Open door review

Clinical studies

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Research in child psychoanalysis: Twenty-five-year follow-up of a severely disturbed child

Tyson, P. (2009). Research in child psychoanalysis: twenty-five-year follow-up of a severely disturbed child. Journal of the American Psychoanalytic Association 57 (4): 919-45. 
Fonagy, P., & Target, M. (1996). Predictors of outcome in child psychoanalysis: A retrospective study of 763 cases at the Anna Freud Centre. Journal of the American Psychoanalytic Association, 44, 27-77.

Summary

The history and current state of research at the Anna Freud Centre reports the evolution of a database that has methodically recorded and systemati­cally organized data from over 750 cases of children referred to the Centre over a forty-five-year period. A long-term follow-up of a small sample of these children suggests the kinds of long-term benefits that can be gained when an individual is treated with intensive psychoanalysis as a child. As an example, the author presents clinical material from the analysis of an eight-year-old along with follow-up interview data twenty-five years later to demonstrate the efficacy and the outcome of a child psychoanalysis and critically discusses the value of distinguishing two different models of psychoanalytic treatments – the “classical model” and the “mental process model”.

The long tradition of research at the Anna Freud Centre, as well as the extensive Hampstead Index database2 of methodically recorded and systematically organized observations from the analysis of children dat­ing back to at least 1960 provided the material, technical, and epistemological support to respond to this challenge. Fonagy, Target and their collegues at the Centre designed and systematically conducted an empirically sound study of the outcome and efficacy of child analysis (for a description of this study and its methodology, see Fonagy and Target 1996). This entailed a systematic file review of 763 cases treated in psychoanalysis or psychotherapy at the Anna Freud Centre. By studying the case records they sought to identify children who had had a successful psychoanalytic outcome and then determine the characteristics of the child or the analysis that contributed to that success. The chil­dren who seemed to gain the most from psychoanalysis, judging by their improved adaptive capacity at the completion of their analysis, were those who presented with severe social and emotional psychopathology, such as difficulties in relating to peers, problems with affect regulation, low frus­tration tolerance, distortions of self-image, fragile reality contact, and idiosyncratic and magical thinking. To support the impression that these more disturbed children had actually the most to gain from psychoanalysis, they designed and con­ducted a twenty-five-year follow-up study. In the course of their file review, the team at the Anna Freud Centre began to recognize that the children with serious pathology had in common a difficulty in differentiating other people’s thoughts and feelings from their own. Consequently they were unable to create representations of the self with specific thoughts and feelings and representations of others with thoughts and feelings separate from and different from their own. This limited them socially, as they were unable to reflect on or anticipate another’s response and so could not choose appropriate action. They could not empathize with others or imagine themselves in another person’s shoes.

In the course of this file review, the research team observed that the techniques that seemed to be effective with the more disturbed children differed from the standard defense and conflict interpretation techniques typically used with neurotic children. They realized that an implicit model of psychoanalytic treatment was often being used with these children instead of—or in addition to—the explicit classical model. This observa­tion led them to delineate two discrete models for the psychoanalytic treatment of emotional disturbance in children. The first, the classical model, involved insight and the modification of unconscious mental rep­resentations through interpretations of conflict, defense, and transference. The second, which they called the “mental process model,” focused primarily on what came to be known as mentalization, the process of reflecting on the thoughts, feelings, and mental states of self and others.

By presenting detailed material from the analysis of an eight-year-old named Peter along with follow-up interview data twenty-five years later, the author provides a convincing explication of the need for and effectiveness of psychoanalysis for some severely disturbed children. She describes her therapeutical challenge to find alternative strategies of intervention after she figured out that the classical model of treatment – interpretation of unconscious conflict aimed at promoting insight – was not helpful and did not lead to elaboration or the introduction of new material in this case. The strategy the author developed in treating Peter was to focus on verbalizing his feelings and mental states, using Katan’s notion (1961, p. 185) that verbalization of affect leads to some measure of control. This analysis predated Fonagy, Target, and their colleagues’ work on mentalization. The author maintained that such verbalization increases ego strength by enabling the individual to distinguish between wishes and fantasies on the one hand, and reality on the other. By consistently labelling Peter’s feelings, and making links to his actions and subsequent feelings, Peter might in time be able himself to label and think about his mental states. To enable Peter to feel that he could control his feelings instead of his feel­ings controlling him became the goal of therapy. Perhaps Peter was one of those cases that alerted the research team to the use of implicit treatment techniques and that led them eventually to differentiate the mental process model. The outcome of Peter’s treatment, examined by a follow-up interview twenty-five years later, can be described as a positive, considering the emotional state he presented as a seven-year-old.

Evaluation

Although epistemological difficulties have discredited the case study as a research method for evaluating the efficacy of psychoanalysis, combining the richness of a case study with empirical research data shows how the two methods together can convincingly demonstrate the effectiveness of psychoanalysis with certain types of severely disturbed children. Child analysis requires a considerable investment of time and money but the cost is minuscule weighed against the cost of maintaining someone like Peter on lifetime disability, not an inconceivable trajectory for someone with the emotional challenges he presented. The Anna Freud Centre research team concluded that the effort and cost of early and intensive psychoanalytic treatment for children like Peter is particu­larly justified because they have the most to gain from psychoanalysis.

Contact

Prof. Phyllis Tyson

Seattle Psychoanalytic Society and Institute

4020 E Madison St, Suite 230, Seattle, WA 98112

Email: phyllis@tysonz.com

Website: www.spsi.org

Psychoanalytic treatment of a patient with a neurotic depression. A systematic clinical single case study

Bruns, G. (2005): Zweifeln am Dasein. Aus der Behandlung eines depressiven Patienten (Existential doubt. From the treatment of a depressive patient). Psyche – Zeitschrift für Psychoanalyse, 59, 816-842.

Summary

The article describes the psychoanalytic treatment of a male patient suffering from a neurotic depression with symptoms of a desperate, depressive mood, conscious and unconscious self-destructive tendencies (suicidality, somatic and psychosomatic diseases, overly ascetical and self-restricted style of living) and sexual symptoms of erectile and libidinal disorder. The depression dates back to childhood and was exacerbated in adulthood by a separation and the psychic conflict connected with it. In the course of the analysis the etiological background emerges more clearly ‒ between the age of 0,5 and 1,5 years of the patient his mother lost her husband, her only daughter, her father and a brother by dead and became depressive. A constellation of the kind described with the concept of the dead mother by André Green showed up. The emotional absence of the mother was made more severe by the complete absence of the father. The patient felt that his mother most intensely suffered from the loss of her daughter and that he had the unspoken and unconscious task to replace his dead elder sister together with comforting his mother. In this constellation he experienced doubts whether he was recognized by his mother as own person and whether he was seen by her at all. These early doubts laid the foundations for persisting doubts if he had the right to live and to follow own wishes or if he had to live for the benefit of another person, especially his mother or another woman substituting her in his mind.

In order to understand these existential doubts of the patient the author draws substantially on an interaction model taken from developmental psychology.

In analysis the existential doubt manifested itself as hunger for contact and confirmation. The psychosomatic symptoms played a special role for these needs: on the one hand they demanded care and attention from doctors, they reduced dependency from the analyst because there were more doctors than one, and they were an unconscious recapitulation of experiences of illness-conditioned abandonment in early childhood. In the course of treatment over five years, the patient was able to gradually overcome his symptoms and to establish a more mature and stable form of self/object differentiation.

Evaluation

The sessions were recorded and based on the records evaluated with regard to the unconscious conflicts which changed during treatment, to transference and countertransference. The evaluation was done with a group of clinically working psychoanalysts in fixed intervals. Based on clinical data and the analyst's countertransference it was examined which psychoanalytical theory of depression and of mental functioning seemed to be most appropriate to understand the patient's symptoms and the intersubjective processes during treatment.
During four years after termination there were follow up meetings with the patient once or twice per year which showed the stability of the development during treatment.

Contact          

Prof. Dr. Georg Bruns

Schubertstr. 54, 28209 Bremen.

E-mail: gj.bruns@t-online.de

Assessing change in analysis terminable

Josephs, L. (2000). Self-criticism and the psychic surface. Journal of the American Psychoanalytic Association, 48, 255-280.

Summary

The current study systematically assesses the progress of a single patient during a four-year treatment episode. As a case study it centers a schizoid patient in her mid-sixties who had made in a lengthy analysis – for much of her adult life – significant clinical improvement. The treating analyst’s impression of clinical improvement was independently verified through systematic analysis of transcripts of audiotapes of thirty-six sessions over a four-year period of treatment. The patient showed significant improvement in measures of character pathology, object relations, mentalization, and superego anxiety.

The presented traditional case study offers a special attention to the impact of taping and the supplemented analysis of verbatim transcripts of the whole period of treatment. The transcripts have been rated by external judges with good levels of interrater reliability (> .70) on measures of character pathology, object relations, reflective functioning, and superego anxiety. Two types of measure were selected for the study. Measures of the first type were selected to assess personality variables such as character pathology and level of objects relations that are presumed to be fairly stable and resistant to change. The research question with these measures was whether long-term intensive treatment could significantly alleviate severe and entrenched character pathology.

Measures of the second type were selected to assess more fluid and psychodynamically significant process variables such as reflective functioning and superego anxiety. The research question with these measures was whether the patient would become more reflective and develop a milder superego over the cours of treatment. If the patient did, future research could then examine how aspects of technique and the therapeutic interaction impact on variables that fluctuate quite a bit during sessions.

The results suggest that some patients with entrenched character pathology who seem to be in analysis interminable may still make clinically significant improvement.

In addition, the study demonstrates that the reflective functioning scale (Fonagy et al. 1998) can be fruitfully adapted for use with transcripts of psychoanalytic sessions and furthermore it offers that the SWAP (Shelder and Westen 1998) can generate a personality profile that is consistent with an established self-repot measure, the MCMIIII, so that it is a suitable measure for assessing change in character structure.

Contact

Email: JOSEPHS@ADELPHI.EDU

The „Medea-Fantasy“ – An unconscious determinant of psychogenic sterility

Leuzinger-Bohleber, M. (2012). The ‘Medea fantasy’: An unconscious determinant of psychogenic sterility. In P. Mariott (Ed.), The Maternal Lineage. Identification, Desire, and Transgenerational Issues (pp. 169-204). London/New York: Routledge.
Leuzinger-Bohleber, M.; Teising, M. (2012): “Without being in psychoanalysis I would never have dared to become pregnant”: Psychoanalytical observations in a multidisciplinary study concerning a woman undergoing prenatal diagnostics. International Journal of Psychoanalysis, 93, 293-315.

Summary

Based on systematic clinical case studies the author describes an important unconscious fantasy found in a specific group of female analysands who had unconsciously sought psychoanalytic treatment for the same symptoms: psychogenic frigidity and sterility. In the six psychoanalyses and four long-term therapies, the analyst and the analysands finally discovered that a central unconscious fantasy, hitherto unrecognised, had determined all these women’s experience of their femininity; with the Greek myth in mind, the author called it the ‘Medea fantasy’. Pivotal to this fantasy was the unconscious conviction that sexual passion carried the risk of existential dependence  on their love partner and of eventual deception and abandonment by him. These women were unconsciously convinced that they would not be able to endure such an abandonment and would react to it with lethally destructive impulses constituting an existential danger to the self and the love object—as well as, in particular, to the products of the relationship with him: their children. For this reason it seemed to them psychically imperative to forgo any creative unfolding of their femininity and symbolically to ‘deaden’ themselves and their bodies. In their long and difficult treatments, it emerged that all these patients had sustained severe traumas in their early object relations, with consequent excessive stimulation of archaic fantasies about the female body and about characteristic modalities of the early relationship with the primary object. For example, it turned out that all these women shared the striking biographical fact that, during their first year of life, their mothers had suffered from severe depressions and been treated with antidepressants. As a result, the mothers had presumably lacked an adequate capacity to present themselves to their babies as helpful, reliable and indestructible objects that could thereby have come to their aid in, for example, the progressive integration of archaic destructive fantasies. These had consequently been preserved in the form of splitoff, unconscious ‘Medea fantasies’. While the traumatic quality of their early object relations had undoubtedly favoured the formation of this unconscious fantasy in the analysands, it has to be discussed whether the Medea fantasy might possibly constitute a ubiquitous unconscious fantasy of femininity.

Evaluation

The systematic clinical case studies have been further discussed with clinicians at different conferences. The “Medea-fantasy” was one of the conceptual frameworks of a large empirical study “Ethical Dilemma Due to Prenatal and Genetic Diagnostics” systematically investigated in 82 psychoanalytical case studies applying the method of psychoanalytic expert validation (see Leuzinger-Bohleber, Engels, Tsiantis, 2008).

Contact

Prof. M. Leuzinger-Bohleber

What do patients want?

Hill, C. (2010) “What do patients want?” Psychoanalytic Perspectives from the Couch. London: Karnac Books.

Summary

This book, based on a doctoral thesis, provides an insight into patients’ experiences of psychoanalysis as they describe the factors, which they considered facilitated or impeded their analytic treatment. It addresses the question “What do patients want?” and explores what led to their different outcomes. The context for this book is a psychoanalytic culture where very little is known or understood about what actually takes place between patient and analyst, from the patient’s perspective. The field of literature on psychoanalytic process and outcome studies has generally privileged the practitioner or researcher’s voice, whilst underutilizing rich published accounts of patients talking about their own experiences. This book was thus an attempt to provide an in-depth understanding of an experience usually mystified, and poorly understood, by those outside the analytic dyad.

Method

A qualitative methodology was used to enable the exploration of this broad question and to provide rich and trustworthy data.  The complexities inherent in psychoanalytic clinical work, carried out behind closed doors and influenced by unconscious phantasies and dynamics, presented challenges, which have been explored and discussed. 

Sample

Eighteen participants were interviewed, eleven women and seven men, ages ranging from 31 to 60, and living in four Australian states.  The criteria for participating were that they had completed (or ended) an analysis, and it was with a professionally recognized psychoanalyst. The patients free-associated to an open question about their experiences, providing very rich accounts of their analyses, which they demonstrated with clinical material. Their stories generally indicated a sophisticated understanding of the analytic process.

Evaluation

The chapters were arranged in a journey format, paralleling the analytic journey itself.  A significant focus was the desire to be a ‘patient-partner’ not a ‘patient-victim’. Major themes, which emerged spontaneously, related to choice of an analyst, procedures around the assessment and ending phases of analysis, the quality of engagement between both partners in the transference/counter-transference relationship, and issues to do with silences, authority and powers of negotiation.  The patients delineated factors, which either facilitated liberating experiences and major life changes, or resulted in dissatisfying or ‘failed’ analyses.  A surprising central theme emerged around a strong paternal transference, which is described in a separate chapter entitled “the analyst as father”. Questions were raised and discussed as to the importance of this specific transference. The patients offered further personal reflections on what they considered as imperative for a ‘good’ analysis. 

Significant findings are discussed in each chapter, then key conceptual issues are brought together at the end, highlighting implications for psychoanalysis, its training procedures, Institute policies and clinical practice.

Contact

Dr. Christine Hill

67 Erin St, Richmond, VIC 3121, Australia.

School of Psychology & Psychiatry, Monash University, Melbourne; IPA Research Fellow.

Email: Christine.hill@monash.edu

 A single-case study on the process and outcome

Szecsödy I & Stoker J (2009) A single-case study on the process and outcome of psychoanalysis. Scand. Psychoanalytic Review 31, 3139-3147

Summary

The present study investigates one person’s psychoanalysis over a period of five years during treatment and two and five years later at follow-up.

Method

Both patient and analyst were interviewed with the AAI yearly and filled out question­naires every year during the treatment.

Findings

According to the interviews, the analysand found “a space for himself in himself” in which he could contain “sorrow, hopefulness, joy, remorse, anger and even desperation”. The psychoanalytic relationship was stabile and consistent, and the main complaints decreased significantly over time. RF scores rose from a sum-score of 5 before the beginning of treatment to 6/7 at the end. 

Self-rating scales showed positive changes already in the first year of treatment and these gains were maintained throughout treatment and also at the two-year and five years follow-up.

Mental attachment representation before the treatment and at termination did show a shift from an insecure attachment representation to a more secure one.

Evaluation

Further discussion and experiences are necessary to deepen our understanding of how to interpret the influence and impact of research on the treatment, on the analyst, the validity of  “informed consent of the analysand“ as well to the specificity of the treatment and the instrument used to study it. 

Contact

Prof. Imre Szecsödy

Karlavägen 27, 6842 Stockholm, Sweden

E-mail: i.szecsody@telia.com

Evaluation of psychic change through the application of empirical and clinical techniques for a 2-year treatment

López Moreno, C. M., Schalayeff, C., Acosta, S. R., Vernengo, P., Roussos, A. J., & Dorfman Lerner, B. (2005). Evaluation of psychic change through the application of empirical and clinical techniques for a 2-year treatment: a single case study. Psychotherapy Research, 15(3), 199-209.

Summary

The authors present results obtained by a combination of clinical and empirical methods used in the evaluation of psychic change involving a single case study carried out during 2 years of nonmanualized psychodynamic psychotherapy.

Method

A multidimensional definition of change that includes clinical (psychoanalytic) and empirical perspectives is provided. The authors used material from supervision sessions and

clinical meetings to assess the psychodynamic diagnosis and evolution.

The following empirical techniques and instruments were used: core conflictual relationship theme (Luborsky & Crits-Christoph, 1990), Symptom Checklist-90-Revised

(Derogatis, 1983), and Differential Elements for a Psychodynamic Diagnostic (C. M. Lopez Moreno et al., 1998).

Results

Several markers of psychic change along the therapeutic process were found. The instruments proved to be sensitive to the changes obtained during the psychotherapy. Used together, the instruments allowed an integrated evaluation of the patient’s evolution during the treatment.

Evaluation

This study is part of a research program (Lopez Moreno et al., 1999) that began with a project grant from the Research Advisory Board of the International Psychoanalytic Association.

Contact

Clara Lopez-Moreno

Asociacion Psicoanalítica Argentina, Universidad de Belgrano, and Asociación Psicoanalítica Argentina

E-mail: calma@pccp.com.ar

A German specimen case of psychoanalysis

Kächele, H., Albani, C., Buchheim, A., Hölzer, M., Hohage, R., Jiménez, J.P., Leuzinger-Bohleber, M., Mergenthaler, E., Neudert-Dreyer, L., Pokorny, D. & Thomä, H. (2006) The German Specimen Case Amalia X: Empirical studies. International Journal of Psychoanalysis 87, 809-826
Buchheim, A., & Kächele, H. (2007). Nach dem Tode der Eltern. Bindung und Verlust {After the death of the parents. Attachment and loss). Forum der Psychoanalyse, 23, 149-160.
Buchholz, M. B., Spiekermann, J., & Kächele, H. (2015). Rhythm and blues. Amalia´s 152nd session. From psychoanalysis to conversation and metaphor analysis - and retour. International Journal of Psycho-Analysis, in press.

The paper provides a perspective on how psychoanalytic process research can be implemented. We detail the Ulm process research model and summarize the manifold empirical studies that were performed on a completely tape-recorded psychoanalytic therapy. The studies demonstrate the many modalities empirical process research has available to objectively study process and outcome phenomena.

Method

The psychoanalytic treatment was first described by a systematic longitudinal description under a fixed set of headings performed by external observers based on the transcribed recordings.. Second topics of special importance were analyzed by external raters using manual based codings. The concepts of emotional insight, self-esteem, dream pattern, suffering, transference, plan analysis etc were studied using systematic time samples.

Using the AAI in a follow-up study after 25 years could show that after the death of both parents of the patient the treatment significant attachment issues came to the fore that had not been dealt with during the treatment (Buchheim & Kächele 2007).

Additional measures using computer-based textanalysis generated new approaches to the material.

Recently we have applied modern conversational analysis technique to highlight microprocesses that escape the naked eye of the clinician (Buchholz et al. 2015).

The case has been intensively studied by the Swiss dream research group of Prof. Boothe (see details under dream)

Evaluation

The case is unusual insofar the complete tape recordings and the transcripts are available for the research community. The findings have been detailed in many other studies.

Contact

Prof. Dr. Dr. Horst Kächele

International Psychoanalytic University

Stromstr, 2-3, 10555 Berlin

E-mail: horst.kaechele@ipu-berlin.de

Verbal expression of emotions in the stage-wise progress of a case of long-term psychodynamic therapy

Gumz, A., Kästner, D., Geyer, M., Wutzler, U., Villmann, T., & Brähler, E. (2010). Instability and discontinuous change in the experience of therapeutic interaction: An extended single-case study of psychodynamic therapy processes. Psychotherapy Research, 20 (4), 398-412.

Summary

The present study is intended to explore how change occurs in the psychotherapeutic processes. Even though current psychotherapy research has an important focus on this specific issue, there is a lack of studies that track the process if emotional change throughout therapy. In terms of making sense of the process of psychodynamic psychotherapy, it seems reasonable to place a primary focus on analysing mechanisms of change at the level of emotions, while recognising that other forms of change (e.g. cognitive, behavioural, physiological) are also important. Emotions are inextricably connected to psychopathological processes.

Our aim in the present study was to build on the findings of previous research by assessing changes in the verbal expression of emotions within the therapeutic dialogue in a psychodynamic long-term therapy by means of continuous measuring throughout a long and complete therapy period.. We hypothesized that changes would occur in the form of transitions and discontinuous changes. A further aim was to verify and develop the applicability of the Clinical Emotions List (Leising et al., 2004) as a measuring instrument for use in this kind of research. Identifying changes at an emotional level opens up the possibility of using various quantitative and qualitative methods to investigate different sessions and therapy phases with regard to the relationship between emotional variables and factors that influence the development within the therapeutic process.

Results

The number of verbalised emotions and the variability of the emotional profile increased during the course of the therapy. These developments occured in three distinct phases. The proportion of positive emotions varied across each stage although there was no linear increase across the case as a whole. The presented results show that the Clinical Emotions List (CEL) is a suitable instrument for assessing changes in emotional expression within the therapy process.

Conclusions

The findings of this study suggest that discontinuous transitions can be regarded as reflecting therapeutic progress (proximate outcomes) at an individual emotional level. Phases of therapy in which transitions occur can be systematically analysed in order to search for factors that influence the development of the therapeutic process. This methodological approach opens up a range of research issues of theoretical and practical importance. The rating instrument used in this study has the potential to be widely used in case study research as a means of identifying processes of emotional transition in individual therapy.

Contact

Email: a.gumz@psychologische-hochschule.de

Chilean Millennium Nucleus: “Psychological intervention and change in depression”. Process-outcome research 1: Foci on psychotherapy.

Dagnino, P., de la Parra, G., Jaramillo, A., Crempien, C., Padilla, O., Gómez-Barris, E., … , & Rodríguez, S. (2014). El devenir del cambio: cómo es y hacia dónde se dirige. Revista Argentina de Clínica Psicológica, 23(1), 23–40.
Dagnino, P., Krause, M., Pérez, C., Valdés, N., & Tomicic, A. (2012). The evolution of communicative intentions during change episodes and throughout the therapeutic process. Research in Psychotherapy: Psychopathology, Process and Outcome (RIPPPO), 15(2), 75–86.
Echávarri, O., González, A., Krause, M., Tomicic, A., Pérez, J. C., Dagnino, P., … Reyes, L. (2009). Cuatro terapias psicodinámicas breves exitosas estudiadas a través de los indicadores genéricos de cambio. Revista Argentina de Clínica Psicológica, 18, 5–19.

Background

Brief dynamic psychotherapy has been increasingly important in the actual clinical practice. For its brevity focalization must be accomplished.

Although the usefulness and the necessity of the focus are accepted, there are many and different conceptualizations of focus. The Operationalized Psychodynamic Diagnosis System (OPD-2) was used for focus identification: relational pattern, internal conflictual configuration and structural vulnerabilities.

The study on foci and the relation between them becomes a research and clinical imperative. But also, the study of the process is of fundamental importance for advancing the science of psychotherapy, for this, change on foci must be considered. Focus can be expected to evolve, transform, or change during a therapeutic process and to have an effect on patient’s change according to the way the therapist and the patient interact.

More than studying the whole session, significant segments can be identified and researched upon. Therefore, the delimitation of episodes of change are necessary.

In sum, when considering the psychotherapy process research reflections about the study of relevant episodes within the session and throughout the process, it can be expected that the foci may evolve, transform, or change. No studies have been found that examine the foci, their relationship and their trajectory during the therapeutic process and not even their change during relevant episodes. Due to these observations and because of their importance for clinical practice, the foci will be studied in this thesis.

Research questions

Which are the foci that therapist and patients work on in natural settings. Will the foci relate to each other and in what way? Do they change over the therapeutic process? In which way will the foci change over the course of the process? And will they relate to change?

Design and method

Multiple single subject design. Change episodes are delimited and OPD Foci are identified for each patient. OPD foci presence is identified in each episode.

Sample:            10 brief dynamic therapies in natural settings

Treatment:            Brief dynamic therapies as usual.

Measures

Operationalized Psychodynamic Diagnosis (OPD-2, Task-Force, 2008)

Generic Change Indicators (GChI, Krause, et al., 2007)

Foci Presence Scale (FPS, Dagnino & de la Parra, 2010)

Results

With only four processes analyzed, we have found that:

In general, foci presence concentrated more on the middle phase of psychotherapy in comparison to the initial and final phases.

The focus on the dysfunctional relational patterns had more presence during the initial phase. In the case of inner conflict focus its presence was stable during all the phases, and the structural vulnerabilities focus showed that its presence increased through the process.

Regarding the relationship among the types of foci and their subjective change, it was found that during the middle phase the presence of the relational pattern focus and the conflict focus relates to higher levels of subjective change.

Evaluation

To examine the patient's foci as usual, that is the therapist without the knowledge of the OPD system, is of both clinical and research importance but the examination of the foci throughout the therapeutic process becomes even more important since the study of the process leads to really comprehend how therapy generates changes in patients' difficulties. Therefore, studying the process of foci change is of fundamental importance for advancing in the science of psychotherapy.

The results confronted us with the question about how foci would develop in unlimited dynamic psychotherapies.

Also no observations were made on other segments of the process that would function as control segments (e.g. stuck episodes) or in unsuccessful therapies.

And it would be interesting to identify the foci in patients with a different structural level, and study how the presence of the foci relates with other process variables (alliance, outcome, etc.)

Contact

Paula Dagnino 

Email: padagnin@uc.cl

An empirical investigation of analytic process: Contrasting a good and poor outcome case

Waldron, S., Gazzillo, F. (2015). Do the processes of psychoanalytic work lead to benefit? Studies by the APS Research Group and the Psychoanalytic Research. Psychoanalytic Inquiry. DOI: 10.1080/07351690.2015.987602
Gazzillo, F., Waldron, S., Genova, F., Angeloni, F., Ristucci,C., Lingiardi, V. (2014). An Empirical Investigation of Analytic Process: Contrasting a Good and Poor Outcome Case. Psychotherapy. http://dx.doi.org/10.1037/a0035243
Waldron, S., Gazzillo, F., Genova, F., & Lingiardi, V. (2013). Relational and classical elements in psychoanalyses: An empirical study with case illustrations. Psychoanalytic Psychology, 30, 567–600. doi:10.1037/a0033959

Summary

The aim of this study was to assess the difference in the analytic processes between two patients with similar personality profiles, who were in analysis during the same time, by two analysts with similar training and working in a similar setting. The authors explored the patients’ personality and changes with the Global Assessment of Functioning Scale (GAF) and the Shedler–Westen Assessment Procedure-200 (SWAP-200) applied by two pairs of independent raters in 16 sessions (8 sessions from the first month of treatment and 8 sessions from the last mont of treatment). In addition, the research group assessed therapeutic processes with the Analytic Process Scales (APS) and the Dynamic Interaction Scales (DIS) applied by three independent raters to 20 sessions, as well as the Helping Alliance Rating Scale (HAR) applied to eight sessions from the beginning of each therapy. The results showed striking differences between the outcomes of these two psychoanalyses that are paralleled by differences in their therapeutic process, i.e. by a better use of classical interventions (clarifications and interpretations centerd on conflicts, transference and problematic patterns of emotions and behaviors), together with a more relational approach to the patients (warmer, more straightforward, more subjectively connotated and more emotionally attuned communications). The authors provide verbatim clinical interactions to illustrate these differences and explore the potential implications of these findings.

Evaluation

The study is based on only two cases and on the assessment of only 20 sessions from an average number of >600 sessions for each treatment, and the authors have not yet collected follow-up data. However, the results of the analysis of 22 additional cases seem to support the data presented (see also Gazzillo et al., 2013; Waldron, Gazzillo,Stukenberg, 2015), giving them greater reliability, and it is the authors’ intention to collect follow-up data on most of the treatments considered in this research.

Contact

Francesco Gazzillo

Via degli Apuli 1, 00185, Roma, Italy

Email: freuwin@ libero.it

Website: http://www.psicologia1.uniroma1.it/static/didattica/IdDocente_373.shtml

Department of Dynamic and Clinical Psychology, “Sapienza” University of Rome: Single cases and process-outcome

Lingiardi, V., Shedler, J., & Gazzillo, F. (2006). Assessing personality change in psychotherapy with the SWAP-200: A case study. Journal of Personality Assessment, 86, 1, 23–32.
Lingiardi, V., Gazzillo, & Waldron, S. (2010). An empirically supported psychoanalysis: The case of Giovanna. Psychoanalytic Psychology, 27, 2, 190-218.
Di Giuseppe M.G., Perry C.J., Petraglia J., Janzen J., & Lingiardi V. (2014). Development of a Q-sort version of the Defense Mechanism Ratings Scales (DMRS-Q) for clinical use. Journal of Clinical Psychology, 70, 5, 452-465.

Summary

The goal of the first two studies was to show how some empirical instruments for the assessment of personality, defense mechanisms and therapeutic process can be useful both for a more fine-grained and reliable description of the patients’ personality and its changes and for a more detailed and precise comprehension of the process factors contributing to a good outcome of an analytic psychotherapy.

In the first study (Lingiardi, Shedler, Gazzillo, 2006) we assessed with the Shedler-Westen Assessment Procedure-200 (SWAP-200; Westen, Shedler 1999a, 1999b) the first ten therapy sessions and the lastten sessions after two years of the treatment of Melania, a patient in her thirties with a borderline personality disorder with histrionic traits and a substance-related disorder. Melania was having a three sessions per week on the coach for two year psychoanalytic psychotherapy.  SWAP-200 is a Q-sort measure consisting of 200 jargon-free items describing both healthy and pathological personality traits. The treating clinician, or a trained rater who knows the patient well, has to sort all the SWAP-200 items in 8 different piles according to their level of descriptivity of the patient’s personality, and in doing so has to follow a fixed distribution aimed at reducing the possible rater’s biases (Block, 1978). An ad hoc computer program translates this assessment in two different personality diagnoses: 1) a PD scale diagnosis following the personality disorders of the Diagnostic and Statistical Manual of Mental Disorders-5 (DSM-5; APA, 2013) redescribed with the SWAP items by a pool of expert clinicians, plus an high-functioning scale; 2) a Q-factor empirically derived taxonomy of personality pathology based on the SWAP description of real patient with personality disorders. Both the PD scale and Q-factor diagnosis are dimensional (the computer specifies in what measure the patient assessed shows the features of each disorder) and categorial (there is a cut-off for giving the full diagnosis of one or more disorders). Moreover, it is possible to use the 30 SWAP items more descriptive of the personality of the patient for developing his/her case formulation. Finally, the qualitative and quantitative comparison between the SWAP items that are more descriptive of the patient's personality in the different periods of a psychotherapy enables a fine-grained understanding of the personality dimensions more (and less) affected by the therapeutic process. The SWAP assessment of Melania conducted by two independent raters showed how her therapy facilitated a substantial improvement in her personality functioning: after two years of treatment, Melania showed no personality disorder and a dramatic increase of ther high-functioning capacities, and her SWAP assessment enabled a sophisticated description of the changes of her personality facilitated by her psychotherapy.

The other empirically supported single case study (Lingiardi, Gazzillo, Waldron, 2010) is the case of Giovanna, a patient in her late twenties with obsessional traits and significant difficulties in intimate relationships. Giovanna, such as Melania, was having a three sessions per week on the couch psychoanalytic psychotherapy. In the case of Giovanna, we assessed 20 transcripted sessions: the first 4, 4 after 6 month, 4 after 12 months, 4 after 18 months and 4 after 24 month. The first 4 sessions, the 4 sessions from the 12th month and the 4 sessions after the 24th month were assessed with the SWAP-200. Moreover, all the sessions were also assessed with other two instruments: the Defense Mechanism Rating Scale (DMRS; Perry, 1990) and the Analytic Process Scales (APS; Waldron et al., 2004a, 2004b). The DMRS provide a qualitative and quantitive profile of the defense mechamism more used by the patient and of her overall level of functioning according to a hierarchy of defense levels going from an action level to a mature level, passing for a denial, borderline, narcissistic, neurotic and obsessional level. The APS, finally, enable the assessment of both the patient and the therapist contributions to the therapeutic process and of the quality of their partecipation to the process itself. The application of these empirical tools to the case of Giovanna showed a substantial improvement in her personality functioning and defense maturity and suggested that this improvement could have been facilitated by the explorative interventions of the therapist (clarification and interpretation of conflicts) and by the overall quality of the analyst interventions and his being attuned to the patient’s feeling. 

Since 2011, in collaboration with the Analytic Process Scales Study Group and the Psychoanalytic Research Consortium (PRC) of New York directed by Sherwood Waldron, Francesco Gazzillo and Vittorio Lingiardi with their research group have started a borader study on the empirical assessment of process and outcome of psychoanalysis. This research project is based on the systematic assessment of 20 audiotaped and transcripted sessions of each of the 31 psychoanalytic treatments of the PRC: the first 4, 4from the 6th month of treatment, 4 from the middle of the therapy, 4 from the 6th week before the termination and the last 4 sessions of each treatment. The first 4+4 sessions are assessed by two independent raters with the Helping Alliance Rating Method (HAR; Luborsky, 1976), the Global Assessment of Functioning Scale (GAF; APA, 2000), and by other two independent raters with the SWAP-200, as well as the Personality Health Index (PHI) and RADIO categories (two SWAP related indexes developed by the APS study group for assessing the level of personality health and some specific personality functioning damains; see Waldron et al., 2011). The last 4+4 sessions are assessed with the same instruments, but not with the HAR. All the sessions are assessed by three independent raters with the APS and the Dynamic Interaction Scales (DIS; Waldron, Gazzillo, Genova, & Lingiardi, 2013). The DIS are twelve rating scales aimed at the empirical assessment of relational and interactional features of patient, therapist and therapeutic couple contributions to the treatment.

In the study written by Waldron, Gazzillo, Genova, and Lingiardi (2013) we showed the inter-rater reliability of the DIS and the information obtained by their application to two psychanalytic treatments: the first one is a poor outcome treatment delivered in the seventies by a therapist with an ego psychology orientation, and the second one is a good outcome analysis delivered thirty years later by a therapist with a relational orientation. DIS seem to differentiate correctly the two analytic approaches, and together with the APS seem to suggest that good outcome psychoalyses are characterized by a more sophisticated use of classical analytic interventions (such as clarifications and interpretations of defenses and conflicts), and a more relational attitude of the therapist, i.e. her/his being more avalaible to show her/his subjective thoughts and feeling, a greater contingency with patient’s feelings, etc.

Given that the two patients involved in this first study had different personality profiles and that their treatments were delivered by different therapists, in different periods, with different theoretical orientations and different durations, in another study, written by Gazzillo, Waldron, Genova, Angeloni, Ristucci, and Lingiardi (2014), we compared two psychoanalyses delivered in the same period, with comparable lenghts and frequency of sessions, by therapists of the same city, and with the same theoretical orientation, and to patient with a very similar personality profile. One of these treatments had a good outcome, and the second one a poor outcome. Our aim was to verify if the process differences between good and poor outcome psychoanalyses outlined in the 2013 study were confirmed also controlling factors such as the theoretical orientation of the therapist, the frequency of sessions, the length of treatment etc. The results of this study seem to confirm most of the differences highlighted in the first study, showing that good outcome psychoanalyses seem to be charachterized by both better classical interventions and a more relational attitude, reducing the contrast between those theoretical and clinical models that stress the therapeutic relevance of an explorative work on one hand, and those one which stress the therapeutic relevance of the patient-therapist emotional relationship. Moreover, in these two last studies, we have tried to bridge the gap between classical clinical case presentation and empirical assessment of patient and therapies using data derived by both the sources.

Finally, the last report, written by Di Giuseppe, Perry, Petraglia, Janzen, and Lingiardi (2014) is focused on the need to provide clinicians with a reliable and valid measure for detecting patient defense mechanisms “inside psychotherapy.” To avoid the limitations of existing methods, we designed a Q-sort based on the theoretical definitions and criteria of the Defense Mechanisms Rating Scales (DMRS-Q), but one that does not require transcripts of clinical interviews or sessions, and may be applied without specific training on defenses. The DMRS-Q is sensitive to changes in psychotherapy and its scores correlate significantly with various aspects of mental functioning, making it potentially available for the psychotherapy process and outcome research as well. We report the results of using the DMRS-Q on a systematic single case study with the aim of detecting changes in defense mechanisms during a long-term psychodynamic psychotherapy. The DMRS-Q reveals change both in quantitative scores and in the literary Defensive Profile Narrative. 

Evaluation

Our goals are identifying the process features of effective psychoanalyses and to outline diagnostic and therapeutic factors that can help us to identify, since the first month of treatment, the analyses that seem not to proceede weel. We illustrated a new reliable and valid measure for detecting patient defense mechanisms “inside psychotherapy”; the DMRS-Q is used in the context of a systematic single case.

Contact

Prof. Vittorio Lingiardi

Department of Dynamic and Clinical Psychology, “Sapienza” University of Rome. Via degli Apuli 1, 00185, Rome.

Email: vittorio.lingiardi@uniroma1.it

Dr. Francesco Gazzillo

Department of Dynamic and Clinical Psychology, “Sapienza” University of Rome. Via degli Apuli 1, 00185, Rome.

Email: francesco.gazzillo@uniroma1.it

Dr. Waldron Sherwood

Chair of the Psychoanalytic Research Consortium, East 94th St., Apt. 11B
New York, NY 10128.

Email: woodywald@earthlink.net

Beneath the surface of the therapeutic interaction: The psychoanalytic method in modern dress

Freedman, N., Lasky, R., & Hurvich, M. (2003).  Two pathways towards knowing psychoanalytic process. In M. Leuzinger-Bohleber, A.U. Dreher & J. Canestri (Eds.) Pluralism and Unity; Methods of Research in Psychoanalysis, (pp. 207-22). London: International Psychoanalytic Association
Bucci, W. & Maskit, B. (2007) Beneath the surface of the therapeutic interaction; The psychoanalytic method in modern dress. Journal of the American Psychoanalytic Association, 55, 1355-1397.

Summary

The study introduces a multi-perspective approach to the data of the analytic situation, including impressions of the treating analyst, ratings of complete sessions by clinical judges using psychoanalytic criteria, and objective linguistic measures. Our basic hypothesis is that successful analytic treatment involves repeated instances of the referential process, which includes Arousal of an emotional experience in the session, a Symbolizing phase involving vivid narratives or descriptions and a phase of Reflection, in which new emotional meanings may be found. Computerized measures of the referential process were applied to 16 recorded and transcribed psychoanalytic sessions of the third year of an analysis of a female patient with a female analyst. The clinical evaluations represent the impressions of the treating analyst and those of analysts who listened to the tapes or read the transcripts. The ratings were based on qualities referred to by the abstract terms 'A' and 'Z' (Freedman, Lasky & Hurvich, 2003): ‘A’ qualities are generally associated with productivity; 'Z' qualities with disorganization.

The 16 sessions were run through the DAAP program using Referential Process measures including the Weighted Referential Activity dictionary (WRAD), Refection (REF) and Disfluency (DF) dictionaries, several dictionaries representing categories of affect and sensory and somatic experience, and several derivative DAAP measures including covariations between pairs of variables.   (See Measures of the Referential Process, ODR this edition for details of procedures.) Significant correlations with the difference score ‘A – Z’ were found in the expected direction, for several measures of patient speech, including Mean WRAD (r = .538, p < .05) and both the REF/WRAD (r = -.698, p < .01) and DF/REF (r = .523, p < .05) covariations. Results were also found for analyst speech and for the relation between analyst impressions and session language.

Evaluation

The claim of this approach is that process research including multiple perspectives has the potential to unite the values of empirical research with a modern version of the psychoanalytic method. The results suggest that computerized referential process measures can be used on session transcripts to gain an overall sense of the productivity of the session. However the study covers only part of a year of a single analysis, so the results, while promising must be considered preliminary. Several studies involving other cases and different sampling procedures are under way applying this approach to other treatments and including outcome assessment.

Contact

Email: wbucci@optonline.net

A metasynthesis of published case studies through Lacan’s L-schema: Transference in perversion

Willemsen, J., Inslegers, R., Meganck, R., Geerardyn, F., Desmet, M., Vanheule, S. (2015). A metasynthesis of published case studies through Lacan's L-schema: transference in perversion. International Journal of Psychoanalysis, in press

This study was produced by members of the Single Case Archive (www.singlecasearchive.com) and using data from this archive. The Single Case Archive compiles clinical and empirical single case studies on psychoanalytically oriented psychotherapies that were published in ISI-ranked journals.

Sample

The sample consisted of 11 case studies on the psychoanalytic treatment of sexual perversion, all published in international scientific journals. Case studies on character perversion were not included. All case studies involved adult male subjects between 25 and 49 years old at the start of treatment (in two case studies age was not reported).

Treatment

The treatment provided in the 11 case studies is individual treatment from various psychoanalytic orientations. For 9 out of 11 case studies treatment duration exceeded 18 months (up to a maximum of 15 years). For one case study treatment duration was 6 months and for another one treatment duration was not mentioned.

Method

The manuscripts of the published case studies were screened for passages in which the author explicitly discusses an aspect of the transference. These passages were read and re-read and thematically coded. These codes were descriptive and stayed close to the manuscript. Then codes were assigned to the Imaginary or the Symbolic dimension of Lacan’s L-schema. In the next step, the codes from the Imaginary and Symbolic axis separately were rearranged into overarching themes. While the formulation of the initial codes was rather descriptive, the final themes were closely adapted to the theoretical terms of the L-schema. A credibility check was performed by the co-authors.

Results

With regards to the Imaginary axis of transference (i.e., transference as resistance) the results reveal three different ways in which the perverse patient draws the therapist in an unconscious bond against the analytic process: (1) by identifying with the image of child in relation to analyst-mother or analyst-father, by identifying with the image of sexual partner, (2) through fusion with the analyst or by pulling the analyst into the perverse world, and (3) by rivalry as manifested in a power struggle or aggression. In this respect, the treatment of perverse patients is difficult for the analyst, and requires a great deal of tolerance and tenacity.

With regard to the Symbolic axis of transference (i.e., transference as a necessary condition for analytical work), we found that the perverse subject is able to formulate a request for help, is able to suspend the satisfaction derived from the symptom in order to talk about it, question motives for thoughts, feelings and actions, his products of the unconscious and his identity. In terms of the L-schema, this indicates that the analyst can function as a representative of the otherness in the Other in the treatment of such patients.

Evaluation

This study is among the first metasyntheses of psychoanalytic case studies. This method has great potential when it comes to empirical research in psychoanalysis, especially for psychoanalytic concepts that resist operationalization in quantitative terms. However, the methodology also suffers from several shortcomings. The method is qualitative and descriptive rather than predictive with regard to the treatment of sexual perversion. In other words, based on our results we cannot conclude that focusing on the Symbolic dimension will be effective in the treatment of perversion, or that treating perversion through psychoanalysis will result in a positive outcome. The scientific method of metasynthesis suffers from some limitations. The data of this metasynthesis are accounts and interpretations made by the authors of published case studies. The case studies used alternate between detailed descriptions of therapeutic processes and more abstract elaborations. As a result, our study is based on clinical data from different levels of abstraction. Moreover, the case reports greatly varied in writing style, psychoanalytic orientation and level of detail. While some case studies provide almost no information on transference, others contained abundant information. These different levels of abstraction and quality of information constitute a drawback to this study.

Contact

Jochem Willemsen PhD

Email: jawill@essex.ac.uk

A review of basic characteristics of patient, therapist, therapy and research method

Desmet, M., Meganck, R., Seybert, C., Willemsen, J., Geerardyn, F., Dclercq, F., . . . Kächele, H. (2013). Psychoanalytic single cases published in ISI-ranked journals: The construction of an online archive. Psychotherapy and Psychosomatics, 82, 120-121.

Single case studies are quintessential for psychoanalytic theory, research and practice. At this moment, however, the field of single case research deals with a lack of surveyability, which hampers the full exploitation of its potentials. This letter presents a review of clinical and empirical single case studies on  psychoanalytically oriented psychotherapies that were published in ISI-ranked journals. Briefer psychoanalytic single cases published in journals contrast with longer, book-format cases both at the level of number and vicissitudes.  The number of longer cases is limited to a few dozen, the number of smaller cases runs up to a few thousand (cfr. infra); longer cases often surprise us with an almost timeless impact on theory and training, smaller cases tend to disappear in the mass of psychoanalytic literature without noticeable impact. The clinical richness typical for single case data in combination with their large number nevertheless constitutes a unique resource. As in no other data-base, the totality of smaller cases offers an opportunity to study the therapeutic experiences of large numbers of patients and therapists in their full clinical complexity. As such, systematic accumulation of quantitative and qualitative data across homogeneous sets of cases could be an invaluable supplement to classical process-outcome research.

The present state of the field of single case research, however, is characterized by a lack of surveyability and accessibility which hampers every effort to accumulate data across cases. Smaller cases are usually published in journal articles, sometimes as the focus of the article, other times as illustrations in the course of conceptual or technical accounts. Abstracts of these articles frequently lack detailed information about the case. They often only mention that a clinical case is presented, without giving further specification. Even if the case is the focus of the article, authors are often unable to compile all relevant information in the limited format of an article abstract.  Consequently, researchers and clinicians that apply standard search procedures in electronic databases are at risk of missing a substantial portion of the single cases relevant to their research questions or clinical issues. Under these conditions, screening of full article texts becomes necessary for selection of a comprehensive set of single cases. This state of affairs makes the search for smaller cases a time-consuming and discouraging enterprise, which is usually neglected or left incomplete. Thus, a fertile field of empirical data is left fallow. 

This article therefore presents a tool that facilitates access to the field of smaller single cases. We first selected all single cases published in ISI ranked journals that met a set of inclusion/exclusion criteria; subsequently, basic characteristics of patient, therapist, therapy and research method were screened in every case study. A summary of this screening is presented in this paper. Full results of the screening for all cases separately is presented in an online and permanently updated archive, which also contains the single cases themselves (www.singlecasearchive.com). The online overview allows the quick identification of relatively homogenous sets of cases in function of specific research question.

Contact

Prof. Mattias Desmet

Department of Psychoanalysis, Ghent University

Website: http://www.psychoanalysis.ugent.be

Website: http://www.singlecasearchive.com

Clinician reports of personality pathology of patients beginning and patients ending psychoanalysis

Cogan, R., Porcerelli, J.H. (2005). Clinician reports of personality pathology of patients beginning and patients ending psychoanalysis. Psychology and Psychotherapy: Theory, Research and Practice, 78, 235-248.
Shedler, J., & Westen, D. (1998). Refining the measurement of Axis II: A Q-sort procedure for assessing personality pathology. Assessment, 5, 333–353.

Summary

The purpose of this work was to use a clinician Q-sort procedure to describe the personality pathology and adaptive functioning of patients beginning and ending psychoanalysis. With a cross-sectional design, Cogan and Porcerelli compared a group of patients beginning and a group of patients ending psychoanalysis. This was the first comprehensive assessment of the personality of patients beginning and patients ending psychoanalysis with a measure that (a) is consistent with Axis II of DSM-IV, (b) includes commonly observed Axis I symptoms which often co-occur with Axis II psychopathology, (c) draws on the expertise of clinicians; and (d) has been psychometrically evaluated in published studies of reliability and validity.

Twenty-six psychoanalysts described a patient beginning psychoanalysis and twenty-eight described a patient ending psychoanalysis using the Shedler–Westen Assessment Procedure 200 (SWAP-200). The SWA-200 is clinically sensitive, reliable, and valid measure of personality disorders, traits, and strengths which harnesses clinician judgments about patients and is consistent with DSM-IV personality disorder categories (Shedler & Westen 1998).

Each clinician also completed questions about themselves, the patient, and the treatment. The most characteristic SWAP-200 items describing patients beginning and patients ending psychoanalysis provide a meaningful picture of the two groups. Among patients at the end of psychoanalysis, scores were significantly lower on the SWAP-200 Paranoid, Schizotypal, Borderline, Histrionic, and Dependent scales and scores were significantly higher on the SWAP-200 High functioning scale and the DSM-IV GAF scale. At the beginning of psychoanalysis, of the 15 most descriptive items, 10 items concerned internal struggles (afraid of rejection or abandonment, guilty, feels inadequate, unhappy, self critical, anxious, competitive,ashamed, submissive, and creates situations that lead to unhappiness). In contrast, at the end of psychoanalysis, of the 15 most descriptive items, four concerned positive aspects of work (satisfaction in pursuing long-term goals, pleasure in accomplishing things, able to use talents effectively, and contentment in life’s activities), three concerned positive relationships with others (fulfilment in mentoring, empathic, able to assert appropriately), and three concerned resilience (resolution of painful experiences from the past; can hear and benefit from hearing emotionally threatening information, and able to recognize alternative viewpoints even when strong feelings are involved).

Evaluation

The findings demonstrate the usefulness of a clinician report measure for the study of psychoanalytic psychotherapy and psychoanalysis. The SWAP-200 allows for the assessment of personality pathology and strengths and also allows for a rank ordering of both pathological and adaptive characteristics.

Contact

Dr. Rosemary Cogan, Ph.D.

Texas Tech University, Lubbock, TX 79409-2051

Email:  r.cogan@ttu.edu

Website: http://www.depts.ttu.edu/psy/people/rcogan.php

Assessing personality change in psychotherapy with the SWAP–200: A case study

Lingiardi, V., Shedler, J., Gazzillo, F. (2006). Assessing personality change in psychotherapy with the SWAP–200: A case study. Journal of Personality Assessment, 86(1), 23–32.
Westen, D., & Shedler, J. (1999a). Revising and assessing Axis II, Part I: Developing a clinically and empirically valid assessment method. American Journal of Psychiatry, 156, 258–272.
Westen, D., & Shedler, J. (1999b). Revising and assessing Axis II, Part II: Toward an empirically based and clinically useful classification of personality disorders. American Journal of Psychiatry, 156, 273–285.

Brief Summary

Many studies document the efficacy of psychotherapy for acute syndromes such as depression, but less is known about personality change in patients treated for personality pathology. The Shedler–Westen Assessment Procedure (SWAP–200; Westen & Shedler, 1999a, 1999b) is an assessment tool that measures a broad spectrum of personality constructs and is designed to bridge the gap between the clinical (idiographic) and empirical (nomothetic) traditions in personality assessment.

In this single case study, Lingiardi, Shedler and Gazzillo demonstrate the use of the SWAP–200 as a measure of change in a case study of a patient diagnosed with borderline personality disorder.

A total of 10 consecutive therapy sessions from early in the treatment and 10 consecutive therapy sessions from late in treatment were tape recorded and transcribed. Two clinical judges reviewed transcripts of the first 10 psychotherapy sessions and provided SWAP–200 descriptions of the patient based on the information available in the transcripts. After 2 years of psychotherapy, the assessment procedure was repeated.

Evaluation

The findings illustrate the personality processes targeted in intensive psychotherapy for borderline personality. Those findings are highly suggestive and point the way toward research strategies that can reliably address a wide range of clinically relevant personality constructs. The methods the authors described in this article represent one step in the direction of integrating the clinical and empirical traditions in personality assessment.

Contact

Jonathan Shedler

Graduate School of Professional Psychology University of Denver, 2460 South Vine Street, Denver, CO 80208
Email: jonathan@shedler.com

Website: http://jonathanshedler.com

Outcomes of psychoanalytical crisis interventions after prenatal diagnostics

Leuzinger-Bohleber, M., Belz, A., Caverzasi, E., Fischmann, T., Hau, S., Tsiantis, J., & Tzavaras, N. (2008). Interviewing women and couples after prenatal and genetic diagnostics. In M. Leuzinger-Bohleber, E.-M. Engels & T. Tsiantis (Eds.), The Janus Face of Prenatal Diagnostics. A European Study Bridging Ethics, Psychoanalysis, and Medicine (pp. 151-218). London: Karnac Books.
Leuzinger-Bohleber, M. (2013). The Medea fantasy: An evitable burden during prenatal diagnostics? Psychoanalysis, gender and medicine in dialogue. In I. Moeslein-Teising & F. Thomson Salo (Eds.), The Female Body. Inside and Outside (pp. 129-151). London: Karnac Books.

Summary

In the frame of a large EU wide study we developed a specific form of crisis interventions and studied their outcome:

First a short summary of the complete study: Achievements in genetic research produce ethical and moral dilemmas which need to be the subject of reflection and debate in modern societies. Moral dilemmas are seen as situations in which a person has a strong moral obligation to choose each of two alternatives for action, but cannot fulfill both. Denial of ambivalences that moral dilemmas arouse constitutes a threat to societies as well as to individual persons. The EU wide study “Ethical Dilemmas Due to Prenatal and Genetic Diagnostics” (016716-EDIG), which was performed from 2005-2008, tried to investigate these dilemmas in detail in a field which seems particularly challenging: prenatal diagnostics (PND). The existence of PND confronts women and their partners with a variety of moral dilemmas: Should they make use of this technique at the risk of hurting the fetus by the technique itself or by being possibly confronted with the decision for or against the termination of pregnancy? Once they have undergone PND, data regarding abnormalities confront women and their partners with moral dilemmas regarding the decision on the life or death of the unborn child, the responsibility for the unborn child, for its well being even with abnormalities and its possible suffering and so on. An important aspect is the conflict of individual beliefs and obligations and those of society’s specific cultures. These dilemmas have not received full attention in our societies and often remain latent, creating a source of distress for women (and partners) and may be a burden on the relationships. Some couples show better coping capabilities, particularly if support by competent professionals is available. However, more research is needed to identify those with vulnerability to psychopathology as a consequence to abortion after PND results or to giving birth to severely handicapped children. Pathology sometimes appears not until years after the decision. Our study was a step in this direction.

The study described existing care systems across participating centres in Germany, Greece, Israel, Italy, Sweden and the United Kingdom. Data was collected in 2 sub-studies. All results were integrated into a discourse on ethical dilemmas. Study (A) recruited two groups of couples (positive or negative PND, total n= 1687). Experiences with PND and connected dilemmas have been explored (questionnaires, interviews). Results have been discussed in interdisciplinary research groups. Study (B) interviewed psychoanalysts and their long-term patients who showed severe psychopathologies as reactions to the dilemmas mentioned. Results of the study help to discuss possible protective and risk factors for women/couples undergoing PND. The results and perspectives for training have been discussed with participating couples, experts, the general public, and politicians in order to develop culturally fair connected clinical practice in this field within the EU, taking into account cultural and religious differences.

The EDIG study offered a unique chance for a multidisciplinary dialogue between ethicists, psychoanalysts, medical doctors, philosophers and cultural anthropologists. Another innovative aspect was the possibility that relatively detailed interviews with women/couples after PND as well as the empirical findings based on large scale questionnaire data could be used by different authors looking at them from different disciplinary and cultural perspectives.

We also could show that women/couples who accepted psychoanalytical crisis interventions during the decision phase after a positive finding of prenatal diagnostics showed less frequently depressions after 8 months (measured e.g. by the Hospital Anxiety and Depression Scale, HADS) than those who had not accepted any help (see Fischmann et al, 2008).

As for the counselling aspect in prenatal diagnostics, one important finding in our study was that the majority was pleased with the fact that professionals left the decision to them, thus stressing that a non-directive approach is preferable. Nevertheless, our data showed that the processing of the decision they made does not end with the act itself, but reminders catch up with them continuously, even though none of the participants thought she had made a wrong decision. So, what one can see here is the ambivalence, and one might go further and say a dilemma, caused by a simple prenatal test, seen in the predominant answer given: “there is no right decision to make in a situation like this”. Individuals are left alone with this and one has to respect their wish to decide by themselves, but support should be offered and given on an individual basis and not programmatically, taking each and every personality into account.

Evaluation

In this European wide large interdisciplinary study an outcome study of psychoanalytical crisis interventions was included.  Women who had accepted such a crisis intervention before deciding for an abortion of their handicapped embryo less frequently developed a serious depression 8 months after the interruption of the pregnancy (according to HADS).

These results motivated us to develop a liaison service with a large gynaegological clinic in Frankfurt offering women/ couples psychoanalytical crisis interventions mostly directely in the hospital during the decision phase after a positive finding in prenatal diagnostics (see Leuzinger-Bohleber, in press).

Contact

Marianne Leuzinger-Bohleber

Email: M.Leuzinger-Bohleber@sigmund-freud-institut.de

Tamara Fischmann

Email: dr.fischmann@sigmund-freud-institut.de

Systematic case studies of psychoanalyses with chronic depressed within the frame of the LAC Depression Study

Leuzinger-Bohleber, M. (in press): Working with severely traumatized, chronic depressed patients. International Journal of Psychoanalysis
Leuzinger-Bohleber, M. (2014): Depression and trauma: the psychoanalysis of a patient suffering from chronic depression. In: Altmann, M.(Ed.) Time for Change. London: Karnac, p.122 ff.

Summary

Surprisingly often in the psychoanalyses of chronically depressed patients, depression represents an unconscious attempt to psychically cope with unbearable psychic pain following severe traumatisation: dissociative states, a chronified psychic state of shock, a disappearance of emotions, an emptying of the self and the object relationships, as well as a disappearance of the psyche in the body are among the possible consequences. The treatment of these difficult groups of analysands can also frequently bring analysts to the limits of the endurable. Often related to this is the repeated danger of denying the trauma, and a re-traumatisation of the analysand in the analytic situation.

This systematic clinical case study discusses the fact that in comparison with other therapeutic approaches, psychoanalysis disposes over a highly differentiated conceptualisation of the psychic determinants and the treatment of chronic depression. However, in order to retain its creativity and innovation as a scientific discipline and to be thus perceived in the non-psychoanalytic world, it must constantly further develop its conceptualization by way of systematic and extra-clinical research as is witnessed in the insufficient conceptual account of severe traumatisation during the genesis of chronic depression. In this connection, several exemplary examples from extra-clinical studies in the sphere of psychotherapeutic research, neurobiology, epigenetics and embodied cognitive science will be accounted for. As will be treated in the final part of this paper, of no less importance are the conceptualizations in clinical research on psychoanalysis, which are based on meticulous, careful analyses of trauma reactivation in the transference, and understanding and working through them in the psychoanalytic relationship.

This systematic clinical case study is based on expert validations wihtin the frame of the LAC Depression Study (see psychoanalytical expert validation, LAC Depression study). Similar expert validated systematic clinical case studies are in preparation.

Evaluation

The systematic clinical case studies within the frame of the large extraclinical LAC Depression Study have proven to be fruitful to communicate the clinical experiences with this difficult to treat group of patients. Book publications with several case studies in German and English are in preparation.

Contact

Marianne Leuzinger-Bohleber 

Email: m.leuzinger-bohleber@sigmund-freud-institut.de

Ulrich Bahrke

Email: bahrke@sigmund-freud-institut.de