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

Altmann de Litvan (Ed.), Bernardi, R., Hernandez, S., Ungar, V., Fitzpatrick-Hanly, M., Leuzinger-Bohleber, M., Gullestad, S., Leibovich de Duarte, A., Sebek, M., White, R., Kantrowitz, J., Hurvich, M., de León, B., Fudin de Winograd, L. & Miller, D., White, R. (2014) Time for change. Tracking transformations in psychoanalysis. London: Karnac

Bernardi, R. (2019). Clinical Research and Systematic Empirical Research: What Can We Learn about Them from Current Controversies? International Journal of Psychoanalysis.

Bernardi, R. (2014a). La formulación clínica del caso. Su valor para la práctica clínica. Revista de Psiquiatría Del Uruguay, 78(2), 157–172.

Bernardi, R. (2010). DSM-5, OPD-2 y PDM: Convergencias y divergencias entre los nuevos sistemas diagnósticos psiquiátricos y psicoanalíticos. Revista de Psiquiatría del Uruguay, 74(2), 179–205.

Brief Summary

The 3-LM is a guide or heuristic to observe clinical materials from three different levels: 1) Phenomenological description of transformations; 2) Identification of the main diagnostic dimensions of change; and 3) Explanatory hypotheses of change. It proposes a second look to what occurs to a particular patient with a particular analyst in the context of their work, taking as a reference not ideal theoretical models, but what takes place in real practice, seaking to assess transformations in the patient, while observing the analytic process with the analyst.

This model centres on patients as persons in their context, the reason that brought them to analysis, and how and in which ways patients’ answers were heard and explored at different moments of their analysis.

This model is used for the group discussion of clinical material and it helps analysts examine the explicit and implicit theories they have applied with patients and consider if other approaches would be better to promote patients’ transformations of the aspects that are worked on in analysis, sheding light on blind spots or specific challenges that the particular patient may pose to the analyst.
With the three-level model, the group of analysts discussing the clinical material acts as a “consensus of experts” that validates or not the analyst’s observations and systematically documents convergences and divergences with clinical observation (method developed in the DPV follow-up study by Leuzinger-Bohleber et al.)

The IPA Clinical Observation Committee has been working on and with the The Three-Level Model for Observing Patient Transformations (3-LM) in different groups formed by analysts in different regions. Up to April 2015 approximately 800 analysts have participated in working groups with the 3-LM.


Analysts participating in the groups are asked to fill a questionnaire with items regarding their evaluation of the changes in the patient ex ante and ex post the group discussion.

Some members of the Committee are working in a research project to study the degree of agreement among analysts with different theoretical assumptions regarding how they assess transformations in patients during long periods of analysis.


Dr. Marina Altmann de Litvan

Asociación Psicoanalítica del Uruguay