Close to the particular.
The Constitution of Knowledge from Case Histories in Psychoanalysis
Department of Psychology, University of Oslo.
Aim: The clinical example or the case history plays a pivotal role in the formation of a clinician. Exploring the impact a case history may have upon a clinician may lead to further our understanding of what characterizes clinical knowledge.
Research questions: A case history probably does not contribute much to a science of man, if there is such a thing. Still, there is a generalizing impetus to the case history, but this generality is not of a scientific kind. These intuitive viewpoints make up a point of departure for a more epistemological inquiry.
Material and method: Starting with a critical discussion of the aspiration of psychoanalysis to be an empirical science (Grünbaum). This issue is pursued further by an inquiry into the philosophical discussion of reasons versus causes. An alternative understanding of Freud’s “craving for generality” is then suggested by following a philosophical line of thought passing from Goethe and Wittgenstein on to Freud. The notion of apercu surfaces as important. Finally, the difficulty to remain close to the particular, is being displayed, epitomizing the need to be more clear about the epistemological role of the case history.
Results: The case history has a formative role, it lies in leaving a form with the clinician.
The generality of the case history resides in how it helps us to see anew. To put it to an extreme, the case histories impart a way of seeing rather than a specific knowledge.
Per Andreas Høglend (principal investigator), Paul
Johansson, Ph.D., Randi Ulberg, M.D.,Ph.D., Kjell-Petter Bøgwald, M.D., Ph.D.,
Svein Amlo*, M.D., Alice Marble*, Psy.D., Mary Cosgrove Sjaastad*, M.D., Øystein
Sørbye, M.D., Oscar Heyerdahl, M.D., Hanne S. Dahl, Psy.D.
First Experimental Study of Transference-interpretation (FEST)
Institute of psychiatry, Vinderen, University of Oslo.
Aim: The study tests long-term effects of psychotherapy for patients with anxiety, depression and personality disorders. The aim is to study in greater detail additional mediators and moderators of the long term effects of transference work.
Research questions: Specific treatment components, moderators, and mediators (mechanisms of change) is studied in order to understand what it is that brings about change, for which patients, and the mechanisms involved.
Material and methods: The present study is a dismantling randomized clinical trial, specifically designed to study long-term effects of transference work, moderators of such effects, and the mechanisms (mediators) underlying them. Patients suffered from anxiety- depressive-, and personality-disorders; Sample size N= 100; Specific inclusion and exclusion criteria; Randomization; Power to detect moderate effect sizes; Primary and secondary hypotheses; Primary and secondary outcome measures; Pre-selected moderators and mediators; Four or five waves of data over the 4 year study period; Evaluators blind to treatment groups; Patients unaware of the technique studied and our hypotheses; Use of treatment manuals; Experienced and specifically trained therapists did both treatments; Comprehensive treatment fidelity checks from more than 500 audio recorded sessions; No Therapist effects; Treatments were completed and a detailed statistical analysis plan specified before the randomization code was broken; Use of mixed model longitudinal analyses; Independent statistician supervised all analyses. Common factors (across all psychotherapies) such as patient expectation, treatment time, therapeutic alliance, therapist competence were equal in both conditions. The only difference between treatments was use or no use of transference work.
Results: Increase of self understanding (insight) during treatment proved to be a mediator (mechanism) for the long-term effect of a core technical ingredient (transference work) in dynamic psychotherapy. Contrary to expectation and clinical “wisdom” we found that more difficult patients, that is patients with long-standing more severe interpersonal problems and personality disorders benefited more from transference interpretations than treatment without this component. This effect was maintained 3 years after treatment termination. Furthermore, use of primary care health resources and also specialist mental health resources were reduced 60 % to 75% in the 3-year follow-up period. A substantial portion of the long-term effects of transference work was mediated by insight, gained during the one year treatment period. Transference work shows the strongest specific effects for patients with low QOR and low therapeutic alliance. Women respond significantly better than men to transference work
Financial support: This study was supported by grants from the Norwegian Research Council, the Norwegian Council of Mental Health, Health and Rehabilitation, and Diakonhjemmet Hospital.
Steinar Lorentzen* (principal investigator), Torleif Ruud
and Per Høglend.
SALT- Short- and Long-term Psychodynamic Group Psychotherapy.
Department of Clinical Medicine, University of Oslo and Clinic for mental health and addiction, Oslo University Hospital.
Time frame: 2004-ongoing.
Aim: To study the significance of treatment duration in psychodynamic group psychotherapy and pre-selected potential patient characteristics moderating the efficacy of treatment (Quality of Object relations, Presence of Personality disorder). Also to study potential, pre-selcted mediators of change (Insight, Attributional Style, Group internalization), including group process variables.
Research questions: To study the significance of the time factor in psychodynamic group therapy. What are the characteristics of patients who will profit from short- and long-term therapy, respectively? What is the impact of the therapeutic alliance and group processes on change? What are the mechanisms of change in group psychotherapy?
Material and methods: 167 patients are randomized to 9 short- or 9 long-term group psychotherapy of 20 and 80 sessions duration. Three sites are involved (Ålesund, Stavanger/Sandnes, Oslo), with 1-2 research coordinators and 2-4 therapists engaged in each site. All therapists treat one short- and one long-term group of eight patients each. The therapies are manualized and supervision is received during the treatments. Change measures: Symptomatic distress, Interpersonal problems, Idiographic Chief complaints, Global satisfaction, Global assessment of Functioning, Self-Esteem. Patients interviewed before therapy and three years after therapy start. They also complete self-ratings of symptoms and interpersonal problems during and after therapy.
Results: Are currently being analyzed.
Financial support: 1.4 million Norwegian kroner (NOK) over three years from Helse Øst. Two research fellows, each 3 years, covered by Helse Sør-Øst.
Erik Stänicke* (principal investigator), Siri Gullestad*,
Bjørn Killingmo*, and Hanne Strømme*.
Analytic change after analysis - A conceptual case-based follow-up study
Research institution: Department of Psychology, University of Oslo, Norway.
Time frame: 2003-2010.
Aim: To conceptually explore analytic change after analysis. Furthermore, the study explores methodological challenges of assessing analytic change following psychoanalysis. Thus, it is not a study that aims to control for change whereby patients’ functioning before and after treatment is compared. It is a conceptual study of analytic change illustrated by a limited number of cases and their experience of change after analysis.
Research questions: The thesis raised questions about the design of a research interview informed by psychoanalysis, how to assess analytic change and questions about concepts of analytic change.
Material and methods: The thesis is a cased-based conceptual study of some nuances in analytic change after analysis. The conceptual exploration takes as its starting point material from follow-up interviews of seven informants, all of whom are former analytic patients. The data were gathered using a psychoanalytic research interview.
Results: The results of the thesis are of a conceptual and methodological character: 1) That relational style is an important dimension in analytic change, and that it can be assessed in the transference in a follow-up interview. 2) Three experiential domains - safety, meaningfulness and sameness - in analytic change were illustrated. Especially were changes in a capacity to identify, differentiate and communicate life topics along these domains explored. 3) It is argued that some patients may show a specific kind of analytic change that is termed "object trust."
Financial support: The National Program for Integrated Clinical Specialist and PhD-training for Psychologists.
Hanne Strømme* (principal investigator), Siri Erika
Gullestad*, Bjørn Killingmo*, Sverre Varvin*, and Erik Stänicke*.
Psychology students’ acquisition of competence in dynamic psychotherapy.
Department of Psychology, University of Oslo, Norway.
Aim: The overall aim of the previous PhD study was to explore student therapists’ process of acquiring competence in dynamic psychotherapy. The present follow-up study includes further analysis of the PhD data material and additionally, a prolongation of the longitudinal period into the first professional years of these former student therapists.
Research questions: The PhD study concerned the design of a research interview informed by psychoanalysis, the process of acquiring dynamic psychotherapeutic competence in supervision and the therapeutic competence of student therapists. The follow-up study addresses competence issues and therapist development after the internship experience.
Material and methods: The study has a multiple single case design, and includes 23 student therapists, their supervisors and their patients. It has an inductive, explorative approach based on the theoretical perspectives of dynamic psychotherapy. The new data collection period ahead involves the 23 former student therapists and additionally potential present supervisors. The methods applied are process research interviews, an essay method to evaluate therapeutic competence and a questionnaire.
Results: The initial results include the design of a research interview informed by psychoanalysis and the identification of a prevalent dynamic process pattern in the supervision processes in the study: The supervisor neglect to the inner drama of the supervisee.
Financial support: Department of Psychology, University of Oslo.
Process-outcome study of psychoanalytic psychotherapy with severely traumatized refugees.
Psychosocial Centre for refugees, University of Oslo.
Aim: To study how traumatized refuges managed inner and external life in exile and how they coped with having been traumatized.
Research questions: How did the relation to problematic psychic experiences related to earlier traumas develop over time in psychodynamic psychotherapy?
Material and method: Five long-term psychotherapies with traumatized refugees treated at the Psychosocial Centre for refugees, University of Oslo. The following methods were used:
Assimilation analysis, Dialogic sequence analysis, Referential Activity analysis and Enunciation analysis
Results: All five patients showed increasing integration/assimilation of problematic experiences in different degrees supporting the value of long-term psychodynamic psychotherapy for this patient group. Theoretical analysis of the trauma concept led to specification and differentiation of the trauma concept.
Financial Support: University of Oslo, Norwegian Research Council.
Sverre Varvin* (principal investigator), Siri Gullestad*,
Bjørn Killingmo*, Inge Refnin*, and Erik Stänicke*.
Process-outcome study of psychoanalysis, the Oslo II study.
Norwegian Psychoanalytic Institute, Oslo.
1997 – ongoing.
Aim: Study of process characteristic and out come of psychoanalysis.
Research questions: What process and outcome profile does each analysand show?
Material and method: 10 patients in ordinary psychoanalysis. Methods were: Adult attachment interview, Rorschach, and symptom rating scales were applied before and after treatment. Each half-year the analysands were interviewed qualitatively on their analytic process.
Results: Full analyses of date has not been performed. Case studies have been made and data from the project was used by Erik Stänicke for his doctoral project: Analytic change after analysis. A conceptual case-based follow-up study.
Financial Support: Research Advisory Board, International Psychoanalytic Association, Sommer Stiftelse, Norwegian Psychoanalytic Institute.
Sverre Varvin* (principal investigator) and Marianne Opaas*.
Prospective follow-up study of psychotherapeutic and psychiatric treatment of severely traumatized refugees.
National centre for the Study of Violence and Traumatic Stress, Oslo.
2006 – ongoing.
Aim and research questions: To study treatment and rehabilitation processes for severely traumatized refugees treated in the psychiatric health services in Norway. The study has three parts: a) Knowledge development, b evaluation, c. praxis.
a. Develop knowledge on extreme traumatisation by studying:
1. psychiatric/psychological and sociocultural aspects of complicated posttraumatic condition: study of the specificity of traumatisation.
2. The effect of psychotherapy on the development of the posttraumatic process.
3. Study of personality and treatment alliance early in therapy
Ad b Evaluate rehabilitation/treatment process
Ad c Develop treatment/rehabilitation model for psychiatric health system.
Material and method: 55 patient treated in District psychiatric centers or in private practice.
Methods: T1: before treatment: AAI, Rorschach, symptoms scales, well-being scales, personality functioning (q-sort), qualitative interviews T2/3: after one year (T2) or when treatment stop before one year (T3): qualitative interviews, rating scales, T4: after three years: Rorschach, symptoms scales, well-being scales, personality functioning (q-sort), qualitative interviews. Further follow-ups are planned
Results: So far few results have been published.
Financial Support: National center for the Study of Violence and Traumatic Stress.
Stephan Hau* and Sverre Varvin* (principal investigators),
Bent Rosenbaum*, Tamara Fischmann*, Vladimir Jovic*, and Marianne
On traumatic dreams. International multicentre study.
IAN (International Aids Network), Belgrade, University of Stockholm, Sigmund Freud Institute, Frankfurt, University of Copenhagen, National Center for the Study of Violence and Traumatic Stress, Norway.
2007 – ongoing.
Aim: The study aims to combine the investigation of dreaming, dream work and trauma. With a better understanding of the influence of trauma on dream work we hope to further develop psychoanalytic understanding of dreams and the clinical work with dreams. In the frame of a larger study on psychological and physiological parameters of PTSD (financed by the EU during 2005-2008) a group of 25 war veterans with PTSD related to traumatic war experiences during the last Balkan war were investigated in the sleep laboratory. They were selected from the larger group (N=100) as they all reported having repetitive war-related dreams at least twice per week. More than 70 spontaneous dream reports were collected under laboratory conditions. The research interviews – performed by psychoanalysts in Belgrade - were tape recorded, transcribed and translated into English. Two research groups, consisting of psychoanalysts from Germany, Norway, Copenhagen, and Sweden are in the process of investigating the manifest dream narratives with two sophisticated evaluation methods in order to describe symbolizing activity and relational interactions in the dreams. At the same time, psychoanalysts from Belgrade will compare these results with psychological measures such as: clinical symptomatology, personality structure, stressful life events (prior to war and war-related), pre-war adjustment, and cognitive and neuropsychological parameters. In order to perform profound statistical analyses, a control group is needed. The aim of the planned study is to generate a comparison group of 25 subjects (war veterans without PSTD/nightmares) and investigate their dreams systematically over a two weeks period of time (they will write a dream diary). The subjects from the control group will follow the procedure as they will come to the lab on two consecutive mornings in order to report their dream memories of dreams dreamt during the preceding night. All interviews will be tape-recorded. The dreams collected in the control group allow us to better compare and contrast the results obtained through the dreams collected in the experimental group of traumatized veterans with chronic PTSD and nightmares.
Research questions: a. Study of mental processes in dreaming of traumatized persons with and without current PTSD, b. Study of relations between mental processes in traumatized patients and important biological processes/variables, c. Shed light on clinical problems in working with traumatized patients, e.g.: understanding of dreams in the analytic process, how to relate to and handle dream material, how to facilitate symbolizing processes.
Material and method: Subjects have been recruited from a large, multicentre and interdisciplinary study of “Psychobiology of PTSD” conducted from 2004 to 2008 in Belgrade. Twenty-five volunteer subjects in the study had current PTSD and most of them were torture survivors. All were clients of the Centre for Rehabilitation of Torture Victims IAN in Belgrade. A control group with the same level of war experiences but no current PTSD is included in the study. The investigated dreams are reported as part of an experimental situation in a sleep laboratory. Two qualitative research methods are used:
Enunciation analysis: This method study the subject’s capacity for symbolising self, objects and self-object relations represented in the dream.
The Moser method: This method includes a process perspective and allows deducting relational capacities and the need for security and withdrawal of the dreamer on the basis of the manifest dream text.
Results: In preparation.
Financial Support: Research Advisory Board, International Psychoanalytic Association.
(principal investigator), Marvin Hurvich*, Rohnda Ward, and Wilma Bucci (New
York participants), and Bent Rosenbaum* and Sverre Varvin* (Nordic participants).
Symbolization in trauma. A study of integration of traumatic experience in psychoanalysis and psychodynamic psychotherapy. International multicentre study.
National Centre for the Study of Violence and Traumatic Stress, University of Oslo, University of Copenhagen, New York University, and Adelphi University.
2009 – ongoing.
Aim: This study aims at identifying central problems of traumatised individuals as they appear in psychotherapeutic and psychoanalytic processes. Previous studies has shown that annihilation anxiety and concomitant desymbolising processes are central counteracting integration. The aim in this study is identify possible integration-desintegration in order to increase the knowledgebase for psychotherapists/psychoanalysts working with these patients.
Research questions: Study of symbolizing and desymbolising processes in psychotherapy/psychoanalysis with traumatized patients: Is it possible to identify dialogical processes leading to integration of traumatic experiences?
Material and method: Transcripts of psychotherapies/psychoanalyses with traumatized patients.
Results: Important processes are identified. The study is on-going but results are presented in: Freedman, N., Hurvich M., Ward, R. (2011). Another kind of evidence. Karnac Books, London.
Financial Support: National Centre for the Study of Violence and Traumatic Stress, University of Oslo.
 Norbert Freedman died in late 2011. The work will be reorganised and continue
Bjørn Killingmo* and Sverre Varvin* (principal investigators),
and Hanne Strømme*.
Study of therapeutic competence.
Department of Psychology, University of Oslo and NKVTS.
2007 – ongoing.
Aim: This study focuses on student therapists’ development of competence during training in dynamic psychotherapy.
Research questions: To what degree had descriptive psychodynamic knowledge been transformed into operative clinical knowledge? To what degree could anti-therapeutic practice be identified? Did results match expectations in the training programme?
Material and method: Sessions deriving from the final phase of psychodynamic therapies (N=21) performed by student therapists in an intensive psychodynamic psychotherapy training programme were analysed qualitatively for their level of psychotherapeutic competence.
Results: 53% of the therapists did not show operative clinical competence in terms of strategic thinking. Strategic competence was present, wholly or partially, in 47%. Only two therapists demonstrated high-level strategic competence. Most therapists demonstrated a lack of capability for strategic thinking and a lack of technical competence, and all therapists found it difficult to relate to negative affects. Patients’ defence mechanisms and the therapists’ helplessness and lack of competence counteracted progress in the therapies. The study demonstrates that it is difficult to acquire dynamic understanding of the therapeutic process and that the beginning therapist will need a longer period of time to acquire operative competence. A sharper focus on internalising therapeutic competence must be implemented in such training programmes.
Financial Support: Department of Psychology, University of Oslo.
Gábor Szőnyi* (principal investigator). Sverre Varvin* and
Hanne Strømme* (Nordic participants).
Training in different psychoanalytic settings: The path (experience) and the outcome. PIEE research project.
European Psychoanalytic Federation and Psychoanalytic Institute for Eastern Europe, Budapest, Oslo, Tel Aviv, Kiev, Ulm and London.
2010 – ongoing.
Aim: The Han Groen-Prakken Psychoanalytic Institute for Eastern Europe (PIEE) accumulated a large amount of experience on organizing training and facilitating the foundation of new study-groups in countries where no psychoanalytic institutes/societies were existing. PIEE differs in many basic characteristics from traditional analytic institutes (e.g. it is a “virtual” institute with no physical base; is international, founded by IPA and EPF; the training analysts who provide personal analyses and supervisions, belong to different national societies, not to PIEE; because of lack of local training analysts a large part of training is carried out in shuttle format; trainings have double objectives: to produce good enough analysts and to foster a development which leads to formation of study groups; the institute will end after it has finished its mission). The number of new analysts (IPA members) and number of new study groups in one-time Soviet ruled countries prove the efficacy of PIEE. It is valuable to have a more thorough research concerning experiences. We have hardly any data of regular trainings regarding training experiences, competences at qualification and the application of obtained analytic competence in later practice provided in traditional analytic training institutes. Therefore, such a project brings important results for all involved into psychoanalytic education – candidates, trainers, training institutes and society executives – independently as to whether they are engaged in regular or non-regular trainings. Further on, the project’s methodology can serve as a base for future studies on other new developments in psychoanalytic education (e.g. skype analysis).
Simultaneously, the project focuses on three areas, in an interconnected way: Experiences during training, outcome (competence) at qualification, and professional application of obtained competence (around 5 years after qualification – analytic career path).
Research questions: Which are the major differences in training experience between trainings carried out in different settings? Do candidates differ at qualification due to having had training in different settings? Do professional activities and analytic competencies of young analysts (at around 5 years after graduation) differ due to having been trained in different settings?
Material and method: Graduates from PIEE training programs compared with graduates from psychoanalytic institutes in Western Europe. Semi-structured interviews, questionnaires, and evaluations of psychoanalytic sessions.
Results: No results yet.
Financial Support: European Psychoanalytic Federation.
Professor Theresa Wilberg (principal investigator), the
Research group of personality psychiatry, including Merete Johansen*.
Ullevål Personality Project (UPP)
Department of personality psychiatry, Oslo University Hospital in collaboration with the University of Oslo.
Aim: The aim of the project was to compare a step-down treatment model (CP) consisting of initial short-term day hospital treatment followed by conjoint group and individual outpatient psychotherapy with outpatient individual psychotherapy (OIP).
Material and methods: UPP is a randomized clinical trial of day hospital treatment followed by outpatient combined psychotherapy compared with outpatient individual therapy for patients with personality disorder. Patients with personality disorders (N = 114) with severe to moderate degree of impairment were randomized to the two treatment modalities. The patients were evaluated at baseline, 8 months and 18 months on a wide range of clinical measures assessing symptoms, interpersonal problems, psychosocial functioning and personality pathology.
Results: At 8 month follow-up there was moderate improvement in both treatments. There was no indication of the superiority of one treatment over the other. The main finding at 18 month follow-up was that the intensive, multimodal combined psychotherapy (CP) was not more effective than outpatient individual psychotherapy (OIP). On the contrary, there was a trend of better results in the OIP treatment. As for efficacy, the study indicates that eclectic psychotherapy provided by private practitioners may be equally or more useful for patients with PDs, compared to the more comprehensive day hospital and outpatient follow-up treatment. However, this conclusion should be regarded as preliminary pending the results from the 36 months follow-up investigation.
Financial support: South-East Regional Health Authority and Oslo University Hospital.
Anders Zachrisson* (principal investigator), Henrik D
Zachrisson (the first study)
Studies in psychoanalytic concept formation.
Department of Psychology, University of Oslo, Norway.
Aim and research questions: The overall aim is to explore aspects of psychoanalytic concept formation and use the results in attempts to develop heuristic models for psychoanalytic understanding. In a previous study with an epistemological turn (Zachrisson & Zachrisson, 2005) we investigated different criteria for validation of psychoanalytic theories and proposed a four-leaf model for the process of validation, combining internal (theory intrinsic) and external correspondence and coherence. Ongoing studies include investigations of
a. the dynamics of psychoanalytic supervision
b. the relation between oedipal dynamics and the conflict over knowledge
c. the relation between ethical transgressions and deviation of method in psychoanalytic treatment.
Material and methods: In the study of supervision, the point of departure is the the view that psychoanalysis is a composite craft, in which seemingly contrary elements like strict rules and creative intuitions have their place and interact. One example of this is the tension in the supervisory relationship between supervisor as instructor acting as an authority for the candidate whilst being a mentor fostering autonomy in the candidate. The main feature of the model is that a number of aspects of supervision are seen as suspended in a field of dynamic tensions between phenomena in real or apparent opposition.
In the Oedipus study, a close reading of Sophocles’ tragedy discloses how Oedipus’ urge for self-knowledge is countered by an opposed wish to turn a blind eye to the truth. This epistemic conflict plays a central part in the psychoanalytic view on human development and mental health, and can be traced back to “Little Hans”.
In the Ethic/method study I explore the boundary concept and argue that the professional (psychiatric/psychological) setting has a stricter ethical articulation than the general interpersonal setting. And further that the psychoanalytic setting has a stricter articulation than the professional. This argument gives us three qualitatively different boundaries of ethical conduct. On that background I propose three levels of boundary transgression: violation refers to the case where an analyst crosses the ethical border of general social setting, crossing refers to the transgression of the professional but not the general ethical border, and finally a boundary stretching refers to the transgression of the analytic but not the professional ethical boundary.
Results: The supervision study is finished and accepted for publication in International Journal of Psychoanalysis. The Oedipus study is under peer review in Journal of American Psychoanalytic Association. The ethic/method study is approaching a preliminary conclusion. I plan to submit a first version of the report in some months.
Financial support: None.