Clinical Evidence, Triangulation of Perspectives and Contextualization. Part 1: The Beginning of Carla’s Treatment

Abstract

We propose to critically evaluate and strengthen the level of clinical evidence in psychoanalysis, using a strategy of triangulating clinical phenomena from different perspectives and increasing contextual knowledge. Insufficient discussion of alternative hypotheses and limited contextual information are two Achilles heels of psychoanalytic case presentations. We examine the concept and quality standards of clinical evidence in psychoanalysis and related disciplines, with particular attention to the contribution of the three-level model (3-LM). We analyze the case of a patient treated with transference-focused psychotherapy (TFP), making explicit the theoretical-clinical agreements and disagreements of the authors. We discuss the strengths and limitations of triangulation and contextualization, concluding that they make clinical work and psychoanalytic writing more reliable, transparent, auditable, and replicable.

Keywords:

• Clinical evidence
• psychoanalytic pluralism
• psychoanalytic case study
• clinical discussion groups
• three-level model
• triangulation
• contextualization
• qualitative clinical research
• psychoanalytic writing
• borderline disorder
• narcissistic disorder

ACKNOWLEDGEMENTS

Thank you to the patient for authorizing us to publish the material, to Dr. Luis Villalba, for authorizing us to include his opinions as the patient’s treating psychiatrist and to Andrea Rodriguez Quiroga and John Clarkin for their valuable comments on the manuscript. We also thank Otto Kernberg, whose collaboration was fundamental to our project.

AUTHOR CONTRIBUTIONS STATEMENT

The Introduction and Methodology were written by Ricardo Bernardi (RB). The clinical material was contributed by Monica Eidlin (ME). The final discussion specifies which opinions are shared by both authors and which are the opinions of one of them. The writing as a whole was done by RB and the writing of each author’s opinions was done by each author.

DISCLOSURE STATEMENT

The authors do not have any relevant financial or non-financial competing interest.

DISCLAIMER

Potentially personally identifying information presented in this article that relates directly or indirectly to an individual, or individuals, has been changed to disguise and safeguard the confidentiality, privacy and data protection rights of those concerned, in accordance with the journal’s anonymization policy https://www.tandfonline.com/journals/upaq20.

Notes

1 It is important to highlight the importance of the changes introduced by ICD-11 in the diagnosis of personality disorders. The Alternative DSM 5, Section III, had already anticipated these changes. The new diagnostic criteria imply a paradigm shift in relation to previous versions of the ICD and the classic version of the DSM-5. Instead of being based on a purely descriptive and atheoretical list of symptoms, the current diagnosis examines the functioning of the person at the level of the self and the relationship with others, which implies a greater clinical richness. The new diagnostic criteria open new possibilities for dialogue of psychoanalysis with the field of psychiatry and mental health (Bach & Simonsen 2021; Blüml et al. 2021; Clarkin 2022). The psychoanalytic literature has not yet sufficiently responded to this challenge.

Additional information

Notes on contributors

Ricardo Bernardi

Ricardo Bernardi: Medical Doctor. Psychiatrist. Master in Psychoanalysis. PhD in Psychology Member of the Uruguayan Psychoanalytical Association (APU) Professor Emeritus at the School Medicine, Uruguay. Full Member of the National Academy of Medicine, Uruguay.

Monica Eidlin

Monica Eidlin: Psychologist. Master in Psychoanalysis Member of the Uruguayan Psychoanalytical Association (APU). Member of the Executive Board of ISTFP (International Society of Transference-Focused Psychotherapy).