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.

[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.