The Negative Therapeutic Reaction: Crisis of Practice or Crisis of Theory?

Why do some patients react adversely to the progress of treatment and, for no obvious clinical reason, get “worse” instead of “better”? Is it possible to grasp constructively the puzzling paradox of the negative therapeutic reaction? Is it possible to reduce existing mysticism about the issues involved?

The question of negative therapeutic reactions has for years been debated by traditional psychoanalytic theorists, with little resolution. However, the psychoanalytic foundation for a more comprehensive understanding of these reactions is available in the two-level conceptualization of intrapsychic conflict contained in Karen Horney's work Neurosis and Human Growth (1). Her first level of conflict linked the phenomenon of neurotic pride and the phenomenon of self-hate into a single entity called “the pride system.” The pride system, she explained, involved both glorification of the self in the form of self-idealizations and despisement of the self in the form of self-hate. Although violently opposed to each other and demarcated in a psychic split, the proud self and the despised self were, nevertheless, seen as dynamically interlocked, understandable only in relation to each other, and making common cause, as Horney said, on an “exalted level.” At the same time, the clash between the proud self and the despised self took place in the context of a second even more pervasive level of conflict involving the total balance of forces in the character structure, the forces supporting health (constructive) versus the forces supporting illness (neurotic). Negative therapeutic crises then were to be understood as the product of these simultaneously conflicting sets of characterological forces, the acuteness of such crises resulting not just from regressive trends in the personality but from the continuing collision of the mobilized forces.

Horney's conceptualization of conflict leads to an understanding of how the pride system (unexamined self-hate and neurotic pride) maintains