The Three-Level Model for Observing Patient Transformations as a tool to explore the common ground

There is a growing interest in regions of the IPA in conducting group discussions of clinical material with an array of methodologies. The Working Party on Comparative Clinical Methods (Tuckett, 2006; Tuckett et al., 2008) focuses on the study of analysts' "explanatory model" of working. Other groups emphasize different aspects of psychoanalytic work, such as the way we listen (Faimberg, 1996), the specificity of psychoanalysis, or other topics of similar clinical relevance. These groups show that analysts with different theoretical and clinical traditions can discuss clinical material together.

I will refer specifically to the Three-Level Model for Observing Patient Transformations (3-LM) (Altmann de Litvan, 2014; Bernardi, 2014a, 2014b) because the ascending inference process discussed earlier plays a key role in this model, and we can, therefore, inquire into the clinical ground that supports theoretical interpretations. In 2011,1 submitted the 3-LM to the IPA Clinical Observation Committee for its implementation with clinical discussion groups. The model constitutes a heuristic guide or tool to observe patients' changes and transformations through three successive levels of analysis. As Green and Wallerstein requested, these groups are made up of analysts with different theoretical frameworks who discuss a large quantity of clinical material selected by the analyst. The material belongs to different periods in a considerably long analysis. Discussions usually take 10 to 12 hours—three or four for each level. Close to 1,000 analysts from various regions have participated in these groups to date (2016).

The first level of observation is phenomenological. Group participants are invited to listen to the material with the "third analytic ear" (Reik, 1968) and to share what resonates with them. They are asked to defer the formulation of interpretations and, instead, to discuss those aspects of the material that, in their view, stand out in relation to patient transformations. Transformations comprise changes in patients' lives and in analysis, more particularly, in the ways in which patients "use" both the analyst (in Winnicott's sense) and their own mental and bodily resources. At the same time, group members are asked to point out which fragments had the greatest impact on them regarding the suggestion of unconscious meanings, even if they cannot yet clearly identify these meanings. They are requested to pay attention to those metaphors or images that most resonate with them. These fragments become anchor points from which subsequent changes can be traced, and lead to new associations in other participants. The shared resonance, in turn, opens new paths of inquiry for the group.

At this point I would like to go back to the Wolfman. I would like to imagine how this first level of analysis would have unfolded with the Wolfman's material if we had had a literal transcription of the analysis. Obviously, we do not have it. Nevertheless, while it is not fully equivalent, we can conduct the exercise by adding to the original account of Freud's case history what the Wolfman himself wrote in his memoir and what his next analyst, Ruth Mack Brunswick, has related (Gardiner, 1971). Doubtless, Freud did not underestimate the resonance of the material or the need to render it carefully in the patient's words.

Freud writes,

I was struck by the fact that from time to time he [the Wolf Man] turned his face towards me, looked at me in a very friendly way as though to propitiate me, and then turned his look away from me to the clock. ... A long time afterwards the patient. . . recalled that [in a tale] the youngest of the seven little goats hid himself in the case of the grandfather's clock while his six brothers were eaten up by the wolf. So what he had meant was: "Be kind to me! Must I be frightened of you? Are you going to eat me up? Shall I hide myself from you in the clock-case like the youngest little goat?"

(Freud, 1918, p. 40)

When Freud says "I was struck," he is talking about his internal resonance. Let us imagine now what would happen if we asked ourselves what other fragments resonate with us when we hear these words. I would like to talk about my own associations. In his memoirs, the Wolfman, Sergei Pankejeff, recalls a photograph of a wolf standing straight with its mouth open in a book that had scared him. He says that when he was 4 years old, his sister announced that she would show him an image of a pretty girl. Instead, she showed him the photograph of a wolf, which terrorized him, and he reacted with a temper tantrum. Yet he adds an interesting comment: he believes that the actual cause of this reaction was not so much his fear of the wolf as his disappointment and anger because his sister had teased him.

We do not know to what extent this anecdote constitutes a screen memory. In any case, in my listening I would focus on the resonance of emotions such as anger and humiliation, which are not dominant affects in Freud's narration of the case. Such emotions lead me to remember the patient's paranoid episode when, years after ending his first analysis, he sought Ruth Mack Brunswick's help upon Freud's advice. Sergei felt that the treatment provided by a doctor (whom Ruth Mack Brunswick, in this new analysis, linked to Freud) had damaged his nose, and that he wanted to kill that doctor.

This type of suspended attention aimed at the entire material does not seek to obtain direct support for a particular theory or interpretation. Obviously, there is no observation free of theory. When discussing "the use of the analyst" or "the patient's transformations," participants tend to evoke the ideas of authors such as Winnicott or Bion. Nonetheless, in the first level, the focus is not on these ideas. Rather, the latter are used only to point in the direction in which observations should be made. The discussion is intended to remain in a nebulous pre-interpretive level that resorts to group members' conceptual frameworks to make it easier for certain traces of the material to stand out on their own merit. For instance, patients' emotions such as rage or humiliation appear in new signifying contexts that are different from those of the above-mentioned interpretations (based on sexuality, oral aggression, and so on). Rather than certainty, this open form of listening aspires to offer greater complexity and new questions in order to reach a deeper understanding of the material.

Looking at the groups' work, we can see the usefulness of this broadened approach, which involves the interlinking of manifold perspectives. In this way, unilateral or rushed interpretations are avoided, and the complexity of the interconnections that are present in the material comes to light. When the material resonates with participants, "lines of force" can be drawn in it and "theory-phantasies" can be evoked (Nieto et al., 1985), thus opening the path for the emergence of new meanings.

The language used by the group plays a key role. For reflection to unfold, the discussion must be held in a spontaneous language, free from technical jargon. Participants should allow themselves to achieve a state of daydreaming or "transformation in dreaming" of their listening. Many contemporary authors highlight this issue, among them, Antonino Ferro (2009). At the same time, participants are asked to add a "second look" (Baranger, Baranger, & Mom, 1983) to this flow of spontaneous associations. This look critically examines what may be happening between patient and analyst at this time and what may happen concurrently in the discussion group. In this way, participants are alert not only to the effect of the material on them but also to what happened in the session and what is happening in the group. They should seek to open manifold perspectives or vertices from where to examine the material. They are always invited to point out which specific parts of the material support their observations or occurrences so as to compare them with the observations and occurrences of the other participants. (At the beginning of the discussion session every participant receives a copy of the material with line numbers.)

Let us look at the other levels of analysis of the 3-LM. In the second level, the discussion aims to identify the major dimensions of change. Concepts used must be objectifiable, on the basis of operationalized categories or dimensions. This procedure involves a change in perspective and, therefore, a complementary, binocular look at clinical phenomena.

The questions that guide group discussions are inspired by the dimensions provided by current psychoanalytic diagnostic systems such as the Psychodynamic Diagnostic Manual, the Level of Personality Functioning Scale (LPFS) of the DSM-5, Section III, and, particularly, the Operationalized Psychodynamic Diagnosis {OPD-2) (OPD Task Force, 2008). These systems, especially OPD-2, offer dimensions such as "Experience of Illness, Relational Patterns, Conflicts and Defenses, Structural Functions" (identity and self and other perception, affect regulation, symbolization, and bonding). These dimensions require that first-level clinical intuitions be supplemented with a research attitude that is highly alert to validity, reliability, and bias prevention.

The third level of the 3-LM invites participants to compare the analyst's implicit or explicit hypotheses with other potential theoretical hypotheses and to discuss possible interpretive strategies and examine the extent to which these hypotheses are consistent with the clinical material. In this way, each of the three levels allows us to explore the clinical common ground from a different angle.

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