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Martha Stark MD – 7 Mar 2020 – Precipitating Disruption to Trigger Repair.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 inherent 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 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," "relentless pursuit of the unattainable" replaced by "acceptance," "re-enactment of unmastered early-on relational traumas” 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 TRANSFORMATIVE POWER
OF OPTIMAL STRESS:
PRECIPITATING DISRUPTION
TO TRIGGER REPAIR
ALSO DESCRIBED AS
THE THERAPEUTIC USE OF OPTIMAL
STRESS TO PROVOKE RECOVERY
“NO PAIN, NO GAIN” 
MARTHA STARK, MD
MarthaStarkMD @ HMS.Harvard.edu
Salt Lake City, UT
Saturday, March 7, 2020
© 2020 Martha Stark, MD
1
FIRST PART
SLIDES 3 – 70
2
CONTROLLED DAMAGE
TO PROVOKE RECOVERY
3
4
5
THE ART OF PRECIOUS SCARS
6
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Martha Stark MD – 7 Mar 2020 – Precipitating Disruption to Trigger Repair.pptx

  • 1. THE TRANSFORMATIVE POWER OF OPTIMAL STRESS: PRECIPITATING DISRUPTION TO TRIGGER REPAIR ALSO DESCRIBED AS THE THERAPEUTIC USE OF OPTIMAL STRESS TO PROVOKE RECOVERY “NO PAIN, NO GAIN”  MARTHA STARK, MD MarthaStarkMD @ HMS.Harvard.edu Salt Lake City, UT Saturday, March 7, 2020 © 2020 Martha Stark, MD 1
  • 4. 4
  • 5. 5
  • 6. THE ART OF PRECIOUS SCARS 6
  • 7. LONG INTRIGUING TO ME HAS BEEN THE IDEA THAT SUPERIMPOSING AN ACUTE PHYSICAL INJURY ON TOP OF A CHRONIC ONE IS SOMETIMES EXACTLY WHAT THE BODY NEEDS IN ORDER TO HEAL IN ESSENCE “CONTROLLED DAMAGE” TO “PROVOKE HEALING” 7
  • 8. BY WAY OF EXAMPLE THE PRACTICE OF WOUND DEBRIDEMENT TO ACCELERATE HEALING SPEAKS DIRECTLY TO THIS CONCEPT OF “CONTROLLED DAMAGE” TO “TRIGGER REPAIR” NOT ONLY DOES DEBRIDEMENT PREVENT INFECTION BY REMOVING FOREIGN MATERIAL AND DAMAGED TISSUE FROM THE SITE OF THE WOUND BUT ALSO IT PROMOTES HEALING BY MILDLY AGGRAVATING THE AREA, WHICH WILL IN TURN “JUMPSTART” THE BODY’S INNATE ABILITY TO “SELF – REPAIR” IN THE FACE OF CHALLENGE 8
  • 9. JUST AS WITH THE BODY WHERE A CONDITION MIGHT NOT HEAL UNTIL IT IS MADE ACUTE SO TOO WITH THE MIND INDEED OVER TIME I HAVE COME TO APPRECIATE THAT THE THERAPEUTIC PROVISION OF “OPTIMAL STRESS” AGAINST THE BACKDROP OF AN EMPATHICALLY ATTUNED AND AUTHENTICALLY ENGAGED THERAPY RELATIONSHIP … 9
  • 10. … IS SOMETIMES THE MAGIC INGREDIENT NEEDED TO OVERCOME THE SEEMINGLY INTRACTABLE RESISTANCE TO CHANGE SO FREQUENTLY ENCOUNTERED IN OUR THERAPY PATIENTS MARTHA STARK (2008, 2012, 2014) 10
  • 11. 11
  • 12. 12
  • 13. AS I HAVE EVOLVED OVER THE COURSE OF THE DECADES, SO TOO MY UNDERSTANDING OF THE HEALING PROCESS HAS EVOLVED – FROM ONE THAT EMPHASIZES THE INTERNAL WORKINGS OF THE MIND TO ONE THAT IS MORE HOLISTIC AND RECOGNIZES THE COMPLEX INTERDEPENDENCE OF MIND AND BODY 13
  • 14. BUT WHETHER THE MIND OR THE BODY IS THE FOCUS, THE PROCESS OF HEALING WILL INVOLVE INCREMENTAL TRANSFORMATION OF LESS HEALTHY DEFENSE INTO MORE HEALTHY ADAPTATION 14
  • 15. 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 15
  • 16. 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 RE – INTEGRATION 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 RELATIONAL EXPERIENCES 16
  • 17. 17
  • 18. THE SANDPILE MODEL AND THE PARADOXICAL IMPACT OF STRESS 18
  • 19. 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 … 19
  • 20. NOT JUST “IN SPITE OF” STRESSFUL INPUT FROM THE OUTSIDE BUT “BY WAY OF” THAT INPUT  20
  • 21. AMAZINGLY ENOUGH THE GRAINS OF SAND BEING STEADILY ADDED TO A 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 ALSO THEY BECOME THE MEANS BY WHICH THE SANDPILE WILL THEN BE ABLE TO BUILD ITSELF BACK UP EVERY 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 21
  • 22. 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 … 22
  • 23. … AT EVER – HIGHER LEVELS OF INTEGRATION, BALANCE, AND HARMONY 23
  • 24. 24
  • 25. WHERE DEFENSE WAS, THERE SHALL ADAPTATION BE 25
  • 26. THE DEVELOPMENTAL PROCESS AND THE THERAPEUTIC PROCESS WHERE ID WAS, THERE SHALL EGO BE WHERE DEFENSE WAS, THERE SHALL ADAPTATION 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 – FROM “LESS EVOLVED” TO “MORE EVOLVED” – 26
  • 27. VIKTOR FRANKL HAS WRITTEN THAT WE CANNOT AVOID SUFFERING; BUT, EVEN SO, WE CAN CHOOSE HOW WE COPE WITH IT, FIND MEANING IN IT, AND MOVE FORWARD WITH RENEWED PURPOSE VIKTOR FRANKL (1997) “BETWEEN STIMULUS AND RESPONSE IS A SPACE. IN THAT SPACE IS OUR POWER TO CHOOSE OUR RESPONSE. IN OUR RESPONSE LIES OUR GROWTH AND OUR FREEDOM.” IN OTHER WORDS IN THAT SPACE IS OUR POWER EITHER TO REACT DEFENSIVELY OR TO RESPOND ADAPTIVELY 27
  • 28. 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 28
  • 29. IN THE PHYSIOLOGICAL REALM A PRIME EXAMPLE OF ADAPTATION IS COLLATERALIZATION WHEN THERE IS ATHEROSCLEROTIC CORONARY ARTERY DISEASE THE DEVELOPMENT OF NEW CORONARY ARTERIES TO SUPPLY THE HEART WITH THE NUTRIENTS AND OXYGEN IT NEEDS TO FUNCTION THIS ADAPTATION MAY ENABLE THE PATIENT TO AVERT A POTENTIAL HEART ATTACK 29
  • 30. THYROID DYSFUNCTION THE BODY ADAPTS BY REDISTRIBUTING ITS BLOOD FLOW FROM LESS ESSENTIAL TO MORE ESSENTIAL ORGAN SYSTEMS THUS THE THIN FRAGILE SKIN, DRY BRITTLE HAIR, AND TELLTALE LOSS OF THE OUTER THIRD OF THE EYEBROWS SO CHARACTERISTIC OF HYPOTHYROIDISM ACIDIC INTERNAL ENVIRONMENT THE BODY ADAPTS BY LEACHING CALCIUM FROM ITS BONES IN AN EFFORT TO BUFFER THE ACIDITY THE GOOD NEWS WILL BE THE RESTORATION OF ACID – BASE BALANCE IN THE BODY THE BAD NEWS WILL BE THE POTENTIAL FOR DEMINERALIZATION OF THE BONES AND DEVELOPMENT OF OSTEOPENIA / OSTEOPOROSIS 30
  • 31. IN ESSENCE ADAPTATION IS A STORY ABOUT MAKING A VIRTUE OUT OF NECESSITY  31
  • 32. GROWING UP (THE TASK OF THE CHILD) AND GETTING BETTER (THE TASK OF THE PATIENT) CAN 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 32
  • 33. 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 33
  • 34. 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 34
  • 35. 35
  • 36. PSYCHODYNAMIC SYNERGY PARADIGM MARTHA STARK (2018) 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” 36
  • 37. PSYCHODYNAMIC SYNERGY PARADIGM THREE “MODES” OF THERAPEUTIC ACTION MUTUALLY ENHANCING NOT MUTUALLY EXCLUSIVE RELEVANT FOR CRISIS INTERVENTION, MEDICATION MANAGEMENT, SHORT – TERM INTENSIVE TREATMENT, AND LONG – TERM IN – DEPTH PSYCHOTHERAPY RELEVANT ALSO FOR WHATEVER THE DEGREE OF HEALTH / PSYCHOPATHOLOGY AND WHETHER HIGH – FUNCTIONING OR LOW – FUNCTIONING BECAUSE IT IS ALL ABOUT THE “THERAPEUTIC PROCESS” INDEED, THE THERAPIST WILL BE ABLE TO OPTIMIZE HER THERAPEUTIC EFFECTIVENESS IF – MOMENT BY MOMENT – SHE IS ABLE TO TRANSITION SEAMLESSLY – BACK AND FORTH – FROM ONE “MODE” TO ANOTHER … 37
  • 38. … BASED UPON WHAT THE THERAPIST SENSES IS MOST “IMMEDIATE” AND “EMOTIONALLY LADEN” FOR THE PATIENT IN THE MOMENT THAT IS, THE “POINT OF EMOTIONAL URGENCY” FOR THE PATIENT BE IT HER RESISTANCE TO DEVELOPING INSIGHT INTO – AND TAKING RESPONSIBILITY FOR – WHY SHE IS SO STUCK IN HER LIFE (MODEL 1) HER REFUSAL TO ACCEPT DISAPPOINTING REALITIES ABOUT THE PEOPLE IN HER LIFE (MODEL 2) HER RELUCTANCE TO HOLD HERSELF ACCOUNTABLE FOR WHAT SHE ENACTS IN HER RELATIONSHIPS (MODEL 3) 38
  • 39. IN OTHER WORDS THE PATIENT’S INTERNAL CONFLICTEDNESS (MODEL 1) THE PATIENT’S RELENTLESS PURSUITS (MODEL 2) THE PATIENT’S COMPULSIVE REPETITIONS (MODEL 3) 39
  • 40. ALL THREE MODELS ARE RELEVANT FOR BOTH (MOMENTARY) “TRAIT” AND (MORE SUSTAINED) “STATE” MODEL 1 FEATURES “NEUROTIC CONFLICTEDNESS” AND IS RELEVANT WHEN, IN THE MOMENT, THE PATIENT IS “RESISTANT” AND / OR “NOT AWARE” WHICH WILL CALL FOR A “CONFLICT STATEMENT” MODEL 2 FEATURES “NARCISSISTIC VULNERABILITY” AND IS RELEVANT WHEN, IN THE MOMENT, THE PATIENT IS “RELENTLESS” AND / OR “NOT ACCEPTING” WHICH WILL CALL FOR A “DISILLUSIONMENT STATEMENT” MODEL 3 FEATURES “NOXIOUS RELATEDNESS” AND IS RELEVANT WHEN, IN THE MOMENT, THE PATIENT IS “RE – ENACTING” AND / OR “NOT ACCOUNTABLE” WHICH WILL CALL FOR AN “ACCOUNTABILITY STATEMENT” 40
  • 41. 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 (RELENTLESS HOPE) MODEL 3 – RELATIONAL CONFLICT THE CHARACTER DISORDERED DEFENSE OF RELENTLESS EXTERNALIZATION AND DENIAL OF RESPONSIBILITY 41
  • 42. 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 42
  • 43. 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) 43
  • 44. 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 HEALTHY RELATIONSHIP “WITH” ULTIMATELY, A MORE ACCOUNTABLE SELF – IN – RELATION 44
  • 45. 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 EARLY – ON RELATIONAL TRAUMAS TO ACCOUNTABILITY FOR ONE’S DYSFUNCTIONAL ACTIONS, REACTIONS, AND INTERACTIONS 45
  • 46. HOW DO WE KNOW WHICH MODEL TO USE? PSYCHODYNAMIC PSYCHOTHERAPY IS LIKE BALLROOM DANCING THERE IS A LEADER AND A FOLLOWER THE PATIENT LEADS AND, FOR THE MOST PART, WE FOLLOW I HAVE COMPLETE FAITH IN THE “THERAPEUTIC PROCESS” AND CONFIDENCE THAT THE PATIENT WILL LEAD US TO WHEREVER SHE NEEDS US TO GO HER NEUROTIC CONFLICTEDNESS (MODEL 1) HER NARCISSISTIC VULNERABILITY (MODEL 2) HER NOXIOUS RELATEDNESS (MODEL 3) AND THIS POINT OF EMOTIONAL URGENCY WILL CONTINUOUSLY SHIFT I “GIVE” STATEMENTS AND RARELY “ASK” QUESTIONS BECAUSE I AM MORE INTERESTED IN “GIVING” TO THE PATIENT THAN IN “ASKING” OF HER THAT SHE “GIVE” (ANSWERS) TO ME MOMENT BY MOMENT, AS WE LISTEN, WE ARE CONTINUOUSLY DECIDING WHETHER TO “SUPPORT” BY BEING WITH THE PATIENT WHERE SHE IS OR TO “CHALLENGE” BY DIRECTING HER ATTENTION TO ELSEWHERE OUR GOAL – AN OPTIMAL BALANCE BETWEEN THE TWO OPTIMAL STRESS 46
  • 47. I WOULD LIKE TO BORROW FROM STEPHEN MITCHELL (1988) A WONDERFUL ANECDOTE THAT CAPTURES THE ESSENCE OF THE QUINTESSENTIAL STRUGGLE IN WHICH ALL OF US ARE ENGAGED AS WE ATTEMPT TO MASTER OUR ART MITCHELL WRITES – “<STRAVINSKY> HAD WRITTEN A NEW PIECE WITH A DIFFICULT VIOLIN PASSAGE. AFTER IT HAD BEEN IN REHEARSAL FOR SEVERAL WEEKS, THE SOLO VIOLINIST CAME TO STRAVINSKY AND SAID HE WAS SORRY, HE HAD TRIED HIS BEST, <BUT> THE PASSAGE WAS TOO DIFFICULT; NO VIOLINIST COULD PLAY IT. STRAVINSKY SAID, ‘I UNDERSTAND THAT. WHAT I AM AFTER IS THE SOUND OF SOMEONE TRYING TO PLAY IT.’” AS THERAPISTS, OUR WORK IS EXQUISITELY DIFFICULT AND FINELY TUNED – AND OFTEN WE WILL NOT BE ABLE TO GET IT JUST RIGHT – PERHAPS, HOWEVER, WE CAN CONSOLE OURSELVES WITH THE THOUGHT THAT IT IS THE EFFORT WE MAKE TO GET IT JUST RIGHT THAT WILL ULTIMATELY COUNT 47
  • 48. 48
  • 49. IN WHAT FOLLOWS THE OPERATIVE CONCEPT WILL BE OPTIMAL STRESS 49
  • 50. 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” 50
  • 51. 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, SERVING INSTEAD SIMPLY TO REINFORCE THE (DYSFUNCTIONAL) STATUS QUO BUT JUST THE RIGHT AMOUNT OF CHALLENGE WILL PROVIDE “JUST THE RIGHT AMOUNT” OF LEVERAGE NEEDED TO PROVOKE, AFTER INITIAL DISRUPTION, EVENTUAL RECONSTITUTION AT A HIGHER LEVEL OF INTEGRATION, FUNCTIONALITY, AND ADAPTIVE CAPACITY OPTIMAL (NONTRAUMATIC) STRESS 51
  • 52. 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 DISRUPTIVE ATTUNEMENT AND SUPPORT WHENEVER NECESSARY BY RESONATING EMPATHICALLY WITH WHERE THE PATIENT IS HOMEOSTATIC ATTUNEMENT SALMAN AKHTAR (2012) 52
  • 53. 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 NECESSARY BECAUSE … 53
  • 54. WHETHER FUNCTIONAL OR DYSFUNCTIONAL SELF – ORGANIZING (CHAOTIC) SYSTEMS SUCH AS THE PATIENT’S LONG – ESTABLISHED AND DEEPLY ENTRENCHED “DEFENSIVE STRUCTURES” ARE INHERENTLY RESISTANT TO CHANGE AFTER ALL “SELF – ORGANIZING SYSTEMS RESIST PERTURBATION” CHARLES KREBS (2013) 54
  • 55. I AM HERE REMINDED OF PORTIA NELSON’S AUTOBIOGRAPHY IN 5 SHORT CHAPTERS WHICH SPEAKS TO BOTH OUR INTENSE ATTACHMENT TO THE “DYSFUNCTIONAL STATUS QUO” AND OUR CAPACITY ULTIMATELY TO CHANGE CHAPTER 1 I WALK DOWN THE STREET THERE IS A DEEP HOLE IN THE SIDEWALK I FALL IN I AM LOST … I AM HELPLESS IT ISN’T MY FAULT IT TAKES FOREVER TO FIND A WAY OUT CHAPTER 2 I WALK DOWN THE SAME STREET THERE IS A DEEP HOLE IN THE SIDEWALK I PRETEND I DON’T SEE IT I FALL IN AGAIN I CAN’T BELIEVE I AM IN THE SAME PLACE BUT IT ISN’T MY FAULT IT STILL TAKES A LONG TIME TO GET OUT 55
  • 56. CHAPTER 3 I WALK DOWN THE SAME STREET THERE IS A DEEP HOLE IN THE SIDEWALK I SEE IT IS THERE I STILL FALL IN … IT’S A HABIT MY EYES ARE OPEN I KNOW WHERE I AM IT IS MY FAULT I GET OUT IMMEDIATELY CHAPTER 4 I WALK DOWN THE SAME STREET THERE IS A DEEP HOLE IN THE SIDEWALK I WALK AROUND IT CHAPTER 5 I WALK DOWN ANOTHER STREET 56
  • 57. I AM ALSO HERE REMINDED OF A SATURDAY NIGHT LIVE SKIT IN WHICH TWO MEN ARE SEATED AROUND A FIRE CHATTING AND ONE SAYS TO THE OTHER – “YOU KNOW HOW WHEN YOU STICK A POKER IN THE FIRE AND LEAVE IT IN FOR A LONG TIME, IT GETS REALLY, REALLY HOT? AND THEN YOU STICK IT IN YOUR EYE, AND IT REALLY, REALLY HURTS? I HATE IT WHEN THAT HAPPENS! I JUST HATE IT WHEN THAT HAPPENS!” 57
  • 58. A POPULAR SONG THAT SPEAKS TO THE NEED SO MANY OF US HAVE TO RECREATE THAT WITH WHICH WE ARE MOST FAMILIAR AND THEREFORE MOST COMFORTABLE IS A ROCK SONG BY THE LATE WARREN ZEVON (1996) ENTITLED “IF YOU WON’T LEAVE ME I’LL FIND SOMEBODY WHO WILL” 58
  • 59. AGAIN “SELF – ORGANIZING SYSTEMS RESIST PERTURBATION” WHAT THIS MEANS IS THAT UNLESS A “CHAOTIC” SYSTEM IS SUFFICIENTLY “PERTURBED” – SUFFICIENTLY “STRESSED” – BY INPUT FROM THE OUTSIDE THEN IT WILL MAINTAIN ITS STATUS QUO AND AS THIS RELATES TO A PATIENT UNLESS THE PATIENT’S “DYSFUNCTIONAL DEFENSES” ARE SUFFICIENTLY “CHALLENGED” BY THE THERAPIST THEN THERE WILL BE INSUFFICIENT IMPETUS FOR THEIR DESTABILIZATION – AND THUS LITTLE INCENTIVE FOR GROWTH – 59
  • 60. IT TOOK ME YEARS TO APPRECIATE SOMETHING THAT IS AT ONCE BOTH SIMPLE AND PROFOUND 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 60
  • 61. 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 “JUMPSTART” THE PATIENT’S RECOVERY … 61
  • 62. BY TAPPING INTO THE PATIENT’S UNDERLYING RESILIENCE, INNATE STRIVING TOWARDS HEALTH, AND INTRINSIC CAPACITY TO SELF – CORRECT IN THE FACE OF OPTIMAL CHALLENGE 62
  • 63. THERAPEUTIC INTERVENTIONS MUST THEREFORE BE “OPTIMALLY STRESSFUL” NOT ONLY SUPPORTIVE BUT ALSO SUFFICIENTLY CHALLENGING THAT THEY WILL PROVIDE THE IMPETUS NEEDED TO DESTABILIZE THE PATIENT’S “DYSFUNCTIONAL DEFENSES” THEREBY CREATING OPPORTUNITIES FOR RESTABILIZATION OF THOSE DEFENSES AT EVER – HIGHER LEVELS OF FUNCTIONALITY AND ADAPTIVE CAPACITY 63
  • 64. IN ESSENCE AGAINST A BACKDROP OF EMPATHIC ATTUNEMENT AND AUTHENTIC ENGAGEMENT THE THERAPIST BY WAY OF ONGOING AND JUDICIOUS USE OF “OPTIMALLY STRESSFUL” INTERVENTIONS WILL REPEATEDLY PRECIPITATE DISRUPTION IN ORDER TO TRIGGER RECOVERY THEREBY GENERATING HEALING CYCLES OF RUPTURE AND REPAIR EVER STRONGER AT THE BROKEN PLACES 64
  • 65. IN OTHER WORDS 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 … 65
  • 66. AWARENESS MODEL 1 ACCEPTANCE MODEL 2 ACCOUNTABILITY MODEL 3 ALL OF WHICH ARE ADAPTATIONS TO THE “STRESS OF LIFE” 66
  • 67. IN ITS ESSENCE 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 … 67
  • 68. … BUT THAT CAN NOW WITHIN THE CONTEXT OF SAFETY PROVIDED BY THE PATIENT’S RELATIONSHIP WITH HER THERAPIST WHO FUNCTIONS ALTERNATELY AS NEUTRAL OBJECT (MODEL 1) EMPATHIC SELFOBJECT (MODEL 2) AUTHENTIC SUBJECT (MODEL 3) BE PROCESSED, INTEGRATED, AND ADAPTED TO THEREBY ENABLING THE PATIENT TO EXTRICATE HERSELF FROM THE BONDS OF HER INTERNAL CONFLICTEDNESS, RELENTLESS PURSUITS, AND COMPULSIVE REPETITIONS 68
  • 69. AT THE END OF THE DAY PSYCHODYNAMIC PSYCHOTHERAPY IS A STORY ABOUT THE DEVELOPMENT OF CAPACITY 69
  • 70. – ADAPTIVE CAPACITY – IN THE FORM OF AWARENESS OF DISCOMFITING TRUTHS ABOUT THE SELF (MODEL 1) ACCEPTANCE OF DISCOMFITING TRUTHS ABOUT THE OBJECT (MODEL 2) ACCOUNTABILITY FOR DISCOMFITING TRUTHS ABOUT THE SELF – IN – RELATION (MODEL 3) 70
  • 71. 71
  • 72. SECOND PART SLIDES 72 – 131 72
  • 73. THREE APPROACHES TO TRANSFORMING DEFENSE INTO ADAPTATION AND THREE OPTIMAL STRESSORS THAT REPRESENT THE “CUTTING EDGE” OF THE “THERAPEUTIC ACTION” COGNITIVE DISSONANCE (MODEL 1) AFFECTIVE DISILLUSIONMENT (MODEL 2) RELATIONAL DETOXIFICATION (MODEL 3) 73
  • 74. THREE APPROACHES TO TRANSFORMING DEFENSE INTO ADAPTATION AND THE THREE OPTIMAL STRESSORS THAT WILL FACILITATE THIS “ACTION” MODEL 1 – RESISTANCE INTO AWARENESS BY WORKING THROUGH THE STRESS OF COGNITIVE DISSONANCE CREATED BY THE EXPERIENCE OF GAIN – BECOME – PAIN MODEL 2 – RELENTLESSNESS INTO ACCEPTANCE BY WORKING THROUGH THE STRESS OF AFFECTIVE DISILLUSIONMENT CREATED BY THE EXPERIENCE OF GOOD – BECOME – BAD MODEL 3 – RE – ENACTMENT INTO ACCOUNTABILITY BY WORKING THROUGH THE STRESS OF RELATIONAL DETOXIFICATION CREATED BY THE EXPERIENCE OF BAD – BECOME – GOOD 74
  • 75. THE PATIENT’S THREE CHALLENGES MODEL 1 – COGNITIVE DISSONANCE THE PATIENT MUST RESOLVE THE INTERNAL DISEQUILIBRIUM SHE WILL EXPERIENCE WHEN DEFENSES ONCE EGO – SYNTONIC BECOME INCREASINGLY EGO – DYSTONIC MODEL 2 – AFFECTIVE DISILLUSIONMENT THE PATIENT MUST CONFRONT – AND GRIEVE – DISAPPOINTING REALITIES ABOUT THE OBJECTS OF HER DESIRE MODEL 3 – RELATIONAL DETOXIFICATION THE PATIENT MUST NEGOTIATE AT THE “INTIMATE EDGE” OF AUTHENTIC ENGAGEMENT WITH HER THERAPIST DARLENE EHRENBERG (1992) 75
  • 76. IN ORDER TO FACILITATE THE “THERAPEUTIC ACTION” “OPTIMALLY STRESSFUL” INTERVENTIONS ALTERNATELY CHALLENGE AND SUPPORT ANXIETY – PROVOKING BUT ULTIMATELY GROWTH – PROMOTING 76
  • 77. MODEL 1 CONFLICT STATEMENTS ARE DESIGNED TO ENCOURAGE THE “RESISTANT” PATIENT TO STEP BACK FROM THE IMMEDIACY OF THE MOMENT IN ORDER TO GAIN INSIGHT INTO BOTH HER INVESTMENT IN MAINTAINING THINGS AS THEY ARE EGO – SYNTONIC AND THE PRICE SHE PAYS FOR DOING SO EGO – DYSTONIC 77
  • 78. 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 78
  • 79. 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 79
  • 80. TO REVIEW “CONFLICT STATEMENTS” WHEN THE SPOTLIGHT IS ON THE PATIENT AS “NOT AWARE” (MODEL 1) “DISILLUSIONMENT STATEMENTS” WHEN THE SPOTLIGHT IS ON THE PATIENT AS “NOT ACCEPTING” (MODEL 2) “ACCOUNTABILITY STATEMENTS” AND “RELATIONAL INTERVENTIONS” WHEN THE SPOTLIGHT IS ON THE PATIENT AS “NOT ACCOUNTABLE” (MODEL 3) 80
  • 81. 81
  • 82. MODEL 1 CONFLICT STATEMENTS AND THE CREATION OF COGNITIVE AND AFFECTIVE DISSONANCE BETWEEN THE “PAIN” AND THE “GAIN” 82
  • 83. 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 TO BE 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” 83
  • 84. 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” AN ANXIETY – PROVOKING REALITY AND THEN WITH COMPASSION AND NEVER JUDGMENT SUPPORT BY RESONATING EMPATHICALLY WITH THE PATIENT’S “DEFENSIVE NEED TO AVOID KNOWING” THAT DISCOMFITING TRUTH 84
  • 85. BE IT AN ANXIETY – PROVOKING TRUTH ABOUT HER INTERNAL OR RELATIONAL DYNAMICS, THE PRICE SHE PAYS FOR MAINTAINING HER DEFENSES, OR THE THERAPEUTIC WORK SHE HAS YET TO DO THE PATIENT DOES INDEED KNOW “BUT” WOULD RATHER NOT AND THEREFORE – MADE ANXIOUS – SHE DEFENDS 85
  • 86. MODEL 1 CONFLICT STATEMENTS STRATEGICALLY DESIGNED TO GENERATE DESTABILIZING TENSION WITHIN THE PATIENT BETWEEN HER KNOWLEDGE OF ANXIETY – PROVOKING BUT AWARENESS – ENHANCING, GROWTH – PROMOTING, AND ULTIMATELY 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 ANXIETY – ASSUAGING DEFENSE 86
  • 87. 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 87
  • 88. ANXIETY – PROVOKING BUT ULTIMATELY AWARENESS – ENHANCING INTERVENTIONS FIRST THE REALITY WHAT THE PATIENT REALLY DOES KNOW AND THEN THE DEFENSE / THE RESISTANCE 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.” 88
  • 89. JUST AS WITH THE EVER – EVOLVING SANDPILE MODEL OF CHAOS THEORY SO TOO THE MODEL 1 “INTERPRETIVE” 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 TO EVOLVE INCREMENTALLY FROM “DEFENSIVE RESISTANCE” TO EVER – HIGHER LEVELS OF “ADAPTIVE AWARENESS” 89
  • 90. ONGOING CHALLENGE AND THEN SUPPORT WITH “OPTIMALLY STRESSFUL” CONFLICT STATEMENTS DESIGNED TO FACILITATE THE DEVELOPMENT OF “DUAL AWARENESS” 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 90
  • 91. 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 ARE PLAYING 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!” 91
  • 92. 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 92
  • 93. 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.” 93
  • 94. THE CREATION OF INTERNAL TENSION BETWEEN “PAIN” AND “GAIN” 94
  • 95. IN ORDER TO INCREASE THE PATIENT’S AWARENESS OF HER AMBIVALENT ATTACHMENT TO HER DYSFUNCTION THE MODEL 1 “INTERPRETIVE” THERAPIST FIRST CHALLENGES BY HIGHLIGHTING WHAT THE PATIENT IS COMING TO UNDERSTAND AS THE PRICE SHE PAYS FOR CLINGING TO HER DYSFUNCTION 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 BACK AND FORTH – BACK AND FORTH IN AN EFFORT TO MAKE THE AMBIVALENTLY HELD DEFENSE LESS EGO – SYNTONIC AND MORE EGO – DYSTONIC 95
  • 96. IN ESSENCE MODEL 1 CONFLICT STATEMENTS STRIVE TO CREATE INCENTIVIZING TENSION WITHIN THE PATIENT BETWEEN HER DAWNING AWARENESS OF JUST HOW COSTLY HER DEFENSES HAVE BECOME 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 THE PATIENT TO TAKE ACTION IN ORDER TO RESOLVE THE INTERNAL TENSION 96
  • 97. TO THAT END THE MODEL 1 “INTERPRETIVE” THERAPIST WILL THEREFORE REPEATEDLY HIGHLIGHT BOTH THE “PRICE PAID” (PAIN) AND THE “INVESTMENT IN” (GAIN) AS LONG AS THE “GAIN” IS GREATER THAN THE “PAIN” MORE EGO – SYNTONIC THAN EGO – DYSTONIC THE PATIENT WILL “MAINTAIN” THE DEFENSE AND “REMAIN” ENTRENCHED BUT AS A RESULT OF THE PATIENT’S EVER – EVOLVING AWARENESS OF BOTH THE “PRICE PAID” AND HER “INVESTMENT IN” ONCE THE “PAIN” BECOMES GREATER THAN THE “GAIN” MORE EGO – DYSTONIC THAN EGO – SYNTONIC THE STRESS AND “STRAIN” OF THE COGNITIVE AND AFFECTIVE DISSONANCE BETWEEN THE “PAIN” AND THE “GAIN” WILL BE SUCH THAT IT WILL PROVIDE THE IMPETUS NEEDED FOR THE PATIENT GRADUALLY … 97
  • 98. … TO RELINQUISH HER ATTACHMENT TO THE DYSFUNCTIONAL DEFENSE THEREBY RESOLVING THE STRUCTURAL CONFLICT NEUROTIC / INTRAPSYCHIC CONFLICT THAT HAD EXISTED BETWEEN THE UNTAMED BUT ULTIMATELY GROWTH – PROMOTING ID DRIVE AND THE RESISTIVE AND GROWTH – IMPEDING BUT ANXIETY – RELIEVING EGO DEFENSE 98
  • 99. AS A RESULT OF “WORKING THROUGH” THE DEFENSE / THE RESISTANCE THE NOW STRONGER AND MORE INSIGHTFUL 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 BY THE EGO AND CHANNELED INTO MORE CONSTRUCTIVE ENDEAVORS AND WORTHWHILE PURSUITS THEIR MODULATED ENERGY NOW PROVIDING THE PROPULSIVE FUEL FOR ACTUALIZATION OF POTENTIAL 99
  • 100. IN OTHER WORDS ONGOING USE OF “OPTIMALLY STRESSFUL” 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” WILL BE “FREED UP” AND CAN THEN BE USED TO “EMPOWER” THE “REALIZATION OF LIFE GOALS” 100
  • 101. FREUD’S (1937) “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 WILL NOW BE 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 IN SYNC NO LONGER IN CONFLICT BUT IN COLLABORATION 101
  • 102. IN ESSENCE THE DEFENSIVE NEED TO “REIN THE HORSE IN” WILL HAVE BECOME INCREMENTALLY 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” 102
  • 103. 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” FEELING COMPELLED TO MAKE WE ARE THEREFORE ALWAYS STRUGGLING TO FIND AN OPTIMAL BALANCE WITHIN OURSELVES BETWEEN WANTING THE PATIENT TO CHANGE AND ACCEPTING THE REALITY OF WHO SHE IS 103
  • 104. 104
  • 105. IMPORTANTLY MODEL 1 CONFLICT STATEMENTS BY LOCATING WITHIN THE PATIENT THE CONFLICT BETWEEN HER ANXIETY – PROVOKING KNOWLEDGE OF A DISCOMFITING 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 105
  • 106. MORE SPECIFICALLY 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 BECAUSE 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 EVER – 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 106
  • 107. IN OTHER WORDS AS A RESULT OF THE JUDICIOUS USE OF CONFLICT STATEMENTS THAT FORCE THE PATIENT TO BECOME AWARE OF – AND TO TAKE RESPONSIBILITY FOR – HER OWN STATE OF INTERNAL “DIVIDEDNESS” ABOUT GETTING BETTER THE THERAPIST WILL BE ABLE MASTERFULLY TO AVOID GETTING DEADLOCKED IN A POWER STRUGGLE WITH THE PATIENT A POWER STRUGGLE THAT CAN EASILY ENOUGH ENSUE IF THE THERAPIST TAKES IT UPON HERSELF TO REPRESENT THE “VOICE OF REALITY” AND OVERZEALOUSLY ADVOCATES FOR THE PATIENT TO DO THE “RIGHT” THING A STANCE THAT THEN LEAVES THE PATIENT – MADE ANXIOUS – NO CHOICE BUT TO BECOME THE “VOICE OF OPPOSITION” 107
  • 108. IT IS TRULY AN UNTENABLE SITUATION FOR THE THERAPIST TO BE THE ONE REPRESENTING THE HEALTHY (ADAPTIVE) “VOICE OF YES” AND FOR THE PATIENT 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 EVEN THOUGH SHE MIGHT SOMETIMES BE UNWILLING / UNABLE TO ACT IN ACCORDANCE WITH THAT KNOWLEDGE IN SUM BY LOCATING THE CONFLICT SQUARELY WITHIN THE PATIENT AND NOT WITHIN THE INTERSUBJECTIVE FIELD BETWEEN PATIENT AND THERAPIST, CONFLICT STATEMENTS FORCE THE PATIENT TO TAKE OWNERSHIP OF BOTH SIDES OF HER AMBIVALENCE ABOUT GETTING BETTER 108
  • 109. 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 MIGHT CHANGE 109
  • 110. IN SUM “OPTIMALLY STRESSFUL” CONFLICT STATEMENTS ARE DESIGNED TO PROVOKE THE RELINQUISHMENT OF DYSFUNCTIONAL DEFENSES BY GENERATING COGNITIVE AND AFFECTIVE DISSONANCE WITHIN THE PATIENT THE “WISDOM OF THE BODY” IS SUCH THAT IT CANNOT TOLERATE THE DISTRESS OF DISEQUILIBRIUM FOR ANY EXTENDED PERIOD OF TIME AND WILL THEREFORE BE “PROVOKED” TO TAKE ACTION IN ORDER TO RESOLVE THE INTERNAL TENSION AND RESTORE HOMEOSTATIC BALANCE 110
  • 111. ULTIMATELY, IT WILL BE THE PATIENT’S EVER – EVOLVING CAPACITY BOTH TO RECOGNIZE (WITH HER HEAD) AND TO EXPERIENCE (WITH HER HEART) THE FUNDAMENTAL CONFLICT BETWEEN “COST” AND “BENEFIT” THAT WILL PROMPT HER TO RELINQUISH HER DYSFUNCTION THAT IS, TO SURRENDER HER UNHEALTHY DEFENSES – DESPITE THEIR ERSTWHILE USEFULNESS – IN FAVOR OF HEALTHIER ADAPTATIONS AS SHE EVOLVES FROM “DEFENSIVE RESISTANCE” TO “ADAPTIVE AWARENESS,” EXPANDED CONSCIOUSNESS, AND ACTUALIZED POTENTIAL 111
  • 112. 112
  • 113. EGO – PROTECTIVE ONE – PERSON DEFENSES vs SELF – PROTECTIVE TWO – PERSON DEFENSES 113
  • 114. PLEASE NOTE THE CRITICAL DISTINCTION BETWEEN EGO – PROTECTIVE ONE – PERSON DEFENSES RELEVANT FOR MODEL 1 AND SELF – PROTECTIVE TWO – PERSON DEFENSES RELEVANT FOR MODELS 2 AND 3 ONE – PERSON (OR INTRAPSYCHIC) DEFENSES ARE MOBILIZED BY AN EGO – MADE ANXIOUS – ATTEMPTING TO PROTECT ITSELF AGAINST THE THREATENED BREAKTHROUGH OF DYSREGULATED AND ANXIETY – PROVOKING ID DRIVES WELL – KNOWN INTRAPSYCHIC DEFENSES REPRESSSION – INTELLECTUALIZATION – RATIONALIZATION COMPARTMENTALIZATION – REACTION FORMATION MOBILIZATION OF WHICH WILL GIVE RISE TO INTERNAL / STRUCTURAL / NEUROTIC CONFLICT HERE THE IMPORTANT RELATIONSHIP IS THE ONE THAT EXISTS BETWEEN THE EGO AND THE ID MODEL 1 INVOLVES THESE ONE – PERSON DEFENSES 114
  • 115. BY CONTRAST TWO – PERSON (OR INTERPERSONAL) DEFENSES ARE MOBILIZED BY A “SELF” – MADE ANXIOUS – ATTEMPTING TO PROTECT ITSELF AGAINST BEING FAILED BY THE OBJECT LESS WELL – KNOWN, BUT JUST AS IMPORTANT, INTERPERSONAL DEFENSES THE NARCISSISTIC NEED FOR VALIDATION BY A MIRRORING SELFOBJECT THE NARCISSISTIC NEED TO FUSE IN FANTASY WITH AN IDEALIZED SELFOBJECT THE MASOCHISTIC DEFENSE OF RELENTLESS HOPE THE SADISTIC DEFENSE OF RELENTLESS OUTRAGE PROJECTIVE IDENTIFICATION – THE NEED FOR OMNIPOTENT CONTROL OF THE OBJECT ALL OF WHICH ARE TWO – PERSON DEFENSES MOBILIZED TO PROTECT THE VULNERABLE SELF FROM BEING FAILED, DISAPPOINTED, ANNIHILATED, OR DESTROYED BY THE OBJECT NOW THE IMPORTANT RELATIONSHIP IS THE ONE THAT EXISTS BETWEEN THE SELF AND THE OBJECT MODELS 2 AND 3 INVOLVE THESE TWO – PERSON DEFENSES 115
  • 116. 116
  • 117. NATURE vs NURTURE MODEL 1 vs MODELS 2 AND 3 “I – IT” vs “I – THOU” RELATIONSHIPS 117
  • 118. MODEL 1 WHAT DERIVES FROM WITHIN THE CHILD NATURE MODELS 2 AND 3 WHAT DERIVES FROM WITHIN THE RELATIONSHIP BETWEEN PARENT AND CHILD NURTURE 118
  • 119. 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 AN UNTAMED ID AND A WEAK EGO BUT SELF PSYCHOLOGISTS AND RELATIONAL THEORISTS CONCEIVE OF PSYCHOPATHOLOGY AS DERIVING FROM THE PARENT AND THE PARENT’S FAILURE OF THE CHILD 119
  • 120. IN OTHER WORDS SELF PSYCHOLOGISTS AND RELATIONAL THEORISTS FOCUS NOT SO MUCH ON NATURE THE PROVINCE OF MODEL 1 AS ON NURTURE THE PROVINCE OF MODELS 2 AND 3 WHETHER THE QUALITY OF PARENTAL CARE MODEL 2 OR THE MUTUALITY OF FIT BETWEEN PARENT AND CHILD MODEL 3 120
  • 121. 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 121
  • 122. MORE SPECIFICALLY 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 (2000) 122
  • 123. THIS DISTINCTION IS CRITICAL BECAUSE A RELATIONSHIP BETWEEN SOMEONE WHO ACTIVELY PROVIDES AND SOMEONE WHO IS THE PASSIVE RECIPIENT OF SUCH PROVISION MODEL 2 IS A FAR CRY FROM THE “MORE SUBSTANTIVE” RELATIONSHIP THAT EXISTS BETWEEN TWO “REAL” PEOPLE MODEL 3 AN INTERSUBJECTIVE RELATIONSHIP INVOLVING TWO SUBJECTS BOTH OF WHOM CONTRIBUTE TO WHAT TRANSPIRES AT THEIR “INTIMATE EDGE” 123
  • 124. AS WE SHALL SEE THE EMPHASIS IN MODEL 2 IS THEREFORE NOT SO MUCH ON THE RELATIONSHIP PER SE AS IT IS ON THE FILLING IN OF THE PATIENT’S DEFICITS BY WAY OF THE THERAPIST’S CORRECTIVE PROVISION OR PERHAPS MORE ACCURATELY AS IT IS ON THE FILLING IN OF DEFICIT BY WAY OF WORKING THROUGH FAILURES IN THE ENVIRONMENTAL PROVISION BY CONTRAST THE EMPHASIS IN MODEL 3 IS TRULY ON A “2 – WAY” RELATIONSHIP BETWEEN TWO “AUTHENTIC SUBJECTS” – TWO “RELATIONAL OBJECTS” – 124
  • 125. IMPORTANTLY AS THE ETIOLOGY HAS SHIFTED FROM NATURE (MODEL 1) TO NURTURE (MODELS 2 AND 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 125
  • 126. BUT ACTUALLY 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) 126
  • 127. ANOTHER IMPORTANT CLINICAL DISTINCTION WHEREAS 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 THE DESPERATE SEARCH FOR A NEW GOOD PARENT “RELENTLESS PURSUITS” IN AN EFFORT TO COMPENSATE FOR EARLY – ON “PARENTAL ERRORS OF OMISSION” 127
  • 128. 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 AND BETTER OUTCOMES EVERY “NEXT TIME” “COMPULSIVE REPETITIONS” IN AN EFFORT TO CORRECT FOR EARLY – ON “PARENTAL ERRORS OF COMMISSION” 128
  • 129. AS IT HAPPENS “ABSENCE OF GOOD” (MODEL 2) AND “PRESENCE OF BAD” (MODEL 3) GENERALLY GO HAND IN HAND BY WAY OF EXAMPLES THE CHILD WHO WAS RARELY PRAISED AND THEREFORE DEVELOPED “STRUCTURAL DEFICIT” WAS PROBABLY ALSO OFTEN CRITICIZED AND THEREFORE ALSO DEVELOPED “PATHOGENIC INTROJECTS” THE CHILD WHO WAS RARELY ADMIRED AND THEREFORE DEVELOPED “STRUCTURAL DEFICIT” WAS PROBABLY ALSO OFTEN DEVALUED AND THEREFORE ALSO DEVELOPED “PATHOGENIC INTROJECTS” BUT THESE SITUATIONS ARE NOT HANDLED THE SAME WAY CLINICALLY 129
  • 130. AS WE SHALL LATER SEE MODEL 2 “ABSENCE OF GOOD” – STRUCTURAL DEFICIT – WILL CREATE THE NEED TO “FIND NEW GOOD” DISPLACEMENT OF THIS NEED WILL GIVE RISE TO “ILLUSION” – POSITIVE MISPERCEPTION OF REALITY – AND “POSITIVE TRANSFERENCE” THE THERAPEUTIC ACTION IN MODEL 2 WILL THEN INVOLVE WORKING THROUGH – BY WAY OF GRIEVING – NOT “POSITIVE TRANSFERENCE” BUT “DISRUPTED POSITIVE TRANSFERENCE” 130
  • 131. MODEL 3 “PRESENCE OF BAD” – PATHOGENIC INTROJECTS – WILL CREATE THE NEED TO “RE – FIND OLD BAD” PROJECTION OF PATHOGENIC INTROJECT WILL GIVE RISE TO “DISTORTION” – NEGATIVE MISPERCEPTION OF REALITY – AND “NEGATIVE TRANSFERENCE” THE THERAPEUTIC ACTION IN MODEL 3 WILL THEN INVOLVE WORKING THROUGH – BY WAY OF NEGOTIATING AT THE INTIMATE EDGE OF AUTHENTIC ENGAGEMENT – “NEGATIVE TRANSFERENCE” 131
  • 132. 132
  • 133. THIRD PART SLIDES 133 – 208 133
  • 135. 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 135
  • 136. 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 136
  • 137. 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 137
  • 138. AS IT HAPPENS THE THERAPIST’S PARTICIPATION AS AN AUTHENTIC SUBJECT MODEL 3 WILL ALMOST INEVITABLY RESULT IN THE THERAPIST’S PARTICIPATION AS SOME VERSION OF THE “OLD BAD OBJECT” BECAUSE OF THE PATIENT’S EVER – PRESENT “COMPULSIVE AND UNWITTING” NEED – HER REPETITION COMPULSION – TO RE – CREATE THE EARLY – ON UNMASTERED RELATIONAL FAILURES IN THE HERE – AND – NOW ENGAGEMENT WITH HER THERAPIST 138
  • 139. THIS “NEED TO BE FAILED” ASPECTS OF WHICH ARE “UNHEALTHY” ASPECTS OF WHICH ARE “HEALTHY” WILL PROMPT THE PATIENT TO EXERT “INTERPERSONAL PRESSURE” JAMES GROTSTEIN (1976) ON THE MODEL 3 THERAPIST TO CONFORM TO THE PATIENT’S “RELATIONAL EXPECTATION” OF ENCOUNTERING “BAD” AND SO IT IS THAT THE “RELATIONAL” THERAPIST – IN HER CAPACITY AS AN “AUTHENTIC SUBJECT” – WILL PARTICIPATE AS SOME VARIANT OF THE “OLD BAD OBJECT” 139
  • 140. MORE SPECIFICALLY THE REPETITION COMPULSION HAS 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 BECAUSE IT WOULD HIGHLIGHT THE FACT THAT THINGS COULD BE, AND COULD THEREFORE HAVE BEEN, DIFFERENT BUT THE HEALTHY PIECE HAS TO DO WITH THE PATIENT’S NEED TO ACHIEVE BELATED MASTERY OF THE PARENTAL FAILURES 140
  • 141. “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 SUPPLEMENT THIS WITH “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.” MARTHA STARK (1994) 141
  • 142. 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 A “NEW BEGINNING” (MICHAEL BALINT 1987) 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 AND THE “DYSFUNCTIONAL RELATIONAL DYNAMICS” TO WHICH THOSE INTROJECTED TRAUMAS HAVE GIVEN RISE 142
  • 143. 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 ADD NEW GOOD TO COMPENSATE FOR DEFICIENCY BY WORKING THROUGH THE EXPERIENCE OF GOOD – BECOME – BAD ILLUSION FOLLOWED BY DISILLUSIONING REALITY “HOPE FOR GOOD” FOLLOWED BY “NOT AS GOOD AS WOULD HAVE BEEN DESIRED” MODEL 3 – STRUCTURAL MODIFICATION CHANGE OLD BAD TO CORRECT FOR TOXICITY BY WORKING THROUGH THE EXPERIENCE OF BAD – BECOME – GOOD DISTORTION FOLLOWED BY DETOXIFYING REALITY “EXPECTATION OF BAD” FOLLOWED BY “NOT AS BAD AS HAD BEEN ANTICIPATED” 143
  • 144. 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 144
  • 145. 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 – THE SEDUCTIVE LURE OF THAT WITH WHICH ONE IS FAMILIAR – IS REPEATEDLY CHALLENGED AND GRADUALLY REPLACED BY MORE ACCURATE (AND LESS TOXIC) PERCEPTIONS OF REALITY 145
  • 146. THE THERAPEUTIC ACTION IN MODEL 2 WORKING THROUGH “POSITIVE TRANSFERENCE DISRUPTED” 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” STRUCTURE – AND CAPACITY – BUILDING “INCREMENTAL ACCRETION OF PSYCHIC STRUCTURE AND ADAPTIVE CAPACITY” “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” 146
  • 147. THE THERAPEUTIC ACTION IN MODEL 3 WORKING THROUGH “NEGATIVE TRANSFERENCE” A STORY ABOUT “NEGOTIATING” THE VARIOUS “MUTUAL ENACTMENTS” AND “THERAPEUTIC IMPASSES” THAT WILL INEVITABLY ARISE AT THE “INTIMATE EDGE” 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 “TOXIC INTERNAL BOLUSES” BY WAY OF “SERIAL DILUTION” AND BY VIRTUE OF THE THERAPIST’S CAPACITY TO PROCESS AND INTEGRATE TOXICITY ON BEHALF OF A PATIENT WHO TRULY DOES NOT KNOW HOW EVENTUAL TRANSFORMATION OF THE PATIENT’S “COMPULSIVE AND UNWITTING DRAMATIC RE – ENACTMENTS” INTO “ACCOUNTABILITY FOR HER DYSFUNCTIONAL ACTIONS, REACTIONS, AND INTERACTIONS” 147
  • 148. IN ESSENCE MODEL 2 “SERIAL ACCRETION” OF PSYCHIC STRUCTURE TO CORRECT FOR “INTERNAL ABSENCE OF GOOD” MODEL 3 “SERIAL DILUTION” OF TOXIC STRUCTURE TO CORRECT FOR “INTERNAL PRESENCE OF BAD” 148
  • 149. AGAIN PLEASE NOTE THE CRITICALLY IMPORTANT CLINICAL DISTINCTION BETWEEN “POSITIVE TRANSFERENCE DISRUPTED” AND “NEGATIVE TRANSFERENCE” MODEL 2 “POSITIVE TRANSFERENCE” NEED NOT BE WORKED THROUGH ONLY ITS “DISRUPTIONS” ACCOMPLISHED BY WAY OF “GRIEVING THE REALITY OF DISILLUSIONMENT” “OPTIMAL DISILLUSIONMENT” LEADING TO “TRANSMUTING INTERNALIZATION” MODEL 3 “NEGATIVE TRANSFERENCE” MUST BE WORKED THROUGH ACCOMPLISHED BY WAY OF “NEGOTIATING AT THE INTIMATE EDGE” “SERIAL DILUTIONS” LEADING TO “RELATIONAL DETOXIFICATION” 149
  • 150. 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 ON THE STAGE OF HER LIFE – THROUGH PROJECTIVE IDENTIFICATION – THE UNMASTERED EARLY – ON RELATIONAL TRAUMAS 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” 150
  • 151. IMPORTANTLY CENTER STAGE FOR BOTH SELF PSYCHOLOGISTS AND RELATIONAL THEORISTS ARE THE “INEVITABLE EMPATHIC FAILURES” OF SELF PSYCHOLOGY (MODEL 2) AND THE “INEVITABLE RELATIONAL FAILURES” OF CONTEMPORARY RELATIONAL THEORY (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 151
  • 152. BY CONTRAST MOST RELATIONAL THEORISTS (MODEL 3) BELIEVE THAT THE THERAPIST’S FAILURES ARE A STORY ABOUT NOT JUST THE THERAPIST AND THE THERAPIST’S INEVITABLE “LACK OF PERFECTION” BUT ALSO THE PATIENT AND THE PATIENT’S INEVITABLE ENACTMENT OF HER UNCONSCIOUS “NEED TO BE FAILED” SO THAT SHE CAN ACHIEVE BELATED MASTERY OF HER UNRESOLVED EARLY – ON RELATIONAL TRAUMAS TO THAT END THE PATIENT IS SEEN AS CONTINUOUSLY EXERTING “INTERPERSONAL PRESSURE” ON THE THERAPIST TO PARTICIPATE IN OLD “FAMILIAL AND THEREFORE FAMILIAR” WAYS STEPHEN MITCHELL (1988) RE – ENACTMENTS TO WHICH THE THERAPIST WILL FIND HERSELF CONTINUOUSLY AND UNCONSCIOUSLY REACTING 152
  • 153. IN OTHER WORDS THE RELATIONAL THERAPIST’S FAILURES ARE SEEN AS CO – CREATED AS OCCURRING IN THE CONTEXT OF AN ONGOING AND CONTINUOUSLY EVOLVING RELATIONSHIP BETWEEN TWO “AUTHENTIC SELVES” AND AS SPEAKING TO THE THERAPIST’S UNWITTING “RECEPTIVITY” TO THE PATIENT’S “PROVOCATIVE ENACTMENT” OF HER UNCONSCIOUS “NEED TO BE FAILED” 153
  • 154. PLEASE NOTE THE IMPORTANCE OF 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 “EMPATHIC” THERAPIST CANNOT TOLERATE – AT LEAST EVERY NOW AND THEN – “BREAKING THE PATIENT’S HEART” (THEREBY AFFORDING THE PATIENT THE EXPERIENCE OF “GOOD – BECOME – BAD”), 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 “RELATIONAL” THERAPIST REFUSES TO PARTICIPATE AS SOMEONE WHO – AT LEAST EVERY NOW AND THEN – “INITIALLY RE – TRAUMATIZES BUT ULTIMATELY RELENTS” (THEREBY AFFORDING THE PATIENT THE EXPERIENCE OF “BAD – BECOME – GOOD”), THE THERAPIST WILL BE ROBBING THE PATIENT OF THE OPPORTUNITY TO REWORK HER INTROJECTED BOLUSES OF TOXICITY VIA “SERIAL DILUTION” AND “RELATIONAL DETOXIFICATION” 154
  • 155. PARENTHETICALLY IN THE PSYCHOANALYTIC LITERATURE “INTERNALIZE” TENDS TO IMPLY “POSITIVE” AS IS TRUE FOR THE “TRANSMUTING INTERNALIZATIONS” OF (MODEL 2) SELF PSYCHOLOGY WHEREAS “INTROJECT” TENDS TO IMPLY “NEGATIVE” AS IS TRUE FOR THE “PATHOGENIC INTROJECTS” OF (MODEL 3) CONTEMPORARY RELATIONAL THEORY IN FACT “INTERNALIZING GOOD” IS AT THE HEART OF THE THERAPEUTIC ACTION IN MODEL 2 WHEREAS “INTROJECTING BAD” INFORMS OUR UNDERSTANDING OF HOW MODEL 3 PSYCHOPATHOLOGY DEVELOPS IN THE FIRST PLACE AND HOW IT CAN THEN BE THERAPEUTICALLY MODIFIED 155
  • 156. MORE SPECIFICALLY HOW DOES THE PATIENT “HANDLE” DISAPPOINTMENT? HEINZ KOHUT (1966) vs W R D FAIRBAIRN (1963) IN THE AFTERMATH OF DISAPPOINTMENT KOHUT WRITES ABOUT “INTERNALIZING GOOD” AS IT HAPPENS, THERE ARE “NO BAD OBJECTS” IN KOHUT’S FORMULATIONS ONLY “STRUCTURAL DEFICITS” AS A RESULT OF “GOOD NOT INTERNALIZED” IN THE AFTERMATH OF DISAPPOINTMENT FAIRBAIRN WRITES ABOUT “INTROJECTING BAD” AS THE “BURDEN” OF THE MOTHER’S “BADNESS” FALLS UPON THE PATIENT HOW MIGHT WE RECONCILE THESE TWO – DISCREPANT – PERSPECTIVES? WE CAN USE KOHUT’S “TRANSMUTING INTERNALIZATIONS” TO INFORM OUR (MODEL 2) UNDERSTANDING OF WHAT HAPPENS IN THE AFTERMATH OF GRIEVING NON – TRAUMATIC DISAPPOINTMENT THAT IS, WHAT HAPPENS WHEN THINGS GO RIGHT WE CAN THEN USE FAIRBAIRN’S “INTROJECTION OF BADNESS” TO INFORM OUR (MODEL 3) UNDERSTANDING OF WHAT HAPPENS IN THE AFTERMATH OF TRAUMATIC DISAPPOINTMENT THAT IS, WHAT HAPPENS WHEN THINGS GO VERY WRONG 156
  • 157. 157
  • 158. MODEL 2 THE CORRECTIVE – PROVISION PERSPECTIVE OF SELF PSYCHOLOGY AND OTHER “DEFICIT” THEORIES 158
  • 159. 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 THE EARLY – ON FAILURES IN ENVIRONMENTAL PROVISION 159
  • 160. 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 RELIABLY PROMOTES STRUCTURAL GROWTH AND DEVELOPMENT OF CAPACITY 160
  • 161. AFTER ALL 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 GRIEVING THE “THWARTING OF DESIRE” “OPTIMAL DISILLUSIONMENT” 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” 161
  • 162. GRIEVING A PROTRACTED PROCESS THAT TRANSFORMS THE PATIENT’S REFUSAL TO CONFRONT THE REALITY OF THE OBJECT’S LIMITATIONS, SEPARATENESS, AND IMMUTABILITY – WHICH FUELS THE RELENTLESSNESS WITH WHICH SHE PURSUES IT – INTO THE CAPACITY TO TOLERATE AND ACCEPT THOSE DISAPPOINTING 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” AND “ADAPTIVELY INTERNALIZING” THE “GOOD THAT HAD BEEN” PRIOR TO THE DISRUPTION IF YOU CANNOT ALWAYS COUNT ON EXTERNAL PROVISION, BEST THAT YOU INTERNALIZE WHATEVER “GOOD SUPPLIES” YOU CAN SO THAT THEY WILL ALWAYS BE THERE FOR YOU AS INTERNAL RESOURCES ARRIVING ULTIMATELY AT A PLACE OF SERENE ACCEPTANCE, FORGIVENESS, AND INNER PEACE 162
  • 163. 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 IT 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 OF 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 163
  • 164. “GRIEF IS NATURE’S WAY OF HEALING A BROKEN HEART” ROBERTA BECKMANN (1991) 164
  • 165. TRAUMATIC LOSS AND HEARTBREAK A POIGNANT CLINICAL VIGNETTE ABOUT ALICIA THE SERENITY PRAYER IS VERY APT HERE – “GOD GRANT ME THE SERENITY TO ACCEPT THE THINGS I CANNOT CHANGE; COURAGE TO CHANGE THE THINGS I CAN; AND WISDOM TO KNOW THE DIFFERENCE” I HAD ALWAYS MISTAKENLY ASSUMED THAT THE PRAYER SPOKE PRIMARILY TO THE IMPORTANCE OF OUR CAPACITY TO ACCEPT DISAPPOINTING REALITIES ABOUT THE PEOPLE IN OUR WORLD, PROMPTING US THEN TO RELINQUISH OUR RELENTLESS HOPE WITH RESPECT TO THEM RATHER NAIVELY, I HAD NOT FULLY APPRECIATED THAT PERHAPS EQUALLY RELEVANT WAS THE IMPORTANCE OF OUR CAPACITY TO ACCEPT DISAPPOINTING REALITIES ABOUT OURSELVES 165
  • 166. AS A RESULT OF GENUINE GRIEVING RELENTLESSNESS AND “GRIEVANCES” (UNMOURNED DISAPPOINTMENTS) WILL BECOME TRANSFORMED INTO THE HEALTHY CAPACITY TO ACCEPT THE SOBERING REALITY THAT WE CANNOT MAKE THE PEOPLE IN OUR WORLD CHANGE … 166
  • 167. … BUT THAT WE CAN – AND MUST – TAKE OWNERSHIP OF – AND RESPONSIBILITY FOR – ALL THAT WE CAN CHANGE WITHIN OURSELVES 167
  • 168. BY THE SAME TOKEN WE MUST COME TO TERMS WITH THE SOBERING REALITY THAT WE CANNOT CHANGE OUR HISTORY BUT THAT WE CAN – AND MUST – CHANGE HOW WE “POSITION” OURSELVES IN RELATION TO IT 168
  • 169. 169
  • 171. I AM HERE REMINDED OF THE NEW YORKER CARTOON IN WHICH A GENTLEMAN, SEATED IN A RESTAURANT BY THE NAME OF 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.” 171
  • 172. AT THE END OF THE DAY MODEL 2 IS ABOUT GRIEVING THE LOSS OF ILLUSIONS ABOUT THE OBJECTS OF OUR DESIRE WHETHER PAST AND / OR PRESENT AND EVOLVING TO A PLACE OF SERENE ACCEPTANCE OF THEIR LIMITATIONS, SEPARATENESS, AND IMMUTABILITY SUCH THAT WE CAN TRULY – AND NONDEFENSIVELY – SAY “IT WAS WHAT IT WAS” “IT IS WHAT IT IS” 172
  • 173. AS AN EMPATHIC SELFOBJECT RESONATING WITH THE PATIENT’S MOMENT – TO – MOMENT EXPERIENCE THE MODEL 2 THERAPIST MIGHT OFFER A GRIEVING 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 MORE EFFECTIVE WERE THE THERAPIST SIMPLY TO ELIMINATE THE EXTRA VERBIAGE AND CUT TO THE CHASE WITH “IT BREAKS YOUR HEART … ” 173
  • 174. SO HOW DO WE HELP THE PATIENT GRIEVE? MODEL 2 DISILLUSIONMENT STATEMENTS ARE DESIGNED TO FACILITATE THE GRIEVING OF A PATIENT WHO, REFUSING TO MOURN, HAS BEEN CLINGING TO ILLUSIONS ABOUT THE OBJECTS OF HER DESIRE “OPTIMALLY STRESSFUL” DISILLUSIONMENT STATEMENTS BOTH CHALLENGE BY SPEAKING TO THE DISILLUSIONING REALITY THAT THE PATIENT IS GRADUALLY COMING (WITH HER HEAD) TO KNOW AND SUPPORT BY RESONATING EMPATHICALLY WITH THE PATIENT’S EXPERIENCE (WITH HER HEART) OF DEVASTATION “YOU ARE COMING TO KNOW THAT … , AND IT BREAKS YOUR HEART … ” 174
  • 175. AS DESCRIBED EARLIER MODEL 1 CONFLICT STATEMENTS HAVE THE FOLLOWING FORMAT “YOU KNOW THAT … , BUT (MADE ANXIOUS BY THAT KNOWING) YOU FIND YOURSELF (DEFENSIVELY REACTING) … ” BY CONTRAST MODEL 2 DISILLUSIONMENT STATEMENTS HAVE THE FOLLOWING FORMAT “YOU KNOW THAT … , AND (IN THE FACE OF THAT KNOWING) IT BREAKS YOUR HEART (ADAPTIVELY RESPONDING) … ” 175
  • 176. IN OTHER WORDS MODEL 1 CONFLICT STATEMENTS – IN AN EFFORT TO ENHANCE AWARENESS – HIGHLIGHT THE PATIENT’S NEED TO DEFEND (“BUT”) MODEL 2 DISILLUSIONMENT STATEMENTS – IN AN EFFORT TO FACILITATE GRIEVING – SUPPORT THE PATIENT’S CAPACITY TO ADAPT (“AND”) 176
  • 177. MODEL 1 CONFLICT STATEMENTS “YOU KNOW THAT TONY WILL ALWAYS PUT HIS DAUGHTER BEFORE YOU (AS HE HAS FOR YEARS AND YEARS NOW), BUT YOU CONTINUE TO HOPE THAT HE MIGHT EVENTUALLY CHANGE.” “YOU KNOW THAT YOUR FATHER WILL NEVER ACTUALLY BE THERE FOR YOU, BUT YOU ARE NOT ABOUT TO GIVE UP HOPE THAT SOMEDAY HE MIGHT.” MODEL 2 DISILLUSIONMENT STATEMENTS “YOU KNOW THAT TONY WILL ALWAYS PUT HIS DAUGHTER BEFORE YOU (AS HE HAS FOR YEARS AND YEARS NOW), AND IT BREAKS YOUR HEART.” “YOU ARE COMING TO UNDERSTAND THAT YOUR FATHER WILL PROBABLY NEVER ACTUALLY BE THERE FOR YOU, AND THE PAIN OF THAT REALIZATION GOES SO DEEP.” 177
  • 178. 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.” 178
  • 179. 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 REALLY FEEL THAT, THE PAIN GOES SO DEEP THAT YOU WONDER HOW YOU’LL SURVIVE. YOU HAD SO HOPED THAT SHE WOULD SOMEDAY RELENT AND 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. 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 WOULD SOMEDAY RELENT, WHICH IS WHY THE PAIN OF THIS MOST RECENT REJECTION GOES SO DEEP.” 179
  • 180. 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 REALIZE THAT YOUR MOTHER WILL NEVER UNDERSTAND JUST HOW MUCH SHE HAS HURT YOU OVER THE COURSE OF THE YEARS, AND THAT IS DEVASTATING BECAUSE YOU HAD SO HOPED THAT SOMEDAY SHE MIGHT COME TO UNDERSTAND – AND APOLOGIZE.” “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 HURTS SO MUCH. YOU HAD SO HOPED THAT YOU COULD GET HIM TO TAKE AT LEAST SOME RESPONSIBILITY FOR HIS ABUSIVENESS.” 180
  • 181. 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 181
  • 182. IN ACTUAL PRACTICE THE PATIENT’S ILLUSIONS OFTEN INVOLVE “UNREALISTIC EXPECTATIONS” ABOUT EITHER THE TREATMENT OR THE RELATIONSHIP WITH THE THERAPIST BY THE SAME TOKEN THE PATIENT’S DISILLUSIONMENT OFTEN INVOLVES UPSET AND OUTRAGE ABOUT THE “LIMITATIONS” INHERENT IN EITHER THE TREATMENT OR THE RELATIONSHIP WITH THE THERAPIST 182
  • 183. MODEL 2 DISILLUSIONMENT STATEMENTS “YOU WOULD SO HAVE WISHED THAT I COULD KNOW WHAT YOU WERE THINKING WITHOUT YOUR HAVING TO ARTICULATE IT; BUT YOU ARE COMING TO SEE THAT IT DOES NOT ALWAYS WORK THAT WAY; AND THAT MAKES YOU VERY SAD.” “ALTHOUGH YOU KNEW IT WOULD TAKE TIME, YOU HAD HOPED THAT YOU WOULD BE FEELING BETTER AFTER THESE SEVERAL WEEKS OF THERAPY, SO IT REALLY UPSETS 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, 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 THE 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 SO MUCH WHEN I DON’T SIMPLY ANSWER YOUR QUESTIONS DIRECTLY.” “YOU HAD SO HOPED THAT WE COULD HAVE A PERSONAL RELATIONSHIP; BUT YOU ARE COMING TO REALIZE, ALBEIT RELUCTANTLY, THAT A THERAPY RELATIONSHIP IS NOT REALLY ABOUT FRIENDSHIP PER SE; AND THAT BREAKS YOUR HEART.” 183
  • 184. IN ESSENCE MODEL 2 DISILLUSIONMENT STATEMENTS CAN HAVE ONE, TWO, OR THREE OF THE FOLLOWING ELEMENTS A HIGHLIGHTING OF (WHAT HAD BEEN) THE PATIENT’S ILLUSION HER RELENTLESS HOPE A HIGHLIGHTING OF THE REALITY OF THE PATIENT’S DISILLUSIONMENT THE DISILLUSIONING REALITY THAT THE PATIENT IS COMING TO “KNOW” – ALBEIT RELUCTANTLY – AN EMPATHIC RESONATING WITH THE PAIN OF THE PATIENT’S GRIEF AS SHE BEGINS TO “FEEL” THE ACTUAL HEARTBREAK 184
  • 185. 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 (NURTURING) 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 2 185
  • 186. THESE STRUCTURE – BUILDING INTERNALIZATIONS WILL ENABLE THE PATIENT TO PRESERVE INTERNALLY A PIECE OF THE ORIGINAL EXPERIENCE OF EXTERNAL GOODNESS THUS THEIR ADAPTIVE VALUE 186
  • 187. AND WILL PROMPT THE PATIENT TO LET GO OF HER RELENTLESS PURSUITS THE INTENSITY OF WHICH HAD BEEN FUELED BY HER IMPAIRED CAPACITY TO BE A “GOOD PARENT UNTO HERSELF” THE DEFICIT IN CAPACITY HAVING CREATED THE NEED FOR EXTERNAL PROVISION IN OTHER WORDS, THE DEFICIT HAVING CREATED THE NEED 187
  • 188. 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 “IT WAS WHAT IT WAS” / “IT IS WHAT IT IS” IN THE PROCESS ALSO MAKING HER PEACE WITH THE REALITY OF THE LIMITS OF HER POWER TO FORCE HER OBJECTS TO CHANGE 188
  • 189. 189
  • 190. MODEL 3 THE INTERSUBJECTI VE PERSPECTIVE OF CONTEMPORARY RELATIONAL THEORY 190
  • 191. 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 191
  • 192. CLASSICAL PSYCHOANALYSTS SPEAK OF SUPEREGO INTROJECTS A CRITICAL SUPEREGO INTROJECT (A HARSHLY PUNITIVE SUPEREGO INTROJECT) WHERE ONCE THE ABUSIVE PARENT HAD RAILED AGAINST THE CHILD, NOW THAT DYNAMIC GETS PLAYED OUT – INTERNALLY – BETWEEN SUPEREGO AND EGO – WITH THE SUPEREGO RAILING AGAINST THE EGO – BUT SOMETIMES IT IS 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 LATTER DELIVERS – BY WAY OF PROJECTIVE IDENTIFICATION – HER “UNMASTERED RELATIONAL TRAUMAS” INTO THE TRANSFERENCE WHERE ONCE THE ABUSIVE PARENT HAD RAILED AGAINST THE CHILD, NOW THAT DYNAMIC GETS PLAYED OUT – RELATIONALLY – BETWEEN THERAPIST AND PATIENT – WITH BOTH ULTIMATELY RAILING AGAINST EACH OTHER ONCE THE THERAPIST IS INDUCTED INTO WHAT THEN BECOMES A MUTUAL ENACTMENT – 192
  • 193. THE RELATIONAL MODEL CONCEIVES OF THE PATIENT AS AN AGENT AS PROACTIVE AS INTENTIONED IN HER ACTIVITIES – EVEN IF UNWITTINGLY – AND AS THEREFORE ACCOUNTABLE AND EMPOWERED – ACCOUNTABILITY GIVING RISE TO EMPOWERMENT – 193
  • 194. 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 WHETHER BY PLAYING OUT WITH THE THERAPIST AN UNMASTERED “RELATIONAL DYNAMIC” OR BY GETTING THE THERAPIST TO EXPERIENCE FIRSTHAND AN UNMASTERED “INTERNAL DYNAMIC” ENACTMENTS INVOLVE UNMASTERED EARLY – ON EXPERIENCES THAT ARE SOMEHOW “KNOWN” BUT HAVE NOT YET BEEN “THOUGHT” CHRISTOPHER BOLLAS’S “UNTHOUGHT KNOWN” (1989) 194
  • 195. 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, AND MORE – EVOLVED, CAPACITY TO PROCESS AND INTEGRATE ON BEHALF OF A 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 ITERATIVE CYCLES WILL HAPPEN REPEATEDLY, THE NET RESULT OF WHICH WILL BE GRADUAL DETOXIFICATION OF THE PATIENT’S INTERNAL PATHOGENICITY 195
  • 196. ALTHOUGH INEVITABLY THE THERAPIST WILL FAIL THE PATIENT IN MANY OF THE SAME WAYS THAT THE PARENT HAD FAILED HER ULTIMATELY THE THERAPIST MUST CHALLENGE THE PATIENT’S PROJECTIONS BY LENDING ASPECTS OF HER “OTHERNESS” OR “EXTERNALITY” TO THE INTERACTION DONALD WINNICOTT (1965) SUCH THAT THE PATIENT WILL HAVE THE EXPERIENCE OF SOMETHING THAT IS “OTHER – THAN – ME” AND CAN “TAKE THAT IN” IN ESSENCE, THE THERAPIST WILL CHALLENGE THE PATIENT’S PROJECTIONS BY LENDING ASPECTS OF HER OWN, AND 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 196
  • 197. WHAT THE PATIENT RE – INTROJECTS WILL ACTUALLY BE AN AMALGAM PART CONTRIBUTED BY THE PATIENT THE ORIGINAL – UNPROCESSED AND TOXIC – PROJECTION AND PART CONTRIBUTED BY THE THERAPIST SOMETHING MORE PROCESSED AND LESS TOXIC 197
  • 198. “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 BETTER” 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 198
  • 199. PROJECTIVE IDENTIFICATION INVOLVES SYMBOLIC REPETITION OF THE ORIGINAL RELATIONAL TRAUMA BUT WITH A MUCH HEALTHIER RESOLUTION THIS TIME THE HALLMARK OF A SUCCESSFUL PROJECTIVE IDENTIFICATION IS THE THERAPIST’S CAPACITY TO TOLERATE WHAT THE PATIENT FINDS INTOLERABLE 199
  • 200. CONTEMPORARY RELATIONAL THEORY POSTULATES THAT IT IS NOT ONLY INEVITABLE BUT ALSO NECESSARY – AND THEREFORE DESIRABLE – FOR THE THERAPIST ULTIMATELY TO 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 TOXIC INTROJECTS AND THEIR NEGATIVE, SELF – SABOTAGING VOICES 200
  • 201. IF THE THERAPIST NEVER ALLOWS HERSELF TO BE DRAWN IN TO PARTICIPATING WITH THE PATIENT IN HER DRAMATIC 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 THE POTENTIAL FOR RE – TRAUMATIZATION 201
  • 202. THE MODEL 3 “RELATIONAL” THERAPIST MUST THEREFORE BE ABLE TO PROVIDE CONTAINMENT SHE MUST BE ABLE NOT ONLY TO TOLERATE BEING MADE INTO THE PATIENT’S OLD BAD OBJECT BUT ALSO ONCE THE THERAPIST HAS INDEED 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 202
  • 203. AND 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 203
  • 204. PLEASE NOTE ALTHOUGH THE EMPHASIS TO THIS POINT HAS BEEN ON “PAIRED” PATHOGENIC INTROJECTS – THE RESULT OF “DYSFUNCTIONAL EARLY – ON RELATIONAL DYNAMICS” – AND ON “NEGOTIATING AT THE INTIMATE EDGE” TO DETOXIFY THEIR PATHOGENICITY THE PATIENT IDENTIFYING WITH EITHER THE MORE “PASSIVE” POLE OR THE MORE “ACTIVE” POLE OF THE “INTROJECTIVE CONFIGURATION” WILLIAM MEISSNER (1976) AND THEN PROJECTING ONTO THE THERAPIST THE “COMPLEMENTARY” POLE MODEL 3 ALSO INVOLVES THE THERAPIST’S “USE OF SELF” TO MODIFY THE PATHOGENICITY OF “UNPAIRED” TOXIC “BOLUSES” THAT THE PATIENT HAS NOT YET BEEN ABLE TO ASSIMILATE INTO HEALTHY PSYCHIC STRUCTURE FOR EXAMPLE, OVERWHELMING RAGE, EXCORIATING GUILT, OR INTOLERABLY PAINFUL GRIEF 204
  • 205. CLINICAL VIGNETTE THE “SHARING” OF GRIEF A PATIENT’S BELOVED GRANDMOTHER HAS JUST DIED THE PATIENT, UNABLE TO FEEL HIS SADNESS BECAUSE IT HURTS “TOO MUCH,” RECOUNTS IN A MONOTONE THE DETAILS OF HIS GRANDMOTHER’S DEATH AS THE THERAPIST LISTENS, SHE BECOMES VERY SAD AS THE PATIENT CONTINUES, THE THERAPIST FINDS HERSELF UTTERING, ALMOST INAUDIBLY, AN OCCASIONAL “OH, NO!” AND “THAT’S AWFUL!” AS THE HOUR PROGRESSES, THE PATIENT HIMSELF BECOMES INCREASINGLY SAD 205
  • 206. PROJECTIVE IDENTIFICATION IN THIS EXAMPLE, THE PATIENT IS INITIALLY UNABLE TO FEEL THE DEPTHS OF HIS GRIEF ABOUT THE GRANDMOTHER’S DEATH BUT BY REPORTING THE DETAILS IN THE “MONOTONIC” MANNER IN WHICH HE DOES, THE PATIENT IS ABLE TO GET THE THERAPIST TO FEEL WHAT HE HIMSELF CANNOT – AND INSTEAD MUST DEFEND AGAINST IN ESSENCE, THE PATIENT EXERTS “INTERPERSONAL PRESSURE” UPON THE THERAPIST TO TAKE ON, AS THE THERAPIST’S OWN, WHAT THE PATIENT DOES NOT YET HAVE THE CAPACITY TO TOLERATE AS THE THERAPIST SITS WITH THE PATIENT AND LISTENS TO HIS STORY, SHE FINDS HERSELF BECOMING VERY SAD, WHICH SIGNALS THE THERAPIST’S QUIET ACCEPTANCE OF THE PATIENT’S DISAVOWED GRIEF THE INDUCTION PHASE OF THE PROJECTIVE IDENTIFICATION WE COULD SAY OF THE PATIENT’S SADNESS THAT IT HAS FOUND ITS WAY INTO THE THERAPIST, WHO, ABLE TO TOLERATE WHAT THE PATIENT FINDS INTOLERABLE, TAKES IT ON “AS HER OWN” THE THERAPIST’S SADNESS IS THEREFORE CO – CREATED – IN PART A STORY ABOUT THE PATIENT (AND HIS DISAVOWED GRIEF) AND IN PART A STORY ABOUT THE THERAPIST (IN WHOM A RESONANT CHORD HAS BEEN STRUCK) 206
  • 207. PROJECTIVE IDENTIFICATION THE THERAPIST, WITH HER GREATER CAPACITY TO EXPERIENCE AFFECT WITHOUT NEEDING TO DEFEND AGAINST IT, IS ABLE BOTH TO TOLERATE THE SADNESS THAT THE PATIENT FINDS INTOLERABLE AND TO PROCESS AND INTEGRATE IT THE RESOLUTION PHASE OF THE PROJECTIVE IDENTIFICATION THE THERAPIST “FEELS” IT BUT IS NOT OVERWHELMED BY IT IT IS THE THERAPIST’S ABILITY TO TOLERATE THE INTOLERABLE THAT MAKES THE PATIENT’S PREVIOUSLY UNMANAGEABLE FEELINGS MORE MANAGEABLE FOR HIM INDEED, THE PATIENT’S GRIEF BECOMES LESS TERRIFYING BY VIRTUE OF THE FACT THAT THE THERAPIST HAS BEEN ABLE TO CARRY THAT GRIEF ON THE PATIENT’S BEHALF A MORE ASSIMILABLE VERSION OF THE PATIENT’S SADNESS IS THEN RETURNED TO THE PATIENT IN THE FORM OF THE THERAPIST’S HEARTFELT UTTERANCES – “OH, NO!” AND “THAT’S AWFUL!” SUCH THAT THE PATIENT FINDS HIMSELF NOW ABLE TO BEAR THE PAIN OF HIS OWN GRIEF – NOW ABLE TO CARRY THAT PAIN ON HIS OWN BEHALF – – NOW ABLE TO TOLERATE WHAT HAD ONCE BEEN INTOLERABLE – 207
  • 208. THIS VIGNETTE IS AN EXAMPLE OF THE THERAPIST’S AUTHENTICITY MODEL 3 AND NOT THE THERAPIST’S EMPATHY MODEL 2 IN OTHER WORDS I AM SPEAKING HERE TO THE DISTINCTION BETWEEN TAKING ON THE PATIENT’S UNASSIMILATED EXPERIENCE “AS” THE THERAPIST’S OWN WHICH IS WHAT HAPPENS IN THIS MODEL 3 EXAMPLE AND TAKING ON THE PATIENT’S UNASSIMILATED EXPERIENCE ONLY “AS IF” IT WERE HER OWN WHICH IS WHAT HAPPENS IN MODEL 2 208
  • 209. 209
  • 210. FOURTH PART SLIDES 210 – 283 210
  • 211. MODEL 3 ACCOUNTABILITY STATEMENTS AND THE “RULE OF THREE” THERE ARE NUMBERS OF RELATIONAL INTERVENTIONS WITHIN THE THERAPIST’S ARMAMENTARIUM THAT SHE CAN USE TO ADDRESS THE “DYSFUNCTIONAL RELATIONAL DYNAMICS” THAT THE PATIENT – IN AN EFFORT TO ACHIEVE MASTERY OF HER UNRESOLVED EARLY – ON RELATIONAL TRAUMAS – IS COMPULSIVELY, UNWITTINGLY, AND CONTINUOUSLY RE – ENACTING ON THE STAGE OF THE TREATMENT 211
  • 212. MODEL 3 ACCOUNTABILITY STATEMENTS CAN INVOLVE INTERPRETING THE PATIENT’S ENACTMENTS AS AN EFFORT EITHER (1) TO DRAW THE THERAPIST IN TO PARTICIPATING AS THE “ABUSIVE” PARENT THE PATIENT ONCE HAD BY WAY OF BEHAVIOR ON THE PATIENT’S PART THAT IS UNCONSCIOUSLY DESIGNED TO PROVOKE 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 (2) 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 ONCE 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 GROWING UP 212
  • 213. 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 … ” 213
  • 214. 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 MORE WILLING (AND ABLE) TO ACKNOWLEDGE HER OWN PART – WITHOUT HAVING TO LOSE FACE – 214
  • 215. MODEL 3 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, HELD ACCOUNTABLE, AND CONTAINED WHICH CAN BE ACCOMPLISHED ONLY IF THE THERAPIST IS WILLING (AND ABLE) TO BRING HER OWN AUTHENTIC SELF INTO THE ROOM AND TO HOLD HERSELF ACCOUNTABLE 215
  • 216. THE RELATIONAL THERAPIST MUST BE TOTALLY PRESENT AND COMPLETELY 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) 216
  • 217. 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 “EMERGENT 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 BOTH THE HERE – AND – NOW OF HER OWN “EMERGENT EXPERIENCE” AND THE HERE – AND – NOW OF THE EVER – EVOLVING THERAPEUTIC ENGAGEMENT DARLENE EHRENBERG’S “INTIMATE EDGE” (1992) DANIEL STERN’S “NOW MOMENTS” (2000) 217
  • 218. CLINICAL VIGNETTE – GREAT TAN, BITCH! THE PATIENT JANET IS A 31 – YEAR – OLD MARRIED WOMAN WHO HAS A HISTORY OF DIFFICULT RELATIONSHIPS WITH ALMOST EVERYONE IN HER LIFE SHE IS PARTICULARLY TROUBLED BY HER LACK OF CLOSE WOMEN FRIENDS JANET HAS BEEN WORKING HARD IN THE TREATMENT, HAS MADE SUBSTANTIAL GAINS IN HER PROFESSIONAL LIFE, AND HAS VERY MUCH IMPROVED THE QUALITY OF HER RELATIONSHIP WITH HER HUSBAND JANET AND HER THERAPIST (A WOMAN) HAVE HAD A GOOD, RELATIVELY UNCONFLICTED RELATIONSHIP JANET CLEARLY LIKES, AND IS RESPECTFUL OF, THE THERAPIST UPON THE THERAPIST’S RETURN FROM A WEEK – LONG VACATION IN FLORIDA, JANET, AT THE END OF THE SESSION AND JUST AS SHE IS LEAVING, TURNS BACK TO HER THERAPIST AND, AS HER PARTING SHOT, BLURTS OUT, “GREAT TAN, BITCH!” THE THERAPIST, TAKEN ABACK AND AT A LOSS FOR WORDS, SAYS NOTHING, SMILES WANLY, AND NODS GOODBYE 218
  • 219. CLINICAL VIGNETTE – GREAT TAN, BITCH! AFTER DISCUSSING THE SITUATION WITH A COLLEAGUE, THE THERAPIST OPENS THE NEXT SESSION WITH THE FOLLOWING “WE HAVE TALKED A LOT ABOUT HOW UPSETTING IT IS FOR YOU TO HAVE SO FEW WOMEN FRIENDS. “I THINK THAT NOW, IN LIGHT OF WHAT HAPPENED AT THE END OF OUR LAST SESSION, I AM COMING TO UNDERSTAND SOMETHING THAT I HAD NEVER BEFORE COMPLETELY UNDERSTOOD. “WHEN YOU LEFT LAST TIME, YOUR PARTING WORDS WERE ‘GREAT TAN, BITCH!’ “I WONDER IF, BY SAYING THAT, YOU WERE TRYING TO SHOW ME WHAT SOMETIMES HAPPENS FOR YOU WHEN YOU FEEL CLOSE TO A WOMAN AND THEN FIND YOURSELF BECOMING COMPETITIVE.” HERE THE THERAPIST IS USING HER “EXPERIENCE OF SELF” – HER COUNTERTRANSFERENTIAL REACTION – TO INFORM AN INTERVENTION THAT IS REASONABLY AUTHENTIC – ALTHOUGH NOT PARTICULARLY EMPATHIC 219
  • 220. CLINICAL VIGNETTE – GREAT TAN, BITCH! THE THERAPIST’S INTENT IS NOT TO RESONATE EMPATHICALLY WITH THE PATIENT’S AFFECTIVE EXPERIENCE IN THE MOMENT RATHER, HER INTENT IS TO ENHANCE THE PATIENT’S UNDERSTANDING OF WHAT SHE MUST CERTAINLY SOMETIMES ENACT IN HER RELATIONSHIPS WITH WOMEN WHEN SHE BEGINS TO FEEL CLOSE – AND THEREFORE COMPETITIVE – WITH THEM THE THERAPIST’S AWARENESS OF HER OWN “COUNTERTRANSFERENTIAL REACTION” TO THE PATIENT’S “PROVOCATIVE ENACTMENT” – OF FEELING TAKEN ABACK AND PUT OFF BY THE PATIENT’S DOOR HANDLE REMARK – ENABLES THE THERAPIST TO OFFER THE PATIENT AN “ACCOUNTABILITY STATEMENT” THAT CHALLENGES THE PATIENT TO TAKE OWNERSHIP OF HER HOSTILE COMPETITIVENESS 220
  • 221. AS ADDITIONAL EXAMPLES MODEL 3 ACCOUNTABILITY STATEMENTS 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) 221
  • 222. MODEL 3 ACCOUNTABILITY STATEMENTS 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 OWN INTERNAL STATE OF 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 WITH YOU FOR BEING SO OFTEN LATE AND WANTING YOU TO UNDERSTAND HOW IT IMPACTS ME, BUT THEN IT OCCURS TO ME THAT IT MIGHT BE MORE IMPORTANT FOR US TO TRY TO UNDERSTAND WHAT YOU MIGHT BE TRYING TO COMMUNICATE TO ME BY WAY OF YOUR FREQUENT LATENESS.” 222
  • 223. 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 SHE WANTS THE THERAPIST’S APPROVAL REGARDING HER 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.” 223
  • 224. MODEL 3 ACCOUNTABILITY STATEMENTS ALTERNATIVELY, 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 IN HERE BETWEEN US TODAY.” “WE ARE BOTH SAD THAT THINGS DID NOT 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.” 224
  • 225. 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?” 225
  • 226. JUST AS WINNICOTT (1949) DISTINGUISHES BETWEEN THE “SUBJECTIVE COUNTERTRANSFERENCE” – WHICH IS PRIMARILY A STORY ABOUT THE THERE – AND – THEN OF THE THERAPIST AND THEREFORE SPECIFIC TO THE THERAPIST – AND THE “OBJECTIVE COUNTERTRANSFERENCE” – WHICH IS PRIMARILY A STORY ABOUT THE HERE – AND – NOW OF THE THERAPEUTIC ENGAGEMENT AND THEREFORE WHAT ANY THERAPIST MIGHT FEEL – I (1994) MAKES A DISTINCTION BETWEEN THE “SUBJECTIVE TRANSFERENCE” – WHICH IS PRIMARILY A STORY ABOUT THE THERE – AND – THEN OF THE PATIENT AND THEREFORE SPECIFIC TO THE PATIENT – AND THE “OBJECTIVE TRANSFERENCE” – WHICH IS PRIMARILY A STORY ABOUT THE HERE – AND – NOW OF THE THERAPEUTIC ENGAGEMENT AND THEREFORE WHAT ANY PATIENT MIGHT FEEL – BE THAT IS IT MIGHT IN MODEL 3, THE PATIENT’S EXPERIENCE OF THE THERAPIST IS ALWAYS THOUGHT TO BE A STORY ABOUT BOTH PATIENT AND THERAPIST 226
  • 227. 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 FREQUENT SILENCES, YOU ARE TRYING TO COMMUNICATE SOMETHING TO ME ABOUT HOW DIFFICULT IT IS FOR YOU TO BE HERE. WERE THAT INDEED TO BE THE CASE, I WOULD NOT WANT TO DO YOU THE DISSERVICE OF SIMPLY DISMISSING IT.” “SOMETIMES IT SEEMS TO ME 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.” 227

Editor's Notes

  1. Welcome. I am Dr. Martha Stark. I thank you all for signing up for my 4-week-long PSYCHODYNAMIC PSYCHOTHERAPY BOOT CAMP entitled THE TRANSFORMATIVE POWER OF OPTIMAL STRESS: FROM CURSING THE DARKNESS TO LIGHTING A CANDLE. The BOOT CAMP has a second title: THE THERAPEUTIC USE OF STRESS TO PROVOKE RECOVERY. Actually, the Course has a third title: NO PAIN, NO GAIN. Although I recorded this Narrated PowerPoint Slide Show a little while ago, I am looking forward to being able to interact directly with all of you over the course of the next 4 weeks – by way of “threaded discussions” or “online chatting” about whatever questions, comments, or reflections, you might find yourself having about the material that I will be presenting each week (each of the 4 1-hour lectures will be presented in easy-to-digest 6 to 8 segments). Interestingly, the “threaded discussions” in which we will all be participating allow for an interesting (and paradoxical) combination of intimacy and anonymity. You can participate as much or as little as you would like – and you can offer as many or as few “posts” as you would like. We just ask, please, that you limit each post to 100 words or fewer. I will be presenting a tremendous amount of material but will be doing a lot of repeating (telling you in advance what I’m going to tell you, then telling you, and then telling you after the fact what I have told you) – but I have organized the material in these bite-size 7-10 minute segments that you can go back to review whenever you might want to. So, please, settle in, buckle up, kick back, crank up the volume, and enjoy! 
  2. This section is entitled Controlled Damage to Provoke Recovery.
  3. This section is entitled Controlled Damage to Provoke Recovery.
  4. Here we have a snapshot of the cover of one of my books – available as a free download through www.freepsychotherapybooks.org
  5. I love this 2004 poem by Christopher Logue entitled “Come to the Edge!” – which I believe captures the essence of a system’s capacity to adapt to stressful input…
  6. And here we see a sweet little girl with angel wings – What if I fall? Oh, but my darling, what if you fly? – a poem by Erin Hanson – a 22-year-old gal from Australia
  7. As I have evolved over the course of the decades, so too my understanding of the healing process has evolved – from one that emphasizes the internal workings of the mind to one that is more holistic and recognizes the complex interdependence of mind and body.
  8. But whether the mind or the body is the primary focus, the process of healing will involve incremental transformation of less healthy defense into more healthy adaptation.
  9. I am here reminded of a Saturday Night Live skit in which two men are seated around a fire chatting, and one says to the other: “You know how when you stick a poker in the fire and leave it in for a long time, it gets really, really hot? And then you stick it in your eye, and it really, really hurts? I hate it when that happens! I just hate it when that happens!”  
  10. And a popular song that speaks to the need so many of us have to recreate that with which we are most familiar and, therefore, seemingly most comfortable is a rock song by the late Warren Zevon entitled “If You Won’t Leave Me I’ll Find Somebody Who Will.”