Martha Stark MD – 20 Mar 2020 – Holistic Psychotherapy – Knowledge, Experience, and Relationship- 3 (289 slides).pptx

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
Danielsen Institute
Friday, March 20, 2020
© 2020 Martha Stark, MD
1

CONTROLLED DAMAGE
TO PROVOKE RECOVERY
3

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

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

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

… 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

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

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

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

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

THE SANDPILE MODEL
AND THE PARADOXICAL
IMPACT OF STRESS
18

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

NOT JUST
“IN SPITE OF”
STRESSFUL INPUT
FROM THE OUTSIDE
BUT
“BY WAY OF”
THAT INPUT 
20

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

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

… AT EVER – HIGHER LEVELS OF
INTEGRATION,
BALANCE,
AND HARMONY
23

WHERE DEFENSE WAS,
THERE SHALL
ADAPTATION BE
25

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 “PSYCHOLOGICAL RIGIDITY” TO “PSYCHOLOGICAL FLEXIBILITY” –
– FROM “LESS EVOLVED” TO “MORE EVOLVED” – 26

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

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

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

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

IN ESSENCE
ADAPTATION
IS A STORY ABOUT
MAKING A VIRTUE
OUT OF NECESSITY 
31

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

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

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

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

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

… 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

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

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”
THE PATIENT IS “RELENTLESS” AND / OR “NOT ACCEPTING”
WHICH WILL CALL FOR A “DISILLUSIONMENT STATEMENT”
MODEL 3 FEATURES “NOXIOUS RELATEDNESS”
THE PATIENT IS “RE – ENACTING” AND / OR “NOT ACCOUNTABLE”
WHICH WILL CALL FOR AN “ACCOUNTABILITY STATEMENT”
40

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

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

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

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

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

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

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

IN WHAT FOLLOWS
THE OPERATIVE CONCEPT
WILL BE
OPTIMAL STRESS
49

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

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

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

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

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

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
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

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
56

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

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

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

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

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

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

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

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

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

AWARENESS
MODEL 1
ACCEPTANCE
MODEL 2
ACCOUNTABILITY
MODEL 3
ALL OF WHICH ARE ADAPTATIONS
TO THE “STRESS OF LIFE”
66

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

… 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

AT THE END OF THE DAY
PSYCHODYNAMIC
PSYCHOTHERAPY
IS A STORY ABOUT
THE DEVELOPMENT
OF CAPACITY
69

– 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

SECOND PART
SLIDES 72 – 131
72

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

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

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

IN ORDER TO FACILITATE THE “THERAPEUTIC ACTION”
INTERVENTIONS
ALTERNATELY CHALLENGE
AND SUPPORT
ANXIETY – PROVOKING
BUT ULTIMATELY
GROWTH – PROMOTING
76

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

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

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

TO REVIEW
“CONFLICT STATEMENTS”
WHEN THE SPOTLIGHT IS ON THE PATIENT AS
“NOT AWARE” (MODEL 1)
“DISILLUSIONMENT STATEMENTS”
“NOT ACCEPTING” (MODEL 2)
“ACCOUNTABILITY STATEMENTS”
AND “RELATIONAL INTERVENTIONS”
“NOT ACCOUNTABLE” (MODEL 3)
80

MODEL 1
CONFLICT
STATEMENTS
AND THE CREATION OF
COGNITIVE AND AFFECTIVE DISSONANCE
BETWEEN THE “PAIN” AND THE “GAIN”
82

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

“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

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

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

“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

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

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

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

“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

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
CAN BE STRATEGICALLY FORMULATED
TO PRECIPITATE (DEFENSIVE) DISRUPTION
IN ORDER TO TRIGGER (ADAPTIVE) REPAIR
92

“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

THE CREATION OF
INTERNAL TENSION
BETWEEN
“PAIN” AND “GAIN”
94

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

IN ESSENCE
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

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

… 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

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

IN OTHER WORDS
ONGOING USE OF “OPTIMALLY STRESSFUL”
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

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

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

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

IMPORTANTLY
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

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

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

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

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

IN SUM
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

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

EGO – PROTECTIVE
ONE – PERSON DEFENSES
vs
SELF – PROTECTIVE
TWO – PERSON DEFENSES
113

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

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

NATURE vs NURTURE
MODEL 1 vs
MODELS 2 AND 3
“I – IT” vs “I – THOU”
RELATIONSHIPS
117

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

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

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

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

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

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

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

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

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

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

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

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

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

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”
WILL THEN INVOLVE WORKING THROUGH
– BY WAY OF NEGOTIATING AT THE
INTIMATE EDGE OF AUTHENTIC ENGAGEMENT –
“NEGATIVE TRANSFERENCE”
131

THIRD PART
SLIDES 133 – 208
133

MODEL 2
CORRECTIVE
PROVISION
“FOR”
vs
MODEL 3
AUTHENTIC
ENGAGEMENT
“WITH”
134

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

MODEL 3 AUTHENTIC ENGAGEMENT
– 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

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

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

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

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

“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

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

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

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

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

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

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

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

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

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

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

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

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

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

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
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

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

MODEL 2
THE
CORRECTIVE – PROVISION
PERSPECTIVE
OF SELF PSYCHOLOGY AND
OTHER “DEFICIT” THEORIES
158

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

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

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

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

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

“GRIEF IS
NATURE’S WAY
OF HEALING
A BROKEN HEART”
ROBERTA BECKMANN (1991)
164

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

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

… BUT THAT WE CAN
– AND MUST –
TAKE OWNERSHIP OF
– AND RESPONSIBILITY FOR –
ALL THAT WE CAN CHANGE
WITHIN OURSELVES
167

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

MODEL 2
DISILLUSIONMENT
STATEMENTS
GRIEVING
AND
ADAPTIVE
TRANSMUTING
STRUCTURE – BUILDING
INTERNALIZATIONS
170

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

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

AS AN EMPATHIC SELFOBJECT
RESONATING WITH THE PATIENT’S
MOMENT – TO – MOMENT EXPERIENCE
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

SO HOW DO WE HELP THE PATIENT GRIEVE?
ARE DESIGNED TO FACILITATE THE GRIEVING
OF A PATIENT WHO, REFUSING TO MOURN,
HAS BEEN CLINGING TO ILLUSIONS
ABOUT THE OBJECTS OF HER DESIRE
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

AS DESCRIBED EARLIER
HAVE THE FOLLOWING FORMAT
“YOU KNOW THAT … ,
BUT (MADE ANXIOUS BY THAT KNOWING)
YOU FIND YOURSELF (DEFENSIVELY REACTING) … ”
BY CONTRAST
HAVE THE FOLLOWING FORMAT
“YOU KNOW THAT … ,
AND (IN THE FACE OF THAT KNOWING)
IT BREAKS YOUR HEART (ADAPTIVELY RESPONDING) … ”
175

IN OTHER WORDS
– IN AN EFFORT TO ENHANCE AWARENESS –
HIGHLIGHT THE PATIENT’S
NEED TO DEFEND (“BUT”)
– IN AN EFFORT TO FACILITATE GRIEVING –
SUPPORT THE PATIENT’S
CAPACITY TO ADAPT (“AND”)
176

“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.”
“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

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

“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

“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

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

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

“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

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

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” 
185

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

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

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

MODEL 3
THE
INTERSUBJECTI VE
PERSPECTIVE
OF CONTEMPORARY
RELATIONAL THEORY
190

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

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

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

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

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

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

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

“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

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

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

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

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

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

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

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

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

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

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

FOURTH PART
SLIDES 210 – 283
210

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

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

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

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

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

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

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

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

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

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

AS ADDITIONAL EXAMPLES
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

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

“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

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

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

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”
THE HERE – AND – NOW OF THE THERAPEUTIC ENGAGEMENT
AND THEREFORE WHAT ANY THERAPIST MIGHT FEEL –
I (1994) MAKES A DISTINCTION BETWEEN
THE “SUBJECTIVE TRANSFERENCE”
THE THERE – AND – THEN OF THE PATIENT
AND THEREFORE SPECIFIC TO THE PATIENT –
AND THE “OBJECTIVE TRANSFERENCE”
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

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

Martha Stark MD – 20 Mar 2020 – Holistic Psychotherapy – Knowledge, Experience, and Relationship- 3 (289 slides).pptx

Martha Stark MD – 20 Mar 2020 – Holistic Psychotherapy – Knowledge, Experience, and Relationship- 3 (289 slides).pptx

Martha Stark MD – 20 Mar 2020 – Holistic Psychotherapy – Knowledge, Experience, and Relationship- 3 (289 slides).pptx

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