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Martha Stark MD – 13 Apr 2023 – The Therapeutic Use of Optimal Stress to Provoke Recovery.pptx

The therapeutic provision of “optimal stress” – against the backdrop of an empathically attuned and authentically engaged therapy relationship – is sometimes the magic ingredient needed to overcome the inherent resistance to change so frequently encountered in patients with longstanding emotional injuries. Ongoing challenge will destabilize and support will then prompt restabilization at ever-higher levels of resilience and adaptive capacity. Growing up (the task of the child) and getting better (the task of the patient) are therefore a story about transforming need into capacity – the need for immediate gratification into the capacity to tolerate delay, the need for perfection into the capacity to tolerate imperfection, the need for external regulation of the self into the capacity to be internally self-regulating, and the need to hold on into the capacity to let go.

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THE THERAPEUTIC USE
OF OPTIMAL STRESS
TO PROVOKE RECOVERY
NO PAIN / NO GAIN 
MARTHA STARK, M.D.
Faculty, Harvard Medical School
MarthaStarkMD @ SynergyMed.solutions
April 2023
Doctoral Counseling Program at AGST Philippines
With deepest appreciation for BILL KIRWAN, Ph.D.
Dr. Tine and Sharen Winar
© 2023 Martha Stark, M.D.
1
2
THERAPEUTIC MODALITIES THAT HAVE
“DEEP AND ENDURING PSYCHODYNAMIC CHANGE”
AS THEIR ULTIMATE GOAL
FOR EXAMPLE, PSYCHOANALYSIS AND OTHER “DEPTH PSYCHOLOGIES,”
INCLUDING – BUT NOT LIMITED TO – ACT, IFS, EMDR, ISTDP, AEDP, EFT, NLP,
SENSORIMOTOR PSYCHOTHERAPY, SOMATIC EXPERIENCING, AND PSYCHOMOTOR PSYCHOTHERAPY
MUST ULTIMATELY BE ABLE TO TRANSFORM
“PSYCHOLOGICAL RIGIDITY”
INTO “PSYCHOLOGICAL FLEXIBILITY”
IN THE EVOCATIVE WORDS OF ACCEPTANCE AND COMMITMENT THERAPY (ACT)
AND “LOW – LEVEL DEFENSE”
INTO “HIGHER – LEVEL / MORE EVOLVED DEFENSE”
IN THE MORE TRADITIONAL WORDS OF PSYCHOANALYSIS AND EGO PSYCHOLOGY
SUCH THAT THE PATIENT
WHATEVER HER STARTING POINT / WHATEVER HER INITIAL LEVEL OF FUNCTIONALITY
WHATEVER HER DIAGNOSIS
WILL BECOME EVER BETTER ABLE
– OVER TIME –
TO MANAGE THE MYRIAD “STRESSORS” IN HER LIFE
TO WHICH SHE IS BEING CONTINUOUSLY EXPOSED
EVER MORE ADEPT AT “RESPONDING ADAPTIVELY AND MINDFULLY”
INSTEAD OF “REACTING DEFENSIVELY AND MINDLESSLY” 3
4
THE ULTIMATE GOAL OF DEEP TREATMENTS
EVER – LESS PSYCHOLOGICAL RIGIDITY
EVER – MORE PSYCHOLOGICAL FLEXIBILITY
OVERVIEW
IN ORDER TO ADVANCE THE PATIENT
FROM RIGID DEFENSE TO MORE FLEXIBLE ADAPTATION
AGAINST A BACKDROP OF EMPATHIC ATTUNEMENT
THE THERAPIST WILL REPEATEDLY
OFFER THE PATIENT
OPTIMALLY STRESSFUL INTERVENTIONS
– JUST THE RIGHT COMBINATION OF CHALLENGE AND SUPPORT –
STRATEGICALLY DESIGNED TO GENERATE
DESTABILIZING INTERNAL TENSION AND HOMEOSTATIC IMBALANCE
BY JUXTAPOSING
– IN AN EMBODIED (LIVED) FASHION –
ANXIETY – PROVOKING CHALLENGE OF THE DEFENSE
WITH ANXIETY – ASSUAGING SUPPORT OF IT
THEREBY CREATING
GROWTH – INCENTIVIZING “MISMATCH EXPERIENCES”
THE WORKING THROUGH OF WHICH
– IN ORDER TO RESOLVE THE INTERNAL TENSION
AND RESTORE THE HOMEOSTATIC BALANCE –
WILL ADVANCE THE PATIENT
TO EVER – HIGHER AND MORE EVOLVED LEVELS
OF RESILIENCE AND ADAPTIVE CAPACITY
5
6
A MISMATCH EXPERIENCE 

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Martha Stark MD – 13 Apr 2023 – The Therapeutic Use of Optimal Stress to Provoke Recovery.pptx

  • 1. THE THERAPEUTIC USE OF OPTIMAL STRESS TO PROVOKE RECOVERY NO PAIN / NO GAIN  MARTHA STARK, M.D. Faculty, Harvard Medical School MarthaStarkMD @ SynergyMed.solutions April 2023 Doctoral Counseling Program at AGST Philippines With deepest appreciation for BILL KIRWAN, Ph.D. Dr. Tine and Sharen Winar © 2023 Martha Stark, M.D. 1
  • 2. 2
  • 3. THERAPEUTIC MODALITIES THAT HAVE “DEEP AND ENDURING PSYCHODYNAMIC CHANGE” AS THEIR ULTIMATE GOAL FOR EXAMPLE, PSYCHOANALYSIS AND OTHER “DEPTH PSYCHOLOGIES,” INCLUDING – BUT NOT LIMITED TO – ACT, IFS, EMDR, ISTDP, AEDP, EFT, NLP, SENSORIMOTOR PSYCHOTHERAPY, SOMATIC EXPERIENCING, AND PSYCHOMOTOR PSYCHOTHERAPY MUST ULTIMATELY BE ABLE TO TRANSFORM “PSYCHOLOGICAL RIGIDITY” INTO “PSYCHOLOGICAL FLEXIBILITY” IN THE EVOCATIVE WORDS OF ACCEPTANCE AND COMMITMENT THERAPY (ACT) AND “LOW – LEVEL DEFENSE” INTO “HIGHER – LEVEL / MORE EVOLVED DEFENSE” IN THE MORE TRADITIONAL WORDS OF PSYCHOANALYSIS AND EGO PSYCHOLOGY SUCH THAT THE PATIENT WHATEVER HER STARTING POINT / WHATEVER HER INITIAL LEVEL OF FUNCTIONALITY WHATEVER HER DIAGNOSIS WILL BECOME EVER BETTER ABLE – OVER TIME – TO MANAGE THE MYRIAD “STRESSORS” IN HER LIFE TO WHICH SHE IS BEING CONTINUOUSLY EXPOSED EVER MORE ADEPT AT “RESPONDING ADAPTIVELY AND MINDFULLY” INSTEAD OF “REACTING DEFENSIVELY AND MINDLESSLY” 3
  • 4. 4 THE ULTIMATE GOAL OF DEEP TREATMENTS EVER – LESS PSYCHOLOGICAL RIGIDITY EVER – MORE PSYCHOLOGICAL FLEXIBILITY
  • 5. OVERVIEW IN ORDER TO ADVANCE THE PATIENT FROM RIGID DEFENSE TO MORE FLEXIBLE ADAPTATION AGAINST A BACKDROP OF EMPATHIC ATTUNEMENT THE THERAPIST WILL REPEATEDLY OFFER THE PATIENT OPTIMALLY STRESSFUL INTERVENTIONS – JUST THE RIGHT COMBINATION OF CHALLENGE AND SUPPORT – STRATEGICALLY DESIGNED TO GENERATE DESTABILIZING INTERNAL TENSION AND HOMEOSTATIC IMBALANCE BY JUXTAPOSING – IN AN EMBODIED (LIVED) FASHION – ANXIETY – PROVOKING CHALLENGE OF THE DEFENSE WITH ANXIETY – ASSUAGING SUPPORT OF IT THEREBY CREATING GROWTH – INCENTIVIZING “MISMATCH EXPERIENCES” THE WORKING THROUGH OF WHICH – IN ORDER TO RESOLVE THE INTERNAL TENSION AND RESTORE THE HOMEOSTATIC BALANCE – WILL ADVANCE THE PATIENT TO EVER – HIGHER AND MORE EVOLVED LEVELS OF RESILIENCE AND ADAPTIVE CAPACITY 5
  • 7. MORE SPECIFICALLY OPTIMALLY STRESSFUL INTERVENTIONS WILL – ALTERNATELY AND REPEATEDLY – FIRST “CHALLENGE” THE DEFENSE BY DIRECTING THE PATIENT’S ATTENTION TO WHERE SHE ISN’T BUT WHERE THE THERAPIST WOULD WANT HER TO GO – SALMAN AKHTAR’S “DISRUPTIVE ATTUNEMENT” (2018) – AND THEN “SUPPORT” THE DEFENSE BY RESONATING EMPATHICALLY WITH WHERE THE PATIENT IS – SALMAN AKHTAR’S “HOMEOSTATIC ATTUNEMENT” (2018) – IN ESSENCE THE THERAPIST WILL BE GENERATING DESTABILIZING TENSION WITHIN THE PATIENT BY FIRST INCREASING HER ANXIETY – WITH CHALLENGE – AND THEN DECREASING IT – WITH SUPPORT – 7
  • 8. 8 STRATEGIC LEVERAGING OF THE PATIENT’S ANXIETY ALTERNATELY INCREASING IT BY CHALLENGING THE DEFENSE AND THEN DECREASING IT BY SUPPORTING THE DEFENSE TO INCENTIVIZE TRANSFORMATION AND GROWTH
  • 9. IN ESSENCE 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 THE BENEFIT OF THE THERAPIST’S LOVING SUPPORT AND BY TAPPING INTO THE PATIENT’S UNDERLYING RESILIENCE, INNATE CAPACITY TO ADAPT TO STRESS, AND INTRINSIC STRIVING TOWARDS HEALTH – BE REVISITED, REPROCESSED, AND REFRAMED SUCH THAT GROWTH – IMPEDING DEFENSES – ONCE NECESSARY FOR SURVIVAL – CAN BE GRADUALLY TRANSFORMED INTO GROWTH – PROMOTING ADAPTATIONS FROM “SAME OLD, SAME OLD” TO “SOMETHING NEW, DIFFERENT, AND BETTER” FROM THE “SOBERING REALITY” OF “WHAT IS” TO THE “ENLIVENING POSSIBILITY” OF “WHAT COULD BE” SUCH THAT THE PATIENT WILL HAVE BECOME STRONGER AT THE BROKEN PLACES 9
  • 10. 10
  • 11. 11
  • 12. 12
  • 14. 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 “MORE SOCIALLY ACCEPTABLE” FOR EXAMPLE SUBLIMATION, HUMOR, ALTRUISM, HUMILITY, AND POSITIVE IDENTIFICATIONS 14
  • 15. RATHER I DEFINE DEFENSES “MORE BROADLY” AS SPEAKING TO ANY OF THE “SELF – PROTECTIVE MECHANISMS” THAT WE MOBILIZE WHEN MADE ANXIOUS IN THE FACE OF STRESSORS – PSYCHOLOGICAL, PHYSIOLOGICAL, AND ENERGETIC – 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 MORE EASILY ABLE TO “TAKE IN OUR STRIDE” TO WHICH I REFER AS “HIGHER – LEVEL DEFENSES” OR “MORE FLEXIBLE ADAPTATIONS” AT ONE END OF THE CONTINUUM – “DEFENSIVE REACTIONS” AT THE OTHER END – “ADAPTIVE RESPONSES” 15
  • 16. EITHER WE – MADE ANXIOUS – “REACT” TO STRESSORS BY “DEFENDING” “DEFENSIVE REACTION” OR WE – MORE RESILIENT – “RESPOND” TO STRESSORS BY “ADAPTING” “ADAPTIVE RESPONSE” 16
  • 17. 17 LIFE IS NOT ABOUT “DEFENSIVELY” WAITING FOR THE STORM TO PASS BUT ABOUT “ADAPTIVELY” LEARNING TO DANCE IN THE RAIN
  • 18. WHAT IS THE RELATIONSHIP BETWEEN DEFENSE – DEFENSIVE REACTION TO STRESSOR – AND ADAPTATION – ADAPTIVE RESPONSE TO STRESSOR – 18
  • 19. THE RELATIONSHIP BETWEEN DEFENSE AND ADAPTATION IS A YIN – YANG RELATIONSHIP THESE SELF – PROTECTIVE MECHANISMS ARE COMPLEMENTARY – NOT OPPOSING – FORCES FURTHERMORE ALL DEFENSES HAVE AN ADAPTIVE COMPONENT JUST AS ALL ADAPTATIONS SERVE A DEFENSIVE FUNCTION NONETHELESS AND MORE GENERALLY ALTHOUGH DEFENSES MIGHT ONCE HAVE BEEN NECESSARY FOR THE PATIENT TO “SURVIVE,” AS RIGID DEFENSES BECOME UPGRADED TO MORE FLEXIBLE ADAPTATIONS, THE PATIENT BECOMES EVER BETTER ABLE TO “THRIVE” THE THERAPEUTIC ACTION IS INDEED DESIGNED TO TRANSFORM “RIGIDITY” INTO “FLEXIBILITY” AND “SURVIVING” INTO “THRIVING” 19
  • 20. 20
  • 21. A DRAMATIC DEMONSTRATION OF THE DIRECT RELATIONSHIP BETWEEN FLEXIBILITY AND THRIVING DECADES AGO, TWO OBSTETRICIANS MADE AN INTRIGUING DISCOVERY ABOUT THE PARADOXICAL RELATIONSHIP BETWEEN REGULARITY OF FETAL HEART RATE AND FETAL MORTALITY THEY DISCOVERED THAT – COUNTERINTUITIVELY – THE MORE METRONOME – LIKE THE HEARTBEAT, THE LESS LIKELY THE FETUS WOULD BE TO SURVIVE WHEREAS THE GREATER THE HEART RATE VARIABILITY, THE MORE LIKELY THE FETUS WOULD BE TO THRIVE IN OTHER WORDS VARIABILITY, ADAPTABILITY, FLEXIBILITY, RESILIENCE, AND TOM BRADY’S PLIABILITY ARE CRITICALLY IMPORTANT FOR THE HEALTH OF BOTH BODY AND MIND HON AND LEE (1965) 21
  • 22. WE CANNOT AVOID SUFFERING BUT WE CAN CHOOSE HOW WE COPE WITH IT, FIND MEANING IN IT, AND MOVE FORWARD WITH RENEWED PURPOSE “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.” AUTHOR UNKNOWN – ALTHOUGH OFTEN MISATTRIBUTED TO THE EXISTENTIAL PSYCHIATRIST VIKTOR FRANKL – 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 22
  • 23. 23 Between stressor and what follows is a space. In that space lies our freedom and our power to choose what we will do. We can either react defensively or respond adaptively.
  • 24. 24
  • 25. 25
  • 26. 26 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.
  • 28. JUST AS A FIELD OF GRASS CAN BE BURNED IN ORDER TO STIMULATE IT TO GROW BACK GREENER, HEALTHIER, AND MORE LUSH THAN BEFORE SO TOO “CONTROLLED DAMAGE” TO THE BODY CAN PROVOKE THE “HEALING CASCADE” 28
  • 29. 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 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 ACUPUNCTURE / ACUPRESSURE / CUPPING RED LIGHT THERAPY / INFRARED SAUNAS / CRYOTHERAPY BRAIN TEASERS AND MENTAL EXERCISES WHEN THE BODY IS OPTIMALLY CHALLENGED, – NO MATTER HOW COMPROMISED IT MIGHT BE IN ITS FUNCTIONALITY – ADAPTIVE RECOVERY WILL BE TRIGGERED BECAUSE OF THE BODY’S INNATE RESILIENCE 29
  • 30. THE THERAPEUTIC USE OF OPTIMAL STRESS TO PROVOKE RECOVERY DEPRIVING YOURSELF 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 (2023) INTERESTINGLY, THE ONLY TYPE OF “CALORIE – RESTRICTION” DIET THAT WILL NOT SLOW DOWN YOUR METABOLISM IS INTERMITTENT FASTING 30
  • 31. 31
  • 32. MORE SPECIFICALLY OPTIMAL CHALLENGE OF THE BRAIN WILL SHARPEN MENTAL ACUITY, DECELERATE COGNITIVE DECLINE, AND COMBAT THE EFFECTS OF AGING ON THE BRAIN JUST AS ATHLETES CAN IMPROVE THEIR “PHYSICAL FITNESS” BY OPTIMALLY CHALLENGING THEIR BODIES WITH “PHYSICAL EXERCISE” SO, TOO, ALL OF US CAN IMPROVE OUR “BRAIN FITNESS” BY OPTIMALLY CHALLENGING OUR MINDS WITH “BRAIN TEASERS” FOR EXAMPLE, MATHEMATICAL PUZZLES, WORD GAMES, CROSSWORD PUZZLES, LOGIC PROBLEMS, AND MEMORY CHALLENGES ANY MENTAL EXERCISE REQUIRING DELIBERATE AND CONCENTRATED EFFORT FOR EXAMPLE, ACTIVE REPETITION, FOCUSED ATTENTION, MEDITATION, REFLECTION, JUGGLING, OR LEARNING ANY NEW SKILL OR NEW LANGUAGE WILL PROMOTE MENTAL AGILITY AND FORESTALL THE INEXORABLE DECLINE IN MENTAL CAPACITY AS WE AGE IN ADDITION TO PUZZLES AND GAMES, OUR BRAINS WILL BE STIMULATED WHENEVER WE ARE EXPOSED TO SITUATIONS THAT ARE NEW, UNUSUAL, DIFFERENT, NOVEL, OR UNEXPECTED WHEN OUR DAILY ROUTINES ARE DISRUPTED OR WHEN WE COMBINE TWO SENSES – A FORM OF CROSS – TRAINING FOR THE BRAIN – LIKE SIMULTANEOUSLY LISTENING TO MUSIC AND SMELLING FLOWERS, WATCHING A SUNSET AND TAPPING OUR FINGERS, OR PRINTING WITH ONE HAND WHILE CURSIVE WRITING WITH THE OTHER 32
  • 33. JUST AS WITH THE BODY – WHERE A CHRONIC CONDITION MIGHT NOT HEAL UNTIL IT IS MADE ACUTE – SO TOO WITH THE MIND INDEED, OVER TIME I HAVE COME TO APPRECIATE THAT ONGOING “THERAPEUTIC PROVISION” OF JUST THE RIGHT COMBINATION OF CHALLENGE AND SUPPORT NAMELY, “OPTIMAL STRESS” 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” 33
  • 34. 34
  • 35. NEUROSCIENTIST CHARLES KREBS (2013) WRITES “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 WHICH IS TO SAY THAT 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” 35
  • 36. IN OTHER WORDS PATIENTS – MUCH AS THEY MIGHT PROTEST THEIR “DESIRE TO CHANGE” – HAVE AN “INNATE INERTIA” THAT MUST BE OVERCOME IF THEY ARE EVER TO BE RELEASED ENERGETICALLY FROM THE TOXICITY OF THEIR PAST AND EMPOWERED TO EMBRACE LOVE, WORK, AND PLAY TO THEIR GREATEST POTENTIAL GOING FORWARD 36
  • 37. 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!” 37
  • 38. 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 38
  • 39. I AM HERE REMINDED OF PORTIA NELSON’S AUTOBIOGRAPHY IN 5 SHORT CHAPTERS (2012) 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 39
  • 40. 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 40
  • 41. 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 41
  • 42. 42
  • 43. INDEED, WE ALL FIND OURSELVES SOMETIMES VERY CONFUSED ABOUT WHAT TO DO NEXT! 43
  • 44. WITH THE THERAPIST’S FINGER EVER ON THE PULSE OF THE PATIENT’S LEVEL OF ANXIETY AND CAPACITY TO TOLERATE FURTHER CHALLENGE THE THERAPIST WILL THEREFORE REPEATEDLY CHALLENGE WHENEVER POSSIBLE BY DIRECTING THE PATIENT’S ATTENTION TO WHERE THE PATIENT IS NOT BUT TO WHERE THE THERAPIST WOULD WANT THE PATIENT TO GO – SALMAN AKHTAR’S (2018) “DISRUPTIVE ATTUNEMENT” – AND SUPPORT WHENEVER NECESSARY BY RESONATING EMPATHICALLY WITH WHERE THE PATIENT IS – SALMAN AKHTAR’S (2018) “HOMEOSTATIC ATTUNEMENT” – 44
  • 46. 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 46
  • 47. 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” 47
  • 48. 48 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”
  • 49. 49
  • 50. HOW DOES THE SANDPILE MODEL OF CHAOS THEORY OFFER A COMPELLING “VISUAL” FOR EVOLUTION OF THE PATIENT THROUGH ITERATIVE HEALING CYCLES OF DESTABILIZATION FOLLOWED BY RESTABILIZATION AT EVER – MORE EVOLVED LEVELS OF COMPLEXITY AND DYNAMIC BALANCE AS A RESULT OF THE CUMULATIVE IMPACT OF OPTIMALLY STRESSFUL INTERVENTIONS 50
  • 51. 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, HURRICANES – AS AN ANALOGY FOR THE ITERATIVE HEALING CYCLES OF DISRUPTION AND REPAIR THAT CHARACTERIZE THE THERAPEUTIC ACTION IN PSYCHODYNAMIC PSYCHOTHERAPY 51
  • 52. 52 THE SANDPILE MODEL OF CHAOS THEORY Bak (1996) ITERATIVE CYCLES OF DESTABILIZATION AND RESTABILIZATION AT EVER – HIGHER LEVELS OF COMPLEXITY AND DYNAMIC BALANCE A COMPELLING “VISUAL” FOR THE CUMULATIVE IMPACT OF OPTIMAL STRESS
  • 53. 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 53
  • 54. HOW IS IT THAT ONGOING EVOLUTION IS POSSIBLE NOT JUST “IN SPITE OF” BUT “BECAUSE OF” THE CYCLES OF DISRUPTION AND REPAIR 54
  • 55. AMAZINGLY ENOUGH THE GRAINS OF SAND BEING STEADILY ADDED TO THE GRADUALLY EVOLVING SANDPILE – MUCH LIKE THE OPTIMALLY STRESSFUL INTERVENTIONS THAT WE OFFER OUR PATIENTS – ARE THE OCCASION FOR BOTH “DISRUPTION” AND “REPAIR” NOT ONLY DO THE GRAINS OF SAND – OPTIMALLY STRESSFUL, GROWTH – INCENTIVIZING “MISMATCH EXPERIENCES” – 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 – (EACH TIME AT A MORE RESILIENT LEVEL OF HOMEOSTASIS) 55
  • 56. 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 BEAR – POIGNANT REMINDERS OF THE MINOR COLLAPSES – INJURIES – WE HAVE ALL SUSTAINED – OVER TIME – BUT, ULTIMATELY, TRIUMPHANTLY OVERCOME 56
  • 57. THE ART OF PRECIOUS SCARS
  • 58. HOW DOES THE GOLDILOCKS PRINCIPLE HIGHLIGHT THE CRITICAL ROLE PLAYED BY GETTING IT JUST RIGHT WITH RESPECT TO EXPOSURE TO STRESSORS 58
  • 59. 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 “THERAPEUTIC LEVERAGE” NEEDED TO PROVOKE – AFTER INITIAL DISRUPTION – EVENTUAL RE – EQUILIBRATION AT A HIGHER, MORE EVOLVED LEVEL OF INTEGRATION, FUNCTIONALITY, AND ADAPTIVE CAPACITY OPTIMAL – NONTRAUMATIC – STRESS 59
  • 60. 60
  • 61. STRESS IS WHEN YOU WAKE UP SCREAMING AND THEN YOU REALIZE YOU HAVEN’T FALLEN ASLEEP YET ANONYMOUS 61
  • 62. WHERE DOES MY PSYCHODYNAMIC SYNERGY PARADIGM COME INTO PLAY 62
  • 63. MY PSYCHODYNAMIC SYNERGY PARADIGM FEATURES FIVE INTERDEPENDENT – AND MUTUALLY ENHANCING – APPROACHES TO ADVANCING THE PATIENT FROM RIGID DEFENSE – “SAME OLD, SAME OLD” – TO MORE FLEXIBLE ADAPTATION – “SOMETHING NEW, DIFFERENT, AND BETTER” – MODEL 1 CLASSICAL PSYCHOANALYTIC (1970 – 1980) MODEL 2 SELF PSYCHOLOGICAL (1980 – 1990) MODEL 3 CONTEMPORARY RELATIONAL (1990 – 2000) MODEL 4 EXISTENTIAL – HUMANISTIC (2000 – 2010) MODEL 5 QUANTUM – NEUROSCIENTIFIC (2010 – 2020) 63
  • 64. ALL FIVE MODELS MAKE USE OF “OPTIMAL STRESS” THAT IS, JUST THE RIGHT BALANCE BETWEEN ANXIETY – PROVOKING CHALLENGE AND ANXIETY – ASSUAGING SUPPORT TO CATALYZE TRANSFORMATION OF RIGID DEFENSE INTO MORE FLEXIBLE ADAPTATION MODEL 1 THE INTERPRETIVE PERSPECTIVE OF CLASSICAL PSYCHOANALYSIS RESISTANCE INTO AWARENESS MODEL 2 THE CORRECTIVE – PROVISION PERSPECTIVE OF SELF PSYCHOLOGY RELENTLESS HOPE INTO ACCEPTANCE MODEL 3 THE INTERSUBJECTIVE PERSPECTIVE OF CONTEMPORARY RELATIONAL THEORY RE – ENACTMENT INTO ACCOUNTABILITY MODEL 4 AN EXISTENTIAL – HUMANISTIC APPROACH TO DISCONNECTION FROM SELF AND FROM LIFE ITSELF RELATIONAL ABSENCE INTO AUTHENTIC PRESENCE MODEL 5 A QUANTUM – NEUROSCIENTIFIC APPROACH TO “ANALYSIS PARALYSIS” REFRACTORY INERTIA INTO ACTUALIZING ACTION 64
  • 65. MY PSYCHODYNAMIC SYNERGY PARADIGM – A C.A.R.E. APPROACH TO DEEP HEALING – Cognitive Affective Relational Existential MODEL 1 – COGNITIVE ENHANCEMENT OF KNOWLEDGE “WITHIN” WORKING THROUGH INVOLVES “INTERPRETING INTERNAL CONFLICTEDNESS” – ACCORDING TO SIGMUND FREUD – MODEL 2 – AFFECTIVE PROVISION OF EXPERIENCE “FOR” WORKING THROUGH INVOLVES “GRIEVING RELENTLESS HOPE” – ACCORDING TO MARTHA STARK – MODEL 3 – RELATIONAL ENGAGEMENT IN RELATIONSHIP “WITH” WORKING THROUGH INVOLVES “NEGOTIATING THE TURBULENCE THAT WILL INEVITABLY ARISE AT THE INTIMATE EDGE” – ACCORDING TO DARLENE EHRENBERG – MODEL 4 – EXISTENTIAL NURTURING OF SURRENDER “TO” WORKING THROUGH INVOLVES “OVERCOMING THE DREAD OF SURRENDER TO ANALYTIC ONENESS” – ACCORDING TO MASUD KHAN AND OFRA ESHEL – MODEL 5 – CONSTRUCTIVIST ENVISIONING OF POSSIBILITIES “BEYOND” WORKING THROUGH INVOLVES “DISENTANGLING, ENVISIONING, AND COMMITTING TO ACTION” – ACCORDING TO BRUCE ECKER – 65
  • 66. MY PSYCHODYNAMIC SYNERGY PARADIGM ONGOING AND JUDICIOUS USE OF OPTIMALLY STRESSFUL, GROWTH – INCENTIVIZING INTERVENTIONS STRATEGICALLY DESIGNED TO CREATE DESTABILIZING, DISCONFIRMATORY “MISMATCH EXPERIENCES” MODEL 1 – CONFLICT STATEMENTS WORKING THROUGH THE STRESS OF “COGNITIVE DISSONANCE” MODEL 2 – DISILLUSIONMENT STATEMENTS WORKING THROUGH THE STRESS OF “AFFECTIVE DISILLUSIONMENT” MODEL 3 – ACCOUNTABILITY STATEMENTS WORKING THROUGH THE STRESS OF “RELATIONAL DETOXIFICATION” MODEL 4 – FACILITATION STATEMENTS WORKING THROUGH THE STRESS OF “EXISTENTIAL DEPENDENCE” MODEL 5 – QUANTUM DISENTANGLEMENT STATEMENTS WORKING THROUGH THE STRESS OF “QUANTUM DISENTANGLEMENT” 66
  • 67. 8
  • 69. GROWTH – INCENTIVIZING “MISMATCH EXPERIENCES” – DESTABILIZING VIOLATIONS OF EXPECTATION – WHAT’S COLORED “BLUE” REFERS TO SOMETHING “HEALTHIER” WHAT’S COLORED “RED” REFERS TO SOMETHING “LESS HEALTHY” MODEL 1 YOU KNOW THAT YOUR MOTHER WILL PROBABLY NEVER APOLOGIZE – ANXIETY – PROVOKING CHALLENGE – BUT YOU KEEP HOPING THAT SHE WILL – ANXIETY – ASSUAGING SUPPORT – MODEL 2 YOU HAD SO HOPED THAT JOSE WOULD LEAVE HIS WIFE – ANXIETY – ASSUAGING SUPPORT – BUT YOU ARE BEGINNING TO GET IT THAT PROBABLY HE NEVER WILL, WHICH BOTH ENRAGES AND DEVASTATES YOU – ANXIETY – PROVOKING CHALLENGE – 69
  • 70. MODEL 3 YOU HAD ASSUMED THAT I TOO, LIKE YOUR FATHER, WOULD BE CRITICAL – ANXIETY – ASSUAGING SUPPORT – BUT YOU ARE BEGINNING TO GET IT THAT NOT ALL RELATIONSHIPS WORK THAT WAY – ANXIETY – PROVOKING CHALLENGE – MODEL 4 A PART OF YOU LONGS TO BE SEEN, HEARD, AND UNDERSTOOD – ANXIETY – PROVOKING CHALLENGE – BUT ANOTHER PART OF YOU IS TERRIFIED OF BEING FOUND – ANXIETY – ASSUAGING SUPPORT – MODEL 5 I HATE MY BODY AND AM CONVINCED THAT NOBODY COULD EVER FIND ME ATTRACTIVE – ANXIETY – ASSUAGING SUPPORT – BUT I CAN ENVISION A TIME WHEN I MIGHT BECOME MORE COMFORTABLE IN MY BODY WERE I TO COMMIT TO EXERCISING MORE REGULARLY AND EATING MORE HEALTHILY – ANXIETY – PROVOKING CHALLENGE – 70
  • 71. AS WE HAVE SEEN ANXIETY – PROVOKING CHALLENGE WILL ALMOST INEVITABLY BE A STORY ABOUT ENVISIONING THE ENLIVENING POSSIBILITY OF “SOMETHING NEW, DIFFERENT, AND BETTER” WHEREAS ANXIETY – ASSUAGING SUPPORT WILL ALMOST INEVITABLY BE A STORY ABOUT RESONATING EMPATHICALLY WITH THE CONDITIONED NEED FOR “SAME OLD, SAME OLD” MODEL 1 YOU KNOW THAT YOUR MOTHER WILL PROBABLY NEVER APOLOGIZE – INTRODUCING THE POSSIBILITY OF “SOMETHING MORE REALITY – BASED” – BUT YOU KEEP HOPING THAT SHE WILL – RESONATING WITH THE NEED FOR “SAME OLD, SAME OLD” – MODEL 2 YOU HAD SO HOPED THAT JOSE WOULD LEAVE HIS WIFE – RESONATING WITH THE NEED FOR “SAME OLD, SAME OLD” – BUT YOU ARE BEGINNING TO GET IT THAT PROBABLY HE NEVER WILL, WHICH BOTH ENRAGES AND DEVASTATES YOU – INTRODUCING THE POSSIBILITY OF “SOMETHING MORE REALITY – BASED” – 71
  • 72. MODEL 3 YOU HAD ASSUMED THAT I TOO, LIKE YOUR FATHER, WOULD BE CRITICAL – RESONATING WITH THE RELATIONAL EXPECTATION OF “SAME OLD, SAME OLD” – BUT YOU ARE BEGINNING TO GET IT THAT NOT ALL RELATIONSHIPS WORK THAT WAY – INTRODUCING THE POSSIBILITY OF “SOMETHING MORE REALITY – BASED” – MODEL 4 A PART OF YOU LONGS TO BE SEEN, HEARD, AND UNDERSTOOD – INTRODUCING THE POSSIBILITY OF A “HEALTHIER” WAY OF RELATING – BUT ANOTHER PART OF YOU IS TERRIFIED OF BEING FOUND – RESONATING WITH THE NEED FOR “SAME OLD, SAME OLD” – MODEL 5 I HATE MY BODY AND AM CONVINCED THAT NOBODY COULD EVER FIND ME ATTRACTIVE – RESONATING WITH THE “SAME OLD, SAME OLD” NARRATIVE – BUT I CAN ENVISION A TIME WHEN I MIGHT BECOME MORE COMFORTABLE IN MY BODY WERE I TO COMMIT TO EXERCISING MORE REGULARLY AND EATING MORE HEALTHILY – INTRODUCING THE POSSIBILITY OF A “NEW, DIFFERENT, AND BETTER” NARRATIVE – 72
  • 74. OPTIMALLY STRESSFUL MODEL 1 CONFLICT STATEMENTS DESTABILIZING JUXTAPOSITION OF “ADAPTIVE CAPACITY TO KNOW” WITH “DEFENSIVE NEED TO RESIST THAT KNOWING” “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 WHEN YOU GREW UP IN A HORRIBLY ABUSIVE HOUSEHOLD WITH A MEAN AND NASTY MOTHER WHO KEPT TELLING YOU THAT YOU WERE A LOSER.” “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 HAD TO SUFFER OVER THE COURSE OF THE YEARS.” “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 HAVE BEEN 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!” 56
  • 75. OPTIMALLY STRESSFUL MODEL 2 DISILLUSIONMENT STATEMENTS DESTABILIZING JUXTAPOSITION OF “DEFENSIVE NEED FOR RELENTLESS HOPE” WITH “ADAPTIVE CAPACITY TO CONFRONT THE REALITY OF DISILLUSIONMENT” AND “ADAPTIVE CAPACITY TO GRIEVE AND EVOLVE TO A PLACE OF ACCEPTANCE” “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 THE ANSWERS – AND IT INFURIATES YOU.” “YOU HAD SO HOPED THAT YOUR DAUGHTER WOULD REACH OUT TO YOU WHEN YOU WERE SICK. BUT YOU ARE BEGINNING TO REALIZE THAT, FOR NOW, YOU ARE NOT A TOP PRIORITY FOR HER – AND IT IS A DEVASTATING LOSS.” “YOU WOULD SO HAVE WISHED THAT I COULD KNOW WHAT YOU WERE THINKING WITHOUT YOUR HAVING TO SAY IT. BUT YOU ARE COMING TO SEE THAT IT DOES NOT ALWAYS WORK THIS WAY – AND THAT BREAKS YOUR HEART.” “YOU HAD SO HOPED THAT WE COULD HAVE A PERSONAL RELATIONSHIP. BUT YOU ARE COMING TO REALIZE, ALBEIT RELUCTANTLY, THAT A THERAPY RELATIONSHIP IS NOT REALLY ABOUT FRIENDSHIP PER SE – AND THAT BREAKS YOUR HEART.” 75
  • 76. OPTIMALLY STRESSFUL MODEL 3 ACCOUNTABILITY STATEMENTS DESTABILIZING JUXTAPOSITION OF “DEFENSIVE NEED TO RE – ENACT” WITH “ADAPTIVE CAPACITY FOR ACCOUNTABILITY” “I WONDER IF THIS FEELING I HAVE IN RELATION TO YOU THAT NO MATTER WHAT I SAY IT WON’T BE GOOD ENOUGH IS LIKE THE FEELING YOU HAVE SPOKEN OF HAVING HAD IN RELATION TO YOUR FATHER, FOR WHOM NOTHING WAS EVER GOOD ENOUGH.” “IT OCCURS TO ME THAT WE HAVE MANAGED TO RECREATE IN HERE THE VERY SAME DYNAMIC THAT HAD CHARACTERIZED YOUR RELATIONSHIP WITH YOUR DOUBLE – BINDING FATHER – NAMELY, THE FEELING WE BOTH HAVE THAT NO MATTER WHAT EITHER OF US MIGHT DO, IT WOULDN’T GET THE OTHER’S APPROVAL! BUT ALL OF THIS, FRUSTRATING AS IT IS, GIVES US AN OPPORTUNITY TO EXPERIENCE, FIRSTHAND, HOW TOXIC THE RELATIONSHIP WITH YOUR FATHER REALLY WAS – EXCEPT THAT NOW WE CAN DO SOMETHING ABOUT IT!” “YOU TELL ME SOMETHING ABOUT YOURSELF. I AM JUST IN THE PROCESS OF DIGESTING IT AND STORING IT FOR FURTHER UNDERSTANDING OF YOU AND THEN ALONG YOU COME – WHAM! – AND TELL ME THAT WHAT I HAVE DIGESTED AND STORED INSIDE ME DID NOT COME FROM YOU AT ALL. THE PROBLEM I FIND IS HOW TO LIVE WITH THE DESPAIR I FEEL OCCASIONED BY YOUR DISAPPEARANCES.” CHRISTOPHER BOLLAS (1989) 76
  • 77. OPTIMALLY STRESSFUL MODEL 4 FACILITATION STATEMENTS DESTABILIZING JUXTAPOSITION OF “ADAPTIVE CAPACITY TO LONG FOR AUTHENTIC ENGAGEMENT” WITH “DEFENSIVE NEED TO RETREAT FROM MOMENTS OF MEETING” “A PART OF YOU YEARNS TO BE SEEN, KNOWN, UNDERSTOOD; BUT ANOTHER PART OF YOU IS TERRIFIED OF BEING FOUND.” “YOU FEEL DESPERATELY LONELY AND DISCONNECTED FROM PEOPLE AND WOULD WISH YOU COULD FEEL THAT YOU BELONGED SOMEWHERE; BUT YOU FIND YOURSELF HOLDING BACK FOR FEAR OF BEING DEVASTATINGLY DISAPPOINTED AND LEFT ONCE AGAIN WITH A SHATTERED HEART.” “A PART OF YOU DESPERATELY WISHES THAT YOU COULD FIND JOY IN BEING ALIVE; BUT ANOTHER PART OF YOU IS SO OVERWHELMED WITH DESPAIR ABOUT THE ABSURDITY OF IT ALL THAT YOU CANNOT IMAGINE EVER BEING ABLE TO EXPERIENCE ANYTHING EVEN REMOTELY CLOSE TO GENUINE HAPPINESS.” “A PART OF YOU LONGS TO HAVE A PARTNER WITH WHOM YOU COULD SHARE WHAT YOU HOLD MOST DEAR AND COULD SPEND THE REST OF YOUR LIFE; BUT ANOTHER PART OF YOU CRINGES AT THE THOUGHT OF PUTTING YOURSELF OUT THERE – IT JUST FEELS TOO RISKY TO OPEN YOUR HEART TO POSSIBILITIES.” 77
  • 78. OPTIMALLY STRESSFUL MODEL 5 QUANTUM DISENTANGLEMENT STATEMENTS DESTABILIZING JUXTAPOSITION OF “DEFENSIVE NEED TO REMAIN ENTRENCHED IN SAME OLD, SAME OLD” WITH “ADAPTIVE CAPACITY TO ENVISION POSSIBILITIES, TAKE OWNERSHIP OF THE NEED TO CHANGE, AND COMMIT TO ACTION IN ALIGNMENT WITH SOMETHING NEW, DIFFERENT, AND BETTER” “EVEN THOUGH MY RIGHT BRAIN IS TERRIFIED OF DRIVING BECAUSE I CAN’T SHAKE THE MEMORY OF WHAT HAD HAPPENED WHEN MY FATHER WAS DRIVING DRUNK AND WE HAD A TERRIBLE ACCIDENT AND I VOMITED BECAUSE I WAS SO INCREDIBLY UPSET, MY LEFT BRAIN KNOWS THAT IF I DRIVE CAREFULLY AND PAY CLOSE ATTENTION, THEN THERE IS NO NEED FOR ME TO BE AFRAID BECAUSE I AM A GOOD DRIVER AND AM ALWAYS VERY CAREFUL.” “EVEN THOUGH I GENERALLY ASSUME THAT PEOPLE WILL BE CRITICAL OF ME BECAUSE MY PARENTS WERE SO UNRELENTINGLY JUDGMENTAL, I CAN ENVISION THE POSSIBILITY THAT SOMEDAY I MIGHT BE ABLE TO FREE MYSELF OF MY SELF – CONSCIOUSNESS AND TAKE MORE OWNERSHIP OF MY RIGHT TO BE HERE ON THIS EARTH.” “EVEN THOUGH I FEEL SO ALIENATED FROM EVERYBODY BECAUSE I WAS NEVER MADE TO FEEL THAT I BELONGED WHEN I WAS A KID, I CAN ENVISION THE POSSIBILITY OF SOMEDAY BEING ABLE TO FEEL LESS ALIENATED. I TAKE OWNERSHIP OF MY NEED TO PUT MYSELF OUT THERE MORE AND I HEREBY COMMIT TO BEING MORE ACTIVELY ENGAGED IN MY LIFE GOING FORWARD.” 78
  • 80. AS WE SIT WITH OUR PATIENTS THERE IS ALWAYS TENSION WITHIN US AS WELL DIALECTICAL TENSION BETWEEN ON THE ONE HAND OUR VISION OF WHO WE THINK THE PATIENT COULD BE WERE SHE BUT ABLE / WILLING TO MAKE HEALTHIER CHOICES AND ON THE OTHER HAND OUR RESPECT FOR THE REALITY OF WHO SHE IS AND FOR THE CHOICES, NO MATTER HOW UNHEALTHY, THAT SHE “FINDS HERSELF” FEELING COMPELLED TO MAKE WE ARE THEREFORE ALWAYS STRUGGLING TO FIND AN OPTIMAL BALANCE WITHIN OURSELVES BETWEEN WANTING THE PATIENT TO CHANGE AND ACCEPTING THE REALITY OF WHO SHE IS 80
  • 81. A NEW EARTH: AWAKENING TO YOUR LIFE’S PURPOSE BY ECKART TOLLE (2008) TOLLE WRITES – “AFTER TWO DUCKS GET INTO A FIGHT, WHICH NEVER LASTS LONG, THEY WILL SEPARATE AND FLOAT OFF IN OPPOSITE DIRECTIONS. THEN EACH DUCK WILL FLAP ITS WINGS VIGOROUSLY A FEW TIMES < AS IF TO PROCESS THE INTERNAL TENSION >, THUS RELEASING THE SURPLUS ENERGY THAT < HAD > BUILT UP DURING THE FIGHT. AFTER THEY FLAP THEIR WINGS, THEY < WILL > FLOAT ON PEACEFULLY, AS IF NOTHING HAD EVER HAPPENED.” TOLLE GOES ON TO WRITE – “WE ARE A SPECIES THAT HAS LOST ITS WAY. EVERYTHING NATURAL, EVERY FLOWER OR TREE, AND EVERY ANIMAL HAVE IMPORTANT LESSONS TO TEACH US IF WE < COULD BUT LET OURSELVES > STOP, LOOK, AND LISTEN. OUR DUCK’S LESSON IS THIS: FLAP YOUR WINGS – < LET GO > – AND RETURN TO THE ONLY PLACE OF POWER: THE PRESENT MOMENT.” PROCESS, INTEGRATE, AND MOVE ON, STRONGER FOR HAVING HAD THE STRESSFUL EXPERIENCE AND TRANSCENDED IT … 81
  • 82. 40
  • 83. OUR PATIENTS CAN INDEED BE “SET FREE” IF WE BUT HAVE THE COURAGE TO OFFER THEM OPTIMALLY STRESSFUL INTERVENTIONS THAT WILL PROVIDE BOTH IMPETUS AND OPPORTUNITY FOR THEM TO ADVANCE THROUGH ITERATIVE HEALING CYCLES OF DISRUPTION – IN REACTION TO OUR CHALLENGE – AND REPAIR – IN RESPONSE TO OUR SUPPORT AND BY TAPPING INTO THEIR INNATE ABILITY TO SELF – CORRECT IN THE FACE OF OPTIMAL CHALLENGE – AT EVER HIGHER LEVELS OF RESILIENCE AND ADAPTABILITY SUCH THAT THEY WILL NO LONGER HAVE THE NEED TO CURSE THE DARKNESS BECAUSE THEY WILL NOW HAVE THE CAPACITY TO LIGHT A CANDLE  83
  • 84. 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 IS THERE NOT A CERTAIN BEAUTY IN BROKENNESS, A QUIET STRENGTH WE ACQUIRE 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 … 84
  • 85. 80 “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
  • 86. 86
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  • 88. 88 THANK YOU! STUART AND HIS BROTHER STEWART
  • 89. IF YOU HAVE ANY QUESTIONS OR WOULD LIKE TO BE ON MY MAILING LIST PLEASE EMAIL ME AT MarthaStarkMD @ HMS.Harvard.edu 89
  • 90. REFERENCES Akhtar, S. 2018. Comprehensive dictionary of psychoanalysis. Philadelphia, PA: Routledge (Taylor & Francis Group). Bak, P. 1999. How nature works: The science of self-organized criticality. Gottingen, Germany: Copernicus Publications. Blumenthal, J. A., et al. Effects of exercise training on older patients with major depression. Arch Intern Med 1999;159(19):2349-2356. Ecker, B. 2015. Memory reconsolidation understood and misunderstood. Int J of Neuropsychotherapy Jan;3(1):2-46. Ehrenberg, D. 1992. The intimate edge: Extending the reach of psychoanalytic interaction. New York: W. W. Norton & Company. Eshel, O. 2019. The emergence of analytic oneness: Into the heart of psychoanalysis. Abingdon, Oxfordshire, England: Routledge (Taylor & Francis Group). Freud, S. 1990. The ego and the id – The standard edition of the complete psychological works of Sigmund Freud. New York: W. W. Norton & Company. Hon, E. H., and S. T. Lee. Electronic evaluations of the fetal heart rate patterns preceding fetal death: Further observations. Am J Obstet Gynecol 1965;87:814-826. Khan, M. 2011. The privacy of the self. London, England: Karnac Books. 90
  • 91. REFERENCES Krebs, C. 1998. A revolutionary way of thinking: From a near fatal accident to a new science of healing. Melbourne, Australia: Hill of Content. Leibenluft, E., and T. A. Wehr. Is sleep deprivation useful in the treatment of depression? Am J Psychiatry 1992;149(2):159-168. Matson, M. 2023. The intermittent fasting revolution: The science of optimizing health and enhancing performance. Cambridge, MA: The MIT Press. Mitchell, S. 1988. Relational concepts in psychoanalysis: An integration. Cambridge, MA: Harvard University Press. Nelson, P. 2012. There’s a hole in my sidewalk: The romance of self-discovery. New York: Atria Books. Stark, M. Hormesis, adaptation, and the sandpile model. Crit Rev Toxicol 2008;38(7):641-644. Stark, M. The sandpile model: Optimal stress and hormesis. Dose Response 2012;10(1):66-74. Tolle, E. 2008. A new earth: Awakening to your life’s purpose. London, England: Penguin Books. Zevon, W. 1996. I’ll sleep when I’m dead. Burbank, CA: Elektra Records. 91