Level I: Conclusions about change and no change in these vignettes

The patient responded more fully to the analyst in finding her feelings, "using her mind and body" in the analysis when the analyst reminded her that "she wouldn't really know" what she felt, and asked her to see what feeling came, and asked her to stay with her feelings.

Anchor point 2: Hide-and-seek

Three groups underlined a second anchor point they called playing hide-and-seek, connecting it to the "use of the analyst," as noted in the intense counter-transference experiences of the analyst in the early sessions before and after breaks. The analyst felt that she had "to tolerate that all thinking and feeling were collapsing" and that Ms C was experiencing the analyst "as trying to control and hurt her."

In the first period of analysis the analyst comments:

Ms C schedules her own vacation without any reference to me. During these times, things would collapse, and Ms C would resort to action and boundaryless sexual goings-on there. ... It was very difficult to connect these things with the breaks in our meetings or to understand anything about what was going on. Part of my counter-transference at these times was that something dangerous and aggressive was happening and that she felt that she was not being protected. But these feelings would become inaccessible, and I would have to tolerate all my thinking and feeling collapsing while she dissociated.

In the second year of analysis (hour 3,2010), when the analysis began at four times a week, Ms C brought memories and a metaphor about hiding and being afraid to be found, from the time after the family moved to the United States from another continent.

P: Two thoughts about coming in today or in general on Wednesdays—one feeling is like having nowhere to hide, and the other one was it feels really vulnerable, and I guess it feels right now like it's revealing something about me, not sure if it's to you—maybe just to myself—that . . . sort of like I can't be trusted with hiding spaces. . . . Right now, it feels like there is this feeling. . . . I'm remembering this thing when I was 6. We moved to the United States—July 6—summer—a townhouse in San Jose. I don't remember what happened, but I was supposed to say "I am sorry'' to my mom and I wouldn't say I was sorry, and so I ran away. I went to cross the street—there were these carports across from each other. I was hiding in some bushes, and it felt scary. It felt scary, like I felt scared she wouldn't find me and that she would.

That all felt scary. ... I don't know how that ended. I think she was calling my name. I'm pretty sure she didn't find me. I have some image I came in and got in trouble and maybe I did say sorry, I don’t know.. . .

A: In these images it seems like there is a very ominous or scary feeling about being found—there isn't any sense of relief or something good coming out of it or being taken care of. Just very exposed in a scary way.

[The analyst returns to the scene that the patient brings and shows her emotions of fear and being scared, but also points out the "relief'' of being found, a relief that was not experienced by the patient with her mother. This intervention helps to modulate the experiencing of separation and affect regulation.]

P: I have no idea what the subject matter was when I was 6 [long silence, the analyst asks what’s going on], I was thinking a little bit about the incident, then thinking about playing hide-and-seek—the image I have of hiding somewhere—it feels totally scary. If someone finds you, it's going to be scary. If someone finds you, they’re scared—it just seems clear to me now—I never thought it was fun to play hide-and-seek—hiding alone somewhere and the moment someone finds you, it just seems really scary, it just seems not fun to me.

Five years later (hour 5, 2015) we found a new meaning of hiding:

P: Yeah. It's sort of reminding me of what I was saying yesterday about selfsatisfaction, being in the back of the car and being in my own world—in that transition, it doesn't feel like you’re hiding. Maybe it's that clear reality that you have your own whole reality, like being in the back of the car. There are all these things that'll never be shared. It's private. Not a secret.

At the beginning of the analysis, the patient reacted to loss and rejection by physical withdrawal, running away, without awareness of her fears or her wish to be found and comforted; she would just collapse, as seen both in the transference during "breaks" or in her description of interactions with her mother. In a dissociated state, she regressed to a paranoid fear of being attacked and controlled. The analyst, too, got pulled into the confusional state and felt paralyzed; neither was able to discuss the interaction or put it into words. By year two, she could start to put into words her fears of humiliation, but she was not aware of wanting to be found, nor could she experience any relief or security in the finding. It was only when the analyst bought up wanting to be found that she could label her feelings "hide-and-seek." By the fifth year, she could appreciate a concept of privacy and a self-identity that is not shared unless you want to. For this anchor point, we see a clear transformation, the ability to name and identify discrete emotions, the ability to describe frightening experiences rather than physically withdraw, and the beginning of identifying needs and wishes, wanting to be found and held. She no longer needed the defence of projection and paranoia.

Level 2: Dimensions of change

Level 2 aims to identify the most important dimensions of transformations in specific dimensions of psychic functioning. This level requires a more focused listening from group participants; it is a secondary process. All group members found changes from the initial moment of the analysis to later moments in every dimension, going from severe limitations of functioning to moderate disturbances, with some limitations on functioning. The dimensions identified as having undergone more changes were "relational patterns with the analyst" and "perception of others, empathy."

Relational patterns'

From the anchor points the group selected, we will re-observe the different relationship patterns. We will see how events with significant others were described by the patient in the past and in recent experience, and observe the patient's present interaction with the analyst, including transference and counter-transference.

Relational patterns outside the analysis

Ms C started treatment in a polyamorous lifestyle, with sex and drugs, and dressed in a sexualized and provocative style. She was aggressive and inhibited, she acted out, and she demonstrated very risky behaviours, which she could not regulate.

Six years later (hour 5, 2015), she brought up polymorphous perverse phantasies:

P: Yeah, when I'm reading—bj myself—it's a very familiar feeling of reading— this would be common in any book—when the character is yearning. In this vampire book that I’m reading, the guy is yearning for blood, but it seems sexual.

A: Is he yearning for blood or a person ? Is he yearning for a person ?

P: [Talks about the man yearning for a beautiful woman]. It feels very familiar to feel that way while reading—the words are giving me a sense of this person's physical experience—a focus on and warmth in the genital region and a pressure that wants to be relieved, and, if you press it against something, it will be more intense and then be relieved—longing and yearning where the pressure is greater—more arousal—finding something to press up against— I think the arousal comes to the groin area. He could suck her neck, but he’d be pressing up against her. The satisfaction would not be from getting the blood in his mouth. But I was thinking earlier how much safer that is—being by myself reading, feeling these things—than actually doing something sexual.

At first overwhelmed by "reactions," the patient developed more subjectivity in her phantasies.

Six years later, as a mother, Ms C had developed a good physical and mental contact with the baby, although she said, "I didn't have a very physical relationship with my parents." The patient observed her mother's difficulties in experiencing a relaxed physical contact, when holding her baby. "She was so awkward." She wondered if her mother would be a safe caretaker for her baby: "My mom would be overwhelmed, frantic, and what that would mean about her taking care of him [the baby] in the future." She said, "Now I'm feeling overwhelmed again. Like where to start, what's really going on . . ., just talking about the sex stuff and not having sex is bringing a lot up."

At the beginning of the analysis, Ms C searched for contact with an object, via action and dissociation, as we saw in the scene of the naked lunch. Sex was a way to feel alive, and seduction was a way to control the object. Objects were just bodies to press against and to facilitate discharge of pressure. She could not even imagine oral pleasures in her object or herself. It was only safe to be walled off, solitary, protected, without involvement. These different types of interaction showed the difficulty she had in achieving emotional intimacy with others. Ms C moved from the "Burning Man," the "naked lunch," with a polymorphous and promiscuous acting out, to marriage. A question arose in the group about what kind of object her husband was for her. Did she love her husband? Had he become a more differentiated object for her? The analyst answered that Ms C and her husband dated for two years before getting married. The analyst thought Ms C loved him. They met in an exercise activity, "walking on ropes." Transformation in relational patterns outside the analysis remained uncertain; it was not clear yet what kind of object her husband was to her and what kind of intimacy she could tolerate or enjoy.

Relational patterns with the analyst

At the beginning of the analytic process Ms C seemed to have no recognition of the other, then (November 2010, four sessions a week) she began showing a need for the analyst: "I'd like to hear from you now." She could use the interpretations about the analytic couple: "I definitely looked at the weekend as [self-]sabotage. ... I felt abandoned by A [her friend]." The analyst interpreted:

A: I think about you at this party Saturday, or when your cousin touched you, or when you left here Friday, feeling abandoned by me—like out there on your own, and feeling how can this happen and no one's looking out for you.

P: I did feel on Friday—we did talk about me going to my cousin's close to the end. I did feel like it was like, "OK . . . good luck." I feel like so much happened yesterday. . . . That statement felt like when I was 6 or 7, if I tell my mom, it's gonna be really unpleasant. I don't want to feel bullied, etc. Or do something just because it'll be easier for him or me. So, I felt really angry about that... and then I had a "date" with a guy for an hour—the guy who's half-Asian and half-Jewish, and dinner with H [ex-boyfriend] to talk about work things.

A: It sounds like you feel unprotected by and angry at them and me also, and then you turn to men.

The focus of the analyst's interpretation referred to separation anxieties and her feelings of abandonment (past and present). In her relationship with the mother, abandonment and separation contained unpleasant and rejection feelings, as we saw in the metaphors of "hide-and-seek."

At five years of analysis (December 2014), we can observe the emergence of a different person, with a wider range of affects and remembering, wanting more contact, planning for the future:

P: Yesterday feeling like I can't believe you're leaving for all this time when I'm so pregnant and so much is going on.... I do feel angry about that. I can feel it in my jaw. It’s because you're not going to be here that I'm in this state— this really efficient "getting things done, everything kind of working out and convenient" state, that’s your doing—like the summer. Whatever excitement on Christmas morning I don’t get to come in the next day and tell you. [She talks about the relationships between M and her and D and her]. I feel sad, in all that—family, love, connection, I don’t get to have that with you—I don't have the support to feel all the different sides—and I have fear about my dad— and just what it's going to be like to have M more involved ... [silence], I am having some feelings about.... With my paycheque.

Ms C noticed more about her relationship with her mother, and that she felt safer and more in contact with the analyst:

P: I feel very not thought of—like the opposite of feeling tracked. I don't have any clue if she understands or knows where I'm at, and I can’t track her either. Yeah, it feels like the opposite of the feeling of when I call you and you call me back. That feels safe. Like I know that you know. I am imagined [sic] you would listen to it soon and that you would know where I was at.

As with her outside relationships, in the beginning of the analysis, she could acknowledge the loss of the analyst over the weekend, but she was quickly forgotten and replaced by sexual interest in a replacement. The analyst was treated as a thing, reflected in the counter-transference. By the fifth year, she was aware of the continuous presence of the analyst inside her, listening to her, allowing her to "survive." In the closeness there were different proximities that were bearable. Intimacy was constructed through the closeness or touching of bodies, and through different mental spaces that were generated. It was not clear how much she could mental-ize the analyst as a separate person with her own concerns and personality differing from hers.

Structural aspects of mental functioning

In the 3-LM, questions on structural functions "aim at exploring further what is described as vulnerabilities, fragilities, deficits, or developmental arrests of the patient. Four dimensions are taken into account, following the OPD-2 criteria" (Bernardi, 2014, pp. 14-15).

The first dimension, "self-perception, sense of identity, and integrity of the self," "refers to the patient's capacity to perceive what occurs in his own mind and to build, based on that, an integrated and differentiated sense of his personal identity and of his capacity to project towards the future" (Bernardi, 2014, p. 15).

The group asked, how capable is the patient of adequately perceiving her own internal states and those of others? And how has that changed? During the first year of treatment Ms C had a very poor grasp of the mental state of her boyfriend, as we observed in the scene of the naked lunch. She had no idea what she was doing. She did not think in the sessions about what her mother's illness had been that caused the hospitalizations, or why her mother had become depressed. When she brought her mother into the session, her thoughts are superficial. The questions "Why did my mother get sick?" or "Why did my mother get depressed?" were never raised. At the beginning of the treatment, when she missed a session, she did not care; time was not so important: "I do not see the future." Ms C was a successful social worker (identified with her successful businessman father), but she showed signs of a strong identification with her depressive mother from when she was a little child. The patient had no "space" for compassion towards or understanding of her mother. First the patient was rather non-verbal: she acted; then, through the course of the analysis, she verbalized more and was able to associate present with past; then, she started giving a place to the past. In the scenes of the naked lunch we see Ms C's difficulty in understanding the thoughts and feelings of others, and how she was challenged by alternative perspectives and became confused about the impact of her actions on others.

In the most recent sessions, she took care of her baby, having decided not to work for the first year, giving "agency and direction to her life"; now she cared about time and the future; she started working on a retirement plan. She also cared about the mother she could become. In this way she was considering the future and time. When she was pregnant, she worried about how delivery would go, and whether she or the baby would die. Being pregnant brought phantasies of a dead mother, and she was defending against them. In the last sessions, she realized that she could become numb (afraid of not feeling things properly), which was different from being dead or completely dissociated. "I am scared not to feel the fear, layers of non-contact."

From being "chill," she became able to depend on someone: a transition from a pathological dependence to an idealizing transference in which she could form a quite profound bond with her analyst. She was tied to the analysis with idealization and dependence. Her core conflictual relationship seemed to be with the "dead mother" (in Green's sense, 1996) (but more needed to emerge in relation to the father). If she depended on this dead mother, she imagined she would die. Therefore, she needed to be self-sufficient—using mechanisms of control and omnipotence. The family reported that she was more able to show conflicts and be naughty before the brother was born, when she was 3 years old, after which she "became happy." She needed her mother, but she could not supply reassurance or meet her needs.

Later, Ms C made important progress in her ability to consider, and have interest in considering others' experiences, although at times it was not easy. In working this through, Ms C theorizesd about others' perspectives, but mostly as they related to possible effects on her. She had been confronting the reality that her analyst had her own world and the implications of that for excluding Ms C. There were references to her sister-in-law and husband, trying to figure out their intentions toward her. At the same time, she showed some empathy and insight toward her mother when the mother was taking care of Ms C's baby, who became fussy. Certainly, there had been progress in empathy, but she was still fairly self-referential in her thinking, understandably, as she grappled with learning more fully her own and others' minds and behaviours (Bender et al., 2011).

The second dimension, "affective regulation," refers to the capacity to regulate impulses, mood affects, and self-esteem, as well as establishing an adequate emotional balance between the needs of oneself and of others. In the beginning hours, she was emotionally quite fragile, with sometimes rapidly shifting states:

P: When things feel on a good path and then something happens, and then, some feeling like too happy or too opened up, and then, something goes wrong, and I feel overwhelmed by it... . The more I put into something, the more risk and pain is involved.

The analyst reflected, "One minute it's bliss and the next minute everything is falling apart." The patient also observed that she was "not totally knowing the boundaries with myself." The analyst also noted that "it seemed that she had no boundaries." Ms C talked about struggling with feelings of abandonment that came up around a phone message exchange with the analyst. While having a more evolved sense of herself as a separate person, Ms C appeared to be significantly attuned to others to regulate her sense of self and emotional well-being.

We see evidence in the later sessions that Ms C had begun to experience her separateness, but this was frightening because it occurred to her that her analyst had her "own world" that did not include Ms C at times.

The third dimension, "internal and external communication and the capacity for symbolization," is crucial for the psychoanalytic process, because these functions enable the psychic and interpersonal processing of lived experiences and their integration, contributing in this way to mental growth and the elaboration of the psychoanalytic work. At the start of the analysis, Ms C had a poor grasp of the internal world of the other. Later in the analysis, she could get into the internal world of herself and the other, and symbolization (less denial of anxiety and more inner dialogue) appeared.

The fourth and last of the structural functions considered is "the capacity to have deep bonds with internal and external objects," which implies the ability to initiate, preserve, and end relationships, to tolerate separations, and to acknowledge the place of a third. The group observed that the bonds with internal objects were fragile at the beginning of the treatment. Ms C treated others as if they were extensions of herself. Later, she saw the analyst as another, as abandoning her, or trying to set the agenda. The group questioned what would happen with the eventual loss of the analyst.

Regarding her bond with others and intimacy, we observed that at the first year of treatment, Ms C's polyamorous and risky sexual behaviour with many partners represented desperate attempts to connect, while at the same time an acting out, which defended her against knowing about her thoughts and feelings. She tried to cultivate detachment from the analyst to protect herself and was terrified of closeness, dependency, and losing control. Ms C's attempts to connect while failing to cultivate enduring close relationships and her need to ferociously pursue connections and then push people away allowed little genuine mutuality in her relations: "We had this really nice vacation and lovely night with M, close and connected—then he got at me at lunch, and then the contrast was too much."

Intimacy is constructed through the closeness or touching of bodies, and through different mental spaces that are generated. The temperature of the affects in a relationship (cold, mild, warm, or hot) determines the way in which people get along together. This patient described a broad spectrum of scary experiences with difficulties in the modulation of the affects and a loss of impulse control. She had difficulty when she felt "boundaryless": she lost her sense of self and needed someone outside her to help bolster her self-esteem. "I had a chain reaction of bad interactions yesterday ..., hysterical reactions to M yelling at me, and my clients calling me racist."

People got angry at her, but she did not realize when she had been provocative. When she brought up the naked lunch and the possibility of having another naked lunch, her boyfriend became violent; later she broke up with him. Suddenly something happened and the relationship was broken.

Later, Ms C was clearly motivated to pursue committed relationships, was long past her phase of prodigious sexual acting out, married, and had a baby. In a more recent session, she seemed to be working hard to sort out the nature of closeness. She reflected that except for her baby, "I haven't had any safe physical relationship that wasn't sexual." She talked about a vampire from her book, wondering about the nature of yearning for connection, exploring if it was possible to feel close to someone without being sexually involved. She had a fantasy of doing something sexual with her analyst. She also described her experience of not being thought of or understood by her sister-in-law, her husband, or her mother. She did, however, have some appreciation of being understood and appreciated by her analyst. While there was progress in her work toward understanding and developing fulfilling and reciprocal relationships and in her relationship with her analyst, the clinical material we have suggests that Ms C had not yet fully achieved a higher level (Bender et al., 2011).

Hypotheses of the group

Members of the group observed important changes in the patient and in the analytic process, but noted areas of work still to be done; she was not yet "cured"; "there were problems to be resolved" with her identification with her mother's depression, the meaning of her becoming "happy" when her brother was born, the intergenerational transmission of trauma (Holocaust: several relatives died in concentration camps). Participants thought that the patient identified herself with a depressed mother ("the dead mother"; Green, 1996). She was fighting this depressive mother inside herself, in acting out, and staying "chill," showing no compassion for her mother. However, she was able to develop maternal capacities with her baby (dream). She was able to observe that her mother's behaviour was flat. But she still could not think much about who her mother was. Her perception of herself had developed considerably. She had better reality testing.

Part 2: 3-LM Level 3—Foci of the analyst’s interventions and hypotheses about therapeutic action

The background of this case is severe childhood trauma. The analyst reports,

In her early childhood, Ms C's mother was likely depressed. During these early years, she was not able to respond to Ms C's emotional needs, but rather Ms C precociously began to attune to and look after her emotionally. Her mother described Ms C as unhappy and oppositional until her brother was born when she was 3, when she became "happy." It appears that she started defensively looking at boys in a sexualized way at a very early age. For example, Ms C experienced acute separation anxiety from her mother when she began preschool, and there are many family stories about her having a "boyfriend" at preschool. She also recalls frequently being dropped off for the weekend at her step-grandmother's house and feeling abandoned by her mother even though she loved her grandmother. Ms C recalls being touched inappropriately by her cousin and trying to tell her mother, who seemed herself to be embarrassed by the information and did nothing to help. When Ms C was about 10, her mother began a multiyear medical treatment with multiple hospitalizations for reasons that were never clear. She now imagines it had something to do with her mother's reproductive organs—perhaps a hysterectomy and subsequent complications. In high school, Ms C felt ugly and started using her body to try to get attention and love. She also describes frequently being left alone for weekends by her parents, without anyone checking in on her and without any particular rules. During these times she would have huge parties that involved drinking, drugs, and sex. There seem to have been many situations during high school and beyond that Ms C eventually understood as rape or at least as situations to which she did not consent. Ms C had several unstable relationships in adulthood, most of them with very narcissistic men who wanted to possess and control her, but some of them with people whom she used and then rejected. In the early part of the treatment she had a relationship with a clearly very disturbed man who eventually became violent with her.

This trauma was re-experienced in the first four hours (2009-2010). The patient was very anxious, prone to putting fears into action, mostly seeking out risky erotic encounters with men and using drugs. It seemed that she had no boundaries; she was always scanning, looking, trying to "connect" with people, and having little sense of her interior life or theirs.

As long as she felt "desired," she felt very "on top" rather than vulnerable, scared, and in need of other people. Ms C quickly became a "good" patient, picking up on what she was supposed to talk about, in keeping with her tendency to mould herself to others.

In working with Level 3, we refer back to change observed in Level 1 and ask how change occurred in the defences of projection and paranoia. There was a consistency in the way the analyst worked with the patient in these early hours. Especially in the first two hours, she was helping the patient sort out what was hers from what was not hers. She was identifying feeling states and naming them. She was helping the patient with time sequences. Typical is the "naked lunch" episode in the first hour, where the patient was split between her idealized experience of being with her boyfriend, described as "serene," "settled," "sweet," "beautiful," "perfect," and the jealous rage in her boyfriend when she disclosed a desire to have a naked lunch with an older colleague. The patient was clueless that she precipitated the attack or was provocative in any way. Here is a typical interchange:

A.- It feels like it's coming out of nowhere—like one minute it's bliss and the next minute everything is falling apart—but maybe there's more to understand [referring to the man’s jealousy],

P: This feeling I can't be happy for too long, but I don't really believe that. I don't know. ...

A: It is interesting that you said that to him, because I think you know that this would upset him and having had lunch naked with someone would upset him.

P: [She says she felt upset that she hadn't been more sensitive to how sensitive he is]. It didn't feel that way at the time. I had just gotten an email from him [ the lawyer]—I didn't have the sense it had this hotness to it. I don’t understand why he has to get so angry.

The patient and analyst could agree on a pattern of idealized bliss and then catastrophe, but the patient disavowed any personal intent or involvement; it was felt as an outside force. But then there was this exchange:

A: I’m not focused on how you should be towards him but more whether there is anything to understand about what goes on with you.

P-. [She remembers something she and I have talked about, how she’ll start talking about someone else when things feel intimate.] In some way like maybe... .It wasn't feeling uncomfortably intimate, but I think we both felt really opened up and intimate. . . . This is maybe a strategy I use at times without being thoughtfid about it.

A: Aware of it.

P-. Yes, aware of it. ... Yes, this feels helpful to think about it that way.

The patient had a flash of awareness ("This might be a strategy") after the analyst referred to understanding "what goes on with you." The patient imagined an implied criticism "without being thoughtful about it," but the analyst shifted focus to suggest that Ms C acted without being "aware of it" (provoking jealousy). This helped Ms C recognize (in a more neutral way) that she (unconsciously) "denied the perception" of her acts of provocation. The patient stayed with this non-judgmental recognition: "[Without being] aware of it... this feels helpful."

The analyst then referred to the analytic frame (change to two sessions a week), to the transference ("us"), and to the disturbing situation ("crisis"):

A.- You have said a few times that you want to talk about what's going to happen with us [adding the second session], and, both times you wanted to do that you came, in a crisis.

The analyst was now working in transference by suggesting that the patient's coming "in a crisis" was unconsciously motivated, to avoid talking about "what's going to happen with us." The analyst pointed out a pattern, which she found in the here-and-now, but, in these early hours, the patient did not respond to the transference interpretation.

However, the patient did begin twice-weekly analytic therapy and then three times a week, and, on November 9,2010,20 months after the "naked lunch" session, she began at four times a week. In the first Wednesday session (after starting the increased frequency), the patient referred to a childhood trauma. She told the analyst about a family party when an older male cousin, who was at the party, touched her hair in an intimate way. The presenting problem of Ms C's disavowal continued to evolve.

P: My adult cousin came in and fixed my hair. I had the scarf on, and he got my hair out from under, etc. It felt pretty noticeable. . . . Intimate . . . and familiar. .. .He used to take care of me when I was a kid. I don’t know if I felt upset by it. . . . I guess I would've preferred if he hadn't. [She cries]. It makes me more sure, but I still have feelings of doubt that's what happened.

Ms C described a "doubt," "knowing and not knowing" that the sexual abuse by this older cousin had "happened" in childhood, even while telling the analyst that this "older cousin" touched her in an "intimate" way, without asking, on the weekend.

A: Maybe you wanted to know that I'm not going to lose track of you and all your feelings as you go on; that this won’t be lost, that I’ll hold onto it.

P: [Crying] Sometimes I feel like if I talk about different things, somehow you think I've forgotten about ... all the different things. Like I’ll be talking about something, and you'll ask me how I feel about coming in tomorrow, and I wonder do you think I've forgotten or I'm not remembering the different things, and the sense that just because I'm not talking about it now, it's not that I’m not thinking about it. I mean sometimes I don't remember. . . . It just felt helpfid to hear you say that. . . . I don't know, now I’m feeling a little uncomfortable.... I think I’m anticipating how I feel apprehensive telling you about Saturday.

In this complex association, the patient feared that the analyst doubted Ms C's capacity to "remember" (trying to deny dissociation, the state of mind in which she did not know the abuse happened), then Ms C could admit "Sometimes I don't remember" and was relieved that the analyst knew this scary thing about her mind. One of the scary things about Saturday was that she came in and out of contact with perceptions of danger.

A: I think about you at this party Saturday, or when your cousin touched you, or when you left here Friday, feeling abandoned by me—like out there on your own, and feeling how can this happen and no one's looking out for you.

P: I did feel on Friday—we did talk about me going to my cousin's close to the end.

I did feel like it was like, “OK .. . good luck."

Ms C felt the analyst was sending her away into danger without caring (with a sarcastic "good luck"). At the end of the session, the analyst interpreted the patient's anger at not being protected (by friends, family, and analyst), which led her to turn to men: "It sounds like you feel unprotected by and angry at them [the friend and parents] and me also, and then you turn to men" (end of session).

The focus of the analyst's interpretation was to interpret a sequence of affects and impulses, which implied an intrapsychic dynamic: a mix of compensation, self-harm, and revenge. When the patient felt unprotected by and angry at caretakers, she got into situations where she both attempted to have a "connection," and gratifying attention, but, at the same time, repeated the abuse by picking men who would hurt her, putting her at risk and making the analyst very anxious. The analyst began to help Ms C to recognize and own unconscious affects and impulses, which underlay her unconscious enactments of dangerous situations. The analyst was also working to help Ms C realize that she used crises to avoid talking about "us" meeting twice a week, a closer connection Ms C wanted and feared.

At Level 3, we note that the analyst did not make interpretations about unconscious fantasy scenarios repressed in early childhood, but consistently noted Ms C's lack of safety, sometimes putting it in the here-and-now transference relationship and interpreting her defence in acting out. The patient did not take up the transference directly but used the transference to feel contained and held.

In these early hours in the first year, we can infer from the foci of interventions that the analyst facilitated insight while furthering safety in the therapeutic relationship. Interpretations, which generate insight in the patient, were directed toward clarification of and sorting out basic psychic activities, naming and differentiating affects, observations of self and other, of what is outside and what is inside. On the relationship side, we can infer a kind of containment of anxiety, taking it in, detoxifying, and interpreting. The analyst thereby provided a basic security and steadiness that the patient lacked; the basic analytic task was to detoxify the projected anxieties. By the second year, we start to see interpretation of disavowal, dissociation, and projected fears.

The analyst began to use transference in a more sophisticated fashion by interpreting the wish and fear for more contact with the analyst, which began to give more insight into paranoia and disavowed affects.

Let us turn to an hour eight years after the start of the analysis, first looking at the hour itself.

The hour started off:

A.- [I gave her the bill and she gave me the cheque. This was also a week before I was going away for a week.]

P: I slept horribly again. I went to bed, then I woke up—then I felt like there was an earthquake. I was sure my bed was vibrating. I sat up. What do I do now? I was a little panicked, that heartbeat feeling—but feeling doubt too. I even stood up out of the bed. . . . And I did feel like not being able to fall asleep had to do with our break coming up. . .. I had this feeling of stability when I thought of the break. ... I was trying to hold onto that feeling.

A: When were you trying to hold onto it?

P: I feel like I am trying to get back to that feeling. No—I want to get to it and explain it and have that feeling be the feeling, I want it to be it. There is probably other feelings [laughs],

A: Bummer, I know. Do you know what they are?

Here we were on familiar ground. The patient had a paranoid fantasy, felt in her body, and started to feel panic anxiety. In the first sessions of the analysis, Ms C was "overwhelmed," totally "panicked," "hysterical" at having angered her boyfriend by making him jealous about the naked lunch; now she was "a little panicked, that heartbeat feeling," but "feeling doubt too about whether the earthquake was real." Yet there were now differences, she could now link her anxiety to the break with the analyst; she could begin to name feeling states and she no longer needed to repeat in action her fears. The analyst made several clarifying remarks, but we can infer that she could just wait.

P: The feeling I had was anticipating not feeling abandoned by you when you were gone. It ivas a different feeling of feeling solid, or trusting the whole feeling of taking you for granted that we talked about, and then there was all this anxiety about that.. . and now it seems like the whole sense of that seems shaky, like the bed. Like scared. Like, oh, I can't rely on that feeling—it wouldn't be smart, or safe—I can't trust, I can't rely on you.

Without the analyst intervening, the patient spontaneously showed her awareness of split transference fantasies, her struggle to keep the analyst as a soothing internal object, and her fears of depending on the analyst. Then, a further revelation:

P: When I was awake, I was thinking about you [after the earthquake], I wonder what time she goes to bed? I don't imagine you go to bed at 9:00. I have an image of people who go to bed at 9.1 wonder, what time do they eat dinner? How much time do you see your kids and how annoyed do you get if you spend a lot of time with them? [She's quiet].

The patient showed a curiosity about the analyst, indicating she could now see the analyst as a separate person, with her own concerns and motivations. After several more clarifying questions, the analyst made a long transference interpretation:

A: Maybe in the middle of the night there was initially some sense of feeling alone and then thinking of me and not knowing what I am doing or where I am, and then maybe that was connected with knowing I am going to be away and... some sense of separation and incompleteness. Some area where we are not overlapping. Then that’s hard to fathom and that’s scary and vulnerable and, then, it becomes more about completing that or doing something to not have that feeling.

Now we see the analyst gather up several of the patient's points, separation fears, awareness of differentiation, and defensive push to action, all placed in the transference. The patient responded with the insight that she had needed to sexualize her fears, then was aware of new feeling states:

P: I guess I felt a surge of anger .. . or sadness about you going away, I guess.

A: Yeah, what did you feel?

P: A flash of oh I could just cry. It was very fleeting. I guess feeling tenderly towards myselffor having a hard time having feelings.

And the patient ended the hour with:

P: This feeling of absence. We won't be together.

Moving to an hour in the following week, Ms C came in with a sore throat and runny nose. She shared more paranoid fantasies with the analyst:

P: This feeling, like being sick, of these invisible, maybe. . . . Like there could be fungus, or something. Thinking about people that are.... The feeling of being weak and vulnerable like I'm not going to survive evolution.

We see a continuation of paranoid states, but she now had the capacity to link her fears to being weak and vulnerable. The change in Ms C's psychic capacities can be observed in the depth and richness of her stories told to the analyst about the paranoid fantasies. The focus of the analyst's interventions remained on the affective states. At this stage, the patient was struggling to talk more openly with her husband (about having sex and his teenage daughter) to be both a mother and sexual. Ms C told her analyst about a difficult "intimate" conversation with her husband about disciplining her 13-year-old stepdaughter, who had come to live with them.

P: I felt brave, I brought up hard things. It's sort of like progress. That's why I brought them up, told you about them. But as I was talking about them, they didn’t feel good.

A: You thought they were going to bring you to a comfortable place, and they didn't.

P: No, I don’t think so.... I brought them up thinking they were kind of "celebratory.” I realized there was this hope, and it wasn't being realized, and then this desperation feeling came up. The hope disappeared. ...

A: These things are kind of challenging, these interactions. And the break is there somewhere. Maybe you're struggling with, as you're saying, feeling kind of vulnerable. ...

A: It does seem kind of exhausting having to fix things all the time....

A: It’s depressing, It's blah, not exciting....

P: It is "unglamorous" and "not sexy.”

A: It’s a little depressing or a little empty.

The analyst was helping her stay with "ordinary unhappiness." The analyst had shifted largely to an interpretive stance on transference, pointing out defensive shifts in the patient away from anxious affects and links to loss. But the concern with safety continued, as the interpretive process is very careful and done in small steps, staying close to the patient's material. The concern with containing had not disappeared, and the analyst still worked to help her patient verbalize her narratives and elaborate her bodily sensations as metaphors for internal states.

We can also see what the analyst did not do. For example, she did not interpret primal scene fantasies when the patient was curious, nor did she interpret rejection by the Oedipal couple, likely inferring that her patient was not ready.

The clinical material indicated a shift in therapeutic action between early and later sessions. At the beginning, the emphasis was on containing and holding. There was little or no interpretation of unconscious fantasy. Rather, the analyst focused on connection and breaks in connection, identifying states of closeness and states of loss. Relationship aspects of therapeutic action predominated. In the later sessions, there was a shift to interpretive efforts. The patient was now able to voice more complex fantasies about the analyst and much of the work is centred on transference and fears of loss of control, of being abandoned, and of being envied. The analyst had become a separate person in her mind, having a separate life, and there was a growing sense of object constancy, an enduring sense of being held in the analyst's mind. Yet the patient still could regress toward paranoia when faced with separations. Thirdness was hinted at but not yet ready for awareness and work. The work appears to have integrated many of the split-off fantasy states, and we see much less evidence of projection or denial.

Results and conclusions

We have presented the results of a long period of analysis (six years) through the "participant observation" of 40 analysts working in three different clinical observations groups. With the results of the questionnaires done before and after the experience, the reports done by the three groups, and the participation in the group discussion, the results reflect not only some illustrative material of one analyst but the views reached about this clinical material by a number of trained psychoanalysts and its resonances in the participants in a formal discussion group, using a setting and a specific method. The challenge has been to understand the clinical material as an insider and describe it for the psychoanalytic community.

We found that analysts with different theoretical frames and belongings (different societies and regions) had an empathic sensitivity and perceived changes in similar ways, as shown in reports and questionnaires.

With regard to the global changes of the patient, the reports describe that some groups underline more external changes, others more internal changes, and others privilege the lens of the different transferential positions that were taking place between analyst and patient. The three groups used these three criteria but with different emphases.

In the questionnaires filled before and after the group discussion we found that most group members report important global changes of the patient—important changes in the patient's use of her own mind and bodily resources for the analysis, and moderate changes in the patient's use of the analyst and her interpretations.

Regarding the 3-LM levels at the descriptive phenomenological level (clinical thinking), we found that the three groups underlined some of the same and some different anchor points, but they concurred in the lines of force: the stress on the analyst of her patient's acting out, her dissociative states, her disavowal. The groups also saw the same changes in Ms C's "use of the analyst and of her interventions," and the same changes in her old defensive strategies, allowing her more safety and continuity in relationships over the course of the analysis. The scenes we have selected, "the naked lunch," the "hide-and-seek," "the family party with abusing older cousin," "the earthquake and fungus fantasies," in response to separations from the analyst, show how the groups work at this level, where images and metaphors in the analysis are observed and others emerge from the clinical observation group. In the unconscious construction of meaning, metaphor plays a salient role. Arnold Mod-ell (2005) suggests that metaphor functions unconsciously as a pattern detector and thus is pivotal to the organization and categorization of emotional memory.

We observe at the beginning of the treatment the intense needs of the patient, who was always looking for contact, which for her was a kind of rudimentary intimacy with mechanisms of dissociation, disavowal, and acting out. Six years later, all her pathology about sexuality was brought into the transferential relationship and into an inhibition with her husband. The analyst worked with the transference and the need of the patient to be in contact, to regulate contact with others, and to self-regulate.

Her story of hiding and being found did not resolve conflict; she wanted to be found but, at the same time, felt it would be humiliating to submit to her mother. In the first period of analysis the analyst reported the difficulties they had during breaks, when the patient would resort to action and boundaryless sexual goings-on, and there were unsuccessful efforts to connect the "acting out" with the breaks in the sessions, another version of hide-and-seek. The analytic process was full of "feelings of fear," loss, and abandonment.

The patient couldn't handle different affects, but she was able, as the analytic process advanced, to use the analyst to get to know that there was a missing affect in her experience of "hide-and-seek" and to know happiness at the reunion with the other. Years later we find a new meaning of hiding: being in the back of the car feels like being in her own world and doesn't feel like hiding, finding her own private space but without secrecy. We can observe the emergence of a different person, with a wider range of affects and remembering, wanting more contact, planning for the future.

In Level 2—Main Dimensions of Change—the group found improvement in all dimensions, changing from important disturbances and severe limitations in functioning to moderate disturbances, with some limitations in functioning in most dimensions. The group found a higher improvement in relational pattern with the analyst that got a higher score (from 2 to 3.5) and empathy that had a very low score at the beginning (1) and arrived to a 3 score.

Discussing the third level, Explanatory Hypotheses of Change, we see a shift from the early hours focused on clarifying and containing, to later hours where unconscious fears could now be explored—predominately fears of abandonment.

Alternative hypotheses that emerged in the group have to do with the personal involvement of the analyst in the process and in the relationship. Hence, questions arose in the group: Why is transgenerational transmission of trauma never brought to the analysis? Why was not the meaning of the different cultural backgrounds in the psyche of the patient worked on?

In the group discussion, ideas tended to lose their connection to their original theoretical framework and were used from a common clinical baseline. Hence, the concept of splitting, projective identification, continent function, and separation anxieties summarized clinical observations and were common, shared concepts closely linked to clinical observations in psychoanalysis. We could say that there was an integration and coherence centred in the patient, and, as the analytic process advanced and transformations took place, other hypotheses and implicit or explicit theories arose.

Clinical observation group members working with the 3-LM valued the fact that everyone talked in descriptive terms, even using metaphors from everyday life. This speech style helped participants develop a more clinical perspective and enabled them to get a better picture of the patient and her emotional functioning, while avoiding the risk of using more theoretically saturated approaches.

The 3-LM is another setting to see the psychoanalytic process, to detect psychoanalytic clinical facts, to make observations and inferences, and to communicate them. Within the group, we identified clinical facts and then we made inferences, trying to separate what was a fact, an observation, and a conceptualization.

Clinical experience and research evidence have confirmed that psychoanalytical treatments (among others) produce positive changes in patients. Our challenge was to answer the questions: How to improve the description of changes? (Level 1); What does exactly change? (Level 2); and How and why does it change? (Level 3).

Note

1 Internal object relations are the building blocks of psychological structures and organizers of motivation and behaviour. The building blocks of psychic structure are made up of a representation of the self, an affect related to or representing a drive, and a representation of the other (the object of the drive). This units of self and other, and the affect linking them are object relations dyads (Clarkin, Yeomans, & Kernberg, 2006, p. 2).

References

Bender, D. S., Morey, L. C., & Skodol, A. E. (2011). Toward a model for assessing level of personality functioning in DSM-5, part I: A review of theory and methods. Journal of Personality Assessment, 93(4), 332-346.

Bernardi, R. (2014). The Three-Level Model (3-LM) for observing patient transformations. In M. Altmann (Ed.), Time for change: Tracking transformations in psychoanalysis—The Three-Level Model (pp. 3-34). London: Kamac.

Clarkin, J. F., Yeomans, F. E., & Kernberg, O. F. (2006). Psychotherapy for borderline personality: Focusing on object relations. Arlington: American Psychiatric Association.

Green, A. (1996). On private madness. London: Kamac.

Modell, A. H. (2005). Emotional memory, metaphor, and meaning. Psychoanalytic Inquiry, 25(4), 555-568.

Nieto, M., Bernardi, R., Altmann, M., Bouza, G., Cárdenas, M., & de León, B. (1985). Investigando la experiencia analítica: una propuesta [Inquiring into the analytic experience: A proposal]. Revista Uruguaya de Psicoanálisis, 83,117-135.

Chapter 3