Rethinking therapeutic action

Like other core psychoanalytic constructs, the theory of therapeutic action is currently in flux, as theorists of differing persuasions propose different mechanisms. In this article, the authors attempt to integrate developments within and without psychoanalysis to provide a working model of the multifaceted processes involved in producing change in psychoanalysis and psychoanalytic psychotherapy. A theory of therapeutic action must describe both what changes (the aims of treatment) and what strategies are likely to be useful in facilitating those changes (technique). The authors believe that single-mechanism theories of therapeutic action, no matter how complex, are unlikely to prove useful at this point because of the variety of targets of change and the variety of methods useful in effecting change in those targets (such as techniques aimed at altering different kinds of conscious and unconscious processes). Interventions that facilitate change may be classified into one of three categories: those that foster insight, those that make use of various mutative aspects of the treatment relationship and a variety of secondary strategies that can be of tremendous importance. They propose that, in all forms of psychoanalytic treatment, we would be more accurate to speak of the therapeutic actions , rather than action .     

The therapeutic action of psychoanalysis

Psychoanalysis does not seek to get rid of symptoms but to question them as witnesses of psychic functioning and as formations of the unconscious. Whatever their nature may be, it is a question of analysing their causes and their functions as they appear and develop during the course of the analytic process. The latter is activated by the transference relationship induced by the method within a specific setting. The aim is to bring about liberating psychic transformations. The extension of the indications and modifications in the expression of psychic suffering have led to the development of psychotherapies. Their relations with psychoanalysis proper have been evolving constantly since the first advances by Ferenczi. This long historical evolution has resulted in their redefinition. Psychoanalytic practices are currently considered to require, depending on the case, different settings and different modes of psychic involvement from the analyst. Contemporary psychoanalysis places emphasis on the internal setting of the analyst (thus his training), analysis of the countertransference, and the risk of anti-analytic aberrations.     

Affect and the therapeutic action of psychoanalysis1

In connection with controversial IJP articles by Stern et al. and Fonagy on the interpretation of the repressed and the recovery of past memories, the author maintains that the affect that is inherent in positive transference is at the heart of therapeutic action. Points of view put forward in the controversy (based on neurobiological knowledge) are related to Freudian metapsychology, as well as to their precursors whose scope was necessarily limited by a lack of access to more recent scientific discoveries. The author demonstrates metapsychological elements of therapeutic action inherent in the intersubjective relationship, especially identification, manifested in introjection and empathy. He describes cognitive development as spontaneously blossoming from the affective nucleus, and he explains the neuroscientic bases of this step forward. The classic (interpretative) psychoanalytic method makes up the cognitive superstructure necessary for the organisation of the mind that has sprung from the affective substructure. As a primary factor in psychic change, interpretation is limited in effectiveness to pathologies arising from the verbal phase, related to explicit memories, with no effect in the pre‐verbal phase where implicit memories are to be found. Interpretation the method used to the exclusion of all others for a century is only partial; when used in isolation it does not meet the demands of modern broad‐spectrum psychoanalysis, as the clinical material presented illustrates.     

The analyst's trust and therapeutic action

The analyst's trust, a neglected topic in psychoanalytic discourse, participates in therapeutic action--through the analyst's emotional openness, "unobjectionable positive counter-transference" (see Fox 1998), the holding environment, and the promoting of adaptive internalizations, among other ways. When the analyst's trust--in the patient, in the analyst's self, and/or in the psychoanalytic process--fails, crucial interactions may occur, capable of destroying treatment, or alternatively, of restoring mutual regulatory functions and potentially leading to important mutative processes. Patients benefit from analysts' becoming sensitive to, having useful ways of thinking about, and working with their states of trust and distrust. The author presents clinical examples to illustrate these points.     

The nature of therapeutic action in psychoanalysis

The nature of therapeutic action varies not only with each patient's psychological predilection for utilizing opportunities for change, but also with the manner in which the analyst or therapist presents opportunity for change. Ideally, the therapist bases the latter on personally identifiable theoretical concepts and aims. This inquiry focuses on a relatively narrow field of clinical material in order to provide as close as possible an examination of therapeutic action. The technical approach provides opportunities for change, minimizing alterations resulting from internalizing processes or suggestion. The therapeutic actions arise from analyst and patient sharing observations of the patient's intrapsychic activities of resistance to drive derivatives the patient briefly allowed into consciousness, and represent processes of ego maturation set in motion by intellectually gained and experientially exercised insights.     

Psychoanalytic goals,therapeutic action,and the analyst's tension

The author draws a distinction between the goals of psychoanalysis and its therapeutic action. Goals are consciously (or at least preconsciously) held by the analyst, and can be clearly articulated. Ideas about the mechanism of therapeutic action, in contrast, are hypothetical constructs, and cannot be completely spelled out. This is bound to leave analysts in a state of tension; we are certain about what we are trying to do, but what we are actually accomplishing is elusive. This tension may be optimal for the analyst, because attention must be paid simultaneously to the idiosyncratic relationship in the dyad and to the broader purposes of the analytic engagement.     

On the action of social groups

This paper deals with the question of whether and when it is appropriate or inappropriate to say that a social group performs an action. After some remarks on the concept of action three kinds of groups are distinguished, i.e. assemblies, institutions, and classes. It is found that in the first two of these cases predication of action is possible: an assembly can act in that all its members act, or some of them do who are interchangeable with any others; and an institution can act because it has a structure and some individuals can act on its behalf. A class, however, cannot be said to act, for its concept may be freely formed, its members cannot be assembled, and it has no organs through which actions could be performed.     

SSRI Reduction of Nonparaphilic Sexual Addiction

The author presents two cases of nonparaphilic sexual addiction (NPSA) with comorbid depression and other psychiatric disorders in which symptoms were relieved during treatment with selective serotonin reuptake inhibitors. NPSA is defined and comorbid disorders, the neurotransmitter hypothesis of sexual function, treatment considerations, and evidence for an obsessive-compulsive disorder vs mood/affect dysregulation disorder etiology for these sexual symptoms are discussed.     

Silence and communication: nonverbal dialogue and therapeutic action

The subject of this article is silence as communication, with the starting point in the silences of three patients in treatment—in one of them his silences lasted up to a year. Silence is also seen as a specific dimension linked to speech, as the treatment of a third patient shows. The nonverbal interaction between patient and analyst is illustrated. This interaction led to a developmental process in each of the patients, characterized by fusion and separation processes, which included a development of three-dimensionality. The curative process taking place in each of the three, not through verbalisation but through the relation, is understood in the light of Modell's (1990) concept of “dependent/containing transference”. The treatment results demonstrate that the “dependent transference” is curative in itself when the therapeutic setting is maintained. The analyst's inner work during the dependent transference is described: a form of nonverbal participation and joint creativity in the intersubjective field.     

From the word to the scene: An expanded conceptualization for therapeutic action

The American Journal of Psychoanalysis -     

The colourless canvas: representation, therapeutic action and the creation of mind

Freud's initial formulations viewed psychoanalysis as working towards the rediscovery of psychic elements - thoughts, feelings, memories, wishes, etc. - that were once known - represented in the mind, articulatable, thinkable - but then disguised and/or barred from consciousness. His subsequent revisions implicated a second, more extensive category of inchoate forces that either lost or never attained psychic representation and, although motivationally active, were not fixed in meaning, symbolically embodied, attached to associational chains, etc. Following Freud's theory of representation, the author conceptualizes these latter forces as "unrepresented" or "weakly represented" mental states that make a demand upon the mind for work and require transformation into something that is represented in the psyche, if they are to be thought about or used to think with. This paper describes, discusses and presents illustrations of this transformational process (figurability),that moves intersubjectively from unrepresented or weakly represented mental states to represented mental states, from force to meaning, from the inchoate to mental order.     

Our changing views of the therapeutic action of psychoanalysis: comparing Strachey and Loewald

A comparison of Strachey and Loewald on the nature of therapeutic action reveals a deep shift in analytic interest away from the structural point of view and toward object relational and interpersonal frames of reference. Loewald's theoretical and technical revisions are far more sweeping than is usually acknowledged, and we can better benefit from his contribution by recognizing the full extent of his originality. Loewald's work also illuminates a major challenge for contemporary psychoanalysis: the need for an integration of the now disparate languages of metapsychology and clinical process.