Negative Therapeutic Reaction
NEGATIVE THERAPEUTIC REACTION
The expression "negative therapeutic reaction" is used to describe a situation in clinical practice wherein there is an exacerbation of the patient's symptoms following a correct series of interpretations. According to Sigmund Freud, this phenomenon was caused by unconscious feelings of guilt, as seen in primary masochism, which he ultimately linked to the death drive. The negative therapeutic reaction has also come to be regarded as an essential key to understanding the limits of ego functioning.
Freud described the negative therapeutic reaction in The Ego and the Id (1923b) as an "inverted" reaction, the patient preferring to suffer than be cured: "The need for illness has got the upper hand in them over the desire for recovery" (p. 49). For Freud this was the expression of a feeling of guilt that found its satisfaction in the state of illness and sought punishment through suffering. This feeling of guilt is difficult to bring to light, because it remains "silent" for the patient, who does not feel guilty, but rather ill. It manifests itself in a resistance to being treated and Freud regarded it as very difficult to overcome.
In "The Economic Problem of Masochism" (1924c), Freud emphasized the fact that the way the unconscious feeling of guilt is satisfied is directly related to the subjective benefit brought by the illness: "The suffering entailed by neuroses is precisely the factor that makes them valuable to the masochistic trend" (p. 166). He thus contrasts the sadism of the superego, which is usually conscious, with the masochism of the ego, which generally remains unconscious. He proposes replacing the expression "unconscious feeling of guilt" with that of "need for punishment."
In "Analysis Terminable and Interminable" (1937c), Freud linked the negative therapeutic reaction, ultimately, to the workings of the death drive, as the phenomenon of resistance to the cure could not be explained as a mere function of the pleasure principle.
Thus, after the second topic, whenever Freud described the negative therapeutic reaction, he emphasized the need for self-punishment, the severity of the superegoand the masochism of the ego. All the self-hatred inside these subjects, driven as they are by a logic of despair, reflects a compromise between an unquenchable desire for vengeance and the need to protect the object from the hostile desires directed against it. The conflict between love and hatred is here predominant, and "if love is always uncertain, hatred is always sure" (Green, 1990), with the result that these subjects do everything to ensure that the form of sado-masochistic relation that they have chosen can be perpetuated for as long as possible.
Thus, the new theorization of the unconscious feeling of guilt that the second topic makes possible offers a logical explanation for the status of suffering: displeasure for one system (the ego), and pleasure for another (the superego); ipso facto, it provides us with a precise economic definition of the negative therapeutic reaction. If the death drive essentially works in silence and is observable only in a form interwoven with the life instinct, the negative therapeutic reaction, through the notion of a cruel and severe superego, and especially through the idea of primary and secondary masochism, offered Freud the possibility of giving a precise clinical form to this speculation. It is, indeed, observable in the process of treatment and thus can in certain conditions be analyzed.
Psychoanalysts have often used the expression negative therapeutic reaction descriptively, to designate the forms of resistance to change that are particularly difficult to overcome in treatment. Jean-Bertrand Pontalis (1981), following several other authors, has criticized the attitude that too easily attributed the reasons for the failure of treatment to the psychic structure of the patient, thereby over-hastily freeing the analyst from their own therapeutic responsibilities. The struggle must not be abandoned in the face of the silent work of the death drive, that "force which is defending itself by every possible means against recovery and which is absolutely resolved to hold on to illness and suffering" (Freud, 1937c, p. 242).
Pontalis has emphasized how often the negative therapeutic reaction has been invoked by analysts to justify their sense of discouragement and how much it needs, in such cases, to be understood as "[their] reaction to those who cause their method to fail merely by saying no." The analyses considered as failures should in fact be understood in relation to the particularities of the transference and counter-transference.
Some authors have attempted to reply to these questions. For Joan Rivière, it is by means of a sort of "self-sacrifice" that these patients refuse to be cured until they have cured their primary internal objects. Harold Searles sees it as the expression of an unconscious tendency to look after the analyst, which is to say the mother. These studies do indeed underline how at the heart of the negative therapeutic reaction there is clearly "the crazy passion to cure the crazy mother inside the Self (Pontalis, 1981).
René Roussillon (1991) has shown that the main clinical phenomenon is constituted by the pair of opposites "paradoxical improvement/worsening." Influenced by the studies of Donald Winnicott, he stresses the role of unintegrated and unsymbolized traumatic experiences that remain split off within the psyche and lead to a permanent disorganization in the subject. For him, Freud applied the name "negative therapeutic reaction" to those moments in the treatment when the patient is overwhelmed by disorganizing experiences, traces of "primal agonies," moments of "psychic death" undergone long ago. The therapeutic process leads the subject to relive those unsymbolized and unintegrated traumatic states. Didier Anzieu has also given the name "paradoxical transference" to this type of situation, one form of which is an intense emotional transference.
Thus, when it can be combined with the analytical work of co-construction, the negative therapeutic reaction no longer appears merely as a troublesome disruption in the analysis, but as an essential way of tackling and working through the functions of the ego that treatment can reveal only in this form. Thus it is the sign that a traumatic kernel is about to be actualized in the analytical space, thereby opening the way for its transference and working-through.
See also: "Analysis, Terminable and Interminable"; Analyzability; "Constructions in Analysis"; Counter-transference; Cure; Death instinct (Thanatos); Ego and the Id, The ; Moral masochism; Need for punishment; Pain; Psychoanalytic treatment; Remembering, Repeating and Working-Through ; Resistance; Self-punishment; Suicide; Superego; Transference; Transference hatred.
Anzieu, Didier. (1975). Le transfert paradoxal. Nouvelle Revue de Psychanalyse, 12, 49-72.
Laplanche, Jean, and Pontalis, Jean-Bertrand. (1988). The language of psycho-analysis (Donald Nicholson-Smith, Trans.) London: Karnac and the Institute of Psycho-Analysis. (Original work published 1967)
Pontalis, Jean-Bertrand. (1981). Non, deux fois non. Nouvelle Revue de Psychanalyse, 24.
Revue Française de Psychanalyse. (2000). Le transfert négatif. Revue française de psychanalyse, 64,2.
Roussillon, René. (1991). Paradoxes et situations limites de la psychanalyse. Paris: Presses Universitaires de France.