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Martha Stark MD – 21 Apr 2023 – 1st of 3 Experiential Workshops on The Art and The Science of Interpretation in Embodied Relational Practice.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
IN EMBODIED
RELATIONAL PRACTICE
MARTHA STARK MD
Faculty, Harvard Medical School
MarthaStarkMD @ SynergyMed.solutions
3 (2-hour) Experiential Workshops in Apr / May / Jun 2023
With special appreciation for Robert Downes, Adele Yaron, and Michael Soth
© 2023 Martha Stark MD
1
MY PSYCHODYNAMIC SYNERGY PARADIGM
FIVE INTERDEPENDENT AND MUTUALLY ENHANCING
“MODES OF THERAPEUTIC ACTION”
ALL OF WHICH ARE DESIGNED TO TRANSFORM
LESS EVOLVED DEFENSE
INTO MORE EVOLVED ADAPTATION
MODEL 1 – FROM “RESISTANCE” TO “AWARENESS”
THE INTERPRETIVE PERSPECTIVE
OF CLASSICAL PSYCHOANALYSIS
MODEL 2 – FROM “RELENTLESS HOPE” TO “ACCEPTANCE”
THE CORRECTIVE – PROVISION PERSPECTIVE
OF SELF PSYCHOLOGY
MODEL 3 – FROM “RE – ENACTMENT” TO “ACCOUNTABILITY”
THE INTERSUBJECTIVE PERSPECTVE
OF CONTEMPORARY RELATIONAL THEORY
MODEL 4 – FROM “RELATIONAL ABSENCE” TO “AUTHENTIC PRESENCE”
AN EXISTENTIAL – HUMANISTIC APPROACH
TO MENDING BROKENNESS AND EASING EXISTENTIAL ANGST
MODEL 5 – FROM “REFRACTORY INERTIA” TO “ACTUALIZING ACTION”
A QUANTUM – NEUROSCIENTIFIC APPROACH
TO OVERCOMING NEURAL ENTRENCHMENT AND ANALYSIS PARALYSIS
2
MOMENT – TO – MOMENT
THE “POINT OF EMOTIONAL URGENCY” WILL SUGGEST
THE MODEL(S) THAT WILL BE MOST RELEVANT
FOR UNDERSTANDING
THE PATIENT’S UNDERLYING PSYCHODYNAMICS
AND FOR THEN SELECTING
THE APPROACH THAT WILL BE MOST USEFUL
MODEL 1
– NEUROTIC CONFLICTEDNESS –
HIGHLIGHT THE PATIENT’S AMBIVALENCE / INTERNAL CONFLICTEDNESS
MODEL 2
– NARCISSISTIC WOUNDEDNESS / INJURY / ENTITLEMENT –
FACILITATE THE PATIENT’S GRIEVING OF HER FRUSTRATIONS AND DISAPPOINTMENTS
MODEL 3
– NOXIOUS RELATEDNESS –
NEGOTIATE TRANSFERENCE / COUNTERTRANSFERENCE ENTANGLEMENTS
AND MUTUAL ENACTMENTS AT THE “INTIMATE EDGE” OF RELATEDNESS
MODEL 4
– NONRELATEDNESS –
HIGHLIGHT THE PATIENT’S AMBIVALENCE ABOUT EVEN BEING IN RELATIONSHIP
MODEL 5
– NONACTUALIZATION –
JUXTAPOSE THE SOBERING REALITY OF “WHAT IS”
WITH THE ENLIVENING POSSIBILITY OF “WHAT COULD BE”
3
Martha Stark MD – 21 Apr 2023 – 1st of 3 Experiential Workshops on The Art and The Science of Interpretation in Embodied Relational Practice.pptx
IN ESSENCE
THE WORKING THROUGH PROCESS
IS DESIGNED
TO ADVANCE THE PATIENT FROM
“PSYCHOLOGICAL RIGIDITY”
TO “PSYCHOLOGICAL FLEXIBILITY”
IN THE EVOCATIVE WORDS OF ACCEPTANCE AND COMMITMENT THERAPY (ACT)
AND “LOW – LEVEL DEFENSE”
TO “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”
5
THE TRANSFORMATION PLAYBOOK
FOR THE WORKING THROUGH PROCESS
A “TRIPARTITE” APPROACH THAT DISTINGUISHES THREE STAGES
THE BEGINNING GAME
“MINIMALLY STRESSFUL” INTERVENTIONS
THAT IDENTIFY THE PLAYERS
AND SET THE STAGE FOR THE ACTION THAT WILL FOLLOW
THE MIDDLE GAME
“OPTIMALLY STRESSFUL” INTERVENTIONS
THAT JUXTAPOSE VARIOUS OF THE PLAYERS
TO CREATE GROWTH – INCENTIVIZING “MISMATCH EXPERIENCES”
THE END GAME
“NO STRESS” INTERVENTIONS
THAT CELEBRATE ADAPTIVE RESOLUTION
– EVEN IF ONLY TEMPORARY AND / OR MAKESHIFT –
AND AN “ACTIONABLE GAME PLAN”
– USUALLY ACCOMPANIED BY A “CLICK OF RECOGNITION” –
AND THEN THE ENTIRE SEQUENCE WILL BE REPLAYED AGAIN AND AGAIN
UNTIL THE PRESENTING PROBLEM HAS BECOME A NON – ISSUE
AND SOME OTHER PROBLEM
– NOW UNEARTHED –
CAN BE ADDRESSED
6
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Martha Stark MD – 21 Apr 2023 – 1st of 3 Experiential Workshops on The Art and The Science of Interpretation in Embodied Relational Practice.pptx

  • 1. THE ART AND THE SCIENCE OF INTERPRETATION IN EMBODIED RELATIONAL PRACTICE MARTHA STARK MD Faculty, Harvard Medical School MarthaStarkMD @ SynergyMed.solutions 3 (2-hour) Experiential Workshops in Apr / May / Jun 2023 With special appreciation for Robert Downes, Adele Yaron, and Michael Soth © 2023 Martha Stark MD 1
  • 2. MY PSYCHODYNAMIC SYNERGY PARADIGM FIVE INTERDEPENDENT AND MUTUALLY ENHANCING “MODES OF THERAPEUTIC ACTION” ALL OF WHICH ARE DESIGNED TO TRANSFORM LESS EVOLVED DEFENSE INTO MORE EVOLVED ADAPTATION MODEL 1 – FROM “RESISTANCE” TO “AWARENESS” THE INTERPRETIVE PERSPECTIVE OF CLASSICAL PSYCHOANALYSIS MODEL 2 – FROM “RELENTLESS HOPE” TO “ACCEPTANCE” THE CORRECTIVE – PROVISION PERSPECTIVE OF SELF PSYCHOLOGY MODEL 3 – FROM “RE – ENACTMENT” TO “ACCOUNTABILITY” THE INTERSUBJECTIVE PERSPECTVE OF CONTEMPORARY RELATIONAL THEORY MODEL 4 – FROM “RELATIONAL ABSENCE” TO “AUTHENTIC PRESENCE” AN EXISTENTIAL – HUMANISTIC APPROACH TO MENDING BROKENNESS AND EASING EXISTENTIAL ANGST MODEL 5 – FROM “REFRACTORY INERTIA” TO “ACTUALIZING ACTION” A QUANTUM – NEUROSCIENTIFIC APPROACH TO OVERCOMING NEURAL ENTRENCHMENT AND ANALYSIS PARALYSIS 2
  • 3. MOMENT – TO – MOMENT THE “POINT OF EMOTIONAL URGENCY” WILL SUGGEST THE MODEL(S) THAT WILL BE MOST RELEVANT FOR UNDERSTANDING THE PATIENT’S UNDERLYING PSYCHODYNAMICS AND FOR THEN SELECTING THE APPROACH THAT WILL BE MOST USEFUL MODEL 1 – NEUROTIC CONFLICTEDNESS – HIGHLIGHT THE PATIENT’S AMBIVALENCE / INTERNAL CONFLICTEDNESS MODEL 2 – NARCISSISTIC WOUNDEDNESS / INJURY / ENTITLEMENT – FACILITATE THE PATIENT’S GRIEVING OF HER FRUSTRATIONS AND DISAPPOINTMENTS MODEL 3 – NOXIOUS RELATEDNESS – NEGOTIATE TRANSFERENCE / COUNTERTRANSFERENCE ENTANGLEMENTS AND MUTUAL ENACTMENTS AT THE “INTIMATE EDGE” OF RELATEDNESS MODEL 4 – NONRELATEDNESS – HIGHLIGHT THE PATIENT’S AMBIVALENCE ABOUT EVEN BEING IN RELATIONSHIP MODEL 5 – NONACTUALIZATION – JUXTAPOSE THE SOBERING REALITY OF “WHAT IS” WITH THE ENLIVENING POSSIBILITY OF “WHAT COULD BE” 3
  • 5. IN ESSENCE THE WORKING THROUGH PROCESS IS DESIGNED TO ADVANCE THE PATIENT FROM “PSYCHOLOGICAL RIGIDITY” TO “PSYCHOLOGICAL FLEXIBILITY” IN THE EVOCATIVE WORDS OF ACCEPTANCE AND COMMITMENT THERAPY (ACT) AND “LOW – LEVEL DEFENSE” TO “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” 5
  • 6. THE TRANSFORMATION PLAYBOOK FOR THE WORKING THROUGH PROCESS A “TRIPARTITE” APPROACH THAT DISTINGUISHES THREE STAGES THE BEGINNING GAME “MINIMALLY STRESSFUL” INTERVENTIONS THAT IDENTIFY THE PLAYERS AND SET THE STAGE FOR THE ACTION THAT WILL FOLLOW THE MIDDLE GAME “OPTIMALLY STRESSFUL” INTERVENTIONS THAT JUXTAPOSE VARIOUS OF THE PLAYERS TO CREATE GROWTH – INCENTIVIZING “MISMATCH EXPERIENCES” THE END GAME “NO STRESS” INTERVENTIONS THAT CELEBRATE ADAPTIVE RESOLUTION – EVEN IF ONLY TEMPORARY AND / OR MAKESHIFT – AND AN “ACTIONABLE GAME PLAN” – USUALLY ACCOMPANIED BY A “CLICK OF RECOGNITION” – AND THEN THE ENTIRE SEQUENCE WILL BE REPLAYED AGAIN AND AGAIN UNTIL THE PRESENTING PROBLEM HAS BECOME A NON – ISSUE AND SOME OTHER PROBLEM – NOW UNEARTHED – CAN BE ADDRESSED 6
  • 8. 8
  • 9. STAGE – SETTING MINIMALLY STRESSFUL INTERVENTIONS “BE WITH THE PATIENT WHERE SHE IS” 9
  • 10. MINIMALLY STRESSFUL INTERVENTIONS ARE DESIGNED TO ELICIT “LITTLE OR NO” ANXIETY GENTLY “TEASE OUT” AND “BRING INTO FOCUS” SOME OF THE “DEFENSIVE” AND “LESS HEALTHY” “RECURRING THEMES, HABITUAL PATTERNS, AND CONDITIONED REPETITIONS” IN THE PATIENT’S LIFE THE AIM OF THESE 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 – THAT IS, WHAT IS MOST “EMOTIONALLY RELEVANT” FOR THEM – 10
  • 11. MORE SPECIFICALLY THESE INTERVENTIONS ARE DESIGNED TO HIGHLIGHT BOTH THE PATIENT’S “AFFECT” AND THE “NARRATIVE” WITH WHICH THAT AFFECT IS ASSOCIATED IN ESSENCE THEY MAKE EXPLICIT – AND GIVE SHAPE TO – THE STORIES / THE NARRATIVES THAT THE PATIENT – AS A YOUNG CHILD – HAD CONSTRUCTED IN A DESPERATE ATTEMPT TO MAKE MEANING OF HER WORLD NAMELY 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 EXPOSED 11
  • 12. IMPORTANTLY MANY OF THESE MINIMALLY STRESSFUL INTERVENTIONS ARE ACTUALLY DOING SOMETHING TO WHICH TERRY REAL (2022) REFERS AS “JOINING THROUGH THE TRUTH” – NAMELY, HIGHLIGHTING PAINFUL, DIFFICULT, AND PROBLEMATIC “TRUTHS” THAT THE PATIENT BOTH DOES AND DOESN’T “KNOW” – “WHEN YOU FEEL THAT YOU HAVE BEEN WRONGED, YOU CAN GET PRETTY UGLY IF YOU HAVE TO.” AGAIN ALTHOUGH THESE MINIMALLY STRESSFUL INTERVENTIONS DO NOT SPECIFICALLY “CATALYZE” TRANSFORMATION OF DEFENSE INTO ADAPTATION, THEY DO “LAY THE GROUNDWORK” FOR THE OPTIMALLY STRESSFUL INTERVENTIONS THAT WILL FOLLOW DURING THE MIDDLE GAME 12
  • 13. GROWTH – INCENTIVIZING OPTIMALLY STRESSFUL INTERVENTIONS ALTERNATELY AND REPEATEDLY “BE WITH THE PATIENT WHERE SHE IS” AND “DIRECT HER ATTENTION TO WHERE SHE ISN’T BUT WHERE YOU WOULD WANT HER TO GO” 13
  • 14. THE HEART OF THE THERAPEUTIC ACTION INVOLVES JUDICIOUS AND ONGOING USE OF OPTIMALLY STRESSFUL, GROWTH – INCENTIVIZING INTERVENTIONS STRATEGICALLY DESIGNED TO GENERATE “MISMATCH EXPERIENCES” FOR THE PATIENT, THE WORKING THROUGH – AND RESOLUTION – OF WHICH WILL REQUIRE OF THE PATIENT THAT SHE REVISIT EXPERIENCES THAT HAD ONCE BEEN TRAUMATIC AND TO WHICH SHE HAD THEREFORE REACTED DEFENSIVELY BUT THAT CAN NOW – WITH THE SUPPORT OF HER THERAPIST AND BY TAPPING INTO HER INTERNAL RESERVES – BE REWORKED – RE – ENACTED, GRIEVED, REPROCESSED, REFRAMED – SUCH THAT SHE WILL ULTIMATELY BE ABLE TO “REPOSITION” HERSELF IN RELATION TO THE TRAUMA – ABLE NOW TO RESPOND ADAPTIVELY INSTEAD OF REACTING DEFENSIVELY – IN OTHER WORDS THE PATIENT WILL BE RETURNING – IN AN EMBODIED FASHION – TO THE SCENE OF THE ORIGINAL CRIME BUT WILL NOW BE ABLE TO NEGOTIATE – IN THE CONTEXT OF A THERAPY RELATIONSHIP THAT WILL INVOLVE BOTH THE RE – EXPERIENCING OF “OLD BAD” AND THE EXPERIENCING OF “NEW GOOD” – A DIFFERENT AND BETTER ENDING – AN ADAPTIVE RESOLUTION – 14
  • 15. IN ESSENCE IT WILL BE THIS “INCENTIVIZED” RETURN TO THE SCENE OF THE ORIGINAL CRIME THAT WILL CREATE BOTH IMPETUS AND OPPORTUNITY FOR A “REDO” OF THOSE EARLY – ON TRAUMATIZING EXPERIENCES – AS THE PATIENT COMPULSIVELY AND UNWITTINGLY RE – ENACTS THEM “AT THE INTIMATE EDGE” OF THE THERAPY RELATIONSHIP – DARLENE EHRENBERG (1992) SUCH THAT ULTIMATELY A MUCH DIFFERENT AND MUCH HEALTHIER OUTCOME CAN BE NEGOTIATED AGAIN FROM GROWTH – IMPEDING TRAUMATIC STRESSORS TO GROWTH – INCENTIVIZING OPTIMAL STRESSORS AND, THEREFORE, FROM DEFENSIVE REACTIONS TO ADAPTIVE RESPONSES 15
  • 16. 16 AN ASCENDING SPIRAL STAIRCASE – WHEREBY ONE KEEPS RETURNING TO PLACES THAT HAD APPEARED TO BE RESOLVED AT THE TIME BUT THAT CAN NOW BE SEEN EVER – MORE CLEARLY – CAPTURES BEAUTIFULLY THE ESSENCE OF AN EVER – EVOLVING PROCESS THAT IS BOTH REPETITIOUS AND PROGRESSIVE THE STEPS BETWEEN LANDINGS REPRESENTING STEPS IN THE WORKING THROUGH PROCESS – THE SANDPILE MODEL OF CHAOS THEORY – AND THE LANDINGS THEMSELVES REPRESENTING INTERMEDIATE “ADAPTIVE RESOLUTIONS” / “ACTIONABLE GAME PLANS” / “CONCILIATORY SYNTHESES” ALONG THE WAY UNTIL THE TOP IS REACHED – THE ULTIMATE “SYNTHESIS” OF THE SEEMINGLY IRRECONCILABLE