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Erik Stänicke, Hanne Strømme, Bjørn Killingmo & Siri Erika Gullestad
To cite this article: Erik Stänicke, Hanne Strømme, Bjørn Killingmo & Siri Erika Gullestad (2015)
Analytic change: Assessing ways of being in a psychoanalytic follow‐up interview, The International
Journal of Psychoanalysis, 96:3, 797-815, DOI: 10.1111/1745-8315.12145
Article views: 20
The article argues that the concepts of relational scenario, structuralized affect
and actualized affect are proposed candidates for observation of changes in
relational ways of being as it is expressed in transference. A psychoanalytic fol-
low-up interview of a former analytic patient is presented in order to illustrate
how change in relational ways of being may be registered and studied. By trian-
gulating the patient’s verbal report of change with nonverbal information and
transference–countertransference dynamics, one may grasp qualitative changes
in relational ways of being. The case presented illustrates a former patient’s
on-going process of working towards representing aggression in a more direct
manner and how this process is made observable with the aid of the proposed
concepts in the interview situation. The proposed concepts of relational
scenario, structuralized and actualized affect discussed are compared to the
concept of transference used in studies of core conflictual relationship theme
(CCRT).
Introduction
Historically, the study of analytic change has focused on various aspects of
personality. In the beginning, the content of dynamic forces and id-deriva-
tives, such as the ability to remember, or changes in dreams, was in the centre.
With the developing focus on character and ego psychology, structural
aspects of the personality came to the fore. In 1935, Balint made a distinction
between a ‘classical’ and ‘romantic’ view on outcome of psychoanalysis
(Balint, 1935; see also Sandler and Dreher, 1996). This distinction demarcates
studies of change that focus on structural versus dynamic changes respec-
tively. With the shift in psychoanalysis brought about by object relation
theory, the distinction between structural and dynamic changes still holds,
but now in a different way. Object relation theory gives prominence to inter-
action in relationships, and also deals with internalization of dialogues with
significant others into established, inner relational configurations that are
actualized in ongoing interaction.
Central to the clinical study of object relations is the ‘total situation’
(Joseph, 1985) created in the treatment and the ‘ways-of-being with the
analyst’ (Stern, 2004) that actualize inner scenarios. Ways of being express
Relevant concepts
In outcome and follow-up studies, it is critical to define relevant variables
of change (Hill and Lambert, 2004). Such definitions reflect the aspects of
personality that a particular treatment method aims to focus on. To many
psychoanalysts it seems relevant to focus on changes in inner object rela-
tions, as work within the domain of the patient’s transference is at the heart
of psychoanalytic treatment. Consequently, assessment of outcome should
also be centred on changes in transference. Such changes may be observed
as changes in qualities of interpersonal action, which we term relational
ways of being. They can be distinct and comprehensive, as when a patient
who has used schizoid withdrawal in every previous social situation
becomes capable of building long-lasting relationships. But often the
changes are subtle, as with former patient Mr A, presented later in this arti-
cle, who is still in the process of working on representing aggression in a
more direct way. Thus, changes in the transference are expressed through
changes in the patient’s ways of being with the other. Clinically, concepts are
needed that can apprehend this relational information.
We propose that the concept of relational scenario (Gullestad and Kill-
ingmo, 2005) may be a candidate for assessing qualities of change in trans-
ference. The concept refers to the relationship between a representation of the
self and a representation of the object having a relative stable pattern which
can be identified in different situations (ibid., pp. 118–22). A relational sce-
nario does not refer to a relationship that is directly observable, but to the
mental relationship pattern behind the observable behaviour, which may
often be unconscious. It comprises an affective definition of the relation-
ship, fantasies about the object as well as a definition of the self in relation
to the other. The concept can help organize observations of interpersonal
interaction so that stable patterns of relational styles become salient.
The concepts of structuralized and actualized affect (ibid., pp. 98–102) can
be helpful in identifying what kind of relational scenario is activated in the
transference. Structuralized affect refers to affect that the patient can talk
about. The affect is already structured in language and narrative. Even if
the affect is experienced it is experienced in a familiar way, characterized by
the person with having an observational stance towards his/her own affect
and narrative which it is part of. Actualized affect, on the other hand, is
identified as it unfolds in interpersonal interaction. It refers to an affective
experience that dominates the patient’s way of relating to the object. It is
not understood but lived – and the patient does not have an observational
stance towards it. Actualized affect is part of the transference signalling
what is at stake for the patient. The distinction between structuralized and
actualized affect may be helpful in detecting relational scenarios operating
in the here-and-now, even when these differ from the structuralized narra-
tive of the patient. Thus, with these concepts, it may be possible to ‘hear’
the unconscious relational message in the transference.
It is important to stress that we understand transference as a phenome-
non that unfolds in a relational situation. As argued later, we need to
develop methods of assessing inner structural change as expressed in the
A case illustration
Following are excerpts from a follow-up interview with participant A.1 The
aim is to illustrate how the concepts introduced in the first section can help to
focus attention on changes in relational ways of being. Mr A is a participant
in the Oslo II study (St€ anicke, 2010; Varvin, 1999).2 The Oslo II study is a
small-scale process–outcome and follow-up study of psychoanalytic treat-
ment within the Norwegian Psychoanalytic Society, comprising seven patients
in four sessions weekly psychoanalysis with Norwegian/ IPA psychoanalysts.
Patients were interviewed twice a year about their experience of being in
analysis, as well as at the end of treatment and in a follow-up study. This lat-
ter study is the focus of the present paper.
The follow-up interviews were conducted at least one year after termina-
tion of treatment but the time since termination date differed – from one to
four years. All participants had agreed to the research design and consented
to the follow-up interviews. The first follow-up interview with Mr A was
1
Mr A has read and approved the analysis of the case illustration.
2
The Oslo II study has been approved by the Data Inspectorate in Norway and received recommenda-
tion by the Regional Committee for medical Research Ethics.
done four years after his analysis. The first author conducted the follow-up
interviews and he was not involved as a treating analyst in the study.
To date, all the seven participants have been interviewed as part of a
follow-up study. Mr A was chosen for this article because his interviews
clearly illustrate the concepts that have been discussed, as well as demonstrat-
ing all three steps involved in assessing the authenticity of an experience of
having changed. The three steps involved in the assessment process were fol-
lowed with all participants. The aim of each step – to identify the structural-
ized and actualized affect and communicate about them – was the same for
every interview. However, participants were to different degrees able to reflect
on their own material, especially as concerned relational issues and conflicts
that were activated in the follow-up interviews (see St€anicke, 2011; St€anicke
and Killingmo, 2013). Mr A was one of three participants that showed a quite
high degree of reflection on his relationship with the interviewer.
The following analysis of the interview with Mr A is not meant as a com-
prehensive analysis of his process of change. The findings are tentative since
there is no control for whether Mr A’s expression of change is causally con-
nected to his analytic treatment. The excerpts are not intended to give a
comprehensive understanding of him. Rather they are presented in order to
illustrate our argument. Thus, only excerpts from the first and the third
interviews are discussed. The second interview does not demonstrate new
perspectives that contribute to our aim with this article.
The interview takes Mr A’s experience of having changed as its starting
point and compares this with what actually unfolds during the interaction
with the interviewer. The main focus of the analysis is to illustrate how the
interview taps one dimension of analytic progress in Mr A and how this
process is still unfolding. The excerpts are selected to demonstrate how Mr
A handles aggression and how he is still working with this important rela-
tional mode. Out of a sample of seven follow-up interviews, Mr A was the
only case in which an overtly negative transference reaction was observed.
Accordingly, this was one of the sampled cases that presented both Mr A
and the interviewer with significant emotional challenges. Through the
course of the interviews, even when Mr A expresses a negative transference,
we can see how he struggles with it in the interview.
First interview
Mr A was contacted by means of a letter stating the aims and frame of the
interviews. When contacted by phone about making an appointment Mr A
said that he found it unpleasant to think that the interview would be
recorded on video. Asked on the phone to elaborate these feelings, he dis-
missed the question and said he could talk about it in the interviews.
Because of this phone conversation, the interviewer did not start the video
recorder at the beginning of the first interview. When Mr A was invited to
talk about the recording, he emphasized that it was the interviewer who set
the premise for the interview. He went on describing a fantasy in which the
video is studied by a large group of students at the university. It is unpleas-
ant to think that they would scrutinize every little movement of his face.
Then, abruptly, Mr A stated that he could accept the recording now that he
had talked about it. The interviewer once more invited him to elaborate on
the topic, but once more the invitation was dismissed. The rest of the inter-
view was videotaped.
This initial exchange between Mr A and the interviewer is important in
understanding the subsequent material. The following material is taken
from the middle of the first interview. In this context Mr A has been talking
about how he now, after analysis, experiences and handles a conflict of
interests among his colleagues at work:
A: It’s, it’s a sort of power-thing that this is about. It’s um … it’s um … thoughts –
it’s like … we’re men in the um … fifties, right, who um … if I were to – well, what
it is doesn’t actually matter very much, but what it takes – I experience this as
power-related … I become a bit like, a bit like um … someone wants to control
more than what is necessary – unrightfully so, in a way by sheer power … urge for
power which I react very strongly to. I don’t want anyone to um … dictate to me.
Interviewer: What would a work conflict like that be like um … in earlier days?
A: [Clears his throat] … I think I would have just backed out, quickly from it. Um
… I would probably have become quite aggressive, without showing it at the time
… to them. … be a bit nice, like.
Interviewer: So would you just have followed them and made out that it was all
right?
A: Yeah, be, be a bit more nice, like, and “I’ll let you decide this” or something like
that. [A bit louder] Been a lot more like defensive, perhaps, compared to um … that
situation and, like in the head been flying off the handle and … and probably … I
had a lot of those, those violent fantasies I mean like um … specific violence, like
knocking people down and hit them in the face, throw them up into the air and….
situation, it seems likely that he was trying to ward off the affective inten-
sity in the dialogue.
To summarize, Mr A’s affective expression, his discourse as well as the
interviewer’s feeling of being in a fight, indicate the activation of a rela-
tional scenario of control and protest. In the beginning, protest was articu-
lated rather directly, through questioning of the video recording. However,
Mr A soon backed off, apparently accepting the frame, while nevertheless
indirectly continuing to hold a critical attitude towards it and to the inter-
viewer. Yet, protest was not articulated in a direct and straightforward
manner, but instead expressed in a displaced form.
In the first interview we cannot observe what Mr A has proclaimed – that
he has changed with regard to handling situations of conflict. In describing
how he has changed as a result of treatment, Mr A declares that psycho-
analysis has helped him with responding to situations of interpersonal con-
flict. Now he “handles it better” and “is more offensive in the situation”.
His story about more direct expression of aggression represents structural-
ized affect. But the transference – and the actualized affects – told another
story: During conflict, protest and aggression were expressed in an implicit
or displaced form.
As concerns the interviewer, he felt threatened by Mr A’s intense affec-
tive expression in the first interview, trying to handle the situation by shift-
ing to an intellectual question. This illustrates, firstly, that conducting an
open-ended interview of this kind may be hard. Containing the patient’s
affects and maintaining one’s openness are not easy tasks. From a theoreti-
cal viewpoint, the interviewer’s fear of aggression may be regarded as
countertransference, i.e. as a response to the patient’s confrontational
stance. In the present interview, this fear was not contained but was
enacted – by detracting attention from the affective centre of the dialogue
through intellectual questioning. Secondly, the interview excerpt illustrates
that what kind of relational scenario is activated is not only dependent on
the patient. The interviewer’s personality will also play a part. Here,
aggressive feelings from the patient evoked counter-aggression in the inter-
viewer, which he tried to avoid. The interviewer felt a strong inner conflict
between anger at participant A’s difficult way of being and his own
research interest in conducting the interviews in a way that would elicit
‘good’ data. This conflict activated at first anxiety, resulting in the anger
being warded off. Well into the first and second interviews the interviewer
became more assertive in his communication. Bodily, this was experienced
in the countertransference as becoming more alert and tense. Indeed, the
interviewer’s way of reacting seems to be parallel to that of the patient.
Both were avoiding the experience of direct conflict but were also probably
tense and ready for a mental fight.
Third interview
At the end of the third interview Mr A talked about how, earlier in his life,
he was inhibited about expressing thoughts that could offend and hurt oth-
ers. The following excerpt is from a longer section where he has been
Interviewer: Yes, and that made your motivation for coming low.
A: YES, that made my motivation for coming low, but also because it’s, it’s noth-
ing, well I don’t know, my mood it, it swings sometimes, but uhm … what do I
come here for, like to sit here and look at the camera – it’s my whole story on tape,
sort of on video and I don’t know you. Do we really um … like each other? Is
there any [Laughs briefly] is there any…
A: Is there any good chemistry here [Laughs briefly]. I sort of thought on my way
here, must I sit here, then um … well, but um … that was fine, you know, it’s a lot
easier than what I had feared and it’s probably that experience I draw on, that …
that there are things you don’t want to do or which you even fear a little. It’s usu-
ally always easier when you get down to it, and it is an all right experience.
Interviewer: Yes, it was easier than you imagined, and the chemistry is fair enough,
but um … but um … yes, I suppose it’s one side of what you are saying that you
haven’t asked to come here, I was the one who…
Interviewer: Yes.
Interviewer: So it’s more like you perhaps deliver something that you feel you have
promised to deliver, then?
A: Yes, I have no interest in sitting here and telling you about … you, yes, it’s …
that’s how it is.
A: So by sheer duty [Laughs], not urge [Laughs], and that’s quite all right.
Interviewer: No, you tell me this directly. Um… I’d say it’s quite understandable.
the end of the last excerpt this topic comes to the fore in the here-and-now
situation. It becomes clear that, all along, Mr A has been occupied with
noticing the interviewer’s reaction to his frank assertion about the inter-
views. In this last section the interviewer, stating that Mr A’s lack of moti-
vation is “quite understandable”, meets Mr A’s protest with an affirmative
comment. Mr A responded by saying that: “You’re not getting hurt …
that’s not an issue”. In the interview, Mr A seems to have feared a confron-
tation in which he expresses his dissatisfaction with the interviewer and the
interviews. However, during the interview he seems to recognize that it was
not the interviewer’s vulnerability that it all hinges on. It is as if he under-
stands that it depends upon his own courage.
Mr A’s internal ‘work’ on being direct and frank towards the interviewer
may have been challenged by the interviewer’s work with his anxiety and
aggression in the countertransference. The interviewer’s statement about Mr
A’s lack of motivation being “understandable” came after a struggle within
the interviewer that was probably unconsciously registered by Mr A. Thus,
the fact that there was a conflict between the two in the interview situation
supports, in our opinion, the interpretation that Mr A – in line with his
own self-report of change – is now able to handle conflicts and also repre-
sent his aggression in a more constructive way in action. His greater free-
dom is not only a question of saying, but of doing.
The interviews with Mr A demonstrate self-assertion on two different lev-
els. Firstly, Mr A gives a report about change involving increased capacity
for active self-assertion. However, contrary to the subjective report of
change, the first interview demonstrated that, although obviously on his
way to becoming more direct in expressing his feelings, Mr A could not
articulate his protest straightforwardly. The last interview, however, demon-
strates active self-assertion as unfolding in the here-and-now. The dialogue
illustrates how Mr A now is able to speak directly about his reluctance and
negative feelings about the interviews as well as the interviewer. Thus, in
the follow-up interviews with Mr A self-assertion is present both as a report
and as lived. The distinction between the two is well captured through the
concepts of structuralized and actualized affect: Mr A’s subjective report of
how he feels he has changed represent a structuralized narrative about self-
assertion, in contrast to actively expressed self-assertion in the here-and-
now situation. More specifically, the interviews illustrate a movement from
a passive protest – that is probably activated by his experience of the inter-
views as a dictation – to an active protest. Throughout the three interviews,
Mr A struggles with being more direct and frank about his negative affects,
working with his relationship to the interviewer to become increasingly
more open and expressive. This process occurring across the interviews may
signify an authentic expression of being in change.
As to the assessment of change, this interview method not only provides
subjective reports about change, but observations of behaviour as well. Mr
A’s capacity to express protest in a straightforward manner stands in sharp
contrast to his earlier relational style which, by his own words, involved a
social representation of being easy-going but at the same time being trapped
in intrapsychic violent fantasies. Certainly, this altered way of being would
Copyright © 2014 Institute of Psychoanalysis Int J Psychoanal (2015) 96
810 €nicke et al.
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Discussion
This article aims to introduce concepts that can make analytic change sali-
ent in relational ways of being. In order to illustrate these concepts we have
presented excerpts from a psychoanalytic follow-up interview with Mr A. In
this case representation of aggression, on a procedural level, could be regis-
tered and studied. The present study has no ambition to conclude whether
or not Mr A’s process of change is really causally connected to him having
undergone psychoanalysis. Neither is the aim to argue that a psychoanalytic
follow-up interview is the best way to study all kinds of personality changes
after analysis. However, the presented interview method can provide rich
material with which to assess authenticity of changes in interpersonal style.
It is also an interview method that can provide complex material for study-
ing psychoanalytically relevant phenomena, such as how experiences of
change are expressed in transference and countertransference. The situation
of the interview allows the participant to show his/her ways of being and
then provides an opportunity to talk about these ways of being in a manner
that can reveal how the participant experiences and thinks about it.
Other studies on the phenomenon of transference in extra-analytic situa-
tions exist and are relevant to the present study. For example, there are
studies that demonstrate, within an experimental paradigm, that transfer-
ence can be “activated without awareness of triggering cues“ (Andersen and
Berk, 1998; Glassman and Andersen, 1999). These studies are interesting
from a psychodynamic viewpoint since the rather complex phenomenon of
transference is shown under experimental conditions. However, the designs
of these studies focus on a rather limited aspect of transference. For exam-
ple, they study the degree to which subliminally triggering cues in partici-
pants lead to more significant-other-derived inferences about a target
person (Glassman and Andersen, 1999). The participants in the study
believed that they were playing a computer game with an unknown partner.
While playing the game, they were exposed to subliminal cues of different
qualities. The study showed that, when the participants where subliminally
presented descriptors of their own significant other while playing the game,
they were more likely to infer their game partner as having significant-other
features. Descriptors, trait words, of their significant other, acted as trigger-
ing cues that influenced how the participants ‘see’ the gaming partner. In
other words, in this experimental situation transference is demonstrated.
This represents a social–cognitive perspective of transference with a focus on
“significant-other-derived inferences about a new person” (ibid., p. 1158).
Another, rather complex study was conducted by Krause and Merten
(1999). Briefly, the study arranged for two people, one taken from a group of
mental health patients and one from a healthy group, to collaborate on a
social task while they were measured on several interaction variables includ-
ing facial expression, eye contact, listener–speaker conditions and verbal dis-
course. In their discussion of the findings, the authors argue that transference
can be understood as a choreographing of scenes containing three elements:
“the author of the scene, an action partner and a sequence of interaction
between them” (ibid., p. 111). This seems to have conceptual affinity with the
concept of ‘relational scenario’ used in the present article, as relational sce-
nario refers to a relationship between a representation of the self and of an
object, with a pattern of interaction that is relatively stable in different situa-
tions. As was experienced in the current study’s interviews, Krause and Mer-
ten also argue that these scenes “nudge” others to “take over a part in a real
object relationship” (ibid., p. 112). They argue that it is the affective part of
scenes that gives them their “seductive power” (ibid., p. 111).
In psychotherapy research there has also been a growing interest in mea-
suring transference. Some of the best-known methods that contribute
directly or indirectly to studying transference are the Missouri Identifying
Transference Scale (Multon et al., 1996), the Plan Formulation Method
(Curtis and Silberschatz, 1997), Ideographic Conflict Formulation Method
(Perry et al., 1989), Configurational Analysis (Horowitz and M€ oller, 2009)
and Core Conflictual Relationship Theme Method (CCRT) (Luborsky,
1977; Luborsky and Crits-Christoph, 1998). These are all methods that aim
at systematic assessment of therapeutic process and outcome, where trans-
ference is a variable that is measured. The methods have in common that
they make use of systematic procedures in coding transcripts of sessions
and use independent and trained scorers. The methods thus make impor-
tant, yet different contributions to the field of formal research on psycho-
therapeutic and psychoanalytic process and outcome. This field is not the
focus, however, of the present study. The present study is focused, rather,
on a more explorative and conceptual goal.
Despite its unsuitability for the purposes of the present study, it is none-
theless interesting to compare the concept of transference used in the pres-
ent article with that used in CCRT. We have argued that it is important to
have concepts of transference, and ways of registering it, that take into
account ways of being and relational style. We also claimed that qualities in
relational ways of being as expressed on a procedural level is somewhat
neglected in the assessment of change. Is it really true to say, however, that
CCRT, as one of the systematic methods that most directly focuses on
transference, has neglected this aspect of analytic change?
Dreher (2000) has critically examined the concept of transference, as
applied in the CCRT method, in a way that clearly depicts the differences in
understanding of this concept. The definition of transference in CCRT seems
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812 €nicke et al.
E. Sta
Conclusion
Outcome research in psychoanalysis is in need of criteria that do justice to
the specific changes sought by psychoanalysis. This article has argued for a
criterion of change in patterns of dynamic ways of relating. When a patient
has gone through an intensive and time-consuming treatment such as psy-
choanalysis, with its focus on insight and reflection, we can probably expect
the patient to show some practice in reflecting about himself. However, clin-
ically we know that self-reflection does not always express a permeating
change. Qualities of relational ways of being more authentic express inner
object relationships and should not be neglected in studies of change.
Translations of summary
€
Analytic Anderung: Beurteilung Wege des Seins in eine psychoanalytischen Follow-up-Inter-
view. Der Autor vertritt die These, dass die Konzepte des Beziehungsszenariums, des strukturalisierten
Affekts und des aktualisierten Affekts Kandidaten f€
ur die Beobachtung von Ver€anderungen relationaler,
€
in der Ubertragung Ausdruck findender Seinsweisen sind. Er illustriert anhand eines psychoanalytis-
ches Follow-up-Interview mit einem ehemaligen Analysepatienten, wie Ver€anderung in relationalen
References
Andersen SM, Berk MS (1998). Transference in everyday experience: Implications of experimental
research for relevant clinical phenomena. Rev Gen Psychol 2:81–120.
Balint M (1935). The final goal of psychoanalytic treatment. Chapter 11 in: Primary love and
psychoanalytic technique. London: Hogarth, 1952.
Clyman RB (1991). The procedural organization of emotions: A contribution from cognitive science to
the psychoanalytic theory of therapeutic action. J Am Psychoanal Assoc 39:349–82.
Crittenden PM (1999–2001). Attachment in adulthood: Coding manual for the dynamic–maturational
approach to the adult attachment interview. Unpublished manuscript, available from the author.
Curtis JT, Silberschatz G (1997). The plan formulation method. In: Eells TD, editor. Handbook of
psychotherapy case formulation, 116–136. New York, NY: Guilford.
Dreher AU (2000). Foundations for conceptual research in psychoanalysis. London: Karnac.