Understanding Therapeutic Action: Psychodynamic Concepts of Cure

As the title promises, the therapeutic action targeted in this edited tome is limited to the scope of what Alonso calls “a host of dynamic therapies,” targeting therapeutic action in the context of broad-based psychoanalytic theories that emphasize relational and self psychological constructs. Lifson’s choice of authors ranges from “heavy hitters” in the psychoanalytic field (e.g., Meissner, Kernberg, Modell, Adler, Paul and Anna Ornstein, Lichtenberg, Mitchell, and Alonso) to lesser known authors (e.g., Teicholz, Herzog, Russell, Fishman, and Stark).

Two of the chapters stand on their own and have their own direction—Kernberg’s on diagnosis in adolescence and the Ornsteins on presenting a schema for psychoanalytic psychotherapy from a self psychological point of view. However, a central theme of this book presents a paradox: that is, Mitchell’s view that Freud’s influence on psychoanalytic theorists has persisted despite the fact that “while Freud’s explanations worked persuasively in his day it can no longer work for us.”

A core theme of this book focuses on the relationship between patient and therapist and the use of that relationship as the “curative” force in the therapy. Mitchell sees “cure” as best occurring in the countertransference because “to study something is to interact with it.” He views Freudian authority as abusive and interpretations as not having as much weight in contemporary psychoanalysis as does the emotional response of the analyst and the struggle between patient and analyst “to find a different kind of emotional connection.” A central message is that analysis has changed from a patient-centered treatment to a patient-therapist relational matrix. Flexibility in method is de rigeur.

Alonso’s opening chapter gets right to the point by reinterpreting the core psychoanalytic concept of “therapeutic neutrality.” Using a relational model, she views the therapist as a “participant observer” or “interventionist.” In this model, the clinician is more transparent than opaque, more flexible than abstinent. The old psychoanalytic adage, “Don’t gratify the patient and remain a blank screen,” is dismissed as possibly increasing the patient’s shame and leading to a stalemate in therapy. Meissner, viewing psychoanalytic cure as discovered “in the therapeutic alliance versus the real relationship,” emphasizes the importance of the real relationship with the analyst in stimulating transference. At times, however, he views the real relationship as becoming a resistance to progress in treatment. He urges us not to give advice to patients because it “crosses the boundary between alliance and reality and undermines the alliance.” Modell views transference as an intersubjective process but warns us that “a relational view of the transference can be overdone.” His focus on memory as retranscription highlights the problems of what is remembered by analysands, especially those suffering from trauma. Adler focuses on how the patient with borderline or narcissistic personality disorder uses the analyst as a transitional object, “selfobject,” and real object for curative purposes. The Ornsteins present a summary of Kohut’s self psychological theory and demonstrate how psychopathology may be the result of “a deficit in the structure of the psyche.” For those patients, “the healing process involves the analyst’s optimal empathic responsiveness to the patient’s subjective experience.” The patient’s obstacle to “cure” is the fear that “in the transference he/she will be retraumatized by his/her openly expressed needs and wishes.” Structure building through transmuting internalization replaces insight as the curative force. Working from a self psychology model, “the acquisition of empathic contact with selfobjects is the essence of psychoanalytic cure.”

Less compelling arguments of what constitutes therapeutic change include the following: 1) Lichtenberg’s concepts of “self righting” (“the inherent tendency to rebound from a deficit”), shared expanding awareness, and the rearrangement or recategorization of symbolic representations, 2) Herzog’s cryptic statement that the analyst’s conclusion that “something has happened” provides an explanation for the reconfiguration of the patient in the process of change or “cure,” 3) Russell’s use of his dream to view “process and involvement” as the curative force; and 4) Fishman’s “listening to affect” (he gives a personal example of when he almost cried in treatment and why not doing so was therapeutic) and his statement that “the patient desires a response from the therapist and feels that it comes from inside their mutual attachment.” Moreover, Lichtenberg says, “psychoanalysis leads not simply to knowing more but to reworking, recategorizing and rearranging.”

Stark summarizes the three models of therapeutic action outlined by Mitchell as representative of when and how therapeutic action must occur. The three models include the drive-conflict model, the deficiency-compensation model, and the relational conflict model. She argues that countertransference “is now seen as inevitable and as offering the therapist one of the most effective ways to understand the internal workings of the patient’s mind.” In this context, she focuses on one type of patient (commonly seen in practice) who needs to be in a relationship with a bad object and uses the therapist by drawing him or her into the inevitable reenactments (with the analyst resisting getting lost in them) in order to allow for change to take place. Mitchell sees “therapeutic action as involving correction for the internal presence of bad objects by way of working through the negative transference.” The relational model helps us to understand why the patient needs to remain attached to the bad objects and why “we must be able to let the patient make us fail him.”

Many psychodynamic theorists and psychoanalysts have placed their bets on a relational model of psychoanalysis. The role of interpretation and insight in psychoanalytically oriented therapy and psychoanalysis is changing rapidly. There is no Holy Grail. For newcomers to the field, this book offers a glimpse into the problems and process of contemporary psychoanalysis. It is worthwhile reading.