From moment to moment, we are continuously deciding how best to position ourselves in relation to our patients and the maladaptive defenses to which they cling – once necessary for them to survive but now interfering with their ability to thrive. On the one hand, we have respect for our patients and for the choices, no matter how unhealthy, that they find themselves continuously making; on the other hand, we have a vision of who we think they could be were they but able/willing to make healthier choices for themselves. Indeed, we are always struggling to find an optimal balance within ourselves between accepting the reality of who our patients are and wanting them to change. Whether we are working within the interpretive framework of classical psychoanalytic theory, the corrective-provision framework of self psychology, or the intersubjective framework of contemporary relational theory, we are therefore ever busy deciding – whether consciously or unconsciously – if we should “be with our patients where they are” (Akhtar’s homeostatic attunement) or “direct their attention to elsewhere” (Akhtar’s disruptive attunement) – a critically important balance that is needed if the analytic endeavor is to be advanced. To demonstrate the translation of these theoretical constructs into clinical practice, I will be proposing a number of broadly applicable “template” interventions that juxtapose both the patient’s “defensive need” to maintain “same old same old” and the patient’s “adaptive capacity” to allow for “something new, different, and better.” Clinical vignettes will be offered that demonstrate judicious and ongoing use of these “optimally stressful” interventions that alternately support and challenge the defense, thereby galvanizing advancement of the patient, over time, from psychological rigidity to psychological flexibility. If indeed the therapeutic goal is deep and sustained psychodynamic change, then it behooves all of us to become comfortable with the concept of provoking – with our interventions – enough incentivizing anxiety and destabilizing stress within our patients that there will be both impetus and opportunity for them, ultimately, to transform rigid defense into more flexible adaptation. The strategic formulation of interpretations specifically designed to generate this optimal stress is indeed both an art and a science.

1. THE ART AND THE SCIENCE
OF INTERPRETATION
MARTHA STARK MD
MarthaStarkMD @ HMS.Harvard.edu
Friday, March 18, 2022
eBook Lecture for IPI
© 2022 Martha Stark MD
1

2. OVERVIEW
EMPATHIC STATEMENTS
HEARTFELT STATEMENTS, NOT HEADY QUESTIONS
STATEMENTS THAT SUPPORT BY RESONATING EMPATHICALLY,
MOMENT BY MOMENT, WITH WHAT THE PATIENT IS ACTUALLY FEELING
HIGHLIGHTING NOT ONLY THE PATIENT’S AFFECT
BUT ALSO THE “STORIES” THAT SHE, AS A YOUNG CHILD,
HAD CONSTRUCTED IN A DESPERATE ATTEMPT TO MAKE SENSE
OF THE DEPRIVATION, NEGLECT, TRAUMA, AND ABUSE
TO WHICH SHE WAS BEING EXPOSED
NARRATIVES THAT HAVE NOW BECOME THE GO – TO (DISTORTED) FILTERS
THROUGH WHICH SHE EXPERIENCES SELF, OTHERS, AND THE WORLD
EXPERIENCE – NEAR, NOT EXPERIENCE – DISTANT
MANIFEST CONTENT, NOT LATENT CONTENT
CONFLICT STATEMENTS
TO FACILITATE THE DEVELOPMENT OF “DUAL AWARENESS”
ARTFULLY TITRATED BLEND OF CHALLENGE AND SUPPORT
TO CREATE “DESTABILIZING ANXIETY” AND INCENTIVIZING “OPTIMAL STRESS”
ITERATIVE HEALING CYCLES OF DISRUPTION (IN REACTION TO THE CHALLENGE)
AND REPAIR (IN RESPONSE TO THE SUPPORT)
GRADUAL REPLACEMENT OF OLD BAD NARRATIVES THAT LIMIT
WITH NEW GOOD NARRATIVES THAT OFFER MORE FREEDOM
AS PSYCHOLOGICAL RIGIDITY AND DEFENSIVE NEED
ARE GRADUALLY TRANSFORMED INTO
PSYCHOLOGICAL FLEXIBILITY AND ADAPTIVE CAPACITY 2

3. THE MEDICAL MODEL OF ”ASKING QUESTIONS”
TO “FERRET OUT THE TRUTH”
THE GOAL BEING TO “MAKE CONSCIOUS THE UNCONSCIOUS”
AND TO HELP THE PATIENT GAIN INSIGHT INTO
THE INNER WORKINGS OF HER MIND;
RECURRING THEMES, PATTERNS, AND REPETITIONS;
AND THE IMPACT OF HER PAST ON HER PRESENT
A “HEADY QUESTION” LIKE –
“THIS SENSE YOU HAVE OF BEING JUDGED BY YOUR FRIEND –
IS THAT PERHAPS A FAMILIAR FEELING FROM WAY BACK?”
INSTEAD OF AN “EMPATHIC STATEMENT” LIKE –
“ … SO PAINFUL – THIS FEELING OF BEING ALWAYS JUDGED … ”
A “HEADY QUESTION” LIKE –
“HOW DID YOU FEEL WHEN YOUR FATHER
KEPT CALLING YOU A LOSER?”
INSTEAD OF AN “EMPATHIC STATEMENT” LIKE –
“ … DEVASTATING AND ABSOLUTELY ENRAGING
WHEN YOUR FATHER KEPT CALLING YOU A LOSER … ” 3

4. “HEADY QUESTIONS” RUN THE RISK
OF ELICITING SOMEWHAT “HEADY ANSWERS”
MORE “HEADY” THAN “HEARTFELT”
MORE “COGNITIVE” THAN “EXPERIENTIAL” OR “EMBODIED”
OVER THE COURSE OF THE YEARS
I HAVE COME TO APPRECIATE THAT WHATEVER THE TREATMENT
– WHETHER CRISIS INTERVENTION, TRAUMA WORK,
SHORT – TERM INTENSIVE, OR LONG – TERM IN – DEPTH –
IT WILL GENERALLY BE MORE EFFECTIVE WHEN
– MOMENT BY MOMENT –
OUR FOCUS IS NOT ON OURSELVES
AND WHAT WE WANT TO FIND OUT
BUT ON THE PATIENT,
WHAT SHE IS EXPERIENCING,
AND WHAT SHE WANTS US TO KNOW
FOR THE MOST PART
I LET THE PATIENT LEAD – AND I FOLLOW
I MAKE STATEMENTS – AND DON’T ASK QUESTIONS
4

5. I TAKE MY CUES FROM THE PATIENT
LISTENING ALWAYS WITH COMPASSION AND NEVER JUDGMENT
– WITH BOTH “HEAD” AND “HEART” –
TO EVERYTHING THE PATIENT IS TELLING ME
– NO MATTER HOW SEEMINGLY IRRELEVANT IT MIGHT BE –
I WILL THEN OFFER “EMPATHIC STATEMENTS” THAT HIGHLIGHT
“WHAT THE PATIENT IS ACTUALLY FEELING”
AND “ABOUT WHAT”
STATEMENTS THAT OFTEN END WITH AN IMPLIED QUESTION MARK
WHEREBY I AM SIGNALING THAT I AM VERY OPEN
TO HAVING MY RENDERING OF THINGS
EDITED, CORRECTED, OR REVISED
IN ORDER TO MAKE IT A MORE ACCURATE REFLECTION
OF WHAT THE PATIENT IS ACTUALLY SAYING
AND WANTING ME TO KNOW
5

6. EXAMPLES OF EMPATHIC STATEMENTS
“ … HARD TO KNOW WHERE TO BEGIN
WHEN EVERYTHING FEELS SO OVERWHELMING … ”
“ … UNCOMFORTABLE TO BE HERE WHEN YOU’RE NOT SURE
THE THERAPY IS REALLY HELPING ANYWAY … ”
“ … UPSETTING TO BE FEELING THIS OUT OF CONTROL … ”
ALL OF WHICH SPEAK TO BOTH
THE PATIENT’S “AFFECT” AND THE “ASSOCIATED THEME”
IN OFFERING THE PATIENT EMPATHIC STATEMENTS,
I AM, OF COURSE, “GIVING” HER SOMETHING
RATHER THAN “ASKING” OF HER THAT SHE “GIVE” ME SOMETHING
NAMELY, ANSWERS TO MY QUESTIONS
“ … TIRED OF THINKING ABOUT WHETHER YOU SHOULD STAY OR GO … ”
“ … DEEP DESPAIR ABOUT EVER BEING ABLE TO FIND A TRUE SOULMATE … ”
“ … TERRIFIED THAT YOU WILL BE DISAPPOINTED … ”
“ … TERRIFIED THAT YOU YOURSELF WILL DISAPPOINT … ”
“ … CONFUSED ABOUT HOW BEST TO USE THE SESSION … ”
6

7. EMPATHIC STATEMENTS THAT HIGHLIGHT
WHAT THE PATIENT IS EXPERIENCING
IN A “SPECIFIC CONTEXT”
“ … PAINFUL TO BE FEELING SO MISUNDERSTOOD BY JUANITA … ”
CAN THEN USUALLY BE “GENERALIZED”
“ … PAINFUL TO BE FEELING ALWAYS SO MISUNDERSTOOD … ”
BY THE SAME TOKEN
EMPATHIC STATEMENTS THAT HIGHLIGHT
WHAT THE PATIENT IS EXPERIENCING
IN THE “PRESENT”
“ … PAINFUL TO BE FEELING SO MISUNDERSTOOD … ”
CAN THEN USUALLY BE “EXTENDED” TO THE “PAST”
“ … PAINFUL TO HAVE BEEN FEELING
SO MISUNDERSTOOD FOR SO LONG NOW … ”
7

8. PLEASE NOTE THAT INSTEAD OF
“I WONDER IF IT IS PAINFUL TO BE FEELING SO UNLOVABLE”
OR
“IT SOUNDS AS IF IT IS PAINFUL TO BE FEELING SO UNLOVABLE”
OR
“IT SEEMS AS IF IT IS PAINFUL TO BE FEELING SO UNLOVABLE”
YOU COULD SIMPLY SAY
“ … PAINFUL TO BE FEELING SO UNLOVABLE … ”
FOLLOWED BY AN IMPLIED QUESTION MARK
THEREBY SIGNALING THAT YOU ARE VERY OPEN
TO HAVING YOUR STATEMENT AMENDED
I DO MY BEST TO ELIMINATE EXTRA WORDS
AT THE BEGINNING OF MY EMPATHIC STATEMENTS
SO THAT I CAN CUT RIGHT TO THE CHASE
“ … PAINFUL TO BE FEELING SO UNLOVABLE … ”
EXTRA WORDS THAT RUN THE RISK
OF PUTTING TOO MUCH DISTANCE
BETWEEN YOU AND THE PATIENT
8

9. EMPATHIC STATEMENTS ARE “EXPERIENCE – NEAR”
– NOT “EXPERIENCE – DISTANT” –
AND ARE DESIGNED TO “VALIDATE” OR “REINFORCE”
THE PATIENT’S ACTUAL “EXPERIENCE” IN THE MOMENT
WHAT’S IN HER CONSCIOUSNESS
OR, PERHAPS, HER PRECONSCIOUS
THEY ARE NOT DESIGNED TO TARGET HER UNCONSCIOUS
I HONOR WHAT THE PATIENT IS ACTUALLY TELLING ME
AND DON’T TRY TO READ BETWEEN THE LINES
OR TO INTERPRET WHAT I THINK MIGHT LIE
BENEATH THE SURFACE
I FOCUS MORE ON THE “MANIFEST CONTENT”
THAN ON THE “LATENT CONTENT”
MY “DEFAULT MODE” ARE THESE EMPATHIC STATEMENTS
THAT FOCUS MORE ON HELPING THE PATIENT TO “FEEL UNDERSTOOD”
THAN ON HELPING HER TO “UNDERSTAND”
SHE, FEELING SUPPORTED, WILL THEN BE MORE INCLINED TO DELVE
MORE DEEPLY INTO WHAT IS REALLY GOING ON INSIDE HER
9

10. BECAUSE EMPATHIC STATEMENTS HIGHLIGHT
NOT ONLY THE PATIENT’S “AFFECT” IN THE MOMENT
BUT ALSO THE “STORY” THAT GOES WITH IT
“ … FEARFUL ALWAYS OF BEING JUDGED … ”
“ … WORRIED ABOUT WHAT I MIGHT BE THINKING … ”
ONGOING USE OF THESE STATEMENTS
NOT ONLY WILL ENABLE THE PATIENT TO FEEL
UNDERSTOOD, VALIDATED, AND SUPPORTED
BUT ALSO WILL START TO GIVE SHAPE
TO THE “FILTERS” THROUGH WHICH
SHE INTERPRETS HER LIFE …
THESE EMPATHIC STATEMENTS DO NOT SPECIFICALLY
”INCENTIVIZE” STRUCTURAL TRANSFORMATION AND GROWTH,
BUT THEY DO LAY THE GROUNDWORK FOR SUBSEQUENT
“OPTIMALLY STRESSFUL” INTERVENTIONS THAT WILL
10

11. EMPATHIC STATEMENTS ARE “MAKING EXPLICIT”
THE MALADAPTIVE, DISEMPOWERING NARRATIVES
THAT THE PATIENT HAD CONSTRUCTED AS A YOUNG CHILD
IN A DESPERATE ATTEMPT TO MAKE SENSE OF
THE TRAUMA AND ABUSE / THE DEPRIVATION AND NEGLECT
TO WHICH SHE WAS BEING EXPOSED
“ … SO AFRAID OF BEING PUNISHED … ”
“ … EXCRUCIATINGLY PAINFUL TO BE FEELING ALWAYS SO INVISIBLE … ”
“ … ENRAGING TO BE FEELING NEVER GOOD ENOUGH … ”
“ … PAINFUL TO BE FEELING SO BROKEN … ”
“STORIES” THE PATIENT HAD “MADE UP”
IN AN EFFORT TO UNDERSTAND
BUT “MADE – UP STORIES” THAT HAVE NOW GENERALIZED
FROM THE SMALL (HER NUCLEAR FAMILY)
TO THE ALL (THE WORLD AROUND HER)
“NARRATIVES” THAT HAVE BECOME THE “GO – TO”
DISTORTED FILTERS, OR LENSES, THROUGH WHICH
SHE EXPERIENCES SELF, OTHERS, AND THE WORLD
11

12. THE PATIENT COMES IN, STATING THAT SHE IS VERY UPSET
ABOUT SOMETHING THAT HAD HAPPENED THE PREVIOUS NIGHT
BUT ALSO STATING VERY CLEARLY THAT
SHE DOES NOT WANT TO TALK ABOUT IT
“OH DEAR! WHAT HAPPENED?”
DOES NOT HONOR WHAT THE PATIENT HAS JUST SAID
A MORE “EMPATHIC (EXPERIENCE – NEAR) RESPONSE” MIGHT BE –
“RIGHT NOW, IT JUST FEELS TOO UPSETTING
TO TALK ABOUT WHAT HAPPENED LAST NIGHT … ”
TO WHICH THE PATIENT MIGHT RESPOND WITH –
“AND I’M AFRAID TO TALK ABOUT IT
BECAUSE I FEEL SO ASHAMED”
TO WHICH WE MIGHT THEN RESPOND WITH –
“YOU WORRY ABOUT HOW YOU MIGHT BE JUDGED …”
OR, FOCUSING ON THE TRANSFERENCE,
“YOU WORRY ABOUT HOW I MIGHT JUDGE YOU … ”
12

13. AS NOTED EARLIER
WE COULD THEN OFFER THE MORE “GENERAL” –
“YOU FIND YOURSELF OFTEN WORRYING
ABOUT HOW YOU MIGHT BE JUDGED … ”
OR WE COULD HIGHLIGHT
THE PROBABLE “GENETIC UNDERPINNINGS” –
“YOU HAVE ALWAYS FOUND YOURSELF WORRYING
ABOUT HOW YOU MIGHT BE JUDGED –
AFTER ALL, YOUR DAD WAS A PRETTY HARSH CRITIC ... ”
AGAIN, WE ARE BEGINNING TO “MAKE EXPLICIT”
SOME OF THE OLD BAD NARRATIVES
ABOUT SELF, OTHERS, AND THE WORLD
THAT THE PATIENT HAD CONSTRUCTED EARLY ON
BEGINNING TO HIGLIGHT THE SPECIFICS OF
OUTDATED, MALADAPTIVE NARRATIVES THAT ARE
PROBABLY MORE IMPORTANT THAN THE SPECIFICS OF
WHAT HAD ACTUALLY HAPPENED THE PREVIOUS EVENING
13

14. … OLD BAD NARRATIVES
THAT ARE DISEMPOWERING,
DISTORTED, AND LIMITING
AND THAT WILL EVENTUALLY NEED TO BE UPDATED
AND REPLACED WITH NEW GOOD NARRATIVES
THAT ARE MORE EMPOWERING,
MORE REALITY – BASED, MORE AFFIRMING –
AND OFFER GREATER FREEDOM
PARENTHETICALLY
ONCE IT HAS BEEN “MADE EXPLICIT” THAT THE PATIENT
WAS HESITATING FOR FEAR OF BEING JUDGED
– A SELF – SABOTAGING NARRATIVE THAT HAS “LIMITED”
THE “EXPANSIVENESS” OF HER GROWTH SINCE CHILDHOOD –
SHE WILL PROBABLY END UP TALKING ABOUT
WHAT HAD ACTUALLY HAPPENED ANYWAY
“DEFENSE ANALYSIS” vs. “ID CONTENT”
“WORKING WITH THE RESISTANCE” 📕 📕 14

15. MOST PEOPLE ARE CONFLICTED ABOUT
MOST THINGS MOST OF THE TIME
WITH ONE PART OF THEM INVESTED IN
“SAME OLD SAME OLD” (OLD BAD)
AND ANOTHER PART OF THEM ABLE TO ENVISION
“SOMETHING NEW AND BETTER” (NEW GOOD)
“CONFLICT STATEMENTS” –
A UNIVERSALLY APPLICABLE INTERVENTION
THAT TARGETS THE PATIENT’S STATE OF
INTERNAL DIVIDEDNESS OR CONFLICTEDNESS
BETWEEN HEALTHY BUT ANXIETY – PROVOKING FORCES
PRESSING FOR “SOMETHING NEW AND BETTER”
AND LESS HEALTHY BUT ANXIETY – ASSUAGING
(DEFENSIVE) COUNTERFORCES
INSISTING UPON “SAME OLD SAME OLD”
15

16. “EMPATHIC STATEMENTS” OFFER “SUPPORT”
BUT “CONFLICT STATEMENTS”
ARE STRATEGICALLLY DESIGNED
TO OFFER AN ARTFUL COMBINATION OF
“CHALLENGE”
– BY INTRODUCING THE POSSIBILITY OF (ADAPTIVE) CHANGE –
AND “SUPPORT”
– BY RESONATING EMPATHICALLY WITH THE PATIENT’S
(DEFENSIVE) INVESTMENT IN STAYING THE SAME –
THE NET RESULT OF THIS
INTUITIVELY TITRATED BLEND OF
“CHALLENGE”
– WHICH WILL PROVOKE THE PATIENT’S ANXIETY –
AND “SUPPORT”
– WHICH WILL EASE IT –
WILL BE THE GENERATION OF
INCENTIVIZING “OPTIMAL STRESS”
NECESSARY IF DEEP, ENDURING, CHARACTEROLOGICAL
TRANSFORMATION AND RENEWAL IS THE ULTIMATE GOAL
16

17. “SELF – ORGANIZING (COMPLEX ADAPTIVE) SYSTEMS
– LIKE US –
RESIST PERTURBATION”
CHARLES KREBS (2013)
THERE MUST BE ENOUGH “CHALLENGE”
TO A DYSFUNCTIONAL (CHAOTIC) SYSTEM
THAT THERE WILL BE “IMPETUS” FOR
DESTABILIZATION OF ITS (DYSFUNCTIONAL) STATUS QUO
BUT ENOUGH “SUPPORT”
THAT THERE WILL BE “OPPORTUNITY”
FOR ITS RESTABILIZATION
AT A HEALTHIER LEVEL OF FUNCTIONALITY
“SUPPORT” REINFORCED BY TAPPING INTO
THE PATIENT’S UNDERLYING RESILIENCE
AND INNATE ABILITY TO SELF – CORRECT
IN THE FACE OF OPTIMAL CHALLENGE
17

18. OPTIMALLY STRESSFUL “CONFLICT STATEMENTS”
ARE THEREFORE DESIGNED
FIRST TO INCREASE ANXIETY BY
“CHALLENGING” THE DEFENSE
AND THEN TO DECREASE ANXIETY BY
“SUPPORTING” THE DEFENSE
ALL WITH AN EYE TO “MAKING EXPLICIT”
THE CONFLICT WITHIN THE PATIENT
BETWEEN THE HEALTHY PART OF HER
THAT HAS THE “ADAPTIVE CAPACITY”
TO KNOW WHAT’S REAL / WHAT’S TRUE
AND THE LESS HEALTHY PART OF HER
THAT HAS THE “DEFENSIVE NEED”
TO RESIST THAT KNOWING
“YOU KNOW THAT EVENTUALLY YOU WILL NEED
TO MAKE YOUR PEACE WITH THE REALITY
OF JUST HOW LIMITED YOUR MOTHER IS;
BUT YOUR FEAR IS THAT WERE YOU EVER TO LET
YOURSELF REALLY FEEL THE PAIN OF THAT,
YOU WOULD NEVER RECOVER.” 18

19. “YOU KNOW THAT IF YOUR RELATIONSHIP WITH ELANA
IS TO SURVIVE, YOU’LL NEED TO TAKE AT LEAST
SOME RESPONSIBILITY FOR THE PART YOU’RE PLAYING
IN THE INCREDIBLY ABUSIVE FIGHTS
THAT YOU AND SHE ARE HAVING;
BUT YOU TELL YOURSELF THAT IT ISN’T REALLY YOUR FAULT
BECAUSE IF SHE WEREN’T SO PROVOCATIVE,
THEN YOU WOULDN’T HAVE TO BE SO VINDICTIVE!”
EVER ATTUNED TO THE IMPORTANCE OF CREATING
AN OPTIMAL BALANCE BETWEEN CHALLENGE AND SUPPORT,
WE MUST CONTINUOUSLY KEEP OUR FINGER
ON THE PULSE OF THE LEVEL OF THE PATIENT’S ANXIETY
ALWAYS FOCUSING
ON WHETHER WE THINK THE PATIENT WILL BE ABLE
TO TOLERATE FURTHER (ANXIETY – PROVOKING) CHALLENGE
– IN WHICH CASE WE WILL INTRODUCE MORE CHALLENGE –
OR WILL REQUIRE ADDITIONAL (ANXIETY – ASSUAGING) SUPPORT
– IN WHICH CASE WE WILL OFFER MORE SUPPORT –
19

20. INDEED, IT COULD BE SAID THAT
WITHOUT SUPPORT, THERAPY NEVER BEGINS
BUT WITHOUT CHALLENGE, THERAPY NEVER ENDS
ALTERNATIVELY
WITHOUT CHALLENGE, THERAPY NEVER BEGINS
BUT WITHOUT SUPPORT, THERAPY NEVER ENDS
BY THE SAME TOKEN, IT COULD BE SAID THAT
WITHOUT EMPATHY, THERAPY NEVER BEGINS
BUT WITHOUT EMPATHIC FAILURE, THERAPY NEVER ENDS
OR
WITHOUT EMPATHIC FAILURE, THERAPY NEVER BEGINS
BUT WITHOUT EMPATHY, THERAPY NEVER ENDS
THEREFORE
CHALLENGE WHENEVER POSSIBLE
– BY DIRECTING THE PATIENT’S ATTENTION TO WHERE SHE IS NOT –
SUPPORT WHENEVER NECESSARY
– BY LANDING WHERE THE PATIENT IS –
20

21. LET US IMAGINE THAT A PATIENT
IS TRYING HARD TO END HER RELATIONSHIP
WITH AN ABUSIVE BOYFRIEND BUT
IS TERRIFIED OF BEING ALONE AGAIN
“ … TERRIFYING TO THINK ABOUT ENDING
THE RELATIONSHIP AND BEING ALONE AGAIN –
SCARED TO DEATH THAT YOU SIMPLY WOULDN’T SURVIVE … ”
WHERE WE ARE RESONATING EMPATHICALLY WITH HER TERROR,
NAMELY, WITH THE “UNHEALTHY COUNTERFORCE”
THAT IS GETTING IN THE WAY OF THE “HEALTHY FORCE”
THAT KNOWS SHE SHOULD END THE ABUSIVE RELATIONSHIP
ALTERNATIVELY, WE COULD OFFER THE FOLLOWING
“OPTIMALLY STRESSFUL” INTERVENTION
“YOU KNOW THAT ULTIMATELY YOU WILL NEED
TO END THE RELATIONSHIP WITH JORGE
BECAUSE HE TREATS YOU SO SHABBILY;
BUT YOU ARE NOT QUITE YET READY TO DO THAT
BECAUSE YOU ARE TERRIFIED OF BEING ALONE AGAIN –
SCARED TO DEATH THAT YOU SIMPLY WOULDN’T SURVIVE.”
21

22. TO REVIEW
CONFLICT STATEMENTS FIRST SPEAK TO
THE PATIENT’S
“ADAPTIVE (AND GROWTH – PROMOTING) CAPACITY”
TO KNOW AN ANXIETY – PROVOKING TRUTH
AND THEN RESONATE EMPATHICALLY WITH
THE PATIENT’S
“DEFENSIVE (AND GROWTH – IMPEDING) NEED”
TO AVOID THAT KNOWING
IN OTHER WORDS
THEY FIRST “CHALLENGE” THE DEFENSE
BY DIRECTING THE PATIENT’S ATTENTION
TO WHERE SHE ISN’T BUT WHERE WE WANT HER TO GO
– SALMAN AKHTAR’S “DISRUPTIVE ATTUNEMENT” –
AND THEN “SUPPORT” THE DEFENSE
BY LANDING WHERE THE PATIENT IS
– SALMAN AKHTAR’S “HOMEOSTATIC ATTUNEMENT”
SALMAN AKHTAR (2012)
22

23. BY LOCATING WITHIN THE PATIENT CONFLICT BETWEEN
WHAT SHE “KNOWS” AND WHAT SHE, MADE ANXIOUS,
FINDS HERSELF (DEFENSIVELY) “THINKING, FEELING, OR DOING”
IN ORDER NOT TO HAVE TO CONFRONT THAT REALITY,
THE THERAPIST IS DEFTLY SIDESTEPPING THE POTENTIAL
FOR CONFLICT BETWEEN HERSELF AND THE PATIENT
MORE SPECIFICALLY
WHEN THE THERAPIST INTRODUCES A CONFLICT STATEMENT WITH
“YOU KNOW THAT … , ” SHE IS FORCING THE PATIENT TO TAKE
RESPONSIBILITY FOR WHAT THE PATIENT REALLY DOES KNOW
IF, INSTEAD, THE THERAPIST
– IN A MISGUIDED ATTEMPT TO URGE THE PATIENT FORWARD –
RESORTS SIMPLY TO TELLING THE PATIENT
WHAT THE THERAPIST KNOWS,
NOT ONLY DOES THE THERAPIST RUN THE RISK OF FORCING
THE PATIENT TO BECOME EVER – MORE ENTRENCHED
IN HER DEFENSIVE STANCE OF PROTEST
BUT THE THERAPIST WILL ALSO BE DEPRIVING THE PATIENT
OF ANY INCENTIVE TO TAKE RESPONSIBILITY
FOR HER OWN DESIRE TO GET BETTER 23

24. IN OTHER WORDS
AS A RESULT OF THE JUDICIOUS USE OF CONFLICT STATEMENTS
THAT FORCE THE PATIENT TO BECOME AWARE OF
– AND TO TAKE RESPONSIBILITY FOR –
HER OWN STATE OF INTERNAL “DIVIDEDNESS” ABOUT GETTING BETTER
– IN OTHER WORDS, HER AMBIVALENCE –
THE THERAPIST WILL BE ABLE MASTERFULLY TO AVOID
GETTING DEADLOCKED IN A POWER STRUGGLE WITH THE PATIENT –
A POWER STRUGGLE THAT CAN EASILY ENOUGH ENSUE
IF THE THERAPIST TAKES IT UPON HERSELF
TO REPRESENT THE “VOICE OF REALITY”
AND OVERZEALOUSLY ADVOCATES FOR THE PATIENT
TO DO THE “RIGHT / HEALTHY” THING
– A STANCE THAT THEN LEAVES THE PATIENT, MADE ANXIOUS,
NO CHOICE BUT TO BECOME THE “VOICE OF OPPOSITION”
“YOU’RE COMING TO UNDERSTAND THAT
YOUR ANGER CAN PUT PEOPLE OFF;
BUT YOU TELL YOURSELF THAT
YOU HAVE A RIGHT TO BE AS ANGRY AS YOU WANT
BECAUSE OF HOW MUCH YOU HAVE SUFFERED
OVER THE COURSE OF THE YEARS.”
24

25. NOTE THE IMPLICIT MESSAGE DELIVERED BY THE THERAPIST
IN THE SECOND PART OF A CONFLICT STATEMENT
WHEN SHE USES SUCH TEMPORAL EXPRESSIONS AS
“FOR NOW” / “RIGHT NOW” / “AT THE MOMENT”
“IN THE MOMENT” / “AT THIS POINT IN TIME”
WHICH SHE WILL DO WHEN SHE IS ADDRESSING
THE PATIENT’S “INVESTMENT” IN THE DYSFUNCTIONAL DEFENSE
THE THERAPIST IS ATTEMPTING TO HIGHLIGHT THE FACT
THAT EVEN IF, FOR NOW, THE PATIENT WOULD SEEM TO BE
ENTRENCHED IN PROTESTING HER RIGHT TO MAINTAIN THINGS
AS THEY ARE, AT ANOTHER POINT IN TIME, THAT COULD CHANGE
“YOU KNOW THAT SOMEDAY YOU’LL HAVE TO LET SOMEBODY IN
IF YOU’RE EVER TO HAVE A MEANINGFUL RELATIONSHIP; BUT, AT
THE MOMENT, THE THOUGHT OF MAKING YOURSELF THAT VULNERABLE
IS SIMPLY OUT OF THE QUESTION. THERE’S ABSOLUTELY NO WAY
YOU’RE WILLING TO RUN THE RISK OF BEING HURT EVER AGAIN.”
“YOU KNOW THAT IF YOU ARE EVER TO GET ON WITH YOUR LIFE,
YOU’LL HAVE TO LET GO OF YOUR CONVICTION THAT YOUR
CHILDHOOD SCARRED YOU FOREVER; BUT IT’S HARD NOT TO FEEL
LIKE DAMAGED GOODS, RIGHT NOW, WHEN YOU GREW UP IN
A HORRIBLY ABUSIVE HOUSEHOLD WITH A MEAN AND NASTY MOTHER
WHO KEPT TELLING YOU THAT YOU WERE A FAILURE.” 25

26. CONFLICT STATEMENTS ARE THE MAINSTAY OF
MODEL 1 IN MY PSYCHODYNAMIC SYNERGY PARADIGM
THE INTERPRETIVE PERSPECTIVE
OF CLASSICAL PSYCHOANALYTIC THEORY
A THEORY THAT, AS WE KNOW, PRIVILEGES
“INSIGHT” OR “AWARENESS”
CONFLICT STATEMENTS ARE SPECIFICALLY FORMULATED
TO FACILITATE DEVELOPMENT OF NOT JUST “AWARENESS”
BUT ALSO “DUAL AWARENESS”
NAMELY, THE PATIENT’S ABILITY TO BECOME “AWARE OF”
BOTH WHAT HER “OBSERVING EGO” HAS THE
“HEALTHY CAPACITY TO KNOW”
AND WHAT HER “EXPERIENCING EGO” HAS THE
”DEFENSIVE NEED TO AVOID KNOWING”
IN OTHER WORDS
BOTH WHAT HER “REFLECTIVE SELF” “KNOWS”
AND WHAT HER “REFLEXIVE SELF,” MADE ANXIOUS,
“FINDS ITSELF (DEFENSIVELY) THINKING, FEELING, OR DOING
IN ORDER NOT TO HAVE TO KNOW”
26

27. ULTIMATELY
DUAL AWARENESS – “WISE MIND”
THE HEALTHY ABILITY TO HOLD “SIMULTANEOUS AWARENESS” OF BOTH
KNOWLEDGE AND EXPERIENCE
OBJECTIVE REALITY AND SUBJECTIVE EXPERIENCE
HEAD AND HEART
LEFT BRAIN AND RIGHT BRAIN
EXPLICIT COGNITIVE AND IMPLICIT EMOTIONAL
REASON AND EMOTION
“HERE – AND – NOW” AND “THERE – AND – THEN”
PRESENT AND PAST
NEW GOOD AND OLD BAD
PROSPECTIVE AND RETROSPECTIVE
UPDATED AND OUTDATED
RESPONSIVE AND REACTIVE
REFLECTIVE AND REFLEXIVE
MINDFUL AND MINDLESS
FLEXIBLE AND RIGID
ADAPTIVE CAPACITY AND DEFENSIVE NEED
ADAPTATION AND DEFENSE 27

28. IN CLOSING
I WOULD LIKE TO BORROW FROM STEPHEN MITCHELL (1988)
A WONDERFUL ANECDOTE THAT CAPTURES THE ESSENCE
OF THE QUINTESSENTIAL STRUGGLE IN WHICH ALL OF US
ARE ENGAGED AS WE ATTEMPT TO MASTER OUR ART
MITCHELL WRITES –
“<STRAVINSKY> HAD WRITTEN A NEW PIECE WITH A DIFFICULT
VIOLIN PASSAGE. AFTER IT HAD BEEN IN REHEARSAL FOR
SEVERAL WEEKS, THE SOLO VIOLINIST CAME TO STRAVINSKY
AND SAID HE WAS SORRY, HE HAD TRIED HIS BEST, <BUT> THE
PASSAGE WAS TOO DIFFICULT; NO VIOLINIST COULD PLAY IT.
STRAVINSKY SAID, ‘I UNDERSTAND THAT. WHAT I AM AFTER
IS THE SOUND OF SOMEONE TRYING TO PLAY IT.’”
AS THERAPISTS, OUR WORK IS EXQUISITELY DIFFICULT
AND FINELY TUNED – AND OFTEN WE WILL NOT BE ABLE
TO GET IT JUST RIGHT – PERHAPS, HOWEVER, WE CAN
CONSOLE OURSELVES WITH THE THOUGHT THAT
IT IS THE EFFORT WE MAKE TO GET IT JUST RIGHT
THAT ULTIMATELY COUNTS
28

29. 29

30. IF YOU WOULD
LIKE TO BE
ON MY MAILING LIST,
PLEASE EMAIL ME AT
MarthaStarkMD @
HMS.Harvard.edu
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31.  REFERENCES
 Akhtar S. 2012. Psychoanalytic listening: Methods, limitations, and
innovations. New York, NY: Routledge / Taylor & Francis Group.
 Freud S. 1923. The ego and the id. New York: W. W. Norton & Co.
 Krebs C. 2013. Energetic kinesiology: Principles and practice.
Middletown, NY: Handspring Publishing.
 Stark M. 1999. Modes of therapeutic action: Enhancement of
knowledge, provision of experience, and engagement in relationship.
Northville, NJ: Jason Aronson.
 Winnicott DW. 1965. The maturational processes and the facilitating
environment. Madison, CT: International Universities Press.
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