A Primer for Handling the Negative Therapeutic Reaction (Book Review)

Author:  Seinfeld, Jeffrey
Publisher:  Jason Aronson, 2002
Reviewed By:  Cress Forester, Fall 2003, pp. 42-44

This deceptively titled “Primer” can be used by students and experienced clinicians alike, for as the author states in his introduction:

The negative therapeutic reaction is one of the most pernicious problems among therapists of all levels of experience. Beginning clinicians are likely to feel that the patient’s worsening condition is the result of their inexperience, inadequacy, and lack of skill. Experienced clinicians are likely to feel that their training and previous treatment encounters offer little help or guidance. (Seinfeld, p. vii).

The problem addressed in this book is that some patients react adversely to what should have been, or appeared to have been, appropriate therapeutic interventions; such patients may also react adversely to the experience of their own progress or successes. This can be frustrating and confusing for the therapist, who may start to feel inadequate or thwarted, or at an impasse with no idea of how to proceed.

Seinfeld presents a way to think about what is happening, to understand it, and from that understanding to work with and through the impasse. He offers a way to see the opportunities within the challenges of working with this problem. While his understanding is firmly grounded in classical object relations theory, he describes his approach as akin to Tai Chi Chuan:

In managing the negative therapeutic reaction the clinician should not attempt to thwart or block it, but instead invite its full expression and make use of it as an opportunity to enable the patient to separate from bad internal objects (p. vii).

Throughout this book, the author uses a “dialogue” format to present his material; the book is written in the form of question and answer, as Seinfeld responds one by one to questions his students have asked him. Rather than providing an extensive, sequential, or in-depth explanation of his understanding, he provides succinct descriptive summaries of core object-relational concepts, using spare references to the work of classical theorists. Each chapter addresses a different aspect of this problematic dynamic, and Seinfeld makes frequent use of detailed case examples to illustrate, clarify, and reiterate the central ideas that inform his approach.

This combination of dialogue, succinct presentation, clinical example, and recapitulation renders the complex concepts underlying Seinfeld’s approach more digestible for the reader. It also makes these ideas easier to think about, and to apply clinically. The reader can find possibilities in this text for handling the frustrating and often confusing transference/countertransference dynamics that lie at the heart of the negative therapeutic reaction.

The first two chapters are densely packed with theoretical material and core concepts that form the basis of Seinfeld’s understanding. He begins by giving a selective historical summary of perspectives on the negative therapeutic reaction. In swift succession he outlines the contributions of several major theorists to the understanding of this problem, and he begins to give an implicit impression of his own perspective, which draws on the insights of others, while adhering to none exclusively. His summaries of other theorists serve to introduce ideas that he later uses in explaining his own approach to treatment.

He describes how Freud first observed that some patients’ conditions paradoxically worsened following his expressions of hopefulness or satisfaction with their progress. Freud initially interpreted this reaction as defiance, and later as arising from an unconscious need for self-punishment related to guilt and sadomasochism; he believed these were derived from the death instinct.

Seinfeld describes how later theorists such as Abraham, Klein, and Grotstein developed and added to this conceptualization, while retaining the idea that the death instinct was responsible for this reaction. Abraham observed the role of unconscious envy and narcissism in the negative therapeutic reaction, while Klein focussed on early object relations and the primitive defenses of splitting, idealization, devaluation, and projective identification. “The split-off envy manifests itself clinically as an inability to accept with gratitude interpretations that are perceived in some part of the patient’s mind as helpful” (Seinfeld, pp. 5-6).

Seinfeld states that the negative therapeutic reaction may occur across diagnoses, though the more pernicious form is usually found in more severe diagnoses, such as the psychoses, borderline personality disorder, and with trauma. He finds it useful to think of this reaction as occurring in the psychotic part of the personality, and draws on Bion’s concepts to describe his meaning: as a result of frustrated instinctual drives, the psychotic part of the personality hates and attacks both reality and the mental functions that relate to reality. This accounts for the patient’s periodic inability to think or to learn from experience—a typical and frustrating aspect of the negative therapeutic reaction.

Seinfeld then introduces Ferenczi’s theories, which specifically describe and address the traumatic origin of the negative therapeutic reaction, in contrast to the intrapsychic interpretations of classical theorists. Seinfeld also uses Ferenczi’s ideas in order to introduce ideas about the importance of the need for attachment, the real relationship with the therapist and with early caregivers, and the potential for the therapist to contribute to the negative therapeutic reaction. Although he agrees with Ferenczi that the therapist may provoke or exacerbate a negative therapeutic reaction, Seinfeld believes that the therapist cannot cause such a reaction unless the patient has some pre-existing vulnerability. He asserts that a negative response to a therapist’s mistake is different from the negative therapeutic reaction.

In the second chapter Seinfeld presents some of the key theoretical constructs from object relations theory that inform his understanding. Here he answers questions such as “what is an internal object?” (p.16), “how does the endopsychic theory relate to the negative therapeutic reaction?” (p. 21), and “what are the motives for the antilibidinal self identifying with the rejecting object?” (p. 22). He answers these questions in the language of object relations theory, but also gives examples from everyday life. He starts to present and describe the crucial concepts of good and bad internal objects, and their relationship to the external other. Internal objects do not accurately reflect the external other, but are distorted versions of the external other; this is due to splitting but also to the patient’s emotional and cognitive limits. The patient may react to the external other as though they were the distorted bad internal object. This leads to some challenging dynamics between patient and therapist, as the patient may react to the therapist as if he/she were a bad (and therefore threatening) object.

Seinfeld draws on Fairbairn, Guntrip and Winnicott’s theories to describe the intrapsychic struggle that arises when the patient’s need for contact with an object coexists with a fear of vulnerability and intimacy. For Seinfeld, it is this struggle that underlies the negative therapeutic reaction. The patient’s uses of idealization, splitting, projective identification, attacks on linking, and identification with bad objects are all in service of this struggle. It is the use of these primitive defenses that leads to the baffling and frustrating interactions characteristic of the negative therapeutic reaction.
Having concisely described these complex object relational theories, Seinfeld gives himself more space in the remainder of his book to expand on his ideas and clarify them through the use of case examples. He allows a chapter each to describe his approach with an “out of contact patient,” a borderline patient, a schizoid patient, and, in addition, its applicability to children. His case material includes brief sections of dialogue that offer concrete examples of some of his interventions.

He continues to introduce more theoretical material, but in the context of his clinical work. Throughout the remaining chapters, Seinfeld gives many examples of common types of therapeutic situations, which he describes and interprets using more everyday, experience-near language—yet still drawing on object relations theory and concepts. The case descriptions make it easier to understand the object relational concepts he uses, and also help the reader to learn how to recognize object relational dynamics as they manifest in clinical work.

In a beginning chapter, Seinfeld describes the four manifestations of the negative therapeutic reaction, and how he works with them. Each manifestation—“ out of contact,” “ambivalent symbiosis,” “therapeutic symbiosis,” and “resolution of the symbiosis”—corresponds to Searles’s stages of progressive work with severely disturbed patients. In his case presentations Seinfeld gives examples of each phase and describes briefly how he works towards helping the patient move through the stages.

Seinfeld devotes a chapter to “the dynamics of the bad object,” which are central to understanding his approach. In this context he presents more explicit examples of the ways in which he allows patients to express themselves fully, while keeping his own focus firmly on their internal object relations. He writes, “I never argued with her about reality. I empathized that the external objects often did reject her….I empathized but then shifted the focus to what she was doing in her mind with the experience” (p. 126-127).

Once a patient has become aware of the difference between internal and external objects (a crucial developmental task) he may ask them about the internal image they have of him, in order to help them understand splitting in the transference (p. 136). Once a patient begins to respond less destructively to disappointment, he feels they may be ready to address their fears of abandonment rather than splitting them off, another critical developmental capacity. At this point he may, again after acknowledging and empathizing with the real situation, also interpret the patient’s dread of abandonment. He cautions however “the therapist should not be overly interpretive. The patient needs to experience the rejecting transference as a way of establishing autonomy” (p. 138).
These themes receive further expression as Seinfeld gives a full chapter each to presentations of his method of “interpreting the tie to the bad internal object,” and “interpreting splitting in the transference.” Again, he uses case examples to illustrate his points, and describes how he invites patients to attend to their internal dialogues so that they can notice their internal object relations. He writes, “I told Marilyn that I was interested not only with how she dealt with her husband in reality, but also with how she dealt with him in her mind” (p. 177).

Seinfeld ends with a chapter on “internalizing a containing object,” and he uses his clinical work with a schizoid patient to clarify his meaning. He describes his method of focusing on “the deficit of a good containing object” (p. 223), and reports that he spent the first year of treatment using interpretations that held and recognized what was missing in the patient’s object relations, while using language that reflected the patient’s inner experience. This included comments that described and addressed the patient’s projective identifications: “you are putting into me that part of yourself that wants you to be more social” (p. 232).

As Seinfeld describes it, the patient initially appeared unable to identify with such interpretations, but eventually became curious. After working for some time in this way, the patient came to sessions with questions both about his way of relating, and how he had become like that. He slowly developed the capacity to allow himself to experience and express a greater range of feelings. As with his other examples, in this case Seinfeld describes a way of working that recognizes and allows the patient their freedom of expression and experience, but adds to that some commentary on their internal object relations. Even when the therapist chooses not to interpret, the therapist’s attention remains with the patient’s internal object relations and with the ways that these are expressed in the transference/counter-transference dynamics. This is the foundation of Seinfeld’s approach.

While writing here, this reviewer sought primarily to understand “what the problem is” and “how to handle it” from within Seinfeld’s perspective. As he presents it, there are actually at least two kinds of problems. The first is that the patient does not respond as the therapist expected or intended, but “worsens.” The second is that the therapist does not know what to make of this. Seinfeld’s resolution of both problems is to provide a particular way for the therapist to think about and understand what is occurring both within the patient, as well as between the patient and therapist. This understanding then leads to different interventions that, over time, lead to different results with the patient.

There are two areas of Seinfeld’s work that are given less attention than they might have been. The first is in his discussion of the role of the therapist in the negative therapeutic reaction; the second, related, area is in his references to countertransference. While he devotes several chapters to what may be going on in the patient, he gives little attention to what happens in the therapist, or how the therapist may be contributing to the patient’s response to treatment. Since he frequently states that it is important to attend to countertransference, and refers to the possibilities for the therapist to contribute to the negative therapeutic reaction, this paucity of attention is noticeable.

At one point he gives a brief description of projective identification as unconscious interpersonal communication, and states that “projective identification can originate from the therapist as well as the patient, and the intensity of the patient’s positive and negative transferences can be affected by the therapist’s projections” (p. 27). Unfortunately, this is where he leaves the matter. Surprisingly, he does not devote any more space to this profoundly important observation.

At several points he makes reference to his own countertransference, but it is always in the context of countertransference that he notices it and uses it to guide the therapy. What is problematic, and all too common in the “negative therapeutic reaction,” is that both patient and therapist inevitably become caught up in unconscious reactions and re-enactments. In such situations the countertransference cannot be used therapeutically because it is out of awareness, which is part of the problem.

At this point it may help to briefly consider the influence of language and theory in treatment. The capacity to think, and to think reflectively rather than just react, is a crucial therapeutic ability. Theoretical concepts and language provide a way to organize and frame reflective thinking, which supports the skillful use of this ability. However, as Westen (2002) so eloquently argues, the use of some psychoanalytic words and terms can unfortunately restrict clinical thinking and work.

The process that Seinfeld terms “the negative therapeutic reaction” seems to be what Rosenfeld (1992) describes in his work on the psychotic aspect of the personality. It may resemble what Elkind (1992) might think of as an impasse related to vulnerabilities within both therapist and patient. Davies and Frawley (1994) see this process as a dissociative relational enactment of prior trauma, which affects both patient and therapist. Each perspective on this therapist-patient interaction suggests different ways of understanding and handling the dynamic, which might be different as well from some of the interventions that Seinfeld suggests. However, each of these other approaches emphasizes unconscious processes in the therapist as well as in the patient. Accordingly, the other authors take considerable space in their books to discuss how to understand the therapist’s unconscious reactions and their impact, both on the patient and on the course of the therapy.

Seinfeld uses the term “negative therapeutic reaction,” to describe what is happening in the therapy. This use of the term originally suggested that the therapist had been providing proper treatment that the patient rejected due to his or her unconscious intrapsychic processes. Seinfeld’s treatment focuses firmly on the patient’s intrapsychic process. Perhaps an unfortunate side effect of the use of the term “negative therapeutic reaction” and of such a strong intra-psychic focus, is that the therapist’s role may be neglected or underestimated.

Davies, J. M., and Frawley, M. G. (1994). Treating the adult survivor of childhood sexual Abuse: A psychoanalytic perspective. New York: Basic Books.
Elkind, S. (1992). Resolving impasses in therapeutic relationships. New York: Guilford.
Rosenfeld, D. (1992). The psychotic aspect of the personality. London: Karnac Books.
Westen, D. (2002). The language of psychoanalytic discourse. Psychoanalytic Dialogues 12 pp. 857-898.

Cress Forester is a licensed psychologist in private practice in San Francisco. She also provides psychotherapy and supervision at Richmond Area MultiServices. She specializes in working with adults with disrupted early attachment, trauma, and dissociative states.

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