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Martha Stark MD – 30 Sep 2018 – The Transformative Power of Optimal Stress.pptx

Psychodynamic psychotherapy affords the patient an opportunity – albeit a belated one – to master 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 capacity to cope with stress, be processed, integrated, and ultimately adapted to. This opportunity for belated mastery of traumatic experiences and transformation of defense into adaptation speaks to the power of the transference, whereby the here-and-now is imbued with the primal significance of the there-and-then. Ultimately, the therapeutic goal is to transform less-evolved defense into more-evolved adaptation – from externalizing blame to taking ownership, from whining and complaining to becoming proactive, from dissociating to becoming more present, from feeling victimized to becoming empowered, from being jammed up to harnessing one's energies and then channeling them into the pursuit of one's dreams, from denial to confronting head-on, from being critical to becoming more compassionate, and from cursing the darkness to lighting a candle. 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. In sum, it could be said that, as a result of intensive psychodynamic psychotherapy, "resistance" will be replaced by "awareness" and "actualization of potential," "relentless pursuit of the unattainable" replaced by "acceptance," "re-enactment of unresolved childhood dramas" replaced by "accountability," "retreat and resignation" replaced by "accessibility," and “relentless despair” replaced by “awakened hope.” The focus throughout will be on the interface between theory and clinical practice.

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THE THERAPEUTIC USE
OF OPTIMAL STRESS:
PRECIPITATING DISRUPTION
IN ORDER TO TRIGGER REPAIR
ALSO KNOWN AS
THE THERAPEUTIC USE OF OPTIMAL
STRESS TO PROVOKE RECOVERY
ALSO KNOWN AS
NO PAIN, NO GAIN 
MARTHA STARK, MD
MarthaStarkMD @ HMS.Harvard.edu
CENTER FOR PSYCHOTHERAPY AND PSYCHOANALYSIS OF NEW JERSEY
SUNDAY, SEPTEMBER 30, 2018
THIS MATERIAL IS COPYRIGHTED 1
2
3
4
PREVIEW
THE THERAPEUTIC USE OF “OPTIMAL STRESS”
TO PROVOKE RECOVERY
THE TASK OF THE CHILD (GROWING UP)
THE TASK OF THE PATIENT (GETTING BETTER)
TRANSFORMATION OF DYSFUNCTIONAL DEFENSE
INTO MORE FUNCTIONAL ADAPTATION
WHERE ID WAS, THERE SHALL EGO BE
WHERE DEFENSE WAS, THERE SHALL ADAPTATION BE
AN ONGOING PROCESS INVOLVING
HEALING CYCLES OF DISRUPTION AND REPAIR
THE THERAPIST WILL PRECIPITATE DISRUPTION
IN ORDER TO TRIGGER REPAIR
BY WAY OF “OPTIMALLY STRESSFUL” INTERVENTIONS THAT
ALTERNATELY CHALLENGE AND THEN SUPPORT THE DEFENSE
5
PREVIEW
ITERATIVE CYCLES OF DESTABILIZATION
IN REACTION TO THE CHALLENGE
AND RESTABILIZATION
IN RESPONSE TO THE SUPPORT AND BY
TAPPING INTO THE PATIENT’S UNDERLYING RESILIENCE
AT EVER – HIGHER LEVELS OF
FUNCTIONALITY AND ADAPTIVE CAPACITY
IN ESSENCE
BY CHALLENGING DEFENSES TO WHICH
THE PATIENT HAS LONG CLUNG,
PSYCHODYNAMIC PSYCHOTHERAPY OFFERS
THE PATIENT AN OPPORTUNITY
ALBEIT A BELATED ONE
TO PROCESS, INTEGRATE, AND ADAPT
TO PREVIOUSLY UNMASTERED
AND THEREFORE DEFENDED AGAINST
EARLY – ON EXPERIENCES
6

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  • 1. THE THERAPEUTIC USE OF OPTIMAL STRESS: PRECIPITATING DISRUPTION IN ORDER TO TRIGGER REPAIR ALSO KNOWN AS THE THERAPEUTIC USE OF OPTIMAL STRESS TO PROVOKE RECOVERY ALSO KNOWN AS NO PAIN, NO GAIN  MARTHA STARK, MD MarthaStarkMD @ HMS.Harvard.edu CENTER FOR PSYCHOTHERAPY AND PSYCHOANALYSIS OF NEW JERSEY SUNDAY, SEPTEMBER 30, 2018 THIS MATERIAL IS COPYRIGHTED 1
  • 2. 2
  • 3. 3
  • 4. 4
  • 5. PREVIEW THE THERAPEUTIC USE OF “OPTIMAL STRESS” TO PROVOKE RECOVERY THE TASK OF THE CHILD (GROWING UP) THE TASK OF THE PATIENT (GETTING BETTER) TRANSFORMATION OF DYSFUNCTIONAL DEFENSE INTO MORE FUNCTIONAL ADAPTATION WHERE ID WAS, THERE SHALL EGO BE WHERE DEFENSE WAS, THERE SHALL ADAPTATION BE AN ONGOING PROCESS INVOLVING HEALING CYCLES OF DISRUPTION AND REPAIR THE THERAPIST WILL PRECIPITATE DISRUPTION IN ORDER TO TRIGGER REPAIR BY WAY OF “OPTIMALLY STRESSFUL” INTERVENTIONS THAT ALTERNATELY CHALLENGE AND THEN SUPPORT THE DEFENSE 5
  • 6. PREVIEW ITERATIVE CYCLES OF DESTABILIZATION IN REACTION TO THE CHALLENGE AND RESTABILIZATION IN RESPONSE TO THE SUPPORT AND BY TAPPING INTO THE PATIENT’S UNDERLYING RESILIENCE AT EVER – HIGHER LEVELS OF FUNCTIONALITY AND ADAPTIVE CAPACITY IN ESSENCE BY CHALLENGING DEFENSES TO WHICH THE PATIENT HAS LONG CLUNG, PSYCHODYNAMIC PSYCHOTHERAPY OFFERS THE PATIENT AN OPPORTUNITY ALBEIT A BELATED ONE TO PROCESS, INTEGRATE, AND ADAPT TO PREVIOUSLY UNMASTERED AND THEREFORE DEFENDED AGAINST EARLY – ON EXPERIENCES 6
  • 7. THE SANDPILE MODEL AND THE PARADOXICAL IMPACT OF STRESS 7
  • 8. THE “SANDPILE MODEL” OF CHAOS THEORY SPEAKS TO THE CUMULATIVE IMPACT OVER TIME OF ENVIRONMENTAL STRESSORS ON AN OPEN SYSTEM MORE SPECIFICALLY THIS SIMULATION MODEL OFFERS AN ELEGANT VISUAL METAPHOR FOR HOW ALL OF US ARE CONTINUOUSLY REFASHIONING OURSELVES AT EVER – HIGHER LEVELS OF COMPLEXITY AND INTEGRATION … 8
  • 9. NOT JUST “IN SPITE OF” STRESSFUL INPUT FROM THE OUTSIDE BUT “BY WAY OF” THAT INPUT  9
  • 10. AMAZINGLY ENOUGH THE GRAINS OF SAND BEING STEADILY ADDED TO THE GRADUALLY EVOLVING SANDPILE ARE THE OCCASION FOR BOTH ITS DISRUPTION AND ITS REPAIR NOT ONLY DO THE GRAINS OF SAND BEING ADDED PRECIPITATE PARTIAL COLLAPSE OF THE SANDPILE BUT THEY BECOME THE MEANS BY WHICH THE SANDPILE WILL BE ABLE TO BUILD ITSELF BACK UP EACH TIME AT A NEW LEVEL OF HOMEOSTASIS THE SYSTEM WILL THEREFORE HAVE BEEN ABLE NOT ONLY TO “MANAGE” THE IMPACT OF THE STRESSFUL INPUT BUT ALSO TO “BENEFIT FROM” THAT IMPACT 10
  • 11. AND AS THE SANDPILE EVOLVES, AN UNDERLYING PATTERN WILL BEGIN TO EMERGE, CHARACTERIZED BY ITERATIVE CYCLES OF DISRUPTION AND REPAIR, DESTABILIZATION AND RESTABILIZATION, DEFENSIVE COLLAPSE AND ADAPTIVE RECONSTITUTION … 11
  • 12. … AT EVER – HIGHER LEVELS OF INTEGRATION, BALANCE, AND HARMONY 12
  • 13. WHERE DEFENSE WAS, THERE SHALL ADAPTATION BE 13
  • 14. THE DEVELOPMENTAL PROCESS AND THE THERAPEUTIC PROCESS WHERE DEFENSE WAS, THERE ADAPTATION SHALL BE ID – EGO ID DRIVE – EGO STRUCTURE ID NEED – EGO CAPACITY NEED – CAPACITY DEFENSIVE NEED – ADAPTIVE CAPACITY DEFENSIVE REACTION – ADAPTIVE RESPONSE REACTION – RESPONSE DEFENSE – ADAPTATION 14
  • 15. INDEED, EGO PSYCHOLOGY IS FOUNDED ON THE PREMISE THAT THE EGO DEVELOPS OUT OF NECESSITY … THAT IT EVOLVES AS AN ADAPTATION TO THE EXIGENCIES OF THE ID, THE IMPERATIVES OF THE SUPEREGO, AND THE DEMANDS OF EXTERNAL REALITY ALL OF WHICH ARE ENVIRONMENTAL STRESSORS WHETHER INTERNAL OR EXTERNAL TO WHICH THE EGO WILL EITHER REACT DEFENSIVELY OR RESPOND ADAPTIVELY 15
  • 16. YIN AND YANG – COMPLEMENTARY (NOT OPPOSING) FORCES FOR EXAMPLE, SHADOW CANNOT EXIST WITHOUT LIGHT DEFENSES DYSFUNCTIONAL UNHEALTHY RIGID UNEVOLVED ADAPTATIONS MORE FUNCTIONAL MORE HEALTHY MORE FLEXIBLE MORE EVOLVED 16
  • 17. IN ESSENCE ADAPTATION IS A STORY ABOUT MAKING A VIRTUE OUT OF NECESSITY  17
  • 18. THE ULTIMATE GOAL OF PSYCHODYNAMIC PSYCHOTHERAPY TO FACILITATE THE PROCESSING AND INTEGRATING OF STRESSFUL EXPERIENCES IN BOTH THE THERE – AND – THEN AND THE HERE – AND – NOW FROM DEFENSIVE REACTION TO ADAPTIVE RESPONSE FROM DEFENSE TO ADAPTATION FROM DYSFUNCTIONAL DEFENSE TO MORE FUNCTIONAL ADAPTATION FROM DYSFUNCTIONAL ACTIONS, REACTIONS, AND INTERACTIONS TO MORE FUNCTIONAL WAYS OF BEING AND DOING FROM DYSFUNCTION TO FUNCTIONALITY FROM UNHEALTHY NEED TO HEALTHY CAPACITY 18
  • 19. FROM EXTERNALIZING BLAME TO TAKING OWNERSHIP FROM WHINING AND COMPLAINING TO BECOMING PROACTIVE FROM BEING EVER CRITICAL TO BECOMING MORE COMPASSIONATE FROM DISSOCIATING TO BECOMING MORE PRESENT FROM FEELING VICTIMIZED TO BECOMING MORE EMPOWERED FROM BEING JAMMED UP TO MOBILIZING ONE’S ENERGIES IN THE PURSUIT OF ONE’S DREAMS FROM DENYING TO CONFRONTING HEAD – ON FROM CURSING THE DARKNESS TO LIGHTING A CANDLE 19
  • 20. GROWING UP (THE TASK OF THE CHILD) AND GETTING BETTER (THE TASK OF THE PATIENT) CAN ALSO BE DESCRIBED AS 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 FOR INTERNAL SELF – REGULATION THE NEED TO HOLD ON INTO THE CAPACITY TO LET GO 20
  • 21. PSYCHODYNAMIC SYNERGY (MARTHA STARK 2018) FOUR MODES OF THERAPEUTIC ACTION MUTUALLY ENHANCING NOT MUTUALLY EXCLUSIVE THE THERAPIST WILL BE ABLE TO OPTIMIZE HER EFFECTIVENESS IF SHE IS ABLE TO TRANSITION MOMENT BY MOMENT FROM ONE “STANCE” TO THE NEXT DEPENDING UPON HER ASSESSMENT OF THE “POINT OF EMOTIONAL URGENCY” ALTERNATELY FUNCTIONING AS “NEUTRAL OBJECT,” “EMPATHIC SELFOBJECT,” “AUTHENTIC SUBJECT,” AND “FACILITATING PRESENCE” 21
  • 22. PSYCHODYNAMIC SYNERGY MODEL 1 THE INTERPRETIVE PERSPECTIVE OF CLASSICAL PSYCHOANALYSIS MODEL 2 THE DEFICIENCY – COMPENSATION PERSPECTIVE OF SELF PSYCHOLOGY AND THOSE OBJECT RELATIONS THEORIES EMPHASIZING INTERNAL “ABSENCE OF GOOD” MODEL 3 THE INTERSUBJECTIVE PERSPECTIVE OF CONTEMPORARY RELATIONAL THEORY AND THOSE OBJECT RELATIONS THEORIES EMPHASIZING INTERNAL “PRESENCE OF BAD” MODEL 4 AN EXISTENTIAL – HUMANISTIC PERSPECTIVE 22
  • 23. MODEL 1 – STRUCTURAL CONFLICT THE NEUROTIC DEFENSE OF RELENTLESS CONFLICTEDNESS MODEL 2 – STRUCTURAL DEFICIT THE NARCISSISTIC DEFENSE OF RELENTLESS NEED FOR VALIDATION AND EXTERNAL REINFORCEMENT MODEL 3 – RELATIONAL CONFLICT THE CHARACTER DISORDERED DEFENSE OF RELENTLESS EXTERNALIZATION AND DENIAL OF RESPONSIBILITY MODEL 4 – RELATIONAL DEFICIT THE SCHIZOID DEFENSE OF RELENTLESS DESPAIR AND PSYCHIC RETREAT 23
  • 24. MODEL 1 – STRUCTURAL CONFLICT DYSFUNCTIONAL INTERNAL DYNAMICS NEUROTIC CONFLICTEDNESS MODEL 2 – STRUCTURAL DEFICIT RELENTLESS PURSUIT OF THE UNATTAINABLE NARCISSISTIC VULNERABILITY MODEL 3 – RELATIONAL CONFLICT DYSFUNCTIONAL RELATIONAL DYNAMICS NOXIOUS RELATEDNESS MODEL 4 – RELATIONAL DEFICIT RELENTLESS DESPAIR ABOUT AUTHENTIC BEING – IN – THE – WORLD NONRELATEDNESS 24
  • 25. MODEL 1 – KNOWLEDGE 1 – PERSON PSYCHOLOGY FOCUS ON PATIENT’S INTERNAL DYNAMICS (1) THERAPIST AS NEUTRAL OBJECT (0) MODEL 2 – EXPERIENCE 1½ – PERSON PSYCHOLOGY FOCUS ON PATIENT’S AFFECTIVE EXPERIENCE (1) THERAPIST AS EMPATHIC SELFOBJECT (½) MODEL 3 – RELATIONSHIP 2 – PERSON PSYCHOLOGY FOCUS ON PATIENT’S RELATIONAL DYNAMICS (1) THERAPIST AS AUTHENTIC SUBJECT (1) MODEL 4 – MOMENTS OF MEETING ½ – PERSON PSYCHOLOGY FOCUS ON PATIENT’S TERROR OF BEING FOUND (½) THERAPIST AS FACILITATING PRESENCE (0) 25
  • 26. MODEL 1 – COGNITIVE ENHANCEMENT OF KNOWLEDGE “WITHIN” ULTIMATELY, A STRONGER, WISER, AND MORE EMPOWERED EGO MODEL 2 – AFFECTIVE PROVISION OF CORRECTIVE EXPERIENCE “FOR” ULTIMATELY, A MORE CONSOLIDATED, ACCEPTING, AND COMPASSIONATE SELF MODEL 3 – RELATIONAL ENGAGEMENT IN RESPONSIBLE RELATIONSHIP “WITH” ULTIMATELY, A MORE ACCOUNTABLE SELF – IN – RELATION MODEL 4 – EXISTENTIAL CREATION OF MOMENTS OF MEETING “BETWEEN” ULTIMATELY, MORE AUTHENTIC BEING – IN – THE – WORLD AND A MORE ACCESSIBLE PRIVATE SELF 26
  • 27. THE THERAPEUTIC ACTION MODEL 1 FROM RESISTANCE TO ACKNOWLEDGING PAINFUL TRUTHS ABOUT ONESELF TO AWARENESS OF THOSE PAINFUL TRUTHS MODEL 2 FROM RELENTLESS HOPE AND REFUSAL TO GRIEVE PAINFUL TRUTHS ABOUT ONE’S OBJECTS TO ACCEPTANCE OF THOSE PAINFUL TRUTHS MODEL 3 FROM COMPULSIVE AND UNWITTING RE – ENACTMENT OF UNMASTERED RELATIONAL TRAUMAS TO ACCOUNTABILITY FOR ONE’S DYSFUNCTIONAL ACTIONS, REACTIONS, AND INTERACTIONS MODEL 4 FROM RELENTLESS DESPAIR AND SCHIZOID RETREAT TO AUTHENTIC MOMENTS OF MEETING AND EMOTIONAL ACCESSIBILITY 27
  • 28. ALL FOUR MODELS ARE RELEVANT FOR BOTH “TRAIT” AND “STATE” MODEL 1 FEATURES “NEUROTIC PERSONALITIES” BUT IS ALSO RELEVANT WHEN, IN THE MOMENT, A PATIENT IS “RESISTANT” AND “NOT AWARE” AND WILL BENEFIT FROM A “CONFLICT STATEMENT” MODEL 2 FEATURES “NARCISSISTIC PERSONALITIES” BUT IS ALSO RELEVANT WHEN, IN THE MOMENT, A PATIENT IS “RELENTLESS” AND “NOT ACCEPTING” AND WILL BENEFIT FROM A “DISILLUSIONMENT STATEMENT” MODEL 3 FEATURES “CHARACTER DISORDERS” BUT IS ALSO RELEVANT WHEN, IN THE MOMENT, A PATIENT IS “RE – ENACTING” AND “NOT ACCOUNTABLE” AND WILL BENEFIT FROM AN “ACCOUNTABILITY STATEMENT” MODEL 4 FEATURES “SCHIZOID PERSONALITIES” BUT IS ALSO RELEVANT WHEN, IN THE MOMENT, A PATIENT IS “RETREATING” AND “NOT ACCESSIBLE” AND WILL BENEFIT FROM A “FACILITATION STATEMENT” 28
  • 29. IN WHAT FOLLOWS THE OPERATIVE CONCEPT WILL BE OPTIMAL STRESS 29
  • 30. BAD STUFF HAPPENS BUT IT WILL BE HOW WELL THE PATIENT IS ABLE TO PROCESS, INTEGRATE, AND ADAPT TO ITS IMPACT PSYCHOLOGICALLY, PHYSIOLOGICALLY, AND ENERGETICALLY THAT WILL MAKE OF IT EITHER A GROWTH – DISRUPTING TRAUMA THAT OVERWHELMS BECAUSE IT IS “TOO MUCH” “TRAUMATIC STRESS” OR A GROWTH – PROMOTING OPPORTUNITY THAT MAKES POSSIBLE TRANSFORMATION AND RENEWAL “OPTIMAL STRESS” 30
  • 31. THE GOLDILOCKS PRINCIPLE TOO MUCH CHALLENGE WILL OVERWHELM AND PLUMMET THE PATIENT INTO FURTHER DECLINE BECAUSE IT WILL BE “TOO MUCH” TO BE PROCESSED AND INTEGRATED TRAUMATIC STRESS TOO LITTLE CHALLENGE WILL OFFER “TOO LITTLE” IMPETUS FOR TRANSFORMATION AND GROWTH BUT JUST THE RIGHT AMOUNT OF CHALLENGE WILL PROVIDE “JUST THE RIGHT AMOUNT” OF LEVERAGE NEEDED TO PROVOKE, AFTER INITIAL DISRUPTION, RECONSTITUTION AT A HIGHER LEVEL OF INTEGRATION, FUNCTIONALITY, AND ADAPTIVE CAPACITY OPTIMAL (NONTRAUMATIC) STRESS 31
  • 32. 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 AND SUPPORT WHENEVER NECESSARY BY RESONATING EMPATHICALLY WITH WHERE THE PATIENT IS 32
  • 33. ALL WITH AN EYE TO CREATING JUST THE RIGHT LEVEL OF DESTABILIZING ANXIETY AND INCENTIVIZING STRESS OPTIMAL STRESS THEREBY OPTIMIZING THE PATIENT’S POTENTIAL FOR TRANSFORMATION AND GROWTH BECAUSE … 33
  • 34. WHETHER FUNCTIONAL OR DYSFUNCTIONAL SELF – ORGANIZING (CHAOTIC) SYSTEMS LIKE THE PATIENT’S LONG – ESTABLISHED AND DEEPLY ENTRENCHED “DEFENSIVE STRUCTURES” ARE INHERENTLY RESISTANT TO CHANGE “SELF – ORGANIZING SYSTEMS RESIST PERTURBATION” CHARLES KREBS (2013) 34
  • 35. WHICH MEANS THAT UNLESS A “CHAOTIC” SYSTEM IS SUFFICIENTLY “PERTURBED” THAT IS, SUFFICIENTLY “STRESSED” BY INPUT FROM THE OUTSIDE, THEN IT WILL MAINTAIN ITS STATUS QUO AND AS THIS RELATES TO THE PATIENT UNLESS THE PATIENT’S DYSFUNCTIONAL DEFENSES ARE SUFFICIENTLY “CHALLENGED” BY THE THERAPIST, THEN THERE WILL BE INSUFFICIENT IMPETUS FOR THEIR DESTABILIZATION AND LIMITED OPPORTUNITY FOR THEIR EVENTUAL RESTABILIZATION AS MORE FUNCTIONAL ADAPTATIONS 35
  • 36. IT TOOK ME YEARS TO APPRECIATE SOMETHING THAT IS AT ONCE BOTH PROFOUND AND OBVIOUS INDEED, IT WILL BE INPUT FROM THE OUTSIDE AND THE PATIENT’S CAPACITY TO PROCESS, INTEGRATE, AND ADAPT TO THE IMPACT OF THIS INPUT THAT WILL ULTIMATELY ENABLE THE PATIENT TO GET BETTER 36
  • 37. BUT MORE IMPORTANTLY IT WILL BE “STRESSFUL” INPUT FROM THE OUTSIDE AND THE PATIENT’S CAPACITY TO PROCESS, INTEGRATE, AND ADAPT TO THE IMPACT OF THIS “STRESS” THAT WILL ULTIMATELY PROVOKE THE PATIENT’S RECOVERY 37
  • 38. THERAPEUTIC INTERVENTIONS MUST THEREFORE BE NOT ONLY SUPPORTIVE BUT ALSO SUFFICIENTLY CHALLENGING THAT THEY WILL PROVIDE THE IMPETUS NEEDED FOR DESTABILIZATION OF THE PATIENT’S DEFENSIVE STRUCTURES THERE WILL THEN BE OPPORTUNITY FOR EVENTUAL RESTABILIZATION AT A HIGHER LEVEL OF FUNCTIONALITY AND ADAPTIVE CAPACITY AS A RESULT OF JUMPSTARTING THE PATIENT’S INNATE CAPACITY TO SELF – CORRECT IN THE FACE OF THE OPTIMAL CHALLENGE 38
  • 39. IN ESSENCE AGAINST A BACKDROP OF EMPATHIC ATTUNEMENT AND AUTHENTIC ENGAGEMENT THE THERAPIST BY WAY OF ONGOING “OPTIMALLY STRESSFUL” INTERVENTIONS WILL REPEATEDLY PRECIPITATE RUPTURE IN ORDER TO TRIGGER REPAIR THEREBY GENERATING HEALING CYCLES OF RUPTURE AND REPAIR EVER STRONGER AT THE BROKEN PLACES 39
  • 40. 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 IT IS NOT SO MUCH EMPATHY AS EMPATHIC FAILURE AGAINST A BACKDROP OF EMPATHY OPTIMAL DISILLUSIONMENT THAT WILL PROVIDE THE THERAPEUTIC LEVERAGE NEEDED TO PROVOKE AFTER INITIAL DESTABILIZATION EVENTUAL RESTABILIZATION AT EVER – HIGHER LEVELS OF … 40
  • 41. AWARENESS MODEL 1 ACCEPTANCE MODEL 2 ACCOUNTABILITY MODEL 3 ACCESSIBILITY MODEL 4 ALL OF WHICH ARE ADAPTATIONS TO THE “STRESS OF LIFE” 41
  • 42. AND SO IT IS THAT THE THERAPEUTIC ACTION OF PSYCHODYNAMIC PSYCHOTHERAPY AFFORDS THE PATIENT AN OPPORTUNITY ALBEIT A BELATED ONE TO PROCESS, INTEGRATE, AND ADAPT TO EXPERIENCES THAT HAD ONCE BEEN OVERWHELMING … AND THEREFORE DEFENDED AGAINST 42
  • 43. … BUT THAT CAN NOW WITHIN THE CONTEXT OF SAFETY PROVIDED BY THE PATIENT’S RELATIONSHIP WITH A THERAPIST WHO FUNCTIONS ALTERNATELY AS NEUTRAL OBJECT (MODEL 1) EMPATHIC SELFOBJECT (MODEL 2) AUTHENTIC SUBJECT (MODEL 3) FACILITATING PRESENCE (MODEL 4) BE PROCESSED, INTEGRATED, AND ADAPTED TO THEREBY ENABLING THE PATIENT TO EXTRICATE HERSELF FROM THE BONDS OF HER INFANTILE ATTACHMENTS AND HER AMBIVALENTLY CATHECTED DYSFUNCTION 43
  • 44. AS WE SHALL SOON SEE THERE ARE FOUR APPROACHES TO TRANSFORMING DEFENSE INTO ADAPTATION AND FOUR OPTIMAL STRESSORS THAT FACILITATE THIS “ACTION” MODEL 1 – RESISTANCE INTO AWARENESS BY WORKING THROUGH THE STRESS OF COGNITIVE DISSONANCE THE EXPERIENCE OF GAIN – BECOME – PAIN MODEL 2 – RELENTLESSNESS INTO ACCEPTANCE BY WORKING THROUGH THE STRESS OF AFFECTIVE DISILLUSIONMENT THE EXPERIENCE OF GOOD – BECOME – BAD MODEL 3 – RE – ENACTMENT INTO ACCOUNTABILITY BY WORKING THROUGH THE STRESS OF RELATIONAL DETOXIFICATION THE EXPERIENCE OF BAD – BECOME – GOOD MODEL 4 – RETREAT INTO ACCESSIBILITY BY WORKING THROUGH THE STRESS OF INFANTILE DEPENDENCE THE EXPERIENCE OF HIDDEN – BECOME – FOUND 44
  • 45. “OPTIMALLY STRESSFUL” INTERVENTIONS INITIALLY ANXIETY – PROVOKING BUT ULTIMATELY GROWTH – PROMOTING 45
  • 46. MODEL 1 CONFLICT STATEMENTS ARE DESIGNED TO ENCOURAGE THE “RESISTANT” PATIENT TO STEP BACK FROM THE IMMEDIACY OF THE MOMENT IN ORDER TO TAKE STOCK OF BOTH HER INVESTMENT IN MAINTAINING THINGS AS THEY ARE AND THE PRICE SHE PAYS FOR DOING SO 46
  • 47. MODEL 2 DISILLUSIONMENT STATEMENTS ARE DESIGNED TO FACILITATE THE NECESSARY GRIEVING THAT THE “RELENTLESS” PATIENT MUST DO AS SHE BEGINS TO CONFRONT PAINFUL REALITIES ABOUT THE OBJECTS OF HER DESIRE THEIR LIMITATIONS, SEPARATENESS, AND IMMUTABILITY 47
  • 48. MODEL 3 ACCOUNTABILITY STATEMENTS ARE DESIGNED TO ENCOURAGE THE “RE – ENACTING” PATIENT TO TAKE RESPONSIBILITY FOR THE UNMASTERED RELATIONAL TRAUMAS THAT SHE IS COMPULSIVELY AND UNWITTINGLY REPLAYING ON THE STAGE OF HER LIFE 48
  • 49. MODEL 4 FACILITATION STATEMENTS ARE DESIGNED TO HIGHLIGHT THE “RETREATING” PATIENT’S INTENSE AMBIVALENCE ABOUT EXPERIENCING AUTHENTIC MOMENTS OF MEETING BECAUSE OF EARLY – ON SHATTERING HEARTBREAK – AMBIVALENCE FUELED BY THE PATIENT’S LONGING TO BE SEEN AND TERROR OF BEING FOUND 49
  • 51. MODEL 1 CLASSICAL PSYCHOANALYSTS TEND TO FOCUS ON INTERNAL CONFLICT BETWEEN ANXIETY – PROVOKING ID DRIVES AND ANXIETY – ASSUAGING EGO DEFENSES BUT I HAVE FOUND IT A LITTLE MORE CLINICALLY USEFUL TO CONCEPTUALIZE THIS DRIVE – DEFENSE CONFLICT AS ONE THAT EXISTS BETWEEN ANXIETY – PROVOKING BUT ULTIMATELY EMPOWERING FORCES PRESSING “YES” AND ANXIETY – ASSUAGING (DEFENSIVE) COUNTERFORCES INSISTING “NO” 51
  • 52. MODEL 1 CONFLICT STATEMENTS “OPTIMALLY STRESSFUL” CONFLICT STATEMENTS ALTERNATELY CHALLENGE AND THEN SUPPORT THEY FIRST CHALLENGE BY SPEAKING TO THE PATIENT’S “ADAPTIVE CAPACITY TO KNOW” CERTAIN ANXIETY – PROVOKING REALITIES AND THEN WITH COMPASSION AND NEVER JUDGMENT SUPPORT BY RESONATING EMPATHICALLY WITH THE PATIENT’S “DEFENSIVE NEED TO AVOID KNOWING” THOSE UNCOMFORTABLE TRUTHS 52
  • 53. BE IT SOME UNCOMFORTABLE TRUTH ABOUT HER INTERNAL DYNAMICS, THE PRICE SHE PAYS FOR MAINTAINING HER DYSFUNCTIONAL STATUS QUO, OR THE THERAPEUTIC WORK SHE HAS YET TO DO THE PATIENT DOES INDEED KNOW, “BUT” WOULD RATHER NOT AND THEREFORE, MADE ANXIOUS, SHE DEFENDS 53
  • 54. MODEL 1 CONFLICT STATEMENTS STRATEGICALLY DESIGNED TO GENERATE DESTABILIZING TENSION WITHIN THE PATIENT BETWEEN HER KNOWLEDGE OF ANXIETY – PROVOKING BUT ULTIMATELY GROWTH – PROMOTING (AND EMPOWERING) REALITIES AND THE DEFENSES SHE MOBILIZES IN ORDER TO EASE THAT ANXIETY THEIR FORMAT “YOU KNOW THAT … , BUT YOU FIND YOURSELF … ” FIRST THE THERAPIST CHALLENGES BY HIGHLIGHTING AN ANXIETY – PROVOKING REALITY AND THEN SHE SUPPORTS BY RESONATING EMPATHICALLY WITH THE PATIENT’S ANXIETY – ASSUAGING DEFENSE 54
  • 55. MODEL 1 CONFLICT STATEMENTS “YOU KNOW THAT … , BUT YOU FIND YOURSELF … ” THE THERAPIST FIRST CHALLENGES BY SPEAKING DIRECTLY TO THE PATIENT’S OBSERVING EGO AND ADAPTIVE CAPACITY TO KNOW SOME PAINFUL TRUTH WHICH WILL INCREASE THE PATIENT’S ANXIETY BUT THEN SUPPORTS BY RESONATING EMPATHICALLY WITH THE PATIENT’S EXPERIENCING EGO AND DEFENSIVE NEED TO DENY SUCH KNOWING WHICH WILL DECREASE THE PATIENT’S ANXIETY THE PATIENT DOES INDEED KNOW, “BUT” WOULD RATHER NOT AND THEREFORE, MADE ANXIOUS, SHE DEFENDS AND “FINDS HERSELF” THINKING, FEELING, OR DOING WHATEVER SHE MUST IN ORDER TO PRESERVE THE STATUS QUO OF THINGS 55
  • 56. ANXIETY – PROVOKING BUT ULTIMATELY AWARENESS – PROMOTING INTERVENTIONS FIRST THE REALITY (THAT IS, WHAT THE PATIENT REALLY DOES KNOW) AND THEN THE DEFENSE / THE RESISTANCE (AND WHAT IS FUELING IT) “YOU KNOW THAT ULTIMATELY YOU’LL NEED TO LET JOSE GO BECAUSE HE, LIKE YOUR DAD, REALLY ISN’T AVAILABLE IN THE WAY THAT YOU WOULD HAVE WANTED HIM TO BE; BUT, FOR NOW, ALL YOU CAN THINK ABOUT IS HOW DESPERATELY YOU WANT TO BE WITH HIM AND HOW HORRIBLE IT WOULD BE TO LOSE HIM.” “YOU KNOW THAT EVENTUALLY YOU’LL NEED TO MAKE YOUR PEACE WITH THE REALITY OF JUST HOW LIMITED YOUR MOTHER IS; BUT YOUR FEAR IS THAT WERE YOU EVER TO LET YOURSELF REALLY FEEL THE PAIN OF THAT, YOU WOULD NEVER RECOVER.” “YOU KNOW THAT SOMEDAY YOU’LL HAVE TO LET SOMEBODY IN IF YOU’RE EVER TO HAVE A MEANINGFUL RELATIONSHIP; BUT, IN THE MOMENT, THE THOUGHT OF MAKING YOURSELF THAT VULNERABLE IS SIMPLY INTOLERABLE. THERE’S NO WAY YOU’RE WILLING TO RUN THE RISK OF BEING HURT EVER AGAIN.” 56
  • 57. JUST AS WITH THE EVER – EVOLVING SANDPILE MODEL OF CHAOS THEORY SO TOO THE MODEL 1 THERAPIST WILL BE GENERATING ITERATIVE CYCLES OF DISRUPTION AND REPAIR BY WAY OF STRATEGICALLY DESIGNED CONFLICT STATEMENTS THAT ALTERNATELY CHALLENGE AND THEN SUPPORT THEREBY PROVIDING BOTH IMPETUS AND OPPORTUNITY FOR THE MODEL 1 PATIENT GRADUALLY TO EVOLVE FROM “DEFENSIVE RESISTANCE” TO EVER – HIGHER LEVELS OF “ADAPTIVE AWARENESS” 57
  • 58. ONGOING CHALLENGE AND THEN SUPPORT ANXIETY – PROVOKING, THEN ANXIETY – ASSUAGING COGNITIVE, THEN AFFECTIVE HEAD, THEN HEART KNOWLEDGE, THEN EXPERIENCE OBJECTIVE, THEN SUBJECTIVE OBSERVING EGO, THEN EXPERIENCING EGO ADULT, THEN CHILD RATIONAL, THEN IRRATIONAL RESPONSE, THEN REACTION LEFT BRAIN, THEN RIGHT BRAIN ADAPTIVE CAPACITY, THEN DEFENSIVE NEED ADAPTATION, THEN DEFENSE 58
  • 59. MODEL 1 CONFLICT STATEMENTS “YOU KNOW THAT ULTIMATELY YOU WILL NEED TO CONFRONT – AND GRIEVE – THE REALITY THAT TOM IS NOT AVAILABLE IN THE WAYS THAT YOU WOULD HAVE WANTED HIM TO BE AND THAT UNTIL YOU MAKE YOUR PEACE WITH THAT PAINFUL REALITY YOU WILL CONTINUE TO BE MISERABLE; BUT, IN THE MOMENT, ALL YOU CAN THINK ABOUT IS HOW ANGRY YOU ARE THAT HE DOESN’T TELL YOU MORE OFTEN THAT HE LOVES YOU.” “YOU KNOW THAT YOU WON’T FEEL TRULY FULFILLED UNTIL YOU ARE ABLE TO GET YOUR THESIS COMPLETED; BUT YOU CONTINUE TO STRUGGLE, FEARING THAT WHATEVER YOU MIGHT WRITE JUST WOULDN’T BE GOOD ENOUGH OR CAPTURE WELL ENOUGH THE ESSENCE OF WHAT YOU ARE TRYING TO SAY.” “YOU KNOW THAT IF YOUR RELATIONSHIP WITH ELANA IS TO SURVIVE, YOU WILL NEED TO TAKE AT LEAST SOME RESPONSIBILITY FOR THE PART YOU PLAY IN THE INCREDIBLY ABUSIVE FIGHTS THAT YOU AND SHE ARE HAVING; BUT YOU TELL YOURSELF THAT IT ISN’T REALLY YOUR FAULT BECAUSE IF SHE WEREN’T SO PROVOCATIVE, THEN YOU WOULDN’T HAVE TO BE SO VINDICTIVE!” 59
  • 60. BY CALLING THE PATIENT’S ATTENTION TO THE CONFLICT THAT EXISTS WITHIN HER BETWEEN THE “OBJECTIVE REALITY” THAT SHE “KNOWS” WITH HER HEAD AND THE “SUBJECTIVE EXPERIENCE” THAT SHE “FEELS” WITH HER HEART MODEL 1 CONFLICT STATEMENTS CAN BE STRATEGICALLY FORMULATED TO PRECIPITATE (DEFENSIVE) DISRUPTION IN ORDER TO TRIGGER (ADAPTIVE) REPAIR 60
  • 61. MODEL 1 CONFLICT STATEMENTS “YOU KNOW THAT EVENTUALLY YOU’LL NEED TO FACE THE REALITY THAT YOUR MOTHER WAS NEVER REALLY THERE FOR YOU AND THAT YOU WON’T GET BETTER UNTIL YOU LET GO OF YOUR HOPE THAT MAYBE SOMEDAY YOU’LL BE ABLE TO MAKE HER CHANGE; BUT YOU’RE NOT QUITE YET READY TO DEAL WITH ALL THE PAIN AROUND THAT BECAUSE YOU ARE AFRAID THAT YOU MIGHT NEVER SURVIVE THE HEARTBREAK AND DESPAIR YOU WOULD FEEL WERE YOU TO FACE THAT DEVASTATING REALITY.” “YOU KNOW THAT YOUR NEED FOR YOUR CHILDREN TO UNDERSTAND YOUR PERSPECTIVE MIGHT BE A BIT UNREALISTIC; BUT YOU TELL YOURSELF THAT YOU HAVE A RIGHT TO THEIR RESPECT – AND THEIR FORGIVENESS.” “YOU’RE COMING TO UNDERSTAND THAT YOUR ANGER CAN PUT PEOPLE OFF; BUT YOU TELL YOURSELF THAT YOU HAVE A RIGHT TO BE AS ANGRY AS YOU WANT BECAUSE OF HOW MUCH YOU HAVE SUFFERED OVER THE YEARS.” “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 WAS ALWAYS CALLING YOU A LOSER.” 61
  • 62. IN ORDER TO INCREASE THE PATIENT’S AWARENESS OF HER AMBIVALENT ATTACHMENT TO HER DYSFUNCTION THE MODEL 1 THERAPIST ALTERNATELY CHALLENGES BY HIGHLIGHTING WHAT THE PATIENT IS COMING TO UNDERSTAND AS THE PRICE SHE PAYS FOR CLINGING TO HER DYSFUNCTION A “PRICE PAID” THAT FUELS THE PATIENT’S AGGRESSIVE CATHEXIS OF THE DEFENSE AND THEN SUPPORTS BY RESONATING EMPATHICALLY WITH WHAT THE THERAPIST IS COMING TO UNDERSTAND AS THE INVESTMENT THE PATIENT HAS IN HOLDING ON TO HER DYSFUNCTION EVEN SO AN “INVESTMENT IN” THAT FUELS THE PATIENT’S LIBIDINAL CATHEXIS OF THE DEFENSE BACK AND FORTH – BACK AND FORTH IN AN EFFORT TO MAKE THE AMBIVALENTLY HELD DEFENSE LESS EGO – SYNTONIC AND MORE EGO – DYSTONIC 62
  • 63. IN ESSENCE MODEL 1 CONFLICT STATEMENTS STRIVE TO CREATE INCENTIVIZING TENSION WITHIN THE PATIENT BETWEEN HER DAWNING AWARENESS OF JUST HOW COSTLY HER DEFENSES ARE WITH AN EYE TO MAKING THEM MORE EGO – DYSTONIC AND HER NEW – FOUND UNDERSTANDING OF JUST HOW INVESTED SHE HAS BEEN IN HOLDING ON TO THEM EVEN SO WITH AN EYE TO HIGHLIGHTING HOW EGO – SYNTONIC THEY ARE ULTIMATELY THE EVER – INCREASING INTERNAL DISSONANCE RESULTING FROM HER EVER – EVOLVING AWARENESS OF BOTH THE COST AND THE BENEFIT OF MAINTAINING HER ATTACHMENT TO HER DYSFUNCTIONAL DEFENSES WILL GALVANIZE HER TO TAKE ACTION IN ORDER TO RESOLVE THE INTERNAL TENSION 63
  • 64. THE MODEL 1 THERAPIST THEREFORE REPEATEDLY HIGHLIGHTS BOTH “PRICE PAID” (PAIN) AND “INVESTMENT IN” (GAIN) AS LONG AS THE “GAIN” IS GREATER THAN THE “PAIN” EGO – SYNTONIC GREATER THAN EGO – DYSTONIC THE PATIENT WILL “MAINTAIN” THE DEFENSE AND “REMAIN” ENTRENCHED BUT AS A RESULT OF THE PATIENT’S EVER – EVOLVING AWARENESS ONCE THE “PAIN” BECOMES GREATER THAN THE “GAIN” EGO – DYSTONIC GREATER THAN EGO – SYNTONIC THE STRESS AND “STRAIN” OF THE COGNITIVE AND AFFECTIVE DISSONANCE BETWEEN “PAIN” AND “GAIN” WILL PROVIDE THE IMPETUS NEEDED FOR THE PATIENT GRADUALLY … 64
  • 65. … TO RELINQUISH HER ATTACHMENT TO THE DYSFUNCTIONAL DEFENSE THEREBY RESOLVING THE STRUCTURAL CONFLICT NEUROTIC / INTRAPSYCHIC CONFLICT THAT HAD EXISTED BETWEEN THE THWARTED BUT ULTIMATELY GROWTH – PROMOTING ID DRIVE AND THE GROWTH – IMPEDING EGO DEFENSE 65
  • 66. AS A RESULT OF “WORKING THROUGH” THE PATIENT’S “RESISTANCE” THE NOW STRONGER AND MORE AWARE EGO WILL BE BETTER ABLE TO “REGULATE” THE ID’S NOW TAMER AND MORE MANAGEABLE ENERGIES SUCH THAT, NO LONGER THWARTED, THEIR POWER CAN BE HARNESSED AND CHANNELED INTO CONSTRUCTIVE ENDEAVORS AND WORTHY PURSUITS 66
  • 67. IN OTHER WORDS ONGOING USE OF MODEL 1 CONFLICT STATEMENTS WILL GENERATE HEALING CYCLES OF DISRUPTION IN REACTION TO THE CHALLENGE AND REPAIR IN RESPONSE TO THE SUPPORT AT EVER – HIGHER LEVELS OF ADAPTIVE CAPACITY SUCH THAT ID “ENERGY” ONCE “REINED IN” BY EGO “RESISTANCE” CAN BE FREED UP AND PUT TO GOOD USE 67
  • 68. FREUD’S “HORSE AND RIDER” IS INDEED AN APT METAPHOR FOR THE THERAPEUTIC ACTION IN MODEL 1 FREUD’S RIDER A NOW STRONGER AND MORE EMPOWERED EGO BY VIRTUE OF THE GREATER AWARENESS IT HAS OF ITS INTERNAL CONFLICTEDNESS BECOMES MORE SKILLED AT HARNESSING THE QUANTUM POWER OF THE HORSE A NOW BETTER REGULATABLE ID BY VIRTUE OF THE WORKING THROUGH PROCESS, WHICH HAS TAMED, MODIFIED, AND INTEGRATED ITS ENERGIES SUCH THAT HORSE AND RIDER WILL NOW BE ABLE TO MOVE FORWARD HARMONIOUSLY AND MORE IN SYNC NO LONGER IN CONFLICT BUT IN COLLABORATION 68
  • 69. IN ESSENCE THE DEFENSIVE NEED TO “REIN THE HORSE IN” WILL HAVE BECOME GRADUALLY TRANSFORMED INTO THE ADAPTIVE CAPACITY TO “GIVE THE HORSE FREE REIN” AS STRUCTURAL CONFLICT EVOLVES INTO STRUCTURAL COLLABORATION AND “JAMMED UP” EVOLVES INTO “EMPOWERED” AND “ACTUALIZED” 69
  • 70. PARENTHETICALLY 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” MAKING 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 70
  • 71. IMPORTANTLY MODEL 1 CONFLICT STATEMENTS BY LOCATING WITHIN THE PATIENT THE CONFLICT BETWEEN HER ANXIETY – PROVOKING KNOWLEDGE OF A DISTRESSING REALITY AND HER ANXIETY – ASSUAGING NEED TO AVOID DEALING WITH IT, THE THERAPIST IS DEFTLY SIDESTEPPING THE POTENTIAL FOR CONFLICT BETWEEN THE PATIENT AND HERSELF 71
  • 72. WHEN THE THERAPIST INTRODUCES A CONFLICT STATEMENT WITH “YOU KNOW THAT … ” SHE IS FORCING THE PATIENT TO TAKE RESPONSIBILITY FOR WHAT THE PATIENT REALLY DOES KNOW BUT IF THE THERAPIST IN A MISGUIDED ATTEMPT TO URGE THE PATIENT FORWARD RESORTS SIMPLY TO TELLING THE PATIENT WHAT THE THERAPIST KNOWS, NOT ONLY DOES THE THERAPIST RUN THE RISK OF FORCING THE PATIENT TO BECOME EVEN MORE ENTRENCHED IN HER DEFENSIVE STANCE OF PROTEST BUT ALSO THE THERAPIST WILL BE ROBBING THE PATIENT OF ANY INCENTIVE TO TAKE RESPONSIBILITY FOR HER OWN DESIRE TO GET BETTER 72
  • 73. TO REPEAT THE THERAPIST WHO IS ABLE TO RESIST THE TEMPTATION TO “GET BOSSY” BY OVERZEALOUSLY ADVOCATING FOR THE PATIENT TO DO THE “RIGHT” THING WILL BE ABLE MASTERFULLY TO AVOID GETTING DEADLOCKED IN A POWER STRUGGLE WITH THE PATIENT SUCH A STRUGGLE CAN EASILY ENOUGH ENSUE WHEN THE THERAPIST TAKES IT UPON HERSELF TO REPRESENT THE “VOICE OF REALITY” A STANCE THAT THEN LEAVES THE PATIENT NO OPTION BUT TO BECOME THE “VOICE OF OPPOSITION” 73
  • 74. IT TRULY IS AN UNTENABLE SITUATION FOR THE THERAPIST TO BE THE ONE REPRESENTING THE HEALTHY (ADAPTIVE) “VOICE OF YES” AND FOR THE PATIENT, MADE ANXIOUS, TO BE THEN STUCK IN THE POSITION OF HAVING TO COUNTER WITH THE UNHEALTHY (DEFENSIVE) “VOICE OF NO” AND SO IT IS THAT IN THE FIRST PART OF A CONFLICT STATEMENT, THE THERAPIST HIGHLIGHTS WHAT THE PATIENT, AT LEAST ON SOME LEVEL, REALLY DOES KNOW IN ESSENCE BY LOCATING THE CONFLICT SQUARELY WITHIN THE PATIENT AND NOT IN THE INTERSUBJECTIVE FIELD BETWEEN THERAPIST AND PATIENT, CONFLICT STATEMENTS FORCE THE PATIENT TO TAKE OWNERSHIP OF BOTH SIDES OF HER AMBIVALENCE ABOUT GETTING BETTER BOTH THE “YES FORCES” AND THE “NO COUNTERFORCES” MOBILIZED IN REACTION TO THOSE “YES FORCES” 74
  • 75. ALSO NOTE THE IMPLICIT MESSAGE DELIVERED BY THE THERAPIST IN THE SECOND PART OF A CONFLICT STATEMENT WHEN SHE USES SUCH TEMPORAL EXPRESSIONS AS “FOR NOW” – “RIGHT NOW” “AT THE MOMENT” – “IN THE MOMENT” “AT THIS POINT IN TIME” WHICH SHE WILL DO WHEN SHE IS ADDRESSING THE PATIENT’S “INVESTMENT IN” THE DYSFUNCTIONAL DEFENSE “YOU KNOW YOU’RE PAYING A STEEP PRICE FOR YOUR REFUSAL TO STOP SMOKING, OF PARTICULAR CONCERN BECAUSE OF YOUR RECURRENT LUNG INFECTIONS; BUT, IN THE MOMENT, YOU FIND YOURSELF FEELING THAT YOU SIMPLY MUST HAVE THE CIGARETTES IN ORDER TO RELIEVE THE MASSIVE ANXIETY THAT YOU ARE FEELING BECAUSE OF THE LAWSUIT.” THE THERAPIST IS ATTEMPTING TO HIGHLIGHT THE FACT THAT EVEN IF, FOR NOW, THE PATIENT WOULD SEEM TO BE INVESTED IN PROTESTING HER RIGHT TO MAINTAIN THINGS AS THEY ARE, AT ANOTHER POINT IN TIME THAT COULD CHANGE 75
  • 76. IN SUM “OPTIMALLY STRESSFUL” CONFLICT STATEMENTS ARE DESIGNED TO PROVOKE THE RELINQUISHMENT OF DYSFUNCTIONAL DEFENSES BY GENERATING COGNITIVE AND AFFECTIVE DISSONANCE THE WISDOM OF THE BODY IS SUCH THAT IT CANNOT TOLERATE THE DISTRESS OF DISEQUILIBRIUM FOR AN EXTENDED PERIOD OF TIME AND WILL THEREFORE BE “PROVOKED” TO TAKE ACTION IN ORDER TO RESOLVE THE INTERNAL TENSION AND RESTORE ORDER 76
  • 77. ULTIMATELY, IT WILL BE THE PATIENT’S EVER – EVOLVING CAPACITY TO RECOGNIZE THE FUNDAMENTAL CONFLICT BETWEEN COST AND BENEFIT THAT WILL SIMPLY FORCE HER TO RELINQUISH HER DYSFUNCTION THAT IS, TO SURRENDER HER UNHEALTHY DEFENSES DESPITE THEIR ERSTWHILE ROBUSTNESS IN FAVOR OF HEALTHIER ADAPTATIONS AS SHE EVOLVES FROM “DEFENSIVE RESISTANCE” TO “ADAPTIVE AWARENESS” AND EXPANDED CONSCIOUSNESS 77
  • 78. NATURE vs. NURTURE I – IT vs. I – THOU RELATIONSHIPS MODEL 1 vs. MODEL 2 AND MODEL 3 78
  • 79. MODEL 1 WHAT DERIVES FROM WITHIN THE CHILD NATURE MODEL 2 AND MODEL 3 WHAT DERIVES FROM WITHIN THE RELATIONSHIP BETWEEN PARENT AND CHILD NURTURE 79
  • 80. AS WE HAVE JUST SEEN CLASSICAL PSYCHOANALYSTS CONCEIVE OF PSYCHOPATHOLOGY AS DERIVING FROM THE PATIENT IN WHOM THERE IS THOUGHT TO BE INTERNAL CONFLICT BETWEEN A WEAK EGO AND AN UNTAMED ID BUT SELF PSYCHOLOGISTS AND OBJECT RELATIONS THEORISTS CONCEIVE OF PSYCHOPATHOLOGY AS DERIVING FROM THE PARENT AND THE PARENT’S FAILURE OF THE CHILD 80
  • 81. IN OTHER WORDS SELF PSYCHOLOGISTS AND OBJECT RELATIONS THEORISTS FOCUS NOT SO MUCH ON NATURE THE PROVINCE OF MODEL 1 AS ON NURTURE THE PROVINCE OF MODEL 2 AND MODEL 3 WHETHER THE QUALITY OF PARENTAL CARE MODEL 2 OR THE MUTUALITY OF FIT BETWEEN PARENT AND CHILD MODEL 3 81
  • 82. BUT PLEASE NOTE THE CRITICAL DISTINCTION BETWEEN QUALITY OF PARENTAL CARE A STORY ABOUT “GIVE” WHICH MAKES OF MODEL 2 A 1½ – PERSON PSYCHOLOGY AND MUTUALITY OF FIT A STORY ABOUT “GIVE – AND – TAKE” WHICH MAKES OF MODEL 3 A 2 – PERSON PSYCHOLOGY 82
  • 83. MODEL 2 AN “I – IT” RELATIONSHIP A 1 – WAY RELATIONSHIP BETWEEN SOMEONE WHO GIVES AND SOMEONE WHO TAKES MODEL 3 AN “I – THOU” RELATIONSHIP A 2 – WAY RELATIONSHIP INVOLVING GIVE – AND – TAKE, MUTUALITY, RECIPROCITY, AND COLLABORATION MARTIN BUBER (1923) 83
  • 84. IMPORTANTLY AS THE ETIOLOGY HAS SHIFTED FROM NATURE (MODEL 1) TO NURTURE (MODEL 2 AND MODEL 3), SO TOO THE LOCUS OF THE THERAPEUTIC ACTION HAS SHIFTED FROM “INSIGHT BY WAY OF INTERPRETATION” TO “A CORRECTIVE EXPERIENCE BY WAY OF THE REAL RELATIONSHIP” THAT IS, FROM WITHIN THE PATIENT TO WITHIN THE RELATIONSHIP BETWEEN THERAPIST AND PATIENT 84
  • 85. BUT ALTHOUGH THERE ARE STILL SOME WHO WRITE ABOUT “A CORRECTIVE EXPERIENCE BY WAY OF THE REAL RELATIONSHIP,” THIS TELESCOPES TWO DIFFERENT CONCEPTS AND OBFUSCATES THE CRITICAL DISTINCTION BETWEEN A THERAPY RELATIONSHIP THAT INVOLVES GIVE AND A THERAPY RELATIONSHIP THAT INVOLVES GIVE – AND – TAKE A “CORRECTIVE EXPERIENCE” IN THE FIRST INSTANCE (MODEL 2) A “REAL RELATIONSHIP” IN THE SECOND (MODEL 3) 85
  • 86. MODEL 2 THEORISTS FOCUS ON THE PRICE THE CHILD PAYS BECAUSE OF WHAT THE PARENT DID NOT DO DEPRIVATION AND NEGLECT “ABSENCE OF GOOD” DEFICIENCY INTERNALLY RECORDED IN THE FORM OF STRUCTURAL DEFICIT AND IMPAIRED CAPACITY TO BE A GOOD PARENT UNTO ONESELF DEFICITS THAT THEN GIVE RISE TO DESPERATE SEARCHES FOR A NEW GOOD PARENT “RELENTLESS PURSUITS” IN AN EFFORT TO COMPENSATE FOR EARLY – ON PARENTAL ERRORS OF OMISSION 86
  • 87. MODEL 3 THEORISTS FOCUS ON THE PRICE THE CHILD PAYS BECAUSE OF WHAT THE PARENT DID DO TRAUMA AND ABUSE “PRESENCE OF BAD” TOXICITY INTERNALLY RECORDED AND STRUCTURALIZED IN THE FORM OF PATHOGENIC INTROJECTS THAT ARE THEN “COMPULSIVELY AND UNWITTINGLY” DELIVERED INTO ONE’S RELATIONSHIPS AGAIN AND AGAIN IN DESPERATE ATTEMPTS TO ENCOUNTER DIFFERENT OUTCOMES THIS NEXT TIME “COMPULSIVE REPETITIONS” IN AN EFFORT TO CORRECT FOR EARLY – ON PARENTAL ERRORS OF COMMISSION 87
  • 89. MODEL 2 EMPATHIC ATTUNEMENT THE MODEL 2 THERAPIST AS AN EMPATHIC SELFOBJECT “DECENTERS” FROM HER OWN EXPERIENCE, JOINS ALONGSIDE THE PATIENT, AND “TAKES ON” THE PATIENT’S EXPERIENCE BUT ONLY “AS IF” IT WERE HER OWN BECAUSE IT NEVER ACTUALLY BECOMES HER OWN 89
  • 90. MODEL 3 AUTHENTIC ENGAGEMENT THE MODEL 3 THERAPIST AS AN AUTHENTIC SUBJECT REMAINS VERY MUCH “CENTERED” WITHIN HER OWN EXPERIENCE AND ALLOWS THE PATIENT’S EXPERIENCE TO “ENTER INTO” HER THEREBY TAKING IT ON “AS” HER OWN AND ALLOWING HERSELF TO BE CHANGED BY IT THE MODEL 3 THERAPIST “USES” HER “SELF” TO FIND, AND TO BE FOUND BY, THE PATIENT 90
  • 91. MODEL 2 AS AN EMPATHIC SELFOBJECT THE THERAPIST PROVIDES A CORRECTIVE EXPERIENCE “FOR” THE PATIENT MODEL 3 AS AN AUTHENTIC SUBJECT THE THERAPIST PARTICIPATES IN A REAL RELATIONSHIP “WITH” THE PATIENT 91
  • 92. AS WE SHALL SEE THE THERAPIST’S PARTICIPATION AS AN AUTHENTIC SUBJECT MODEL 3 WILL ALMOST INVARIABLY RESULT IN THE THERAPIST’S PARTICIPATION AS THE OLD BAD OBJECT BECAUSE OF THE PATIENT’S EVER – PRESENT “COMPULSIVE AND UNWITTING” NEED THAT IS, HER REPETITION COMPULSION TO RE – CREATE THE EARLY – ON UNMASTERED RELATIONAL FAILURES IN THE HERE – AND – NOW ENGAGEMENT WITH HER THERAPIST 92
  • 93. THE REPETITION COMPULSION BOTH UNHEALTHY AND HEALTHY COMPONENTS THE UNHEALTHY COMPONENT HAS TO DO WITH THE PATIENT’S NEED TO HAVE MORE OF SAME, NO MATTER HOW DYSFUNCTIONAL, BECAUSE THAT IS ALL THE PATIENT HAS EVER KNOWN HAVING SOMETHING DIFFERENT WOULD CREATE ANXIETY BUT THE HEALTHY PIECE HAS TO DO WITH THE PATIENT’S NEED TO ACHIEVE BELATED MASTERY OF THE PARENTAL FAILURES 93
  • 94. “IF THE THERAPIST DOES NOT PARTICIPATE AS A NEW GOOD OBJECT, THE THERAPY MAY NEVER GET UNDER WAY. “BUT IF HE DOES NOT PARTICIPATE AS THE OLD BAD ONE, IT MAY NEVER END.” JAY GREENBERG (1986) I WOULD WANT TO ADD, HOWEVER, THAT IF THE THERAPIST DOES NOT PARTICIPATE AS THE OLD BAD OBJECT, THE THERAPY MAY NEVER GET UNDER WAY. BUT IF SHE DOES NOT PARTICIPATE AS A NEW GOOD ONE, IT MAY NEVER END. 94
  • 95. BOTH OF WHICH CAPTURE BEAUTIFULLY THE DELICATE BALANCE THAT EXISTS BETWEEN THE THERAPIST’S PARTICIPATION AS A NEW GOOD OBJECT SO THAT THERE CAN BE A STARTING OVER AND THE THERAPIST’S PARTICIPATION AS THE OLD BAD ONE SO THAT THERE CAN BE AN OPPORTUNITY TO ACHIEVE BELATED MASTERY OF THE INTROJECTED RELATIONAL TRAUMAS 95
  • 96. IN OTHER WORDS, OVER THE COURSE OF A TREATMENT, THE PATIENT SHOULD HAVE AN OPPORTUNITY TO EXPERIENCE HER THERAPIST AS BOTH A NEW GOOD OBJECT AND THE OLD BAD ONE MODEL 2 – STRUCTURAL GROWTH BY WORKING THROUGH THE EXPERIENCE OF GOOD – BECOME – BAD ILLUSION FOLLOWED BY DISILLUSIONMENT “HOPE FOR GOOD” FOLLOWED BY “NOT AS GOOD AS THE PATIENT WOULD HAVE WANTED” MODEL 3 – STRUCTURAL MODIFICATION BY WORKING THROUGH THE EXPERIENCE OF BAD – BECOME – GOOD DISTORTION FOLLOWED BY REALITY “EXPECTATION OF BAD” FOLLOWED BY “NOT AS BAD AS THE PATIENT HAD FEARED” 96
  • 97. UNLIKE MODEL 2, WHICH PAYS SCANT ATTENTION TO THE PATIENT’S PROACTIVITY IN RELATION TO THE THERAPIST, MODEL 3 ADDRESSES ITSELF SPECIFICALLY TO THE FORCE – FIELD CREATED BY THE PATIENT WHO UNDER THE SWAY OF HER REPETITION COMPULSION AND FOR REASONS BOTH HEALTHY AND “NOT” IS EVER INTENT UPON RE – CREATING THROUGH PROJECTIVE IDENTIFICATION THE EARLY – ON UNMASTERED RELATIONAL TRAUMA BY DRAWING THE THERAPIST IN TO PARTICIPATING IN WAYS SPECIFICALLY DETERMINED BY THE PATIENT’S EARLY – ON DEVELOPMENTAL HISTORY PATRICK CASEMENT (1992) INTERNALLY RECORDED AND STRUCTURALIZED IN THE FORM OF PATHOGENIC INTROJECTS AND “DYSFUNCTIONAL RELATIONAL CONFIGURATIONS” 97
  • 98. MODEL 2 THE NEED TO “FIND NEW GOOD” DISPLACEMENT OF THIS NEED WILL GIVE RISE TO “ILLUSION” (POSITIVE MISPERCEPTION OF REALITY) AND “POSITIVE TRANSFERENCE” MODEL 3 THE NEED TO “REFIND OLD BAD” PROJECTION OF PATHOGENIC INTROJECT WILL GIVE RISE TO “DISTORTION” (NEGATIVE MISPERCEPTION OF REALITY) AND “NEGATIVE TRANSFERENCE” 98
  • 99. “ABSENCE OF GOOD” (MODEL 2) AND “PRESENCE OF BAD” (MODEL 3) GENERALLY GO HAND IN HAND FOR EXAMPLE, THE CHILD WHO WAS RARELY PRAISED WAS PROBABLY ALSO OFTEN CRITICIZED THE CHILD WHO WAS RARELY ADMIRED WAS PROBABLY ALSO OFTEN DEVALUED BUT THESE SITUATIONS ARE NOT HANDLED THE SAME WAY CLINICALLY MODEL 2 INVOLVES “POSITIVE TRANSFERENCE” (AND “POSITIVE TRANSFERENCE DISRUPTED”) MODEL 3 INVOLVES “NEGATIVE TRANSFERENCE” 99
  • 100. MODEL 2 WORKING THROUGH “POSITIVE TRANSFERENCE DISRUPTED” STRUCTURAL GROWTH ADD “NEW GOOD” FILL IN DEFICIT CONSOLIDATE THE SELF vs. MODEL 3 WORKING THROUGH “NEGATIVE TRANSFERENCE” STRUCTURAL MODIFICATION CHANGE “OLD BAD” DETOXIFY INTERNAL DEMONS 100
  • 101. AS WE HAD EARLIER DISCUSSED THE THERAPEUTIC ACTION IN MODEL 1 INVOLVES WORKING THROUGH THE STRESS OF GAIN – BECOME – PAIN AS DYSFUNCTIONAL DEFENSES – ONCE EGO – SYNTONIC – ARE REPEATEDLY CHALLENGED AND RENDERED INCREASINGLY EGO – DYSTONIC 101
  • 102. BUT THE THERAPEUTIC ACTION IN MODEL 2 INVOLVES WORKING THROUGH THE STRESS OF GOOD – BECOME – BAD AS THE PATIENT’S DEFENSIVE NEED TO CLING TO ILLUSION IS REPEATEDLY CHALLENGED AND GRADUALLY REPLACED BY MORE ACCURATE (AND SOBERING) PERCEPTIONS OF REALITY AND THE THERAPEUTIC ACTION IN MODEL 3 INVOLVES WORKING THROUGH THE STRESS OF BAD – BECOME – GOOD AS THE PATIENT’S DEFENSIVE NEED TO CLING TO DISTORTION BECAUSE THAT IS ALL SHE HAS EVER KNOWN IS REPEATEDLY CHALLENGED AND GRADUALLY REPLACED BY MORE ACCURATE (AND LESS TOXIC) PERCEPTIONS OF REALITY 102
  • 103. MORE SPECIFICALLY THE THERAPEUTIC ACTION IN MODEL 2 INVOLVES WORKING THROUGH POSITIVE TRANSFERENCE DISRUPTED THE EXPERIENCE OF GOOD – BECOME – BAD DISILLUSIONMENT THEREBY TRANSFORMING RELENTLESS HOPE INTO SERENE ACCEPTANCE AND THE THERAPEUTIC ACTION IN MODEL 3 INVOLVES WORKING THROUGH NEGATIVE TRANSFERENCE THE EXPERIENCE OF BAD – BECOME – GOOD DETOXIFICATION THEREBY TRANSFORMING RE – ENACTMENT INTO ACCOUNTABILITY 103
  • 104. THE THERAPEUTIC ACTION IN MODEL 2 WORKING THROUGH THE STRESS OF GOOD – BECOME – BAD A STORY ABOUT “CONFRONTING” – AND “GRIEVING” – THE REALITY OF THE “LIMITATIONS, SEPARATENESS, AND IMMUTABILITY” OF THE PATIENT’S “OBJECTS” BOTH PAST AND PRESENT OPTIMAL DISILLUSIONMENT ADAPTIVE TRANSMUTING INTERNALIZATION INCREMENTAL ACCRETION OF PSYCHIC STRUCTURE GRADUAL FILLING IN OF STRUCTURAL DEFICIT EVENTUAL TRANSFORMATION OF THE PATIENT’S RELENTLESS PURSUIT OF THE UNATTAINABLE INTO SERENE ACCEPTANCE OF PAINFUL REALITIES ABOUT THE OBJECTS OF HER DESIRE 104
  • 105. THE THERAPEUTIC ACTION IN MODEL 3 WORKING THROUGH THE STRESS OF BAD – BECOME – GOOD A STORY ABOUT NEGOTIATING THE VARIOUS “MUTUAL ENACTMENTS” AND “THERAPEUTIC IMPASSES” THAT WILL INEVITABLY ARISE AT THE “INTIMATE EDGE” (DARLENE EHRENBERG 1992) OF “AUTHENTIC ENGAGEMENT” AS A RESULT OF THE PATIENT’S “PROJECTIVE IDENTIFICATIONS” THE THERAPIST’S PROVISION OF CONTAINMENT BY VIRTUE OF HER CAPACITY BOTH TO RELENT AND TO HOLD HERSELF ACCOUNTABLE INCREMENTAL “RELATIONAL DETOXIFCATION” OF THE PATIENT’S “INTERNAL DEMONS” BY WAY OF “SERIAL DILUTIONS” AND BY VIRTUE OF THE THERAPIST’S CAPACITY TO PROCESS AND INTEGRATE ON BEHALF OF A PATIENT WHO TRULY DOES NOT KNOW HOW EVENTUAL TRANSFORMATION OF THE PATIENT’S COMPULSIVE AND UNWITTING RE – ENACTMENTS INTO ACCOUNTABILITY FOR HER DYSFUNCTIONAL ACTIONS, REACTIONS, AND INTERACTIONS 105
  • 106. PLEASE NOTE THE FOLLOWING CRITICALLY IMPORTANT CLINICAL DISTINCTION “NEGATIVE TRANSFERENCE” vs. “POSITIVE TRANSFERENCE DISRUPTED” WHEREAS MODEL 3 “NEGATIVE TRANSFERENCE” INVOLVES “PROJECTION OF PATHOGENIC INTROJECT” AND “NEGATIVE MISPERCEPTION” OF REALITY (“DISTORTION”) MODEL 2 “POSITIVE TRANSFERENCE” INVOLVES “DISPLACEMENT OF NEED” AND “POSITIVE MISPERCEPTION” OF REALITY (“ILLUSION”) WHEREAS MODEL 3 “NEGATIVE TRANSFERENCE” MUST BE WORKED THROUGH BY “NEGOTIATING AT THE INTIMATE EDGE” MODEL 2 “POSITIVE TRANSFERENCE” NEED NOT BE WORKED THROUGH ONLY ITS “DISRUPTIONS” ARE WORKED THROUGH BY “GRIEVING THE REALITY OF DISILLUSIONMENT” “OPTIMAL DISILLUSIONMENT” 106
  • 107. THE THERAPIST’S CAPACITY BOTH TO TOLERATE “BEING SEEN AS BAD” (MODEL 2) AND TO TOLERATE “BEING MADE BAD” (MODEL 3) IF THE MODEL 2 THERAPIST CANNOT TOLERATE “BREAKING THE PATIENT’S HEART” EVERY NOW AND AGAIN, THE THERAPIST WILL BE ROBBING THE PATIENT OF THE OPPORTUNITY ADAPTIVELY TO INTERNALIZE MISSING PSYCHOLOGICAL FUNCTIONS VIA OPTIMAL DISILLUSIONMENT AND TRANSMUTING INTERNALIZATION SO TOO IF THE MODEL 3 THERAPIST REFUSES TO PARTICIPATE EVERY NOW AND AGAIN AS SOMEONE WHO “INITIALLY RE – TRAUMATIZES BUT ULTIMATELY RELENTS,” THE THERAPIST WILL BE ROBBING THE PATIENT OF THE OPPORTUNITY TO REWORK HER INTROJECTED BOLUSES OF TOXICITY VIA SERIAL DILUTION 107
  • 108. FINALLY CENTER STAGE FOR BOTH SELF PSYCHOLOGISTS (MODEL 2) AND RELATIONAL THEORISTS (MODEL 3) ARE “INEVITABLE EMPATHIC FAILURES” (MODEL 2) AND “INEVITABLE RELATIONAL FAILURES” (MODEL 3) BUT THE TWO MODELS CONCEIVE OF SUCH FAILURES VERY DIFFERENTLY SELF PSYCHOLOGISTS (MODEL 2) CONTEND THAT FAILURES ARE UNAVOIDABLE BECAUSE THE THERAPIST IS NOT, AND CANNOT BE EXPECTED TO BE, PERFECT 108
  • 109. BUT MOST RELATIONAL THEORISTS (MODEL 3) BELIEVE THAT THE THERAPIST’S FAILURES ARE A STORY ABOUT NOT JUST THE THERAPIST AND HER LACK OF PERFECTION BUT ALSO THE PATIENT AND THE PATIENT’S EXERTING OF PRESSURE ON THE THERAPIST TO PARTICIPATE IN OLD “FAMILIAL AND THEREFORE FAMILIAR” (STEPHEN MITCHELL 1988) WAYS IN OTHER WORDS THE RELATIONAL THERAPIST’S FAILURES ARE SEEN AS CO – CREATED, AS OCCURRING IN THE CONTEXT OF AN ONGOING, CONTINUOUSLY EVOLVING RELATIONSHIP BETWEEN TWO PEOPLE, AND AS SPEAKING TO THE PATIENT’S UNCONSCIOUS NEED TO BE FAILED – SO THAT SHE CAN ACHIEVE BELATED MASTERY OF HER UNRESOLVED RELATIONAL TRAUMAS 109
  • 110. MODEL 2 THE CORRECTIVE – PROVISION PERSPECTIVE OF SELF PSYCHOLOGY AND OTHER “DEFICIT” THEORIES 110
  • 111. MODEL 2 CORRECTIVE – PROVISION MODEL DEFICIENCY – COMPENSATION MODEL THE MODEL 2 EMPATHIC THERAPIST PROVIDES THE “HOLDING” AND THE “BEING MET” THAT WERE NOT PROVIDED CONSISTENTLY AND RELIABLY BY THE PARENT THIS REPARATION FUNCTIONS AS A SYMBOLIC CORRECTIVE FOR THE EARLY – ON DEPRIVATION AND NEGLECT 111
  • 112. AS PREVIOUSLY NOTED ALTHOUGH SOME MODEL 2 THEORISTS BELIEVE THAT IT IS THIS EXPERIENCE OF GRATIFICATION ITSELF THAT IS COMPENSATORY AND ULTIMATELY HEALING, MOST BELIEVE THAT IT IS THE OPTIMAL STRESS CREATED BY THE EXPERIENCE OF FRUSTRATION AGAINST A BACKDROP OF GRATIFICATION FRUSTRATION (DISILLUSIONMENT) PROPERLY GRIEVED THAT IS, OPTIMAL DISILLUSIONMENT THAT MOST EFFECTIVELY PROMOTES STRUCTURAL GROWTH AND DEVELOPMENT OF CAPACITY 112
  • 113. AGAIN IF THERE IS NO THWARTING OF DESIRE, THEN THERE WILL BE NOTHING THAT NEEDS TO BE MASTERED AND THEREFORE NO IMPETUS FOR ADAPTIVE TRANSMUTING INTERNALIZATION BUT WORKING THROUGH THE THWARTING OF DESIRE WILL ENABLE THE PATIENT TO ACCEPT THE REALITY THAT SHE WILL NEVER BE ABLE TO HAVE ALL THAT SHE SHOULD HAVE HAD AS A CHILD AND FOR WHICH SHE HAS SPENT A LIFETIME SEARCHING BUT THAT WHAT SHE HAS IS “GOOD ENOUGH” 113
  • 114. I AM HERE REMINDED OF THE NEW YORKER CARTOON IN WHICH A GENTLEMAN, SEATED IN A RESTAURANT NAMED THE DISILLUSIONMENT CAFÉ, IS AWAITING THE ARRIVAL OF HIS ORDER THE WAITER RETURNS TO HIS TABLE AND ANNOUNCES, “YOUR ORDER IS NOT READY, AND NOR WILL IT EVER BE.” 114
  • 115. GRIEVING IS A PROTRACTED PROCESS THAT TRANSFORMS THE PATIENT’S REFUSAL TO CONFRONT THE PAIN OF HER GRIEF ABOUT THE OBJECT’S LIMITATIONS, SEPARATENESS, AND IMMUTABILITY INTO THE CAPACITY TO TOLERATE AND ACCEPT THOSE INESCAPABLE REALITIES IN THE CONTEXT OF THE TREATMENT, IT INVOLVES WORKING THROUGH OPTIMAL DISILLUSIONMENT THAT IS, POSITIVE TRANSFERENCE DISRUPTED BY CONFRONTING THE PAIN OF HER GRIEF, ADAPTIVELY INTERNALIZING THE GOOD THAT HAD BEEN THERE PRIOR TO THE DISRUPTION IF YOU CANNOT ALWAYS COUNT ON EXTERNAL PROVISION, BEST THAT YOU INTERNALIZE WHATEVER GOOD YOU CAN SO THAT IT WILL ALWAYS BE THERE FOR YOU AND ARRIVING ULTIMATELY AT A PLACE OF SERENE ACCEPTANCE, FORGIVENESS, AND INNER PEACE 115
  • 116. GRIEVING GENUINE GRIEVING REQUIRES OF US THAT, AT LEAST FOR PERIODS OF TIME, WE BE FULLY PRESENT WITH THE ANGUISH OF OUR GRIEF, THE PAIN OF OUR REGRET, AND THE INTENSITY OF THE RAGE WE EXPERIENCE WHEN CONFRONTED WITH SOBERING REALITIES ABOUT OURSELVES, OUR RELATIONSHIPS, AND OUR WORLD WE MUST NOT ABSENT OURSELVES FROM OUR GRIEF; WE MUST ENTER INTO AND EMBRACE IT WE CANNOT EFFECTIVELY GRIEVE WHEN WE ARE DISSOCIATED, MISSING IN ACTION, OR FLEEING THE SCENE WE NEED TO BE ENGAGED, IN THE MOMENT, MINDFUL OF ALL THAT IS GOING ON INSIDE US, GROUNDED, FOCUSED, AND IN THE HERE – AND – NOW IF WE ARE IN DENIAL, CLOSED, SHUT DOWN, NUMB, REFUSING TO FEEL, OR PROTESTING THE UNFAIRNESS OF IT ALL, THEN NO REAL GRIEVING CAN BE DONE 116
  • 117. “GRIEF IS NATURE’S WAY OF HEALING A BROKEN HEART” (ROBERTA BECKMANN 1991) 117
  • 119. AS AN EMPATHIC SELFOBJECT RESONATING WITH THE PATIENT’S MOMENT – TO – MOMENT EXPERIENCE THE MODEL 2 THERAPIST MIGHT OFFER THE PATIENT ANY OF THE FOLLOWING “I WONDER IF IT BREAKS YOUR HEART … ” “IT SOUNDS AS IF IT BREAKS YOUR HEART … ” “IT SEEMS AS IF IT BREAKS YOUR HEART … ” “IT MUST BREAK YOUR HEART … ” BUT PERHAPS IT WOULD BE BETTER SIMPLY TO CUT TO THE CHASE WITH “IT BREAKS YOUR HEART … ” 119
  • 120. SO HOW DO WE HELP THE PATIENT GRIEVE? MODEL 2 DISILLUSIONMENT STATEMENTS ARE DESIGNED TO FACILITATE THE GRIEVING OF A PATIENT WHO IS BEGINNING TO ACKNOWLEDGE THE PAIN OF HER GRIEF FIRST THE THERAPIST CHALLENGES BY SPEAKING TO THE DISILLUSIONING REALITY THAT THE PATIENT IS GRADUALLY COMING TO ACKNOWLEDGE AND THEN THE THERAPIST SUPPORTS BY RESONATING EMPATHICALLY WITH THE PATIENT’S EXPERIENCE OF HEARTBREAK “YOU ARE COMING TO KNOW THAT … , AND IT BREAKS YOUR HEART … ” “YOU ARE BEGINNING TO REALIZE THAT PROBABLY YOUR FATHER, AN ALCOHOLIC FOR OVER 35 YEARS NOW, WILL PROBABLY NEVER BE WILLING TO ACKNOWLEDGE THAT HE HAS A SERIOUS DRINKING PROBLEM, AND THAT BREAKS YOUR HEART.” 120
  • 121. MODEL 2 DISILLUSINOMENT STATEMENTS CAN ALSO INCLUDE A HIGHLIGHTING OF WHAT THE PATIENT “HAD SO HOPED” COULD BE … THEREBY BOTH ACKNOWLEDGING THE “HOPE THAT HAD BEEN” AND REINFORCING THE REALITY THAT THIS HOPE IS NO LONGER A VIABLE OPTION “YOU KNOW THAT … , AND IT BREAKS YOUR HEART BECAUSE YOU HAD SO HOPED THAT … ” “YOU KNOW THAT ULTIMATELY YOU WILL NEED TO LET JOSE GO BECAUSE HE, LIKE YOUR DAD, REALLY ISN’T AVAILABLE IN THE WAY THAT YOU WOULD HAVE WANTED HIM TO BE, AND IT BREAKS YOUR HEART BECAUSE YOU HAD SO HOPED THAT, WITH HIM, IT WOULD BE DIFFERENT.” 121
  • 122. MODEL 2 DISILLUSIONMENT STATEMENTS “YOU KNOW THAT EVENTUALLY YOU WILL NEED TO MAKE YOUR PEACE WITH THE REALITY THAT YOUR MOTHER IS VERY LIMITED IN TERMS OF HER CAPACITY TO HOLD HERSELF ACCOUNTABLE. BUT WHEN YOU LET YOURSELF GO THERE, THE PAIN GOES SO DEEP THAT YOU WONDER HOW YOU’LL SURVIVE. YOU HAD SO HOPED THAT SHE WOULD SOMEDAY APOLOGIZE.” “YOU KNOW THAT EVENTUALLY YOU WILL NEED TO LET GO OF YVONNE BECAUSE SHE REALLY IS NOT CAPABLE OF BEING IN AN INTIMATE RELATIONSHIP RIGHT NOW. AND THE PAIN OF THAT HURTS SO MUCH BECAUSE YOU HAD SO DESPERATELY WANTED THINGS TO WORK OUT. WHEN IT WAS GOOD, IT WAS SO GOOD!” “ON SOME LEVEL, YOU KNEW THAT EVENTUALLY YOU WOULD NEED TO CONFRONT THE REALITY THAT YOUR FATHER WOULD PROBABLY NEVER ACCEPT YOU. BUT, EVEN SO, YOU HAD DESPERATELY HOPED THAT PERHAPS HE MIGHT SOMEDAY RELENT, WHICH IS WHY THE PAIN OF HIS MOST RECENT REJECTION GOES SO DEEP.” 122
  • 123. MODEL 2 DISILLUSIONMENT STATEMENTS “YOU KNOW THAT EVENTUALLY YOU WILL NEED TO FACE THE REALITY THAT YOUR FATHER WILL NEVER CHANGE, AND THAT BREAKS YOUR HEART. YOU HAD SO HOPED HE WOULD.” “YOU ARE BEGINNING TO RECOGNIZE THAT TONY WILL NEVER BE ABLE TO LOVE YOU IN THE WAY THAT YOU WOULD HAVE WANTED HIM TO, AND THAT IS DEVASTATING.” “AS YOU BEGIN TO ADMIT TO YOURSELF THAT PROBABLY ELANA WILL NEVER BE RIGHT FOR YOU, IT MAKES YOU VERY SAD BECAUSE YOU HAD SO HOPED THAT SHE WOULD EVENTUALLY COME ’ROUND TO LOVING YOU.” “IN THOSE MOMENTS WHEN YOU LET YOURSELF REMEMBER JUST HOW LIMITED YOUR FATHER IS AND JUST HOW DEFENSIVE HE BECOMES WHENEVER YOU TRY TO HOLD HIM ACCOUNTABLE, IT FEELS TOTALLY OVEWHELMING AND DEVASTATING. YOU HAD SO HOPED THAT YOU COULD GET HIM TO TAKE AT LEAST SOME RESPONSIBILITY FOR HIS ABUSIVE BEHAVIOR.” 123
  • 124. MODEL 2 DISILLUSIONMENT STATEMENTS DISILLUSIONMENT STATEMENTS ARE OF COURSE ALSO USED FOR WORKING THROUGH DISRUPTED POSITIVE TRANSFERENCES BECAUSE THEY FACILITATE THE PATIENT’S ACCESSING OF HER GRIEF ABOUT THE THERAPIST’S LACK OF PERFECTION FIRST THE THERAPIST HIGHLIGHTS THE PATIENT’S ILLUSIONS ABOUT THE THERAPIST’S PERFECTION AND THEN THE THERAPIST RESONATES EMPATHICALLY WITH THE PATIENT’S EXPERIENCE OF DISILLUSIONMENT DISAPPOINTMENT IN THE FACE OF THE THERAPIST’S IMPERFECTIONS DISILLUSIONMENT STATEMENTS CAN THEREFORE BE USED TO HIGHLIGHT THE DISCREPANCY BETWEEN THE ILLUSION OF THE THERAPIST AS INFALLIBLE AND THE REALITY OF THE THERAPIST AS FALLIBLE 124
  • 125. MODEL 2 DISILLUSIONMENT STATEMENTS “SOMETIMES YOU WOULD WISH THAT I COULD KNOW WHAT YOU WERE THINKING WITHOUT YOUR HAVING TO ARTICULATE IT, WHICH IS WHY IT MAKES YOU SAD WHEN I DON’T ALWAYS GET IT RIGHT.” “ALTHOUGH YOU KNEW IT WOULD TAKE TIME, YOU HAD HOPED THAT YOU WOULD BE FEELING BETTER AFTER THESE SEVERAL WEEKS OF THERAPY, SO IT BOTHERS YOU THAT YOU STILL FEEL BAD.” “YOU WERE SO HOPING THAT I WOULD NOT MAKE THE SAME KINDS OF MISTAKES THAT EVERYONE ELSE IN YOUR LIFE HAS MADE, WHICH IS WHY IT MAKES YOU VERY SAD THAT I TOO HAVE NOW LET YOU DOWN.” “YOU HAD WANTED SO MUCH FOR ME TO BE ABLE TO MAKE IT ALL BETTER, AND IT UPSETS YOU TERRIBLY THAT I DON’T SEEM TO BE ABLE TO MAKE YOUR PAIN GO AWAY.” “ON SOME LEVEL, YOU KNEW THAT I DIDN’T HAVE ALL THE ANSWERS. EVEN SO, YOU WERE HOPING THAT I MIGHT, WHICH IS WHY IT ANGERS YOU WHEN I DON’T ALWAYS HAVE ANSWERS TO YOUR QUESTIONS.” 125
  • 126. MODEL 2 DISILLUSIONMENT STATEMENTS A HIGHLIGHTING OF THE PATIENT’S ILLUSION HER RELENTLESS HOPE A HIGHLIGHTING OF THE REALITY OF THE PATIENT’S DISILLUSIONMENT THE DISILLUSIONING REALITY THAT THE PATIENT TRULY DOES KNOW EVEN THOUGH IT STILL MAKES HER SOMEWHAT ANXIOUS EMPATHIC RESONATING WITH THE PAIN OF THE PATIENT’S GRIEF “A PART OF YOU WOULD SO HAVE WANTED TO HAVE A PERSONAL RELATIONSHIP WITH ME; BUT ANOTHER PART OF YOU KNOWS THAT THE THERAPY RELATIONSHIP IS NOT ABOUT FRIENDSHIP PER SE; AND THAT BREAKS YOUR HEART. IT MAKES YOU FEAR THAT YOU WILL NEVER GET OVER THE PAIN OF FEELING SO ALONE IN THIS WORLD.” “A PART OF YOU FINDS YOURSELF WANTING TO KNOW EVER MORE ABOUT ME AND MY FAMILY; BUT ANOTHER PART OF YOU UNDERSTANDS THE NEED FOR LIMITS IN OUR RELATIONSHIP; AND EVEN THE THOUGHT OF THAT IS ABSOLUTELY DEVASTATING.” 126
  • 127. IF THE EXPERIENCE OF DISILLUSIONING HEARTBREAK THE STRESSFUL EXPERIENCE OF GOOD – BECOME – BAD CAN BE ADEQUATELY PROCESSED AND INTEGRATED THAT IS, GRIEVED THE PATIENT WILL ADAPTIVELY INTERNALIZE THOSE SELFOBJECT FUNCTIONS THAT THE OBJECT HAD BEEN PERFORMING PRIOR TO ITS DISILLUSIONMENT OF HER TRANSMUTING (STRUCTURE – BUILDING) INTERNALIZATIONS THEREBY FILLING IN DEFICIT AND CONSOLIDATING THE SELF FROM “SOME HOLES” TO “WHOLESOME”  THE THERAPEUTIC ACTION IN MODEL 2 127
  • 128. THESE STRUCTURE – BUILDING INTERNALIZATIONS WILL ENABLE THE PATIENT TO PRESERVE INTERNALLY A PIECE OF THE ORIGINAL EXPERIENCE OF EXTERNAL GOODNESS (THUS THEIR ADAPTIVE VALUE) 128
  • 129. AT THE END OF THE DAY MODEL 2 IS ABOUT THE PATIENT’S CONFRONTING – AND GRIEVING – THE REALITY OF THE OBJECT’S LIMITATIONS, SEPARATENESS, AND IMMUTABILITY AND, AFTER RELENTING, FORGIVING, INTERNALIZING, SEPARATING, LETTING GO, AND MOVING ON, ARRIVING ULTIMATELY AT A PLACE OF SERENE ACCEPTANCE IN THE PROCESS, ALSO MAKING HER PEACE WITH THE REALITY OF THE LIMITS OF HER POWER TO FORCE HER OBJECTS TO CHANGE 129
  • 130. MODEL 3 THE INTERSUBJECTI VE PERSPECTIVE OF CONTEMPORARY RELATIONAL THEORY 130
  • 131. THE LOCUS OF THE THERAPEUTIC ACTION IN THIS RELATIONAL MODEL ALWAYS INVOLVES MUTUALITY OF INFLUENCE – BOTH THERAPIST AND PATIENT CONTINUOUSLY CHANGING BY VIRTUE OF BEING IN RELATIONSHIP WITH EACH OTHER 131
  • 132. CLASSICAL PSYCHOANALYSTS SPEAK OF SUPEREGO INTROJECTS A CRITICAL SUPEREGO INTROJECT OR A HARSHLY PUNITIVE SUPEREGO INTROJECT AND WHERE ONCE THE ABUSIVE PARENT HAD RAILED AGAINST THE CHILD, NOW THAT DYNAMIC GETS PLAYED OUT BETWEEN SUPEREGO AND EGO (WITH THE SUPEREGO RAILING AGAINST THE EGO) BUT I FIND IT TO BE MORE CLINICALLY USEFUL TO CONCEIVE OF SUCH PATHOGENIC INTROJECTS AS EXISTING IN PAIRS CRITICIZER AND CRITICIZEE / VICTIMIZER AND VICTIM / SEDUCER AND SEDUCEE AND AS GIVING RISE TO DYSFUNCTIONAL RELATIONAL DYNAMICS THE THERAPEUTIC ACTION IN MODEL 3 THEN BECOMES A STORY ABOUT NEGOTIATING THE TURBULENCE THAT WILL INEVITABLY EMERGE AT THE INTIMATE EDGE OF AUTHENTIC ENGAGEMENT BETWEEN THERAPIST AND PATIENT ONCE THE PATIENT DELIVERS THE DYSFUNCTIONAL RELATIONAL DYNAMIC OF HER THERE – AND – THEN INTO THE HERE – AND – NOW OF THE TRANSFERENCE AND WHERE ONCE THE ABUSIVE PARENT HAD RAILED AGAINST THE CHILD, NOW THAT DYNAMIC GETS PLAYED OUT BETWEEN THERAPIST AND PATIENT (WITH BOTH ULTIMATELY RAILING AGAINST EACH OTHER) 132
  • 133. THE RELATIONAL MODEL CONCEIVES OF THE PATIENT AS AN AGENT, AS PROACTIVE, AS INTENTIONED IN HER ACTIVITIES, AND AS THEREFORE ACCOUNTABLE AND EMPOWERED 133
  • 134. IN FACT THE PATIENT’S ACTIVITY IN RELATION TO THE THERAPIST IS SEEN AS AN ENACTMENT THE UNCONSCIOUS INTENT OF WHICH IS TO ENGAGE THE THERAPIST IN SOME FASHION EITHER BY ELICITING (PROVOKING) FROM THE THERAPIST A “FAMILIAL AND THEREFORE FAMILIAR” REACTION OR BY COMMUNICATING TO THE THERAPIST SOMETHING DEEPLY IMPORTANT (BUT NOT YET “OWNED”) ABOUT THE PATIENT’S TOXIC INTERNAL WORLD 134
  • 135. TWO PHASES OF A PROJECTIVE IDENTIFICATION (MARTHA STARK 1999) THE INDUCTION PHASE COMMENCES ONCE THE PATIENT PROJECTS ONTO THE THERAPIST SOME ASPECT OF THE PATIENT’S EXPERIENCE THAT HAS BEEN TOO TOXIC FOR THE PATIENT TO PROCESS AND INTEGRATE AND THEN EXERTS PRESSURE ON THE THERAPIST TO ACCEPT THAT PROJECTION, THEREBY INDUCTING THE THERAPIST INTO THE PATIENT’S ENACTMENT THE RESOLUTION PHASE IS USHERED IN ONCE THE THERAPIST STEPS BACK FROM HER PARTICIPATION IN WHAT HAS BECOME A MUTUAL ENACTMENT AND BRINGS TO BEAR HER OWN, MORE – EVOLVED CAPACITY TO PROCESS AND INTEGRATE ON BEHALF OF THE PATIENT, WHO TRULY DOES NOT KNOW HOW – SUCH THAT WHAT IS THEN RE – INTROJECTED BY THE PATIENT CAN BE MORE EASILY ASSIMILATED INTO HEALTHY PSYCHIC STRUCTURE AND, IF ALL GOES WELL, THESE CYCLES WILL HAPPEN REPEATEDLY, THE NET RESULT OF WHICH WILL BE GRADUAL DETOXIFICATION OF THE PATIENT’S INTERNAL TOXICITY 135
  • 136. ALTHOUGH INEVITABLY THE THERAPIST WILL FAIL THE PATIENT IN SOME OF THE SAME WAYS THAT THE PARENT HAD FAILED HER, ULTIMATELY THE THERAPIST WILL CHALLENGE THE PATIENT’S PROJECTIONS BY LENDING ASPECTS OF HER “OTHERNESS” OR HER “EXTERNALITY” (DONALD WINNICOTT 1965) TO THE INTERACTION SUCH THAT THE PATIENT WILL HAVE THE EXPERIENCE OF SOMETHING THAT IS “OTHER – THAN – ME” AND CAN THEN TAKE THAT IN IN ESSENCE, THE THERAPIST WILL CHALLENGE THE PATIENT’S PROJECTIONS BY LENDING ASPECTS OF HER OWN GREATER CAPACITY TO PROCESS AND INTEGRATE, SUCH THAT THE PATIENT WILL HAVE THE EXPERIENCE OF BEING ABLE TO TAKE IN SOMETHING THAT IS NOW MORE PROCESSED, LESS TOXIC, AND MORE MANAGEABLE 136
  • 137. WHAT THE PATIENT INTROJECTS WILL BE AN AMALGAM, PART CONTRIBUTED BY THE THERAPIST SOMETHING MORE PROCESSED AND LESS TOXIC AND PART CONTRIBUTED BY THE PATIENT THE ORIGINAL PROJECTION PARENTHETICALLY IN THE PSYCHOANALYTIC LITERATURE “INTERNALIZE” TENDS TO IMPLY “POSITIVE” AS IN “TRANSMUTING INTERNALIZATION” WHEREAS “INTROJECT” TENDS TO IMPLY “NEGATIVE” AS IN “PATHOGENIC INTROJECT” 137
  • 138. NEGOTIATING AT THE INTIMATE EDGE WILL GENERALLY INVOLVE THESE SERIAL DILUTIONS GRADUATED DETOXIFICATION ITERATIVE CYCLES OF INDUCTION AND RESOLUTION “MORE OF SAME” AND THEN “SOMETHING NEW” WILL HAPPEN REPEATEDLY RESULTING ULTIMATELY IN STRUCTURAL MODIFICATION NOTE THAT IT IS THE SECOND (RESOLUTION) PHASE OF THE PROJECTIVE IDENTIFICATION THAT CONSTITUTES THE CHALLENGE AND THE FIRST (INDUCTION) PHASE THAT REINFORCES AND SUPPORTS THE DYSFUNCTIONAL STATUS QUO 138
  • 139. A SUCCESSFUL PROJECTIVE IDENTIFICATION INVOLVES SYMBOLIC REPETITION OF THE ORIGINAL RELATIONAL TRAUMA BUT WITH A MUCH HEALTHIER RESOLUTION THIS TIME 139
  • 140. CONTEMPORARY RELATIONAL THEORY POSTULATES THAT IT IS NOT ONLY INEVITABLE BUT ALSO NECESSARY AND THEREFORE DESIRABLE THAT ULTIMATELY THE THERAPIST WILL FAIL THE PATIENT AND IN THE VERY WAYS THAT THE PATIENT MOST NEEDS TO BE FAILED IF SHE IS EVER TO HAVE THE OPPORTUNITY TO MODIFY HER INTERNAL DEMONS 140
  • 141. IF THE THERAPIST NEVER ALLOWS HERSELF TO BE DRAWN IN TO PARTICIPATING WITH THE PATIENT IN HER RE – ENACTMENTS, WE SPEAK OF A FAILURE OF ENGAGEMENT AND LOST OPPORTUNITY IF, HOWEVER, THE THERAPIST ALLOWS HERSELF TO BE DRAWN IN TO THE PATIENT’S INTERNAL DRAMAS BUT THEN GETS OVERWHELMED, LOSES HER WAY, AND CANNOT FIND HER WAY OUT, WE SPEAK OF A FAILURE OF CONTAINMENT AND POTENTIAL RE – TRAUMATIZATION 141
  • 142. THE THERAPIST MUST BE ABLE TO PROVIDE CONTAINMENT THE RELATIONAL THERAPIST MUST BE ABLE NOT ONLY TO TOLERATE BEING MADE INTO THE PATIENT’S OLD BAD OBJECT BUT ALSO ONCE THE THERAPIST HAS ALLOWED HERSELF TO BE DRAWN IN TO PARTICIPATING IN WHAT HAS BECOME A MUTUAL ENACTMENT TO EXTRICATE HERSELF BY STEPPING BACK WHICH WILL ENABLE HER TO RECOVER HER OBJECTIVITY AND THEREBY HER THERAPEUTIC EFFECTIVENESS 142
  • 143. BUT IN ORDER TO PROVIDE EFFECTIVE CONTAINMENT THE THERAPIST MUST HAVE THE CAPACITY TO RELENT IN OTHER WORDS, THE THERAPIST MUST HAVE BOTH THE WISDOM TO RECOGNIZE AND THE INTEGRITY TO ACKNOWLEDGE CERTAINLY TO HERSELF AND PERHAPS TO THE PATIENT AS WELL HER OWN PARTICIPATION IN THE DRAMA THAT IS BEING PLAYED OUT BETWEEN THEM ON THE STAGE OF THE TREATMENT IN ESSENCE THE THERAPIST MUST HAVE THE CAPACITY BOTH TO RELENT AND TO HOLD HERSELF ACCOUNTABLE FOR HER ENACTMENTS 143
  • 144. MODEL 3 ACCOUNTABILITY STATEMENTS INVOLVE INTERPRETING THE PATIENT’S ENACTMENTS AS AN EFFORT EITHER TO DRAW THE THERAPIST IN TO PARTICIPATING AS THE “ABUSIVE” PARENT THE PATIENT HAD BY WAY OF BEHAVIOR ON THE PATIENT’S PART THAT IS UNCONSCIOUSLY DESIGNED TO ELICIT AN “ABUSIVE” REACTION FROM THE THERAPIST THIS IS A “DIRECT NEGATIVE TRANSFERENCE” IN WHICH THE THERAPIST IS MADE INTO THE “ABUSIVE” PARENT AND THE PATIENT ONCE AGAIN ASSUMES THE ROLE OF THE “ABUSED” CHILD OR TO GET THE THERAPIST TO UNDERSTAND FIRSTHAND WHAT IT WAS LIKE FOR THE PATIENT GROWING UP BY WAY OF BEHAVIOR ON THE PATIENT’S PART THAT INVOLVES UNCONSCIOUSLY DOING UNTO THE THERAPIST WHAT THE “ABUSIVE” PARENT HAD DONE UNTO THE PATIENT AS A CHILD THIS IS AN “INVERTED NEGATIVE TRANSFERENCE” IN WHICH THE PATIENT ASSUMES THE ROLE OF THE “ABUSIVE” PARENT AND THEN BECOMES “ABUSIVE” TO THE THERAPIST IN AN EFFORT TO GET THE THERAPIST TO UNDERSTAND WHAT IT WAS LIKE FOR THE PATIENT AS A CHILD GROWING UP 144
  • 145. 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 … ” 145
  • 146. THE THERAPIST IS HERE HOLDING HERSELF ACCOUNTABLE FOR HER CONTRIBUTION TO THE PATIENT’S “ACTING OUT” / “ENACTMENT” FRAMING THE PATIENT’S PROVOCATIVE ENACTMENT IN THIS WAY NAMELY, THAT IT IS AN UNDERSTANDABLE REACTION TO THE THERAPIST’S INABILITY / REFUSAL TO UNDERSTAND SOMETHING IMPORTANT ABOUT THE PATIENT’S INTERNAL EXPERIENCE MAY THEN MAKE IT A LITTLE EASIER FOR THE PATIENT HERSELF TO TOLERATE BEING HELD ACCOUNTABLE IN OTHER WORDS WHEN THE THERAPIST ACKNOWLEDGES HER PART, THE PATIENT MAY THEN BE BETTER ABLE TO ACKNOWLEDGE HER OWN PART WITHOUT LOSING FACE 146
  • 147. FOCUS ON THE HERE – AND – NOW ENGAGEMENT THE RELATIONAL THERAPIST’S INTEREST IS IN FACILITATING THE PATIENT’S CAPACITY FOR HEALTHY RELATEDNESS BOTH BY ENHANCING THE PATIENT’S UNDERSTANDING OF WHAT SHE PLAYS OUT IN HER RELATIONSHIPS AND BY PROVIDING THE PATIENT WITH THE EXPERIENCE OF BEING FOUND THIS CAN ONLY BE DONE IF THE THERAPIST CAN BRING HER OWN AUTHENTIC SELF INTO THE ROOM 147
  • 148. THE RELATIONAL THERAPIST MUST BE FULLY PRESENT AND FULLY ENGAGED IN THE THERAPEUTIC ENCOUNTER “UNLESS THE THERAPIST AFFECTIVELY ENTERS THE PATIENT’S RELATIONAL MATRIX OR, RATHER, DISCOVERS HIMSELF WITHIN IT – UNLESS THE THERAPIST IS IN SOME SENSE CHARMED BY THE PATIENT’S ENTREATIES, SHAPED BY THE PATIENT’S PROJECTIONS, ANTAGONIZED AND FRUSTRATED BY THE PATIENT’S DEFENSES – THE TREATMENT IS NEVER FULLY ENGAGED, AND A CERTAIN DEPTH WITHIN THE ANALYTIC EXPERIENCE IS LOST.” (STEPHEN MITCHELL 1988) 148
  • 149. IN OTHER WORDS IF THERAPIST AND PATIENT ARE TO FIND EACH OTHER AS “SUBJECTS,” THEN BOTH MUST DARE TO BRING THEMSELVES INTO THE ROOM TO THAT END, THE RELATIONAL THERAPIST USES HER “AUTHENTIC” SELF TO PARTICIPATE IN THE THERAPEUTIC ENCOUNTER SHE STRIVES TO REMAIN CENTERED IN, AND EVER ATTUNED TO, HER OWN INTERNAL PROCESS OR SUBJECTIVITY SO THAT SHE CAN USE HER COUNTERTRANSFERENCE (HER EXPERIENCE OF SELF) TO FIND, AND TO BE FOUND BY, THE PATIENT THE THERAPIST’S ATTENTION IS THEREFORE ALWAYS DIRECTED TO THE HERE – AND – NOW ENGAGEMENT (OR LACK THEREOF) BETWEEN THEM DARLENE EHRENBERG’S “INTIMATE EDGE” DANIEL STERN’S “NOW MOMENTS” 149
  • 150. MODEL 3 ACCOUNTABILITY STATEMENTS SO THE THERAPIST MAY CHOOSE TO SHARE SOMETHING ABOUT HER EXPERIENCE OF BEING IN THE ROOM WITH THE PATIENT “I WONDER IF THE FRUSTRATION AND HELPLESSNESS I AM FEELING NOW IN RELATION TO YOU IS SIMILAR TO THE FRUSTRATION AND HELPLESSNESS YOU HAVE TALKED OF FEELING IN RELATION TO YOUR FATHER.” “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) 150
  • 151. MODEL 3 ACCOUNTABILITY STATEMENTS OR, AS IRWIN HOFFMAN (2001) HAS SUGGESTED, IF THE THERAPIST IS AWARE OF FEELING CONFLICTED IN RELATION TO THE PATIENT, SHE MAY CHOOSE TO SHARE THE FACT OF THIS CONFLICTEDNESS WITH THE PATIENT “I WANT TO TELL YOU ‘X,’ BUT I AM AFRAID THAT ‘Y.’” HERE THE THERAPIST IS EXPRESSING ALOUD THE CONFLICT WITH WHICH SHE IS STRUGGLING – A CONFLICT THAT MIGHT WELL BE REFLECTIVE OF THE PATIENT’S INTERNAL DIVIDEDNESS “I AM TEMPTED TO GIVE YOU THE ADVICE FOR WHICH YOU ARE LOOKING, BUT MY FEAR IS THAT WERE I TO DO SO, I WOULD BE ROBBING YOU OF THE IMPETUS TO FIND YOUR OWN ANSWERS.” “I FIND MYSELF FEELING ANGRY AT YOU FOR BEING LATE AND WANTING TO TELL YOU HOW IT IMPACTS ME, BUT THEN IT OCCURS TO ME THAT IT MIGHT BE MORE IMPORTANT FOR US TO UNDERSTAND WHAT YOU MIGHT BE TRYING TO COMMUNICATE BY WAY OF YOUR LATENESS.” 151
  • 152. MODEL 3 ACCOUNTABILITY STATEMENTS “I AM TEMPTED TO RESPOND TO YOUR REQUEST BY SAYING THAT OF COURSE YOU CAN BORROW ONE OF THE MAGAZINES IN MY WAITING ROOM, BUT I AM ALSO REALIZING THAT WERE I SIMPLY TO SAY OK, WE MIGHT LOSE AN OPPORTUNITY TO UNDERSTAND SOMETHING MORE ABOUT YOU AND, PERHAPS, ABOUT US.” TO A PATIENT WHO SAYS HE WANTS THE THERAPIST’S APPROVAL REGARDING HIS DECISION TO TERMINATE – A TERMINATION THAT THE THERAPIST THINKS IS PREMATURE – “I AM TEMPTED SIMPLY TO OFFER YOU THE APPROVAL YOU ARE SEEKING – IT IS, AFTER ALL, IMPORTANT THAT YOU DO WHAT FEELS RIGHT FOR YOU. BUT I AM ALSO AWARE OF FEELING, WITHIN MYSELF, THAT THE TIME IS TOO SOON AND THAT WERE I TO SUPPORT YOUR DECISION TO LEAVE, I MIGHT ULTIMATELY BE DOING YOU A DISSERVICE.” 152
  • 153. MODEL 3 ACCOUNTABILITY STATEMENTS THE THERAPIST MAY CHOOSE TO FOCUS THE PATIENT’S ATTENTION ON WHAT IS TRANSPIRING IN THE ROOM BETWEEN THEM “THERE SEEMS TO BE A LOT OF TENSION BETWEEN US TODAY.” “WE ARE BOTH SAD THAT THINGS DIDN’T TURN OUT AS WE HAD HOPED THEY WOULD.” “I AM GUESSING THAT WE ARE BOTH FEELING FRUSTRATED AND A LITTLE CONFUSED. LET’S REWIND SO THAT WE CAN THINK ABOUT WHERE WE MIGHT HAVE GOTTEN OFF TRACK.” 153
  • 154. MODEL 3 ACCOUNTABILITY STATEMENTS THE THERAPIST MAY ENCOURAGE THE PATIENT TO ELABORATE UPON HER EXPERIENCE OF THE THERAPIST’S CONTRIBUTION TO WHAT IS HAPPENING IN THE ROOM IN MODEL 3, THE PATIENT’S TRANSFERENCE IS ALWAYS THOUGHT TO HAVE CONTRIBUTIONS FROM BOTH PATIENT AND THERAPIST AND THEREFORE TO BE CO – CONSTRUCTED OR CO – CREATED TO THAT END, THE RELATIONAL THERAPIST MIGHT ASK “IS THERE SOMETHING I HAVE DONE OR SAID THAT HAS LED YOU TO BELIEVE THAT I DON’T CARE?” “HAVE YOU NOTICED ANYTHING ABOUT ME THAT WOULD SEEM TO SUGGEST MY DISCOMFORT WITH YOUR DECISION?” I AM HERE REMINDED OF MY PATIENT WHO TOLD ME THAT HE THOUGHT I WAS BEING “UNCONSCIOUSLY CRITICAL” OF HIM! ULTIMATELY, WE BOTH LAUGHED … 154
  • 155. MODEL 3 ACCOUNTABILITY STATEMENTS THE THERAPIST MAY DRAW THE PATIENT’S ATTENTION TO WHAT THE THERAPIST THINKS THE PATIENT IS CONTRIBUTING TO THE INTERACTION “I WONDER IF, BY WAY OF YOUR LATENESS, YOU ARE TRYING TO COMMUNICATE SOMETHING TO ME ABOUT HOW DIFFICULT IT IS FOR YOU TO BE HERE. IF THAT WERE INDEED THE CASE, I WOULD NOT WANT TO DO YOU THE DISSERVICE OF SIMPLY DISMISSING IT.” “SOMETIMES IT SEEMS THAT, WHEN YOU’RE VULNERABLE AND TELLING ME SOMETHING VERY IMPORTANT, AFTER A LITTLE WHILE YOU BECOME VERY STILL AND I LOSE TRACK OF YOU. I WONDER IF, IN THAT STILLNESS, YOU ARE ATTEMPTING TO SHOW ME HOW YOU, AS A CHILD, WERE SOMETIMES ABANDONED AFTER AN INTENSE CONNECTION.” 155
  • 156. MODEL 3 IS ABOUT ACCOUNTABILITY AND THEREFORE EMPOWERMENT THE RULE OF THREE (MARTHA STARK 2016) WHENEVER A PATIENT SAYS OR DOES SOMETHING THAT THE MODEL 3 THERAPIST EXPERIENCES AS PROVOCATIVE A “PROVOCATIVE ENACTMENT” IN ORDER TO FORCE THE PATIENT TO TAKE OWNERSHIP OF WHAT SHE IS IMPLICITLY ATTEMPTING TO COMMUNICATE, THE THERAPIST MIGHT 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 EGO ALL THREE RELATIONAL INTERVENTIONS DEMAND OF THE PATIENT THAT SHE MAKE HER INTERPERSONAL INTENTIONS MORE EXPLICIT AND THAT SHE TAKE RESPONSIBILITY FOR HER PROVOCATIVE ENACTMENT 156
  • 157. IN SUM THE RELATIONAL PERSPECTIVE OF MODEL 3 IS A STORY ABOUT TRANSFORMING THE PATIENT’S DEFENSIVE NEED TO PLAY OUT HER UNMASTERED RELATIONAL DRAMAS COMPULSIVELY AND UNWITTINGLY ON THE STAGE OF HER LIFE INTO THE ADAPTIVE CAPACITY TO TAKE OWNERSHIP OF HER DYSFUNCTIONAL WAYS OF ACTING, REACTING, AND INTERACTING 157
  • 158. MODEL 4 THE EXISTENTIAL – HUMANISTIC PERSPECTIVE A HEART SHATTERED, THE PRIVATE SELF, AND RELENTLESS DESPAIR “I GAVE YOU A PART OF ME THAT I KNEW YOU COULD BREAK – BUT YOU DIDN’T” 158
  • 159. MODEL 4 IS A STORY ABOUT SCHIZOID WITHDRAWAL BECAUSE OF TRAUMATIC EARLY – ON HEARTBREAK MODEL 4 IS NOT A STORY ABOUT PEOPLE “ON THE AUTISM SPECTRUM” 159
  • 160. THE THERAPEUTIC ACTION IN MODEL 1 INVOLVES WORKING THROUGH THE STRESS OF GAIN – BECOME – PAIN THE THERAPEUTIC ACTION IN MODEL 2 INVOLVES WORKING THROUGH THE STRESS OF GOOD – BECOME – BAD THE THERAPEUTIC ACTION IN MODEL 3 INVOLVES WORKING THROUGH THE STRESS OF BAD – BECOME – GOOD AND THE THERAPEUTIC ACTION IN MODEL 4 INVOLVES WORKING THROUGH THE STRESS OF HIDDEN – BECOME – FOUND AS THE PATIENT’S DEFENSIVE “DENIAL OF OBJECT NEED” IS CHALLENGED BY THE EXPERIENCE OF MOMENTS OF MEETING AND GRADUALLY REPLACED BY MORE AUTHENTIC BEING – IN – THE – WORLD 160
  • 161. PATIENTS WHO HAVE NEVER FULLY CONFRONTED – AND GRIEVED – THE PAIN OF THEIR EARLY – ON HEARTBREAK WILL OFTEN CLING TENACIOUSLY TO THEIR HOPE THAT PERHAPS SOMEDAY THE “OBJECT OF THEIR DESIRE” WILL BE FORTHCOMING BUT THERE ARE OTHERS WHO IN THE AFTERMATH OF THEIR EARLY – ON HEARTBREAK WILL FIND THEMSELVES WITHDRAWING COMPLETELY FROM THE “WORLD OF OBJECTS” – THEIR HEART SHATTERED 161
  • 162. ONLY THEN TO FIND THEMSELVES OVERWHELMED BY INTENSE FEELINGS OF ISOLATION, ALIENATION, AND EMPTINESS THE COMPETENT, ACCOMPLISHED, CHEERFUL, COMPLIANT “FALSE (PUBLIC) SELF” THEY PRESENT TO THE WORLD BELYING THE TRUTH THAT LIES HIDDEN WITHIN NAMELY, THEIR PRIVATE TURMOIL, TORMENTED HEARTBREAK, HARROWING LONELINESS, AND ANNIHILATING TERROR AS WELL AS THEIR STYMIED CREATIVITY AND DESPERATE – ALBEIT CONFLICTED – LONGING FOR MEANINGFUL CONNECTEDNESS WITH THE WORLD 162
  • 163. WHEREAS THE RELENTLESS HOPE OF THE MODEL 2 PATIENT AND THE RELENTLESS OUTRAGE OF THE MODEL 3 PATIENT SPEAK TO THE PATIENT’S INTENSE – ALBEIT MALADAPTIVE – ENGAGEMENT WITH THE WORLD OF OBJECTS, THE RELENTLESS DESPAIR OF THE MODEL 4 PATIENT SPEAKS TO THE PATIENT’S UTTER LACK OF ANY REAL ENGAGEMENT WITH THE WORLD OF OBJECTS 163
  • 164. RELEVANT HERE IS VIKTOR FRANKL’S “EXISTENTIAL DESPAIR” MAN’S SEARCH FOR MEANING (1997) D = S – M “EXISTENTIAL DESPAIR” EQUALS “SUFFERING” WITHOUT “MEANING” MY SLIGHT PARAPHRASE “RELENTLESS DESPAIR” EQUALS “SOLITARY SUFFERING” WITHOUT “MEANINGFUL MOMENTS OF MEETING” I BELIEVE THAT “MOMENTS OF MEETING” ARE AN IMPORTANT PART OF WHAT GIVE LIFE ITS MEANING 164
  • 165. MARTIN HEIDEGGER’S “INAUTHENTIC EXISTENCE” THE IMPORTANCE OF “AUTHENTICITY” AS GIVING MEANING, PURPOSE, WORTHWHILENESS, AND DIRECTION TO LIFE AUTHENTIC BEING – IN – THE – WORLD REFERS TO THE ATTEMPT TO LIVE ONE’S LIFE ACCORDING TO THE NEEDS OF ONE’S INNER BEING RATHER THAN TO THE DEMANDS OF ONE’S EARLY CONDITIONING OR OF SOCIETY AUTHENTIC BEING – IN – THE – WORLD ALWAYS INVOLVES THIS ELEMENT OF FREEDOM AND CHOICE “INAUTHENTICITY” REFERS TO LIVING ONE’S LIFE AS DETERMINED BY OUTSIDE FORCES, EXPECTATIONS, PRESSURES, AND DEMANDS 165
  • 166. KELLY CLARKSON HER EMOTIONALLY RAW, VULNERABLE, AND HAUNTINGLY BEAUTIFUL SONGS SPEAK OF THE HEARTBREAK AND SUBSEQUENT SHUTDOWN THAT SHE EXPERIENCED BECAUSE OF HER FATHER’S TRAUMATIC ABANDONMENT OF HER AND HER FAMILY WHEN SHE WAS SIX YEARS OLD THE ESSENCE OF WHICH SHE CAPTURES IN HER WELL – KNOWN SONG ENTITLED “BECAUSE OF YOU” WHERE SHE MAKES REFERENCE TO THE “FALSE SELF” THAT SHE NOW PRESENTS TO THE WORLD IN ORDER TO COVER THE PAIN OF THAT EARLY – ON HEARTBREAK AT THE HANDS OF HER FATHER 166
  • 167. RICHARD CORY BY EDWIN ARLINGTON ROBINSON THIS NARRATIVE POEM ALSO CAPTURES POIGNANTLY THE GREAT DIVIDE THAT CAN EXIST BETWEEN THE PUBLIC (OR FALSE) SELF AND THE PRIVATE (OR TRUE) SELF ON THE SURFACE OF THINGS RICHARD CORY APPEARS TO HAVE IT ALL RICHES, GRACE, IMPECCABLE GOOD MANNERS, CHARM, GLITTER, IMPERIAL GOOD LOOKS BUT DESPITE HIS REGAL BEARING AND ENVIABLE WEALTH, HIS LIFE IS EMPTY AND INTERNALLY IMPOVERISHED AND “ONE CALM SUMMER NIGHT” HE SIMPLY GOES HOME AND “PUTS A BULLET THROUGH HIS HEAD” TO END IT ALL 167
  • 168. SIMON AND GARFUNKEL’S WELL – KNOWN “I AM A ROCK” (1966) CAPTURES TO PERFECTION THE ESSENCE OF THE MODEL 4 PATIENT’S EXPERIENCE OF BEING – IN – THE – WORLD A WINTER’S DAY ~ IN A DEEP AND DARK ~ DECEMBER I AM ALONE ~ GAZING FROM MY WINDOW TO THE STREETS BELOW ON A FRESHLY FALLEN SILENT SHROUD OF SNOW I AM A ROCK ~ I AM AN ISLAND I’VE BUILT WALLS ~ A FORTRESS DEEP AND MIGHTY THAT NONE MAY PENETRATE I HAVE NO NEED OF FRIENDSHIP, FRIENDSHIP CAUSES PAIN IT’S LAUGHTER AND IT’S LOVING I DISDAIN I AM A ROCK ~ I AM AN ISLAND DON’T TALK OF LOVE ~ BUT I’VE HEARD THE WORDS BEFORE IT’S SLEEPING IN MY MEMORY I WON’T DISTURB THE SLUMBER OF FEELINGS THAT HAVE DIED IF I NEVER LOVED I NEVER WOULD HAVE CRIED I AM A ROCK ~ I AM AN ISLAND I HAVE MY BOOKS ~ AND MY POETRY TO PROTECT ME I AM SHIELDED IN MY ARMOR HIDING IN MY ROOM, SAFE WITHIN MY WOMB I TOUCH NO ONE AND NO ONE TOUCHES ME I AM A ROCK ~ I AM AN ISLAND AND A ROCK FEELS NO PAIN ~ AND AN ISLAND NEVER CRIES 168
  • 169. DONALD WINNICOTT’S FALSE SELF A SELF – PROTECTIVE DEFENSIVE ARMOR MOBILIZED EARLY – ON IN LIFE TO PROTECT THE PRIVACY OF THE “TRUE SELF” FROM IMPINGEMENT BY A MATERNAL ENVIRONMENT PERCEIVED AS INTRUSIVE AND POTENTIALLY DANGEROUS THE PERSON WHO EVENTUALLY DEVELOPS A “FALSE SELF” NEVER HAD THE EXPERIENCE OF A “GOOD – ENOUGH MOTHER” ABLE TO PROVIDE A PROTECTIVE ENVELOPE A “FACILITATING OR HOLDING ENVIRONMENT” WITHIN WHICH HER YOUNG CHILD’S “INHERITED POTENTIAL” COULD BECOME ACTUALIZED 169
  • 170. AT A TIME WHEN IT IS AGE – APPROPRIATE FOR THE INFANT TO HAVE A MOTHER UPON WHOM SHE CAN “ABSOLUTELY DEPEND” – AN “UNFALTERINGLY RELIABLE” MOTHER ABLE TO RECOGNIZE AND RESPOND TO HER INFANT’S EVERY NEED – THE MOTHER’S INABILITY TO “MEET THE OMNIPOTENCE” OF HER YOUNG CHILD WILL BE ABSOLUTELY ANNIHILATING AS A RESULT, THE NASCENT TRUE SELF OF THE INFANT THE POTENTIAL SOURCE OF SPONTANEITY AND CREATIVITY WILL GO INTO HIDING, AVOIDING AT ALL COSTS THE POSSIBILITY OF EXPOSING ITSELF WITHOUT BEING SEEN OR RESPONDED TO ITS ESSENCE WILL REMAIN “INCOMMUNICADO” ITS CORE UNRECOGNIZED, UNACKNOWLEDGED, UNDEVELOPED DESPERATE TO BE KNOWN BUT TERRIFIED OF BEING FOUND 170
  • 171. WHAT THEN CRYSTALLIZES OUT WILL BE A FALSE SELF A PUBLIC (OR SOCIAL) SELF THAT GRADUALLY BECOMES EVER MORE ADEPT AT ACCOMMODATING ITSELF CHAMELEON – LIKE TO WHATEVER IT SENSES IS EXPECTED OF IT ALL THE WHILE KEEPING HIDDEN ITS UNDERLYING ANGUISH AND BROKEN – HEARTED DESPAIR THE PERSON WILL LIVE, BUT THE EXISTENCE WILL BE EMPTY, HOLLOW, SHALLOW, FALSE, EMPTY, AND TERRIFYINGLY LONELY IT WILL BE A LIE ONE BASED ON COMPLIANCE AND CONFORMITY NOT ONE BASED ON AUTHENTICITY OR TRUTH THE PERSON WILL MAKE A SHOW OF BEING REAL, BUT IT WILL ONLY BE “AS IF” SHE IS REAL BECAUSE HER LIFE WILL BE A SHAM, A CHARADE, A PART SHE IS PLAYING, A BORROWED IDENTITY – ONE ASSUMED FOR THE OCCASION 171
  • 173. AMY AND HER NEED FOR OMNIPOTENT CONTROL I PRESENT NOW A CLINICAL VIGNETTE THAT DEMONSTRATES THE POWERFULLY HEALING IMPACT OF A THERAPIST’S WILLINGNESS TO HONOR HER PATIENT’S NEED FOR OMNIPOTENT CONTROL OF HER OBJECTS WHEN THAT EGO NEED HAS BEEN TRAUMATICALLY THWARTED EARLY – ON EVEN IF INADVERTENTLY BY AN IMPINGING AND ANNIHILATING MATERNAL ENVIRONMENT 173
  • 174. AMY AND HER NEED FOR OMNIPOTENT CONTROL MORE SPECIFICALLY THIS CASE SPEAKS TO THE TRANSFORMATIVE POWER OF REVISITING PLAYFULLY THE MATURATIONAL STAGE OF “ABSOLUTE DEPENDENCE” IN ORDER TO CORRECT FOR EARLY – ON TRAUMATIC FRUSTRATION OF THE CHILD’S DEFENSIVELY REINFORCED “EGO NEED TO BE MET” 174
  • 175. AMY AND HER NEED FOR OMNIPOTENT CONTROL AT THE END OF THE DAY I BELIEVE THAT WHAT WAS TRANSFORMATIVE FOR AMY WAS MY ABILITY TO CREATE A SAFE SPACE INTO WHICH SHE COULD DELIVER WHAT MOST NEEDED TO BE DELIVERED, NAMELY, HER NEED TO BE ABLE TO FEEL IN CONTROL SO THAT SHE WOULD BE ABLE TO RISK BECOMING “ABSOLUTELY DEPENDENT” ON ME A STAND – IN FOR HER MOTHER WITHOUT HAVING TO FEAR A CATASTROPHICALLY ANNIHILATING RESPONSE THAT WOULD SHATTER HER HEART 175
  • 176. I GAVE YOU A PART OF ME THAT I KNEW YOU COULD BREAK – BUT YOU DIDN’T IT IS ONLY RECENTLY THAT I HAVE COME TRULY TO APPRECIATE HOW POWERFULLY HEALING IT CAN BE FOR A PATIENT WHOSE HEART WAS FRAGMENTED EARLY – ON BY AN IMPINGING MATERNAL ENVIRONMENT TO BE GIVEN AN OPPORTUNITY IN THE HERE – AND – NOW ENGAGEMENT WITH HER THERAPIST TO BE IN CONTROL AS MUCH AS IS POSSIBLE AN OPPORTUNITY TO BECOME “ABSOLUTELY DEPENDENT” ON SOMEONE WHOSE STALWART RELIABILITY AND UNCONDITIONAL PREDICTABILITY THE PATIENT IS COMING, OVER TIME, TO TRUST 176
  • 177. MICHAEL BALINT’S (1992) “BENIGN REGRESSION TO DEPENDENCE” FOR THOSE PATIENTS WHO HAVE DEVELOPED A “BASIC FAULT” BECAUSE OF FAILURE IN THE EARLY – ON ENVIRONMENTAL PROVISION, BALINT SPEAKS TO THE THERAPEUTIC VALUE OF “BENIGN REGRESSION TO DEPENDENCE” AND OF ALLOWING FOR A “HARMONIOUS INTERPENETRATING MIX – UP” BETWEEN THERAPIST AND PATIENT SO THAT, AT LEAST FOR A WHILE, THE PATIENT CAN HAVE THE SELF – AND LIFE – AFFIRMING EXPERIENCE OF BEING PEACEFULLY MERGED WITH ANOTHER A “NEW BEGINNING” 177
  • 178. ALONG THESE SAME LINES CHRISTOPHER BOLLAS’S (1989) “ORDINARY REGRESSION TO DEPENDENCE” A REGRESSION THAT WILL BE “ARRESTED BY THE THERAPIST’S INTERPRETATIONS” BUT “FOSTERED BY THE THERAPIST’S RECEPTIVITY” WINNICOTT’S “REGRESSION TO ABSOLUTE DEPENDENCE” BALINT’S “BENIGN REGRESSION IN THE SERVICE OF THE EGO” AND BOLLAS’S “ORDINARY REGRESSION TO DEPENDENCE” CAPTURE THE ESSENCE OF WHAT I BELIEVE IS AT THE HEART OF WHAT WE MUST “PROVIDE” FOR OUR MODEL 4 PATIENTS NAMELY, AN OPPORTUNITY TO EXPERIENCE “THERAPEUTIC REGRESSION TO DEPENDENCE” AN OPPORTUNITY TO “REGRESS IN ORDER TO REDO” 178
  • 179. KEITH URBAN AND CARRIE UNDERWOOD I AM HERE REMINDED OF KEITH URBAN AND CARRIE UNDERWOOD’S BEAUTIFUL DUET CALLED “THE FIGHTER” IN WHICH A WOMAN HERE REPRESENTING THE MODEL 4 PATIENT WHOSE “PRECIOUS HEART” HAS BEEN BROKEN AT AN EARLIER TIME IN HER LIFE KEEPS ASKING FOR, AND NEEDING, REASSURANCE THAT WERE SHE TO FALL, WERE SHE TO CRY, WERE SHE TO BE SCARED, HER MAN HERE REPRESENTING THE MODEL 4 THERAPIST WOULD BE THERE TO CATCH HER AND TO HOLD HER TIGHT 179
  • 180. IN A BRILLIANT 1972 PAPER PUBLISHED IN THE INTERNATIONAL JOURNAL OF PSYCHOANALYSIS MASUD KHAN WRITES ABOUT THE IMPORTANCE OF GIVING PATIENTS WHO HAVE EMOTIONALLY WITHDRAWN FROM THE WORLD OF OBJECTS AN OPPORTUNITY TO “OVERCOME THEIR DREAD OF SURRENDER TO RESOURCELESS DEPENDENCE” ON THE THERAPIST AN EMOTIONAL SURRENDER THAT HOPEFULLY WILL BE EXPERIENCED BY THE PATIENT AS “TRANSCENDENT” AND “TRANSFORMATIVE” AND NOT SIMPLY AS A “DEFEAT” KHAN’S “RESOURCELESS DEPENDENCE” IS AKIN TO WINNICOTT’S “ABSOLUTE DEPENDENCE,” BALINT’S “BENIGN REGRESSION,” AND BOLLAS’S “ORDINARY REGRESSION” 180
  • 181. ARNOLD MODELL’S (1996) “DENIAL OF OBJECT NEED” AND “ILLUSIONS OF GRANDIOSE SELF – SUFFICIENCY” PARTICULARLY RELEVANT FOR UNDERSTANDING MODEL 4 PATIENTS IS ARNOLD MODELL’S BEAUTIFULLY FINE – TUNED RENDERING OF PATIENTS WHO HAVE PSYCHICALLY RETREATED FROM THE WORLD OF OBJECTS IN ORDER TO PROTECT THE “COHESIVENESS OF A PRECARIOUSLY ESTABLISHED SELF” FROM BEING “SHATTERED” BY AN “INTOLERABLY UNEMPATHIC RESPONSE” FROM THE OBJECT MODELL SUGGESTS THAT TO AVOID POTENTIAL “DISSOLUTION OF THE INTEGRITY AND COHERENCE” OF A “FRAGILE SELF,” SUCH PATIENTS WILL ASSUME A “STANCE OF SELF – PROTECTIVE ISOLATION” – A DEFENSIVE POSTURE SUPPORTED BY “ILLUSIONS OF GRANDIOSE SELF – SUFFICIENCY,” “DENIAL OF OBJECT NEED,” AND “AFFECTIVE NONRELATEDNESS” 181
  • 182. MODELL HIGHLIGHTS THAT IT IS CRITICALLY IMPORTANT FOR THE THERAPIST TO BE EXQUISITELY ATTUNED TO THE PATIENT’S INTENSE AMBIVALENCE ABOUT BEING IN RELATIONSHIP CONFLICT BETWEEN BEING FOUND AND REMAINING HIDDEN INDEED ALTHOUGH A PART OF THE PATIENT YEARNS TO BE KNOWN AND SEEN BY THE THERAPIST, ANOTHER PART OF THE PATIENT ZEALOUSLY GUARDS THE SACROSANCTITY OF HER PRIVACY, KEEPING HIDDEN WHAT MOST MATTERS TO HER, REFUSING TO LET ANYONE IN 182
  • 183. EVER APPRECIATING, HOWEVER, THAT THERE IS AT LEAST A PART OF THE PATIENT THAT YEARNS TO BE SEEN, THE MODEL 4 THERAPIST MUST USE HER INTUITION TO DECIDE WHETHER, IN THE MOMENT, THE PATIENT IS WANTING TO BE FOUND OR NEEDING, AT LEAST FOR THE TIME BEING, TO REMAIN HIDDEN, NOT KNOWN, NOT SEEN TO BE INTIMATE IS TO RUN THE RISK OF HAVING ONE’S HEART SHATTERED, BUT TO BE SEPARATE IS TO RUN THE RISK OF EGO DISSOLUTION AND FRAGMENTATION OF THE SELF THE DILEMMA FOR SUCH PATIENTS IS HOW TO BE A PART OF THE WORLD WITHOUT BEING DESTROYED, BUT HOW TO BE APART FROM THE WORLD WITHOUT DISAPPEARING 183
  • 184. R D LAING’S DIVIDED SELF LAING, A STUDENT OF EXISTENTIALISM AND LONG INTERESTED IN THE EXPERIENCE OF BEING – IN – THE – WORLD, WRITES ABOUT THE “DIVIDED SELF” AS SPEAKING TO THE DEFENSIVE “SPLIT IN THE SELF” THAT DEVELOPS IN SOME PATIENTS AS A REACTION TO “ONTOLOGICAL INSECURITY” (1960) ONTOLOGICAL INSECURITY SPEAKS TO THE LACK OF MEANING, ORDER, AND CONTINUITY IN ONE’S LIFE AND CONSEQUENT INSECURITY ABOUT ONE’S EXISTENCE SPLITTING OF THE SELF IS THEN AN ATTEMPT TO MANAGE THE DEEP ANXIETY AND DREAD THAT ARISE FROM THIS UNCERTAINTY ABOUT THE HUMAN CONDITION AND THE STATE OF THE WORLD IN GENERAL 184
  • 185. DONALD BURNHAM’S NEED – FEAR DILEMMA ALSO RELEVANT HERE ARE THE FORMULATIONS OF DONALD BURNHAM, AN AMERICAN PSYCHIATRIST WHO (SOME FIFTY YEARS AGO) WAS OBSERVING THAT MANY OF THE INPATIENTS WITH WHOM HE WAS WORKING AT CHESTNUT LODGE IN MARYLAND, WERE STRUGGLING WITH SOMETHING TO WHICH HE REFERRED AS THE “NEED – FEAR DILEMMA” (1969) ALSO AN APT CONCEPT FOR THE INTERNAL DIVIDEDNESS THAT CHARACTERIZES MODEL 4 PATIENTS THESE “SCHIZO – DYNAMICS” SPEAK TO BOTH THE PATIENT’S DESPERATE NEED TO FIND CONNECTION AND MERGER WITH OTHERS AND HER EQUALLY INTENSE FEAR OF BEING DESTROYED AND CONSUMED IN THE PROCESS 185
  • 186. ALTHOUGH THERE IS OBVIOUSLY A CONTINUUM IN TERMS OF THE CAPACITY TO BE ENGAGED IN THE WORLD THE MODEL 4 PATIENT’S EXPERIENCE OF OVERWHELMING HELPLESSNESS AND TERROR HAS A LOT IN COMMON, IN ITS EXTREME FORM, WITH MELANIE KLEIN’S “PSYCHOTIC ANXIETY” MARGARET MAHLER’S “ORGANISMIC DISTRESS” WILFRED BION’S “NAMELESS DREAD” MAX SCHUR’S “PRIMARY ANXIETY” JOHN FROSCH’S “BASIC ANXIETY” MARGARET LITTLE’S “ANNIHILATION ANXIETY” HEINZ KOHUT’S “DISINTEGRATION ANXIETY” DONALD WINNICOTT’S “UNTHINKABLE ANXIETY” WINNICOTT’S “FEAR OF BREAKDOWN” MAY ALSO BE RELEVANT HERE, ALTHOUGH WINNICOTT POSTULATES THAT THIS FEAR OF BREAKDOWN IS ACTUALLY THE FEAR OF A BREAKDOWN THAT HAS ALREADY HAPPENED BUT THAT COULD NOT BE EXPERIENCED AT THE TIME 186
  • 188. MODEL 4 FACILITATION STATEMENTS INSPIRED BY LAING’S CONCEPT OF THE DIVIDED SELF; BURNHAM’S CONCEPT OF THE NEED – FEAR DILEMMA; THE PSYCHOANALYTIC CONTRIBUTIONS OF FAIRBAIRN, GUNTRIP, WINNICOTT, BALINT, KHAN, BOLLAS, AND MODELL; AND THE PHILOSOPHICAL CONTRIBUTIONS OF HEIDEGGER AND FRANKL I HAVE DESIGNED A PSYCHOTHERAPEUTIC INTERVENTION FOR PATIENTS WHO – WHETHER MOMENTARILY (STATE) OR MORE CHARACTEROLOGICALLY (TRAIT) – HAVE NOT ONLY SELF – PROTECTIVELY RETREATED FROM ENGAGEMENT WITH THE WORLD OF OBJECTS BUT ALSO NIHILISTICALLY RETREATED FROM LIFE ITSELF 188
  • 189. MODEL 4 FACILITATION STATEMENTS HIGHLIGHT NOT ONLY THE PATIENT’S TERROR OF BEING ONCE AGAIN DESTROYED BY AN ANNIHILATING OBJECT BUT ALSO HER DESPERATE LONGING TO RE – ENGAGE WITH THE WORLD “A PART OF YOU IS DESPERATE TO BE SEEN, KNOWN, AND UNDERSTOOD; BUT ANOTHER PART OF YOU IS TERRIFIED OF BEING FOUND.” “A PART OF YOU LONGS FOR CONNECTION WITH OTHERS; BUT YOU HOLD BACK FOR FEAR OF BEING ONCE AGAIN DEVASTATED.” IN SPEAKING TO THE VARIOUS LAYERS OF THE PATIENT’S EXPERIENCE OF BEING – IN – THE – WORLD, FACILITATION STATEMENTS RESPECT THE COMPLEXITY OF THE PATIENT’S EXPERIENCE OF BEING – ENGAGED – IN – LIFE 189
  • 190. MODEL 4 FACILITATION STATEMENTS “YOUR FEEL DESPERATELY LONELY AND DISCONNECTED FROM PEOPLE AND WOULD WISH THAT YOU COULD FEEL THAT YOU BELONGED SOMEWHERE; BUT YOU FIND YOURSELF HOLDING BACK FOR FEAR OF BEING DEVASTATINGLY DISAPPOINTED AND WITH A SHATTERED HEART ONCE AGAIN.” “A PART OF YOU WOULD WANT TO BE ABLE TO FIND SOMETHING THAT COULD MAKE YOUR LIFE FEEL MORE MEANINGFUL; BUT ANOTHER PART OF YOU FEARS THAT IT IS SIMPLY NOT IN THE CARDS FOR YOU EVER TO FIND ANY REAL PLEASURE IN LIFE OR IN COMPANIONSHIP.” “A PART OF YOU WISHES THAT YOU COULD SIMPLY ENJOY BEING WITH PEOPLE; BUT ANOTHER PART OF YOU FEELS SO EMPTY AND INADEQUATE THAT YOU CANNOT IMAGINE EVER BEING ABLE TO BE COMFORTABLE AROUND PEOPLE.” “A PART OF YOU LONGS TO HAVE A PARTNER WITH WHOM YOU COULD SHARE YOUR LIFE; BUT ANOTHER PART OF YOU CRINGES AT THE THOUGHT OF PUTTING YOURSELF OUT THERE AND MAKING YOURSELF THAT VULNERABLE.” 190
  • 191. WITH HER FINGER EVER ON THE PULSE OF THE PATIENT’S LEVEL OF ANXIETY AND CAPACITY TO TOLERATE FURTHER CHALLENGE, THE THERAPIST – USING HER INTUITION TO DETERMINE WHEN THE MOMENT MIGHT BE RIGHT – WILL THEREFORE OFFER FACILITATION STATEMENTS IN AN EFFORT TO ENCOURAGE THE MODEL 4 PATIENT TO BECOME AWARE OF – AND TAKE RESPECTFUL OWNERSHIP OF – BOTH SIDES OF HER AMBIVALENCE ABOUT BEING – IN – THE – WORLD, BEING PRESENT, BEING CONNECTED, BEING AUTHENTIC, BEING ALIVE, AND HAVING HOPE 191
  • 192. MODEL 4 FACILITATION STATEMENTS “A PART OF YOU WOULD WANT TO BE ABLE TO TRUST ME; BUT ANOTHER PART OF YOU HOLDS BACK FOR FEAR OF BEING BETRAYED. TOO MANY PEOPLE HAVE ALREADY SHATTERED YOUR WORLD BY PROMISING AND THEN NOT DELIVERING.” “A PART OF YOU IS DESPERATE TO BE ABLE TO FEEL THAT YOU BELONG IN THE WORLD; BUT ANOTHER PART OF YOU IS TERRIFIED THAT YOU WILL ALWAYS FEEL THAT YOU ARE ON THE OUTSIDE AND HAVE NO PLACE HERE.” “A PART OF YOU VERY MUCH WANTS TO GET BETTER AND RECOGNIZES THAT COMING IN EVERY WEEK AND SHARING WHATEVER YOU MIGHT BE FEELING PROBABLY GIVES YOU THE BEST CHANCE OF MAKING THAT HAPPEN; BUT ANOTHER PART OF YOU IS EXHAUSTED, DISCOURAGED, AND NOT AT ALL SURE THAT YOU HAVE IT IN YOU TO KEEP TRYING.” 192
  • 193. BY WAY OF REVIEW THE MODEL 4 OFFERS PROFOUNDLY RESPECTFUL, “OPTIMALLY STRESSFUL” FACILITATION STATEMENTS THAT HIGHLIGHT THE PATIENT’S INTERNAL CONFLICTEDNESS BETWEEN REMAINING HIDDEN AND BEING FOUND PROVIDES A NONDEMANDING, RELIABLE, DEPENDABLE, PREDICTABLE PRESENCE THAT HONORS THE PATIENT’S AMBIVALENCE ABOUT BEING IN RELATIONSHIP WITH THE THERAPIST AND GIVES HER THE OPPORTUNITY TO REGULATE THEIR INTERPERSONAL SPACE AND DEGREE OF EMOTIONAL INTIMACY IN ESSENCE THE THERAPIST “MEETS THE OMNIPOTENCE” OF THE PATIENT BY RECOGNIZING AND RESPONDING TO HER EVERY NEED SUCH THAT THE PATIENT WILL BE ABLE TO FEEL (AND BE) MORE IN CONTROL OF HER ENVIRONMENT 193
  • 194. THE THERAPEUTIC ACTION IN MODEL 4 INVOLVES CREATING A “SAFE SPACE” INTO WHICH THE PATIENT, OVER TIME, WILL BE ABLE TO DELIVER WHAT MOST MATTERS TO HER OFFERING THE PATIENT AN OPPORTUNITY TO BECOME “ABSOLUTELY DEPENDENT” UPON SOMEONE WHOM SHE COMES TO EXPERIENCE, AT LEAST FOR A WHILE, AS “ABSOLUTELY NECESSARY” FOR HER SENSE OF SAFETY IN THIS WORLD WHICH WILL, OF NECESSITY, INVOLVE HELPING HER OVERCOME HER “DREAD OF SURRENDER TO RESOURCELESS DEPENDENCE” PROVIDING A “HOLDING (OR FACILITATING) ENVIRONMENT” THAT WILL FOSTER EMERGENCE OF THE PATIENT’S “TRUE” SELF IMPLICITLY INVITING THE PATIENT TO ENTER INTO A “HARMONIOUS INTERPENETRATING MIX – UP” (BALINT 1992) SUCH THAT THERAPIST AND PATIENT CAN BECOME PEACEFULLY MERGED 194
  • 195. THE THERAPEUTIC ACTION IN MODEL 4 FROM SCHIZOID WITHDRAWAL, PSYCHIC RETREAT, AFFECTIVE NONRELATEDNESS, EMOTIONAL DETACHMENT, EXISTENTIAL ANGST, RELENTLESS DESPAIR, HAUNTING LONELINESS, AND A LIFE “UNLIVED” TO MEANINGFUL MOMENTS OF MEETING THAT RESTORE PURPOSE, MEANING, AND DIRECTION TO AN EXISTENCE THAT WOULD OTHERWISE HAVE REMAINED DESOLATE, IMPENETRABLE, BARREN, AND EMPTY AND A HEART THAT WOULD OTHERWISE HAVE REMAINED BROKEN AND INCONSOLABLE FROM DENIAL OF OBJECT NEED SUPPORTED BY ILLUSIONS OF GRANDIOSE SELF – SUFFICIENCY TO ACKNOWLEDGMENT OF VULNERABILITY AND OF THE NEED FOR OBJECTS 195
  • 196. WHETHER BALINT’S “HARMONIOUS INTERPENETRATING MIX – UP” OR WINNICOTT’S “IN – BETWEEN SPACE,” “TRANSITIONAL AREA,” “POTENTIAL SPACE,” OR “INTERMEDIATE AREA OF EXPERIENCE,” ALL OF THE MODEL 4 CONCEPTS SPEAK TO THE CO – CREATION OF A SYNERGISTIC AND MYSTICAL “SPACE – BETWEEN” CONTAINING INTERLOCKING ASPECTS OF BOTH PATIENT AND THERAPIST IN THE WORDS OF PRAGLIN (2006) THIS TRANSFORMATIVE “IN – BETWEEN” IS A “MEETING – GROUND OF POTENTIALITY AND AUTHENTICITY” – LOCATED NEITHER SOLELY WITHIN THE PATIENT NOR SOLELY WITHIN THE THERAPIST IN ORDER TO CREATE THIS POWERFULLY HEALING TRANSITIONAL SPACE THE MODEL 4 THERAPIST MUST, FOR THE MOST PART, SIMPLY STAY OUT OF THE WAY AND ALLOW HERSELF TO BE CONTROLLED (AND DELIGHT IN THAT) – OFFERING NO RESISTANCE AND FOSTERING AN ATMOSPHERE OF SAFETY, RELIABILITY, AND DEPENDABILITY SHE IS A “SOULFUL PRESENCE” WHO ASKS VERY LITTLE OF THE PATIENT 196
  • 197. TO SUMMARIZE THE FEATURES OF THE MODEL 4 PATIENT’S EXPERIENCE OF BEING – IN – THE – WORLD RAW HEARTBREAK ~ HARROWING LONELINESS ~ RELENTLESS DESPAIR SCHIZOID WITHDRAWAL ~ EXISTENTIAL ANGST RETREAT, RESIGNATION, AND DEFEAT ~ EMOTIONAL DETACHMENT INNER EMPTINESS ~ INTERNAL IMPOVERISHMENT PSYCHIC DEADNESS ~ SOLITARY SUFFERING ~ CRIPPLING ANXIETY ANNIHILATION TERROR ~ DREAD ~ PANIC ~ ATTACHMENT INSECURITY ONTOLOGICAL INSECURITY ~ A SHATTERED SOUL A FRACTURED HEART ~ BROKENNESS ~ SPIRITUAL ISOLATION RECLUSIVENESS ~ SUBSTANCE ABUSE AND OTHER PRIVATE ADDICTIONS PERVERSIONS ~ IDIOSYNCRATIC PREOCCUPATIONS AN ACTIVE, RICH, AND INTRICATELY DETAILED FANTASY LIFE DESPERATION ~ A BLACK HOLE ~ COLD SOLITUDE ~ IMPENETRABILITY INACCESSIBILITY ~ PROFOUND HOPELESSNESS ~ UTTER DESOLATION A VULNERABLE, FRAGILE, AND TENUOUSLY ESTABLISHED SELF OVERWHELMING HELPLESSNESS ~ DENIAL OF OBJECT NEED ILLUSIONS OF GRANDIOSE SELF – SUFFICIENCY ~ AFFECTIVE NONRELATEDNESS DEFENSIVE QUEST FOR AN ILLUSORY SELF – SUFFICIENCY A DIVIDED SELF ~ A PRIVATE SELF ~ A FALSE SELF LIES ~ SECRETS ~ PRETENSIONS ~ CONCEALMENTS ~ DISSEMBLING INAUTHENTIC BEING – IN – RELATIONSHIP ~ INAUTHENTIC BEING – IN – THE – WORLD OVERWHELMING FEELINGS OF ALIENATION AND ESTRANGEMENT A LIFE UNLIVED AND DEVOID OF MEANINGFUL MOMENTS OF AUTHENTIC MEETING WITH OTHERS ~ THE ONGOING STRUGGLE TO RECONCILE THE DIALECTICAL TENSION BETWEEN THE NEED TO BE MET AND THE FEAR OF BEING FOUND AND BETWEEN EXISTENCE AS MEANINGFUL AND AS ABSURD 197
  • 198. TO WRAP UP  198
  • 199. IN THOSE MOMENTS WHEN THE SPOTLIGHT IS ON THE PATIENT AS “NOT AWARE” OR “NOT ACTUALIZED” (MODEL 1), THINK “CONFLICT STATEMENT” IN THOSE MOMENTS WHEN THE SPOTLIGHT IS ON THE PATIENT AS “NOT ACCEPTING” (MODEL 2), THINK “DISILLUSIONMENT STATEMENT” IN THOSE MOMENTS WHEN THE SPOTLIGHT IS ON THE PATIENT AS “NOT ACCOUNTABLE” (MODEL 3), THINK “ACCOUNTABILITY STATEMENT” OR “RELATIONAL INTERVENTION” IN THOSE MOMENTS WHEN THE SPOTLIGHT IS ON THE PATIENT AS “NOT ACCESSIBLE” (MODEL 4), THINK “FACILITATION STATEMENT” 199
  • 200. 200
  • 201. 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? 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 … 201
  • 202. 202
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  • 207. FOUR MODES OF THERAPEUTIC ACTION MODEL 1 – STRUCTURAL CONFLICT MODEL 2 – STRUCTURAL DEFICIT MODEL 3 – RELATIONAL CONFLICT MODEL 4 – RELATIONAL DEFICIT 207
  • 208. MODEL 1 – ENHANCEMENT OF KNOWLEDGE “WITHIN” THE INTERPRETIVE PERSPECTIVE OF CLASSICAL PSYCHOANALYSIS A DRIVE – DEFENSE MODEL THAT PRIVILEGES THE CURATIVE POWER OF INSIGHT IT IS A 1 – PERSON PSYCHOLOGY BECAUSE ITS FOCUS IS ON THE PATIENT AND THE INTERNAL WORKINGS OF HER MIND THE THERAPIST IS NOT SUPPOSED TO BRING “WHO SHE IS” INTO THE ROOM – AND, IF SHE DOES, IT IS CALLED COUNTERTRANSFERENCE 208
  • 209. MODEL 2 – PROVISION OF CORRECTIVE EXPERIENCE “FOR” THE DEFICIENCY – COMPENSATION PERSPECTIVE OF SELF PSYCHOLOGY AND THOSE OBJECT RELATIONS THEORIES THAT EMPHASIZE INTERNAL ABSENCE OF GOOD (DEFICIENCY) AND THEREFORE POSITS CORRECTIVE – PROVISION AS THE CURATIVE AGENT IT IS A 1½ – PERSON PSYCHOLOGY BECAUSE ITS FOCUS IS ON THE PATIENT AND HER RELATIONSHIP WITH A THERAPIST WHOM SHE EXPERIENCES AS EITHER AN EMPATHIC SELFOBJECT WHEN THE FRAME OF REFERENCE IS SELF PSYCHOLOGY OR A GOOD OBJECT / GOOD MOTHER WHEN THE FRAME OF REFERENCE IS OBJECT RELATIONS THEORY BUT WHETHER DESCRIBED AS AN EMPATHIC SELFOBJECT OR A GOOD OBJECT, IN MODEL 2 THE THERAPIST IS CONSIDERED A HALF PERSON BECAUSE IT IS NOT WHO SHE IS THAT MATTERS BUT WHAT SHE CAN PROVIDE 209
  • 210. MODEL 3 – ENGAGEMENT IN AUTHENTIC RELATIONSHIP “WITH” THE INTERSUBJECTIVE PERSPECTIVE OF CONTEMPORARY RELATIONAL THEORY AND THOSE OBJECT RELATIONS THEORIES THAT EMPHASIZE INTERNAL PRESENCE OF BAD (TOXICITY) AND POSITS COLLABORATIVE NEGOTIATION OF THE TURBULENCE THAT WILL INEVITABLY EMERGE AT THE INTIMATE EDGE OF AUTHENTIC ENGAGEMENT BETWEEN THERAPIST AND PATIENT AS THE TRANSFORMATIVE AGENT IT IS A 2 – PERSON PSYCHOLOGY BECAUSE ITS FOCUS IS ON PATIENTS AND THERAPISTS WHO RELATE TO EACH OTHER AS “REAL” PEOPLE IN MODEL 3 THE THERAPIST IS CONSIDERED A WHOLE PERSON 210