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Classic Articles |
Among the most controversial issues in psychoanalysis and psychoanalytic therapy is the mechanism of change. Some proponents of classical theory and technique argue that change depends on the resolution of intrapsychic conflict through transference interpretations, while others view the therapeutic relationship itself as the most powerful vehicle of change. Much of this controversy began with the classic article in this issue of the Journal. Strachey's view has come to be known as the classic model of therapeutic action in psychoanalysis that has served as the point of departure for all other theories.
The core of Strachey's view is a mutative interpretation focused on transference distortion. The action is predicated on the assumption that the analyst is placed in the position of an auxiliary superego by the patient. In that role, the analyst provides permission for the patient to express a small quantity of the energy from the id in the form of an aggressive wish or impulse. The analyst is also in the role of the object of the patient's id impulses. However, the patient recognizes that the analyst is not in reality acting like the archaic object targeted by the aggressive impulse. Hence, the patient becomes aware that there is a difference between the projected internal object and the real external object. The new object of the analyst is then taken in as a less aggressive introject, which in turn ultimately modifies the harshness of the superego.
In this sequence there are two phases of the mutative interpretation. In the first phase, the analyst makes the patient aware of a certain state of internal tension, which is related to the patient's superego threat of punishment in response to an id impulse. The second phase involves the patient's awareness, when the aggressive impulse from the id emerges into consciousness, that the fantasy object and the real analyst are different. Strachey emphasizes that in this phase the analyst must avoid at all costs acting like the fantasy object by becoming shocked or angered at the patient's expression of id impulse. Only when the analyst maintains a quality of restraint can the patient recognize the discrepancy between real and internal objects and thus internalize the analyst as a new object that modifies the superego.
It is ironic that in the 65 years since the appearance of this paper, Strachey's view has been often portrayed as one that sees therapeutic action as emphasizing interpretation rather than relationship. A careful reading of this classic paper suggests that an internalization of a new relationship and a modification of the patient's internal object relations are crucial to the therapeutic action, even though it may have been set in motion by an interpretive intervention. This model of therapeutic action that emphasizes the internalization of the analyst is usually attributed more to the work of Hans Loewald,1 who compared analysis to a reparenting process in which the child internalizes aspects of the parent. Meanwhile, on the other side of the Atlantic, Bion and Winnicott were elaborating the concepts of containment and holding in an effort to describe similar models of therapeutic action. The therapist "holds" or "contains" affects and internal self- and object representations that the patient has projected because they are difficult to tolerate. After "detoxifying" or modifying those affects and internal representations, the analyst returns them to the patient in a modified form. Ogden2 has clarified that this process actually results in a change in the interactional mode between therapist and patient so that the treater and the patient generate a new way of experiencing old psychological contents.
This juxtaposition of insight through interpretation with the internalization of a new relationship has become less frequent in recent years. In place of the polarization has been a recognition that insight and "corrective" relational experiences are compatible processes that work synergistically.3–6 In the actual crucible of psychoanalytic work, sorting out what is relationship and what is insight may be a highly complicated undertaking. An understanding relationship will probably be impossible to maintain unless there is also insight into what is going on in the relationship.6
One of the most sophisticated views of therapeutic action that draws on the combined effect of insight and the therapeutic relationship is the model of Jones,7 which he terms "repetitive interaction structures." This model lends itself to newer conceptual theoretical models in psychoanalysis, such as role responsiveness, enactment, projective identification, and intersubjectivity. Jones has noted through his research that the therapist and patient interact in repetitive ways throughout the therapy and that specific structures of interaction appear to relate to patient change. The patterns of interaction reflect the psychological structures of both the analyst and the patient. The therapeutic interaction itself is related to recognizing the interactions, experiencing them, and understanding their meaning. In that regard, both experiential or relational aspects and explanatory or interpretive aspects of the treatment are important.
There has undoubtedly been a delay in fully recognizing the value of the noninterpretive mechanisms of change in psychoanalytic therapy. To some degree this delay reflects a stigmatization of supportive therapy and of the nonexpressive elements in treatment, which are often referred to as "nonspecific." Yet Wallerstein's8 final report of the Menninger Psychotherapy Research Project emphasized that lasting structural change may occur through noninterpretive supportive approaches. Moreover, he noted that even in the most expressive of treatments, such as psychoanalysis, a surprising number of supportive elements are present. To some extent Strachey anticipated this development in the final sentence of his paper: "The fact that the mutative interpretation is the ultimate operative factor in the therapeutic action of psycho-analysis does not imply the exclusion of many other procedures (such as suggestion, reassurance, abreaction, etc.) as elements in the treatment of any particular patient" (p. 159).
Today we are more inclined to think of psychoanalytic therapy as occurring on an expressive–supportive continuum that balances interpretive and noninterpretive interventions. The management of the therapeutic relationship is itself part of the technique of psychoanalytic therapy and should not be relegated to a "nonspecific" aspect of the treatment. In addition, we also recognize that the polarization between expressive and supportive strategies is unwarranted. As many patients in psychoanalytic therapy will readily acknowledge, being understood through an interpretation may be the most supportive experience imaginable.
References
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