V New uses of the 3-LM in the transmission of psychoanalysis and in professional development

Chapter 10

The 3-LM's contribution to developments in analytical treatment

Beatriz de León de Bernardi, Luisa Pérez Suquilvide, Marina Altmann de Litvan, Nancy Delpréstito, Marianne Leuzinger-Bohleber, Lisa Kallenbach-Kaminski, Rosemarie Kennel, Anju Labuhn, Luise Laezer, Susanne Landsiedel-Anders, Sebastian Ohlmes, Gertrud Reerink, Sarah Römisch, Jörg Scharff, Karin Schwind, Erwin Sturm, Heike Westenberger-Breuer, Liliana Fudin de Winograd, and Mayela Falvy

Introduction—Beatriz de León de Bernardi

This chapter will show the uses of 3-LM in the transmission of psychoanalysis and in professional development. Experiences in Montevideo, Frankfurt, Buenos Aires, and Peru have integrated candidates into 3-LM group workshops. In this chapter, a variety of these experiences with candidates will be described. The different institutional contexts have adapted the 3-LM to the realities and demands of psychoanalytic communities. Various modalities are used in setting up the 3-LM groups: some only for candidates, others in which the candidates participate together with members of their psychoanalytic society and institute, and in some cases qualified members are brought in as consultants. There have also been formal modifications in the time allotted for group discussion, which needs to be adapted to the institutional schedules. On several occasions the 3-LM group process has been carried out in two or three meetings with intervals of several months. Sometimes, parts of the model have been used. In some cases, the transformations of the patient have been studied and described on the phenomenological level. In other cases, the transformations of the patient have been discussed considering the Level-2 dimensions of the changes that have occurred, and the theoretical-clinical conceptualization of how the changes came about, at Level 3. New questions on the analyst's interpretative foci and mechanisms of change have recently been incorporated into the work of the 3-LM third level.

These experiences have been productively evaluated by participants and have raised new questions to be explored. The most valuable aspect of these experiences lies in contributing to the creation of a space for analysts-in-training that allows them as participants and careful observers of the clinical material presented to reflect and intervene without the pressures of institutional evaluation, thinking about the transformations or absence of transformation that have occurred in the patient, promoting internal evaluation in relation to the ways they work with their patients. The priority given by the model to the richness of the clinical phenomena favours an attitude of research that becomes the basis for candidates' future personal development, offering a complementary starting point to the demands of psychoanalytic training.

The Montevideo experiences

Part I: Analyst’s focus and mechanisms of change in analysis: New questions in work with the third level of 3-LM— Luisa Pérez Suquilvide and Beatriz de León de Bernardi

We present clinical material that shows one experience in Montevideo, Uruguay, with modifications to the questions in the third level of conceptualization of the 3-LM. The Education Committee and the Scientific Committee of the Uruguayan Psychoanalytic Association supported this activity.

Two groups, comprising 12 analysts-in-training and analysts with different levels of training, worked with one moderator each and on the same clinical material in two stages, with a three-month interval between them. In the first stage, the groups addressed Levels 1 and 2. In the second, participants in both groups merged into one of 14 participants and worked with the two moderators.

The patient

Joseph is a 30-year-old professional, married, with three children. The first child was the product of an unwanted pregnancy during his late adolescence. In the first meeting, the analyst describes him as a very rational person, correctly and formally dressed in an overcoat, suit, and laced leather shoes. This clothing surprised the analyst as unusual and unexpected in a person of his age. He found Joseph's discourse lacking in emotion, meticulous, monotonous, and dull, in contrast with the content: Joseph felt overwhelmed and had difficulty in organizing his life. He linked his feelings of guilt and anger to the birth of his first child. When the pregnancy occurred, he felt that he had no choice and submitted to the situation as well as to the family's demands: "You have to graduate." He victimized himself in the face of this situation and blamed himself for his absence during the first months of this child's life, when he devoted himself to his career. He still maintains a conflicted relationship with this son.

In the transference, the analyst experienced the patient's hostility while the patient did not make any contact with it. He made his analyst feel stupid and worthless. He responded to the analyst's interventions repeatedly, with "It's not that." At times, he placed the analyst in the role of the idealized figure of his grandfather, with whom he could think.

Levels I and 2 of 3-LM

Phenomenological observation and discussion of the patient’s transformations

Both groups observed positive changes linked to Joseph's subjective wellbeing. His experience of being overwhelmed disappeared; he began to feel that he could manage his life. His contact with his emotions, his ability to express them, and his capacity to relate to his children and friends improved. He moved from a position in which he did not allow himself to choose, often subject to the desires of those around him, to a position in which he began to make professional and emotional choices. He moved on to "playing at the big table," a metaphor that became an anchor point throughout the process. The two groups highlighted different aspects of the material. For one group, the narcissistic aspects of Joseph showed less change. The other group emphasized the weight of his moral ideals, which led him to assume altruistic behaviours that were detrimental to him. This aspect changed in the course of the analysis.

Dimensions of change that occurred in the analysis (Level 2)

The group worked on the changes in Joseph's "experience of illness," his interpersonal relationships, the predominant conflicts, and the structural aspects of his mental functioning.

Joseph appeared initially overwhelmed: "The wave passed me by." This expression represents a first anchor point. He could not cope with his work, his home, or his children. At the same time, he had an experience of confinement and of a house in disarray, of being on hold. He made his wife, parents, partner, and children responsible for his problems and felt misunderstood and subjected to the desires and decisions of others: "I didn't choose it"—an expression that he repeated throughout treatment.

After he had spent a year and two months in analysis, having increased the number of sessions, an anchor point containing a metaphor for Joseph's subjective situation showed modifications. He was anguished, afraid of the very changes he wanted, like "throwing oneself into the water" without knowing how to swim. Pleasant childhood memories, such as bathing in the sea with his father and his son also appeared as "murky waters," showing conflicts in his experience, e.g., the son being "lost in the sea" in a dream. The analyst referred to aspects of the child inside that Joseph feared to modify: "You got stuck in that child who could not say 'I don't want.'" The fear of loss concurred with the possibility of losing what he called "this space," referring to his analysis (for financial reasons), but also with a fear of deepening the relationship with his wife, which, although the analyst persisted, Joseph did not want to address.

Both the death of his paternal grandfather, an idealized figure, and his wife's affair had substantial impacts on him. While Joseph was open to address his grief over his grandfather's death in the analysis, he could not make contact with his pain and anger regarding his wife's affair, nor recognize his defensive denial and avoidance.

The group discussed how far the patient and analyst agreed on the transformations expected through the analysis. For the analyst, the expectation was that Joseph would be able to get in touch with his emotions, while for Joseph, the purpose of analysis seemed to be to put his life in order and to be able to choose.

Interpersonal relationships

At the beginning of the analysis, Joseph was more inclined to submit to others as figures of authority and did not show bonds of intimacy—problems that changed throughout the process. He maintained distant relationships characterized by submission to his wife and father. He felt cared for by his mother, but criticized: "What she gives you she charges you for." The rivalry with his sister seemed to cover up incestuous aspects: "We were unbearably on top of each other, but never in a positive way."

The second anchor point was "the Truco table"¹ in which he visualized the "big guys," family, and professionals. In the beginning, he felt he could not take part in the game as he felt less than they were, with no ability to compete in the way he wanted. At the beginning of the analysis, the transferential relationship was ambivalent. He was asking for help while he devalued the analyst for his interventions and the handling of fees. This relationship changed throughout the process: the analyst felt less controlled and became less bored. Joseph could recognize that he needed help and that the analytical space was important to him. He could voice his pain and anger and could hold onto the relationship with the analyst as a man who did not "slap him down." There were changes in the relationship with his son, whom he could previously approach only from the "cramped" position. He was able to play and have fun with him. He could relate this with the relationship he had with his father. The group questioned the extent of changes in his emotional distance and to his capacity to experience intimacy, especially with a woman.

Predominant conflicts

Submission vs. control and conflict with the demands of excessive superego moral ideals led Joseph to assume masochistic positions. An intense Oedipal rivalry emerged with the father, but, throughout the process, he could ask him for help and dared to grow and compete in his work. The

Truco game (card game) metaphor, in addition to this Oedipal rivalry, showed his conflicts about greed: he wanted to take it all. There was a predominance of defences of repression, denial, intellectualization, and isolation. They became more flexible throughout the analysis, as did the projection. The patient was able to perceive his internal states such as pain, rage, and pleasure better and began to recognize them in others (e.g., his son's and his wife's discomfort). His capacity for empathy increased.

Mental functioning

Joseph showed a strong identity but with secondary conflicting identities linked to hostile aspects with his father and negative oedipal aspects with the mother. At first he had difficulty regulating his impulses and emotions. Joseph could not control his anger and grumbling about his son for every small thing and could cry at a client's observation about his work. However, he appeared very controlled in his speech and presentation in the analysis, without emotions, moving in an all-or-nothing pattern of emotional regulation. At the end of the analysis, he regulated his self-esteem better, being able to face challenges with "the big guys" of his profession and being happy about it. He began to do things that he liked, that felt he deserved and could enjoy, in contrast to the image of his late adolescence, crushed by obligations. He brought dreams, associations, and childhood memories to the analysis, which opened up the possibility of thinking about himself. However, the group wondered if Joseph achieved a genuine capacity for symbolization. The relationship with his internal objects ceased to be so persecutory. With respect to his external objects, he improved his relationship with his son, he managed to get a new partner, and the analyst gave him an affectionate pat on the back at the end of the analysis.

Finally, both groups agreed that Joseph had a neurotic organization of his personality at the beginning of the analysis.

The Third Level of 3-LM seeks to understand the mechanisms implicit in the patient's changes. How and why have they occurred? The group analyzes the foci of interventions and interpretations of the analyst, their variation throughout the analysis, what kind of interventions worked best, and aspects that the analyst left out.

The foci of the analyst and their modification

The first focus of the analyst was on Joseph's masochistic functioning. The group understood some of the analyst's interventions as provocative and aimed at easing the patient's rigid defences. In some interpretations, the analyst's discomfort was evident, understood as a counter-transferential aspect linked to the patient's aggressiveness.

The interpretative foci (what in the patient's mind and problems the interpretations addressed) varied. The analyst sought to ensure that Joseph did not deny reality (his wife's affair) and could get in touch with his emotions: "What seems to be falling far short in our work here is your bond with your wife." "Is it comfortable for you not to work on this issue with me?" "Where did she come from?" "Didn't she go back to sleep?" "It's all very reasonable, but you got angry." "You're very angry and very hurt." "You get pretty disconnected, huh?"

The analyst supported Joseph in discriminating and separating his childhood objects and his current bonds throughout the analysis. His work helped Joseph to think more freely about himself, able to choose according to his interests, while still taking care of those around him. At the end of the analysis, the analyst enabled Joseph's decision to end the analysis, despite thinking that some conflicts needed further analytic work.

Types of interventions by the analyst and mechanisms of change in the patient

The group analyzed the possible mechanisms of change, discussing whether the analyst offered himself as a "new object," representing for Joseph a new emotional experience in containment and support. The transferential relationship changed from one in which Joseph repeated a way of being with someone in which he viewed himself as passive and the analyst as active through his interventions and interpretations. In the first stage of the analysis, he felt that the analyst "slapped" him with his interventions, repeating an aspect of his relationship with his father. Joseph stopped slapping his son, showing that the experience in the transference had affected his bonds with others. His ideals changed with transformations in trans-generational ideals represented by endurance, resistance, and work. Joseph showed ideals that were more flexible. Thus, he developed personal interests, which brought him significant changes and satisfaction in his professional life and relationships, and a more appropriate location in his chronological age.

Another mechanism of change was the introjection of the analytical function. This permitted Joseph to move from the obsessive rumination of the beginning phase to the reflexive function in the ending phase. The analyst acted as an auxiliary self, mirroring the split affects, adjusting to the transferential movements that Joseph proposed, including his proposal to end the analysis. The patient managed to incorporate the desire to know about himself and to have a less naive view of himself.

Aspects of the material left out of the analyst’s interventions

The group highlighted the patient's slip of the tongue—"Thinking that this is what I want as a woman"—which the analyst noticed but did not explore. Following the slip would have opened a path to enable contact with a passive, unconscious desire, "me as a woman," and to approach homosexual ambivalence. In the clinical material offered, it seems that the analyst could not work on the bond between Joseph's mother and father in depth. The internal image of the mother was of someone who crushed him and did not allow him to make his own decisions, resulting in a persecutory mother to the extent that there was no discrimination: "the mother hen who later charges you." In the transference, the analyst also gives and charges. The father appeared devaluated, despite Joseph's recognizing his help. He changed from submission to the authority figures to competition in his professional growth:

They told us that they consider us competition and on the one hand, it generated a little fear in me, and on the other hand it gave me a lot of pride in what we are achieving.... It is like they tell me to play but at the same time I feel, "Be careful not to bother the big guys."

The group discussed the fact that his aggressiveness did not appear more directly in transference with a male analyst. The analyst pointed out that there were changes in the patient's physical presence and in his way of expressing his emotions, such as the "soft hand" Joseph gave him at the beginning of the treatment turned into a "firm hand" at the end.

As an alternative hypothesis, the group raised the question of how the patient would have reacted if the analyst had proposed an adjustment of the fee, adapting the fee to the increase in his income. Some participants suggested that the analyst might not have proposed this change because the patient was under supervision in the training program, and he feared the patient would leave treatment.

Alternative theoretical hypotheses

Finally, we discussed ideas from different theoretical frameworks as alternative explanatory hypotheses for the patient's changes.

Joseph arrived with a rigid presentation, obsessive defences, and a masochistic enjoyment. The group discussed which theory it would be more appropriate to select in working on these difficulties. The analyst preferred the Freudian theory about Oedipal conflict, castration anxiety, and desire. At the beginning of the analysis, Joseph's ego appeared suffocated, crushed by superego ideals and the external reality in which he lived. The analytic work sought to make defensive functions and the permeability between psychic instances more flexible.

Members of the group proposed a Kleinian perspective to understand the patient's conflicts. They suggested a transformation in a schizo-paranoid functioning with the integration of split-off aspects of idealizationdevaluation, giving place to depressive affects. An alternating dynamic between schizo-paranoid and depressive positions, or, as Marucco (1999) describes it, the coexistence of different psychic levels of functioning. From this perspective, the incorporation of the good object allowed him to finish the analysis.

From a Winnicottian perspective, Joseph acquired the capacity to be alone in the absence of the analyst. From a Bionian perspective, he was able to incorporate the reverie function of the analyst, which would allow him to consult in the future if needed.

Conclusion

In both groups, participants worked intensively. In the second meeting, they took up the new questions proposed to discuss in Level 3. The integration of the two groups showed different emphases on the problems of the patient, although there was agreement on the changes observed. The three-month interval between the groups' meetings allowed participants a retrospective reflection and a resignification of the material. This schedule had a positive influence on the psychoanalytic conceptualization of the patient's transformations.

The new questions proposed in the third level contributed to rethinking the theoretical-clinical problems raised in the first levels and complemented the discussion of alternative theoretical hypotheses. They allowed critical reflection on central aspects in the analysis, which the analyst had not addressed, on the ending of the analysis, and on the explanatory theoretical hypotheses on the mechanisms of change.

Part 2: Working in changes of the different foci of analyst interventions with the third level—Marina Altmann de

Litvan and Nancy Delprestito

In this space we seek to show a work experience aimed at candidates, using the Three-Level Model. The clinical material belongs to a candidate-in-training who, out of generosity and curiosity, suggested to start penetrating this work model. This is an ongoing analysis material that poses certain questions to the analyst, which are connected to the patient's change process. This was discussed by a group in which both candidates and analysts participated.²

It is interesting, then, to observe what this new experience of using the model for a group to understand, think, and rethink the material offered, considering what the analyst added as well. We believe this last point to be extremely important because, at the beginning, we all held a personal view on the material, and, in the course of the exchange about the first two levels, our view on the patient was modified.

For this purpose, we will use the clinical observation of Level 3 as an example, the aim of which is to understand how and why changes occurred

• (or did not occur). Therefore, it discusses the explicit and implicit theories (Sandler, 1983; Canestri, 2006; Bleger, 2012) by which transformations can be explained, starting with those that are revealed in the analyst's interpretations. Participants were asked to propose alternative hypotheses or points of view coming from their own theoretical and technical frames (Bernardi, 2015). We will focus on groups of questions:
  • 1 What were the foci of the analyst's interventions and interpretations? Did the interpretative foci change throughout the analysis? Which interventions worked best?
  • 2 What parts of the clinical material were not pointed out by the analyst? Would you consider another type of intervention or alternative hypothesis that might have been useful to the patient?

Characteristics of the work proposal

The clinical material (four sessions: first interview, a session that took place two years later, and two more interviews) was given to the participants prior to the beginning of the discussion, and previous readings and videos were recommended to learn how the 3-LM works.

At the beginning of the first module they had to complete the form to first respond individually and, at the end of the work, they had to complete a new form to respond after the group experience.

In the discussion group, in view of the fact that the changes that had taken place were slight, it was suggested they meet again a few months later to see if what the group had contributed had resulted in modifications to the analysis. This was a novel experience that yielded very good results. This situation is quite rare in this type of approach.

The analyst accepted this new challenge, and, after a few months, we met again to continue working, particularly on Level 3 of the model.

As previously mentioned, we chose Level 3 to reflect on different alternative hypotheses, upon having observed slight changes in interpersonal and proximity relationships, as well as in the transferential bond, and taking into account the two years of analysis that the patient had undergone.

Presentation of the patient

J consulted because his partner, with whom he had a little child, told him she wanted a separation. Faced with this situation, he consulted at his partner's behest, yet unaware of his partner's problems, which he did not perceive as threatening. Although they were constantly fighting and making up, their relationship stayed the same.

His discourse was of marked disconnection from his affections. J said, "It is hard for me to express affection." When he expressed negative affection, he did not seem to consider its impacts. This could be seen very clearly in his relationship with the analyst. J displayed a series of obsessive symptoms: "I do not tolerate yawning." He pushed away or rejected smells, or anything related to the other's body. He presented "rituals," such as going to the bathroom right before starting every session. At the beginning of the sessions a method was developed, by which he remained silent unless the analyst started talking. He markedly controlled the analyst, by comparing her clothes with those of his partner. When his analyst got pregnant, it could be clearly observed that he rejected her, as he made hostile comments that she kept receiving by not answering accordingly. He made a bodily use of the analyst.

A distinctive feature of this patient was that, in each stage of his life, he had a different name. His first name was linked to his childhood, the second one to his adolescence, and the third one was his current name. Consequently, depending on the peer group he was with, he called himself differently, thus interrupting his existential continuity.

He came from a vulnerable economic background, but he currently was a professional who has overcome these hardships. However, when he contacted his old friends, he changed his clothes, thus hiding what he has achieved and displaying marked feelings of guilt.

Another key point was the death of his father, which clearly showed a "frozen" mourning. For example, his father's car had not been used since his death, and it had been hidden in the garage, out of sight. At this point of the treatment, he could open up and work on his loss. We think that it was through the work on the mourning for his father that his positive affections of love and sadness began to appear.

Over the course of almost three years of treatment, very slight changes in the closeness and proximity to his partner occurred.

In the discussion of Levels 1 and 2, the group agreed that the patient had a neurotic organization, with very rigid obsessive-type defences, yet still did not form a clear obsessive structure. Since his identity was fragile, there was a dependence conflict, a marked mistrust, and submission. Additionally, he had a poor capacity for empathy.

1 What were the foci of the analyst's interventions and interpretations? Did the interpretative foci change throughout the analysis? Which interventions worked best?

During the first years, the analyst's focus was to generate a high-trust environment between the two of them. J was a patient with a rigid defensive world, who attended his sessions thinking about everything he was going to say, all prepared, and distant from his affections.

Later, mourning for the dead father emerged. The analyst changed the focus of her interventions by trying to soften the hardness of his father perception, for all his references to his father were negative, which prevented him from the mourning that had been frozen until that moment.

The father had left a car, which had remained covered in his garage, so no one used it in over 10 years. The analyst used this object as a metaphor for what was frozen, and the patient could work differently on the relationship with his dead father, who was also dead inside him. Therefore, this prevented J from being a father to his own son. The analyst focused on the repression of representations linked to positive affects. She interpreted, for example, "It seems to me that today you talked about the love you feel for your father and the good he left in you."

The group, in complete agreement, proposed that during a whole period the analyst should place herself as a "new object," containing his cold, distant, and hostile stories. This was meant to promote a space of trust and a relationship of proximity, mainly as part of the transferential relationship, when the discourse became hostile towards the analyst.

2 What parts of the clinical material were not pointed out by the analyst? Would you consider another type of intervention or alternative hypothesis that might have been useful to the patient?

Sessions began once the analyst began to speak. In turn, the patient always asked to go to the bathroom before entering the office. This style had become a ritual, making it hard for the analyst to study these actions and look for a meaning in the affects that appeared in his actions.

Another thing observed by the group was the omission of sexuality and his relationship with the female figure and with the analyst in transference. This focus appeared clearly in a dream the patient had. It was a long dream, so only some parts are discussed: "I sort of had a lover . . . and at some point I gave her a kiss and we went down . . . and she asked me if I still was with that woman, my partner.... We went up and down a narrow path." The analyst's interventions were aimed at breaking down the dream into questions, omitting interventions that targeted the forbidden, incestuous childish sexuality that he kept repressed.

In another moment the patient said, "The contact with the semen: I ejaculated but not inside her; I went to the bathroom to wash my hands for fear that I could have sperm and thus get her pregnant." This way of telling the story in a stark way made it difficult for the analyst to find the right words to express the content of fantasies or fears that were typical of the mapping of his childish sexuality, which were deeply rooted rituals.

Members of the group only read the analyst's interventions, and finding that the analyst had intervened mostly in an interrogative way was revealing. This method made the group think that she was implicitly using a classic Freudian model, which promoted associations such as those that arise from dream analysis.

The group proposed an alternative mode to try to make the patient talk about his feelings. Therefore, instead of using an interrogative mode in relation to his thoughts, like "What do you think?," "What are you thinking about?," the analyst was asked to encourage his talking about his emotions: "How do you feel about this?" Considering that J was highly disconnected from his affects, the analyst's interventions further strengthened his rationalization mechanisms. The analyst was surprised by these observations, while at the same time perceived her difficulty in formulating interpretations that evoked and touched on unconscious content.

Final reflections

As opposed to the initial question—"What does the use of a methodology such as the 3-LM to discuss clinical material offer to analysts-in-training and to analysts who have completed their curricular training?"—we can say the following.

Addressing the analytical training, different authors (Altmann & Franch, 2006; Altmann et al., 2015) have pointed out that "the analytic function" is consolidated over the years through a construction of the analyst that is supported by the tripod: seminars, supervision, and personal analysis. In this construction of the analyst as such, which occurs during training, the analytical thinking achieved is emphasized.

In training, the "analytic function" is amplified and enriched when the group produces new outlooks that amplify the internal dialogue of the analyst with themselves and with their own clinical thinking and the one generated by the workgroup. This links personal theories with different theoretical frameworks, thus enabling dialogue from the most concrete clinical thinking to the most abstract.

However, this emphasis on the subject-in-training sometimes leaves the patient aside, yet the emphasis is key to methodologies such as the 3-LM. The model of the three levels allows for observation of external and internal relationships and psychic changes of different degrees and qualities.

The weight of the unconscious transmission, in groups or individually, should not leave aside inclusion of the working models that have been developed by the different working parties of the International Psychoanalytical Association and the Federation of Psychoanalytic Societies of Latin America. These group experiences provide a new perspective in training by establishing a third group view of an analytical process over long treatments.

We continue ratifying what the 3-LM offers. It provides the opportunity to analyze clinical material that spans several years with a protocol that invites reflecting analytically, with questions that look at separate dimensions of a psychoanalytic process, thus helping to locate aspects in which psychic changes were or were not produced (in the descriptive level and in the second level of the dimensions of change). Additionally, it enables the formation of alternative hypotheses that can promote delving into conflicting aspects of the patient and of the analytic relationship. Working with different levels of conceptualization allows the candidate to reconsider concepts with greater accuracy. The model strongly focuses on the patient, and how the patient has benefitted over the analytic process or how the process could be modified, by delving into the material and establishing a more rigorous structure.

Thus, we find that "mini partial theories" arise from analysis of the analyst's interpretations, which are directly linked to the problems presented by the patient. This is what we mean by "clinical thinking."

Therefore it is enriching for the analytic training to have these methodologies introduced, following what Bohleber (2012) and de León and Bernardi (2005) claim about the importance of the free circulation of alternative ideas and their discussion in a respectful, critical, and creative environment.

The Frankfurt experience

Part 3: The Three-Level Model for Observing Patient Transformations: The Frankfurt Psychoanalytical

Institute—Marianne Leuzinger-Bohleber, Lisa Kallenbach-Kaminski, Rosemarie Kennel, Anju Labuhn, Luise Laezer, Susanne Landsiedel-Anders, Sebastian Ohlmes, Gertrud

Reerink, Sarah Römisch, Jörg Scharff, Karin Schwind, Erwin Sturm, and Heike Westenberger-Breuer

Institutional context

The question of how psychoanalysis educates its next generation is as old as psychoanalysis itself. After the IPA decision that in the future, three to five weekly sessions in psychoanalytic training will be accepted, many controversies have been rekindled (see, inter alia Bohleber, 2019).

In 2000, under the presidency of David Tuckett, the European Psychoanalytical Federation (EPF) initiated groups to discuss and optimize training and exchange among psychoanalysts of different traditions and cultures. After 10 years, a mid-term review was carried out at the EPF Congress in Copenhagen (2011) to decide which groups should be continued. The Clinical Comparison Methods (CCM) groups, for example, used detailed reports of psychoanalytic sessions to examine how psychoanalysts work with their patients, what specific treatment techniques they use, what models they have in mind, and how they are influenced by their conscious and unconscious identifications with specific psychoanalytic groups, concepts, etc. One of the most important results of the CCM groups, in my opinion (MLB), was that a new culture of mutual listening to each other was created. Instead of the unfruitful "wars of faith" about which psychoanalytic theory was "the best," "the true and only," it was now necessary to critically reflect together on the opportunities, but also the risks of theoretical pluralism in contemporary psychoanalysis.

In view of these achievements, I (MLB) proposed in a panel at the EPF conference in Copenhagen that this culture of mutual listening and understanding in times of theoretical, clinical, and scientific pluralism should now be made fruitful for our central concern in psychoanalytic treatment: to focus on the changes of patients in psychoanalysis. As important as the analysts, their theories, and treatment techniques are, psychoanalysis is not an end in itself. Ultimately they always serve the desire to initiate lasting psychological transformations desired by our patients (Leuzinger-Bohleber & Arnold, 2020). Only because patients are suffering and wish that they would feel better after psychoanalysis or psychoanalytic treatment do they seek us out. This also applies in a particularly challenging way to training cases.

The Project Committee on Clinical Observation of the IPA (formed in 2009) faced up to this complex task and developed the Three-Level Model for Observing Patient Transformations (3-LM) in the last nine years, which is presented in great detail in this volume (see also Altmann, 2014). The application of the 3-LM to observing patient transformations in international groups has become very' popular among psychoanalysts in the IPA. On the one hand it is based on tried and tested forms of case discussion (supervision/interview) and, on the other hand, an invitation to systematize discussions and assessments within a formal framework. It offers the possibility for psychoanalysts with different theoretical orientations to refer to common criteria.

Our group in Frankfurt used these promising opportunities of the 3-LM in two different institutional contexts.

Supplement to the quantitative research in the LAC

Depression Study

We used it as a supplement to the sophisticated quantitative research of the large outcome study, the LAC Depression Study, in which 252 cognitive-behavioural and psychoanalytic long-term treatment with chronically depressed patients have been investigated (see Leuzinger-Bohleber et al., 2019a, 2019b). With the help of the 3-LM we investigated the transformations in several psychoanalyses in detail and systematically in the weekly clinical conference. The 3-LM enabled us to conduct a series of single case studies to improve the quality of the narrative summaries of these treatments focusing on different aspects of the transformations of the patients. Some of these narrative case studies now will be published in Was nur erzählt und nicht gemessen werden kann. . . . [What can only be told and not measured. . .], edited by M. Leuzinger-Bohleber, U. Bahrke, and A. Negele (2020).

Tool for understanding transformation processes in training cases at the Frankfurt Psychoanalytic Institute

Based on these inspiring clinical and research experiences in the frame of the LAC study, the idea was bom to offer the 3-LM to a group of training candidates. The aim was to discover together if and how the 3-LM is suitable to discuss training cases systematically and creatively in a mixed group of candidates and training analysts. The aim was to examine in clinical psychoanalytical terms whether and how transformation takes place in the hope that the insights gained will prove helpful for the candidates involved.

Application of the 3-LM in psychoanalytic training

In the last three semesters, weekly evening sessions were held, in which about six candidates and four training analysts took part. After an introductory session in the 3-LM, one candidate presented one of her ongoing psychoanalyses in four sessions each. We discussed seven psychoanalyses. In the first session, the initial interviews, the health insurance report, and a psychoanalytic session from the initial phase were presented in detail, leading to the definition of "anchor points" (Bernardi, 2014, p. 8; i.e., central issues and conflicts) that are important for the patient, whose transformation, i.e., change or modification over the course of treatment, is to be studied. In the second session—each time after a short summary of the analytical process since the discussed session—a psychoanalytic session from a later phase—in the third session a recent psychoanalytic session—was discussed in detail. The fourth session served to discuss the transformations that had taken place with reference to the third level of the 3-LM.

Impressions of group members involved in working with the 3-LM

All members of the 3-LM group at FPI found the 3-LM experience an intense, enriching experience. The intensive study of detailed clinical material from the same psychoanalysis over four evenings proved to be worthwhile and expanded insight into conscious and unconscious dimensions of the analytical process. Although the detailed documentation of the often intensive and sometimes controversial group discussions was time-consuming, it resulted in a valuable report of the successive understanding of the clinical material. It proved to be helpful for the candidates as well as for the participating group members not to lose sight of the forest for the trees.

It took some time for the group to find a productive way to discuss Level 3 and the attempt to illuminate the transformations that had taken place from different theoretical perspectives. These discussions became increasingly fruitful. To mention just one example, discussing Level 3 of the third psychoanalysis, which we had discussed, the training analysts tried to apply a developmental-psychological, gender-specific approach, trauma-specific considerations, Kleinian object relationship theory, and a drive theory explanation to the same clinical material. It remains an open question whether this can offer the candidate a helpful orientation in times of theoretical pluralism, or whether it represents an excessive demand. One candidate described how she struggled in her treatment to avoid theoretical "top-down" views ("putting theories on top of each other"). The differentiation of the three levels of 3-LM is intended as an aid in dealing with this danger. First, an attempt is made to discuss transformations on a phenomenological level (Level 1). Level 2 is about individual dimensions of observation, which are to be described with clinical material, very concretely (e.g., looking at the changes in the patient's relationship with his external libidinal objects, his inner objects, his transference relationship with the psychoanalyst, etc.). Only in Level 3 is an attempt made to "play with the theories," in the sense of dealing with the richness of theories in contemporary psychoanalysis. Depending on the setting of the (theoretical) kaleidoscope, other structures become visible in the complexity of the clinical material.

One specific problem area should be mentioned briefly. One teaching analyst had feared that our seminar could lead to conflicts with the supervisors of the training cases. This concern was not justified. The 3-LM offer is intended as a supplement, not as an alternative to regular supervision and technical seminars within the psychoanalytic training. It is well known that the continuity and the holding function of a (responsible) supervisor for a training case is needed to provide a safe, holding, reflective "home base" in the sense of case-based learning. However, the downsides of such a personalized learning model have been the subject of repeated critical discussion within the IPA (e.g., by Otto Kemberg). The master-student relationship carries certain dangers, such as submission to authority, hindering one's own innovative and creative development, etc. It sometimes reminds one of religious as opposed to scientific institutions. The experiences in the small 3-LM group are especially interesting against this background, as they enabled the recurring experience that perceptions, perspectives, understanding of sense structures, etc., could be quite different among the four training analysts (as well as the candidates), sometimes complementing or contradicting each other, etc. However, it is always important to stress that the 3-LM discussions are about expanding psychoanalytic understanding in an open space of creative clinical thinking. Its aims are not evaluations and assessments! This is particularly important in difficult treatments: the responsibility for the treatment lies, of course, with the treating analyst and his or her supervisor!

We also discussed whether the great amount of time and intergenera-tional commitment is really worth it. In this context a modification of our approach in 2019/2020 proved to be useful: the four training analysts each committed to only four evenings (the discussion of one case). This limited the commitment and time of these colleagues. An additional advantage was that candidates lying on the couch of one of the training analysts could participate in those evenings where other training psychoanalysts were present.

It is also very important that the 3-LM is accepted as a regular component of psychoanalytic training, because today's candidates are very busy. Therefore it is also helpful for some candidates if they can use the 3-LM seminar as a direct and indirect preparation of their case presentation to conclude their analytical training.

The following is just one exemplary feedback from one of the candidates.

Making lived psychoanalysis tangible for the next generation—Luise Laezer

While even the best-case seminar, in which one presents one's own case once during the semester, remains an important experience, and the considerations coming from the group and from the lecturers refer mainly to the respective presented session, the 3-LM model seminar with four sessions per case offers the opportunity for an in-depth exchange, in which the entire treatment, from the beginning to the current phase of treatment, and even beyond that comes into view. This is something very special and valuable.

Not only was I able to experience what the training analysts were thinking clinically and conceptually about one specific session, I also had the opportunity to observe the different trains of thought of the experienced training analysts throughout the complete analysis of the treatment. I was able to feel how training analysts, drawing on their experience and including past and current cases, deal with the wealth of transference/ counter-transference observations, how they would react professionally in difficult clinical situations, how they would "digest" them and embed them conceptually. I could observe that some working hypotheses have to be discarded, that it is always a challenge to acknowledge ignorance and that we analysts can nevertheless trust the analytical method, the "talking cure," again and again.

What was unusual about the exchange was the composition of the group. While the team teaching in normal clinical seminars of our psychoanalytical training with two, sometimes even three lecturers for 15 candidates is a great gain, the distribution of four training analysts and six candidates was almost a 1:1 supervision and felt like an authentic meeting of the generations at eye level. Throughout the two semesters of the 3-LM seminar in which I have participated, the hard work of the candidates in their treatments was recognized at every moment, which was a balm for the analytical psyche in training. My analytical superego also found relief in the two semesters, because it no longer pressed so hard for "the one correct" interpretation and "the one correct" theory, but increasingly enjoyed the variety of psychoanalytical concepts.

From the perspective of a candidate I can say that through the 3-LM seminar the lived and even suffered psychoanalysis, as a profession in its most diverse facets and its great moments, became tangible, and tangible for me. Just as good surgeons can only pass on their experience to the next generation in their joint practical work at the operating table, the 3-LM seminar enabled me to participate in such a practical transfer of psychoanalytic experience and experience. Many thanks to you, my dear teachers!

Notes

• 1 Truco (trick) is a card game from Rio de la Plata, the most popular one in Uruguay, in which two individuals or teams compete against each other to gain points by beating the other's cards based on a given hierarchy and lying to fool their opponents.
• 2 Psychoanalytic Association of Uruguay. Three groups of 10-14 analysts and candidates. Clinical observation group organized by the Committee of Clinical Observation, the Education Committee, and the Scientific Committee. Levels 1 and 2 were developed over two sessions, and Level 3 was developed three months later during one session.

References

Altmann, M. (2014). Time for change: Tracking transformations in psychoanalysis—The Three-Level Model. London: Karnac.

Altmann, M., & Franch, N. (2006). La formación analítica y la actividad analítica profesional en América Latina [Analytic training and professional practice in Latin America]. Sub Comité de Investigación-Educación de FEPAL [FEPAL Training Research Sub Committee]. Unpublished.

Altmann, M., Marucco, N. Devoto, T., Andrade, A., Franco, G., Minuchin, L., Mion, C, Petrucci, J., Rojas Urrego, A., Yamhure, E., & Baptista Franca, J. (2015) ¿Cómo ven los analistas el futuro del psicoanálisis en América Latina? [How do analysts see the future of psychoanalysis in Latin America]. Comité de Educación de FEPAL [FEPAL Training Committee] Research. Presented at FEPAL Congress.

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: Karnac.

Bernardi, R. (2015). What kind of discipline is psychoanalysis? International Journal of Psychoanalysis, 96, 731-754.

Bleger, J. (2012). Theory and practice in psychoanalysis: Psychoanalytic Praxis 1. International Journal of Psychoanalysis, 93(4), 993-1003.

Bohleber, W. (2012). The use of public and of private implicit theories in the clinical situation. In J. Canestri (Ed.), Putting theory to work: How are theories used in practice? (pp. 79-81). London: Kamac.

Bohleber, W. (2019). Die Geschichte des Eiitington Modells und seine Bedeutung für die psychoanalytische Ausbildung. Psyche - Zeitschrift für Psychoanalyse, 7,477-496.

Canestri, J. (2006). Implicit understanding of clinical material beyond theory. In J. Canestri (Ed.), Psychoanalysis from practice to theory (pp. 13-28). Chichester: John Wiley.

de León, B., & Bernardi, R. (2005). Contratransferencia y vulnerabilidad del analista [Analyst's counter-transference and vulnerability]. In S. Lewkowicz & C. Laks Eizirik (Eds), Verdad, realidad y contribuciones Latinoamericanas al psicoanálisis [Truth, reality and Latin American contributions to psychoanalysis] (pp. 23-41). Montevideo: International Psychoanalytic Library.

Leuzinger-Bohleber, M., & Arnold, S.E. (2020): Introduction: outcome research and the future of psychoanalysis. In M. Leuzinger-Bohleber, M. Solms, & S.E. Arnold (Eds), Outcome research and the future of psychoanalysis: Clinicans and researchers in dialogue (pp. 1-26). Abingdon: Routledge.

Leuzinger-Bohleber, M., Hautzinger, M., Fiedler, G., Keller, W., Bahrke, U., Kallenbach, L., & Küchenhoff, H. (2019a). Outcome of psychoanalytic and cognitive-behavioural long-term therapy with chronically depressed patients: A controlled trial with preferential and randomized allocation. Canadian Journal of Psychiatry, 64(1), 47-58.

Leuzinger-Bohleber, M., Kaufhold, J., Kallenbach, L., Negele, A., Ernst, M., Keller, W., & Beutel, M. (2019b). How to measure sustained psychic transformations in long-term treatments of chronically depressed patients: Symptomatic and structural changes in the LAC Depression Study of the outcome of cognitive-behavioural and psychoanalytic long-term treatments. International Journal of Psychoanalysis, 100(1), 99-127.

Leuzinger-Bohleber, M., & Bahrke, U. 1., & Negele, A. (Eds). (2020). Was nur erzählt und nicht gemessen werden kann. . . . Veränderungsprozesse in Psychoanalysen der LAC Depressionsstudie [What can only be told and not measured. . . . Change processes in psychoanalysis of the LAC Depression study]. Giessen: Psychosozial Verlag.

Marucco, N. C. (1999). Las neurosis hoy: en las vías de acceso a las "zonas psíquicas." In N. C. Marucco (Ed.), Cura analítica y transferencia. De la represión a la desmentida. Buenos Aires: Amorrortu.

Sandler, J. (1983). Reflections on some relations between psychoanalytic concepts and psychoanalytic practice. International Journal of Psychoanalysis, 64,35M5.

Experiences in progress

Part 4: A Buenos Aires experience with candidates of the Argentine Society of Psychoanalysis—Liliana Fudin de Winograd

Introduction

For a few years we've been implementing the 3-LM in the Argentine Society of Psychoanalysis' (SAP) Training Institute, as we consider it a significant tool to help our candidates (psychoanalysts-in-training) deepen and expand their capacities for observation in their practice.

In 2019 we realized that it would be impossible to have all participants use our original format of two consecutive meetings of four to eight hours. We couldn't burden our students with 12 additional hours of training, given that they worked long hours, spent significant time in training, and had family commitments.

For this reason, we arranged a format of two five-hour sessions, one in May and one in October. For both we used the same clinical material: a first interview consisting of the candidate's notes, and two sessions, one before the patient completed her first year of therapy and one when the patient began her third year. We used transcripts for the latter two sessions.

We focused on Level 1 in the first five-hour session, and on Levels 2 and 3 in the second session. Most of the psychoanalysts-in-training already knew the 3-LM because they'd worked with it in prior years. We also invited two experienced SAP psychoanalysts to participate, one in discussions at Level 1 and one in discussions at Levels 2 and 3. We shared the clinical material with them, and they joined the group after the candidates had discussed the material by themselves for two hours. For Level 1, we asked the expert to focus on phenomenological aspects. For Levels 2-3, we asked the expert to adapt the 3-LM as appropriate.

We invited these two experienced psychoanalysts because the 3-LM coordinators thought it important that our candidates learn from psychoanalysts who emphasized observation of what was happening during a session. Both had worked with David Liberman, who had included a focus on the linguistic aspects of the clinical material, based on the hypothesis that changes in the patient's linguistics corresponded to changes in the patient's psychical structure. Besides, both experts had made unique contributions to the understanding of the interactions between patient and therapist.

Conclusion

The experience led to significant insights for all participants. We realized how important the coordinator (or coordinating function) was to help students categorize their observations, as categorizing observations improves the analyst's ability to follow and understand the patient's transformations.

LEVEL I

The observations made by the candidates as a group agreed with those of the experienced guest analyst. The latter remarked that students' observations that might have seemed unrelated were delicately intertwined, and such intertwining created what could be considered, epistemologically, a "coherent" empirical understanding. He also emphasized how important the therapist's phenomenological descriptions were when integrated into the interpretations, for the patient to begin to understand his own problems.

LEVEL 2

The expert asked for more clinical material to better understand the candidate's work. We gave him transcripts of two sessions that took place in between the two sessions, the transcripts of which we had already provided. We shared the additional two transcripts with the candidates in the Level-2 meeting.

At this level, we coordinators didn't refer to the questions in the 3-LM protocol but observed that the group discussion answered most of them spontaneously. The experienced guest analyst, also an experienced educator, explained how to diagnose and evaluate a therapeutic process, demonstrating with examples from his own observations regarding the clinical material discussed.

We conclude that both meetings using the variation on the model enriched and consolidated our candidates' competences in observing patients' transformations.

The Peruvian experience

Contribution of the 3-LM Model to the psychoanalytic

training in the SPP—Mayela Falvy

The opportunity to conduct a Three-Level Model group with the analysts-in-training of the Institute of the Peruvian Psychoanalytic Society was promoted by Oscar Rey de Castro, the scientific secretary of the institute, and there was a very good attendance.

The 3-LM group experience had a variety of aims: importantly, to make the model more widely available, especially with respect to its objective to refine observational skills in the clinical work of the candidates, and more broadly, to develop their imaginations and creativity in the psychoanalytic field.

From the beginning, the group was both interested and perplexed. The clinical material was handed out in advance and raised concerns and also curiosity about the numbered lines, in accordance with the model. The importance of considering the different phases of the analysis (beginning, middle, end or recent) in order to visualize the changes or absence of changes that occurred during the treatment was discussed.

The clinical material was read without interruption, with the goal that the candidates would be engaged by what they perceived, and the effect was to arouse a certain unsettledness, since analytic material is usually read in paragraphs, with pauses for discussion and understanding of certain lines in the text. It was possible to continue without interruption, and that modified the group's way of attending and analytical listening.

The candidates' contributions took place spontaneously and highlighted the content of the material that aroused interest. Little by little the connections between the lines in the sessions were made and observations and comments arose freely among the group. There was no difficulty in getting into the task; although it was important to present the model as a very valuable kind of work to expand analytic openness and deepen clinical thinking, it was also to contribute to the enrichment of the candidate's individual process in becoming an analyst. It was pointed out that the experiences and the concerns arising while working with the 3-LM would contribute to the candidate's incorporation work as psychoanalysts of the Peruvian Psychoanalytic Society.

As the group work went on, the commitment to the task became stronger. Comments and open contributions flowed among the participants; they entered dialogue, making references to the lines in the material, showing consistencies and inconsistencies with ideas on difficulties and change being discussed. Although some comments referred to analytic authors and theories, these were translated in order to return to the observations and creative reflections that were arising. There was a natural affective tone, and differences were respected. The analyst-in-training who presented the case maintained her role, intervening or not intervening, according to what was presented in the clinical material. It was interesting to witness the active participation and natural exchanges among the group members, which continued during the breaks.

I believe that the 12 hours of work over two days motivated all the analysts-in-training. Throughout the work, the group maintained interest in the way change happened in the patient, her expressions and verbalizations, and also kept highlighting the dispositions and abilities of the candidate to stay with the difficult moments that the case offered. With respect to the transference and counter-transference, there were variations and developments in the discussions, which modified the group's perception of the patient. The observations evolved from a generic view based on the symptoms, towards recognition of the presence of a person in deep anguish, with unresolved conflicts, and the urgent demand to be tolerated in the real world.

The articulations of the analysts-in-training also underwent transformations. The language evolved and became more open and colloquial, expressing affects and emotions, and even doubts and uncertainties were shared with curiosity and commitment.

It was a wonderful experience that generated positive feedback. It is also important to notice that the intensity of the training seems to make it difficult to increase the frequency of this kind of encounter. I would take this into account for future projects.

Chapter I I