Cohabitation and the negative therapeutic reaction

Borderline and psychotic patients especially, but not exclusively, show genuine motivation towards achieving insight and change and then suddenly behave as if these have never been desired. When this shift occurs after a helpful interpretation it can be thought of as a negative therapeutic reaction. Patients can feel taken over by perceptions which drive them to think and behave in ways they later disagree with. These observations have led the author, along with colleagues at the Willesden Centre for Psychological Treatment, to recognise a situation of internal cohabitation of two autonomous minds in the one body which is a development of but not identical to Bion's concepts of psychotic and non-psychotic personalities. Some of the psychoanalytic literature on the different modes of mental functioning are reviewed and problems of appropriate conceptualisations are discussed. Clinical examples are presented to illustrate that differentiating the genuine negative therapeutic reaction from reactions to poor interpretations is facilitated and leads to further understanding of the patient's psychotic personality if the psychotherapist can hold in mind both the patient's and the therapist's psychotic and non-psychotic personalities.     

One kind of negative therapeutic reaction

A case is reported in which a young man for several years experienced his analysis primarily as a source of pain. Each new insight he achieved was an occasion for increased distress rather than liberation. Considerable analytic work elucidating motives for this negative therapeutic reaction produced no change in it. Eventually, it could be determined that the patient's need to suffer within the treatment relationship served a specific form of denial in fantasy that has not, to the author's knowledge, been described elsewhere. The importance of covert libidinal, object-preservative aims in such frustrating and destructive impasses is discussed, as well as the role of countertransference enactment.     

Comments on the concept of the so-called negative therapeutic reaction

The author recommends a consistent analytic rather than therapeutical or educational response to the negative therapeutic reaction whenever it occurs in the treatment process. This attitude is especially helpful in cases where strivings for autonomy are active behind the negative therapeutic reaction and where these are jeopardized by the intermingling of the patient's projective identifications with those of the therapist.     

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.     

Communicative psychoanalysis: Contributions to clinical practice and the development of a science of psychoanalysis

Robert Langs' communicative approach to psychoanalysis has lead to new clinical insights and to a promising line of quantitative research. Fundamental concepts of the communicative approach are explained and illustrated with a clinical example. Characteristics of the approach, which distinguish it from other modern, interactive analytic theories are discussed; as well as a critical clinical insight derived from the communicative approach. The approach's unique contributions to the development of a science of psychoanalysis are explained. The advantages and problems of the communicative method are also discussed throughout the paper.     

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.