends on adequate experiences of caregiving and is vital in ensuring the possibility of human communication. As such, it is a capacity that is vulnerable to experiences of neglect and maltreatment. We suggest that as well as compromising the capacity to think about one's own and other people's feelings, such experiences may have the further adverse consequence of leading the individual to experience and risk becoming conscious of certain dangerously maladaptive, destructive states of mind which in normal development remain inaccessible to conscious experience. Phenomenologically, such states of mind are experienced as fragmentation and disturbances of consciousness. We discuss the clinical implications of these reflections and the limitations they place on psychoanalytic work in the context of their impact on the work with Mr K. L'auteur de cet article réinterroge le phénomène de la conscience d'un point de vue psychanalytique. Classiquement parlant et suivant la conception de Freud, qui tenait la conscience uniquement pour un reflet ou une perception de l'activité psychique inconsciente, les psychanalystes ont eu tendance à considérer que toute approche qui privilégiait l'expérience consciente était potentiellement réductrice et risquait de passer à côté des structures plus profondes du psychisme. A partir du cas de M. K, un patient présentant des troubles de la conscience, l'auteur de cet article a été conduit à envisager l'hypothèse que notre capacité d’éprouver le fait que nous soyons des agents intentionnellement conscients dans un monde d'objets cohérents, n'est pas seulement une modalité de la perception. Il s'agit bien plutôt de l'acquisition au cours du développement d'une aptitude, qui dépend dans une certaine mesure d'une expérience suffisamment bonne des soins qui nous ont été prodigués en tant qu'individus, en même temps qu'elle est une condition indispensable pour établir la communication humaine. En tant que telle, cette capacité demeure vulnérable au manque de soins ou à la maltraitance. L'auteur postule que ces expériences négatives peuvent non seulement porter atteinte à la capacité du sujet de réfléchir à ses propres sentiments et à ceux des autres, mais également avoir des conséquences délétères en ce qu'elles entraînent chez l'individu une prise de conscience risquée de certains états d'esprits dangereusement inadaptés et destructeurs qui, dans le cadre du développement normal, demeurent habituellement inaccessibles à la conscience. D'un point de vue phénoménologique, les états d'esprit de ce type sont vécus comme une fragmentation et un trouble de la conscience. L'auteur examine les implications cliniques de ces observations et les limites qu'elles imposent à la pratique psychanalytique dans le cadre de leur impact sur le travail avec M. K. In diesem Beitrag erläutern wir die Gründe für eine psychoanalytisch basierte Neubetrachtung des Phänomens Bewusstsein. Im Gefolge Freud, der das Bewusstsein lediglich als eine Widerspiegelung oder Wahrnehmung unbewusster psychischer Aktivität verstand, neigten Psychoanalytiker dazu, die Fokussierung auf bewusstes Erleben als potenziell reduktionistisch anzusehen; sie betonten insbesondere die Gefahr, die tieferen psychischen Strukturen zu übersehen. Wir beschreiben den Fall eines Patienten, Mr. K., der unter Bewusstseinsstörungen litt, welche uns zwangen, die Möglichkeit in Betracht zu ziehen, dass die Fähigkeit, sich als bewussten, intentionalen Urheber in einer kohärenten Objektwelt zu erleben, nicht lediglich eine Wahrnehmungsmodalität darstellt, sondern das Ergebnis eines Reifungs‐ und Entwicklungsprozesses, der zu einem gewissen Grad angemessene frühe Betreuungserfahrungen voraussetzt und eine ausschlaggebende Rolle für die Entwicklung menschlicher Kommunikation spielt. In diesem Sinn verstanden, handelt es sich um eine Fähigkeit, die durch Vernachlässigungs‐ und Misshandlungserfahrungen beeinträchtigt wird. Wir vertreten die Ansicht, dass solche Erfahrungen nicht nur der Fähigkeit Abbruch tun, über eigene Gefühle und über die Gefühle anderer Menschen nachzudenken; sie können außerdem zur Folge haben, dass das Individuum gefährlich fehlangepasste, destruktive psychische Zustände erlebt und sich ihrer bewusst zu werden droht, die der bewussten Wahrnehmung in der normalen Entwicklung unzugänglich bleiben. Phänomenologisch betrachtet, werden solche psychischen Zustände als Bewusstseinsfragmentierung und –störung erlebt. Wir diskutieren die klinischen Implikationen dieser Überlegungen und die Grenzen, die sie der psychoanalytischen Arbeit im Kontext ihrer Auswirkungen auf die Arbeit mit Mr. K. auferlegten. In questo lavoro sosteniamo la necessità di riconsiderare psicoanaliticamente i fenomeni della coscienza. Classicamente, sulla scia di Freud, che vedeva la coscienza come un mero riflesso o percezione dell'attività mentale inconscia, è prevalsa, tra gli psicoanalisti, la tendenza a considerare l'attenzione all'esperienza conscia come potenzialmente riduzionistica, comportando, quindi, il rischio di trascurare le strutture più profonde della mente. Descriviamo il caso del Sigun paziente i cui disturbi del vissuto della coscienza ci hanno obbligati a considerare la possibilità che il sentirci agenti consapevoli e capaci di intenzionalità, in un mondo coerente e popolato da oggetti, non sia solamente una modalità della percezione, quanto piuttosto un'acquisizione evolutiva e maturativa che, in una certa misura, dipende da una buona esperienza di accudimento ed è vitale nell'assicurare e rendere possibile la comunicazione umana. Proprio in quanto dipendente dall'ambiente umano, questa capacità risente dei vissuti di negligenza e maltrattamento. Proponiamo che, oltre a compromettere la capacità di riflettere sui propri stati emotivi e su quelli degli altri, tali esperienze possono avere ulteriori conseguenze avverse e condurre l'individuo a vivere e a correre il rischio di diventare consapevole di stati mentali pericolosamente maladattivi e distruttivi che, in un percorso evolutivo normale, rimangono inaccessibili all'esperienza cosciente. Fenomenologicamente, tali stati della mente sono vissuti come frammentazione e disturbi della coscienza. Prendiamo infine in esame le implicazioni cliniche di queste riflessioni e quanto questi stati costituiscano un limite per il lavoro psicoanalitico, nel resoconto del loro impatto sul lavoro con il Sig. K. En este trabajo, argumentamos en favor de una reconsideración de los fenómenos de la consciencia desde una perspectiva basada en el psicoanálisis. Clásicamente, siguiendo a Freud, para quien la consciencia era simplemente una reflexión o percepción de la actividad mental inconsciente, los psicoanalistas tendieron a considerar el énfasis en la experiencia consciente como un enfoque potencialmente reduccionista, que corría el riesgo de obviar las estructuras más profundas de la mente. Describimos el caso del Sr.un paciente que sufría de perturbaciones de la consciencia que nos obligaron a tener en cuenta la posibilidad de que la capacidad de percibirnos como agentes conscientes e intencionales en un mundo coherente de objetos no sea simplemente una modalidad de la percepción, sino un logro madurativo y evolutivo que depende, en cierta medida, de haber tenido una experiencia adecuada de provisión de cuidados y es vital para garantizar la comunicación humana. En ese sentido, es una capacidad vulnerable a las experiencias de negligencia y maltrato. Sugerimos que, además de comprometer la capacidad para pensar acerca de los sentimientos propios y de los demás, estas experiencias pueden tener la consecuencia adversa adicional de llevar al individuo a experimentar y tomar consciencia de ciertos estados peligrosamente maladaptativos y destructivos de la mente que permanecen inaccesibles a la experiencia consciente cuando el desarrollo es normal. Desde un punto de vista fenomenológico, estos estados de la mente son percibidos como fragmentaciones y perturbaciones de la consciencia. Analizamos las implicancias clínicas de estas reflexiones y las limitaciones que plantean a la tarea analítica en el contexto de su impacto sobre el trabajo con el Sr. K.

SummaryProfessor Sami Timimi recently expressed concerns about the Improving Access to Psychological Therapies (IAPT) programme. We argue that the concerns are largely unfounded and provide readers with an update on the programme.