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MARTHA STARKS MODES OF THERAPEUTIC ACTION:

REVIEW AND CRITIQUE


Jon Snodgrass, Ph.D.
Professor of Human Development
Department of Sociology
California State University
Los Angeles 90032
(323) 343-2215
jsnodgr@calstatela.edu
The author holds a Ph.D. in Sociology from the University of Pennsylvania
(1972) and a Ph.D. in Child Psychoanalytic Psychotherapy from Reiss-Davis
Child Study Center in Los Angeles (1985). He is in Private practice in South
Pasadena, CA and licensed as a Research Psychoanalyst by the Medical Board
of the State of California.
The ConTexT of PsyChodynamiC Theory
The Foreword to Martha Starks, Modes of Therapeutic Action (2000) states, Contemporary [psy-
chodynamic] thinking is a return to fascination with the impact of external reality on personality,
particularly the reality of culture class, race, gender or trauma (xii). The effects of social
divisions on individuals (and group) behavior, however, are historically the domain of sociology.
Here psychology sounds like sociology? The expansion of psychodynamic theory to a relational
focus is the reverse of psychological reductionism. The relationship between two or more subjects
is objectifed and not explicable by any psychic processes. The trend is led by psychologists
using terms like: cognitive-behavioral theory and evidence-based theory. Sociology meanwhile is
globalizing to encompass international stratifcation.
Anna Freud turned psychoanalysis toward the study of the ego and away from her fathers
pre-occupation with the unconscious in the 1920s. She took leadership of the psychoanalytic
movement when he was incapacitated by cancer of the throat and jaw. This trend toward ego
psychology mistook the imaginary for the real, becoming the main criticism of the psychoanalytic
establishment by Lacan (Mitchell and Black 1995, 198).
Anna Freud was caught between: her mother and father, the predominately male movement and
her role as a new woman leader, the Vienna and London schools of psychoanalysis, and child and
adult forms of psychotherapy. It is not surprising then that she argued for strengthening the ego
via insight and building defenses. The Ego and the Mechanisms of Defense (1936) is her major
contribution. Her survival strategy employed consciousness as a bulwark against the intrusion of
instinctual drives and social reality.
As an Austrian migr to England, Anna Freud was ensnared in world politics. During the crisis of
World War II, when the ego was overwhelmed with the external struggle against evil, she devoted
herself to saving the children of London from the German blitz. The impetus toward the relational
in psychotherapy originally came from her work with diffcult cases, i.e., orphaned children. After
the war, the psychoanalytic movement continued to split over external versus internal world views.
The leadership of the internal viewpoint fell to Melanie Klein who stressed the role of phantasy
in the unconscious. She considered herself loyal to the classical perspective and the true heir
of Sigmund Freudians original conception of the unconscious. Ironically, Freud sided with his
daughter. Biographer Ernest Jones supported Klein, excusing the old man saying, he was so
dependent on his daughters ministrations and affections he could not be quite open-minded in the
matter (Peters 1985, 97).
In England, the external emphasis appeared in the form of Ego Psychology, as well as, the British
Object Relations School. Fairbairn, developed the latter theory working with abused children. The
interaction of the ego with reality was the center of attention. In classic psychoanalytic theory,
mediated by the ego, the confict was between the superego and the instinctual drives.
Fairbairn spoke of internal objects in the ego, but Klein spoke of internal objects in unconscious
phantasy. On the continent, Lacan ignored both viewpoints, claiming that the unconscious was the
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internalization of cultural authority, i.e., the law of the father. To Freud, culture arose out of the
unconscious, but to the French school, culture shaped the unconscious. It was in fact, structured
like a language, said Lacan.
Thus, the socialization of the unconscious took place everywhere. Max Webers thesis in sociology
concerned the rationalization of modern society. The ego psychology of Anna Freud prevailed over
the concept of unconscious phantasy in Klein. In the United States her work is scarcely known.
Here, Anna Freuds student, Erik Erikson, built the lifespan development movement based on
identity formation in the ego.
An indigenous psychotherapy appeared in the United States in Harry Stack Sullivans Interpersonal
Psychoanalysis. As the name suggests, his perspective was an early expression of the relational
trend, fxed on an individuals past and present. Sullivan was known for work with schizophrenics.
Stridently anti-Freudian and anti-unconscious, his theory is not psychoanalytic.
Three sTark models: Cold, medium and Warm
Stark describes her book as a synthesis of the modern relational and classic psychoanalytic models.
The hidden world of phantasy is not really included in her treatise. Klein, for example, is cited as
not understanding internal bad objects. She had little to say about ... the patients attachment to
these savage beasts (79). This is equivalent to saying Anna Freud knew nothing about the ego
and its defenses.
Relying on relational schools, Stark reviews three models of psychodynamic theory. She clarifes
that she does not offer the paradigms as a set of technical procedures to be followed in practice.
She presents them instead as conceptual options for thinking about work with a client (24). The
models emphasize sequentially: the therapist, the patient and the pair. There is ambiguity and
overlap, for the models are not mutually distinct.
There is also a ranking of the categories refective of the evolution (early, middle and late) of
psychodynamic theory, moving from the classical to the modern period. This trajectory in the
Stark scheme means the classical mode of interpretation is considered obsolete when used alone.
Sometimes it serves as the villain of the piece (xv) but at other times, she speaks of a balanced
use of the models. The suitability of models for different clients or diagnoses, is not pursued by
the author.
Her books subtitle provides labels to identify the three bearers of theory and therapy: 1. Enhancement
of knowledge, 2. Provision of experience and 3. Engagement in relationship. She uses another set
of terms: 1. Drive or Structural Confict Model, 2. Defciency Compensation Confict Model, and
3. Relational Confict Model. A fourth set is: 1. Ego Psychology, 2. Object Relations Psychology
and Self-Psychology, and 3. Relational Psychology.
In Model 1, the therapist attempts to be a neutral object focusing on the pa-
tients internal dynamics. Stark calls this a one-person model because it does
not conceive of the therapist as a participant in the relationship, but simply an
objective observer of what is going on inside the patient. This is the classic
psychoanalytic model.
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In Model 2, the therapist recognizes the longing of the patient for relationship.
This model includes all of the object relations and self-psychology approaches.
No longer is the therapists sole aim to render the unconscious conscious, thus
resolving the patients internal conficts. The goal of treatment becomes flling
the process defcits that the patient brings to treatment. Instead of a neutral
analysis of the patients dilemma, the patients relational needs for empathy,
validation, and support are top priority.
Emphasis is on the defcits that prevent the patient from being able to care lov-
ingly for him-herself. The therapist, by being empathic, listening without judg-
ment, and being fully there for the patient, helps to supply some to these defcits
and gives the patient a new experience of what is possible. Stark calls this a one-
and-one half person model because the therapist is present only in a partial sense.
In Model 3, the therapists are relational therapists who believe that what heals is
the interactive engagement with an authentic other: the therapeutic relationship
itself. Stark conceives of this as a two-person model in which the therapist re-
mains centered and responds authentically from his/her own feelings.
The Model 3 relational therapist must be able to provide information and insight
when needed, as required by Model 1, and corrective experience in the form of
empathy and support when appropriate, as required by Model 2, but the therapist
must also be able to do more. The Model 3 therapist must pay attention to the
force feld created by the patient in an attempt to draw the therapist into parti-
cipating in ways determined by the patients early history.
This is a more complex task than either of the other two and it involves all three
ways of relating. Failures in therapy are due not just to incorrect interpretations
or inadequate supplying of what was missed, but also due to pressures exerted
by the patient to reenact the familiar and familial. Only the patient-therapist pair
together has the opportunity to spot that process and help the patient create a
healthier resolution of those original hurts (68).
Stark believes healing in psychotherapy ultimately arises from the authentic relationship or
the authentic engagement of the therapist and the patient existing in Model 3. Authenticity,
therefore, is a crucial concept in her book. An authentic therapist endeavors to apply all three
models as appropriate while working with a patient. The ideal is for, the therapist to achieve an
optimal balance between formulating interpretations, offering some form of corrective provision
and engaging interactively in relationship (4).
As the only model that is truly authentic, he third Model integrates the three approaches into what
Stark calls two-person psychology. She writes, the therapeutic action involves a corrective
experience by way of the real relationship we are suggesting that the therapist offers the patient
something that the patient should have received reliably and consistently as a child, but never did
(19). Healing requires both parties to bring an authentic self to the interaction, described as the
counter-transference meeting the transference.
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Case VigneTTe: Child TyranT (34-36)
Stark provides clinical examples of therapeutic action. Corrective provision, for example, is
illustrated with a latency age girl the author treated for two years. The child had an obsessive need
for omnipotent control over the therapist in sessions and acted despotic toward her therapist. The
author explains, I always did the very best I could to accommodate myself to every single
one of her imperious commands . I did not interpret her need for control (35). Stark said she
practiced Model 2. corrective provision and eventually the child gave up her domineering ways.
A feature of Starks treatment is that nothing real was given to the child. The doctor played the role
of fulflling the childs fantasies about being in total control. The child never had real control, nor
was her real need for control ever met by the doctor. The child pretended to have control and the
therapist pretended to allow her to have control, but this was entirely role playing. It was a game
and not authentic on both sides. Under the doctors authority, the child was permitted to think and
act like she was in charge. The hierarchical structure of their real relationship is evident as Stark
repeatedly refers to her my little friend.
In this case, the healing does not come from the social interaction, which may have been playful,
or more serious, at different times. Starks willingness to join her patient in play, however, is
engagement at a mental level. What mattered is not the provision of real or imagined needs in their
relationship. Being together without judgment, represents a genuine psychological, not behavioral,
act. Their activities together might have taken many other forms and still have accomplished the
healing. The game was not authentic, but the agreement to play together was sincere.
What is decisive in the treatment is the mental act behind the behavioral form in dealing with
the case. This means the form can vary widely, but the mental act contains the essential healing
essence in seeing no difference between therapist and patient. They might have engaged in other
activities, as long as minds were joined in the pursuit of understanding and being understood. It is
not the behavioral form, but the thought that heals the patient and the therapist. The need to control
others always imprisons the self in the mind.
This distinction between thinking and behaving raises the prospect of a fourth model of therapeutic
action. An additional mode is implied within the three models of her study. Stark writes, for
example, the models are for conceptualizing, not for implementing treatment plans. She alludes
to Model 4, It is always the therapist intention [not behavior] that places her intervention in
Model 1, 2 or 3 (236). The fourth model emphasizes the mental tie between therapist and client.
Therapeutic action implies some active agent like medicine on a wound.
model 4
Stark alludes to Model 4 when she writes, the therapist can optimize her effectiveness if she
has the capacity to hold in her mind an intuitive sense of whether the therapeutic action in the
moment involves knowledge, experience or relationship (5). What matters here is not which
model is practiced, but holding the options in mind, and by inference, holding the patient in mind.
It is the mental, not the behavioral act that heals. For this reason the therapist herself must want to
heal to become a healer.
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The shift to Model 4 is away from the social relationship to the mental relationship of the therapist
and patient in the mind. The mental act is primary while the social activity is secondary, as an effect
of the mental action. Models 1-3 reverse the cause and effect relationship. Model 4 therapeutic
action originates in the decision making of the therapist-patient, to join in understanding and
extends to the relational. Minds heal relationships, but relationships do not heal minds.
Stark had a healing experience with her own therapist when he rearranged his offce furniture
to suit her specifcations (36-37). Model 4 suggests that the rearrangement of the furniture and
the momentary control over him, however, were not the cause of healing. The analysts decision
showed the patient that her desire for omnipotent control was not perceived by him as threatening
to his ego. Thus, accepting her in his mind, he allowed her plan to take over the offce layout. But,
had he been afraid of her, he would need to control her, disallowing the change and demonstrating
an identical problem with authority.
Because Stark brings the problem in her mind to both situations (child patient and personal
analyst) the need for omnipotent control appeared in both treatment cases. As long as the confict
exists in the social relationship, it cannot be resolved because it replicates externally by persisting
psychologically. The problem originates in thinking and transfers, and counter-transfers, to rela-
tionships. A therapist controls her mind, not her patient, nor the furniture, demonstrating the option
to heal.
Case VigneTTe: holding-uP The TheraPisT (58-61)
Stark provided clinical vignette to illustrate the concept of authentic engagement. She worked
with a middle aged lawyer, a specialist in domestic violence, enduring a painful romantic breakup.
After six months of treatment, Stark heard the client refer to her gun and learned, for the frst
time, the patient was armed during therapy. Stark said she was terrifed and that the patient knew
it. Understandably, the aroused doctor needed control and tried to negotiate a compromise. The
patient, however, felt the need to have her gun with her at all times (59).
I knew it was important that I be able to contain my fear in relation to Cindy but I couldnt
quite pull it off in time (60). Unlike the child case above, this situation expresses a real power
struggle between the therapist and the adult patient. Stark could not allow her patient back into the
offce with a loaded weapon and the patient refused to attend treatment without it. The therapist
considered herself a failure because she was unable to control her counter-transference fear re-
action. Stark thought she had caused the client to not return. Candidly, she tells us that her failure
still haunts me (61).
Stark had an authentic counter-transference reaction, but rather than healing the patient, or the
therapist, she condemns herself as a failure for years thereafter. She believes she should have
controlled her fear in order to continue therapy and to succeed in healing the client. This one-
sided analysis means she thinks she should fx the problem single-handedly. It indicates the need
for omnipotent social control persisting in the mind of the doctor who is harsh (stark) in her self-
relationship
This is a one person analysis because the client is given no credit for the treatment failure. At the
turning point of six months, it appears that the client decided to prosecute the therapist for failing
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her in treatment. The decision coincides with the patients personal history of blaming her mother
and romantic partner for failures in relationships. The therapist attacks herself, justifed due to her
guilt over not being the all-powerful doctor. It was the client, however, who wanted to terminate
either the therapy or the therapist.
Stark does not understand the patients transference relationship since her expectation is to have
total control of the situation by herself. The one person understanding contradicts her argument,
by not allowing an interpretation, characteristic of the classic mode, concerning the magnitude
of clients hostility. Nor is there sympathy for her own counter-reaction that might mitigate the
injury. Stark does not recognize the patients independent right: to be self-destructive, to end the
professional relationships and to blame others as the cause of it.
In her previous book, A Primer on Working with Resistance (1994) Stark emphasized that resistance
to insight into the counter-transference is the result of not grieving the losses of childhood and not
allowing reality to be as it is. Applied to her situation with the attorney, the problem may be seen
as the failure to grieve the loss of omnipotent social control and to accept being powerlessness to
heal the client. In her chapter on Mastering Resistance by Way of Grieving Stark asks, What
must the patient come to understand before he can move on?
Her answer is quoted below, except therapist-patient is substituted in the quote each time Stark
uses one or the othertherapist or patient. Starks entire chapter might be read making this
substitution because the resistance in the transference-counter-transference relationship is always
identical in principle, but not necessarily in form. Both were so scared, they were not sure they
could trust one another to allow healing to occur and this mirrored defcits of trust in their self-
relationship.
Eventually the patient-therapist must feel his disappointment, his heartache, and
his outrage about all this; he must face, head on, the intolerably painful reality
of the patient-therapists limitationsnamely, the patient-therapists inability to
make up entirely for the bad parenting the patient-therapist had as a child (29).
The patient-therapist will master his or her resistance to the extent that the patient-therapist is
able to grieve the loss of omnipotent control over reality in exchange for mind control knowing
that something lost is illusory. This understanding begins as a theoretical level and learned more
deeply over time through practice. An interactional model is problematic in strengthening, rather
than giving-up the egothe false self which never forgives and never heals.
Book auThor
Martha Stark, M.D., a graduate of the Harvard Medical School and the Boston Psychoanalytic
Institute, is a psychiatrist-psychoanalyst in private practice in Newton Centre, MA. Dr. Stark is
on the faculty of both the Boston Psychoanalytic Institute and the Massachusetts Institute for
Psychoanalysis. She is also a Clinical Instructor in Psychiatry at the Harvard Medical School, has
a teaching appointment at the Massachusetts Mental Health Center, and is on the faculty of the
Center for Psychoanalytic Studies at the Massachusetts General Hospital

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referenCes
Cornog, M., & Perper, T. (2001). Modes of Therapeutic Action (Book Review). Journal of Sex
Education & Therapy, 26(1): 68.
Stark, M. (2000). Modes of Therapeutic Action: Enhancement of Knowledge, Provision of
Experience, and Engagement in Relationship. Northvale, New Jersey: Jason Aronson.
Stark, M. (1994). A Primer on Working with Resistance. Northvale, New Jersey: Jason Aronson.
Quiz QuesTions
Can a therapist be authentic according to Stark without using the counter-transference?
The authentic therapist helps create an authentic patient in the healing process according to
Stark?
(Revised 6-2010)
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