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.     

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.     

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.     

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.     

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

The American Journal of Psychoanalysis -     

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.     

Moments of complexity and enigmatic action: a Jungian view of the therapeutic field

In presenting clinical case material for a panel on archetypes and/or primal phantasies an initial discussion of archetypes as emergent phenomena organizing 'moments of complexity' is given(1) . The relationship of such moments to 'moments of meeting' as developed by the Boston Change Process Study Group is commented on and explored within the context of the case. A condensed report of a multi-year analytic treatment of a bipolar patient having a severe trauma history is offered for discussion. Several unusual, enigmatic events are detailed to illustrate the occurrence of moments of complexity. Dreams highlighting psychological transformation stemming from a changing relationship to emerging archetypal material related to a psychotic process in the patient are offered to further detailed moments of complexity.     

Mobilizing fundamental modes of development: empathic availability and therapeutic action

A positive developmental thrust becomes mobilized by virtue of therapeutic action. This thrust is specified in terms of a set of fundamental modes of development that are biologically prepared and have been identified through recent research. The modes are first apparent in infancy and continue throughout life. The setting conditions which allow for the fundamental modes of development to be reactivated are provided by the therapeutic relationship. It is hypothesized that the empathic availability of the therapist enables these modes to operate as powerful background influences. Developmental aspects of empathy and of availability highlight the importance of adult regulatory functions and the construction of shared meaning.     

On the signals underlying conscious awareness of action

To investigate whether conscious judgments of movement onset are based solely on pre-movement signals (i.e., premotor or efference copy signals) or whether sensory feedback (i.e., reafferent) signals also play a role, participants judged the onset of finger and toe movements that were either active (i.e., self initiated) or passive (i.e., initiated by the experimenter). Conscious judgments were made by reporting the position of a rotating clock hand presented on a computer screen and were then compared to the actual measured time of movement onset. In line with previous studies, judgment errors were found to be anticipatory for both finger and toe movements. There was a significant difference between judgment errors for active and passive movements, with judgments of active movements being more anticipatory than judgments of passive movements. This is consistent with a pre-movement (from here on referred to as an “efferent”) account of action awareness because premotor and efference copy signals are only present in active movements, whereas the main source of movement information in passive movements is sensory feedback which is subject to time delays of conduction (and hence predicts later judgment times for passive movements). However, judgments of active toe movement onset time were less anticipatory than judgments of active finger movement onset time. This pattern of results is not consistent with a pure efferent account of conscious awareness of action onset - as this account predicts more anticipatory judgments for toe movements compared to finger movements. Instead, the data support the idea that conscious judgments of movement onset are based on efferent (i.e., premotor, efference copy) and reafferent (i.e., feedback from the movement) components.     

On the relation between sensory input and action

The role of sensory return in movement has recently been considered in relation to models involving feedforward control and in the comparison of predicted and actual states. The author suggests that sensory feedback may also have other effects at the level of movement initiation. The experiences of 3 individuals with differing impairments are reported, 1 with acute withdrawal of movement and position sense, 1 with acute meningitis, and the 3rd after prolonged immobilization following a heel injury. All were surprised to find difficulty in turning an intention to move into action in the affected body areas. One suggested that he had "forgotten what to do," even though the original injury had healed. The path from intention to movement may be dependent on feedback from the peripheral sensory apparatus at levels below attention, at least until voluntary action is required.     

Subjective reality, objective reality, modes of relatedness, and therapeutic action

This paper describes a dialectic believed to be at the heart of therapeutic interaction within a relational model. The dialectic consists of the interrelationship of two modes: the dyadic and the triadic. In the dyadic mode, the analyst responds with aspects of his or her self that singularly reflect the patient's subjectivity. This mode of attunement is uniquely suited to bringing the patient's experience into a place where it can then be seen and known. In the triadic mode, realities are recognized that are important to, but still outside of, the subjectivity of the patient. The analyst invites the patient to see him- or herself not only from inside his or her own space, but also from a point outside, through the perspective of others. The analyst is charged with asymmetric but not exclusive responsibility for negotiating and sustaining a fluid and flexible relationship between these modes. Optimally, this occurs through spontaneous and authentic engagement informed by intuition, empathy, and clinical judgment. However, when this dialectic loses its robust and kinetic quality (as frequently occurs in approaches ranging from the classical to the postmodern), an impermeable dyad is formed by extruding potentially triangulating aspects of reality (and subjectivity). This can result in curiosity and the openness of uncertainty being replaced by closed-mindedness and proclamation.