psychodynamic theory case study

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Clinical case studies in psychoanalytic and psychodynamic treatment.

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Theoretical pluralism in psychoanalytic case studies

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• Centre for Psychoanalytic Studies, University of Essex, Colchester, UK

This manuscript provides a review of the clinical case study within the field of psychoanalytic and psychodynamic treatment. The method has been contested for methodological reasons and because it would contribute to theoretical pluralism in the field. We summarize how the case study method is being applied in different schools of psychoanalysis, and we clarify the unique strengths of this method and areas for improvement. Finally, based on the literature and on our own experience with case study research, we come to formulate nine guidelines for future case study authors: (1) basic information to include, (2) clarification of the motivation to select a particular patient, (3) information about informed consent and disguise, (4) patient background and context of referral or self-referral, (5) patient's narrative, therapist's observations and interpretations, (6) interpretative heuristics, (7) reflexivity and counter-transference, (8) leaving room for interpretation, and (9) answering the research question, and comparison with other cases.

Introduction

Psychoanalysis has always been, according to its inventor, both a research endeavor and a therapeutic endeavor. Furthermore it is clear from Freud's autobiography that he prioritized the research aspect; he did not become a doctor because he wished to cure people in ill health ( Freud, 2001 [1925] ). His invention of the psychoanalytic approach to therapy, involving the patient lying down and associating freely, served a research purpose as much as a therapeutic purpose. Through free association, he would be able to gain unique insight in the human mind. Next, he had to find a format to report on his findings, and this would be the case study. The case study method already existed in medicine ( Forrester, 2016 ), but Freud adjusted it considerably. Case studies in medical settings were more like case files, in which the patient was described or reduced to a number of medical categories: the patient became a case of some particular ailment ( Forrester, 2016 ). In Freud's hands, the case study developed into Kranken Geschichten in which the current pathology of the patient is related to the whole of his life, sometimes even over generations.

Although Freud's case studies have demonstrably provided data for generations of research by analysts ( Midgley, 2006a ) and various scholars ( Pletsch, 1982 ; Sealey, 2011 ; Damousi et al., 2015 ), the method of the case study has become very controversial. According to Midgley (2006b) , objections against the case study method can be grouped into three arguments. First there is the data problem: case studies provide no objective clinical data ( Widlöcher, 1994 ), they only report on what went right and disregard any confusion or mistakes ( Spence, 2001 ). Second, there is the data analysis problem: the way in which the observations of the case study are analyzed lack validity; case studies confirm what we already know ( Spence, 2001 ). Some go even so far to say that they are purely subjective: Michels calls case studies the “crystallization of the analyst's countertransference” ( Michels, 2000 , p. 373). Thirdly, there is the generalizability problem: it is not possible to gain generalizable insight from case studies. Reading, writing and presenting case studies has been described as being a group ritual to affirm analysts in their professional identity, rather than a research method ( Widlöcher, 1994 ).

These criticisms stand in contrast to the respect gained by the case study method in the last two decades. Since the 1990s there has been an increasing number of psychoanalytic and psychodynamic clinical case study and empirical case studies being published in scientific journals ( Desmet et al., 2013 ; Cornelis et al., in press ). It has also been signaled that the case study method is being revived more broadly in the social sciences. In the most recent, fifth edition of his seminal book on case study research, Yinn (2014) includes a figure showing the steady increase of the frequency with which the term “case study research” appears in published books in the period from 1980 to 2008.

KEY CONCEPT 1. Clinical case study A clinical case study is a narrative report by the therapist of what happened during a therapy together with the therapist's interpretations of what happened. It is possible that certain (semi)-structured assessment instruments, such as a questionnaire or a diagnostic interview are included in clinical case studies, yet it is still the therapist that uses these, interprets and discusses them.

KEY CONCEPT 2. Empirical case studies In an empirical case study data are gathered from different sources (e.g., self-report, observation,…) and there is a research team involved in the analyses of the data. This study can take place either in a naturalistic setting (systematic case study) or in a controlled experimental environment (single-case experiment).

In addition to the controversy about the case study method, psychoanalysis has developed into a fragmented discipline. The different psychoanalytic schools share Freud's idea of the unconscious mind, but they focus on different aspects in his theoretical work. Some of the schools still operate under the wings of the International Psychoanalytic Association, while others have established their own global association. Each school is linked to one or several key psychoanalysts who have developed their own version of psychoanalysis. Each psychoanalytic school has a different set of theories but there are also differences in the training of new psychoanalysts and in the therapeutic techniques that are applied by its proponents.

Based on this heterogeneity of perspectives in psychoanalysis, a research group around the Single Case Archive investigated the current status of case study research in psychoanalysis ( Willemsen et al., 2015a ). They were particularly interested to know more about the output and methodology of case studies within the different psychoanalytic schools.

KEY CONCEPT 3. Single case archive The Single Case Archive is an online archive of published clinical and empirical case studies in the field of psychotherapy ( http://www.singlecasearchive.com ). The objective of this archive is to facilitate the study of case studies for research, clinical, and teaching purposes. The online search engine allows the identification of sets of cases in function of specific clinical or research questions.

Our Survey Among Case Study Authors About their Psychoanalytic School

In order to investigate and compare case studies from different psychoanalytic schools, we first had to find a way of identifying to which school the case studies belonged. This is very difficult to judge straightforwardly on the basis of the published case study: the fact that someone cites Winnicott or makes transference interpretations doesn't place him or her firmly within a particular psychoanalytic school. The best approach was to ask the authors themselves. Therefore, we contacted all case study authors included in the Single Case Archive (since the time of our original study in 2013, the archive has expanded). We sent emails and letters in different languages to 445 authors and received 200 replies (45% response rate). We asked them the following question: “ At the time you were working on this specific case, to which psychoanalytic school(s) did you feel most attached? ” Each author was given 10 options: (1) Self Psychology (1.a Theory of Heinz Kohut, 1.b Post-Kohutian Theories, 1.c Intersubjective psychoanalysis), (2) Relational psychoanalysis, (3) Interpersonal psychoanalysis, (4) Object relational psychoanalysis (4.a Theory of Melanie Klein, 4.b Theory of Donald W. Winnicott, 4.c Theory of Wilfred R. Bion, 4.d Theory of Otto F. Kernberg), (5) Ego psychology (or) “Classic psychoanalysis” (5.a Theories of Sigmund Freud, 5.b Ego psychology, 5.c Post-Ego psychology), (6) Lacanian psychoanalysis, (7) Jungian psychoanalysis, (8) National Psychological Association for Psychoanalysis (NPAP) related theory, (9) Modern psychoanalysis related to the Boston or New York Graduate School of Psychoanalysis (BGSP/NYGSP), (10) Other. Respondents could indicate one or more options.

Analysis of the responses indicated that the two oldest schools in psychoanalysis, Object-relations psychoanalysis and Ego psychology, dominate the field in relation to case studies that are published in scientific journals. More than three quarters of all case study authors (77%) reported these schools of thought to be the ones with which they considered themselves most affiliated. Three more recent schools were also well-represented among case studies: Self Psychology, Relational Psychoanalysis, and Interpersonal Psychoanalysis. Lacanian Psychoanalysis, Jungian Psychoanalysis, NPAP related Theory and Modern Psychoanalysis related to the BGSP/NYGSP were only rarely mentioned by case study authors as their school of thought. This does not mean that clinicians or researchers within these latter schools do not write any case studies. It only means that they publish few case studies in the scientific journals included in ISI-ranked journals indexed in Web of Science. But they might have their own journals in which they publish clinical material.

Our survey demonstrated that the majority of case study authors (59%) feel attached to more than one psychoanalytic school. This was in fact one of the surprising findings in our study. It seems that theoretical pluralism is more rule than exception among case study authors. There were some differences between the psychoanalytic schools though in terms of pluralism. Case study authors who feel attached to Self Psychology and Interpersonal Psychoanalysis are the most pluralistic: 92 and 86%, respectively also affiliate with one or more other psychoanalytic schools. Case study authors who feel attached to Object Relations Psychoanalysis are the “purest” group: only 69% of them affiliate with one or more other psychoanalytic schools.

KEY CONCEPT 4. Theoretical pluralism A situation in which several, potentially contradicting, theories coexist. It is sometimes interpreted as a sign of the immaturity of a science, under the assumption that a mature science should arrive at one single coherent truth. Others see theoretical pluralism as unavoidable for any applied discipline, as each theory can highlight only part of reality.

Psychoanalytic Pluralism and the Case Study Method

We were not really surprised to find that Object Relations psychoanalysis and Ego psychology were the most dominant schools in the field of psychoanalytic case studies, as they are very present in European, Latin-American and North-American psychoanalytic institutes. We were more surprised to find such a high degree of pluralism among these case study authors, given the fact that disputes between analysts from different schools can be quite ardent ( Green, 2005 ; Summers, 2008 ). Others have compared the situation of psychoanalytic schools with the Tower of Babel ( Steiner, 1994 ).

It has been argued that the case study method contributes to the degree of theoretical pluralism within psychoanalysis. The reason for this is situated in the reasoning style at the basis of case study research ( Chiesa, 2010 ; Fonagy, 2015 ). The author of a psychoanalytic case study makes a number of observations about the patient within the context of the treatment, and then moves to a conclusion about the patient's psychodynamics in general. The conclusion he or she arrives at inductively gains its “truth value” from the number and quality of observations it is based on. This style of reasoning in case study research is very similar to how clinicians reason in general. Clinicians look for patterns within patients and across patients. If they make similar observations in different patients, or if other psychoanalysts make similar observations in their patients, the weight of the conclusion becomes greater and greater. The problem with this reasoning style is that one can never arrive at definite conclusions: even if a conclusion is based on a large number of observations, it is always possible that the next observation disconfirms the conclusion. Therefore, it could be said, it is impossible to attain “true” knowledge.

The above argument is basically similar to objections against any kind of qualitative research. To this, we argue with Rustin (2003) that there is not one science and no hierarchy of research methods. Each method comes with strengths and weaknesses, and what one gains in terms of control and certainty in a conventional experimental setup is lost in terms of external validity and clinical applicability. Numerous researchers have pleaded for the case study approach as one method among a whole range of research methods in the field of psychoanalysis ( Rustin, 2003 ; Luyten et al., 2006 ; Midgley, 2006b ; Colombo and Michels, 2007 ; Vanheule, 2009 ; Hinshelwood, 2013 ). Leuzinger-Bohleber makes a distinction between clinical research and extra-clinical research ( Leuzinger-Bohleber, 2015 ). Clinical research is the idiographic type of research conducted by a psychoanalyst who is working with a patient. Unconscious phantasies and conflicts are symbolized and put into words at different levels of abstraction. This understanding then molds the perception of the analyst in subsequent clinical situations; even though the basic psychoanalytic attitude of “not knowing” is maintained. The clinical case study is clinical research par excellence . Extra-clinical research consists in the application of different methodologies developed in the natural and human sciences, to the study of the unconscious mind. Leuzinger-Bohleber refers to empirical psychotherapy research, experimental research, literature, cultural studies, etc. We believe that the clinical case study method should step up and claim its place in psychoanalytic research, although we agree that the method should be developed further. This paper and a number of others such as Midgley (2006b) should facilitate this methodological improvement. The clinical research method is very well-suited to address any research question related to the description of phenomena and sequences in psychotherapy (e.g., manifestation and evolution of symptoms and therapeutic relationship over time). It is not suitable for questions related to causality and outcome.

We also want to point out that there is a new evolution in the field of psychotherapy case study research, which consists in the development of methodologies for meta-studies of clinical case studies ( Iwakabe and Gazzola, 2009 ). The evolution builds on the broader tendency in the field of qualitative research to work toward integration or synthesis of qualitative findings ( Finfgeld, 2003 ; Zimmer, 2006 ). The first studies which use this methodology have been published recently: Widdowson (2016) developed a treatment manual for depression, Rabinovich (2016) studied the integration of behavioral and psychoanalytic treatment interventions, and Willemsen et al. (2015b) investigated patterns of transference in perversion. The rich variety of research aims demonstrates the potential of these meta-studies of case studies.

KEY CONCEPT 5. Meta-studies of clinical case studies A meta-study of clinical case studies is a research approach in which findings from cases are aggregated and more general patterns in psychotherapeutic processes are described. Several methodologies for meta-studies have been described, including cross-case analysis of raw data, meta-analysis, meta-synthesis, case comparisons, and review studies in general.

Lack of Basic Information in Psychoanalytic Case Studies

The second research question of our study ( Willemsen et al., 2015a ) concerned the methodological, patient, therapist, and treatment characteristics of published psychoanalytic case studies. All studies included in the Single Case Archive are screened by means of a coding sheet for basic information, the Inventory of Basic Information in Single Cases (IBISC). The IBISC was designed to assess the presence of basic information on patient (e.g., age, gender, reasons to consult), therapist (e.g., age, gender, level of experience), treatment (e.g., duration, frequency, outcome), and the methodology (e.g., therapy notes or audio recoding of sessions). The IBISC coding revealed that a lot of basic information is simply missing in psychoanalytic case studies ( Desmet et al., 2013 ). Patient information is fairly well-reported, but information about therapist, treatment and methodology are often totally absent. Training and years of experience are not mentioned in 84 and 94% of the cases, respectively. The setting of the treatment is not mentioned in 61% of the case studies. In 80% of the cases, it was not mentioned whether the writing of the case studies was on the basis of therapy notes, or audiotapes. In 91% of the cases, it was not mentioned whether informed consent was obtained.

Using variables on which we had more comprehensive information, we compared basic information of case studies from different psychoanalytic schools. This gave us a more detailed insight in the type of case studies that have been generated within each psychoanalytic school, and into the difference between these schools in terms of the kind of case study they generate. We found only minimal differences. Case studies in Relational Psychoanalysis stand out because they involve older patients and longer treatments. Case studies in Interpersonal Psychoanalysis tend to involve young, female patients and male therapists. Case study authors from both these schools tend to report on intensive psychoanalysis in terms of session frequency. But for the rest, it seems that the publication of case studies throughout the different psychoanalytic schools has intensified quite recently.

Guidelines for Writing Clinical Case Studies

One of the main problems in using psychoanalytic case studies for research purposes is the enormous variability in quality of reporting and inconsistency in the provision of basic information about the case. This prevents the reader from contextualizing the case study and it obstructs the comparison of one case study with another. There have been attempts to provide guidelines for the writing of case studies, especially in the context of analytic training within the American Psychoanalytic Association ( Klumpner and Frank, 1991 ; Bernstein, 2008 ). However, these guidelines were never enforced for case study authors by the editors from the main psychoanalytic journals. Therefore, the impact of these guidelines on the field of case study research has remained limited.

Here at the end of our focused review, we would like to provide guidelines for future case study authors. Our guidelines are based on the literature and on our experience with reading, writing, and doing research with clinical case studies. We will include fragments of existing case studies to clarify our guidelines. These guidelines do not provide a structure or framework for the case study; they set out basic principles about what should be included in a case study.

Basic Information

First of all, we think that a clinical case study needs to contain basic information about the patient, the therapist, the treatment, and the research method. In relation to the patient , it is relevant to report on gender, age (or an age range in which to situate the patient), and ethnicity or cultural background. The reader needs to know these characteristics in order to orientate themselves as to who the patient is and what brings them to therapy. In relation to the therapist , it is important to provide information about professional training, level of professional experience, and theoretical orientation. Tuckett (2008) emphasizes the importance for clinicians to be explicit about the theory they are using and about their way of practicing. It is not sufficient to state membership of a particular group or school, because most groups have a wide range of different ways of practicing. In relation to the treatment itself, it is important to be explicit about the kind of setting, the duration of treatment, the frequency of sessions, and details about separate sequences in the treatment (diagnostic phase, follow-up etc.). These are essential features to share, especially at a time when public sector mental health treatment is being subjected to tight time restrictions and particular ways of practising are favored over others. For example short-term psychotherapies are being implemented in public services for social and economic reasons. While case studies carried out in the public sector can give us information on those short-term therapies, private practice can offer details about the patient's progress on a long-term basis. Moreover, it is important to report whether the treatment is completed. To our astonishment, there are a considerable number of published case studies on therapies that were not finished ( Desmet et al., 2013 ). As Freud (2001 [1909] , p. 132) already advised, it is best to wait till completion of the treatment before one starts to work on a case study. Finally, in relation to the research method , it is crucial to mention which type of data were collected (therapy notes taken after each session, audio-recordings, questionnaires, etc.), whether informed consent was given, and in what way the treatment was supervised. Clinicians who would like to have help with checking whether they included all necessary basic information case use the Inventory for Basic Information in Single Cases (IBISC), which is freely available on http://www.singlecasearchive.com/resources .

Motivation to Select a Particular Patient

First of all, it is crucial to know what the motivation for writing about a particular case comes from. Some of the following questions should be kept in mind and made explicit from the beginning of the case presentation. Why is it interesting to look at this case? What is it about this case or the psychotherapist's work that can contribute to the already existing knowledge or technique?

“This treatment resulted in the amelioration of his [obsessive-compulsive] symptoms, which remained stable eight years after treatment ended. Because the standard of care in such cases has become largely behavioral and pharmacological, I will discuss some questions about our current understanding of obsessive-compulsive phenomena that are raised by this case, and some of the factors that likely contributed to the success of psychoanalytic treatment for this child ( McGehee, 2005 , p. 213–214).”

This quotation refers to a case that has been selected on the basis of its successful outcome. The author is then interested to find out what made this case successful.

Informed Consent and Disguise

As regulations on privacy and ethics are becoming tighter, psychotherapists find themselves with a real problem in deciding what is publishable and what is not. Winship (2007) points out that there is a potential negative effect of research overregulation as clinicians may be discouraged from reporting ordinary and everyday findings from their clinical practice. But he also offers very good guidelines for approaching the issue of informed consent. A good practice is asking for consent either at the start of the treatment or after completion of the treatment: preferably not during treatment. It is inadvisable to complete the case study before the treatment has ended. It is also advisable that the process of negotiating consent with the patient is reported in the case study.

“To be sure that Belle's anonymity was preserved, I contacted her while writing this book and told her it would not be published without her complete approval. To do this, I asked if she would review every word of every draft. She has ( Stoller, 1986 , p. 217).”

In relation to disguise, one has to strike a balance between thin and thick disguise. Gabbard (2000) suggests different useful approaches to disguising the identity of the patient.

Patient Background and Context of Referral or Self-Referral

It is important to include relevant facts about the patient's childhood, family history, siblings, any trauma or losses and relationship history (social and romantic) and the current context of the patient's life (family, working, financial). The context of referral is also key to understanding how and why the patient has come to therapy. Was the patient encouraged to come or had wanted to come? Has there been a recent crisis which prompted the intervention or an on-going problem which the patient had wanted to address for some time?

“Michael was one of the youngest children in his family of origin. He had older brothers and sisters who had been received into care before his birth. His parents separated before he was born. There had been some history of violence between them and Michael was received into care on a place of safety order when he was an infant because his mother had been unable to show consistent care toward him ( Lykins Trevatt, 1999 , p. 267).”

Patient's Narrative, Therapist's Observations, and Interpretations

A case study should contain detailed accounts of key moments or central topics, such as a literal transcription of an interaction between patient and therapist, the narration of a dream, a detailed account of associations, etc. This will increase the fidelity of the case studied, especially when both patient's and therapist's speech are reported as carefully as possible.

“Martha spoke in a high-pitched voice which sounded even more tense than usual. She explained that her best friend's mum had shouted at her for being so withdrawn; this made her angry and left her feeling that she wanted to leave their home for good. I told Martha that she often tried to undo her bad feelings by acting quickly on her instincts, as she did not feel able to hold her feelings in her mind and bring them to her therapy to think about with me. Martha nodded but it was not clear whether she could really think about what I just said to her. She then said that she was being held in the hospital until a new foster placement could be found. “In the meantime,” she said in a pleased tone, “I have to be under constant supervision” ( Della Rosa, 2015 , p. 168).”

In this example, observations of nonverbal behavior and tonality are also included, which helps to render a lively picture of the interaction.

Interpretative Heuristics

In which frame of reference is the writer operating? It is important to know what theories are guiding the therapist's thinking and what strategies he employs in order to deal with the clinical situation he is encountering. Tuckett (1993) writes about the importance of knowing what “explanatory model” is used by the therapist in order to make sense of the patient and to relate his own thinking to a wider public for the purpose of research. This idea is also supported by Colombo and Michels (2007) who believe that making theoretical orientations as explicit as possible would make the case studies intelligible and more easily employed by the research community. This can be done by the therapists explaining why they have interpreted a particular situation in the way they have. For example, Kegerreis in her paper on time and lateness (2013) stresses throughout how she is working within the object-relations framework and looking out for the patient's use of projective mechanisms.

“She was 10 minutes late. Smiling rather smugly to herself she told me that the wood supplied for her new floor had been wrongly cut. The suppliers were supposed to come and collect it and hadn't done so, so she had told them she was going to sell it to a friend, and they are now all anxious and in a hurry to get it.

I said she now feels as if she has become more powerful, able to get a response. She agrees, grinning more, telling me she does have friends who would want it, that it was not just a ploy.

She said she had found it easier to get up today but was still late. I wondered if she had a sense of what the lateness was about. She said it was trying to fit too much in. She had been held up by discussing the disposal of rubble with her neighbors.

I said I thought there was a link here with the story about the wood. In that she had turned the situation around. She had something that just didn't work, had a need for something, but it was turned around into something that was the suppliers' problem. They were made to feel the urgency and the need. Maybe when she is late here she is turning it around, so it is me who is to be uncertain and waiting, not her waiting for her time to come.

We maybe learn here something of her early object relationships, in which being in need is felt to be unbearable, might lead to an awful awareness of lack and therefore has to be exported into someone else. One could go further and surmise that in her early experience she felt teased and exploited by the person who has the power to withhold what you need ( Kegerreis, 2013 , p. 458).”

There can be no doubt reading this extract about the theoretical framework which is being used by the therapist.

Reflexivity and Counter-Transference

A good case study contains a high degree of reflexivity, whereby the therapist is able to show his feelings and reactions to the patient's communication in the session and an ability to think about it later with hindsight, by himself or in supervision. This reflexivity needs to show the pattern of the therapist's thinking and how this is related to his school of thought and to his counter-transferential experiences. How has the counter-transference been dealt with in a professional context? One can also consider whether the treatment has been influenced by supervision or discussion with colleagues.

“Recently for a period of a few days I found I was doing bad work. I made mistakes in respect of each one of my patients. The difficulty was in myself and it was partly personal but chiefly associated with a climax that I had reached in my relation to one particular psychotic (research) patient. The difficulty cleared up when I had what is sometimes called a ‘healing’ dream. […] Whatever other interpretations might be made in respect of this dream the result of my having dreamed it and remembered it was that I was able to take up this analysis again and even to heal the harm done to it by my irritability which had its origin in a reactive anxiety of a quality that was appropriate to my contact with a patient with no body ( Winnicott, 1949 , p. 70).”

Leaving Room for Interpretation

A case study is the therapist's perspective on what happened. A case study becomes richer if the author can acknowledge aspects of the story that remain unclear to him. This means that not every bit of reported clinical material should be interpreted and fitted within the framework of the research. There should be some loose ends. Britton and Steiner (1994) refer to the use of interpretations where there is no room for doubt as “soul murder.” A level of uncertainty and confusion make a case study scientifically fruitful ( Colombo and Michels, 2007 ). The writer can include with hindsight what he thinks he has not considered during the treatment and what he thinks could have changed the course for the treatment if he had been aware or included other aspects. This can be seen as an encouragement to continue to be curious and maintain an open research mind.

Answering the Research Question, and Comparison with Other Cases

As in any research report, the author has to answer the research question and relate the findings to the existing literature. Of particular interest is the comparison with other similar cases. Through comparing, aggregating, and contrasting case studies, one can discover to what degree and under what conditions, the findings are valid. In other words, the comparison of cases is the start of a process of generalization of knowledge.

“Although based on a single case study, the results of my research appear to concur with the few case studies already in the field. In reviewing the literature on adolescent bereavement, it was the case studies that had particular resonance with my own work, and offered some of the most illuminating accounts of adolescent bereavement. Of special significance was Laufer's (1966) case study that described the narcissistic identifications of ‘Michael’, a patient whose mother had died in adolescence. Both Laufer's research and my own were conducted using the clinical setting as a basis and so are reflective of day-to-day psychotherapy practice ( Keenan, 2014 , p. 33).”

As Yinn (2014) has argued for the social sciences, the case study method is the method of choice when one wants to study a phenomenon in context, especially when the boundaries between the phenomenon and the context are fussy. We are convinced that the same is true for case study methodology in the fields of psychoanalysis and psychotherapy. The current focused review has positioned the research method within these fields, and has given a number of guidelines for future case study researchers. The authors are fully aware that giving guidelines is a very tricky business, because while it can channel and stimulate research efforts it can as well-limit creativity and originality in research. Moreover, guidelines for good research change over time and have to be negotiated over and over again in the literature. A similar dilemma is often pondered when it comes to qualitative research ( Tracy, 2010 ). However, our first impetus for providing these guidelines is pedagogical. The three authors of this piece are experienced psychotherapists who also work in academia. A lot of our students are interested in doing case study research with their own patients, but they struggle with the methodology. Our second impetus is to improve the scientific credibility of the case study method. Our guidelines for what to include in the written account of a case study, should contribute to the improvement of the quality of the case study literature. The next step in the field of case study research is to increase the accessibility of case studies for researchers, students and practitioners, and to develop methods for comparing or synthesizing case studies. As we have described above, efforts in that direction are being undertaken within the context of the Single Case Archive.

Author Contributions

JW has written paragraphs 1–4; ER and JW have written paragraph 5 together; SK has contributed to paragraph 5 and revised the whole manuscript.

Conflict of Interest Statement

The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

Author Biography

Bernstein, S. B. (2008). Writing about the psychoanalytic process. Psychoanal. Inq. 28, 433–449. doi: 10.1080/0735516908022126694

CrossRef Full Text | Google Scholar

Britton, R., and Steiner, J. (1994). Interpretation: selected fact or overvalued idea? Int. J. Psychoanal. 75, 1069–1078.

PubMed Abstract | Google Scholar

Chiesa, M. (2010). Research and psychoanalysis: still time to bridge the great divide? Psychoanal. Psychnol. 27, 99–114. doi: 10.1037/a0019413

Colombo, D., and Michels, R. (2007). Can (should) case reports be written for research use? Psychoanal. Inq. 27, 640–649. doi: 10.1080/07351690701468256

Cornelis, S., Desmet, M., Meganck, R., Cauwe, J., Inslegers, R., Willemsen, J., et al. (in press). Interaction between obsessional symptoms interpersonal dynamics: an empirical single case study. Psychoanal. Psychnol. doi: 10.1037/pap0000078

CrossRef Full Text

Damousi, J., Lang, B., and Sutton, K. (2015). Case Studies and the Dissemination of Knowledge . New York, NY: Routledge.

Google Scholar

Della Rosa, E. (2015). The problem of knowledge in psychotherapy with an adolescent girl: reflections on a patient's difficulty in thinking and issues of therapeutic technique. J. Child Psychother. 41, 162–178. doi: 10.1080/0075417X.2015.1048125

Desmet, M., Meganck, R., Seybert, C., Willemsen, J., Van Camp, I., Geerardyn, F., et al. (2013). Psychoanalytic single cases published in ISI-ranked journals: the construction of an online archive. Psychother. Psychosom. 82, 120–121. doi: 10.1159/000342019

PubMed Abstract | CrossRef Full Text | Google Scholar

Finfgeld, D. L. (2003). Metasynthesis: the state of the art – so far. Qual. Health Res. 13, 893–904. doi: 10.1177/1049732303253462

Fonagy, P. (2015). “Research issues in psychoanalysis,” in An Open Door Review of Outcome and Process Studies in Psychoanalysis, 3rd Edn. , eds M. Leuzinger-Bohleber and H. Kächele (London: International Psychoanalytic Association), 42–60.

Forrester, J. (2016). Thinking in Cases . Cambridge: Polity.

Freud, S. (2001 [1909]). Analysis of a Phobia in a Five-Year-Old Boy, 10th Standard Edn. London: Vintage Books.

Freud, S. (2001 [1925]). An Autobiographical Study, 20th Standard Edn. London: Vintage Books.

Gabbard, G. O. (2000). Disguise or consent: problems and recommendations concerning the publication and presentation of clinical material. Int. J. Psychoanal. 81, 1071–1086. doi: 10.1516/0020757001600426

Green, A. (2005). The illusion of common ground and mythical pluralism. Int. J. Psychoanal. 86, 627–632.

Hinshelwood, R. D. (2013). Research on the Couch . London: Routledge.

Iwakabe, S., and Gazzola, N. (2009). From single-case studies to practice-based knowledge: aggregating and synthesizing case studies. Psychother. Res. 19, 601–611. doi: 10.1080/10503300802688494

Keenan, A. (2014). Parental loss in early adolescence and its subsequent impact on adolescent development. J. Child Psychother. 40, 20–35. doi: 10.1080/0075417X.2014.883130

Kegerreis, S. (2013). “When I can come on time I'll be ready to finish”: meanings of lateness in psychoanalytic psychotherapy. Br. J. Psychother. 29, 449–465. doi: 10.1111/bjp.12053

Laufer, M. (1966). Object loss in adolescence. Psychoanal. Study Child 31, 269–293.

Leuzinger-Bohleber, M. (2015). “Development of a plurality during the one hundred year old history of research of psychoanalysis,” in An Open Door Review of Outcome and Process Studies in Psychoanalysis, 3rd Edn. , eds M. Leuzinger-Bohleber and H. Kächele (London: International Psychoanalytic Association), 18–32.

Klumpner, G. H., and Frank, A. (1991). On methods of reporting clinical material. J. Am. Psychoanal. Assoc. 39, 537–551. doi: 10.1177/000306519103900211

Luyten, P., Blatt, S. J., and Corveleyn, J. (2006). Minding the gap between positivism and hermeneutics in psychoanalytic research. J. Am. Psychoanal. Assoc. 54, 571–610. doi: 10.1177/00030651060540021301

Lykins Trevatt, D. (1999). An account of a little boy's attempt to recover from the trauma of abuse. J. Child Psychother. 25, 267–287. doi: 10.1080/00754179908260293

McGehee, R. H. (2005). Child psychoanalysis and obsessive-compulsive symptoms: the treatment of a ten-year-old boy. J. Am. Psychoanal. Assoc. 53, 213–237. doi: 10.1177/00030651050530011301

Michels, R. (2000). The case history. J. Am. Psychoanal. Assoc. 48, 355–411. doi: 10.1177/00030651000480021201

Midgley, N. (2006a). Re-reading “Little Hans”: Freud's case study and the question of competing paradigms in psychoanalysis. J. Am. Psychoanal. Assoc. 54, 537–559. doi: 10.1177/00030651060540021601

Midgley, N. (2006b). The “inseparable bond between cure and research”: clinical case study as a method of psychoanalytic inquiry. J. Child Psychother. 32, 122–147. doi: 10.1080/00754170600780273

Pletsch, C. E. (1982). Freud's case studies and the locus of psychoanalytic knowledge. Dynamis 2, 263–297.

Rabinovich, M. (2016). Psychodynamic emotional regulation in view of Wolpe's desensitization model. Am. J. Psychol. 129, 65–79. doi: 10.5406/amerjpsyc.129.1.0065

Rustin, M. (2003). Research in the consulting room. J. Child Psychother. 29, 137–145. doi: 10.1080/0075417031000138415

Sealey, A. (2011). The strange case of the Freudian case history: the role of long case histories in the development of psychoanalysis. Hist. Human Sci. 24, 36–50. doi: 10.1177/0952695110383460

Spence, D. P. (2001). Dangers of anecdotal reports. J. Clin. Psychol. 57, 37–41. doi: 10.1002/1097-4679(200101)57:1<37::AID-JCLP5>3.0.CO;2-S

Steiner, R. (1994). “The tower of Babel” or “After Babel in contemporary psychoanalysis”? – Some historical and theoretical notes on the linguistic and cultural strategies implied by the foundation of the International Journal of Psycho-Analysis, and on its Relevance today. Int. J. Psychoanal. 75, 883–901.

Stoller, R. J. (1986). Sexual Excitement: Dynamics of Erotic Life . London: Maresfield Library.

Summers, F. (2008). Theoretical insularity and the crisis of psychoanalysis. Psychoanal. Psychnol. 25, 413–424. doi: 10.1037/0736-9735.25.3.413

Tracy, S. J. (2010). Qualitative quality: eight “big tent” criteria for excellent qualitative research. Qual. Inq. 16, 837–851. doi: 10.1177/1077800410383121

Tuckett, D. (1993). Some thoughts on the presentation and discussion of the clinical material of psychoanalysis. Int. J. Psychoanal. 74, 1175–1190.

Tuckett, D. (2008). Psychoanalysis Comparable and Incomparable: The Evolution of a Method to Describe and Compare Psychoanalytic Approaches . New York, NY: Routledge.

Vanheule, S. (2009). Psychotherapy and research: a relation that needs to be reinvented. Br. J. Psychother. 25, 91–109. doi: 10.1111/j.1752-0118.2008.01103.x

Widdowson, M. (2016). Transactional Analysis for Depression: A Step-by-step Treatment Manual . Abingdon: Routledge.

Widlöcher, D. (1994). A case is not a fact. Int. J. Psychoanal. 75, 1233–1244.

Willemsen, J., Cornelis, S., Geerardyn, F. M., Desmet, M., Meganck, R., Inslegers, R., et al. (2015a). Theoretical pluralism in psychoanalytic case studies. Front. Psychol. 6:1466. doi: 10.3389/fpsyg.2015.01466

Willemsen, J., Inslegers, R., Meganck, R., Geerardyn, F., Desmet, M., and Vanheule, S. (2015b). A metasynthesis of published case studies through Lacan's L-schema: transference in perversion. Int. J. Psychoanal. 96, 773–795. doi: 10.1111/1745-8315.12179

Winnicott, D. W. (1949). Hate in the counter-transference. Int. J. Psychoanal. 30, 69–74.

Winship, G. (2007). The ethics of reflective research in single case study inquiry. Perspect. Psychiatr. Care 43, 174–182. doi: 10.1111/j.1744-6163.2007.00132.x

Yinn, R. K. (2014). Case Study Research: Design and Methods . Thousand Oaks, CA: Sage.

Zimmer, L. (2006). Qualitative meta-synthesis: a question of dialoguing with texts. J. Adv. Nurs. 53, 311–318. doi: 10.1111/j.1365-2648.2006.03721.x

Keywords: clinical case study, methodology, psychotherapy research, psychoanalysis, psychoanalytic schools, theoretical pluralism, review

Citation: Willemsen J, Della Rosa E and Kegerreis S (2017) Clinical Case Studies in Psychoanalytic and Psychodynamic Treatment. Front. Psychol . 8:108. doi: 10.3389/fpsyg.2017.00108

Received: 29 November 2016; Accepted: 16 January 2017; Published: 02 February 2017.

Reviewed by:

Copyright © 2017 Willemsen, Della Rosa and Kegerreis. This is an open-access article distributed under the terms of the Creative Commons Attribution License (CC BY) . The use, distribution or reproduction in other forums is permitted, provided the original author(s) or licensor are credited and that the original publication in this journal is cited, in accordance with accepted academic practice. No use, distribution or reproduction is permitted which does not comply with these terms.

*Correspondence: [email protected]

Disclaimer: All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher.

Clinical Case Studies in Psychoanalytic and Psychodynamic Treatment

Affiliation.

• 1 Centre for Psychoanalytic Studies, University of Essex Colchester, UK.
• PMID: 28210235
• PMCID: PMC5288375
• DOI: 10.3389/fpsyg.2017.00108

This manuscript provides a review of the clinical case study within the field of psychoanalytic and psychodynamic treatment. The method has been contested for methodological reasons and because it would contribute to theoretical pluralism in the field. We summarize how the case study method is being applied in different schools of psychoanalysis, and we clarify the unique strengths of this method and areas for improvement. Finally, based on the literature and on our own experience with case study research, we come to formulate nine guidelines for future case study authors: (1) basic information to include, (2) clarification of the motivation to select a particular patient, (3) information about informed consent and disguise, (4) patient background and context of referral or self-referral, (5) patient's narrative, therapist's observations and interpretations, (6) interpretative heuristics, (7) reflexivity and counter-transference, (8) leaving room for interpretation, and (9) answering the research question, and comparison with other cases.

Keywords: clinical case study; methodology; psychoanalysis; psychoanalytic schools; psychotherapy research; review; theoretical pluralism.

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The Psychodynamic Formulation: Its Purpose, Structure, and Clinical Application

• Samuel Perry , M.D. ,
• Arnold M. Cooper , M.D. , and
• Robert Michels , M.D.

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The authors present a brief written psychodynamic formulation that focuses on central conflicts, anticipates transferences and resistances, and helps guide all psychiatric treatments. After placing the presenting problem in the context of the patient’s life and identifying nondynamic determinants of the psychopathology, the formulation explains the development of central conflicts and their repetitive effect on the patient’s behavior. It concludes by describing how these conflicts will be manifested in treatment. Three sample formulations and their application are presented to illustrate the value of this clinical tool.

In the course of supervising mental health professionals, we have noted that a comprehensive psychodynamic formulation is seldom offered and almost never incorporated into the written record. Our experience is reflected in the psychiatric and psychoanalytic literature, where psychodynamics are often discussed but psychodynamic formulations are rarely presented. In this paper we discuss the purpose and structure of the psychodynamic formulation, provide three illustrations, and indicate how these formulations can help guide all treatments.

P urpose of the formulation

In many respects a dynamic formulation and a clinical diagnosis share a common purpose. Although both hold intellectual, didactic, and research interests, their primary function is to provide a succinct conceptualization of the case and thereby guide a treatment plan. Like a psychiatric diagnosis, a psychodynamic formulation is specific, brief, focused, and therefore limited in its intent, scope, and wisdom. It concisely and incisively clarifies the central issues and conflicts, differentiating what the therapist sees as essential from what is secondary. Also like the diagnosis, additional information and changes over time may lead to modifications of the patient’s dynamics and how they are formulated, with corresponding alterations in treatment. Again, like the diagnosis, the psychodynamic understanding of a patient serves as a stabilizing force in conducting any form of therapy; its general effect is conservative, discouraging a change in tack with every slight shift of the wind.

One common misconception is that a psychodynamic formulation is indicated only for those patients in a long-term, expressive psychotherapy. This belief ignores the fact that the success of any treatment may involve supporting, managing, or even modifying aspects of the patient’s personality. Therapeutic effectiveness or failure often hinges on how well or poorly the therapist understands the patient’s dynamics, predicts what resistances the patient will present, and designs an approach that will circumvent, undermine, or surmount these obstacles.

A second common misconception is that the construction of a psychodynamic formulation is primarily a training experience. For example, MacKinnon and Yudofsky ( 1 ), while agreeing with the importance of understanding a patient’s psychodynamics, state: “A written case formulation is principally for the education of the clinician or for clinical case conferences. The thought and preparation involved in this exercise constitute an important learning experience for the beginning student of psychiatry.” These authors then later suggest, “Even an experienced therapist can benefit from this task in a confusing or difficult case.” Although MacKinnon and Yudofsky are here referring to a complete case formulation (which includes the present illness, psychopathology, developmental data, diagnostic classification, and prognosis), one may erroneously conclude that a written psychodynamic formulation is a task reserved for special situations rather than a fundamental component of all treatments.

A third common misconception, related to the second, is that the construction of a psychodynamic formulation must be elaborate and time-consuming. This view derives in part from various reviews in the psychiatric literature that, in an attempt to be inclusive, describe in detail all the requirements of a thorough evaluation ( 1 – 4 ) or the multiple dynamic conflicts that may influence any aspect of human behavior ( 5 , 6 ). The trainee may get the impression that anything short of an exhaustive dynamic explanation of each symptom or character trait is too simplified to be of value. This impression is often inadvertently reinforced when the supervisor points out some less essential aspects of the case that have been omitted in the condensed overview. A more helpful didactic approach accepts that the initial formulation is by necessity partial and tentative, but by describing the patient’s leading unconscious needs and incipient defenses, the formulation may be sufficient to predict initial transferences and guide supportive or directive interventions. In time, as the clinical impression deepens, the linkage of current behavior to formative experiences and intrapsychic conflicts will become more clear and substantiated.

A fourth misconception is the notion that the formulation need not be written, as though somehow a patient’s psychodynamics “go without saying.” Our concern here is that if the formulation is never actually constructed and recorded, the patient’s psychodynamics will remain mysterious, ambiguous, and all encompassing. E.M. Forster allegedly said, “I never know what I think until I read what I write.” His point—and ours—is that the process of writing helps one achieve a clearer point of view. The written psychodynamic formulation is therefore valuable, even if seen only by the therapist who wrote it. The therapist who has a clear formulation of the patient’s central conflicts is more capable of communicating that understanding to the patient in a consistent way. In addition, the dynamically prepared therapist is more likely to anticipate and recognize patterns of resistance or acting out than lag one step behind, using ad hoc (or even post hoc) formulations to respond to specific events.

A fifth and final misconception is that therapists will become so invested in their dynamic formulations that they will not be able to hear or accept material that does not fit a preconceived mold. On the contrary, constructing a dynamic formulation helps one to recognize its incompleteness, to inquire about pieces of the puzzle that are missing, to appreciate that not every piece fits neatly into place, and to accept the inevitable complexities and limited knowledge of every clinical situation. Furthermore, the formulation not only helps therapists accept their own limitations, it helps them accept the patient’s pathology as well. The patient’s behaviors in treatment—dependent, angry, avoidant, defiant, passive-aggressive, seductive, suspicious, noncompliant, and so on—are seen as manifestations of the patient’s dynamics, as characteristic problems that can be predicted and understood and for which therapeutic interventions have been planned. As a result, the patient is not put in the paradoxical and untenable position of having to overcome his or her psychopathology as a prerequisite for treatment.

S tructure of the formulation

As we conceive it, the psychodynamic formulation is relatively brief (500–750 words) and has four parts: 1) a summary of the case that describes the patient’s current problems and places them in the context of the patient’s current life situation and developmental history; 2) a description of nondynamic factors that may have contributed to the psychiatric disorder; 3) a psychodynamic explanation of the central conflicts, describing their role in the current situation and their genetic origins in the developmental history; and 4) a prediction of how these conflicts are likely to affect treatment and the therapeutic relationship.

P art 1: S ummarizing statement

The opening paragraph outlines why this particular patient presents with this diagnosis and these particular problems at this particular time. By eliminating extraneous information, it succinctly identifies the patient, the precipitating events, the extent and quality of interpersonal relationships, the most salient predisposing features of the past history, and those prominent behaviors which the formulation will attempt to explain psychodynamically. This outline is not intended to summarize the entire case but rather to highlight the clinical situation that the psychodynamic formulation will address. By analogy, these first sentences are similar to the condensed admission note placed in the medical chart by the ward attending physician in contrast to the detailed history presented by the third-year medical student.

P art 2: D escription of nondynamic factors

After the essential features of the case have been thoughtfully distilled, this second paragraph mentions the nondynamic factors that may have contributed to the psychiatric disorder, such as genetic predisposition, mental retardation, social deprivation, overwhelming trauma, and drugs or any physical illness affecting the brain. Noting other etiological factors sidesteps two potential pitfalls. First, it underscores that even if nondynamic factors have played a major role in causing the disorder, the psychodynamics of the patient cannot be ignored in the choice and implementation of the treatment ( 2 ). Second, mentioning other etiological factors serves as a. reminder that certain experiences of the patient may have psychodynamic meaning even though they do not stem from psychodynamic causes. Because meaning and cause are often confused, the clinical value of distinguishing the two is worth illustrating with the following brief vignettes.

A homemaker with a very strong personal and family history of bipolar affective illness develops another major depressive episode when her youngest child leaves for college. It would be an error to ignore the likely contribution of genetic factors in the etiology of her depression, to attribute it solely to conflicts precipitated by the child’s departure, and to fail to consider pharmacological interventions. However, even though the biological predisposition is essential for the occurrence of the illness, both the biology and the precipitating trigger must be understood psychosocially with their dynamic meanings. The feelings of unworthiness and guilt accompanying the depression may, for example, represent an unforgivable gap between a need to be a perfect mother and a self-image (conscious or unconscious) of being imperfect, bitter, angry, and uncaring. The therapist who understands these specific dynamics may therefore state, “Your youngest child’s leaving and this depression make you feel that you have failed as a mother, a role that is very important to you.” Such dynamically informed empathic remarks may tighten the therapeutic alliance, be therapeutic in their effect, increase compliance with medication if that is indicated, and synergistically enhance a placebo response.

A young man with paranoid schizophrenia becomes disorganized under the stress of writing his senior college thesis. He becomes convinced that his previously admired political science professor is now using a KGB device to control the patient’s thoughts and prevent the unusually perceptive manuscript from being published. While recognizing the biological and environmental factors that have caused the psychotic episode, the dynamic formulation also helps explain the meaning of the delusion: the conscious wish for acclaim and the fear of being controlled; the preconscious recognition of being inadequate and of losing control; and the unconscious wish to be controlled, an intolerable wish that is associated with vulnerable dependency and therefore projected. Equipped with this dynamic understanding, the therapist can tailor his or her interventions accordingly. For example, in the neuroleptic management, the therapist will consider the patient’s fears of being controlled by explaining in detail the type, dosage, rationale, risks, benefits, and side effects of all medication. The therapeutic stance will be influenced by the meaning of the patient’s relationship with the college professor; the therapist will avoid a premature frightening intimacy as he or she remains a somewhat distant but friendly helper who is especially candid and honest yet does not expect or require the patient’s trust or submission. The psychotherapeutic interventions will address the conscious wishes and fears (e.g., “You wanted to write an outstanding thesis but felt the professor was controlling you”) and in time the preconscious concern (e.g., “You were worried you weren’t doing well”), but because pointing out unconscious wishes (e.g., “You secretly would like to be cared for”) would be perceived as intrusive and similar to the professor’s thought control, these interpretations would be avoided. The point here is not to describe the treatment of paranoid psychosis but to illustrate how an appreciation of a specific patient’s psychodynamics can be useful in guiding the clinical management even in the presence of situational and biological determinants of the disorder.

A woman is biologically predisposed to panic attacks that respond to imipramine maintenance; however, the psychodynamic formulation reveals that for this rigid Catholic patient the attacks represent both fears of and wishes for losing control, a state that is unconsciously perceived as an opportunity for the expansion of forbidden sexual wishes. In response to the fear, the patient at times overmedicates herself with the tricyclic or becomes agoraphobic; in response to the wish, she sometimes “forgets” her medication, has a panic attack, and then becomes disproportionately guilty and depressed for being “irresponsible” (and for unconsciously acting on forbidden impulses). Accordingly, in consideration of the psychodynamic meaning associated with this patient’s biological disorder, the therapist combines his or her pharmacological management with directive, exploratory, and expressive techniques, advising the patient to read appropriate materials that explain the nature of the disorder and diminish unwarranted concerns of acting irresponsibly during an attack, exploring and clarifying for the patient the developmental derivatives of her conflict, and encouraging the patient to recount her dreams and fantasies. This dynamically informed process enables the patient to understand her illness and its meaning, to express her sexual wishes more adaptively than by her intermittent noncompliance with medication, and over time to feel less guilty about her forbidden desires.

A fireman hospitalized for a severe burn develops a posttraumatic stress disorder. The psychodynamic formulation acknowledges the situational precipitants but also elucidates that for this man the intrusive thoughts and nightmares represent a conscious fear of going crazy and an unconscious fear of being a helpless dependent boy, a fear he has reacted against over the years by assuming a machismo style. In consideration of these dynamics, the psychiatric consultant addresses not only the conscious fear by reassuringly educating the patient about his acute posttraumatic stress disorder and its favorable prognosis, but also addresses the unconscious fear of passivity by supporting the patient’s manliness and the heroic nature of his injury. This permits the development of a transference relationship in which the terror of the trauma can be reworked.

An elderly retired executive with a mild dementia has become so rigid and demanding that his wife has lost her freedom and patience. The psychodynamic formulation accepts the organic determinants of his change in behavior, but also notes that the patient’s inflexibility is partly due to a long-standing conscious need to be in charge, a recent preconscious recognition of his cognitive decline, unconscious feelings of anxiety and shame related to loss of adult capacities, and reparative attempts to maintain a sense of security and control by regulating his own life and the lives of those around him. By explaining these dynamics to the wife the therapist increases her tolerance, and by suggesting more adaptive ways for the patient to feel secure (clocks in every room, limited demands and expectations, consistent environment, titrated stimuli, written schedule, and so forth) the therapist is able to channel his or her dynamic understanding into simple, practical interventions.

These highly condensed examples are not intended to illustrate all the subtleties, complexities, and applications of a psychodynamic formulation but merely to indicate that the presence of nondynamic factors—genetic, traumatic, organic, and so forth—does not preclude the clinical value of understanding a patient’s psychodynamics and, conversely, that a psychodynamic formulation does not ignore the effect of nondynamic factors on the patient’s mood, thoughts, and behavior. The dynamic formulation is consistent with the biopsychosocial model ( 7 ), is relevant to all forms of psychiatric treatment, and is not reserved only for those psychiatric conditions in which biological features are less well defined (e.g., personality disorders) and only for those treatments that are insight oriented (e.g., exploratory psychotherapy). Even for disorders that are more clearly nondynamic in their etiology (e.g., schizophrenia, dementia) and for treatments that are more biomedical in their approach (e.g., psychopharmacotherapy), the therapist who formulates not only the cause but also the specific meaning of the illness will be better prepared, when appropriate, to communicate this understanding empathically ( 8 ) and to intervene effectively rather than with stereotyped responses. A “pseudohumanitarian” approach, a form of verbal handholding that does not consider the character style of a particular patient, may be experienced by paranoid patients as intrusive, by histrionic patients as seductive, by obsessive patients as demeaning, by depressed patients as undeserved and therefore guilt provoking, and by dependent or phobic patients as a sanction for further regression or avoidance. To be effective, the therapist must recognize those capacities of the patient which are temporarily or permanently deficient and for which “an auxiliary ego” is indicated, the unconscious meanings of these defects to the patient, and the available strengths of the patient that will be encouraged and enhanced. As described later the psychodynamic formulation facilitates this task by helping the therapist to conceptualize the issues systematically rather than relying only on intuition.

P art 3: P sychodynamic explanation of central conflicts

If the first part of a psychodynamic formulation is similar to a clarification (a synthetic integration of the available data), this third part is more like an interpretation (an integrative inference based on psychoanalytic principles that considers unconscious fantasies and motives). As in the clinical situation, this interpretation is of necessity speculative, a hypothesis that will be tested and modified by additional data. Unlike the clinical situation, though, this interpretation is primarily a guide for the therapist; in most instances it does not directly represent what the patient will be told.

This section of the formulation is most useful clinically if it does not attempt to explain too much in too many ways but instead focuses on the central conflicts and then uses prototypic psychodynamic models to explain how these conflicts are being resolved. The danger of not focusing on the central conflicts and of not using standard psychodynamic models is that the formulation (and consequently perhaps the treatment itself) will lack an integrative coherence.

Identifying the central conflicts requires both inductive and deductive reasoning. The aim is to find a small number of pervasive issues that run through the course of the patient’s illness and can be traced back through his or her personal history, and then to explain how the patient’s attempts to resolve these central conflicts have been both maladaptive (producing symptoms and character pathology) and adaptive (characterizing his or her general style of pleasure, productivity, and personal relationships). Conflicts are opposing motives and wishes, both conscious and unconscious; central conflicts are repetitive, link and explain a number of important behaviors, and usually contain elements that are hidden from the patient’s awareness. For example, a man may consciously wish to be less depressed but unconsciously fear that recovery will both lead to an uncontrolled expression of his own rage and free others to express their resentment against him if he is not protected by illness.

Once the central conflicts and themes have been identified, they are formulated psychodynamically. At present, at least three models of mental functioning are being used by dynamic psychiatrists. These models are overlapping and differ in the emphasis they give to one or another aspect of development and psychopathology. In practice, most psychiatrists prefer one model, on the basis of prior training and personal predilection, but use other models as the clinical situation may require. If the original model does not seem to be conceptually useful, the therapist sees if the formulation of a given patient will be more fruitful when cast in terms of an alternative model. As with many other sciences, the absence of a meta-model to explain all data makes this trial and error unavoidable.

Even though an admixture of different models is often clinically necessary, it is useful theoretically and conceptually to understand the basic concepts, virtues, and limitations of prototypic psychodynamic models. Recognizing the oversimplification involved, we will describe the three most common: 1) ego-psychological ( 9 ); 2) self-psychological ( 10 ); and 3) object relations ( 11 , 12 ). They all share the core concept of dynamic unconscious mental activity; that is, they assume that human behavior is constantly influenced by unconscious thoughts, wishes, and mental representations. These three models also assume that complex psychological functions pass through a regular sequence of epigenetic stages and phases (each of which carries its own particular vulnerabilities and opportunities and involves an interaction between nature and nurture) and that the distortions, fixations, and regressions occurring at different stages will leave their mark on later development. In short, these models assert that all individuals have an inner life that is important in understanding their outer life and that they are each the product of their personal history.

The ego-psychological model emphasizes the central role of the adaptive efforts of the ego both during development and in therapy. Behavior, mediated by the ego, is viewed as a defensive compromise among 1) wishes and impulses; 2) inner conscience, self-observation, and criticism; and 3) the potentialities and demands of reality. Effective ego functions allow an appropriate delay between peremptory wishes and actions and protect the individual from excessive anxiety or depression while providing for security, pleasure, and effectiveness. A dynamic formulation that uses this model will describe the nature of unconscious wishes, unconscious fears, characteristic defenses, and the resulting patterns of inhibition, symptoms, and character, tracing each of these through the individual’s life. The ego-psychological model gives special focus to derivatives of forbidden sexual and aggressive strivings, their resolution during the oedipal phase, and the ongoing residual intrapsychic conflicts and defensive compromises that determine character and symptoms. This model gives less attention to interpersonal issues and to very early, pre-oedipal influences on development.

The self-psychological model postulates a psychological structure, the self, that develops toward the realization of goals that are both innate and learned. Two broad classes of these goals can be identified: one consists of the individual’s ambitions, the other of his or her ideals. Normal development involves the child’s grandiose idealization of self and others, the exhibitionistic expression of strivings and ambitions, and the empathic responsiveness of parents and others to these needs. Under these conditions, the child’s unfolding skills, talents, and internalization of empathic objects will lead to the development of a sturdy self and capacities for creativity, joy, and continuing empathic relationships. In this model, genetic formulations will trace character problems to specific empathic failures in the child’s environment that distorted and inhibited the development of the self and the capacity to maintain object ties. The formulation will also describe how the individual has defensively compensated for these failures of self-development and will suggest the therapeutic strategy needed to support the resumption of self-development that had been arrested in the past, emphasizing the special transference needs of the patient. The self-psychological model is especially useful for formulating the narcissistic difficulties that are present in many types of patients (not just narcissistic personality disorder); however, the model lacks a clear conception of intrapsychic structure, and it is less useful for formulating fixed repetitive symptoms that arise from conflicts between one’s conscience and sexual-aggressive wishes.

The object relations model conceives of psychic structures as developing through the child’s construction of internal representations of self and others. These representations range from the primitive and fantastic to the relatively realistic; they are associated with widely varying affects (e.g., anger, sadness, feelings of safety, fear, pleasure) as well as with various wishes and fantasies (e.g., of sex, of control, or of devouring and being devoured). The growing child struggles with contradictory representations and feelings of self and others, tending to split the good and bad images into different representations. At this early level of development, one may feel that one has two different mothers, for example—a good, gratifying one and a bad, frustrating one. In the more mature individual, these images are integrated into coherent representations of a self and others with multiple complex qualities, selected and formed in part to help to maintain an optimal measure of self-esteem, tolerable affects, and satisfaction of wishes.

Using this model, the psychodynamic formulation focuses on the nature of the self and object representations and the prominent conflicts among them. A special emphasis is given to developmental failures in integrating the various partial and contradictory representations of self and others and to the displacement and defensive misattribution of aspects of self or others. The object relations model is especially useful for formulating the fragmented inner world of psychotic and borderline patients who experience themselves and others as unintegrated parts; however, the model may be less useful for relatively healthier patients in whom conflict may more easily be described in terms of ego psychology.

P art 4: P redicting responses to the therapeutic situation

This final section of the formulation is related to the prognosis, but rather than predicting the overall course of the patient’s disorder, it focuses on the meaning and use that the patient will make of treatment. Particular emphasis is placed on understanding the probable manifestations of transference (both positive and negative) and the forms and modes of resistance. The phrasing of this prediction will be linked to the psychodynamic model used in the preceding section. For example, the ego-psychological model may emphasize what specific ego strengths and deficits the patient brings to the therapeutic situation and what defense mechanisms are likely to predominate as the patient deals with central conflicts. The self-psychological model will emphasize the role of the therapist’s empathic responsiveness and the analysis of empathic failures in the process of forming new internal structures of the self—for example, the patients’ needs to idealize either themselves or the therapist or, at other times, to ignore the therapist except as a source of admiration for exhibitionistic strivings. Finally, the object relations model will emphasize which inner representations of self and of others are likely to be activated and potentially enacted in the therapeutic situation. All three models suggest possible patterns of transference and resistance, offering valuable guides for the therapist.

S ample psychodynamic formulations

Although the following psychodynamic formulations lack the authenticity, specificity, and richness of a formulation that is accompanied by a fuller knowledge of the individual history, they are intended to convey something of the format of prototypic dynamic formulations. The same patient is used to illustrate each of the psychodynamic models described previously. These illustrations are admittedly somewhat artificial because, as we have indicated, in clinical practice therapists tend to use one primary model, introducing secondary models to explain features of the patient that do not easily fit the primary model. However, by presenting each of the models in its pure form, we hope to demonstrate the common utility of all the models as well as highlight the potential and unavoidable impact of theory on treatment.

T he ego-psychological model

Part 1: Mr. A, a 52-year-old married businessman, presents on his own initiative with a depressive syndrome after being once again passed over for promotion. He himself does not understand this “rejection,” but it is probably related to his lifelong tendencies to procrastinate and to annoy his superiors either by being obsequious or by challenging their authority. He has a history of two untreated depressive syndromes, one in his 30s that also followed a professional failure and one in his 40s that followed his son’s “defiant” marriage to a woman of another religion. Mr. A’s father was a sickly, professionally frustrated “type A personality” who died of a heart attack when Mr. A was in his teens. His mother has always been a “martyr” with smoldering despair characterized by chronic insomnia, self-doubt, obsessive ruminations, and social withdrawal. She never sought treatment.

Part 2: Mr. A has essential hypertension, for which he takes methyldopa, 250 mg t.i.d.; his mother’s history suggests a genetic predisposition to unipolar depression.

Part 3: Mr. A’s central conflict is between an unconscious wish to kill off his competitors and an unconscious fear that he will be killed if he acts on that wish. Whenever he expresses derivatives of his competitive wish directly, he becomes frightened of retaliation; he therefore resorts to expressing the wish indirectly by passive-aggressive maneuvers (e.g., procrastination). Conversely, whenever he responds to this fear of retaliation by being solicitous and obedient, he inwardly feels resentful and diminished. To contain this struggle, Mr. A has developed intellectual mechanisms that, although adaptive for certain aspects of his work, are mal-adaptive interpersonally in that they isolate him emotionally from others.

Mr. A’s tendency to view every situation as a competitive struggle can be traced to unresolved anal and oedipal conflicts. During early childhood, Mr. A’s depressed mother could not tolerate her son’s assertiveness and declarations of independence; instead she imposed her will on Mr. A and insisted that he eat, sleep, be toilet trained, and behave exactly the way she wanted so that her son would not be any trouble and add to her woes. As a result, Mr. A entered the oedipal period with a view that any endeavor was a power struggle, in essence asking himself, “Do I give in and bury the rage over being controlled, or do I assert myself and risk being punished either directly by my mother or internally by the guilt I feel by making her more depressed?”

This view of the world was then enhanced by competition from Mr. A’s perfectionistic and controlling father, who, frustrated by his own limitations and illness, would harshly reprimand Mr. A for any assertion within the family or failure outside of it. Fearing retaliation and struggling against his feelings of passivity, Mr. A identified with the aggressor—father and developed an even more punitive superego. Mr. A’s need to repress his competitive rage and envy was reinforced by his father’s chronic heart disease; Mr. A feared that if he were to act assertively, he would kill off his rival. When the father did die during Mr. A’s adolescence, the guilt over this unconscious oedipal victory made Mr. A even more wary of directly asserting himself in the future. All three of Mr. A’s depressive episodes were precipitated by failing to beat out competitors (colleagues or his son), unconsciously reminiscent of earlier defeats with his mother and father, but Mr. A is unaware that he is equally afraid to win and face the resultant retaliation and guilt.

Part 4: Unconsciously Mr. A is likely to view treatment as another competition. Fearful and dependent at first, when his depression begins to improve and he feels more like a “winner,” he may respond with guilty fear for a triumph so undeserved in one who unconsciously is consumed with murderous wishes. In response to this guilt, he may sabotage his improvement by prematurely stopping treatment or, less destructively, by focusing on residual depressive symptoms, the side effects of antidepressant medication, or his hypertension (an affliction that unconsciously has become his punishment for killing his father). This behavior will alternate with Mr. A’s viewing the therapist as the winner (i.e., the authority figure to whom he is beholden). Frightened of challenging the victor directly, Mr. A may indirectly defy this authority by appearing compliant, apologetic, and grateful but passive-aggressively “forgetting” appointments or his medication and devaluing the treatment.

T he self-psychological model

Parts 1 and 2 are as in the previous material.

Part 3: Mr. A’s central problem consists of his low self-esteem and consequent need for continual recognition and approval from others, along with his inability to accept any limitations either in himself (which lead to disapproval from others) or in others (which reduce the value of their approval when it occurs). Presumably, during childhood his depressed mother and sickly father were so self-absorbed with their problems that they were unable to respond empathically to his age-appropriate aspirations; at the same time, both parents narcissistically invested in their son the hopes that his achievements would make up for their failures. Throughout his life Mr. A has strived to earn the accolades he never received as a child, and although this pursuit has lead to some professional success, his self-doubt and instability of self-objects take their toll, leading to a lack of confidence, to inappropriate solicitous behavior, and to procrastination of challenging tasks. In addition, having internalized his parents’ grand expectations (in order to repair his sense of deficit as well as to compensate for theirs), he is unable to accept the limitations of others (e.g., his bosses’ or his son’s) or himself (e.g., physical illness, aging, his professional plateau). Being passed over for promotion was an injury to a sense of self that was already enfeebled; the rejection reawakened early empathic failures and unrealized ambitions. The resultant loss of self-esteem then contributed to the current depression.

Part 4: In treatment, Mr. A will attempt to elicit the therapist’s admiration and will have grand (though unconscious) expectations about what can be accomplished, idealizing both himself and the therapist. However, when the therapist fails to respond with just the right empathic quality, Mr. A will be hurt and secretly enraged, and when the real limitations of Mr. A or the therapist are exposed, Mr. A is likely to devalue the entire enterprise and become more discouraged. Potential countertransference problems may arise if the therapist prematurely limits Mr. A’s need to be admired and to idealize the therapist.

T he object relations model

Parts 1 and 2 are as in the earlier material.

Part 3: Mr. A’s central problem is his failure to integrate the good and bad representations of himself and others. During childhood, his depressed mother could not respond to her son’s need and demands. Mr. A, unconsciously frightened that his resultant rage would destroy the very one on whom he depended, repressed his bad angry self and acted like the good obedient son. This splitting was reinforced by interactions with the controlling father who punitively viewed any of Mr. A’s independent assertions as acts of defiance. Mr. A, frightened that his competitive rage would either kill off the sickly father or lead to retaliation, again repressed his bad angry self. During adolescence, when the surge toward a more autonomous identity was most intense, Mr. A’s father died. Responding to unconscious guilt for a forbidden wish that had come true (i.e., killing off the father), Mr. A was even more compelled to keep the bad (assertive) self repressed and to maintain a tie to the lost object, both by an identification with the father’s perfectionism, and to punish himself for any success. Although this splitting has enabled Mr. A to be relatively successful and to seem basically well intentioned, the facade is fragile. The efforts with his superiors to appear “the good son” are exaggerated, leading to obsequious and subservient behavior. Furthermore, when the bad angry self breaks through the repression, procrastination and obstinacy are the result. These signals of the bad self lead to increased self-punitive and restrictive reactions in order to keep his rage contained.

Mr. A’s repression and splitting are compounded by his use of projection; that is, he projects onto others his unconscious bad self. This process only reinforces his experience of others as either unnurturing mothers or unsupportive, controlling fathers. This projection of the bad self contributed to Mr. A’s viewing his son’s marriage as an act of defiance. Similarly, when passed over for promotion, Mr. A not only experienced this rejection as reminiscent of enraging childhood rejections, devaluations, and abandonment but also viewed it as a retaliation for projected hostile wishes from his bad self. His depression is therefore in part the result of his punitive conscience condemning him for projected hostile wishes and for failing to meet the perfectionistic ideals of the good self.

Part 4: In treatment Mr. A will at first be quite ingratiating, the good son depressively condemning himself for past and present failures and wary that he will not meet the therapist’s expectations (Mr. A’s own projections). However, as Mr. A projects his resentful and defiant self, the therapist may be perceived as being both emotionally uncaring and as controlling, projections that will reinforce in the transference those early experiences with the mother and father, respectively. The therapist should be prepared for the likelihood that Mr. A’s rise in self-esteem will initially be accompanied by denigration of the therapist. The therapist must also anticipate that whenever Mr. A does express the resentful affects associated with the bad self, Mr. A’s conscience will clamp down punitively and cause Mr. A to become temporarily more depressed.

C linical application of the formulation

Although there are differences among the three formulations, it is important to point out the similarities in their clinical conclusions and applications. All three formulations alert the therapist that after an initial honeymoon period, difficulties are likely to develop in the therapeutic relationship. The ego-psychological model conceives of this falling out in terms of passive-aggressive defensive mechanisms, the self-psychological model predicts a devaluation of the therapist in response to inevitable empathic failures and limitations, and the object relations model anticipates that the patient’s angry and defiant self will be projected onto the therapist.

All three formulations also alert the therapist to similar countertransference problems: the ego-psychological model places these problems in terms of competitive struggles with the patient over issues of control, the self-psychological model considers problems of the therapist’s being initially idealized and then devalued, and the object relations model suggests that the therapist may at times feel compelled to identify with the patient’s projections and then assume the role of the uncaring and punitive figure the patient most fears and expects.

All three formulations indicate that the patient’s dynamics may directly affect his depressive symptoms and compliance with whatever treatment is prescribed. The ego-psychological model views this resistance in terms of guilty fear accompanying his improvement and a need to indirectly defy authority. The self-psychological model predicts a phase of discouragement and unwillingness to accept the disappointing therapy. The object relations model foresees that depressive feelings may recur if this patient retreats from the emergence of his angry bad self during recovery and that poor compliance will accompany the view of the therapist as punitive and uncaring.

Finally, all three formulations share many similarities in indicating what therapeutic interventions will be required to manage the anticipated transferences, countertransferences, and resistances. They all see that this patient in particular will need a nonjudgmental atmosphere where anger and resentment can be expressed spontaneously, he will need appropriate recognition and reinforcement of his strengths (such as his intellectual capacities), and he will need a modicum of control in his treatment (such as deciding within reason the time of day he takes his medication).

Despite these basic similarities, the different conceptual models will no doubt have some influence on the treatment’s emphasis and language. We suspect that these differences would be most apparent in the nature of interpretations used in an exploratory psychotherapy and less apparent in directive, behavioral, supportive, or psychopharmacological treatment. Using the ego-psychological model, the therapist is likely to focus on the relationship between the patient’s current difficulties and earlier competitive struggles with his parents. Using the self-psychological model, the therapist will direct interpretations toward helping the patient appreciate the doubts and yearnings that underlie his fragile grandiosity and will trace perceived empathic failures in the therapist to those failures that occurred in the patient’s childhood. Finally, using the object relations model, the therapist will attempt to intercept a destructive negative transference and acting out both by interpreting the patient’s misperceptions of the therapist as someone (like the father) wanting to control the patient and by encouraging the patient to express through fantasies, memories, and dreams those angry feelings associated with the bad self, thereby indicating a capacity (unlike the mother) to tolerate unpleasant affects.

However, in closing, it must be emphasized that the differences that may occur in an insight-oriented psychotherapy are relatively subtle compared to the more important value of the psychodynamic formulation in conceptualizing central conflicts and anticipating the transferences, countertransferences, and resistances that occur in all treatments.

(Reprinted with permission from the American Journal of Psychiatry 1987 ; 144 :543–550)

1 MacKinnon RA, Yudofsky SC: DSM-III diagnosis and the psychodynamic case formulation, in The Psychiatric Evaluation in Clinical Practice. Philadelphia, Lippincott, 1986 Google Scholar

2 Frances A, Clarkin J, Perry S: Clinical evaluation in treatment planning, in Differential Therapeutics in Psychiatry: The Art and Science of Treatment Selection. New York, Brunner/Mazel, 1984 Google Scholar

3 Whitehorn JC: Guide to interviewing and clinical personality study. Archives of Neurology and Psychiatry 1944 ; 52:197–216 Crossref ,  Google Scholar

4 Stevenson I: The Psychiatric Examination. Boston, Little, Brown, 1969 Google Scholar

5 MacKinnon R, Michels R: General principles of psychodynamics, in The Psychiatric Interview in Clinical Practice. Philadelphia, Lippincott, 1971 Google Scholar

6 Waelder R: Basic Theory of Psychoanalysis. New York, International Universities Press, 1960 Google Scholar

7 Engel G: The need for a new medical model: a challenge for biomedicine. Science 1977 ; 196:129–136 Crossref ,  Google Scholar

8 Viederman M, Perry S: Use of a psychodynamic life narrative in the treatment of depression in the physically ill. Gen Hosp Psychiatry 1980 ; 3:177–185 Crossref ,  Google Scholar

9 Brenner C: An Elementary Textbook of Psychoanalysis. New York, International Universities Press, 1955 Google Scholar

10 Kohut H: The Restoration of the Self. New York, International Universities Press, 1977 Google Scholar

11 Sandler J, Rosenblatt B: The concept of the representational world. Psychoanal Study Child 1962 ; 17:128–145 Crossref ,  Google Scholar

12 Kernberg O: A historical overview, in Object Relations Theory and Clinical Psychoanalysis. New York, Jason Aronson, 1976 Google Scholar

• Case Formulation, Behavior Analysis, and Diagnostic Interviews
• Formulation 20 May 2013

• Research article
• Open access
• Published: 24 October 2019

Psychodynamic case formulations without technical language: a reliability study

• Øystein Sørbye 1 ,
• Hanne-Sofie J. Dahl 2 ,
• Tracy D. Eells 3 ,
• Svein Amlo 4 ,
• Anne Grete Hersoug 5 ,
• Unn K. Haukvik 5 ,
• Cecilie B. Hartberg 6 ,
• Per Andreas Høglend 5 &
• Randi Ulberg 6 , 5  

BMC Psychology volume  7 , Article number:  67 ( 2019 ) Cite this article

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Metrics details

To bridge the gap between symptoms and treatment, constructing case formulations is essential for clinicians. Limited scientific value has been attributed to case formulations because of problems with quality, reliability, and validity. For understanding, communication, and treatment planning beyond each specific clinician-patient dyad, a case formulation must convey valid information concerning the patient, as well as being a reliable source of information regardless of the clinician’s theoretical orientation. The first aim of the present study is to explore the completeness of unstructured psychodynamic formulations, according to four components outlined in the Case Formulation Content Coding Method (CFCCM). The second aim is to estimate the reliability of independent formulations and their components, using similarity ratings of matched versus mismatched cases.

This study explores psychodynamic case formulations as made by two or more experienced clinicians after listening to an evaluation interview. The clinicians structured the formulations freely, with the sole constraint that technical, theory-laden terminology should be avoided. The formulations were decomposed into components after all formulations had been written.

The results indicated that most formulations were adequately comprehensive, and that overall reliability of the formulations was high (> 0.70) for both experienced and inexperienced clinician raters, although the lower bound reliability estimate of the formulation component deemed most difficult to rate - inferred mechanisms - was marginal, 0.61.

Conclusions

These results were achieved on case formulations made by experienced clinicians using simple experience-near language and minimizing technical concepts, which indicate a communicative quality in the formulations that make them clinically sound.

Trial registration

linicalTrials.gov Identifier: NCT00423462 . https://doi.org/10.1007/s00432-018-2781-7 ., January 18, 2007.

Peer Review reports

Constructing an adequate case formulation is broadly recognized as a core competency for clinicians [ 1 ] and a central capacity required to pass the certifying examinations of the American Board of Psychiatry & Neurology [ 2 ]. A case formulation is defined as a set of hypotheses about the causes, precipitants and maintaining factors of a patient’s psychological, interpersonal and behavioral problems [ 3 , 4 , 5 ]. The primary function of case formulations is to provide a “map” that guides the clinicians in practice and should differentiate what the clinician and patient see as essential from what is secondary or not relevant. There is a wide array of models for making case formulations, from theoretical-specific [ 6 ] to trans-theoretical models [ 7 ]. A case formulation, regardless of model, is intended to give meaning and context to the chosen intervention whether it is a certain kind of individual psychotherapy, medication management, group therapy, residential treatment, etc. According to Horowitz [ 8 ], it fills “a gap that otherwise would exist between diagnosis and treatment” (p. IX). Specifically, board-certified psychiatrists in the United States are expected “to develop and document an integrative case formulation that includes neurobiological, phenomenological, psychological and sociocultural issues involved in diagnosis and management” [ 9 ].

While our primary focus is on case formulation in a psychotherapeutic context as practiced by psychiatrists, clinical case formulation can be useful across many mental health disciplines – including social work and psychology - and in multiple types of clinical practice, including medication management. For example, Tasman [ 10 ] observed that treatment adherence in pharmacotherapy can be enhanced by conducting a case formulation prior to prescribing. While each discipline and practice may require unique information elements in a formulation, some elements are common to all disciplines, for example, a problem list and an explanatory mechanism that accounts for symptoms and problems. Some definitions of case formulation include an explicit treatment plan, others do not. The treatment plan may be based on the formulation, but not part of it.

Despite the widely acknowledged importance and value of case formulation in clinical settings, formulation has had limited scientific impact because of problems with quality, reliability and undetermined validity [ 11 ]. With regard to quality, evidence suggests that the skills necessary to make a case formulation are difficult to acquire [ 12 ]. Kuyken and colleagues [ 13 ] measured the quality of case formulations by 115 mental health professionals. Only 44% were deemed “good enough”. Eells and colleagues [ 14 ] evaluated 56 intake formulations from an outpatient clinic. Ninety-five percent contained descriptive information, but less than half addressed hypothesized predisposing life events and/or inferred psychological mechanisms, which are necessary in a proper case formulation. Comparable results were obtained in the evaluation of biopsychosocial formulations developed by psychiatry residents [ 15 ].

Within the psychodynamic tradition, psychoanalysts have tended to conceptualize the dynamics of a given case based on their own theoretical positions, often in rather abstract meta-psychological terms, which had limited communicative and scientific value [ 16 , 17 ]. Seitz [ 18 ] described how a group of psychoanalysts failed to arrive at consensus formulations of cases. He noted that the judges applied different levels of inference when interpreting the clinical data, which led the group to an impasse as to what was centrally important. The formulation method used in this study was based on Malan’s overall case formulation system [ 19 ]. Malan never formally tested the reliability of his method. A basic prerequisite for scientific progress in this area is a certain level of agreement among clinicians about case formulations. In an early review, Barber and Crits-Christoph [ 20 ] found that structured psychodynamic case formulations are more likely to be reliable. Garb [ 21 ] also concluded that inter-rater reliability of structured psychodynamic formulation methods is good if clinicians share the same theoretical orientation and the formulations compared are decomposed into separate components. So far, only structured methods, breaking the formulations down into components and using standard language, have achieved acceptable to good reliability [ 4 , 13 , 20 , 21 , 22 ]. The Case Formulation Content Coding Method (CFCCM) [ 3 , 4 , 14 ] is an example of a structured model. The CFCCM is a method to categorize information clinicians use when conceptualizing a patient. One CFCCM task is to segment a formulation into one of four content areas that are described in most models of case formulations. The main content areas are: (1) symptoms and problems (2) precipitating stressors, (3) predisposing life events, and (4) an explanatory mechanism that links the preceding categories together and offers an explanation of the precipitants and maintaining influences of the individual’s problems. In general, the primary task of content coders is to independently read a written formulation and mark whether a formulation element is present. After completing a set of formulations, the coders compare their codes and discuss disagreement until consensus is reached. The number of content areas addressed in a formulation can serve as a measure of completeness. Interrater reliability can be assessed both for an entire formulation and for each of the four components.

The first aim of the present study is to explore the completeness of unstructured psychodynamic formulations, by decomposing each formulation according to the Case Formulation Content Coding Method (CFCCM) [ 3 , 4 , 14 ], and examine whether or not each formulation contains all components. The second aim is to estimate the reliability of independent formulations and their components, using similarity ratings of matched versus mismatched cases [ 22 ].

The data for this report is based on the First Experimental Study of Transference (FEST) study, a randomized clinical trial designed to study the impact of specific techniques in dynamic psychotherapy [ 23 , 24 ]. A total of 122 patients were referred to FEST study clinicians by primary care physicians, private specialist practitioners, and public outpatient departments. These patients sought psychotherapy due to depressive disorders, anxiety disorders, personality disorders, and interpersonal problems, as diagnosed using DSM-III-R criteria. The study clinicians assessed the patients for eligibility. Patients with psychosis, bipolar illness, organic mental disorder, substance abuse, and those with other mental health problems that caused long-term inability to work (> 2 years) were also excluded. Each of the 100 participants included in the study gave written informed consent and were then randomly assigned to receive weekly sessions of dynamic psychotherapy for 1 year either with or without transference interpretations [ 25 , 26 ]. The study protocol was approved by The Regional Ethics Committee, Health Region South East, Norway. The study ID number in www.clinicaltrials.gov is FEST307/95. Patient anonymity has been preserved.

Semi-structured interviews

The clinical research team consisted of the psychotherapists in the FEST study who were six psychiatrists and one clinical psychologist. They had received their dynamic psychotherapy training at one of four training institutes and had between 10 and 25 years of experience doing psychotherapy. All seven clinicians were in private practice. After taking history and assessment of background variables by the patients’ therapists, one of the clinicians (not the patient’s psychotherapist) conducted a 2-h semi-structured psychodynamic interview, modified from Sifneos [ 27 ], and Malan and Osimo [ 28 ]. The interview was more open-ended than diagnostic interviews. The interview should focus on behavior, affective experiences, symptoms and problems, and especially current and past maladaptive/adaptive relationships. The interviewer should conduct the interview trying to elucidate warded off material, such as wishes, motives, fears and conflicts, and also help the patient to explore meaningful experiences in detail. The clinician should pay attention to sudden changes in behavior or avoidance of certain topics. The interview was audio recorded.

• Case formulations

A minimum of two, but most often three or more other clinicians from the research team listened to the interview. Subsequently, the clinicians independently wrote a psychodynamic case formulation based on the patient’s clinical history, diagnostic evaluation, and the psychodynamic interview. The formulation should include “a core neurotic conflict” [ 19 ] that was seen as central to the patient’s difficulties, and specific stressors to which the patient was assumed vulnerable. Neurotic conflicts indicate how patients repeatedly handle emotional and instinctual impulses in ways that may increase their psychological problems. A treatment plan was not included in the formulation. The clinicians were asked to write the formulations using simple, experience-near terminology with a minimum of technical and theoretical language. Otherwise, they were free to develop the formulations according to their own wish. More than 400 case formulations were written, with an average of 4.2 per patient.

To examine the completeness of the formulations, the first author segmented each of the 425 formulations into four components, according to the Case Formulation Content Coding Method (CFCCM), described earlier. Another evaluator examined the work of the first author and disagreements were discussed until consensus was reached.

To assess reliability, we used three pairs of raters. All raters volunteered to be participants in the study. One pair of raters served as clinicians in the FEST study, each of whom had contributed a number of case formulations themselves. They were both psychiatrists and trained psychoanalysts and had more than 20 years of clinical experience. The second pair of raters, a psychiatrist and a specialist in psychology, had not been clinicians in the study. They had their training from a different psychodynamic institute than the fist pair, had long clinical experience, and were psychotherapy supervisors. The third pair of raters was resident psychiatrists, early in their training, with little clinical experience, and barely any knowledge of dynamic psychotherapy. The raters were given a text on a sheet of paper that contained two case formulations and they did not know whether the two formulations were from the same patient (matched pair), or from different patients (mismatched). Each sheet had a random number to ensure blindness on matched or mismatched formulations. The degree of similarity was rated on a Likert scale from 1 to 7. A rating of “7” means that all phrases (thought units) show complete or near complete agreement in meaning. A rating of “1” means that none of the phrases have the same meaning. A score of “4” means that half of the phrases are similar in meaning (For example the same description of the relationship to father, but different or missing concerning mother). The most important content of formulations to rate for similarity should be the patient’s interpersonal relations and personal reactions. Demographic and descriptive information in the text should be regarded as less important. A few times descriptive information indicated a mismatched pair. The raters were advised to disregard this information when evaluating the formulations.

We evaluated the reliability of the whole formulation, as well as that of the “predisposing life events” and “inferred mechanism” components. Regarding the whole formulation, the three pairs of clinicians rated 30 pairs of matched whole formulations and 30 pairs of mismatched whole formulations. In addition, the more experienced clinicians (the first two pairs) rated the two subcomponents; Predisposing life events and Inferred mechanisms. These four judges rated 100 matched and 100 mismatched pairs of formulations for similarity.

Rater training

The first author trained the other raters. Each rater wrote down a similarity score and then, without changing it, discussed it with the other rater and first author. The training was surprisingly easy, and after training on ten matched and ten mismatched pairs, the rest of the samples were rated independently, without discussion. The discussion between the raters during the calibration period revealed that some differences in rating could be explained by different levels of inference, for example regarding the underlying psychopathology.

Completeness

Table  1 shows that 95% of all formulations included information about symptoms. About 83% included at least some information about precipitating stressors. However, one clinician included information about stressors in only 50% of the formulations. Although using some experience-near terms, this clinician used some theoretical constructs and technical language as well, the others managed to avoid this and followed the instructions. Almost all, 99% of the formulations included information about predisposing life events, and 98% included information about an inferred mechanism (See Table  2 for an example of a full case formulation).

Reliability of unstructured formulations

The three pairs of clinicians rated 30 randomly selected pairs of matched whole formulations and 30 randomly selected pairs of mismatched formulations. The interrater reliability for the level of similarity for one randomly drawn rater (ICC two-way random, absolute agreement [ 29 ]) was excellent, ICC = 0.82 (95% CI 0.75–0.87). The difference in the levels of similarity of same-case pairs versus mismatched pairs across the six evaluators was 4.6 versus 1.9, a mean difference of 2.7 (95% CI 2.1–3.2), ( t  = 10.4, dfs = 57, p  < 0.001). Each of the six raters rated matched and mismatched pairs significantly different (Tables  3 and 4 ).

The first four raters were experienced psychodynamic clinicians. The reliability (Intraclass Correlation Coefficient; ICC) of their ratings was 0.79 (95% CI 0.70–0.85). Two raters had no experience in practicing dynamic psychotherapy. The reliability of their ratings was excellent, ICC = 0.91 (95% CI 0.82–0.95).

Reliability of two of the formulation components

The two single components in CFCCM requiring more inference: “Predisposing life” (See Table  5 .) events and “Inferred mechanism” (See Table  6 ), were deemed most difficult to formulate and to rate for similarity. The four experienced judges rated 100 matched and 100 mismatched pairs of formulations for similarity. The interrater reliability (ICC) for “Predisposing life events” was 0.82 (95% CI 0.78–0.85). The difference in levels of similarity of matched and mismatched pairs across the four raters was 4.8 versus 2.0. The means are significantly different (t = 17.3, dfs = 198, p  < 0.000). The mean difference was 2.9 (95% CI 2.5–3.2). Each of the four raters rated matched and mismatched pairs significantly different (Table  4 ).

The interrater reliability for “Inferred mechanism” was 0.67 (95% CI 0.61–0.73). The difference in levels of similarity of matched and mismatched pairs across the four raters was 3.9 versus 1.7. The means are significantly different (t = 15.0, dfs = 198, p  < 0.000). The mean difference was 2.2 (95% CI 1.9–2.5). Each of the four raters rated matched and mismatched pairs significantly different (Table  4 ).

The main finding in this study is that case-formulations as written by experienced clinicians, without any specific structure or labeling of statements into components, could be rated reliably by experienced as well as less experienced judges. Eells and colleagues [ 14 ] also found that novices performed as well as experienced therapists in some comparisons, particularly total formulation quality. They speculated that this could be the result of recent formal training, while experienced clinicians had been out of formal training for years and were overconfident and did not see a need for calibration. It is also possible that inexperienced raters are more “open minded” and read the narratives without so many preconceived theoretical ideas. To the best of our knowledge, this is the first study to rate unstructured formulations reliably. The clinicians in this study were asked to write the formulations using simple experience-near terms, with a minimum of technical language and theoretical jargon. This instruction may have been an important condition that helped achieve the level of agreement that we found. However, the similarity of matched cases was on average only 4.6. That is, the raters thought that only a little more than half of the phrases were similar in meaning. Since our formulations are not based on standard categories, this is to be expected. Furthermore, the formulations are based on a comprehensive semi-structured dynamic interview. From the rich material the clinician must, by inference, select what is essential from what is secondary. Since our knowledge about the causes of mental disorders is limited, selection of what constitutes for example predisposing factors may vary among clinicians. Little is known about how clinicians process clinical information and generate inferences about therapeutic mechanisms and their connections to symptoms and problems. Therapists probably engage in in a great deal of intuitive as well as rational-analytic thinking [ 30 ]. The sources of the lower agreement in a number of cases may also be the quality of the dynamic interview or the formulation method rather than the ability of the clinicians to construct reliable narratives. The formulation method in this study was based on Malan’s overall case formulation system. Malan never formally tested the reliability of his method, but DeWitt et al. [ 31 ], using Malan’s method, reported that the overall similarity was only 2.9 on matched cases. So far only studies using structured methods report findings of similarity [ 22 , 32 ] comparable to our study.

To what degree the raters were able to follow the instruction “not to pay attention to descriptive information”, may also have affected the differences in reliability scores. It is probably difficult not to be influenced by contradicting data. This may have inflated our findings. Our findings, however, indicates that highly experienced clinicians can construct reliable formulations. This may not depend on asking clinicians to categorize the information systematically into four components as advocated by Eells [ 3 , 4 ]. However, by decomposing the formulations into the four components, we could show that both the components, “predisposing life events” and “inferred mechanism” could be rated reliably. It should be noted that for similarity ratings of Inferred mechanisms the lower bound reliability estimate (95% confidence interval) was marginal (0.61). Furthermore, the average degree of similarity for matched cases fell barely at the balance point (4 on the Likert scale from 1 to 7) of equal amounts of overlap and non-overlap. In fact, two of the four evaluators were below this balance point. Mismatched cases were rated well below the balance point. The significant difference in similarity between matched and mismatched cases indicate that psychodynamic formulations as written in this study are to some degree specific to the individual patient, and not some global narrative that apply to most cases.

The inferred mechanism may be the most important part of the psychodynamic case formulation. Eells and colleagues [ 14 ], in a study of less experienced clinicians, reported that only 43% inferred a psychological mechanism in their case formulation. Asking clinicians to refer to all components may improve completeness and quality, at least for less experienced clinicians. In this study, almost all case formulations studied had an inferred mechanism. Most inferred mechanisms, however, were a summary of current problems activated by certain stressors, which supposedly were determined by childhood environmental factors, especially relationships to parents and siblings. Concrete experience-near terminology and a relatively low inference level was used in most formulations.

The seven evaluators who wrote the case formulation narratives in this study were experienced psychodynamic clinicians. They had worked together over many years preparing for this psychotherapy study. Hence, they had training in the use of several clinician-rated measures and evaluation of patient self-reports. This may be some of the reasons for the completeness of formulations, and reliability estimates comparable to studies using more structured and standardized methods. Using highly experienced and scientifically trained clinicians to write the formulations may increase internal validity but limit generalizability. Whether our findings can be generalized to narratives written by less experienced clinicians with little or no specific scientific training remains to be seen. To increase the scientific value of psychodynamic case formulations, further studies should examine the reliability and validity of unstructured formulations made by less experienced clinicians.

Clinicians can probably improve the reliability of their formulations by using low-level inferences and avoiding highly speculative inferences. It may be particularly important to ask the patients whether they agree with the formulation. Therapist-patient agreement on the formulation may improve therapeutic alliance and might even be more important than inter-clinician agreement. More generally, clinicians should be aware of heuristics and biases that can lead to unsound judgement.

A major clinical and training implication of these findings is that very experienced clinicians appear able to produce reliable, and thus clinically relevant formulations without elaborate instructions about how to structure the formulation. Further, the use of experience-near, non-theory laden language may facilitate increased clinical utility of a formulation.

In summary, this study shows that when experienced clinicians freely develop case formulations, they include symptoms and problems, precipitating stressors, predisposing life events, and an inferred mechanism. Additionally, when the clinicians apply a phenomenological approach using a simple experience-near language and minimize technical concepts, other clinicians, both experienced and not, are able to reliably score which formulation is descriptive for which person. This indicates that the case formulations comprise a communicative quality that makes them clinically sound. One may speculate that such case formulations can be helpful when choosing and structuring an intervention. Consequently, they may fill the gap between the symptoms and diagnoses that bring patients to seek help, and the personalized tailored treatment.

Availability of data and materials

Data from the First Experimental Study of Transference - interpretations (FEST) was used. The data set supporting the results of this article is available from the PI, Per Høglend on reasonable request.

Abbreviations

Case Formulation Content Coding Method

First Experimental Study of Transference - interpretations

Intraclass Correlation Coefficient

APA Presidential Task Force on Evidence-Based Practice. Evidence-based practice in psychology. Am Psychol. 2006. https://doi.org/10.1037/0003-066X.61.4.271 .

Yager J, Kay J. Assessing psychotherapy competence in psychiatric residents: getting real. Harv Rev Psychiatry. 2003. https://doi.org/10.1080/10673220303956 .

Eells TD. Psychotherapy case formulation. Washington, DC: American Psychological Association Books; 2015.

Book   Google Scholar  

Eells TD, Lombart GL, Kendjelic EM, Turner LC, Lucas CP. The quality of psychotherapy case formulations: a comparison of expert, experienced, and novice cognitive–behavioral and psychodynamic therapists. J Consult Clin Psychol. 2005. https://doi.org/10.1037/0022-006X.73.4.579 .

Levenson H, Strupp HH. Cyclical maladaptive patterns: case formulation in time-limited dynamic psychotherapy. In: Eells TD, editor. Handbook of psychotherapy case formulation. New York: Guilford Press; 1997.

Google Scholar  

Perry JC, Cooper SH. A preliminary report on defenses and conflicts associated with borderline personality disorder. J Am Psychoanal Assoc. 1986. https://doi.org/10.1177/000306518603400405 .

Ridley CR, Jeffrey CE. The conceptual framework of thematic mapping in case conceptualization. J Clin Psychol. 2017. https://doi.org/10.1002/jclp.22353 .

Horowitz MJ. Formulation as a basis for planning psychotherapy treatment. Washington DC: American Psychiatric Press; 1997.

American Board of Psychiatry & Neurology Psychiatry and neurology core competencies - version 4.1. 2009. Retrieved from database: https://www.abpn.com/wp-content/uploads/2015/02/2011_core_P_MREE.pdf. Accessed 4 Oct 2018.

Tasman A, Riba MB, Silk KR. The doctor-patient relationship in pharmacotherapy: improving treatment effectiveness. New York: Guilford Press; 2000.

Flinn L, Braham L, das Nair R. How reliable are case formulations? A systematic literature review. Br J Clin Psychol. 2015. https://doi.org/10.1111/bjc.12073 .

Eells TD, Lombart KG, Salsman N, Kendjelic EM, Schneiderman CT, Lucas CP. Expert reasoning in psychotherapy case formulation. Psychother Res. 2011. https://doi.org/10.1080/10503307.2010.539284 .

Kuyken W, Fothergill CD, Musa M, Chadwick P. The reliability and quality of cognitive case formulation. Behav Res Ther. 2005. https://doi.org/10.1016/j.brat.2004.08.007 .

Eells TD, Kendjelic EM, Lucas CP. What’s in a case formulation? Development and use of a content coding manual. J Psychother Pract Res. 1998;7:144–53.

PubMed   PubMed Central   Google Scholar  

McClain T, O’Sullivan PS, Clardy JA. Biopsychosocial formulation: recognizing educational shortcomings. Acad Psychiatry. 2004. https://doi.org/10.1176/appi.ap.28.2.88 .

Meehl PE. Psychodiagnosis: selected papers; 1973. p. 225–302. U of Minnesota Press

Popper KR. The logic of scientific discovery. London: Hutchinson; 1959.

Seitz PFD. The consensus problem in psychoanalytic research. In: Gottschalk L, Auerbach L, editors. Methods of research in psychotherapy. New York: Appleton-Century-Crofts; 1966.

Malan DH. Individual psychotherapy and the science of psychodynamics. New York: Butterworth; 1979.

Barber JP, Crits-Christoph P. Advances in measures of psychodynamic formulations. J Consult Clin Psychol. 1993. https://doi.org/10.1037/0022-006X.61.4.574 .

Garb HN. Studying the clinician: judgment research and psychological assessment. Washington. DC: American Psychological Association; 1998.

Crits-Christoph P, Cooper A, Luborsky L. The accuracy of therapists’ interpretations and the outcome of dynamic psychotherapy. J Consult Clin Psychol. 1988;56:490–5.

Article   Google Scholar  

Høglend P, Amlo S, Marble A, Bøgwald KP, Sørbye Ø, Sjaastad MC, Heyerdahl O. Analysis of the patient-therapist relationship in dynamic psychotherapy: an experimental study of transference interpretations. Am J Psychiatr. 2006;163:1739–46. https://doi.org/10.1176/ajp.2006.163.10.1739 .

Article   PubMed   Google Scholar  

Høglend P, Bøgwald K-P, Amlo S, Marble A, Ulberg R, Sjaastad MC, Sørbye Ø, Oscar H, Johansson P. Transference interpretations in dynamic psychotherapy: Do they really yield sustained effects? Am J Psychiatr. 2008. https://doi.org/10.1176/appi.ajp.2008.07061028 .

Freud S. The dynamics of transference. In: Strachey J, editor. The standard edition of the complete psychological works of Sigmund Freud, vol. 12. London: Hogarth Press; 1912. p. 97–108.

Ulberg R, Amlo S, Critchfield KL, Marble A, Høglend P. Transference interventions and the process between therapist and patient. Psychother. 2014. https://doi.org/10.1037/a0034708 .

Sifneos PE. Short-term psychotherapy anxiety-provoking therapy: a treatment manual. New York: Basic Books; 1992. p. 2008.

Malan DH, Osimo F. Psychodynamics, training, and outcome in brief psychotherapy. Oxford: Taylor & Francis; 1992.

Shrout PE, Fleiss JL. Intraclass correlations: uses in assessing rater reliability. Psychol Bull. 1979. http://dx.doi.org/10.1037/0033-2909.86.2.420 .

Caspar F. What goes on in the psychotherapist’s mind? Psychother Res. 1997;7:105–25.

DeWitt KN, Kaltreider NB, Weiss DS, Horowitz MJ. Judging change in psychotherapy. Reliability of clinical formulations. Arch Gen Psychiatry. 1983;40:1121–8. https://doi.org/10.1001/archpsyc.1983.01790090083013 .

Perry JC, Augusto F, Cooper SH. Assessing psychodynamic conflicts: reliability of the ideographic conflict formulation method. Psychiatry. 1989;52:289–301. https://doi.org/10.1080/00332747.1989.11024451 .

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Acknowledgements

The authors first of all want to thank the patients for their highly valuable contribution and willingness to participate in the study. The authors secondly thank; Kjell Petter Bøgwald, MD, PhD; Oscar Heyerdahl, MD; Alice Marble, PsyD; and Mary Cosgrove Sjaastad, MD for their contribution in peer supervision, development of research questions and decisions of outcome measures, and for providing treatment data to the study. They are all psychotherapists in private practice.

The present study is funded by the Division of Mental Health and Addiction, University of Oslo, Norway. The funding body had no role in the study design, data collection, analysis, interpretation, writing, or the decision to submit the manuscript for publication.

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Øystein Sørbye

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Tracy D. Eells

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Contributions

ØS is the first author of this study and has the main responsibility for analyses of data. ØS together with H-SJD have the main responsibility writing of the present manuscript. TDE has supervised analyses and participated in all parts of writing the paper. PAH is the principal investigator in FEST. He has participated in analysing the data and writing the paper. SA is the clinical director in FEST. SA, AGH, RU, UKH, and CBH have participated in providing and analysing treatment data and writing the paper. All authors read and approved the manuscript.

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ØS, H-SJD, SA, AGH, PAH, and RU are member of the FEST-research group. ØS, H-SJD, SA, AGH, PAH, and RU are psychotherapists and researchers. UKH and CBH are brain researchers and not especially trained in psychotherapy or psychodynamic therapy. ØS, PAH, and SA have participated in the research group from the planning of FEST. RU and H-SJD have used data from FEST in their dissertations. H-SJD is the second author of this study. She is a researcher in the FEST-research group with responsibility for micro-process analyses. H-SJD is the main supervisor in the present study. PAH is the principal investigator in FEST. TDE is an international collaborator for the FEST research group. He has special competence on case formulation in psychotherapy. All authors have participated in providing and analysing.

Corresponding author

Correspondence to Hanne-Sofie J. Dahl .

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The study has been performed in accordance with the Declaration of Helsinki. The Regional Ethics Committee for Health Region South East in Norway approved the study protocol, the information given to the patients, and the consent form. Patient material and data collected including case material were accepted for use in research and publishing as well as teaching.

Reference number: First Experimental Study of Transference- interpretations (FEST307/95). Each participant gave a written consent to participate in a psychotherapy research trial.

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Sørbye, Ø., Dahl, HS.J., Eells, T.D. et al. Psychodynamic case formulations without technical language: a reliability study. BMC Psychol 7 , 67 (2019). https://doi.org/10.1186/s40359-019-0337-5

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Four Psychodynamic Case Formulation

• Published: October 2014
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Psychodynamic case formulation is a vital component of the assessment process and is used to inform the treatment and prognosis. The chapter defines the concept and reviews its history in the literature regarding clinician agreement, needs assessment, and more recently, reliability, validity, and prediction of treatment, to the contemporary understanding of the generic components, with the difference in theoretical approaches. A case example is illustrated by Summer’s updated psychodynamic formulation approach. It covers: (1) a summary of the patient’s current problems in the context of her current life and developmental history, described psychodynamically; (2) a description of nondynamic factors that may have contributed to the psychiatric disorder; (3) an integrative inference based on psychoanalytic principles that considers unconscious fantasies and motives; and (4) the use that the patient will make of treatment. Particular emphasis is placed on understanding manifestations of transference and the forms and modes of resistance.

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Learn More Psychology

• Freudian Psychology

Case Studies of Sigmund Freud

Introduction to sigmund freud's case histories, including little hans, anna o and wolf man..

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Accounts of Freud ’s treatment of individual clients were key to his work, including the development of psychodynamic theory and stages of psychosexual development . Whilst the psychoanalyst’s use of case studies to support his ideas makes it difficult for us to prove or disprove Freud’s theories, they do provide fascinating insights into his day-to-day consultations with clients and offer clues as to the origins of his influential insights into how the human mind functions:

Little Hans

Perhaps the best known case study published by Freud was of Little Hans. Little Hans was the son of a friend and follower of Freud, music critic Max Graf. Graf’s son, Herbert, witnessed a tragic accident in which a horse carrying a heavily loaded cart collapsed in the street. Five year old Little Hans developed a fear of horses which led him to resist leaving the house for fear of seeing the animals. His father detailed his behavior in a series of letters to Freud and it was through these letters that the psychoanalyst directed the boy’s treatment. Indeed, the therapist and patient only met for a session on one occasion, but Freud published his case as a paper, Analysis of a Phobia in a Five-Year-Old Boy (1909), in support of his theory of the Oedipus complex and his proposed stages of psychosexual development.

Freud Cases

• Rat Man: A Case of 'Obsessional Neurosis'
• Dora Case Study
• Inside the Mind of Daniel Schreber
• The Case of Little Hans

Little Hans’ father relayed to Freud his development and noted that he had begun to show an intense interest in the male genitals, which the therapist attributed to him experiencing the phallic stage of psychosexual development. During this stage, the erogenous zone (the area of the body that one focuses on to derive pleasure) switches to the genitals. At this stage, signs of an Oedipus complex may also be observed, whereby a child competes with their father to retain their position as the central focus of their mother’s affection. Freud believed that this was supported by a fantasy which Little Hans had described, in which a giraffe and another, crumpled, giraffe entered the room. When the boy took the latter from the first giraffe, it objected. Freud believed that the giraffes symbolised his parents - the crumpled giraffe represented his mother, whom he would share a bed with when his father was absent, and the first giraffe was symbolic of his father. Children may also develop castration anxiety resulting from a fear that the father will castrate them in order to remove the threat that they pose to the parents’ relationship.

The boy’s fear of horses, according to Freud, was caused by a displacement of fear for his father onto the animals, whose blinkers made them resemble the man wearing his glasses.

Freud believed that Little Hans’ fear of horses disappeared as his described fantasies that indicated the resolution of his castration anxiety and an acceptance of his love for his mother.

Read more about Little Hans here

Dr. Sergeï Pankejeff (1886-1979) was a client of Sigmund Freud , who referred to him as “Wolf Man” owing to a symbolic dream which he described to him. Freud detailed his sessions with Wolf Man, which commenced in February of 1910, in a 1918 paper entitled From the History of an Infantile Neurosis .

Wolf Man first saw Freud having suffered from deteriorating health since experiencing gonorrhea at the age of eighteen. He described how he was unable to pass bowel movements without the help of an enema, and felt as though he was separated from the rest of the world by a veil.

Freud persuaded Wolf Man to undergo treatment until a set date, after which their sessions should cease, in the belief that his patient would lower his resistance to the therapist’s investigation. Wolf Man agreed, and described to Freud the events of his childhood.

Initially, Wolf Man had been an agreeable child but became combative when his parents returned from their travels. He had been cared for by a new nanny whilst they had been absent and his parents blamed their relationship for his misbehavior. He also recalled developing a fear of wolves, and his sister would taunt him with an illustration in a picture book. However, Wolf Man’s fears extended towards other creatures, including beetles, caterpillars and butterflies. On one occasion, whilst he was pursuing a butterfly, fear overcame him and he was forced to end his pursuit. The man’s conflicting account suggested an early alternation between a phobia of, and taunting of, insects and animals such as horses.

Wolf Man’s unusual behavior was not limited to a fear of animals, and he developed a zealous religious worship routine, kissing every icon in the house before bed time, whilst experiencing blasphemous thoughts.

Wolf Man recalled a dream which had caused him some distress when he had awoken. In the dream, he was laid in bed when he looked out of the window and noticed six or seven white wolves sat in a tree outside. The wolves, which had tails that did not match their bodies, were watching him in his room.

Freud linked this nightmare to a story which Wolf Man’s grandfather had told him, in which a wolf named Reynard lost his tail whilst using it as bait for fishing. He believed that Wolf Man suffered from castration anxiety, which explained the fox-like tails of the wolves in the dream, and his fear of caterpillars, which he used to dissect. The man had also witnessed his father chopping a snake into pieces, which Freud believed had contributed to this anxiety.

Read more about Wolf Man here

The obsessive thoughts of Rat Man were discussed in 1909 paper Notes upon a Case of Obsessional Neurosis . Rat Man’s true identity is unclear, but many believe him to have been Ernst Lanzer (1978-1914), a law graduate of the University of Vienna.

Rat Man suffered from obsessive thoughts for years and underwent hydrotherapy before consulting Freud in 1907, having been impressed by the understanding that the psychoanalyst had professed in his published works. The subject of his thoughts would often involve a sense of anxiety that misfortune would affect a close friend or relative and he felt that he needed to carry out irrational behavior in order to prevent such a mishap from occurring. The irrationality of such thoughts was demonstrated by his fears for the death of his father, which continued even after his father had passed away.

Freud used techniques such as free association in order to uncover repressed memories . Rat Man’s recollection of past events also proved useful to Freud. He described one occasion during his military service, when a colleague revealed to him the morbid details of a torture method that he had learnt of. This form of torture involved placing a container of live rats onto a person and allowing the animals to escape the only way that they could - by burrowing through the victim.

This description stayed with Rat Man and he began to fear that this torture would be imposed upon a relative or friend. He convinced himself that the only way to prevent it would be to pay an officer whom he believed had collected a parcel for him from the post office. When he was prevented from satisfying this need, Rat Man began to feel increasingly anxious until his colleagues agreed to travel to the post office with him in order for the officer to be paid in the order that Rat Man felt was necessary.

Freud attributed Rat Man’s anxieties to a sense of guilt resulting from a repressed desire that he had experienced whilst younger to see women he knew unclothed. As our ego develops, our moral conscience leads us to repress the unreasonable or unacceptable desires of the id , and in the case of Rat Man, these repressed thoughts left behind “ ideational content ” in the conscious. As a result, the subject of anxiety and guilt that he felt whilst younger was replaced with fear of misfortune occurring when he was older.

Read more about Rat Man here

Other Influential Accounts

Whilst Freud saw many clients at his practise in Vienna, and cases such as Wolf Man, Rat Man and Dora are well documented, the psychoanalyst also applied psychodynamic theory to his interpretation of other patients, such Anna O, a client of his friend, Josef Breuer. The autobiographical account of Dr. Daniel Schreber also formed the basis of a 1911 paper by Freud detailing his interpretation of the man’s fantasies.

Anna O (a pseudonym for Austrian feminist Bertha Pappenheim) was a patient of Freud’s close friend, physician Josef Breuer. Although Freud never personally treated her (Anna’s story was relayed to him by Breuer), the woman’s case proved to be influential in the development of his psychodynamic theories. Freud and Breuer published a joint work on hysteria, Studies on Hysteria , in 1895, in which Anna O’s case was discussed.

Seeking treatment from Breur for hysteria in 1880, Anna O experienced paralysis in her right arm and leg, hydrophobia (an aversion to water) which left her unable to drink for long periods, along with involuntary eye movements, including a squint. She also found herself mixing languages whilst speaking to carers and would see hallucinations such as those of black snakes and skeletons, and would wake anxiously from her daytime sleep with cries of “tormenting, tormenting”.

During her talks with Breuer, Anna enjoyed telling fairytale-like stories, which would often involve sitting next to the bedside of a sick person. A dream that she recalled was also of a similar nature: she was sat next to the bed of an ill person in bed when a black snake approached the invalid. Anna wanted to protect the person from the snake but felt paralysed and was unable to warn off the snake.

Freud and Breuer considered the subject of this dream to be linked to an earlier experience. Prior to her own illness, Anna’s father had contracted tuberculosis and she had spent considerable lengths of time caring for him by his bedside. During this period, Anna had fallen ill, preventing her from accompanying her father in his final days and he passed away on April 1881. The trauma of caring for her father may have affected Anna, and Breuer believed that the paralysis she experienced in reality was a result of that which she had experienced in the dream. Furthermore, he linked her hydrophobia to another traumatic event some time previously, when she had witnessed a dog drinking from a glass of water that she was supposed to use. The revulsion she felt had stayed with her and manifested in a later aversion to water.

The conscious realisation of the causes behind her suffering, according to Breuer, helped Anna to make a recovery in 1882. She valued the “talking therapy” that he had provided, describing their sessions as “chimney sweeping”.

Read more about Anna O here

Dr. Daniel Schreber

Freud’s interpretation of client’s past experiences and dreams was not limited to the patients he saw at his Vienna clinic. German judge Dr. Daniel Schreber (1842-1911) wrote a book, Memoirs of My Nervous Illness (1903) - in which he detailed the fantasies that he experienced during the second of three periods of illness - whilst confined in the asylum of Sonnenstein Castle.

Upon reading the book, Freud offered his own thoughts on the causes of Schreber’s fantasies, which were published in his 1911 paper Notes upon an autobiographical account of a case of paranoia (dementia paranoides) .

Initially suffering whilst standing as a candidate in the 1884 Reichstag elections, Schreber had begun to experience hypochondria, for which he sought the help of Professor Paul Flechsig. After six months, treatment ended, but he returned to Flechsig in 1893, bothered again by hypochondria and now sleeplessness also. Schreber recalled thoughts during a half-asleep state in which he noted that “it really must be very nice to be a woman submitting to the act of copulation” (Freud, 1911). He would eventually turn against Professor Flechsig, accusing him of being a “soul murderer”, and thoughts of emasculation also developed into extended fantasies - Schreber convinced himself that he had been assigned a role of savior of the world, and that he must be turned in a woman in order for God to impregnate with him, creating a new generation which would repopulate the planet.

In his response to Schreber’s account, Freud focussed on the religious nature of the fantasies. Whilst Schreber was agnostic, his thoughts suggested religious doubts and what Freud described as “redeemer delusion” - a sense of being elevated to the role of redeemer of the world. The process of emasculation that Schreber felt was necessary was attributed by Freud to “homosexual impulses”, which the psychoanalyst suggests were directed towards the man’s father and brother. However, feelings of guilt for experiencing such desires led to them being repressed.

Freud also understood Schreber’s sense of resentment towards Flechsig in terms of transference - his feelings towards his brother had been subconsciously transferred to the professor, whilst those towards his father had been transferred to a godly figure.

Read more about Daniel Schreber here

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A Case Using Brief Psychodynamic Therapy

By Leanne Tamplin

Wendy is a 54 year old woman who has two adult children and has been married for twenty-nine years. Her husband, Steve, has recently and unexpectedly informed her that he no longer loves her and that he wants a divorce. Wendy was shocked to hear this, and she now reports that she is constantly crying and feels extremely anxious. Wendy has not told anyone about this situation, although she and Steve have agreed to explain his decision to their children within the week.

In this scenario, the counsellor will be using a brief psychodynamic approach. For ease of writing, the Counsellor is abbreviated to “C”.

Wendy attended eighteen appointments over an eight month period. The first six appointments were held weekly, the next ten were fortnightly, and the last two were spaced out over two months. Wendy and Steve have been married for twenty-nine years and have lived in the same area for all of that time. They have two children – Damien 24 years of age, and Amanda 26 years. Damien still lives at home with his parents.

Wendy has not yet told anyone, neither family nor friends, about her situation and becomes anxious when she considers doing this. She and Steve have agreed to tell their children within the next week, and Steve plans to move out of the family home at that time. Wendy and Steve are no longer sleeping in the same bed, although up until his recent disclosure, they had been sleeping together and kissing and hugging from time to time. Wendy’s reported anxiety/depression symptoms included: difficulty sleeping, difficulty relaxing, thinking about Steve/their marriage/the future all the time, feeling exhausted, feeling “tightness” in her chest and her throat, a loss of appetite, crying several times every day, and a loss of interest in “everything”.

Session Details

In the initial appointment, Wendy reported a very distressing couple of weeks. She began to describe her situation starting at twelve months ago when Steve began attending a gym and reading personal development books. Wendy stated that at that time, Steve seemed to change, and she thought it was a part of a “mid-life crisis” that he would eventually recover from. Around the same time, Wendy confronted Steve because she felt that they weren’t communicating much and she was feeling “left out” of his new interests. At that time, Steve told Wendy that he thought they were “drifting apart”. As a result of this conversation, Wendy then made a concentrated effort to improve things – she created opportunities for them to be together, she encouraged their discussions with one another, and she shared more of herself and her feelings in their conversations. That was the last time they had discussed anything about their relationship, and Wendy thought that things had been much improved by her efforts over the last twelve months. When Steve told her over dinner a week ago that he didn’t feel that he loved her anymore and that he would like a divorce, Wendy was shocked and devastated.

C’s role in these initial stages was to listen, to assist Wendy to expand and elaborate on her story, to help her to identify her emotions, and to provide her with unconditional positive regard and a non-judgmental environment. From a psychodynamic perspective, these early sessions were also about developing a productive therapeutic relationship and trying to understand Wendy’s life from her perspective, that is, to walk in her shoes. C listened empathically and shared in the variety of emotions that Wendy reported, including shock, anger, sadness, devastation, betrayal, disappointment, frustration, disbelief, and a sense of complete lack of control. These were discussed at length, as well as the situations that had caused the emotions. As a brief psychodynamic counsellor expects that there will be around twenty appointments, or more, there was no need to hurry Wendy. C and Wendy travelled through each event and emotion as they occurred.

Wendy reported that although the sessions were difficult, she felt “relief” when she left and looked forward to her next appointment. She described an almost immediate, but minor, decrease in her anxiety symptoms, with a continuing reduction over time. After discussion, she re-introduced the use of her own relaxation strategies that she had used successfully in the past.

C encouraged Wendy to allow herself to express her feelings as much, and as often, as possible. In response to this suggestion, she began a journal and wrote in it regularly, she accepted and catered for times alone to cry, and she gradually began to discuss her situation with close and trusted family, friends, and work colleagues. This latter action required extensive discussion about her fears of disclosure and how she would manage the repercussions.

In the first three appointments, the focus was on “holding” Wendy during her crisis, and on allowing Wendy to express herself and to describe her situation in it’s entirety, without judgment or analysis. After this stage, however, C began reporting to Wendy any observations or thoughts about what was happening for her, as well as identifying patterns in her actions and highlighting significant steps that she had taken. For example, in session seven, C noticed that Wendy was reluctant to criticise Steve for his behaviour. C described this observation to Wendy and asked her if she had noticed it herself. Wendy had not noticed, but once it was brought to her attention, she said that she could see it clearly. She said that she still loved Steve, and that she held onto the hope that he would change his mind. She went on to describe her plan to take him back should that occur. C empathised with the sudden and drastic change that had occurred in Wendy’s life and her plans for the future, and normalised her reaction to cling to the possibility of her life returning to the familiar and to having some feeling of control. C also explored this further, asking Wendy: how likely she thought Steve’s return was; how this event might take place; and how she thought she would respond if it occurred. In this way, Wendy’s beliefs and feelings about Steve were opened up, accepted, and their impact was acknowledged. Wendy was later able to identify the value of this belief in keeping her “together” at this point, and also said that she understood the reality that he was unlikely to return. This is an important occurrence in brief psychodynamic therapy, as it is an example of the unconscious becoming conscious.

At the commencement of the twelfth session, Wendy reported that she had a terrible week where she had cried frequently. She had spoken to Steve and had been very disappointed with his distance and coldness towards her. She described these events while laughing and speaking quickly and minimising their significance. C challenged this incongruence between Wendy’s behaviour and her words, by describing the observation to Wendy. Wendy reported that she was probably speaking fast because she had just met with a friend who would not be able to handle the truth about her devastation. Her quick speaking and laughing, Wendy suggested, was how she acted “together” when she didn’t want people to know how distressed she really was. C asked if this was also how she felt in our counselling sessions (note: from a psychodynamic perspective, often an experience a client is describing in relation to others can be a reflection of the experience they are having in the counselling room). Wendy said that she did want to improve her well-being, and so had hoped that she would be “together” when she came to counselling this time.

C asked Wendy to discuss the consequences of appearing “not together”. During this conversation, Wendy said that she felt that it was hard to be herself and that, in fact, she had not been able to be herself since Steve told her twelve months ago that they were drifting apart. From that time on, she had been acting as if everything was okay, when really she felt scared and alone. C and Wendy then talked about the possible impact of this kind of “pretending” on her marital relationship, on the counselling relationship, and on her relationships generally. They discussed where this behaviour may have been learned (Wendy felt it was from her parents’ relationship) and what had caused her to begin using it. After some long conversation about this, Wendy admitted that she had not been happy in her marriage for some time because she was afraid of losing Steve and afraid of being “left out”. It was at that point that she saw her “pretending” in her marriage as a form of self-protection.

During this conversation, Wendy also said that laughing about her problems was to make it easier for her friend to cope with the sad news. Wendy realised that she tried to make her distress easier for everyone to cope with, including Steve. She reported that she was even making it as easy as possible for Steve to leave her. She decided then that she would no longer do this, and would instead be true to her own feelings and express them whenever necessary. She stated that she would start to be herself around Steve, and everyone else. From this point on in our sessions, whenever she noticed herself laughing and talking fast about her sadness, she slowed down, took a deep breath, and connected with her true self. Developing this kind of insight is integral to successful brief psychodynamic therapy, and it sometimes starts with the counsellor paying attention to a small but significant occurrence within the therapy room.

From session fourteen, Wendy began a level of mourning for the lost relationship and her lost future – she described the loss as if she had begun accepting that it was really over. Wendy decided to bring family photos to counselling and reflected on the great events in their marriage. Wendy also started speaking more easily about negative experiences in their marriage and described times when she had felt taken advantage of and belittled. C saw this as evidence of Wendy’s increasing acceptance of the reality that the marriage was not perfect, and also as a way for Wendy to move further away from it.

Wendy often stated “what do I do now?”. C encouraged Wendy to begin to think about the things she had always wanted to do but had sacrificed when she married to have a family. Over time, Wendy made some solid decisions about her future concerning:

• Full-time work
• Disclosing her story to others
• Travelling to an island for a holiday
• Not waiting for Steve’s next move before she made hers
• Making some goals for the next two years that she could achieve with or without Steve

When Wendy raised fears of her ability to accomplish the goals she had set herself, C would encourage her to reflect on the personal traits she had demonstrated in counselling, and in her ability to handle Steve’s decision. In particular, she could see her own strength, her courage, and her honesty with herself as attributes that could get her through. Gradually, Wendy became more assertive and started living her life “as if” he would not come back, even though she continued to hope that he would return.

Wendy was keen to start thinking about ending counselling in session sixteen. C and Wendy agreed to two more appointments over two months in order to reflect on her progress over the last six months and identify how she would continue to progress without counselling. At session eighteen, Wendy’s anxiety symptoms were no longer present and she was feeling more in control of her life. She continued to cry and mourn her lost relationship regularly, although the frequency of her tears had greatly reduced.

Key Concepts of Brief Psychodynamic Therapy Applied:

• Developing a positive therapeutic relationship, including the use of empathy
• “Holding” a client through a crisis – not physically, but psychological holding to give them a sense of stability and certainty.
• Looking at the here-and-now in the counselling relationship
• Making the unconscious, conscious and fostering insight
• The underlying belief that providing a safe environment for a client to explore their experiences will give them the opportunity to understand themselves better, change their patterns, and make sense of the situations at hand.

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The Case Study Method in Psychodynamic Psychology: Focus on Addiction

• Original Paper
• Published: 07 November 2016
• Volume 45 , pages 215–226, ( 2017 )

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• Lance M. Dodes 1 , 2 &
• Josh Dodes 3  

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The case study method has been essential in psychoanalysis and psychodynamic therapy, since it is the only way to describe and explore the deepest levels of the human psyche. Addiction is no more and no less than a particular psychological mechanism, identical at its core to other psychological compulsions, and is therefore best understood and reported by this method that explores the mind in depth. We will discuss the value of the case report method in general and in specific with regard to psychoanalysis and addiction, criticisms raised about this method, and comparisons of it with nomothetic research.

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The Soul of Therapy: The Therapist’s Use of Self in the Therapeutic Relationship

The Biopsychosocial Approach: Towards Holistic, Person-Centred Psychiatric/Mental Health Nursing Practice

Existential approaches and cognitive behavior therapy: challenges and potential.

Bornstein, R. F. (2007). Nomothetic psychoanalysis. Psychoanalytic Psychology, 24 , 590–602.

Article   Google Scholar  

Damasio, A. (2012). Self comes to mind: Constructing the conscious brain . New York: Vintage Books.

Google Scholar  

Director, L. (2002). The value of relational psychoanalysis in the treatment of chronic drug and alcohol use. Psychoanalytic Dialogues, 12 , 551–579.

Dodes, L. (1990). Addiction, helplessness, and narcissistic rage. Psychoanalytic Quarterly, 59 , 398–419.

PubMed   Google Scholar  

Dodes, L. (1996). Compulsion and addiction. Journal of the American Psychoanalytic Association, 44 , 815–835.

Article   PubMed   Google Scholar  

Dodes, L. (2002). The heart of addiction . New York: HarperCollins.

Dodes, L. (2009). Addiction as a psychological symptom. Psychodynamic Practice, 15 , 381–393.

Dodes, L. (2011). Breaking addiction: A 7-step handbook for ending any addiction . New York: HarperCollins.

Dodes, L., & Dodes, Z. (2014). The sober truth: Debunking the bad science behind 12-step programs and the rehab industry . Boston: Beacon Press.

Eagle, M. N., & Wolitzky, D. L. (2011). Systematic empirical research versus clinical case studies: A valid antagonism? Journal of the American Psychoanalytic Association, 59 , 791–817.

Eriksson, J. (2010). The epistemological status of the case history and the play-character of clinical psychoanalysis: Two doctoral dissertations. Scandinavian Psychoanalytic Review, 33 , 40–46.

Flyvbjerg, B. (2006). Five misunderstandings about case-study research. Qualitative Inquiry, 12 , 219–245.

Fonagy, P. (2013). There is room for even more doublethink: The perilous status of psychoanalytic research. Psychoanalytic Dialogues, 23 , 116–122.

Article   PubMed   PubMed Central   Google Scholar  

Gottdiener, W. H., & Suh, J. J. (2012). Expanding the single-case study: A proposed psychoanalytic research program. Psychoanalytic Review, 99 , 81–102.

Hoffman, I. Z. (2012). Response to Safran: The development of critical psychoanalytic sensibility. Psychoanalytic Dialogues, 22 , 721–731.

Ioannidis, J. (2005). Why most published research findings are false. PLOS Medicine, 2 (8). Retrieved from http://buster.zibmt.uni-ulm.de/dpv/dateien/DPV-Wiss-False-Research-Findings.pdf .

Irwin, J. W. (1996). Science or hermeneutics? Psychoanalysis in search of self-definition. Modern Psychoanalysis, 21 , 61–89.

Jones, E. E., & Windholz, M. (1990). The psychoanalytic case study: Toward a method for systematic inquiry. Journal of the American Psychoanalytic Association, 38 , 985–1015.

Josephs, L., Anderson, E., Bernard, A., Fatzer, K., & Streich, J. (2004). Assessing progress in analysis interminable. Journal of the American Psychoanalytic Association, 52 , 1185–1214.

Khantzian, E. (1978). The ego, the self and opiate addiction: Theoretical and treatment considerations. International Journal of Psychoanalysis, 5 , 189–198.

Krystal, H., & Raskin, H. (1970). Drug dependence: Aspects of ego function . Detroit: Wayne State University Press.

Longhofer, J., & Floersch, J. (2012). The coming crisis in social work: Some thoughts on social work and science. Research on Social Work Practice, 22 , 499–519.

Lothane, Z. (2001). A response to Grünbaum’s “A century of psychoanalysis critical retrospect and prospect” (and other texts): Requiem or reveille? International Forum of Psychoanalysis, 10 , 113–132.

Lush, M. (2011). Clinical facts, turning points and complexity theory. Journal of Child Psychotherapy, 37 , 31–51.

Luyten, P., Blatt, S. J., & Corveleyn, J. (2006). Minding the gap between positivism and hermeneutics in psychoanalytic research. Journal of the American Psychoanalytic Association, 54 , 571–610.

Marks-Tarlow, T. (2015). Commentary on dynamical systems therapy: Theory and practical applications. Psychoanalytic Dialogues, 25 , 131–135.

Midgeley, N. (2006). The inseparable bond between cure and research: Clinical case study as a method of psychoanalytic inquiry. Journal of Child Psychotherapy, 32 , 122–147.

Milkman, H., & Frosch, W. (1973). On the preferential abuse of heroin and amphetamine. Journal of Nervous and Mental Disease, 156 , 242–248.

Moos, R. H., & Moos, B. S. (2006). Participation in treatment and Alcoholics Anonymous: A 16-year follow-up of initially untreated individuals. Journal of Clinical Psychology, 62 , 735–750.

Pine, F. (1988). The four psychologies of psychoanalysis and their place in clinical work. Journal of the American Psychoanalytic Association, 36 , 571–596.

Rabinovich, M., & Kacen, L. (2013). Qualitative coding methodology for interpersonal study. Psychoanalytic Psychology, 30 , 210–231.

Robins, L., Helzer, J., & Davis, D. (1975). Narcotic use in Southeast Asia and afterward. Archives of General Psychiatry, 32 , 955–961.

Rothenberg, M. A. (2004). Down to cases: The ethical value of “non-scientificity” in dyadic psychoanalysis. Journal of the American Psychoanalytic Association, 52 , 125–150.

Safran, J. D. (2012). Doublethinking or dialectical thinking: A critical appreciation of Hoffman’s “doublethinking” critique. Psychoanalytic Dialogues, 22 , 710–720.

Thelen, E. (2005). Dynamic systems theory and the complexity of change. Psychoanalytic Dialogues, 15 , 255–283.

Tillman, J. G., Clemence, A. J., & Stevens, J. L. (2011). Mixed methods research design for pragmatic psychoanalytic studies. Journal of the American Psychoanalytic Association, 59 , 1023–1040.

Waldron, S. Jr. (1997). How can we study the efficacy of psychoanalysis? Psychoanalytic Quarterly, 66 , 283–322.

Waldrup, M. M. (1992). Complexity: The emerging science at the edge of order and chaos . New York: Touchstone Books.

Wallerstein, R. S. (2009). What kind of research in psychoanalytic science? International Journal of Psycho-Analysis, 90 , 109–133.

Warren, C. S. (2012). Faustian science and the future of psychoanalysis. Journal of the American Psychoanalytic Association, 60 , 131–144.

Wieder, H., & Kaplan, E. (1969). Drug use in adolescents. Psychoanalytic Study of the Child, 24 , 399–431.

Wurmser, L. (1974). Psychoanalytic considerations of the etiology of compulsive drug use. Journal of the American Psychoanalytic Association, 22 , 820–843.

Wurmser, L. (1984). The role of superego conflicts in substance abuse and their treatment. International Journal of Psychoanalytic Psychotherapy, 10 , 227–258.

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Dodes, L.M., Dodes, J. The Case Study Method in Psychodynamic Psychology: Focus on Addiction. Clin Soc Work J 45 , 215–226 (2017). https://doi.org/10.1007/s10615-016-0610-5

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Little Hans – Freudian Case Study

Saul Mcleod, PhD

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Saul Mcleod, PhD., is a qualified psychology teacher with over 18 years of experience in further and higher education. He has been published in peer-reviewed journals, including the Journal of Clinical Psychology.

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Case Study Summary

• Little Hans was a 5-year-old boy with a phobia of horses. Like all clinical case studies, the primary aim was to treat the phobia.
• However, Freud’s therapeutic input in this case was minimal, and a secondary aim was to explore what factors might have led to the phobia in the first place, and what factors led to its remission.
• From around three years of age, little Hans showed an interest in ‘widdlers’, both his own penis and those of other males, including animals. His mother threatens to cut off his widdler unless he stops playing with it.
• Hans’s fear of horses worsened, and he was reluctant to go out in case he met a horse. Freud linked this fear to the horse’s large penis. The phobia improved, relating only to horses with black harnesses over their noses. Hans’s father suggested this symbolized his moustache.
• Freud’s interpretation linked Hans’s fear to the Oedipus complex , the horses (with black harnesses and big penises) unconsciously representing his fear of his father.
• Freud suggested Hans resolved this conflict as he fantasized about himself with a big penis and married his mother. This allowed Hans to overcome his castration anxiety and identify with his father.

Freud was interested in the role of infant sexuality in child development. He recognised that this approach may have appeared strange to people unfamiliar with his ideas but observed that it was inevitable for a psychoanalyst to see this as important. The case therefore focused on little Hans’s psychosexual development and it played a key role in the formulation of Freud’s ideas within the Oedipus Conflict , such as the castration complex.

‘Little Hans’ was nearly five when has was seen by Freud (on 30th March 1908) but letters from his father to Freud provide the bulk of the evidence for the case study. These refer retrospectively to when Hans was less than three years old and were supplied to Freud through the period January to May 1908 (by which time little Hans was five years old).

The first reports of Hans were when he was 3 years old when he developed an active interest in his ‘widdler’ (penis), and also those of other people. For example, on one occasion, he asked, ‘Mummy, have you got a widdler too?

Throughout this time, the main theme of his fantasies and dreams was widdlers and widdling.  When he was about three and a half years old his mother told him not to touch his widdler or else she would call the doctor to come and cut it off.

When Hans was almost 5, Hans’ father wrote to Freud explaining his concerns about Hans. He described the main problem as follows:

He is afraid a horse will bite him in the street, and this fear seems somehow connected with his having been frightened by a large penis’.

The father went on to provide Freud with extensive details of conversations with Hans. Together, Freud and the father tried to understand what the boy was experiencing and undertook to resolve his phobia of horses.

Freud wrote a summary of his treatment of Little Hans, in 1909, in a paper entitled “ Analysis of a Phobia in a Five-year-old Boy. “

Case History: Little Hans’ Phobia

Since the family lived opposite a busy coaching inn, that meant that Hans was unhappy about leaving the house because he saw many horses as soon as he went out of the door.

When he was first asked about his fear Hans said that he was frightened that the horses would fall down and make a noise with their feet.  He was most frightened of horses which were drawing heavily laden carts, and, in fact, had seen a horse collapse and die in the street one time when he was out with his nurse.

It was pulling a horse-drawn bus carrying many passengers and when the horse collapsed Hans had been frightened by the sound of its hooves clattering against the cobbles of the road.  He also suffered attacks of more generalized anxiety . Hans’ anxieties and phobia continued and he was afraid to go out of the house because of his phobia of horses.

When Hans was taken to see Freud (on 30th March 1908), he was asked about the horses he had a phobia of. Hans noted that he didn’t like horses with black bits around the mouth.

Freud believed that the horse was a symbol of his father, and the black bits were a mustache.  After the interview, the father recorded an exchange with Hans where the boy said ‘Daddy don’t trot away from me!

Over the next few weeks Hans” phobia gradually began to improve.  Hans said that he was especially afraid of white horses with black around the mouth who were wearing blinkers.  Hans” father interpreted this as a reference to his mustache and spectacles.

• In the first, Hans had several imaginary children. When asked who their mother was, Hans replied “Why, mummy, and you”re their Granddaddy”.
• In the second fantasy, which occurred the next day, Hans imagined that a plumber had come and first removed his bottom and widdler and then gave him another one of each, but larger.

Freud’s Interpretation of Hans’ Phobia

After many letters were exchanged, Freud concluded that the boy was afraid that his father would castrate him for desiring his mother. Freud interpreted that the horses in the phobia were symbolic of the father, and that Hans feared that the horse (father) would bite (castrate) him as punishment for the incestuous desires towards his mother.

Freud saw Hans” phobia as an expression of the Oedipus complex . Horses, particularly horses with black harnesses, symbolized his father. Horses were particularly suitable father symbols because of their large penises.

The fear began as an Oedipal conflict was developing regarding Hans being allowed in his parents” bed (his father objected to Hans getting into bed with them).

Hans told his father of a dream/fantasy which his father summarized as follows:

‘In the night there was a big giraffe in the room and a crumpled one: and the big one called out because I took the crumpled one away from it.  Then it stopped calling out: and I sat down on top of the crumpled one’.

Freud and the father interpreted the dream/fantasy as being a reworking of the morning exchanges in the parental bed.  Hans enjoyed getting into his parent’s bed in the morning but his father often objected (the big giraffe calling out because he had taken the crumpled giraffe – mother – away).

Both Freud and the father believed that the long neck of the giraffe was a symbol for the large adult penis.  However Hans rejected this idea.

The Oedipus Complex

Freud was attempting to demonstrate that the boy’s (Little Hans) fear of horses was related to his Oedipus complex .  Freud thought that, during the phallic stage (approximately between 3 and 6 years old), a boy develops an intense sexual love for his mothers.

Because of this, he sees his father as a rival, and wants to get rid of him.  The father, however, is far bigger and more powerful than the young boy, and so the child develops a fear that, seeing him as a rival, his father will castrate him.

Because it is impossible to live with the continual castration-threat anxiety provided by this conflict, the young boy develops a mechanism for coping with it, using a defense mechanis m known as identification with the aggressor .

He stresses all the ways that he is similar to his father, adopting his father’s attitudes, mannerisms and actions, feeling that if his father sees him as similar, he will not feel hostile towards him.

Freud saw the Oedipus complex resolved as Hans fantasized himself with a big penis like his father’s and married to his mother with his father present in the role of grandfather.

Hans did recover from his phobia after his father (at Freud’s suggestion) assured him that he had no intention of cutting off his penis.

Critical Evaluation

Case studies have both strengths and weaknesses. They allow for detailed examinations of individuals and often are conducted in clinical settings so that the results are applied to helping that particular individual as is the case here.

However, Freud also tries to use this case to support his theories about child development generally and case studies should not be used to make generalizations about larger groups of people.

The problems with case studies are they lack population validity. Because they are often based on one person it is not possible to generalize the results to the wider population.

The case study of Little Hans does appear to provide support for Freud’s (1905) theory of the Oedipus complex.  However, there are difficulties with this type of evidence.

There are several other weaknesses with the way that the data was collected in this study. Freud only met Hans once and all of his information came from Hans father. We have already seen that Hans’ father was an admirer of Freud’s theories and tried to put them into practice with his son.

This means that he would have been biased in the way he interpreted and reported Hans’ behavior to Freud. There are also examples of leading questions in the way that Hans’ father questioned Hans about his feelings. It is therefore possible that he supplied Hans with clues that led to his fantasies of marriage to his mother and his new large widdler.

Of course, even if Hans did have a fully-fledged Oedipus complex, this shows that the Oedipus complex exists but not how common it is.  Remember that Freud believed it to be universal.

At age 19, the not-so Little Hans appeared at Freud’s consulting room having read his case history.  Hans confirmed that he had suffered no troubles during adolescence and that he was fit and well.

He could not remember the discussions with his father, and described how when he read his case history it ‘came to him as something unknown’

Finally, there are problems with the conclusions that Freud reaches. He claims that Hans recovered fully from his phobia when his father sat him down and reassured him that he was not going to castrate him and one can only wonder about the effects of this conversation on a small child!

More importantly, is Freud right in his conclusions that Hans’ phobia was the result of the Oedipus complex or might there be a more straightforward explanation?

Hans had seen a horse fall down in the street and thought it was dead. This happened very soon after Hans had attended a funeral and was beginning to question his parents about death. A behaviorist explanation would be simply that Hans was frightened by the horse falling over and developed a phobia as a result of this experience.

Gross cites an article by Slap (an American psychoanalyst) who argues that Hans’ phobia may have another explanation. Shortly after the beginning of the phobia (after Hans had seen the horse fall down) Hans had to have his tonsils out.

After this, the phobia worsened and it was then that he specifically identified white horses as the ones he was afraid of. Slap suggests that the masked and gowned surgeon (all in white) may have significantly contributed to Hans’ fears.

The Freud Archives

In 2004, the Freud Archives released a number of key documents which helped to complete the context of the case of little Hans (whose real name was Herbert Graf).

The released works included the transcript of an interview conducted by Kurt Eissler in 1952 with Max Graf (little Hans’s father) as well as notes from brief interviews with Herbert Graf and his wife  in 1959.

Such documents have provided some key details that may alter the way information from the original case is interpreted. For example, Hans’s mother had been a patient of Freud herself.

Another noteworthy detail was that Freud gave little Hans a rocking horse for his third birthday and was sufficiently well acquainted with the family to carry it up the stairs himself.

It is interesting to question why, in the light of Hans’s horse phobia, details of the presence of the gift were not mentioned in the case study (since it would have been possible to do so without breaking confidentiality for either the family or Freud himself).

Information from the archived documents reveal much conflict within the Graf family. Blum (2007, p. 749) concludes that:

“Trauma, child abuse [of Hans’s little sister], parental strife, and the preoedipal mother-child relationship emerge as important issues that intensified Hans’s pathogenic oedipal conflicts and trauma. With limited, yet remarkable help from his father and Freud, Little Hans nevertheless had the ego strength and resilience to resolve his phobia, resume progressive development, and forge a successful creative career.”

Support for Freud (Brown, 1965)

Brown (1965) examines the case in detail and provides the following support for Freud’s interpretation.

1 . In one instance, Hans said to his father –“ Daddy don”t trot away from me ” as he got up from the table. 2 . Hans particularly feared horses with black around the mouth.  Han’s father had a moustache. 3. Hans feared horses with blinkers on. Freud noted that the father wore spectacles which he took to resemble blinkers to the child. 4 . The father’s skin resembled white horses rather than dark ones.  In fact, Hans said, “Daddy, you are so lovely. You are so white”. 5 . The father and child had often played at “horses” together.  During the game the father would take the role of horse, the son that of the rider.

Ross (2007) reports that the interviews with Max and Herbert Graf provide evidence of the psychological problems experienced by Little Hans’s mother and her mistreatment of her husband and her daughter (who committed suicide as an adult).

Ross suggests that “Reread in this context, the text of “A Phobia in a Five-year-old Boy” provides ample evidence of Frau Graf’s sexual seduction and emotional manipulation of her son, which exacerbated his age-expectable castration and separation anxiety, and her beating of her infant daughter.

The boy’s phobic symptoms can therefore be deconstructed not only as the expression of oedipal fantasy, but as a communication of the traumatic abuse occurring in the home.

Blum, H. P. (2007). Little Hans: A centennial review and reconsideration . Journal of the American Psychoanalytic Association, 55 (3), 749-765.

Brown, R. (1965). Social Psychology . Collier Macmillan.

Freud, S. (1905). Three essays on the theory of sexuality . Se, 7.

Freud, S. (1909). Analysis of a phobia of a five year old boy. In The Pelican Freud Library (1977), Vol 8, Case Histories 1, pages 169-306

Graf, H. (1959). Interview by Kurt Eissler. Box R1, Sigmund Freud Papers. Sigmund Freud Collection, Manuscript Division, Library of Congress, Washington, DC.

Graf, M. (1952). Interview by Kurt Eissler. Box 112, Sigmund Freud Papers. Sigmund Freud Collection, Manuscript Division, Library of Congress, Washington, DC.

Ross, J.M. (2007). Trauma and abuse in the case of Little Hans: A contemporary perspective . Journal of the American Psychoanalytic Association, 55 (3), 779-797.

Further Information

• Sigmund Freud Papers: Interviews and Recollections, -1998; Set A, -1998; Interviews and; Graf, Max, 1952.
• Sigmund Freud Papers: Interviews and Recollections, -1998; Set A, -1998; Interviews and; Graf, Herbert, 1959.
• Wakefield, J. C. (2007). Attachment and sibling rivalry in Little Hans: The fantasy of the two giraffes revisited. Journal of the American Psychoanalytic Association, 55(3), 821-848.
• Bierman J.S. (2007) The psychoanalytic process in the treatment of Little Hans. Psychoanalytic Study of the Child, 62: 92- 110
• Re-Reading “Little Hans”: Freud’s Case Study and the Question of Competing Paradigms in Psychoanalysis
• An” Invisible Man”?: Little Hans Updated

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A clinical case study of a psychoanalytic psychotherapy monitored with functional neuroimaging

Anna buchheim.

1 Institute of Psychology, University of Innsbruck, Innsbruck, Austria

Karin Labek

Steffen walter.

2 Department of Psychosomatic Medicine and Psychotherapy, University of Ulm, Ulm, Germany

Roberto Viviani

3 Department of Psychiatry and Psychotherapy III, University of Ulm, Ulm, Germany

This case study describes 1 year of the psychoanalytic psychotherapy using clinical data, a standardized instrument of the psychotherapeutic process (Psychotherapy process Q-Set, PQS), and functional neuroimaging (fMRI). A female dysthymic patient with narcissistic traits was assessed at monthly intervals (12 sessions). In the fMRI scans, which took place immediately after therapy hours, the patient looked at pictures of attachment-relevant scenes (from the Adult Attachment Projective Picture System, AAP) divided into two groups: those accompanied by a neutral description, and those accompanied by a description tailored to core conflicts of the patient as assessed in the AAP. Clinically, this patient presented defense mechanisms that influenced the relationship with the therapist and that was characterized by fluctuations of mood that lasted whole days, following a pattern that remained stable during the year of the study. The two modes of functioning associated with the mood shifts strongly affected the interaction with the therapist, whose quality varied accordingly (“easy” and “difficult” hours). The PQS analysis showed the association of “easy” hours with the topic of the involvement in significant relationships and of “difficult hours” with self-distancing, a defensive maneuver common in narcissistic personality structures. In the fMRI data, the modes of functioning visible in the therapy hours were significantly associated with modulation of the signal elicited by personalized attachment-related scenes in the posterior cingulate ( p = 0.017 cluster-level, whole-volume corrected). This region has been associated in previous studies to self-distancing from negatively valenced pictures presented during the scan. The present study may provide evidence of the possible involvement of this brain area in spontaneously enacted self-distancing defensive strategies, which may be of relevance in resistant reactions in the course of a psychoanalytic psychotherapy.

INTRODUCTION

The empirical investigation of the psychoanalytic process and outcome is of great importance to advance our knowledge of the psychoanalytic theory of treatment. Several studies have demonstrated the efficacy of long-term and short-term psychoanalytic treatment in randomized controlled trials (e.g., Gabbard et al., 2002 ; Leichsenring et al., 2004 ; Leichsenring and Rabung, 2008 , 2011 ). Nevertheless, many clinicians and researchers argue that detailed single case studies, a time-honored instrument of psychoanalytic inquiry and knowledge dissemination ( Donnellan, 1978 ; Edelson, 1985 ; Kächele et al., 2009 ) are still an essential complement to clinical trials in furthering our understanding of the psychoanalytic process and its relation to outcome (e.g., Kächele et al., 2006 , 2009 ). Single case research has been often indicated as one of the most suitable approach for evaluating psychoanalytic treatments ( Wallerstein and Sampson, 1971 ; Edelson, 1988 ; Hilliard, 1993 ). Recently, single case studies based on operationalized instruments have been developed in different domains (e.g., Kazdin, 1982 ). These efforts have produced psychotherapy studies focusing on computerized text-analytic measures (e.g., Mergenthaler and Kächele, 1996 ), process and outcome research (e.g., Hilliard, 1993 ; Orlinsky et al., 2004 ; Gullestad and Wilberg, 2011 ), and the combination of psychotherapy research and fMRI ( Schiepek et al., 2009 , 2013 ).

The aim of the present study was exploring for the first time the feasibility of single case research of an ongoing psychoanalysis in a neurobiological context using repeated fMRI measurements. We pursued the integration of clinical presentation, of operationalized formal instruments to describe the individual psychotherapeutic process, and of neuroimaging techniques to monitor the psychotherapeutic process on both the clinical and the neural levels. To this end, we collected functional neuroimaging data at monthly intervals from a patient undergoing psychoanalytic psychotherapy during exposure to attachment-relevant pictures ( Buchheim et al., 2006 , 2008 ). The main question we wanted to address was the extent to which the data from functional neuroimaging could be brought to bear on our theoretical understanding of the psychoanalytic process. Likewise, we were interested in verifying if existing interpretations of cortical activity gained in controlled experimental settings from neuroimaging studies would maintain their explanatory power in the context of the single case study of a psychoanalytic process. A crucial issue was therefore the existence of an association between symptoms, the character of the relationship with the therapist in individual therapy hours, and variation in the signal from the attachment-relevant scenes probe in the scanner.

MATERIALS AND METHODS

One year of psychoanalytic therapy of a patient with a chronic depressive disorder and narcissistic traits was assessed at monthly intervals ( N = 12 sessions) with an established measure for the characterization of therapy (The Psychotherapy Process Q-Set, PQS; Jones, 2000 ), and with a functional neuroimaging probe that was successfully used to elicit signal in an adult attachment context in a previous study of the psychoanalytic treatment of recurrent depression ( Buchheim et al., 2012 ).

The patient, a 42-years-old female lawyer, suffered from rapidly fluctuating affective states. Waking up the morning she knew that “this will be an easy day” or “this will be a difficult day.” Her capacity for successful work and concentration was reduced when she felt depressed and in a “difficult day mood.” During these occasions she isolated herself, tended to withdraw from relationships, and worked hard to hide her emotional vulnerability. This chronic and fluctuating depressive pathology and a fragile, vulnerable perception of self and others brought her in psychoanalytic treatment.

In order to obtain an objective assessment of the psychotherapy process describing the psychodynamic pattern of the patient and the interaction between the patient and the therapist, one session every 4 weeks (first session of the week) at regular intervals (compatible with interruptions due to vacations and illnesses) was audiotaped, transcribed, and analyzed with the PQS approach (12 sessions in all). The PQS ( Jones, 2000 ; German version: Albani et al., 2007 ) is a rating instrument designed to provide a basic vocabulary for the description and classification of psychotherapy processes in a form suitable to quantitative analysis (Q-sort methodology). The PQS captures a wide range of events in the psychotherapeutic session attributable to both the therapist’s activity and the patient, including transference manifestations, resistance, and the accompanying affective states.

Functional neuroimaging scans were taken on the same days as the recorded therapy hours. As in a previous study ( Buchheim et al., 2012 ), attachment-relevant scenes were used to capture individual attachment-related features relevant for the psychotherapeutic relationship. In the scanner, the patient looked at the scenes used in a formal measure for the assessment of adult attachment representations (Adult Attachment Projective Picture System, AAP; Buchheim et al., 2006 , 2008 ; George and West, 2012 ). These scenes were alternately accompanied by sentences neutrally describing their content, or by sentences that referred to the personally relevant content evoked by them as extracted by a previous AAP interview. The contrast of interest was the difference between the signal evoked by the personalized and the neutral textual descriptions of the scenes. This contrast detected neural substrates activated by the appraisal of the personal element in the attachment scenes, at the net of generic activations due to the perceptual encoding of the scenes and reading the textual description.

Note that we did not have access to changes in brain function during therapy, since the functional neuroimaging sessions necessarily took place after, and not during, therapy hours. However, we were aided in our attempt in establishing a link between mind states, therapy, and neural substrates by the oscillations of the patient between “difficult” and “easy” days, a change in mood that may have been relatively stable from the therapy hour to the functional neuroimaging session. Hence, the data we present document changes in these modes of emotional functioning that had consequences on the quality of the therapy hours, rather than the therapy hours themselves. The question of interest was the extent to which clinical data from the therapy hours and neural activation were reciprocally informative of the mental states at the base of the “easy” and “difficult” moods. This focus also allowed us to sidestep the issue of change over the course of therapy, which would possibly be confounded by habituation or learning effects in the neuroimaging data.

PARTICIPANTS

The analyst was a very experienced training analyst with an interest in research. She agreed to take part in our study and to audiotape one therapy session a month for the PQS analysis. She works in a private practice as a psychiatrist.

The patient also agreed to take part in the study. She was given information about the study and signed a declaration of her willingness to participate for 1 year and to be assessed with several questionnaires and the functional neuroimaging scans. The treatment was paid by the health insurance. This study was approved by the ethical committee by the University of Ulm in the context of the Hanse-Neuro-Psychoanalysis Study ( Buchheim et al., 2008 , 2012 ). The patient gave written informed consent to the publication of the data. However, the case report should be written taking into consideration the need to protect the identity of the patient.

This patient was treated with a standard long-term psychoanalysis with a frequency of two face-to-face sessions per week. Standard key techniques included exploration, clarification, and interpretation. Interpretive interventions aimed to enhance the patient’s insight into her repetitive conflicts sustaining her problems; supportive interventions aimed to strengthen abilities that were temporarily inaccessible to the patient’s owing to acute stress (e.g., traumatic events) or were not sufficiently developed (e.g., Fonagy and Kächele, 2009 ; Shedler, 2010 ). The establishment of a helping (or therapeutic) alliance is regarded as an important component of supportive interventions. Transference, defined as the repetition of past experiences in present interpersonal relations, constitutes another important dimension of the therapeutic relationship. In psychodynamic psychotherapy, transference is regarded as a primary source of understanding and therapeutic change (e.g., Fonagy and Kächele, 2009 ). In this low frequency therapy, the analyst followed an intersubjective approach, characterized by the focus on the inner and outer reality of the patient’s self and object representations and the aim to increase the patient’s capacity to differentiate between reality and fantasy by enhancing self-reflection (e.g., Ogden, 1977 , 1989 ; Fonagy et al., 2004 ; Dreyer and Schmidt, 2008 ).

CLINICAL AND BEHAVIORAL OUTCOME VARIABLES

The clinical and behavioral outcome data served different purposes. First, the monitoring of symptoms with self-rating scales documented changes in affective symptoms at the days of the data collection. In clinical studies, these data describe the level of symptoms and document changes during therapy (in the present case study, these measures indicated a substantially stable state over the year of the study, as detailed below). Second, the clinical rating of the hour by the therapist and the PQS documented the exchange between patient and analyst during therapy through the clinical impression and an operationalized assessment instrument. Variation in these data provided correlates to explore with the neuroimaging probe. Third, the AAP interview provided material on core attachment issues specific to the patient for the preparation of the stimuli used in the neuroimaging sessions. Almost as a side product, it also provided an assessment of the attachment pattern of this patient at the beginning of study. The AAP interview, however, is not administrable on a monthly basis and for this reason could not be used as a clinical correlate of the neuroimaging data in the present setting. Fourth, a post-scan self-rating questionnaire was administered to evaluate reported involvement with the stimuli presented during the scan session. These data were meant as an aid in interpreting the fMRI analysis. Finally, the results section also reports on the patient using a more customary clinical description informed by psychoanalytic views. We considered the clinical description an integral part of the results, this being a single case study. This description is meant to provide guidance on the psychopathology of this patient, to be compared with the functional role of neural structures identified in the neuroimaging study.

Clinical rating of the hour by the therapist

The analyst rated on a clinical level dichotomously if the 12 sessions were “difficult” or “easy.” According to her documentation the classification in “difficult” or “easy” was very clearly identifiable. The “difficult” sessions started with silence and remained quiet and inhibited. The “easy” sessions started fluently and remained talkative.

Psychopathology monitoring with self-rating scales

At each scanning session, the patient filled a number of self-rating scales documenting her psychopathological state. State depressiveness was rated with the Collegium Internationale Psychiatriae Scalarum (CIPS)-depressiveness scale ( Zerssen, 1976 ). This is a self-rating depressiveness scales provided in two parallel series of questions, which may be used in alternative turns in sequential assessments. The general burden of symptoms was gaged with the outcome questionnaire (OQ)-burden subscale (German version: Haug et al., 2004 ).

Psychotherapy process Q-set

The PQS is an operationalized instrument for the characterization of therapy hours ( Jones, 2000 ). It consists of 100 items covering a wide range of aspects in the behavior of the patient and her interaction with the therapist. Unlike most rating instruments, the items are not arranged in predefined groups that considered together provide scores on clinical dimensions identified a priori . Instead, a typical use of this instrument in psychotherapy research is the identification of hallmark of hours with specific characteristics. For example, one may attempt to identify items correlating with a negative therapeutic reaction, ascertained clinically in a carefully monitored therapy sample. Among their uses, these items can identify both the unity and coherence of treatment sessions, and detects changes between hours and patients. The PQS-instrument shows excellent inter-rater reliability, item reliability, concurrent, and predictive validity for several studies and various types of treatment samples (see Levy et al., 2012 ). The inter-rater reliability, assessed for all 100 items and tested by correlating the Q-sorts of multiple raters, is high as evidenced by levels of inter-rater agreement/reliability (kappa ranges from 0.83 to 0.89). Reliability varies from adequate to excellent for individual items, giving values between 0.50 and 0.95 (see Levy et al., 2012 ). In this study verbatim transcribed sessions were coded by two independent raters, who were blind to all therapy hours. Two independent trained judges rated all 12 psychotherapy sessions and achieved a correspondence of kappa between 0.80 and 0.97.

Statistical analysis of behavioral data

Because of the inherently correlational and explorative character of data obtained with the PQS, we investigated the tendency of PQS scores to covary across items with a principal component analysis. To compute significance levels of principal components, we carried out 2000 Monte Carlo simulations in which principal component analyses were computed on data with the same item range and distribution, but varying independently from each other. Significance values were computed as quantiles of the first and second components of the simulations (to test the significance of the first and second component, respectively). Significant components provide evidence that a set of therapy characteristics occur together, suggesting the existence of recurrent interaction dynamics.

Hypothesis testing on PQS items were conducted on the linear trend (the months of therapy from 1 to 12) and on the classification of “easy” and “difficult” hours provided by the analyst. The first test documented the existence of a change in the tendency of these interaction dynamics to occur with different frequencies at the beginning and at the end of the period of the study. The second test constituted an objective verification of the clinical impression of the analyst. Tests were carried out independently on each PQS item, correcting for the multiple comparison using a permutation method with 2000 steps ( Blair et al., 1994 ). In this approach, at each permutation the maximal (minimal) t -value obtained from conducting the test on the PQS item was recorded. The significance levels of high (low) t -values, with adjustment for multiple testing, were given by the quantiles of the recorded maximal (minimal) t -values.

Self-rating questionnaire after fMRI sessions

To monitor the extent of emotional involvement and autobiographical character of the three core sentences during the course of the psychotherapy, we administered a self-rating questionnaire to the patient after each fMRI session. In the questionnaire the patient was asked to rate the personalized sentences from the AAP scenes used in the scanner by answering the following two questions: “How much of the sentence applies to you autobiographically?” and “How strong did this sentence move you emotionally?” The patient had to assign a score between 1 and 7, where 1 meant not at all, 4 meant middle intensity, and 7 meant very much.

AAP interview

Attachment classification and fMRI-stimuli were derived from the AAP ( George and West, 2012 ), an established and validated interview to assess attachment representations, based on a set of eight picture stimuli. The stimuli are line drawings of a neutral scene and seven attachment scenes (e.g., illness, separation, solitude, death, and threat). The AAP classification system designates the four main adult attachment groups identified using the AAI classification system (secure, dismissing, preoccupied, unresolved). Classifications are based on the rating of several scales (e.g., agency of self, connectedness, synchrony, deactivation) on the basis of verbatim transcripts of the stories to the seven attachment activating stimuli.

Administration involves asking participants in a semi-structured format to describe the scene in the picture, including what characters are thinking or feeling, and what they think might happen next. Three core sentences that represented the attachment pattern of the participants were extracted from the audiotaped responses to each AAP picture stimulus by two independent certified judges (e.g., “A girl is incarcerated in that big room,” “My mother suffered until the end and the ambulance came often”). These sentences were paired to the respective picture to constitute the “personally relevant” trials tailored to each participant. These same pictures, paired to sentences describing only the environment of the depicted situation (e.g., “There is a window with curtains on the left and right,” “There is a bed with a big blanket”) constituted the “neutral” trials (see also Buchheim et al., 2012 ).

NEUROIMAGING OUTCOME VARIABLES

The neuroimaging session took place on the same day as the recorded psychotherapy hour. It consisted of the task in the scanner and in the administration of a rating instrument to assess the patient’s reaction to the items presented in the scanner.

Neuroimaging task

In each trial, the patient looked at pictures of attachment-relevant AAP scenes, accompanied by a short descriptive text. Each picture was presented for 20 s, followed by a fixation point for about the same duration ( Figure ​ Figure1 1 ). The AAP consists of a set of seven of such pictures; this set was repeated 12 times, for a total of 84 trials. Repetitions of the set were divided into two groups: those in which the descriptive text was a neutral rendering of the figures appearing in the scene ( neutral trials ), and those where the description was tailored to core conflicts of the patient as assessed in the initial AAP interview ( personally relevant trials ).

Schematic representation of the AAP scenes and sentences used in the functional neuroimaging study (example of a personalized trial) .

Image acquisition

MRI data were recorded using a 3-T Magnetom Allegra head scanner (Siemens, Erlangen, Germany), equipped with a standard head coil. In each session, 508 EPI T 2 *-weighted whole brain volumes were acquired (TR/TE = 2500/30 ms, flip angle 90°, FOV 192 mm, matrix 64 × 64, voxel size 3 mm × 3 mm, slice thickness 3 mm, 44 slices, standard AC–PC orientation). Sessions were repeated in monthly intervals for a year, for a total of 12 sessions.

Preprocessing and statistical analysis of neuroimaging data

Data were analyzed with the Statistical Parametric Mapping (SPM) package ( Frackowiak et al., 2003 ), using a voxelwise approach. After realignment and normalization into Montreal Neurological Institute (MNI) space, volumes were smoothed with a Gaussian isotropic kernel (8 mm full width-half maximum). The blood oxygenation level-dependent (BOLD) response function was modeled by convolving the trial onsets with a standard hemodynamic response function. Effects of interest were estimated for each session separately (in a model that included presentation of the scene + textual description combination and whether the combination was personalized or not) and brought to the second level to account for a random effect of sessions ( Penny and Holmes, 2007 ). At the second level, main effects were tested with one-sample t -tests. The interaction between quality of the hour and personalized effect was given by an additional second-level regressor indicating whether the hour was “easy” or “difficult.” This regressor is orthogonal to the one-sample t -test of the personalized effect ( Viviani, 2010 ).

The main effect of interest of the study was given by the contrast personally relevant vs. neutral, and its interaction with the index of the quality of the session, as indicated by the therapist and its operational characterization through the PQS scores. To identify regions associated with the presentation of the personalized trials, we performed a whole-brain estimation of the model voxel by voxel. The significance levels reported in the text of section “Results” are corrected at cluster level ( Poline and Mazoyer, 1993 ; Friston et al., 1994 ) for the whole volume.

The post-scan self-rating scales were analyzed separately from neuroimaging data using the freely available package R (The R Foundation for Statistical Computing, www.r-project.org , Vienna, Austria; repeated measures regression: function lmer , package lme4, version 2.13.1; Bates and Maechler, 2009 ). The dependent variable (emotional involvement or extent of autobiographical character of the scene–sentence couple) was modeled in a repeated measurements linear model as an effect of the hour character (“easy” or “difficult”) and the personally relevant AAP scene as fixed effects, and the session and the sentences as grouping variables for the random effects.

CLINICAL DESCRIPTION OF THE PATIENT

The patient, a 42-years-old lawyer, suffered since the birth of her first daughter from rapidly fluctuating affective states. From a clinical point of view, the patients had a moderate functioning level. During the so-called “difficult day”-states she isolated herself and tended to withdraw herself in relationships and hide her emotional vulnerability in contrast to the so-called “easy days”-states, where the patient felt self-conscious and full of personal strength. Regarding her personality structure she showed some narcissistic features ( Kernberg, 1984 ; Cain et al., 2008 ; Pincus and Lukowitsky, 2010 ), being self-centered and rather achievement oriented. She defined herself frequently via money, success, and reputation. When she felt in her job that clients were not as satisfied with her work as she expected from herself she broke down and was ruminating anxiously if they will come back. This pattern demonstrated that her self-esteem fluctuated according to the gratifying or frustrating experiences in relationships and how she evaluated the distance between the goals and aspirations. Because of her harsh super-ego demand for perfection she was in an instable inner state and self-esteem could be diminished rapidly.

The patient lived in a long-lasting relationship. However, she characterized the relationship with her husband as competitive with respect to their tendency to experience rivalry and envy. Moreover, there was a clear discrepancy between her self-perception and the perception that significant others had of the patient. Although easier days were subjectively felt more pleasant by the patient, her husband reportedly found it very difficult to deal with her. This often led to constant, seemingly unsolvable conflicts and to repeatedly considering separation.

One of her major unconscious defensive structure seemed to circle around fantasies of success and grandiosity, leading to her dependency to be admired by others and to bouts of insecurity disrupting her sense of grandiosity or specialness (for a description of the related dynamic, see Kernberg and Yeomans, 2013 ).

According to the observations of the analyst collected over 1 year of clinical work, the following topics may be considered key to the psychodynamic understanding of the patient and her treatment:

1. On “difficult” days the patient showed a severely inhibited capacity to think and to express feelings and thoughts and fell into silence. On “easy” days the patient talked expansively and her personality appeared strong.

2. The association of the fluctuating symptoms with unresolved loss experiences and fear due to uncontrollable guilt-feelings.

As we shall see later, these two core issues could be retrieved in the formal assessment of the interaction between the patient and the therapist using the PQS methodology.

From a psychodynamic and biographic perspective the analyst suggested that two events of death were useful to understand the nature of the patient’s symptoms. These events revealed the underlying vulnerability of the patient with respect to this issue and the related latent feelings of helplessness and impotence. When the patient was 30-years old her mother died unexpectedly. She felt guilty, because she was unable to call the emergency doctor in time. Moreover, the tragic loss through death of a colleague some years previously coincided with the birth of her first child, a son. Again the patient felt guilty, because she was not able to reach her colleague in time to be able to help her. Her fluctuating depressive symptoms might be interpreted as the outcome of this defensive structure. On “easy days” her functioning was predominantly characterized by externalization with an increase of activity and personal strength, while on “difficult days” internalization led to inhibition of activity and severe self-doubts. These latter phases were characterized by affective distance between the patient and her object world in an effort to preserve the illusion of control relative to object loss ( Modell, 1975 ).

Since the patient demonstrated a complex chronic affective disorder with difficult personality traits and a rigid defensive structure, there was an indication for long-term psychoanalytic treatment with two sessions per week ( Leichsenring and Rabung, 2011 ). The treatment setting was face-to-face, thus creating a positive stable counterpole to her mood changes. The positive stabilizing effect of the therapy was noticeable early in the treatment even though the total process was taking a very long time. The treatment centered on the deeper understanding of her uncontrollable mood-shifts and her impaired self-perception and perception of others. The question of failure and/or the continuing of the analytic work were constantly present. The transference relationship was mirrored by her experiences of loss: she failed to prevent the unexpected deaths, and for a long time the analyst and the patient failed to prevent the unexpected mood-shifts and to find ways how she could regulate and stabilize her affective instability. Gradually, the patients internalized a better perception of herself and it became easier for the patient to succeed regulating her mood toward the state characterizing “easy” days. One major focus of the treatment was to increase the patient’s ability to react timely in case of severe events like illness or death, and therefore to be able to process these potential traumatic events in a more controlled and integrated way.

ATTACHMENT DATA

The patient was administered the AAP interview at the beginning of the fMRI experiments and 1 year later. The AAP interview had two purposes. On the one hand we assessed the patient’s attachment representation at the beginning of the fMRI assessment and on the other hand we extracted core sentences of the patient’s narratives in the AAP interview as the personalized stimulus material in the fMRI setting (see Section “Neuroimaging Task”). The patient was classified as unresolved (i.e., disorganized). Unresolved stories typically leave characters without protection, describe feelings of extreme mental distress that have not been diminished or transformed, or leave threatening images looming without addressing them further. The patient demonstrated a lack of resolution especially in the AAP Picture “Cemetery” where the loss of the father was associated with mourning, loneliness and a present dialogue with the dead father, which indicated a spectral quality.

ANALYSIS OF SELF-RATING SCALES

Analysis of the CIPS-depressiveness score gave a mean value of 12.2 (SD 5.2, range 8–19), indicating affective symptoms of moderate intensity. The regression of the scores over time failed to demonstrate the existence of changes. Nominally, in the examined monthly sessions the patient became more depressed during the year she was monitored ( Figure ​ Figure2 2 ), but the result was far from significant ( t = 1.05; df = 10, p = 0.34, two-tailed).

Plot of depressiveness scores ( y -axis) over the 12 months of the study ( x -axis) .

The general burden of symptom, as measured by the OQ subscale, was on average 41.75 (SD 5.0, range 33.53), indicating alternating degree of symptom severities crossing the line of norm values ( Haug et al., 2004 ). Like depressiveness, the symptom burden also increased lightly, but not significantly, during this period ( t = 1.16, df = 10, p = 0.27, two-tailed).

The analysis of the PQS scores took place in three steps. In the first step, we undertook an explorative analysis to answer the question of whether there were consistent changes over therapy hours across different items of the PQS, by carrying out a principal component analysis of the PQS scores. This analysis aimed at detecting items that were high or low together in the same hour, without imposing a priori constraints on what these items should be, as would be the case if items had been grouped into preformed scores. We also looked at whether these changes were consistent with a linear trend (i.e., a gradual change over time). In the second step, we looked at the existence of items that were associated with the analyst’s classification of the hours in good and bad. In the final step, we looked at whether changes detected during the explorative analysis related to the changes associated with the analyst’s judgment.

In the principal component analysis of PQS scores, the first detected component, which explained about 32% of the variance of PQS items over time, was highly significant ( p < 0.001). A second component only reached trend significance ( p = 0.06), explaining 16.7% of the overall variance over time. Further components, explaining 13% of the variance of less, failed to reach significance even at trend level. The 10 items scoring highest in the first and second components are shown in Table ​ Table1 1 .

Ten highest scoring items from the principal component analysis of the PQS.

Several items in the principal component analysis scored negative values. The PQS manual contains specific indications to score items as distinctively low. In the first component, a low score on item 54 is given for rambling or incoherent communications, and on item 23 for lack of a guiding discourse thread; on item 13 for the patients appearing bored or dull, and on item 74 grave or somber. Considered together with items with high scores (whose interpretation is immediate), they show that component one prevalently collected items suggesting difficult or inhibited communication of the patient toward the analyst, with frequent phases of silence. These occurred together with other items suggesting the presence of a tense, sober mood (items 7, 13, 74).

The second component appears to characterize form and content of the intervention of the analyst (items 31, 40, 45, 63, 66) and the sometimes difficult reaction of the patient to them (items 1, 49, 95).

We then tested the existence of a linear trend in the changes over time in these component scores. This would have been the case, for example, if the character of the hours changed over the year of therapy, and these components reflected this systematic change. However, the regression of the component scores on the time trend was not significant (first component: t = 0.99, df = 9, p = 0.35, two-tailed; second component: t = 0.82, df = 9, p = 0.43, two-tailed), suggesting that they did not change over time ( Figure ​ Figure3 3 ). Even if the main components did not appear to reflect a change over time, it is conceivable that some other isolated item did. To verify this hypothesis, we tested the regression of each item score over time separately, correcting the significance level for the 100 tests. Also this analysis failed to detect items reflecting a change over the year of therapy. The item that was most associated with time was item 76 (“Therapist suggests that patient accept responsibility for his or her problems,” which however failed to reach significance ( t = 4.22, p = 0.14, two-tailed corrected for multiple comparisons). In summary, change over time in the PQS scores did not document a systematic change after 1 year of therapy relative to the beginning of the monitoring period.

Plot of first component scores over time, together with the respective linear trends (on the x -axis by the monthly session). In blue, first component scores; in green, second component scores. Both component scores display a small tendency to increase over time, which however was not significant.

In the second step of the analysis we looked at the existence of items that were associated with the analyst’s classification of the hours in “easy” and “difficult.” Both easy and difficult hours occurred during this year, and a logistic regression of the occurrence of easy hours over time showed the absence of a significant time trend ( z = -0.53, p = 0.60). The separate regression of each PQS item on the analyst indicator of the quality of the hour detected three significant items, after correcting significance levels for multiple comparisons: item 12 (“Silences occur during the hour”), t = -9.16, p = 0.004 (two-tailed, corrected); item 61 (“Patient feels shy and embarrassed (vs. un-self-conscious and assured.),” t = -5.76, p = 0.03; item 54 (“Patient is clear and organized in self-expression”), t = 5.39, p = 0.04. A fourth item reached trend significance, item 7 (“Patient is anxious or tense (vs. calm and relaxed).”), t = -4.95, p = 0.063.

Finally, we looked at whether changes detected during the explorative principal component analysis in the form of component scores related to the changes associated with the analyst’s judgment. There was a significant association between the first component scores and the analyst’s indicator of the quality of the hour ( t = -5.03, df = 9, p = 0.0006). The second component, in contrast, was not significantly associated ( t = 1.01, df = 9, p = 0.33).

In summary, there was at least one set of PQS items that changed together across therapy hours. These changes were not associated with a time trend, indicating stability of the underlying psychotherapy pattern; however, they were associated with the occurrence of “easy” and “difficult” days. This result did not change if the PQS items were regressed individually on time and day difficulty.

CORE PSYCHODYNAMIC FEATURES OF THE PATIENT AND PQS RESULTS: AN EXPLORATORY COMPARISON

We compared the clinical features of “difficult” and “easy” days with the first component from the PQS, obtained independently from information on the day difficulty (see Table ​ Table2 2 ). This comparison revealed convergent patterns. The clinical description of the analyst, emphasizing the difficulties of expression of the patient, is consistent with the items in the first component detailing inhibited communication, silence, or ineffective content on difficult days. The identification by the analyst of unresolved feelings of loss corresponds to the items related to tense and sober mood. We conclude that the PQS analysis could validate the subjective evaluations of the analyst.

Clinical characteristics compared to PQS-items (principal component analysis).

ANALYSIS OF POST-SCAN SELF-RATING QUESTIONNAIRE

The patient was asked after each fMRI session to rate personalized sentences from the fMRI task with respect of self-involvement and autobiographical content (see Section “Materials and Methods”). The analysis of emotional self-involvement revealed that the rating was on the whole significantly higher in the fMRI sessions that followed “easy” therapy hours ( t = 2.08, df = 9, p = 0.03, one-tailed). This result did not change if the autobiographical rating was added as a confounding covariate to the model ( t = 2.08). This expanded model also revealed that the autobiographical rating was in the individual items associated with the level of emotional involvement rating ( t = 3.9, df = 193, p < 0.001). In contrast, there was no significant change in ratings of the autobiographical character of the personalized sentences in association of the quality of the hour ( t = 1.27, df = 9, p = 0.12 one-tailed).

In summary, these self-rating data confirmed the existence of a qualitative difference between “easy” and “difficult” days that involved the stimuli presented in the scanner through the tendency of a higher self-rated emotional involvement on “easy” days. However, over and above this association, there was an even stronger association at each individual rating between the level of self-involvement and the level of autobiographical character of the scene + text combination.

NEUROIMAGING RESULTS

When viewing the pictures described by personalized text, relative to those with neutral descriptions, the patient activated several areas, prevalently on the left. The most prominent activations involved the ventrolateral and the dorsolateral prefrontal cortex, the perigenual portion of the medial prefrontal cortex, the posterior cingulate and precuneus, the middle temporal gyrus, and the anterior tip of the inferior temporal gyrus, and the occipital/calcarine cortex (see Figure ​ Figure4A 4A and Table ​ Table3 3 ). No area was significantly more active when looking at the neutral scenes.

(A) Parametric maps of activations detected in the personally relevant vs. neutral contrast, overlaid on a template image. (B) Parametric maps of the interaction of the same contrast with hour quality, as rated by the therapist. Slices positioned at MNI coordinates x = -6 (left) and z = 40 (right). For illustration purposes, the parametric map was thresholded at p < 0.005, uncorrected, and a cluster size of 150 voxels (1.2 cm 3 ). a, precuneus and posterior cingulate, active at both the contrast personally relevant vs. neutral and its interaction with hour quality; b, calcarine cortex; c, perigenual medial prefrontal cortex; d, dorsolateral prefrontal cortex. Areas a and c (labeled in green) belong to the “default network system”; area d to the dorsal attentional network (in blue). The red label b refers to primary visual areas.

Activations for the contrast personalized vs. neutral.

The interaction of the effect of personal relevance with goodness of therapy hours was significant in the posterior cingulate/precuneal region (MNI coordinates, x , y , z : -6, -60, 40, t = 6.7, cluster size in voxels: 633, p = 0.017). Here, the signal while looking at personalized scenes was higher when the therapy hour was bad. This area, shown in Figure ​ Figure1B 1B , was part of the medial prefrontal network that was associated with viewing personalized scenes ( Figure ​ Figure1A 1A ). Other, smaller areas detected in the interaction failed to reach significance. No significant interaction was observed in the opposite direction.

We also tested the interaction between the effect of personal relevance and a linear time trend, to detect changes in activation that developed during the year of therapy. In the interaction with the positive time trend, a cluster extending from the left post-central gyrus to the middle frontal gyrus was significant (MNI coordinates, x , y , z : -54, -12, 40, t = 10.2, cluster size in voxels: 1410, p < 0.001). This interaction partially overlapped with the prefrontal interaction in Figure ​ Figure4A 4A (d, dorsolateral prefrontal cortex). No effect was observed in the interaction with a negative time trend.

Recently, the issue of the relationship between Freudian thought or psychoanalytic theory and technique more generally and neuroscience has been the object of renewed interest ( Carhart-Harris et al., 2008 ; Carhart-Harris and Friston, 2010 ; Solms and Panksepp, 2012 ; Zellner, 2012 ; Schmeing et al., 2013 ). In the present study, we attempted to integrate a clinical description of the psychoanalytic process with two empirical instruments, one providing an operationalized assessment of the therapeutic interaction, and the other information on brain activity based on a functional neuroimaging probe. Our aim was to explore the extent to which the two main mental states of the patient and their effect on the psychoanalytic interaction could be observed not only at the clinical level, but also through the data delivered by these two additional instruments.

Analysis of the symptomatic scales gave the picture of a patient with affective symptom severity of moderate intensity, occurring in a patient with a personality with narcissistic features, as described in detail in Section “Results.” The unresolved attachment pattern emerging from the AAP interview is consistent with the analyst’s clinical presentation and with recent attachment data on patients, comorbid with borderline personality disorder and narcissistic personality disorder ( Diamond et al., 2012 ).

The analysis of the PQS data showed that sessions differed along a main axis, defined by the first component. This component was highly correlated with the judgment of the analyst on the quality of the sessions. This analysis revealed that “easy” hours were associated with items describing the deeper understanding of relationship issues, “difficult” hours with silence in the therapy hours and difficulties of the patient to feel at ease. Furthermore, there was no evidence in the PQS data of a linear trend over time that reflected systematic changes from the initial to the final phases of the year monitored by the study. In summary, the main change across sessions present in the PQS data was the one documented by the analyst through her judgment in a phase of therapy where the patient remained stable. This source of change was not associated with a time trend, as “easy” or “difficult” days did not occur more often at the beginning or end of the observation year. This allows excluding the confounds of habituation or learning effects from the regressor representing quality of the hour.

The activation pattern in the contrast of the main effect personally relevant vs. neutral ( Figure ​ Figure4A 4A ) was characterized by the presence of two main groups of areas. The first included areas that are often active in functional neuroimaging studies and that are known to be active while carrying out a focused task ( Duncan and Owen, 2000 ). This group includes the ventrolateral and the dorsolateral prefrontal cortex, and the occipital/calcarine cortex (for visually presented stimuli). The second group may be considered more specific for the material used in the present study, and included areas in the medial wall (anterior cingulate, and the posterior cingulate and precuneus). The activation pattern of these areas was consistent with the activation found in studies in the literature in which participants were asked to judge the degree to which stimuli presented during the scan were attributed to the self, or were felt to be part on oneself/one’s own description ( Figure ​ Figure5 5 ; for a systematic review and meta-analysis of the literature, see van der Meer et al., 2010 ; Qin and Northoff, 2011 ). The medial prefrontal cortex may also be associated with changes after the therapy of affective disorders ( Messina et al., 2013 ). We therefore considered the areas in this second group as those most likely involved in processing the personally relevant content of the stimuli.

Areas in the medial face of the brain associated with self-representation. This image synthesizes data in the neuroimaging literature of studies concerned with self-referentiality using automated keyword search and meta-analytic methods (from www.neurosynth.org , search key “self-referential”; Yarkoni et al., 2011 ). Slices positioned at MNI coordinates x = -6 (left) and z = 40 (right). The comparison with the activation detected in the study in the contrast personally relevant vs. neutral contrast ( Figure ​ Figure4 4 ) shows correspondence of activation in the areas in the medial aspect of the brain: the precuneus and posterior cingulate (a) and the perigenual medial prefrontal cortex (c).

Within this pattern of activation of areas associated to the self and personal relevance, the posterior cingulate cortex was modulated by the interaction with the quality of the therapy hours that had immediately preceded the scan. This association represent evidence of a neural substrates accompanying opposing mental states that, as shown in the self-rating scales, the judgment of the analyst on the quality of the hour, and the formal instrument for assessing the therapeutic exchange, represented a coherent constellation of internally experienced and interpersonally exchanged affect.

The posterior cingulate cortex has been shown in other studies to be modulated by self-distancing from negatively valenced pictures presented during the scan ( Koenigsberg et al., 2010 ) or when down-regulating the reaction to a negative stimulus by self-distraction ( Kanske et al., 2011 ). Of particular interest in the present context is the study by van Reekum et al. (2007) , in which gaze fixations were recorded while participants viewed aversive scenes and were left free to choose the down-regulating strategy. This area highly correlated with the amount of eye movements of the participants, who were directing their gaze so as to avoid the focal area of the image where the disturbing content was represented. This area was also reported to be active in regulation strategies adopted by patients with personality disorders characterized by poor emotion regulation ( Koenigsberg et al., 2009 ; Doering et al., 2012 ; Lang et al., 2012 ).

The self-rating data collected after the scan confirmed the association between the enactment of a self-distancing strategy from the material and the quality of the hour. On “difficult” days, the patient indicated that her overall emotional involvement with the visuotextual material was lower than on the “easy” days. This corresponded to a higher activity in the posterior cingulate area, associated in the previous studies with self-distancing emotion regulation strategies. In view of the documented association between the quality of the hour and the quality of the interaction with the therapist, and the clinical judgment of the therapist himself, the present study provides evidence on the possible involvement of the posterior cingulate area in spontaneously enacted self-distancing emotion-handling strategies representing defensive maneuvers in the course of a psychoanalytic therapy.

Among the areas active in the contrast personally relevant vs. neutral there were also areas prevalently involved in attentional processes (dorsolateral prefrontal cortex; Figure ​ Figure4A 4A letter c). Also this area was modulated during the year of therapy, showing a progressive increase of the signal due to personally relevant trials. This suggests a dissociation of the areas detected in the contrast personally relevant vs. neutral, with the posterior medial area associating with quality of the hour, and the dorsolateral prefrontal areas associating with change over time. The change over time in the dorsolateral prefrontal cortex might be due to a progressive loss of attentional pull of the non-relevant trials, or to the increased recruitment of attentional resources in looking at scenes in the personally relevant trials. From a clinical point of view it could mean that the patient was more effective in appraising and reflecting on her own personal core attachment-related issues.

There are several noteworthy limitations of this study. First, treatment did not follow a manualized psychoanalytic psychotherapy. However, it was conducted by adhering to specific core techniques, as described in section “Materials and Methods,” by a very experienced psychoanalyst. Second, in the attachment paradigm used in the scanner no pictures without attachment content were present. This is consistent with the choice to investigate personal relevance in the context of material likely to evoke core emotional issues, as in previous work ( Buchheim et al., 2012 ). Future work will have to address the issue of the neural response to attachment pictures of the kind used in the AAP in comparison with neutral pictures of similar content and complexity, but differing attachment relevance and interpersonal quality or emotionality, and its capacity to capture affective psychopathology. Third, the fluctuation between two cognitive–emotional states (easy and difficult days, easy and difficult sessions) may have been indicative of pattern transitions that may be analyzed with approaches focusing on self-organization and non-linear dynamics in psychotherapy (see e.g., Boston Change Process Study Group, 2005 ; Schiepek et al., 2009 , 2013 ). However, this aspect of the psychotherapeutic interaction fell outside of the scope of the present study.

In summary, this case report gives indications on the interplay between activity in neural circuits and quality of the psychotherapeutic sessions in the context of psychoanalytic process research. In this specific single case, major characteristics of the patient’s defensive structure could be demonstrated on a behavioral and neural level and validated the subjective evaluation of the analyst. Specifically, affective distancing has been identified in the literature as a hallmark defensive maneuver in personality organization with narcissistic traits ( Modell, 1975 ). Using functional neuroimaging, we were able to objectify the defensive structure of this patient during this phase of psychoanalytic treatment and the occurrence of difficult sessions.

Conflict of Interest Statement

The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

Acknowledgments

This study was in part funded by the German Psychoanalytic Association, whose generous support is here gratefully acknowledged. The authors declare no conflict of interest. We thank Prof. Dr. Horst Kächele, International Psychoanalytic University Berlin, for his encouragement and the inspiration for initiating this research. We are also grateful to Dr. Carolina Seybert, International Psychoanalytic University Berlin, for training and supervising the PQS scoring.

• Albani C., Ablon S., Kächele H. (2007). Der “Psychotherapie Prozess Q-Set” von Enrico E. Jones . Deutsche Version und Anwendungen . Ulm: Ulmer Textbank [ Google Scholar ]
• Bates D. M., Maechler M. (2009). lme4: Linear Mixed-effects Models Using S4 Classes. R Package Version 0.999375-31. Available at: http://CRAN.R-project.org/package=lme4 (accessed December 12, 2011) [ Google Scholar ]
• Blair R. C., Higgins J. J., Karniski W., Kromrey J. D. (1994). A study of multivariate permutation tests which may replace Hotelling’s T2 test in prescribed circumstances. Multivariate Behav. Res. 29 141–163 10.1207/s15327906mbr2902_2 [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Boston Change Process Study Group. (2005). The “something more” than interpretation revisited: sloppiness and co-creativity in the psychoanalytic encounter. J. Am. Psychoanal. Assoc. 53 693–729 10.1177/00030651050530030401 [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Buchheim A., Erk S., George C., Kächele H., Kircher T., Martius P., et al. (2008). Neural correlates of attachment trauma in borderline personality disorder: a functional magnetic resonance imaging study. Psychiatry Res. 163 223–235 10.1016/j.pscychresns.2007.07.001 [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Buchheim A., Erk S., George C., Kächele H., Ruchsow M., Spitzer M., et al. (2006). Measuring attachment representation in an fMRI environment: a pilot study. Psychopathology 39 144–152 10.1159/000091800 [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Buchheim A., Viviani R., Kessler H., Kächele H., Cierpka M., Roth G., et al. (2012). Changes in prefrontal-limbic function in major depression after 15 months of long-term psychotherapy. PLoS ONE 7 : e33745 10.1371/journal.pone.0033745 [ PMC free article ] [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Cain N. M., Pincus A. L., Ansell E. B. (2008). Narcissism at the crossroads: phenotypic description of pathological narcissism across clinical theory, social/personality psychology, and psychiatric diagnosis. Clin. Psychol. Rev. 28 638–656 10.1016/j.cpr.2007.09.006 [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Carhart-Harris R. L., Friston K. J. (2010). The default mode, ego-functions and free-energy: a neurobiological account of Freudian ideas. Brain 133 1265–1283 10.1093/brain/awq010 [ PMC free article ] [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Carhart-Harris R. L., Mayberg H. S., Malizia A. L., Nutt D. (2008). Mourning and melancholia revisited: correspondence between principles of Freudian metapsychology and empirical findings in neuropsychiatry. Ann. Gen. Psychiatry 7 9 10.1186/1744-859X-7-9 [ PMC free article ] [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Diamond D., Clarkin J., Horz S., Levy K., Fisher-Kern M., Cain N., et al. (2012). Attachment and reflective function in patients with co-morbid NPD/BPD. Paper presented at the 2nd International Congress on Borderline Personality Disorder and Allied Disorders Amsterdam, The Netherlands: September 29, 2012 [ Google Scholar ]
• Doering S., Enzi B., Faber C., Hinrichs J., Bahmer J., Northoff G. (2012). Personality functioning and the cortical midline structures. An exploratory fMRI study. PLoS ONE 7 : e49956 10.1371/journal.pone.0049956 [ PMC free article ] [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Donnellan G. J. (1978). Single-subject research and psychoanalytic theory. Bull. Menninger Clin. 42 352–357 [ PubMed ] [ Google Scholar ]
• Dreyer K.-A., Schmidt M. G. (2008). Niederfrequente psychoanalytische Psychotherapie . Theorie, Technik, Therapie Stuttgart: Klett Cotta [ Google Scholar ]
• Duncan J., Owen A. M. (2000). Common regions of the human frontal lobe recruited by diverse cognitive demands. Trends Neurosci. 23 475–483 10.1016/S0166-2236(00)01633-7 [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Edelson M. (1985). The hermeneutic turn and the single case study in psychoanalysis. Psychoanal. Contemp. Thought 8 567–614 [ Google Scholar ]
• Edelson M. (1988). Psychoanalysis: A Theory in Crisis . Chicago: University of Chicago Press [ Google Scholar ]
• Fonagy P., György G, Elliot L. J., Target M. (2004). Affect Regulation, Mentalization, and the Development of the Self . New York: Other Press [ Google Scholar ]
• Fonagy P., Kächele H. (2009). “Psychoanalysis and other long-term dynamic psychotherapies,” in New Oxford Textbook of Psychiatry 2nd Edn. Vol. 2 eds Gelder M. G., Lopez-Ibor J. J., Andreasen N. (Oxford University Press; ) 1337–1349 [ Google Scholar ]
• Frackowiak R. S. J., Friston K. J., Frith C., Dolan R., Price C. J., Zeki S., et al. (2003). Human Brain Function . London: Academic Press [ Google Scholar ]
• Friston K. J., Worsley K. J., Frackowiak R. S. J., Mazziotta J. C., Evans A. C. (1994). Assessing the significance of focal activations using their spatial extent. Hum. Brain Mapp. 1 214–220 [ PubMed ] [ Google Scholar ]
• Gabbard G. O., Gunderson J. G., Fonagy P. (2002). The place of psychoanalytic treatments within psychiatry. Arch. Gen. Psychiatry 59 505–510 10.1001/archpsyc.59.6.505 [ PubMed ] [ CrossRef ] [ Google Scholar ]
• George C., West M. (2012). The Adult Attachment Projective Picture System. Attachment Theory and Assessment in Adults . New York: The Guilford Press [ Google Scholar ]
• Gullestad F., Wilberg T. (2011). Change in reflective functioning during psychotherapy: a single-case study. Psychother. Res. 21 97–111 10.1080/10503307.2010.525759 [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Haug S., Puschner B., Lambert M. J., Kordy H. (2004). Veränderungsmessung in der Psychotherapie mit dem Ergebnisfragebogen (EB-45). Z. Differentielle Diagn. Psychol. 25 141–151 10.1024/0170-1789.25.3.141 [ CrossRef ] [ Google Scholar ]
• Hilliard R. B. (1993). Single-case methodology in psychotherapy process and outcome research. J. Cogn. Clin. Psychol. 61 373–380 10.1037/0022-006X.61.3.373 [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Jones E. E. (2000). Therapeutic Action. A Guide to Psychoanalytic Therapy . Nothvale, NJ: Jason Aronson Inc [ Google Scholar ]
• Kächele H., Albani C., Buchheim A., Hölzer M., Hohage R., Jimenez J. P., et al. (2006). The German specimen case amalia X: empirical studies. Int. J. Psychoanal. 87 1–18 10.1007/3-540-29882-7_1 [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Kächele H., Schachter J., Thomä H. (eds) (2009). .From Psychoanalytic Narrative to Empirical Single Case Research. Implications for Psychoanalytic Practice . New York: Routledgse [ Google Scholar ]
• Kanske P., Heissler J., Schönfelder S., Bongers A., Wessa M. (2011). How to regulate emotion? Neural networks for reappraisal and distraction. Cereb. Cortex 21 1379–1388 10.1093/cercor/bhq216 [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Kazdin A. E. (1982). Single Case Research Designs: Methods for Clinical and Applied Settings . Oxford: Oxford University Press [ Google Scholar ]
• Kernberg O. F. (1984). Severe Personality Disorders: Psychotherapeutic Strategies . New Haven, CT: Yale University Press; 10.1521/bumc.2013.77.1.1 [ CrossRef ] [ Google Scholar ]
• Kernberg O. F., Yeomans F. E. (2013). Borderline personality disorder, bipolar disorder, depression, attention deficit/hyperactivity disorder, and narcissistic personality disorder: practical differential diagnosis. Bull. Menninger Clin. 77 1–22 [ PubMed ] [ Google Scholar ]
• Koenigsberg H. W., Fan J., Ochsner K. N., Liu X., Guise K., Pizzarello S., et al. (2010). Neural correlates of using distancing to regulate emotional responses to social situations. Neuropsychologia 48 1813–1822 10.1016/j.neuropsychologia.2010.03.002 [ PMC free article ] [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Koenigsberg H. W., Fan J., Ochsner K. N., Liu X., Guise K. G., Pizzarello S., et al. (2009). Neural correlates of the use of psychological distancing to regulate responses to negative social cues: a study of patients with borderline personality disorder. Biol. Psychiatry 66 854–863 10.1016/j.biopsych.2009.06.010 [ PMC free article ] [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Lang S., Kotchoubey B., Frick C., Spitzer C., Grabe H. J., Barnow S. (2012). Cognitive reappraisal in trauma-exposed women with borderline personality disorder. Neuroimage 59 1727–1734 10.1016/j.neuroimage.2011.08.061 [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Leichsenring F., Rabung S. (2008). Effectiveness of long-term psychodynamic psychotherapy: a meta-analysis. JAMA 13 1551–1565 10.1001/jama.300.13.1551 [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Leichsenring F., Rabung S. (2011). Long-term psychodynamic psychotherapy in complex mental disorders: update of a meta-analysis. Br. J. Psychiatry 199 15–22 10.1192/bjp.bp.110.082776 [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Leichsenring F., Rabung S., Leibing E. (2004). The efficacy of short-term psychodynamic psychotherapy in specific psychiatric disorders. A meta-analysis. Arch. Gen. Psychiatry 61 1208–1216 10.1001/archpsyc.61.12.1208 [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Levy R. A., Ablon J., Thomae H., Kaechele M. D., Ackerman H., Erhardt I., et al. (2012). “A session of psychoanalysis as analyzed by the psychotherapy process Q-set: Amalia X, session 152,” in Psychodynamic Psychotherapy Research: Practice Based Evidence and Evidence Based Practice eds Raymond A., Levy J., Ablon S., Kaechele H. (New York: Springer) [ Google Scholar ]
• Mergenthaler E., chele H. (1996). Applying multiple computerized text-analytic measures to single psychotherapy cases. J. Psychother. Pract. Res. 5 307–317 [ PMC free article ] [ PubMed ] [ Google Scholar ]
• Messina I., Sambin M., Palmieri A., Viviani R. (2013). Neural correlates of psychotherapy in anxiety and depression: a meta-analysis. PLoS ONE 8 : e74657 10.1371/journal.pone.0074657 [ PMC free article ] [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Modell A. H. (1975). A narcissistic defence against affects and the illusion of self-sufficiency. Int. J. Psycho-Anal. 56 275–282 [ PubMed ] [ Google Scholar ]
• Ogden T. H. (1977). Projective Identification and Psychotherapeutic Technique . Lanham, MD: Jason Aronson [ Google Scholar ]
• Ogden T. H. (1989). The Primitive Edge of Experience . Northvale, NJ: Jason Aronson [ Google Scholar ]
• Orlinsky D. E., Ronnestad M. H., Willutzki U. (2004). “Fifty years of psychotherapy process-outcome research: continuity and change,” in Bergin and Garfield’s Handbook of Psychotherapy and Behavior Change ed. Lambert M. J. (New Jersey: Wiley & Sons; ) 307–389 [ Google Scholar ]
• Penny W. D., Holmes A. J. (2007). “Random-effects analysis,” in Human Brain Function eds Frackowiak R. S., Friston K. J., Frith C. D., Dolan R. J., Price C. J., Zeki S., Ashburner J., Penny W. D. (San Diego: Elsevier Academic Press; ) 156–165 [ Google Scholar ]
• Pincus A. L., Lukowitsky M. R. (2010). Pathological narcissism and narcissistic personality disorder. Annu. Rev. Clin. Psychol. 6 421–446 10.1146/annurev.clinpsy.121208.131215 [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Poline J.-B., Mazoyer B. M. (1993). Analysis of individual positron emission tomography activation maps by detection of high signal-to-noise pixel clusters. J. Cereb. Blood Flow Metab. 13 425–437 10.1038/jcbfm.1993.57 [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Qin P., Northoff G. (2011). How is our self related to midline regions and the default-mode network? Neuroimage 57 1221–1233 10.1016/j.neuroimage.2011.05.028 [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Schiepek G., Tominschek I., Karch S., Lutz J., Mulert C., Meindl T., et al. (2009). A controlled single case study with repeated fMRI measures during the treatment of a patient with obsessive-compulsive disorder: testing the nonlinear dynamics approach to psychotherapy. World J. Biol. Psychiatry 10 658–668 10.1080/15622970802311829 [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Schiepek G., Tominschek I., Heinzel S., Aigner M., Dold M., Unger A., et al. (2013). Discontinuous patterns of brain activation in the psychotherapy process of obsessive compulsive disorder: converging results from repeated fMRI and daily self-reports. PLoS ONE 8 : e71863 10.1371/journal.pone.0071863 [ PMC free article ] [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Shedler J. (2010). The efficacy of psychodynamic psychotherapy. Am. Psychol. 65 98–109 10.1037/a0018378 [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Schmeing J. B., Kehyayan A., Kessler H., Do Lam A. T. A., Fell J., Schmidt A. C., et al. (2013). Can the neural basis of repression be studies in the MRI scanner? New insights from two free association paradigms. PLoS ONE 8 : e62358 10.1371/journal.pone.0062358 [ PMC free article ] [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Solms M., Panksepp J. (2012). The ‘Id’ knows more than the ‘ego’ admits: neuropsychoanalytic and primal consciousness perspectives on the interface between affective and cognitive neuroscience. Brain Sci. 2 147–175 10.3390/brainsci2020147 [ PMC free article ] [ PubMed ] [ CrossRef ] [ Google Scholar ]
• van der Meer L., Costafreda S., Aleman A., David A. S. (2010). Self-reflection and the brain: a theoretical review and meta-analysis of neuroimaging studies with implications for schizophrenia. Neurosci. Biobehav. Rev. 34 935–946 10.1016/j.neubiorev.2009.12.004 [ PubMed ] [ CrossRef ] [ Google Scholar ]
• van Reekum C. M., Johnstone T., Urry H. L., Thurow M. E., Schaefer H. S., Alexander A. L., et al. (2007). Gaze fixations predict brain activation during the voluntary regulation of picture-induced negative affect. Neuroimage 36 1041–1055 10.1016/j.neuroimage.2007.03.052 [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Viviani R. (2010). Unbiased ROI selection in neuroimaging studies of individual differences. Neuroimage 50 184–189 10.1016/j.neuroimage.2009.10.085 [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Wallerstein R. S., Sampson H. (1971). Issues in research in the psychoanalytic process. Int. J. Psychoanal. 52 11–50 [ PubMed ] [ Google Scholar ]
• Yarkoni T., Poldrack R. A., Nichols T. N., Van E. D. C., Wager T. D. (2011). Large-scale automated synthesis of human functional neuroimaging data. Nat. Methods 8 665–670 10.1038/nmeth.1635 [ PMC free article ] [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Zellner M. R. (2012). Toward a materialist metapsychology: major operating principles of the brain provide a blueprint for a fundamentally psychodynamic infrastructure. Psychoanal. Rev. 99 563–588 10.1521/prev.2012.99.4.563 [ CrossRef ] [ Google Scholar ]
• Zerssen D. V. (1976). Depressivitäts-Skala . Weinheim: Beltz [ Google Scholar ]