L’épisiotomie est un élargissement chirurgical de l’orifice vaginal réalisé à l’aide d’une incision du périnée au cours de l’accouchement et notamment pendant la dernière étape de l’expulsion. Très souvent étudiée sous un angle somatique, cette pratique chirurgicale a été très peu abordée sous un angle psychologique. Ce manque de donnée est d’autant plus marqué qu’il n’existe aucune étude d’orientation psychodynamique portant sur l’épisiotomie. Le but de ce travail de thèse est d’évaluer l’impact psychique de l’incision du périnée en divisant trois axes d’évaluation : les effets de l’épisiotomie, les facteurs de risques et les facteurs protecteurs inhérents au vécu difficile de l’épisiotomie et enfin le vécu de l’épisiotomie en fonction des caractéristiques individuelles du sujet. Pour ce faire une étude longitudinale comparant l’effet de l’épisiotomie aux autres modes d’accouchement (césarienne, voie basse avec périnée intact ou pseudo-intact et déchirure) a été réalisée sur 43 femmes. Elle s’est appuyée sur une rencontre prénatale 1 mois avant l’accouchement, une évaluation 2 jours et 2 mois après l’accouchement et enfin 3 rencontres post-natales (3 mois, 9mois, 1 an). Chaque rencontre s’est appuyée sur la réalisation d’entretiens (semi-directifs et libres), de questionnaires (SF36, QIC, EPDS, CPQ, WOMBLSQ4, Traumaq) et l’emploi du test de Rorschach. Les principaux résultats montrent que l’épisiotomie implique une satisfaction liée à l’accouchement plus faible 2 mois après l’accouchement. De même, elle est préférentiellement associée à la présence de douleurs, dyspareunies et dépressions 3 mois après l’accouchement. En outre, elle est considérée avec la survenue d’une déchirure comme un des modes d’accouchement les plus difficilement vécus. Notre étude a également montré qu’une qualité de mentalisation effondrée préservait les femmes d’un vécu difficile lié à l’épisiotomie. Enfin, l’analyse qualitative a mis en évidence la présence de dysfonctionnements sexuels et angoisses somatopsychiques spécifiquement liés à l’épisiotomie. Pour finir, nous avons montré que le vécu subjectif personnel colorait la perception de l’épisiotomie notamment au travers de la dynamique transférentielle projetée sur l’équipe médicale mais aussi lors de la reviviscence de traumatismes psychiques. L’ensemble de ces résultats est également commenté en fonction des perspectives théoriques et cliniques soulevées visant à améliorer le bien-être des femmes en salle d’accouchement et en suite de couche / Episiotomy is an enlargement of the vaginal orifice made by a surgical incision of the perineum during the delivery and especially during the last stage of expulsion. Mostly studied in a somatic angle, this surgical practice has been very little studied from a psychological point of view. Moreover, there is no psychodynamic study on episiotomy. The aim of this research is to evaluate the psychical impact of episiotomy with three different types of evaluations: the effects of episiotomy, the risk and protective factors associated with the difficult experience of episiotomy and finally the subjective and individual experiences. We conducted a longitudinal study which was performed on 43 women. It compared the effect of episiotomy with other modes of delivery (caesarean section, vaginal approach with intact or pseudo-intact perineum and perineal injuries). It relied on a prenatal appointment (1 month before delivery), an assessment 2 days and 2 months after the delivery and finally 3 postnatal meetings (3 months, 9 months, 1 year). Each one of them was based on interviews (semi-directive and free), questionnaires (SF36, QIC, EPDS, CPQ, WOMBLSQ4, Traumaq) and the use of the Rorschach test. The main results show that 2 months after delivery, episiotomy implies a lower satisfaction related to childbirth. Perineal incision has stronger correlation with the presence of pain, dyspareunia and depression 3 months after childbirth. In addition, with the perineal injuries group, episiotomy is considered as one of the most difficult ways to give birth. Our study also showed that a low quality of mentalization protect women from a hard experience related to episiotomy. Finally, the qualitative analysis showed that episiotomy is specifically linked to sexual dysfunctions and somatopsychic anxieties. To finish, we have shown that personal subjective experiences influence the perception of episiotomy (particularly through the transferential dynamics projected on the medical team and the revival of psychical traumas). All these results are also commented in a theoretical and clinical point of view which aims to improve the well-being of women in the delivery room and afterwards

<p>Major Depression is a common and complex disorder that is often difficult to treat. Mentalization, facilitated by secure attachment, has been found to serve as a protective function against Borderline Personality Disorder. The aim of the current study was to investigate whether mentalization has the same protective function against depression and to analyze the connection between mentalization and self-rated attachment. Furthermore, the relation between Anxious/Avoidant attachment patterns and the anaclitic/introjective sub-types of depression were examined. Twenty participants with Major Depressive Disorder were interviewed with the <em>Depression Specific Reflective Function Interview</em> (DSRF) and SCID-I. They also completed the self-report questionnaires Experiences in Close Relationships (ECR), Depressive Experiences Questionnaire (DEQ) and Montgomery Åsberg Depression Rating Scale (MADRS). The results revealed a relation between high mentalization ability as measured by DSRF and low levels of depression and between an anxious attachment pattern and introjective depression. Moreover, low scores on DSRF combined with high levels of anaclitic and introjective symptoms accounted for 65% of observer rated depression severity. The results suggest that depression treatment might benefit from focusing on increasing the mentalizing ability and reducing anxious attachment patterns and from an awareness of the symptoms characterized by both the introjective and anaclitic sub-types of depression.</p>

Major Depression is a common and complex disorder that is often difficult to treat. Mentalization, facilitated by secure attachment, has been found to serve as a protective function against Borderline Personality Disorder. The aim of the current study was to investigate whether mentalization has the same protective function against depression and to analyze the connection between mentalization and self-rated attachment. Furthermore, the relation between Anxious/Avoidant attachment patterns and the anaclitic/introjective sub-types of depression were examined. Twenty participants with Major Depressive Disorder were interviewed with the Depression Specific Reflective Function Interview (DSRF) and SCID-I. They also completed the self-report questionnaires Experiences in Close Relationships (ECR), Depressive Experiences Questionnaire (DEQ) and Montgomery Åsberg Depression Rating Scale (MADRS). The results revealed a relation between high mentalization ability as measured by DSRF and low levels of depression and between an anxious attachment pattern and introjective depression. Moreover, low scores on DSRF combined with high levels of anaclitic and introjective symptoms accounted for 65% of observer rated depression severity. The results suggest that depression treatment might benefit from focusing on increasing the mentalizing ability and reducing anxious attachment patterns and from an awareness of the symptoms characterized by both the introjective and anaclitic sub-types of depression.

Studier som undersöker hemlösa människors upplevelser med annat fokus än det elände de befinner sig i kan bidra med förståelse och kunskap som behövs för att kunna hjälpa de sämst ställda. Det salutogena begreppet känsla av sammanhang (KASAM) hos försäljare av Situation Sthlm, en grupp hemlösa, före detta hemlösa och socialt utsatta människor, är inte tidigare känt och syftet med den här studien är att kvantitativt undersöka var på KASAM-13 skalan försäljare av Situation Sthlm befinner sig och kvalitativt att beskriva hur fyra individer ur urvalet upplever och beskriver sin känsla av sammanhang.   Slutsatser av studien kan sammanfattas i att levnadsvillkor påverkar en persons känsla av sammanhang, att försäljare av Situation Sthlm har KASAM-värden (54,67 p.) långt från medelvärdet i en befolkningsundersökning (70.83 p.) och att en låg skattning på KASAM Livsfrågeformulär (under medelvärdet 54,67) inte behöver betyda att en person inte upplever känsla av sammanhang i sitt liv och omvänt, en hög skattning (över medelvärdet 54,67 p.) inom undersöknings-gruppen försäljare av Situation Sthlm av KASAM behöver inte betyda att en person upplever känsla av sammanhang. / Studies examining homeless people's experiences with different focus than the misery they are in can help with understanding and knowledge needed to help people in need. The salutogenetic concept sense of coherence (SOC) of vendors of Situation Sthlm, a group homeless, formerly homeless and socially vulnerable people, is not known and the purpose of this study is to quantitatively examine where on the SOC-13 scale vendors of Situation Stockholm is placed and qualitatively to describe how four individuals from the sample perceive and describe their sense of coherence.  Conclusions from the study can be summarized in that living conditions affect a person's sense of coherence, that vendors of Situation Sthlm has SOC-values (54,67 p.) far from the mean in a population survey (70,83 p.) and that a low score (below 54,67 p) of the SOC Life Questionnaire does not necessarily mean that a person does not experience a sense of coherence in life and conversely, a high SOC-score (above 54,67 p.) within the study  group vendors of Situation Sthlm  does not mean that a person experience sense of coherence.

Mentalisering innebär förmågan att förstå och tänka kring egna och andra människors intentioner och inre mentala tillstånd. Mentaliseringssvikt uppstår när man brister i denna förmåga. Mentaliseringssvikt har visats vara vanligt hos individer diagnostiserade med borderline personlighetsstörning, och då de har liknande symtombild som individer med uppmärksamhetsstörning (ADHD) har det påtalats att mentaliseringssvikt kan vara en betydelsefull faktor även hos denna grupp. I denna studie genomfördes 6 semistrukturerade intervjuer som analyserades med en induktiv tematisk analys med syftet att undersöka erfarenheter av mentalisering hos individer diagnostiserade med ADHD. Frågeställningar var följande: hur beskrivs upplevelser som har med mentalisering att göra, och hur upplevs de påverka ens sociala interaktioner och relationer? 3 teman framgick: 1. Mina interpersonella relationer är både trivsamma och mödosamma, 2. Tankar och känslor påverkar mig intensivt samt 3. Jag utvecklas och har fått större självkännedom från mina konstruktiva men också destruktiva strategier. Resultatet diskuterades i relation till att denna grupp av intervjudeltagare upplevt eller upplever mentaliseringssvikt. Framtida forskning föreslås utforska kopplingar mellan ADHD och mentaliseringssvikt vidare. / Mentalization is the ability to understand and to think about your own and other people’s intentions and internal mental states. Impaired mentalizing occur when there is a lack of this ability. Impaired mentalizing is common among individuals diagnosed with borderline personality disorder, and since they have symptoms similarities with individuals diagnosed with attention deficit hyperactivity disorder (ADHD) it has been discussed whether impaired mentalizing might be a significant factor among this group of individuals as well. 6 semi-structured interviews were completed in this study and was analysed through an inductive thematic analysis. The purpose of this study was to examine experiences of mentalizing among a group of individuals diagnosed with ADHD. The questions of interest were the following: how do individuals with ADHD describe their experiences that is related to mentalizing, and what are their experiences of mentalization affecting their social interactions and relationships? 3 themes emerged: 1. My interpersonal relationships are both pleasant and strenuous, 2. Thoughts and feelings affect me intensely and also, 3. I develop and have gotten greater self-awareness from my constructive and destructive strategies. The results are discussed in relation to this group of interview participants having experienced or is experiencing impaired mentalizing. Future research is suggested to focus further on linkages between ADHD and impaired mentalization.

Questa tesi approfondisce, da un punto di vista teorico e applicativo, l’analisi della capacità di “mettersi nei panni degli altri”definita come un costrutto life-span, si sviluppa dalla prima infanzia ma non smette di evolversi fino all’età adulta. La sua traiettoria evolutiva è legata al contesto, alle interazioni, alle esperienze e allo sviluppo cognitivo ed emotivo degli individui. Dalla letteratura emerge come tale capacità sia spesso oggetto di sovrapposizioni concettuali con altri costrutti della psicologia dello sviluppo come la “Teoria della Mente" (Premack & Woodruff, 1978; Wimmer & Perner, 1985), detta anche "mindreading" (Baron-Cohen, Jolliffe, Mortimore & Robertson, 1997); il "perspective-taking" (Carpendale & Lewis, 2006; Moll & Meltzoff, 2011; Sullivan, Bennett, Carpenter & Lewis, 2008); la "funzione riflessiva" (Fonagy & Target, 1997); e la "mentalizzazione" (Fonagy, Bateman & Luyten, 2012). Grazie all’approfondimento di tali costrutti, si arriva a comprendere essi siano spesso declinati con il concetto di mentalizzazione, che viene analizzato nella sua evoluzione storica e in relazione ad altri costrutti come il legame di attaccamento (Bowlby, 1969) e la mind-mindedness (Meins, 2002). L’analisi del costrutto prosegue con la presentazione di tre lavori di ricerca che lo esplorano, da un punto di vista teorico (i primi due) e applicativo (il terzo), dalla sua massima evoluzione nell’età adulta fino al suo manifestarsi e potenziarsi in età evolutiva. La prima ricerca si concentra sulla validazione italiana di una scala che misura l'affettività mentalizzata, un costrutto che integra nel processo di regolazione delle emozioni la mentalizzazione in età adulta. La seconda verifica come la capacità di "mettersi nei panni degli altri", consolidata in preadolescenza, si manifesta all'interno dei legami di attaccamento tra bambini e insegnanti e infine, il terzo lavoro studia se tale capacità possa essere migliorata nel contesto scolastico e avere un impatto sui costrutti relazionali e sociali legati al processo decisionale in campo economico, come l'equità, l'altruismo e la donazione. / This thesis explores, from a theoretical and applicative perspective, the ability to "put oneself in the shoes of others", defined as a life-span construct, which develops from early childhood but does not stop evolving until adulthood. Its developmental trajectory is linked to the context, interactions, experiences and cognitive and emotional development of individuals. The literature shows how this capacity is often the subject of conceptual overlaps with other constructs of developmental psychology such as the "Theory of Mind" (Premack & Woodruff, 1978; Wimmer & Perner, 1985), also known as "mindreading" (Baron-Cohen, Jolliffe, Mortimore & Robertson, 1997); perspective-taking (Carpendale & Lewis, 2006; Moll & Meltzoff, 2011; Sullivan, Bennett, Carpenter & Lewis, 2008); the "reflective function" (Fonagy & Target, 1997); and "mentalisation" (Fonagy, Bateman & Luyten, 2012). Thanks to the in-depth study of these constructs, we come to understand that they are often declined with the concept of mentalisation, which is analysed in its historical evolution and in relation to other constructs such as the attachment bond (Bowlby, 1969) and mind-mindedness (Meins, 2002). The analysis of the construct continues with the presentation of three research works that explore it, from a theoretical point of view (the first two) and from an applicative point of view (the third), from its maximum evolution in adulthood to its manifestation and enhancement in developmental age. The first research focuses on the Italian validation of a scale measuring mentalized affectivity, a construct that integrates mentalization in adulthood into the process of emotion regulation. The second examines how the ability to "put oneself in the shoes of others", which is consolidated in preadolescence, manifests itself within the attachment bonds between children and teachers and finally, the third work studies whether this ability can be improved in the school context and have an impact on relational and social constructs linked to economic decision-making, such as fairness, altruism and donation.

Therapists’ reactions towards patients are important for the therapeutic process, and is influenced by therapist and patient characteristics. This study aimed to improve the understanding of therapists’ emotional reactions by investigating if patients’ attachment and ability to mentalize predicted therapist countertransference in psychotherapy. Multilevel modeling was used to analyse 87 therapy-dyads in psychotherapy. Patient attachment, measured pre-treatment using self-reports, and mentalization operationalized as Reflective functioning (RF) were hypothesized to predict therapist self-reported emotional experiences (conceptualized as countertransference) over the complete treatment and in different treatment phases. Results showed that lower patient RF predicted more negative therapist countertransference in complete treatment. In the middle and final phases of therapy, lower RF predicted more negative countertransference, and higher RF predicted more positive countertransference. Higher level of avoidant attachment in patients predicted more relaxed therapist countertransference in the final phase of treatment. Findings indicate that patients’ mentalizing ability is important to consider in psychotherapy, as it has informational value for the therapeutic process. / Terapeuters reaktioner gentemot patienter är en viktig del i den psykoterapeutiska processen, och påverkas av terapeuters och patienters personliga egenskaper. Den här studien syftade till att utvidga förståelsen för terapeuters känslomässiga reaktioner genom att undersöka om patienters anknytning och mentaliseringsförmåga predicerar terapeuters motöverföring i psykoterapi. Multilevel-modeling användes för att analysera 87 behandlingsdyader i psykoterapi. Patienters anknytning, mätt innan behandling genom självskattning, och mentalisering operationaliserat som reflektivt fungerande (RF) förväntades predicera terapeuters självskattade emotionella upplevelser (konceptualiserat som motöverföring) över hela behandlingsperioden och i olika behandlingsfaser. Resultaten visade att lägre RF hos patienter predicerade mer negativ motöverföring hos terapeuter över hela behandlingsperioden. I mitten- och slutfaserna av terapin predicerade lägre RF mer negativ motöverföring, och högre RF predicerade mer positiv motöverföring. Högre nivåer av undvikande anknytning hos patienter predicerade mer avslappnad motöverföring hos terapeuter i slutfasen. Fynden indikerar att patienters mentaliseringsförmåga är viktigt att beakta i psykoterapi, eftersom det har informativt värde för den terapeutiska processen.

Thèse numérisée par la Division de la gestion de documents et des archives de l'Université de Montréal.

La représentation que se font les patients souffrant d’un trouble de personnalité limite (TPL) de leur expérience de tristesse est un domaine de recherche important tant pour la conceptualisation du trouble que pour son traitement. Ces patients sont connus pour vivre une grande détresse qui se manifeste à travers divers symptômes (Bland, Williams, Scharer, & Manning, 2004). Un nombre élevé de patients présentant un TPL se suicident (Paris, 2002), font au moins une tentative de suicide au cours de leur vie (Oldham, 2006) et s’automutilent (p.ex., Brown, Williams, & Collins, 2007). La recherche sur la souffrance du TPL s’entend sur un paradoxe : ces patients souffrent beaucoup, mais ils vivent peu de tristesse. Leur souffrance prend une forme distincte en qualité, celle-ci demandant à être davantage étudiée empiriquement et théoriquement. L’objectif de cette thèse est d’explorer la représentation de la tristesse de participants souffrant d’un TPL. Alors qu’à notre connaissance aucune étude n’a encore poursuivi cet objectif spécifique, différentes pistes de réflexion ont été soulevées dans la documentation scientifique pour expliquer la nature de la souffrance du TPL en ce qui a trait au tempérament, au fonctionnement mental, à la dépression, à l’organisation de la personnalité et aux événements traumatiques. La première étude de cette thèse vise à réfléchir théoriquement et cliniquement à la tristesse, afin d’en raffiner la définition, entre autres par opposition à la détresse. Elle propose une distinction tant au plan métapsychologique que phénoménologique de ces deux expériences, en se basant sur des théories évolutionnistes des émotions et sur différentes conceptions psychanalytiques du fonctionnement mental et des relations objectales. Une vignette clinique illustre cette réflexion. La seconde étude vise à explorer, par une démarche qualitative, les principaux thèmes abordés par des participants souffrant d’un TPL lorsqu’ils racontent des épisodes de tristesse. Sept participants avec un diagnostic de TPL évalué à l’aide du SCID-II (First, Gibbon, Spitzer, & Williams, 1997) ont participé à une entrevue semi-dirigée visant le rappel de deux épisodes relationnels de tristesse. Suivant la méthode d’analyse phénoménologique interprétative (Smith, 1996), une analyse thématique de quatorze épisodes de tristesse a été effectuée conjointement par deux candidates au doctorat pour décrire la représentation de la tristesse de ces participants. Cinq thèmes ont été identifiés : 1) agression, 2) relation brisée par l’autre, 3) affectivité négative indifférenciée, 4) soi défectueux et 5) débordement. Les résultats suggèrent que la représentation de la tristesse du TPL n’est pas associée à la perte, mais plutôt à l’impression d’avoir été endommagé par une attaque infligée par quelqu’un d’autre. Il s’agit d’une expérience peu mentalisée que l’individu semble tenter de réguler dans la sphère interpersonnelle. Cette expérience ne représenterait pas de la tristesse à proprement parler. Les conclusions ont permis d’élaborer une nouvelle hypothèse de recherche : l’expérience de tristesse des patients souffrant d’un TPL ne correspond pas à la tristesse proprement dite, mais à une forme de détresse interpersonnelle impliquant à la fois des déficits du fonctionnement mental et une organisation particulière de la personnalité. Les implications cliniques et théoriques sont discutées. / The exploration of the phenomenology of sadness in patients with Borderline Personality Disorder (BPD) is relevant to the understanding of the pathology and to its treatment. BPD patients tend to experience distress intensely and frequently, and inefficient attempts at regulating this emotional experience is known to be associated with symptoms, such as suicidal or parasuicidal gestures (Bland, Williams, Scharer, & Manning, 2004; Brown, Williams, & Collins, 2007; Oldham, 2006; Paris, 2002). The literature on psychological suffering in BPD reveals an apparent contradiction: these patients experience a large amount of suffering, but they appear to not experience sadness. The nature of their suffering seems to be distinct from sadness, and has yet to be more fully explored empirically and theoretically. The present thesis aims at exploring the phenomenology of sadness in BPD. To our knowledge, no research has specifically attempted to investigate this particular topic, but some etiological pathways for understanding BPD suffering have been explored: temperament, mental functioning, depression, personality organization and traumatic events. The first study proposes a theoretical and clinical investigation of the concept of sadness and defines it in opposition to distress. This distinction between sadness and distress focuses on phenomenological and metapsychological perspectives, and is in line with evolutionary theories of emotion and psychoanalytic formulations on mental functioning and object relationships. A case study illustrates this investigation. The second study aims at exploring the phenomenology of sadness through an investigation of the major themes that BPD participants talk about when they are asked to recall episodes of sadness. Seven individuals with a diagnosis of BPD on the SCID-II (First, Gibbon, Spitzer, & Williams, 1997) participated in a semi-structured interview. Following the Interpretative Phenomenological Analysis principles (Smith, 1996), a thematic analysis of 14 transcripts was performed by two doctoral students in order to outline the representation of sadness of BPD participants. Five themes were found: 1) aggression, 2) relationship broken off by the other, 3) undifferentiated negative affect, 4) self being defective, and 5) overwhelming experience. The results suggest that ‘sadness’ in those episodes is not associated with a representation of loss, but with a state of being ‘damaged’ by the aggression and/or the breaking off of the relationship inflicted by the other. This is a non-mentalized experience that the participants tend to regulate in the interpersonal field. This experience should not be conceptualized as sadness proper. In conclusion, a new hypothesis emerges: the experience of sadness for BPD patients is not really sadness, but a form of interpersonally-focused distress. This emotional experience is characterized by a deficit in mental functioning and by a particular personality organization. Clinical and theoretical implications are discussed.

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