Therapeutic Action and The Analyst's Responsibility - Greenberg Paper

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(2015). Journal of the American Psychoanalytic Association, 63(1):15-

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Therapeutic Action and the Analyst's Responsibility
Jay Greenberg
Models of the psychoanalytic situation can usefully be thought of
as fictions. Viewed this way, the models can be understood as
narrative structures that shape what we are able to see and how
we are able to think about what happens between us and our
analysands. Theories of therapeutic action are elements of what
can be called a “controlling fiction,” mediating between these
theories and our very real responsibilities, both to our preferred
method and to a suffering patient. This venture into comparative
psychoanalysis is illustrated by a discussion of published case
material.
Almost eighty years ago Edward Glover introduced the first and perhaps
still the most important symposium on the problem of therapeutic action with
a warning. A great deal goes on in every clinical encounter, Glover noted,
and much of what goes on will contribute to therapeutic change. With a
breadth of vision that may surprise contemporary readers, he noted that in
addition to the effects of interpretation the analyst's humaneness, endurance,
and unconscious attitude toward the analysand are likely to affect the
outcome. In light of this, he concluded, arguing for the priority of any one
element amounts to what he characterized as “mere special pleading” (Glover
1937, p. 132).
We continue to write about and to debate therapeutic action precisely
because of the problem that Glover identified; so much happens in any
treatment that any attempt to identify what is essential is unlikely to be
satisfying. And I would take this a step further: it is very difficult, ultimately,
even to say what psychoanalysis really is.1 It is relatively easy to say what
we are trying to accomplish when we meet with patients; put
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1 The value of defining psychoanalysis is, of course, itself hotly debated.
See Blass (2010) for a recent discussion of the issues involved.
Training and Supervising Analyst, William Alanson White Institute; Editor,
Psychoanalytic Quarterly.
Submitted for publication May 24, 2014.
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Copyrighted Material. For use only by UCL. Reproduction prohibited. Usage subject to PEP terms & conditions (see terms.pep-web.org).
in the broadest possible terms, we are hoping to help deepen their experience
of themselves and of the worlds in which they live. It is also easy to say,
although here our answers will be more personal, why we want to do this: for
each of us it reflects a range of therapeutic, ethical, and even aesthetic
commitments.
We meet our patients with our goals and commitments in mind, but what do
we do with them when we are together? We can easily agree that what we do
is have a conversation with them, a peculiar sort of conversation to be sure,
but a conversation nonetheless (see Lear 2003). So far, so good. But since
we believe that the kinds of conversations we have with patients radically
transform their lives (and may to a greater or lesser extent transform our
own), it must be a very special conversation. How do we even describe the
nature of that conversation?
Freud, of course, believed that the psychoanalytic conversation was unique
and sui generis; as a result, he found it hard to describe. Thus, in an important
passage in “Observations on Transference-Love” he maintained that the
course we must follow in conducting an analysis “is one for which there is no
model in real life” (Freud 1915, p. 166). In place of detailed description he
often turned to poetic, generative metaphors that he hoped would convey what
was happening in the psychoanalytic situation. He used many of these; not all
of them, as we will see, are compatible with each other. Three of Freud's
best-known metaphors come quickly to mind. Analysis is an archaeological
excavation in which the clinician/scientist slowly and carefully unearths
remnants of a buried past, allowing the reconstruction of a history that has
been lost to repression (Breuer and Freud 1895; Freud 1937). Or analysis is
a chess game in which the correct moves—with the exception of the opening
and the endgame—are determined by the unfolding and unpredictable
situation at any moment (Freud 1913). Or analysis is like a military
engagement in which positions are attacked and defended, the eventual
outcome shaped by the larger strategic importance of what might seem to be
unimportant issues (Freud 1912).
Describing the psychoanalytic situation has not gotten any easier since
Freud, and those who have made the attempt have relied on metaphor much as
he did; some theorists are explicit that their concepts are metaphoric, while
others are not. A quick and incomplete overview of some of our more
compelling metaphors reveals a range that is both rich and vexing. Analysis
recapitulates the relationship between child and
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father (Strachey 1934); analysis recapitulates the relationship between child

and mother (Loewald 1960); analysis is an encounter between two adults
(Fromm 1991); analysis is a relationship between a person who projects
unmetabolized protoexperience into a receptive container (Bion 1967); the
psychoanalytic situation is a dynamic field in which both participants
contribute to and experience something new and unique to the dyad—a
creation that is shaped to a significant extent by the mutual though
asymmetrical projective identifications of both parties (Baranger and
Baranger 1962).
This is why I characterize the situation as vexing; the metaphors lead us in
so many different directions. This is, of course, characteristic of metaphors.
As the philosopher Donald Davidson (1978) has put it, a metaphor “calls
something to our attention” (p. 218). Strikingly, Davidson analogizes the
function of metaphor to the function of a dream; despite not being literally
true, both have the capacity to “make us appreciate some fact” (p. 217). But,
he goes on, just what is called to any one person's attention is
underdetermined by the metaphor itself, as the meanings of a dream are
underdetermined by its manifest content; “in fact,” Davidson writes, “there is
no limit to what a metaphor calls to our attention, because what we see is also
shaped by our sensitivities and our experience” (p. 218).
Davidson's understanding of metaphor as interactive reminds me of the
way we read works of fiction; the author “calls something to our attention,”
and our attention is further directed by our commitments, proclivities, and
interests. This leads me to think of our descriptions of the psychoanalytic
situation as fictions, in the sense that they are narratives that direct our
attention to certain aspects of what is going on while, of necessity, diverting
attention from other aspects.
Let me say a bit more about this way of thinking about our way of
describing the psychoanalytic conversation before returning to the problem of
therapeutic action. I find it useful to conceptualize the broader metaphors that
have been used as what I call “controlling fictions.” Controlling fictions
would include, among others, such formulations as Freud's archaeological
metaphor, models of the analytic conversation as one or another variant of
parent-child interaction, and, more recently, the concept of the bipersonal
field, widespread in non-anglophone traditions and increasingly in North
America as well.
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I use the idea of a “controlling” fiction because these broad concepts

generate a particular narrative account of what happens within the
psychoanalytic situation, and each fiction has elements that derive from it.
These subsidiary elements—the characters of the story, the events that are
considered salient, the relationship among events that form the “plot”—are
shaped by the controlling fiction; I would go so far as to say that they are
created by it.
Nothing within the psychoanalytic situation can be understood—can be
seen, really—in the absence of some controlling fiction. Although he would
certainly have bristled at the notion that anything about the discipline he
created was even remotely fictive, Freud (1914) hinted at this when he
defined psychoanalysis as an inquiry guided by the assumptions of
transference and resistance. By this he did not simply mean that holding these
assumptions was necessary for the conduct of a psychoanalytic treatment.
More deeply, he implied that only an observer who embraced them could see
transference and resistance at work, thus allowing him to distinguish a
psychoanalytic session from an ordinary if somewhat eccentric conversation.
And of course any psychoanalytic description of that conversation would rest
on the observer's particular way of understanding the workings of
transference and resistance.
Consider a currently popular concept such as Ogden's version of the
“analytic third” (1994). The analytic third, a neo-creation of the dyad
different from what either participant would or could come up with in any
other context or in any other relationship, has no conceptual space in
descriptions of the analytic situation anchored in the controlling fiction of
Freud's archaeological model. To begin with, we can locate the analytic third
only by exploring the analyst's inner experience, including his or her feelings,
preoccupations, bodily sensations, and so on, and there is no warrant for
routinely paying attention to these within the archaeological model. And
because of this the only relevant objects of investigation within the
archaeological model are the patient's memories, fantasies, and defenses—
that is, contents and processes of his or her mind that can be known only if the
analyst takes great care not to disturb them through precisely the sort of
personal influence that is inherent in the concept of the “third” as Ogden
defines it.
Another example: In defining the version of the bipersonal field that she
and Willy Baranger developed, Madeleine Baranger (2005) emphasizes that
“the field is much more than interaction and intersubjective
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relations” (p. 62). Rather, she asserts, understanding what happens within the
field requires what she terms “a metapsychology of the couple.” Baranger
conceptualizes the “couple,” in a way similar to how Ogden conceptualizes
the analytic third, as a new and unique object of investigation that emerges
within the analytic field. But I would suggest—in stark contrast to what the
Barangers and Ogden have in mind—that neither the couple nor the third
exists independently of the controlling fiction that creates it; they are elements
of a particular way of narrating an analysis.
Investigating any of these narrative elements can certainly lead to
interesting, evocative, perhaps therapeutic ways of understanding what needs
to be understood. But we must not forget that it is the controlling fiction that
creates the elements in the first place. Not all psychoanalytic models support
the notion of a couple with its own unique metapsychology, not even all
models that are anchored in field theory. Harry Stack Sullivan's North
American interpersonal version of field theory, for example, says nothing
about a couple; the controlling fiction that characterizes interpersonal
psychoanalysis requires a metapsychology of two individuals and a theory
that accounts for the ways in which they affect each other (Stern 2013).
What can be said about the “couple” can of course be said about the
“individual,” another narrative element that comes into existence only under
the sway of a particular controlling fiction. Seen from this point of view,
concepts such as wishes, fantasies, and resistances that are said to exist
independently of specific relational contexts also depend on larger narrative
choices. Skepticism about whether the couple exists is balanced by equally
steadfast skepticism about the existence of the individual.2 But both
narratives are also illuminating to analysts committed to viewing things
through the lens that they offer; like dreams and metaphors, both can bring
something unexpected to mind.
Consider a simple example: Treating the analyst's apparently narcissistic
ruminations as part of a co-constructed analytic third can lead to
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2 Sullivan (1940, 1950) provocatively referred to “the illusion of personal
individuality.” As Fiscalini (2006) has noted, in doing so Sullivan was
denying the legitimacy of individuality as a subject of psychiatric study,
another example of the way in which a controlling fiction (in this case the
idea that psychiatry is the study of interpersonal relations) determines what
can be thought about, and even what can be seen.
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interesting discoveries about what the dyad has created. But it will make it
more difficult to recognize ways in which the analyst's irritability, self-
absorption, or anxiety has made contact and engagement with the patient more
difficult on a given day. And, more to the point, it will make it more difficult
to track down ways in which the patient's material has inadvertently triggered
anxieties that interfere with the analyst's analytic capacity. In a model
anchored in the interaction of two individuals, this interference can be
entirely independent of any intention of the patient's. Viewed from this
interactive perspective, the conclusions drawn from exploration of the
“analytic third” may appear to be an avoidance of the analyst's own
unconscious process, or even a rationalization of his or her shortcomings.
All this suggests that in our attempts to understand what goes on between
analyst and analysand we are always trafficking in competing, often
incommensurable narratives. Casting this in broad terms, I would say that any
understanding of what is “really” going on can take shape only in the context
of some controlling fiction. Or to put it another way, there is no way of
conceptualizing what is real that is not to a significant extent fictive. Novelists
know this, of course, and psychoanalysts can and should learn from them.
Let me turn now to what I see as the intimate connection between the
controlling fiction and our theories of therapeutic action. I have suggested that
the controlling fiction creates the characters and the events that populate our
narrative accounts of the psychoanalytic situation. Theories of therapeutic
action are central elements of that narrative; they link events, create ideas
about cause and effect, and in doing so describe the arc that a treatment has
followed, regardless of whether it has succeeded or failed. Consider a few
examples, obviously highly schematized, of the various ways success is
explained:
“Because the analyst interpreted the patient's infantile fantasy of devouring
and incorporating her father's penis, the patient was able to begin to work
through her guilt and eventually to assert herself more effectively and even
competitively with male coworkers.”
“Because the analyst was able to receive and contain the unspeakable fear
of being smothered that the patient could only evacuate through projective
identification, the patient gradually became able to symbolize and to think
about that fear; soon he could dream about it, and with that his agoraphobia
slowly subsided.”
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“Because the analyst, mindful that the patient was an adult and capable of
learning about her impact on others, shared her countertransference
experience, the patient came to see that she used her seductiveness to avoid
the feelings of shame that had always plagued her; this eventually freed her to
engage in relationships more authentically and to find more satisfaction, both
professionally and in her romantic life.”
“Because the analyst found a way to see and to respond affirmingly to the
despair about being recognized and admired that was hidden by the patient's
arrogant boasting and grandiose claims, the patient was able to consolidate a
more stable sense of himself as capable and effective; this eventually made it
possible for him to continue the work toward his doctorate that had come to a
standstill.”
I imagine that the reader will easily identify the various theoretical
traditions from which these descriptions are drawn; despite being
hypothetical and, as I said, highly schematized, they ring true, perhaps
because they are so identifiable. Note as well that each description contains
the same structural elements; consider the first two of these. First, there is a
behavior of the analyst (interpretation, containment, countertransference
disclosure, providing an essential developmental experience that had been
missed); next there is an internal change in the patient that is linked to what
the analyst has done (working through previously unconscious guilt,
developing a capacity to symbolize and therefore to think about things that had
been inchoate and capable of expression only through action, learning about
her impact on others and how that had regulated an internal state, developing
psychic structure that had been undeveloped because of inadequate
environmental provision). For some theorists the account of therapeutic action
can stop here, with the description of what have been characterized as
“treatment goals” (Ticho 1972).
But for the sake of illustration I have taken things a step further, so that
achieving treatment goals leads in turn to the accomplishment of “life goals”
(Ticho 1972). Our hypothetical patients, having used analysis well,
accomplished what I imagine they came in for: they have overcome fears,
moved forward professionally, established more stable relationships. Their
treatments have been helpful and—the crucial point—they have been helpful
precisely because of what the analyst has done and because of the internal
changes that these interventions have brought about. The requirements of any
theory of therapeutic action have been met.
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Now let us imagine that the clinicians who have conducted these treatments
convene at an updated version of the 1936 Marienbad Symposium, where
Glover delivered the warning with which I began this paper. Each clinician
tells his or her story, recounting the events of the treatments and linking them
to the internal and external changes being reported. Each report is convincing
on its own terms.
This is where the idea of a controlling fiction intersects with our
conversations about the theory of therapeutic action. If, as I have suggested,
we can't even describe the events of an analysis in the absence of some
controlling fiction, then certainly there is no way to step outside our narrative
structure to conceptualize a sequence of events that has led to benign change.
Consider, in the schematic sequences I have sketched out, the number of ideas
that have meaning only within the context of some controlling fiction. In
talking about the analyst's interventions—the elements of therapeutic action
that should be most amenable to theory-free description—I mentioned
interpretation, containment, self-disclosure, and mirroring or recognition. But
of course each of these goes far beyond description; a naive observer viewing
a “containing” analyst might see only silence; watching an analyst “mirror” a
patient, the same observer might see flattery. And so on.
Next consider the inner change that grew out of these interventions:
amelioration of a harsh superego, development of alpha function, assumption
of personal responsibility, consolidation of healthy narcissism within a more
stable self-structure. Here theory creates the language itself.
This is why I believe that the elements out of which any vision of
therapeutic action is constructed come into existence and have meaning only
under the influence of a particular controlling fiction. And similarly, the
controlling fiction dictates a narrative arc that creates what is seen as a causal
chain. Theories of therapeutic action are theories of causation. Recall that
each of my schemas began with the word “because”; one way to put things is
to say that the way we see the characters and plot of any psycho-therapeutic
engagement depends on our preferred controlling fiction. To my eye this does
not make our discussions of therapeutic action less interesting, but it does
fatally compromise any attempt to adjudicate among different formulations.
That is why in today's pluralistic world Glover's idea of “mere special
pleading” seems more relevant than ever.
Let me anticipate an objection at this point: although the concepts I have
mentioned emerge from and are embedded in larger theoretical
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structures, some will say that with enough work they can be unpacked and
understood across conceptual divides. If we are open to talking with each
other we can understand what an interpretation is, even if some of us are more
interested in interpreting intrapsychic conflict and others are more interested
in interpreting disavowed relational experience. And, having reached some
consensus, we can go on to evaluate the efficacy of interpretation in
comparison with other sorts of intervention.
Ecumenicism and optimism are, of course, always appealing. But let me
suggest that the situation is actually more complex, darker, and more
interesting. Consider a situation that arises frequently and is vitally important
in any analysis. Working with a radical version of field theory derived from
the Barangers’ model, Civitarese (2005) describes a patient who, a week
before the summer break, announces that her father has suddenly decided to
separate from her mother. She asks for advice on how to help her mother,
persisting until he feels “cornered” (p. 1310). “I choose to focus on the
characters of the session,” Civitarese comments, “and try to reply simply,
saying that it is a very sad situation, that perhaps her mother is the one who is
suffering most now, that [if I were she] I would ask myself how I could help
my mother … and, in fact, I ask her, after a few minutes of silence, what can
be done to help her” (p. 1310; emphasis added). He sees what he says to the
patient as a “narrative, unsaturated interpretation” (p. 1312; emphasis
added), concepts to which I will return shortly.
Civitarese's report of this moment is particularly illuminating because he
has told us exactly what he did with his patient, the words he spoke. And he
has gone on to conceptualize an event within the analysis that was constituted
by his speaking those words; he characterizes what he said as a particular sort
of interpretation. Let us take a close look at the relationship between the
reality and the conceptualization, the latter shaped by the analyst's preferred
controlling fiction.
Reading the vignette, I experience, as I imagine most psychoanalysts
would, the pressures the analyst is under and the tensions he feels. It is a
familiar situation: an emergency arises in a patient's life that both mirrors and
eclipses the emergency developing within the treatment. We feel complicit in,
if not to blame for, the emergencies, and certainly obliged not to go off on
vacation leaving the patient in a collapsed state. But at the same time we do
feel “cornered” by the patient's demands and by her demandingness.
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Most of us, in these circumstances, would like to say something to our

analysand that would reflect our understanding of what is happening between
the two of us at the moment. That is, we would like to offer some version of
an interpretation that would relate her distress to the impending interruption of
the treatment. But the patient has made it clear that she doesn't want this kind
of interpretation; she insists that she needs advice and that she needs it
urgently. The intensity and the relentlessness of her demand reconfigure the
analytic moment. Different analysts will, of course, hear different dynamics at
work. Some will focus on anxiety born of helplessness; others will be attuned
to a vengefulness that contributes to the urgency of the situation, leaving them
wary about doing anything that seems like submitting to rather than confronting
the patient's aggression. There are, of course, other possibilities as well.
So far what I have described is the sort of thing we talk about routinely in
case conferences; we spend a great deal of our professional lives immersed
in uncertainty about the meanings of what is going on. And we all know that
despite and in the midst of our uncertainty we must act. But what I have in
mind goes beyond the meaning of the patient's demand and turns the focus on
the analyst's action: I ask how we describe what he has done.
We know that Civitarese chose a particular action that he reports
straightforwardly: he encouraged the patient to ask herself how she could help
her mother. His choice is certain to affect the analysis and the analysand in
many ways: it will shape the relationship in the moment, will influence the
patient's state of mind in the short run, and will have effects on her that will
evolve over time. This immerses us in the problem of therapeutic action,
because theories of therapeutic action describe events in the analysis and link
these events to changes in the patient or in the dyad.
Usually when analysts complain about the difficulty of talking about
therapeutic action they refer to the problem of defining the relevant changes,
either in terms of treatment goals or life goals. Here I am taking things a step
further and suggesting that there is as much ambiguity in defining the events
that have led to the change as there is in defining the change itself.
Consider Civitarese's vignette. He would say that any change in the patient
and/or the dyad was the result of his unsaturated interpretation. This view—
this theory of therapeutic action—rests on the idea that the needy mother is a
“character” within the session that has been created by the workings of the
analytic field. This definition in turn depends on what I
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have been calling the “controlling fiction” of the field; Civitarese's version of
field theory defines every image that emerges in the minds of the patient and
the analyst as a character. Thus, the mother the patient is describing carries
the helplessness that grows out of the experience of abandonment; it is the
patient's way of communicating what she is feeling in relation to the analyst,
but which she is unable to experience more directly.
On the basis of this assumption—that the mother is a repository of the
patient's unsymbolized and evacuated proto-experience—anything the analyst
says about the patient/mother image is by definition an interpretation. It is an
interpretation because it puts words to experience that as yet has no words,
and it is “unsaturated” because it does not burden the patient with the weight
of transferential meanings the analyst believes she cannot bear. This all leads
to a clear theory of therapeutic action: any benign change can be attributed to
the generativity of the interpretation and to the analyst's presenting it in a form
that allows the patient to hear and to begin processing it.
But of course the comment is an interpretation only in the context of
Civitarese's theory. Seen from another perspective, telling the patient to think
first about how she can help her mother would not look like an interpretation
at all. For example, analysts working with an interactive model—one that
assumes an encounter between two individuals, each responding to his or her
own wishes, fears, internal objects, and so on—would likely see things quite
differently.
Many alternatives come quickly to mind: Civitarese's intervention could be
understood as a retreat to support or advice-giving stemming from the
analyst's guilty reaction to the analysand's forceful but indirect indictment of
him for abandoning her in a moment of need; it could be seen as the analyst's
withholding of an interpretation in an attempt to escape from or retaliate for
the feeling of being “cornered”; perhaps it reflects the analyst's anxiety that
confronting the patient with the realities of the present moment will lead her
to abandon him. I hope it is clear in what I am saying that I am not assuming
that one way of understanding the dynamics of this exchange is more “correct”
than another; nor do I have any information that would lead me to believe that
one intervention is more analytically or therapeutically effective (this is, of
course, true of virtually any clinical vignette).
Now let us assume that the intervention led, at least in the short run, to
some benign change. The patient becomes less anxious; perhaps she
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finds a way to engage effectively with her mother without feeling that she has
betrayed her father; she is able to miss her analyst during the break rather than
collapsing under the weight of the various abandonments. We are left with
competing theories to explain this improvement. Field theorists assert that it
was caused by the analyst's ability to find a useful interpretation and to
convey it with the right amount of “saturation,” so that the patient was able to
hear it and put it to use. Analysts working with a more interactive model, by
contrast, would see the change as resulting from some other kind of event: the
analyst's support and advice-giving that recognized a legitimate need; his
resilience and nonretaliation in the face of feeling cornered. Perhaps the
change is a transient improvement that reflects the patient's manic sense of
triumph over having successfully attacked the analyst's analytic identity,
provoking a counterattack that undermines his authority. We have competing
theories, and of course there are many others. What is most interesting about
them is that each rests on events that come into sight only when viewed
through the lens of a particular controlling fiction.
I am aware, of course, that I am focusing somewhat reductively on a
specific moment in a long, complex, and nonlinear process. But the building
blocks of all analyses are specific moments, and theories of therapeutic action
require that we link these moments in one way or another to change in the
patient. And as Civitarese's case illustrates, it is impossible even to describe
what these moments are in the absence of a controlling fiction.
To put things in a nutshell, I think it would be difficult to decide whether
the patient got better because the analyst interpreted or precisely because he
did not.
Here we encounter one of the most troubling aspects of the way in which
psychoanalytic theory is constructed. I have argued so far that not only our
theories of therapeutic action but our description of the events making up the
psychoanalytic situation are ultimately fictive. That is, our theories of
therapeutic action are coherent, persuasive, interesting narratives that are in
essence logical deductions from competing and incompatible controlling
fictions. Unfortunately, they appear coherent and persuasive, and perhaps they
are even interesting, only to those who accept the controlling fiction from
which they derive. It is hard even to imagine a method that would adjudicate
among different controlling fictions in a way that would help us feel
comfortable.
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And yet the patient in front of us—Civitarese's patient is a good example—

is very real, and her crisis is very real. This means that the analyst's
responsibility to act, to deal effectively with the patient's suffering in one way
or another, is also very real. The responsibility cuts two ways, both of them
palpable presences in our consulting room. First, we are responsible for
acting in ways that will contribute to our patients' well-being. And at the same
time we feel responsible to a particular method for accomplishing this. Both
responsibilities have unconscious as well as conscious elements; consciously
the patient is a person who has come to us seeking help, and our method is
one that we believe offers the requisite kind of help. Unconsciously the
patient plays a role in the constantly shifting landscape of our internal world;
occasionally we get a glimpse of the role that he or she plays, only to find that
our grip on awareness is elusive. And at the same time our responsibility to a
method is shaped both by our conscious belief in its efficacy and by our
transferentially loaded commitment to the people and institutions that have
contributed to our development as psychoanalysts.
Consider the range of options available to an analyst in Civitarese's
position. We may interpret, within or outside the transference; we may contain
the patient's unbearable affect; we may mirror her desire to help her mother;
we may offer support or advice; we may confront the aggression that leaves
us feeling “cornered,” relying to a greater or lesser degree on self-disclosure
in doing so; we may tune into and engage her affect state; we may step back
from the moment to take what the Barangers call a “second look” at what has
been co-constructed within the session. There are of course many other
options; my emphasis here is on the range of choices and on the urgency the
analyst is likely to feel to make the “right” choice when facing a patient in
crisis.
Putting things this way highlights another fact of analytic life that isn't often
discussed. Theory asserts that the unconscious is timeless, and clinical
experience teaches us that time as it gets lived in the psychoanalytic situation
never moves in one direction. And we all know that analysis takes a very long
time and that most of the time not much seems to be happening in a session.
Because of this it is easy to believe that things move slowly in treatment. But
Civitarese's vignette and countless other examples make clear just how
quickly things do happen and just how little time the analyst has to choose
among the available options.
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This is the point at which our preferred controlling fiction, the theories of
therapeutic action that derive from them, and our sense of the analyst's
responsibility converge. I would put it this way: the controlling fiction
prescribes the analyst's responsibilities via the theory of therapeutic action
that is one element of the controlling fiction. The analyst, faced with the need
to choose quickly among a multitude of available responses (silence, of
course, is one response), filters the possibilities through a theory of
therapeutic action. This filtering is likely to be preconscious or even
unconscious; most of the time we will think that something is amiss if we
struggle consciously with how to respond. The analyst's theory of therapeutic
action is most often implicit (Sandler 1983), and it will not necessarily match
any of the formalized theories that are written about.
Because there has been relatively little discussion in our literature of what
I am calling the various “controlling fictions” with which we work, there has
been no comparative study of the responsibilities of the analyst entailed by
these different models.3 Although a full discussion of this issue is beyond my
scope here, I do want to briefly mention that these differences exist and that
they decisively shape not only ways of understanding the nature of the
analyst's participation in the psychoanalytic process but every analyst's
clinical choices as well. I will illustrate this briefly by sketching out the
responsibilities that I believe are inherent in two approaches that, although
both can be considered intersubjective, are based on very different
controlling fictions.
First, consider the responsibility inherent in contemporary
Kleinian/Bionian theory and clinical practice. Although the point is
debatable, I characterize their approach as intersubjective in the sense that the
analysand's projective identifications necessarily affect the analyst's thoughts
and feelings. The controlling fiction in this model is that the analyst functions
as a container for the patient's unbearable, unsymbolized proto-experience,
which is evacuated via projective identification. The derivative theory of
therapeutic action focuses on the analyst's ability to receive these projected
contents, to metabolize them through his or her reverie, and to return them to
the patient in a way the patient can bear. All of this is based on an etiological
hypothesis: the move from the paranoid/schizoid to the depressive position,
and thus the capacity both to
—————————————
3 Wilson's interesting discussion of the analyst's “desire and responsibility”
(2013) bears on this, but approaches the problem from a different angle.
- 28 -
symbolize and to establish stable object relationships depends on the mother's

ability to receive and detoxify the infant's projective identifications. Only
when the unbearable is rendered bearable by the intervention of the other
does thinking become possible, and the inability to think is seen as the cause
of much if not all psychopathology.
Bionian thinking about the analyst's responsibility is a direct translation of
these ideas: the analyst is enjoined to receive and to contain what is
projected, and a successful analytic process depends on the analyst's
processing but not acting on it. Bion's ideas about the analyst being without
memory or desire (1967) and his reminders about the need for “negative
capability” (1970) underscore this way of conceptualizing the analyst's
responsibility.
Let me speculate, as an aside, that I imagine a Bionian analyst sharply
criticizing Civitarese's intervention with his patient. I suspect that the Bionian
would not see what Civitarese said as an interpretation at all; it would look
much more like an abandonment of analytic function resulting from his failure
to contain his patient's aggressive response to the impending separation. An
intervention can be an interpretation or an enactment; it all depends on the
observer's controlling fiction.
In contrast, in North America the earliest intersubjective models were
developed within interpersonal psychoanalysis. In one branch of the
interpersonal tradition, the one developed by Erich Fromm and his followers,
the controlling fiction that shaped conceptualizations of the psychoanalytic
situation was that it is an encounter between two adults, both of whom
inevitably bring complete versions of their personalities to it. The theory of
therapeutic action that follows is that the analysand learns about the
interpersonal world he lives in and the impact he has on it through an
encounter with another person, a kind of encounter that is difficult if not
impossible to experience in everyday life because of our tendency to retreat
anxiously from authentic engagement.
As with the Bionian approach, the controlling fiction and its attendant
theory of therapeutic action is anchored in an etiological hypothesis.
Interpersonal falseness—what Edgar Levenson (1983) called “mystification”
that leads to confusion about the world the child (and eventually the patient)
lives in—is the cause of illness, and so honesty leading to awareness is the
cure. Thus, the analyst's responsibility is to bring his or her self into the
relationship; spontaneity and authenticity—not containment and often not even
tact—is what the analysand needs. This in turn depends on
- 29 -
the analyst's courage, first in confronting his or her own reactions, next in
finding a way to let the patient know something about what is going on. The
North American openness to self-disclosure as a legitimate analytic
intervention began with this tradition, although there continues to be a wide
range of opinion among interpersonal analysts about its efficacy.
Of course interpersonal analysts would be no less critical of Civitarese's
case than Bionians. But for them the issue would be the analyst's failure to
deal authentically with his feeling of being cornered. Not dealing directly
with this—again, self-disclosure would be one route to this but not the only
one—deprives the patient of her right to know how she affects other people,
thus short-circuiting the analysis itself. The retreat to advice-giving is
infantilizing and likely to lead to an iatrogenic regression, perhaps even to
pseudocompliance enacted through a flight into health. If the analyst cannot
confront his own feelings about what the patient is doing to him, how can the
patient confront her feelings about what is happening to her? And how can she
come to know the interpersonal world within which all of this is going on,
including her own role in creating it?
It goes without saying that analysts of all theoretical persuasions take their
responsibilities very seriously; as I have mentioned, these responsibilities
reflect commitment both to the well-being of our patients and to our own
professional identities and relationships. But analysts also know that the
particulars of these terribly real responsibilities derive from concepts that are
ways of narrating infinitely complex realities; we know, at least
preconsciously, that the foundations of our theoretical edifice are ultimately
fictive.
This is the analyst's dilemma and a source of tension that we don't discuss
often enough. Perhaps putting things this way deepens our appreciation of
what Glover implied at Marienbad. Our theories of therapeutic action are
links in a chain that connects a controlling fiction to an urgent reality, and we
plead for one point of view over another in search of a certainty that I am
afraid will elude us forever.
References
Baranger, M. (2005). Field theory. In Truth, Reality, and the Psychoanalyst:
Latin American Contributions to Psychoanalysis, ed. S. Lewkowicz & S.
Flechner. London: International Psychoanalytic Association, pp. 49-71.
Baranger, W., & Baranger, M. (1962). The analytic situation as a dynamic
field. International Journal of Psychoanalysis 89:795-826, 2008. [→]
- 30 -
Bion, W.R. (1967). Second Thoughts: Selected Papers on Psycho-Analysis.

New York: Aronson.
Bion, W.R. (1970). Attention and Interpretation: A Scientific Approach to
Insight in Psycho-Analysis and Groups. London: Tavistock Publications.
[→]
Blass, R. (2010). Affirming ‘that's not psycho-analysis!’ On the value of the
politically incorrect act of attempting to define the limits of our field.
International Journal of Psychoanalysis 91:81-99. [→]
Breuer, J., & Freud, S. (1895). Studies on hysteria. Standard Edition 2.
Civitarese, G. (2005). Fire at the theatre: (Un)reality of/in the transference
and interpretation. International Journal of Psychoanalysis 86:1299-
1316. [→]
Davidson, D. (1978). What metaphors mean. In Philosophical Perspectives
on Metaphor, ed. M. Johnson. Minneapolis: University of Minnesota
Press, 1981, pp. 200-220.
Fiscalini, J. (2006). On coparticipant inquiry and the person self: Reply to
Itzkowitz. Contemporary Psychoanalysis 42:463-469. [→]
Freud, S. (1912). The dynamics of transference. Standard Edition 12:99-108.
[→]
Freud, S. (1913). On beginning the treatment. Standard Edition 12:123-144.
[→]
Freud, S. (1914). On the history of the psycho-analytic movement. Standard
Edition 14:7-66. [→]
Freud, S. (1915). Observations on transference-love. Standard Edition
12:159-171. [→]
Freud, S. (1937). Constructions in analysis. Standard Edition 23:257-269.
[→]
Fromm, E. (1991). Causes for the patient's change in analytic treatment.
Contemporary Psychoanalysis 27:581-601. [→]
Glover, E. (1937). Introduction to symposium on the therapeutic results of
psycho-analysis. International Journal of Psychoanalysis 18:125-132.
[→]
Lear, J. (2003). Therapeutic Action: An Earnest Plea for Irony. New York:
Other Press.
Levenson, E. (1983). The Ambiguity of Change. New York: Basic Books.
Loewald, H.W. (1960). On the therapeutic action of psycho-analysis.
Ogden, T.H. (1994). The analytic third: Working with intersubjective clinical
facts. International Journal of Psychoanalysis 75:3-19. [→]
Sandler, J. (1983). Reflections on some relations between psychoanalytic
theory and psychoanalytic practice. International Journal of
Psychoanalysis 64:35-45. [→]
Stern, D.B. (2013). Field theory in psychoanalysis: Part I. Harry Stack
Sullivan and Willy and Madeleine Baranger. Psychoanalytic Dialogues
23:487-501. [→]
Strachey, J. (1934). The nature of the therapeutic action of psycho-analysis.
- 31 -
Sullivan, H.S. (1940). Conceptions of Modern Psychiatry. New York:

Norton.
Sullivan, H.S. (1950). The illusion of personal individuality. Psychiatry
13:317-332.
Ticho, E. (1972). Termination of psychoanalysis: Treatment goals, life goals.
Psychoanalytic Quarterly 41:315-331. [→]
Wilson, M. (2013). Desire and responsibility: The ethics of
countertransference experience. Psychoanalytic Quarterly 82:435-476.
[→]
275 Central Park West, Apt. 1BB
New York, NY 10024
E-mail: jaygreenberg275@aol.com
- 32 -
Article Citation [Who Cited This?]

Greenberg, J. (2015). Therapeutic Action and the Analyst's Responsibility.
J. Amer. Psychoanal. Assn., 63(1):15-32
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(2015). Journal of the American Psychoanalytic Association, 63(1):15-

father (Strachey 1934); analysis recapitulates the relationship between child

I use the idea of a “controlling” fiction because these broad concepts

Most of us, in these circumstances, would like to say something to our

And yet the patient in front of us—Civitarese's patient is a good example—

symbolize and to establish stable object relationships depends on the mother's

Bion, W.R. (1967). Second Thoughts: Selected Papers on Psycho-Analysis.

Sullivan, H.S. (1940). Conceptions of Modern Psychiatry. New York:

Article Citation [Who Cited This?]

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