Changes in dreams in the psychoanalysis of traumatized, chronically depressed patients in the frame of the LAC Depression Study1 applying the 3-LM
Marianne Leuzinger-Bohleber, with a discussion by Carolyn S. Ellman
The question of how patients change in the course of psychoanalysis touches on the complex and difficult question of their outcome. In Germany and other Western countries it is closely connected to outcome research. To "prove" the outcomes of psychoanalyses and psychoanalytic therapies has become a major issue in Germany in order to save the still very generous support of psychoanalyses and psychoanalytic long-term treatments (300 sessions are paid for by the insurance companies) (see, e.g., Leichsenring, 2008; Leuzinger-Bohleber & Arnold, 2020). I was responsible for two endeavours in this context: a large follow-up study by the German Psychoanalytical Association in the 1990s (see Leuzinger-Bohleber et al., 2003) and—since 2005—the large multicentric LAC Depression Study comparing short-term and long-term outcomes of psychoanalyses and psychoanalytic long-term therapies of chronically depressed patients on the one hand and cognitive-behavioural therapies on the other hand (see Leuzinger-Bohleber, Hautzinger et al., 2019).
A bitter pill that psychoanalytic researchers have to swallow is that in these comparative studies, which must follow the criteria of evidencebased medicine in order to be taken seriously in the non-psychoanalytic world, the focus is mainly on symptom reduction (see also, e.g., Fonagy et al., 2015). Psychoanalysts certainly also want psychopathological symptoms to be alleviated in their treatments, but their aim in psychoanalyses and long-term psychoanalytic treatments is on transformation of patients' inner object world and the associated unconscious fantasies and conflicts, the "structural changes." Therefore, it was important in the LAC study that, using the elaborate and scientifically accepted method of Operationalized Psychodynamic Diagnostics (OPD), we showed that after threeyears of psychoanalytic treatments, structural changes were observed more frequently in chronically depressed patients than in the group who were treated by cognitive behavioural therapists (see Leuzinger-Bohleber, Kaufhold et al., 2019).
In this chapter I would like to discuss another "outcome criterion" for psychoanalysis and psychoanalytic long-term treatments: changes in dreams and in dealing with dreams, as one "via regia to the unconscious" (Freud, 1900). I have investigated such changes by using a theorybased, computer-supported content analysis (e.g., Leuzinger-Bohleber, 1989, 2012). The results were replicated by Kaechele et al. (2006). In the meantime, Moser and von Zeppelin (1997) have developed an elaborate coding method for reliable investigation of the manifest dream content. Fischmann and Leuzinger-Bohleber (2013) used this coding system to investigate the changes of manifest dreams in individual psychoanalyses in the LAC study. They were able to show that analogous changes can also be detected in dreams in the sleep laboratory, as well as with neurobio-logical methods (fMRI) in the same individuals. In the following sections I would like to illustrate such changes of dreams in a relatively detailed case study (see Chapter 3).
Within the limited scope of this chapter, I am unable to address the epistemological, philosophical, and methodological questions of psychoanalytical research that are always connected to research endeavours, such as the LAC study (see Leuzinger-Bohleber & Arnold, 2020). I also cannot summarize the conceptual and interdisciplinary discourses on psychoanalytical and empirical dream research here (see Bleichmar, 1996; Bohleber, 2010; Fonagy et al., 2012; Weinstein & Ellman, 2012).