Jon snodgrass is a Professor of sociology at California State university, Los Angeles. He is a licensed Research Psychoanalyst by the Medical Board of the State of California. The effects of social divisions on individuals (and group behavior) are historically the domain of sociology. The expansion of psychodynamic theory to a "relational" focus is the reverse of psychological reductionism.
Descrição original:
Título original
32283417 Martha Stark Modes of Therapeutic Action Review and Critique 5 2010
Jon snodgrass is a Professor of sociology at California State university, Los Angeles. He is a licensed Research Psychoanalyst by the Medical Board of the State of California. The effects of social divisions on individuals (and group behavior) are historically the domain of sociology. The expansion of psychodynamic theory to a "relational" focus is the reverse of psychological reductionism.
Direitos autorais:
Attribution Non-Commercial (BY-NC)
Formatos disponíveis
Baixe no formato PDF, TXT ou leia online no Scribd
Jon snodgrass is a Professor of sociology at California State university, Los Angeles. He is a licensed Research Psychoanalyst by the Medical Board of the State of California. The effects of social divisions on individuals (and group behavior) are historically the domain of sociology. The expansion of psychodynamic theory to a "relational" focus is the reverse of psychological reductionism.
Direitos autorais:
Attribution Non-Commercial (BY-NC)
Formatos disponíveis
Baixe no formato PDF, TXT ou leia online no Scribd
Jon Snodgrass, Ph.D. Professor of Human Development Department of Sociology California State University Los Angeles 90032 (323) 343-2215 jsnodgr@calstatela.edu The author holds a Ph.D. in Sociology from the University of Pennsylvania (1972) and a Ph.D. in Child Psychoanalytic Psychotherapy from Reiss-Davis Child Study Center in Los Angeles (1985). He is in Private practice in South Pasadena, CA and licensed as a Research Psychoanalyst by the Medical Board of the State of California. The ConTexT of PsyChodynamiC Theory The Foreword to Martha Starks, Modes of Therapeutic Action (2000) states, Contemporary [psy- chodynamic] thinking is a return to fascination with the impact of external reality on personality, particularly the reality of culture class, race, gender or trauma (xii). The effects of social divisions on individuals (and group) behavior, however, are historically the domain of sociology. Here psychology sounds like sociology? The expansion of psychodynamic theory to a relational focus is the reverse of psychological reductionism. The relationship between two or more subjects is objectifed and not explicable by any psychic processes. The trend is led by psychologists using terms like: cognitive-behavioral theory and evidence-based theory. Sociology meanwhile is globalizing to encompass international stratifcation. Anna Freud turned psychoanalysis toward the study of the ego and away from her fathers pre-occupation with the unconscious in the 1920s. She took leadership of the psychoanalytic movement when he was incapacitated by cancer of the throat and jaw. This trend toward ego psychology mistook the imaginary for the real, becoming the main criticism of the psychoanalytic establishment by Lacan (Mitchell and Black 1995, 198). Anna Freud was caught between: her mother and father, the predominately male movement and her role as a new woman leader, the Vienna and London schools of psychoanalysis, and child and adult forms of psychotherapy. It is not surprising then that she argued for strengthening the ego via insight and building defenses. The Ego and the Mechanisms of Defense (1936) is her major contribution. Her survival strategy employed consciousness as a bulwark against the intrusion of instinctual drives and social reality. As an Austrian migr to England, Anna Freud was ensnared in world politics. During the crisis of World War II, when the ego was overwhelmed with the external struggle against evil, she devoted herself to saving the children of London from the German blitz. The impetus toward the relational in psychotherapy originally came from her work with diffcult cases, i.e., orphaned children. After the war, the psychoanalytic movement continued to split over external versus internal world views. The leadership of the internal viewpoint fell to Melanie Klein who stressed the role of phantasy in the unconscious. She considered herself loyal to the classical perspective and the true heir of Sigmund Freudians original conception of the unconscious. Ironically, Freud sided with his daughter. Biographer Ernest Jones supported Klein, excusing the old man saying, he was so dependent on his daughters ministrations and affections he could not be quite open-minded in the matter (Peters 1985, 97). In England, the external emphasis appeared in the form of Ego Psychology, as well as, the British Object Relations School. Fairbairn, developed the latter theory working with abused children. The interaction of the ego with reality was the center of attention. In classic psychoanalytic theory, mediated by the ego, the confict was between the superego and the instinctual drives. Fairbairn spoke of internal objects in the ego, but Klein spoke of internal objects in unconscious phantasy. On the continent, Lacan ignored both viewpoints, claiming that the unconscious was the 2 internalization of cultural authority, i.e., the law of the father. To Freud, culture arose out of the unconscious, but to the French school, culture shaped the unconscious. It was in fact, structured like a language, said Lacan. Thus, the socialization of the unconscious took place everywhere. Max Webers thesis in sociology concerned the rationalization of modern society. The ego psychology of Anna Freud prevailed over the concept of unconscious phantasy in Klein. In the United States her work is scarcely known. Here, Anna Freuds student, Erik Erikson, built the lifespan development movement based on identity formation in the ego. An indigenous psychotherapy appeared in the United States in Harry Stack Sullivans Interpersonal Psychoanalysis. As the name suggests, his perspective was an early expression of the relational trend, fxed on an individuals past and present. Sullivan was known for work with schizophrenics. Stridently anti-Freudian and anti-unconscious, his theory is not psychoanalytic. Three sTark models: Cold, medium and Warm Stark describes her book as a synthesis of the modern relational and classic psychoanalytic models. The hidden world of phantasy is not really included in her treatise. Klein, for example, is cited as not understanding internal bad objects. She had little to say about ... the patients attachment to these savage beasts (79). This is equivalent to saying Anna Freud knew nothing about the ego and its defenses. Relying on relational schools, Stark reviews three models of psychodynamic theory. She clarifes that she does not offer the paradigms as a set of technical procedures to be followed in practice. She presents them instead as conceptual options for thinking about work with a client (24). The models emphasize sequentially: the therapist, the patient and the pair. There is ambiguity and overlap, for the models are not mutually distinct. There is also a ranking of the categories refective of the evolution (early, middle and late) of psychodynamic theory, moving from the classical to the modern period. This trajectory in the Stark scheme means the classical mode of interpretation is considered obsolete when used alone. Sometimes it serves as the villain of the piece (xv) but at other times, she speaks of a balanced use of the models. The suitability of models for different clients or diagnoses, is not pursued by the author. Her books subtitle provides labels to identify the three bearers of theory and therapy: 1. Enhancement of knowledge, 2. Provision of experience and 3. Engagement in relationship. She uses another set of terms: 1. Drive or Structural Confict Model, 2. Defciency Compensation Confict Model, and 3. Relational Confict Model. A fourth set is: 1. Ego Psychology, 2. Object Relations Psychology and Self-Psychology, and 3. Relational Psychology. In Model 1, the therapist attempts to be a neutral object focusing on the pa- tients internal dynamics. Stark calls this a one-person model because it does not conceive of the therapist as a participant in the relationship, but simply an objective observer of what is going on inside the patient. This is the classic psychoanalytic model. 3 In Model 2, the therapist recognizes the longing of the patient for relationship. This model includes all of the object relations and self-psychology approaches. No longer is the therapists sole aim to render the unconscious conscious, thus resolving the patients internal conficts. The goal of treatment becomes flling the process defcits that the patient brings to treatment. Instead of a neutral analysis of the patients dilemma, the patients relational needs for empathy, validation, and support are top priority. Emphasis is on the defcits that prevent the patient from being able to care lov- ingly for him-herself. The therapist, by being empathic, listening without judg- ment, and being fully there for the patient, helps to supply some to these defcits and gives the patient a new experience of what is possible. Stark calls this a one- and-one half person model because the therapist is present only in a partial sense. In Model 3, the therapists are relational therapists who believe that what heals is the interactive engagement with an authentic other: the therapeutic relationship itself. Stark conceives of this as a two-person model in which the therapist re- mains centered and responds authentically from his/her own feelings. The Model 3 relational therapist must be able to provide information and insight when needed, as required by Model 1, and corrective experience in the form of empathy and support when appropriate, as required by Model 2, but the therapist must also be able to do more. The Model 3 therapist must pay attention to the force feld created by the patient in an attempt to draw the therapist into parti- cipating in ways determined by the patients early history. This is a more complex task than either of the other two and it involves all three ways of relating. Failures in therapy are due not just to incorrect interpretations or inadequate supplying of what was missed, but also due to pressures exerted by the patient to reenact the familiar and familial. Only the patient-therapist pair together has the opportunity to spot that process and help the patient create a healthier resolution of those original hurts (68). Stark believes healing in psychotherapy ultimately arises from the authentic relationship or the authentic engagement of the therapist and the patient existing in Model 3. Authenticity, therefore, is a crucial concept in her book. An authentic therapist endeavors to apply all three models as appropriate while working with a patient. The ideal is for, the therapist to achieve an optimal balance between formulating interpretations, offering some form of corrective provision and engaging interactively in relationship (4). As the only model that is truly authentic, he third Model integrates the three approaches into what Stark calls two-person psychology. She writes, the therapeutic action involves a corrective experience by way of the real relationship we are suggesting that the therapist offers the patient something that the patient should have received reliably and consistently as a child, but never did (19). Healing requires both parties to bring an authentic self to the interaction, described as the counter-transference meeting the transference. 4 Case VigneTTe: Child TyranT (34-36) Stark provides clinical examples of therapeutic action. Corrective provision, for example, is illustrated with a latency age girl the author treated for two years. The child had an obsessive need for omnipotent control over the therapist in sessions and acted despotic toward her therapist. The author explains, I always did the very best I could to accommodate myself to every single one of her imperious commands . I did not interpret her need for control (35). Stark said she practiced Model 2. corrective provision and eventually the child gave up her domineering ways. A feature of Starks treatment is that nothing real was given to the child. The doctor played the role of fulflling the childs fantasies about being in total control. The child never had real control, nor was her real need for control ever met by the doctor. The child pretended to have control and the therapist pretended to allow her to have control, but this was entirely role playing. It was a game and not authentic on both sides. Under the doctors authority, the child was permitted to think and act like she was in charge. The hierarchical structure of their real relationship is evident as Stark repeatedly refers to her my little friend. In this case, the healing does not come from the social interaction, which may have been playful, or more serious, at different times. Starks willingness to join her patient in play, however, is engagement at a mental level. What mattered is not the provision of real or imagined needs in their relationship. Being together without judgment, represents a genuine psychological, not behavioral, act. Their activities together might have taken many other forms and still have accomplished the healing. The game was not authentic, but the agreement to play together was sincere. What is decisive in the treatment is the mental act behind the behavioral form in dealing with the case. This means the form can vary widely, but the mental act contains the essential healing essence in seeing no difference between therapist and patient. They might have engaged in other activities, as long as minds were joined in the pursuit of understanding and being understood. It is not the behavioral form, but the thought that heals the patient and the therapist. The need to control others always imprisons the self in the mind. This distinction between thinking and behaving raises the prospect of a fourth model of therapeutic action. An additional mode is implied within the three models of her study. Stark writes, for example, the models are for conceptualizing, not for implementing treatment plans. She alludes to Model 4, It is always the therapist intention [not behavior] that places her intervention in Model 1, 2 or 3 (236). The fourth model emphasizes the mental tie between therapist and client. Therapeutic action implies some active agent like medicine on a wound. model 4 Stark alludes to Model 4 when she writes, the therapist can optimize her effectiveness if she has the capacity to hold in her mind an intuitive sense of whether the therapeutic action in the moment involves knowledge, experience or relationship (5). What matters here is not which model is practiced, but holding the options in mind, and by inference, holding the patient in mind. It is the mental, not the behavioral act that heals. For this reason the therapist herself must want to heal to become a healer. 5 The shift to Model 4 is away from the social relationship to the mental relationship of the therapist and patient in the mind. The mental act is primary while the social activity is secondary, as an effect of the mental action. Models 1-3 reverse the cause and effect relationship. Model 4 therapeutic action originates in the decision making of the therapist-patient, to join in understanding and extends to the relational. Minds heal relationships, but relationships do not heal minds. Stark had a healing experience with her own therapist when he rearranged his offce furniture to suit her specifcations (36-37). Model 4 suggests that the rearrangement of the furniture and the momentary control over him, however, were not the cause of healing. The analysts decision showed the patient that her desire for omnipotent control was not perceived by him as threatening to his ego. Thus, accepting her in his mind, he allowed her plan to take over the offce layout. But, had he been afraid of her, he would need to control her, disallowing the change and demonstrating an identical problem with authority. Because Stark brings the problem in her mind to both situations (child patient and personal analyst) the need for omnipotent control appeared in both treatment cases. As long as the confict exists in the social relationship, it cannot be resolved because it replicates externally by persisting psychologically. The problem originates in thinking and transfers, and counter-transfers, to rela- tionships. A therapist controls her mind, not her patient, nor the furniture, demonstrating the option to heal. Case VigneTTe: holding-uP The TheraPisT (58-61) Stark provided clinical vignette to illustrate the concept of authentic engagement. She worked with a middle aged lawyer, a specialist in domestic violence, enduring a painful romantic breakup. After six months of treatment, Stark heard the client refer to her gun and learned, for the frst time, the patient was armed during therapy. Stark said she was terrifed and that the patient knew it. Understandably, the aroused doctor needed control and tried to negotiate a compromise. The patient, however, felt the need to have her gun with her at all times (59). I knew it was important that I be able to contain my fear in relation to Cindy but I couldnt quite pull it off in time (60). Unlike the child case above, this situation expresses a real power struggle between the therapist and the adult patient. Stark could not allow her patient back into the offce with a loaded weapon and the patient refused to attend treatment without it. The therapist considered herself a failure because she was unable to control her counter-transference fear re- action. Stark thought she had caused the client to not return. Candidly, she tells us that her failure still haunts me (61). Stark had an authentic counter-transference reaction, but rather than healing the patient, or the therapist, she condemns herself as a failure for years thereafter. She believes she should have controlled her fear in order to continue therapy and to succeed in healing the client. This one- sided analysis means she thinks she should fx the problem single-handedly. It indicates the need for omnipotent social control persisting in the mind of the doctor who is harsh (stark) in her self- relationship This is a one person analysis because the client is given no credit for the treatment failure. At the turning point of six months, it appears that the client decided to prosecute the therapist for failing 6 her in treatment. The decision coincides with the patients personal history of blaming her mother and romantic partner for failures in relationships. The therapist attacks herself, justifed due to her guilt over not being the all-powerful doctor. It was the client, however, who wanted to terminate either the therapy or the therapist. Stark does not understand the patients transference relationship since her expectation is to have total control of the situation by herself. The one person understanding contradicts her argument, by not allowing an interpretation, characteristic of the classic mode, concerning the magnitude of clients hostility. Nor is there sympathy for her own counter-reaction that might mitigate the injury. Stark does not recognize the patients independent right: to be self-destructive, to end the professional relationships and to blame others as the cause of it. In her previous book, A Primer on Working with Resistance (1994) Stark emphasized that resistance to insight into the counter-transference is the result of not grieving the losses of childhood and not allowing reality to be as it is. Applied to her situation with the attorney, the problem may be seen as the failure to grieve the loss of omnipotent social control and to accept being powerlessness to heal the client. In her chapter on Mastering Resistance by Way of Grieving Stark asks, What must the patient come to understand before he can move on? Her answer is quoted below, except therapist-patient is substituted in the quote each time Stark uses one or the othertherapist or patient. Starks entire chapter might be read making this substitution because the resistance in the transference-counter-transference relationship is always identical in principle, but not necessarily in form. Both were so scared, they were not sure they could trust one another to allow healing to occur and this mirrored defcits of trust in their self- relationship. Eventually the patient-therapist must feel his disappointment, his heartache, and his outrage about all this; he must face, head on, the intolerably painful reality of the patient-therapists limitationsnamely, the patient-therapists inability to make up entirely for the bad parenting the patient-therapist had as a child (29). The patient-therapist will master his or her resistance to the extent that the patient-therapist is able to grieve the loss of omnipotent control over reality in exchange for mind control knowing that something lost is illusory. This understanding begins as a theoretical level and learned more deeply over time through practice. An interactional model is problematic in strengthening, rather than giving-up the egothe false self which never forgives and never heals. Book auThor Martha Stark, M.D., a graduate of the Harvard Medical School and the Boston Psychoanalytic Institute, is a psychiatrist-psychoanalyst in private practice in Newton Centre, MA. Dr. Stark is on the faculty of both the Boston Psychoanalytic Institute and the Massachusetts Institute for Psychoanalysis. She is also a Clinical Instructor in Psychiatry at the Harvard Medical School, has a teaching appointment at the Massachusetts Mental Health Center, and is on the faculty of the Center for Psychoanalytic Studies at the Massachusetts General Hospital
7 referenCes Cornog, M., & Perper, T. (2001). Modes of Therapeutic Action (Book Review). Journal of Sex Education & Therapy, 26(1): 68. Stark, M. (2000). Modes of Therapeutic Action: Enhancement of Knowledge, Provision of Experience, and Engagement in Relationship. Northvale, New Jersey: Jason Aronson. Stark, M. (1994). A Primer on Working with Resistance. Northvale, New Jersey: Jason Aronson. Quiz QuesTions Can a therapist be authentic according to Stark without using the counter-transference? The authentic therapist helps create an authentic patient in the healing process according to Stark? (Revised 6-2010) 8