EPF / WPIP / Report and Working Document Draft 1.3 / Appendix 2:
EXAMPLE OF POSSIBLE RESEARCH PERSPECTIVES
Initiating Psychoanalysis:
Rudi Vermote, November 03
Background.
During the Working Party on Initiating Psychoanalysis, we agreed that a first interview could
be considered as good when a phenomenon happened which was described as ‘ changing the
level’
Questions
1. Is it possible to define this level of intrapsychic functioning during the first interview and to
detect changes in this level ? This also begs the question whether there is one level or many?
2. Is it possible to operationalise this level and find measures which are sensitive to rate
changes of this level?
Some scales of intrapsychic functioning ( see Open Door Review of Outcome Studies in
PA , Eds. Fonagy et al. 2002)
1.Fonagy et al..(1998) constructed an 11 point scale on Reflective Functioning (RF)which
measures the degree of understanding oneself and others in terms of mental states ( feelings,
beliefs, intentions, desires). In other words: to what degree a theory of mind has been formed
to understand the actions of self and others: Bordelines have a significantly lower RF than
normals and the RF of parents predicts the attachment of children.
The RFscale is applied on the Adult Atachment Interview ( AAI) (Main et al.,1991) and has
an established reliability and validity.
2. Bion GRID scale.
According to Bion(1963) it is possible to categorise every statement, feeling, thought and
action of analyst and patient during a session. These categories reflect the level and the use of
thoughts in processing emotional and sensorial experiences. These categories are brought
together in a GRID. This makes it possible to have a fine grain representation of changes of
the level of intrapsychic functioning during a session..
We developed a 6 point scale to rate this level of psychic functioning during parts of an
interview and on the global interview. As an interview we use the Object Relations Inventory
( see below).
3. The Differentiation Relatedness Scale (Blatt et al,1996), is a ten point scale which measures
the level of self-object representations in two dimensions: the degree of differentiation of self
and other and the establishment of increasingly mature levels of interpersonal relatedness The
reliability and validity of the DRS are good. Changes in the scores of representation of
mother, father, self and therapist predicted therapeutic change over a period of two years.
However this measure does not reflect a dimension which changes during one session.
The DRS is measured on an Object Relations Inventory ( ORI), a semi-structured interview in
which the patient is asked to tell without being interrupted about his mother, father, a
significant other (such as partner, friend, therapist…) and self.
For an on going process-outcome study (Vermote, Vertommen, Corveleyn et al., 2002), we
adapted this ORI in a way that it becomes possible to rate not only the DRS, but also the RF
and the Bion GRID scale on it.
The inter-rater reliability of the DRS,of the RF and of the Bion GRID scale is good on this
slightly adapted ORI. The validity of rating the RF on the ORI instead of on the AAI is
currently being tested.
Method
To many of us the simple questions of the ORI ( tell me about your mother, father, a
significant other and yourself) are standard questions in a first interview. The idea which grew
during the workshop on ‘initiating PA’ was whether it would be possible to have these simple
questions in mind while taking a regular first interview.
These specific fragments may then be cut out from the global interview , resulting in uniform
transcripts, corresponding to a regular ORI. This procedure would make it possible to rate the
described measures of intra-psychic functioning on the first interview without using additional
questionnaires or tests.
This means concretely that :
1. At one point or another during the first interview the four open questions:’tell me about
your mother, father, a significant other and yourself’ should be asked. To make it possible to
rate the Bion scale and the DRS, it is important to let the patient answer without interruption,
so that we can have an idea of the way he associates freely and explores the question. In other
words, the interviewer must take care not to close an eventual associative answer by putting
questions which start a more rational thinking process in the patient.
2. However, it is important to realise that the RFcapacity becomes manifest in reaction to such
‘ Why’ questions. Therefore we suggest to take a specific example from the answers on the
questions mentioned above, when possible on 2-3 of the four questions. , or to ask for such an
example and to explore with this concrete example the degree the patient understands the
other and him or herself in terms of mental states. Exploring such a specific example may be
at any point of the interview, but not in a way that it interrupts the first spontaneous answer to
each of the four questions. For instance : ‘In telling me about your father , some minutes ago ,
you mentioned that he has been drinking for some years, do you have an idea what this meant
for him? What did it mean exactly for you ?
Planning
We will test whether it is possible to use this procedure on the interviews which will be
presented during the next Working Party in Brussels.
All remarks and suggestions are welcome.
References
Bion, W.R. (1963). Elements of Psychoanalysis. London: Maresfield Reprints
Blatt, S.J., Stayner,D., Auerbach, J., Behrends, R.S.(1996), Change in object and self
representations in long-term, intensive, inpatient treatment of seriously disturbed adolescents
and young adults. Psychiatry, 59, 82-107.
Fonagy, P., Target, M., Steele, H., Steele, M. ( 1998a). Reflective Functioning Manual Version
5. London: UCL, Psychoanalysis Unit. Unpublished manual.