1. RELENTLESS HOPE:
THE REFUSAL TO GRIEVE
MARTHA STARK MD
MarthaStarkMD @ HMS.Harvard.edu
Friday, April 29, 2022 – 9:00 - 10:00 am (ET)
Keynote for the CURE Program Annual Symposium
© 2022 Martha Stark MD
1

2. LEARNING OBJECTIVES
SUMMARIZE WHAT THE RELENTLESS PATIENT
IS REFUSING TO CONFRONT
EXPLAIN WHY A “BAD OBJECT” IS
INFINITELY BETTER THAN “NO OBJECT” AT ALL
DESCRIBE THE ROLE OF GRIEVING IN
“WORKING THROUGH” THE PATIENT’S RELENTLESSNESS
DISCUSS THE IMPORTANCE OF ACCOUNTABILITY
ON THE PARTS OF BOTH PATIENT AND THERAPIST
SPEAK TO THE DIFFERENCE BETWEEN
“RELENTLESS HOPE” AND “REALISTIC HOPE”
I HAVE NO FINANCIAL CONFLICTS OF INTEREST
2

3. “PRETENDING
THAT IT CAN BE
WHEN IT CAN’T
IS HOW PEOPLE
BREAK THEIR HEARTS”
ELVIN SEMRAD (2003)
3

4. RELENTLESS HOPE
MARTHA STARK (2017)
A DEFENSE TO WHICH
THE PATIENT CLINGS
IN ORDER
NOT TO HAVE TO FEEL
THE PAIN OF HER DISAPPOINTMENT
IN THE OBJECT
THE HOPE A DEFENSE
ULTIMATELY AGAINST GRIEVING
4

5. THE PATIENT’S REFUSAL TO DEAL WITH
THE PAIN OF HER GRIEF ABOUT THE OBJECT
FUELS THE RELENTLESSNESS
WITH WHICH SHE PURSUES IT
BOTH THE RELENTLESSNESS OF HER HOPE
– THINK “LIBIDO” –
THAT SHE MIGHT YET BE ABLE
TO MAKE THE OBJECT OVER INTO WHAT
SHE WOULD WANT IT TO BE
AND THE RELENTLESSNESS OF THE OUTRAGE
– THINK “AGGRESSION” –
SHE EXPERIENCES IN THOSE MOMENTS
OF DAWNING RECOGNITION THAT
– DESPITE HER BEST EFFORTS AND MOST FERVENT DESIRE –
SHE MIGHT NEVER BE ABLE
TO MAKE THAT ACTUALLY HAPPEN
5

6. EQUALLY IMPORTANTLY
WHAT FUELS THE RELENTLESSNESS
OF THE PATIENT’S PURSUIT
IS THE FACT THAT THE OBJECT
IS OUTSIDE THE SPHERE OF HER OMNIPOTENCE
– THINK WINNICOTT –
AND IS THEREFORE UNABLE
TO BE EITHER POSSESSED OR CONTROLLED
INDEED
UNDERLYING THE PATIENT’S RELENTLESS PURSUIT IS
THE “ILLUSION” THAT SHE HAS “OMNIPOTENT CONTROL”
OVER THE OBJECT OF HER DESIRE
AN ILLUSION OFTEN ACCOMPANIED BY
AN ENTITLED SENSE THAT SOMETHING IS HER DUE
6

7. PARADOXICALLY
SUCH PATIENTS ARE NEVER RELENTLESS
IN THEIR PURSUIT OF GOOD OBJECTS
INSTEAD
THEIR RELENTLESS PURSUIT
IS OF THE BAD OBJECT
IN OTHER WORDS
IT IS NEVER ENOUGH THAT THE PATIENT SIMPLY FIND
A NEW GOOD OBJECT TO COMPENSATE
FOR HOW BAD THE OLD ONE HAD BEEN
RATHER
THE COMPELLING NEED BECOMES FIRST TO CREATE
– OR, MORE ACCURATELY, TO RE – CREATE –
THE OLD BAD OBJECT
AND THEN TO PRESSURE, MANIPULATE,
PROD, FORCE, COERCE
THIS OLD BAD OBJECT TO CHANGE
7

8. A POPULAR SONG
THAT SPEAKS DIRECTLY
TO THIS ISSUE
OF THE PATIENT’S
RELENTLESS NEED TO RECREATE
THE EARLY – ON TRAUMATIC FAILURE SITUATION
IS A ROCK SONG BY
THE LATE WARREN ZEVON (2007)
ENTITLED
“IF YOU WON’T LEAVE ME
I’LL FIND SOMEBODY WHO WILL”
8

9. THE PATIENT CAN REFIND THE OLD BAD OBJECT
IN ANY ONE OF THREE WAYS
SHE CAN CHOOSE A GOOD OBJECT
AND THEN EXPERIENCE IT AS BAD
– PROJECTION –
SHE CAN CHOOSE A GOOD OBJECT
AND THEN EXERT INTERPERSONAL PRESSURE ON IT
TO BECOME BAD
– PROJECTIVE IDENTIFICATION –
OR
SHE CAN SIMPLY CHOOSE A BAD OBJECT
TO BEGIN WITH
9

10. AGAIN
CHOOSING A GOOD OBJECT
IS NOT A VIABLE OPTION
A GOOD OBJECT SIMPLY WILL NOT SATISFY
RATHER, THE NEED
– FUELED BY HER REPETITION COMPULSION –
WILL BE TO RE – ENCOUNTER THE OLD BAD OBJECT
AND THEN TO COMPEL THIS BAD OBJECT
TO BECOME GOOD
WHICH WILL THEN SYMBOLICALLY CORRECT FOR
THE UNMASTERED RELATIONAL TRAUMAS
THAT THE PATIENT HAD EXPERIENCED EARLY ON
AT THE HANDS OF THE INFANTILE OBJECT
10

11. AGAIN
THE PATIENT’S REFUSAL TO DEAL WITH
THE PAIN OF HER GRIEF ABOUT THE OBJECT
– AND THE FACT THAT IT CANNOT BE CONTROLLED –
FUELS THE RELENTLESSNESS
WITH WHICH SHE PURSUES IT
BOTH THE RELENTLESSNESS
OF HER ENTITLED SENSE
THAT SOMETHING IS HER DUE
AND THE RELENTLESSNESS
OF HER OUTRAGE
IN THE FACE OF ITS BEING DENIED
HOPING AGAINST HOPE
SHE PURSUES THE OBJECT OF HER DESIRE
WITH A VENGEANCE
REFUSING TO RELENT, REFUSING TO ACCEPT,
REFUSING TO FORGIVE 11

12. AN EXTENDED CLINICAL VIGNETTE
THAT SPEAKS TO THIS ISSUE
OF A PATIENT’S UNWILLINGNESS
– OR, PERHAPS, INABILITY –
TO RELENT AND TO FORGIVE
SARA AND
MY UNFORGIVABLE MISTAKE
12

13. FAIRBAIRN’S INTENSE ATTACHMENTS (1963)
“A BAD OBJECT IS INFINITELY BETTER
THAN NO OBJECT AT ALL”
ACCOUNTS IN LARGE PART
FOR THE RELENTLESSNESS
WITH WHICH PATIENTS
PURSUE THE UNATTAINABLE
BOTH THE RELENTLESSNESS
OF THEIR UNREALISTIC HOPE
AND ENTITLED SENSE
THAT SOMETHING IS THEIR DUE
AND THE RELENTLESSNESS
OF THEIR UNWAVERING OUTRAGE
IN THE FACE OF ITS BEING DENIED
13

14. MANY THEORISTS HAVE WRITTEN
ABOUT INTERNAL BAD OBJECTS TO WHICH
THE PATIENT IS FIERCELY ATTACHED
BUT FEW HAVE ADDRESSED
THE CRITICAL ISSUE OF WHAT EXACTLY
FUELS THESE INTENSE ATTACHMENTS
IT IS TO FAIRBAIRN THAT WE MUST LOOK
TO UNDERSTAND THE SPECIFIC NATURE
OF THE PATIENT’S INTENSE ATTACHMENTS
TO HER INTERNAL BAD OBJECTS
ATTACHMENTS THAT MAKE IT DIFFICULT
FOR HER TO SEPARATE FROM
THE INFANTILE OBJECT
WHICH SHE MUST DO IF SHE IS
EVER TO EXTRICATE HERSELF
FROM HER RELENTLESS PURSUITS
AND HER COMPULSIVE RE – ENACTMENTS
14

15. HOW ARE BAD EXPERIENCES
AT THE HANDS OF THE INFANTILE OBJECT
INTERNALLY RECORDED AND STRUCTURALIZED?
FAIRBAIRN WRITES –
WHEN A CHILD’S NEED FOR CONTACT
IS FRUSTRATED BY THE PARENT,
THE CHILD DEALS WITH HER FRUSTRATION
BY DEFENSIVELY INTROJECTING THE BAD PARENT
IT IS AS IF THE CHILD FINDS IT INTOLERABLY PAINFUL
TO BE DISAPPOINTED BY THE PARENT AND SO THE CHILD
– TO PROTECT HERSELF AGAINST THE PAIN OF
HAVING TO KNOW JUST HOW BAD THE PARENT REALLY IS –
INTROJECTS THE PARENT’S BADNESS
– IN THE FORM OF AN INTERNAL BAD OBJECT (PATHOGENIC INTROJECT) –
BASICALLY
THE CHILD TAKES THE BURDEN OF
THE PARENT’S BADNESS UPON HERSELF IN ORDER
NOT TO HAVE TO FEEL THE PAIN OF HER GRIEF 15

16. DEFENSIVE INTROJECTION OF THE PARENT’S BADNESS
HAPPENS ALL THE TIME IN SITUATIONS OF ABUSE
THE PATIENT WILL RECOUNT EPISODES OF
OUTRAGEOUS ABUSE AT THE HANDS OF A PARENT
AND THEN REPORT THAT SHE FEELS
NOT ANGRY AT THE PARENT BUT GUILTY
AFTER ALL
IT IS EASIER TO EXPERIENCE HERSELF AS UNLOVABLE
THAN TO ALLOW HERSELF TO KNOW THE HORRID TRUTH
ABOUT HER PARENT AS HAVING BEEN ABUSIVE
– FOR HAVING SOMEHOW PROVOKED IT / FOR HAVING GOTTEN IN THE WAY
FOR HAVING HAD TOO MANY NEEDS / FOR HAVING BEEN TOO DIFFICULT
OR, EVEN, FOR HAVING BEEN BORN –
IN OTHER WORDS
IT IS EASIER TO EXPERIENCE HERSELF AS BAD
AND AS HAVING DESERVED THE ABUSE
THAN TO CONFRONT THE INTOLERABLY
PAINFUL REALITY THAT THE PARENT
SHOULD NEVER HAVE DONE WHAT SHE DID
16

17. MORE GENERALLY
A CHILD WHOSE HEART HAS BEEN BROKEN
BY HER PARENT WILL DEFEND HERSELF
AGAINST THE PAIN OF HER DISAPPOINTMENT BY
TAKING ON THE PARENT’S BADNESS AS HER OWN
THEREBY ENABLING HER TO PRESERVE
THE ILLUSION OF HER PARENT AS GOOD
AND AS ULTIMATELY FORTHCOMING
IF SHE (THE CHILD) COULD BUT GET IT RIGHT
IN ESSENCE
BY DEFENSIVELY INTROJECTING THE BAD PARENT,
THE CHILD IS ABLE TO MAINTAIN AN ATTACHMENT
TO HER ACTUAL PARENT AND, AS A RESULT, IS ABLE TO HOLD
ON TO HER “UNRELENTING” HOPE – AN ILLUSION – THAT
PERHAPS SOMEDAY, SOMEHOW, SOME WAY,
WERE SHE TO BE BUT GOOD ENOUGH, TRY HARD ENOUGH,
AND SUFFER DEEPLY ENOUGH, SHE MIGHT YET
BE ABLE TO COMPEL THE PARENT TO CHANGE
17

18. AGAIN
AS FAIRBAIRN WRITES –
“A RELATIONSHIP WITH A BAD OBJECT
IS INFINITELY BETTER
THAN NO RELATIONSHIP AT ALL”
BECAUSE,
ALTHOUGH THE OBJECT IS BAD,
THE CHILD CAN AT LEAST STILL
“RELENTLESSLY” HOPE
THAT THE OBJECT
MIGHT SOMEDAY BECOME GOOD
18

19. BUT WHAT DOES FAIRBAIRN SUGGEST
IS THE SPECIFIC NATURE
OF THE CHILD’S INTENSE ATTACHMENT
TO THIS INTERNAL BAD OBJECT?
ACCORDING TO FAIRBAIRN
A BAD PARENT IS A PARENT WHO FRUSTRATES
HER CHILD’S LONGING FOR CONTACT
BUT, FAIRBAIRN WRITES, A SEDUCTIVE PARENT
– WHO FIRST SAYS “YES” AND THEN SAYS “NO” –
IS A VERY BAD PARENT
FAIRBAIRN’S INTEREST IS IN THESE VERY BAD PARENTS
– THESE SEDUCTIVE PARENTS –
THEREFORE, WHEN THE CHILD HAS BEEN FAILED
BY A PARENT WHO IS SEDUCTIVE,
THE CHILD
– AS HER FIRST LINE OF DEFENSE –
WILL INTROJECT THIS EXCITING
BUT ULTIMATELY REJECTING PARENT
19

20. SPLITTING IS THE SECOND LINE OF DEFENSE
ONCE THE BAD OBJECT IS INSIDE,
IT IS SPLIT INTO TWO PARTS
THE EXCITING OBJECT
THAT OFFERS THE ENTICING PROMISE
OF A SPECIAL RELATIONSHIP
AND THE REJECTING OBJECT
THAT ULTIMATELY FAILS TO DELIVER
IS THE REJECTING (DEPRIVING) OBJECT
A GOOD OBJECT OR A BAD OBJECT?
IS THE EXCITING (ENTICING) OBJECT
A GOOD OBJECT OR A BAD OBJECT?
20

21. SPLITTING OF THE EGO GOES HAND IN HAND
WITH SPLITTING OF THE OBJECT
*NOTE THAT FAIRBAIRN DOES NOT CONCEIVE OF THE ID
AS SEPARATE FROM THE EGO
RATHER, HE POSITS THE EXISTENCE OF AN EGO THAT HAS
NOT ONLY INTERNAL OBJECTS
BUT ALSO ITS OWN RESERVOIR OF ENERGY
– BOTH LIBIDO AND AGGRESSION –
SO FAIRBAIRN’S EGO IS A DYNAMIC STRUCTURE
– A STRUCTURE WITH ITS OWN ENERGY –
FAIRBAIRN’S LIBIDINAL EGO ATTACHES ITSELF
TO THE EXCITING OBJECT AND LONGS FOR CONTACT,
HOPING AGAINST HOPE THAT THE OBJECT
WILL BE FORTHCOMING
FAIRBAIRN’S ANTILIBIDINAL EGO
– WHICH IS A REPOSITORY FOR ALL THE HATRED AND DESTRUCTIVENSS
THAT HAVE ACCUMULATED AS A RESULT OF FRUSTRATED LONGING –
ATTACHES ITSELF TO THE REJECTING OBJECT
AND RAGES AGAINST IT
21

22. SO WHAT, THEN, IS THE SPECIFIC NATURE
OF THE PATIENT’S INTENSE ATTACHMENT
TO THE BAD OBJECT?
IT IS, OF COURSE, AMBIVALENT
IT IS BOTH LIBIDINAL
AND ANTILIBIDINAL
– OR AGGRESSIVE –
IN NATURE
THE BAD OBJECT IS BOTH
LOVED
– BECAUSE IT EXCITES –
(WHICH IS WHY IT IS LIBIDINALLY CATHECTED)
AND HATED
– BECAUSE IT REJECTS –
(WHICH IS WHY IT IS AGGRESSIVELY CATHECTED)
22

23. IN ANY EVENT
THE THIRD LINE OF DEFENSE IS REPRESSION
– (UNCONSCIOUS) REPRESSION OF THE EGO’S ATTACHMENT
TO THE EXCITING / REJECTING OBJECT –
ACCORDING TO FAIRBAIRN, THEN,
AT THE CORE OF THE REPRESSED IS
NOT AN IMPULSE, NOT A TRAUMA, NOT A MEMORY
BUT A FORBIDDEN RELATIONSHIP
– AN INTENSELY CONFLICTED RELATIONSHIP
WITH A BAD OBJECT THAT IS BOTH LOVED AND HATED –
OVER TIME, THIS AMBIVALENT ATTACHMENT TO THE
“INTERNAL OBJECT” WILL BE COMPULSIVELY RE – ENACTED
ON THE STAGE OF THE PATIENT’S LIFE
SUCH THAT SHE WILL FIND HERSELF REACTING TO THE
“EXTERNAL OBJECTS OF HER DESIRE”
WITH BOTH LONGING AND AVERSION, YEARNING AND REVULSION
ALTHOUGH BECAUSE THE ATTACHMENT IS REPRESSED,
THE PATIENT MIGHT BE UNAWARE THAT BOTH SIDES EXIST 23

24. WHAT THIS MEANS CLINICALLY IS THAT
PATIENTS WHO ARE RELENTLESS
IN THEIR PURSUIT OF THE
BAD – EXCITING / REJECTING – OBJECT
MUST ULTIMATELY ACKNOWLEDGE
BOTH THEIR INTENSE HUNGER FOR THE OBJECT
AND THEIR OUTRAGED HATRED OF THE OBJECT
BECAUSE IT FAILS THEM REPEATEDLY
IT WAS THEREFORE TO FAIRBAIRN
THAT WE HAD TO TURN
IN ORDER BETTER TO APPRECIATE THAT
THE INTENSITY OF THE PATIENT’S ATTACHMENT
TO THE BAD OBJECT
IS FUELED BY AMBIVALENCE
24

25. ALTHOUGH FAIRBAIRN’S CLAIM
IS THAT HE IS WRITING
ABOUT SCHIZOID PERSONALITIES,
I BELIEVE THAT THE MANNER
IN WHICH HE CONCEPTUALIZES
THE “ENDOPSYCHIC SITUATION” OF THESE
SO – CALLED SCHIZOID PERSONALITIES
CAPTURES, IN A NUTSHELL,
THE PSYCHODYNAMICS
OF SADOMASOCHISTIC PATIENTS
IN FACT
MY CONTENTION WILL BE THAT
THE PATIENT’S RELENTLESS PURSUIT
OF THE BAD OBJECT HAS BOTH
MASOCHISTIC AND SADISTIC COMPONENTS
25

26. PARENTHETICALLY (AND IMPORTANTLY)
MY INTEREST IS NOT SPECIFICALLY
IN HOW SADOMASOCHISM
GETS PLAYED OUT IN THE SEXUAL ARENA
RATHER
I CONCEIVE OF SADOMASOCHISM
AS A DYSFUNCTIONAL RELATIONAL DYNAMIC
THAT WILL GET PLAYED OUT
– TO A GREATER OR LESSER DEGREE –
IN MOST OF THE RELENTLESS PATIENT’S
SIGNIFICANT RELATIONSHIPS
26

27. THE PATIENT’S RELENTLESS HOPE
– WHICH FUELS HER MASOCHISM –
IS THE STANCE TO WHICH
SHE DESPERATELY CLINGS
IN ORDER TO AVOID CONFRONTING
CERTAIN INTOLERABLY PAINFUL REALITIES
ABOUT THE OBJECT AND ITS IMMUTABILITY
AND HER RELENTLESS OUTRAGE
– WHICH FUELS HER SADISM –
IS THE STANCE TO WHICH
SHE RESORTS IN THOSE MOMENTS
OF DAWNING RECOGNITION
THAT THE OBJECT IS SEPARATE
AND CANNOT BE FORCED
TO BE SOMETHING IT ISN’T
27

28. THE MASOCHISTIC DEFENSE
OF RELENTLESS HOPE
AND THE SADISTIC DEFENSE
OF RELENTLESS OUTRAGE
GO HAND IN HAND
AND BOTH SPEAK TO THE PATIENT’S
REFUSAL TO CONFRONT THE TRUTH
ABOUT THE BAD (IMMUTABLE) OBJECT
28

29. MORE SPECIFICALLY
MASOCHISM IS A STORY ABOUT THE PATIENT’S HOPE
HER RELENTLESS HOPE
– HER HOPING AGAINST HOPE –
THAT PERHAPS SOMEDAY, SOMEHOW, SOME WAY
WERE SHE TO BE BUT GOOD ENOUGH,
TRY HARD ENOUGH, BE PERSUASIVE ENOUGH,
PERSIST LONG ENOUGH, SUFFER DEEPLY ENOUGH,
OR BE MASOCHISTIC ENOUGH,
SHE MIGHT YET BE ABLE TO EXTRACT FROM THE OBJECT
– SOMETIMES THE PARENT HERSELF,
SOMETIMES A STAND – IN FOR THE PARENT –
THE RECOGNITION AND LOVE DENIED HER AS A CHILD
IN OTHER WORDS
THAT SHE MIGHT YET BE ABLE TO COMPEL
THE IMMUTABLE OBJECT TO RELENT
29

30. AND, SO, EVEN IN THE FACE OF INCONTROVERTIBLE
EVIDENCE TO THE CONTRARY,
THE PATIENT PURSUES THE OBJECT
OF HER DESIRE WITH A VENGEANCE
THE INTENSITY OF THIS RELENTLESS PURSUIT
FUELED BY HER ENTITLED CONVICTION
THAT THE OBJECT COULD GIVE IT
– WERE THE OBJECT BUT WILLING –
SHOULD GIVE IT
– BECAUSE THAT IS THE PATIENT’S DUE –
AND WOULD GIVE IT
– WERE SHE (THE PATIENT) BUT ABLE TO GET IT RIGHT –
THE PATIENT’S INVESTMENT IS NOT SO MUCH
IN THE SUFFERING PER SE
AS IT IS IN HER WILLINGNESS TO SUFFER (IF NEED BE)
BECAUSE OF HER PASSIONATE HOPE
THAT PERHAPS THIS NEXT TIME …
30

31. SADISM IS, THEN,
THE RELENTLESS PATIENT’S REACTION
TO THE LOSS OF HOPE SHE EXPERIENCES
IN THOSE MOMENTS OF DAWNING RECOGNITION
THAT SHE IS NOT ACTUALLY GOING TO GET
WHAT SHE HAD SO DESPERATELY WANTED
AND FELT SHE NEEDED TO HAVE
IN ORDER TO GO ON
IN THOSE MOMENTS
OF ANGUISHED HEARTBREAK AND OUTRAGE
WHEN SHE IS CONFRONTED HEAD – ON
WITH THE INESCAPABLE REALITY
OF THE OBJECT’S SEPARATENESS
AND REFUSAL TO RELENT
31

32. THE HEALTHY RESPONSE TO THE LOSS OF HOPE
IS TO CONFRONT THE PAIN
OF ONE’S DISAPPOINTMENT
GRIEVE THE LOSS OF ONE’S ILLUSIONS
ABOUT THE OBJECT
AND ADAPTIVELY INTERNALIZE
WHATEVER GOOD
THERE WAS IN THE RELATIONSHIP
A GROWTH – PROMOTING PROCESS
DESCRIBED IN SELF PSYCHOLOGY
AS TRANSMUTING
– OR STRUCTURE – BUILDING –
INTERNALIZATION
BUT THE RELENTLESS PATIENT DOES SOMETHING ELSE …
32

33. WITH THE DAWNING RECOGNITION THAT THE OBJECT
CAN BE NEITHER POSSESSED AND CONTROLLED
NOR MADE OVER INTO WHAT SHE WOULD WANT IT TO BE,
THE RELENTLESS PATIENT WILL REACT
– WHETHER IN ACTUAL FACT OR SIMPLY IN FANTASY –
WITH THE SADISTIC UNLEASHING OF A TORRENT
OF ABUSE DIRECTED EITHER TOWARDS HERSELF
– FOR HAVING FAILED TO GET WHAT SHE
HAD SO DESPERATELY WANTED –
OR TOWARDS THE DISAPPOINTING OBJECT
– FOR HAVING FAILED TO PROVIDE IT –
SHE WILL ALTERNATE BETWEEN
ENRAGED PROTESTS AT HER OWN INADEQUACY
AND SCATHING REPROACHES AGAINST THE OBJECT
FOR HAVING THWARTED HER DESIRE
IN ESSENCE
SADISM IS THE RELENTLESS PATIENT’S
REACTION TO THE LOSS OF HOPE
33

34. IN ANY EVENT
THE SADOMASOCHISTIC CYCLE
WILL BE REPEATED ONCE
THE (SEDUCTIVE) OBJECT
THROWS THE PATIENT A FEW CRUMBS
THE PATIENT
– EVER HUNGRY FOR SUCH MORSELS –
WILL BECOME ONCE AGAIN HOOKED
AND REVERT TO HER ORIGINAL
STANCE OF SUFFERING,
SACRIFICE, AND SURRENDER
IN A REPEAT ATTEMPT TO GET
WHAT SHE SO DESPERATELY WANTS
AND FEELS SHE MUST HAVE
34

35. A CLINICAL MOMENT
SO IF, DURING A THERAPY SESSION,
A PATIENT SUDDENLY BECOMES ABUSIVE,
WHAT QUESTION MIGHT THE THERAPIST THINK TO POSE?
WERE THE THERAPIST TO ASK
“HOW DO YOU FEEL THAT I HAVE FAILED YOU?”
AT LEAST SHE WILL HAVE KNOWN
ENOUGH TO ASK THE QUESTION
BUT SHE WILL ALSO THEREBY BE INDIRECTLY
SUGGESTING THAT THE ANSWER WILL BE
PRIMARILY A STORY ABOUT THE PATIENT
– AND THE PATIENT’S DISTORTED PERCEPTION
OF HAVING BEEN FAILED –
IT IS BETTER, THEREFORE, THAT THE THERAPIST ASK
“HOW HAVE I FAILED YOU?”
35

36. NOW SHE WILL BE SIGNALING HER RECOGNITION
OF THE FACT THAT SHE HERSELF MIGHT WELL
HAVE CONTRIBUTED TO THE PATIENT’S EXPERIENCE
OF DISILLUSIONMENT AND HEARTACHE
– PERHAPS BY NOT FULFILLING AN IMPLICIT PROMISE EARLIER MADE
OR BY REFUSING TO ACKNOWLEDGE HER
UNRELENTING COMMITMENT TO A CERTAIN PERSPECTIVE
OR BY FAILING TO ADMIT TO AN ERROR IN JUDGMENT
OR BY DENYING HER MISTIMING OF AN INTERPRETATION –
INDEED, THE THERAPIST MUST HAVE BOTH
THE WISDOM TO RECOGNIZE
AND THE INTEGRITY TO ACKNOWLEDGE
– CERTAINLY TO HERSELF AND PERHAPS TO THE PATIENT AS WELL –
THE PART SHE HERSELF MIGHT HAVE PLAYED
IN THE DRAMA BEING RE – ENACTED BETWEEN THEM
36

37. OVER TIME
I HAVE COME INCREASINGLY TO APPRECIATE THAT WHEN
A THERAPEUTIC IMPASSE ARISES IN THE TREATMENT
IT IS OFTEN BECAUSE PATIENT AND THERAPIST
ARE ENGAGED IN A “POWER STRUGGLE”
A DEADLOCKED SITUATION THAT HAS BEEN CO – CREATED
– WITH CONTRIBUTIONS FROM BOTH –
THE “RELENTLESS” PATIENT INSISTING “YES!”
THE EQUALLY “UNRELENTING” THERAPIST PROTESTING “NO!”
“I NEED A HUG”
“I NEED TO KNOW THAT YOU LOVE ME”
“WHAT DO YOU THINK I SHOULD DO?”
“I WANT TO BE YOUR FRIEND”
“CAN’T WE HAVE COFFEE TOGETHER SOME TIME?”
BUT, AGAIN, THESE THERAPEUTIC STALEMATES
ARE USUALLY A STORY ABOUT
NOT ONLY THE PATIENT
BUT ALSO THE THERAPIST
37

38. IF THERAPEUTIC IMPASSES
ARE EVER TO BE RESOLVED,
THEN ULTIMATELY NOT ONLY THE PATIENT
BUT ALSO THE THERAPIST
MUST BE ABLE
– AND WILLING –
TO RELENT
… AND THE THERAPIST
MIGHT NEED TO DO IT FIRST
WHICH IS WHAT I THINK
I INADVERTENTLY DID WITH SARA
– IN THE VIGNETTE THAT I HAD PRESENTED AT THE BEGINNING –
WHEN I FINALLY RELENTED,
BROKE DOWN, AND CRIED
… WHICH THEN ENABLED SARA TO RELENT –
SHE BROKE DOWN AND THEN SHE BEGAN TO CRY
38

39. INTERNAL vs. RELATIONAL SADOMSOCHISTIC DYNAMICS
TO THIS POINT
OUR FOCUS HAS BEEN ON THE WAY IN WHICH
SADOMASOCHISM MANIFESTS ITSELF RELATIONALLY
AND WE HAD USED FAIRBAIRN TO HELP US UNDERSTAND
THE UNDERLYING ENDOPSYCHIC SITUATION
NAMELY
THAT THE PATIENT HAS BOTH A LIBIDINAL AND
AN AGGRESSIVE ATTACHMENT TO THE BAD OBJECT
– THUS THE AMBIVALENCE OF HER ATTACHMENT
AND THE RELENTLESSNESS OF HER PURSUIT –
THESE SAME PATIENTS HAVE BOTH A LIBIDINAL AND
AN AGGRESSIVE ATTACHMENT TO THE BAD SELF
– MANIFESTING AS SELF – INDULGENCE ON THE ONE HAND
AND SELF – DESTRUCTIVENESS ON THE OTHER –
39

40. AS AN EXAMPLE
A PATIENT WITH A SERIOUS EATING DISORDER
AFTER THE PATIENT HAS BEEN ON A
CALORIE – RESTRICTED DIET FOR A WHILE,
SHE WILL BEGIN TO FEEL DEPRIVED,
WILL BECOME RESENTFUL,
AND WILL THEN FEEL ENTITLED TO GRATIFY HERSELF
BY INDULGING IN COMPULSVE OVEREATING
WHICH WILL THEN MAKE HER FEEL GUILTY
AND PROMPT HER TO PUNISH HERSELF
BY SEVERELY RESTRICTING HER CALORIES ONCE AGAIN
WHICH WILL THEN MAKE HER FEEL DEPRIVED,
ANGRY, AND ENTITLED TO INDULGE
IN YET ANOTHER EATING BINGE
ITERATIVE CYCLES OF DEPRIVATION,
SELF – INDULGENCE, GUILT, SELF – PUNISHMENT
40

41. SADOMASOCHISM CAN BE PLAYED OUT
EITHER RELATIONALLY
– IN THE FORM OF ALTERNATING CYCLES OF
RELENTLESS HOPE AND RELENTLESS OUTRAGE –
OR INTERNALLY
– IN THE FORM OF ALTERNATING CYCLES OF
SELF – INDULGENCE AND SELF – DESTRUCTIVENESS –
AND, OF COURSE, THEY OFTEN CO – EXIST
RELATIONALLY
THE MASOCHISTIC DEFENSE OF RELENTLESS HOPE
AND THE SADISTIC DEFENSE OF RELENTLESS OUTRAGE
INTERNALLY
THE MASOCHISTIC DEFENSE
OF RELENTLESS SELF – INDULGENCE
AND THE SADISTIC DEFENSE
OF RELENTLESS SELF – TORMENT
41

42. WHEN SADOMASOCHISM IS PLAYED OUT RELATIONALLY,
THE PATIENT MUST ULTIMATELY CONFRONT
– AND GRIEVE –
THE REALITY OF THE OBJECT’S LIMITATIONS
AND ARRIVE AT A PLACE OF SERENE ACCEPTANCE
OF THE OBJECT’S FLAWS, IMPERFECTIONS,
AND INADEQUACIES
HAVING MADE HER PEACE WITH THE REALITY
THAT THE OBJECT IS “GOOD ENOUGH”
WHEN SADOMASOCHISM IS PLAYED OUT INTERNALLY,
THE PATIENT MUST ULTIMATELY CONFRONT
– AND GRIEVE –
THE REALITY OF HER OWN LIMITATIONS
AND ARRIVE AT A PLACE OF HUMBLE ACCEPTANCE
OF HER OWN FLAWS, IMPERFECTIONS,
AND INADEQUACIES
HAVING MADE HER PEACE WITH THE REALITY
THAT SHE HERSELF IS “GOOD ENOUGH” 42

43. CONCLUSION
“GRIEVING IS NATURE’S WAY
OF HEALING A BROKEN HEART”
ROBERTA BECKMANN (1991)
AT THE END OF THE DAY
A PATIENT WHO IS CAUGHT UP IN THE THROES
OF NEEDING HER OBJECTS
TO BE OTHER THAN WHO THEY ARE
MUST BE GIVEN THE OPPORTUNITY TO CONFRONT
– AND GRIEVE –
THE EXCRUCIATINGLY PAINFUL REALITY THAT
NO ONE WILL EVER BE FOR HER
THE GOOD PARENT FOR WHOM SHE HAS SPENT
A LIFETIME SEARCHING
– THE GOOD PARENT SHE SHOULD HAVE HAD EARLY – ON
BUT NEVER, CONSISTENTLY AND RELIABLY, DID –
43

44. IF ALL GOES WELL
IT WILL BE WITHIN THE CONTEXT OF SAFETY
PROVIDED BY THE RELATIONSHIP WITH HER THERAPIST
THAT THE PATIENT WILL BE ABLE, AT LAST, TO FEEL
THE PAIN AGAINST WHICH SHE HAS SPENT
A LIFETIME DEFENDING HERSELF
IN THE PROCESS, GRADUALLY TRANSFORMING
BOTH HER RELENTLESS NEED
TO POSSESS AND CONTROL
AND, WHEN THWARTED, HER RETALIATORY NEED
TO PUNISH AND DESTROY
INTO THE ADAPTIVE CAPACITY TO RELENT, GRIEVE,
ACCEPT, FORGIVE, INTERNALIZE WHAT GOOD THERE WAS,
SEPARATE, LET GO, AND MOVE ON
– ULTIMATELY EVOLVING TO A PLACE OF APPRECIATION AND
GRATITUDE FOR ALL THE GOOD THAT WAS (AND IS)
A JAPANESE SAYING –
“TRUE HAPPINESS IS NOT GETTING WHAT YOU WANT
BUT COMING TO WANT <AND APPRECIATE> WHAT YOU HAVE”
44

45. HAROLD SEARLES (1979)
HAS SUGGESTED
THAT REALISTIC HOPE
ARISES IN THE CONTEXT
OF SURVIVING DISAPPOINTMENT
IN CLOSING
I AM HERE REMINDED OF
THE NEW YORKER CARTOON
IN WHICH A GENTLEMAN
– SEATED AT A TABLE IN A RESTAURANT
NAMED THE DISILLUSIONMENT CAFÉ –
IS AWAITING THE ARRIVAL OF HIS ORDER
THE WAITPERSON RETURNS TO HIS TABLE
AND ANNOUNCES,
“YOUR ORDER IS NOT READY,
AND NOR WILL IT EVER BE”
45

46. 46
THANK YOU!
STUART AND HIS BROTHER STEWART

47. IF YOU WOULD
LIKE TO BE ON
MY MAILING LIST
(AND ARE NOT YET),
PLEASE EMAIL ME AT
MarthaStarkMD @
HMS.Harvard.edu
47

48. 48

49. REFERENCES
BECKMANN R. 1991. CHILDREN WHO GRIEVE: A MANUAL FOR CONDUCTING
SUPPORT GROUPS. Learning Publications.
FAIRBAIRN W.R.D. 1963. SYNOPSIS OF AN OBJECT – RELATIONS THEORY OF
PERSONALITY. INTERNATIONAL JOURNAL OF PSYCHOANALYSIS 44:224 – 225.
RAKO S. 2003. SEMRAD: THE HEART OF A THERAPIST. BLOOMINGTON, IN:
iUniverse.
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, NY:
International Universities Press.
STARK M. 2017. RELENTLESS HOPE: THE REFUSAL TO GRIEVE
(International Psychotherapy Institute eBook).
WINNICOTT D.W. 1965. THE MATURATIONAL PROCESSES AND THE
FACILITATING ENVIRONMENT. Madison, CT: International Universities Press.
49