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Time for Change

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How can we, analysts, evaluate whether analysis is generating transformations in our patients? The IPA Project Committee on Clinical Observation and Testing offers a tool: The Three-Level Model for Observing Patient Transformations (3-LM); a guide for refining, conceptualizing, and systematizing clinical observations about patient transformations. It seeks to enhance clinical observations, making them more accurate and more useful for theory testing and theory building through a systematic analysis of clinical material.Time for Change: Tracking Transformations in Psychoanalysis - The Three-Level Model focuses on the question of how to observe changes in psychoanalysis. It presents the model and the outcome of having worked with the 3-LM tool, which has been applied to adult patients, adolescents and children, as well as in analytic training. The 3-LM goes from clinic to theory, from implicit to explicit theory, from unquestioned hypotheses to reviewed hypotheses enriched by the work on the clinical material after its discussion by several participants with different perspectives. Firstly, the 3-LM seeks to make a careful characterization of the patient and his/her problems and capacities when (s)he enters analysis. Then, it observes later moments of his/her treatment and the positive or negative changes that have occurred during treatment, what has not changed, the relevance of changes, and how changes are explained. Reports are elaborated in each group which state the convergences and divergences that emerged during the group discussion. Approximately 700 analysts from different parts of the world have participated in these clinical observation groups. They have found that this tool has proved useful and friendly for analysts, for it rescues and re-values the richness of the clinical experience between analyst and patient. It also allows us analysts to exercise our abilities and clinical sharpness as well as acquiring precision when communicating our work. It provides us with one way to monitor our work in a more subtle and meticulous way, offering a second look at the material for the benefit of both analyst and patient.

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CHAPTER ONE The three-level model (3-LM) for observing patient transformations

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CHAPTER ONE

The three-level model (3-LM) for observing patient transformations

Ricardo Bernardi

Introduction he description of the transformations or changes that occur in patients over the course of their analysis is of great theoretical and practical importance. A guide or heuristic is proposed below for observing and describing these changes, using three successive levels of analysis and named, for this reason, “three-level model for observing patient transformations” (3-LM). Each of these levels, which will be described in this paper, suggest specific questions, which are intended to serve as a guide for group discussion or for the analyst’s personal reflection. From the heuristic point of view, the

3-LM is expected to enhance and refine the clinical observation and description of transformations that occur during lengthy periods of analysis, or through a complete treatment.

A wider and more detailed description of patient transformations offers a better basis for understanding the analytic process and its mechanisms of change. The word “process” refers to a succession of states whose transformations or changes will be better identified and understood the longer the time and the wider the context taken into account. Analytical papers frequently study in depth especially

 

Chapter One - The Three-Level Model (3-LM) for Observing Patient Transformations

ePub

Ricardo Bernardi

Introduction

The description of the transformations or changes that occur in patients over the course of their analysis is of great theoretical and practical importance. A guide or heuristic is proposed below for observing and describing these changes, using three successive levels of analysis and named, for this reason, “three-level model for observing patient transformations” (3-LM). Each of these levels, which will be described in this paper, suggest specific questions, which are intended to serve as a guide for group discussion or for the analyst's personal reflection. From the heuristic point of view, the 3-LM is expected to enhance and refine the clinical observation and description of transformations that occur during lengthy periods of analysis, or through a complete treatment.

A wider and more detailed description of patient transformations offers a better basis for understanding the analytic process and its mechanisms of change. The word “process” refers to a succession of states whose transformations or changes will be better identified and understood the longer the time and the wider the context taken into account. Analytical papers frequently study in depth especially meaningful moments of analysis. This inescapable perspective could usefully be complemented by the clinical observation of patient changes over prolonged periods of time, to which less attention has been paid in the literature. Psychoanalysis owns conceptual and clinical tools to envisage these kinds of descriptions, but it is not easy to integrate them because they belong to diverse and sometimes conflicting theoretical and technical points of view. However, when core aspects of these concepts are put together in a complex and coherent way, the result is highly challenging and enriching. This chapter examines and discusses the concepts that are most useful to answer the key questions: to what extent has the patient clinically improved (or worsened) during analysis? What are the main dimensions of the changes and what are the hypotheses that can best explain them?

 

Chapter Two - Leticia: The Emergence of Questions about Herself

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Silvana Hernández Romillo

The case of Leticia, and its discussion in a working group that followed the three-level model for observing patient transformations (3-LM), was briefly introduced in Chapter One. As Leticia's analyst, I must say that everything related to her analytic treatment and its discussion greatly stirred my interest. This essay takes up again, and expands, the ideas shared by the group. In particular, I explore the initial difficulties I encountered, the effects of group discussion on my work and thoughts, and the subsequent progress of Leticia's analysis. (Asking Leticia for permission to publish this material also led to new developments that are worth including here, with her consent.)

The beginning

Considered in the context of my twenty years as an analyst, Leticia's case posed difficulties I had rarely encountered before. In the first place, there was her peculiar reserve. As I stated in the material I presented to the working group, I was struck by her robot-like way of walking and her slow, monotonous voice, and especially by her silences and her recurring “I don't know” answer whenever she had to talk about her inner feelings. Beyond mentioning her insecurity or her sense of being unable to do things right, she felt she had very little to say. “Nothing special happened in my childhood,” she would claim. It seemed as though she searched inside herself and found nothing valuable to communicate—or did not even experience anything valuable.

 

CHAPTER TWO Leticia: the emergence of questions about herself

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CHAPTER TWO

Leticia: the emergence of questions about herself

Silvana Hernández Romillo

he case of Leticia, and its discussion in a working group that followed the three-level model for observing patient transformations (3-LM), was briefly introduced in Chapter One. As

Leticia’s analyst, I must say that everything related to her analytic treatment and its discussion greatly stirred my interest. This essay takes up again, and expands, the ideas shared by the group. In particular, I explore the initial difficulties I encountered, the effects of group discussion on my work and thoughts, and the subsequent progress of Leticia’s analysis. (Asking Leticia for permission to publish this material also led to new developments that are worth including here, with her consent.)

T

The beginning

Considered in the context of my twenty years as an analyst, Leticia’s case posed difficulties I had rarely encountered before. In the first place, there was her peculiar reserve. As I stated in the material I presented to the working group, I was struck by her robot-like way of walking and her slow, monotonous voice, and especially by her

35

 

Chapter Three - Irina: An Adolescent

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The usefulness of the three-level model for observing patient transformations

Marina Altmann de Litvan

Introduction

The aim of this chapter is to use the three-level model for observing patient transformations to interpret specific clinical observations. I write from the perspective of the patient's analyst in order to describe the new insights about the patient that emerged from the group discussion following the model (Montevideo Focus Group: Marina Altmann de Litvan, Ricardo Bernardi, Beatriz De León de Bernardi, Nancy Delpréstitto, Alejandro Garbarino, Silvana Hernández Romillo, Adela Leibovich de Duarte, Evelyn Tellería, and Clara Uriarte, March 2011). My intention is to show how the model works, what transformations (as observed by the working group) occurred or did not occur during the analytic process in the case of this particular patient, and how the model contributed to achieving more accurate psychoanalytic observations.

As outlined in Chapter One (by Ricardo Bernardi), the 3-LM looks at clinical material at three different levels: phenomenological description, the different dimensions of change, and the theoretical hypotheses of the analyst (the third level is developed in Chapter Seven, by Adela Leibovich de Duarte). Our work aimed to assess (i) how the analyst's mind identifies the different reasons that bring a patient to therapy; (ii) how the analyst understands what happens in the transference and countertransference relationship in the analytic process; (iii) how these issues lead to positive changes, negative changes, or no change at all. The clinical material considered in this article, which focuses on an adolescent female, was selected to test the very first version of the 3-LM.

 

CHAPTER THREE Irina: an adolescent

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CHAPTER THREE

Irina: an adolescent

The usefulness of the three-level model for observing patient transformations

Marina Altmann de Litvan

Introduction he aim of this chapter is to use the three-level model for observing patient transformations to interpret specific clinical observations. I write from the perspective of the patient’s analyst in order to describe the new insights about the patient that emerged from the group discussion following the model (Montevideo Focus

Group: Marina Altmann de Litvan, Ricardo Bernardi, Beatriz De León de Bernardi, Nancy Delpréstitto, Alejandro Garbarino, Silvana

Hernández Romillo, Adela Leibovich de Duarte, Evelyn Tellería, and

Clara Uriarte, March 2011). My intention is to show how the model works, what transformations (as observed by the working group) occurred or did not occur during the analytic process in the case of this particular patient, and how the model contributed to achieving more accurate psychoanalytic observations.

 

Chapter Four - Tracking Patient Transformations: The Function of Observation in Psychoanalysis

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Virginia Ungar

Introduction: observation in psychoanalysis

The function of observation in clinical work with patients is both important and controversial. It is commonly held that the act of observing entails paying careful attention to, and engaging all our senses with, objects or phenomena (regarded as external) in order to study them “as presented in reality” (though we are well aware of the difficulties implied in this statement).

To observe should not only mean to “watch” or to “look at”, since good observation requires the concerted action of all senses. Precisely on this point, Bion tells us in his Cogitations (1992) that “private to the individual himself, the term ‘common sense’ is felt to be an adequate description covering an experience felt to be supported by all the senses without disharmony” (p. 10).

Traditionally, the concept of psychoanalytic observation has been favoured by the English school of psychoanalysis, in whose writings the notion of unconscious fantasy may be permeated with an emphasis on the perceptual and the visual. I think it important to call our attention at this point to the fact that, when referring to blind spots, Freud employed a visual metaphor.

 

CHAPTER FOUR Tracking patient transformations: the function of observation in psychoanalysis

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CHAPTER FOUR

Tracking patient transformations: the function of observation in psychoanalysis

Virginia Ungar

Introduction: observation in psychoanalysis he function of observation in clinical work with patients is both important and controversial. It is commonly held that the act of observing entails paying careful attention to, and engaging all our senses with, objects or phenomena (regarded as external) in order to study them “as presented in reality” (though we are well aware of the difficulties implied in this statement).

To observe should not only mean to “watch” or to “look at”, since good observation requires the concerted action of all senses. Precisely on this point, Bion tells us in his Cogitations (1992) that “private to the individual himself, the term ‘common sense’ is felt to be an adequate description covering an experience felt to be supported by all the senses without disharmony” (p. 10).

 

CHAPTER FIVE Depression and trauma: the psychoanalysis of a patient suffering from chronic depression

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CHAPTER FIVE

Depression and trauma: the psychoanalysis of a patient suffering from chronic depression

An exemplary case study based on the three levels of clinical observation

Marianne Leuzinger-Bohleber

Preliminary remarks

From focusing the analyst’s mind on the transformations of the patients t the EPF Conference in Copenhagen in April 2010, I was asked to participate in a panel devoted to reflections concerning the achievements of the ten years of Working Parties within the EPF. To summarise: in my perspective, one of the great achievements of the Clinical Working Parties, initiated by David

Tuckett in 2000, is that the endless feuds between different psychoanalytical schools have become subdued. Particularly in the Clinical

Working Parties (CCM, see Tuckett, 2008), but also in the other groups of the EPF initiatives, who regularly met and worked together for nearly ten years, a new culture of curiosity and respect was created for the Others, for different clinical and conceptual thoughts of colleagues from many different regions within the EPF and from different

 

Chapter Five - Depression and Trauma: The Psychoanalysis of a Patient Suffering from Chronic Depression

ePub

An exemplary case study based on the three levels of clinical observation

Marianne Leuzinger-Bohleber

Preliminary remarks

From focusing the analyst's mind on the transformations of the patients

At the EPF Conference in Copenhagen in April 2010, I was asked to participate in a panel devoted to reflections concerning the achievements of the ten years of Working Parties within the EPF. To summarise: in my perspective, one of the great achievements of the Clinical Working Parties, initiated by David Tuckett in 2000, is that the endless feuds between different psychoanalytical schools have become subdued. Particularly in the Clinical Working Parties (CCM, see Tuckett, 2008), but also in the other groups of the EPF initiatives, who regularly met and worked together for nearly ten years, a new culture of curiosity and respect was created for the Others, for different clinical and conceptual thoughts of colleagues from many different regions within the EPF and from different “schools” (Kleinans, contemporary Freudians, “object relationalists”, Kohutians, intersubjectivists, etc.). This culture helped to overcome the unproductive competition for the “right” or “wrong” theoretical point of view, the “right” or “wrong” interpretation, clinical attitude, etc. A new appreciation for the richness of contemporary pluralism within European psychoanalysis developed. In my eyes, this is an immense liberation from narrow-mindedness or even pseudo-religious structures, which have proved to be so destructive for psychoanalysis as a scientific discipline in the past (see, e.g., Makari, 2008; Zaretsky, 2004).

 

Chapter Six - Close to Observation: Some Reflections on the Value of the Three-Level-Model for Studying Change

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Siri Erika Gullestad

Observation and interpretation

In his work “On narcissism”, Freud discusses the differences between a speculative theory and a theory erected on empirical interpretation (Freud, 1914c). The latter will not envy speculation its “smooth, logically unassailable foundation”, but will content itself with nebulous basic concepts

which it hopes to apprehend more clearly in the course of its development, or which it is even prepared to replace by others. For these ideas are not the foundation of the science upon which everything rests. That foundation is observation alone. They are not at the bottom, but the top of the whole structure, and they can be replaced and discarded without damaging it. (Freud, 1914c, p. 77)

This formulation implies that: (1) psychoanalysis is fundamentally an empirical science; the starting point for its concepts is clinical observation; (2) psychoanalytical science is aware of the fact that its concepts are tentative and imperfect and in continuous development towards greater precision. At the same time, it is prepared to replace existing concepts with new ones, if necessary. With his dictum, Freud establishes an attitude of principle towards psychoanalysis as a discipline and demonstrates an approach to research characterised by openness, flexibility, and fundamental respect for the unbiased observation. To Freud, theory is the servant of clinical practice—not the other way round. Every psychoanalytic concept starts and ends in observation.

 

CHAPTER SIX Close to observation: some reflections on the value of the three-level-model for studying change

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CHAPTER SIX

Close to observation: some reflections on the value of the three-level-model for studying change

Siri Erika Gullestad

Observation and interpretation n his work “On narcissism”, Freud discusses the differences between a speculative theory and a theory erected on empirical interpretation (Freud, 1914c). The latter will not envy speculation its “smooth, logically unassailable foundation”, but will content itself with nebulous basic concepts

I

which it hopes to apprehend more clearly in the course of its development, or which it is even prepared to replace by others. For these ideas are not the foundation of the science upon which everything rests. That foundation is observation alone. They are not at the bottom, but the top of the whole structure, and they can be replaced and discarded without damaging it. (Freud, 1914c, p. 77)

This formulation implies that: (1) psychoanalysis is fundamentally an empirical science; the starting point for its concepts is clinical observation; (2) psychoanalytical science is aware of the fact that its concepts are tentative and imperfect and in continuous development towards greater precision. At the same time, it is prepared to replace existing concepts with new ones, if necessary. With his dictum, Freud

163

 

Chapter Seven - Working with the Third Level of the Three-Level Model: The Incidence of our Theoretical Model on our Clinical Thinking

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Adela Leibovich de Duarte

The Scottish philosopher, David Hume, affirmed in the Treatise of Human Nature (1739) that people have a need to understand and explain everything they observe because that makes the world more meaningful.

This intrinsic need to understand and explain the world that surrounds us includes our need to recognise and try to make sense of the others with whom we share, or do not share, perceptions and conceptions about it. The recognition of otherness is intrinsically interwoven in our general understanding of the world. According to Bowlby (1969, 1973), the processing of that information takes place in the context of our “internal working model” that helps us to perceive events and construct our plans for the future.

Our subjectivity exists in an intersubjective space, and, as Mitchell (2000) states, one mind presumes other minds. It is precisely in an intersubjective space that the analytic encounter takes place, as it is the encounter between two different subjectivities who usually share a general common cultural background and the same language. The recognition of otherness is intrinsically interwoven in our clinical work.

 

CHAPTER SEVEN Working with the third level of the three-level model: the incidence of our theoretical model on our clinical thinking

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CHAPTER SEVEN

Working with the third level of the three-level model: the incidence of our theoretical model on our clinical thinking*

Adela Leibovich de Duarte

he Scottish philosopher, David Hume, affirmed in the Treatise of

Human Nature (1739) that people have a need to understand and explain everything they observe because that makes the world more meaningful.

This intrinsic need to understand and explain the world that surrounds us includes our need to recognise and try to make sense of the others with whom we share, or do not share, perceptions and conceptions about it. The recognition of otherness is intrinsically interwoven in our general understanding of the world. According to

Bowlby (1969, 1973), the processing of that information takes place in the context of our “internal working model” that helps us to perceive events and construct our plans for the future.

Our subjectivity exists in an intersubjective space, and, as Mitchell

 

Chapter Eight - A Traumatised Patient in Analysis: Observing Patients’ Transformations

ePub

Margaret Ann Fitzpatrick-Hanly

Introduction

The transformations that occur during analysis have multiple aspects and raise a wide range of questions. What changes? How does change occur? When? Why? These problems have been extensively discussed in literature. The aim here is not to answer these questions themselves, but to study ways in which a better clinical observation can contribute to advance in the study of their answers (Guidelines, three-level model, Appendix I).

The three-level model for observing patient transformations was developed by the IPA Committee on Clinical Observation to guide groups of psychoanalysts in observing change and no change in a patient in psychoanalysis, using a brief history and the verbatim records of selected psychoanalytic sessions. Several kinds of observation come into play in an analytic process, as well as in writing clinical reports and clinical papers, and a rich language for observational functions exists in all psychoanalytic cultures. Grinberg (1990) quotes Fleming and Benedek (1964) on a range of observational abilities to be transmitted in the education of psychoanalysts: “listening with floating attention (the self acts as an instrument of reception and perception, with a synthetical function)”; inferring “interpretations from latent material, but without formulating them yet”; estimating “the degree of resistance and anxiety in the patient, and developing empathy with the patient's regressive state (function of sensitivity)”; “judging the moment and distribution of responses and interventions”; “grasping, at the greatest possible depth, reactions of transference and countertransference”; “recognizing the dynamic trends and changes session to session” (Grinberg, 1990, p. 294).

 

PART III A PATIENT, A CONCEPT, AND A CASE

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PART III

A PATIENT, A CONCEPT,

AND A CASE

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Chapter Nine - Transformations in Paula with “No History”

ePub

Michael Šebek

When I was invited to present the case material by the IPA Project Committee on Clinical Observation and Testing in order to study transformations by using expert work groups and Ricardo Bernardi's three-level model for observing patient transformations (3-LM) in the IPA Congress in Prague 2013, I was very pleased to have this extraordinary possibility to discuss my work with many respected colleagues from different parts of the psychoanalytic world. As for this 3-LM, I had no experience with its application before.

I decided to present the case of Paula because, during the time of treatment, I was aware of several interesting changes but I had done no work on their systematic conceptual elaboration.

Paula

Paula was thirty years old when she asked for the first visit, after being referred by a colleague. She has an inconspicuous appearance, no make-up, various grey colours in her dress, quiet voice, signs of scopophobia, not very talkative. She slowly said that her life is not “juicy”, that somatic problems took away all remaining self-esteem, that she is single and is afraid of serious relations with men, in fact, with anybody. She feels she has no value, and that she is the main cause of her troubles. She often has the feeling that what she is telling is not “true”, or as if someone else were speaking instead of her. She conveys that she has “no history”, “no emotions”, and that “nothing really serious” happened in her childhood with her mother, father, and two younger brothers: “I cannot really complain”. Then she describes, without any recognisable emotion, the “automatic” feel of her life: journeys to work and back home, each day the same, no excitation, no sex, no pleasures. Furthermore, she does social work in the town department dealing with homeless people.

 

CHAPTER EIGHTA traumatised patient in analysis: observing patients’ transformations

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CHAPTER EIGHT

A traumatised patient in analysis: observing patients’ transformations

Margaret Ann Fitzpatrick-Hanly

Introduction he transformations that occur during analysis have multiple aspects and raise a wide range of questions. What changes?

How does change occur? When? Why? These problems have been extensively discussed in literature. The aim here is not to answer these questions themselves, but to study ways in which a better clinical observation can contribute to advance in the study of their answers (Guidelines, three-level model, Appendix I).

The three-level model for observing patient transformations was developed by the IPA Committee on Clinical Observation to guide groups of psychoanalysts in observing change and no change in a patient in psychoanalysis, using a brief history and the verbatim records of selected psychoanalytic sessions. Several kinds of observation come into play in an analytic process, as well as in writing clinical reports and clinical papers, and a rich language for observational functions exists in all psychoanalytic cultures. Grinberg (1990) quotes

 

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