Assessment of Change in Psychoanalysis

Participant

Maria was forty-three years old when she sought psychoanalysis. She was divorced, had no children, lived by herself, and was slightly overweight. A college graduate, she held an executive position in a company based in Lisbon.

She sought psychoanalysis because, as she claimed, she “wasn’t living her life.” She reported depressive feelings and a tendency to inhibit affect such as anger. Frequently she had symptomatic complaints such as headaches or a sore throat. In the intake interview, Maria referred to themes such as her sense of guilt, fear of trusting people, and need to feel in control.

When Maria was less than four years old, her mother died. The young girl then moved to her paternal grandparents’ home with her father and a younger brother. Regarding her mother’s death, she said that people always thought that she had faced it better than her brother had. Deep inside, however, she felt it was the opposite, but she could hardly express her feelings. Additionally, she mentioned that she used to ignore her siblings. No one outside her family gave her the attention she craved, and she envied schoolmates and friends for their ease in social relations.

When she was six Maria was manifesting secondary enuresis, and her father took her to a psychologist. Looking back, Maria noted that she had always avoided anything related to pleasure. Three years later her father remarried, and they moved to another house. Maria had an intense reaction, feeling that her father was betraying her. When she was ten a second sibling was born (a girl), and a month later Maria was sent away to boarding school, to return home only at holidays. Nevertheless, she said she was excited about this change because she could attend the same school as her mother.

Regarding her stepmother, she said the relationship was grounded in a mutual feeling of resentment and rivalry concerning Maria’s father but also in the hope for a tie-in between daughter and mother.

Maria felt she was her father’s privileged daughter, but she felt guilty for not being able to fulfill his wishes. For some time, Maria wanted to be a boy, once she learned that her father had wanted one when her mother was pregnant with her. From then on, she rejected everything related to the female role.

When Maria was twelve she had a traumatic experience in which a man took her to a private place and tried to pull up her skirt. She became anxious and eventually told her father. A year later she began having claustrophobic symptoms that manifested when she was visiting some caves and that continued into adulthood. For example, Maria would be anxious and unable to move when she was expected to disembark from an airplane with other passengers.

In adolescence Maria felt that her father was very demanding; nothing she did was ever enough for him. She also felt that she lived in a family environment of repressed sexuality. She discovered the intellectualization of sexuality issues as a way to hide her internal confusion, which was heightened by her religious belief that sex is associated with loss of control.

When Maria was twenty, she went abroad to take a postgraduate course and met a boy with whom she lived for a time. She said that this period was the first time she had felt free of her father’s control. After three years or so, she moved to another European country and found another boyfriend. The couple’s relationship did not last, however, and she returned to Lisbon, where she soon married. Their sexual life was not satisfactory to her, she reported, adding that she was in love with the man only until they were married. The marriage lasted for two and a half years and ended when her husband fell in love with a colleague. At the time, Maria was undergoing fertility treatment, but she did not become pregnant. Her father died shortly afterward, and she again left the country to work abroad. When she began to feel depressed, she undertook a psychoanalytically oriented psychotherapy three times a week for a year and a half, during which time her claustrophobic symptoms disappeared. She then returned to Portugal and shortly thereafter began her psychoanalysis.

From the beginning of the analysis, Maria revealed her main conflicts. In the first stage of analysis, Maria elaborated on the difficulty of defying her father, his repression of sexuality, and her feelings of resentment toward him for preferring her stepmother. In a number of sessions she talked about her difficulties with feminine identification. As a child she had not played with dolls, and had envied her brother because their grandfather would take him for walks. She experienced feelings of anger toward her father and her bosses, along with slight irritation with the analyst. In the transference Maria particularly feared being criticized by the analyst. Sessions about her father alternated with sessions about feelings of loss and grief regarding her mother, including regret for not having had more contact with her. The overall feeling was one of sadness and abandonment, and in the transference Maria was concerned that the analyst did not understand her or was not sufficiently empathic.

Maria’s loss of her mother created a sense of failure and insecurity that led her to please others lest she be abandoned. Maria talked about her efforts to anticipate what others would think and say so she could accommodate them. This insecurity was reinforced by her father’s remarriage and demanding attitude.

In love relationships, Maria tended to push men away as soon as she felt attracted to them, thereby avoiding incestuous fantasies or abandonment. Though she eventually married a man who took care of her, she was not really attracted to him. Moreover, Maria’s early loss of her mother brought difficulties at the level of early feminine and maternal identification, as shown by her lack of interest in dolls. The extended period before her father remarried, the way he treated her as if she were his partner, and the family’s idealization of her mother all hindered her sexual identification and heightened her wish for a male identity, which gave rise to envy and competition with men. She competed with colleagues, especially male colleagues. In addition, Maria could not envision herself as a mother; indeed, later in the analysis it became clear that when she was married she did everything she could to avoid getting pregnant, including avoiding sexual relations when she knew she was fertile.

A conventional psychoanalytic contract was established, with three sessions a week at a fixed time, place, and fee. The treatment lasted for three years and eight months, for a total of 383 sessions. The analyst, a candidate in training, had ten years of experience and a Freudian orientation. His clinical style was characterized by few interventions per session, with interpretations directed mainly to central conflicts. The patient usually saw the interpretations as meaningful and soon began trying to elaborate on them during the session and in following sessions.

The transference has changed from a slight hostility in the early months of analysis (she later said that at the beginning she preferred her previous therapist) to a positive and slightly erotic transference that continued with ups and downs until the end of the third year of analysis, when she was confronted with a more real analyst. She was angry at the analyst’s failures (he arrived quite late for one session and another session ended early, in both cases for reasons beyond his control).

Instrument

We used a Portuguese translation of the CHAP scales, developed by Sandell (1997). The translation was done by Sá (2008) by comparing it with a previous translation (Cunha 2006). The CHAP scales aim to assess whether the patient feels that he or she is being qualitatively “transformed” as a person and how much and in what ways he or she now feels different, consciously and unconsciously.

Based on content analyses of post-therapy interviews, the CHAP scales define four aspects of change: symptoms, adaptive capacity, self-insight, and basic conflicts. The experience of having changed in terms of symptoms may be expressed in a number of ways, such as when the patient says she has no (or fewer) symptoms, does not mention symptoms at all, or reports experiencing the same symptoms as before but being able to use them adaptively or no longer suffering from them. Adaptive capacity is seen when the patient recounts situations that she could not have managed before but now approaches in adaptive ways without experiencing conflict or symptoms. Self-insight is indicated when the patient describes how she now understands previously incomprehensible habits, attitudes, relationships, and actions. Basic conflicts derive from traumata and relational complications and act as filters through which new situations are perceived, interpreted, and acted upon.

In the CHAP instruction manual, the definition of each rating variable is accompanied by an extensive but nonexhaustive list of twelve to twenty examples of signs of change to help the evaluator understand the meaning of each variable: for example, symptoms (S), “Symptoms have decreased in number, frequency, duration, severity, strength”; adaptive capacity (AC), “Patient relates concrete situations where he/she has acted more adequately than before, e.g., more assertively, flexibly, nonaggressively”; insight (I), “Patient says he/she realizes and understands the background and meaning of his/her problems”; basic conflicts (BC), “Patient is not as rigid, stereotypical, extreme as he used to be”; and extratherapeutic factors (EF), “Patient has changed while in some relation posing as therapy (‘pseudo-therapy’).” A single incident or sign of change may indicate change in only one variable (pure) or in more than one variable (mixed). The CHAP rating procedure has adequate reliability and validity (Sandell 1987b). In the present study interrater agreement was obtained by the following formula: total number of incidents where there was agreement divided by the total of agreement plus the total of disagreements. The median agreement between the two raters for all the 383 sessions was .92, with a range between .86 (symptoms) and .96 (insight) across the five scale variables.

Procedure

The data were notes from all sessions of a full psychoanalysis of 383 sessions. Notes were taken by the analyst after each session; initially they were taken not for research purposes but for supervision. The notes have a descriptive character, containing statements (as near verbatim as possible) by patient and analyst, and at times include the analyst’s subjective comments regarding the process. To ensure confidentiality, the analyst deleted any details that might have allowed identification of the patient before the researchers’ ratings.

In this study, we use CHAP in a way different from its original use. Rather than use it to analyze interviews after the end of the treatment, we use it to identify changes session by session. The CHAP manual notes that in addition to follow-up interviews, regular therapy sessions, recorded either on tape or in process notes or similar documents, can be used for rating the experience of change. We chose to rate incidents in two phases. In the first we looked for incidents of change across sessions, while in the second we classified the incidents according to the five variables. Each session was read to identify sentences indicating change. In this study these sentences are identified as incidents (several examples of change incidents are given in the results section). Identifying an incident of change was not difficult. Often the patient used linguistic markers like “now” or “then” that facilitated the identification. Sometimes the verb tense in the sentence allowed us to realize that there had been something different from the previous state. It was more difficult, however, to identify the type of change—for example, to say whether it was a change in adaptive capacity or in the basic conflict—but use of the CHAP manual and training has resolved most of the difficulty.

The study began with a training phase to improve the correct identification of change incidents with guidance of the CHAP manual (Sandell 1997). For this purpose one-sixth of all the sessions were randomly selected and independently evaluated by the two raters (master’s students in psychology). The training consisted first in identifying the incidents and then in a classification in five variables. Every ten rated sessions, the raters and the senior researcher discussed disagreements using the CHAP manual. The training was considered satisfactory when the agreement was greater than .80. The analysis began with reading the initial sessions in order to identify the patient’s symptoms, conflicts, and characteristics at the beginning of treatment.

After the training phase, all 383 sessions were read in chronological order to identify incidents of change. Subsequently, the sessions were reread but in a random sequence. The next step involved the classification of incidents according to the five CHAP variables.

Number of Incidents per Variable

In all, 606 incidents of change were identified in the 383 sessions, with 109 sessions involving no change incident. There were fewer sessions without changes in the third year of analysis. In the first two years, on average, about one change incident occurred per session. From the second year (from June 2006) until the end of the analysis, with the exception of September and October 2006 and April and July 2007, the number of change incidents increased to about two incidents per session on average.

The distribution among the five rating variables revealed 198 incidents related to basic conflicts, 157 related to adaptive capacity, 154 related to insight, and 97 (a significantly lower number) related to symptoms. Only four incidents related to extratherapeutic factors were identified.

Most of the incidents were rated on only one variable (pure) rather than more than one rating variable (mixed incidents). On the symptoms scale, only 67% of incidents were considered pure, whereas a significantly higher percentage of incidents on the other scales were considered pure: insight, 95%; basic conflicts, 87%; and adaptive capacity, 86%. Sixteen incidents revealed simultaneous changes in both symptoms and basic conflicts, and fifteen incidents revealed simultaneous changes in symptoms and adaptive capacity. The four incidents related to extratherapeutic factors were all mixed, two with adaptive capacity, one with insight, and one with basic conflicts.

Change Incidents over Time

Figure 1 shows the number of incidents for each of the five rating variables over the four years of psychoanalysis. Relative frequencies (number of incidents per number of sessions) are grouped in periods of three months. The results presented in Figure 1 are based on ratings by one of the two raters, the translator of the CHAP manual.

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Figure 1.

Relative frequency of change incidents for the five dimensions grouped in periods of three months

In the first trimester (May, June, and July 2004), the number of incidents was relatively similar for all the variables (8 incidents for basic conflicts, 7 for adaptive capacity, 6 for symptoms, 8 for insight). In the second trimester, however, incidents related to insight were much more evident (21 incidents); this was the largest number of change incidents related to insight during the first year (a total of 52 incidents related to insight). Interestingly, in the second year few change incidents occurred. However, in the third year the number of incidents increased across all variables, especially related to basic conflicts, adaptive capacity, and insight. Although incidents related to symptoms were generally infrequent, the number of incidents related to symptoms also reached a peak during the third year, at 41. The last year of psychoanalysis (actually only eight months) was similar to the third year, with more changes in adaptive capacity and basic conflicts. Extratherapeutic changes appeared occasionally, but as exceptions, during the entire course of psychoanalysis.

Examples of Incidents of Change at Different Stages of Psychoanalysis

To illustrate types of change incidents at different stages, we present some change incidents related to Maria’s loss and grief concerning her mother and her own subsequent reluctance to become a mother. The death of Maria’s mother was addressed from the beginning of the psychoanalysis: “I was the one who reacted more intensely [compared with her siblings], but I could not show it” (session 1). “The death of my mother gives me sadness but also anger. . . . I should have felt angry at the time, but I was not able to. I think that from then on I needed to be well behaved. . . . I had never realized the meaning of anger” (insight; session 4).

Early in the second year of the analysis, Maria confessed that she had done her best not to become pregnant. She thought she would not be a good mother and was afraid that something would happen to her children: “I did not see myself in the role of mother. I did not want children; it terrified me. I believed myself incapable of raising them. I always thought I would not be a decent mother, a mother like I thought I should be” (session 128). “But to think that I would be responsible for someone . . . if anything happened to my child . . . if something happened to them would be unbearable. . . . I remember thinking that I could die. What would they feel if their mother died?” (session 129). However, at the end of the second year, these feelings began to change: “One of my colleagues announced that she is pregnant. In the afternoon, I realized that I was weird. When I was coming here, I realized that I was envious” (insight; session 166).

In the third year of the psychoanalysis, we observed greater changes. Maria no longer needed to hide her sadness and idealize her childhood. She accepted the loss of her mother and felt empowered to live her own life. During this year, the loss of her mother and her grief were addressed repeatedly but to a lesser extent than in the second year. She changed from feeling that she would not be able to be a mother to actually wanting to become pregnant and feeling that she was indeed able to be a mother: “When my mother died, her story came to an end, but not mine. . . . In a way, it seems like I did not know this—as if in some way I thought I had died a bit, or I had to live with this burden of being alive” (insight; session 237). “I started to cry, thinking about my mother. Suddenly, I realized that more than the lack of my mother, I miss not being able to share good things with her; I cannot laugh with her” (starts crying) (insight; session 261). “After weeping, I found myself writing a letter to my mother. It made me feel better. It was what I used to say here, that I could not be happy, and then it was as if the knot or stone inside me shattered, and I felt as if I was allowed to live, to laugh” (basic conflicts; session 261). “Another thing was that I thought about adopting. I woke up one day and had a flash [of insight]. I was afraid that I was deceiving myself. Maybe it was to redeem myself from the guilt of having avoided having children” (insight; session 261). “Although I thought I was incapable of being a mother. . . , now I would be able to do the job” (basic conflicts; session 341). “When I meet people I have not seen for a while and notice that they have children, I find myself with gnawing envy, and this is more intense when they are older people with small children” (insight; session 363).

Overcoming Core Conflicts

In the content analysis of change incidents, we explored when the patient’s main conflicts were overcome. Maria’s insight into and elaboration on her conflicts occurred repeatedly throughout the analysis; nonetheless, we were able to identify phases in which changes were more salient and definitive.

Regarding the loss/mourning conflict, Maria changed from needing to hide her sadness and idealize her childhood to accepting the loss of her mother and feeling empowered to live her own life. This topic was addressed repeatedly but was overcome only after the second year and a half of analysis (see the incidents of session 261 above: “then it was as if the knot or stone inside me shattered”).

For the first time, Maria felt the desire to be a mother, feeling that she had the capacity to be a mother, wanting to become pregnant, and envying couples with children. At the end of the third year, she already felt able to be a good mother. The topic appeared in both her dreams and her speech (“I dreamed I was pregnant . . . ” (insight; session 338); “When I thought I was incapable of being a mother, there were several things . . . ; now I would be able to handle them” (basic conflict; session 341; see also the incident of session 363 above).

Regarding her insecurity, Maria no longer constantly worried about what others thought of her. She began to trust herself and others and to dare to share feelings and experiences with them. At the end of the third year, Maria noted: “Now, I show more ability to say what I like without worrying about what others will think, or if they will criticize me” (basic conflict; session 307). Then, after three and a half years, Maria said, “I speak of myself with a naturalness I did not have. Now I have no desire to hide. I make comments about myself, unimportant comments, that I did not before. But I notice that I do it with a lightness that I did not” (basic conflict; session 363).

Maria’s interactions with other people began to be guided by spontaneity, and her relationships deepened; she began to be receptive and welcoming toward others, and stopped fending people off. At the beginning of the third year, she said: “A coworker . . . was there all weepy, and I asked her why. She burst into tears . . . , and she told me that I had changed so much now. I asked how, and she said I was so aloof before” (basic conflict; session 233). At the end of the third year, Maria said: “today I noticed a curious thing. My office has become a place to open one’s heart for my colleagues” (basic conflict; session 327).

Maria began to be able to be intimate with men, and she no longer attempted to keep them at a distance when she was attracted to them or when she wanted them to care for her, something she confessed would occur with her husband. Her guilt associated with sexuality also waned, and her relationships with men began to be more flexible. She no longer wanted to be like men, and she felt comfortable with her desire to seduce them. At the end of the third year of analysis, Maria started dating men: “Since September, I have been regularly dating a friend with whom I go to concerts and toward whom I have mixed feelings” (adaptive capacity; session 315). She also resumed sexual activity (adaptive capacity; session 342). Referring to two men whom she had been regularly dating, she stated: “Now, I have to manage the time to date one and then the other” (session 325). Moreover, after three and a half years of therapy, she noted: “With men I also feel more relaxed . . . without the fear of being the wrong person” (basic conflict; session 372).

Maria’s competition with colleagues and her boss diminished, and she became more collaborative and creative. Her colleagues began to enjoy working with her and asking for her help in both professional and personal matters. At the end of the third year, she stated: “At work, my boss and I seem to be on a honeymoon. There are lots of projects. I put the old scores aside” (adaptive capacity; session 302). “Of course I’ve changed a lot . . . ; one of the things he [the boss] said was that now I’m the old Maria he once knew and that he likes to work with me” (basic conflict; session 325).