Psychotherapy Research

ISSN: 1050-3307 (Print) 1468-4381 (Online) Journal homepage: https://www.tandfonline.com/loi/tpsr20

Differentiation in Self- and Object-Perception as

a Goal in Psychodynamic Short-Term Therapy: A
Cluster-Analytical Evaluation

Tamara Fischmann , Johannes Kaufhold , Gerd Overbeck & Ralph Grabhorn

To cite this article: Tamara Fischmann , Johannes Kaufhold , Gerd Overbeck & Ralph Grabhorn
(1999) Differentiation in Self- and Object-Perception as a Goal in Psychodynamic Short-
Term Therapy: A Cluster-Analytical Evaluation, Psychotherapy Research, 9:4, 468-484, DOI:
10.1080/10503309912331332871

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Psychotherapy Research 9(4) 468-484, 1999

DIFFERENTIATION IN SELF- AND

OBJECT-PERCEPTIONAS A GOAL
IN PSYCHODYNAMIC SHORT-TERM THERAPY:
A CLUSTER-ANALYTICAL EVALUATION
Tamara Fischmann
Sigmund-Freud-Institute, Frankfurt/Main
Johannes Kaufhold
Johann Wolfgang Goethe University, FrankfudMain
Gerd Overbeck
Ralph Grabhorn
University Hospital for Psychosomatic Medicine and Psychotherapy,
Johann Wolfgang Goethe University

In this paper, the question is examined as to how object relationship

patterns can be adequately recorded and evaluated in the therapy pro-
cess. Based on the consideration that the differentiation of object percep-
tion and its relationship patterns is a goal of psychodynamic therapy, a
method for measuring repetitive interaction patterns is presented as an
indicator of change. An approach based on cluster analysis offers the
opportunity to record and evaluate the entire structure of a therapy with-
out taking individual qualitative features out of their context to one an-
other and to the specific object. The therapy records of a 3-month inpa-
tient psychotherapy were evaluated with a content analysis, using the
Structural Analysis of Social Behavior (SASB). The results of the cluster-
analytical evaluation of this content analysis provide convincing evidence
that the structure of the described object relationships can be recorded,
and their transformation processes can be demonstrated with this pro-
cess in the course of the therapy.

The detailed analysis of psychotherapeutic processes is becoming increasingly im-

portant within the framework of qualitative-empirical psychotherapy research. Spe-
cial attention is being focused o n the coverage of therapeutic changes that imply
changes in self-perception as well as new object-relationship experiences. Finding
precisely what is the “change in the structure of the patients’ behavior in relation-
ships” (Strupp & Binder, 1993, p. 161, which is shaped by internalized self-object
representations stemming from interactive experience, can be regarded as a substantial
goal of psychodynamic therapy (Sandler, 1989).

An expanded version of this paper was presented at the 28th Annual Society for Psychotherapy Re-
search (SPR) Meeting in Geilo, Norway, on June 27, 1997.
Address correspondence to Tamara Fischmann, Sigmund-Freud-Institute, Myliusstr. 20,60323 Frankfurt,
Germany.

468
DIFFERENTIATION IN SELF- AND OBJECT-PERCEPTION 469

This paper describes a method suitable for analyzing relationship experiences,

exemplified in the case of an anorexic patient. With the help of a procedure based
on cluster analysis, the aim is to evaluate the changes that have occurred in the rela-
tionship experience, based on self- and object-relationship patterns reported in therapy.
Taking a multifactorial clinical picture comprising biological, sociocultural, and
psychodynamic factors into account (Garfinkel & Garner, 1982; Fichter, 1985), the
eating disorder is unanimously regarded as a severe psychosomatic illness linked
to corresponding changes and/or disturbances in self-perception and relationship
experiences. Based on clinical experience to date, and supported by comprehen-
sive literature (e.g., Feiereis, 1989; Csef, 19971, it can be assumed in psychogenic-
psychodynamic terms that in the case of anorexic patients, the narcissistic person-
ality disorder with the struggle for differentiation and autonomy (Overbeck, 1979;
Herzog, Munz, & Kachele, 1996) plays quite a central role by causing drive conflicts
that result from developmental demands. The intrapsychically and interpersonally
anchored conflicts underlying the illness are manifested as behavioral disorders in
the patient’s own body, which functions as a self-object. In other words, there is a
shift from the psychosocial dimension to a somatic one (Selvini-Palazzoli, 1988).
Consequently, a major therapeutic goal in the treatment of anorexia is to bring the
patient’s identity conflict from the symflom level back to the relationship level.
Starting from these theoretical assumptions, an attempt is made in this paper to
answer the questions as to whether, in the framework of inpatient psychodynamic
short-term therapy: (1) changes occur in the variability of self and object perception,
(2) qualitative changes occur in the described relationship patterns, and (3) “resocializa-
tion” of the original relationship conflict is recognizable, in the form of a shift of the
conflict from the body back to the external objects.

METHOD AND APPROACH

One method that allows us to depict the perception of oneself and others is the Struc-
tural Analysis of Social Behavior (SASB) (Benjamin, 1974). By means of verbatim
protocols of therapy sessions, reported interpersonal and intrapsychic behavior is
recorded and analyzed in categories with three foci: the other, the self, and the in-
troject. To describe prevailing interactional relationship patterns, that is to say, “How
does the other person treat me and how do I react?”and vice versa, it is necessary to
summarize categories that are interactionally related to each other in terms of a re-
lationship pattern. One method that enables a grouping of individual categories with
respect to a criterion is the cluster analysis. Based on this analysis, prevailing repeti-
tive patterns can be determined, which ultimately permits the description of (reported)
typical behavior patterns in the interpersonal domain. To do this, so-called “thought
units”-the smallest semantic units of meaning-from the speech inputs are first
differentiated (cf., Tress & Junkert, 19931, and, drawing on a method by Grande (19971,
are finally summarized into interaction sequences (IS). Then, referents (objects) are
determined, with which the patient describes an interaction in these sequences. The
selection of objects and their summary into object groups should be guided by clini-
cal or scientific issues, always bearing in mind that this selection represents an im-
portant predecision, which may influence the findings. Therefore, when studying
the course of therapeutic processes, object groups should be selected in such a way
that an object differentiation can be represented. To do this, the objects must be
summarized into exclusive groups against the background of theoretical consider-
470 FISCHMANN ET AL.

ations. The question raised here regarding changes in object perception in a n inpa-
tient short-term therapy based on the concept of reenactment Uanssen, 1987) made
it necessary to differentiate between objects outside the ward (“outside objects”) and
on the ward (“inpatient objects”). For the object group of outside objects, we consid-
ered all of the interactions described by the patient with her father, stepmother, sis-
ter, friend, staff in the department of internal medicine, and the health insurance
provider. As for the “inpatient objects,” we evaluated the interactions with the indi-
vidual therapists, the therapy team, other patients, and in-group therapy. The clini-
cal picture of anorexia strongly suggests that all interactions that involve coming to
terms with oneself, the body, and the illness, should be summarized in a separate
group-“parts of self.”“Others”involve a group of people who are generally men-
tioned by the patient, but cannot be classified distinctly under one of the above
mentioned groups. Accordingly, we defined the following four object groups for this
study material: (1) objects outside the ward (outside objects), (2) Objects on the ward
(inpatient objects), (3) parts of the self, and (4) Others.
After defining the objects and the interaction sequences, one of the three foci is
then determined for every thought unit within such a sequence: other, self, and in-
troject, respectively. The focus other involves actions actively directed toward the
other. The focus self, on the other hand, involves reactive behavior. Because the
codings plotted on the focus introject do not represent any concrete interactions with
other objects, but rather how one deals with oneself, this focus has not been consid-
ered in the following study (see Figure 1).
Once a focus has been determined, every thought unit is scored in terms of the
distinctness o n the two dimensions, affiliation (horizontal axis), and interdependence
(vertical axis). Due to the circumplex structure of these orthogonally related dimen-
sions in the underlying model, this results in an assignment to one of the eight codings
of a focus’ (cf., Tress & Junkert, 1993) (see Figure 2 ) .
After the objects and the respective codings have been determined for the indi-
vidual interaction sequences, the latter are not only examined with regard to their fre-
quency, but are also summarized-with the help of a hierarchical cluster analysis -
into patterns that can be assigned to the individual objects and thus yield a compre-
hensive picture of the self-object relationship patterns. Following Grande’s approach
(19971, the “average linkage between groups” is used as the fusion procedure, with
the Jaccard coefficient as a measure of similarity. The repetitive patterns are thus de-
termined on the basis of two substantive criteria: (1) a Jaccard coefficient of s,, = .452,
and (2) an SASB cluster must occur at least three times (in the case of N,, I 8 0 interac-
tion sequencesI3 or four times (in the case of N,, 2 80 interaction sequences) in the

‘The interrater reliability of the rater group for determining the thought units and the “ratings” after
rater training has been completed was K = .73.
*A threshold value of s,, = .45 means in content that two interaction sequences are similar to one an-
other if the share of codings deviating from one another no longer exceeds the coinciding coding,
except minimally. A threshold value that is too high thus harbors the risk of overdifferentiation, that
interaction sequences which are similar in content will be separated from one another by mistake be-
cause of marginal deviations, whereas one which is too low will result in interaction sequences with
clearly deviating relationship characteristics being wrongly evaluated as similar.
3When establishing a repetition criterion, it should be borne in mind that, depending on the number of
required repetitions, patterns may result as a coincidental product of the cluster analysis. Grande (1997)
found that in N = 80 relationship episodes and a repetition criterion of 3, as well as in N = 120 relationship
episodes and a repetition criterion of 4, a pattern previously determined occurred at random in one of ten
patients, and with a frequency that just barely fulfills the repetition criterion. However, if the pattern occurs
more frequently than reqbired by the repetition criterion, the probability of error drops to less than 10%.
DIFFERENTIATION IN SELF- AND OBJECT-PERCEPTION 47 1

FOCUS: OTHER SELF INTROJECT

Tr a nsit ive Intransitive Action

Action State Inward

EMANCIPATE :SEPARATE

+6-

0-
- -
-3-
-6-

FIGURE 1. SASB dimensions.

interaction sequences summarized into a group. This number ensures that the pattern
is, in fact, a frequent one.
In order to describe and draw conclusions about changes in the therapy pro-
cess, the therapy is subdivided into phases, which may vary, depending o n the
material studied. The units studied, however, should contain codings from at least
two conversations (cf., Grande, 1997). In the current case, the therapy was sub-
divided into three parts, in line with the clinical inpatient concept: admission (ther-
apy hours: 1-61, working through phase (therapy hours: 7-13), and separation
phase (therapy hours: 14-19). Figure 3 shows how objects in Phase 1 are grouped
according to their similarity in a hierarchical cluster analysis. These groups can
be used to determine the repetitive patterns based o n the above mentioned
criteria.
472 FISCHMANN ET AL.

EMANCIPATE
SEPARATE
(xll-x21)

WALL OFF

ATTACK ACTIVE LOVE

RECOIL REACT1VE LOVE
(xi 7-x27) (xl3-x23)

CONTROL
SUBMIT
(XI 5x25)
FIGURE 2. SASB cluster model.

SAMPLE CASE

The therapy examined here is the 3-month inpatient psychotherapy of a 27-year-

old female patient with chronic anorexia (DSM IV; ICD10: F50.01, which was carried
out at the hospital for psychosomatic medicine and psychotherapy of theJohaM Wolfgang
Goethe University. The concept for inpatient therapy, which is limited to 3 months, can
be classified among the “integrative treatment models” Qanssen, 1987), that is, several
therapists (the team) and various therapeutic components (such as analytically oriented
iwbvidual and group therapy, creative therapy, body-oriented psychotherapy, and music
therapy-as well as sports and progressive muscle relaxation-are combined in the
therapeutic process.’ During the treatment in this case, the patient’s weight increased
from 88 pounds to 99 pounds, her height is 5 feet 6 inches. The psychological test re-
sults of the SCL-90-R (GSI admission 2.36 and discharge 1.6) also indicate a change in
the direction of normality (for details, cf., Grabhom et al., 1994).

RESULTS

All of the behavior patterns reported by the patient in the 19 individual therapy
sessions were encoded according to the above described procedure. For the 320
interaction sequences with a total of 933 codings, 11 repetitive patterns were iden-
tified in Phase 1, six in Phase 2, and nine in Phase 3, which fulfilled the repetition
criterion.
DIFFERENTIATION IN SELF- AND OBJECT-PERCEPTION 473

Object Groups Jaccard Coefficient = .45 Repetitive Patterns

j..inbj~ -.... ,
I Out. Obi.
1 Out Obi
Others
I Others

In ObJ
In ObJ.
In ObJ
In ObJ
In Obi

_ .

II I

t I I I
1S-P25-P27
0

FIGURE 3. Cluster solution in Phase 1. In a hierarchical cluster analysis, the objects

are evaluated with regard to their similarity, and summarized into groups according to
this criterion. In the dendogram, the typical form of representation, short lines between
two objects mean a high degree of similarity and long lines a high degree of disparity.
The objects that are summarized last exhibit the highest degree of disparity.
474 FISCHMANN ET AL.

VARIABILITY OF THE SELF AND OBJECT PERCEPTIONS

IN THE COURSE OF THERAPY

With respect to the codings, much of the spectrum in the SASB model is already
used at the beginning of the therapy (10 of the 16 possible codings). At the end of the
therapy, the patient makes use of it almost entirely (14 of the 16 possible codings).
Nonetheless, a few codings dominate in the individual phases. Throughout the therapy
the patient primarily describes the objects with IGNORE, CONTROL and ATIACK
and describes herself mainly with SUBMITand RECOIL, but also with WALL OFF(see
Table 1). A rigidity in the object perception is manifested, in that these three most fre-
quent codings make up 71.1% of the object descriptions in the first third, 63% in the
second third, and 61.8%in the last third. The rigidity is less pronounced in her percep-
tion of self. Here the patient uses three codings to describe herself in the individual
phases in slightly over half of the cases (Phase 1:53.1%; Phase 2: 51.1%;Phase 3: 50.8%).
On the whole, the patient feels herself to be more variable than her partners in interac-
tion (see Table 1).

Table 1. Frequency of the SASB Clusters

~

Phase 1 Phase 2 Phase 3

Referent SASB-Cluster % SASB-Cluster % SASB-Cluster YO
Patient SUBMIT 20.3 SUBMIT 20.5 RECOIL * 25.1
BLAME * 16.4 RECOIL 16.6 SUBMIT 13.3
WALL OFF * 16.4 SEPARA TE 14.0 SULK * 12.3
RECOIL 13.3 CONTROL 7.9 WALL OFF * 11.3
SULK 7.8 DISCLOSE * 7.9 SEPARATE 77
CONTROL 7.0 SULK 6.1 BLAME 5.6
TRUST 4.7 WALL OFF 6.1 DISCLOSE * 5.1
ACTIVE LOVE 3.9 BLAME 4.8 7RUST 4.6
AlTACK 3.9 liPUST 3.9 ATTACK 3.6
SEPARA TE 2.3 AFFIRM 3.5 CONTROL 3.1
IGNORE 1.6 IGNORE 2.6 AFFIRM 2.1
AFFIRM 0.8 ATI'ACK 1.7 l7EAcnVE L O W 2.1
PROTECT 0.8 REACnVELOVE 1.7 ACTIVE LOVE 1.5
DISCLOSE 0.8 EMANCIPATE 1.3 EMANCIPATE 1.o
ACTIVELOVE 1.3 PROTECT 1.o
IGNORE 0.5
Objects IGNORE * 27.7 CONTROL * 28.6 IGNORE * 29.2
CONTROL * 24.1 ATTACK 18.8 A'ITACK 19.4
A'ITACK 19.3 IGNORE 15.6 BLAME 13.2
BLAME 13.3 AFFIRM * 9.1 CONTROL 11.8
PROTECT 6.0 BLAME 7.1 SEPARATE 8.3
EMANCIPATE 2.4 EMANCIPATE 4.5 PROTECT 4.9
SEPARA TE 2.4 SEPARA 7E 4.5 AFFIRM 3.5
AFFIRM 1.2 PROTECT 3.9 EMANCIPATE 2.1
SUBMIT 1.2 DISCLOSE 1.9 DISCLOSE 2.1
RECOIL 1.2 WALL OFF 1.9 WALL OFF 2.1
WALL OFF 1.2 ACTIVE LOVE 1.3 liPUST 1.4
SUBMIT 1.3 SUBMIT 1.4
RECOIL 1.3 SULK 0.7
*p < .05; across phases
DIFFERENTIATION IN SELF- AND OBJECT-PERCEPTION 475

Distinct differences with respect to the frequency of individual codings are no-
ticeable between the individual therapy phases, which are expressed in a signifi-
cantly higher frequency of individual categories in the individual phases as opposed
to others. In the object perception, these are the codings IGNORE and CONTROL in
the first phase, the codings CONTROL and AFFIRM in the middle therapy segment,
and IGNORE in the last phase.
In the perception of self, the patient describes herself with BLAME and WALL
OFF with a significantly higher frequency in the first phase, whereas the codings
SEPARATE, CONTROL, and DISCLOSE occur with significantly higher frequency in
her descriptions of self in the middle phase. At the end of the therapy, RECOIL, SULK,
WALL OFF, and DZSCLOSE dominate by comparison to the other phases.

CHANGE IN THE PATTERN OF INTERACTION

OVER THE COURSE OF THERAPY

Following the above described evaluation of frequencies of individual catego-

ries, the changes occurring in interaction patterns will now be looked at more closely,
by evaluating the coding patterns found by means of the hierarchical cluster analy-
sis. Figure 3 shows the cluster solution for the repetitive interaction patterns.

FIRST THIRD OF THE THERAPY

Two patterns (6 and 7; see Figure 4 ) are noticeable in this phase of the therapy,
which are formed almost exclusively from interactions with parts of the self. In these
two repetitive patterns, the patient describes interactions with those parts of herself
in which she feels overwhelmed (ATTACK) and also controlled (CONTROL) by her
needs and her illness, is at their mercy (SUBMZT RECOZL), as illustrated by the fol-
lowing quotations.

CONTROL
N=9 Self (out. Obj., in. Obj.)
RECOIL

“. . . , whenever my illness trips me up because I am horribly handicapped by it

. . . there’s no longer any ground under my feet that’s somewhat tangible, something
for me to stand on . . . this craving was there again, the urge to gorge myself and the
fear that even that little bit that I eat . . . I will gain 2 pounds.”

ATTACK

SUBMIT x N=4 Self

“I started out with a cookie and this craving was there and last night I just wasn’t able
to resist it. . . . that it was a miracle that I had always been able to control it somehow.
And last night I just couldn’t any more. That was a real setback, that really hurt . . .”
476 FISCHMANN ET AL.

I Fpl
Other
IGNORE

2
in. Obj. .k IGNoR-

kJ$T
in. Obj.

f BLAME- BLAME R
BLAME
4.
out. Obj
out. O b j

5.

6.
3out. O b j
out. Obj
Other
out. Obi
J
I

CONTROL
f SUBMllbJ)
RECOIL
f
W
Self
Self

ATTACK

FIGURE 4. Repetitive patterns in the first third of the therapy.

At the beginning of the therapy she blames the inpatient objects for not having
any time for her,’for not offering to help her.

2. ?IGNoR- N=5 in. Obj.

“Last night I had this very strong feeling because I tried, when I noticed that I
wouldn’t be able to manage this craving right now. In the dayroom I tried to talk
with the others but it was like running into a brick wall . . , why you can’t get any
help, no help at all from the doctors, right when I know that I just can’t make it by
myself anymore.”
DIFFERENTIATION IN SELF- AND OBJECT-PERCEPTION 477

The patient describes people from her past (stepmother, father, friend) as hurting
and accusative (BLAME), and her reactions are always the same, which she describes
as distancing herself (WALL OFF), accompanied by a feeling of giving in (SUBMIT).

BLAME

WALL OFF R N=4 out. Obj.

“No, no, especially since my stepmother was always saying w e were losers, and
that really got to me . . . so I’m just there, spent all of my time in the stable, just to
keep out of this woman’s way . . . So I tended to take the easy way out . . . , by
giving in.”
The patient experiences the controlling (CONTROL) measure of being moved
to the internal medicine ward as a relief (TRUST).

CONTROL

TRUST R N=4 out. Obj.

“Fed through the tube, I gained eight pounds. It was anything but nice the first
few days, then I got used to it, I learned to accept it. I felt pretty good there because
then-well, somehow I wasn’t responsible for my own existence anymore, I was
safe, in other words-and that was really a big relief for me in a way.”
At the same time, she reported two further patterns of interaction. One pattern
was one in which the others are either inconsiderate, ignore her, or reject her (IG-
NORE), and she consistently avoids contact (WALL OFF). The other pattern was one
in which she and her interaction partners show each other that they do not want to
have anything to d o with each other and/or do not accept each other (BLAME). This
brings to light her overall sensitivity (easily hurt or insulted) and mutual denigration.

“That was at the time when I broke off contact with my father. Because I was so
sick and tired of having to wait around all the time . . .”

3. .;t; BLAME- BLAME R N=4 Self, (out. Obj., in. Obj.)

“Yes, but the other side doesn’t accept my wanting to have something for myself
. and that is what makes me so aggressive.”
478 FISCHMANN ET AL.

SECOND THIRD OF THE THERAPY

In this phase (Figure 5) there are no purely “physical patterns,” that is, no pat-
terns of interaction with parts of the self, which was still the case at the beginning of
the therapy. Instead, she finds a place for these in various objects. She reports on the
parts of her self in the same way she had in the first phase of the therapy, namely as
controlling (CONTROL) and attacking (A’ITACK). But now she reports the same thing
again in connection with inpatient and outpatient objects. She reacts accordingly,
but now toward a broader spectrum of objects with submission (SUBMIT) and with-
drawal (RECOIL), the latter more in the sense of protest.

2.
JB ATTACK &2 coNTRDsia N=8 out. Obj., (Self, in. Obj.)

1.
out. Obj
out. Obj
Other
Other
out. Obj
in. Obj.
in. Obj.
out. Obj
out. Obj
in. Obj.
--
out. Obj

out. Obj
in. Obj.

w
out. Obj
Self
2. out. Obj 1
out. Obj
out. Obi
””..-”,.
L
out. Obj.
in. Obj.
CONTROL
t - 8
3. out. Obj.

in. Obj.
in. Obj.
Au SUBMIT
A

4.
ATTACK

w
out. Obj.
out. Obj.

w
IGNORE
in. Obj.
‘in. Obj.
5.

FIGURE 5. Repetitive patterns in the second third of the therapy.

DIFFERENTIATION IN SELF- AND OBJECT-PERCEPTION 479

“Yes, but I had always, I think I will only be accepted if I am exactly the way
the other people want me to be, and that, after all, once in a while I do react differ-
ently than other people think I do or should and then I’m not accepted again. . . .
Although I am trying this out, let’s say, to look and see what will happen if I, if I try
to be myself for once.”
She also reports on new experiences with her objects, namely about objects that
she does not want to understand or cannot understand (IGNORE), but she can now
speak about them, open up (DISCLOSE) about her disappointment (SULK).

- IGNORE

. . Because I just always had the feeling that he, he [my father1 just doesn’t un-
I‘.

derstand me, he doesn’t want to understand me, and he can’t show his feelings either,
he’s so awfully reserved . . . and yesterday was really the first time that I, that I tried to
explain something to him.”
Apart from this, she reports a complex pattern about the expectations that oth-
ers have of her (CONTROL), in relation to which she can set herself off for the first
time (SEPARAirE),even if she does not always succeed in doing so (SUBMIT), and in
this connection as well, that others can accept what she would like (EMANCIPATE).

SUBMIT
w N=l 1 out. Obj., in. Obj., Other

“So many horribly difficult situations arise for me on the weekends, because on
the one hand I am now far enough that I do not always want other people to decide
what I do, but on the other hand I notice that I am still simply not able to d o that yet.
But now I’ve noticed, what I never knew before, where this pressure, or this ten-
sion, actually comes from, or when it happens. And that’s only when others can tell
me what to do. If I let others tell me what to do, . . . But often they do not want to
control me at all.”

LAST THIRD OF THE THERAPY

During the last third of therapy (Figure 61, if the patient feels threatened by her
impulses (parts of the self) and the objects in the last part of the therapy, she can
defend herself (A’ITACK). In the following example, she speaks of the craving that
she perceives in herself and the others.

7. ? R N=5 Self, in. Obj. (out. Obj.)

480 FISCHMANN ET AL.

out. Obj
out. Obj
out. Obj . 1

Self
Other ATTACK
in. Obj.
1. In. Obj.
In. Obj.
Self
Self
3 P RECOIL &
WALL OFF
in. Obj.
Other
Other
-
Other

F- R
=-
out. Obj
in. Obj.
out. Obj
in. Obj. IGNORE
In. Obj.
SUBMIT &
2. out. Obj
out. Obj
in. Obj.
in. Obj.
in. Obj.
In. Obj.
in. Obj.

-
out. Obj
mt. Obj.
n. Obj. J I
n. Obj.
3. n. Obj.
but. Obj.
n. Obj.
-
n. Obj.
but. Obj.
But. Obj.
Self
4. Self
n. Obj.
but. Obj.
-
rut. Obj.

5.
but. Obj.
hut. Obj.
but. Obj.
but. Obj.
3ther
f wb IGNORE

but. Obj.
mt. Obj.
6.
Self J I
Self
-
Self
but. Obj.

7.
Self
Self
n. Obj.
-
-
n. Obj.
R R
but. Obj.
Jther PROTECT
8.
n. Obj.
n. Obj.
n. Obj.
‘kwb.k
FIGURE 6. Repetitive patterns in the last third of the therapy.

“. . . that I’ve seen, in other words the parts or things that have been bothering
me now about the other person, that I knew really bothered me, and then all of a
sudden I noticed, well that’s actually a part of you, you’re the very same way. And
maybe that’s, that’s also why I’m so upset, so irritated, inside now.”
She also notices that she is confronted by needs and objects that are not just con-
trolling, but, on the contrary, are simply there (SEPARAE), but she is still unsure of
DIFFERENTIATION IN SELF- AND OBJECT-PERCEPTION 48 1

herself, because, “I just don’t want to accept it that way yet” (RECOIL, Pattern 6). In
this phase, she comes to terms with feared disappointments by outside objects to a
greater degree. In this phase, she still describes feeling as if she had to be well be-
haved (SUBMIT), especially when she is confronted by a lack of understanding (IG-
NORE), but also by control (CONTROL). She now no longer breaks off contact, but
remains, albeit submissively, in the relationship (Patterns 5 and 4 ) . In the course of
this coming to terms, she deals with all objects in the form familiar to her, but at the
same time with greater variability (Pattern 1, A’ITACK =x=RECOIL and WALL OFF;
Pattern 2, IGNORE *e SUBMfland SULKand RECOZL; Pattern 3, BLAME =x= SULK).
Moreover, one pattern of interaction becomes more important for the first time,
when she acknowledges the inpatient objects as protecting objects that provide se-
curity (PROTECT), and she feels good about this (TRUST).

8 . t wb PROTECT
N=5 in. Obj., (out. Obj., Other)

“. . . so, when the day is over, and I have time in the evening to think that all
through again and then a whole lot of things really start bothering me, and I have
often taken advantage of the opportunity to talk about it with a therapist. That, of
course, naturally gives me a bit of security.”

SUMMARY AND INTERPRETATION OF THE RESULTS

As far as the variability of self and object perception is concerned, the frequency
evaluation of individual codings shows a rigidity in the object perception as opposed
to a greater variability in the perception of self from the very beginning. Although
no changes come to light in the course of the therapy, there are differences in the
dominance of codings between individual phases, which reflects the dynamics of
the therapeutic process.
The substantive connection of the codings with the repetitive patterns of the cluster
solution yield a much more differentiated picture. In the self perception, the cluster
solution exhibits separate patterns for the parts of self in the first third of the therapy,
in which the patient’s narcissistic world comes to light. In the object perception, mu-
tual offense or ignoring and distance-to which the patient feels helplessly exposed-
predominate in the interactions of this phase. In the second third of the therapy,
there are no longer any purely “physical patterns.” They are dissolved in object-
relation patterns, whereby the codings of these patterns are similar to those of the
physical patterns in the first phase. It can be said that the conflict with the body is
“resocialized” back to the original relationship conflict, to the extent that in these
relationship descriptions parts of the self move toward external objects, not only
substantively in manner but also personally, “with whom.” This is expressed in the
fact that there is a significant decline of more than 50% in the total number of inter-
actions reported on parts of the self, from 28.4% in the first phase to 11.6%in the last
phase. Moreover, in the last two phases, she acquires new “good” object experi-
ences and altogether more repetitive patterns, indicating a greater variability on the
patient’s part in dealing with her objects. The “good”object experiences are also
retained, in spite of the separation phase in the last third of the therapy, and there is
482 FISCHMANN ET AL.

no withdrawal into the world of the body. Although she also resorts to old relationship
patterns in the last two phases, she is now able to express her feelings and needs.
The course of treatment distinctly shows the tough struggle of a female patient
with chronic anorexia, both with her self and her others. It seems clinically relevant
to us that her narcissistic world begins to loosen up, with a distinct turning to exter-
nal objects. Catamnestic studies have shown (Deter & Herzog, 1995) that normaliza-
tion at the symptom level (weight, amenorrhea) is usually delayed, but can still occur
up to nine years after therapeutic treatment. In that sense, the changes occurring in
the microprocess, while quantitatively low, can be understood not just in clinical
terms, but are also significant in a treatment of anorexia.

DISCUSSION

A key concern of the paper was to review an approach based on cluster analysis to
describe the process in the course of a therapy, with the differentiation of self and
object perception. The results show that the pure frequency evaluation of individual
codings is not enough to show a sufficiently differentiated picture of the change within
short-term therapy in a female patient with severely disturbed interaction patterns.
In numerous works within psychotherapy research, however, the object relations
are analyzed precisely by means of qualitative features (cf., Luborsky & Crits-Christoph,
1990; Hildenbrand et al., 1994). Those mentioned most frequently are used to char-
acterize the course of the relationship. The repetitive interaction patterns (determined
here by means of interaction sequences) have the advantage that they record more
complex interaction patterns, and they are also based directly on the patient’s for-
mulations through concrete interactions with other persons. For this reason, they
coincide with the content of the patient’s statements in the course of the therapy,
which allows a greater measure of clinical validity to be achieved. The cluster-analytical
evaluation of the SASB content analysis thus proves to be a method which, in spite
of the tremendous effort in comparison to other content-analytic procedures, goes
beyond the simple description of isolated features. The analysis of the overall struc-
ture of the cluster soIution, moreover, permits a comprehensive representation of
the reported interactions with other people, and thus permits a differentiated insight
into the patient’s self and object representations.
With respect to the exemplary case of a female patient with an eating disorder,
one finds that changes have taken place in the self and object perception within this
short-term therapy. The evaluation of such changes within a therapy is difficult and
not always clear cut. In the current case, it was possible to validate them with test
diagnostic findings and results of other qualitative procedures (see Grabhorn, 1994),
which coincided with the contents described here and support an evaluation of the
changes as an improvement.
With regard to detailed process research, however, the question is still how
these changes occurred. The influence of inpatient treatment must of course be
taken into consideration just as much as the psychotherapeutic work in the various
other verbal and nonverbal therapies. In a future evaluation step, w e will examine
the extent to which the changes in the therapy can be attributed to the interac-
tional therapeutic process in individual therapy. The therapists’ codings will also
be evaluated by means of cluster analysis for this. Of central importance will be
the question of the extent to which the patient’s changed self and object percep-
DIFFERENTIATION I N SELF- AND OBJECT-PERCEPTION 483

tions are based on the therapist’s statements, in which case the changes would be
attributable to interventions by the therapist.

REFERENCES

Benjamin, L. S. (1974). Structural analysis of so-
cial behavior. Psychological Review, 81, 392-
425.
Benjamin, L. S. (1993). Intelpersonaldiagnosisand
treatment of personality disorder. New York/
London: The Guilford Press.
Csef, H. (1997). Psychotherapie der Magersucht
und Bulimia netvosa. Psychotherapeut,42,381-
392.
Deter, H.-Ch., & Herzog, W. (1995). Langzeitverlauf
der Anorexia nervosa. Gottingen: Vandenhoeck
und Rupprecht.
Feiereis, H. (1989). Diagnostik und Therapie der
Magersucht und Bulimie. Munich: Marseille.
Fichter, M. M., (1985). Magersucht und Bulimie.
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Garfinkel, P. E., &Garner, D. M. (1982). Anorexia
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York: Brunner/Mazel.
Grabhorn, R., Overbeck, G., Kernhof, K., Jordan,
J., 61 Muller, T. (1994). Veranderung der Selbst-
Objekt-Abgrenzung einer essgestorten Patientin
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273-283.
Grande, T. (1997). Suizidale Beziehungsmuster.
Eine Untersuchungntit derstrukturalen Analyse
sozialen Verhaltens (SASB). Opladen: West-
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Herzog, W., Munz, D., & Kachele, H. (1996).
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Hartkamp, N. (1994). Untersuchung kurzthera-
peutischer Prozesse mit der SASB/CMP-
Methode. In H. Faller and J. Frommer (Eds.),
Qualitative Psychotherapieforschung(pp. 246-
276). Heidelberg: Asanger.
Janssen, P. L. (1987). Psychoanalytische Therapie
in der Klinik. Stuttgart: Klett-Cotta.
Luborsky, L., & Crits-Christoph, P. (1990). Under-
standing transference. New York: Basic Books.
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Selvini-Palazzoli, M. (1988). The theoretic process
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Zusammenfassung
In dieser Arbeit wird der Frage nachgegangen, wie sich Objekt-Beziehungsmuster im TherapieprozeR
adaquat erfassen lassen. Ausgehend von der Uberlegung, daR die Differenzierung der Objektwahrnehmung
und deren Beziehungsgestaltung als ein Ziel psychodynamischer Therapie gilt, wird eine Methode zur
Messung repetitiver Interaktionsmuster als ein Indikator von Veraenderung vorgestellt. Ein clusteranalytisches
Vorgehen bietet die Moglichkeit, die Gesamtstruktur einer Therapie zu erfassen, ohne einzelne qualitative
Merkmale aus ihrem Kontext zueinander und zum spezifischen Objekt zu reisen. Die Therapieprotokolle
einer dreimonatigen stationaren Psychotherapie wurden inhaltsanalytisch mit Hilfe der “Structural Analy-
sis of Social Behavior” (SASB) ausgewertet. Die Ergebnisse der clusteranalytischen Auswertung dieser
Inhaltsanalyse belegen uberzeugend, daR die Struktur der geschilderten Objektbeziehungen erfaRt und
deren Transformationsprozesse im Verlauf der Therapie mit diesem Vorgehen aufgezeigt werden konnen.

Resume
Cette etude naturaliste examine la relation entre des patterns interpersonnels d e base mesures par la
methode du T h h e Relationnel Conflictuel Central (CCRT) et la psychopathologie chez 55 patients
selectionnes pour une psychotherapie psychodynamique d e longue duree. La psychopathologie a ete
484 FISCHMANN ET AL.

6valuCe selon DSM-111-R, par un auto-questionnaire de s y m p t h e s et par le Karolinska Profile Psycho-

dynamique (KAPP). Les patients avec des diagnosticsDSM-111-R differents n'ont pas montrk de difference
dans leur CCRT obtenu sur la base d'interviews RAP (Paradigme d'Anecdotes Relationnelles). Par ailleurs,
le manque de flexibilite (a pervasiveness dans l'emploi des diffkrentes composantes du CCRT n'a
pas kte associe A des sympt8mes psychiatriques. Une seule correlation significative entre pathologie de
caractere et CCRT a etk trouvee; une experience de position sociale problkmatique a Ctk associee B des
reponses de I'autre plus nkgatives. Nous discutons des limitations de la methode du CCRT et de
I'echantillon.

Resumen
En este trabajo se examina el problema de c6mo registrar y evaluar adecuadamente en el proceso
terapeutico las pautas de relacion objetal. Como indicador de cambio, se presenta un mktodo para
medir ias pautas de interacci6n repetitivas que se apoya en la consideraci6n de que un objetivo de la
terapia psicodinimica es discriminar el objeto de la percepci6n y sus pautas relacionales. El enfoque
basado en el analisis de cluster ofrece la oportunidad de registrar y evaluar la estructura total de una
terapia sin sacar 10s rasgos cualitativos individuales fuera de su context0 de relaci6n reciproca o con el
objeto especifico. Se evaluaron 10s registros de una psicoterapia durante sus 3 meses de internaci6n
con un anilisis de contenido, usando el Analisis Estructural del Comportamiento Social (SASB). Los
resultados de la evaluaci6n de este anilisis dan evidencia de que la estructura de las relaciones objetales
descritas son pasibles de registro y de que en el curso de la terapia pueden demostrarse sus procesos
de transformation.

Received December 30,1997

Revision Received December 12,1998
Accepted December 22,1998