Introduction

Contemporary psychotherapy aims to provide patients with the best possible treatment based on evidence from research. It does this by ensuring that established and effective methods and techniques are brought into work to facilitate change in mental health (cf. Hill & Norcross, 2023, for an overview).

Despite the fact that this premise is not as clear or precise as it sounds at first, as many psychotherapy studies unveil future challenges for the field (Cuijpers et al., 2019). Also, pinning down the relevant mechanisms of change in psychotherapy still needs further work (cf. e.g. Wucherpfennig et al., 2023), as does research on what works for whom (cf. Heinonen et al., 2022). Even though there is rich evidence from research on the value and evidence of approaches that reach out beyond mere adherence to treatment manuals and general guidelines – for example regarding the use of case studies, a prominent field of psychoanalytic tradition (Willemsen, Della Rossa & Kegerreis, 2017; Kaluzeviciute & Morton, 2023) – contemporary psychotherapy research leaves the impression of being largely oriented towards evidence-based approaches in the narrower sense of treatment manuals, whereas case studies’ or other tools’ impact (e.g. clinical reasoning of experienced therapists and their “practical wisdom; cf. Higgs et al., 2018; Willemsen, 2022) appears to stay limited (Willemsen, 2023).

That being stated, it can be asked: What happens when, in a treatment conducted in accordance with treatment guidelines and thus based on state-of-the-art research evidence on efficacy, despite careful diagnostics and treatment planning, something comes up that is not described in the manual or guidelines and is thus unexpected?

One should not view this as a collapse of the architecture of evidence-based psychotherapy. Manuals naturally allow for some flexibility, and it is this flexibility that links adherence to a treatment manual to positive therapy outcome (Collyer at al., 2020; Webb et al., 2010). Manuals can be adapted or tailored to individual cases. They can also address comorbidities or complex cases and they can also be sided with single case oriented approaches.

However, the crucial point is a different one. The idea of a manualized, guideline-based treatment necessarily involves an ‘inside’ and an ‘outside’. One can make adjustments which provides a more differentiated manual. But the boundary between what is inside and what is outside still exists; there will always be something that is ‘outside’, relative to the manual or guideline (and thus what is therapeutically planned, foreseeable, or controllable). Something will occur that causes a disruption, both in a single session and in a process that spans over several hours, and does not ‘fit’ in with what was to be expected, even in the most individualized treatment plan.

In addition to the important research on and clinical implementation of monitoring tools and corresponding feedback regarding patients and treatments that are ‘not on track’ (Schilling et al., 2021) it is worth examining the dynamics of emotions and/or of the therapeutic alliance in a single treatment. This means we should look at possible crises that emerge.

This can be done through techniques for dealing with relationship crises, as formulated in the understanding of processes of rupture and repair (Eubanks et al., 2018). This involves a manualized approach to recognizing, understanding, and working through relationship crises (Eubanks-Carter et al., 2015), which proves to be an important element of effective psychotherapy. Research conducted in the vein of psychoanalysis and psychodynamic psychotherapy shows evidence of approaches that highlight working with recurring relational patterns that manifest within the therapeutic relationship, the expression of emotions, the exploration of mental defence mechanisms or the meaning of past experience (see for a recent example on the growing number of studies: Leichsenring et al., 2023). Also, “CORE” ingredients in psychoanalytic competence have been formulated (Lemma et al., 2008; see also Parth et al., 2019). This underlines some important value psychoanalysis has to offer to the field of psychotherapy and psychotherapy research today: Thouroughly taking into consideration relational (and unconscious) aspects that play a role in mental illnesses and psychotherapeutic treatment of these.In the present work, however, I want to stress a more general point, namely, making the unusual the center of therapeutic work and reflection. Through that, I shall make the case for the unfamiliar ground psychotherapy sometimes has to act upon, as well as for the therapeutic capacity (or, attitude) to be receptive for disruptions and deal with them.

It will become evident that psychoanalysis offers a pivotal contribution here that is important and will remain important for psychotherapy in general. There is an uncommon factor in psychotherapy, in that things are usually less common than we can foresee, especially when we make the therapeutic relationship one of the centers of our work (which we should). While using the term “uncommon factor” I want to stress the uncommonness of certain unforeseen events during individual psychotherapeutic processes. This should, at this point, be regarded along the lines of a position paper; the term is not intended to describe a specific factor in psychotherapy efficacy (as opposed to “common factors”) but rather condense the argument to pay attention to that which is uncommon in psychotherapeutic treatments. It also reflects previous works on the “common ground” in psychoanalysis inasmuch as it makes the case for to view as the common ground of psychoanalysis the capacity to act on uncommon, that is: unfamiliar ground. The uncommon this is not only the individual and unique patient being distinct from the “average” patient who might be addressed in a treatment manual but also the uncommon, unfamiliar or even uncanny in patient themselves that is supposed to be addressed in order for mental change to come about. I will propose to view this as negative psychotherapeutic skills that are described by psychoanalysis through various concepts (such as containment, holding or reverie) and, furthermore, that therein lies an important contribution of psychoanalysis to mental health practice in general.

What is Psychoanalysis?

Having made the proposition that psychoanalysis can help present-day psychotherapy to encounter the unusual und uncommon, one needs to take a step back and ask what psychoanalysis is set to mean today (cf. Storck 2023).

More so than in other psychotherapeutic orientations and their framework theories, the question arises what constitutes the core of psychoanalysis. This has been discussed repeatedly since Wallerstein’s (1992) work in the late 1980s under the term of a “common ground” in psychoanalysis.

Obviously, psychoanalysis does need a common ground, a shared reference point for what is meant when something, especially in psychotherapeutic practice, is labeled as ‘psychoanalytic’.

Firstly, regarding patients who enter psychoanalysis or psychodynamic treatment. One should be able to explain what will be done, why it isdone, and why that is called psychoanalytic. It should not remain unclear or mystified what psychoanalysis is.

Secondly, marking a psychoanalytic common ground is necessary to clarify what training in psychoanalysis or psychodynamic psychotherapy entails: What are the specific therapeutic skills to be developed, what is to be taught and learned, and at which point is someone qualified as a psychoanalyst or psychodynamic therapist? Without this being made clear, training becomes opaque – and unattractive for future trainees. I will come back to that later in terms of how negative therapeutic skills that enable psychotherapists to move on uncommon, unfamiliar ground can be taught and acquired.

And thirdly, communication about a common ground is important for scholarly exchange among psychoanalysts and with practitioners of other therapeutic orientations, as well as in research. To make the case for psychoanalytic contributions to psychotherapy in general, there has to be some understanding of what psychoanalysis is.

One can try and define the common ground in psychoanalysis by looking at its major concepts (the unconscious, relational patterns, defence mechanisms, mental conflict, personality functioning) and how treatment is conducted with regard to respective conceptualizations (transference and countertransference, resistance, interpretation) or specific settings (use of the couch, number of weekly sessions).

This also involves to determine the common ground of psychoanalysis through the therapeutic stance (cf. Plakun, 2023) obtained; i.e., a specific aspect of the methodology that has less to do with what is done and more with the grounds on which it is done, it is more about attitude than technique. Even though the term ‘therapeutic stance’ is not well defined at all, we can claim that a psychoanalytic approach involves allowing disruptions to occur — seen relative to the treatment goals or the patient’s mental functioning. In what follows, I will draw upon that aspect more thoroughly.

The Capacity for Receptivity and to be Affected

Conducting a psychoanalytic or psychodynamic treatment relies on what has been described as taking a position of evenly-suspended attention (Freud, 1912e), offering a holding function (Winnicott, 1960), entering a state of reverie and containing (Bion, 1970) or transforming those “raw” mental elements that enter transference and countertransference through projective identification (Bion, 1959; Ogden, 1979) by means of an analytic alpha function that allows to form mental representations (Bion, 1970). Set aside different conceptual notions, these are different ways to conceptualize the following: When following the goal to let unconscious aspects of mental functioning which are assumed to play an important role in symptom formation enter the therapeutic process, the therapist has to enter some sort of professional state in which he or she is affected by that which is not yet mentally represented or understood. This calls for a capacity to “not know” in advance as well as to respond to something unexpected (or, even, to live through “catastrophic change” within the psychotherapeutic relationship; Bion).

Schneider (2020) referred to this kind of therapeutic stance, in reference to Beckett, as ‘lessness’ which is an attitude defined by negation, though not in a moral or evaluative sense of the ‘negative’, but as a counterpart to a positivity that can only focus on what can be recognized or foreseen as what it might be or mean. Understanding the psychoanalytic stance as ‘lessness’ emphasizes that providing a helpful insight-oriented relationship in the consulting room is directed toward what both patient and therapist do not yet know or understand. “Lessness” thus means to refrain from putting things “in order” all too soon but rather let that which is unknown and possibly disruptive unfold in the process in order to understand and eventually integrate it. Contrasting “lessness” with those therapeutic functions that can be described positively (e.g. providing active support but also formulating an intervention that is supposed to address some specific mental representation or process) it can be seen that it calls for some “negative” approach (yet, not in an evaluative sense of the negative).

Angeloch (2022) used the image of the helmsman Palinurus from Virgil’s Aeneid to argue for the corresponding ‘negative’ type of understanding (and implicitly, the stance that is supposed to come within it). In a storm, Palinurus clings to the ship’s steering wheel so tightly that it is torn from its fastening by the wind and waves, resulting in a shipwreck. Angeloch argues that here, surrendering to the forces of nature (= the ‘stormy’ process) and thus letting go of the attempts to stay on the set course would have allowed the ship and its helmsman for the possibilities to respond to the gusts instead of being destroyed.

This may sound overly poetic (which it is, given the Virgil reference), but the point is made that in psychotherapy, there are also moments and processes where it is not the firmest grip that steers the process appropriately, but rather a letting go. I want to stress here that this is not meant as an argument against standardization or guidelines, neither against “active” therapeutic responsibility and care — Palinurus undoubtedly also needs a course; he must know the maps and be aware of where his ship is currently located; and of course, he needs to keep in mind the other persons who boarded the ship he is supposed to navigate safely through whatever turbulences might come up. He is in need of agreed-upon helmsman skills as is any psychotherapist. Also, not all psychotherapeutic treatments share the same balance between maintaining a course and letting go. But there is some value in recognizing when holding onto the helm leads to a shipwreck (or, put less dramatically, stagnation).

While touching upon other concepts meant to explain the central features of the therapeutic stance, such as reverie, containing or the capacity to make use of projective identification, what I propose as a “negative skill” (to be clarified later) underlines that actively refraining from “doing something” and thus letting oneself be dragged onto uncommon ground is a key feature of what makes psychoanalysis helpful. To nonetheless describe this capacity as part of a “set” of psychotherapeutic skills, albeit a negative one, means to argue for the fact that it actually can be taught and learned and thus be part of psychotherapeutic training (instead of being some mystified kind of “genius ingredient” in effective psychotherapists).

Therefore, I have proposed (Storck, 2023) to determine one key element regarding the psychoanalytic stance as follows: Psychoanalysis entails curiosity and the capacity to expose oneself to the unknown/unfamiliar/uncommon (in the form of an experience of crisis). This can be part of processes of change in a treatment inasmuch as, in the long run, it contributes to enabling patients to tolerate and deal with unfamiliar feelings and relational patterns themselves.

The Contribution of Psychoanalysis to Psychotherapy

Psychoanalysis has much to offer, in its methodological expansion beyond the consulting room, in its treatment-focused approach to various patient groups (manualized and non-manualized), or in working with complex mental and psychosomatic disorders. But what of this elaborated psychoanalytic stance of allowing oneself to be affected and of letting go can be transferred or integrated with regard to other psychotherapeutic approaches?

Prerequisites for Psychotherapy Integration

Distinct knowledge cultures and epistemologies of psychoanalysis and other psychotherapeutic approaches (most notably evident in the cognitive-behavioral orientation) become particularly relevant when the task of integrative or modular psychotherapy (Herpertz & Schramm, 2022) is considered. What is required to combine psychotherapeutic methods or techniques from different orientations within a concrete treatment?

One initial challenge lies in the fact that particular methods, such as the interpretive work oriented at transference and countertransference, are based on the epistemological assumptions of psychoanalysis, including its understanding of what mental health is. A second challenge arises from the fact that concepts are embedded in conceptual fields or ‘constellations’ (see Storck, 2022a). E.g., the concept of transference is interconnected with other psychoanalytic concepts, such as (dynamic) unconscious, object representation, defense mechanisms, resistance, or regression.

Any attempt to integrate methods or techniques, therefore, necessitates a reflection on knowledge cultures and methodologies (Prohaska & Norcross, 2018; Sell & Benecke, 2020; Sell, 2014), as well as a metatheoretical mediation to relate terms from different orientations (for example, “cognitive dissonance” and “ambivalence conflict”) to one another. This is not an impossible task, but it does call for conceptual work in Theoretical Psychotherapy (Storck, 2022a). While this cannot be discussed here I limit myself to calling into attention the use for conceptual groundwork on the history of psychotherapy, major concepts and controversies (both within different psychotherapeutic orientations and in-between these), or the philosophy, psychology or sociology of psychotherapy.

Negative Personal Skills in Psychotherapy

An important way in which psychoanalytic assumptions and approaches can be valuable for other psychotherapeutic orientations, lies in the field of personal competence/skills in psychotherapy (Hill & Norcross, 2023).

The discourse on psychotherapeutic skills is vibrant within psychotherapy research and training (Rief et al., 2021). One subset of this discourse are psychotherapist’s personal skills, which are not solely about employing methods and techniques that have proven to be effective (as well as recognizing when and how to deviate from treatment manuals). It is also about what single psychotherapists can rely upon within themselves. If we refrain from an unfruitful discourse about talent or genius in psychotherapy, the question arises as to how personal skills can be developed and cultivated (cf. Castonguay & Hill, 2017).

Personal skills in psychotherapists should be described precisely as to make them ‘teachable’ in a practical sense (Montan et al., 2022). Also, personal skills are not limited to self-reflection alone.

Here, I see the crucial contribution of psychoanalysis to professional psychotherapy. Personal skills can encompass many aspects, and psychoanalysis describes a distinct area that I have called ‘negative skills’ (Storck, 2022a, b; see also Mertens & Storck, 2023; Gelhard, 2018). Again, here, ‘negative’ does not refer to a negative in a moral sense; rather, negative skills are marked by a passive receptivity and the capacity to be affected – in other words, the skills that lie in letting go, not-taking-action or the questioning of one’s own set skills (as well as a pre-formulated plan of action).

The psychoanalytic stance described above, of allowing oneself to be momentarily ‘disrupted’ and questioning oneself is what, when formulated as personal negative skills, allows for a transfer to and integration into other psychotherapeutic orientations. Negative skills lie precisely in keeping one’s own active skills in suspension, not clinging to pre-formed techniques, but rather allowing what arises from affectively in the therapeutic relationship to take place through a ‘crisis-positive receptivity’. This can provide the foundation for keeping a patient emotionally engaged and enabling them to collaboratively navigate through a crisis experience that could not have been foreseen.

The described suspension of active therapeutic skills does not preclude other therapeutic techniques. It is not to suggest that allowing things to happen in and of itself alone brings about therapeutic change. However, this stance articulated by psychoanalysis is, in my view, particularly significant for contemporary psychotherapy. Labelling its key ingredient as a negative personal skills offers a starting point from that it can be integrated into other approaches as well as be taught in psychotherapeutic training without having to review the whole set of psychoanalytic concepts (e.g. containment, projective identification) and mediate them towards other approaches. Rather, a particular form of empathy (e.g. Bolognini, 2009) in a more general sense, is described.

I refer to this inclusion of a stance marked by negative skills as an ‘uncommon factor’ in psychotherapy because it involves venturing into areas of the therapeutic process that represent unknown territory, not yet mapped in the sense of manualized derivable algorithms of therapeutic action. In my view, this is part of any psychotherapy, and dealing with it will likely prove to be an important part of processes of change that focus on the individual patient and therapy process. Coining this an “uncommon factor” is not meant to say that it is something completely apart from other general features of effective psychotherapy but rather to mark the contribution of the capacity to tolerate the unfamiliar, unexpected or “troubling” during psychotherapeutic processes. As such, it can be regarded as an “ingredient” that might render concrete “positive” strategies or interventions effective in the first place: A factor that helps to include the uncommon and unfamiliar.

Dealing with difficult clinical situations spans various levels, of course also in terms of taking psychotherapeutic action “positively”. It seems crucial to explore the rupture in the working alliance, which is beginning to manifest. After all, it concerns the patient’s disrupted trust in the therapist as a person and in the therapy process as providing something beneficial. Following Safran and Muran’s (2000) considerations regarding alliance ruptures and their repair would be advisable here. Another level of intervention would involve assisting a patient in regulating his or her intense emotions and promoting mentalization towards the conflict with his partner, understanding what led to it and how he views it today, the day after (Taubner et al., 2019).

These two exemplary methodological approaches (exploring and repairing the rupture; regulating affect and promoting mentalization) do not contradict the previously described personal negative skills (in terms of letting go). The latter describes the current affective resonance and the ability to hold the patient’s affects. Even when resorting to the mentioned established techniques, conducting the therapy in this particular session still involves acknowledging one’s own disturbance and proceeding in light of that. The exploration of the rupture and supporting the patient in his current affective state will only succeed if the therapist is willing to depart from familiar ground and does not already know which approach (regulation, reflection) foster change.

Future Directions

Apart from empirical investigations on “negative skills” and their role in effective psychotherapy across different orientations, one important consequence of the proposition made here is to try and integrative negative skills more directly into psychotherapeutic training. Given the “negative” aspect (shown via the term “lessness”) this proves difficult. One direction could be to sensitize (in courses on treatment technique as well as in supervision or intervision) psychotherapists in training for moments in a session where “not-acting” might be helpful. It appears to be likely that this capacity is acquired through intensive work in (video-based) supervision – which does justice to the specific role of learning when and how not to act. In the field of educational theory Gelhard (2018) introduced the idea of a “negativistic” theory of learning and Reichenbach (2023) connected a similar notion with a general idea of professional training as “formation” (Bildung, in german, which means both “education” and “formation”, also touching upon (professional) “training”). Psychotherapy training, then, also should include aspects of personal professional development (see also Willemsen et al., 2023), alongside the mere acquisition of evidence-based technique.

The approach proposed here, to incorporate psychoanalytic stance and negative personal skills into other areas, is, however, demanding if work is to be conducted in an ethical sound way. As prerequisites, the following can be identified: Sufficient and ongoing self-reflection through personal therapy, supervision, and intervision. Furthermore, engaging with the conceptual foundations and possible metatheoretical mediations between concepts from different directions. Also, offering patients a sound description of why and how the therapeutic relationship is set into action to understand and promote change.

If these criteria are sufficiently met, we can argue for the fruitful contributions of psychoanalysis to psychotherapy and mental health practice today, namely:

Based on the assumption that in each psychotherapy, we encounter something that is not included in what manuals and treatment guidelines describe or that even can be expected in an individualized treatment plan, we are in need of findings ways to move on ‘uncommon ground’. Psychoanalysis offers such ways inasmuch as it describes how to take a specific therapeutic stance that entails a form of receptivity towards the unfamiliar und unforeseen as well as the capacity to be affected by it. This can be described as negative personal skills in terms of being able to letting go of and suspending a pre-formed plan of action. Relying on negative personal skills does not discard other treatment techniques or stand in opposition to these but are rather something these are embedded in. Thus, we can identify and address an ‘uncommon factor’ in psychotherapy and mental health practice: the factor that should be kept in mind when attempting to provide prerequisites for change.