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VI Clinical observation groups and the psychoanalysis of children

Chapter 12

Observing transformations and interventions in a child analysis through the 3-LM

Observing transformations and interventions in a child analysis through the 3-LM: The case of a 5-year-old girl

Marina Altmann de Litvan, Griselda Revella, and Patricia Singer

Introduction—Marina Altmann de Litvan

This section presents the clinical observation of children using the 3-LM by the IPA Clinical Observation Committee. The method was adapted for this stage of development by Altmann de Litvan, Miller, and Bernardi, and already presented in our first book, Time for Change: Tracking Transformations in Psychoanalysis—The Three-Level Model (2014).

Here clinical cases are presented that have been observed using the model, along with some reflection upon it.

Several childhood aspects were key in this process: the role of play, the influence of interpersonal factors, family, etc.

In this second book, we thought it interesting to present two examples of patients that—in the clinical material—reflect the evidence on the transformations they underwent during their analyses. One case shows in detail the work on different levels on a 5-year-old girl. The second is the case of a 5-year-old boy who lost his mother at a very young age.

Observing transformations and interventions in a child analysis' through the 3-Level Model: The case of a 5-year-old girl—Marina Altmann de Litvan, Griselda Revella, and Patricia Singer


This chapter is about the use of a version of the Three-Level Model for Observing Patient Transformations (3-LM) designed for children. It was formulated by Marina Altmann de Litvan, Delfina Miller, and Ricardo Bernardi (2014) and published in Time for Change: Tracking Transformations in Psychoanalysis—The Three-Level Model.2

The model explores whether analytic intervention fosters intrapsychic, intersubjective, and structural transformations, taking into account the patient's stage of development.

In this section, we will describe the application of the model to clinical material of a girl in analysis from 5 to 9 years old. To apply the model, we selected clinical vignettes capturing different moments of her analysis.

We used the 3-LM as a guide, forming a working group to observe and evaluate the analytic process and possible transformations.

The girl was in analysis starting with two weekly sessions during the first three years, and one weekly session during her last year of analysis.

Introduction to the patient

Lorena, aged 5 years and 5 months, was referred to the analyst by her school because she was having a hard time getting along with her teacher and peers, displayed markedly oppositional behaviour, and was not open to learning.

When she was 3 years old, her parents were referred to a specialist because Lorena's teacher observed that she was flapping her arms, walking on her toes, couldn't step firmly on the floor, and avoided eye contact.

Concerned with Lorena's oppositional behaviour in school, the parents came to see the analyst. They choose to sit on the same couch, squeezing next to each other and leaving the other couch empty. They feel overwhelmed and lost and say, "None of the strategies ever worked," referring to Lorena's constant arguing with her parents.

The parents say that Lorena is unlike her older siblings, who did not cause any problems growing up, and the father says that it would be "impossible to uncover one in order to cover the other," when he refers to her constant attention-seeking behaviour.

The mother, anguished, asks herself what she can do to help her daughter. She describes aspects of her own life, a hostile relationship, and much rivalry with her mother and sisters—a chain of women in which she feels diminished.

The mother describes her past and how she was able to get through her childhood "doing whatever she could and without therapy." She seems to project it in her daughter, setting off a permanent tension between the intrusion and the absence of libido.

During the parents' narrative, the child is lost, without a name; an empty space is marked by the empty couch, to such an extent that, when the analyst needs to refer to the child, it is hard for her to remember her name. It feels as if the parents bring a dark shadow into the room with them. In response, the analyst did intense parallel work with the parents during the child's treatment.

When Lorena was 3, a series of traumatic family events occurred, and the girl was "thrown in school for various hours per day," according to the mother.

Since the initial sessions, Lorena shows not only how fragile but also how resourceless she is. When the analyst first meets Lorena, her rigid body, hypertonia, and dark look in her eyes stand out. She is short and slim, has a robot-like walk, a hoarse voice, and dark hair. Everything about her projects darkness.

In view of the above, the working group set out to explore Lorena's clinical material, applying the 3-LM, starting at a descriptive level, continuing with a second level to identify the main dimensions of the transformations, following with a third level testing the explanatory hypotheses of transformation. At each level, the group explored what transformations occurred in each of the points considered.

Level I: Phenomenological description of the transformations

The 3-LM poses a series of questions for this level, and the working group selected several for discussion: Which parts of the clinical material have special resonance within the participants of the clinical observation group regarding the transformation? How does the patient use her own mind and body during the session? Are there changes in the answer to these questions in view of the intensity of transference?

There are different anchor points (lines of force, as named by Marta Nieto, 1965) that capture complex problems in the psychic functioning, such as play, fears, fantasies of madness and death, body, and family interactions.

By applying the 3-LM, analysts can go back to the original hypotheses explaining central issues explicit or implicit in the points, moving back and forth between earlier and later sessions. By exploring these lines of force, we can better understand their dynamic meanings and vicissitudes in later phases of analysis.

Analysis of play

In the version for child patients, the 3-LM emphasizes the role of play, since it is a natural form of expression for the patient, as well as a valuable means of exchange with the analyst, where the patient displays desires, anxieties, fantasies, defences, and object relations. Not only can it be used to evaluate the patient's development level, abilities, and personality organization, it is fundamentally through play that we will foster the growth and emotional development of the child. Sexual drives, knowledge drives, infant sexual theories, and expression through play are clearly linked and displayed in a pleasant act, compromising the body during the enactment (Freud, 1905). Their nature allows us to understand the dynamic level of conflicts and structural aspects of the organization of the psychic apparatus. Their creative display separates them from the fixedness of the symptom (Freud, 1908).

Since it is an activity driven by desire, it allows the child to play out a script in which it displays unconscious dynamics without losing the commitment of the id with a reality that nurtures it and that they transform. Playing is therefore an expression of the psychic work that reveals and leads to structuring. It is a link between the hallucinatory realization of desires and the realization of desire by an examination and modification of reality, in that passage, never completely achieved, that goes from the reality principle to the pleasure principle (Volinski de Hoffnung et al., 1986). It was by precisely focusing on the study of play that Melanie Klein (1962) based a large part of her theories about the development of mental functioning, the nature of infant psyche, focusing on the close contact between conscious and unconscious anxieties, fantasies, and defences.

A child's play displays projection, elaboration, and unloading, so we emphasize the need to interpret the child's play. In order to do so, we play with the child and for the child, in transference, enabling the symbolic repair of internal objects and of the representation of the child's self. The interpretation, in turn, favours the display of the game, as it relieves the child's effort to withhold repression by helping to synthesize and integrate the different contents. The close relationship between fantasies and structuring allow us to influence mental organization through analysis.

By playing and interpreting play we are able to modify the fantasies about internal and external objects and the anxieties and defences attached to them. Thereby, we can generate a transformation in the child's functioning. We agree with Winnicott that, in order to carry out infant analysis, the analyst must know how to play, and the patient must be able to play (referred to by Volinski de Hoffnung et al., 1986). The play that takes place during analysis in that intermediate space between the analyst and the patient is a valuable creation for analyst and patient. Its structuring condition, especially of play that occurs during treatment, is the reason we focus on the analyst's observation, not only to understand the child but also, in this case, to evaluate the analytic process and the patient's development.

Communication during child sessions occurs mainly through action and play, sometimes accompanied with language. Even when action and play imply different levels of symbolization, we can identify a sequence tied to unconscious fantasies that goes from the more corporal expressions linked to release and exploration to other levels of increased symbolization.

This "making" is a precursor to thought, and this display of action and play allow the analyst to observe the child's functioning and evaluate changes.

One aspect of the analysis that stood out for the working group was the patient's type of play. On this subject, Paulina Kemberg (1996) asks some important questions. Is it age-appropriate? Are there changes in the type of play throughout the process? What themes does the child develop? What affects prevail? What kind of relationship is established with the analyst during play?

Play in this analytic process varied from symbolic to concrete body expressions.

The analyst explains:

I realized that it was hard for her to start playing. For a long time, Lorena would begin saying, "I'm not sure what I want to play with." I felt that the freedom to choose a play and to use a space to play made Lorena uncomfortable. It was new to her. Later, she became obsessed with classifying things by size, ordering different spaces, and designating a particular space for each animal. The excessive attention paid to the smaller animals attracts my attention, and I wonder if it was her way of showing me her subjective experience of feeling very diminished, lost, and without a place.

Of all the animals, a small pig became her favourite object. In every session she worried about losing it. She says,

P: Not again! Things got complicated with the cow and lion... . All the cows are mixed up. I'm going to line them up, so they look tidier and they don't fall down. The little yellow cow will go last. Things got a little complicated. The little elephants in front because they’re so small.

A: You are trying to arrange the places in your family. This worries you a lot.

P: Yes, in my little head. My little head thinks a lot about what I need to do. This small one goes last, no, the mother last. And I'm not sure what to do with the shark. I'm going to think about it, in front of the crocodile, that takes the places. Since it's so small, small things, very small things, I mean very small things, very small, get lost.... Yes, I'm scared I’m going to lose my favourite toys because that’s how small things get lost, or the tiles will open up and they'll fall through.

Here Lorena shows clearly how she uses her mind and body during the session. The analyst's interpretative focus is on providing order for the child's confusion. Lorena says that her little head is full of complications as she tries to play. When she does, there is danger, mix-ups, and falls.

She seems to be able to put her confusion and fragility into words and she starts showing some of her important resources.

The narrative continues:

P: Yes, the words have a shiny road. The words are here: book, table, food. I need to go to the bathroom to go poop.... The small ones are driving me crazy.... I need to go poop.

A: Perhaps poop is a way to show me the awful things you feel inside.

The working group observes how her play expresses the strength of a pre-Oedipal sexuality, both oral and anal.

We believe that there are moments of much anguish, where the amount of symbolic play decreases and the child acts out her inner experiences.

Likewise, separating herself from the feces refers to distances that can be "illuminated" with language. Perhaps she feels that what she loses in letting go of her feces can be recovered with the "luminous" words she receives from her analyst.

Of the two levels that she uses to express her losses, verbal and action, we emphasize the following: "I would like to play what I never saw and what I always saw," as an auspicious sign of transference that brings to mind Christopher Bollas's phrase "the unthought known" (1987).

She says,

P-. I make a lot of noise because I don't like school. . . . Come on, help me build a house. No, instead, costumes for animals. One had to be the wolf, better yet dogs, better there's a girl, no, a monster. . . . I turned into a little pig, oink, oink. Do you want to jump in the mud with me? (Let's play that we're little pigs lying in the mud).

Lorena stands up and says, "I'm full of bananas; the bananas are falling, the bananas are on my head."

A: You're very worried. You don't know how your new teacher will greet you, but you're neither a little pig, nor a boy with bananas; you’re a beautiful girl!

P-. I'm going to draw before leaving . .. a girl.

A: A girl just like you! With a skirt, long hair.

P-. Yes, with ornaments. . .. Keep it and take a photo of it.

I feel an aura of emotion surrounding both of us.

After that, she asks me to take a photo of her next to her drawing. She looks at herself in my cell phone, while I look at her look at herself.

In this manner, Lorena shows us a "piggy" side of her experience that starts transforming with the display of anal aspects, put into action but not interpreted at this moment. "Are we going to jump into the mud? Are we both going to jump?" Here Lorena shows the way she uses the analyst in this game.

There is anal content to be explored without feeling that either the analyst or the patient is being destroyed. It is a paradigmatic expression of playing with children in analysis, where we do not always use words, and play shows how we actively immerse ourselves in the anal experiences without getting trapped.

The group believed that there was a path leading from the lonely little pig towards the beautiful "little girl."

Using the phrase "beautiful little girl," the analyst seems to want to reflect and support the child, as well as protect her from her monstrous feelings.

Fears and fantasies

Two aspects the group worked on were fears and fantasies of madness and death.

Lorena's fear of madness is inferred from the very beginning when she says, "There are too many things here also," showing how she feels about excess and that her madness is the result of what she feels are too many things, none of them having their own space.

She needs to refer to her head, as if it were detached from her body, distant, referring to a certain disassociation, a split in the psyche-soma integration: "I'm going to use my small head to decide what toys I want... my small head thinks a lot about what I need to do."

In transference, Lorena brings her feelings of non-existence, during a session filled with psychic disorganization. She is spinning like a tornado, inventing words and shouting, "I went crazy because I didn't know who to call. . . . Imagine I'm not here, that I don't exist, and then I say to you 'Boo!'" In a state of intense anguish that disorganizes Lorena and destroys her symbolic possibilities, the experience of not existing leaves her tangled in a state of madness.

Later on in analysis, the patient comes to the session with a storybook:

P: This is the beginning of the book.... We're going to start at the beginning: these are the classrooms, and here we have the school principal who is working. If a child is bad, then they are sent to the principal. . . . The principal writes down whether the child behaves good or bad... .1 was a bit bad, but they didn't send me to the principal because I was good. What the boy said scares me that I screamed. But if a ghost comes then that also scares me, because I’m thinking that a ghost came to class and it’s going to take me to the ghost's classroom; it's a cave with lakes that has ghosts and vampires. I don't want to!.. . Before that painting was without a before, a painter came and painted something scary. I'd better look at a children's painting.

The working group discusses that there is confusion between the story that Lorena is reading and her fantasies, and some of the group members believe that the word "ghost" marks a tipping point. The girl fears that she will be carried off by killer ghosts and vampires that are not in the book.

The idea triggered a long group discussion about the differences between the child's excessive fantasizing and approaching delirium, as well as whether or not to add medication. This could facilitate a smoother approximation to the "before" that is being "painted" with fear during the analysis.


The working group's observation about the body is especially important in this patient. The body appears robot-like, rigid, and fragile, with a small head that Lorena perceives as detached from her body. Lorena uses her own body as well as the analyst's to express her anguish and conflicts. She brings it to the sessions as something small, large, that defecates and that can go down the toilet along with her feces. It plays in the mud, expressing her anal experiences. It freezes like a statue to defend itself, or it avoids eye contact, etc. Nevertheless, since the beginning of analysis, this body has been able to "loosen up" as soon as she walks into the sessions.

Throughout the process, we see how these experiences change. This happens as the need for her body to achieve "psychic consistency" is expressed to overcome "cutting" structuring experiences relieving the anguishes of liquefaction and fragmentation that invade her at times.

The body, initially rigid, was her means of defence and self-support, and a way to avoid the anguish of a terrifying fall. Gradually, during the sessions, it loosens up and "rocks slowly back and forth like a cradle," using other forms of self-expression such as dance and gymnastics, as freer forms of movement. The analyst can start to see a more feminine patient and less "disguised." A body that showed signs of suffering passively with constant falls becomes active, faced with the possibility of playing, inviting her analyst "to dive into the mud." An important transformation in the patient's psychic-soma integration is observed.

We considered how much she needs to be looked at, and this need had been closely related to her body, since the beginning of her analysis when Lorena avoided eye contact, always bowing her head, until later when she began to look directly into the analyst's eyes. It is during analysis that the girl's desire to "play the game that she never saw" comes up, increasing her desire to see herself mirrored in the other, and with less fear about what she will find. The working group ties this to a mother with flaws in her structuring look over her daughter. The girl displays fears of repetition—in transference—of finding the dis-encounter that makes her mad in the mother's look, in the "face"—look—of the analyst.

Later on, in the course of analysis, during the session described in the vignette, an emotionally intense moment occurs in which the analyst takes a photograph of the drawing, and Lorena asks if they can look at the photograph together. The demand is for an analyst-mother to look at her, look at herself. The analyst reflects the girl with her drawings and starts "putting her together," generating a display of mirroring—that marks a moment of significant transformation.

Family-parent binding interactions

Patterns of interpersonal relationships

The working group used questions from the child's version of the 3-LM to guide the discussion: What is the parents' point of view? What is the relationship with her parents, siblings, and peers?

The group pointed out that changes occur in the entire family over the course of analysis. At the beginning, the parents cannot process the differences between family members. How could they, when the mother feels that Lorena is just like her and that Lorena suffers her brothers and sisters just like she did? Lorena says that nobody knows how to treat her and expresses it angrily—"Nobody knows how to treat me"—opening the way for transference.

The mother says,

The same thing happened to me. I was able to make it, doing whatever I could and without therapy. My sister was the beautiful one, and I was the rebel without a cause. My problem was my sister that was just too perfect.

We discussed the look in the mother's eyes, how she wants to see her daughter, and the anguish she feels in not being able to do so. Intrusion and absence stand out in the relationship. Identifying her history with that of her children, the mother develops intrusion and she cannot respond to her daughter's needs because she cannot see her otherness. We discuss whether the mother needs to "take in" her daughter in order to process her own history.

Based on interviews held exclusively with the mother, aspects of the mother's past that affect the mother-child bond were explored. The mother is able to relocate herself in relation to her own mother and daughter, therefore diminishing projection.

At the end of the process, Lorena's mother acknowledges her daughter's achievements:

Lorena wrote me the following for my birthday: "Mom, enjoy your birthday." She was worried about finding her place in the world, and she finally found it. Something clicked. I can see it: she no longer says silly things or talks nonsense. ... Now she has her feet on the ground, and it's easier to find common ground.... Also, I'm trying to stop my mother, because she's in everybody's business; she gets me all worked up.

During the interviews with both parents, the great difficulties and lack of discrimination in the place of each family member were explored. The effects these had on the child's psyche and her feelings of having "no place" were pointed out.

The father, who previously referred to Lorena with a certain distance and theory, began to approach her differently. Lorena started playing hide-and-seek with him, asking the analyst to join in as "her accomplice." Shifts in the family allowed increased discrimination and affection between family members, with the possibility of understanding Lorena in a different way, showing how the parents' representation of Lorena was changing.

On one level, we have observations about the child's bonding with her real parents, siblings, or peers that were expressed mainly during interviews with the parents, teachers, and others.

On another level, we have observations that the working group of psychoanalysts explored mainly on the structural interplay "id, ego, superego" (Freud) and the inner world (Klein), along with modifications in the family environment, that occurred possibly as a result of the child's inner changes.

The patient's rigidity and distance from her siblings was of concern. A year into analysis, the parents describe the changes in the relationship with her siblings and peers:

Lorena is doing great; she plays with her siblings and enjoys drawing with them. At school, there are also changes with the new friends that she has made. She pretends to be the mother of the new girls in school. . . . She describes all the details. It’s a huge change. The same thing happens with her cousins, when she plays with them; now everything is fine. Before she would scream at everybody. Now her cousin hugs her and she doesn't mind.

Since the drawing of the "beautiful girl" at one and a half years into analysis, the subjective experience gains ground, and the difference between fantasy and reality becomes clearer.

Perhaps the teachers' comments at the beginning of the analysis generated fear of a serious outcome and acted as a shocking warning for the parents.

Level 2: Identification of the main dimensions of change

At this level, the working group analyzes patient transformations according to the diagnostic dimensions using a language close to experience and not saturated with theory.

The model demands that we conceptualize the problem from the patient's point of view. What is the patient struggling against? The question is not asking for theory. Instead, it is asking for the phenomena observed. The patient is their point of reference. The model asks that we avoid psychoanalytic jargon and that we document our perceptions with data collected from the sessions.

The Model's Level 2 leads us to initially consider the child's subjective experience of illness.

In this case, Lorena comes to analysis feeling diminished, extremely small, with a fear of losing herself and disappearing. At times the fear of going mad, overwhelmed by an excess of mental content and not being able to contain herself, takes over and leaves Lorena in a state of serious psychic disorganization. During many sessions, she spins like a tornado, shouts, and speaks incoherently, revealing her great inner confusion: "Imagine that I'm not here, I don't exist, and then I scream 'Boo' at you.... Fruitghetti is not food, fruitghetti is food."3

The group analyzed the modifications of these aspects that occurred during the treatment. Three years into analysis, there is a variation in the subjective experience. The analyst sees the child as a "beautiful" girl, and more importantly the girl is able to take the image and make it her own, leaving behind her feelings of "small little pig" that she had at the beginning of the analysis.

During her third year of analysis, Lorena is approaching the Oedipal stage of development. We find Lorena concerned about fitting in with her friends, and with fears of exclusion.

P: I have to tell you something really serious that happened to me . . . it's something unusual.. .. My friend is a bit strange; she says yes to everything, she is very "tapete"*... I gave her all of my snack today; I give her good things and she doesn't. Did you see all the good things I do for her?

A: Yes, you do many things to have friends and you are finding things that you don’t like, things that make you very mad.

P: The red fury, I'm going to draw it with an ugly face.

Lorena uses verbal language to describe how serious her problems are. She has to deal with jealousy and the rivalry in her group of girlfriends. She is feeling anger, fear of rejection. Her feelings are strong but now with a different intensity, and her psychic apparatus keeps her contained and away from a state of disorganization.

In view of the above vignette, we asked ourselves what would happen to the hostility that the work in analysis could have stirred. Part of the working group believed that some of the "strange" aspects were still there, latent, and projected in her friend. Likewise, the group considered the tension and transition between the dual relationships and the access to Oedipal conflicts (triangulation).

Main defences

The working group considered this an important issue and used the following model questions for discussion: What are the main intrapsychic conflicts (and the related affects)? Are the defences adequate and flexible or predominantly dysfunctional or distorting or restricting the inner and outer experiences? How did these aspects change?

As for the conflicts, the strength of pre-Oedipal aspects and primary failures in the conformation of the psychic apparatus were inferred from the material.

When Lorena was 3 years old, she walked on her toes and flapped her arms, aspects that suggested important flaws in the conformation of her primary identification.

The group believed that the girl used first autistic and manic defences that later evolved into more neurotic-like modalities.

The defence expressed at the beginning of analysis in a "rigid" and "robot-like body" gave way to artistic and creative resources such as dance and gymnastics, among others.

Likewise, the group observed that she was coming into contact with her affects when she expressed the "red fury" with her friends. She also drew them with "ugly faces," in clear contrast with the non-mental defences such as the initial freezing enacted in different types of play.

According to the 3-LM proposal, each dimension implies adopting a new approach to the clinical material, with the aim to observe the transformations from a new perspective triggered by each new question.

Mental functioning and psychic structure

We asked ourselves about the girl's mental functioning and psychic structure using the following questions as guidelines: How capable is Lorena of adequately perceiving her own inner states and those of others? And of recognizing and representing her affects?

Even though at the beginning we saw that the patient was mixed up and lost in her "complications" of being small, big, girl, boy, and her anger and fears, we believe that analysis has allowed the patient to put most of her past in order. She is now able to recognize her affects, to discriminate between sadness and fury, and to integrate and relate them to her process of finding others.

We observe a girl who is struggling to integrate conflicts of Oedipus rivalry, competition, exclusion, and giving to please others; a girl who still feels "tapete," strange, who seeks drawing as a means of expressing this aspect of herself.

P: M is a bit strange. She never says no.. .. She is very "tapete. "

A: What does "tapete" mean?

P: In My Little Pony, Pony is very "tapete," very shy, very good. I can't explain it. I’m going to draw it for you.

Sensory regulation

To explore this aspect, the group selected a question for their discussions: What is her ability to control the degree, intensity, and nature of her responses to sensory stimuli?

We were interested in the patient's sensitivity to noise and "commotion," as she calls it:

P: Where are those sounds coming from? I don't want any sounds; the phone, the computer, there's never going to be any sounds. I wasn't the one.

A: What are the sounds that worry you like? Are they coming from one of the rooms in the house?

P: I know, from the room upstairs, the playroom. I don't know how to control them; I don't know how to control the house [she is playing with a toy house].

The noise she experiences is too intense for her; she cannot tolerate it and is incapable of controlling it.

We analyzed vignettes of some sessions where we were concerned about aspects of perception and how the child's thinking was affected by them. For example, this was clear when Lorena started describing specific scenes from her book and then shifted towards a narrative with an excess of ghostly content, adding things that were not connected to one another.

Regulation of affects

To explore this issue, the working group uses several questions from the model for discussion: How does the child feel? And does she perceive in others the wide range of affects expected in children of her age? How does the child regulate her impulses and affects in order to foster adaptation, satisfaction, and self-esteem, with flexibility in the use of defences or coping strategies?

The working group observed the continuous work that was done during the analysis on affects regulation.

It took a long journey for the patient to get involved with her different affects and to get her psyche more organized.

At the beginning of analysis, affects disorganized the Lorena's psyche. There were sessions in which she spent time spinning her body like a tornado or using bizarre words or rambling.

After three years in analysis, we saw that she was still using projective mechanisms. However, she could describe her affects differently. She could name fury and jealousy, and she talked about how serious her problems were. There was a change in the way she talked about herself and regulated her affects, keeping in mind the relationship with peers developed during the treatment:

P: I have to tell you something serious that happened at school. I ended up helping a friend, and she got really angry. It's very strange. She turned red, tomato, apple. V is very strange; today I shared my snack with her, and she didn't.

A: You're really angry.

P-. Yes, like a fire in flames. Fire, plus tomato, and more... [laughs].

A: We're laughing right now, but you get really angry when V does that to you.

We observed a stronger tie between words—affects showing how Lorena was able to regulate her affects and impulses, reducing the rigidity of her defences.

The patient resorted to sensory aspects to express anger, such as "red fury," angry, "red, tomato, apple."

Her desire to be the chosen one, as she struggled with duality and triangulation, can be expressed with anger. Although she had improved the drive for control, we asked ourselves how permanent her achievements would be over time.

Attachment with internal and external objects

The group selected for discussion other questions from the model: How profound and stable is the child's relationship with internal and external objects? And how prepared is the patient to make and break off relationships and cope with separations? How does she handle relationships that imply the existence of a third person?

As for transference, the group observed that the analyst respected the time Lorena needed, which was crucial if we considered that construction in the child's play showed her potential to build more stable and safer inner spaces and objects.

The material collected at the beginning of analysis pointed to a good prognosis with respect to bonding, along with fears and doubts about being able to procure a space of containment in the minds of others:

P: We need a driver; I don’t like the idea of only one passenger. Ah! There's no room for this girl; she will have to go somewhere else.

A: There is a place for her here. We are getting to know each other. You're probably asking yourself if there is a place for you also, here with me.

P: Yes, we're getting to know each other. I have a problem: it falls.... I'm going to put things away, but it's such a small box. . . . How are so many toys going to fit in such a small box?

We believed that, through transference, Lorena was generating abilities that could potentially help her contain herself and have good internal objects that could allow her to bond without feeling like she did in the past, when she was "falling through a black hole."

We referred to a past session in which Lorena leaned on two rigid feminine statues to stop herself from falling. The analyst joined her and pointed out how hard the sculptures were. Lorena said she wanted to draw a girl and later photograph her, as a way of being contained in the mind of the analyst ("save it"), and to be recreated later, in transference, as a photo with cheerful and feminine content.

This transformation from two rigid feminine statues into a colourful girl who could be "saved" in the analyst's psyche shows a containment function destined to be incorporated by the patient.

Nevertheless, the group had its doubts about the stability of the patient's achievements over time in her relationships with internal and external objects, as well as to whether she would be able to cope with the inclusion of a third person.

Level 3: Testing of explanatory hypotheses of transformations

At this level, the working group discussed the theoretical hypotheses explaining the transformations, as well as the possibilities of how and why they occurred. They discussed explicit and implicit theories explaining the observed transformations, starting with those manifested in the analyst's interpretations.

What was the main focus that guided the analyst? What were the analyst's main theories and hypotheses, explicit and implicit, supporting her work? Did they change during the treatment?

Structural flaws gave way to great pain and fantasies of collapsing, that led the working group to infer that, before she was 3 years old, Lorena could have had experiences of "a never-ending fall" (Winnicott, 1971) and fantasies of a "fragmented body."

The analyst worked mainly on the more primary aspects of discrimination between id-not id, and it was only approaching the third year of analysis that we observed Oedipal aspects related to exclusion, jealousy, and rivalry becoming more relevant.

Another point of view discussed was the persistence of an unresolved issue that could be re-enacted during puberty and was linked to the patient's "strange" characteristics: the flapping, and the walking on her toes early on.

The group explored two hypotheses. Some believed that Lorena did everything to feel appreciated, but the anger and feelings of not being loved persisted; meanwhile, others thought that anger did not disorganize her and was not reflected in her body. The analyst's look, which expressed empathy and support, had been essential to the development of Lorena's feelings of being loved.

A "stiff" little girl once arrived at the analyst's office with an inner feeling that she was going mad, unable to cope with her parents' conflicts projected entirely on her, tangled in a serious state of confusion. Then we started seeing transformations in her ability to discriminate herself from her primary objects, giving way to her own resources that were previously "frozen."

From the spectrum of conceptual frameworks underlying the analyst's interventions, we observed that the beginning of the analysis, there was a tendency towards Kleinian theory (1962) (e.g., "You have things that are very good, and you are realizing that there is a friend who is very jealous"). This was followed by a Winnicottian approach with holding and handling playing an important role. There were also signs of Bion (1975), since the analyst attempted to regulate affects permanently, developing an intense reverie function from the beginning.

The Freudian interventions of presence-absence could be conceptualized as Winnicottian also, if we believed that the analyst's aim was to reinforce the presence of a stable object beyond separations: "Like the two of us, we didn't see each other during the holidays and we meet again; with Mom and Dad sometimes you don't see them and afterwards you see them again."

Between the analyst and the patient, there a series of functions was displayed, where the analyst accompanied the patient, mirroring and marking her affects, so that the child could continue becoming more familiar with her own material.

The analyst regulated the affects, supporting them and observing to what extent there was return and synchronization between the two. Of all these functions, support stood out, generating a structure that allowed her to grow up. We pointed out the necessary and important faults related to Winnicott's theory (1962).

During our group discussion it was enlightening to observe how the analyst worked different theoretical approaches and how the theories implicit in her mind operated during the sessions, in transference with the patient.

We saw how she contributed to the development of psychoanalytical and libidinal availability, not only in the child but also in the parents.

During the discussion several alternative hypotheses were discussed.

The weight of transgenerational aspects and their relationship with the transference

The mother seemed to have integrated in her mind that she was a very demanding mother, an aspect that was projected massively onto her daughter.

The group observed that Lorena was struggling with these aspects projected onto her, aiming to find her place as a daughter in the family. This implied parallel work with the parents to relocate the child and allow the parental functions to be re-established, not only in its libidinal aspect but also in cutting and support.

Regarding the cutting function, an observation was made when Lorena said, "Today I brought a penguin; the penguin's name is Pingiii," leaving out the "-no" ending, highlighting the limit in its failed function.5

Hypothesis explaining “avoidant attachment”

We explored again the meaning of "oppositional"—to what extent it was related to a disorder present in the patient early in analysis, which consisted of avoidance of eye contact and an avoidant attachment, making it difficult for the child to bond with others.

The place of trauma in Lorena

Previously, we referred to a series of events that the child experienced before she was 3. Since the events were not explained to Lorena, they became part of her traumas. Added to the mother's lack of reverie, they could be considered failures of her maternal function (Bion, 1975) that could have caused a feeling of non-existence in the child.

What is the nature of the changes observed? How profound are they? And what is the stability sought?

We believed that patient's transformations occurred fundamentally at the structural level and allowed improvement in her psychic functions.

As previously mentioned, there was a unique coexistence of evolved aspects with good possibilities of symbolization, along with other aspects of failure in Lorena's psychic structure. Primary failures were a source of intense psychic suffering, experiences of threat, disorganization, and madness that led her to use her primary defences of turning her body into a "robot."

We considered that the Oedipal conflicts were not sufficiently displayed. More work of the analyst was necessary in order to organize her mental functioning and elaborate her traumatic experiences.

An open question remained unanswered of what would happen during the patient's puberty, since she displayed intense psychotic anxieties. We had reasons to believe that we needed to be alert to the coming of puberty and drive reactivation.


The purpose of this chapter was to provide an example of how the 3-LM model works in longitudinal approaches applied to child analyses. It explores the achievements and limitations this process has and opens the floor to discussions.


This chapter describes how the Three-Level Model (3-LM) was applied to observe the analysis of a girl from 5 to 9 years old. During the observation with the 3-LM, the focus was on intrapsychic, intersubjective, and structural changes. It also included the analyst's work with the child's parents. The purpose of applying the model was to understand whether or not the analytic intervention fostered these changes.

The 3-LM allows analysts to review hypotheses explaining the main reasons that brought the patient to analysis in the first place, jumping back and forth between earlier and later sessions and exploring the clinical material initially at a phenomenological level. At the model's second level, the different dimensions of transformations are considered. At the third level, several are posed: What was the analyst's main focus during the analysis? Which are the official theories inferred in the analysis of interpretations? Finally, we ask ourselves whether other alternative hypotheses, besides those introduced by the analyst, would be possible.


1 The working group for clinical observation of transformations of a child patient was formed at the Uruguayan Psychoanalytic Association (Asociación Psicoanalítica del Uruguay or APU) in October and November 2015.

Moderator: Marina Altmann de Litvan.

Reporter: Griselda Revella.

Presenter of Clinical Material: Patricia Singer.

Participants: Patricia Arévalo, Tatiana Santander, Luisa Pérez, Gabriela Pouse, Sandra Press, Nahir Bonifacino, Silvia Braun, Fernanda Cubría, Silvia Sapriza, Maria Bauer, Jacqueline Hirschfeld, Adriana Gandolfi, Mariel Brizo-lara, Claudia Gaione, Ana De Barbieri, Ximena Malmierca, Nancy Delpréstito, and Ilana Luksenburg.

  • 2 For additional information about the 3-LM Model, see References.
  • 3 The patient makes up the word "fruitghetti," combining the words "fruit" and "spaghetti."
  • 4 Later the patient will describe what she means by "tapete."
  • 5 In Spanish the word for "penguin" is pingüino.


Altmann de Litvan, M., Miller, D., & Bernardi, R. (2014). Three-Level Model for observing child patient transformations. In M. Altmann de Litvan (Ed.), Time for change: Tracking transformations in psychoanalysis—The Three-Level Model (pp. 303-319). London: Karnac.

Bion, W. (1975). Aprendiendo de la experiencia [Learning from experience], Buenos Aires: Paidos.

Bollas, C. (1987). La sombra del objeto. Psicoanálisis de lo sabido no pensado [The shadow of the object: Psychoanalysis of the unthought known]. Buenos Aires: Amorrortu.

Freud, S. (1905). Three essays on the theory of sexuality. S.E. 7 (pp. 123-246).

Freud, S. (1908). On the sexual theories of children. S.E. 9 (pp. 205-226).

Kernberg, P., Chazan, S., & Normandin, L. (1996). Cornell Play Therapy Scales. New York: The New York Hospital Cornell University Medical Center.

Klein, M. (1962). La técnica psicoanalítica del juego [Psychoanalytic play technique]. Nuevas direcciones en psicoanálisis. Buenos Aires: Paidós.

Nieto, M. (1965). Algunos problemas del analista como investigador [Some problems faced by analysts as researchers]. Revista de la Asociación Psicoanalítica del Uruguay, 1(7), 5-27.

Volinsky de Hoffnung, P., Medici C. Sapriza, S., Altmann, M., Braun, S., Cuttinella, O., Ihlenfeld, S., López, C., & Vallespir, N. (1986). El juego en psicoanálisis de niños [Children play in psychoanalysis]. In El juego en psicoanálisis de niños, 1, 129-194. Laboratorio de Psicoanálisis de Niños. Asociación Psicoanalítica del Uruguay.

Winnicott, D. W. (1962). La integración del yo en el desarrollo del niño [Ego integration and child development]. In Los procesos de maduración y el ambiente facilitador [The maturational process and the facilitating environment] (pp. 56-63). London: Hogarth Press.

Winnicott, D. W. (1971). Realidad y juego [Playing and reality]. Buenos Aires: Granica.

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