Modes of therapeutic action

The primary mode of the therapeutic action of psychoanalytic psychotherapy is considered to be insight. Insight can be defined as the conscious recognition of the role of unconscious factors on current experience and behaviour. Unconscious factors encompass unconscious feelings, experiences, and fantasies. Insight is more than mere intellectual knowledge. Thoma and Kachele(38> consider insight to be equidistant from emotional experience and intellect. Etchegoyen (39> distinguished descriptive insights from demonstrated (ostensive) insights which represent a more direct form of knowing, implying emotional contact with an event one has experienced previously.

Although specific formulations of the effect of insight depend on the theoretical framework in which explanations are couched, there is general agreement that insight has its therapeutic effect by in some way integrating mental structures. (38> Hanna Segal(40) sees the healing of defensively created splits in the patient's representation of self and others as crucial. One may be more specific by specifying split or part-objects as isolated representations of intentional beings whose motivation is insufficiently well understood for these to be seen as coherent beings. (41> In this case insight could be seen as a development of the capacity to understand internal and external objects in mental state terms, thus lending them coherence and consistency. The same phenomenon may be described as an increasing willingness on the part of the patient to see the interpersonal world from a third person perspective. (42>

A simple demonstration to the patient of such an integrated picture of self or others is not thought to be sufficient. (21) The patient needs to work through a newly arrived at integration. Working through is a process of both unlearning and learning—actively discarding prior misconceptions and assimilating learning to work with new constructions. The technique of working through is not well described in the literature, yet it represents the critical advantage of long-term over short-term therapy. Working through should be systematic and much of the advantage of long-term treatment may be lost if the therapist does not follow through insights in a relatively consistent and coherent manner.

In contrast to the emphasis on insight and working through are those clinicians who, as we have seen, emphasize the relationship aspect of psychoanalytic therapy (Balint, Winnicott, Loewald, Mitchell, and many others). This aspect of psychoanalytic therapy was perhaps most eloquently described by Loewald when he wrote about the process of change as 'set in motion, not simply by the technical skill of the analyst but by the fact that the analyst makes himself available for the development of a new "object-relationship" between the patient and the analyst '.(43) Sandler and Dreher(44) have recently observed 'while insight is aimed for it is no longer regarded as an absolutely necessary requirement without which the analysis cannot proceed'. There is general agreement that the past polarization of interpretation and insight on the one hand, and bringing about change by presenting the patient with a new relationship on the other, was unhelpful. It seems that patients require both, and both may be required for either to be effective. (45>

It has been suggested that change in analysis will always be individualized according to the characteristics of the patient or the analyst. (46) For example, Blatt(47> suggested that patients who were 'introjective' (preoccupied with establishing and maintaining a viable self-concept rather than establishing intimacy) were more responsive to interpretation and insight. By contrast, anaclitic patients (more concerned with issues of relatedness than of self-development) were more likely to benefit from the quality of the therapeutic relationship than from interpretation.

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