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PubMed1990

Helping patients by analyzing self-criticism.

This paper is addressed to patients' need for help with punitive self-critical attitudes. Such help has not always been sufficiently provided by psychoanalysts, owing to an unrecognized failure of neutrality. Historically, a gradual overemphasis on the concept of an unconscious sense of guilt has acted as a barrier to the appreciation of shame. An alternative concept, punitive unconscious self-criticism, which stands in contrast to constructive self-criticism and is common to the painful affects of guilt, shame, humiliation, and depression, can facilitate helpful analytic treatment. Heinz Kohut's contributions are examined. His analytic stance is differentiated from his theories of development. In the former, characterized by an affirmative attitude, he takes a position of functional neutrality toward shame and pays consistent though unstated attention to the effects of punitive unconscious self-criticism. The affirmative attitude can be employed without adoption of Kohut's self psychology, i.e., without abandoning the basic psychoanalytic approach to mental conflict and development. The concept of punitive unconscious self-criticism and the concept of divergent conflict, provide sufficient explanatory power. Clinical examples are used to illustrate these ideas.

Adolescent↗
PubMed2000

Affect and pictographic image: the constitution of meaning in mental life.

The author explores the processes of revealing, creating and working through new meaning in mental life and relates these processes to specific methods of producing representations of emotional experience through their transformation into unconscious symbolism in the form of imagery. Drawing on several dreams and other experiences from a detailed clinical case, the author argues for the value of considering three interpenetrating levels of meaning that operate simultaneously in mental life, namely hidden meaning, absent meaning and potential meaning: 'hidden' meaning resulting from dynamic forms of repression, absent meaning from a pregnant pressure exerted on psychic life by unconscious internal objects whenever any new emotional situation confronts the ego. Absent meaning is not just waiting in the unconscious to become explicit in a unique form. It is in its very nature to remain partially absent and it can never be rendered wholly conscious. All symbolic constructions that are expressed at first by unconscious imagery found especially in dreams are attempts to capture and represent the absent meaning. The concept of potential meaning refers to experiences produced by the interpretation of absent meaning, and consists of a specific case of this latter. Potential-meaning, when interpreted, rearticulates meanings on a specific symbolic field, and opens up new experiential possibilities, thus creating new meanings that expand the possibilities for emotional development. The author's ideas draw on the formulations of Aulagnier, Bion, Ferro, Green and Khan.

Affect↗
PubMed2005

The four antinomies of the death instinct.

Matte Blanco examines four paradoxical positions that arise out of Freud's writings on the death instinct. He notes that death is not a content known to the unconscious. Furthermore, the absence of time and space in the unconscious means that the conditions necessary for any process such as instinct are similarly absent. Matte Blanco demonstrates the way in which the antinomies that he explores can be explained in terms of the logics that obtain in the unconscious, and he suggests that the concept of the death instinct is one of the most profound expressions of the relationship between the modes that underlie conscious and unconscious logic.

Death↗
PubMed2002

An essay on dreaming, psychical working out and working through.

In this paper the author attempts to expand the idea put forward by Freud who considered dreams as a special form of unconscious thinking. It is the author's contention that the psychical working-out function performed by dreams is a form of unconscious thinking, which transforms affects into memories and mental structures. He also attempts to clarify the way in which meaning is built and transformed in mental life. In that respect the unconscious internal world is seen as a form of unconscious thinking, a private theatre where meaning is generated and transformed. He focuses on what happens to feelings in dreams in connection with the meanings as a result of and an expression of the several stages of working through. The dream world is described as the setting where the mind gives expressive pictorial representation to the emotions involved in a conflict: a first step towards thinkability. The dreamwork also constitutes a process through which meaning is apprehended, built on and transformed at an expressive non-discursive level, based on representation through figurative/pictorial images. The author draws on Meltzer's formulation to conjecture that the working-through function of dreams, mainly in response to interpretations, is performed by a process of progression in formal qualities of the representations made available by dreaming in the form he has called affective pictograms. It is through progression in formal qualities of the representation that the thinking capabilities of the affective life develop and become part of the process of what is called metaphorically the metabolisation of emotional life. This process takes place through migration of meaning across various levels of mental process. In this perspective the analyst's interpretations of dreams effect what linguists call transmutation of the symbolic basis, a process that is necessary to help the mind to improve its capacity to think. Something expressed on the evocative plane and condensed into a pictographic image is then transformed into verbal language that expresses meaning. These conceptions are illustrated by a detailed clinical case.

Adult↗
PubMed2001

The secret life of the psychoanalyst.

In this article I have discussed what philosophers formally call subdoxastic about. Subdoxastic states are unconscious states about something that lead to conscious beliefs and conscious experiences. In the field of psychoanalysis Sullivan's (1953) "malevolent transformation" is a simple example of this. We all known how patients who have unconsciously undergone this kind of transformation of beliefs about people often appear more or less openly, depending on how well they are able to hide it, to be paranoid, suspicious, angry, and mistrustful of everybody, with the result that their conscious behavior and attitude alienate people and drive them away, resulting in experiences serving to verify the patients' beliefs. Psychoanalysts, we hope, are more subtle. Because they operate in a situation where there is little consensual validation and public scrutiny, the temptation to such syndromes as "compromise of integrity" or "partial private schemata" is very strong, leading to enactments that can be damaging to both patient and analyst and ultimately to burnout, as I have described it in this article. It is necessary, therefore, for analysts to keep a careful check on their conscious value systems and beliefs and to maintain continuing self-analysis for the subdoxastic factors that shape such beliefs. It is not possible to hide this from patients, and we must assume that sooner or later the patient gets to know the analyst pretty well. Analysts displaying the syndromes just mentioned, which are more subtle than ordinary character pathology such as that which forms the all-too-pervasive narcissistic analyst, may not even be aware they are doing so if they do not maintain a continual self-scrutiny, and if they do not pay close attention to their patients' material. This material--the patients' dreams, free associations, behavior, and enactments in the analytic process--often reflects not only transference but also constitutes a response to the analyst's unconscious and conscious value systems, which in turn are based on the subdoxastic factors that make the analyst the person that he or she is. Some patients may even precipitate crises or other situations that test the analyst's value system and force the analyst to display his or her secret self in immediate decisions that cannot be avoided. This is especially true if the patient is frightened or terribly threatened by factors in the secret self of the analyst; in this situation the patient may behave like a child who knows his or her father or mother is really very angry under a seemingly calm exterior, and as a result the child deliberately precipitates a display of that parental anger to get it out on the surface, get it over with, and reduce the child's anxiety. I have called for a genealogical study of analysts' choices of theoretical orientation in various cultures, and herein I am calling for a study of the subdoxastic factors in each individual analyst's theoretical orientation. Every theoretical orientation is based on a value system and a set of desires that determine the goals the analyst consciously or unconsciously wishes for the patient to actualize in the treatment process in order for the analyst to feel that he or she has catalyzed a "successful" treatment. This is a preliminary formulation. Further work is needed to distinguish between countertransference in the sense that we ordinarily use that concept today, and these subdoxastic factors determining the analyst's theoretical orientation and value systems, as well as to increase our focus on a subclass of these factors, the cultural ambience and background practices that Heidegger, for example, has identified as being crucial in the formation of the analyst's self as well as that of the patient.

Burnout, Professional↗
PubMed1991

Interpretation and empathy: reading Lacan with Kohut.

This paper reads Lacan's exploration of the unconscious through the prism of Kohut's emphasis upon empathy as the basis for psychoanalytic interpretation. Lacan described the disconnexion characterizing human relationships; our experience of each other and of ourselves is radically alienated by the unconscious. Lacan's unconscious is structured like a language, revealing its complexity through symbolic forms. Language and desire always belong to the Other, a dislocation underlying all transferences. In psychoanalysis, transferences provide interpretive access to the language of the unconscious. For Kohut, interpretation depends on the prior establishment of a stable, sustaining transference; human connexion is a lifelong necessity and full understanding an achievable aim. Lacan's more structural approach to the inner world provides an important counterweight to Kohut's narrow preoccupation with the two-person field, while Kohut's concept of maternal mirroring lends a humane dimension to the icy realms of Lacan's intellectual structures. Despite enormous differences, each of these contemporary rediscoverers of Freud's legacy serves to supplement the perspective of the other.

Empathy↗
PubMed1989

Recovery to +1Gz and +2Gz following +Gz-induced loss of consciousness: operational considerations.

With the development of aircraft autorecovery technology, the need to understand the effects of potential inflight recovery profiles on human physiology has become important. Eight male volunteer subjects were exposed to +7Gz with an onset rate of 6 G.s-1 until they were unconscious. The subjects did not wear anti-G suits and did not perform anti-G straining maneuvers. The subjects controlled the centrifuge utilizing an F-16A stick, thereby deliberately self-inducing their unconsciousness. Following +Gz-induced loss of consciousness (G-LOC), recovery to the usual +1Gz level was compared to recovery to a +2Gz level by comparing absolute, relative, and total incapacitation times. The mean (+/- S.D.) absolute incapacitation time (period of unconsciousness) was 11.9 +/- 2.9 s for recovery to a +1Gz level and 12.9 S (+/- 6.9 S.D.) for recovery to a +2Gz level. The mean relative incapacitation time (period of confusion/disorientation) was 3.6 +/- 2.3 s for recovery to a +1Gz level as compared to 2.9 +/- 0.8 s for recovery to a +2Gz level. The total incapacitation time (sum of the absolute and relative incapacitation) was 15.6 +/- 2.7 s for recovery to a +1Gz level and 16.0 s (+/- 6.8 S.D.) for recovery to a +2Gz level. No significant differences in any of the incapacitation times were found when comparing recovery to +1Gz and +2Gz. The mean time from the onset of +Gz-stress to the onset of unconsciousness was approximately 7 s.(ABSTRACT TRUNCATED AT 250 WORDS)

Adult↗
PubMed1984

[Significance of basic concepts in depth psychology for psychosomatics].

The concept of "the unconscious" is considered the central concept of depth psychology. While the unconscious in Freud's conception consists essentially of repressed material and through conversion can result in psychosomatic illnesses, C. G. Jung saw in the "collective unconscious", which he discovered, the source of all psychic and spiritual development. Mediation between the collective unconscious and the conscious is effected by means of the "archetypes", whose function can be compared with the instincts. Archetypes are manifested through symbols, whose assimilation by consciousness is a prerequisite for psychic and physical health. Consideration of the archetype of the physician suggests that the grounding of medical science in depth psychology would modify not only our understanding of illnesses, but also the physician's understanding of himself.

Freudian Theory↗
PubMed1994

What is a clinical fact? Clinical psychoanalysis as inductive method.

This paper is an inquiry into the nature of clinical facts in psychoanalysis. The attainment of representability of psychic reality being requisite for insight, the author examines inductive processes on the part of both analyst and analysand, which are to be considered proper aspects of the study of clinical facts. It is argued that the analyst chooses his interpretations guided in good measure by nonverbal material, based on how he intuits that he is 'used' by the analysand and the ways the analysand feels 'used' by him; such nonverbal clues on the nature of the unconscious relational 'frames' operating in sessions guide him to select relevant associations from the universe of the analysand's verbal utterances. He thus comes to voice his interpretations, purveying a 'mapping' of psychic reality that typically makes use of a new viewpoint for description. Insight is achieved when the analysand attains ostensive refutation or redefinition of his unconscious 'theories' about the relationship, and this happens only in concrete individual situations, when the effects of his relational unconscious 'theories' come to be contrasted observationally in diverse 'screens', perceptual and mnemic, against the background of the analyst's neutrality: in such a way unconscious 'theories' attain the Pcs.-Cs. domain of the 'no'.

Adolescent↗
PubMed1994

Some remarks about the 'controversial discussions'.

In 1943-44, the British Psycho-Analytical Society held the 'Controversial Discussions' in an attempt to resolve various disagreements then current in the theory, practice and teaching of psychoanalysis. This paper selects and assesses in some detail some of the arguments that emerged around the concepts of 'unconscious phantasy' and 'unconscious conflict'. Inter alia, they included arguments about assumed early events, about ways of interpreting and assessing evidence, about modes and different levels of conceptualisation, about interpretations of Freud and about changes in psychoanalyic theory. Attempts to achieve mutual understanding existed side by side with total and sometimes rancorous disagreement. Attention is given to sometimes irresolvable communicative and conceptual difficulties that arose and still arise, from differences in meaning that different psychoanalytic thinkers assigned and still assign to each of the two conceptual terms, 'unconscious phantasy' and 'unconscious conflict'.

Fantasy↗
PubMed1996

[Slip technique, process dissociation model and multinomial modeling: new tools for experimental detection of "Freudian slips"].

The study reported here was conducted as a test of the so-called "weak Freudian hypothesis", which claims that unconscious thoughts are relevant for the generation of speech errors. Spoonerisms were induced experimentally using the so-called SLIP technique. Motley and Baars (1976) demonstrated an increase in speech error rates when spoonerisms were primed semantically. The extensively discussed problems of "unawareness" of briefly presented stimuli were circumvented by using a modified version of Jacoby's process dissociation technique which allows a model-based estimation of conscious and unconscious processes within a task. The two reported experiments combined a wordstem completion task for estimating probabilities of perceptual processes and a SLIP task under identical perceptual conditions. A joint multinomial model was constructed for data analysis. The SLIP technique was successfully applied using German stimuli, adequate experimental variations raised the error rate from 7% in experiment 1 to 19% in experiment 2. Neither the replication of Motley and Baars' results nor unconscious priming of speech errors were statistically confirmed. Despite this negative result, the descriptive pattern of parameter estimates is psychologically meaningful: primes that remained unconscious resulted in a higher speech error probability than primes that were perceived consciously. Conscious perception might trigger control processes that act in opposition of speech errors. Statistical problems of the particular multinomial model and possible solutions in future research are discussed.

Adult↗
PubMed1998

[Losing consciousness: role of the venous lactate levels in the diagnosis of convulsive crises].

OBJECTIVES: This prospective study was conducted to evaluate the usefulness of venous lactate assay in the diagnosis of generalized seizures. PATIENTS AND METHODS: Over a three month period, 78 consecutive adults admitted to the emergency unit for unconsciousness were included in the study. Three study groups were defined: patients with generalized seizures (n = 22), unconscious patients without seizure (n = 34) and known epileptic patients with unexplained malaises (n = 22). Patients with a disease susceptible of increasing lactate levels were excluded. Peripheral venous blood was drawn to determine lactates, bicarbonates and pH on a blood gas analyzer. All determinations were performed within 5 minutes of blood withdrawal. CPK level was also determined with an enzymatic method. RESULTS: In patients who had seizures, venous lactate levels were higher than those in patients who had no seizures: 4.3 +/- 0.5 mmol/l in generalized seizure patients versus 1.64 +/- 0.1 and 2.2 +/- 1.39 in unconscious patients without seizure and known epileptic patients with unexplained malaise respectively. The threshold lactate level of 2.5 mmol/l given by ROC curves gave a 0.97 specificity and a 0.73 sensitivity. DISCUSSION: The acidosis observed in patients with generalized seizures results from the combined effects of respiratory and metabolic acidosis. High lactate level would be a consequence of hypoxemia, per seizure rise in catecholamines, and aerobic and anaerobic metabolism in muscles during the tonic-clonic phase. In patients presenting in an unconscious state, increased lactate levels, even when determined up to 2 hours after venous blood withdrawal, could be a useful parameter for the diagnosis of epileptic seizure.

Adult↗
PubMed1992

Direct interpretation of dreams: typology.

The dream typology assorts dreams into three major categories: dreams whose origin is endogenous, exogenous, or relational. Dreams of the first type arise from somatic needs, feelings, and states that accompany organismic adjustments to system requirements. Dreams of the second type are initiated by kinetic and dispositional tendencies toward engagement and exploration of the outer world. And dreams of the third type derive from interpersonal dispositions to interaction and relationship with other people. Within each category, dreams may occur at different levels of complexity. The dream typology permits the integration of psychoanalytic observations about the dreams from a variety of perspectives within a common framework. Freud's view that a dream is a wish fulfillment finds its primary niche in endogenous need, wish fulfillment, and convenience dreams. Kohut's observations about self-state dreams and inner regulation (1971, 1977) are accommodated to the middle range of endogenous dreams, and Jung's individuation dreams (1930) occupy the advanced range. Similarly, Bonime's interpersonal approach to dream interpretation (1962) is encompassed by relational dreams of the middle level. In addition, types and modes of dreams that are only infrequently encountered in clinical psychoanalysis are accommodated. The dream typology suggests that different psychoanalytic theories are like the position papers that might have derived from the fabled committee of learned blind who were commissioned to determine the appearance of an elephant. Each individual got a hold on some part, but could not see the whole; so for each, the part became the whole. The psychoanalytic theorist is in exactly an analogous position because, in fact, he is blind to the extent of the unconscious and is constrained to what he can infer. What he can infer depends on cohort, client population, and how he calibrates his observations. The result has been procrustean interpretation, dissention, and a remarkable stasis in the psychoanalytic theory of the unconscious. The theory of the unconscious that arises from the method of direct interpretation reflects a differentiated inner world with variegated landscapes of images and frameworks. The derivatives of the unconscious are determined by complex decision rules, symbol systems, and syntax. Images and dreams possess a primary autonomy from the conscious mind and arise through the configural mind, which serves the construction and synthesis of experience and knowledge. The derivatives emerge out of common human nature conjoined with concrete human experience. For this reason, dreams and images appear universal.(ABSTRACT TRUNCATED AT 400 WORDS)

Cognition↗
PubMed2001

Evaluation of two processed EEG analyzers for assessment of sedation after coronary artery bypass grafting.

OBJECTIVES: Processed EEG monitoring has been suggested for sedation depth evaluation in intensive care unit (ICU) patients. The present study investigated the efficacy of two processed EEG monitors using SEF90% or SEF95% and BIS to differentiate between conscious (Ramsay score 4) and unconscious sedation (Ramsay score 6). DESIGN AND SETTING: Prospective, randomized trial in a surgical ICU of a university teaching hospital. PATIENTS: Patients recovering from elective coronary bypass grafting. INTERVENTION: One of two EEG analyzers was installed (A: Aspect A-1000 measuring SEF95% and BIS; D: Drager pEEG measuring SEF90%). At ICU admission unconscious sedation (Ramsay score 6), and at three 30-min intervals conscious sedation (Ramsay score 4) were investigated. MEASUREMENTS AND RESULTS: Fourteen patients were monitored by A and 14 by D. The interindividual variability (coefficient of variation 32-69 %) was large for all three processed EEG methods. SEF90% of analyzer D and BIS of analyzer A showed a statistically significant difference between unconscious and conscious sedation (11 +/- 3 and 17 +/- 6 Hz, p = 0.005; 74 +/- 10 and 83 +/- 10, p = 0.02). Positive and negative predictive values for SEF90% of analyzer D (0.57, 95% CI 0.34-0.77; and 0.92, 95% CI 0.64-0.99) and BIS of analyzer A (0.55, 95 % CI 0.32-0.76; and 0.87, 95 % CI 0.60-0.98) were too low for discrimination between conscious and unconscious sedation. CONCLUSIONS: The use of processed EEG monitoring cannot be recommended for assessing sedation depth after cardiac surgery.

Aged↗
PubMed1994

Outcome of severe anoxic/ischemic brain injury in children.

The outcome of 25 children who had anoxic or ischemic brain injuries at 2 months to 14 years of age is reported. Follow-up was from 1 to 14 years after injury; causes were near-drowning, 11; suffocation, 7; cardiac arrest, 3; electrocution with cardiac arrest, 2; strangulation, 1; aborted sudden infant death syndrome, 1. All patients were unconscious for at least 24 hours. Of 11 remaining in vegetative states, 5 died. Seven children regained some language skills and are in special education or self-contained classrooms. Seven are profoundly impaired and show only a social smile. Cognitive and motor outcomes were correlated with the severity of injury as indicated by the duration of unconsciousness. All children who regained language skills or the ability to walk were unconscious less than 60 days. Dystonic rigidity was observed in all children who were nonambulatory. Outcome was also correlated with the cause of injury; mortality, cognitive outcome, feeding outcome, and duration of unconsciousness were all worse in children with near-drowning.

Adolescent↗
PubMed2003

Interaction between emergency medical dispatcher and caller in suspected out-of-hospital cardiac arrest calls with focus on agonal breathing. A review of 100 tape recordings of true cardiac arrest cases.

AIM: One of the objectives of this study was to assess the emergency medical dispatchers (EMDs) ability for the identification and prioritisation of cardiac arrest (CA) cases, and offering and achievements of dispatcher-assisted bystander cardiopulmonary resuscitation (CPR). The other objective was to give an account of the frequency of agonal respiration in cardiac arrest calls and the caller's descriptions of breathing. METHODS: Prospective study evaluating 100 tape recordings of the EMD calls of emergency medical service (EMS)-provided advanced life support- (ALS) cases, of out-of-hospital cardiac arrest. RESULTS: The quality of EMD-performed interviews was highly commended in 63% of cases, but insufficient or unapproved in the remaining 37%. The caller's state of mind was not a major problem for co-operation. Among the 100 cases, 24 were suspected to be unconscious and in respiratory arrest. A further 38 cases were presented as unconscious with abnormal breathing. In only 14 cases dispatcher-assisted bystander CPR was offered by the EMD, and in 11 of these it was attempted, and completed in eight. Only four of the cases were unconscious patients with abnormal breathing. The incidence of suspected agonal breathing was estimated to be approximately 30% and the descriptions were; difficulty, poorly, gasping, wheezing, impaired, occasional breathing. CONCLUSIONS: Among suspected cardiac arrest cases, EMDs offer CPR instruction to only a small fraction of callers. A major obstacle was the presentation of agonal breathing. Patients with a combination of unconsciousness and agonal breathing should be offered dispatcher-assisted CPR instruction. This might improve survival in out-of hospital cardiac arrest.

Allied Health Personnel↗
PubMed2003

Cerebral blood flow and metabolism after cardiopulmonary resuscitation. A pathophysiologic and prognostic positron emission tomography pilot study.

BACKGROUND: Prolonged coma is not an uncommon clinical problem following resuscitation from cardiac arrest. Early and precise prediction of outcome is highly desirable for ethical and economical reasons. The aims of this study were to use positron emission tomography (PET) to investigate the regional dynamic changes of cerebral blood flow and metabolism during the early period after cardiopulmonary resuscitation (CPR) in unconscious patients and to evaluate if PET may be a potential prognostic evaluator. METHODS AND RESULTS: PET and Glasgow Coma Scale examinations were sequentially performed on days 1, 3 and 7 in seven patients remaining comatose post CPR. Each PET included regional determinations of cerebral blood flow (rCBF), oxygen metabolism (rCMRO(2)), oxygen extraction ratio (rOER), and cerebral blood volume (rCBV). One patient was excluded due to complex trauma problems. Three patients remained unconscious until death and three woke up. All patients initially exhibited low CMRO(2) and CBF. Increased OER was only found exceptionally and when present was predominantly in focal areas. The comatose patients showed progressive depression of CMRO(2) and after 1 week had lower CMRO(2) than those patients who woke up. This difference was most pronounced in the putamen and occipital cortex. Two of the seven patients developed large focal infarcts. CONCLUSIONS: An initially low CMRO(2) was common to all patients. Early development of subclinical focal ischemic lesions was also common. The progressive depression of CMRO(2) over the first week in those patients remaining unconscious may be an indication of prolonged but not necessarily permanent coma. Further studies are required to identify pathophysiological features that can predict the long-term clinical outcome in patients who remain unconscious after 1 week.

Aged↗
PubMed2005

[The project of a law concerning patients' rights at the end of life].

A bill about Patients' rights and the end of life was adopted unanimously by the National Assembly on November 30, 2004. Article 1 provides that the physician is not obligated to continue treatment "when the latter appears futile, disproportional and has no effect other than artificially maintaining the patient's life". Article 2 recognizes that painkillers administered at high doses to terminally ill patients may as a side effect "shorten the patient's life". Conscious patients and the families of unconscious patients must be so informed, and the discussion must be mentioned in the patient's file. Physicians must respect their patients' refusal of treatment, even in life-threatening situations. On the other hand, patients who are not terminally ill must await the expiration of a mandatory waiting period before the physicians must comply with their wishes to refuse care. Article 3 specifies that any treatment can be withheld or withdrawn, including artificial nutrition. The law specifies that it is applicable in 4 different sets of situations: for patients who are or are not terminally and for those who are or are not conscious. Article 9 makes clear that futile treatment of unconscious patients can be withheld or withdrawn. Article 7 specifies that adults may draw up advance directives to indicate their wishes for their end of life and their desires regarding the withholding or withdrawal of treatment. Withholding or withdrawing active treatment is authorized under 3 conditions: the consent from the patient, or if he or she is unconscious, the approval of the health-care proxy, or a family member or close friend if the patient is unconscious; the inclusion of the decision in the patient's medical file, and a group decision-making process.

Advance Directives↗