1. FROM DEFENSE TO ADAPTATION:
THE EVER – EVOLVING
PSYCHODYNAMIC PROCESS
THE THERAPEUTIC USE
OF OPTIMAL STRESS
TO PROVOKE RECOVERY
NO PAIN, NO GAIN 
MARTHA STARK MD
Faculty, Harvard Medical School
MarthaStarkMD @ HMS.Harvard.edu
Monday / February 28, 2022
Dr. Guy Balice / Dr. Carilyn Guedes / Dr. Richard Espinoza
and the good people they teach
© 2022 Martha Stark MD
1

2. 2
THIS 1969 POEM
BY
CHRISTOPHER
LOGUE
CAPTURES
THE ESSENCE OF
OUR CAPACITY
TO ADAPT TO
STRESSFUL INPUT
… WHEN PUSH
COMES TO SHOVE

3. 3

4. 4

5. PREVIEW
RELEVANT FOR BOTH CHILD (GROWING UP)
AND PATIENT (GETTING BETTER)
THE THERAPEUTIC USE OF “OPTIMAL STRESS”
TO “PROVOKE” TRANSFORMATION AND GROWTH
TRANSFORMATION OF DYSFUNCTIONAL DEFENSE
INTO MORE FUNCTIONAL ADAPTATION
WHERE ID WAS, THERE SHALL EGO BE
WHERE DEFENSE WAS, THERE SHALL ADAPTATION BE
AN ONGOING PROCESS INVOLVING
HEALING CYCLES OF DISRUPTION AND REPAIR
THE THERAPIST WILL PRECIPITATE DISRUPTION
IN ORDER TO TRIGGER REPAIR
BY WAY OF “OPTIMALLY STRESSFUL” INTERVENTIONS THAT
ALTERNATELY CHALLENGE AND THEN SUPPORT THE DEFENSE
5

6. PREVIEW
THE DEVELOPMENTAL PROCESS
AND THE THERAPEUTIC PROCESS
FROM PSYCHOLOGICAL RIGIDITY
TO PSYCHOLOGICAL FLEXIBILITY
FROM DEFENSIVE REACTION
TO ADAPTIVE RESPONSE
FROM OUTDATED DEFENSE
TO UPDATED ADAPTATION
WHERE DEFENSE WAS,
THERE SHALL ADAPTATION BE
6

7. PREVIEW
THREE MODELS
IN MY PSYCHODYNAMIC SYNERGY PARADIGM
MODEL 1 – ENHANCEMENT OF KNOWLEDGE “WITHIN”
THE INTERPRETIVE PERSPECTIVE
OF CLASSICAL PSYCHOANALYSIS
COGNITVE – STRENGTHENING OF THE “EGO”
MODEL 2 – PROVISION OF EXPERIENCE “FOR”
THE CORRECTIVE – PROVISION PERSPECTIVE
OF SELF PSYCHOLOGY
AFFECTIVE – CONSOLIDATION OF THE “SELF”
MODEL 3 – ENGAGEMENT IN RELATIONSHIP “WITH”
THE INTERSUBJECTIVE PERSPECTIVE
OF CONTEMPORARY RELATIONAL THEORY
RELATIONAL – ACCOUNTABILITY FOR THE “SELF – IN – RELATION”
7

8. PREVIEW
FROM RIGID DEFENSE TO MORE FLEXIBLE ADAPTATION
DEFENSES – THE THREE “Rs”
ADAPTATIONS – THE THREE “As”
MODEL 1 – “RESISTANCE” TO “AWARENESS”
THE INTERPRETIVE PERSPECTIVE
OF CLASSICAL PSYCHOANALYSIS
MODEL 2 – “RELENTLESS HOPE” TO “ACCEPTANCE”
THE CORRECTIVE – PROVISION PERSPECTIVE
OF SELF PSYCHOLOGY
MODEL 3 – “RE – ENACTMENT” TO “ACCOUNTABILITY”
THE INTERSUBJECTIVE PERSPECTIVE
OF CONTEMPORARY RELATIONAL THEORY
8

9. PREVIEW
THREE APPROACHES TO
TRANSFORMING DEFENSE INTO ADAPTATION
THREE OPTIMAL STRESSORS – THE THREE “Ds”
MODEL 1 – “RESISTANCE” TO “AWARENESS”
BY WORKING THROUGH THE STRESS OF
“COGNITIVE DISSONANCE”
THE EXPERIENCE OF GAIN – BECOME – PAIN
MODEL 2 – “RELENTLESS HOPE” TO “ACCEPTANCE”
BY WORKING THROUGH THE STRESS OF
“AFFECTIVE DISILLUSIONMENT”
THE EXPERIENCE OF GOOD – BECOME – BAD
MODEL 3 – “RE – ENACTMENT” TO “ACCOUNTABILITY”
BY WORKING THROUGH THE STRESS OF
“RELATIONAL DETOXIFICATION”
THE EXPERIENCE OF BAD – BECOME – GOOD
9

10. PREVIEW
FROM RIGID DEFENSE TO MORE FLEXIBLE ADAPTATION
FROM CURSING THE DARKNESS TO LIGHTING A CANDLE
MODEL 1 – “RESISTANCE” TO “AWARENESS”
CLASSICAL PSYCHOANALYSIS
THE THERAPEUTIC ACTION FOCUSES ON “INTERPRETING”
ANXIETY – PROVOKING TRUTHS ABOUT THE “SELF”
MODEL 2 – “RELENTLESS HOPE” TO “ACCEPTANCE”
SELF PSYCHOLOGY
THE THERAPEUTIC ACTION FOCUSES ON “GRIEVING”
ANXIETY – PROVOKING TRUTHS ABOUT THE “OTHER”
MODEL 3 – “RE – ENACTMENT” TO “ACCOUNTABILITY”
CONTEMPORARY RELATIONAL THEORY
THE THERAPEUTIC ACTION FOCUSES ON “TAKING OWNERSHIP OF”
ANXIETY – PROVOKING TRUTHS ABOUT THE “SELF – IN – RELATION”
10

11. PREVIEW
BY WAY OF “OPTIMALLY STRESSFUL” THERAPEUTIC INTERVENTIONS
THAT SUPERIMPOSE AN ACUTE INJURY ON TOP OF A CHRONIC ONE
– THEREBY TRIGGERING HEALING CYCLES OF DISRUPTION AND REPAIR –
PSYCHODYNAMIC PSYCHOTHERAPY
AFFORDS THE PATIENT AN OPPORTUNITY
– ALBEIT A BELATED ONE –
TO MASTER EXPERIENCES THAT
HAD ONCE BEEN OVERWHELMING
– AND, THEREFORE, DEFENDED AGAINST –
BUT THAT CAN NOW
– WITH ENOUGH SUPPORT FROM THE THERAPIST
AND BY TAPPING INTO THE PATIENT’S
UNDERLYING RESILIENCE
AND CAPACITY TO COPE WITH STRESS –
BE PROCESSED, INTEGRATED,
AND ULTIMATELY ADAPTED TO
– FROM OUTDATED DEFENSE TO UPDATED ADAPTATION – 11

12. EMPATHIC INTERVENTIONS
HOMEOSTATIC ATTUNEMENT vs. DISRUPTIVE ATTUNEMENT
SALMAN AKHTAR (2012)
12

13. MY PSYCHODYNAMIC SYNERGY PARADIGM FEATURES
THREE “OPTIMALLY STRESSFUL” STATEMENTS
CORRESPONDING TO EACH OF THE THREE MODELS
– CLASSICAL PSYCHOANALYTIC, SELF PSYCHOLOGICAL,
AND CONTEMPORARY RELATIONAL –
BUT THESE “INCENTIVIZINGLY DESTABILIZING” STATEMENTS
WILL BE MOST EFFECTIVE IF OFFERED AGAINST
THE BACKDROP OF “EMPATHIC STATEMENTS”
THAT FIRST RESONATE EMPATHICALLY WITH WHAT
THE PATIENT IS ACTUALLY FEELING IN THE MOMENT
AND THEN HIGHLIGHT THE “THEME” OR “NARRATIVE”
ASSOCIATED WITH THAT FEELING
STATEMENTS THAT OFTEN END WITH AN IMPLIED QUESTION MARK
WHEREBY I AM SIGNALING THAT I AM VERY OPEN
TO HAVING MY RENDERING OF THINGS
EDITED, CORRECTED, OR REVISED
IN ORDER TO MAKE IT A MORE ACCURATE REFLECTION
OF WHAT THE PATIENT IS ACTUALLY SAYING
AND WANTING ME TO KNOW
13

14. EXAMPLES OF EMPATHIC STATEMENTS
“ … HARD TO KNOW WHERE TO BEGIN
WHEN EVERYTHING FEELS SO OVERWHELMING … ”
“ … UNCOMFORTABLE TO BE HERE WHEN YOU’RE NOT SURE
THE THERAPY IS REALLY HELPING ANYWAY … ”
“ … UPSETTING TO BE FEELING THIS OUT OF CONTROL … ”
ALL OF WHICH SPEAK TO BOTH
THE PATIENT’S “AFFECT” AND THE “ASSOCIATED THEME”
IN OFFERING THE PATIENT EMPATHIC STATEMENTS,
I AM, OF COURSE, “GIVING” HER SOMETHING
RATHER THAN “ASKING” OF HER THAT SHE “GIVE” ME SOMETHING
NAMELY, ANSWERS TO MY QUESTIONS
“ … TIRED OF THINKING ABOUT WHETHER YOU SHOULD STAY OR GO … ”
“ … DEEP DESPAIR ABOUT EVER BEING ABLE TO FIND A TRUE SOULMATE … ”
“ … TERRIFIED THAT YOU WILL BE DISAPPOINTED … ”
“ … TERRIFIED THAT YOU YOURSELF WILL DISAPPOINT … ”
“ … CONFUSED ABOUT HOW BEST TO USE THE SESSION … ”
14

15. EMPATHIC STATEMENTS THAT HIGHLIGHT
WHAT THE PATIENT IS EXPERIENCING
IN A “SPECIFIC” CONTEXT
“ … PAINFUL TO BE FEELING SO MISUNDERSTOOD BY JUANITA … ”
CAN THEN USUALLY BE “GENERALIZED”
“ … PAINFUL TO BE FEELING ALWAYS SO MISUNDERSTOOD … ”
BY THE SAME TOKEN
EMPATHIC STATEMENTS THAT HIGHLIGHT
WHAT THE PATIENT IS EXPERIENCING
IN THE “PRESENT”
“ … PAINFUL TO BE FEELING SO MISUNDERSTOOD … ”
CAN THEN USUALLY BE “EXTENDED” TO THE “PAST”
“ … PAINFUL TO HAVE BEEN FEELING
SO MISUNDERSTOOD FOR SO LONG NOW … ”
15

16. PLEASE NOTE THAT INSTEAD OF
“I WONDER IF IT IS PAINFUL TO BE FEELING SO UNLOVABLE”
OR
“IT SOUNDS AS IF IT IS PAINFUL TO BE FEELING SO UNLOVABLE”
OR
“IT SEEMS AS IF IT IS PAINFUL TO BE FEELING SO UNLOVABLE”
YOU COULD SIMPLY SAY
“ … PAINFUL TO BE FEELING SO UNLOVABLE … ”
FOLLOWED BY AN IMPLIED QUESTION MARK
THEREBY SIGNALING THAT YOU ARE VERY OPEN
TO HAVING YOUR STATEMENT AMENDED
I DO MY BEST TO ELIMINATE EXTRA WORDS
AT THE BEGINNING OF MY EMPATHIC STATEMENTS
SO THAT I CAN CUT RIGHT TO THE CHASE
“ … PAINFUL TO BE FEELING SO UNLOVABLE … ”
EXTRA WORDS RUN THE RISK OF PUTTING TOO MUCH DISTANCE
BETWEEN THE THERAPIST AND THE PATIENT
16

17. EMPATHIC STATEMENTS ARE “EXPERIENCE – NEAR”
– NOT “EXPERIENCE – DISTANT” –
AND ARE DESIGNED TO “VALIDATE” OR “REINFORCE”
WHEREVER THE PATIENT MIGHT BE IN THE MOMENT
WHAT IS IN HER CONSCIOUSNESS
OR PERHAPS HER PRECONSCIOUS
THEY ARE NOT DESIGNED TO TARGET HER UNCONSCIOUS
WITH EMPATHIC STATEMENTS
I AM HONORING WHAT THE PATIENT IS TELLING ME
AND NOT TRYING TO READ BETWEEN THE LINES
OR TO INTERPRET WHAT I THINK MIGHT LIE
BENEATH THE SURFACE
MY FOCUS IS MORE ON THE “MANIFEST CONTENT”
THAN ON THE “LATENT CONTENT”
MY “DEFAULT MODE” ARE THESE EMPATHIC STATEMENTS
THAT FOCUS MORE ON HELPING THE PATIENT “TO FEEL UNDERSTOOD”
THAN ON HELPING HER “TO UNDERSTAND”
SHE, FEELING SUPPORTED, WILL THEN BE MORE INCLINED TO DELVE
MORE DEEPLY INTO WHAT IS REALLY GOING ON INSIDE HER 17

18. BECAUSE EMPATHIC STATEMENTS HIGHLIGHT
NOT ONLY THE PATIENT’S “AFFECT” IN THE MOMENT
BUT ALSO THE “STORY” THAT GOES WITH IT
“ … FEARFUL ALWAYS OF BEING JUDGED … ”
“ … WORRIED ABOUT WHAT I MIGHT BE THINKING … ”
ONGOING USE OF THESE STATEMENTS
NOT ONLY WILL ENABLE THE PATIENT TO FEEL
UNDERSTOOD, VALIDATED, AND SUPPORTED
BUT ALSO WILL START TO GIVE SHAPE
TO THE “FILTERS” THROUGH WHICH
THE PATIENT INTERPRETS HER LIFE …
THESE EMPATHIC STATEMENTS DO NOT SPECIFICALLY
”INCENTIVIZE” STRUCTURAL TRANSFORMATION AND GROWTH,
BUT THEY DO LAY THE GROUNDWORK FOR SUBSEQUENT
“OPTIMALLY STRESSFUL” INTERVENTIONS THAT WILL
18

19. EMPATHIC STATEMENTS ARE “MAKING EXPLICIT”
THE MALADAPTIVE, DISEMPOWERING NARRATIVES
THAT THE PATIENT HAD CONSTRUCTED AS A YOUNG CHILD
IN A DESPERATE ATTEMPT TO MAKE SENSE OF
THE TRAUMA AND ABUSE / THE DEPRIVATION AND NEGLECT
TO WHICH SHE WAS BEING EXPOSED
“ … SO AFRAID OF BEING PUNISHED … ”
“ … EXCRUCIATINGLY PAINFUL TO BE FEELING ALWAYS SO INVISIBLE … ”
“ … ENRAGING TO BE FEELING NEVER GOOD ENOUGH … ”
“ … PAINFUL TO BE FEELING SO BROKEN … ”
“STORIES” THE PATIENT HAD “MADE UP”
IN AN EFFORT TO UNDERSTAND
BUT “MADE – UP STORIES” THAT HAVE NOW GENERALIZED
FROM THE SMALL (HER NUCLEAR FAMILY)
TO THE ALL (THE WORLD AROUND HER)
“NARRATIVES” THAT HAVE BECOME THE “GO – TO”
DISTORTED FILTERS, OR LENSES, THROUGH WHICH
SHE EXPERIENCES SELF, OTHERS, AND THE WORLD
19

20. LET US IMAGINE THAT THE PATIENT IS TRYING HARD
TO END HER RELATIONSHIP WITH AN ABUSIVE BOYFRIEND
BUT IS TERRIFIED OF BEING ALONE AGAIN
“ … FRIGHTENING TO THINK ABOUT ENDING
THE RELATIONSHIP AND BEING ALONE AGAIN –
TERRIFIED THAT YOU SIMPLY WOULDN’T SURVIVE … ”
HERE WE ARE OFFERING THE PATIENT AN “EMPATHIC STATEMENT”
IN WHICH WE ARE “RESONATING EMPATHICALLY” WITH HER TERROR
NAMELY, WITH THE “UNHEALTHY (DEFENSIVE) COUNTERFORCE”
THAT IS GETTING IN THE WAY OF THE “(ADAPTIVE) HEALTHY FORCE”
THAT KNOWS SHE SHOULD END THE ABUSIVE RELATIONSHIP
ALTERNATIVELY, WE COULD OFFER HER
AN “OPTIMALLY STRESSFUL” “CONFLICT STATEMENT”
“YOU KNOW THAT ULTIMATELY YOU WILL NEED
TO END THE RELATIONSHIP WITH JORGE
BECAUSE HE TREATS YOU SO SHABBILY;
BUT YOU ARE NOT QUITE YET READY TO DO THAT
BECAUSE YOU ARE TERRIFIED OF BEING ALONE AGAIN –
SCARED TO DEATH THAT YOU SIMPLY WOULDN’T SURVIVE.”
20

21. “EMPATHIC STATEMENTS” OFFER “SUPPORT”
BUT “CONFLICT STATEMENTS”
ARE STRATEGICALLLY DESIGNED
TO OFFER AN ARTFUL COMBINATION OF
“CHALLENGE”
– BY INTRODUCING THE POSSIBILITY OF CHANGE –
AND “SUPPORT”
– BY RESONATING EMPATHICALLY WITH THE PATIENT’S
(DEFENSIVE) INVESTMENT IN STAYING THE SAME –
THE NET RESULT OF THIS
INTUITIVELY TITRATED BLEND OF
“CHALLENGE”
– WHICH WILL PROVOKE THE PATIENT’S ANXIETY –
AND “SUPPORT”
– WHICH WILL EASE IT –
WILL BE THE GENERATION OF
INCENTIVIZING “OPTIMAL STRESS”
NECESSARY IF DEEP, ENDURING, CHARACTEROLOGICAL
TRANSFORMATION AND RENEWAL IS THE ULTIMATE GOAL
21

22. “YOU KNOW THAT IF YOU ARE EVER TO GET ON WITH YOUR
LIFE, YOU’LL HAVE TO LET GO OF YOUR CONVICTION
THAT YOUR CHILDHOOD SCARRED YOU FOREVER;
BUT IT’S HARD NOT TO FEEL LIKE DAMAGED GOODS
WHEN YOU GREW UP IN A HORRIBLY ABUSIVE HOUSEHOLD
WITH A MEAN AND NASTY MOTHER
WHO KEPT TELLING YOU THAT YOU WERE A FAILURE.”
“YOU KNOW THAT, ULTIMATELY, YOU’LL NEED TO LET MIGUEL GO
BECAUSE HE, LIKE YOUR DAD, REALLY ISN’T AVAILABLE
IN THE WAYS THAT YOU WOULD HAVE WANTED HIM TO BE;
BUT, FOR NOW, ALL YOU CAN THINK ABOUT IS HOW DESPERATELY
YOU NEED HIM AND HOW HORRIBLE IT WOULD BE TO LOSE HIM.”
“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 COURSE OF THE YEARS.”
22

23. THESE “OPTIMALLY STRESSFUL” STATEMENTS
ARE DESIGNED
FIRST TO INCREASE ANXIETY BY
“CHALLENGING” THE DEFENSE
AND THEN TO DECREASE ANXIETY BY
“SUPPORTING” THE DEFENSE
ALL WITH AN EYE TO “MAKING EXPLICIT”
THE CONFLICT WITHIN THE PATIENT
BETWEEN THE HEALTHY PART OF HER
THAT HAS THE “ADAPTIVE CAPACITY”
TO KNOW WHAT’S REAL / WHAT’S TRUE
AND THE LESS HEALTHY PART OF HER
THAT HAS THE “DEFENSIVE NEED”
TO RESIST THAT KNOWING
“YOU KNOW THAT EVENTUALLY YOU WILL 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.” 23

24. THE ULTIMATE GOAL OF CONFLICT STATEMENTS
DEVELOPMENT OF DUAL AWARENESS – “WISE MIND”
THE HEALTHY ABILITY TO HOLD
“SIMULTANEOUS AWARENESS” OF BOTH
KNOWLEDGE AND EXPERIENCE
OBJECTIVE REALITY AND SUBJECTIVE EXPERIENCE
HEAD AND HEART
LEFT BRAIN AND RIGHT BRAIN
REASON AND EMOTION
“HERE – AND – NOW” AND “THERE – AND – THEN”
PRESENT AND PAST
NEW GOOD AND OLD BAD
PROSPECTIVE AND RETROSPECTIVE
UPDATED AND OUTDATED
RESPONSIVE AND REACTIVE
REFLECTIVE AND REFLEXIVE
MINDFUL AND MINDLESS
FLEXIBLE AND RIGID
ADAPTIVE CAPACITY AND DEFENSIVE NEED
24

25. FROM DEFENSE TO ADAPTATION
25

26. THE RELATIONSHIP BETWEEN DEFENSE AND ADAPTATION
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
ALTHOUGH DEFENSES MIGHT
ONCE HAVE BEEN NECESSARY
FOR THE PATIENT TO SURVIVE,
THEY MUST ULTIMATELY
BE REPLACED BY ADAPTATIONS
IF THE PATIENT IS TO THRIVE
26

27. THE ULTIMATE GOAL OF PSYCHODYNAMIC PSYCHOTHERAPY
IS TO FACILITATE THE INCREMENTAL PROCESSING
AND INTEGRATING OF STRESSFUL EXPERIENCES
IN BOTH THE “THERE – AND – THEN” AND THE “HERE – AND – NOW”
FROM DEFENSIVE REACTION
TO ADAPTIVE RESPONSE
FROM RIGID AND OUTDATED DEFENSE
TO MORE FLEXIBLE AND UPDATED ADAPTATION
FROM DYSFUNCTIONAL DEFENSE
TO MORE FUNCTIONAL ADAPTATION
FROM DYSFUNCTIONAL ACTIONS, REACTIONS, AND INTERACTIONS
TO MORE FUNCTIONAL WAYS OF BEING AND DOING
FROM UNHEALTHY NEED
TO HEALTHY CAPACITY
FROM DISEMPOWERING AND RESTRICTIVE
TO MORE EMPOWERING AND EXPANSIVE 27

28. FROM EXTERNALIZING BLAME
TO TAKING OWNERSHIP
FROM WHINING AND COMPLAINING
TO BECOMING PROACTIVE
FROM DENYING
TO CONFRONTING HEAD – ON
FROM BEING CRITICAL
TO BECOMING MORE COMPASSIONATE
FROM DISSOCIATING
TO BECOMING MORE PRESENT
FROM FEELING VICTIMIZED
TO TAKING OWNERSHIP
FROM BEING JAMMED UP
TO MOBILIZING ONE’S ENERGIES
IN THE PURSUIT OF ONE’S DREAMS
FROM CURSING THE DARKNESS
TO LIGHTING A CANDLE 28

29. GROWING UP (THE TASK OF THE CHILD)
AND GETTING BETTER (THE TASK OF THE PATIENT)
CAN ALSO BE DESCRIBED AS
TRANSFORMING NEED INTO CAPACITY
THE NEED FOR IMMEDIATE GRATIFICATION
INTO THE CAPACITY TO TOLERATE DELAY
THE NEED FOR PERFECTION
INTO THE CAPACITY TO
TOLERATE IMPERFECTION
THE NEED FOR EXTERNAL REGULATION OF THE SELF
INTO THE CAPACITY FOR
INTERNAL SELF – REGULATION
THE NEED TO HOLD ON
INTO THE CAPACITY TO LET GO
29

30. MY PSYCHODYNAMIC
SYNERGY PARADIGM
3 MODES OF THERAPEUTIC ACTION
30

31. MY PSYCHODYNAMIC SYNERGY PARADIGM
IS AN INTEGRATIVE APPROACH TO HEALING
FEATURING THREE INTERDEPENDENT
– MUTUALLY ENHANCING (NOT MUTUALLY EXCLUSIVE) –
MODES OF THERAPEUTIC ACTION
MODEL 1
THE INTERPRETIVE PERSPECTIVE
OF CLASSICAL PSYCHOANALYSIS
MODEL 2
THE CORRECTIVE – PROVISION 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”
31

32. MODEL 1 – COGNITIVE
ENHANCEMENT OF KNOWLEDGE “WITHIN”
ULTIMATELY, A STRONGER, WISER,
AND MORE EMPOWERED “EGO”
MODEL 2 – AFFECTIVE
PROVISION OF EXPERIENCE “FOR”
ULTIMATELY, A MORE CONSOLIDATED
AND COMPASSIONATE “SELF”
MODEL 3 – RELATIONAL
ENGAGEMENT IN RELATIONSHIP “WITH”
ULTIMATELY, A MORE ACCOUNTABLE
“SELF – IN – RELATION”
32

33. MODEL 1 – THINKING
1 – PERSON PSYCHOLOGY
FOCUSES ON THE PATIENT’S INTERNAL DYNAMICS
MODEL 2 – FEELING
1½ – PERSON PSYCHOLOGY
FOCUSES ON THE PATIENT’S AFFECTIVE EXPERIENCE
MODEL 3 – DOING
2 – PERSON PSYCHOLOGY
FOCUSES ON THE PATIENT’S RELATIONAL DYNAMICS
HEAD, HEART, AND HAND
33

34. IN TRUTH
WE ARE ALL A LITTLE
NEUROTIC, NARCISSISTIC,
AND NOXIOUS IN OUR RELATEDNESS
MODEL 1 – KNOWLEDGE
THE INTERPRETIVE PERSPECTIVE
OF CLASSICAL PSYCHOANALYSIS
NEUROTIC CONFLICTEDNESS
MODEL 2 – EXPERIENCE
THE CORRECTIVE – PROVISION PERSPECTIVE
OF SELF PSYCHOLOGY
NARCISSISTIC VULNERABILITY
MODEL 3 – RELATIONSHIP
THE INTERSUBJECTIVE PERSPECTIVE
OF CONTEMPORARY RELATIONAL THEORY
NOXIOUS RELATEDNESS
34

35. MODEL 1
WHERE RESISTANCE WAS,
THERE SHALL AWARENESS BE
MODEL 2
WHERE RELENTLESSNESS WAS,
THERE SHALL ACCEPTANCE BE
MODEL 3
WHERE RE – ENACTMENT WAS,
THERE SHALL ACCOUNTABILITY BE
35

36. THE TRANSFORMATIVE POWER
OF “OPTIMAL STRESS”
36

37. 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”
AND PLUMMETS THE PATIENT INTO FURTHER DECLINE
OR A GROWTH – PROMOTING OPPORTUNITY
THAT MAKES POSSIBLE TRANSFORMATION AND RENEWAL
37

38. THE OPERATIVE CONCEPT HERE WILL BE
THE ONGOING GENERATION OF
“DESTABILIZING ANXIETY”
AND “INCENTIVIZING STRESS”
“OPTIMAL STRESS”
HANS SELYE’S “EUSTRESS” vs. “DISTRESS” (1978)
THE CREATION OF
JUST THE RIGHT BALANCE
BETWEEN “CHALLENGE”
– TO PROVOKE “DISRUPTION” –
AND “SUPPORT”
– TO JUMPSTART “REPAIR” –
38

39. IN THE PHYSICAL REALM
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”
BY WAY OF EXAMPLES
HIGH – INTENSITY INTERVAL TRAINING (HIIT) / INTERMITTENT FASTING
ELECTROCONVULSIVE THERAPY (ECT) / TRANSCRANIAL MAGNETIC STIMULATION (TCM)
CARDIAC DEFIBRILLATION
ACUPUNCTURE / ACUPRESSURE / CUPPING
RED LIGHT THERAPY / INFRARED SAUNAS / CRYOTHERAPY
HOMEOPATHIC REMEDIES / VACCINES AND OTHER IMMUNOTHERAPIES
PLATELET – RICH PLASMA (PRP) / PLATELET – RICH FIBRIN (PRF)
DERMABRASION / FRAXEL LASER TREATMENTS
BRAIN TEASERS AND MENTAL EXERCISES
HYPERBARIC OXYGEN
“PRECIPITATE DISRUPTION” TO “TRIGGER (ADAPTIVE) RECOVERY”
39

40. A PRIME EXAMPLE OF “CREATING INJURY” TO “STIMULATE HEALING”
PROLOTHERAPY
A HIGHLY EFFECTIVE TREATMENT
FOR CHRONIC LIGAMENT AND TENDON WEAKNESS
IT INVOLVES INJECTING A MILDLY IRRITATING AQUEOUS SOLUTION
– e. g., DEXTROSE, WATER, AND A LOCAL ANESTHETIC (LIDOCAINE) –
INTO THE AFFECTED LIGAMENT OR TENDON
IN ORDER TO INDUCE A MILD INFLAMMATORY REACTION
IN ESSENCE, IT WILL “TURN ON” THE BODY’S HEALING PROCESS
AND RESULT ULTIMATELY IN STRENGTHENING
OF THE DAMAGED CONNECTIVE TISSUE
AND ALLEVIATION OF CHRONIC MUSCULOSKELETAL PAIN
BY CONTRAST – CORTISONE INJECTIONS MIGHT WELL PROVIDE
IMMEDIATE PAIN RELIEF OVER THE SHORT – TERM BUT TISSUE
DESTRUCTION AND EXACERBATION OF PAIN OVER THE LONG – TERM
– BECAUSE OF THE CATABOLIC EFFECTS OF STEROID HORMONES –
PROLOTHERAPY INJECTIONS, HOWEVER, SUPPORT THE NATURAL
HEALING PROCESS BY STIMULATING THE HEALING CASCADE
– RESULTING ULTIMATELY IN OVERALL STRENGTHENING
OF THE CONNECTIVE TISSUE MATRIX AND RELIEF OF PAIN – 40

41. JUST AS WITH THE BODY
– WHERE A CHRONIC CONDITION MIGHT NOT HEAL UNTIL IT IS MADE ACUTE –
SO TOO WITH THE MIND
INDEED
OVER TIME I HAVE COME TO APPRECIATE THAT
WHETHER CRISIS INTERVENTION / TRAUMA WORK
SHORT – TERM INTENSIVE / LONGER – TERM IN – DEPTH
THE THERAPEUTIC PROVISION OF JUST
THE RIGHT COMBINATION OF “CHALLENGE” AND “SUPPORT”
NAMELY, “OPTIMAL STRESS”
– AGAINST THE BACKDROP OF SECURE ATTACHMENT,
EMPATHIC ATTUNEMENT, AUTHENTIC ENGAGEMENT,
AND A COLLABORATIVE ALLIANCE –
IS SOMETIMES THE “DESTABILIZING PROVOCATION” NEEDED
BOTH TO OVERCOME THE RESISTANCE TO CHANGE
SO FREQUENTLY ENCOUNTERED IN OUR PATIENTS
AND TO TRANSFORM THE DEFENSIVE NEED
TO MAINTAIN THINGS AS THEY ARE
INTO THE ADAPTIVE CAPACITY TO EVOLVE 41

42. A HUMOROUS EXAMPLE OF THIS “RESISTANCE TO CHANGE”
A SATURDAY NIGHT LIVE SKIT IN WHICH
TWO MEN ARE SEATED AROUND A FIRE
CHATTING AND ONE SAYS TO THE OTHER –
“YOU KNOW HOW WHEN YOU STICK
A POKER IN THE FIRE AND LEAVE IT IN
FOR A LONG TIME,
IT GETS REALLY, REALLY HOT?
AND THEN YOU STICK IT IN YOUR EYE,
AND IT REALLY, REALLY HURTS?
I HATE IT WHEN THAT HAPPENS!
I JUST HATE IT WHEN THAT HAPPENS!”
42

43. OR THE ROCK SONG
BY THE LATE WARREN ZEVON (1996)
ENTITLED
“IF YOU WON’T LEAVE ME
I’LL FIND SOMEBODY WHO WILL”
WHICH SPEAKS TO THE NEED
WE ALL HAVE TO RECREATE
THE “FAMILIAL AND THEREFORE FAMILIAR”
STEPHEN MITCHELL (1988)
BECAUSE THAT IS ALL WE HAVE EVER KNOWN
HAVING SOMETHING DIFFERENT
WOULD CREATE ANXIETY
43

44. I AM HERE REMINDED OF PORTIA NELSON’S
AUTOBIOGRAPHY IN 5 SHORT CHAPTERS (1993)
WHICH HIGHLIGHTS BOTH
OUR DEFENSIVE NEED TO MAINTAIN THINGS AS THEY ARE
AND OUR ADAPTIVE CAPACITY ULTIMATELY TO CHANGE
CHAPTER 1
I WALK DOWN THE STREET
THERE IS A DEEP HOLE IN THE SIDEWALK
I FALL IN
I AM LOST … I AM HELPLESS
IT ISN’T MY FAULT
IT TAKES FOREVER TO FIND A WAY OUT
CHAPTER 2
I WALK DOWN THE SAME STREET
THERE IS A DEEP HOLE IN THE SIDEWALK
I PRETEND I DON’T SEE IT
I FALL IN AGAIN
I CAN’T BELIEVE I AM IN THE SAME PLACE
BUT IT ISN’T MY FAULT
IT STILL TAKES A LONG TIME TO GET OUT
44

45. 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
45

46. IN TRUTH
“SELF – ORGANIZING (CHAOTIC) SYSTEMS
– LIKE ALL OF US! –
RESIST PERTURBATION”
CHARLES KREBS (2013)
THERE MUST BE ENOUGH “CHALLENGE”
TO A DYSFUNCTIONAL SYSTEM
THAT THERE WILL BE “IMPETUS”
FOR ITS DESTABILIZATION
BUT ENOUGH “SUPPORT”
THAT THERE WILL BE “OPPORTUNITY”
FOR ITS RESTABILIZATION
AT A HEALTHIER LEVEL
OF FUNCTIONALITY AND ADAPTABILITY
SUPPORT REINFORCED BY TAPPING INTO
THE SYSTEM’S UNDERLYING RESILIENCE
AND INNATE CAPACITY TO SELF – CORRECT
IN THE FACE OF OPTIMAL CHALLENGE
46

47. INDEED, IT COULD BE SAID THAT
WITHOUT SUPPORT, THERAPY NEVER BEGINS
BUT WITHOUT CHALLENGE, THERAPY NEVER ENDS
ALTERNATIVELY
WITHOUT CHALLENGE, THERAPY NEVER BEGINS
BUT WITHOUT SUPPORT, THERAPY NEVER ENDS
BY THE SAME TOKEN, IT COULD BE SAID THAT
WITHOUT EMPATHY, THERAPY NEVER BEGINS
BUT WITHOUT EMPATHIC FAILURE, THERAPY NEVER ENDS
OR
WITHOUT EMPATHIC FAILURE, THERAPY NEVER BEGINS
BUT WITHOUT EMPATHY, THERAPY NEVER ENDS
47

48. MORE SPECIFICALLY
IT IS NOT SO MUCH EMPATHY AS
EMPATHIC FAILURE AGAINST A BACKDROP OF EMPATHY
OPTIMAL DISILLUSIONMENT
IT IS NOT SO MUCH GRATIFICATION AS
FRUSTRATION AGAINST A BACKDROP OF GRATIFICATION
OPTIMAL FRUSTRATION
IT IS NOT SO MUCH SUPPORT AS
CHALLENGE AGAINST A BACKDROP OF SUPPORT
OPTIMAL STRESS
THAT WILL PROVIDE THE THERAPEUTIC LEVERAGE
NEEDED TO PROVOKE FIRST DESTABILIZATION
AND THEN RESTABILIZATION
AT A HIGHER LEVEL OF ADAPTIVE CAPACITY
BECAUSE DEEP, ENDURING, CHARACTEROLOGICAL CHANGE
REQUIRES THIS “INCENTIVIZING” OPTIMAL STRESS
48

49. THE GOLDILOCKS PRINCIPLE OF STRESS
TOO MUCH CHALLENGE
WILL OVERWHELM AND PROMPT DEFENSE BECAUSE
IT IS “TOO MUCH” TO BE PROCESSED AND INTEGRATED
TRAUMATIC STRESS
TOO LITTLE CHALLENGE
WILL OFFER TOO LITTLE IMPETUS FOR
TRANSFORMATION AND GROWTH AND WILL SERVE SIMPLY
TO REINFORCE THE (DYSFUNCTIONAL) STATUS QUO
BUT JUST THE RIGHT AMOUNT OF CHALLENGE
WILL PROVIDE JUST THE RIGHT AMOUNT OF LEVERAGE
NEEDED TO JUMPSTART, AFTER INITIAL DISRUPTION,
RECOVERY AT A HIGHER LEVEL OF
INTEGRATION, FUNCTIONALITY, AND ADAPTIVE CAPACITY
OPTIMAL (NON – TRAUMATIC) STRESS
49

50. WITH THE THERAPIST’S FINGER
EVER ON THE PULSE
OF THE LEVEL OF THE PATIENT’S ANXIETY
AND CAPACITY TO TOLERATE FURTHER CHALLENGE
THE THERAPIST WILL THEREFORE
CHALLENGE WHENEVER POSSIBLE
BY DIRECTING THE PATIENT’S
ATTENTION TO WHERE THE PATIENT IS NOT
(SALMAN AKHTAR’S “DISRUPTIVE ATTUNEMENT”)
SUPPORT WHENEVER NECESSARY
BY LANDING WHERE THE PATIENT IS
(SALMAN AKHTAR’S “HOMEOSTATIC ATTUNEMENT”)
50

51. ALL WITH AN EYE
TO CREATING JUST THE
RIGHT LEVEL OF
“INCENTIVIZING ANXIETY”
AND “DESTABILIZING STRESS”
OPTIMAL STRESS
THEREBY OPTIMIZING THE POTENTIAL
FOR TRANSFORMATION AND GROWTH
AND MAKING POSSIBLE
DEEP, ENDURING, CHARACTEROLOGICAL CHANGE
51

52. IN ESSENCE
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
. 52

53. BUT MORE SPECIFICALLY
IT WILL BE “STRESSFUL INPUT”
FROM THE OUTSIDE
AND THE PATIENT’S CAPACITY
TO PROCESS, INTEGRATE, AND ADAPT TO
THE IMPACT OF THIS “STRESS”
THAT WILL ULTIMATELY
PROVOKE RECOVERY
.
53

54. AND ADVANCE THE PATIENT TO
EVER – MORE EVOLVED LEVELS OF
AWARENESS
MODEL 1
ACCEPTANCE
MODEL 2
ACCOUNTABILITY
MODEL 3
54

55. THESE THREE “As” ARE A REFLECTION
OF THE PATIENT’S RESILIENCE AND HEALTH
AWARENESS OF ANXIETY – PROVOKING
TRUTHS ABOUT THE “SELF”
(MODEL 1)
ACCEPTANCE OF ANXIETY – PROVOKING
TRUTHS ABOUT THE “OBJECTS OF HER DESIRE”
(MODEL 2)
ACCOUNTABILITY FOR ANXIETY – PROVOKING
TRUTHS ABOUT THE “SELF – IN – RELATION”
(MODEL 3)
ALL THREE “As” ARE ADAPTATIONS
TO THE “STRESS OF LIFE”
55

56. AGAIN
– BY SUPERIMPOSING AN ACUTE INJURY ON TOP OF A CHRONIC ONE –
OPTIMALLY STRESSFUL THERAPEUTIC INTERVENTIONS
WILL TRIGGER HEALING CYCLES OF DISRUPTION AND REPAIR
SUCH THAT PSYCHODYNAMIC PSYCHOTHERAPY
WILL AFFORD THE PATIENT AN OPPORTUNITY
– ALBEIT A BELATED ONE –
TO MASTER EXPERIENCES THAT
HAD ONCE BEEN OVERWHELMING
– AND, THEREFORE, DEFENDED AGAINST –
BUT THAT CAN NOW
– WITH ENOUGH SUPPORT FROM THE THERAPIST
AND BY TAPPING INTO THE PATIENT’S
UNDERLYING RESILIENCE
AND CAPACITY TO COPE WITH STRESS –
BE PROCESSED, INTEGRATED,
AND ULTIMATELY ADAPTED TO
– FROM OUTDATED DEFENSE TO UPDATED ADAPTATION –
56

57. STRESS IS WHEN
YOU WAKE UP SCREAMING
AND THEN YOU REALIZE
YOU HAVEN’T FALLEN
ASLEEP YET
ANONYMOUS
57

58. NATURE
(MODEL 1)
vs.
NURTURE
(MODELS 2 AND 3)
58

59. WHEREAS CLASSICAL PSYCHOANALYSIS
CONCEIVES OF THE PATIENT’S PSYCHOPATHOLOGY
AS DERIVING FROM THE PATIENT
– IN WHOM THERE IS PRESUMED TO BE AN IMBALANCE
OF FORCES AND THEREFORE INTERNAL CONFLICT –
BETWEEN DYSREGULATED FORCES
ARISING FROM THE ID
AND DEFENSIVE COUNTERFORCES
ARISING FROM AN EGO MADE ANXIOUS
CONTEMPORARY PSYCHOANALYSIS
CONCEIVES OF THE PATIENT’S PSYCHOPATHOLOGY
AS DERIVING FROM THE PARENT
– AND THE PARENT’S TRAUMATIC FAILURE OF THE CHILD –
I AM SPEAKING HERE TO THE DISTINCTION BETWEEN
NATURE
– WHAT DERIVES FROM WITHIN THE CHILD (MODEL 1) –
AND NURTURE
– WHAT DERIVES FROM WITHIN THE RELATIONSHIP
BETWEEN PARENT AND CHILD (MODELS 2 AND 3) –
59

60. 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
60

61. 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
61

62. 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,
COLLABORATION, AND INTERACTIVE REGULATION
AN INTERSUBJECTIVE RELATIONSHIP
INVOLVING TWO SUBJECTS
– BOTH OF WHOM CONTRIBUTE TO WHAT TRANSPIRES
AT THEIR “INTIMATE EDGE” (DARLENE EHRENBERG) –
MARTIN BUBER (2000)
62

63. 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
THE PATIENT’S DEFICITS BY WAY OF
WORKING THROUGH FAILURES
IN THE ENVIRONMENTAL PROVISION
AS SUCH, IT INVOLVES “DISRUPTED POSITIVE TRANSFERENCE”
AND “GRIEVING DISILLUSIONMENT”
BY CONTRAST
THE EMPHASIS IN MODEL 3 IS
TRULY ON A “2 – WAY” RELATIONSHIP
BETWEEN TWO “AUTHENTIC SUBJECTS”
AS SUCH, IT INVOLVES “NEGATIVE TRANSFERENCE”
AND “NEGOTIATING PROJECTIVE IDENTIFICATION”
63

64. WHEN A PARENT FAILS HER CHILD,
HOW IS THAT FAILURE INTERNALLY RECORDED
AND STRUCTURALIZED?
INTERESTINGLY, SOME THEORISTS FOCUS ON
THE PRICE THE CHILD PAYS
BECAUSE OF WHAT THE PARENT “DID NOT DO”
– “ABSENCE OF GOOD” IN THE PARENT – CHILD RELATIONSHIP
GIVES RISE TO DEFICIT AND IMPAIRED CAPACITY IN THE CHILD –
MODEL 2 
WHEREAS OTHER THEORISTS FOCUS ON
THE PRICE THE CHILD PAYS
BECAUSE OF WHAT THE PARENT “DID DO”
– “PRESENCE OF BAD” IN THE PARENT – CHILD RELATIONSHIP
GIVES RISE TO INTERNAL BAD OBJECTS,
PATHOGENIC INTROJECTS,
DYSFUNCTIONAL RELATIONAL CONFIGURATIONS –
MODEL 3 
64

65. MORE SPECIFICALLY
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 WHICH 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”
65

66. 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
WHICH ARE THEN “COMPULSIVELY AND UNWITTINGLY”
RE – ENACTED ON THE STAGE OF ONE’S LIFE
– AGAIN AND AGAIN –
IN A DESPERATE ATTEMPT TO ENCOUNTER
DIFFERENT AND BETTER OUTCOMES EVERY “NEXT TIME”
“COMPULSIVE RE – ENACTMENTS” IN AN EFFORT
TO CORRECT FOR EARLY – ON
“PARENTAL ERRORS OF COMMISSION”
66

67. CENTER STAGE IN MODELS 2 AND 3 ARE
THE THERAPIST’S “INEVITABLE FAILURES” OF THE PATIENT
TO HIGHLIGHT THE DISTINCTION BETWEEN
A MODEL OF THERAPEUTIC ACTION THAT INVOLVES “GIVE”
– AND IS THEREFORE 1 – WAY –
AND A MODEL THAT INVOLVES “GIVE – AND – TAKE”
– AND IS THEREFORE 2 – WAY –
CONSIDER THE FOLLOWING –
SELF PSYCHOLOGY (MODEL 2)
CONTENDS THAT THE THERAPIST
WILL INEVITABLY FAIL HER PATIENT
BECAUSE THE THERAPIST IS ONLY HUMAN
– IS NOT, AND CANNOT BE EXPECTED TO BE, PERFECT –
BUT HOW DOES CONTEMPORARY RELATIONAL THEORY
CONCEIVE OF SUCH FAILURES?
67

68. IN MODEL 3, SUCH FAILURES ARE THOUGHT TO BE
NOT JUST A STORY ABOUT THE THERAPIST
– AND HER LACK OF PERFECTION –
BUT ALSO A STORY ABOUT THE PATIENT
– AND HER EXERTING OF “INTERPERSONAL PRESSURE”
ON THE THERAPIST TO PARTICIPATE
IN OLD “FAMILIAL AND THEREFORE FAMILIAR” WAYS –
STEPHEN MITCHELL (1988)
IN OTHER WORDS
THE MODEL 3 THERAPIST’S FAILURES ARE THOUGHT
NOT TO HAPPEN IN A VACUUM BUT TO BE CO – CREATED
THEY OCCUR IN THE CONTEXT OF AN
ONGOING, CONTINUOUSLY EVOLVING RELATIONSHIP
BETWEEN TWO REAL PEOPLE
AND SPEAK TO THE PATIENT’S
COMPULSIVE AND UNWITTING “NEED TO BE FAILED”
IN WAYS SPECIFICALLY DETERMINED
BY HER EARLY – ON HISTORY
PATRICK CASEMENT (1992)
68

69. WITH RESPECT TO THESE (MODEL 3) “COMPULSIVE RE – ENACTMENTS”
AS WITH EVERY REPETITION COMPULSION
THERE ARE 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
69

70. MODELS 2 AND 3
BUT WHETHER THE PATHOGENIC FACTOR
IS AN ERROR OF OMISSION (MODEL 2)
– DEPRIVATION AND NEGLECT –
OR AN ERROR OF COMMISSION (MODEL 3)
– TRAUMA AND ABUSE –
THE VILLAIN IN THE PIECE IS THOUGHT TO BE
NOT THE CHILD BUT THE PARENT
NOT SURPRISINGLY, AS THE ETIOLOGY HAS SHIFTED
– OVER THE DECADES –
FROM NATURE TO NURTURE,
SO TOO THE LOCUS OF THE THERPEUTIC ACTION
HAS SHIFTED FROM INSIGHT
TO EXPERIENCE AND RELATIONSHIP
– THAT IS, FROM WITHIN THE PATIENT (MODEL 1)
TO WITHIN THE RELATIONSHIP BETWEEN
THERAPIST AND PATIENT (MODELS 2 AND 3) –
70

71. “OPTIMALLY STRESSFUL”
TEMPLATE INTERVENTIONS
FOR THE THREE MODELS
INTERVENTIONS THAT SUPERIMPOSE
AN ACUTE INJURY
ON TOP OF A CHRONIC ONE
THINK “PROLOTHERAPY” 
71

72. “PRECIPITATE DISRUPTION” TO “TRIGGER RECOVERY”
“OPTIMALLY STRESSFUL”
INTERVENTIONS
ALTERNATELY CHALLENGE
THEN SUPPORT
ANXIETY – PROVOKING
IN THE SHORT – TERM
BUT GROWTH – PROMOTING
IN THE LONG – TERM
72

73. MODEL 1
THE INTERPRETIVE PERSPECTIVE
OF CLASSICAL PSYCHOANALYSIS
OPTIMALLY STRESSFUL
“CONFLICT STATEMENTS”
“YOU KNOW THAT … , BUT (MADE ANXIOUS)
YOU FIND YOURSELF THINKING / FEELING / DOING
IN ORDER NOT TO HAVE TO KNOW … ”
73

74. MODEL 2
THE CORRECTIVE – PROVISION PERSPECTIVE
OF SELF PSYCHOLOGY
OPTIMALLY STRESSFUL
“DISILLUSIONMENT STATEMENTS”
“YOU HAD SO HOPED THAT … ,
BUT YOU ARE BEGINNING TO REALIZE THAT … ,
AND IT DEVASTATES / ENRAGES YOU … ”
74

75. MODEL 3
THE INTERSUBJECTIVE PERSPECTIVE
OF CONTEMPORARY RELATIONAL THEORY
OPTIMALLY STRESSFUL
“RELATIONAL INTERVENTIONS”
HIGHLIGHT
EITHER GETTING OTHERS TO DO UNTO HER
IN THE HERE – AND – NOW
SOME VERSION OF WHAT HAD BEEN DONE UNTO HER
IN THE THERE – AND – THEN
OR DOING UNTO OTHERS
IN THE HERE – AND – NOW
SOME VERSION OF WHAT HAD BEEN DONE UNTO HER
IN THE THERE – AND – THEN
75

76. MODEL 3 – THE “RULE OF THREE”
RELEVANT WHENEVER A PATIENT SAYS OR DOES SOMETHING
THAT THE THERAPIST EXPERIENCES AS PROVOCATIVE
– A “PROVOCATIVE ENACTMENT” –
IN ORDER TO COMPEL THE PATIENT TO TAKE OWNERSHIP OF
WHAT SHE IS “PLAYING OUT” ON THE STAGE OF THE TREATMENT,
THE THERAPIST MIGHT ASK THE PATIENT ANY OF THE FOLLOWING
“HOW ARE YOU HOPING THAT I WILL RESPOND?”
WHICH ADDRESSES THE ID
“HOW ARE YOU FEARING THAT I MIGHT RESPOND?”
WHICH ADDRESSES THE SUPEREGO
“HOW ARE YOU IMAGINING THAT I WILL RESPOND?”
WHICH ADDRESSES THE EGO
ALL THREE “ACCOUNTABILITY STATEMENTS” DEMAND OF THE PATIENT
THAT SHE MAKE HER “INTERPERSONAL INTENTIONS” MORE EXPLICIT
AND THAT SHE TAKE RESPONSIBILITY FOR HER “PROVOCATIVE ENACTMENT”
76

77. MODEL 1
OPTIMALLY STRESSFUL
“CONFLICT STATEMENTS”
77

78. MODEL 1
OPTIMALLY STRESSFUL
“CONFLICT STATEMENTS”
“YOU KNOW THAT … , BUT (MADE ANXIOUS)
YOU FIND YOURSELF THINKING / FEELING / DOING
IN ORDER NOT TO HAVE TO KNOW … ”
78

79. 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
THE CONFLICT WITHIN HER
BETWEEN WHAT SHE REALLY DOES KNOW
AND HOW SHE (MADE ANXIOUS) FINDS HERSELF
(DEFENSIVELY) REACTING
IN ORDER NOT TO HAVE TO ACKNOWLEDGE IT
“YOU KNOW THAT … , BUT (MADE ANXIOUS)
YOU FIND YOURSELF THINKING / FEELING / DOING
IN ORDER NOT TO HAVE TO KNOW … ”
FIRST HIGHLIGHT HER ADAPTIVE (GROWTH – PROMOTING) CAPACITY /
THEN RESONATE EMPATHICALLY WITH
HER DEFENSIVE (GROWTH – DISRUPTING) NEED 79

80. MODEL 1 “OPTIMALLY STRESSFUL” CONFLICT STATEMENTS
“YOU KNOW THAT EVENTUALLY
YOU’LL NEED TO MAKE YOUR PEACE
WITH THE REALITY THAT YOUR FATHER
WILL NEVER BE THERE FOR YOU
IN THE WAYS THAT YOU
WOULD HAVE WANTED HIM TO BE;
BUT YOUR FEAR, IN THE MOMENT,
IS THAT WERE YOU EVER
TO LET YOURSELF REALLY FEEL
THE HEARTBREAK OF THAT,
YOU WOULD NEVER RECOVER.”
FIRST CHALLENGE BY HIGHLIGHTING
WHAT THE PATIENT REALLY DOES KNOW
– YOU KNOW THAT –
THEN SUPPORT BY RESONATING EMPATHICALLY
WITH HOW SHE PROTECTS HERSELF
– BUT YOU FIND YOURSELF … IN ORDER NOT TO HAVE TO KNOW –
80

81. “YOU KNOW THAT IF YOUR RELATIONSHIP WITH ELANA
IS TO SURVIVE, YOU’LL NEED TO TAKE AT LEAST
SOME RESPONSIBILITY FOR THE PART YOU’RE PLAYING
IN THE INCREDIBLY ABUSIVE FIGHTS
THAT YOU AND SHE 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!”
EVER ATTUNED TO THE IMPORTANCE OF CREATING
AN OPTIMAL BALANCE BETWEEN CHALLENGE AND SUPPORT,
WE MUST CONTINUOUSLY KEEP OUR FINGER
ON THE PULSE OF THE LEVEL OF THE PATIENT’S ANXIETY
ALWAYS FOCUSING
ON WHETHER WE THINK THE PATIENT WILL BE ABLE
TO TOLERATE FURTHER (ANXIETY – PROVOKING) CHALLENGE
– IN WHICH CASE WE WILL INTRODUCE MORE CHALLENGE –
OR WILL REQUIRE ADDITIONAL (ANXIETY – ASSUAGING) SUPPORT
– IN WHICH CASE WE WILL OFFER MORE SUPPORT –
81

82. BY LOCATING WITHIN THE PATIENT CONFLICT BETWEEN
WHAT SHE “KNOWS” AND WHAT SHE, MADE ANXIOUS,
FINDS HERSELF (DEFENSIVELY) “THINKING, FEELING, OR DOING”
IN ORDER NOT TO HAVE TO CONFRONT THAT REALITY,
THE THERAPIST IS DEFTLY SIDESTEPPING THE POTENTIAL
FOR CONFLICT BETWEEN HERSELF AND THE PATIENT
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
IF, INSTEAD, 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 THE THERAPIST WILL ALSO BE DEPRIVING THE PATIENT
OF ANY INCENTIVE TO TAKE RESPONSIBILITY
FOR HER OWN DESIRE TO GET BETTER 82

83. 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
BECOMING 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 / HEALTHY” THING
– A STANCE WHICH THEN LEAVES THE PATIENT, MADE ANXIOUS,
NO CHOICE BUT TO BECOME THE “VOICE OF OPPOSITION”
“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.” 83

84. 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
THE THERAPIST IS ATTEMPTING TO HIGHLIGHT THE FACT
THAT EVEN IF, FOR NOW, THE PATIENT WOULD SEEM TO BE
ENTRENCHED IN PROTESTING HER RIGHT TO MAINTAIN THINGS
AS THEY ARE, AT ANOTHER POINT IN TIME, THAT COULD CHANGE
“YOU KNOW THAT SOMEDAY YOU’LL HAVE TO LET SOMEBODY IN
IF YOU’RE EVER TO HAVE A MEANINGFUL RELATIONSHIP; BUT, AT
THE MOMENT, THE THOUGHT OF MAKING YOURSELF THAT VULNERABLE
IS SIMPLY OUT OF THE QUESTION. THERE’S ABSOLUTELY NO WAY
YOU’RE WILLING TO RUN THE RISK OF BEING HURT EVER AGAIN.”
“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, RIGHT NOW, WHEN YOU GREW UP IN
A HORRIBLY ABUSIVE HOUSEHOLD WITH A MEAN AND NASTY MOTHER
WHO KEPT TELLING YOU THAT YOU WERE A FAILURE.” 84

85. THE CREATION OF
INTERNAL TENSION
BETWEEN
“PAIN” AND “GAIN”
85

86. IN ORDER TO INCREASE THE PATIENT’S AWARENESS OF HER
AMBIVALENT ATTACHMENT TO HER DYSFUNCTIONAL DEFENSES
THE MODEL 1 “INTERPRETIVE” THERAPIST
FIRST CHALLENGES BY HIGHLIGHTING
WHAT BOTH THERAPIST AND PATIENT
ARE COMING TO UNDERSTAND
AS THE “PRICE” THE PATIENT IS PAYING
FOR CLINGING TO HER DEFENSES
AND THEN SUPPORTS BY RESONATING EMPATHICALLY
WITH WHAT BOTH THERAPIST AND PATIENT
ARE COMING TO UNDERSTAND
AS THE “INVESTMENT” THE PATIENT HAS
IN HOLDING ON TO THEM EVEN SO
BACK AND FORTH – BACK AND FORTH
IN AN EFFORT TO MAKE
THE PATIENT’S AMBIVALENTLY HELD DEFENSES
EVER LESS EGO – SYNTONIC AND EVER MORE EGO – DYSTONIC
86

87. 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
AND RESTORE HOMEOSTATIC BALANCE
87

88. WITH RESPECT TO THE OUTDATED DEFENSE – IN ESSENCE
THE MODEL 1 THERAPIST WILL
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 …
88

89. … 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 FORCES
AND THE RESISTIVE
AND GROWTH – IMPEDING BUT ANXIETY – RELIEVING
EGO COUNTERFORCES
89

90. 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
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
90

91. 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 GROWTH – PROMOTING POWER OF THE HORSE
– A NOW BETTER REGULATABLE ID
BY VIRTUE OF THE WORKING THROUGH PROCESS –
WHICH HAS TAMED AND MODIFIED 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
91

92. CONCLUSION
92

93. 93

94. OPTIMAL STRESS
STRONGER AT THE BROKEN PLACES
IS THERE NOT A CERTAIN BEAUTY IN BROKENNESS,
A BEAUTY NEVER ACHIEVED BY THINGS UNBROKEN?
IF A BONE IS FRACTURED AND THEN HEALS,
THE AREA OF THE BREAK WILL BE STRONGER
THAN THE SURROUNDING BONE
AND WILL NOT AGAIN EASILY FRACTURE
ARE WE TOO NOT STRONGER AT OUR BROKEN PLACES?
IS THERE NOT A CERTAIN BEAUTY IN BROKENNESS,
A QUIET STRENGTH WE ACQUIRE
FROM SURVIVING ADVERSITY AND HARDSHIP
AND MASTERING THE EXPERIENCE OF
DISAPPOINTMENT, HEARTBREAK, AND DEVASTATION?
AND, THEN, WHEN WE FINALLY RISE ABOVE IT,
DON’T WE RISE UP IN QUIET TRIUMPH,
EVEN IF ONLY WE NOTICE …
94

95. 95

96. 96

97. 97

98. 98
MY
LITTLE
MINION
FRIENDS
STUART
AND
HIS
BROTHER
STEWART
WANTED
TO
SAY
“HI!”
AND
TO THANK
DR. BALICE
DR. GUEDES
DR. ESPINOZA
AND
SARAH
SEEMAN

99. IF YOU WOULD LIKE
TO BE ON MY
MAILING LIST,
PLEASE EMAIL ME AT
MarthaStarkMD @
HMS.Harvard.edu
TO LET ME KNOW
99

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