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The material for psychoanalytic work derives from both the content of the patient's story and the form our exchange with the patient takes, such as the effects of transference and countertransference, implicit relational patterns, enactments, and so forth. Clinicians intentionally convey specific messages and adopt certain relational postures, such as a benevolent curiosity and an attitude of acceptance and empathy, to establish an atmosphere of emotional safety and to draw a patient into the therapeutic interaction. Simultaneously, patient and therapist are both unwittingly pulled into unexpected forms of interaction, shaped by the impact they have on each other. The greatest therapeutic leverage is usually found when we are able to forge meaningful connections between what we learn about the patient from their narrative and both the intentional and unwitting dimensions of the therapeutic interaction.
Discussion of therapeutic action usually refers to issues that unfold in the therapeutic relationship over a long period. We can, of course, consider the degree to which the patient Louise derives therapeutic benefit from this single session with Paul Wachtel and speculate about what contributed to it, but the goals and cadence of a consultation are different from an ongoing treatment relationship, and we are confronted with some clinical and conceptual challenges. Just as Wachtel and Louise have never met before, we have no background on her case; without such context, there are limitations to what we can say. However, we can observe actions on Wachtel's part that clearly enable Louise to open up and tell her story. As she begins to relax and reveal the many different sides of her personality, we can also see their way
of being with each other become shaped by their impact on each other. By the end of the hour, the pair have spoken about Louise's very troubling current situation as well as the circumstances that led up to it, and they have explored her personal h