Martha Stark MD – 17 Feb 2023 – Seminar 1 – A How-To Playbook for the Middle Game in Psychodynamic Psychotherapy.pptx

A HOW – TO PLAYBOOK
FOR THE MIDDLE GAME
IN PSYCHODYNAMIC PSYCHOTHERAPY
“LIKE THE MIDDLEGAME IN CHESS,
THERE IS NO PLAYBOOK TO GUIDE US”
PATRICIA COUGHLIN (2022)
MARTHA STARK MD
Faculty, Harvard Medical School
MarthaStarkMD @ SynergyMed.solutions
February 2023 – SEMINAR 1
International Association for Relational Psychoanalysis and Psychotherapy (IARPP)
AUSTRALIA
With heartfelt thanks to LEENA CHAUGULE and MEG CARLEY
for hosting this FUNDRAISER for UKRAINIAN PSYCHOTHERAPISTS!
© 2023 Martha Stark MD
1

WHAT FOLLOWS WILL BE
MY RATHER BOLD ATTEMPT
TO FORMULATE
AN OVERARCHING CONCEPTUAL FRAMEWORK
FOR THIS “MIDDLE GAME”
IN ESSENCE
A “HOW – TO PLAYBOOK” FOR THE INCREMENTAL TRANSFORMATION
IN THE EVOCATIVE WORDS OF ACCEPTANCE AND COMMITMENT THERAPY (ACT)
OF “PSYCHOLOGICAL RIGIDITY” INTO “PSYCHOLOGICAL FLEXIBILITY”
AND IN THE MORE TRADITIONAL WORDS OF PSYCHOANALYSIS AND EGO PSYCHOLOGY
OF “LOW – LEVEL DEFENSE” INTO “HIGHER – LEVEL DEFENSE”
OF “RIGID DEFENSE” INTO “MORE FLEXIBLE ADAPTATION”
SUCH THAT THE PATIENT
– WHATEVER HER STARTING POINT, HER INITIAL LEVEL OF FUNCTIONALITY, OR HER DIAGNOSIS –
WILL BECOME EVER BETTER ABLE
– OVER TIME –
TO MANAGE THE MYRIAD “STRESSORS” IN HER LIFE
– EVER BETTER ABLE TO “RESPOND ADAPTIVELY” INSTEAD OF “REACTING DEFENSIVELY” –
2

AT THE END OF THE DAY
THERAPEUTIC MODALITIES THAT HAVE
“DEEP AND ENDURING PSYCHODYNAMIC CHANGE”
AS THEIR ULTIMATE GOAL
FOR EXAMPLE
PSYCHOANALYSIS AND OTHER “DEPTH PSYCHOLOGIES”
INCLUDING, BUT NOT LIMITED TO,
ACCEPTANCE AND COMMITMENT THERAPY – STEVEN HAYES
INTERNAL FAMILY SYSTEMS – RICHARD SCHWARTZ
CORE PROCESS PSYCHOTHERAPY – MAURA SILLS
EYE MOVEMENT DESENSITIZATION AND REPROCESSING THERAPY – FRANCINE SHAPIRO
INTENSIVE SHORT – TERM DYNAMIC PSYCHOTHERAPY – HABIB DAVANLOO
ACCELERATED EXPERIENTIAL DYNAMIC PSYCHOTHERAPY – DIANA FOSHA
EMOTIONALLY FOCUSED THERAPY – SUSAN JOHNSON
NEUROLINGUISTIC PROGRAMMING – RICHARD BANDLER AND JOHN GRINDER
SENSORIMOTOR PSYCHOTHERAPY – PAT OGDEN
SOMATIC EXPERIENCING – PETER LEVINE
PSYCHOMOTOR PSYCHOTHERAPY – PESSO BOYDEN SYSTEM PSYCHOMOTOR
MUST INDEED BE ABLE
TO CATALYZE TRANSFORMATION
OF “DEFENSIVE RIGIDITY”
INTO “MORE ADAPTIVE FLEXIBILITY”
3

FROM MINDLESS TO MORE MINDFUL
FROM THOUGHTLESS TO MORE THOUGHTFUL
FROM REFLEXIVE TO MORE REFLECTIVE
FROM AUTOMATIC TO MORE INTENTIONAL
FROM DYSFUNCTIONAL TO MORE FUNCTIONAL
FROM SUBCONSCIOUS TO MORE CONSCIOUS
FROM SUBCORTICAL TO MORE CORTICAL
FROM DORSAL VAGAL SHUTDOWN TO VENTRAL VAGAL SOCIAL ENGAGEMENT
STEPHEN PORGES (2017)
FROM SIMPLY SURVIVING TO ACTUALLY THRIVING
FROM LESS HEALTHY TO MORE HEALTHY
FROM LESS EVOLVED TO MORE EVOLVED
FROM “SAME OLD, SAME OLD” TO “SOMETHING NEW, DIFFERENT, AND BETTER”
FROM RIGID DEFENSE
TO MORE FLEXIBLE ADAPTATION
FROM DEFENSE TO ADAPTATION
4

A HUMOROUS EXAMPLE OF BEING MINDLESS,
THOUGHTLESS, REFLEXIVE, AND DYSFUNCTIONAL
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!”
6

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
BECAUSE IT WOULD HIGHLIGHT THE FACT
THAT THINGS COULD BE
– AND COULD THEREFORE HAVE BEEN –
DIFFERENT
7

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
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
8

CHAPTER 3
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 AROUND IT
CHAPTER 5
I WALK DOWN ANOTHER STREET
9

WHAT IS REQUIRED OF THERAPISTS
WHO ARE COMMITTED TO DOING DEEP WORK?
THAT THEY BE EVER ATTUNED TO THE LEVEL OF THE PATIENT’S ANXIETY
– ALWAYS APPRECIATING THE THERAPEUTIC VALUE OF “LEVERAGING” IT
TO “INCENTIVIZE” CHANGE –
THAT THEY DEVELOP COMFORT WITH USING THIS LEVEL
TO GUIDE THEM IN THEIR INTERVENTIONS
– “CHALLENGING” THE DEFENSE WHENEVER POSSIBLE (TO PROVIDE “IMPETUS”) –
– “SUPPORTING” THE DEFENSE WHENEVER NECESSARY (TO PROVIDE “OPPORTUNITY”) –
THEREBY CREATING A “MISMATCH EXPERIENCE” FOR THE PATIENT
AND THAT THEY EMBRACE THE TRANSFORMATIVE POWER
OF “WORKING THROUGH” THIS “GROWTH – INCENTIVIZING” OPTIMAL STRESS
– THAT IS, JUST THE RIGHT COMBINATION OF CHALLENGE AND SUPPORT –
ALL OF WHICH ARE CRITICALLY IMPORTANT IF
TRANSFORMATION OF “OUTDATED AND RIGID DEFENSE”
– “SAME OLD, SAME OLD” –
INTO “UPDATED AND MORE FLEXIBLE ADAPTATION”
– “SOMETHING NEW, DIFFERENT, AND BETTER” –
IS THE ULTIMATE GOAL
IN SUM
WHETHER THE TREATMENT IS CRISIS INTERVENTION, TRAUMA WORK,
SHORT – TERM INTENSIVE, OR LONGER – TERM BROADER – BASED
THE THERAPEUTIC GOAL WILL BE TO ADVANCE PATIENTS
FROM “RIGID” TO “FLEXIBILE” AND FROM “CONSTRICTED” TO “WIDE OPEN”
BY WAY OF “OPTIMAL CHALLENGE” 10

11
STRATEGIC LEVERAGING
OF THE PATIENT’S ANXIETY
TO INCENTIVIZE TRANSFORMATION

12
“COME TO
THE EDGE”
AN EVOCATIVE POEM
BY
CHRISTOPHER
LOGUE
(1969)
CAPTURES
THE
ESSENCE
OF OUR
CAPACITY
TO ADAPT
TO STRESS
… WHEN
PUSH
COMES
TO SHOVE

PLEASE NOTE THE CRITICAL ROLE PLAYED
BY GROWTH – INCENTIVIZING “OPTIMAL STRESS”
IN JUMP – STARTING RECOVERY
THE GOLDILOCKS PRINCIPLE
TOO MUCH CHALLENGE
WILL OVERWHELM AND PLUMMET THE SYSTEM
INTO FURTHER DECLINE
BECAUSE IT WILL BE “TOO MUCH”
TO BE PROCESSED, INTEGRATED, AND ADAPTED TO
TRAUMATIC STRESS
TOO LITTLE CHALLENGE
WILL OFFER “TOO LITTLE” IMPETUS AND OPPORTUNITY
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 “THERAPEUTIC LEVERAGE” NEEDED TO PROVOKE
– AFTER INITIAL DISRUPTION –
EVENTUAL RE – EQUILIBRATION
AT A HIGHER, MORE – EVOLVED LEVEL
OF INTEGRATION, FUNCTIONALITY,
AND ADAPTIVE CAPACITY
OPTIMAL – NONTRAUMATIC – STRESS 14

PLEASE NOTE
I DO NOT “LIMIT” DEFENSES
TO THE WELL – KNOWN
AND MORE TRADITIONAL ONES
AT ONE END OF THE CONTINUUM
“LOW – LEVEL DEFENSES”
FOR EXAMPLE
REPRESSION, REGRESSION, DENIAL,
DISSOCIATION, DISPLACEMENT, PROJECTION,
ISOLATION OF AFFECT, INTELLECTUALIZATION,
AND REACTION FORMATION
AT THE OTHER END
“HIGHER – LEVEL” OR “MORE MATURE DEFENSES”
THAT ARE “MORE ADAPTIVE” AND “MORE SOCIALLY ACCEPTABLE”
FOR EXAMPLE
SUBLIMATION, HUMOR, ALTRUISM,
HUMILITY, AND POSITIVE IDENTIFICATIONS
17

RATHER
I DEFINE DEFENSES “MORE BROADLY”
AS SPEAKING TO ANY OF THE
“SELF – PROTECTIVE MECHANISMS”
THAT WE MOBILIZE WHEN MADE ANXIOUS
IN THE FACE OF STRESSORS
– WHETHER INTERNAL STRESSORS OR EXTERNAL ONES –
AT ONE END OF THE CONTINUUM
WHAT HAPPENS “REFLEXIVELY”
WHEN WE ARE CONFRONTED WITH STRESSORS
THAT “OVERWHELM” US WITH ANXIETY
TO WHICH I REFER AS “LOW – LEVEL DEFENSES”
OR “RIGID DEFENSES”
AT THE OTHER END
WHAT HAPPENS “MORE REFLECTIVELY”
WHEN WE ARE CONFRONTED WITH STRESSORS
THAT WE ARE ABLE TO “TAKE IN OUR STRIDE”
TO WHICH I REFER AS “HIGHER – LEVEL DEFENSES”
OR “MORE FLEXIBLE ADAPTATIONS”
AT ONE END OF THE CONTINUUM – “DEFENSIVE REACTIONS”
AT THE OTHER END – “ADAPTIVE RESPONSES”
18

EITHER WE
– MADE ANXIOUS –
“REACT” TO STRESSORS BY “DEFENDING”
“DEFENSIVE REACTION”
OR WE
– MORE RESILIENT –
“RESPOND” TO STRESSORS BY “ADAPTING”
“ADAPTIVE RESPONSE”
19

20
LIFE IS
NOT ABOUT
“DEFENSIVELY”
WAITING FOR
THE STORM
TO PASS
BUT ABOUT
“ADAPTIVELY”
LEARNING
TO DANCE
IN THE RAIN

WE CANNOT AVOID SUFFERING
BUT WE CAN CHOOSE HOW WE COPE WITH IT, FIND MEANING IN IT,
AND MOVE FORWARD WITH RENEWED PURPOSE
“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.”
AUTHOR UNKNOWN
– ALTHOUGH OFTEN MISATTRIBUTED TO THE EXISTENTIAL PSYCHIATRIST VIKTOR FRANKL –
AS THIS APPLIES TO THE CLINICAL SITUATION
IN THAT SPACE IS OUR POWER
EITHER TO “REACT DEFENSIVELY”
– BY WALLOWING IN OUR DESPAIR AND ABNEGATING RESPONSIBILITY FOR OUR LIVES –
OR TO “RESPOND ADAPTIVELY”
– BY ACKNOWLEDGING THAT, DESPITE OUR DESPAIR, FROM THIS POINT FORWARD
THE MEANING WE MAKE OF OUR LIVES IS ENTIRELY UP TO US –
NOT ONLY DO WE HAVE THE FREEDOM TO CREATE THAT MEANING
BUT WE ALSO HAVE THE RESPONSIBILITY TO DO SO
IT HAS BEEN SUGGESETED THAT 10% OF WHAT HAPPENS TO US IS “LIFE”
BUT 90% IS HOW WE “REACT” OR “RESPOND” TO IT
21

WITH IT BEING UNDERSTOOD THAT
THE RELATIONSHIP BETWEEN DEFENSE AND ADAPTATION
IS A YIN – YANG RELATIONSHIP
THESE “SELF – PROTECTIVE MECHANISMS”
ARE COMPLEMENTARY – NOT OPPOSING – FORCES
FOR EXAMPLE, LIGHT CANNOT EXIST WITHOUT SHADOW
FURTHERMORE
ALL DEFENSES HAVE AN ADAPTIVE COMPONENT
JUST AS ALL ADAPTATIONS SERVE A DEFENSIVE FUNCTION
NONETHELESS AND MORE GENERALLY
ALTHOUGH DEFENSES MIGHT ONCE
HAVE BEEN NECESSARY
FOR THE PATIENT TO “SURVIVE,”
AS DEFENSES BECOME
UPDATED TO ADAPTATIONS,
THE PATIENT BECOMES
BETTER ABLE TO “THRIVE”
THE THERAPEUTIC ACTION
IS INDEED DESIGNED
TO TRANSFORM “SURVIVING” INTO “THRIVING” 23

JUST AS WE CAN BURN
A FIELD OF GRASS
IN ORDER TO STIMULATE IT
TO GROW BACK
GREENER, HEALTHIER, AND MORE LUSH
THAN BEFORE
“CONTROLLED DAMAGE”
TO THE BODY
CAN
“JUMP – START HEALING”
26

IN THE PHYSIOLOGICAL 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
ISCHEMIC PRECONDITIONING / INTERMITTENT HYPOXIC TRAINING / HYPERBARIC OXYGEN
HOMEOPATHIC REMEDIES / VACCINES AND OTHER IMMUNOTHERAPIES / MEDICINAL PLANTS
DERMABRASION / FRAXEL LASER TREATMENTS / RADIOFREQUENCY MICRONEEDLING
PLATELET – RICH PLASMA (PRP) / PLATELET – RICH FIBRIN (PRF)
VAMPIRE GUM REJUVENATION / BOTOX / STEM CELL FACELIFTS
ELECTROCONVULSIVE THERAPY (ECT) / TRANSCRANIAL MAGNETIC STIMULATION (TMS)
CARDIAC DEFIBRILLATION
PULSE WAVE THERAPIES (SHOCKWAVE THERAPY AND SOUND THERAPY)
ACUPUNCTURE / ACUPRESSURE / CUPPING
RED LIGHT THERAPY / INFRARED SAUNAS / CRYOTHERAPY
BRAIN TEASERS AND MENTAL EXERCISES
WHEN THE BODY IS “OPTIMALLY CHALLENGED,”
NO MATTER HOW COMPROMISED IT MIGHT BE IN ITS FUNCTIONALITY
“ADAPTIVE RECOVERY” WILL BE TRIGGERED
BECAUSE OF THE BODY’S “INNATE RESILIENCE” 27

THE THERAPEUTIC USE OF OPTIMAL STRESS
TO PROVOKE RECOVERY
DEPRIVING YOURSELF OF HALF A NIGHT’S SLEEP ONCE A WEEK
PREFERABLY THE SECOND HALF OF THE NIGHT (FOR EXAMPLE, FROM 3 TO 7 AM)
CAN PRODUCE A RAPID, EVEN IF SHORT – LIVED,
RESTABILIZATION OF MOOD AND RECOVERY FROM DEPRESSION
THE “STRESS” OF INTERRUPTING NORMAL SLEEP PATTERNS
MAY “RESYNCHRONIZE DISTURBED CIRCADIAN RHYTHMS”
LEIBENLUFT AND WEHR (1992)
INTERMITTENT FASTING
A 36 – HOUR WATER FAST ONCE A WEEK
(FOR EXAMPLE, FROM AFTER DINNER ON MONDAY EVENING
TO BEFORE BREAKFAST ON WEDNESDAY MORNING)
CAN SO SIGNIFICANTLY REDUCE THE TOTAL BODY BURDEN
THAT MENTAL CLARITY AND FOCUS CAN BE IMPROVED DRAMATICALLY
AND A SENSE OF OVERALL WELL – BEING RESTORED
INTERMITTENT FASTING IS ALSO ASSOCIATED WITH INCREASED LEVELS
OF BRAIN – DERIVED NEUROTROPHIC FACTOR (BDNF)
DEPLETED LEVELS OF WHICH ARE THOUGHT TO BE ASSOCIATED WITH DEPRESSION
MARK MATTSON (2015)
INTERESTINGLY, THE ONLY TYPE OF “CALORIE – RESTRICTION” DIET
THAT WILL NOT SLOW DOWN YOUR METABOLISM IS INTERMITTENT FASTING
28

MORE SPECIFICALLY
OPTIMAL CHALLENGE OF THE BRAIN WILL
SHARPEN MENTAL ACUITY, DECELERATE COGNITIVE DECLINE,
AND COMBAT THE EFFECTS OF AGING ON THE BRAIN
JUST AS ATHLETES CAN IMPROVE THEIR “PHYSICAL FITNESS” BY
OPTIMALLY CHALLENGING THEIR BODIES WITH “PHYSICAL EXERCISE”
SO, TOO, ALL OF US CAN IMPROVE OUR “BRAIN FITNESS” BY
OPTIMALLY CHALLENGING OUR MINDS WITH “BRAIN TEASERS”
FOR EXAMPLE, MATHEMATICAL PUZZLES, WORD GAMES,
CROSSWORD PUZZLES, LOGIC PROBLEMS, AND MEMORY CHALLENGES
ANY MENTAL EXERCISE REQUIRING
DELIBERATE AND CONCENTRATED EFFORT
FOR EXAMPLE, ACTIVE REPETITION, FOCUSED ATTENTION, MEDITATION,
REFLECTION, JUGGLING, OR LEARNING ANY NEW SKILL OR NEW LANGUAGE
WILL PROMOTE MENTAL AGILITY AND FORESTALL THE
INEXORABLE DECLINE IN MENTAL CAPACITY AS WE AGE
IN ADDITION TO PUZZLES AND GAMES,
OUR BRAINS WILL BE STIMULATED WHEN WE ARE EXPOSED TO SITUATIONS
THAT ARE NEW, UNUSUAL, DIFFERENT, NOVEL, OR UNEXPECTED
WHEN OUR DAILY ROUTINES ARE DISRUPTED
OR WHEN WE COMBINE TWO SENSES
– A FORM OF CROSS – TRAINING FOR THE BRAIN –
LIKE SIMULTANEOUSLY LISTENING TO MUSIC AND SMELLING FLOWERS,
WATCHING A SUNSET AND TAPPING OUR FINGERS,
OR PRINTING WITH ONE HAND WHILE CURSIVE WRITING WITH THE OTHER
29

BY THE SAME TOKEN – IN THE PSYCHOLOGICAL REALM
THE THERAPEUTIC PROVISION
OF “GROWTH – INCENTIVIZING”
OPTIMAL STRESS
IS NECESSARY
IF DEEP AND SUSTAINED
PSYCHODYNAMIC CHANGE
IS THE ULTIMATE GOAL
OF TREATMENT
MORE SPECIFICALLY
OPTIMALLY STRESSFUL
THERAPEUTIC INTERVENTIONS
ARE SPECIFICALLY DESIGNED
TO GENERATE “INTERNAL TENSION”
BY ALTERNATELY CHALLENGING
AND THEN SUPPORTING THE DEFENSE
– PRECIPITATING DISRUPTION IN ORDER TO TRIGGER REPAIR –
AND CREATING THIS “INTERNAL DISSONANCE”
WILL BE DONE REPEATEDLY
AS PART OF THE WORKING THROUGH PROCESS
30

MORE SPECIFICALLY
CHALLENGING THE PATIENT’S RIGID DEFENSES
– AGAINST A BACKDROP OF “EMPATHIC RESONANCE” – TANIA SINGER (2013)
WILL CREATE “HOMEOSTATIC IMBALANCE”
A STATE OF “DISEQUILIBRIUM”
THAT CANNOT, HOWEVER, BE TOLERATED FOR LONG
PROMPTING “RESTORATION OF EQUILIBRIUM”
– THAT IS, “RE – EQUILIBRATION” –
BUT EACH TIME AT A HEALTHIER LEVEL OF
“HOMEOSTASIS” AND “ADAPTIVE CAPACITY”
A LEVEL EVER – MORE EVOLVED
BECAUSE OF THE SYNERGY BETWEEN
THE THERAPIST’S “EXTERNAL SUPPORT”
AND THE PATIENT’S “INTERNAL RESOURCES”
THAT IS
HER “UNDERLYING RESILIENCE”
HER “INNATE STRIVING TOWARDS HEALTH”
HER “INTRINSIC CAPACITY TO ADAPT TO (OPTIMAL) STRESS”
THE “WISDOM OF HER BODY” – WALTER B. CANNON (1932)
31

THE NET RESULT OF THESE “ITERATIONS”
WILL BE THE GENERATION
OF ONGOING “HEALING CYCLES”
OF “DISRUPTION” AND “REPAIR”
– “DESTABILIZATION” AND “RESTABILIZATION” –
BUT EACH TIME AT EVER – HIGHER LEVELS OF ADAPTABILITY
SUCH THAT PSYCHOLOGICAL RIGIDITY
WILL EVENTUALLY BECOME TRANSFORMED
INTO PSYCHOLOGICAL FLEXIBILITY
– RIGID DEFENSE INTO MORE FLEXIBLE ADAPTATION –
– “SAME OLD, SAME OLD” INTO “SOMETHING NEW, DIFFERENT, AND BETTER” –
32

WE MIGHT THEREFORE SAY OF
PSYCHODYNAMIC PSYCHOTHERAPY
THAT IT OFFERS THE FOLLOWING
PSYCHODYNAMIC PSYCHOTHERAPY
AFFORDS THE PATIENT
BOTH IMPETUS AND OPPORTUNITY
– ALBEIT BELATEDLY –
TO MASTER TRAUMATIC 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 INTRINSIC CAPACITY TO ADAPT TO STRESS –
BE REVISITED, REPROCESSED, AND REFRAMED
SUCH THAT GROWTH – IMPEDING DEFENSES
– ONCE NECESSARY FOR SURVIVAL –
CAN BE GRADUALLY TRANSFORMED
INTO GROWTH – PROMOTING ADAPTATIONS
STRONGER AT THE BROKEN PLACES
33

BRIEFLY
MY PSYCHODYNAMIC SYNERGY PARADIGM
– A SYNERGISTIC APPROACH TO DEEP HEALING –
FIVE DIFFERENT APPROACHES TO
GALVANIZING TRANSFORMATION
OF PSYCHOLOGICAL RIGIDITY
INTO PSYCHOLOGICAL FLEXIBILITY
PSYCHODYNAMIC APPROACHES THAT INVOLVE
– WHETHER DIRECTLY OR INDIRECTLY –
SUPERIMPOSING AN ACUTE INJURY
ON TOP OF A CHRONIC ONE
* * TO JUMP – START RECOVERY * *
38

FIVE INTERDEPENDENT AND MUTUALLY ENHANCING
“MODES OF THERAPEUTIC ACTION”
MODEL 1 – ENHANCEMENT OF KNOWLEDGE “WITHIN”
THE INTERPRETIVE PERSPECTIVE
OF CLASSICAL PSYCHOANALYSIS
MODEL 2 – PROVISION OF EXPERIENCE “FOR”
THE CORRECTIVE – PROVISION PERSPECTIVE
OF SELF PSYCHOLOGY
MODEL 3 – ENGAGEMENT IN RELATIONSHIP “WITH”
THE INTERSUBJECTIVE PERSPECTVE
OF CONTEMPORARY RELATIONAL THEORY
MODEL 4 – NURTURING OF SURRENDER “TO”
AN EXISTENTIAL – HUMANISTIC APPROACH
TO MENDING BROKENNESS AND EASING EXISTENTIAL ANGST
MODEL 5 – ENVISIONING OF POSSIBILITIES “BEYOND”
A QUANTUM – NEUROSCIENTIFIC APPROACH
TO OVERCOMING NEURAL ENTRENCHMENT AND ANALYSIS PARALYSIS
39

– A C.A.R.E. APPROACH TO DEEP HEALING –
Cognitive Affective Relational Existential
MODEL 1 – COGNITIVE
“STRUCTURAL CONFLICT”
– NEUROTIC CONFLICTEDNESS –
MODEL 2 – AFFECTIVE
“STRUCTURAL DEFICIT”
– NARCISSISTIC VULNERABILITY –
MODEL 3 – RELATIONAL
“RELATIONAL CONFLICT”
– NOXIOUS RELATEDNESS –
MODEL 4 – EXISTENTIAL
“RELATIONAL DEFICIT”
– NONRELATEDNESS –
MODEL 5 – CONSTRUCTIVIST
“NEURAL ENTRENCHMENT”
– NONACTUALIZATION –
40

OPTIMALLY STRESSFUL INTERVENTIONS
MODEL 1 – ENHANCEMENT OF KNOWLEDGE “WITHIN”
CONFLICT STATEMENTS
MODEL 2 – PROVISION OF EXPERIENCE “FOR”
DISILLUSIONMENT STATEMENTS
MODEL 3 – ENGAGEMENT IN RELATIONSHIP “WITH”
ACCOUNTABILITY STATEMENTS
MODEL 4 – NURTURING OF SURRENDER “TO”
FACILITATION STATEMENTS
MODEL 5 – ENVISIONING OF POSSIBILITIES “BEYOND”
QUANTUM DISENTANGLEMENT STATEMENTS
41

THE VARIOUS STATEMENTS WILL FACILITATE
ADVANCEMENT FROM DEFENSE TO ADAPTATION
MODEL 1 – INTERPRETING
FROM “RESISTANCE” TO “AWARENESS”
MODEL 2 – GRIEVING
FROM “RELENTLESS HOPE” TO “ACCEPTANCE”
MODEL 3 – NEGOTIATING
FROM “RE – ENACTMENT” TO “ACCOUNTABILITY”
MODEL 4 – SURRENDERING
FROM “RELATIONAL ABSENCE” TO “AUTHENTIC PRESENCE”
MODEL 5 – DISENTANGLING AND ENVISIONING
FROM “REFRACTORY INERTIA” TO “ACTION”
AND “ACTUALIZATION OF POTENTIAL”
42

ADVANCEMENT FROM DEFENSE TO ADAPTATION
BY WORKING THROUGH “GROWTH – INCENTIVIZING”
OPTIMAL STRESSORS
MODEL 1 – COGNITIVE DISSONANCE
FROM “RESISTANCE” TO “AWARENESS”
MODEL 2 – AFFECTIVE DISILLUSIONMENT
FROM “RELENTLESS HOPE” TO “ACCEPTANCE”
MODEL 3 – RELATIONAL DETOXIFICATION
FROM “RE – ENACTMENT” TO “ACCOUNTABILITY”
MODEL 4 – EXISTENTIAL DEPENDENCE
FROM “RELATIONAL ABSENCE” TO “AUTHENTIC PRESENCE”
MODEL 5 – QUANTUM DISENTANGLEMENT
FROM “REFRACTORY INERTIA” TO “ACTION”
AND “ACTUALIZATION OF POTENTIAL”
43

AGAIN, ALL FIVE MODELS
CAPITALIZE UPON
THE THERAPEUTIC PROVISION
OF OPTIMAL STRESS
TO ADVANCE THE PATIENT
FROM LONGSTANDING,
DEEPLY ENTRENCHED,
MALADAPTIVE RIGIDITY
– OUTDATED DEFENSE / “SAME OLD, SAME OLD” –
TO NEWFOUND,
MORE EVOLVED,
MORE ADAPTIVE FLEXIBILITY
– UPDATED ADAPTATION / “SOMETHING NEW, DIFFERENT, AND BETTER” –
THE ULTIMATE GOAL BEING
DEEP AND ENDURING PSYCHODYNAMIC CHANGE
AS ONE OF MY MENTORS ALWAYS DELIGHTED IN TELLING US,
IF THE PATIENT ASKS YOU WHERE THE BATHROOM IS,
YOU CAN TELL HER – BUT DON’T CALL IT THERAPY!
45

STRESS IS WHEN
YOU WAKE UP SCREAMING
AND THEN YOU REALIZE
YOU HAVEN’T FALLEN
ASLEEP YET
ANONYMOUS
46

THE “POOREST UNDERSTOOD”
AND
“TWO MOST ENIGMATIC WORDS”
IN PSYCHOANALYSIS
ARE “WORKING THROUGH”
PETER GIOVACCHINI (1986)
“THIS WORKING – THROUGH OF
THE RESISTANCES < DEFENSES >
MAY IN PRACTICE
TURN OUT TO BE
AN ARDUOUS TASK
FOR THE SUBJECT
OF THE ANALYSIS
AND A TRIAL OF PATIENCE
FOR THE ANALYST”
SIGMUND FREUD (1914)
49

PSYCHODYNAMIC SYNERGY PARADIGM
FOR DECADES
I HAVE BEEN TRYING TO FORMULATE
AN “OVERARCHING CONCEPTUAL FRAMEWORK”
FOR THE “WORKING THROUGH” PROCESS
A THEORETICAL FRAMEWORK THAT WOULD MAKE EXPLICIT
THE PROCESS WHEREBY PSYCHOLOGICAL RIGIDITY
– DEFENSE / “SAME OLD, SAME OLD” –
COULD BE INCREMENTALLY TRANSFORMED INTO
PSYCHOLOGICAL FLEXIBILITY
– ADAPTATION / “SOMETHING NEW, DIFFERENT, AND BETTER” –
AND I THINK I HAVE FINALLY SUCCEEDED
IN DEVELOPING WHAT I CALL
A “TRANSFORMATION PLAYBOOK”
THAT ROUGHLY OUTLINES THE “STEPS” INVOLVED
SO WHAT FOLLOWS IS AN OVERVIEW OF THE PIECES OF THE PUZZLE
THAT I HAVE USED TO CREATE THIS “TRANSFORMATION PLAYBOOK”
FOR THE GRADUATED MORPHING OF DEFENSE INTO ADAPTATION
51

“HEGEL’S DIALECTIC”
WHEREBY THE CONTRADICTION
BETWEEN A PROPOSITION (THESIS)
AND ITS NEGATION (ANTITHESIS)
IS RESOLVED BY ADVANCING
TO A HIGHER LEVEL OF TRUTH (SYNTHESIS)
THIS SYNTHESIS
– AN ADAPTIVE RECONCILING
OF TWO SEEMINGLY IRRECONCILABLE ENTITIES –
WILL BE THE RESULT OF WORKING THROUGH
AN “OPTIMALLY STRESSFUL” “GROWTH – INCENTIVIZING”
“MISMATCH EXPERIENCE”
– A “VIOLATION OF EXPECTATION” –
CREATED BY
THE THERAPIST’S REPEATED JUXTAPOSITION
OF THESIS
– THE BENEFIT – OR UPSIDE – OF A DEFENSE –
AND ANTITHESIS
– THE COST – OR DOWNSIDE – OF THAT DEFENSE –
53

ALL DONE WITH AN EYE TO GENERATING
ENOUGH INTERNAL TENSION
THAT THE STRESS AND STRAIN
OF THIS DISSONANCE
– A “GROWTH – INCENTIVIZING” “MISMATCH EXPERIENCE” –
WILL PROVIDE
THE THERAPEUTIC LEVERAGE
NEEDED FOR THE PATIENT
GRADUALLY TO RELINQUISH
THE TENACITY
OF HER ATTACHMENT
TO THE DEFENSE
IN FAVOR OF
A “MORE ACCEPTABLE” “ADAPTIVE SOLUTION”
– A “COMPROMISE POSITION” –
ONE THAT WILL BE “ONLY SOMEWHAT COSTLY”
AND AT LEAST “GOOD ENOUGH”
– EVEN IF NOT ALWAYS THE “IDEAL RESULT” –
AN “ADAPTIVE RECONCILIATION”
– SYNTHESIS –
OF TWO SEEMINGLY IRRECONCILABLE ENTITIES
– THESIS AND ANTITHESIS –
54

PARENTHETICALLY
WE MUST NEVER LOSE SIGHT OF THE FACT THAT
ALL DEFENSES HAVE BOTH
AN “UPSIDE” AND A “DOWNSIDE”
– WHETHER CONSCIOUSLY OR UNCONSCIOUSLY –
IN OTHER WORDS
DEFENSES ARE ALWAYS “AMBIVALENTLY CATHECTED”
WHICH MEANS THAT THEY ARE ALWAYS INVESTED WITH
BOTH LIBIDINAL AND AGGRESSIVE ENERGY
– FREUD’S (1914) “ADHESIVENESS OF THE ID” –
AS SUCH, THEY WILL BE RELINQUISHED ONLY WITH RELUCTANCE
“LIBIDINALLY CATHECTED”
– BECAUSE THEY DO “GRATIFY” AND SERVE TO “PROTECT” –
AS WELL AS “AGGRESSIVELY CATHECTED”
– BECAUSE, INEVITABLY, THEY DO ALSO “FRUSTRATE” –
IN OTHER WORDS
DEFENSES ARE “EGO – SYNTONIC”
– INASMUCH AS THEY DO PROVIDE “GAIN” –
AS WELL AS “EGO – DYSTONIC”
– INASMUCH AS THEY DO ALSO CAUSE “PAIN” –
WORKING THROUGH THE DEFENSE
WILL INCREMENTALLY MAKE IT
EVER – MORE EGO – DYSTONIC
AND EVER – LESS EGO – SYNTONIC
55

AGAIN
PSYCHODYNAMIC INTERVENTIONS
THAT REPEATEDLY JUXTAPOSE
THE “ANXIETY – ASSUAGING BENEFIT” (THESIS)
AND THE “ANXIETY – PROVOKING COST” (ANTITHESIS)
OF HOLDING ON TO THE DEFENSE
WILL CREATE “HOMEOSTATIC IMBALANCE”
A STATE OF “DISEQUILIBRIUM”
THAT CANNOT, HOWEVER, BE TOLERATED FOR LONG
PROMPTING “RESTORATION OF EQUILIBRIUM”
– THAT IS, “RE – EQUILIBRATION” –
BUT EACH TIME
AT A MORE – EVOLVED LEVEL OF
“HOMEOSTASIS” AND “ADAPTIVE CAPACITY”
BECAUSE OF THE SYNERGY BETWEEN
THE THERAPIST’S EXTERNAL SUPPORT
AND THE PATIENT’S UNDERLYING RESILIENCE
56

* * OVERVIEW OF MY PSYCHODYNAMIC SYNERGY PARADIGM * *
ADVANCEMENT FROM DEFENSE TO ADAPTATION (SYNTHESIS)
BY WORKING THROUGH
“OPTIMALLY STRESSFUL” “GROWTH – INCENTIVIZING” “MISMATCH EXPERIENCES”
CREATED BY THE “JUXTAPOSITION” OF TWO SEEMINGLY IRRECONCILABLE ENTITIES
THAT IS, THE BENEFIT OF THE DEFENSE (THESIS) AND THE COST OF THE DEFENSE (ANTITHESIS)
MODEL 1 – FROM RESISTANCE TO AWARENESS
INTERPRET RESISTANCE BY JUXTAPOSING GAIN AND PAIN
TO CREATE THE MISMATCH EXPERIENCE OF COGNITIVE DISSONANCE
– GAIN – BECOME – PAIN –
MODEL 2 – FROM RELENTLESS HOPE TO ACCEPTANCE
GRIEVE RELENTLESS HOPE BY JUXTAPOSING “GOOD” AND “BAD”
TO CREATE THE MISMATCH EXPERIENCE OF AFFECTIVE DISILLUSIONMENT
– GOOD – BECOME – BAD –
MODEL 3 – FROM RE – ENACTMENT TO ACCOUNTABILITY
NEGOTIATE RE – ENACTMENT BY JUXTAPOSING “BAD” AND “GOOD”
TO CREATE THE MISMATCH EXPERIENCE OF RELATIONAL DETOXIFICATION
– BAD – BECOME – GOOD –
MODEL 4 – FROM RELATIONAL ABSENCE TO AUTHENTIC PRESENCE
NURTURE RELATIONAL ABSENCE BY JUXTAPOSING “LOST” AND “FOUND” / “HIDDEN” AND “SEEN”
TO CREATE THE MISMATCH EXPERIENCE OF EXISTENTIAL DEPENDENCE
– LOST – BECOME – FOUND / HIDDEN – BECOME – SEEN –
MODEL 5 – FROM REFRACTORY INERTIA TO ACTION AND ACTUALIZATION OF POTENTIAL
DECONSOLIDATE REFRACTORY INERTIA BY JUXTAPOSING “OLD BAD” AND “NEW GOOD” /
“SAME OLD, SAME OLD” AND “SOMETHING NEW, DIFFERENT, AND BETTER”
TO CREATE THE MISMATCH EXPERIENCE OF QUANTUM DISENTANGLEMENT
– OLD BAD – BECOME – NEW GOOD –
– SAME OLD, SAME OLD – BECOME – SOMETHING NEW, DIFFERENT, AND BETTER – 57

HEGEL’S DIALECTIC WOULD HAVE IT
THAT THE PROCESS OF CHANGE
ALWAYS INVOLVES THE “SYNTHESIS” OF
TWO CONTRADICTORY, MISMATCHED, AND
SEEMINGLY IRRECONCILABLE FORCES
– “THESIS” AND “ANTITHESIS” –
58
WORKING THROUGH – MY ADDITION

IMPORTANTLY
THE SYNTHESIS THAT RESULTS FROM
RECONCILING THESIS AND ANTITHESIS
USUALLY BECOMES A NEW THESIS
– ALONG WITH A NEW CORRELATIVE ANTITHESIS –
AND THE PROCESS
– THE “FRACTAL PATTERN” –
WILL START ALL OVER AGAIN
– FRACTAL SIGNIFIES THE REPETITION OF SIMILAR PATTERNS THROUGHOUT –
Version 1, Version 2, Version 3, etc.
60
WORKING THROUGH

61
WORKING THROUGH
WORKING THROUGH
WORKING THROUGH

WHETHER DIRECTLY OR INDIRECTLY
AND WHETHER EXPLICITLY OR IMPLICITLY
GROWTH – INCENTIVIZING PSYCHODYNAMIC INTERVENTIONS
WILL JUXTAPOSE ANXIETY – ASSUAGING THESIS
– THE BENEFIT OF THE DEFENSE –
AND ANXIETY – PROVOKING ANTITHESIS
– THE COST OF THE DEFENSE –
IN ORDER TO ARRIVE AT A SYNTHESIS
– A COMPROMISE POSITION –
AGAIN
REPEATED JUXTAPOSITION
OF THE UPSIDE AND THE DOWNSIDE
– ALTERNATELY “STABILIZING” AND “DESTABILIZING” THE DEFENSE –
WILL CREATE
GROWTH – INCENTIVIZING THERAPEUTIC LEVERAGE
SUCH THAT
IN ORDER TO RESOLVE THE INTERNAL TENSION
– BETWEEN “MISMATCHED” THESIS AND ANTITHESIS –
AND THEREBY RESTORE THE HOMEOSTATIC BALANCE
“SAME OLD, SAME OLD”
– RIGID DEFENSE –
WILL ULTIMATELY MORPH INTO
“SOMETHING NEW, DIFFERENT, AND BETTER”
– MORE FLEXIBLE ADAPTATION –
62

63
When I let go
of the
SAME OLD
SAME OLD
that I am,
I become the
SOMETHING
NEW
DIFFERENT
AND
BETTER
that I
might be.

IN ESSENCE
THE PROCESS OF RECONCILIATION
WILL INVOLVE
THE INTRODUCTION OF
EITHER NEW INFORMATION
OR NEW EXPERIENCE
THAT IS
DISCREPANT / DISCORDANT / CONTRADICTORY
SUCH THAT
THE SYNTHESIS
OF THESIS AND ANTITHESIS
WILL BE CATALYZED
BY THE GROWTH – INCENTIVIZING
TRANSFORMATIONAL MISMATCH
64

NEUROSCIENTISTS HAD LONG BELIEVED THAT ONCE A NEW EXPERIENCE
– ESPECIALLY A TRAUMATIC ONE –
HAD BEEN STORED IN LONG – TERM MEMORY,
IT WOULD BE PERMANENTLY INSTALLED
PERHAPS IT COULD THEN BE MODIFIED BY SUBSEQUENT EXPERIENCES,
BUT ITS ESSENCE WOULD NONETHELESS REMAIN INTACT
LURKING JUST BENEATH THE SURFACE AS A SOMATIC MEMORY
EVER VULNERABLE TO BEING REACTIVATED AND RE – EXPERIENCED
– THEREBY REINFORCING ITS INTENSITY –
BEFORE ONCE AGAIN RETURNING TO BODY CONSCIOUSNESS
THIS WAS VERY MUCH IN KEEPING WITH HEBB’S POSTULATE
– ADVANCED IN 1949 BY THE NEUROPSYCHOLOGIST DONALD HEBB –
“NEURONS THAT FIRE TOGETHER, WIRE TOGETHER”
MEANING THAT REACTIVATED AND RE – EXPERIENCED MEMORIES
ARE SIMPLY REINFORCED THROUGH REPETITION
– AND NEVER RESOLVED –
BUT WE NOW KNOW THAT, FORTUNATELY, THIS IS NOT THE WHOLE STORY
WERE THIS TO BE THE CASE
THEN WE WOULD CERTAINLY BE DOING OUR PATIENTS A GRAVE DISSERVICE
WERE WE TO BE EVER – BUSY INVITING THEM (IN THE TREATMENT)
TO REVISIT – AND RE – EXPERIENCE – THEIR EARLY – ON TRAUMAS
WITHOUT THEN OFFERING THEM, AS AN ALTERNATIVE,
SOMETHING NEW, DIFFERENT, AND COMPELLINGLY BETTER
65

FORTUNATELY
OVER THE COURSE OF THE PAST TWO DECADES,
A DEDICATED GROUP OF TRAILBLAZING COGNITIVE NEUROSCIENTISTS
– DISSATISFIED WITH THE DETERMINISTIC IDEA THAT MEMORIES ARE FOREVER –
HAVE BEEN USING ADVANCED NEUROIMAGING TECHNIQUES
– INCLUDING FUNCTIONAL MRIs, SCANNING MICROSCOPY, AND OPTOGENETICS –
TO MAP OUT WHAT HAPPENS IN THE BRAIN
WHEN A THOUGHT IS BEING THOUGHT, A FEELING FELT,
AND A MEMORY REMEMBERED
THEIR FOCUS HAS BEEN ON HOW OLD MEMORIES
– CONSOLIDATED IN LONG – TERM MEMORY AND
DISTRIBUTED IN NETWORKS THROUGHOUT THE CORTICOLIMBIC SYSTEM –
CAN BE SUBSEQUENTLY UPDATED AND RECONSOLIDATED
INDEED
THESE RESEARCHERS ARE DISCOVERING THAT THE BRAIN
– IN RESPONSE TO ONGOING NEW INFORMATION AND EXPERIENCE –
IS CONTINUOUSLY ADAPTING
– BY MODIFYING ITSELF AT THE LEVEL OF THE NEURAL SYNAPSE –
IN ORDER TO STAY CURRENT AND RELEVANT
THIS LEARNING PROCESS
– INVOLVING BOTH THE DESTRUCTION OF OLD NEURAL NETWORKS
AND THE CONSTRUCTION OF NEW ONES –
SPEAKS TO THE ADAPTIVE CAPACITY OF THE BRAIN
AND THE DYNAMIC NATURE OF MEMORY
– IN ESSENCE, THE BRAIN’S REMARKABLE NEURPLASTICITY –
66

MORE SPECIFICALLY
NEUROSCIENTISTS HAVE RECENTLY MADE
THE GROUNDBREAKING DISCOVERY
THAT WHEN MEMORIES ARE REACTIVATED AND RE – EXPERIENCED,
THE NETWORK OF SYNAPSES ENCODING THESE MEMORIES
WILL BECOME UNLOCKED FOR A TIME – LIMITED PERIOD
THIS UNLOCKING – OR DECONSOLIDATION – SIGNALS
THE OPENING OF A RECONSOLIDATION WINDOW
– A BRIEF WINDOW OF OPPORTUNITY
WHEN MEMORIES BECOME TRANSIENTLY FRAGILE
AND SENSITIVE TO MODIFICATION BY ENVIRONMENTAL INPUT –
BOTH THIS DEDICATED GROUP OF COGNITIVE NEUROSCIENTISTS
WHO STUDY MEMORY RECONSOLIDATION IN THEIR LABORATORIES
AND THE SIMILARLY IMPASSIONED GROUP
– SPEARHEADED BY BRUCE ECKER (2015) AND DAVID FEINSTEIN (2019) –
OF NEUROSCIENTIFICALLY INCLINED CLINICIANS
WHO STUDY IT IN THEIR OFFICES
AGREE THAT FOUR TO SIX HOURS IS THE CRITICAL TIME FRAME
FOR THE DESTABILIZED SYNAPSES ENCODING THE TRAUMATIC MEMORIES
TO REMAIN MALLEABLE AND THEREFORE VULNERABLE TO
UPDATING BY NEW INFORMATION AND EXPERIENCE
SUCH THAT THESE SYNAPSES CAN BE REWIRED
– UNDER THE RIGHT CIRCUMSTANCES –
AND THE TRAUMATIC MEMORIES THEY ENCODE REPROGRAMMED
67

68
AN ASCENDING
SPIRAL STAIRCASE
– WITH ITS SERIES OF LANDINGS –
IS AN EVOCATIVE
VISUAL METAPHOR
FOR NEUROPLASTICITY
AND THE INCREMENTAL
MORPHING
OF DEFENSE
INTO ADAPTATION
WITH EACH
SUCCESSIVE LANDING
REPRESENTING
A NEW SYNTHESIS
OF BOTH THE THESIS
AND THE ANTITHESIS
THAT HAD COME BEFORE
AND WITH THE STAIRS
THEMSELVES
– FROM ONE LEVEL TO THE NEXT –
REPRESENTING
THE STEPS IN THE
WORKING THROUGH
PROCESS

THE BEGINNING GAME
(A LANDING)
RESISTANCE, RELENTLESS HOPE, RE – ENACTMENT,
RELATIONAL ABSENCE, AND REFRACTORY INERTIA
THE USE OF “MINIMALLY STRESSFUL” INTERVENTIONS
THAT WILL TEASE OUT THE DEFENSE
AND GENTLY HIGHLIGHT
BOTH THE ANXIETY – ASSUAGING BENEFIT (THESIS)
AND THE ANXIETY – PROVOKING COST (ANTITHESIS)
OF HOLDING ON TO IT
IN ESSENCE
THE “PLAYERS”
ARE BEING IDENTIFIED
THE BEGINNING GAME THEREFORE
LAYS THE GROUNDWORK
AND SETS THE STAGE
FOR THE ACTUAL WORKING THROUGH
THAT WILL TAKE PLACE
IN THE MIDDLE GAME
– AS THE STAIRS ARE BEING CLIMBED –
70

71
“THE BEGINNING GAME” – MINIMAL STRESS

THE MIDDLE GAME
(THE STAIRS BETWEEN LANDINGS)
– THE HEART OF THE WORKING THROUGH PROCESS –
INTERPRETING, GRIEVING, NEGOTIATING, SURRENDERING, AND DISENTANGLING / ENVISIONING
THE USE OF “OPTIMALLY STRESSFUL” INTERVENTIONS
THAT WILL OFFER BOTH IMPETUS AND OPPORTUNITY
FOR TRANSFORMATION AND GROWTH
BY ALTERNATELY CHALLENGING THE DEFENSE
– TO DESTABILIZE IT –
AND THEN SUPPORTING THE DEFENSE
– TO RESTABILIZE IT –
– JUXTAPOSING BOTH COST (ANTITHESIS) AND BENEFIT (THESIS) –
ALL DONE WITH AN EYE TO INTRODUCING
A MISMATCH EXPERIENCE
– VIOLATION OF EXPECTATION, PREDICTION ERROR, HOMEOSTATIC IMBALANCE, DISEQUILIBRIUM,
DESTABILIZING ANXIETY, GROWTH – INCENTIVIZING DISSONANCE, THERAPEUTIC LEVERAGE –
SUCH THAT THE SYSTEM WILL BE FORCED
TO RE – EQUILIBRATE
IN ORDER TO RESOLVE THE INTERNAL TENSION
AND RESTORE HOMEOSTATIC BALANCE
EVERY SUCCESSIVE RESTABILIZATION
– AS EACH STEP (BETWEEN LANDINGS) ON THE SPIRAL STAIRCASE IS BEING CLIMBED –
REPRESENTING AN EVER – HIGHER LEVEL OF ADAPTABILITY
BECAUSE OF THE WORKING THROUGH THAT IS BEING DONE
72

73
“THE MIDDLE GAME” – OPTIMAL STRESS

THE END GAME
(THE NEXT HIGHER LANDING)
AWARENESS, ACCEPTANCE, ACCOUNTABILITY,
AUTHENTIC PRESENCE, AND ACTUALIZING ACTION
THE USE OF “CELEBRATORY” INTERVENTIONS
THAT WILL OFFER NO STRESS WHATSOEVER
RATHER
THEY WILL SERVE
TO REINFORCE AND CELEBRATE
THE NEWFOUND RECONCILIATION
OF THE TWO
SEEMINGLY IRRECONCILABLE ENTITIES
ADAPTATION, SYNTHESIS,
COMPROMISE POSITION, ADAPTIVE RESOLUTION
REMINISCENT OF FREUD’S HORSE AND RIDER
AS A RESULT OF WORKING THROUGH
THE MISMATCH EXPERIENCE,
THE “DEFENSIVE REACTION” OF NEEDING TO REIN THE HORSE IN
WILL HAVE BECOME INCREMENTALLY TRANSFORMED INTO
AN “ADAPTIVE RESPONSE” OF BEING ABLE TO GIVE THE HORSE FREE REIN
FROM CONFLICT TO COLLABORATION
74

75
“THE END GAME” – NO STRESS

THE WORKING THROUGH PROCESS
– WHICH MAKES POSSIBLE THE ASCENT (BY WAY OF THE STAIRS)
FROM ONE LANDING TO THE NEXT HIGHER ONE –
WILL INVOLVE THESE EVER – EVOLVING “ITERATIONS”
– REPETITIONS PRODUCING “SUCCESSIVELY CLOSER APPROXIMATIONS”
TO THE ULTIMATE SYNTHESIS –
FROM THE BEGINNING GAME OF MINIMAL STRESS
AND THE TEASING OUT OF EACH NEW THESIS
AND ITS CORRELATIVE ANTITHESIS
SUPPORT THE DEFENSE
THROUGH THE MIDDLE GAME OF OPTIMAL STRESS
AND THE ONGOING GENERATION OF “MISMATCH TENSION”
BETWEEN THESIS AND ANTITHESIS
CHALLENGE AND THEN SUPPORT THE DEFENSE
** IT IS IN THIS MIDDLE GAME THAT
THE ACTUAL “WORKING THROUGH” TAKES PLACE **
TO THE END GAME OF NO STRESS
AND THE CELEBRATION OF A (TEMPORARY) SYNTHESIS
OF THESIS AND ANTITHESIS
SUPPORT THE ADAPTATION
A DÉTENTE OF SORTS / A CEASEFIRE
UNTIL THE EVOLUTIONARY CYCLE STARTS ALL OVER AGAIN
76

77
PROVIDE
MINIMAL
STRESS
PROVIDE
OPTIMAL
STRESS
REPEAT

THE INCREMENTAL MORPHING
OF A CATERPILLAR INTO A BUTTERFLY
IS ANOTHER VISUAL METAPHOR
FOR THE EVOLUTIONARY PROCESS
WHEREBY UNEVOLVED DEFENSE
GRADUALLY MORPHS
INTO MORE EVOLVED ADAPTATION
78

80
I THANK
HANNA LEVENSON
FOR HAVING
CALLED MY ATTENTION
TO THIS EVOCATIVE
QUOTE BY ANAIS NIN

THESIS
THE PATIENT HAS A VERY
SPECIAL RELATIONSHIP
WITH HER DAD
ANTITHESIS
BUT SHE COMES TO UNDERSTAND
THAT IT IS PROBABLY INTERFERING
WITH HER ABILITY TO FIND
AN APPROPRIATE LIFE PARTNER
HER UNRESOLVED OEDIPAL LONGINGS
IN RELATION TO HER DAD
MUST BE WORKED THROUGH
SYNTHESIS
THE PATIENT ULTIMATELY
FINDS SOMEONE LIKE HER DAD
82

THESIS
THE PATIENT INDULGES HERSELF
TOO MUCH WITH FOOD
ANTITHESIS
SHE NOW HAS A SERIOUS
WEIGHT PROBLEM
THAT IS INTERFERING
WITH HER HEALTH
SHE MUST WORK THROUGH
HER FEELINGS OF DEPRIVATION
IN RELATION TO HER MOTHER
SYNTHESIS
THE PATIENT DECIDES TO TRY
INTERMITTENT FASTING
83

THESIS
THE PATIENT SMOKES
A PACK OF CIGARETTES A DAY
TO RELIEVE HER STRESS
ANTITHESIS
SHE HAS COME TO APPRECIATE
THAT HER RECURRENT LUNG INFECTIONS
ARE PROBABLY EXACERBATED BY THE SMOKING
SHE MUST TAKE MORE RESPONSIBILITY
FOR MAKING HEALTHIER LIFESTYLE CHOICES
AND LEARN BETTER WAYS TO MANAGE HER STRESS
SYNTHESIS
THE PATIENT DECIDES TO TRY
SMOKING ONLY 10 CIGARETTES A DAY
AND TO TAKE UP EXERCISE
84

THESIS
THE PATIENT HAS BEEN HAVING AN AFFAIR
WITH A MARRIED MAN AND SHE DESPERATELY WISHES
THAT HE WOULD LEAVE HIS WIFE
ANTITHESIS
HE HAS MADE IT VERY CLEAR THAT HE NEVER WILL
SHE MUST GRIEVE THE REALITY THAT
SHE WILL NEVER BE ABLE
TO HAVE HIM EXCLUSIVELY AS HER OWN
(JUST AS SHE WAS NEVER ABLE TRULY TO HAVE HER DAD)
SYNTHESIS
THE PATIENT DECIDES TO CONTINUE THE AFFAIR
BUT HER EXPECTATIONS HAVE BECOME A LITTLE MORE
REALISTIC AND SHE KNOWS THAT SHE SHOULD NOT
BE PUTTING ALL HER EGGS IN THE ONE BASKET
85

IN TRUTH
MOST EVOLUTIONARY PROCESSES
– AND NOT JUST THE WORKING THROUGH PROCESS IN PSYCHODYNAMIC PSYCHOTHERAPY –
INVOLVE RECONCILING TWO SEEMINGLY
IRRECONCILABLE – DIAMETRICALLY OPPOSED – ENTITIES
– THESIS AND ITS CORRELATIVE ANTITHESIS –
IN ORDER TO ARRIVE ULTIMATELY AT AN ADAPTIVE RESOLUTION
– SYNTHESIS –
BUT, AS NOTED EARLIER, A SYNTHESIS THAT THEN BECOMES
A NEW THESIS AND THE STARTING POINT FOR A WHOLE NEW CYCLE
Version 1, Version 2, Version 3, etc.
THE DEVELOPMENTAL PROCESS
THE GROWTH PROCESS
THE CHANGE PROCESS
THE CREATIVE PROCESS
THE WRITING PROCESS
PREPARING A NEW SET OF POWERPOINT SLIDES
LEARNING A NEW LANGUAGE
LEARNING A NEW SKILL
NEGOTIATING A NEW RELATIONSHIP
ADAPTING TO EVER – CHANGING ENVIRONMENTS
TRANSITIONING FROM CATERPILLAR TO BUTTERFLY
EVOLUTION IS RESPONSIBLE FOR BOTH THE REMARKABLE SIMILARITIES
THAT WE SEE ACROSS ALL LIFE FORMS AND THEIR BREATHTAKING DIVERSITY
86

END OF SEMINAR 1
Thank you so much
for your support of the
Ukrainian Psychotherapists
We will hope to see
you again in April
for SEMINAR 2
88

IF YOU WOULD LIKE
TO BE ON MY
MAILING LIST,
PLEASE EMAIL ME AT
MarthaStarkMD @
SynergyMed.solutions
TO LET ME KNOW
AND MY WEBSITE IS
www.SynergyMed.solutions
90

REFERENCES
Akhtar, S. 2012. Psychoanalytic listening: Methods, limitations, and
innovations. New York, NY: Routledge / Taylor & Francis Group.
Bacal, H. 1998. Optimal responsiveness: How therapists heal their
patients. Northvale, NJ: Jason Aronson.
Bak, P. 1996. How nature works: The science of self-organized
criticality. New York: Springer Publishing.
Beckmann, R. 1991. Children who grieve: A manual for conducting
support groups. Learning Publications.
Benjamin, J. 2017. Beyond doer and done to: Recognition theory,
intersubjectivity, and the third. London and New York: Routledge
(Taylor & Francis Group).
Bollas, C. 1989. The shadow of the object: Psychoanalysis of the
unthought known. New York: Columbia University Press.
Brach, T. 2004. Radical acceptance: Embracing your life with the heart
of a Buddha. New York: Random House.
92

Calabrese, E. J. Hormesis: A conversation with a critic. Environmental
Health Perspectives 2009 Sep;117(9):1339-1343.
Cannon, W. B. 1932. The wisdom of the body. New York: W. W. Norton
& Co.
Casement, P. 1992. Learning from the patient. New York: Guilford
Press.
Coughlin, P. 2022. Facilitating the process of working through in
psychotherapy: Mastering the middle game. London and New York:
Routledge (Taylor & Francis Group).
Ecker, B. 2015. Memory reconsolidation understood and
misunderstood. International Journal of Neuropsychotherapy
Jan;3(1):2-46.
Ehrenberg, D. 1992. The intimate edge: Extending the reach of
psychoanalytic interaction. New York: W. W. Norton & Co.
Feinstein, D. 2019. Energy psychology: Efficacy, speed, mechanisms.
Explore 15(5):340-351.
93

Freud, A. 1979. The ego and the mechanisms of defense: The writings
of Anna Freud. Madison, CT: International Universities Press.
Freud, S. 1914. Remembering, repeating and working through (Further
recommendations on the technique of psycho-analysis II). Standard
Edition of the Complete Psychological Works of Sigmund Freud,
Volume XII (1911-1913). London, UK: Hogarth Press.
Giovacchini, P. 1986. Developmental disorders: The transitional space
in mental breakdown and creative integration. Northvale, NJ: Jason
Aronson.
Goleman, D. 2007. Social intelligence: The new science of human
relationships. New York: Bantam Books.
Hemingway, E. 1929. A farewell to arms. New York: Charles Scribner’s
Sons.
Hoffman, I. 2001. Ritual and spontaneity in the psychoanalytic
process. Abingdon-on-Thames, UK: Routledge / Taylor & Francis.
Kohut, H. 1966. Forms and transformations of narcissism. Journal of
the American Psychoanalytic Association 14(2):243-272.
94

Krebs, C. 2013. Energetic kinesiology: Principles and practice. London,
UK: Handspring Publishing.
Leibenluft, E., Wehr, T. 1992. Is sleep deprivation useful in the
treatment of depression? The American Journal of Psychiatry, 149(2),
159-168.
Mattson, M. P. Lifelong brain health is a lifelong challenge: From
evolutionary principles to empirical evidence. Ageing Research
Reviews 2015;20:37-45.
Mitchell, S. 1988. Relational concepts in psychoanalysis: An
integration. Cambridge, MA: Harvard University Press.
Nelson, P. 1993. There’s a hole in my sidewalk: The romance of self
discovery. Hillsboro, OR: Beyond Words Publishing.
Paracelsus, T. 2004. The archidoxes of magic. Turner R (trans).
Temecula, CA: Ibis Publishing.
Real, T. 2022. Us: Getting past you and me to build a more loving
relationship. Santa Monica, CA: Goop Press.
Russell, P. 1980. The theory of the crunch (unpublished manuscript).
95

Searles, H. 1979. The development of mature hope in the patient-
therapist relationship. In Countertransference and Related Subjects:
Selected Papers, pp. 479-502. New York: International Universities
Press.
Selye, H. 1978. The stress of life. New York: McGraw-Hill Book Co.
Stark, M. 1994a. Working with resistance. Northvale, NJ: Jason
Aronson.
----- 1994b. A primer on working with resistance. Northvale, NJ: Jason
Aronson.
----- 1999. Modes of therapeutic action: Enhancement of knowledge,
provision of experience, and engagement in relationship. Northvale,
NJ: Jason Aronson.
----- 2015. The transformative power of optimal stress: From cursing
the darkness to lighting a candle (International Psychotherapy
Institute eBook). www . FreePsychotherapyBooks . org
Tull, D. 2018. Relational mindfulness: A handbook for deepening our
connection with ourselves, each other, and the planet. Somerville, MA:
Wisdom Publications.
96

Winnicott, D. W. 1949. Hate in the counter-transference. International
Journal of Psychoanalysis 30:69-74.
Zevon, W. 1996. I’ll sleep when I’m dead. Burbank, CA: Elektra
Records.
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Martha Stark MD – 17 Feb 2023 – Seminar 1 – A How-To Playbook for the Middle Game in Psychodynamic Psychotherapy.pptx

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Martha Stark MD – 17 Feb 2023 – Seminar 1 – A How-To Playbook for the Middle Game in Psychodynamic Psychotherapy.pptx