VIII Three-Level Model

Three-Leve I Model

Chapter I 5

Guidelines for organizing 3-LM groups

Margaret Ann Fitzpatrick Hanly,

Ricardo Bernardi, and

Marina Altmann de Litvan

The 3-LM is a flexible model that has evolved over time. The model is used as a guide in clinical groups, in various settings, to explore a psychoanalytic clinical material and can be adapted to meet the needs of our different institutions (see Chapter 10). The model's aim is to ask more and more useful, cogent, and accurate questions that help to understand the changes in patients in analysis. For this reason, we present here ideas and methods updated in the current version (still evolving), which present the model's objectives, various ways of organizing discussion groups and questions formulated to guide the 3-LM discussion groups.

About the 3-LM

This description of the Three-Level Model, written as a proposal by Ricardo Bernardi in May 2011, is updated into a current 3-LM Manual by Margaret Ann Fitzpatrick Hanly, Ricardo Bernardi, and Marina Altmann de Litvan.

Method of analysis of clinical observation: Three-Level

Model for Observing Patient Transformations

The aim of the Project Committee on Clinical Observation is to promote a more accurate and systematic clinical observation, useful for theory testing and theory building. The committee's first book on the Three-Level Model, Time for Change: Tracking Transformation in Psychoanalysis—The Three-Level Model (2014) presents a full account of the model and the thinking behind it.

The model aims to enrich and refine clinical observation, analyzing its functioning and different levels of clinical practice, focused on the transformation that occurs in the patient during analysis. The transformation in the psychoanalytic patient is prioritized, although the model takes into account the fact that change occurs in the context of the mutual relationship between patient and analyst.

The transformations that occur during analysis have multiple facets and raise a wide range of questions: What changes? How does change occur? When? Why? These problems have been discussed extensively in the literature. The aim here is not to answer the questions themselves but to study ways in which a better clinical observation can contribute to advance the study of their answers.

The guidelines for the Three-Level Model that are presented here outline a method for heuristic evaluation of change and no change in psychoanalysis, ways to refine, systematize, and conceptualize clinical observations. The model can be used in personal reflections or in group deliberations, when the analyst feels that it is necessary to take a "second look" (Baranger et al., 1983) at the session material. The model can also be used as an open guide for analysts in discussion groups who want to enhance clinical observation through systematic analysis of a clinical material. The committee is especially interested in fostering these discussion groups in local IPA societies.

The three levels or steps considered in the model are the following:

Level I: Phenomenological description of the transformations

The first aim of the model is to refine the description of the transformations that took place in an analysis over several years, through a group discussion using the phenomenological descriptions of the analysis—that is, using ordinary language and quoting passages from the verbatim sessions taken at intervals over the course of the analysis. The presenting analyst includes in the clinical material a brief history and five or six detailed verbatim sessions, selecting sessions in a spontaneous way that allows the analyst to transmit the psychoanalytical meaning and resonance of her or his experience. (Other materials, such as tape-recorded sessions, can be used.) The 3-LM clinical material should include notes on the patient's experiences, and tones also conveyed (preconsciously) in the analyst's reading, as well as the analyst's key counter-transference reflections, and other clinical phenomena that can support inferences about the underlying unconscious processes.

The analytic sessions selected during two or more points in the analysis permit a focus on the appraisal of the transformations at a macro level. The individual sessions describe transformations that occur in the interaction between patient and analyst at a micro level, with details of the patient's response to an interpretation.

Aims of the group discussion at Level I

Listening as a group to the analytic session material read by the analyst and sorting out the main presenting problems and changes in the patient can help participants increase their sensitivity to unfamiliar clinical situations and make them more aware of blind spots and subtleties in the clinical material.

Level 2: Identification of the main diagnostic dimensions of change

The aim in the second-level discussions is to identify the main "dimensions," conceptually, along which the transformations in the patient occur. A systematic and valid description of change requires that at least two points of reference be compared, and requires that the group refer to sufficiently ample data concerning the initial problems of the patient, in his or her mental and interpersonal functioning, as well as intrapsychic conflicts.

The following dimensions are considered indispensable for adequate understanding of psychic transformations:

• 1 Patient's subjective experience of illness and concept, and expectations of change.
• 2 Patterns of interpersonal relationships in the external world and in the transference-counter-transference relationship
• 3 Main intrapsychic conflicts.
• 4 Mental functioning and psychic structure: (a) capacity for self and other perception; (b) regulation (of impulses, affects, and self-esteem); (c) internal and external communication (including aspects related with bodily self); (d) attachment with internal and external objects.
• 5 Type of personality disorder (if any).
• 6 Therapeutic foci: analyst's view of the aspects that play a central role in the psychodynamics of the clinical picture, causing or maintaining the disturbances and that require treatment.
• 7 Follow-up information about the evolution between and after the chosen points of reference.

Aims of the group discussion at Level 2

First, to contextualize the transformations of the patient, finding a more comprehensive description of what is wrong in the patient. Second, to analyze changes in the patient according to diagnostic dimensions (using questions from Level 2 selected by the moderator) described in a language that is experience-near and theoretically unsaturated. Given the multiplicity of theories, it is a good idea to start the discussion using a phenomenological language based on words that comprise the smallest common denominator of the diverse existing theoretical versions of these concepts. (At Level 3 there will be the opportunity to reformulate and develop these theoretical aspects from multiple perspectives.)

Level 3: Hypotheses on links between interventions and observed changes

Transformations during analysis are brought about by interpretive strategies that are related to different explanatory theoretical models and approaches. Level 3 explores which problems the analyst focused on in the clinical material, and any changes in the focus over time. Questions lead to observations about the effect on the patient of specific interventions. At Level 3, participants deliberate on possible change mechanisms or curative factors brought about by interventions in this analysis. The Level 3 discussion also engages in an enquiry into aspects of the clinical material that were not addressed by the analyst. Hypotheses can then be made concerning alternative interpretations related to passages in the verbatim sessions, which could have addressed problems observed in the patient or process.

The aim of the discussion at this level is not to make decisions about whether an alternative interpretation would have worked better, but to examine the clinical support for each hypothesis. "Testing" a hypothesis should be understood as attempting to enhance the observational base of theoretical hypotheses, thereby developing the capacity to link theoretical concepts with clinical data, and to make predictions or conjectures that can stimulate new clinical observations.

Aims of the group discussion at Level 3

To observe what the interpretations address in the clinical material, patterns of interpretations, and the effects on the patient of interpretations. To test and enhance the observational base of theoretical hypothesis about how the interpretations facilitate change.

The three levels of group discussion could properly be regarded as contributing an expert validation of clinical inferences concerning change and observations on how change happens.

Practical guidelines for 3-LM clinical observation groups—Marina Altmann de Litvan, chair 201 1-2017, and Margaret Ann Fitzpatrick Hanly, chair 2017-2021

The Committee on Clinical Observation welcomes all analysts who are interested in the creation of one or more IPA Clinical Observation Groups in their own psychoanalytic societies, and encourages them to follow the steps described in this guide.

The practical guidelines presented here aim to give groups of analysts a method to apply the Three-Level Model for Observing Patient

Transformations to psychoanalytic clinical material. Should your group find any difficulty, please do not hesitate to contact us through our IPA e-mail address: This email address is being protected from spam bots, you need Javascript enabled to view it

There are many adaptations of the 3-LM format for groups that can be made. 3-LM groups have been moderated for candidates in one and a half- or two-hour seminars over several weeks of a course or for professional development groups once a month for six or seven months.

Please contact us and ask us for our latest version of the Three-Level Model for Observing Patient Transformations (3-LM).

About the clinical material

General considerations

The 3-LM has been designed to evaluate change in the patient. The presenter is asked to include material that shows the changes as well as material that could question these changes (respecting qualitative research criteria). The presenter is asked to include in the report the motives that lead her or him to present this specific material, to reflect on whether expectations were met. When a follow-up is possible, after the 3-LM group discussion the analyst will report on whether there has been an effect (positive or negative) on the analyst's work with the patient.

The analyst’s doubts about change in the analysis

All psychoanalytic clinical materials raise questions about how and how much the patient has changed, since all analyses have limitations. The analyst may have in mind certain doubts about the gains the patient has made when choosing the material, but is asked not to make these explicit until the relevant moments in the group process.

Specifics on sessions to be selected

The clinical material will be chosen in a way that allows a good description of the opening situation for patient and analyst and transformations through the course of the analysis. The analyst is asked not to give her or his theoretical ideas but a brief history of the session material.

• 3-LM clinical material:
• 1 A brief history, with an account of the patient (such as stated reasons for coming to analysis, kinds of suffering known or indirectly communicated, childhood events told at the onset, crises, family trauma, etc.) and the characteristics of the setting (frequency, use of the couch, etc.).

• 2 Verbatim session material from the first and second sessions (or an early important session), and one or two sessions from two, possibly three, later phases of the analysis (that show significant aspects of the process) (Verbatim session material is a detailed transcription ("he said/she said") made by the analyst during and after an analytic session, with the associations of the patient and interpretations of the analyst, differentiating them with notations P and A.).
• 3 A general analytic context for the sessions when needed, in order to introduce a session or give some key information about the periods between the selected sessions.
• 4 After the presenter selects the clinical material, he/she discusses it with the moderator.
• 5 The clinical material for the group discussion is usually 20-25 pages, with pages and lines numbered.

Confidentiality

The confidentiality rule means that the presenter will have carefully modify all information that could identify the patient. The presenter of the clinical material takes the responsibility to respect the confidentiality rule, deleting or changing any biographical information that could enable the patient's identification in any way (names of people, educational institutions, enterprises, etc., but also any participation in well-known events or other identifiable situations). The presenter will judge if she or he needs to have consent from the patient. Participants will not use or disseminate the material without the presenter's explicit consent.

Notes on moderating a 3-LM group

Committee members and moderators have worked consistently to improve the art of moderating the clinical observation groups. The task of the moderator is to facilitate the group discussion while bringing pertinent open-ended questions from each level of the model to guide discussion. Here are some notes on different methods.

The moderator hands out the 3-LM questions and the Forms to the group.

• 1 A brief introduction to the 3-LM and outline of the schedule.
• 2 Level 1

a The presenter reads the entire material and opens group discussion with Level-1 questions, or

b The presenter reads the material in three segments (history and opening sessions; mid-analysis sessions; late analysis sessions) with brief discussion in between (bringing in the Leve-1 questions as relevant).

3 First report

The reporter reviews the anchor points and change points discussed by the group. The group makes corrections and additions to the summary on anchor points and change points.

4 Level 2

The moderator opens Level 2, selecting first the questions that help to conceptualize those areas of difficulty and change most discussed from the different dimensions of Level 2. Thus, Level 2 moves organically from Level-1 discussion with its points of consensus and its debates.

5 Second report

The reporter makes a second report after the second main break that summarizes the group consensus and debate on main difficulties and change and no change observed in the material. The group discusses briefly, making corrections and additions.

6 Level 3

The moderator reads the first three questions in Level 3.

a The moderator opens a free discussion on foci of the interpretations, theories behind them, and hypotheses on alternative interpretations, or

b The moderator begins by reading just the interpretations in some sessions to recall the group's ideas on opening, middle, and end phase interpretations and effects on the patient, or:

c The moderator reads question four at Level 3 and opens discussion of mechanisms of change, hypotheses on theories of therapeutic action behind the interpretations, and hypotheses on possible alternative interpretations grounded in the clinical material.

7 Final report

The moderator helps reporter with suggested revisions for the final report, which is sent to the group.

Summary of the reporter’s roles

• 1 The reporter writes a brief report summing up the discussion on anchor points and change points at Level 1 and reads the report to the group.
• 2 The reporter takes notes as the group gives feedback on any points of group discussion that need to be corrected or added.
• 3 The reporter makes a second brief report on the second phases of group discussion and on the group process, conceptualizing the problems and changes and absence of changes, which is discussed, revised, and added to by the group.

4 The reporter writes up a final report (based on the first two reports, and on the further observations of the 3-LM group at Level 2 and Level 3). Two or three weeks later, the report is sent to the moderator for suggested revision, then to the presenting analyst and then sent to the group.

Questions for group discussion: Adults

Current Version, 2020

Box 15.1 Questions about Level I: Phenomenological description of transformations

• 1 Which parts of the clinical material had special resonance for the group participants and can be considered as anchor points that make it possible to track changes in the patient? What is the relationship of these anchor points to the foci of the analyst's interpretations?
• 2 Are there changes in the analytic process in (a) how the patient uses the analyst and his or her interventions?; (b) how the patient uses his or her own mind and body during the session? Are there noticeable changes in the course of one session? And through time, between different sessions?
• 3 In which of the following areas is it possible to observe changes? (a) Capacity to love and sexuality; (b) Family and social relationships; (c) Occupation and leisure; (d) Interests and creativity; (e) Symptoms and subjective well-being. Which is the patient's perspective regarding his changes?
• 4 What aspects of the material suggest the existence of positive changes, negative changes, or the nonexistence of changes? Which prevail?

Box 15.2 Questions about Level 2: Dimensions of change

1 Subjective experience of illness and contextual factors

a What are the patient's subjective experiences, beliefs and expectations about his/her problems and treatment? How much does the patient recognize his or her problems? How much does the patient foresee possibilities of change? To what extent do patient and analyst agree on the expected transformations?

b Are there contextual factors that affect the therapeutic process? (For example, crises, traumatic experiences, somatic illnesses, drugs, etc.? How capable is the patient of facing these situations?)

c How have these aspects changed? How much has the patient's understanding of his or her problems and therapeutic possibilities changed?

2 Patterns of interpersonal relationship and how they have changed

a What are the interpersonal relationships of the patient like, especially in the bonds that imply closeness and intimacy?

b How does the patient experience others, and how does the patient experience himself or herself in relation to others? How do others experience the patient, and how do they experience themselves in relation to the patient (in transference-counter-transference and in other meaningful bonds)?

c To what extent can I relate the patient's current relational patterns to the experiences lived in his or her childhood and with the bonds that the patient establishes with the analyst?

d How have these aspects changed?

3 Main intrapsychic conflicts and how they have changed

a What are the main conflicts (e.g., individuation vs. dependency; submission vs. control; need for care vs. self-sufficiency; self-worth, guilt, Oedipal conflict, identity conflict)? Which are the dominant unconscious fantasies that can be inferred from conflicts and relational patterns?

b Are the prevailing defences adequate and flexible or dysfunctional, distorting, or limiting internal and external experiences?

c How have these aspects changed?

4 Structural aspects of mental functioning

a What is the level of mental functioning in the following areas? Are there signs of change?

1) Perception of self and others; identity

How capable is the patient of adequately perceiving his or her own internal states and those of others? Is the patient able to empathize, tolerating and understanding different points of view? Does the patient have an integrated feeling of his or her own identity, open to the possibility of unconscious aspects? What are the characteristics of the identifications (especially pathological ones)? Does the patient manage to connect with his or her past and give direction to his or her life, with a sense of agency and short- and long-term wishes and goals?

2) Affective regulation

Is the patient able to adequately regulate impulses, affects, and self-esteem? Do the patient's ideals and values help him or her to handle his or her emotions? Does the patient manage to regulate his or her need for self-esteem when facing internal and external demands? How much does the patient achieve an adequate balance between his or her own interests and those of the others?

• 3) Internal and external communication; symbolization How rich is the dialogue with the patient and others, based on affective experiences, bodily self, fantasies, dreams, sexuality, symbolic representations, and capacity to play and creativity?
• 4) Attachment with internal and external objects

How deep and stable and differentiated are the relationships with internal and external objects? How much can the patient start and end relationships and tolerate separations? How does the patient handle relationships that imply the existence of a third person? How have these aspects changed?

5 Type of disorder

a Is it possible to identify a type of personality disorder or other kind of mental or bodily disorder?

b How severe are the disturbances in personality functioning? How much is the analytic work conditioned by the structural vulnerabilities in mental functioning?

c How have these aspects changed?

Box 15.3 Questions about Level 3: Hypotheses on links between interventions and observed links

1 What were the foci of the analyst's interventions? How did the foci change over the course of the analysis?

• 2 What can be observed about the impact on the patient of the different foci of interventions, in different phases in the analysis?
• 3 Do you consider that some interventions were especially effective? Which ones?
• 4 Which aspects of the analysis facilitate inner processes that lead to change in the patient (mechanisms of change/curative factors)? (The group should be that the analyst's intentions in giving certain interventions—what the analyst is aiming it—may be different from what we outside observers see as factors in the change observed.)
• 5 What parts of the clinical material did the analyst not address? And what other kinds of intervention could the 3-LM group hypothesize might have been useful?

Questions for group discussion: Children—

Adapted by Marina Altmann de Litvan, Delfina Miller, and Ricardo Bernardi, 2014

Level I: Phenomenological description of transformations

• 1 Which aspects of the material (supplied by the child, parents, teachers, or other informants) suggest the existence of positive or negative transformations, or the absence of transformations?
• 2 Which of these changes may be attributed to the growth of the child regarding the development patterns that were highlighted in the material presented (for example, dream, feeding, sphincter control, psychomotor development, relationships)?
• 3 Which may be attributed to changes in the environment (family events such as separations, divorce, death, newborns, accidents, moving, etc.).
• 4 As noted, we give a special place to the child's play. First, we observe whether it is adequate to the child's age, and which phase of libidinal development it refers to.

Regarding these aspects, we shall note transformations or the absence of them, taking as a model the evaluation of play proposed by Kernberg, Chazan, and Normandin (1996):

a Type of play (sensory-motor, exploration, construction, phantasy) b Narrative (originality, elaboration, organization, sequence) c Subjects (presentation, elaboration, processing) d Affects (which and how many, with which intensity and adequacy, level, and way of regulation)

e Expressed relationships (with the analyst, among characters within the game)

• 5 Which transformations can be observed in the course of one session? And through different moments in time?
• 6 In which of these areas are meaningful changes perceived showing transformations in the functioning and well-being of the child?

a Symptoms and subjective well-being

b Relationship within child's family, and with peers, teachers, etc.

c School performance and interests

7 Changes in treatment regarding

a How does the child accept the treatment (for example, attitude regarding the setting)?

b How does the child use the therapist?

c How does the child use the therapist's interventions?

d How does the child use his or her own mind and body during the session?

e How does the child use the mind and body of the child's caregivers?

• 8 How have therapist and patient participated in the transformational process? Which is the perspective of each of them about transformations? What is the perspective from the child's caregivers and teachers in this regard? What relations can be established between the transformations and the characteristics of the analytic process?
• 9 Which parts of the clinical material have a special resonance in participants regarding the transformational process?

Level 2: Dimensions of change

The following questions seek to identify the dimensions in which transformations could occur. They are based mainly on OPD-2 (OPD2 Task Force, 2008) and PDM (2006) proposals.

Subjective experience of illness

1 Which are the patient's main problems and symptoms, according to the analyst? What subjective experience does the child have of them? Which are the child's beliefs regarding what occurs and his or her expectations of treatment?

How much is the patient aware of his or her problems? What is the parents' perspective about the child's problems? What is the teachers' perspective about them? How much does the child see the ways that could lead him or her to a change? And parents? How much do analyst, patient, and parents (other informants could correspond, too) agree about the expected transformations?

• 2 How did these aspects change? How much has changed the understanding of problems in the child and the expectancy of transformation possibilities? How has this been modified in parents (or caregivers, teachers, etc.)?
• 3 Are there contextual factors that affect the therapeutic process (e.g., crises, traumatic experiences, somatic illnesses, etc.)? How capable is the patient of facing these situations?

Patterns of interpersonal relationships

RELATIONAL PATTERNS OUTSIDE ANALYSIS

• 1 How are the patient's interpersonal relationships, especially in bonds that imply closeness and intimacy? Do they have depth, range, and consistency?
• 2 How does the child experience others? How does the child experience himself or herself in relation to others (e.g., does the child feel comfortable and relaxed in the presence of the adult)? Is the child friendly, avoidant, or does the child seek for excessive attention? How is his or her visual, verbal, and bodily contact? How do others (mother, father, siblings, peers) experience the child and themselves in relation to the child? How is the child's relationship with them? How are these aspects observed in the sessions?

RELATIONAL PATTERNS WITH THE ANALYST

• 1 What characteristics does the transferential-counter-transferential relationship have? For example, how is the relationship with the therapist? Is it comfortable and relaxed? Does the child show hesitancy to connect at the beginning? Is the child's play isolated and solitary in the analysis? Are the child's bonds in the play reciprocal, of co-operation? Of competence? Is there inhibition? Do the child relate in a close and intimate way? Can this relating be expressed through words?
• 2 How have these relational patterns changed?

MAIN INTRAPSYCHIC CONFLICTS

1 Which are the main conflicts and affects related to them (for example, individuation, self-esteem, guilt, oedipal conflict, identity conflict)? Which are the prevailing unconscious phantasies that can be inferred from conflicts? How much consciousness does the child have of them?

And the parents? Can they calm down and provide adequate measures for containment and facing of the conflict? To regulate anxiety, to acknowledge, to tolerate, and to soothe, helping to encode conflicts with the internal and external reality as enduring resolution?

• 2 Are defences against conflicts adequate and flexible or mainly dysfunctional (distorting or restricting internal and external experiences)?
• 3 Which affects accompany this dynamics? For example, does the child manifest aggression? Caution? Fear? Pleasure? Joy? Reactions of frustration? Anger? Rage? Surprise? Uneasiness? Sadness? Feeling lost? Is the child able to control himself or herself? Is the child worried about the effects of these on others?
• 4 How have these aspects changed?

MENTAL OR PERSONALITY FUNCTIONING: STRUCTURE

1 What is the level of the child's mental functioning in the following areas?

a Self-perception and perception of others. Identity.

How capable is the child, according to the expected level of development, to adequately perceive his or her own internal states and those of the others? Can the child feel empathy, tolerating and understanding different points of view? Does the child have an integrated sense of his or her own identity that corresponds to the expected level of development? Can the child integrate in his or her identity or past, especially the traumatic experiences in the way that would be expected considering the child's level of development? Which are the characteristics of the prevailing identifications?

How is the child's self-perception and self-representation (inte-grated/contradictory, adequate/inadequate, dystonic/syntonic)? How are the child's affective states in this regard? Does he or she feel disdain, appreciation, shame, pride, for himself or herself?

How are the child's object representations (e.g., enabling, persecutory, idealized, devaluated, fragile)?

How are the child's manifestations regarding the dependency and autonomy expected for his or her level of development? For example, does the child show goodwill and want to do things independently? Does the child insist on things being done as he or she wants? Does the child get angry if it is not like that? Does the child get angry if he or she does not achieve what he or she wants?)

Does the child act freely according to his or her desires and obligations? Does the child act reactively (e.g., does the child present oppositional manifestations)?

Does he or she show flexibility or stubbornness and obstinacy? Does the child show pleasure in success only when approval is shown to him or her?

How have these aspects changed?

b Sensorj^ regulation

Considering the expected level for the child's development, how is his or her ability to control the degree, intensity, and nature of his or responses to sensory stimuli (e.g., excessive response with fear, anxiety, negativism, stubbornness, self-absorption)? How does the child react to different stimuli (sounds, lights, touch) (e.g., lack of response, excessive response, etc.)? Does the father or mother have the capacity to provide a feeling of vitality and enthusiasm? Can the father/mother regulate physiological states (sleep, hunger, activation, sedation, pain, temperature)? How much do parents manage to understand what is happening to the child and have an answer that helps him or her?

What is the child's general level of activity? How much does it vary?

Can the child focus of attention on one activity or interaction? What average time does he or she devote to one specific toy or activity? Is the child frequently distracted?

Regarding the psyche-soma integration, we can wonder: How does the child feel his or her body? Does the child like it? Are there signs in bodily posture that call one's attention? And in his or her way of walking?

Does the child have organic illnesses? Does he or she frequently become ill?

Which are the child's manifestations and experiences about them? What are parents' experience about the child's illness? Has this incidence of somatic factors revealed any situation? If so, has he or she been able to discover in analysis the factors that precede his or her psyche-soma disorganization, such as apathy, depression, withdrawal?

How strong is the influence of factors depending on the context (e.g., changes linked to development, somatic illnesses, medication, acute or chronic stressors, traumatic situations, etc.) and how capable is the patient of facing these difficulties? How do parents influence these aspects?

c Affective regulation

Which attachment style and reflexive capacity does the child show? And the parents? What regulation model was suggested and approved? For example, we consider the following aspects regarding his father or mother: does the parent have the capacity as an adult for tenderness, for erogeneity inhibited in its end? Does the parent have the capacity to take into consideration the reasons behind actions from others? To consider the feelings, mental states, and desires of his or her child? To anticipate danger and neglect? To regulate the child's anxiety and anguish? Does the father or mother have the capacity to build a bond of safe attachment, including tolerance of both early dependence and growing autonomy?

Taking the above into account, we define the following.

How does the child feel in himself or herself and perceive in others the wide range of affects expected at his or her age? How much does the child manage to process impulses and emotional experiences in a way that favours his or her adaptation and satisfaction?

Do the child's norms and ideals help acknowledging and tolerating his or her emotional experiences in the face of adversities, keeping a stability in accordance with his or her level of emotional development?

Can the child regulate his or her self-esteem when facing internal and external demands? Can the child balance his or her interests and those of the others protecting him or her and his or her bonds?

Can the child regulate relationships with others (capacity for intimacy, reciprocity, taking care of himself or herself and the other in relationships)?

How much is the child able to integrate positive and negative feelings towards himself or herself and others?

How would you place the child with regard to the level of development expected for his or her age? And regarding the model received from the family?

How have these aspects changed?

d Internal and external communication and symbolization

In this regard, we ask, How rich is the dialogue of the child with himself or herself and others, based on affective experiences, phantasies, dreams, sexuality, bodily self, and symbolic representations? How would you place it regarding the level of development expected for the child's age?

Does the child count on the necessary tools and has he or she adequately developed them? For instance, is his or her vocalization and speech production adequate for his or her age? Does the child understand others' speech well? Is the primary thought process and/or verbalisations in the play expected for his or her age? How does the child use the information to resolve problems?) Can the father or mother help in this process?

How have these aspects changed?

e Bonds with internal and external objects

How deep and stable are the child's relationships with internal and external objects? How much can he or she create relationships of intimacy and reciprocity based on stable representations and on representations differentiated between himself or herself and others? How does the child handle the relationships that imply the existence of a third?

How capable is the child of initiating and finishing relationships and facing separations?

How would you place the child regarding the expected level of development for his or her age?

How have these aspects changed?

Level 3: Testing of explanatory hypotheses of change

Therapeutic foci

• 1 Which aspects have received special attention from the analyst in his or her interventions, that one can suppose the analyst considers play a central psychodynamic role in the clinical case, originating or maintaining conflicts? How much do analyst, child, caregivers, and teachers coincide on the need to work around them?
• 2 Have these foci of the analytic work changed through time? Why?

Level and type of disorder

• 1 Do the child's symptoms integrate in one syndrome? Is it possible to identify a type of development disorder, personality disorder, or any other kind of disorder?
• 2 Is the level of personality organization orientated towards a functioning that is healthy, neurotic, border, or psychotic?

Could the therapeutic work be centred in neurotic conflicts, or was it necessary to previously, or at the same time, attend to structural failures in the functioning and psychic integration that affected the stability of conflicts and therapeutic work? How have these aspects changed?

Explanatory hypotheses of change

• 1 Which are the main theories and hypotheses from the analyst (explicit or implicit) that can be seen in his or her work? Have they changed through treatment?
• 2 Which other explanatory hypotheses of change could be suggested from different theoretical perspectives? Which are the most and least convincing aspects of each of these different hypotheses and how could they be refined in order to better adjust to the clinical material?

Forms 1, 2, and 3

Instructions for moderators

These forms serve several purposes. They seek to gather information about changes in the psychoanalytic treatments discussed by the groups. They also collect information on the operation of the 3-LM in the group discussion. Finally, they are intended to help personal reflection and group on central questions posed by the model.

Form I

Form 1 is to be completed individually by participants after they have read all the clinical material and at any time before group discussion begins. Their initial personal opinion is of interest, as it will allow the investigation of personal opinions and the effect of the group discussion on them.

Form 2

To be completed by the moderator, after the three levels have been worked on, in discussion with group members. First, the moderator will investigate how many participants agree on overall assessment of the changes in the patient, using the same questions posed in Form 1. Second, the moderator will explore the number of agreed on changes in the severity of the disturbances at the beginning and end of treatment. The two kinds of question complement each other.

The moderator will try to have the group reach as much consensus as possible (with reference to data discussed) and record it according to the instructions on Form 2. The group consensus on the changes is fundamental, as it will serve as a criterion for the classification of cases.

Form 3

The moderator will ask participants to complete Form 3 individually before leaving. The aim of this form is to record the individual assessment of the changes in the patient after group discussion. Both the overall (or global) assessment (using the same questions as in Form 1) and assessments in each of the dimensions of change identified in Level 2, are of interest. The form also asks how useful the participants consider the discussion of each of the 3-LM levels to be.

Select bibliography

Altmann, M. (2013). Tracking transformations in a psychoanalytic process: Unconscious and explicit. International Journal of Psychoanalysis, 94(6), 1191-1193.

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

Altmann de Litvan, M. (Ed.). (2015). Tiempo de cambio: Indagando las transformaciones en psicoanálisis: El Modelo de los Tres Niveles. London: Karnac.

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Appendix I 5.1

Form I Individual conclusions before group discussion

Case identification (moderator):________________________________________

Name of participant:________________________________________________

Place:Date:

Please let us know your personal opinion after reading the material and before group discussion:

Comparison of initial interviews No change Slight positive Moderate Major changes

with later moments of analysis or worse changes changes

Global change of the patient

Changes in the patient’s “use" of the analyst and his or her interpretations

Changes in the patient’s use of his or her own mental and bodily resources for the analysis

Comments:

Appendix I 5.2

Form 2 Group consensus after discussion

Identification of the case:_________________________________________________

Name of participant:________________________________________________

Place:Date:

Group conclusion on the global changes of the patient

At the end of the group discussion, the moderator will ask if the group can reach consensual conclusions about the changes. Only the options where more than half of the group agree will be marked with a cross.

Comparison of initial interviews with No change Slight positive Moderate Major changes

later moments of analysis or worse change changes

Global change of the patient Changes in the patient’s “use" of the analyst and his or her interpretations

Changes in the patient’s use of his or her own mental and bodily resources for the analysis

Comments:_________________________________________________

Global Personality Organization (PDM-2)

The moderator will ask if there is majority agreement in the group about the level of organization of the personality at the beginning and in the last sessions, taking into account mental functioning in aspects such as identity, object relationships, defences, reality testing, etc.

Beginning of the analysis

Psychotic

1 2

Borderline 3 4 5

Neurotic 6 7 8

Healthy

9 10

Level at the beginning (more than half of the participants must agree): (Two consecutive levels can be marked if the point of agreement is between the two)

Number of participants who agree on that opinion:

Number of participants present:______________________________________

No majority agreement (mark here with an X):

Clarifications:________________________________________________________________

Final sessions

Psychotic Borderline Neurotic

Healthy

• 9 10
• 1 2 3 4 5 6 7 8

Level in the last sessions (more than half of the group must agree):

(Two consecutive levels can be marked if the point of agreement is between the two)

Number of participants who agree on that opinion:

Number of participants present:______________________________________

No majority agreement (mark here with an X):

Clarifications:________________________________________________________________

Definitions

Healthy personality: Characterized by mostly 9-10 scores in mental functions. Life problems rarely get out of hand, and enough flexibility to accommodate to challenging realities. (Use 9 for people at the high-functioning neurotic level.)

Neurotic level: Characterized by mostly 6-8 scores; basically a good sense of identity, good reality testing, mostly good intimacies; fair resiliency, fair affect tolerance and regulation; rigidity and limited range of defences and coping mechanisms; favours defences such as repression, reaction formation, intellectualization, displacement, and undoing. (Use 6 for people who go between borderline and neurotic levels.)

Borderline level: Characterized by mostly 3-5 scores; recurrent relational problems; difficulty with affect tolerance and regulation; poor impulse control, poor sense of identity, poor resiliency; favours defences such as splitting, projective identification, idealization/ devaluation, denial, omnipotent control, and acting out. (Use 3 for people who go between psychotic and borderline levels.)

Psychotic level: Characterized by mostly 1-2 scores; delusional thinking; poor reality testing and mood regulation; extreme difficulty functioning in work and relationships; favours defences such as delusional projection, psychotic denial, and psychotic distortion.

(There are no sharp cutoffs between categories. Use your clinical judgment.)

Appendix I 5.3

Form 3 Individual conclusions after group discussion

(Form to be completed before leaving)

Name of participant:________________________________________________

Place:Date:

After discussing the group's opinion on the changes, we would like you to let us know your personal opinion on the following topics. We are very grateful for your response.

Level I: Phenomenological. Global description of changes

Comparison of initial interviews with later No changes Slight positive Moderate Major moments of analysis or worse changes changes changes

Global change of the patient

Changes in the patient’s “use” of the analyst and his or her interpretations

Changes in the patient’s use of his or her own mental and bodily resources for the analysis

Level 2: Main dimensions of change (OPD-2)

Score 1-10 (1 = maximum disturbances; 10 = minimum or imperceptible disturbances)

0 = No data/doesn't apply

Dimensions Initial moment Later moments

Experience of illness: understanding of difficulties and hints of possible changes

Relational patterns outside the analysis

Relational patterns with the analyst

Defences and conflicts

Self-perception, sense of identity and integrity of the self

Perception of the others. Empathy

Regulation of impulses, affects, and self-esteem

Regulation of the relationship with others (self-care and care of the other, reciprocity)

Internal communication and symbolization (bodily and

mental self)

Dimensions Initial moment Later moments

Communication with others (depth and richness of affects and representations)

Bonds with internal objects

Bonds with others. Capacity to establish and end bonds, to face separation, and the existence of a third

Evaluation of group discussion

Usefulness of the model in observing and Not much, or Somewhat Quite Very understanding changes not at all

How useful did you find the group activity in

refining your observation of the material?

How useful did you find the 3-LM group to

conceptualize the dimensions of change?

How satisfactory was the discussion on

linking interventions with observed changes?

Other comments you would like to add: