1. THE ART AND THE SCIENCE
OF INTERPRETATION
“LIKE THE MIDDLE GAME IN CHESS,
THERE IS NO PLAYBOOK TO GUIDE US”
PATRICIA COUGHLIN (2022)
MARTHA STARK MD
Faculty, Harvard Medical School
MarthaStarkMD @ HMS.Harvard.edu
Sunday / November 13, 2022
Baltimore Society for Psychoanalytic Studies
THANK YOU, CAMAY WOODALL 😊
© 2022 Martha Stark MD
1

2. THE “POOREST UNDERSTOOD”
AND
“TWO MOST ENIGMATIC WORDS”
IN PSYCHOANALYSIS
ARE “WORKING THROUGH”
PETER GIOVACCHINI (1986)
“THIS WORKING – THROUGH OF
THE RESISTANCES < DEFENSES >
MAY IN PRACTICE
TURN OUT TO BE
AN ARDUOUS TASK
FOR THE SUBJECT
OF THE ANALYSIS
AND A TRIAL OF PATIENCE
FOR THE ANALYST”
SIGMUND FREUD (1914)
2

3. 2 – SLIDE OVERVIEW
THE “THERAPEUTIC PROVISION” OF “OPTIMAL STRESS”
NECESSARY IF “DEEP AND ENDURING PSYCHODYNAMIC CHANGE”
IS THE ULTIMATE GOAL OF TREATMENT
“CHALLENGE” THAT OFFERS “IMPETUS”
AND “SUPPORT” THAT OFFERS “OPPORTUNITY”
FOR TRANSFORMATION AND GROWTH
SUCH THAT
“RIGID DEFENSE” WILL BE REPLACED BY “MORE FLEXIBLE ADAPTATION”
“DEFENSIVE REACTION” WILL BE REPLACED BY “ADAPTIVE RESPONSE”
“SAME OLD, SAME OLD” NARRATIVES
WILL BE REPLACED BY “SOMETHING NEW, DIFFERENT, AND BETTER”
THE “DEFENSIVE NEED” FOR “OLD BAD”
WILL BE REPLACED BY THE “ADAPTIVE CAPACITY” FOR “NEW GOOD”
TWO PRIMARY INTERVENTIONS –
(1) “MINIMALLY STRESSFUL” “CLARIFYING” INTERVENTIONS
WHICH “PROVIDE SUPPORT” AND “SET THE STAGE”
(2) “OPTIMALLY STRESSFUL” “GROWTH – INCENTIVIZING” INTERVENTIONS
WHICH “PROVIDE CHALLENGE AND SUPPORT” AND “GENERATE THERAPEUTIC LEVERAGE”
THE CONSTRUCTION OF WHICH IS
BOTH A “SCIENCE” AND AN “ART” 3

4. 2 – SLIDE OVERVIEW
THE “GENERATION” OF ONGOING “HEALING CYCLES” OF
“DISRUPTION” AND “REPAIR”
WHICH WILL CREATE “HOMEOSTATIC IMBALANCE”
A STATE OF “DISEQUILIBRIUM”
THAT CANNOT, HOWEVER, BE TOLERATED FOR LONG
PROMPTING “RESTORATION OF EQUILIBRIUM”
– “RE – EQUILIBRATION” –
BUT EACH TIME
AT A NEW – MORE – EVOLVED – LEVEL OF
“HOMEOSTASIS” AND “ADAPTIVE CAPACITY”
AS A RESULT OF THE “SYNERGY” OF
THE THERAPIST’S “EXTERNAL SUPPORT”
AND THE PATIENT’S “INTERNAL RESOURCES”
THAT IS, THE PATIENT’S “UNDERLYING RESILIENCE,”
THE “WISDOM OF HER BODY,” HER “INNATE STRIVING TOWARDS HEALTH,”
AND HER “INTRINSIC CAPACITY TO ADAPT TO (OPTIMAL) STRESS”
EVENTUAL “TRANSFORMATION” OF “PSYCHOLOGICAL RIGIDITY”
INTO “PSYCHOLOGICAL FLEXIBILITY”
REINFORCEMENT OF “INNATE RESILIENCE” WITH “ADAPTIVE RESILIENCE”
4

5. THE PSP “WORKING THROUGH PROTOCOL”
A TRIPARTITE APPROACH THAT “LEVERAGES” THE PATIENT’S ANXIETY
– BY ALTERNATELY “INCREASING” AND THEN “DECREASING” IT –
IN ORDER TO CREATE “DESTABILIZING ANXIETY,” “INCENTIVIZING STRESS,”
AND GRADUATED “EVOLVING” OF THE PATIENT FROM “DEFENSE” TO “ADAPTATION”
OPTION #1 – “SUPPORT” THE DEFENSE
SUPPORT THE DEFENSE
BY “BEING WITH THE PATIENT WHERE SHE IS”
– WHICH WILL “DECREASE” HER ANXIETY –
OPTION #2 – ALTERNATELY “CHALLENGE”
AND THEN “SUPPORT” THE DEFENSE
REPEATEDLY CHALLENGE THE DEFENSE
BY “DIRECTING THE PATIENT’S ATTENTION
TO WHERE THE THERAPIST WANTS HER TO GO”
– WHICH WILL “INCREASE” HER ANXIETY –
AND THEN SUPPORT THE DEFENSE
BY “BEING WITH THE PATIENT WHERE SHE IS”
– WHICH WILL “DECREASE” HER ANXIETY –
OPTION #3 – “SUPPORT” THE ADAPTATION
SUPPORT THE ADAPTATION
BY “BEING WITH THE PATIENT WHERE SHE IS”
– WHICH WILL “DECREASE” HER ANXIETY –
5

6. THE PSP “WORKING THROUGH PROTOCOL”
– FROM “DEFENSE” TO “ADAPTATION” –
ALTERNATELY AND REPEATEDLY “CHALLENGING”
AND THEN “SUPPORTING” THE PATIENT’S DEFENSE
– WHICH HAPPENS IN THE OPTION #2 –
WILL EVENTUALLY “DISRUPT”
THE (DYSFUNCTIONAL) “HOMEOSTATIC BALANCE”
OF THE PATIENT’S “SELF – PROTECTIVE MECHANISMS”
BUT, AS NOTED EARLIER, SYSTEMS CANNOT TOLERATE
“HOMEOSTATIC IMBALANCE” FOR EXTENDED PERIODS OF TIME
IN ORDER TO “RESOLVE THE INTERNAL TENSION” CREATED BY THIS “IMBALANCE”
THE SYSTEM WILL, THEREFORE, BE FORCED TO “RE – EQUILIBRATE”
THE “SYNERGY” OF THE THERAPIST’S “EXTERNAL SUPPORT”
AND THE PATIENT’S “INTERNAL RESOURCES”
– THE “WISDOM OF HER BODY,” HER “UNDERLYING RESILIENCE,”
HER “INNATE STRIVING TOWARDS HEALTH,”
AND HER “INTRINSIC CAPACITY TO COPE WITH STRESS” –
WILL BE SUCH THAT ULTIMATELY “EQUILIBRIUM” WILL BE “RESTORED”
– BUT THIS TIME AT A NEW – MORE FUNCTIONAL – LEVEL OF HOMEOSTASIS –
WHERE “PSYCHOLOGICAL RIGIDITY” WAS,
THERE SHALL “PSYCHOLOGICAL FLEXIBILITY” BE
WHERE “INNATE RESILIENCE” WAS,
THERE SHALL “ADAPTIVE RESILIENCE” BE
6

7. MORE SPECIFICALLY
THE PSP “WORKING THROUGH PROTOCOL”
– FROM “DEFENSE” TO “ADAPTATION” –
– FROM “SAME OLD, SAME OLD” TO “SOMETHING NEW, DIFFERENT, AND BETTER” –
– FROM “DEFENSIVE NEED” FOR “OLD BAD” TO “ADAPTIVE CAPACITY” FOR “NEW GOOD” –
OPTION #1 – “SUPPORT” “SAME OLD, SAME OLD”
SUPPORT
BY HIGLIGHTING THE “DEFENSIVE NEED” FOR “OLD BAD”
OPTION #2 – ALTERNATELY AND REPEATEDLY “CHALLENGE”
AND THEN “SUPPORT” “SAME OLD, SAME OLD”
CHALLENGE EITHER
BY HIGHLIGHTING THE “COST” OF “OLD BAD”
OR BY INTRODUCING THE “POSSIBILITY” OF “NEW GOOD”
AND THEN SUPPORT
BY HIGHLIGHTING THE “BENEFIT” OF “OLD BAD”
OPTION #3 – “SUPPORT” “SOMETHING NEW, DIFFERENT, AND BETTER”
SUPPORT
BY HIGHLIGHTING THE “ADAPTIVE CAPACITY” FOR “NEW GOOD”
7

8. 8
WITH RESPECT TO
INTRODUCING THE
ANXIETY – PROVOKING
POSSIBILITY OF
“NEW GOOD”
‘IF YOU WANT
SOMETHING
YOU NEVER HAD,
YOU HAVE TO DO
SOMETHING
“NEW,
DIFFERENT,
AND
BETTER”
AND
LET GO OF
“SAME OLD,
SAME OLD.”

9. THE PSP “WORKING THROUGH PROTOCOL”
– FROM “DEFENSE” TO “ADAPTATION” –
– FROM “SAME OLD, SAME OLD” TO “SOMETHING NEW, DIFFERENT, AND BETTER” –
OPTION #1 – “SUPPORT” – TO “PROVIDE THE BACKDROP”
“MINIMALLY STRESSFUL” “CLARIFYING” INTERVENTIONS THAT
BOTH “SUPPORT” “SAME OLD, SAME OLD”
– BY “TEASING OUT” “RECURRING THEMES, PATTERNS, AND REPETITIONS” –
(“PAINFUL, DIFFICULT TRUTHS”)
AND “SET THE STAGE”
FOR “OPTIMALLY STRESSFUL” “GROWTH – INCENTIVIZING” INTERVENTIONS
OPTION #2 – “CHALLENGE” AND “SUPPORT” – TO “CREATE DISSONANCE”
“OPTIMALLY STRESSFUL” “GROWTH – INCENTIVIZING” INTERVENTIONS THAT
ALTERNATELY AND REPEATEDLY “CHALLENGE” “SAME OLD, SAME OLD”
– EITHER BY “HIGHLIGHTING” THE “PRICE PAID” FOR “SAME OLD, SAME OLD”
OR BY INTRODUCING THE “POSSIBILITY” OF “SOMETHING NEW, DIFFERENT, AND BETTER” –
AND THEN “SUPPORT” “SAME OLD, SAME OLD”
– BY “HIGHLIGHTING” THE “INVESTMENT IN” “SAME OLD, SAME OLD” –
OPTION #3 – “SUPPORT” – TO “AFFIRM AND CELEBRATE
THE NEWFOUND ADAPTATION”
“REINFORCING” INTERVENTIONS THAT
“SUPPORT” “SOMETHING NEW, DIFFERENT, AND BETTER” 9

10. THE PSP “WORKING THROUGH PROTOCOL”
– FROM “DEFENSE” TO “ADAPTATION” –
– FROM “SAME OLD, SAME OLD”
TO “SOMETHING NEW, DIFFERENT, AND BETTER” –
OPTION #1 – “SUPPORT” THE DEFENSE
TO “PROVIDE THE BACKDROP” / “SET THE STAGE”
“YOU HOLD BACK FROM GETTING TOO CLOSE
FOR FEARING OF BEING HURT AGAIN.”
OPTION #2 – “CHALLENGE” AND “SUPPORT” THE DEFENSE
TO “CREATE DISSONANCE”
“YOU KNOW THAT YOU MIGHT NEVER FIND YOUR SOULMATE
BY PLAYING IT SO SAFE, BUT YOU’RE JUST NOT WILLING
TO TAKE THE RISK. YOU’VE ALREADY BEEN HURT TOO MANY TIMES.”
OPTION #3 – “SUPPORT” THE ADAPTATION
TO “AFFIRM THE NEW NORMAL”
“YOU SURPRISED YOURSELF AND HAD TO ADMIT
THAT IT WASN’T SO BAD AFTER ALL
WHEN YOU FOUND YOURSELF ACTUALLY
ENJOYING YOUR CONVERSATION WITH JOSE AT THE BAR.”
10

11. THE PSP “WORKING THROUGH PROTOCOL”
OPTION #1 – “SUPPORT” THE DEFENSE
TO “PROVIDE THE BACKDROP” / “SET THE STAGE”
“YOU KEEP HOPING THAT YOUR MOTHER
WILL EVENTUALLY APOLOGIZE
FOR ALL THOSE HORRIBLE THINGS SHE DID TO YOU
WHEN YOU WERE YOUNG – AND SO VULNERABLE.”
OPTION #2 – “CHALLENGE” AND “SUPPORT” THE DEFENSE
TO “CREATE DISSONANCE”
“YOU KNOW THAT SHE PROBABLY WON’T EVER TAKE
RESPONSIBILITY FOR WHAT SHE DID TO YOU
(BECAUSE, EVEN AFTER ALL THESE YEARS, SHE NEVER HAS),
BUT YOU FIND YOURSELF CONTINUING TO HOPE EVEN SO.”
OPTION #3 – “SUPPORT” THE ADAPTATION
TO “AFFIRM THE NEW NORMAL”
“EVERY NOW AND THEN YOU HAVE MOMENTS
OF HEARTBREAKING CLARITY WHEN YOU
CONFRONT THE REALITY THAT YOUR MOTHER
JUST DOESN’T REALLY HAVE IT IN HER
TO HOLD HERSELF ACCOUNTABLE – AND TO APOLOGIZE.”
11

12. THE PSP “WORKING THROUGH PROTOCOL”
OPTION #1 – “SUPPORT” THE DEFENSE
TO “PROVIDE THE BACKDROP” / “SET THE STAGE”
“YOU HEADED INTO THE KITCHEN WHEN YOU FOUND YOURSELF
HAVING AN ‘I – WANNA – EAT – SNICKERDOODLES’ MOMENT.
IT KIND OF FELT AS IF YOU DIDN’T HAVE A CHOICE BUT TO DO THAT.”
OPTION #2 – “CHALLENGE” AND “SUPPORT” THE DEFENSE
TO “CREATE DISSONANCE”
“YOU KNEW THAT YOU WOULD LATER REGRET IT
AND, EVEN AT THE TIME, YOU WERE ACUTELY AWARE
OF THE FACT THAT, TECHNICALLY, YOU COULD HAVE CHOSEN
TO HEAD, INSTEAD, INTO THE BATHROOM FOR A
WONDERFULLY RELAXING DIP IN THE JACUZZI.
BUT, IN THE MOMENT, DEVOURING THOSE DELICIOUSLY SWEET
AND TANTALIZINGLY SCRUMPTIOUS SNICKERDOODLES
FELT LIKE THE MUCH MORE COMPELLING ALTERNATIVE.”
OPTION #3 – “SUPPORT” THE ADAPTATION
TO “AFFIRM THE NEW NORMAL”
“YOU ALWAYS FEEL REALLY GROUNDED, CENTERED, AND EMPOWERED
WHEN YOU ARE ABLE TO OVERCOME YOUR ‘I – WANNA – EAT’ IMPULSES
AND ARE ABLE TO GET YOURSELF
INTO THE BATHROOM FOR THOSE WONDERFULLY
DELICIOUS, SWEET, AND RELAXING DIPS IN THE JACUZZI.”
12

13. THE PSP “WORKING THROUGH PROTOCOL”
OPTION #1 – “SUPPORT” THE DEFENSE – TO “PROVIDE THE BACKDROP”
“IT’S IMPORTANT TO YOU THAT YOU BE ABLE TO MAXIMIZE
THE POTENTIAL OF EVERY MOMENT OF YOUR TIME.
YOU ARE DETERMINED NOT TO MAKE A DECISION
THAT MIGHT TURN OUT TO HAVE BEEN A BAD CHOICE,
ONE THAT WASTES A LOT OF YOUR TIME AND ENERGY.”
OPTION #2 – “CHALLENGE” AND “SUPPORT” THE DEFENSE – TO “CREATE DISSONANCE”
“YOU KNOW THAT BECAUSE YOU DEMAND OF YOURSELF ABSOLUTE
PERFECTION, IT IS OFTEN ALMOST IMPOSSIBLE FOR YOU
TO FIGURE OUT YOUR BEST NEXT STEP.
BUT YOU CANNOT TOLERATE THE THOUGHT OF MAKING A BAD DECISION.
SO YOU KNOW THAT, AT SOME POINT, WE WILL PROBABLY NEED
TO TAKE A CLOSER LOOK AT WHY YOU HAVE
SUCH ‘ZERO TOLERANCE’ FOR ‘MISTAKES’
AND THAT IF WE CAN FIGURE THAT OUT,
YOU WILL PROBABLY BE A LOT HAPPIER AND LESS ‘JAMMED UP.’
BUT, FOR NOW, YOU ARE DETERMINED TO HOLD OFF ON DECIDING
WHETHER YOU SHOULD LEAVE YOUR JOR OR NOT – AT LEAST
UNTIL YOU CAN BE MORE CERTAIN THAT YOUR CHOICE WILL BE THE RIGHT ONE.”
OPTION #3 – “SUPPORT” THE ADAPTATION – TO “AFFIRM THE NEW NORMAL”
“WHENEVER YOU HAVE LET YOURSELF GO FOR IT AND HAVE DARED TO RISK
DISAPPOINTING YOURSELF, YOU USUALLY FIND THAT YOU ARE ABLE TO MAKE
THINGS WORK OUT PRETTY WELL FOR YOURSELF IN THE LONG RUN – LIKE
WHEN YOU MADE THE BOLD DECISION TO LEAVE BOSTON TO HEAD TO LA.” 13

14. THE PSP “WORKING THROUGH PROTOCOL”
OPTION #1 – “SUPPORT” THE DEFENSE
TO “PROVIDE THE BACKDROP” / “SET THE STAGE”
“THE RELATIONSHIP WITH RICARDO HAS BECOME FRIGHTENINGLY TOXIC.
AND IT BREAKS YOUR HEART TO THINK THAT IT HAS COME TO THIS.”
OPTION #2 – “CHALLENGE” AND “SUPPORT” THE DEFENSE
TO “CREATE DISSONANCE”
“YOU KNOW THAT, AT SOME POINT, YOU WILL HAVE TO LEAVE RICARDO
IF YOU ARE EVER TO HAVE A CHANCE AT HAPPINESS BECAUSE
STAYING WITH HIM IS DOING SUCH A NUMBER ON YOUR SELF – ESTEEM.
BUT IT TERRIFIES YOU TO THINK ABOUT BEING OUT THERE ON YOUR OWN.
YOU’RE AFRAID THAT YOU JUST WON’T BE ABLE TO MAKE IT
AND WILL THEN BE FILLED WITH REGRET
THAT YOU LEFT THE SECURITY OF A MARRIAGE,
EVEN IF TO A MAN YOU NO LONGER LOVED.”
OPTION #3 – “SUPPORT” THE ADAPTATION
TO “AFFIRM THE NEW NORMAL”
“IT IS SO SCARY TO BE PLANNING FOR THE INFORMAL SEPARATION.
BUT YOU ARE BEGINNING TO LET YOURSELF KNOW
THAT YOU DESERVE HAPPINESS
AND THAT YOU DO NOT NEED TO CONSIGN YOURSELF
TO A LIFETIME OF MISERY WITH THIS MAN
WHO TREATS YOU WITH SUCH CONTEMPT AND, EVEN, HOSTILITY.”
14

15. 15

16. “OPTIMALLY STRESSFUL”
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 “SAME OLD, SAME OLD”
WHICH IS WHY IT IS “EGO – SYNTONIC”
AND THE PRICE SHE PAYS FOR DOING SO
IN AN EFFORT TO MAKE IT MORE “EGO – DYSTONIC”
16

17. “OPTIMALLY STRESSFUL”
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
17

18. “OPTIMALLY STRESSFUL”
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
MORE SPECIFICALLY
TO TAKE OWNERSHIP OF
THE EARLY – ON TRAUMATIC FAILURE SITUATIONS
THAT SHE IS EVER – BUSY
RECREATING IN HER CURRENT RELATIONSHIPS
18

19. – EVER “EMPATHICALLY ATTUNED” TO THE PATIENT’S “INTERNAL STATE” –
THE PSP THERAPIST – WHENEVER POSSIBLE – WILL OFFER
THESE “OPTIMALLY STRESSFUL” INTERVENTIONS
– CONFLICT STATEMENTS, DISILLUSIONMENT STATEMENTS, AND ACCOUNTABILITY STATEMENTS –
ALL OF WHICH ARE STRATEGICALLY DESIGNED
BOTH TO “SUPPORT” THE PATIENT’S DEFENSES
– BY “BEING WITH THE PATIENT WHERE SHE IS” –
AND TO “CHALLENGE” THE PATIENT’S DEFENSES
– BY “DIRECTING THE PATIENT’S ATTENTION TO ELSEWHERE” –
ALWAYS WITH AN EYE TO GENERATING ONGOING
“HEALING CYCLES” OF “DISRUPTION” AND “REPAIR”
– REPEATED “DESTABILIZATION” OF “DEFENSIVE NEED”
AND SUBSEQUENT “RESTABILIZATION” AT EVER – MORE ROBUST
LEVELS OF “RESILIENCE” AND “ADAPTIVE CAPACITY” –
AS “INNATE RESILIENCE” IS REINFORCED BY “ADAPTIVE RESILIENCE”
SUCH THAT THE PATIENT WILL ULTIMATELY EVOLVE
FROM “RESTRICTIVE DEFENSE” TO “MORE EXPANSIVE ADAPTABILITY”
THE DESIGN OF THESE “GROWTH – INCENTIVIZING” INTERVENTIONS
– THAT “PRECIPITATE DISRUPTION” IN ORDER TO “TRIGGER RECOVERY” –
IS INDEED BOTH AN “ART” (INTUITIVE) AND A “SCIENCE” (ANALYTIC)
19

20. MORE SPECIFICALLY
MODEL 1 CONFLICT STATEMENTS –
COGNITIVE / “HEAD” / THOUGHTS
TARGET THE PATIENT’S “INTERNAL CONFLICTEDNESS”
AND RELUCTANCE TO “ACKNOWLEDGE”
ANXIETY – PROVOKING “TRUTHS”
ABOUT THE “SELF”
MODEL 2 DISILLUSIONMENT STATEMENTS –
AFFECTIVE / “HEART” / FEELINGS
TARGET THE PATIENT’S “RELENTLESS PURSUITS”
AND RELUCTANCE TO “CONFRONT AND GRIEVE”
ANXIETY – PROVOKING “TRUTHS”
ABOUT THE “OBJECTS OF HER DESIRE”
MODEL 3 ACCOUNTABILITY STATEMENTS –
RELATIONAL / “HAND” / BEHAVIORS
TARGET THE PATIENT’S “COMPULSIVE RE – ENACTMENTS”
AND RELUCTANCE TO “TAKE OWNERSHIP OF”
ANXIETY – PROVOKING “TRUTHS”
ABOUT THE “SELF – IN – RELATION”
(THE STONE CENTER AT WELLESLEY COLLEGE)
20

21. 21
HEAD
MODEL 1
HEART
MODEL 2
HANDS
MODEL 3

22. MODEL 1 – COGNITIVE
“CLASSICAL PSYCHOANALYSIS”
THE THERAPEUTIC ACTION FOCUSES ON “INTERPRETING”
ANXIETY – PROVOKING TRUTHS
ABOUT THE “SELF”
– AND FEATURES OPTIMALLY STRESSFUL “CONFLICT STATEMENTS” –
MODEL 2 – AFFECTIVE
“SELF PSYCHOLOGY” AND OTHER “DEFICIT THEORIES”
THE THERAPEUTIC ACTION FOCUSES ON “GRIEVING”
ANXIETY – PROVOKING TRUTHS
ABOUT THE “OBJECTS OF HER DESIRE”
– AND FEATURES OPTIMALLY STRESSFUL “DISILLUSIONMENT STATEMENTS” –
MODEL 3 – RELATIONAL
“CONTEMPORARY RELATIONAL THEORY”
THE THERAPEUTIC ACTION FOCUSES ON “OWNING”
ANXIETY – PROVOKING TRUTHS
ABOUT THE “SELF – IN – RELATION”
– AND FEATURES OPTIMALLY STRESSFUL “ACCOUNTABILITY STATEMENTS” –
22

23. MODEL 1 – INTERPRETING
– JUDICIOUS AND ONGOING USE OF
OPTIMALLY STRESSFUL “CONFLICT STATEMENTS” –
THE THERAPEUTIC ACTION INVOLVES
“RESOLVING INTERNAL CONFLICTEDNESS”
BY “INTERPRETING THE RESISTANCE”
MODEL 2 – GRIEVING
– JUDICIOUS AND ONGOING USE OF
OPTIMALLY STRESSFUL “DISILLUSIONMENT STATEMENTS” –
THE THERAPEUTIC ACTION INVOLVES
ADAPTIVELY “INTERNALIZING EXTERNAL GOOD”
BY “GRIEVING DISAPPOINTMENT”
MODEL 3 – NEGOTIATING
– JUDICIOUS AND ONGOING USE OF
OPTIMALLY STRESSFUL “ACCOUNTABILITY STATEMENTS” –
THE THERAPEUTIC ACTION INVOLVES
“DETOXIFYING INTERNAL BADNESS”
BY “NEGOTIATING AT THE INTIMATE EDGE OF RELATEDNESS”
DARLENE EHRENBERG (1992)
23

24. PLEASE NOTE
IF YOU DO INDEED EMBRACE THE IDEA
THAT “OPTIMAL STRESS” IS NEEDED TO “INCENTIVIZE”
“DEEP AND SUSTAINED PSYCHODYNAMIC CHANGE,”
THEN IT WILL BE IMPORTANT
THAT YOU HELP THE PATIENT “WORK THROUGH”
“OPTIMALLY STRESSFUL” SITUATIONS
THAT ARISE FOR HER OUTSIDE THE TREATMENT
BUT IT WILL BE EVEN MORE IMPORTANT
THAT YOU GIVE THE PATIENT
OPPORTUNITIES TO “WORK THROUGH”
“OPTIMALLY STRESSFUL” SITUATIONS
THAT ARISE FOR HER INSIDE THE TREATMENT
– NAMELY, IN THE RELATIONSHIP WITH YOU –
(BOTH THE “TRANSFERNCE” AND THE “REAL RELATIONSHIP”)
OFFERING “WISE COUNSEL” AND “PROBLEM – SOLVING ADVICE”
MIGHT WELL HELP THE PATIENT TEMPORARILY
BUT WILL NOT “TRIGGER” “CHARACTEROLOGICAL CHANGE”
24

25. AS WE SHALL SEE
WHAT THIS MEANS IS THAT YOU MUST BE ABLE TO TOLERATE
SOMETIMES BEING EXPERIENCED AS A “BAD OBJECT” (MODEL 2)
AND SOMETIMES EVEN BEING MADE INTO A “BAD OBJECT” (MODEL 3)
INDEED
IF THE MODEL 2 THERAPIST CANNOT TOLERATE
– AT LEAST EVERY NOW AND THEN –
“BREAKING THE PATIENT’S HEART”
THE THERAPIST WILL BE ROBBING THE PATIENT
OF THE OPPORTUNITY “ADAPTIVELY TO INTERNALIZE”
“MISSING PSYCHOLOGICAL FUNCTIONS”
BY WAY OF “OPTIMAL DISILLUSIONMENT,” “TRANSMUTING INTERNALIZATION,”
AND “SERIAL ACCRETION” OF ”SELF STRUCTURE”
BY THE SAME TOKEN
IF THE MODEL 3 THERAPIST
REFUSES TO PARTICIPATE AS SOMEONE WHO
– AT LEAST EVERY NOW AND THEN –
“INITIALLY RE – TRAUMATIZES BUT ULTIMATELY RELENTS”
THE THERAPIST WILL BE ROBBING THE PATIENT
OF THE OPPORTUNITY “ADAPTIVELY TO REWORK”
HER “INTROJECTED BOLUSES OF TOXICITY”
BY WAY OF “PROJECTIVE IDENTIFICATION,” “RELATIONAL DETOXIFICATION,”
AND “SERIAL DILUTION” OF “PATHOGENIC INTROJECTS”
25

26. 26

27. AS WE SHALL SEE
“OPTIMALLY STRESSFUL” INTERVENTIONS
USE THE CONJUNCTIONS “BUT” AND “AND”
TO JUXTAPOSE “PARTS” OF THE PATIENT’S “SELF – EXPERIENCE”
THEREBY CREATING “INTERNAL TENSION / DISSONANCE” BETWEEN
THE “LESS – HEALTHY PARTS”
THAT HAVE THE “NEED TO DEFEND” IN THE FACE OF STRESSORS
AND THE “MORE – HEALTHY PARTS”
THAT HAVE THE “CAPACITY TO ADAPT”
MODEL 1 CONFLICT STATEMENTS
– FROM “RESISTANCE” TO “AWARENESS” –
“ADAPTIVE CAPACITY” FOR “AWARENESS”
BUT “DEFENSIVE NEED” TO “RESIST”
MODEL 2 DISILLUSIONMENT STATEMENTS
– FROM “RELENTLESS HOPE” TO “ACCEPTANCE” –
“DEFENSIVE NEED” FOR “RELENTLESS HOPE”
BUT “ADAPTIVE CAPACITY” TO “CONFRONT”
AND “ADAPTIVE CAPACITY” TO “GRIEVE”
MODEL 3 ACCOUNTABILITY STATEMENTS
– FROM “RE – ENACTMENT” TO “ACCOUNTABILITY” –
“DEFENSIVE NEED” TO “RE – ENACT”
BUT “ADAPTIVE CAPACITY” FOR “ACCOUNTABILITY”
27

28. THE OVERARCHING AIM OF THESE
“OPTIMALLY STRESSFUL” INTERVENTIONS
MODEL 1 – ENHANCEMENT OF KNOWLEDGE “WITHIN”
THE INTERPRETIVE PERSPECTIVE
OF CLASSICAL PSYCHOANALYSIS
COGNITIVE – “TAMING OF THE ID”
AND “STRENGTHENING OF THE EGO”
MODEL 2 – PROVISION OF EXPERIENCE “FOR”
THE CORRECTIVE – PROVISION PERSPECTIVE
OF SELF PSYCHOLOGY
AFFECTIVE – “FILLING IN OF DEFICIT”
AND “CONSOLIDATION OF THE SELF”
MODEL 3 – ENGAGEMENT IN RELATIONSHIP “WITH”
THE INTERSUBJECTIVE PERSPECTIVE
OF CONTEMPORARY RELATIONAL THEORY
RELATIONAL – “DETOXIFICATION OF PATHOGENICITY”
AND “ACCOUNTABILITY FOR THE RELATIONAL SELF”
28

29. THE NET RESULT OF “WORKING THROUGH”
THE PATIENT’S “RIGID DEFENSES”
MODEL 1
A STRONGER, MORE EMPOWERED, AND MORE AWARE “EGO”
NO LONGER AS “RESISTANT” TO ACKNOWLEDGING
DISCOMFITING TRUTHS ABOUT THE “SELF”
MODEL 2
A MORE CONSOLIDATED, COMPASSIONATE, AND ACCEPTING “SELF”
NO LONGER AS “RELENTLESS” IN ITS ENTITLED PURSUIT OF
EXTERNAL PROVISION FROM THE “OBJECT”
MODEL 3
A MORE ACCOUNTABLE “SELF – IN – RELATION”
NO LONGER AS COMPULSIVELY AND UNWITTINGLY “RE – ENACTING”
UNMASTERED EARLY – ON RELATIONAL TRAUMAS
AT THE “INTIMATE EDGE” OF RELATEDNESS
29

30. 30

31. MODEL 1
THE
INTERPRETIVE
PERSPECTIVE
OF
CLASSICAL
PSYCHOANALYSIS
“STRUCTURAL CONFLICT”
BETWEEN “HEALTHY (BUT ANXIETY – PROVOKING) FORCES”
PRESSING “YES”
AND “UNHEALTHY (BUT ANXIETY – RELIEVING) COUNTERFORCES”
DEFENDING “NO”
31

32. MOST OF OUR PATIENTS ARE CONFLICTED
ABOUT MOST THINGS MOST OF THE TIME
WITH ONE PART OF THEM
INVESTED IN MAINTAINING “SAME OLD, SAME OLD”
AND ANOTHER PART OF THEM BEGINNING TO APPRECIATE
– ALBEIT IT WITH EVER – INCREASING ANXIETY –
BOTH THE “PRICE PAID” FOR THAT MISPLACED LOYALTY
AND THE “POSSIBILITY” OF
“SOMETHING NEW, DIFFERENT, AND BETTER”
MODEL 1 CONFLICT STATEMENTS
ARE UNIVERSALLY APPLICABLE INTERVENTIONS
THAT TARGET THESE STATES OF
“INTERNAL DIVIDEDNESS” OR “CONFLICTEDNESS”
ON THE ONE HAND
HIGHLIGHTING THE PATIENT’S EVER – EVOLVING “AWARENESS”
OF HER “INVESTMENT IN” “SAME OLD, SAME OLD”
ON THE OTHER HAND
HIGHLIGHTING THE PATIENT’S EVER – EVOLVING “AWARENESS”
OF THE “PRICE PAID” FOR THAT INVESTMENT
– AND THAT IT DOESN’T HAVE TO BE THAT WAY FOR ALWAYS –
32

33. AS WE KNOW, “MINIMALLY STRESSFUL” EMPATHIC STATEMENTS
OFFER “SUPPORT” AND “PROVIDE THE BACKDROP” / “SET THE STAGE”
BUT DO NOT SPECIFICALLY INCENTIVIZE DEEP AND ENDURING CHANGE
“OPTIMALLY STRESSFUL” CONFLICT STATEMENTS,
HOWEVER, ARE STRATEGICALLY DESIGNED
TO OFFER AN ARTFUL COMBINATION OF
“CHALLENGE”
– BY HIGHLIGHTING EITHER THE “PRICE PAID” FOR “OLD BAD”
OR THE “POSSIBILITY” OF “NEW GOOD” –
AND “SUPPORT”
– BY RESONATING EMPATHICALLY WITH THE “INVESTMENT IN” “OLD BAD” –
THE NET RESULT OF THIS
INTUITIVELY TITRATED BLEND OF
“CHALLENGE”
– WHICH PROVOKES THE PATIENT’S ANXIETY –
AND “SUPPORT”
– WHICH EASES IT –
WILL BE THE GENERATION OF
INCENTIVIZING “OPTIMAL STRESS”
NECESSARY IF DEEP AND ENDURING
PSYCHODYNAMIC CHANGE IS THE ULTIMATE GOAL
33

34. “WORKING THROUGH THE RESISTANCE”
“OPTIMALLY STRESSFUL”
MODEL 1 CONFLICT STATEMENTS
“YOU KNOW THAT … , BUT (MADE ANXIOUS)
YOU FIND YOURSELF THINKING / FEELING / DOING
IN ORDER NOT TO HAVE TO KNOW … ”
34

35. “WORKING THROUGH THE RESISTANCE” 📕 📕
“OPTIMALLY STRESSFUL” CONFLICT STATEMENTS
ARE STRATEGICALLY DESIGNED
FIRST TO INCREASE ANXIETY
BY “CHALLENGING” THE DEFENSE
YOU HAVE THE “ADAPTIVE CAPACITY” TO “KNOW” ... ,
AND THEN TO DECREASE ANXIETY
BY “SUPPORTING” THE DEFENSE
BUT YOU HAVE THE “DEFENSIVE NEED” TO “RESIST” THAT “KNOWING” ...
ALL WITH AN EYE
FIRST TO “MAKING EXPLICIT”
THE CONFLICT WITHIN THE PATIENT
BETWEEN THE “HEALTHY PART” OF HER
– THAT DOES INDEED “KNOW” –
AND THE “LESS – HEALTHY PART” OF HER
– THAT “RESISTS” THAT “KNOWING” –
AND THEN TO “GENERATING GROWTH – PROMOTING DISSONANCE”
BETWEEN THOSE TWO “PARTS” OF HER “SELF – EXPERIENCE”
35

36. “OPTIMALLY STRESSFUL” MODEL 1 CONFLICT STATEMENTS
FIRST “CHALLENGE” BY “DIRECTING THE PATIENT’S ATTENTION TO WHERE YOU WANT HER TO GO”
AND THEN “SUPPORT” BY “RESONATING EMPATHICALLY WITH WHERE SHE IS”
“YOU KNOW THAT IF YOU ARE EVER TO GET ON
WITH YOUR LIFE, YOU’LL HAVE TO LET GO OF YOUR CONVICTION
THAT YOUR CHILDHOOD SCARRED YOU FOREVER. BUT IT’S HARD
NOT TO FEEL LIKE DAMAGED GOODS WHEN YOU GREW UP
IN A HORRIBLY ABUSIVE HOUSEHOLD WITH A MEAN AND NASTY
MOTHER WHO KEPT TELLING YOU THAT YOU WERE A LOSER.”
“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 HAD TO SUFFER
OVER THE COURSE OF THE YEARS.”
“YOU KNOW THAT IF YOUR RELATIONSHIP WITH ELANA
IS TO SURVIVE, YOU’LL NEED TO TAKE AT LEAST SOME
RESPONSIBILITY FOR THE PART YOU’RE PLAYING IN THE
INCREDIBLY ABUSIVE FIGHTS THAT YOU AND SHE HAVE BEEN 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!” 36

37. BY LOCATING WITHIN THE PATIENT
THE CONFLICT BETWEEN
WHAT SHE (ADAPTIVELY) “KNOWS”
AND WHAT SHE, MADE ANXIOUS,
(DEFENSIVELY) “FINDS HERSELF”
“THINKING, FEELING, OR DOING”
IN ORDER NOT TO HAVE TO CONFRONT
THAT “ANXIETY – PROVOKING REALITY,”
THE THERAPIST IS DEFTLY SIDESTEPPING
THE POTENTIAL FOR CONFLICT
BETWEEN HERSELF AND THE PATIENT
MORE SPECIFICALLY
WHEN THE THERAPIST INTRODUCES
A CONFLICT STATEMENT WITH
“YOU KNOW THAT … , ”
SHE IS FORCING THE PATIENT
TO TAKE RESPONSIBILITY
FOR WHAT THE PATIENT
– ALBEIT BEGRUDGINGLY –
REALLY DOES KNOW 37

38. IF, INSTEAD, THE THERAPIST
– IN A MISGUIDED ATTEMPT TO URGE THE PATIENT FORWARD –
RESORTS SIMPLY
TO TELLING THE PATIENT
WHAT THE THERAPIST KNOWS,
NOT ONLY
WILL THE THERAPIST
BE RUNNING THE RISK
OF FORCING THE PATIENT
TO BECOME EVER – MORE ENTRENCHED
IN HER DEFENSIVE STANCE OF PROTEST
BUT THE THERAPIST WILL ALSO
BE DEPRIVING THE PATIENT
OF ANY INCENTIVE
TO TAKE RESPONSIBILITY
FOR HER OWN DESIRE TO GET BETTER
38

39. IN OTHER WORDS
AS A RESULT OF
THE JUDICIOUS AND ONGOING 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
– IN OTHER WORDS, HER “AMBIVALENCE” –
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 (ADAPTIVE) “VOICE OF REALITY”
BY OVERZEALOUSLY ADVOCATING FOR THE PATIENT
TO DO THE “RIGHT / HEALTHY” THING
– A STANCE THAT THEN LEAVES THE PATIENT, MADE ANXIOUS,
NO CHOICE BUT TO BECOME THE (DEFENSIVE) “VOICE OF OPPOSITION” –
39

40. PLEASE 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”
THE THERAPIST IS ATTEMPTING
TO HIGHLIGHT THE FACT
THAT EVEN IF, FOR NOW,
THE PATIENT WOULD SEEM TO BE
ENTRENCHED IN PROTESTING
HER NEED TO MAINTAIN THINGS
AS THEY ARE,
AT ANOTHER POINT IN TIME,
THAT COULD CHANGE
40

41. “OPTIMALLY STRESSFUL” MODEL 1 CONFLICT STATEMENTS
FIRST “CHALLENGE” TO “PROVOKE” ANXIETY
AND THEN “SUPPORT” TO “EASE” IT
“YOU KNOW THAT ULTIMATELY
YOU WILL NEED TO CONFRONT AND GRIEVE THE REALITY
THAT TOM, LIKE YOUR DAD, 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 WHAT YOU CAN DO TO MAKE HIM LOVE YOU MORE.”
“YOU KNOW THAT SOMEDAY
YOU WILL HAVE TO LET SOMEBODY IN
IF YOU’RE EVER TO HAVE
A MEANINGFUL RELATIONSHIP.
BUT, AT THE MOMENT, THE THOUGHT
OF MAKING YOURSELF THAT VULNERABLE
IS SIMPLY OUT OF THE QUESTION.
THERE IS ABSOLUTELY NO WAY
YOU ARE WILLING TO RUN THE RISK
OF BEING HURT EVER AGAIN.”
41

42. AS WE SHALL SEE
PARTICULARLY USEFUL FOR “WORKING THROUGH”
THE PATIENT’S “CONFLICTEDNESS”
BETWEEN EMBRACING “NEW GOOD”
AND REMAINING ENTRENCHED IN “OLD BAD” ARE
“YOU KNOW IT COULD BE BETTER”
CONFLICT STATEMENTS
WHICH HIGHLIGHT
THE “ANXIETY – PROVOKING GOOD THAT COULD BE”
AND
“PRICE PAID”
CONFLICT STATEMENTS
WHICH HIGHLIGHT
THE “ANXIETY – PROVOKING COST OF BAD”
BOTH OF WHICH ARE
STRATEGICALLY DESIGNED TO GENERATE
“GROWTH – INCENTIVIZING” DISSONANCE
42

43. “YOU KNOW IT COULD BE BETTER”
CONFLICT STATEMENTS
TO CREATE
“INTERNAL DISSONANCE”
BETWEEN
THE “POSSIBILITY” OF “NEW GOOD”
AND THE “REALITY” OF “OLD BAD”
43

44. IN ORDER TO “GENERATE TENSION” WITHIN THE PATIENT
BETWEEN HER “EVER – EVOLVING AWARENESS”
OF THE “DISCREPANCY” BETWEEN
THE “POSSIBILITY” OF “SOMETHING NEW, DIFFERENT, AND BETTER”
AND THE “REALITY” OF “SAME OLD, SAME OLD”
WHENEVER POSSIBLE
THE THERAPIST WILL, THEREFORE, OFFER
“YOU KNOW IT COULD BE BETTER” CONFLICT STATEMENTS
THAT HIGHLIGHT BOTH “POSSIBILITY” AND “REALITY”
“YOU KNOW THAT < POSSIBILITY > ... ,
BUT YOU REMAIN < REALITY > EVEN SO ... ”
“YOU KNOW THAT < SOMETHING NEW, DIFFERENT, AND BETTER > ... ,
BUT YOU REMAIN < SAME OLD, SAME OLD > EVEN SO ... ”
IN THE HOPE OF “GALVANIZING” THE PATIENT
TO “TAKE ACTION”
TO “ACTUALIZE” THE “ENVISIONED POSSIBILITY”
44

45. MODEL 1
“YOU KNOW IT COULD BE BETTER” CONFLICT STATEMENTS
FIRST “CHALLENGE” BY “DIRECTING THE PATIENT’S ATTENTION”
TO THE “POSSIBILITY” OF “NEW GOOD”
AND THEN “SUPPORT” BY “RESONATING EMPATHICALLY”
WITH THE “REALITY” OF “OLD BAD”
“YOU KNOW THAT IT WOULD BE SO MUCH MORE REWARDING
WERE YOU TO GET A JOB THAT CAPITALIZED UPON
YOUR STRENGTHS AND WHAT YOU MOST ENJOY DOING,
NAMELY, CONNECTING WITH PEOPLE. BUT YOU FIND
YOURSELF HESITATING BECAUSE IT IS SIMPLY TOO
OVERWHELMING TO THINK ABOUT LOSING THE FINANCIAL
SECURITY THAT YOU HAVE IN YOUR CURRENT POSITION.”
“YOU KNOW THAT YOU WILL NOT ACTUALLY BE HAPPY UNTIL
YOU GET OUT OF THE TOXIC RELATIONSHIP WITH JORGE
AND LET YOURSELF FIND SOMEONE WHO WILL REALLY
APPRECIATE – AND LOVE – YOU. BUT THE THOUGHT OF
ENDING IT WITH JORGE, WHEN YOU HAVE SPENT SO MANY
YEARS TRYING TO MAKE IT WORK, IS ABSOLUTELY DEVASTATING –
AND YOUR FEAR IS THAT YOU SIMPLY WOULDN’T SURVIVE.” 45

46. “PRICE PAID”
CONFLICT STATEMENTS
TO CREATE
“INTERNAL DISSONANCE”
BETWEEN
THE “PAIN / COST”
OF “OLD BAD”
AND THE “GAIN / BENEFIT”
OF “OLD BAD”
46

47. IN ORDER TO “SPOTLIGHT” THE “AMBIVALENCE” OF
THE PATIENT’S “ATTACHMENT” TO HER “DEFENSE”
AND TO “GENERATE TENSION” WITHIN THE PATIENT
BETWEEN HER “EVER – EVOLVING AWARENESS” OF
BOTH THE “COST” AND THE “BENEFIT”
OF CLINGING TO THE DEFENSE
WHENEVER POSSIBLE
THE THERAPIST WILL, THEREFORE, OFFER
“PRICE PAID” CONFLICT STATEMENTS
THAT HIGHLIGHT BOTH THE “PAIN” AND THE “GAIN”
“YOU KNOW THAT < PAIN > ... ,
BUT YOU REMAIN < GAIN > EVEN SO ... ”
“YOU KNOW THAT < PRICE PAID > ... ,
BUT YOU REMAIN < INVESTED IN > EVEN SO ... ”
IN THE HOPE OF MAKING THE “AMBIVALENTLY HELD DEFENSE”
“LESS EGO – SYNTONIC” AND “MORE EGO – DYSTONIC”
AND OF “GALVANIZING” THE PATIENT TO “TAKE ACTION”
TO “RESOLVE THE INTERNAL DISSONANCE”
AND “RESTORE THE HOMEOSTATIC BALANCE”
47

48. MODEL 1 “PRICE PAID” CONFLICT STATEMENTS
FIRST “CHALLENGE” BY “DIRECTING THE PATIENT’S ATTENTION”
TO THE “PAIN / COST / PRICE PAID”
AND THEN “SUPPORT” BY “RESONATING EMPATHICALLY”
WITH THE “(SECONDARY) GAIN / BENEFIT / PAYOFF” OF “OLD BAD”
“YOU KNOW THAT YOU ARE PAYING A STEEP PRICE
FOR YOUR REFUSAL TO STOP SMOKING –
OF PARTICULAR CONCERN
BECAUSE OF YOUR RECURRENT LUNG INFECTIONS.
BUT, AT THIS POINT, YOU ARE NOT QUITE YET PREPARED TO
TAKE THAT STEP BECAUSE YOU FEEL YOU HAVE SO LITTLE
ELSE IN YOUR LIFE THAT GIVES YOU ANY REAL PLEASURE.”
“YOU KNOW THAT YOU WILL NEED SOMEDAY
TO GET SERIOUS ABOUT LOSING THE EXTRA WEIGHT
BECAUSE IT REALLY IS BEGINNING TO IMPACT YOUR HEALTH.
BUT, RIGHT NOW, YOU CAN’T IMAGINE BEING ABLE
TO PUT YOURSELF ON A RESTRICTIVE DIET
BECAUSE YOU ARE ALREADY FEELING SO DEPRIVED
IN ALL THE OTHER AREAS OF YOUR LIFE.”
48

49. A MNEMONIC TO HELP YOU REMEMBER 😊
WHERE DEFENSE WAS, THERE SHALL ADAPTATION BE
AS LONG AS THE (SECONDARY) “GAIN” IS
GREATER THAN THE “PAIN”
– THE DEFENSE “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 “COST” AND THE “BENEFIT”
ONCE THE “PAIN” BECOMES
GREATER THAN THE “GAIN”
– THE DEFENSE “MORE EGO – DYSTONIC THAN EGO – SYNTONIC” –
THE STRESS AND “STRAIN” OF THE
“COGNITIVE AND AFFECTIVE DISSONANCE”
– THEREBY CREATED –
BETWEEN THE “PAIN” AND THE “GAIN”
WILL BE SUCH THAT
IT WILL PROVIDE THE IMPETUS
NEEDED FOR THE PATIENT GRADUALLY … 49

50. … TO “RELINQUISH HER ATTACHMENT”
TO THE “DYSFUNCTIONAL DEFENSE”
IN ORDER TO
“RESOLVE THE STRUCTURAL CONFLICT”
AND “RESTORE THE HOMEOSTATIC BALANCE”
AS A RESULT OF THIS “WORKING THROUGH”
OF THE “DEFENSE” / “RESISTANCE”
THE “NOW STRONGER” AND “MORE INSIGHTFUL” EGO
WILL BE BETTER ABLE TO “REGULATE”
THE ID’S “NOW TAMER” AND “MORE MANAGEABLE” ENERGIES
– AGANI, FREUD’S WELL – KNOWN “STRENGTHEN THE EGO” AND “TAME THE ID” –
SUCH THAT
– NO LONGER THWARTED –
THE ID’S “POWER”
CAN BE “HARNESSED” BY THE EGO
AND “CHANNELED” INTO
“MORE CONSTRUCTIVE ENDEAVORS”
AND “WORTHWHILE PURSUITS”
THE ID’S “MODULATED ENERGY”
NOW PROVIDING THE “PROPULSIVE FUEL”
FOR “FORWARD MOVEMENT”
50

51. IN OTHER WORDS
ONGOING USE OF “OPTIMALLY STRESSFUL” CONFLICT STATEMENTS
WILL HAVE “STRENGTHENED THE EGO” AND “TAMED THE ID”
SUCH THAT “ID ENERGY”
– ONCE “REINED IN” BY “EGO RESISTANCE” –
WILL NOW BE “FREED UP” ENOUGH
THAT IT CAN BE USED TO “EMPOWER”
THE “REALIZATION OF LIFE GOALS”
FREUD’S (1937) “HORSE AND RIDER”
IS INDEED AN APT METAPHOR
FOR THE “THERAPEUTIC ACTION” IN MODEL 1
AS A RESULT OF THE “WORKING THROUGH PROCESS”
FREUD’S RIDER
– A “NOW STRONGER” AND “MORE EMPOWERED” EGO –
WILL HAVE BECOME “MORE SKILLED”
AT “HARNESSING THE “POWER” OF THE HORSE
– A “NOW BETTER REGULATABLE” ID –
SUCH THAT HORSE AND RIDER
WILL BE ABLE TO MOVE FORWARD
HARMONIOUSLY AND IN SYNC
– NO LONGER IN CONFLICT BUT IN COLLABORATION –
51

52. INDEED
AS THE HORSE (ID) IS “TAMED”
AND THE RIDER (EGO) “STRENGTHENED”
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”
52

53. 53

54. MODEL 2
THE
CORRECTIVE – PROVISION
PERSPECTIVE
OF SELF PSYCHOLOGY AND
OTHER “DEFICIT” THEORIES
“STRUCTURAL DEFICIT”
– “IMPAIRED CAPACITY” TO BE A “GOOD PARENT” TO ONESELF –
THIS “DEFICIT” CREATES THE “NEED”
THE “NEED” IS TO FIND
IN THE “HERE – AND – NOW”
THE “GOOD PARENT” WHO WAS NOT TO BE FOUND
IN THE “THERE – AND – THEN”
A “NEED” THAT THEN FUELS
THE “RELENTLESSNESS” OF THE PATIENT’S “PURSUITS”
54

55. THE “THERAPEUTIC ACTION” IN MODEL 2
A CORRECTIVE – PROVISION MODEL
– A DEFICIENCY – COMPENSATION MODEL –
YES, THE MODEL 2 THERAPIST
PROVIDES THE “HOLDING”
AND THE “BEING MET”
THAT WERE NOT
CONSISTENTLY AND RELIABLY
PROVIDED BY THE PARENT
THIS REPARATION FUNCTIONS
AS A “SYMBOLIC CORRECTIVE”
FOR THE EARLY – ON
“RELATIONAL DEPRIVATION AND NEGLECT”
THE EARLY – ON “FAILURES IN ENVIRONMENTAL PROVISION”
BUT THERE IS MORE ...
55

56. ALTHOUGH SOME MODEL 2 THEORISTS
BELIEVE THAT IT IS
THE “EXPERIENCE OF GRATIFICATION” ITSELF
THAT WILL BE “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” –
HOWARD BACAL’S (1998) “OPTIMAL RESPONSIVENESS”
THAT WILL PROVIDE
BOTH “IMPETUS” AND “OPPORTUNITY”
FOR “FILLING IN OF STRUCTURAL DEFICIT”
AND “CONSOLIDATION OF THE “SELF”
56

57. AFTER ALL
IF THERE IS NO “THWARTING OF DESIRE,”
THEN THERE WILL BE NOTHING
THAT NEEDS TO BE MASTERED
AND, THEREFORE, NO “IMPETUS”
FOR “INTERNALIZING” WHATEVER “GOOD SUPPLIES”
– “ENVIRONMENTAL PROVISIONS” –
THERE HAD BEEN PRIOR TO “BEING THWARTED”
THESE “TRANSMUTING INTERNALIZATIONS”
– TRANSMUTING = STRUCTURE – BUILDING –
HEINZ KOHUT (1966)
ARE INDEED “ADAPTIVE”
INASMUCH AS THEY MAKE IT POSSIBLE
FOR THE PATIENT TO “PRESERVE INTERNALLY”
A PIECE OF THE “ORIGINAL EXPERIENCE”
OF “EXTERNAL GOODNESS”
57

58. SO 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, TO GRIEVE, TO ACCEPT, TO FORGIVE,
TO INTERNALIZE WHAT GOOD THERE WAS,
TO SEPARATE, TO LET GO, AND TO MOVE ON
ULTIMATELY EVOLVING TO A PLACE OF
APPRECIATION AND GRATITUDE
FOR ALL THE GOOD THAT WAS (AND IS)
58

59. AS “STRUCTURAL DEFICIT” IS “FILLED IN”
AND “EXTERNAL GOODNESS” “INTERNALIZED”
THE “RELENTLESSNESS” WITH WHICH THE PATIENT
“PURSUES” THE “OBJECTS OF HER DESIRE”
– THAT IS, HER “RELENTLESS HOPE” AND “REFUSAL TO ACCEPT”
THE “LIMITATIONS, SEPARATENESS, AND IMMUTABILITY” OF HER OBJECTS –
WILL BE GRADUALLY “TAMED”
AND SHE WILL EVOLVE TO A PLACE OF
“SERENE ACCEPTANCE”
OF THE SOBERING 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” 😊
59

60. “OPTIMALLY STRESSFUL” MODEL 2 DISILLUSIONMENT STATEMENTS
FACILITATE THE “NECESSARY GRIEVING” OF “DISAPPOINTMENTS”
“YOU HAD SO HOPED THAT … ,
BUT YOU ARE BEGINNING TO REALIZE THAT … ,
AND IT DEVASTATES / ENRAGES YOU … ”
THE THERAPEUTIC GOAL IS TO CREATE “INCENTIVIZING” TENSION
BETWEEN “DEFENSIVE NEED” FOR “RELENTLESS HOPE”
AND “ADAPTIVE CAPACITY” TO “CONFRONT, GRIEVE, AND ACCEPT”
FIRST “HIGHLIGHT” WHAT “HAD BEEN”
THE PATIENT’S “ILLUSION”
– “DEFENSIVE NEED” FOR “RELENTLESS HOPE” –
THEN “HIGHLIGHT” THE “REALITY”
OF THE PATIENT’S “DISILLUSIONMENT”
– “ADAPTIVE CAPACITY” TO “CONFRONT” –
FINALLY, “RESONATE EMPATHICALLY”
WITH THE “PAIN” OF THE PATIENT’S “GRIEF”
– “ADAPTIVE CAPACITY” TO “FEEL” THE ACTUAL “HEARTBREAK” –
60

61. “OPTIMALLY STRESSFUL” MODEL 2 DISILLUSIONMENT STATEMENTS
“YOU HAD SO HOPED THAT I WOULD TELL YOU WHAT TO DO.
BUT YOU ARE BEGINNING TO REALIZE THAT I DON’T SIMPLY
GIVE YOU THE ANSWERS – AND IT INFURIATES YOU.”
“YOU HAD SO HOPED THAT YOUR DAUGHTER
WOULD REACH OUT TO YOU WHEN YOU WERE SICK.
BUT YOU ARE BEGINNING TO REALIZE THAT,
FOR NOW, YOU ARE NOT A TOP PRIORITY FOR HER –
AND IT IS A DEVASTATING LOSS.”
“YOU HAD SO HOPED THAT YOUR HUSBAND WOULD ASK
YOU HOW HE COULD HELP WITH THE DINNER PREPARATIONS.
BUT YOU ARE STARTING TO APPRECIATE THAT OFFERING
TO HELP WITH HOUSEHOLD THINGS LIKE THAT IS NOT
HIS THING – AND IT SADDENS AND UPSETS YOU TERRIBLY.”
“YOU WOULD SO HAVE WISHED THAT I COULD KNOW WHAT YOU
WERE THINKING WITHOUT YOUR HAVING TO SAY IT.
BUT YOU ARE COMING TO SEE THAT IT DOES NOT ALWAYS
WORK THIS WAY – AND THAT BREAKS YOUR HEART.”
61

62. “OPTIMALLY STRESSFUL” MODEL 2 DISILLUSIONMENT STATEMENTS
“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.”
“YOU HAD SO HOPED THAT YOUR MOTHER WOULD APOLOGIZE.
BUT YOU ARE BEGINNING TO ACCEPT THAT SHE SIMPLY
DOES NOT HOLD HERSELF ACCOUNTABLE,
WHICH IS BOTH ENRAGING AND DEVASTATING.”
“ALTHOUGH YOU KNEW IT WOULD TAKE TIME, YOU HAD HOPED THAT YOU
WOULD BE FEELING BETTER AFTER THESE SEVERAL WEEKS OF THERAPY.
IT REALLY UPSETS YOU THAT YOU ARE STILL FEELING SUCH DESPAIR.”
“YOU HAD BEEN HOPING THAT I WOULD NOT MAKE THE SAME KINDS OF
MISTAKES THAT EVERYONE ELSE IN YOUR LIFE HAS, WHICH IS WHY
IT IS SO UPSETTING THAT I, TOO, HAVE NOW LET YOU DOWN.”
“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 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 YOUR PAIN GO AWAY.” 62

63. “OPTIMALLY STRESSFUL” MODEL 2 DISILLUSIONMENT STATEMENTS
“YOU KNOW THAT EVENTUALLY YOU WILL NEED TO FACE THE REALITY
THAT YOUR FATHER WILL NEVER CHANGE, AND THIS REALIZATION
IS DEVASTATING BECAUSE YOU HAD SO HOPED THAT 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 IT IS EXCRUCIATINGLY
PAINFUL BECAUSE YOU HAD SO HOPED THAT SOMEDAY
SHE MIGHT ACTUALLY COME TO UNDERSTAND – AND APOLOGIZE.”
“AS YOU BEGIN TO ADMIT TO YOURSELF THAT PROBABLY
PEDRO WILL NEVER BE RIGHT FOR YOU, IT MAKES
YOU INCREDIBLY 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.”
63

64. 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, SHUT DOWN, CLOSED, NUMB,
REFUSING TO FEEL, OR PROTESTING THE UNFAIRNESS
OF IT ALL, THEN NO REAL GRIEVING CAN BE DONE
64

65. 65
“GRIEF IS NATURE’S WAY
OF HEALING A BROKEN HEART”
ROBERTA BECKMANN (1991)

66. GRIEVING
IT IS 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”
ARRIVING ULTIMATELY AT A PLACE OF SERENE
ACCEPTANCE, FORGIVENESS, AND INNER PEACE
IF YOU CANNOT ALWAYS COUNT ON RECEIVING IT FROM THE OUTSIDE,
BETTER THAT YOU INTERNALIZE WHATEVER “EXTERNAL PROVISIONS”
YOU CAN SO THAT THEY WILL ALWAYS BE THERE FOR YOU
AS “INTERNAL RESOURCES” 66

67. THE BAD NEWS WILL BE
THE SADNESS THE PATIENT EXPERIENCES
AS SHE BEGINS TO ACCEPT
THE SOBERING REALITY
THAT DISAPPOINTMENT
IS AN INEVITABLE AND NECESSARY
ASPECT OF RELATIONSHIP
THE GOOD NEWS, HOWEVER, WILL BE
THE WISDOM SHE ACQUIRES
AS SHE COMES TO APPRECIATE
EVER – MORE PROFOUNDLY
THE SUBTLETIES AND NUANCES OF RELATIONSHIP
AND BEGINS TO MAKE HER PEACE
WITH THE HARSH REALITY
OF LIFE’S MANY CHALLENGES
SADDER, YES, BUT ALSO WISER
67

68. 68

69. AS A RESULT OF GENUINE GRIEVING
“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
BUT THAT WE CAN
– AND MUST –
TAKE OWNERSHIP OF
– AND RESPONSIBILITY FOR –
ALL THAT WE CAN CHANGE WITHIN OURSELVES
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
AND HOW WE “POSITION” OURSELVES
IN OUR LIFE GOING FORWARD
69

70. 70

71. HAROLD SEARLES (1979) HAS SUGGESTED
THAT “REALISTIC HOPE”
ARISES IN THE CONTEXT OF
“SURVIVING DISAPPOINTMENT”
71

72. “TRUE HAPPINESS
IS NOT ABOUT
GETTING WHAT YOU WANT
BUT COMING TO WANT
AND APPRECIATE
WHAT YOU HAVE.”
JAPANESE SAYING
72

73. 73
I AM HERE REMINDED OF THE NEW YORKER CARTOON
IN WHICH A GENTLEMAN,
SEATED IN A RESTAURANT NAMED 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.”

74. 74

75. MODEL 3
THE INTERSUBJECTIVE PERSPECTIVE
OF CONTEMPORARY RELATIONAL THEORY
WITH ITS FOCUS ON
THE PATIENT’S “PATHOGENIC INTROJECTS”
“FILTERS” THAT WILL INEVITABLY
CONTAMINATE THE PATIENT’S EXPERIENCE
OF SELF, OTHERS, AND THE WORLD
AND GIVE RISE TO “RELATIONAL CONFLICT”
WHEN “PROJECTED”
THE “HERE – AND – NOW ENGAGEMENT”
BETWEEN TWO “AUTHENTIC SUBJECTS”
AND THE “TURBULENCE” THAT WILL INEVITABLY
ARISE AT THEIR “INTIMATE EDGE”
WHEN THE THERAPIST EITHER
“REACTS DEFENSIVELY” OR “RESPONDS ADAPTIVELY”
TO THE PATIENT’S “PROJECTIONS”
THE “CONTRIBUTIONS” OF BOTH
TO THE “INTERSUBJECTIVE” “IN – BETWEEN”
“CO – CREATION” AND “MUTUALITY OF IMPACT”
USE OF THE THERAPIST’S “AUTHENTIC SELF”
TO “FIND” – AND TO BE “FOUND BY” – THE PATIENT 75

76. “OPTIMALLY STRESSFUL”
MODEL 3 “ACCOUNTABILITY STATEMENTS”
– “RELATIONAL INTERVENTIONS” –
STRATEGICALLY DESIGNED TO TEASE OUT
TRANSFERENCE – COUNTERTRANSFERENCE ENTANGLEMENTS
PROJECTIVE IDENTIFICATIONS / “CRUNCH SITUATIONS” (PAUL RUSSELL)
MUTUAL ENACTMENTS / CO – CREATED THERAPEUTIC IMPASSES
THE “THERAPEUTIC ACTION”
INVOLVES “NEGOTIATING”
AT THE “INTIMATE EDGE”
OF “AUTHENTIC RELATEDNESS”
THE OVERARCHING GOAL OF WHICH
IS DEVELOPMENT OF
“ACCOUNTABILITY”
AND “RELATIONAL MINDFULNESS”
– ON THE PARTS OF BOTH PATIENT AND THERAPIST –
DEBORAH EDEN TULL (2018)
76

77. 77

78. MODEL 3 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 LAMELY, AND NODS GOODBYE
78

79. ALTHOUGH DURING THE SESSION THE THERAPIST (MADE ANXIOUS)
“REACTS DEFENSIVELY” BY “GOING BLANK,”
BETWEEN SESSIONS THE THERAPIST IS ABLE TO “RECOVER HER
THERAPEUTIC EFFECTIVENESS” BY “STEPPING BACK” ENOUGH
FROM HER EXPERIENCE OF HAVING BEEN “SLAMMED”
THAT, NOW LESS ANXIOUS, SHE IS ABLE TO “RESPOND ADAPTIVELY”
AND OPENS THE NEXT SESSION WITH –
“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 COURAGEOUSLY USING HER “EXPERIENCE OF SELF”
– HER COUNTERTRANSFERENTIAL REACTION –
TO “SHINE A LIGHT ON” A CRITICALLY IMPORTANT
PIECE OF THE PATIENT’S “RELATIONAL DYNAMICS”
79

80. MODEL 2 VERSUS MODEL 3
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 TO ONESELF –
DEFICITS WHICH WILL THEN GIVE RISE TO THE
DESPERATE SEARCH FOR A “NEW GOOD” PARENT
“RELENTLESS PURSUITS”
IN AN EFFORT TO CORRECT FOR EARLY – ON
“PARENTAL ERRORS OF OMISSION”
80

81. 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”
AND “DYSFUNCTIONAL RELATIONAL DYNAMICS”
WHICH WILL THEN BE REPEATEDLY RE – ENACTED
– BY WAY OF “PROJECTIVE IDENTIFICATION” –
ON THE STAGE OF THE TREATMENT
– IN BOTH THE “TRANSFERENCE” AND THE “REAL RELATIONSHIP” –
IN A DESPERATE ATTEMPT TO ENCOUNTER
A BETTER OUTCOME EVERY “NEXT TIME”
“COMPULSIVE RE – ENACTMENTS”
IN AN EFFORT TO CORRECT FOR EARLY – ON
“PARENTAL ERRORS OF COMMISSION”
81

82. MODEL 2 VERSUS MODEL 3
ON THE ONE HAND
– AS AN “EMPATHIC SELFOBJECT” –
THE MODEL 2 THERAPIST
“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
ON THE OTHER HAND
– AS AN “AUTHENTIC SUBJECT” –
THE MODEL 3 THERAPIST
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
THE MODEL 3 THERAPIST IS CONTINUOUSLY PAYING ATTENTION
TO THE PATIENT’S IMPACT ON HER
AGAIN, “USING” HER EXPERIENCE OF “SELF” TO “FIND” THE PATIENT
82

83. – AS AN “EMPATHIC SELFOBJECT” –
THE MODEL 2 THERAPIST
PROVIDES
A CORRECTIVE EXPERIENCE
“FOR” THE PATIENT
– BUT AS AN “AUTHENTIC SUBJECT” –
THE MODEL 3 THERAPIST
PARTICIPATES
IN A REAL RELATIONSHIP
“WITH” THE PATIENT
83

84. – AS AN “AUTHENTIC SUBJECT” AND ALMOST INEVITABLY –
THE MODEL 3 THERAPIST
WILL EVENTUALLY BE DRAWN IN TO
“PARTICIPATING COUNTERTRANSFERENTIALLY”
AS SOME VARIANT OF
THE PATIENT’S “OLD BAD OBJECT”
BECAUSE OF THE THERAPIST’S
UNCONSCIOUS “RECEPTIVITY”
TO THE PATIENT’S EVER – PRESENT
“RELATIONAL EXPECTATION” OF “BEING FAILED”
WHICH IS FUELING THE PATIENT’S
“COMPULSIVE AND UNWITTING” RE – CREATION
– IN THE HERE – AND – NOW ENGAGEMENT WITH HER THERAPIST –
OF HER EARLY – ON
UNMASTERED RELATIONAL FAILURES
ASPECTS OF THESE “COMPULSIVE RE – ENACTMENTS” ARE UNHEALTHY
ASPECTS ARE HEALTHY
84

85. AGAIN
THIS 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
SHE 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
85

86. 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 UNWITTINGLY EVER INTENT UPON RE – CREATING
– THAT IS, “RE – ENACTING” BY WAY OF PROJECTIVE IDENTIFICATION –
THE EARLY – ON “TRAUMATIC FAILURE SITUATION”
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” / “INTERNAL BAD OBJECTS”
AND “DYSFUNCTIONAL RELATIONAL CONFIGURATIONS”
86

87. WHAT ARE “ENACTMENTS”?
THE PATIENT’S “ACTIVITY” IN RELATION TO
THE THERAPIST IS OFTEN CONSIDERED AN
“ENACTMENT”
THE UNCONSCIOUS INTENT OF WHICH IS TO
ENGAGE THE THERAPIST IN SOME FASHION
EITHER 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)
87

88. “ENACTMENTS” GENERALLY GIVE RISE TO “PROJECTIVE IDENTIFICATION”
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,
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”
88

89. PROJECTIVE IDENTIFICATION
INVOLVES SYMBOLIC
REPETITION OF THE
ORIGINAL RELATIONAL TRAUMA
BUT WITH A MUCH HEALTHIER
RESOLUTION THIS TIME
– “ADAPTIVE RESOLUTION” –
AT THE END OF THE DAY
THE HALLMARK OF A
SUCCESSFUL PROJECTIVE IDENTIFICATION
IS THE THERAPIST’S CAPACITY TO TOLERATE
WHAT THE PATIENT FINDS INTOLERABLE
89

90. CENTER STAGE
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
THE FAILURES ARE UNAVOIDABLE BECAUSE THE THERAPIST IS NOT
– AND CANNOT BE EXPECTED TO BE –
PERFECT
BY CONTRAST
RELATIONAL THEORISTS (MODEL 3) BELIEVE THAT
THE 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 “INTROJECTED BADNESS”
90

91. IN OTHER WORDS
THE MODEL 3 THERAPIST’S FAILURES
ARE SEEN AS CO – CREATED
AS OCCURRING IN THE CONTEXT OF
AN ONGOING AND CONTINUOUSLY EVOLVING
RELATIONSHIP BETWEEN TWO “AUTHENTIC SUBJECTS”
AND AS SPEAKING TO
THE THERAPIST’S UNWITTING “RECEPTIVITY”
TO THE PATIENT’S “PROVOCATIVE ENACTMENT”
OF HER UNCONSCIOUS “NEED TO BE FAILED”
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 DRAMAS
BUT THEN GETS OVERWHELMED, LOSES HER WAY,
AND IS UNABLE TO RECOVER HER CENTEREDNESS,
WE SPEAK OF A FAILURE OF CONTAINMENT
AND THE POTENTIAL FOR RE – TRAUMATIZATION
91

92. 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 (1949)
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
“CONTAIN” THE PATIENT’S PROJECTIONS
BY LENDING ASPECTS OF HER OWN, 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
92

93. IN ESSENCE
WHAT THE PATIENT RE – INTROJECTS
WILL 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
93

94. A LOT IS REQUIRED OF THE MODEL 3 THERAPIST
IF SHE IS TO BE ABLE EFFECTIVELY
TO PROVIDE “CONTAINMENT”
SHE MUST FIRST BE ABLE
TO TOLERATE “BEING MADE INTO”
THE PATIENT’S “OLD BAD OBJECT”
AND, ONCE SHE HAS ALLOWED HERSELF
TO BE DRAWN IN TO PARTICIPATING
IN WHAT BECOMES
A TRANSFERENCE / COUNTERTRANSFERENCE
ENTANGLEMENT,
SHE MUST THEN BE ABLE
TO “EXTRICATE” HERSELF
BY STEPPING BACK
WHICH WILL ENABLE HER TO RECOVER HER “OBJECTIVITY”
AND, THEREBY, HER “THERAPEUTIC EFFECTIVENESS”
94

95. IN ESSENCE
THE THERAPIST MUST HAVE
THE “CAPACITY TO RELENT”
FURTHERMORE
THE THERAPIST MUST ALSO 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 COUNTERTRANSFERENTIAL ENACTMENT
95

96. WHEREAS THE THERAPEUTIC ACTION IN MODEL 2
IS ABOUT 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”
– TRANSMUTING INTERNALIZATIONS BUILD STRUCTURE AND CAPACITY –
“INCREMENTAL ACCRETION” OF
“SELF – REGULATORY 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 “WORLD OF OBJECTS”
96

97. THE THERAPEUTIC ACTION IN MODEL 3
IS ABOUT 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”
97

98. WHEREAS MODEL 2 IS ABOUT
“SERIAL ACCRETION”
OF PSYCHIC STRUCTURE
TO CORRECT FOR
“INTERNAL ABSENCE OF GOOD,”
MODEL 3 IS ABOUT
“SERIAL DILUTION”
OF TOXIC STRUCTURE
TO CORRECT FOR
“INTERNAL PRESENCE OF BAD”
BY THE SAME TOKEN
WHEREAS MODEL 2 IS ABOUT
“CONFRONTING AND GRIEVING”
TO “ADD NEW GOOD,”
MODEL 3 IS ABOUT
“NEGOTIATING MUTUAL ENACTMENTS”
TO “MODIFY OLD BAD”
98

99. PARENTHETICALLY
IN THE PSYCHOANALYTIC LITERATURE
WHEREAS “INTERNALIZE”
TENDS TO IMPLY “POSITIVE”
WITNESS THE “TRANSMUTING INTERNALIZATIONS”
OF (MODEL 2) SELF PSYCHOLOGY
“INTROJECT”
TENDS TO IMPLY “NEGATIVE”
WITNESS THE “PATHOGENIC INTROJECTS”
OF (MODEL 3) CONTEMPORARY RELATIONAL THEORY
BY THE SAME TOKEN
WHEREAS “INTERNALIZING GOOD”
IS AT THE HEART OF
THE “THERAPEUTIC ACTION” IN MODEL 2
“INTROJECTING BAD”
INFORMS OUR UNDERSTANDING OF
HOW MODEL 3 “RELATIONAL CONFLICT”
DEVELOPS IN THE FIRST PLACE
AND HOW IT CAN THEN BE “RESOLVED”
99

100. “OPTIMALLY STRESSFUL” MODEL 3 CONTAINING STATEMENTS
FOR THOSE PATIENTS WHO NEED “CONTAINMENT”
FIRST “RESONATE WITH THEIR (DYSREGULATED) AFFECT”
THEN “HIGHLIGHT THE (CONTAINING) REALITY
THAT THEY DO – ALBEIT RELUCTANTLY – KNOW”
“PERHAPS YOU WOULD WISH THAT YOU COULD STAY;
BUT, AS YOU KNOW, OUR TIME IS UP AND WE DO NEED TO STOP.”
“WHEN YOU GET ANGRY LIKE THIS, YOU THINK ABOUT QUITTING;
BUT WE BOTH KNOW THAT SOMEDAY
YOU’RE GOING TO HAVE TO STOP RUNNING.”
“AT TIMES LIKE THIS, YOU THINK ABOUT NEVER COMING BACK
BECAUSE IT HURTS TOO MUCH TO BE HERE;
BUT WE BOTH KNOW THAT,
IF YOU’RE EVER TO GET BETTER, THEN SOMEDAY YOU’RE
GOING TO HAVE TO GIVE SOMEBODY A SECOND CHANCE.”
“YOU JUST CAN’T SHAKE THIS CONVICTION THAT IF YOU FEEL HURT BY ME,
THEN YOU GET TO DO ANYTHING YOU WANT, INCLUDING BREAKING THE RULES,
WHICH YOU AND I BOTH KNOW WE NEED TO HAVE
IN ORDER FOR OUR RELATIONSHIP TO CONTINUE.”
100

101. AGAIN, THE “OPTIMALLY STRESSFUL” “RULE OF THREE”
IS DESIGNED TO INSIST THAT THE “RE – ENACTING” PATIENT
TAKE RESPONSIBILITY FOR HER “PROVOCATIVE ENACTMENTS”
MORE SPECIFICALLY, THE “RULE OF THREE” BECOMES RELEVANT
WHENEVER A PATIENT SAYS OR DOES SOMETHING
THAT THE THERAPIST EXPERIENCES AS PROVOCATIVE
– A “PROVOCATIVE ENACTMENT” –
IN ORDER TO COMPEL THE PATIENT TO TAKE OWNERSHIP OF
WHAT SHE IS “PLAYING OUT” ON THE STAGE OF THE TREATMENT,
THE THERAPIST CAN ASK THE PATIENT ANY OF THE FOLLOWING –
“HOW ARE YOU HOPING THAT I WILL RESPOND?”
WHICH ADDRESSES THE ID
“HOW ARE YOU FEARING THAT I MIGHT RESPOND?”
WHICH ADDRESSES THE SUPEREGO
“HOW ARE YOU IMAGINING THAT I WILL RESPOND?”
WHICH ADDRESSES THE EXECUTIVE FUNCTIONING OF THE EGO
– THE DORSOLATERAL PREFRONTAL CORTEX (DLPFC) OF THE BRAIN –
ALL THREE “RELATIONAL INTERVENTIONS” DEMAND OF THE PATIENT
THAT SHE MAKE HER “INTERPERSONAL INTENTIONS” MORE EXPLICIT
101

102. “OPTIMALLY STRESSFUL” MODEL 3 ACCOUNTABILITY STATEMENTS
MORE GENERALLY, THE THERAPIST MIGHT CHOOSE TO SHARE –
SOMETHING ABOUT HER OWN EXPERIENCE
OF BEING IN THE ROOM WITH THE PATIENT
OR HER OWN STATE OF INTERNAL CONFLICTEDNESS
AS A RESULT OF SOMETHING HAPPENING BETWEEN THEM
ALTERNATIVELY
THE THERAPIST MIGHT CHOOSE TO HIGHLIGHT –
HOW THE PATIENT GETS OTHERS TO DO UNTO HER
IN THE HERE – AND – NOW
SOME VERSION OF WHAT HAD BEEN DONE UNTO HER
IN THE THERE – AND – THEN
– “DIRECT NEGATIVE TRANSFERENCE” –
OR HOW THE PATIENT DOES UNTO OTHERS
IN THE HERE – AND – NOW
SOME VERSION OF WHAT HAD BEEN DONE UNTO HER
IN THE THERE – AND – THEN
– “INVERTED NEGATIVE TRANSFERENCE” –
(WITNESS, FOR EXAMPLE, THE CONCEPT OF “IDENTIFICATION WITH THE AGGRESSOR”) 102

103. AS ADDITIONAL EXAMPLES
MODEL 3 ACCOUNTABILITY STATEMENTS
THE THERAPIST MIGHT CHOOSE TO SHARE SOMETHING ABOUT
HER EXPERIENCE OF BEING IN THE ROOM WITH THE PATIENT
“I GUESS I AM IN THE DOG HOUSE THESE DAYS!”
“I WONDER IF THE FRUSTRATION AND HELPLESSNESS
I AM FEELING NOW IN RELATION TO YOU IS SIMILAR
TO THE FRUSTRATION AND HELPLESSNESS YOU HAVE
SPOKEN 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) 103

104. MODEL 3 ACCOUNTABILITY STATEMENTS
AS IRWIN HOFFMAN (2001) HAS SUGGESTED
IF THE THERAPIST IS AWARE OF FEELING CONFLICTED IN
RELATION TO THE PATIENT, SHE MAY CHOOSE TO SHARE
THE FACT OF THIS CONFLICTEDNESS WITH THE PATIENT
“I WANT TO TELL YOU ‘X,’ BUT I AM AFRAID THAT ‘Y.’”
HERE THE THERAPIST IS EXPRESSING ALOUD THE CONFLICT WITH
WHICH SHE IS STRUGGLING – A CONFLICT THAT MIGHT WELL BE
REFLECTIVE OF THE PATIENT’S OWN INTERNAL STATE OF DIVIDEDNESS
“I AM TEMPTED TO GIVE YOU THE ADVICE FOR
WHICH YOU ARE LOOKING, BUT MY FEAR IS THAT
WERE I TO DO SO, I WOULD BE ROBBING YOU OF
THE IMPETUS TO FIND YOUR OWN ANSWERS.”
“I FIND MYSELF FEELING ANGRY WITH YOU FOR BEING SO OFTEN
LATE AND WANTING YOU TO UNDERSTAND HOW IT IMPACTS ME.
BUT THEN IT OCCURS TO ME THAT IT MIGHT BE MORE IMPORTANT
FOR US TO TRY TO UNDERSTAND WHAT YOU MIGHT BE TRYING
TO COMMUNICATE TO ME BY WAY OF YOUR FREQUENT LATENESS.”
104

105. MODEL 3 ACCOUNTABILITY STATEMENTS
“I AM TEMPTED TO RESPOND TO YOUR REQUEST BY
SAYING THAT OF COURSE YOU CAN BORROW ONE OF
THE MAGAZINES IN MY WAITING ROOM. BUT I AM ALSO
REALIZING THAT WERE I SIMPLY TO SAY ‘OK,’ WE MIGHT
THEN 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.”
105

106. MODEL 3 ACCOUNTABILITY STATEMENTS
“I WONDER IF THIS FEELING I HAVE IN RELATION
TO YOU THAT NO MATTER WHAT I SAY IT WON’T BE
GOOD ENOUGH IS LIKE THE FEELING YOU HAVE SPOKEN
OF HAVING HAD IN RELATION TO YOUR FATHER,
FOR WHOM NOTHING WAS EVER GOOD ENOUGH.”
“I FIND MYSELF FEELING SO ANGRY AT YOUR MOTHER.
I WONDER IF SOME OF THOSE FEELINGS ARE ACTUALLY
A STORY ABOUT FEELINGS YOU HAVE ABOUT YOUR MOTHER –
FEELINGS YOU WOULD RATHER NOT HAVE TO ACKNOWLEDGE.”
“IT OCCURS TO ME THAT WE HAVE MANAGED TO RECREATE
IN HERE THE VERY SAME DYNAMIC THAT HAD CHARACTERIZED YOUR
RELATIONSHIP WITH YOUR DOUBLE – BINDING FATHER –
NAMELY, THE FEELING WE BOTH HAVE THAT
NO MATTER WHAT EITHER OF US MIGHT DO,
IT WOULDN’T GET THE OTHER’S APPROVAL!
BUT ALL OF THIS, PAINFUL AS IT IS, GIVES US AN OPPORTUNITY
TO EXPERIENCE, FIRSTHAND, HOW TOXIC
THE RELATIONSHIP WITH YOUR FATHER REALLY WAS –
EXCEPT THAT NOW WE CAN DO SOMETHING ABOUT IT!”
106

107. MODEL 3 IS ULTIMATELY A STORY ABOUT
THE THERAPIST’S “USE” OF HER “AUTHENTIC SELF”
– HER “COUNTERTRANSFERENCE” –
TO FACILITATE MODIFICATION OF
THE PATIENT’S “SENSE OF SELF” AS “BAD”
MORE SPECIFICALLY
MODIFYING THE PATIENT’S
“SENSE OF SELF” AS “BAD”
WILL REQUIRE “TOUGHING IT OUT”
AT THE “INTIMATE EDGE”
OF “AUTHENTIC RELATEDNESS”
BOTH PARTICIPANTS
BRINGING HEART AND SOUL TO
THE “INTERSUBJECTIVE SPACE BETWEEN”
SUCH THAT THIS TIME
THERE CAN INDEED BE A “DIFFERENT OUTCOME”
107

108. IN SUM
THE RELATIONAL PERSPECTIVE
OF MODEL 3 IS A STORY
ABOUT TRANSFORMING
THE PATIENT’S “DEFENSIVE NEED”
TO RE – ENACT
– COMPULSIVELY AND UNWITTINGLY –
HER UNMASTERED EARLY – ON
RELATIONAL DRAMAS
ON THE STAGE OF HER LIFE
INTO THE “ADAPTIVE CAPACITY”
TO TAKE RESPONSIBILITY FOR
HER DYSFUNCTIONAL WAYS OF
ACTING, REACTING, AND INTERACTING
108

109. 109

110. IN CLOSING
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
110

111. 111

112. 112

113. 113

114. 114

115. IF YOU WOULD LIKE
TO BE ON MY
MAILING LIST,
PLEASE EMAIL ME AT
MarthaStarkMD @
HMS.Harvard.edu
TO LET ME KNOW
115

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