The Patient's Sense Of Therapeutic Action: An Introduction

THE THERAPEUTIC ACTION OF PSYCHOANALYSIS as described by both Strachey and Loewald are among the most quoted references in the analytic literature. Strachey (1934) emphasized the mutative transference interpretation that changed the patient's superego. Loewald (1960) nearly 30 years later added a more interactive dimension. Both articles address what helps from the analyst's theoretical perspective. More recent literature maintains this focus on the analyst's view of what is helpful. The patient's sense of what is therapeutic, however, is rarely if ever explored.

Patients know or at least have a variety of feelings and ideas about what is and has been helpful during treatment. At some point or perhaps at regular intervals, I suggest reviewing with the patient what has seemed therapeutic. We ordinarily hesitate to ask patients their specific views of what has been helpful or even negative during treatment. I will offer some examples where such reviews occurred. I will also comment on the patient's changing sense of what was therapeutic as time passes after treatment. There is a difference remembering while in treatment with an analyst as compared with remembering after analysis. A background issue for this talk is Levenson's (1992) observation that "to varying degrees devaluation of the patient's experience still operates in contemporary psychoanalysis" (p. 556).

After 6 months of treatment I asked a 40-year-old woman who had a supervisory position what stood out as helpful. From my standpoint we had been working on her feelings about a previous therapist she felt was dogmatic, authoritarian, and insisted she write down all her dreams. She answered, "You're easy to be with, but that's not what you're asking." She then recalled one comment that helped. She had been distressed about a young woman she supervised who asked her a lot of questions and was very anxious about her performance and evaluation. She could not see