Turning Points in Treatments

A particular bias that seems to run through the clinical case literature of psychoanalysis and psychotherapy is the highlighting of the concept of the dramatic “turning point” in treatment, though it is not usually explicitly referred to as such. However, many articles built around clinical case reports, whether they are trying to make a contribution to theory or to clinical practice, share a common format. The problem at issue is first presented, usually within the context of its historical unfolding. Then the illustrative case material is entered upon, in which a particular patient and a particular treatment course are presented up until some point of difficulty or impasse. At that point, some interaction or sequence of interactions is detailed (over whatever time span, but often brief), during which new clarifications emerge that both set the clinical course back on target and illuminate the theoretical conceptualization that the author is advancing. The overall effect is often to leave the reader with the impression of a pending treatment stalemate that got resolved and turned around at some turning point of understanding and clarification, which then served to make the overall theoretical point of the article.

What constitutes such a “turning point,” and the extent to which one can discern one within a treatment process, depend of course both on one's criteria for the phenomenon and on one's sensitivity to it. Within our PRP sample of 42, there were 7 instances (one-sixth of our total) where, in terms of our research overview, such a conception could be applied. In 4 instances, the turning points led to an upward treatment course, and in 3 they led downward—and 1 of these 7 instances was indeed startlingly dramatic. How much these are discerned as such by the patient and the therapist within the treatment interaction, and the extent to which they agree on the assessment and the timing of the phenomenon, are of course matters of interest; the whole question of ho