WHAT ENABLES PATIENTS TO GET BETTER?

An Overview of My First Three Modes of Therapeutic Action

 

by Martha Stark, MD / Faculty, Harvard Medical School

 

What is it that enables patients to get better?  How does psychotherapy work?  How do we conceptualize the process by which patients grow and change?         

 

I have developed an integrative model of therapeutic action that takes into consideration many different schools of thought.  It is my belief, however, that most psychotherapeutic models boil down to advocating either knowledge, experience, or relationship – that is, either enhancement of knowledge, provision of experience, or engagement in relationship – as the primary therapeutic agent (Stark 1994a, 1994b, 1999).

 

I will therefore begin by summarizing these three different models of therapeutic action.  As will soon become clear, although there is significant overlap amongst the three perspectives, each one contains elements that distinguish it from the other two.

 

The models of therapeutic action are therefore not mutually exclusive but mutually enhancing.  And if our goal is to optimize the therapeutic potential of each moment, we will be most effective if we have a deep appreciation for, and some facility with, all three modalities.

 

The Interpretive Perspective of Classical Psychoanalysis

 

The first is the interpretive model of classical psychoanalysis.  Structural conflict is seen as the villain in the piece and the goal of treatment is thought to be a strengthening of the ego by way of insight.  Whether expressed as (a) the rendering conscious of what had once been unconscious (in topographic terms); (b) where id was, there shall ego be (in structural terms); or (c) uncovering and reconstructing the past (in genetic terms), in Model 1 it is the truth that is thought to set the patient free.

 

Interpretations, particularly of the transference, are considered the means by which self-awareness is expanded.

 

Resolution of Structural Conflict

 

How do interpretations lead to resolution of structural conflict? 

 

As the ego gains insight by way of interpretation, the ego becomes stronger.  This increased ego strength enables it to experience less anxiety in relation to the id's sexual and aggressive impulses; the ego's defenses, therefore, become less necessary.  As the defenses are gradually relinquished, the patient's conflicts about her sexual and aggressive drives are gradually resolved.

 

The Therapist as an Objective Observer

 

The Model 1 therapist sees herself not as a participant in a relationship but as an objective observer of the patient.  Her unit of study is the patient and the patient's internal dynamics.  The therapist conceives of her position as outside the therapeutic field and of herself as a blank screen onto which the patient casts shadows that the therapist then interprets. 

 

Model 1 is clearly a one-person psychology.

 

Freud’s Bias

 

In some way it is not surprising that Freud would have been reluctant to recognize the importance of the actual relationship – because Freud never had any relationship whatsoever with an analyst.  His, of course, was a self‑analysis.  By way of a meticulous analysis of his dreams, he was able to achieve insight into the internal workings of his mind, thereby strengthening his ego and resolving his intrapsychic conflicts.

 

The Transition to a More Relational Perspective

 

But there were those analysts both here and abroad who found themselves dissatisfied with a model of the mind that spoke to the importance not of the relationship between patient and therapist but of the relationships amongst id, ego, and superego.  Both self psychologists in the United States and object relations theorists in Europe began to speak up on behalf of the individual as someone who longed for connection with others.

 

In fact, Fairbairn (1963), writing as early as the 1940s, contended that the individual had an innate longing for object relations and that it was the relationship with the object and not the gratification of impulses that was the ultimate aim of libidinal striving.  He noted that the libido was "primarily object-seeking, not pleasure-seeking." 

 

Nature vs. Nurture

 

Both the self psychologists and the European (particularly the British) object relations theorists were interested not so much in nature (the nature of the child's drives) but in nurture (the quality of maternal care and the mutuality of fit between mother and child). 

 

Whereas Freud and other classical psychoanalysts conceived of the patient's psychopathology as deriving from the patient (in whom there was thought to be an imbalance of forces and, therefore, internal conflict), self psychologists, object relations theorists, and contemporary relational analysts conceive of the patient's psychopathology as deriving from the parent (and the parent's failure of the child). 

 

Internal Recording of Parental Failures

 

How were such parental failures thought to be internally recorded and structuralized?  Interestingly, some theorists (Balint 1968) focused on the price the child paid because of what the parent did not do; in other words, absence of good in the parent/child relationship was thought to give rise to structural deficit (or impaired capacity) in the child.  But other theorists (Fairbairn 1963) focused on the price the child paid because of what the parent did do; in other words, presence of bad in the parent/child relationship was thought to be internally registered in the form of pathogenic introjects or internal bad objects – filters through which the child would then experience her world.

 

But whether the pathogenic factor was seen as an error of omission (absence of good) or an error of commission (presence of bad), the villain in the piece was no longer thought to be the child but the parent – and, accordingly, psychopathology was no longer thought to derive from the child's nature but from the nurture the child had received during her formative years.  No longer was the child considered an agent (with unbridled sexual and aggressive drives); now the parent was held accountable – and the child was seen as a passive victim of parental neglect and abuse. 

 

From Insight to Corrective Experience

 

When the etiology shifted from nature to nurture, so too the locus of the therapeutic action shifted from insight by way of interpretation to corrective experience by way of the real relationship (that is, from within the patient to within the relationship between patient and therapist). 

 

No longer was the goal thought to be insight and rendering conscious the unconscious so that structural conflict could be resolved; now the goal of treatment became filling in structural deficit and consolidating the self by way of the therapist's restitutive provision. 

 

With the transitioning from a one-person to a two-person psychology, sexuality (the libidinal drive) and aggression took a back seat to more relational needs – the need for empathic recognition, the need for validation, the need to be admired, the need for soothing, the need to be held.

 

From Drive Object to Good Object

 

The therapist was no longer thought to be primarily a drive object but, rather, either a selfobject (used to complete the self by performing those functions the patient was unable to perform on her own) or a good object/good mother (operating in loco parentis).  

 

To repeat:  The deficiency-compensation model – embraced by the self psychologists and by those object relations theorists who focused on the internal recording of traumatic parental failure in the form of deficit – conceived of the therapeutic action as involving some kind of corrective experience at the hands of a therapist who was experienced by the patient as a new good (and, therefore, compensatory) object. 

 

From Structural Conflict to Structural Deficit

 

In Model 2, then, the patient was seen as suffering not from structural conflict but from structural deficit – that is, an impaired capacity to be a good parent unto herself.  The deficit was thought to arise in the context of failure in the early-on environmental provision, failure in the early-on relationship between parent and infant.  

 

Now the therapeutic aim was the therapist's provision in the here-and-now of that which was not provided by the parent early-on – such that the patient would have the healing experience of being met and held. 

 

Experience vs. Actual Participation

 

Of note is that some deficiency-compensation theorists (most notably the self psychologists) focused on the patient's experience of the therapist as a new good object; others (the Model 2 object relations theorists) appeared to focus more on the therapist's actual participation as that new good object.

 

But what all the deficiency-compensation models of therapeutic action had in common was that they posited some form of corrective provision as the primary therapeutic agent.

 

A “New Beginning”

 

It was then in the context of the new relationship between patient and therapist that there was thought to be the opportunity for a new beginning (Balint 1968) – the opportunity for reparation, the new relationship a corrective for the old one. 

 

“I-It” vs. “I-Thou”

 

But although relationship was involved, it was more an I-It than an I-Thou relationship (Buber 1966)  – more a one-way relationship between someone who gave and someone who took than a two-way relationship involving give-and-take, mutuality, and reciprocity. 

 

It is for this reason that self psychology, which is a prime example of a deficiency-compensation model, has been described as a one-and-a-half-person psychology (Morrison 1997) – it is certainly not a one-person psychology, but then nor is it truly a two-person psychology.

           

And Michael Balint (1968) – also an advocate for the corrective-provision approach – speaks directly to the I-It aspect of the patient/therapist relationship with the following:  "It is definitely a two-person relationship in which, however, only one of the partners matters; his wishes and needs are the only ones that count and must be attended to; the other partner, though felt to be immensely powerful, matters only in so far as he is willing to gratify the first partner's needs and desires or decides to frustrate them; beyond this his personal interests, needs, desires, wishes, etc., simply do not exist" (p. 23).

 

In other words, the emphasis in a deficiency-compensation model is not so much on the relationship per se as it is on the filling in of the patient's deficits by way of the therapist's corrective provision. 

 

But this relationship between a person who provides and a person who is the recipient of such provision is a far cry from the relationship that exists between two real people – an intersubjective relationship that involves two subjects, both of whom contribute to what transpires at the intimate edge (Ehrenberg 1992) between them.

 

And so it is that (in the past twenty or twenty-five years) some contemporary theorists have begun to make a distinction between the therapist's provision of a corrective experience for the patient and the therapist's participation in a real relationship with the patient – a distinction between the therapist's participation as a good object (Model 2) and the therapist's participation as an authentic subject (Model 3).   

 

Give vs. Give-and-Take

 

We are speaking here to the distinction between a model of therapeutic action that conceives of the therapy relationship as involving give (the therapist's give) and a model that conceives of the therapy relationship as involving give-and-take (both participants giving and taking).

 

From Corrective Experience to Interactive Engagement

 

Let us return to the issue of what constitutes the therapeutic action.  There are an increasing number of contemporary theorists who believe that what heals the patient is neither insight nor a corrective experience.

 

Rather, what heals, they suggest, is interactive engagement with an authentic other; what heals is the therapeutic relationship itself – a relationship that involves not subject and drive object, not subject and selfobject, not subject and good object, but, rather, subject and subject, both of whom bring themselves (warts and all) to the therapeutic interaction, both of whom engage, and are engaged by, the other.

 

Mutuality of Impact

 

Relational (or Model 3) theorists who embrace this perspective conceive of patient and therapist as constituting a co-evolving, reciprocally mutual, interactive dyad – each participant both proactive and reactive, each both initiating and responding.  For the relational therapist, the locus of the therapeutic action always involves this mutuality of impact – a prime instance of which is projective identification. 

 

The Patient as Proactive

 

Unlike Model 2, which pays relatively little attention to the patient's proactivity in relation to the therapist, Model 3 addresses itself specifically to the force-field created by the patient in an effort to draw the therapist in to participating in ways specifically determined by the patient's early-on history and internally recorded in the form of pathogenic introjects – ways the patient needs the therapist to participate if she (the patient) is ever to have a chance to master her internal demons.

 

Refinding the Old Bad Object

 

More specifically, in a relational model of therapeutic action, the patient with a history of early-on traumas is seen, then, as having a need to re-find the old bad object – the hope being that perhaps this time there will be a different outcome. 

 

In order to demonstrate the distinction between a theory that posits unidirectional influence (a corrective-provision model) and a theory that posits bidirectional – reciprocal – influence (a relational model), I offer the following:

 

Inevitability of Empathic Failure

 

As we know, self psychology (the epitome of a corrective-provision model) speaks to the importance of the therapist's so-called inevitable empathic failures (Kohut 1966).  Self psychologists contend that these failures are unavoidable because the therapist is not, and cannot be expected to be, perfect. 

 

How does relational theory conceive of such failures?  Many relational theorists believe that a therapist's failures of her patient are not just a story about the therapist (and her lack of perfection) but also a story about the patient and the patient's exerting of interpersonal pressure on the therapist to participate in ways both familial and, therefore, familiar (Mitchell 1988). 

 

Relational theory believes that the therapist's failures do not simply happen in a vacuum; rather, they occur in the context of an ongoing, continuously evolving relationship between two real people – and speak to the therapist's responsiveness to the patient's (often unconscious) enactment of her need to be failed. 

 

The Patient’s Transferential Activity as an Enactment

 

In Model 3, the patient is seen as an agent, as proactive, as able to have an impact, as exerting unrelenting pressure on the therapist to participate in ways that will make possible the patient's further growth.  The relational therapist, therefore, attends closely to what the patient delivers of herself into the therapy relationship (in other words, the patient's transferential activity).

 

In fact, relational theory conceptualizes the patient's activity in relation to the therapist as an enactment, the unconscious intent of which is to engage (or to disengage) the therapist in some fashion – either by way of eliciting some kind of response from the therapist or by way of communicating something important to the therapist about the patient's internal world.  In fact, the patient may know of no other way to get some piece of her subjective experience understood than by enacting it in the relationship with her therapist. 

 

Provocative vs. Inviting vs. Entitled

 

I use the word provocative to describe the patient's behavior when she is seeking to recreate the old bad object situation (so that she can rework her internal demons), inviting to describe her behavior when she is seeking to create a new good object situation (so that she can begin anew), and entitled to describe her behavior when, confronted with an interpersonal reality that she finds intolerable, she persists even so – relentless in her pursuit of that to which she feels entitled and relentless in her outrage at its being denied.

 

The Therapist as Container for the Patient’s Projections

 

If the Model 3 therapist is to be an effective container for – and psychological metabolizer of – the patient's disavowed psychic contents, the therapist must be able not only to tolerate being made into the patient's old bad object but also to extricate herself (by recovering her objectivity and, thereby, her therapeutic effectiveness) once she has allowed herself to be drawn in to what has become a mutual enactment.

 

The therapist must have both the wisdom to recognize and the integrity to acknowledge her own participation in the patient's enactments; even if the problem lies in the intersubjective space between patient and therapist, with contributions from both, it is crucial that the therapist have the capacity to relent – and to do it first. 

 

Patient and therapist can then go on to look at the patient's investment in getting her objects to fail her, her compulsive need to recreate with her contemporary objects the early‑on traumatic failure situation. 

 

Failure of Engagement vs. Failure of Containment

 

If the therapist never allows herself to be drawn in to participating with the patient in her enactments, we speak of a failure of engagement.  If, however, the therapist allows herself to be drawn in to the patient's internal dramas but then gets lost, we speak of a failure of containment – and the potential is there for the patient to be retraumatized.

 

Although initially the therapist may indeed fail the patient in much the same way that her parent had failed her, ultimately the therapist challenges the patient's projections by lending aspects of her otherness, or, as Winnicott (1965) would have said, her externality to the interaction – such that the patient will have the experience of something that is other‑than‑me and can take that in.  What the patient internalizes will be an amalgam, part contributed by the therapist and part contributed by the patient (the original projection). 

 

In other words, because the therapist is not, in fact, as bad as the parent had been, there can be a better outcome.  There will be repetition of the original trauma but with a much healthier resolution this time – the repetition leading to modification of the patient's internal world and integration on a higher level. 

 

A Corrective Relational Experience

 

It is in this way that the patient will have a powerfully healing corrective relational experience, the experience of bad-become-good.

 

In the relational model, it is the negotiation of the relationship and its vicissitudes (a relationship that is continuously evolving as patient and therapist act/react/interact) that constitutes the locus of the therapeutic action.  It is what transpires in the here-and-now engagement between patient and therapist that is thought to be transformative. 

 

And so this third model of therapeutic action is the relational (or interactive) perspective of contemporary psychoanalytic theory.  No longer is the emphasis on the therapist as object – object of the patient's sexual and aggressive drives (Model 1), object of the patient's narcissistic demands (Model 2), or object of the patient's relational need to be met and held (Model 2).  In this contemporary relational model, the focus is on the therapist as subject – an authentic subject who uses the self (that is, uses her countertransference) to engage, and to be engaged by, the patient.

 

Unless the therapist is willing to bring her authentic self into the room, the patient may end up analyzed – but never found. 

 

How the Therapist Positions Herself

 

As noted earlier, the empathic attunement of Model 2 requires of the therapist that she decenter from her own subjectivity in order to join alongside the patient; the therapist will then be able to enter into the patient’s experience and take it on, but only as if it were her own because it never actually becomes her own.  The therapist, by remaining ever focused on, and attuned to, the patient’s moment-by-moment experience will be able to resonate empathically with the patient’s experience, such that the patient will have the profoundly satisfying experience of being heard and understood – or, in the words of self psychology, validated.  Empathic attunement is not about the therapist’s experience; it is about the patient’s experience.

 

The authentic engagement of Model 3, however, requires of the therapist that she remain very much centered within her own subjectivity, the better to allow the patient’s experience to enter into her; the therapist, ever open to being impacted, will then take on the patient’s experience as her own, such that the therapist’s experience will come to be informed by both the there-and-then of the therapist’s early-on history and the here-and-now of the therapeutic engagement.  The therapist, by remaining ever focused on, and attuned to, her own moment-by-moment experience, will then be able to lend aspects of her own capacity to a psychological processing and integrating of what she is experiencing as a result of being in relationship with the patient, such that the patient will have the profoundly healing experience of knowing that she is not alone, of knowing that someone else is present with her, of knowing that someone else is sharing her experience.  Authentic engagement is not so much about the patient’s experience as it is about the sharing of experience between patient and therapist.

 

In essence, empathic attunement and authentic engagement represent different ways the therapist can position herself in relation to the patient.  It is not that one approach is better than the other one or more evolved; rather, it is that these are two different, and complementary, approaches.  By being empathic, the therapist will create certain possibilities for the unfolding of the therapeutic action – but at the expense of other options; by the same token, by being authentic, the therapist will create certain other possibilities for the unfolding of the therapeutic action – but at the expense of other options.  I am here reminded of Robert Frost’s “The Road Not Taken” (2002).  The therapist is continuously choosing one path over another, all the while knowing that in making the choices she is making she will never know where the other paths might have led.

 

How the Therapist Listens vs. How the Therapist Responds

 

Parenthetically, it is important to keep in mind that there is a distinction between how the therapist listens and how the therapist then responds.  In the first instance, we are speaking to how the therapist comes to know the patient; in the second instance, we are speaking to how the therapist, based upon what she has come to know, then intervenes.  When a therapist is said to be empathic, it is therefore not clear whether the speaker is suggesting that the therapist is listening empathically and/or responding empathically; what is meant, however, will usually be clear from the context.

 

The important point to be made here is that a good therapist will listen simultaneously – even though paradoxically – with objectivity (Model 1), empathy (Model 2), and authenticity (Model 3).  In other words, a good therapist will come to know the patient by focusing on neither the patient’s nor her own experience but on what she observes (Model 1), by focusing on the patient’s experience (Model 2), and by focusing on her own experience (Model 3).  All three modes of listening will offer important information about the patient and the therapy relationship.

 

How the therapist then decides to intervene will be a story about both what the therapist has come to know and how the therapist conceptualizes the ever-evolving therapeutic action – whether, in the moment, it involves primarily enhancement of knowledge within, provision of corrective experience for, or engagement in authentic relationship with.

 

So how exactly do we conceive of the process by which patients are healed?  In order to understand the therapeutic process, we will think about how the therapist positions herself moment by moment in relation to the patient.  My belief is that the position she assumes will affect both what she comes to know (afference) and how she then intervenes (efference). 

 

How the Therapist Comes to Know

 

With respect to how the therapist arrives at understanding of the patient, I contend that the most effective listening stance is one in which the therapist achieves an optimal balance between positioning herself as object, as selfobject, and as subject. 

 

(1) As a neutral object, the therapist positions herself outside the therapeutic field in order to observe the patient.  Her focus is on the patient's internal dynamics.

 

(2) As an empathic selfobject, the therapist joins alongside the patient in order to immerse herself in the patient's subjective reality.  Her focus is on the patient's affective experience.

 

(3) As an authentic subject, the therapist remains very much centered within her own experience – using that experience (in other words, the countertransference) to deepen her understanding of the patient.  Her focus is on the here-and-now engagement between them. 

 

To this point, the therapist is simply gathering information; she has not yet done anything with what she has come to know. 

 

How the Therapist Then Intervenes

 

With respect to how the therapist then intervenes, my belief is that the most effective interventive stance is one in which the therapist achieves an optimal balance between formulating interpretations, offering some form of corrective provision, and engaging interactively in relationship. 

 

(1) The therapist formulates interpretations with an eye to advancing the patient's knowledge of her internal dynamics.  The ultimate goal is resolution of the patient's structural conflicts.

 

(2) The therapist offers some form of corrective provision with an eye either to validating the patient's experience or, more generally, to providing the patient with a corrective experience.  The ultimate goal is filling in the patient's structural deficits and consolidating the patient's self.

 

(3) The therapist engages the patient interactively in relationship with an eye to advancing the patient's knowledge of her relational dynamics and/or to deepening the connection between the two of them.  The ultimate goal is resolution of the patient's relational difficulties and development of her capacity to engage healthily and authentically in relationship.

 

With each patient, whatever her diagnosis, whatever her underlying psychodynamics, the optimal therapeutic stance is one that is continuously changing.  In fact, moment-by-moment, the therapist's position shifts.

 

The stance the therapist assumes is sometimes spontaneous and unplanned, sometimes more deliberate and considered.  In other words, there are times when the therapist finds herself unwittingly drawn in to participating with the patient in a particular way because the intersubjective field has pulled for that form of participation.  But there are other times when the therapist makes a more conscious choice, based on what she intuitively senses the patient most needs in the moment in order to heal. 

 

How the therapist decides to intervene, therefore, depends on both what she has come to understand about the patient by virtue of the listening position she has assumed and what she thinks the patient most needs – whether enhancement of knowledge, provision of experience, or engagement in relationship.

 

At any given point in time, the therapist is also profoundly affected by what had come before – in the moments leading up to the current moment.  Past and present are always inextricably linked; no moment in time stands on its own.  And so it is that how the therapist chooses to intervene in the moment depends also on what had transpired in the moments preceding. 

 

My intent is to provide the therapist with a way to conceptualize the options available to her as she sits with her patient – with respect both to how she arrives at understanding and to what she then does or says.

 

I am offering not a prescription for what the therapist should do but rather a description of what the therapist already does do.

 

Knowledge, Experience, and Relationship

 

In sum, I believe that the three modes of therapeutic action (knowledge, experience, and relationship) are not mutually exclusive but mutually enhancing.  The conceptual framework I am offering here is a synthetic one that integrates three perspectives: 

 

(1) the interpretive perspective of classical psychoanalytic theory;

 

(2) the corrective-provision (or deficiency-compensation) perspective of self psychology and those object relations theories emphasizing the absence of good; and

 

(3) the relational (or interactive) perspective of contemporary psychoanalytic theory and those object relations theories emphasizing the presence of bad. 

 

The impetus for my effort to integrate the three models stems from my belief that none of the three is sufficient, on its own, to explain our clinical data or to guide our interventions.  Although there is of course some overlap, each model contains elements lacking in the other two. 

 

Obviously, no model can begin to do justice by something this complex and multifaceted, but my hope is that the integrative model I am proposing will prompt therapists to become more aware of the choices they are continuously making about how they listen to the patient and how they then intervene. 

 

Whereas Model 1 is a one-person psychology and Model 2 is a one-and-a-half-person psychology, Model 3 is truly a two-person psychology. 

 

And whereas the Model 1 therapist is seen as a neutral object (whose focus is on the patient's internal process) and the Model 2 therapist is seen as an empathic selfobject or good object/good mother (whose focus is on the patient's moment-by-moment affective experience), the Model 3 therapist is seen as an authentic subject (whose focus is on the intimate edge between them).

 

In Model 1, although the short-term goal is enhancement of knowledge, the ultimate goal is resolution of structural conflict.  In Model 2, although the immediate goal is provision of (corrective) experience, the long-range goal is filling in of structural deficit.  In Model 3, although the short-term goal is engagement in relationship (and a deepening of connection between patient and therapist), the ultimate goal is development of capacity for healthy, authentic relatedness.

 

And, finally, whereas Model 2 is about offering the patient an opportunity to find a new good object – so that there can be restitution, Model 3 is about offering the patient an opportunity to re-find the old bad one – so that the traumatogenic early-on interactions can be worked through in the context of the patient's here-and-now engagement with the therapist. 

 

Along these same lines, Greenberg (1986) has suggested that if the therapist does not participate as a new good object, the therapy never gets under way; and if she does not participate as the old bad one, the therapy never ends – which captures exquisitely the delicate balance between the therapist's participation as a new good object (so that there can be a new beginning) and the therapist's participation as the old bad object (so that there can be an opportunity to achieve belated mastery of the internalized traumas). 

 

Indeed, psychoanalysis has come a long way since the early days when Freud was emphasizing the importance of sex and aggression.  No longer is the spotlight on the patient's drives (and their vicissitudes); now the spotlight is on the patient's relationships (and their vicissitudes).

 

And where once psychoanalysis focused on the relationship that exists between structures within the psyche of the patient, contemporary psychoanalysis focuses more on the relationship that exists between the patient and her objects – or, more accurately, the intersubjective relationship that exists between the patient and her subjects.  In Benjamin's (1988) words:  "...where objects were, subjects must be" (p. 44).

 

                                                                  Conclusion

 

I am proposing that the repertoire of the contemporary therapist includes formulating interpretations, offering some form of corrective provision, and engaging interactively in a relationship that is reciprocally mutual. 

 

I think that the most therapeutically effective stance is one in which the therapist is able to achieve an optimal balance between (a) positioning herself outside the therapeutic field (in order to formulate interpretations about the patient and her internal process so as to facilitate resolution of the patient's structural conflict), (b) decentering from her own experience (in order to offer the patient some form of corrective provision so as to facilitate the filling in of the patient's structural deficit), and (c) remaining very much centered within her own experience (in order to engage authentically with the patient in a real relationship so as to facilitate resolution of the patient's relational difficulties).

 

Casement (1985), in speaking to how the therapist positions himself optimally in relation to the patient, suggests the following:  The therapist must "learn how to remain close enough to what the patient is experiencing" to be able to be affected by the patient – “while preserving a sufficient distance" to function as therapist.  "But that professional distance should not leave him beyond the reach of what the patient may need him to feel.  A therapist has to discover how to be psychologically intimate with a patient and yet separate, separate and still intimate" (p. 30).   

 

In the language we have been using here, the therapist must empathically join the patient where she is even as the therapist preserves her distance so that she can still function interpretively.  But the therapist should never be so far away that the patient cannot find her and engage her authentically.  Intimate without losing the self, separate without losing the other. 

 

It will be a challenge for any therapist to attempt to hold in mind, simultaneously, the three different perspectives without pulling for premature closure – closure that may ease the therapist's anxiety but will probably limit the realm of therapeutic possibilities.  The most effective therapists will be those who (a) manage somehow to tolerate – perhaps, even, for extended periods of time – the experience of not knowing or, in Bollas's (1989) words, the experience of necessary uncertainty; (b) are open to being shaped by the patient's need and by whatever else might arise within the context of their intersubjective relationship; and, more generally, (c) are willing to bring the best of themselves, the worst of themselves, and the most of themselves into the room with the patient – so that each will have the opportunity to find the other. 

 

 

References

 

Balint, M. 1992. The basic fault: Therapeutic aspects of regression. New York and London: Routledge, 2nd ed.

 

Buber, M. 1966. Tales of the Hasidim: The early masters. New York: Schocken.

 

Casement, P. 1985. Forms of interactive communication. In On learning from the patient, 72-101. London and New York: Tavistock.

 

Ehrenberg, D. 1992. The intimate edge: Extending the reach of psychoanalytic interaction. New York: W.W. Norton & Co.

   

Fairbairn, W.R.D. 1963. Synopsis of an object relations theory of personality. Int J Psychoanal 44:224-255.

 

Freud, S. 1923. The ego and the id. New York: W.W. Norton & Co.

 

----- 1937.  Analysis terminable and interminable. Int J Psycho-Anal 18:373-405.

 

Greenberg, J.R. 1986. The problem of analytic neutrality. Contemp Psychoanal 22:76-86.

 

Hoffman, I. 1983. The patient as interpreter of the analyst’s experience. Contemp Psychoanal 19:389-422.

 

Kohut, H. 1966. Forms and transformations of narcissism. J Am Psychoanal Assoc 14(2):243-272.

----- 1984. How does analysis cure? Chicago: University of Chicago Press.   

 

Malin, A., and Grotstein, J. 1966. Projective identification in the therapeutic process. Int J Psychoanal 47:26-31.

 

Mitchell, S. 1988. Relational concepts in psychoanalysis: An integration. Cambridge, MA: Harvard University Press.

 

Morrison, A. 1997. Shame: The underside of narcissism. Berkeley, CA: The Analytic Press.

 

Ornstein, P. 1974. On narcissism: Beyond the introduction – highlights of Kohut’s contribution to the psychoanalytic treatment of narcissistic personality disorders. Annual Psychoanal 2:127-149.

 

Renik, O. 1993. Analytic interaction: Conceptualizing technique in light of the analyst’s irreducible subjectivity. Psychoanal Q 62(4):553-571.

 

Stark, M. 1994a. Working with resistance. Northvale, NJ: Jason Aronson.

 

----- 1994b. A primer on working with resistance. Northvale, NJ: Jason Aronson.

 

----- 1999. Modes of therapeutic action: Enhancement of knowledge, provision of experience, and engagement in relationship. Northvale, NJ: Jason Aronson.

 

----- 2008. Hormesis, adaptation, and the sandpile model. Crit Rev Toxicol 38(7):641-644.

 

----- 2012. The sandpile model: Optimal stress and hormesis. Dose Response 10(1):66-74.

 

----- 2014. Optimal stress, psychological resilience, and the sandpile model. In Hormesis in health and disease, ed. S. Rattan and E. Le Bourg, 201-224. Boca Raton: CRC Press/Taylor & Francis.

 

----- 2015. Integrative psychotherapy: Healing the MindBodyMatrix. In Integrative therapies for depression: Redefining models for assessment, treatment, and prevention, ed. J.M. Greenblatt and K. Brogan. Boca Raton: CRC Press/Taylor & Francis.

 

Winnicott, D.W. 1960. The theory of the parent-infant relationship. Int J Psycho-Anal 41:585-595.

 

----- 1990. The maturational processes and the facilitating environment. UK, London: Karnac Books.

 

Zevon, W. 1996. I’ll sleep when I’m dead. Burbank, CA: Elektra Records.

 

                

© 2020  Martha Stark, MD ~ Founder / CEO, SynergyMed for MindBodyHealth ~ 617.244.7188 ~ MarthaStarkMD@HMS.Harvard.edu


www.SynergyMed.Solutions ~ www.MindBodyHealth.Solutions

COMPLIMENTARY MindBodyHealth CONSULTATION FOR CLIENTS

COMPLIMENTARY Clinical Supervision SESSION FOR CLINICIANS