An anonymous quote but very to the point is the following: I gave you a part of me that I knew you could break – but you didn’t. Patients who have never fully confronted – and grieved – the pain of their early-on heartbreak will often cling tenaciously to their hope that perhaps someday the “object of their desire” will be forthcoming. But there are others who, in the aftermath of their early-on heartbreak, will find themselves withdrawing completely from the “world of objects” – their heart shattered… To protect themselves from being once again devastated, these latter patients retreat, withdraw, detach themselves from relationships, from the world – psychic retreat, schizoid withdrawal, emotional detachment from life itself – only then to find themselves overwhelmed by intense feelings of isolation, alienation, and emptiness – the competent, accomplished, cheerful, compliant “false (public) self” that they present to the world belying the truth of what lies hidden, namely, their private turmoil, tormented heartbreak, harrowing loneliness, and annihilating terror as well as their stymied creativity and desperate (albeit conflicted) longing for meaningful connectedness with the world. Instead of “relentless hope” (which figures prominently in my Model 2, with its focus on the patient’s “relentless pursuits”) and, when thwarted, “relentless outrage” (which figures prominently in my Model 3, with its focus on the patient’s “compulsive repetitions”), the experience-of-being-in-the-world for these latter (Model 4) patients will be one of “relentless despair” – a “profound hopelessness” that they keep masked by a self-protective “false self” armor that obscures their underlying brokenness and the “thwarted potential” of their “true self.” Whereas the relentless hope of the Model 2 patient and the relentless outrage of the Model 3 patient speak to the patient’s intense – albeit maladaptive – engagement with the world of objects, the relentless despair of the Model 4 patient speaks to the patient’s complete lack of any real engagement with the world of objects.

1. A HEART SHATTERED,
RELENTLESS DESPAIR,
AND
THE UNLIVED LIFE
Martha Stark MD
Master Series in Clinical Practice ~ William James College
Friday, June 22, 2018 ~ 9:00 am – 4:30 pm
MarthaStarkMD@HMS.Harvard.edu
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2. MODEL 4
A HEART SHATTERED AND THE UNLIVED LIFE
THE PRIVATE (TRUE) SELF vs. THE PUBLIC (FALSE) SELF
AN EXISTENTIAL – HUMANISTIC
APPROACH TO THE THERAPEUTIC ACTION
RELENTLESS DESPAIR ABOUT
AUTHENTIC BEING – IN – THE – WORLD
FROM NIHILISTIC REJECTION OF EXISTENCE
TO EXISTENTIAL ACCEPTANCE OF ITS DUALITIES
RESONATE EMPATHICALLY WITH THE INTRINSIC CONFLICT BETWEEN
“BEING FOUND vs. REMAINING HIDDEN”
DONALD BURNHAM’S “NEED – FEAR DILEMMA”
“NEED TO BE MET vs. FEAR OF BEING FOUND”
LONGING FOR MEANINGFUL AND AUTHENTIC MOMENTS OF MEETING vs.
TERROR OF BEING FOUND AND DESPAIR ABOUT AUTHENTIC BEING – IN – THE – WORLD
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3. PSYCHODYNAMIC SYNERGY ~
A SYNERGY OF FOUR MODALITIES
MODEL 1 ~ STRUCTURAL CONFLICT ~ 1 – PERSON PSYCHOLOGY
THE INTERPRETIVE PERSPECTIVE OF CLASSICAL PSYCHOANALYSIS
MODEL 2 ~ STRUCTURAL DEFICIT ~ 1½ – PERSON PSYCHOLOGY
THE CORRECTIVE – PROVISION PERSPECTIVE OF
SELF PSYCHOLOGY AND THOSE OBJECT RELATIONS
THEORIES THAT EMPHASIZE INTERNAL ABSENCE OF GOOD
MODEL 3 ~ RELATIONAL CONFLICT ~ 2 – PERSON PSYCHOLOGY
THE INTERSUBJECTIVE PERSPECTIVE OF CONTEMPORARY
RELATIONAL THEORY AND THOSE OBJECT RELATIONS
THEORIES THAT EMPHASIZE INTERNAL PRESENCE OF BAD
MODEL 4 ~ RELATIONAL DEFICIT ~ ½ – PERSON PSYCHOLOGY
THE EXISTENTIAL – HUMANISTIC APROACH
TO THE THERAPEUTIC ACTION
3

4. PSYCHODYNAMIC SYNERGY ~ A SYNERGY OF FOUR MODALITIES
MODEL 1 ~ STRUCTURAL CONFLICT ~ 1 – PERSON PSYCHOLOGY
THE INTERPRETIVE PERSPECTIVE OF CLASSICAL PSYCHOANALYSIS
DYSFUNCTIONAL INTERNAL DYNAMICS
NEUROTIC CONFLICTEDNESS
MODEL 2 ~ STRUCTURAL DEFICIT ~ 1½ – PERSON PSYCHOLOGY
THE CORRECTIVE – PROVISION PERSPECTIVE OF
SELF PSYCHOLOGY AND THOSE OBJECT RELATIONS
THEORIES THAT EMPHASIZE INTERNAL ABSENCE OF GOOD
RELENTLESS PURSUIT OF THE UNATTAINABLE
NARCISSISTIC VULNERABILITY
MODEL 3 ~ RELATIONAL CONFLICT ~ 2 – PERSON PSYCHOLOGY
THE INTERSUBJECTIVE PERSPECTIVE OF CONTEMPORARY
RELATIONAL THEORY AND THOSE OBJECT RELATIONS
THEORIES THAT EMPHASIZE INTERNAL PRESENCE OF BAD
DYSFUNCTIONAL RELATIONAL DYNAMICS
NOXIOUS RELATEDNESS
MODEL 4 ~ RELATIONAL DEFICIT ~ ½ – PERSON PSYCHOLOGY
THE EXISTENTIAL – HUMANISTIC APROACH TO THE THERAPEUTIC ACTION
RELENTLESS DESPAIR ABOUT AUTHENTIC BEING – IN – THE – WORLD
NONRELATEDNESS 4

5. MODEL 1 ~ STRUCTURAL CONFLICT
THE NEUROTIC DEFENSE OF RELENTLESS CONFLICTEDNESS
AVOIDANCE, PARALYSIS, AND UNACTUALIZED POTENTIAL
MODEL 2 ~ STRUCTURAL DEFICIT
THE NARCISSISTIC DEFENSE OF RELENTLESS NEED
FOR VALIDATION AND EXTERNAL PROVISION
INSATIABLE HUNGER
MODEL 3 ~ RELATIONAL CONFLICT
THE CHARACTER DISORDERED DEFENSE OF RELENTLESS
EXTERNALIZATION AND DENIAL OF RESPONSIBILITY
DYSFUNCTIONAL RELATEDNESS, A SENSE OF ONESELF AS EVER
THE VICTIM, AND A DECREASED SENSE OF PERSONAL AGENCY
MODEL 4 ~ RELATIONAL DEFICIT
THE SCHIZOID / NIHILISTIC DEFENSE OF RELENTLESS DESPAIR
UNRELENTING LONELINESS, SCHIZOID WITHDRAWAL, EXISTENTIAL ANGST, RETREAT
AND RESIGNATION, EMOTIONAL DETACHMENT, INNER EMPTINESS, PSYCHIC DEADNESS,
SOLITARY SUFFERING, ANNIHILATION TERROR, DENIAL OF OBJECT NEED,
ILLUSIONS OF GRANDIOSE SELF – SUFFICIENCY, AFFECTIVE NONRELATEDNESS,
IMPENETRABILITY, OVERWHELMING FEELINGS OF ALIENATION AND ESTRANGEMENT,
AND THE ONGOING STRUGGLE TO RECONCILE THE DIALECTICAL TENSION
BETWEEN THE NEED TO BE MET AND THE FEAR OF BEING FOUND
AND BETWEEN LIFE AS MEANINGFUL AND LIFE AS ABSURD AND POINTLESS
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6. PSYCHODYNAMIC SYNERGY ~
A SYNERGY OF FOUR MODALITIES
MODEL 1 ~ STRUCTURAL CONFLICT
FROM RESISTANCE TO AWARENESS
MODEL 2 ~ STRUCTURAL DEFICIT
FROM RELENTLESS HOPE TO ACCEPTANCE
MODEL 3 ~ RELATIONAL CONFLICT
FROM RE – ENACTMENT TO ACCOUNTABILITY
MODEL 4 ~ RELATIONAL DEFICIT
FROM RETREAT TO ACCESSIBILITY
FROM RELENTLESS DESPAIR TO AWAKENED HOPE
FROM RELATIONAL ABSENCE TO AUTHENTIC PRESENCE
FROM NIHILISTIC REJECTION OF EXISTENCE
TO EXISTENTIAL ACCEPTANCE OF ITS DUALITIES
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7. HOW THE THERAPIST POSITIONS HERSELF
MOMENT BY MOMENT
THE OPTIMAL THERAPEUTIC STANCE WILL
BE ONE THAT IS CONTINUOUSLY SHIFTING
SOMETIMES SPONTANEOUS
AND UNPLANNED
SOMETIMES MORE CONSIDERED
AND DELIBERATE
SOMETIMES THE THERAPIST WILL FIND
HERSELF UNWITTINGLY DRAWN IN
TO PARTICIPATING IN A CERTAIN WAY
BUT AT OTHER TIMES THE THERAPIST WILL
MAKE A MORE CONSCIOUS CHOICE BASED
ON WHAT SHE SENSES THE PATIENT MOST
NEEDS IN THE MOMENT IN ORDER TO HEAL
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8. IF, IN THE MOMENT, THE PATIENT IS PRIMARILY
“NOT AWARE”
THEN MODEL 1 CONFLICT STATEMENTS
“NOT ACCEPTING”
THEN MODEL 2 DISILLUSIONMENT STATEMENTS
“NOT ACCOUNTABLE”
THEN MODEL 3 ACCOUNTABILITY STATEMENTS
“NOT ACCESSIBLE AND / OR NOT AUTHENTIC”
THEN MODEL 4 FACILITATION STATEMENTS
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9. MODEL 1 ~ STRUCTURAL CONFLICT
OBJECTIVE NEUTRALITY
CONFLICT STATEMENTS ~ FROM RESISTANCE TO AWARENESS
WORKING THROUGH THE RESISTANCE
COGNITIVE DISSONANCE ~ THE STRESS OF GAIN – BECOME – PAIN
MODEL 2 ~ STRUCTURAL DEFICIT
EMPATHIC ATTUNEMENT
DISILLUSIONMENT STATEMENTS ~ FROM RELENTLESS HOPE TO ACCEPTANCE
GRIEVING
OPTIMAL DISILLUSIONMENT ~ THE STRESS OF GOOD – BECOME – BAD
MODEL 3 ~ RELATIONAL CONFLICT
AUTHENTIC ENGAGEMENT ~ SHARED MIND AND SHARED HEART
ACCOUNTABILITY STATEMENTS ~ FROM RE – ENACTMENT TO ACCOUNTABILITY
NEGOTIATING AT THE INTIMATE EDGE OF AUTHENTIC RELATEDNESS
RELATIONAL DETOXIFICATION ~ THE STRESS OF BAD – BECOME – GOOD
MODEL 4 ~ RELATIONAL DEFICIT
SOULFUL PRESENCE ~ ROCK – SOLID RELIABILITY AND STALWART DEPENDABILITY
FACILITATION STATEMENTS ~ FROM RETREAT TO ACCESSIBILITY
FROM RELATIONAL ABSENCE TO AUTHENTIC PRESENCE
OVERCOMING THE DREAD OF SURRENDER TO RESOURCELESS DEPENDENCE
IN ORDER TO FACILITATE THE EMERGENCE OF MOMENTS OF MEETING
ABSOLUTE DEPENDENCE ~ THE STRESS OF HIDDEN – BECOME – FOUND
DIALECTICAL TENSION ~ THE STRESS OF
DENIAL – OF – EXISTENCE – BECOME – ACCEPTANCE – OF – ITS – DUALITIES 9

10. MODEL 4 ~ RELATIONAL DEFICIT
THE EXISTENTIAL – HUMANISTIC APROACH TO THE THERAPEUTIC ACTION
ATTACHMENT INSECURITY ~ INAUTHENTIC BEING – IN – RELATIONSHIP
ONTOLOGICAL INSECURITY ~ INAUTHENTIC BEING – IN – THE – WORLD
FROM SCHIZOID RETREAT TO ACCESSIBILITY / EMOTIONAL AVAILABILITY
FROM RELENTLESS DESPAIR TO AUTHENTIC BEING – IN – THE – WORLD
AND AWAKENED HOPE
(HOPE THAT WAS THERE ALL ALONG, WAITING TO BE FOUND)
FROM RESIGNATION TO A LIFE LIVED
FROM RELATIONAL ABSENCE TO AUTHENTIC PRESENCE
FACILITATION STATEMENTS ~
RESONATE EMPATHICALLY WITH THE DUALITIES OF EXISTENCE, RECONCILE
THE DIALECTICAL TENSION BETWEEN POLARITIES, AND EVOLVE TO A HIGHER
LEVEL OF INTEGRATION, COMPLEX UNDERSTANDING, AND DYNAMIC BALANCE
FROM OPPOSITION TO COMPLEMENTARITY
EVOLVE FROM THE DICHOTOMIZATION OF “EITHER / OR”
“A PART OF YOU NEEDS … , BUT ANOTHER PART OF YOU FEARS …”
TO THE COMPLEMENTARITY OF “BOTH / AND”
“YOU HAVE THE FEAR AND THE DESPAIR … ,
BUT, AS YOU KNOW, YOU DO HAVE A CHOICE …”
JUST AS IN QUANTUM MECHANICS, WHERE PARTICLES AND WAVES
ARE THOUGHT TO BE DIFFERENT MANIFESTATIONS OF A SINGLE REALITY
DEPENDING UPON THE OBSERVER’S PERSPECTIVE
FROM LAING’S “DIVIDED SELF” TO BROMBERG’S “MULTIPLICITY OF SELF” 10

11. THE EXISTENTIAL – HUMANISTIC APROACH TO THE THERAPEUTIC ACTION
RONALD FAIRBAIRN ~ AMBIVALENT ATTACHMENT TO THE BAD (EXCITING / REJECTING) OBJECT
A BAD OBJECT IS INFINITELY BETTER THAN NO OBJECT AT ALL
MARTIN HEIDEGGER ~ INAUTHENTIC AND AUTHENTIC EXISTENCE
DONALD WINNICOTT ~ ABSOLUTE DEPENDENCE ~ THE NEED FOR OMNIPOTENT CONTROL
GOOD ENOUGH MOTHER ~ ENVIRONMENTAL PROVISION ~ CONTINUITY OF BEING
ALONE IN THE PRESENCE OF ~ PRIMARY ALONENESS ~ TRANSITIONAL SPACE
FALSE SELF THAT PROTECTS THE TRUE SELF FROM IMPINGEMENT
MICHAEL BALINT ~ BENIGN REGRESSION TO DEPENDENCE ~ BASIC FAULT ~ A NEW BEGINNING
HARMONIOUS INTERPENETRATING MIX – UP
HARRY GUNTRIP ~ SCHIZOID WITHDRAWAL, EMOTIONAL DETACHMENT,
AND INABILITY TO EXPERIENCE MOMENTS OF AUTHENTIC MEETING
VIKTOR FRANKL ~ MAN’S SEARCH FOR MEANING ~ DESPAIR EQUALS SUFFERING WITHOUT MEANING
BETWEEN STIMULUS AND RESPONSE IS A SPACE
ALBERT CAMUS ~ ACCEPTING ABSURDITY AROUSES A REVOLT THAT CAN BECOME FRUITFUL
DONALD BURNHAM ~ NEED – FEAR DILEMMA ~ SCHIZO – DYNAMICS
MASUD KHAN ~ PRIVACY OF THE SELF ~ DREAD OF SURRENDER TO RESOURCELESS DEPENDENCE
R D LAING ~ DIVIDED SELF ~ ONTOLOGICAL INSECURITY
ARNOLD MODELL ~ DENIAL OF OBJECT NEED ~ ILLUSIONS OF GRANDIOSE SELF – SUFFICIENCY
SELF – PROTECTIVE ISOLATION ~ MASSIVE AFFECT BLOCK
1 – PERSON vs. 2– PERSON DEFENSES
DEFENSE OF AFFECTIVE NONRELATEDNESS TO AVOID DISSOLUTION OF THE
INTEGRITY AND COHESIVENESS OF A PRECARIOUSLY ESTABLISHED SELF
BY AN IMPINGING AND POTENTIALLY DESTRUCTIVE OBJECT 11