From this position it spearheads the direction of research into psychoanalysis, psychotherapy, psychiatry and medicine. The methodology is therefore likely to achieve a higher degree of credibility, dependability, confirmability and transferability than single case studies while also retaining greater correspondence with practice, and hence to be endowed with more authenticity than more practice-distant positivistic methods.
Second, we expected to gain more information about the transferability of results through the method of forming types by understanding. In terms of methodology more broadly speaking, we hope to contribute to the development of standards for systematic qualitative research in psychoanalysis. The process of forming types by understanding will be illustrated through our example of psychotherapy with suicidal men.
The process makes use of psychoanalytical methods, and also employs systematic qualitative methods stemming from social research. Here we will describe the processes used in our study. The case is presented and discussed in a supervisory research seminar, and from this a full case report is written.
As an example a full case report is included in Appendix 1. A group discussion of each case takes place to address the research questions, developed from the "triangle of understanding":. Which transference relationship is an expression of which form of suicidality? In repeated iteration, through moving between discussion of case material and general themes or "aspects" from the material, clusters of similar cases are put together in a group discussion.
A single prototypical case for each cluster is selected by choosing the one case which best represents the cluster. Protocols are developed from these case discussions. Members of the group can be thought of as taking up involuntary roles, such as "the practitioner", "the reality prover" the person in the group who questions the arguments and interpretations critically , "the expert" or "the methodologist" to keep the group process moving.
The protocols of both case discussion processes for Hamburg in German and for London in English are attached in the Appendices 2 and 3. The "sighting-disc-rating" was initially developed for the method of forming types by understanding STUHR et al. The rating offers a possibility to gain measurable data on similarities and differences between each single case and each prototype. The prototypes are placed on the outer circle of a sighting-disc and each individual case in the centre. Each research group participant determines the proximity of each specific individual case to each of the prototypes by means of tangents.
Discussion continues until unanimous agreement on the tangents is reached. The "sighting-disc-rating" facilitates description of the similarity or difference of each single case to each prototype. This allows the "storage" of similar types of cases. The cases that are repeatedly and unanimously assessed as being similar in a specific aspect are grouped together.
Going back to the case material, the common aspects developed in the case-contrasting process are described—again at a meta-psychological level—as ideal types. After this, in a more generalising effort, each case is assigned to the ideal type, which is most characteristic of the case. The process for comparison by the London-based group included translation into English of the "case book" composed of 20 cases of suicidal men seen in TZS.
The four raters based in the Tavistock's Adolescent Department formed a research group and the group took part in a workshop on "forming types by understanding", where the method, the clinical situation of the patients and the general psychotherapeutic orientation of TZS were explained. The results of the study were not revealed to ensure that the group remained blind to the earlier study and its outcomes. Each participant in the Tavistock research discussion group read the case book, and the group met for three consecutive days for a total of 21 hours to discuss the cases, starting with individual case discussion, and moving on to comparing cases and developing more general themes.
In these 4. The results of the sighting-disc-rating were discussed and one agreement for each comparison was defined.
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Similarities and differences were discussed and recorded. A process note was written for the whole discussion process see Appendix 3. The study was carried out on a sample of the 20 most recent male patients who had had at least five psychotherapy sessions at TZS. Men living alone were over-represented in the sample compared to the patients at TZS. One man had a homosexual orientation Case T , all other men were heterosexuals.
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All 20 patients had suicidal intentions, 12 patients had a history of suicide attempts, 11 of which occurred less than six months before the beginning of psychotherapy. Neither the therapists nor the patients knew anything about the selection of patients for a study during the first five psychotherapeutic sessions. In addition to providing out-patient clinical psychiatric psychotherapy, TZS also maintains a "Suicidality and Psychotherapy" research group which is nationally and internationally active in the field of scientific study for the understanding and therapy of suicidal behaviour.
Patients are referred or recommended for treatment by other physicians or psychologists, but also come of their own accord in a suicidal crisis FIEDLER et al. The Tavistock Clinic, now a Foundation Trust in the National Health Service, provides a mental health service for children and families, adolescents and adults, in which psychoanalytic psychotherapy is an important model of intervention.
Additionally it is a national and international training centre, providing trainings for the mental health personnel, psychotherapy and the application of psychoanalytic thinking to a wide range of professionals. The rating of clinical texts in this study is undertaken by psychoanalytic psychotherapists, who are members of the Adolescent Department's research group. The first process in Hamburg of analysis of this sample and the assignation of ideal types provided a basis for the comparison.
A total of four ideal types was developed. Illustration 1: The four ideal types "Disconnected", "Hurt", "Stormy" and "Object dependent" are formed out of similar prototypes big circles and single cases small circles. Similarity also occurs between different ideal types: e. This feeling corresponds with the suicidal dynamics of repeated rejection experiences. The patient acts with an aggressive reproach in both in the transference and suicidal events. This can be interpreted as a re-actualisation of the conflictual experience of parental exclusion.
This ideal type contains a strongly ambivalent relationship with their father, which, in the transference, determines the therapeutic relationship. Their bond with their mother, on the other hand, seems "pale" and unsubstantial. In this ideal type, patients make suicide attempts with highly lethal potential. Correspondingly, in-patient psychiatric treatment is frequent before the start of psychotherapy. At the beginning of therapy, the patients appear to be in a very bad, partly acute somatic condition.
Any alcohol or cannabis consumption causes withdrawal from important relationships. Ideal Type B "Hurt": There is often an aggressive entanglement between the patient and the therapist, in which the patient, anticipating rejection, is passively or actively aggressive. Aggressive emotions predominate in the counter-transference.
Similarly, suicidal dynamics are characterised by real experiences of loss, which mobilise aggression, and simultaneously temporary unbearable feelings of emptiness, immediate need for another person to be here and the awareness of having failed in important relationship goals in life. Real trauma occurs frequently in biographies, and triangulation experiences are absent.
In childhood, these patients experienced themselves as self-object 2 of the mother, whereas the father was mostly experienced as absent. Often a significant woman mother, girlfriend, female therapist recommended treatment. Both hospitalized and out-patient psychiatric-psychotherapeutic treatments are frequent. This ideal type shows evidence of chronic suicidality although perhaps not so much as in "Stormy" and "Object Dependent" ideal types , and patients are more likely to come for treatment shortly before than after a planned or threatened suicide attempt. The men are often strongly built, sporty and well-dressed, but exude a sense of great tension.
The need to conceal some physical defect, weakness, hypochondriac anxieties or insecurities is frequent. Ideal type C "Stormy": A stormy transference e. This is a reproduction of the comfort-searching side of a late adolescent separation-dependency conflict. Suicidal feelings are, therefore, connected with separation experiences, as well as with the development of a fixation on a certain psycho-social development level. Very intensive, ambivalent bonds to the mother appear in the biographies.
Patients often report destructive parental relationships, that is, of fathers physically threatening the mother, as if the patients feel they had to protect their mother and her life. At the same time, identification with the violent father is highly ambivalent. Emotions are inadequately controlled. Their outward appearance is based on one-dimensional, aggressive male concepts, e.
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They have a tendency to have strong outbursts of emotion. Ideal type D "Object dependent ": In the transference relationship, there must be no "third" element, not even as an explanation for the current experience. Therefore, only concrete matters can be queried and dealt with. Accordingly, these men want the women who have turned away from them to return. The biography seems simplistic and conceals a lack of emotional experience. One has the impression that an experience of chronic emotional neglect is warded off by idealising and identifying with family norms e.
Patients report supposedly pleasant childhoods, although the description seems evasive. In connection with a specific counter-transference experience under pressure and having to make "sense" of everything alone the impression is formed that they were emotionally neglected in childhood. Stable psycho-social arrangements can support for a long time defence against feelings and conflicts associated with the neglect. Patients only become suicidal when these relationship constellations and their inherent defence mechanisms are threatened.
If alcohol is consumed in the framework of a suicidal experience, it is an unconscious cry for help to an inanimate object, which, however, provides no protection. In the sample, there is one special case Case U of an abused and abusing man who has little similarity with all other cases, and is marked by a specifically highly aversive counter-transference reaction. Also, another two prototypical constellations were heuristically developed that were not in the sample, which are rarely seen at the Therapy Centre: older men and patients with acute psychiatric illnesses, such as seriously depressive episodes or chronic schizophrenic psychoses.
The special case and the heuristically "composed" constellations point out that there are probably further types of suicidal men who, within other cultural paradigms, and also in other clinical settings, e. Concreteness 3 leads to distress in therapist. Table 1: Results from the first discussion: There are four ideal types with the cases assigned to them, the prototypical cases are indicated. Case U is indicated as a special case, which could not be assigned to any ideal type. The second process undertaken by the Tavistock group—blind to the findings of the TZS group—led to the formation of three ideal types: [ 48 ].
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These men present a "thin-skinned narcissism" BRITTON, that causes every approach from the outside to be experienced as an attack. The resulting aggression must be projected into the outer world again. These men still fight, because they come into treatment in contrast to some homeless suicidal people but in the transference relationship they unconsciously, and thus actively destroy all therapeutic attempts to come into a contact with them. So the transference situation is characterised by withdrawal.
The main biographical aspect is that of a loner. Ideal type B "Sado-masochistic enmeshed" : These men create unpleasant relationships; in current relationships with partners or past relationships with parents they cannot separate but cannot live together either. In this ideal type there are only a few suicide attempts. It was hard for the members of the discussion group to "stay in the room" with these patients, meaning that they expressed the wish not to discuss these cases any longer.
In biographies there are lots of controlling and enmeshed relations with suicidal parents with mental illnesses as well as absent fathers and frightening and controlling mothers. Ideal type C "Psychotic—unrealistic" : These patients resorted to "psychotic" solutions, in psychoanalytic terms: they would fall in love in order not to experience their anxiety and separateness. The lack of anxiety is the result of the defence of splitting relatedness to "good" and "bad" so that the anxiety is projected into the "bad" object and thus is experienced as not belonging to the self.
The transference situation is characterised by a tendency to merge or fuse with the therapist. The biographies often reveal intense and idealised relations. Table 2: Results from the second expert discussion: There are three ideal types with the cases assigned to them; the prototypical case is indicated.
Illustration 2: The ideal types of the second formation process are projected on the ideal types of the first formation process. Red: Ideal type "Withdrawn", yellow: "Psychotic-unrealistic", blue: "Sadomasochistic-enmeshed". Initial observations appear to show that the TZS and Tavistock groups developed different sets of ideal types, which are identified through both the different groupings of cases and the different language used to describe ideal type.
The two groups were using different criteria—especially theoretical—to assess the cases, which resulted in different classifications as ideal types. This is evidenced by the fact that all three ideal types of the Tavistock group spread over three of the four ideal types of the first group. On the other hand, there are some similarities between the two research groups, which can be discerned through closer examination.
Moreover, no patient from the ideal type "Withdrawn" London group was placed in the ideal type "Stormy" Hamburg group ; no patient from the type "sado-masochistic enmeshed" came from the ideal type "disconnected" and no patient from "psychotic-unrealistic" came from "object dependant". This analysis leads to the hypothesis that the diagnostic assessment criteria, which generated most similarities stems from experience-based criteria, that is, from the counter transference aspect.
Psychotherapists can "feel" one patient to be similar to another, but how they explain this phenomenon may be very different due to the use of different theoretical approaches. Both groups of therapists were quite similar in their assessments of aspects they could feel and experience in the therapeutic relationship out of a common clinical experience. These are experiences about the quality of the therapeutic contact, whether the patient and the therapist is remote and distant or whether there is an intensive, aggressive, manipulative or idealising transference situation.
Another similarity in both groups seems to be the assessment of aspects of the transference relationship, for example, the discussion of illusory or unrealistic relationships or relationships in which no inner meaning can be found. It seems very likely that similarities found by both groups arise from clinical experiences of the quality of the therapeutic relationship.
On the other hand, differences seem to stem from the two quite distinct theoretical approaches used by the two groups to understand the interactional patterns within the cases. It is important, therefore, and consistent with our methodological approach, to explore the nature of these differences. The TZS group of German psychoanalytic psychotherapists had their theoretical background in the work of the psychoanalyst Heinz HENSELER who influenced the psychoanalytic understanding of suicide in German psychiatry for decades with a self-psychological understanding of suicidality as a narcissistic crisis.
This framework emphasises the elemental conflict between life and destructive forces, the projection of destructive elements into others and the impact of these on the therapeutic relationship, generating re-enactments of sado-masochistic relatedness. We embarked on this study with the hope and expectation that some forms of similarities across the two groups would be found, and that these would provide evidence for the transferability of findings beyond the immediate context of the study.
At the same time, we were aware of the potential differences between the two groups of researchers, who had different national and historical backgrounds and, following from this, different heritages in terms of psychoanalytic theory and practice. The two groups also differed in their knowledge of the cases. Given these differences we expected that the study would provide both differences and similarities that we could find and account for. Our findings show that the groups differed in the way they developed ideal types, the descriptions for these and the theoretical frameworks that drove the conceptions that formed our clustering, as described above, into different ideal types.
We found that similarities existed at the level of the clinical experience. This analysis suggests some ways of analysing the data, comparing these through the clustering of similar cases and the similarities of descriptors within ideal type categories provide a starting point for developing transferability. Qualitative research does not usually focus on transferability and generalisability of results, except in the demand to work thoroughly, to give a clear description of the material, patients or persons who are investigated, and to present the material and the methodical steps so that anyone can follow the heuristic steps from the material to the concluding results.
Rather, some qualitative researchers such as MAYRING claim that generalisability is very important for qualitative research to come to results that can lead to political, medical or psychotherapeutic action. In psychoanalytical discussions the question of the frame and limits of general statements are not very often discussed; theoretical considerations stemming from very different cultural and theoretical backgrounds are often presented without mentioning these limitations.
Therefore it is of value to show on which level the same material can lead to different but also, on another level, similar results when examined by different experts. In a quasi experimental setting it can be shown that speaking about patients may on the one hand lead to totally different interpretations and on the other lead to similar results. From a methodological perspective, the possibility to find common interpretations can be defined as a form of "moderatum" or mid-range generalisations as defined by WILLIAMS , p. Moderatum generalizations I advocate are, then, the bridge between the ideographic and nomothetic.
They can provide testable evidence of structure and outcomes of structure. Their limits lie in the logical problem of inductive inference and in the ontological problems of categorial equivalence". These results lead to the suggestion to present the clinical material in a way that the therapeutic relationship can be understood easily, that the reader is able to remember own experiences with similar patients and through this may connect with the clinical knowledge.
This can be achieved by presenting the case without theoretical metapsychological considerations by just "telling the story" as DENEKE advocates. Inter- subjectivity is and should not be ruled out in finding an understanding of another person's inner world because the process of understanding is only possibly done through the researcher's personal and partly unconscious inner relations to the material.
This being said, the finding that a thorough use of transference and counter-transference analysis produces some similarities between the two groups of researchers provides evidence for the credibility of this instrument, without stretching its meaning to the domain of impersonal "truth". Future development of the method would focus on the meaning of differences in order to both appreciate the different approaches within different national and theoretical backgrounds and to get beneath these distinctions to appreciate the clinical phenomena.
As a continuative research a case report can be used to interpret an ongoing process between two groups , which always share not only their interpretations of the material but also the theoretical, personal and cultural reasons for them. This may lead to more scientific consistency in an interpretive science like psychoanalysis. This case report is a translation from one of the Hamburg case reports as an example of the 20 reports. The initial material stems from session protocols.
The case reports were written by the therapists. Each participant in both groups had to read the case reports in advance before the case-contrasting discussions. At the time of his first appointment Mr. At the first appointment I greet a very tall, lanky year-old man, visibly worn out by his ill physical condition. He attempts to be relaxed when greeting me.
His depressed and resigned state of mind beneath the surface can be sensed at once. During our talks, he keeps staring into the distance. He remarks that since his suicide attempt his situation has not changed. For him the kind of life he is leading makes no sense. The acute reason for this is the separation from his girlfriend he was with for many years. She has decided to live with another man. For over six years there have been continual see-saw changes. He finds it difficult to have a close relationship with somebody, but he does long for one.
In fact, his girlfriend stuck with him for quite a while. He prefers living with his half-blind sheep dog, which he "needs". In contrast, he defines his attachment to his girlfriend as a "desire" for her. It is terrible for him to realize that when he had opened up to her more than ever before, she chose another man she had known for some time already. She still takes care of his dog, and they are still in touch. He only feels fine when he is busy doing something he likes to do.
Then he feels easy, acting out his abilities. He always needs a certain atmosphere, for example when he makes music, or when he thinks of the time he worked for an artist in P. He then used to work with pleasure and loved what he did. He also liked living in a motor home with his dog. On my inquiry he tells me about some events from the past years, especially about his father's death, as well as the deaths of several friends. During our talks I have the impression that Mr.
It becomes clear to me that the attention he received when he was under watch is exactly what he needs. Obviously he has a talent for mobilising doctors, nurses and orderlies; even the cleaning woman and surrounding patients seemed to attend to him in a touching way, as well as a woman from the social services at the University Hospital Hamburg-Eppendorf, Mrs. At the same time he conveys the impression that all this does not have an effect upon him; as soon as he is alone the inner emptiness comes back immediately. Soon after our first appointment Mr.
Since it is impossible for me, we meet again only one week later at the fixed date. Right from the beginning he says he regrets he did not have the opportunity to talk to me earlier. My first impression is that as soon as he feels lonely and needy he wants to talk to somebody. Then he tells me he has checked out of the in-patient clinic and has found accommodation in a hostel of the Salvation Army. The previous weekend he felt very lonely there, although the director took care of him very much.
He tried to hang himself with a cable but did not succeed. He explains that he was missing the warming atmosphere of the ward. The following three conversations are underpinned by an event that is still disturbing Mr. He tells me that his ex-girlfriend offered to cook for him at her house on his birthday. He went to her house at the time agreed upon, but she did not open the door. He called her from a public phone.
She answered the phone and told him she was still in bed. It was clear to him that she was in bed with her current boyfriend. He felt like being kicked onto the street. After his initial fury he felt "like in a film", so humiliated. She apparently showed no empathy at all. He felt so unprotected having disclosed his wishes to her so sincerely that now he could only "completely shut himself down" again. All he is now seeking is calm, he says, and finally the inner film will stop. What he finds particularly bad is that now he has nobody to take care of his dog, because he has become so dependent on his girlfriend.
Every time he has to go to her house to fetch the dog, he feels extremely mortified and humiliated. His dog symbolizes the part of himself not being currently attended to. As a consequence, he has fallen into a state of inner unrest, and he describes this as an undifferentiated physical condition. He has started drinking more and more beer in the evenings to calm himself, at least a little.
At the end of the fifth session, I mention the possibility of a medical treatment, as I could see no way of easing the effects of the conflict with his girlfriend. This he felt as a rejection, and it must have reminded him of an earlier, similar experience.
I suspect these "on and off" - changes with his girlfriend are something he initially experienced with his mother. I also think the separation from a woman unconsciously means death for Mr. After the separation from his girlfriend Mr. He then fell asleep. However, he had not switched off the radio so that the taxi centre noticed he did not react and tried to track him down. Somehow he got into the clinic. He could not stand being rejected so massively, having disclosed his innermost feelings to his girlfriend so sincerely.
He felt he had no place in this world any more. He has always experienced a longing for death, always being beneath the surface. The experience that nothing good or nice is permanent for him and that in the end he is always left alone is not bearable for him any longer. He remembers his youth in this small town mainly as a time when he was part of a music scene with friends, a phase symbolising for him an independent way of life he now misses.
The family lived in large premises where his mother's parents also stayed in a house. His father ran a photo shop on the premises. The grandmother dominated the clan, whereas the father spent much time in his shop, using it as a place to retire to. He was always in a state of slight inebriation, apparently feeling constantly under pressure to be successful in his job. As a child Mr. The atmosphere in his family was stamped by his "rustic father" and his beautiful mother, who came from a civil servant's household.
During his last years at home the relationship between his parents continued to deteriorate. Finally his mother divorced his father, whom she eventually came to despise. After the divorce his father was in a very bad state of mind. When he the patient once went home for a visit he worked for the alternative civilian service in Husum at the rescue service 5 , he found his father dead. He had apparently "croaked", as the patient said, from too much alcohol. After his civilian service his mother obtained an apprenticeship as a TV-technician for him, which he finished.
Later he worked in this profession at the Federal Post for 7 years until he had problems with his back, which made it impossible for him to work in that job any longer. That friend was a heroin addict and is now dead. Other friends of his died of AIDS.
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He feels he has experienced so many separations and deaths that he has lost all hope that anything good can last. In Hamburg he worked as a free-lancer for an artist for some time, living on his premises in a mobile home with his dog. When that artist could not pay him any longer, he started working as a taxi-driver. He has known his ex- girlfriend for six years. She is a very active woman who sometimes reminds him of his mother.
They he and his mother understand each other very well. His relationship with his girlfriend, however, is characterised by ups and downs. She often finds he is lacking initiative and sometimes completely spoils the atmosphere by her reproaches and bossy behaviour. On the other hand, he appreciates her domestic abilities. She has a nice flat and he very much enjoys having meals with her. But he does not feel he can really relax there as it is not his flat.
Wir waren also in einem genuinen therapeutischen Bereich. Bei G erfolgte der Verlust mit 7 Jahren. R und K, beide sehr unter Druck, machten hier "viel Wind". Eine zweite, sich evtl. So ist der Suizidversuch stark im Zusammenhang damit, Hilfe zu mobilisieren. Vorherrschend ist eher eine anale Struktur. Am Nachmittag wurde es dann sehr anstrengend.
Es ist also offen, ob die Aspekte der Biografie notwendig oder nur hinreichend sind. Hierzu fanden sich dann F, O, Q und etwas auch H. Hierzu fanden sich dann L, D, U und S. Nicht zuzuordnen waren M und T. Als Sonderfall entpuppte sich immer wieder H. Dann aber ist die Diskussion sehr stockend.
Die Gruppe setzt sich also aus Therapeuten, Diskutanten, des jetzt mitdiskutierenden Therapeuten, aber auch zwei Teilnehmern zusammen, die keine Therapeuten waren, wobei einer OF nicht am gesamten Diskussionsprozess des Marathons beteiligt ist. OF, der nochmals deutlich macht, wie die aktuelle Sicht auf die Biografie zu verstehen ist, bringt das Bild eines Schwimmenden, in Not geratenen, der von einem Boot aufgenommen wird und zum Hergang eines Schiffsuntergangs befragt wird.
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Save to Library. Preuss and Inga Becker. Schwerpunkte der Psychotherapie bei transsexuellen Entwicklungen more. Behandlung und Begutachtung von Transsexuellen more. Publication Date: Publication Name: Psychotherapeut. Spezifische Modifikationen psychotherapeutischer Arbeit und Zielsetzungen werden dargestellt. Die Gefahr von Fehlindikationen irreversibler Operationen kann damit verringert werden. Usually therapeuts of transsexual patients, who decide over somatic sex reassignement, have to engage also in psychotherapy in a broad sense. In this setting patients have more time to develop insight and have better chances to explore other options and find individual solutions with regard to irreversible sex reassignement surgery.