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Publications: Book Reviews
Review of Therapeutic Action: A Guide to Psychoanalytic Therapy

Title: Therapeutic Action: A Guide to Psychoanalytic Therapy
Author: Jones, Enrico E.
Publisher: Northvale, NJ: Jason Aronson, 2000
Reviewed By: John S. Auerbach, Winter 2002, pp. 41-43

Psychoanalysis is in crisis, assailed by many opponents, but one of its problems--specifically, the lack of empirical validation for its theories--is of its own making. Thus, empirical research constitutes a minuscule proportion of the thousands of pages that appear in psychoanalytic journals each year, but here is a more personal case in point: Not too long ago, I had the opportunity to participate in a day-long conference on what is mutative in psychoanalysis, and although the conference was fascinating in many respects, only one of the 12 people who spoke that day mentioned that the question being debated was an empirical one, requiring studies of actual psychoanalytic sessions and session transcripts. That speaker was I, and for my trouble, I was told by several of my fellow panelists that empirical research was irrelevant to psychoanalysis and even a perversion of it. Perhaps it was my recognition that perversion is a subject near and dear to the heart of psychoanalysis that kept me from taking offense. Nevertheless, such anti-empirical attitudes are shortsighted in an age in which psychoanalysis must compete with cognitive-behavioral and medication treatments that purport to do what psychoanalysis can do, just quicker, cheaper, and more effectively, and that are supported by a burgeoning literature of published results. But more important, in my view, is that if we want to know what makes psychoanalysis and psychoanalytic therapies work, then we will have to study actual psychoanalytic sessions, not highly subjective case reports, and this is where Enrico Jones comes in.

Jones, like a handful of other investigators (e.g., Hartvig Dahl, Lester Luborsky, Hans Strupp, Wilma Bucci, Joseph Weiss, Harold Sampson, Donald Spence, among others), has devoted himself to the empirical study of the psychoanalytic process. His book, Therapeutic Action: A Guide to Psychoanalytic Therapy, is one of the fruits of this labor and is his attempt to render his research efforts accessible to the working psychoanalytic clinician. To a great extent, he succeeds in this aim. Jones conceptualizes the psychoanalytic process as involving what he terms interaction structures: ďRepeated, mutually influencing interactions between analyst and patient that are a fundamental aspect of therapeutic actionĒ (p. xv). He further proposes that this construct unites insight and relationship as therapeutic factors in psychoanalysis because insight ďcan develop only in the context of a relationship where the therapist endeavors to understand the mind of the patient through the medium of their interactionĒ (p. xvi). In short, Jones argues that insight (or interpretation) and relationship cannot be viewed apart from each other. This is not a new idea, and it is one with which I am in substantial agreement, but the best part of Jonesís book is that he supplies evidence to support his views. Mostly, this evidence is in the form of extensive quotations from session transcripts--transcripts that reveal how interaction structures unfold, how therapists get caught up in them, often despite their best efforts at, for lack of a better term, neutrality, and how therapists might interpret and modify them. The extensive quotations from therapy sessions serve at least four purposes. First, they engage us, as readers, in the clinical material in a way that makes us forget that we are actually reading about the findings of a research program. Second, they present what actually happens in those sessions, not what therapists, via highly processed case reports, say happened. Third, they enable readers to draw their own inferences about the meanings of the interactions that are reported, rather than just accepting the clinicianís (or Jonesís) opinion. And fourth, they teach us as clinicians a great deal about how we might interact with our patients in more therapeutic ways.

Thus, it is the session transcripts that are the heart of this book--what make it useful in a way that most books about psychotherapy are not--but Jones also has quantitative data in support of his views. These data are in the form of Q-set ratings of therapy sessions, ratings that permit a systematic and empirically valid exploration of those sessions. Arguing that the clinical case study is still central to the psychoanalytic enterprise, Jones thus presents a way in which the single case can be used in a scientifically adequate way. Briefly, Jonesís Psychotherapy Process Q-set comprises 100 items describing patient behavior, therapist behavior, and the nature of therapist-patient interaction. Clinical judges apply these 100 items to session transcripts by sorting them into nine categories, ranging from least characteristic (1) to most characteristic (9), with a neutral category (5) in the middle. The number of items in each category (5 items at each of the extremes, 18 items in the middle) conforms to a normal distribution. For a given psychotherapy, Jones and colleagues subject these session-by-session ratings to factor analysis and then use time-series analysis to identify causal relationships among the identified factors over the course of treatment.

To illustrate this methodology, Jones presents three case studies. In the first, a successful treatment, Jones presents data showing how a specific maladaptive interaction structure, one in which the patient provoked rescue from the therapist, decreased over the course of a therapy and how this decrease predicted a decrease in manifest symptoms as well. Examination of session transcripts suggested that therapist interpretation of this interaction structure was responsible for its diminution over the course of the treatment. In the second, a less successful treatment, the data showed instead that increases in symptoms led to increases in the maladaptive therapist-patient interaction structure. In this case, angry therapist-patient interaction intensified whenever the patient became more depressed. Here, examination of session transcripts suggested that therapist participated in enactment of this maladaptive interpersonal pattern and was unable to gain enough emotional distance from it to interpret it in a way that the patient could use. Finally, in the third case, Jones presents data showing how an interaction structure--specifically, a supportive, positive therapist-patient relationship--can result in a reduction in manifest symptoms over the course of treatment. Here, a neutral, exploratory stance on the part of the therapist led to increased patient dysphoria, but the patientís symptoms decreased when the therapist took a more active stance in challenging her self-criticism. In reading these case studies, I found myself wishing that Jones had presented more of the results of his time-series analyses because it is this statistical technique that he is using to establish the causal relationships he describes. My belief is also that psychoanalysis is a science and that attempts at the psychoanalytic study of psychoanalysis should not be watered down, but it is certainly understandable that the author preferred not to burden his readers with statistical procedures they were likely to find intimidating and difficult to comprehend. Fortunately, Jones presents enough references to his own empirical work that more conscientious readers can track down the actual details of the research if they so desire.

As for those details, I very much admire the combination of empirical and clinical sophistication that can be found in Jonesís work, but I also find myself with many questions about it. For example, I wonder whether ratings of individual sessions taken as a whole unit, rather than ratings of smaller time units within a given session, really captures the nature of the therapist-patient interaction. Jonesís data would say that this is so, but it seems to me nonetheless that much of the clinical richness that other therapy process researchers grasp through the use of smaller units of analysis is lost through the focus on the individual session. Also, I found somewhat problematic Jonesís methodology for arriving at consensus case formulations insofar as it relies heavily, albeit not exclusively, on traditional psychoanalytic categories (i.e., conflictedness, defense-impulse configurations, historical antecedents, wishes, and transference) but does not assess dimensions like level of object relations or capacity for intersubjectivity that are stressed in more recent approaches to psychoanalytic diagnosis and that would be more congruent with the interaction-structure concept (e.g., Auerbach & Blatt, in press; Blatt, Auerbach, & Levy, 1997; Blatt & Lerner, 1983; Diamond, Kaslow, Coonerty, & Blatt, 1990; Fonagy et al., 1996).

In addition, perhaps because of my own intersubjectivist and relational leanings, I had many questions as well about Jonesís discussions of the relative roles of past memory and present interaction in the treatment process and of the nature of timeworn and increasingly problematic clinical concepts like neutrality, abstinence, and anonymity. Space precludes an extensive discussion of these issues in this context, except perhaps to speculate that Jones may be uncomfortable with the ways in which his interaction-structure concept, with its emphasis on the bidirectionality of therapist-patient interaction, undercuts the idea that therapist can maintain a neutral stance, at least as this concept is traditionally understood (see Aron, 1996). I would also note that I agree with Jonesís argument that a therapist has much better access to present interaction structures than to patientsí reports of past events, and yet recent research indicates that a childís attachment style is highly predictable from the attachment styles of his or her parents (van Ijzendoorn, 1995). Thus, the factual validity of patient memories may not be easily ascertainable, but there is now considerable research evidence suggesting that attachment style, something very much like Jonesís interaction-structure concept, has real, rather than fantasy, developmental roots.

But these are relatively minor criticisms of Jonesís work, and besides his discussion of these issues is balanced and fair. Furthermore, his concept of interaction structures does much to obviate the increasingly sterile debate on interpretative versus relational factors in producing therapeutic change, and his highly sophisticated research does much to show how interpretive and relational factors actually interact with each other in the clinical situation. Finally, his many clinical examples, drawn from actual patient-therapist interactions, do much not only to bring alive the interaction-structure concept but also to teach us how to be better therapists. For all of these reasons, I must give this book a most enthusiastic recommendation, perhaps especially to those who believe that psychoanalysis cannot be studied scientifically or has no need of empirical support.

Aron, L. (1996). A meeting of minds: Mutuality in psychoanalysis. Hillsdale, NJ: Analytic Press.
Auerbach, J. S., & Blatt, S. J. (in press). The concept of mind: a developmental analysis. In R. Lasky (Ed.), Symbolization and desymbolization: Essays in honor of Norbert Freedman. New York: Other Press.
Blatt, S. J., Auerbach, J. S., & Levy, K. N. (1997). Mental representations in personality development, psychopathology, and the therapeutic process. Review of General Psychology, 1, 351-374.
Blatt, S. J., & Lerner, H. D. (1983). Investigations in the psychoanalytic theory of object relations and object representation. In J. Masling (Ed.) Empirical studies of psychoanalytic theories (Vol 1., pp.189-249). Hillsdale, NJ: Analytic Press.
Diamond, D., Kaslow, N., Coonerty, S., & Blatt, S. J. (1990). Change in separation-individuation and intersubjectivity in long-term treatment. Psychoanalytic Psychology, 7, 363-397
Fonagy, P., Leigh, T., Steele, M. Steele, H., Kennedy, R., Mattoon, G., Target, M., & Gerber, A. (1996). The relation of attachment status, psychiatric classification, and response to psychotherapy. Journal of Abnormal Psychology, 64, 22-31.
van Ijzendoorn, M. H. (1995). Adult attachment representations, parental responsiveness, and infant attachment: a meta-analysis on the predictive validity of the Adult Attachment Interview. Psychological Bulletin, 117, 387-403.

John S. Auerbach, PhD, is Coordinator of the Post-Traumatic Stress Program at the James H. Quillen Veterans Affairs Medical Center and an Associate Professor of Psychiatry and Behavioral Sciences in the James H. Quillen College of Medicine at East Tennessee State University and a Research Affiliate in Psychiatry at Yale University School of Medicine, and member of the editorial board of Psychoanalytic Psychology In addition, he is private practice in Johnson City, Tennessee. Besides posttraumatic stress disorder, his interests include borderline disorders

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