Modes of Therapeutic Action

by Martha Stark

How do we position ourselves, moment by moment, in relation to our patients and how do these positions inform both what we come to know about our patients and how we intervene? Do we participate as neutral object, as empathic self-object, or as authentic subject? Do we strive to enhance the patient's knowledge, to provide a corrective experience, or to work at the intimate edge? In an effort to answer these and other clinically relevant questions about the process of psychotherapeutic change, Martha Stark has developed a comprehensive theory of therapeutic action that integrates the interpretive perspective of classical psychoanalysis (Model 1), the corrective-provision perspective of self psychology and those object relations theories emphasizing the internal 'absence of good' (Model 2), and the relational perspective of contemporary psychoanalysis and those object relations theories emphasizing the internal 'presence of bad' (Model 3). Model I is about knowledge and insight. It is a one-person psychology because its focus is on the patient and the internal workings of her mind. Model 2 is about corrective experience. It is a one-and-a-half-person psychology because its emphasis is not so much on the relationship per se, but on the filling in of the patient's deficits by way of the therapist's corrective provision; what ultimately matters is not who the therapist is, but, rather, what she can offer. Model 3 is about relationship, the real relationship. It is a two-person psychology because its focus is on patients and therapists who relate to each other as real people; it is about mutuality, reciprocity, and intersubjectivity. Whereas Model 2 is about 'give' and involves the therapist's bringing the best of who she is into the room, Model 3 is about 'give-and-take' and involves the therapist's bringing all of who she is into the room. As Dr. Stark repeatedly demonstrates in numerous clinical vignettes, the three modes of therapeutic actionDknowledge, experience, and relationshipDare not mutually exclusive but mutually enhancing. If, as therapists, we can tolerate the necessary uncertainty that comes with the recognition that there is an infinite variety of possibilities for change, then we will be able to enhance the therapeutic potential of each moment and optimize our effectiveness as clinicians.

Genres: Psychology

408 pages, Paperback

First published April 1, 1999

Reviews

[Steven Berger · Rating 3 out of 5]

Goodness. This book took me the best part of 3 months to complete, and although it was an interesting and worthwhile journey, I finished feeling that the approach to writing the book had been 'why use one word when you can use 20?' and many of the subjects came up and were re-written and re-thought time and time again.

The downside here is that what should have been a great book with a highly interesting viewpoint and a clear description of modes of therapy instead felt like a slog.

[Dovilė Stonė · Rating 5 out of 5]

Modes Of Therapeutic Action

Autorė integruoja klasikines psichodinaminės psichoterapijos mokyklas, daugiausia dėmesio skirdama intersubjektyvumui, tai ir rekomenduoju tiems kolegoms, kurie darbe nori įprasminti savo ir paciento tarpusavio sąveiką.

Knygą tirštai prispalvinau markeriu - kad ateityje galėčiau grįžti prie praktikoje naudingų vietų.

Parankus autorės pasiūlytas terapeuto laikysenos stilių skirstymas į 3 "režimus", vertingi ir praktiniai pavyzdžiai. Toks labiau kontroversiškas momentas tas, kad autorė tikrai daug kartojasi, bet tuo pačiu ji vis pagilina ar kitaip įkontekstina tas pakartotas tezes. Man toks stilius šįkart tiko - lengviau mąstyti kartu su autore ir įsisavinti pagrindinius principus, ypač prisėdus tęsti skaitymą po ilgesnių pertraukų.

“...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.” (Stark, 1999, p. 21)

“Unless the therapist is willing to bring her authentic self into the room, the patient may end up analyzed-but never found.” (Stark, 1999, p. 23)

“How is it that interpretations lead to resolution of structural conflict? As the ego gains insight by way of interpretations, it becomes stronger. This increased ego strength enables the ego to experience less anxiety in relation to the id; the ego's defenses therefore become less necessary. As the patient begins to relinquish her defenses, she becomes less conflicted-and we speak then of the patient's structural conflict as having been resolved.” (Stark, 1999, p. 34)

“Growing up (the task of the child) and getting better (the task of the patient) have to do with learning to master the disenchantment that comes with the recognition of just how imperfect (yet good-enough) the world really is. Moving from infantile need to mature capacity has to do with coming to terms with the loss of illusions about the perfection or the perfectibility of the world. It has to do with transforming the need for one's objects to be other than, better than, who they are into the capacity to accept them as they are.” (Stark, 1999, p. 55)

“The patient comes with a story to tell and to enact; the therapist both interprets the patient's story and participates with the patient in the making of it. "Reality" is not merely discovered; it is created on a moment-by-moment basis.” (Stark, 1999, p. 88)

“the child's unrelenting hopefulness is what fuels the intensity with which she remains attached to the internal bad object.” (Stark, 1999, p. 106)

“The goal of treatment is movement of the patient out of disconnection and isolation to connection and empowerment. It is an interactive process that involves empowering the patient so that she dares to risk exposure of her vulnerabilities and to acknowledge her underlying longing for connection. In order to accomplish this movement, the therapist must also dare to be authentic, vulnerable, and emotionally present.” (Stark, 1999, p. 121)

“There is a paradox involved here: it is only by means of staying grounded in one's own reality that one can locate another; but it is only by means of locating another that one can become more grounded in one's own reality.” (Stark, 1999, p. 171)

“the patient's transference is always a story about both the reality of who the therapist is and the meaning the patient makes of that reality (that is, how the patient interprets it).” (Stark, 1999, p. 235)

“Just as the therapist interprets the patient's unconscious, so too the patient can interpret the therapist's unconscious. And just as the therapist's interpretation may enable the patient to become aware of something within her that she had not previously recognized, so too the patient's interpretation may enable the therapist to become aware of something within her that she had not previously recognized.” (Stark, 1999, p. 248)

“In fact, part of the reason people become pathologically dependent upon others may have to do with their inability to hold within themselves both sides of their conflict-their tendency, by way of projective identification, to draw others into holding important (but unacknowledged) aspects of themselves.” (Stark, 1999, p. 294)

Masochism is, I believe, about hope, relentless hope-the hoping against hope that perhaps someday, somehow, someway, if one were but good enough, tried hard enough, and suffered long enough, one might eventually be able to extract from the object (a stand-in for the heartbreaking parent) the love one was denied as a child. I believe, therefore, that the investment of the sadomasochist is not so much in the suffering per se as it is in the hope, the illusion, that, perhaps this time ...

[Robin · Rating 5 out of 5]

A powerful read for anyone in a therapeutic career. The clinical vignettes are so helpful and clear.

[Don · Rating 4 out of 5]

This book badly needed an editor. There’s a ton of repetition, and much of its organization doesn’t make a lot of sense. And yet this is such a needed book for psychodynamic therapists, and Stark’s writing itself is incredibly clear. Her thesis is that within the psychodynamic tradition there are three main models and that effective therapists will be versed in all three models and will pull from each as needed.

Stark writes that the three models posit different causes of psychopathology and different solutions. The classical model holds that the cause of psychopathology is internal conflict, the object relations model says it's an absence of good objects, and the relational model says it’s the presence of bad objects. The classical model holds that the solution is insight, the object relations models says it’s a corrective emotional experience, and the relational model says it’s hand-to-hand combat with the therapist.

Stark doesn’t say much about the classical model, perhaps because that’s the original recipe and she assumes we already know what we need to know about that. She writes with real passion about the relational model. Okay, it’s not quite hand-to-hand combat, but some of her vignettes make it feel something like that — the patient using projective identification to turn the therapist into a bad object, the therapist transforming into a bad object before our very eyes but managing to pull herself out of the enactment just in the nick of time, thus giving the patient the corrective experience of the bad object becoming good. For the first time ever, relational psychoanalysis is starting to make sense to me, and my appetite for Stephen Mitchell’s Relational Concepts in Psychoanalysis has been whetted. And also my appetite for some UFC action.

If there’s a flaw in this book, aside from the atrocious editing, it’s that Stark clearly favors the relational model. There’s nothing wrong with having a preference, but she gives the impression that all the models are equally valid while not truly believing that. For instance, she nicely describes the differences between patients with relational conflict and those with relational deficit, the former possessing a strong unconscious need to be failed and the latter having a overwhelming fear of being failed. And although these distinctions were originally made by object relations theorists, Stark goes into depth explaining how relational therapists treat both patients (becoming bad objects with the former and sharing their own emotional experiences with the latter) while more or less dismissing how the object relations people treat such individuals.

All and all, however, I found tremendous value in this book. I especially recommend it for beginning psychodynamic therapists who have a fuzzy understanding of the different psychoanalytic models, although Mitchell and Black’s Freud and Beyond is probably a better place to start.