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Thirty years ago, most American analysts adhered to the driveconflict model of pathogenesis and believed that change occurred primarily through interpretation, insight, and conflict resolution. They distinguished between facilitative changes — establishment of the therapeutic alliance, intensification of transference through transference interpretation — and definitive changes — identification and internalization, increased awareness of psychic continuity, utilization of insight, and renunciation of infantile wishes.
By the 1970s, a second major psychoanalytic paradigm emerged that encompassed overlapping theories of object relations, self psychology, intersubjectivity, and relational psychoanalysis. It replaced the earlier one-person model with a two-person model, using interactional, interpersonal, and subjectivist paradigms. All emphasize the therapeutic or working alliance as distinct from transference, the emotionally charged therapeutic relationship as a coequal one.
Conflict and deficit are universal and mutually interact in the course of development. To the degree that one sees one or the other as critical in pathology, one will favour particular technical prescriptions. Whatever theory one subscribes to, conventional wisdom holds that psychothera-peutic change occurs in gradual cumulative ways.
Yet change need not be gradual. Change moments are moments when the patient's perceptual, cognitive, or emotional world is experienced as suddenly significantly altered. They are experienced as discontinuous and seem to interrupt the therapy, to speed, alter, or torpedo its course, often to the surprise of both patient and therapist.