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

1. THE ART AND THE SCIENCE
OF INTERPRETATION
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

7. 7
MINIMALLY
STRESS
OPTIMALLY
STRESS
CELEBRATE
REPEAT

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
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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
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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