While Freudian and Kleinian conceptions of therapeutic action made sense in their day, many contemporary analysts believe there is more going on in analysis than interpretation leading to insight resulting in cure. This change has resulted in part from a shift in thinking about the analyst’s role. Most analysts no longer believe they stand outside the object they study, interpreting material as an objective observer, but find that to study something is to interact with it, and through this interaction, the object is not just objectively discovered, but also subjectively created by the two participants. Many analysts no longer believe their repertoire of interpretations has any great effect on treatment, and report that patients of successful analyses do not tend to remember or put much weight on the analyst’s interpretations (Mitchell, 1996). In the latter half of the 20th century and the first half-decade of the 21st century, analysts have had to come to grips with the idea that, “ no matter how fond we analysts are of our theories and interpretations . . . we must deal with the fact that something else is going on” (Mitchell, p. 169).
Psychoanalysts realized something more was needed in conceptualizing how psychoanalysis works when interpretations failed to achieve what they were intended to achieve. When the analyst arrives at a way of understanding the configurations of the patient’s subjective world he delivers this understanding in the form of an interpretation. What analysts discovered was that some patients cannot hear the interpretation as the analyst meant them to hear it, but instead hear it as something else, often depositing the interpretation into the very categories the analyst is trying to get the patient to think about and understand. For example, if an analyst had reason to interpret that a patient tended to respond to the analyst as if the analyst was the patient’s disapproving father, the patient would only interpret the interpretation as another instance of the psychoanalyst’s disapproval, in place of understanding the more sophisticated semantic link the analyst was attempting to highlight. “This seems to be precisely the problem that we have been tracing with the traditional model of therapeutic action. Interpretations are credited with pulling the patient out of his or her psychopathology; yet interpretations are deeply mired in the very pathology analysts use them to cure. There must be something else on which the analyst can rest his or her weight while tugging on his or her interpretive bootstraps” (Mitchell, 1996). This “something else” is the relationship, sometimes called the therapeutic or working alliance, that is established between analyst and analysand. The model of psychoanalysis that emphasizes this relationship as the primary cause of psychological change is known as the relational model (Greenberg & Mitchell, 1983).
For the relational model of psychoanalysis, which includes the theories of object relations, contemporary ego psychology, interpersonal psychology and intersubjectivity theory, and self psychology, growth of a person is not impeded by unconscious conflict within the psyche that results from warring impulses and prohibitions against these impulses, as in classical theory, but is considered to be an arrest in psychic development caused by actual trauma (Mitchell & Black, 1995). Somewhere in the natural development of a child the process is thwarted due to the absence of crucial parental provisions, such as empathy and emotional attunement (Mitchell & Black, 1995). Relational analysts see it as their role to re-activate psychic growth where it was arrested by offering analogues of “good-enough” parental experiences. It isn’t the patient’s conscious insight into their conflicts caused by the analyst’s interpretations that leads to the amelioration of symptoms, but the discovery of a new experience in which undeveloped potentials are provided with a “facilitating environment” in which to unfold and flourish. The course of analysis depends on the ability of the analyst to remediate developmental failures through the provision of therapeutic actions that represent a unique therapeutic contact (Greenberg & Mitchell, 1983).
The movement to a more relational dimension in understanding the aetiology of mental pathology represents a shift in psychoanalysis from a “one-person” psychology, where conflicts in intra-psychic, unconscious fantasy in one mind (the patient’s) dictate how symptoms unfold in reality, to a “two (or three) person,” interpersonal (or intersubjective) psychology in which problems occur only within a relational matrix that includes a child‘s real mother and father, and the analyst in reality and in the transference. Before therapy, the relational school considers the patient to be trapped in a closed world of archaic object relationships, or relationships with “internal” parents that influence, via transference, everyday interactions with others. The analyst’s primary function is to open the patient’s world and enter into it, fundamentally altering the patient’s internal objects and creating new relational possibilities. In other words, the analyst provides the patient with whatever basic parental responsiveness was missed by the patient.
Relational analysts may use interpretation, but they consider interpretation to be an insufficient tool when used by itself without a strong relationship with the analyst. It is considered an illusion that analysts can treat a wide spectrum of psychopathological conditions successfully through the sole medium of interpretation (Gedo, 1986). In this model, it is well-accepted that the information in the interpretation alone is not what brings about change, but the nature of the relationship that develops around interpretations, such as the patient’s awareness that the analyst understands without judging, cares without impinging, and is affected without being overwhelmed or retaliating. What the analyst does or says may be less important than who the analyst is, or how they are (Chessick, 1996; Strauss, 1999). This includes the emotional involvement of the analyst, for, as Lichtenberg (1996) warns, “If the analyst does not get emotionally involved sooner or later in a manner he had not intended the analysis will not proceed to a successful conclusion” (p. 131).The many ways the analyst is can be represented by the term “holding” (Winnicott, 1965).In this conception of therapeutic action, the analyst is a containing, maternal figure who mentally “holds” the patient, or provides reliable, empathic, even loving support. For this reason, relational psychoanalysis can be described as the maternal position of psychoanalysis, with interpretation serving as the paternal position (Seinfeld, 1993).
Lomas (1987) confirms that the analyst’s personality and actions eclipse his words in importance. Speech constitutes just one aspect of social interaction, and people are more frequently judged by what they do than by what they say. Actions speak louder than words. Words matter to the extent that one means what one says, and patients only accept what is said to the extent that it matches their experience of the analyst. Correct interpretations are not enough to help the patient. The psychoanalyst must act in a healing way, and this includes the psychoanalyst’s warmth. For Lomas, psychoanalysis is not an intellectualized technique but ordinary living in an unusual situation. It is the meeting of two people in a room for the purpose of experiencing a long-term relationship. Analysts help people by talking and playing with them in a direct, earthy, open, and genuine way. Psychoanalysis should be conducted in a down-to-earth style, but Lomas argues that the Freudian technique that is often recommended for arriving at useful interpretations makes this difficult, especially since psychoanalytic literature is primarily an exposition, justification, and celebration of Freudian interpretation (Lomas, 1987). Lomas agrees with Freud that people shy away from the terror, mystery, uncertainty, and tragedy of living by falling into sickness, but “ . . . as therapists we do the same in our work, escaping unbearable tensions in a thousand ways. One such way . . . is to substitute a theory, a technique, a set of rules, designed to give us access to the patient’s psyche, for the unknown, uncharted, hazardous path that every new session presents, and to which we need to bring everything, inside and outside psychotherapeutic schools of thought, that life has taught us” (Lomas, p. 13).
The richness and complexity that is engendered when two people meet regularly over a long period of time and speak about matters of personal importance cannot be encompassed by a formula. What is effective is an intervention by an analyst who is guileless enough to treat the patient not as a monster or an object of analytic curiousity, but “ . . . simply as another man, whose sufferings elicit his sympathy and whose courage and pride he admires” (Lomas, p. 169). Spontaneous, naïve, passionate responses by the analyst may occasionally be the only interventions that work. This does not mean that analysts should not offer interpretations. It does suggest that healing is not always commensurate with knowing the truth. The analyst can form and share his judgements, but he must bring flexibility, empathy, compassion, and lack of dogmatism to such judgements. “To do this well he needs to know his patient; and perhaps to love him” (Lomas, p. 177).
Much disagreement between the interpretive and relational models converges on the notion of insight. The Freudian and Kleinian approaches were in many ways based on the medical model of treating an illness by discovering and correcting its cause, which was thought to result in the patient’s insight. Insight caused change. What is less well known is that many of Freud’s patients refused to get well in response to his attempts to infuse them with insight about the link between their problems and the hypothesized causes (Gaylin, 2000). Relational thinkers now argue that quite often the patient’s symptom does not disappear when insight into the cause of the symptom emerges, and that insight is just a step in the journey toward change, not the whole journey. “Knowledge alone does not inform conduct. Insight is rarely a transformative event. Still, insight is a useful, perhaps necessary ingredient for change . . .” (Gaylin, p. 147). While insight may be necessary, it should only be attempted when the patient is ready to receive it. If knowledge alone were enough to modify conduct, Gaylin argues, the psychoanalyst would simply inform the patient of his conflicts, elucidate their sources, and effect the magical cure. “But premature knowledge is often harmful, coming before the patient is prepared to face it. The insights must come when the patient is ready to receive them . . .” (Gaylin, p. 212).
Relational theorists point out that insight may be the product and not the cause of change, and this change may result from relational factors that include interpretation but encompass much more than interpretation. For example, insight can result from non-interpretive responses of the psychoanalyst, such as his facial expressions, body posture, tone of voice, and emotional, spontaneous reactions. Implicit here is the idea that the force required to make a difficult change may derive from a passionate, emotional, not necessarily verbal experience between the psychoanalyst and patient (Lomas, p. 1987). Knowledge, self-understanding, and insight may only acquire special meaning and true utility when shared with another human being. Thus, only within the safety of the therapeutic alliance with the psychoanalyst will insight and self-awareness emerge (Gaylin, 2000).
