Understanding and Explaining Therapeutic Behaviour: Why Do We Do What We Do?

S. Giac Giacomantonio

I present these ideas in a spirit of open inquiry, and hope that they might open dialogue on the matter in the forum of the Newsletter.

One of the regular attenders at the self psychology conferences was recently describing the experience to a colleague who had never attended. The description of the panels over recent years went something like, "Every year someone presents a case involving progressively more unlikely or outrageous interventions, and the case always includes a therapeutic success and a happy ending." With the descriptors of "unlikely" and "outrageous", the unacquainted colleague might have begun to wonder whether we self psychologists were flirting with the possibility of "going too far".

We might ask ourselves whether it is in fact possible "to go too far" in a psychoanalytic treatment, and if so, how would we recognise having gone too far, and how would we distinguish that from worthy innovation and progress in self psychology? Much of what is now considered the most straight-laced and 'classical' of self-psychological interventions, would likewise, in the 1970s, have been considered unlikely and outrageous, and even earned the old, thinly-veiled criticism of "good psychotherapy, but not psychoanalysis". What is the boundary, if any, between acceptable interventions and unacceptable ones? What kind of intervention makes a treatment no longer psychoanalysis, and does any of us care anymore?

If I recall the presentations that I think my colleague referred to, I would have to say that I myself would have classed some as excellent and creative psychoanalytic interventions, others as relatively ineffective at best, and others still as countertransference enactments at the expense (despite enjoyment) of the patient. Naturally, someone else would likewise draw a line, though probably in another place. I think, however, that in disagreeing about where to draw the line, the debate might slip sadly into a dispute on the issue of whether or not certain behaviours themselves could be defined as inappropriate, or as fully acceptable, or as 'necessary provisions', or perhaps even as the very essence of a universally curative process. I personally feel that it cannot be at the level of classifying specific behaviours that we could hope to make useful progress in the matter. I believe it is at the level of theory that we stand to gain, or to lose the most, as we try to broaden our understanding of therapeutic change beyond the old ideas about the exclusive use of verbal interpretation of transference. The old obsession with whether we are still doing psychoanalysis, might have a more useful renaissance, at least in the domain of theory.

Some authors espouse not only the idea that admissible interventions include those that are unique or un-specifiable, but even the idea that the curative interventions are by definition not specifiable, because they are specific to every dyad. To repeat, I believe that it is not a problem that we have today a much broader palette of behaviours as analysts, but I do believe that our ability to explain theoretically the relative success or failure of such innovate or even 'outrageous' interventions seems to lag somewhat behind. Once we begin to generate theories that specifically permit any behaviour or intervention, leaving only the requirement that the patient benefit from it, we have simultaneously begun to enter a new arena of theoretical dangers, even if our patients are responding well and enjoying their analyses. I submit here a few such potential dangers, which I offer with the argument that we must be cautious, should we indeed be travelling in such a direction theoretically:

I. The problem of the failsafe treatment
If we ever reached the point where any intervention were OK, provided that it made the patient better (however stringently defined), we would run the risk of espousing an untestable yet simultaneously failsafe therapy. If any definition of treatment came to place fewer and fewer restrictions on the actual conduct of an analysis, save that of a happy patient, it would approach a state that is tantamount to equating the treatment with the successful outcome directly. In such a hypothetical state of affairs, the treatment in question could never be tested in terms of its efficacy: if therapy worked, it was self psychology, if it didn't, then it wasn't self psychology. You can never test a therapy defined as 'that which makes our patients better'. We need to be more specific in pre-defining the treatment, whose successful execution could then be tested against the successful execution of alternative interventions, in terms of outcome.

II. The problem of the over-inclusive treatment
A theory that comes to equate the treatment with the outcome, also suffers the danger of over-inclusion. As the theory specifies less and less in terms of specific interventions, any number of activities or interactions suddenly become self-psychological interventions. The departure from Kohut's position of interpretation of transference as the sine qua non of self-psychological treatment (Kohut, 1981, 1984) has surely led to a broader, more comprehensive understanding of the many pathways to therapeutic change, but the line between specifically psychoanalytic pathways to change and any other positive, wholesome, or even invigorating experiences as pathways to change, seems to have become of less interest to some theoreticians. In response to the critique that "anything goes" in contemporary self psychology, some might reply that the maintenance of a link to some theoretical constructs is sufficient: "As long as I understand the intervention in terms of concepts like the selfobject, it must be self-psychological analysis". Is nothing else needed? Let's consider an example:

As a music teacher, I believe that the successful development of a musical performer always requires accessing and working in tandem with the budding aspirations for self-expression that the average student brings, be they conscious or unconscious. A music teacher cannot hope to train a successful performer without recruiting that part of the student that we as self psychologists would call the grandiose self. The desire to display oneself, and to express oneself for the involvement and enjoyment of others, must be found, understood, integrated, and recruited by the training if it is to permit the student to reach his or her potential as a performer. There can be no good performance without the "juice" of the "ambitions pole". Over the years of the teacher-student relationship, there are countless interactions where the teacher's responses have decisive influence on the student's preparedness to give him-/herself over to the exhibitionism and grandiosity that lead slowly, over time, to a stable confidence in (and sophistication of) his/her creative self-expression. Attending the self psychology conferences of recent years, I heard a number of ideas about what is both necessary and sufficient as psychoanalytic treatment, ideas which seemed (to me) unable to explain why this description of teaching music is different to psychoanalysis. It might be a case of my own ignorance of, or unfamiliarity with some of the newer theories in depth, but any theories of therapeutic change that lacked such a discriminant definition, would point more to a problem of theory than a problem of how we are conducting ourselves as analysts (or teachers for that matter). If the definition of our discipline ever became sufficiently broad as to include the music lessons here described, or inspiring lectures or movies, etc, then the world would suddenly be full of psychoanalysts masquerading as bartenders, hairdressers, good friends, or perhaps even good operas or bottles of good wine.

III. The problem of theories of the X factor
Since the deposing of interpretation from a central place in the conduct of an analysis, many other propositions have been put forth about what the analyst must do to promote therapeutic change in the patient. Many such contributions would include reference to certain experiences in the 'relationship' between the analyst and patient, and there are many and varied explanations of precisely what this relational component should be. Much academic psychology literature on therapeutic change has emphasised non-specific factors as curative in all forms of psychotherapy, where "non-specific" refers to factors other than those specified by the theory as curative (e.g., it's not the interpretation in analysis that cures, it's not the cognitive restructuring in CBT that cures, etc,). The role of our theory is, of course, to try to specify how analysis cures, and because no theory is perfect, there will always be an X factor, that is, a factor in the process that lies outside of what we presently understand and can presently explain. The minimum requirement of every new theory is that it takes the boundary between what we already know and what lies beyond as the X factor, and moves this boundary to expand, a little further, the region of what is understood. That is, a theory must leave us with a little less on the X factor-side of the boundary, such that we understand more than before.

As the prescription of analytic behaviour loosens—as indeed it should—the parallel risk on the theoretical side of the ledger is that of a kind of circularity. The most concerning position that a theoretical contribution could take, would be to offer as theory, the idea that the specific, curative factors are of necessity unknown and unknowable, e.g., unique relationship experiences that cannot be specified in advance. Every successful analysis is unique, but it is our job theoretically to identify what they all have in common. Otherwise, we would lose our clarity on what it was that we were evaluating, testing, or refining. Again, this is another side effect of the hypothetical "self psychology is what makes the self better" argument. It is simply not sensible to make a theory that offers us nothing beyond labelling the non-specific factor as a specific factor, without a parallel explanation of something that what was formerly unexplainable or unexplained. It does our field a disservice for a theory to specify that curative factors are unspecifiable. By definition, you can't have a theory that is simply a statement of the existence of the X factor.

Summary
Psychoanalysis has undergone much development and change over recent decades, and one could easily draw a circle around self psychology and cite the entire movement as such a development. Within self psychology the boundaries are likewise expanding, which leads hopefully to a broader effect of treatment, through a parallel broadening of ideas about what it is that analysts do to help their patients. Some people seeing the clinical developments in self psychology will surely criticise us for taking an "anything goes" attitude to treatment, but I believe there is a greater risk to the field in the area of theoretical clarity, which risk cannot be tackled by addressing the behavioural dimension of innovative interventions, whether we are endorsing or proscribing specific interventions. The risk can only be tackled by addressing the characteristics that any good theory must possess, and measuring our innovations against these characteristics as criteria. The solution to "anything goes" is not a rigid prescription of behaviour, but rather a conceptual, theoretical clarity about why we do what we do, and what distinguishes other approaches to treatment, however successful, from psychoanalysis.

S. Giac Giacomantonio is a Lecturer in psychoanalytic studies in the Department of Psychiatry at the University of Queensland. He is the National Convenor of the Australian Psychological Society's Psychoanalytic Interest Group, and is a co-founder of the Brisbane Psychoanalytic Self Psychology Group.

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