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Martha Stark MD – 13 Nov 2022 – Part 1 – The Art and The Science of Interpretation.pptx

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.

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THE ART AND THE SCIENCE
OF INTERPRETATION
“LIKE THE MIDDLE GAME IN CHESS,
THERE IS NO PLAYBOOK TO GUIDE US”
PATRICIA COUGHLIN (2022)
MARTHA STARK MD
Faculty, Harvard Medical School
MarthaStarkMD @ HMS.Harvard.edu
Sunday / November 13, 2022
Baltimore Society for Psychoanalytic Studies
THANK YOU, CAMAY WOODALL 😊
© 2022 Martha Stark MD
1
MY PRESENTATION TODAY REPRESENTS
MY RATHER BOLD EFFORT TO CONCEPTUALIZE
A “BROAD STROKES FRAMEWORK” FOR
THIS “MIDDLE GAME” IN PSYCHODYNAMIC PSYCHOTHERAPY
IN ESSENCE, A “HOW – TO PLAYBOOK” FOR “WORKING THROUGH”
THE TRANSFORMATION OF “DEFENSE” INTO “ADAPTATION”
AT THE HEART OF WHICH ARE THE FOLLOWING FOUR ELEMENTS –
STAYING EVER ATTUNED TO THE LEVEL OF THE PATIENT’S ANXIETY
AND UNDERSTANDING THAT IT IS OK TO “LEVERAGE” IT
BY SOMETIMES INCREASING IT AND SOMETIMES DECREASING IT
AGAINST THE BACKDROP OF “EMPATHIC ATTUNEMENT” AND “SECURE ATTACHMENT,”
GENERATING “OPTIMAL STRESS”
– JUST THE RIGHT COMBINATION OF “CHALLENGE” AND “SUPPORT” –
TO “INCENTIVIZE” THE TRANSFORMATION OF “DEFENSE” INTO “ADAPTATION”
DEVELOPING COMFORT, THEREFORE, WITH
BOTH “CHALLENGING” AND “SUPPORTING”
THE PATIENT’S LONGSTANDING “UNHEALTHY DEFENSES”
APPRECIATING THE IMPORTANCE
OF “SUPPORTING” AND “CELEBRATING”
THE PATIENT’S HARD – EARNED “HEALTHIER ADAPTATIONS” 2
LEARNING OBJECTIVES
DESCRIBE THE “RATIONALE” FOR
“SOMETIMES BEING WITH THE PATIENT WHERE SHE IS”
– “HOMEOSTATIC ATTUNEMENT” – (SALMAN AKHTAR (2012))
AND “SOMETIMES DIRECTING HER ATTENTION TO ELSEWHERE”
– “DISRUPTIVE ATTUNEMENT” – (SALMAN AKHTAR (2012))
DESIGN A “MINIMALLY STRESSFUL” EMPATHIC INTERVENTION
THAT “SUPPORTS” THE DEFENSE
CONSTRUCT AN “OPTIMALLY STRESSFUL” CONFLICT STATEMENT
THAT ALTERNATELY “CHALLENGES” AND THEN “SUPPORTS” THE DEFENSE
DISTINGUISH BETWEEN “MINIMALLY STRESSFUL”
INTERVENTIONS THAT “SUPPORT” THE DEFENSE
AND “OPTIMALLY STRESSFUL” INTERVENTIONS
THAT BOTH “CHALLENGE” AND “SUPPORT” THE DEFENSE
CREATE A “CELEBRATORY” STATEMENT
THAT “SUPPORTS” THE NEWFOUND ADAPTATION
SUMMARIZE THE REASON THAT “OPTIMAL STRESS”
PROVIDES BOTH “IMPETUS” AND “OPPORTUNITY”
FOR “DEEP AND ENDURING PSYCHODYNAMIC CHANGE”
I HAVE NO FINANCIAL CONFLICTS OF INTEREST
OR, AS ERIC PLAKUN WOULD SAY,
PERHAPS I HAVE PSYCHOLOGICAL CONFLICTS BUT NO FINANCIAL CONFLICTS 3
2 – SLIDE OVERVIEW
THE “THERAPEUTIC PROVISION” OF “OPTIMAL STRESS”
NECESSARY IF “DEEP AND ENDURING PSYCHODYNAMIC CHANGE”
IS THE ULTIMATE GOAL OF TREATMENT
“CHALLENGE” THAT OFFERS “IMPETUS”
AND “SUPPORT” THAT OFFERS “OPPORTUNITY”
FOR TRANSFORMATION AND GROWTH
SUCH THAT
“RIGID DEFENSE” WILL BE REPLACED BY “MORE FLEXIBLE ADAPTATION”
“DEFENSIVE REACTION” WILL BE REPLACED BY “ADAPTIVE RESPONSE”
“SAME OLD, SAME OLD” NARRATIVES
WILL BE REPLACED BY “SOMETHING NEW, DIFFERENT, AND BETTER”
THE “DEFENSIVE NEED” FOR “OLD BAD”
WILL BE REPLACED BY THE “ADAPTIVE CAPACITY” FOR “NEW GOOD”
TWO PRIMARY INTERVENTIONS –
(1) “MINIMALLY STRESSFUL” “CLARIFYING” INTERVENTIONS
WHICH “PROVIDE SUPPORT” AND “SET THE STAGE”
(2) “OPTIMALLY STRESSFUL” “GROWTH – INCENTIVIZING” INTERVENTIONS
WHICH “PROVIDE CHALLENGE AND SUPPORT” AND “GENERATE THERAPEUTIC LEVERAGE”
THE CONSTRUCTION OF WHICH IS
BOTH A “SCIENCE” AND AN “ART” 4
5
THE “SCIENCE” AND THE “ART” OF DESIGNING
“MINIMALLY STRESSFUL” INTERVENTIONS
– THAT “PROVIDE SUPPORT” AND “SET THE STAGE” –
AND “OPTIMALLY STRESSFUL” INTERVENTIONS
– THAT “INCENTIVIZE DEEP AND ENDURING CHANGE” –
2 – SLIDE OVERVIEW
THE “GENERATION” OF ONGOING “HEALING CYCLES” OF
“DISRUPTION” AND “REPAIR”
WHICH WILL CREATE “HOMEOSTATIC IMBALANCE”
A STATE OF “DISEQUILIBRIUM”
THAT CANNOT, HOWEVER, BE TOLERATED FOR LONG
PROMPTING “RESTORATION OF EQUILIBRIUM”
– “RE – EQUILIBRATION” –
BUT EACH TIME
AT A NEW – MORE – EVOLVED – LEVEL OF
“HOMEOSTASIS” AND “ADAPTIVE CAPACITY”
AS A RESULT OF THE “SYNERGY” OF
THE THERAPIST’S “EXTERNAL SUPPORT”
AND THE PATIENT’S “INTERNAL RESOURCES”
THAT IS, THE PATIENT’S “UNDERLYING RESILIENCE,”
THE “WISDOM OF HER BODY” – WALTER B. CANNON (1932)
HER “INNATE STRIVING TOWARDS HEALTH,”
AND HER “INTRINSIC CAPACITY TO ADAPT TO (OPTIMAL) STRESS”
EVENTUAL “TRANSFORMATION” OF “PSYCHOLOGICAL RIGIDITY”
INTO “PSYCHOLOGICAL FLEXIBILITY”
REINFORCEMENT OF “INNATE RESILIENCE” WITH “ADAPTIVE RESILIENCE” 6
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  • 1. THE ART AND THE SCIENCE OF INTERPRETATION “LIKE THE MIDDLE GAME IN CHESS, THERE IS NO PLAYBOOK TO GUIDE US” PATRICIA COUGHLIN (2022) MARTHA STARK MD Faculty, Harvard Medical School MarthaStarkMD @ HMS.Harvard.edu Sunday / November 13, 2022 Baltimore Society for Psychoanalytic Studies THANK YOU, CAMAY WOODALL 😊 © 2022 Martha Stark MD 1
  • 2. MY PRESENTATION TODAY REPRESENTS MY RATHER BOLD EFFORT TO CONCEPTUALIZE A “BROAD STROKES FRAMEWORK” FOR THIS “MIDDLE GAME” IN PSYCHODYNAMIC PSYCHOTHERAPY IN ESSENCE, A “HOW – TO PLAYBOOK” FOR “WORKING THROUGH” THE TRANSFORMATION OF “DEFENSE” INTO “ADAPTATION” AT THE HEART OF WHICH ARE THE FOLLOWING FOUR ELEMENTS – STAYING EVER ATTUNED TO THE LEVEL OF THE PATIENT’S ANXIETY AND UNDERSTANDING THAT IT IS OK TO “LEVERAGE” IT BY SOMETIMES INCREASING IT AND SOMETIMES DECREASING IT AGAINST THE BACKDROP OF “EMPATHIC ATTUNEMENT” AND “SECURE ATTACHMENT,” GENERATING “OPTIMAL STRESS” – JUST THE RIGHT COMBINATION OF “CHALLENGE” AND “SUPPORT” – TO “INCENTIVIZE” THE TRANSFORMATION OF “DEFENSE” INTO “ADAPTATION” DEVELOPING COMFORT, THEREFORE, WITH BOTH “CHALLENGING” AND “SUPPORTING” THE PATIENT’S LONGSTANDING “UNHEALTHY DEFENSES” APPRECIATING THE IMPORTANCE OF “SUPPORTING” AND “CELEBRATING” THE PATIENT’S HARD – EARNED “HEALTHIER ADAPTATIONS” 2
  • 3. LEARNING OBJECTIVES DESCRIBE THE “RATIONALE” FOR “SOMETIMES BEING WITH THE PATIENT WHERE SHE IS” – “HOMEOSTATIC ATTUNEMENT” – (SALMAN AKHTAR (2012)) AND “SOMETIMES DIRECTING HER ATTENTION TO ELSEWHERE” – “DISRUPTIVE ATTUNEMENT” – (SALMAN AKHTAR (2012)) DESIGN A “MINIMALLY STRESSFUL” EMPATHIC INTERVENTION THAT “SUPPORTS” THE DEFENSE CONSTRUCT AN “OPTIMALLY STRESSFUL” CONFLICT STATEMENT THAT ALTERNATELY “CHALLENGES” AND THEN “SUPPORTS” THE DEFENSE DISTINGUISH BETWEEN “MINIMALLY STRESSFUL” INTERVENTIONS THAT “SUPPORT” THE DEFENSE AND “OPTIMALLY STRESSFUL” INTERVENTIONS THAT BOTH “CHALLENGE” AND “SUPPORT” THE DEFENSE CREATE A “CELEBRATORY” STATEMENT THAT “SUPPORTS” THE NEWFOUND ADAPTATION SUMMARIZE THE REASON THAT “OPTIMAL STRESS” PROVIDES BOTH “IMPETUS” AND “OPPORTUNITY” FOR “DEEP AND ENDURING PSYCHODYNAMIC CHANGE” I HAVE NO FINANCIAL CONFLICTS OF INTEREST OR, AS ERIC PLAKUN WOULD SAY, PERHAPS I HAVE PSYCHOLOGICAL CONFLICTS BUT NO FINANCIAL CONFLICTS 3
  • 4. 2 – SLIDE OVERVIEW THE “THERAPEUTIC PROVISION” OF “OPTIMAL STRESS” NECESSARY IF “DEEP AND ENDURING PSYCHODYNAMIC CHANGE” IS THE ULTIMATE GOAL OF TREATMENT “CHALLENGE” THAT OFFERS “IMPETUS” AND “SUPPORT” THAT OFFERS “OPPORTUNITY” FOR TRANSFORMATION AND GROWTH SUCH THAT “RIGID DEFENSE” WILL BE REPLACED BY “MORE FLEXIBLE ADAPTATION” “DEFENSIVE REACTION” WILL BE REPLACED BY “ADAPTIVE RESPONSE” “SAME OLD, SAME OLD” NARRATIVES WILL BE REPLACED BY “SOMETHING NEW, DIFFERENT, AND BETTER” THE “DEFENSIVE NEED” FOR “OLD BAD” WILL BE REPLACED BY THE “ADAPTIVE CAPACITY” FOR “NEW GOOD” TWO PRIMARY INTERVENTIONS – (1) “MINIMALLY STRESSFUL” “CLARIFYING” INTERVENTIONS WHICH “PROVIDE SUPPORT” AND “SET THE STAGE” (2) “OPTIMALLY STRESSFUL” “GROWTH – INCENTIVIZING” INTERVENTIONS WHICH “PROVIDE CHALLENGE AND SUPPORT” AND “GENERATE THERAPEUTIC LEVERAGE” THE CONSTRUCTION OF WHICH IS BOTH A “SCIENCE” AND AN “ART” 4
  • 5. 5 THE “SCIENCE” AND THE “ART” OF DESIGNING “MINIMALLY STRESSFUL” INTERVENTIONS – THAT “PROVIDE SUPPORT” AND “SET THE STAGE” – AND “OPTIMALLY STRESSFUL” INTERVENTIONS – THAT “INCENTIVIZE DEEP AND ENDURING CHANGE” –
  • 6. 2 – SLIDE OVERVIEW THE “GENERATION” OF ONGOING “HEALING CYCLES” OF “DISRUPTION” AND “REPAIR” WHICH WILL CREATE “HOMEOSTATIC IMBALANCE” A STATE OF “DISEQUILIBRIUM” THAT CANNOT, HOWEVER, BE TOLERATED FOR LONG PROMPTING “RESTORATION OF EQUILIBRIUM” – “RE – EQUILIBRATION” – BUT EACH TIME AT A NEW – MORE – EVOLVED – LEVEL OF “HOMEOSTASIS” AND “ADAPTIVE CAPACITY” AS A RESULT OF THE “SYNERGY” OF THE THERAPIST’S “EXTERNAL SUPPORT” AND THE PATIENT’S “INTERNAL RESOURCES” THAT IS, THE PATIENT’S “UNDERLYING RESILIENCE,” THE “WISDOM OF HER BODY” – WALTER B. CANNON (1932) HER “INNATE STRIVING TOWARDS HEALTH,” AND HER “INTRINSIC CAPACITY TO ADAPT TO (OPTIMAL) STRESS” EVENTUAL “TRANSFORMATION” OF “PSYCHOLOGICAL RIGIDITY” INTO “PSYCHOLOGICAL FLEXIBILITY” REINFORCEMENT OF “INNATE RESILIENCE” WITH “ADAPTIVE RESILIENCE” 6
  • 7. 7 “COME TO THE EDGE” AN EVOCATIVE POEM BY CHRISTOPHER LOGUE (1969) CAPTURES THE ESSENCE OF OUR CAPACITY TO ADAPT TO STRESS … WHEN PUSH COMES TO SHOVE
  • 8. 8 AND HERE WE SEE A SWEET LITTLE GIRL WITH ANGEL WINGS “What if I fall?” “Oh, but my darling, what if you fly?” A TENDER POEM BY e.h.
  • 9. “NUANCED PHRASEOLOGY” “YOU FIND YOURSELF” WHEN A PATIENT IS HAVING AN “ANXIETY – PROVOKING” FEELING BUT HAVING TROUBLE “ACKNOWLEDGING” IT THE THERAPIST CAN ALWAYS SAY SOMETHING LIKE “YOU FIND YOURSELF FEELING REALLY ANGRY RIGHT NOW.” INSTEAD OF “YOU ARE FEELING REALLY ANGRY RIGHT NOW.” THE THERAPIST IS INDIRECTLY LETTING THE PATIENT “OFF THE HOOK” A BIT BY INTIMATING THAT THE PATIENT’S ANGER MIGHT WELL BE SOMETHING THAT HAS COME UPON HER (TAKEN HER BY SURPRISE) AND SOMETHING FOR WHICH SHE IS, THEREFORE, NOT ENTIRELY RESPONSIBLE PARADOXICALLY, THE PATIENT MIGHT WELL THEN BE ABLE MORE EASILY TO “ACKNOWLEDGE” THE “ANXIETY – PROVOKING” FEELING “YOU WOULD RATHER NOT” / “YOU WOULD RATHER” BY SAYING THAT THE THERAPIST KNOWS THE PATIENT “WOULD RATHER NOT” OR “WOULD RATHER” BE FEELING WHAT SHE IS FEELING, THE THERAPIST IS INDIRECTLY HIGLIGHTING THE PATIENT’S “AGENCY” AND, HERE TOO, ATTEMPTING TO MAKE IT A BIT EASIER FOR THE PATIENT THEN TO “ACKNOWLEDGE” THE “ANXIETY – PROVOKING” FEELING “YOU WOULD PROBABLY RATHER NOT BE FEELING ANGRY BUT, EVEN SO, FIND YOURSELF FEELING REALLY ANGRY RIGHT NOW.” INSTEAD OF “YOU ARE FEELING REALLY ANGRY RIGHT NOW.” 9
  • 10. “FOR NOW” / “AT THIS POINT IN TIME” / “RIGHT NOW” / “AT THIS MOMENT” HERE THE THERAPIST IS USING A LITTLE BIT OF “SUBLIMINAL STIMULATION” TO HIGHLIGHT THE FACT THAT PERHAPS, AT SOME LATER POINT IN TIME, THE PATIENT MIGHT BE ABLE TO TAKE HEALTHY ACTION INSTEAD OF REMAINING STUCK “EVEN THOUGH YOU STOPPED LOVING YOUR WIFE YEARS AGO, AT THIS POINT IN TIME, YOU CAN’T IMAGINE EVER LEAVING HER.” INSTEAD OF “EVEN THOUGH YOU STOPPED LOVING YOUR WIFE YEARS AGO, YOU CAN’T IMAGINE EVER LEAVING HER.” “EVERY NOW AND THEN” / “SOMETIMES” / “PERHAPS” / “ON SOME LEVEL” / “A LITTLE” “MAYBE” / “POSSIBLY” / “AT TIMES” / “A PART OF YOU” / “SOME PART OF YOU” THE THERAPIST CAN USE “QUALIFIERS” TO “LIMIT” THE “INTENSITY” OF SOMETHING THAT IS “ANXIETY – PROVOKING,” THEREBY “PERHAPS” MAKING IT EASIER FOR THE PATIENT TO “ACKNOWLEDGE” “SOMETIMES YOU FIND YOURSELF FEELING ANGRY.” INSTEAD OF “YOU ARE FEELING ANGRY.” “A PART OF YOU IS ENRAGED.” INSTEAD OF “YOU ARE ENRAGED.” “EVERY NOW AND THEN PERHAPS YOU FIND YOURSELF FEELING A LITTLE ANGRY.” INSTEAD OF “YOU ARE FEELING ANGRY.” “I AM REALIZING” INSTEAD OF “I REALIZE” “I REALIZE” IS MORE “STATIC” – “I AM REALIZING” IS MORE “DYNAMIC” AND HIGHLIGHTS AN ONGOING “PROCESS” 10
  • 11. 1
  • 12. AT THE END OF THE DAY AND WHETHER EXPLICITLY OR IMPLICITLY “THERAPEUTIC MODALITIES” THAT HAVE “DEEP AND ENDURING PSYCHODYNAMIC CHANGE” AS THEIR ULTIMATE GOAL FOR EXAMPLE, PSYCHOANALYSIS AND OTHER “DEPTH PSYCHOLOGIES,” INCLUDING ACT, IFS, EMDR, ISTDP, AEDP, EFT, NLP, SENSORIMOTOR PSYCHOTHERAPY, SOMATIC EXPERIENCING, PSYCHOMOTOR PSYCHOTHERAPY, HYPNOTHERAPY, etc. MUST BE ABLE TO “CATALYZE” TRANSFORMATION OF (1) “PSYCHOLOGICAL RIGIDITY” INTO “PSYCHOLOGICAL FLEXIBILITY” – IN THE EVOCATIVE WORDS OF ACCEPTANCE AND COMMITMENT THERAPY (ACT) – (2) “LOW – LEVEL DEFENSE” INTO “HIGHER – LEVEL DEFENSE” OR “RIGID DEFENSE” INTO “MORE FLEXIBLE ADAPTATION” – IN THE MORE TRADITIONAL WORDS OF PSYCHOANALYSIS AND EGO PSYCHOLOGY – SUCH THAT THE PATIENT – WHATEVER HER “STARTING POINT” / WHATEVER HER “DIAGNOSIS” – WILL, OVER TIME, BECOME EVER – BETTER ABLE TO MANAGE THE MYRIAD “STRESSORS” IN HER LIFE – EVER – BETTER ABLE TO “RESPOND ADAPTIVELY” THAN TO “REACT DEFENSIVELY” – MY “PSYCHOANALYTICALLY INFORMED” PSYCHODYNAMIC SYNERGY PARADIGM (PSP) IS A “DEPTH PSYCHOLOGY” IN THIS TRADITION 12
  • 13. PLEASE NOTE I DO NOT “LIMIT” DEFENSES TO THE WELL – KNOWN AND MORE TRADITIONAL ONES AT ONE END OF THE CONTINUUM – “LOW – LEVEL DEFENSES” – FOR EXAMPLE, REPRESSION, REGRESSION, DENIAL, DISSOCIATION, DISPLACEMENT, PROJECTION, ISOLATION OF AFFECT, INTELLECTUALIZATION, AND REACTION FORMATION – AT THE OTHER END – “HIGHER – LEVEL OR MORE MATURE DEFENSES” THAT ARE “MORE ADAPTIVE AND SOCIALLY ACCEPTABLE” – FOR EXAMPLE, SUBLIMATION, HUMOR, ALTRUISM, HUMILITY, AND POSITIVE IDENTIFICATION – RATHER I DEFINE DEFENSES “MORE BROADLY” AS SPEAKING TO ANY OF THE “SELF – PROTECTIVE MECHANISMS” THAT WE MOBILIZE WHEN WE ARE MADE ANXIOUS IN THE FACE OF STRESSORS – WHETHER INTERNAL STRESSORS OR EXTERNAL ONES – AT ONE END OF THE CONTINUUM – WHAT HAPPENS “REFLEXIVELY” WHEN WE ARE CONFRONTED WITH STRESSORS THAT “OVERWHELM” US WITH ANXIETY – TO WHICH I REFER AS “LOW – LEVEL DEFENSES” OR “RIGID DEFENSES” AT THE OTHER END – WHAT HAPPENS “MORE REFLECTIVELY” WHEN WE ARE CONFRONTED WITH STRESSORS THAT WE ARE ABLE TO “TAKE IN OUR STRIDE” – TO WHICH I REFER AS “HIGHER – LEVEL DEFENSES” OR “MORE FLEXIBLE ADAPTATIONS” – AND, AGAIN, THE THERAPEUTIC GOAL WILL BE TO TRANSFORM THESE “MINDLESS DEFENSES” INTO “MORE MINDFUL ADAPTATIONS” 13
  • 14. WITH IT BEING UNDERSTOOD THAT THE RELATIONSHIP BETWEEN DEFENSE AND ADAPTATION IS A YIN – YANG RELATIONSHIP THESE ARE COMPLEMENTARY – NOT OPPOSING – FORCES FOR EXAMPLE, LIGHT CANNOT EXIST WITHOUT SHADOW ALTHOUGH DEFENSES MIGHT ONCE HAVE BEEN NECESSARY FOR THE PATIENT TO “SURVIVE,” AS DEFENSES BECOME “UPGRADED” TO ADAPTATIONS, THE PATIENT BECOMES BETTER ABLE TO “THRIVE” THE THERAPEUTIC ACTION IS INDEED DESIGNED TO TRANSFORM “SURVIVING” INTO “THRIVING” 14
  • 15. 15
  • 16. 16
  • 17. BRIEFLY THE PSYCHODYNAMIC SYNERGY PARADIGM FEATURES FIVE “MODES OF THERAPEUTIC ACTION” FIVE DIFFERENT APPROACHES TO “CATALYZING” TRANSFORMATION OF “PSYCHOLOGICAL RIGIDITY” INTO “PSYCHOLOGICAL FLEXIBILITY” 17
  • 18. THE PSYCHODYNAMIC SYNERGY PARADIGM (PSP) – A SYNERGISTIC APPROACH TO HEALING – FIVE INTERDEPENDENT AND MUTUALLY ENHANCING “MODES OF THERAPEUTIC ACTION” MODEL 1 – ENHANCEMENT OF KNOWLEDGE “WITHIN” THE INTERPRETIVE PERSPECTIVE OF CLASSICAL PSYCHOANALYSIS MODEL 2 – PROVISION OF EXPERIENCE “FOR” THE CORRECTIVE – PROVISION PERSPECTIVE OF SELF PSYCHOLOGY MODEL 3 – ENGAGEMENT IN RELATIONSHIP “WITH” THE INTERSUBJECTIVE PERSPECTVE OF CONTEMPORARY RELATIONAL THEORY MODEL 4 – FACILITATION OF SURRENDER “TO” AN EXISTENTIAL – HUMANISTIC APPROACH TO MENDING BROKENNESS AND EASING EXISTENTIAL ANGST MODEL 5 – ENVISIONING OF POSSIBILITIES “BEYOND” A QUANTUM – NEUROSCIENTIFIC APPROACH TO OVERCOMING ANALYSIS PARALYSIS 18
  • 19. THE PSYCHODYNAMIC SYNERGY PARADIGM (PSP) “STRUCTURAL CONFLICT” – CLASSICAL PSYCHOANALYTIC COGNITIVE “STRUCTURAL DEFICIT” – SELF PSYCHOLOGICAL AFFECTIVE “RELATIONAL CONFLICT” – CONTEMPORARY RELATIONAL RELATIONAL “RELATIONAL DEFICIT” – EXISTENTIAL – HUMANISTIC EXISTENTIAL “STRUCTURAL DISSOCIATION” – QUANTUM – NEUROSCIENTIFIC CONSTRUCTIVIST ALL FIVE PSP MODELS CAPITALIZE UPON THE “THERAPEUTIC PROVISION” OF “OPTIMAL STRESS” TO ADVANCE THE PATIENT FROM “RIGID DEFENSE” TO “MORE FLEXIBLE ADAPTATION” WITH AN EYE TO INCENTIVIZING “DEEP AND SUSTAINED PSYCHODYNAMIC CHANGE” 19
  • 20. 8
  • 21. OVER THE COURSE OF A THERAPY HOUR PSP THERAPISTS WILL FIND THEMSELVES SHIFTING BACK AND FORTH FROM ONE MODEL TO THE NEXT BASED UPON WHAT THEY “INTUITIVELY SENSE” IS THE “POINT OF EMOTIONAL URGENCY” FOR THE PATIENT – THAT IS, WHAT IS MOST “EMOTIONALLY FRAUGHT” FOR HER IN THE MOMENT – WHETHER HER “RESISTANCE” TO GAINING INSIGHT INTO WHAT UNDERLIES HER INTERNAL CONFLICTEDNESS (MODEL 1 – STRUCTURAL CONFLICT) HER “RELENTLESS PURSUIT” OF THE UNATTAINABLE IN A DESPERATE ATTEMPT TO FILL IN FOR MISSING PIECES (MODEL 2 – STRUCTURAL DEFICIT) HER “RE – ENACTMENT” OF UNMASTERED EARLY – ON RELATIONAL TRAUMAS ON THE STAGE OF HER LIFE (MODEL 3 – RELATIONAL CONFLICT) STEPHEN MITCHELL (1988) HER “RETREAT” FROM THE WORLD AND “RELENTLESS DESPAIR” (MODEL 4 – RELATIONAL DEFICIT) OR HER “REFRACTORY INERTIA,” “RELENTLESS INACTION,” AND “ROOTEDNESS TO THE SPOT” (MODEL 5 – “STRUCTURAL DISSOCIATION” (JANINA FISHER (2017)) / “NEURAL ENTRENCHMENT” / “QUANTUM ENTANGLEMENT”) 21
  • 22. MODEL 1 – “STRUCTURAL CONFLICT” THE INTERPRETIVE PERSPECTIVE OF CLASSICAL PSYCHOANALYSIS NEUROTIC CONFLICTEDNESS MODEL 2 – “STRUCTURAL DEFICIT” THE CORRECTIVE – PROVISION PERSPECTIVE OF SELF PSYCHOLOGY NARCISSISTIC VULNERABILITY / WOUNDEDNESS / ENTITLEMENT MODEL 3 – “RELATIONAL CONFLICT” THE INTERSUBJECTIVE PERSPECTVE OF CONTEMPORARY RELATIONAL THEORY NOXIOUS RELATEDNESS MODEL 4 – “RELATIONAL DEFICIT” AN EXISTENTIAL – HUMANISTIC APPROACH TO MENDING BROKENNESS AND EASING EXISTENTIAL ANGST NONRELATEDNESS MODEL 5 – “STRUCTURAL DISSOCIATION” A QUANTUM – NEUROSCIENTIFIC APPROACH TO OVERCOMING INERTIA NONACTION IN TRUTH, WE ARE ALL A LITTLE NEUROTIC, NARCISSISTIC, NOXIOUS IN OUR RELATEDNESS, NONRELATED, AND NONACTUALIZED 22
  • 23. 23
  • 24. AGAIN, FIVE PSYCHODYNAMIC SYNERGY PARADIGM (PSP) “MODELS” FIVE INTERDEPENDENT “MODES OF THERAPEUTIC ACTION” FIVE “OPTIMALLY STRESSFUL” “GROWTH – INCENTIVIZING” INTERVENTIONS – ALL OF WHICH TARGET THE PATIENT’S “DEFENSES” IN ORDER TO ADVANCE HER FROM “PSYCHOLOGICAL RIGIDITY” TO “PSYCHOLOGICAL FLEXIBILITY” – MODEL 1 – COGNITIVE CONFLICT STATEMENTS – FROM “RESISTANCE” TO “AWARENESS” – MODEL 2 – AFFECTIVE DISILLUSIONMENT STATEMENTS – FROM “RELENTLESS HOPE” TO “ACCEPTANCE” – MODEL 3 – RELATIONAL ACCOUNTABILITY STATEMENTS CONTAINING STATEMENTS THE “RULE OF THREE” – FROM “RE – ENACTMENT” TO “ACCOUNTABILITY” – MODEL 4 – EXISTENTIAL FACILITATION STATEMENTS – FROM “RELATIONAL ABSENCE” TO “AUTHENTIC PRESENCE” – MODEL 5 – CONSTRUCTIVIST QUANTUM DISENTANGLEMENT STATEMENTS – FROM “REFRACTORY INERTIA” / “ANALYSIS PARALYSIS” TO “ACTION” AND “ACTUALIZATION OF POTENTIAL” – 24
  • 25. BUT OUR PRIMARY FOCUS TODAY WILL BE ON THE THREE MAJOR PSYCHOANALYTIC SCHOOLS – KNOWLEDGE, EXPERIENCE, AND RELATIONSHIP – THE FIRST OF WHICH IS CLASSICAL THE SECOND AND THIRD OF WHICH ARE MORE CONTEMPORARY MODEL 1 THE INTERPRETIVE PERSPECTIVE OF CLASSICAL PSYCHOANALYSIS – SIGMUND FREUD / ANNA FREUD / HEINZ HARTMANN / DAVID RAPAPORT – MODEL 2 THE CORRECTIVE – PROVISION PERSPECTIVE OF SELF PSYCHOLOGY AND THOSE OBJECT RELATIONS THEORIES EMPHASIZING INTERNAL “ABSENCE OF GOOD” – RESULTING FROM “RELATIONAL DEPRIVATION AND NEGLECT” – – HEINZ KOHUT / MICHAEL BALINT / PAUL AND ANNA ORNSTEIN – MODEL 3 THE INTERSUBJECTIVE PERSPECTIVE OF CONTEMPORARY RELATIONAL THEORY AND THOSE OBJECT RELATIONS THEORIES EMPHASIZING INTERNAL “PRESENCE OF BAD” – RESULTING FROM “RELATIONAL TRAUMA AND ABUSE” – – STEPHEN MITCHELL / JAY GREENBERG / JESSICA BENJAMIN / JEAN BAKER MILLER – 25
  • 26. BY WAY OF DEMONSTRATION (AND TO WHET YOUR APPETITES A BIT) OPTIMALLY STRESSFUL – MODEL 1 – “CONFLICT STATEMENTS” ARE DESIGNED TO RESOLVE “INTERNAL CONFLICT” BY FOSTERING “AWARENESS” – THEY ALTERNATELY INCREASE ANXIETY AND THEN DECREASE IT – “YOU KNOW THAT YOUR MOTHER WILL NEVER APOLOGIZE, BUT YOU FIND YOURSELF CONTINUING TO WISH THAT SHE WOULD.” “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. YOU’VE SIMPLY BEEN HURT TOO MANY TIMES IN THE PAST.” OPTIMALLY STRESSFUL – MODEL 2 – “DISILLUSIONMENT STATEMENTS” ARE DESIGNED TO FACILITATE “GRIEVING” AND ULTIMATELY “ACCEPTANCE” – THEY TOO ALTERNATELY INCREASE ANXIETY AND THEN DECREASE IT – “YOU HAD SO HOPED THAT I WOULD TELL YOU WHAT TO DO, BUT YOU ARE BEGINNING TO REALIZE THAT I DON’T SIMPLY GIVE YOU ANSWERS – AND IT INFURIATES YOU.” “YOU HAD SO HOPED THAT YOUR MOTHER WOULD APOLOGIZE, BUT YOU ARE BEGINNING TO ACCEPT THAT SHE SIMPLY DOES NOT HOLD HERSELF ACCOUNTABLE AND PROBABLY NEVER WILL – WHICH IS BOTH ENRAGING AND DEVASTATING.” 26
  • 27. OPTIMALLY STRESSFUL – MODEL 3 – “ACCOUNTABILITY STATEMENTS” THE “RULE OF THREE” IS DESIGNED TO INSIST THAT THE “RE – ENACTING” PATIENT TAKE RESPONSIBILITY FOR HER “PROVOCATIVE ENACTMENTS” MORE SPECIFICALLY, THE “RULE OF THREE” BECOMES RELEVANT WHENEVER A PATIENT SAYS OR DOES SOMETHING THAT THE THERAPIST EXPERIENCES AS PROVOCATIVE – A “PROVOCATIVE ENACTMENT” – IN ORDER TO COMPEL THE PATIENT TO TAKE OWNERSHIP OF WHAT SHE IS “PLAYING OUT” ON THE STAGE OF THE TREATMENT, THE THERAPIST CAN ASK THE PATIENT ANY OF THE FOLLOWING – “HOW ARE YOU HOPING THAT I WILL RESPOND?” WHICH ADDRESSES THE ID “HOW ARE YOU FEARING THAT I MIGHT RESPOND?” WHICH ADDRESSES THE SUPEREGO “HOW ARE YOU IMAGINING THAT I WILL RESPOND?” WHICH ADDRESSES THE EXECUTIVE FUNCTIONING OF THE EGO – THE DORSOLATERAL PREFRONTAL CORTEX (DLPFC) OF THE BRAIN – ALL THREE “RELATIONAL INTERVENTIONS” DEMAND OF THE PATIENT THAT SHE MAKE HER “INTERPERSONAL INTENTIONS” MORE EXPLICIT 27
  • 28. OPTIMALLY STRESSFUL – MODEL 3 – “ACCOUNTABILITY STATEMENTS” CAN BE INTRODUCED IN ANY OF THE FOLLOWING WAYS – “IT OCCURS TO ME THAT, BY WAY OF YOUR BEHAVIOR IN HERE WITH ME, YOU ARE HELPING ME TO UNDERSTAND SOMETHING THAT I HAD NEVER BEFORE ENTIRELY UNDERSTOOD … ” “I THINK THAT YOU HAVE BEEN TRYING TO COMMUNICATE SOMETHING IMPORTANT TO ME THAT I HAD BEEN REFUSING TO SEE … ” “I WONDER IF MY DIFFICULTY APPRECIATING JUST HOW DESPERATE YOU WERE MADE YOU FEEL THAT YOU HAD TO DO SOMETHING DRAMATIC IN ORDER TO GET MY ATTENTION … ” DON’T HESITATE TO ”THROW YOURSELF UNDER THE BUS” 28
  • 29. TO “LAY THE GROUNDWORK” FOR THE INTRODUCTION OF THESE “ANXIETY – PROVOKING” BUT “GROWTH – INCENTIVIZING” INTERVENTIONS THE THERAPIST CAN CALL UPON ANY NUMBER OF “MINIMALLY STRESSFUL” “CLARIFYING” INTERVENTIONS THAT WILL NOT ONLY “PROVIDE SUPPORT” BUT ALSO “MOVE THE BALL FORWARD” A BIT BY GENTLY “TEASING OUT” SOME OF THE “LESS – THAN – HEALTHY” “RECURRING THEMES, PATTERNS, AND REPETITIONS” IN THE PATIENT’S LIFE INTEGRATION STATEMENTS PATH – OF – LEAST – RESISTANCE STATEMENTS DAMAGED – FOR – LIFE STATEMENTS COMPENSATION STATEMENTS ENTITLEMENT STATEMENTS MASOCHISM STATEMENTS SADISM STATEMENTS PARADOXICAL INTERVENTIONS EMPATHIC STATEMENTS 29
  • 30. IN ESSENCE “MINIMALLY STRESSFUL” “CLARIFYING” INTERVENTIONS “SUPPORT” BY NONJUDGMENTALLY “SPOTLIGHTING” SOME OF THE “REALLY DIFFICULT TRUTHS” IN THE PATIENT’S LIFE – THE “LESS – THAN – HEALTHY” AND “USUALLY – DEFENSIVE” “RECURRING THEMES, PATTERNS, AND REPETITIONS” IN THE PATIENT’S LIFE OF WHICH SHE IS “AT LEAST PARTIALLY” AWARE BUT ABOUT WHICH SHE IS “NOT PARTICULARLY” ANXIOUS – “JOINING THROUGH THE TRUTH” TERRY REAL (2020) THESE “CLARIFYING” INTERVENTIONS WHICH “SUPPORT” BY “BEING WITH THE PATIENT WHERE THE PATIENT IS” “SET THE STAGE” FOR THE INTRODUCTION OF “OPTIMALLY STRESSFUL” “GROWTH – INCENTIVIZING” INTERVENTIONS WHICH WILL BOTH “CHALLENGE” BY “DIRECTING THE PATIENT’S ATTENTION TO WHERE THE THERAPIST WANTS HER TO GO” AND “SUPPORT” BY “BEING WITH THE PATIENT WHERE SHE IS” THEREBY “TARGETING” DEFENSES OF WHICH THE PATIENT IS FULLY AWARE, PARTIALLY AWARE, AND NOT AWARE – WHICH (HOPEFULLY) WILL MAKE HER “OPTIMALLY” ANXIOUS – 30
  • 32. BY WAY OF DEMONSTRATION (AND TO WHET YOUR APPETITES A BIT) “MINIMALLY STRESSFUL” “CLARIFYING” INTERVENTIONS INTEGRATION STATEMENTS FOR THOSE PATIENTS WHO ARE HAVING TROUBLE HOLDING IN MIND SIMULTANEOUSLY BOTH THE “GOOD” AND THE “BAD” ASPECTS OF THEIR EXPERIENCE IN OTHER WORDS PATIENTS WITH TENUOUSLY ESTABLISHED “LIBIDINAL OBJECT CONSTANCY” / “EVOCATIVE MEMORY CAPACITY” “HARD TO REMEMBER” / “HARD TO IMAGINE” “WHEN YOU’RE FEELING THIS BAD, IT’S HARD TO REMEMBER THAT YOU HAD EVER FELT GOOD AND IT’S HARD TO IMAGINE THAT YOU COULD EVER FEEL GOOD AGAIN.” “WHEN YOUR HEART IS BREAKING AS IT IS NOW, YOU CAN’T IMAGINE THAT YOU COULD EVER DARE TO TRUST AGAIN.” “WHEN YOU’RE FEELING THIS ANGRY AT ME, IT’S HARD TO REMEMBER THAT YOU USED TO FEEL GOOD ABOUT ME AND EVEN LOOKED FORWARD TO COMING.” “WHEN YOU FEEL THIS DESPAIRING, YOU CAN’T REMEMBER EVER HAVING HAD ANY HOPE WHATSOEVER.” 32
  • 33. ALSO BY WAY OF DEMONSTRATION (AND TO WHET YOUR APPETITES A BIT) “MINIMALLY STRESSFUL” “CLARIFYING” INTERVENTIONS PATH – OF – LEAST – RESISTANCE STATEMENTS FOR THOSE PATIENTS WHO ARE “REACTING DEFENSIVELY” RATHER THAN “RESPONDING ADAPTIVELY” EASIER TO “REACT DEFENSIVELY” THAN TO “RESPOND ADAPTIVELY” “IT’S EASIER TO GIVE UP THAN TO KEEP FIGHTING FOR WHAT YOU REALLY BELIEVE IN.” “IT’S EASIER TO EXPERIENCE YOURSELF AS DISEMPOWERED THAN TO TAKE OWNERSHIP OF THE POWER AND AGENCY THAT YOU ACTUALLY DO HAVE.” “IT’S EASIER TO EXPERIENCE YOURSELF AS HAVING NO ACCOUNTABILITY THAN TO TAKE RESPONSIBILITY FOR YOUR LIFE.” “IT’S EASIER TO HOLD ON TO THE HOPE THAT YOUR HUSBAND MIGHT SOMEDAY CHANGE THAN TO CONFRONT THE REALITY THAT HE PROBABLY NEVER WILL.” 33
  • 34. 34
  • 35. WHATEVER THE “STARTING POINT” / WHATEVER THE “DIAGNOSIS” FROM “PSYCHOLOGICAL RIGIDITY” TO “PSYCHOLOGICAL FLEXIBILITY” FROM “MINDLESS AND REFLEXIVE DEFENSE” TO “MORE MINDFUL AND REFLECTIVE ADAPTATION” FROM “DEFENSE” WHEN “LIFE STRESSORS” CANNOT BE EFFECTIVELY MANAGED TO “ADAPTATION” WHEN “LIFE STRESSORS” CAN BE MORE EASILY TAKEN IN STRIDE THE ULTIMATE GOAL OF TREATMENT IN “DEPTH PSYCHOLOGIES” IS TO FACILITATE DEVELOPMENT OF EVER – MORE “RESILIENCE,” “ADAPTABILITY,” “FLEXIBILITY,” “VARIABILITY,” “FLUIDITY OF FLOW,” AND TOM BRADY’S “PLIABILITY” FROM “INNATE RESILIENCE” TO “ADAPTIVE RESILIENCE” PLEASE NOTE THAT THE GOAL IS NOT SPECIFICALLY TO TARGET SYMPTOMS 35
  • 36. WE CANNOT AVOID SUFFERING BUT WE CAN CHOOSE HOW WE COPE WITH IT, FIND MEANING IN IT, AND MOVE FORWARD WITH RENEWED PURPOSE EXISTENTIAL PSYCHIATRIST VIKTOR FRANKL IS REPUTED TO HAVE WRITTEN “BETWEEN STIMULUS AND RESPONSE IS A SPACE. IN THAT SPACE IS OUR POWER TO CHOOSE OUR RESPONSE. IN OUR RESPONSE LIES OUR GROWTH AND OUR FREEDOM.” AS THIS APPLIES TO THE CLINICAL SITUATION IN THAT SPACE IS OUR POWER EITHER TO “REACT DEFENSIVELY” – BY WALLOWING IN OUR DESPAIR AND ABNEGATING RESPONSIBILITY FOR OUR LIVES – OR TO “RESPOND ADAPTIVELY” – BY ACKNOWLEDGING THAT, DESPITE OUR DESPAIR, FROM THIS POINT FORWARD THE MEANING WE MAKE OF OUR LIVES IS ENTIRELY UP TO US – NOT ONLY DO WE HAVE THE FREEDOM TO CREATE THAT MEANING BUT WE ALSO HAVE THE RESPONSIBILITY TO DO SO IT HAS BEEN SUGGESETED THAT 10% OF WHAT HAPPENS TO US IS “LIFE” BUT 90% IS HOW WE “REACT” OR “RESPOND” TO IT 36
  • 37. 37
  • 38. AGAIN AND WHETHER EXPLICITLY OR IMPLICITLY “THERAPEUTIC MODALITIES” DESIGNED TO “CATALYZE” “DEEP AND ENDURING PSYCHODYNAMIC CHANGE” WILL ULTIMATELY ADVANCE THE PATIENT – BY WAY OF ONGOING “HEALING CYCLES” OF “DISRUPTION” AND “REPAIR” – – RARELY “STRAIGHT – LINE” PROGRESSION – FROM “PSYCHOLOGICAL RIGIDITY” TO “PSYCHOLOGICAL FLEXIBILITY” FROM MINDLESS TO MORE MINDFUL FROM THOUGHTLESS TO MORE THOUGHTFUL FROM REFLEXIVE TO MORE REFLECTIVE FROM AUTOMATIC TO MORE INTENTIONAL FROM DYSFUNCTIONAL TO MORE FUNCTIONAL FROM SUBCONSCIOUS TO MORE CONSCIOUS FROM SUBCORTICAL TO MORE CORTICAL FROM DORSAL VAGAL SHUTDOWN TO VENTRAL VAGAL SOCIAL ENGAGEMENT STEPHEN PORGES (2017) FROM SIMPLY SURVIVING TO ACTUALLY THRIVING FROM LESS HEALTHY TO MORE HEALTHY FROM LESS EVOLVED TO MORE EVOLVED FROM “RIGID DEFENSE” TO “MORE FLEXIBLE ADAPTATION” FROM “DEFENSE” TO “ADAPTATION” 38
  • 39. 39 LIFE IS ABOUT NOT “DEFENSIVELY” WAITING FOR THE STORM TO PASS BUT “ADAPTIVELY” LEARNING TO DANCE IN THE RAIN
  • 40. AS WE SHALL SOON SEE THE PSP “WORKING THROUGH PROTOCOL” WILL INVOLVE “WORKING THROUGH GROWTH – IMPEDING RIGIDITY” 📕📕 SUCH THAT “DEFENSIVE NEED” WILL BE “TAMED” AND “ADAPTIVE CAPACITY” “STRENGTHENED” – “TAME” THE “NEED” AND “STRENGTHEN” THE “CAPACITY” – WHICH HARKENS BACK TO FREUD’S WELL – KNOWN GOAL OF “WORKING THROUGH” IN ORDER TO “TAME THE ID” AND “STRENGTHEN THE EGO” BY WAY OF EXAMPLES TAME THE “DEFENSIVE NEED” FOR ILLUSION AND RELENTLESS HOPE AND STRENGTHEN THE “ADAPTIVE CAPACITY” FOR ACCEPTANCE AND REALISTIC HOPE TAME THE “DEFENSIVE NEED” TO EXPERIENCE THE WORLD AS ALWAYS VICTIMIZING AND STRENGTHEN THE “ADAPTIVE CAPACITY” TO TAKE OWNERSHIP OF BEING SOMETIMES PROVOCATIVE TAME THE “DEFENSIVE NEED” TO RETREAT SELF – PROTECTIVELY FROM THE WORLD AND STRENGTHEN THE “ADAPTIVE CAPACITY” TO VENTURE FORTH EVEN SO TAME THE “DEFENSIVE NEED” TO KEEP DOING SAME OLD, SAME OLD AND STRENGTHEN THE “ADAPTIVE CAPACITY” TO ENVISION SOMETHING NEW, DIFFERENT, AND BETTER TAME THE “DEFENSIVE NEED” TO WHINE AND COMPLAIN ABOUT LIFE’S INJUSTICES AND STRENGTHEN THE “ADAPTIVE CAPACITY” TO APPRECIATE THE GOOD THAT LIFE DOES HAVE TO OFFER 40
  • 41. AGAIN ON THE ONE HAND, DEFENSES ARE MOBILIZED WHEN WE ARE CONFRONTED WITH SITUATIONS THAT OVERWHELM US WITH ANXIETY ON THE OTHER HAND, ADAPTATIONS BECOME POSSIBLE WHEN WE HAVE BUILT UP ENOUGH RESILIENCE THAT WE CAN TAKE THAT ANXIETY IN OUR STRIDE FROM “LESS – EVOLVED NEED” TO “MORE – EVOLVED CAPACITY” FROM “DEFENSIVE NEED” TO “ADAPTIVE CAPACITY” FROM THE DEFENSIVE NEED FOR IMMEDIATE GRATIFICATION TO THE ADAPTIVE CAPACITY TO TOLERATE DELAY FROM THE DEFENSIVE NEED FOR PERFECTION TO THE ADAPTIVE CAPACITY TO TOLERATE IMPERFECTION FROM THE DEFENSIVE NEED FOR EXTERNAL REGULATION OF THE SELF TO THE ADAPTIVE CAPACITY FOR INTERNAL SELF – REGULATION FROM THE DEFENSIVE NEED TO HOLD ON TO THE ADAPTIVE CAPACITY TO LET GO 41
  • 42. FROM EXTERNALIZING BLAME TO TAKING OWNERSHIP FROM WHINING AND COMPLAINING TO BECOMING PROACTIVE FROM DENYING TO CONFRONTING HEAD – ON FROM BEING CRITICAL TO BECOMING MORE COMPASSIONATE FROM DISSOCIATING TO BECOMING MORE PRESENT FROM FEELING VICTIMIZED TO TAKING RESPONSIBILITY FROM CURSING THE DARKNESS TO LIGHTING A CANDLE FROM BEING DISEMPOWERED AND CONFINED TO BEING MORE EMPOWERED AND EXPANSIVE FROM BEING JAMMED UP TO MOBILIZING ONE’S ENERGIES IN THE PURSUIT OF ONE’S DREAMS FROM “DEFENSIVE REACTION” TO “ADAPTIVE RESPONSE” FROM “OUTDATED NARRATIVES” TO “UPDATED NARRATIVES” ABOUT SELF, OTHERS, AND THE WORLD FROM “SAME OLD, SAME OLD” TO “SOMETHING NEW, DIFFERENT, AND BETTER” 42
  • 43. 43 When I let go of the SAME OLD SAME OLD that I am, I become the SOMETHING NEW DIFFERENT AND BETTER that I might be.
  • 44. JON FREDERICKSON (2017) OFFERS DEFENSES ARE THE LIES WE TELL OURSELVES TO AVOID FEELING THE PAIN IN OUR LIVES ADAPTATIONS ARE THE ADJUSTMENTS WE EMBRACE TO MAKE THE BEST OF (BEST OF, BEST OF) A BAD SITUATION (BAD SITUATION) GLADYS KNIGHT & THE PIPS (1973) / MARTHA STARK (2022) EITHER WE – MADE ANXIOUS – “REACT” TO STRESSORS BY “DEFENDING” RESISTANCE (MODEL 1), RELENTLESS HOPE (MODEL 2), RE – ENACTMENT (MODEL 3) OR WE – MORE RESILIENT – “RESPOND” TO STRESSORS BY “ADAPTING” AWARENESS (MODEL 1), ACCEPTANCE (MODEL 2), ACCOUNTABILITY (MODEL 3) ALL THREE “Rs” ARE DEFENSES MOBILIZED TO AVOID DEALING WITH “PAINFUL TRUTHS” ABOUT THE SELF, ONE’S OBJECTS, AND THE SELF – IN – RELATION (OR THE RELATIONAL SELF) ALL THREE “As” ARE ADAPTATIONS ACCEPTED AS NECESSARY IN ORDER EFFECTIVELY TO MANAGE THE “STRESS OF LIFE” HANS SELYE (1978) 44
  • 46. IN ESSENCE ADAPTATION IS A STORY ABOUT MAKING A VIRTUE OUT OF NECESSITY  46
  • 47. 47
  • 48. “CONTROLLED DAMAGE” TO THE “BODY” IN ORDER TO “JUMP – START HEALING” 48
  • 49. IN THE PHYSIOLOGICAL REALM SUPERIMPOSING AN ACUTE PHYSICAL INJURY ON TOP OF A CHRONIC ONE IS SOMETIMES EXACTLY WHAT THE BODY NEEDS IN ORDER TO HEAL IN ESSENCE “CONTROLLED DAMAGE” TO “PROVOKE HEALING” BY WAY OF EXAMPLES HIGH – INTENSITY INTERVAL TRAINING (HIIT) / INTERMITTENT FASTING ISCHEMIC PRECONDITIONING / INTERMITTENT HYPOXIC TRAINING / HYPERBARIC OXYGEN HOMEOPATHIC REMEDIES / VACCINES AND OTHER IMMUNOTHERAPIES / MEDICINAL PLANTS DERMABRASION / FRAXEL LASER TREATMENTS / RADIOFREQUENCY MICRONEEDLING PLATELET – RICH PLASMA (PRP) / PLATELET – RICH FIBRIN (PRF) VAMPIRE GUM REJUVENATION / BOTOX / STEM CELL FACELIFTS ELECTROCONVULSIVE THERAPY (ECT) / TRANSCRANIAL MAGNETIC STIMULATION (TMS) CARDIAC DEFIBRILLATION PULSE WAVE THERAPIES (SHOCKWAVE THERAPY AND SOUND THERAPY) ACUPUNCTURE / ACUPRESSURE / CUPPING RED LIGHT THERAPY / INFRARED SAUNAS / CRYOTHERAPY BRAIN TEASERS AND MENTAL EXERCISES IT IS BECAUSE OF “INNATE RESILIENCE” THAT “OPTIMALLY CHALLENGING” A “COMPROMISED BODILY SYSTEM” WILL JUMP – START “ADAPTIVE RECOVERY” AND “REINFORCE” THE SYSTEM’S UNDERLYING HEALTH 49
  • 50. IN OTHER WORDS IF THE SYSTEM HAS ENOUGH “INNATE – UNDERLYING – RESILIENCE” “MODERATE AMOUNTS OF STRESS” WILL “PROVOKE MODEST OVERCOMPENSATION” “INTERMITTENT EXPOSURES” WILL “PROMPT ADAPTATION” “MILD AGGRAVATIONS” WILL “STIMULATE THE HEALING CASCADE” ALL OF WHICH STRESSORS ARE, IN ESSENCE, ACTIVATING THE “HEALING RESPONSE” / THE “HORMETIC RESPONSE” “ADAPTIVE RECOVERY” IS THE MANIFESTATION OF A “HORMETIC – BIPHASIC – DOSE – RESPONSE” AND SPEAKS TO THE SYSTEM’S ABILITY TO “ADAPT TO (OPTIMAL) STRESS” HORMESIS IS A LITTLE – KNOWN BUT ALMOST UNIVERSAL DOSE – RESPONSE PHENOMENON CHARACTERIZED BY “BENEFIT” ALONG ONE PORTION OF THE DOSE – RESPONSE CURVE AND “COST” ALONG ANOTHER IN THE WELL – KNOWN WORDS OF PARACELSUS (1999) – “THE DIFFERENCE BETWEEN A MEDICINE AND A POISON IS THE DOSAGE THEREOF.” CERTAINLY RELEVANT FOR “DOSES OF STRESS” IN OTHER WORDS, THE “REACTION / RESPONSE TO STRESS” DOES NOT DEMONSTRATE “STRAIGHT – LINE PROGRESSION” 50
  • 51. MORE SPECIFICALLY THE GOLDILOCKS PRINCIPLE TOO MUCH CHALLENGE WILL OVERWHELM AND PLUMMET THE SYSTEM INTO FURTHER DECLINE BECAUSE IT WILL BE “TOO MUCH” TO BE PROCESSED, INTEGRATED, AND ADAPTED TO TRAUMATIC STRESS TOO LITTLE CHALLENGE WILL OFFER “TOO LITTLE” IMPETUS AND OPPORTUNITY FOR TRANSFORMATION AND GROWTH, SERVING INSTEAD SIMPLY TO REINFORCE THE – DYSFUNCTIONAL – STATUS QUO BUT JUST THE RIGHT AMOUNT OF CHALLENGE WILL PROVIDE “JUST THE RIGHT AMOUNT” OF “LEVERAGE” NEEDED TO PROVOKE – AFTER INITIAL DISRUPTION – EVENTUAL RE – EQUILIBRATION AT A HIGHER LEVEL OF INTEGRATION, FUNCTIONALITY, AND ADAPTIVE CAPACITY OPTIMAL – NONTRAUMATIC – STRESS 51
  • 52. 4
  • 53. THE “THERAPEUTIC USE” OF “OPTIMAL STRESS” TO “PROVOKE RECOVERY” DEPRIVING ONESELF OF HALF A NIGHT’S SLEEP ONCE A WEEK PREFERABLY THE SECOND HALF OF THE NIGHT (FOR EXAMPLE, FROM 3 TO 7 AM) CAN PRODUCE A RAPID, EVEN IF SHORT – LIVED, RESTABILIZATION OF MOOD AND RECOVERY FROM DEPRESSION THE “STRESS” OF INTERRUPTING NORMAL SLEEP PATTERNS MAY “RESYNCHRONIZE DISTURBED CIRCADIAN RHYTHMS” LEIBENLUFT AND WEHR (1992) INTERMITTENT FASTING A 36 – HOUR WATER FAST ONCE A WEEK (FOR EXAMPLE, FROM AFTER DINNER ON MONDAY EVENING TO BEFORE BREAKFAST ON WEDNESDAY MORNING) CAN SO SIGNIFICANTLY REDUCE THE TOTAL BODY BURDEN THAT MENTAL CLARITY AND FOCUS CAN BE IMPROVED DRAMATICALLY AND A SENSE OF OVERALL WELL – BEING RESTORED INTERMITTENT FASTING IS ALSO ASSOCIATED WITH INCREASED LEVELS OF BRAIN – DERIVED NEUROTROPHIC FACTOR (BDNF) DEPLETED LEVELS OF WHICH ARE THOUGHT TO BE ASSOCIATED WITH DEPRESSION MARK MATTSON (2015) PARENTHETICALLY, THE ONLY TYPE OF “CALORIE – RESTRICTING” DIET THAT DOES NOT SLOW DOWN YOUR METABOLISM IS INTERMITTENT FASTING 53
  • 54. “CREATING INJURY” TO “STIMULATE HEALING” PROLOTHERAPY A HIGHLY EFFECTIVE TREATMENT FOR CHRONIC LIGAMENT AND TENDON WEAKNESS IT INVOLVES INJECTING A MILDLY IRRITATING AQUEOUS SOLUTION – FOR EXAMPLE, DEXTROSE, WATER, AND A LOCAL ANESTHETIC (LIDOCAINE) – INTO THE AFFECTED LIGAMENT OR TENDON IN ORDER TO INDUCE A MILD INFLAMMATORY REACTION IN ESSENCE, IT WILL “TURN ON” THE BODY’S HEALING PROCESS AND RESULT ULTIMATELY IN STRENGTHENING OF THE DAMAGED CONNECTIVE TISSUE AND ALLEVIATION OF CHRONIC MUSCULOSKELETAL PAIN BY CONTRAST – CORTISONE INJECTIONS MIGHT WELL PROVIDE IMMEDIATE PAIN RELIEF OVER THE SHORT – TERM BUT TISSUE DESTRUCTION AND EXACERBATION OF PAIN OVER THE LONG – TERM – BECAUSE OF THE CATABOLIC EFFECTS OF STEROID HORMONES – PROLOTHERAPY INJECTIONS, HOWEVER, SUPPORT THE NATURAL HEALING PROCESS BY STIMULATING THE HEALING CASCADE – RESULTING ULTIMATELY IN OVERALL STRENGTHENING OF THE CONNECTIVE TISSUE MATRIX AND RELIEF OF PAIN – 54
  • 55. ANOTHER EXAMPLE THE PRACTICE OF WOUND DEBRIDEMENT TO ACCELERATE HEALING SPEAKS DIRECTLY TO THIS CONCEPT OF “CONTROLLED DAMAGE” TO “TRIGGER REPAIR” NOT ONLY DOES DEBRIDEMENT PREVENT INFECTION BY REMOVING FOREIGN MATERIAL AND DAMAGED TISSUE FROM THE SITE OF THE WOUND BUT IT ALSO PROMOTES HEALING BY MILDLY AGGRAVATING THE AREA, WHICH WILL IN TURN “JUMP – START” THE BODY’S INNATE ABILITY TO “SELF – REPAIR” IN THE FACE OF CHALLENGE 55
  • 56. 56
  • 57. THE PATIENT’S INNATE “RESISTANCE TO CHANGE” “CHAOTIC SYSTEMS – WHICH WE ALL ARE – “RESIST DISRUPTION” PROPOSED DEFINITION OF “PSYCHODYNAMIC PSYCHOTHERAPY” 57
  • 58. JUST AS WITH THE BODY – WHERE A CHRONIC CONDITION MIGHT NOT HEAL UNTIL IT IS MADE ACUTE – SO TOO WITH THE MIND WHETHER CRISIS INTERVENTION, TRAUMA WORK, SHORT – TERM INTENSIVE, OR LONGER – TERM IN – DEPTH INDEED, OVER TIME I HAVE COME TO APPRECIATE THAT ONGOING THERAPEUTIC PROVISION OF JUST THE RIGHT COMBINATION OF “CHALLENGE” AND “SUPPORT” NAMELY, “OPTIMAL STRESS” AGAINST THE BACKDROP OF “SUPPORT” PROVIDED BY WAY OF “MINIMALLY STRESSFUL” “CLARIFYING” INTERVENTIONS WILL SOMETIMES BE THE “DESTABILIZING PROVOCATION” NEEDED BOTH TO OVERCOME THE INHERENT “RESISTANCE TO CHANGE” SO FREQUENTLY ENCOUNTERED IN EVEN OUR MOST “WELL – INTENTIONED” PATIENTS AND TO TRANSFORM THEIR “DEFENSIVE NEED” TO MAINTAIN THINGS AS THEY ARE – “SAME OLD, SAME OLD” – INTO THE “ADAPTIVE CAPACITY” TO EVOLVE – TO “SOMETHING NEW, DIFFERENT, AND BETTER” – 58
  • 59. 20
  • 60. CHARLES KREBS (2013) HIGHLIGHTS THAT “OPEN, SELF – ORGANIZING, COMPLEX ADAPTIVE (CHAOTIC) SYSTEMS RESIST PERTURBATION” EXAMPLES OF “CHAOTIC SYSTEMS” INCLUDE ROAD TRAFFIC, OCEAN TURBULENCE, SAND DUNES, AND THE “SELF – PROTECTIVE MECHANISMS” MOBILIZED BY ANXIOUS PATIENTS DESPERATELY ATTEMPTING TO MANAGE THE “STRESSORS” IN THEIR LIVES NO MATTER HOW COMPROMISED THEY MIGHT BE IN THEIR FUNCTIONALITY “SELF – ORGANIZING SYSTEMS” – FUELED AS THEY ARE BY THEIR HOMEOSTATIC TENDENCY TO REMAIN CONSTANT OVER TIME – ARE INHERENTLY “RESISTANT TO CHANGE” IN OTHER WORDS, OUR PATIENTS – MUCH AS THEY MIGHT PROTEST THEIR “DESIRE TO CHANGE” – HAVE AN “INNATE INERTIA” THAT MUST BE OVERCOME IF THEY ARE EVER TO BE ENERGETICALLY RELEASED FROM THE TOXICITY OF THEIR PAST AND EMPOWERED TO EMBRACE LOVE, WORK, AND PLAY TO THEIR GREATEST POTENTIAL GOING FORWARD 59
  • 61. A HUMOROUS EXAMPLE OF “RESISTANCE TO CHANGE” A SATURDAY NIGHT LIVE SKIT IN WHICH TWO MEN ARE SEATED AROUND A FIRE CHATTING AND ONE SAYS TO THE OTHER – “YOU KNOW HOW WHEN YOU STICK A POKER IN THE FIRE AND LEAVE IT IN FOR A LONG TIME, IT GETS REALLY, REALLY HOT? AND THEN YOU STICK IT IN YOUR EYE, AND IT REALLY, REALLY HURTS? I HATE IT WHEN THAT HAPPENS! I JUST HATE IT WHEN THAT HAPPENS!” 61
  • 62. OR THE ROCK SONG BY THE LATE WARREN ZEVON (1996) ENTITLED “IF YOU WON’T LEAVE ME I’LL FIND SOMEBODY WHO WILL” WHICH SPEAKS TO THE NEED WE ALL HAVE TO RECREATE THE “FAMILIAL AND THEREFORE FAMILIAR” STEPHEN MITCHELL (1988) BECAUSE THAT IS ALL WE HAVE EVER KNOWN HAVING SOMETHING DIFFERENT WOULD CREATE ANXIETY BECAUSE IT WOULD HIGHLIGHT THE FACT THAT THINGS COULD BE – AND COULD THEREFORE HAVE BEEN – DIFFERENT 62
  • 63. I AM HERE REMINDED OF PORTIA NELSON’S AUTOBIOGRAPHY IN 5 SHORT CHAPTERS (1993) WHICH HIGHLIGHTS BOTH OUR “DEFENSIVE NEED” TO “MAINTAIN THINGS AS THEY ARE” AND OUR “ADAPTIVE CAPACITY” ULTIMATELY TO “CHANGE” CHAPTER 1 I WALK DOWN THE STREET THERE IS A DEEP HOLE IN THE SIDEWALK I FALL IN I AM LOST … I AM HELPLESS IT ISN’T MY FAULT IT TAKES FOREVER TO FIND A WAY OUT CHAPTER 2 I WALK DOWN THE SAME STREET THERE IS A DEEP HOLE IN THE SIDEWALK I PRETEND I DON’T SEE IT I FALL IN AGAIN I CAN’T BELIEVE I AM IN THE SAME PLACE BUT IT ISN’T MY FAULT IT STILL TAKES A LONG TIME TO GET OUT 63
  • 64. CHAPTER 3 I WALK DOWN THE SAME STREET THERE IS A DEEP HOLE IN THE SIDEWALK I SEE IT IS THERE I STILL FALL IN … IT’S A HABIT MY EYES ARE OPEN I KNOW WHERE I AM IT IS MY FAULT I GET OUT IMMEDIATELY CHAPTER 4 I WALK DOWN THE SAME STREET THERE IS A DEEP HOLE IN THE SIDEWALK I WALK AROUND IT CHAPTER 5 I WALK DOWN ANOTHER STREET 64
  • 65. SO WITH RESPECT TO OUR INTERVENTIONS ONGOING AND JUDICIOUS USE OF “OPTIMALLY STRESSFUL” THERAPEUTIC INTERVENTIONS MUST, THEREFORE, OFFER PATIENTS ENOUGH “CHALLENGE” THAT THERE WILL BE “IMPETUS” FOR “DESTABILIZATION” OF THEIR “DYSFUNCTIONAL DEFENSES” BUT ENOUGH “SUPPORT” THAT THERE WILL BE “OPPORTUNITY” FOR “RESTABILIZATION” OF THOSE “SELF – PROTECTIVE MECHANISMS” AT EVER – HEALTHIER LEVELS OF “FUNCTIONALITY” AND “ADAPTABILITY” 64
  • 66. 66
  • 67. AGAIN WITH THE THERAPIST’S FINGER EVER ON THE PULSE OF THE LEVEL OF THE PATIENT’S “ANXIETY” AND CAPACITY TO TOLERATE FURTHER CHALLENGE THE THERAPIST WILL REPEATEDLY “CHALLENGE WHENEVER POSSIBLE” BY “DIRECTING THE PATIENT’S ATTENTION TO WHERE SHE IS NOT” – “DISRUPTIVE ATTUNEMENT” – AND “SUPPORT WHENEVER NECESSARY” BY “RESONATING EMPATHICALLY WITH WHERE THE PATIENT IS” – “HOMEOSTATIC ATTUNEMENT” – SALMAN AKHTAR (2012) AND WILL OFTEN BOTH “CHALLENGE” AND “SUPPORT” 67
  • 69. 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 IN ESSENCE WITHOUT SUFFICIENT CHALLENGE, THERE WILL BE NO IMPETUS FOR GROWTH BUT WITHOUT ADEQUATE SUPPORT, THERE WILL BE NO SUCH OPPORTUNITY – THE MORAL OF THE STORY – YOU NEED TO PROVIDE BOTH “CHALLENGE” AND “SUPPORT” FROM BEGINNING TO END 69
  • 70. IN OTHER WORDS IT IS NOT SO MUCH EMPATHY AS EMPATHIC FAILURE AGAINST A BACKDROP OF EMPATHY “OPTIMAL DISILLUSIONMENT” IT IS NOT SO MUCH GRATIFICATION AS FRUSTRATION AGAINST A BACKDROP OF GRATIFICATION “OPTIMAL FRUSTRATION” IT IS NOT SO MUCH SUPPORT AS CHALLENGE AGAINST A BACKDROP OF SUPPORT “OPTIMAL STRESS” THAT WILL PROVIDE THE “THERAPEUTIC LEVERAGE” NEEDED TO “PROVOKE” ALTERNATING CYCLES OF DESTABILIZATION AND THEN RESTABILIZATION AT EVER – MORE ROBUST LEVELS OF “ADAPTIVE CAPACITY” “DEEP AND ENDURING PSYCHODYNAMIC CHANGE” REQUIRES THIS ONGOING GENERATION OF “DESTABILIZING ANXIETY” AND “INCENTIVIZING STRESS” 70
  • 71. 71 JUDICIOUS USE OF “OPTIMAL STRESS” PROVIDES BOTH “IMPETUS” AND “OPPORTUNITY” FOR THE PATIENT TO EVOLVE – THROUGH “HEALING CYCLES” OF “DISRUPTION” AND “RECOVERY” – FROM “ILLNESS” TO “WELLNESS”
  • 72. TO REITERATE NO MATTER WHERE THE PATIENT’S “STARTING POINT” OR WHATEVER HER “LEVEL OF FUNCTIONALITY” STRATEGICALLY FORMULATED “OPTIMALLY STRESSFUL” INTERVENTIONS WILL ALWAYS HAVE THERAPEUTIC IMPACT BECAUSE THEY WILL BE “TAPPING INTO” (1) THE PATIENT’S INNATE RESILIENCE (2) THE “WISDOM OF HER BODY” (3) HER INTRINSIC STRIVING TOWARDS HEALTH (4) HER INBORN CAPACITY TO SELF – CORRECT IN THE FACE OF OPTIMAL CHALLENGE AGAIN, IT WILL BE THE ONGOING “SYNERGY” BETWEEN THE THERAPIST’S “EXTERNAL SUPPORT” – “ENVIRONMENTAL PROVISION” – AND THE PATIENT’S “INTERNAL RESOURCES” THAT WILL ENABLE THE PATIENT – IN THE AFTERMATH OF EACH “PERTURBATION” – TO RECONSTITUTE AT EVER – HEALTHIER LEVELS OF “DYNAMIC BALANCE” AND “ADAPTIVE CAPACITY” THEREBY REINFORCING “INNATE RESILIENCE” WITH “ADAPTIVE RESILIENCE” 71
  • 73. TO REVIEW THE CUTTING – EDGE OF THE “THERAPEUTIC ACTION” INVOLVES PROVIDING JUST THE RIGHT DOSES OF “CHALLENGE” AND “SUPPORT” SUCH THAT THERE WILL BE JUST THE RIGHT BALANCE BETWEEN “DESTABILIZATION” OF THE “DYSFUNCTIONAL STATUS QUO” AND ITS “RESTABILIZATION” AT A “MORE FUNCTIONAL LEVEL” AND SO THAT PATIENTS WON’T HAVE TO REMAIN ENTRENCHED IN “SAME OLD, SAME OLD,” WON’T HAVE TO KEEP STICKING HOT POKERS IN THEIR EYES, WON’T HAVE TO KEEP SETTING THEMSELVES UP TO BE ABANDONED BY PEOPLE THEY LOVE, AND WON’T HAVE TO KEEP FALLING INTO DEEP HOLES IN SIDEWALKS WHENEVER POSSIBLE – AND ALWAYS AGAINST THE BACKDROP OF “SUPPORT” AND “SECURE ATTACHMENT” – THE THERAPIST WILL THEREFORE “PRECIPITATE DISRUPTION” IN ORDER TO “TRIGGER REPAIR” BY WAY OF “OPTIMALLY STRESSFUL” INTERVENTIONS THAT EFFECTIVELY SUPERIMPOSE AN ACUTE – “GROWTH – INCENTIVIZING” – INJURY ON TOP OF A CHRONIC – “GROWTH – IMPEDING” – ONE THEREBY TAPPING INTO THE SYSTEM’S “UNDERLYING RESILIENCE” AND “INTRINSIC STRIVING TOWARDS HEALTH” 73
  • 74. PROPOSED DEFINITION FOR “PSYCHODYNAMIC PSYCHOTHERAPY” BY WAY OF “OPTIMALLY STRESSFUL” THERAPEUTIC INTERVENTIONS THAT SUPERIMPOSE AN ACUTE INJURY ON TOP OF A CHRONIC ONE – THEREBY TRIGGERING “HEALING CYCLES” OF “DISRUPTION” AND “REPAIR” – PSYCHODYNAMIC PSYCHOTHERAPY AFFORDS THE PATIENT BOTH “IMPETUS” AND “OPPORTUNITY” – ALBEIT BELATEDLY – TO MASTER TRAUMATIC EXPERIENCES THAT HAD ONCE BEEN OVERWHELMING – AND, THEREFORE, DEFENDED AGAINST – BUT THAT CAN NOW – WITH ENOUGH SUPPORT FROM THE THERAPIST AND BY TAPPING INTO THE PATIENT’S UNDERLYING RESILIENCE AND INTRINSIC CAPACITY TO ADAPT TO STRESS – BE REVISITED, REPROCESSED, AND REFRAMED SUCH THAT GROWTH – IMPEDING DEFENSES CAN BE GRADUALLY UPGRADED TO GROWTH – PROMOTING ADAPTATIONS STRONGER AT THE BROKEN PLACES 74
  • 75. 75
  • 76. 76
  • 77. 77
  • 78. 78
  • 79. THE SANDPILE MODEL AND THE “PARADOXICAL IMPACT” OF “OPTIMAL STRESS” 79
  • 80. THE PARADOXICAL IMPACT OF STRESS THE “SANDPILE MODEL” OF CHAOS THEORY OFFERS AN ELEGANT VISUAL DEMONSTRATION OF THE CUMULATIVE IMPACT – OVER TIME – OF ENVIRONMENTAL STRESSORS ON OPEN SYSTEMS – THINK “HOURGLASS” – I USE THIS “SANDPILE MODEL” WHICH SIMULATES THE EVOLUTION – OVER TIME – OF OPEN, SELF – ORGANIZING (CHAOTIC) SYSTEMS – LIKE THE STOCK MARKET, NEURAL NETWORKS, WATERFALLS – AS A VISUAL METAPHOR FOR THE “THERAPEUTIC ACTION” OF “PSYCHODYNAMIC PSYCHOTHERAPY” 80
  • 81. 81 THE SANDPILE MODEL OF CHAOS THEORY PER BAK (1996) ITERATIVE CYCLES OF DESTABILIZATION AND RESTABILIZATION AT EVER – HIGHER LEVELS OF INTEGRATION AND COMPLEXITY A VISUAL METAPHOR FOR THE CUMULATIVE IMPACT – OVER TIME – OF OPTIMAL STRESS ON MIND AND BODY
  • 82. THE PARADOXICAL IMPACT OF STRESS BOTH THE “SANDPILE MODEL” AND THE “THERAPEUTIC ACTION” FEATURE THE “EMERGENCE” – OVER TIME – OF “ITERATIVE CYCLES” OF “DESTABILIZATION” – A “DEFENSIVE REACTION” TO THE “CHALLENGE” – AND “RESTABILIZATION” – AN “ADAPTIVE RESPONSE” TO THE “SUPPORT” AS THESE “CHAOTIC SYSTEMS” EVOLVE TO EVER – MORE RICHLY TEXTURED LAYERS OF RESILIENCE, COMPLEXITY, INTEGRATION, AND DYNAMIC BALANCE NOT JUST “IN SPITE OF” ENVIRONMENTAL STRESSORS BUT “BY WAY OF” THOSE STRESSORS 82
  • 83. HOW SO? AMAZINGLY ENOUGH THE GRAINS OF SAND BEING STEADILY ADDED TO THE GRADUALLY EVOLVING SANDPILE – MUCH LIKE THE “OPTIMALLY STRESSFUL” INTERVENTIONS THAT WE ARE STEADILY OFFERING OUR PATIENTS – ARE THE OCCASION FOR BOTH “DISRUPTION” AND “REPAIR” NOT ONLY DO THE GRAINS OF SAND – SO, TOO, OUR THERAPEUTIC INTERVENTIONS – PERIODICALLY PRECIPITATE PARTIAL COLLAPSES OF THE SANDPILE – DESTABILIZATION OF THE PATIENT’S DEFENSES – (DESCRIBED AS “MINOR AVALANCHES” IN CHAOS THEORY) BUT THEY ALSO BECOME THE MEANS BY WHICH THE SANDPILE – THE PATIENT’S INFRASTRUCTURE – WILL THEN BE ABLE TO BUILD ITSELF BACK UP – ITS STRUCTURAL INTEGRITY REINFORCED – (EVERY TIME AT A MORE – RESILIENT LEVEL OF HOMEOSTASIS) 83
  • 84. THE SYSTEM – THE PATIENT – WILL THEREFORE HAVE BEEN ABLE NOT ONLY TO “MANAGE” THE IMPACT OF THE STRESSFUL INPUT BUT ALSO TO “BENEFIT FROM” THAT IMPACT FROM “DEFENSIVE COLLAPSE” TO “ADAPTIVE RECONSOLIDATION” AT EVER – MORE ROBUST LEVELS THE IRREGULARITIES IN THE SANDPILE – MUCH LIKE THE SCARS WE ALL BEAR – POIGNANT REMINDERS OF THE “MINOR COLLAPSES” – INJURIES – WE HAVE ALL SUSTAINED – OVER TIME – BUT, ULTIMATELY, TRIUMPHANTLY OVERCOME 84
  • 85. THE ART OF PRECIOUS SCARS 85
  • 86. OPTIMAL STRESS STRONGER AT THE BROKEN PLACES IS THERE NOT A CERTAIN BEAUTY IN BROKENNESS, A BEAUTY NEVER ACHIEVED BY THINGS UNBROKEN? IF A BONE IS FRACTURED AND THEN HEALS, THE AREA OF THE BREAK WILL BE STRONGER THAN THE SURROUNDING BONE AND WILL NOT AGAIN EASILY FRACTURE ARE WE, TOO, NOT STRONGER AT OUR BROKEN PLACES? AND DO WE NOT ACQUIRE A QUIET STRENGTH FROM SURVIVING ADVERSITY AND HARDSHIP AND MASTERING THE EXPERIENCE OF DISAPPOINTMENT, HEARTBREAK, AND DEVASTATION? AND, THEN, WHEN WE FINALLY RISE ABOVE IT, DON’T WE RISE UP IN QUIET TRIUMPH, EVEN IF ONLY WE NOTICE … 86
  • 87. 86
  • 88. STRESS IS WHEN YOU WAKE UP SCREAMING AND THEN YOU REALIZE YOU HAVEN’T FALLEN ASLEEP YET ANONYMOUS 88
  • 89. AGAIN, THE THERAPIST MUST KEEP HER FINGER EVER ON THE PULSE OF THE LEVEL OF THE PATIENT’S “ANXIETY” AND CAPACITY TO TOLERATE FURTHER CHALLENGE – THAT IS, ON THE PATIENT’S CAPACITY TO TOLERATE “OPTIMALLY STRESSFUL” INTERVENTIONS THAT JUXTAPOSE “CHALLENGE” AND “SUPPORT” – TO “LAY THE GROUNDWORK” FOR THE INTRODUCTION OF THESE “ANXIETY – PROVOKING” BUT “GROWTH – INCENTIVIZING” INTERVENTIONS THE THERAPIST CALLS UPON ANY NUMBER OF “JOINING THROUGH THE TRUTH” “MINIMALLY STRESSFUL” “CLARIFYING” INTERVENTIONS THAT WILL NOT ONLY “PROVIDE SUPPORT” BUT ALSO “MOVE THE BALL FORWARD” A BIT BY GENTLY “TEASING OUT” SOME OF THE “LESS – THAN – HEALTHY” “RECURRING THEMES, PATTERNS, AND REPETITIONS” IN THE PATIENT’S LIFE INTEGRATION STATEMENTS PATH – OF – LEAST – RESISTANCE STATEMENTS DAMAGED – FOR – LIFE STATEMENTS COMPENSATION STATEMENTS ENTITLEMENT STATEMENTS MASOCHISM STATEMENTS SADISM STATEMENTS PARADOXICAL INTERVENTIONS EMPATHIC STATEMENTS ALL OF WHICH NONJUDGMENTALLY HIGHLIGHT SOME OF THE “RATHER PAINFUL AND DIFFICULT TRUTHS” IN THE PATIENT’S LIFE 88
  • 90. 89 DESIGNING “MINIMALLY STRESSFUL” “CLARIFYING” INTERVENTIONS THAT TEASE OUT “RECURRING THEMES, PATTERNS, AND REPETITIONS”
  • 91. “MINIMALLY STRESSFUL” “CLARIFYING” INTERVENTIONS INTEGRATION STATEMENTS FOR THOSE PATIENTS WHO ARE HAVING TROUBLE HOLDING IN MIND SIMULTANEOUSLY BOTH THE “GOOD” AND THE “BAD” ASPECTS OF THEIR EXPERIENCE IN OTHER WORDS PATIENTS WITH TENUOUSLY ESTABLISHED “LIBIDINAL OBJECT CONSTANCY” / “EVOCATIVE MEMORY CAPACITY” “HARD TO REMEMBER” / “HARD TO IMAGINE” “WHEN YOU’RE FEELING THIS BAD, IT’S HARD TO REMEMBER THAT YOU HAD EVER FELT GOOD AND IT’S HARD TO IMAGINE THAT YOU COULD EVER FEEL GOOD AGAIN.” “WHEN YOUR HEART IS BREAKING AS IT IS NOW, YOU CAN’T IMAGINE THAT YOU COULD EVER DARE TO TRUST AGAIN.” “WHEN YOU’RE FEELING THIS ANGRY AT ME, IT’S HARD TO REMEMBER THAT YOU USED TO FEEL GOOD ABOUT ME AND EVEN LOOKED FORWARD TO COMING.” “WHEN YOU FEEL THIS DESPAIRING, YOU CAN’T REMEMBER EVER HAVING HAD ANY HOPE WHATSOEVER.” 90
  • 92. “MINIMALLY STRESSFUL” “CLARIFYING” INTERVENTIONS PATH – OF – LEAST – RESISTANCE STATEMENTS FOR THOSE PATIENTS WHO ARE “REACTING DEFENSIVELY” RATHER THAN “RESPONDING ADAPTIVELY” EASIER TO “REACT DEFENSIVELY” THAN TO “RESPOND ADAPTIVELY” “IT’S EASIER TO GIVE UP THAN TO KEEP FIGHTING FOR WHAT YOU REALLY BELIEVE IN.” “IT’S EASIER TO EXPERIENCE YOURSELF AS DISEMPOWERED THAN TO TAKE OWNERSHIP OF THE POWER AND AGENCY THAT YOU ACTUALLY DO HAVE.” “IT’S EASIER TO EXPERIENCE YOURSELF AS HAVING NO ACCOUNTABILITY THAN TO TAKE RESPONSIBILITY FOR YOUR LIFE.” “IT’S EASIER TO HOLD ON TO THE HOPE THAT YOUR HUSBAND MIGHT SOMEDAY CHANGE THAN TO CONFRONT THE REALITY THAT HE PROBABLY NEVER WILL.” 91
  • 93. THE “I CAN’T, YOU CAN, AND YOU SHOULD” DYANMIC FOR THOSE PATIENTS WHO EXPERIENCE THEMSELVES AS SO “DAMAGED” FROM WAY BACK THAT THEY CAN’T IMAGINE BEING HELD ACCOUNTABLE FOR THEIR LIVES NOW DAMAGED – FOR – LIFE – AND – THEREFORE – NOT – RESPONSIBLE – NOW STATEMENTS WHO FIND THEMSELVES, THEREFORE, LOOKING TO OTHERS TO “COMPENSATE” THEM FOR THE EARLY – ON “DAMAGE” COMPENSATION STATEMENTS AND WHO – QUITE FRANKLY – FEEL THAT THIS “COMPENSATION” IS THEIR DUE ENTITLEMENT STATEMENTS DISTORTION – DISTORTED SENSE OF SELF AS “NOT HAVING” ILLUSION – ILLUSORY SENSE OF OBJECT AS “HAVING” ENTITLEMENT – ENTITLED SENSE THAT “GETTING” IS THEIR “DUE” ALL OF WHICH ARE DEFENSIVE REACTIONS 92
  • 94. “MINIMALLY STRESSFUL” “CLARIFYING” INTERVENTIONS DAMAGED – FOR – LIFE – AND – THEREFORE – NOT – RESPONSIBLE – NOW STATEMENTS “YOU FEEL SO DAMAGED BECAUSE OF ALL THE ABUSE YOU SUFFERED AS A CHILD THAT YOU CANNOT IMAGINE EVER BEING ABLE TO DO ANYTHING NOW TO MAKE YOUR LIFE BETTER.” COMPENSATION STATEMENTS “WHEN YOU ARE FEELING DESPERATE, AS YOU ARE NOW, YOU FIND YOURSELF WISHING THAT SOMEONE WOULD UNDERSTAND JUST HOW BAD YOU FEEL AND DO SOMETHING TO HELP EASE YOUR PAIN.” ENTITLEMENT STATEMENTS “BECAUSE YOU FEEL THAT WHAT YOUR FATHER DID TO YOU WAS SO UNFAIR, DEEP DOWN YOU HARBOR THE CONVICTION THAT THE WORLD NOW OWES YOU.” “BECAUSE YOUR MOTHER NEVER UNDERSTOOD YOU AND LEFT YOU SO MUCH ON YOUR OWN, YOU’RE NOW FEELING THAT UNLESS SOMEONE IS WILLING TO GO MORE THAN HALFWAY, THEN YOU’RE SIMPLY NOT INTERESTED.” 93
  • 95. “MINIMALLY STRESSFUL” “CLARIFYING” INTERVENTIONS MASOCHISM STATEMENTS FOR THOSE PATIENTS WHO – BECAUSE IT SIMPLY “HURTS TOO MUCH” – REFUSE TO “CONFRONT” – AND “GRIEVE” – THE REALITY THAT THE “OBJECT OF THEIR DESIRE” WILL NEVER CHANGE INSTEAD, THEY HOLD ON TO THEIR DEFENSIVE – AND RELENTLESS – “HOPING AGAINST HOPE” “BECAUSE IT IS SO PAINFUL TO HAVE TO CONFRONT THE TRUTH ABOUT YOUR HUSBAND AND HIS ONGOING INSENSITIVITY TO YOU AND YOUR FEELINGS, YOU FIND YOURSELF CONTINUING TO HOPE THAT PERHAPS, IF YOU TRY HARD ENOUGH, ARE PERSUASIVE ENOUGH, PERSIST LONG ENOUGH, AND SUFFER DEEPLY ENOUGH, THEN YOU MIGHT YET BE ABLE TO COMPEL HIM TO CHANGE.” “BECAUSE IT HURTS TOO MUCH TO CONFRONT THE REALITY THAT YOUR FATHER WILL NEVER BE WILLING TO APOLOGIZE FOR ALL THAT HE DID TO YOU WHEN YOU WERE GROWING UP, YOU KEEP HOPING THAT IF YOU TRY HARD ENOUGH, PERSIST LONG ENOUGH, AND SUFFER DEEPLY ENOUGH, THEN HE MIGHT YET RELENT AND BE WILLING TO ACKNOWLEDGE THAT HE KNOWS HE CAUSED YOU TERRIBLE HEARTBREAK DURING ALL THOSE YEARS OF HIS DRINKING.” 94
  • 96. “MINIMALLY STRESSFUL” “CLARIFYING” INTERVENTIONS SADISM STATEMENTS FOR THOSE PATIENTS WHO – IN THOSE MOMENTS OF DAWNING RECOGNTION THAT WHAT THEY HAD SO DESPERATELY WANTED AND FELT THEY NEEDED TO HAVE IN ORDER TO SURVIVE IS SIMPLY NOT GOING TO HAPPEN – ARE DEFENSIVELY PRONE TO EXPERIENCING THEMSELVES AS HAVING BEEN “MISTREATED” AND / OR “VICTIMIZED” THEY WILL OFTEN THEN FIND THEMSELVES FEELING THAT THEY EITHER HAVE NO CHOICE BUT TO RETALIATE OR ARE ENTITLED TO RETALIATE “WHEN YOU’RE FEELING THAT YOU’VE BEEN WRONGED, YOU CAN GET PRETTY UGLY IF YOU HAVE TO!” “WHEN YOUR MOTHER IS DOING HER ‘USUAL,’ IT HURTS SO MUCH TO BE FEELING SO MISUNDERSTOOD THAT YOU FIND YOURSELF THINKING ABOUT WHAT YOU CAN DO TO HURT HER BACK. YOU WANT TO HER GET A TASTE OF HER OWN MEDICINE.” “WHEN YOU FEEL THAT YOU ARE BEING MISTREATED, IT MAKES YOU SO ANGRY THAT YOU FEEL YOU HAVE NO CHOICE BUT TO RESPOND IN KIND.” 95
  • 97. “MINIMALLY STRESSFUL” “CLARIFYING” INTERVENTIONS PARADOXICAL INTERVENTIONS FOR THOSE PATIENTS WHO ARE DEEPLY ENTRENCHED IN MAINTAINING “SAME OLD, SAME OLD” ALTHOUGH THE PATIENT HAS BEEN GIVING “LIP SERVICE” TO WANTING TO CHANGE, IT IS CLEAR FROM WHAT THE PATIENT IS ACTUALLY DOING THAT THE PATIENT IS NOT, IN FACT, PREPARED TO CHANGE THE THERAPIST THEREFORE “LETS GO” OF HER OWN “NEED” FOR THE PATIENT TO CHANGE AND “ACCEPTS” THE REALITY THAT THE PATIENT IS NOT PREPARED TO CHANGE – AT LEAST “NOT FOR NOW” IN ESSENCE, THE THERAPIST “GOES WITH THE RESISTANCE” BY “PRESCRIBING THE SYMPTOM” “I THINK I AM BEGINNING TO SEE WHY YOU FEEL THAT YOU CANNOT AFFORD TO TRUST ANYONE. BASED ON WHAT YOU’RE TELLING ME ABOUT THE NUMBERS OF TIMES YOUR TRUST HAS BEEN BETRAYED AND YOUR HEART BROKEN IN THE PAST, I CAN NOW UNDERSTAND WHY YOU FEEL THAT YOU SIMPLY MIGHT NEVER FIND SOMEONE WITH WHOM YOU WOULD WANT TO SPEND THE REST OF YOUR LIFE. ALTHOUGH IT MIGHT MEAN BEING ALONE FOREVER, AT LEAST YOU’LL KNOW THAT NO ONE WILL EVER BE ABLE TO HURT YOU EVER AGAIN.” 96
  • 98. “MINIMALLY STRESSFUL” “CLARIFYING” INTERVENTIONS PARADOXICAL INTERVENTIONS IN ESSENCE, THE THERAPIST USES HER “EMPATHIC UNDERSTANDING” OF THE PATIENT TO OFFER HER A PARADOX TO THE PATIENT WHO, EVEN AFTER A YEAR, HAS NOT BEEN ABLE TO MOBILIZE HIMSELF TO UPDATE HIS RESUME – DESPITE HIS PROCLAIMED INTENTION TO DO SO “ALTHOUGH EVERY SINGLE DAY YOU DREAD GOING TO WORK, YOU HATE YOUR BOSS, AND YOUR JOB IS INCREDIBLY TEDIOUS, IT DOES PROVIDE YOU WITH FINANCIAL SECURITY, AS YOU OFTEN REMIND US. SO, I THINK I AM BEGINNING TO APPRECIATE THAT, AT THIS POINT IN YOUR LIFE, PERHAPS IT DOESN’T REALLY MAKE SENSE FOR YOU TO BE MOVING FORWARD WITH APPLYING FOR A NEW JOB. PERHAPS AT SOME POINT IN THE FUTURE, BUT NOT RIGHT NOW.” TO A DESPERATELY UNHAPPY 45 – YEAR – OLD MAN MARRIED FOR 20 YEARS “YOU HATE IT THAT YOUR WIFE ABUSES YOU IN ALL THE WAYS THAT SHE DOES. AND YOU TELL ME REPEATEDLY THAT YOU STOPPED LOVING HER LONG AGO. BUT THEN YOU BEGIN TO THINK ABOUT HOW OLD AND TIRED YOU FEEL AND DECIDE THAT PERHAPS IT IS TOO LATE, THAT THE TIME TO HAVE LEFT HER MIGHT ALREADY HAVE COME AND GONE.” IF THE PATIENT IS MADE ANGRY BY THE THERAPIST’S PARADOXICAL INTERVENTION, THEN THE PATIENT’S ANGER MIGHT WELL EMPOWER HER – MIGHT WELL PROVIDE THE NECESSARY MOTIVATION (OR IMPETUS) FOR HER TO TAKE ACTION – IF ONLY TO PROVE THE THERAPIST WRONG! 97
  • 99. “MINIMALLY STRESSFUL” “CLARIFYING” INTERVENTIONS WITNESS STATEMENTS THE THERAPIST MAKES EXPLICIT THAT SHE IS A WITNESS TO WHAT THE PATIENT IS FEELING – “I SEE HOW MUCH PAIN YOU ARE IN.” – “I SEE HOW DESPERATELY YOU WANT TO GET BETTER.” – NOTE THE SUBTLE DISTINCTION BETWEEN “I SEE HOW LONELY YOU ARE FEELING.” AND “I HEAR HOW LONELY YOU ARE FEELING.” “I SEE HOW SAD YOU BECOME WHEN YOU TALK ABOUT YOUR MOTHER AND HOW SHE NEVER UNDERSTOOD.” AND “I HEAR HOW SAD YOU BECOME WHEN YOU TALK ABOUT YOUR MOTHER AND HOW SHE NEVER UNDERSTOOD.” IT FEELS GREAT TO BE ABLE TO KNOW THAT HOW LONELY AND SAD YOU ARE IS BEING “HEARD.” BUT SOMETIMES IT IS EVEN MORE VALIDATING AND REASSURING TO BE ABLE TO KNOW THAT HOW LONELY AND SAD YOU ARE IS BEING “SEEN.” 98
  • 100. 94
  • 101. 100
  • 102. “MINIMALLY STRESSFUL” “CLARIFYING” INTERVENTIONS “EMPATHIC STATEMENTS” ARE MY “DEFAULT MODE” THEY “SUPPORT” BY “RESONATING EMPATHICALLY” – MOMENT BY MOMENT – WITH THE PATIENT’S “AFFECT” AND THE “NARRATIVE” WITH WHICH THAT AFFECT IS ASSOCIATED THEY ARE OFTEN “NEEDED” TO “PROVIDE SUPPORT” AND “LAY THE GROUNDWORK” FOR “ANXIETY – PROVOKING” “OPTIMALLY STRESSFUL” INTERVENTIONS – THAT WILL BOTH “CHALLENGE” AND “SUPPORT” – 101
  • 103. 102
  • 104. OVER THE COURSE OF THE YEARS I HAVE COME TO APPRECIATE THAT WHATEVER THE TREATMENT – WHETHER CRISIS INTERVENTION, TRAUMA WORK, SHORT – TERM INTENSIVE, OR LONGER – TERM IN – DEPTH – IT WILL GENERALLY BE MORE EFFECTIVE TO “MAKE STATEMENTS” THAN TO “ASK QUESTIONS” “QUESTIONS” RUN THE RISK OF ELICITING SOMEWHAT “HEADY ANSWERS” – MORE “INTELLECTUAL” THAN “HEARTFELT” – FOR THE MOST PART THEREFORE I LET THE PATIENT “LEAD” AND I “FOLLOW” I “MAKE STATEMENTS” AND DON’T “ASK QUESTIONS” IN OFFERING THE PATIENT STATEMENTS I AM, OF COURSE, “GIVING” HER SOMETHING RATHER THAN “ASKING” OF HER THAT SHE “GIVE” ME SOMETHING – NAMELY, ANSWERS TO MY QUESTIONS – 103
  • 105. SO I TAKE MY CUES FROM THE PATIENT AND AM GENERALLY, THEREFORE, ONE STEP BEHIND HER – NOT AHEAD OF HER 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 APPEAR TO BE – I WILL THEN OFFER “EMPATHIC STATEMENTS” THAT HIGHLIGHT “WHAT THE PATIENT IS ACTUALLY FEELING RIGHT THEN” 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 104
  • 106. “MINIMALLY STRESSFUL” “CLARIFYING” INTERVENTIONS EXAMPLES OF EMPATHIC STATEMENTS “IT IS HARD TO KNOW WHERE TO BEGIN WHEN EVERYTHING FEELS SO OVERWHELMING.” “IT IS UNCOMFORTABLE TO BE HERE WHEN YOU’RE NOT SURE THE THERAPY IS REALLY HELPING ANYWAY.” “IT IS UPSETTING TO BE FEELING THIS OUT OF CONTROL.” ALL OF WHICH SPEAK TO BOTH THE PATIENT’S “AFFECT” AND THE “ASSOCIATED THEME” THAT IS, THE “STORY” OR “NARRATIVE” THAT GOES WITH THE FEELING “YOU ARE TIRED OF THINKING ABOUT WHETHER YOU SHOULD STAY OR GO.” “YOU HAVE SUCH DEEP DESPAIR ABOUT EVER BEING ABLE TO FIND A TRUE SOULMATE.” “YOU ARE TERRIFIED THAT YOU WILL BE DISAPPOINTED.” “YOU ARE TERRIFIED THAT YOU YOURSELF WILL DISAPPOINT.” “YOU ARE CONFUSED ABOUT HOW BEST TO USE THE SESSION.” “YOU WORRY ABOUT WHAT I MIGHT BE THINKING.” 105
  • 107. EMPATHIC STATEMENTS THAT HIGHLIGHT WHAT THE PATIENT IS EXPERIENCING IN A “SPECIFIC CONTEXT” “IT IS PAINFUL TO BE FEELING SO MISUNDERSTOOD BY JUANITA.” CAN THEN USUALLY BE “GENERALIZED” FROM THE “SMALL” TO THE “ALL” “IT IS PAINFUL TO BE FEELING ALWAYS SO MISUNDERSTOOD.” BY THE SAME TOKEN EMPATHIC STATEMENTS THAT HIGHLIGHT WHAT THE PATIENT IS EXPERIENCING IN THE “PRESENT” “IT IS PAINFUL TO BE FEELING SO MISUNDERSTOOD.” CAN THEN USUALLY BE “EXTENDED” TO THE “PAST” “IT IS PAINFUL TO HAVE BEEN FEELING SO MISUNDERSTOOD FOR SO LONG NOW.” 106
  • 108. WITH RESPECT TO THE “FRAMING” OF AN “EMPATHIC STATEMENT” PLEASE NOTE THAT INSTEAD OF “I WONDER IF IT IS PAINFUL TO BE FEELING SO MISUNDERSTOOD.” OR “IT SOUNDS AS IF IT IS PAINFUL TO BE FEELING SO MISUNDERSTOOD.” OR “IT SEEMS AS IF IT IS PAINFUL TO BE FEELING SO MISUNDERSTOOD.” OR “IT MUST BE PAINFUL TO BE FEELING SO MISUNDERSTOOD.” YOU COULD SIMPLY SAY “IT IS PAINFUL TO BE FEELING SO MISUNDERSTOOD.” FOLLOWED BY THE 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 “IT BREAKS YOUR HEART THAT SHE DOESN’T SEEM TO CARE.” EXTRA WORDS RUN THE RISK OF PUTTING TOO MUCH DISTANCE BETWEEN THE THERAPIST AND THE PATIENT 107
  • 109. EMPATHIC STATEMENTS ARE “EXPERIENCE – NEAR” – NOT “EXPERIENCE – DISTANT” – AND ARE “DESIGNED” TO “VALIDATE” OR “REINFORCE” THE PATIENT’S “EXPERIENCE” IN THE MOMENT AND TO “TEASE OUT” “RECURRING THEMES, PATTERNS, AND REPETITIONS” IN HER CONSCIOUSNESS AND SOMETIMES HER PRECONSCIOUS THEY ARE NOT DESIGNED TO TARGET HER UNCONSCIOUS I AM HONORING WHAT THE PATIENT IS ACTUALLY SAYING I AM NOT TRYING TO READ BETWEEN THE LINES OR TO INTERPRET WHAT I THINK MIGHT LIE BENEATH THE SURFACE I AM FOCUSING MORE ON THE “MANIFEST CONTENT” THAN ON THE “LATENT CONTENT” THE AIM OF THESE EMPATHIC STATEMENTS IS TO HELP THE PATIENT “FEEL UNDERSTOOD,” NOT TO HELP THE PATIENT “UNDERSTAND” WHEN PATIENTS FEEL UNDERSTOOD, THEY ARE LESS LIKELY TO GET DEFENSIVE AND MORE LIKELY TO DELIVER INTO THE RELATIONSHIP WHAT MOST MATTERS TO THEM 108
  • 110. 109 EMPATHIC STATEMENTS HIGHLIGHT WHAT IS IN THE PATIENT’S CONSCIOUS – OR PRECONSCIOUS – MIND THEY ARE NOT DESIGNED TO TARGET HER UNCONSCIOUS “OPTIMALLY STRESSFUL” INTERVENTIONS ARE DESIGNED TO DO THAT!
  • 111. IN OTHER WORDS EMPATHIC STATEMENTS ARE SPECIFICALLY DESIGNED NOT ONLY TO “HIGHLIGHT” WHAT THE PATIENT IS ACTUALLY “FEELING” BUT ALSO TO “MAKE EXPLICIT” – AND “GIVE SHAPE TO” – THE “STORIES” (OR “NARRATIVES”) THAT THE PATIENT – AS A YOUNG CHILD – HAD CONSTRUCTED IN A DESPERATE ATTEMPT TO MAKE SENSE OF THE RELATIONAL DEPRIVATION AND NEGLECT – “ABSENCE OF GOOD” / “ERRORS OF OMISSION” – AND THE RELATIONAL TRAUMA AND ABUSE – “PRESENCE OF BAD” / “ERRORS OF COMMISSION” – TO WHICH SHE WAS BEING SUBJECTED 110
  • 112. BUT “MADE – UP” AND “DISEMPOWERING” STORIES THAT HAVE NOW GENERALIZED FROM THE “SMALL” (HER NUCLEAR FAMILY) TO THE “ALL” (THE WORLD AROUND HER) “NARRATIVES” THAT HAVE NOW BECOME THE “GO – TO” DISTORTED FILTERS THROUGH WHICH SHE EXPERIENCES SELF, OTHERS, AND THE WORLD AGAIN THESE EMPATHIC STATEMENTS DO NOT SPECIFICALLY “INCENTIVIZE” STRUCTURAL TRANSFORMATION AND GROWTH, BUT THEY DO “LAY THE GROUNDWORK” FOR THE “OPTIMALLY STRESSFUL” INTERVENTIONS THAT WILL FOLLOW 111