Application of the 3-LM in the LAC study:

One example

The case was studied with the Three-Level Model for Observing Patient Transformations (3-LM) in the frame of the LAC study. This model is discussed in other chapters of this volume. In weekly clinical conferences we discussed the treatment sessions that had been partially taped and systematically documented our discussion and applied the 3-LM. Based on this joint clinical research, narrative case reports that have been "expert-validated"2 belong to the most important results of this study (see, e.g., Leuzinger-Bohleber, Negele, & Bahrke, 2020). These case studies convey psychoanalytic insights about the psychodynamics of chronic depression, its complex individual and cultural determinants, as well as details of treatment to the psychoanalytic and non-psychoanalytic community (see also Altmann de Litvan, 2014).

The psychoanalysis of Mr. W (see below) has been investigated with the help of the 3-LM. As anchor points I chose the changes of dreams, taking into account the manifest as well as latent meanings of dreams and their changes.

“As far as I can remember, I have always been depressed” (Mr. W)

Assessment interviews and short biography3

The patient came to the Outpatient Department of the Sigmund Freud Institute. He reported that he had always been depressive, but in the last two years his state had become steadily worse. He could hardly concentrate at work and suffered from severe sleep and eating disturbances: "I feel empty inside, like a dark hole: I can't imagine being important for anybody, not even for my wife." Before the interview the patient had not left his dark room for several weeks.

On enquiry he reported that his wife had had three miscarriages, the last one two years earlier. "This time she had been 3 months pregnant. Therefore we had already imagined a life with the baby. I was very sad." He reported that this event strengthened his depressive mood, but that it had always existed.

The patient was the younger one of two sons. His mother was a housewife and his father a natural scientist. During the assessment he did not have a single memory of the first years of his life, only of the time at primary school when his mother increasingly slipped into alcoholism.

It was horrible. We had to hide alcoholic drinks from her or even had to take them away from her. She was angry, cross, uncontrolled, yelled at us or was just drunken. My father was very helpless and took refuge in work. The whole issue was up to me and my brother. It overshadowed my whole childhood and adolescence.

Fortunately the patient had a close and good relationship to his brother, who was two years older.

The patient described his social isolation and severe feelings of inferiority since his first years in school and particularly during adolescence. After his A-levels he completed basic military service. Also during this time he suffered because he hardly had any friendly contacts. Afterwards he studied in natural sciences (like his brother) and completed university time. When he was 30 years old he met his future wife, who was a natural scientist too.

The patient was highly motivated for treatment. During the assessment he showed a surprisingly differentiated capacity for self-reflection and was able to report dreams. He dreamed repeatedly of standing on a high object, such as a bookshelf, which suddenly started to quiver until he eventually fell down, and he woke up in a panic. These associations led to his mother's addiction, which made the "ground under him quiver" when he was a child and pushed the family into an abyss. The patient responded to the attempt to understand this dream in the first assessment interviews with another dream and his hopes connected with therapeutic treatment:

P: I'm getting around by bicycle, wanting to reach any destination. . . . Then I suddenly stand in front of an abyss. I see my brother and a companion down in the valley. I take a big ladder and want to climb down to them in the abyss. But when I'm on the ladder, it starts to shake: it shakes and shakes so that I get scared that I might fall down. My brother’s companion shouts to me that this would not work out and that I should ascend the ladder again and take the path down further right. . . . I follow his advice and really find my way down.

The patient told me that this was the first dream in which he was not alone and from which he did not wake up in panic, and instead found a solution based on someone else's advice. Therein we saw his hope to find a way out of his loneliness and to leave behind the "shaking ladder" with the help of the professional relationship with his analyst, prognostically a positive indicator for the beginning treatment.

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