‘Mr K’ – A successful case of analytic oriented therapy documented empirically: the role of the therapeutic relationship and reflexive self-awareness

Abstract

A successful case of analytic treatment over the course of 250 sessions is described from different perspectives, including considerations from the two-year follow-up. The therapeutic alliance and the patient’s experiencing were evaluated. Pre-treatment diagnosis was validated via diagnostic interview. Symptoms and interpersonal problems were assessed at intervals. Data were analysed using two different time-series analyses. Aspects of agency with regard to mentalizing capacity were assessed with the Metacognitive Assessment Scale. We obtained the following main results: (1) Symptoms and interpersonal problems improved continuously until the end of treatment. Symptom severity fell to below the clinical cut-off. This successful outcome remained stable at the two-year follow-up. (2) The therapeutic relationship improved during the therapeutic process. (3) The patient’s capability for reflexive self-awareness, operationalized as experiencing, decreased. (4) The metacognitive mastery of the patient increased. The following conclusions were made after combining the empirical data with the clinical observations: (1) Mr K improved clinically in terms of symptoms, self-regulation and interpersonal problems as a result of his gaining affect control. (2) The patient’s experiencing does not capture a positive outcome in all cases. (3) Aspects of agency (i.e. metacognitive mastery) deserve further attention in psychoanalytic treatments.

Keywords:

• single case study
• psychoanalytic treatment
• the therapeutic relationship
• mentalization
• experiencing

Notes

1. This case forms part of a research project on single case studies registered internationally (Registration: ISRCTN-Nr. 75536830, Current Controlled Trials LTd c/o BioMed Central Ltd).

2. Ratings were performed by two trained and reliable coders (trained at the Anna Freud Centre, London). The methodology differed from the classical approach to coding RF in the Adult Attachment Interview (AAI) but focused on demand questions (those for which the participant’s answer requires spontaneous and explicit mentalizing), which the therapist asked in the first three therapy sessions.

3. ‘Hypermentalizing’ is a desperate attempt to understand a situation via intense thinking about it that is characterized by poor constructive problem solving. This is associated with anxiety and tension, e.g., heightened worries about the wellbeing of a partner and one’s own responsibility/guilt for their wellbeing.

4. The therapist was not part of the research team and did not contribute to any analyses. No results were shared with him or with the patient. The therapy (with a total of 250 sessions) was audiorecorded over the whole course of treatment. Data from different perspectives were obtained during therapy and two years after the end of treatment (see Figure 1).

5. Audio data of the 241st–250th session were lost due to human error; only the data of the questionnaires were available.

6. Metacognition Assessment Scale 2009-R (unpublished manual by Carcione et al., 2009).

7. Time series analyses were conducted by Prof. Dr. B. Schmitz (Heidelberg, Germany), a specialist in this field (Schmitz, 1990, 1989).

8. A person using a deactivating strategy appears to be emotionally distant and cool. Mentalizing is seemingly well developed and functional, yet internally, the person is in a state of distress, often without being aware of it. At times, such individuals experience the physiological correlates of stress (e.g. high blood pressure) but not the accompanying psychological aspects/representations. Therefore, mentalizing is often limited to a focus on external experiences. A dissociation between subjective and biological distress ensues (Bateman & Fonagy, 2013, p. 597).

9. In hyperactivating strategies, the relational system is intensely activated. They lead to an intense and rapid affective experience of people concerned – negative and positive affects oscillate. Mentalizing is equally rapidly compromised alongside a reduced capacity to form objective judgements (Bateman & Fonagy, 2013, p. 597).