1. PRACTICAL
CLINICAL INTERVENTIONS
FOR INCENTIVIZING CHANGE
A “Reference Guide”
for All Therapists
MARTHA STARK MD
MarthaStarkMD @ HMS.Harvard.edu
Thursday, May 4, 2023 – 6:00 to 8:00 pm (ET)
Hosted by the Massachusetts Association
for Psychoanalytic Psychology
With special appreciation for Lotte Smith – Hansen
© 2023 Martha Stark MD

3. LEARNING OBJECTIVES
SUMMARIZE THE REASON THAT “OPTIMAL STRESS”
NAMELY, JUST THE RIGHT BALANCE BETWEEN
ANXIETY – PROVOKING “CHALLENGE” AND ANXIETY – ASSUAGING “SUPPORT”
PROVIDES BOTH “IMPETUS” AND “OPPORTUNITY”
FOR “DEEP AND ENDURING PSYCHODYNAMIC CHANGE”
COMPOSE A “MINIMALLY STRESSFUL” STATEMENT
THAT “SUPPORTS” BY “JOINING” THE DEFENSE
EXPLAIN HOW THESE “MINIMALLY STRESSFUL” INTERVENTIONS
– FEATURED DURING THE “BEGINNING GAME” –
SET THE STAGE FOR THE THERAPEUTIC ACTION THAT WILL FOLLOW
CONSTRUCT AN “OPTIMALLY STRESSFUL” STATEMENT
THAT ALTERNATELY “CHALLENGES” AND THEN “SUPPORTS” THE DEFENSE
DESCRIBE HOW THESE “OPTIMALLY STRESSFUL” INTERVENTIONS
– FEATURED DURING THE “MIDDLE GAME” –
CREATE GROWTH – INCENTIVIZING “MISMATCH EXPERIENCES”
– THE WORKING THROUGH OF WHICH WILL ADVANCE THE PATIENT
FROM RIGID DEFENSE TO MORE FLEXIBLE ADAPTATION –
I HAVE NO FINANCIAL CONFLICTS OF INTEREST
OR, AS ERIC PLAKUN WOULD SAY,
PERHAPS I HAVE PSYCHOLOGICAL CONFLICTS BUT NO FINANCIAL CONFLICTS
3

4. MY
PSYCHODYNAMIC
SYNERGY
PARADIGM
4

5. MY PSYCHODYNAMIC SYNERGY PARADIGM
A C.A.R.E. APPROACH TO DEEP HEALING
Cognitive – Affective – Relational – Existential
FOUR INTERDEPENDENT AND MUTUALLY ENHANCING
“MODES OF THERAPEUTIC ACTION”
MODEL 1 – COGNITIVE
THE INTERPRETIVE PERSPECTIVE
OF CLASSICAL PSYCHOANALYSIS
MODEL 2 – AFFECTIVE
THE CORRECTIVE – PROVISION PERSPECTIVE
OF SELF PSYCHOLOGY
MODEL 3 – RELATIONAL
THE INTERSUBJECTIVE PERSPECTIVE
OF CONTEMPORARY RELATIONAL THEORY
MODEL 4 – EXISTENTIAL
AN EXISTENTIAL – HUMANISTIC APPROACH
TO MENDING BROKENNESS AND EASING DESPAIR
5

6. THERAPEUTIC MODALITIES THAT HAVE
DEEP AND ENDURING PSYCHODYNAMIC CHANGE
AS THEIR ULTIMATE GOAL
FOR EXAMPLE, PSYCHOANALYSIS AND OTHER “DEPTH PSYCHOLOGIES,”
INCLUDING – BUT NOT LIMITED TO – ACT, IFS, EMDR, ISTDP, AEDP, EFT, NLP,
SENSORIMOTOR PSYCHOTHERAPY, SOMATIC EXPERIENCING, AND PSYCHOMOTOR PSYCHOTHERAPY
MUST ULTIMATELY BE ABLE TO TRANSFORM
“PSYCHOLOGICAL RIGIDITY”
INTO “PSYCHOLOGICAL FLEXIBILITY”
IN THE EVOCATIVE WORDS OF ACCEPTANCE AND COMMITMENT THERAPY (ACT)
AND “LOW – LEVEL DEFENSE”
INTO “HIGHER – LEVEL / MORE EVOLVED DEFENSE”
IN THE MORE TRADITIONAL WORDS OF PSYCHOANALYSIS AND EGO PSYCHOLOGY
SUCH THAT THE PATIENT
WHATEVER HER STARTING POINT / WHATEVER HER INITIAL LEVEL OF FUNCTIONALITY
WHATEVER HER DIAGNOSIS
WILL BECOME EVER BETTER ABLE
– OVER TIME –
TO MANAGE THE MYRIAD “STRESSORS” IN HER LIFE
TO WHICH SHE IS BEING CONTINUOUSLY EXPOSED
EVER MORE ADEPT AT “RESPONDING ADAPTIVELY AND MINDFULLY”
INSTEAD OF “REACTING DEFENSIVELY AND MINDLESSLY” 6

7. THE ULTIMATE GOAL OF DEEP TREATMENTS
EVER – LESS PSYCHOLOGICAL RIGIDITY
EVER – MORE PSYCHOLOGICAL FLEXIBILITY

9. INDEED
THE THERAPEUTIC ACTION
IN ALL FOUR OF MY PSYCHODYNAMIC MODELS
– CLASSICAL PSYCHOANALYTIC, SELF PSYCHOLOGICAL,
CONTEMPORARY RELATIONAL, AND EXISTENTIAL – HUMANISTIC –
DOES INDEED INVOLVE ADVANCEMENT OF THE PATIENT
– THROUGH ITERATIVE HEALING CYCLES OF DISRUPTION AND REPAIR –
FROM RIGID DEFENSE TO MORE FLEXIBLE ADAPTATION
– FROM “SAME OLD, SAME OLD” TO “SOMETHING NEW, DIFFERENT, AND BETTER” –
MODEL 1 – FROM “RESISTANCE” TO “AWARENESS”
A COGNITIVE APPROACH THAT FOCUSES ON “INTERPRETING”
MODEL 2 – FROM “RELENTLESS HOPE” TO “ACCEPTANCE”
AN AFFECTIVE APPROACH THAT FOCUSES ON “GRIEVING”
MODEL 3 – FROM “RE – ENACTMENT” TO “ACCOUNTABILITY”
A RELATIONAL APPROACH THAT FOCUSES ON “NEGOTIATING”
MODEL 4 – FROM “RELATIONAL ABSENCE” TO “AUTHENTIC PRESENCE”
AN EXISTENTIAL APPROACH THAT FOCUSES ON “SURRENDERING”
9

10. When I let go
of the
“defensive”
SAME OLD
SAME OLD
that I am,
I become the
“adaptive”
SOMETHING
NEW
DIFFERENT
AND
BETTER
that I
might be.

11. THE PATIENT’S CONTINUOUSLY SHIFTING
“POINTS OF EMOTIONAL URGENCY”
WILL INFORM THE THERAPIST’S CHOICE
OF THE MODEL(S) THAT WILL BE MOST RELEVANT
– MOMENT – TO – MOMENT –
FOR UNDERSTANDING
THE PATIENT’S UNDERLYING PSYCHODYNAMICS
AND FOR THEN SELECTING
THE APPROACH THAT WILL BE MOST USEFUL
MODEL 1
NEUROTIC CONFLICTEDNESS – CONFLICT STATEMENTS
TO HIGHLIGHT INTERNAL CONFLICTEDNESS / AMBIVALENCE
MODEL 2
NARCISSISTIC VULNERABILITY – DISILLUSIONMENT STATEMENTS
TO FACILITATE GRIEVING OF DISILLUSIONMENT / DISAPPOINTMENT
MODEL 3
NOXIOUS RELATEDNESS – ACCOUNTABILITY STATEMENTS
TO FACILITATE NEGOTIATION OF MUTUAL ENACTMENTS
AT THE “INTIMATE EDGE” OF RELATEDNESS
DARLENE EHRENBERG (1992)
MODEL 4
NONRELATEDNESS – FACILITATION STATEMENTS
TO HIGHLIGHT NEED / FEAR OF ENGAGEMENT WITH THE WORLD / LIFE ITSELF
11

12. SO HOW ARE
DEFENSES
– AND ADAPTATIONS –
HERE
BEING DEFINED
12

13. PLEASE NOTE
I DO NOT “LIMIT” DEFENSES
TO THE WELL – KNOWN
AND MORE TRADITIONAL ONES
AT ONE END OF THE CONTINUUM
“LOW – LEVEL DEFENSES”
FOR EXAMPLE
REPRESSION, REGRESSION, DENIAL,
DISSOCIATION, DISPLACEMENT, PROJECTION,
ISOLATION OF AFFECT, INTELLECTUALIZATION,
AND REACTION FORMATION
AT THE OTHER END
“HIGHER – LEVEL” OR “MORE MATURE DEFENSES”
THAT ARE “MORE ADAPTIVE” AND “MORE SOCIALLY ACCEPTABLE”
FOR EXAMPLE
SUBLIMATION, HUMOR, ALTRUISM,
HUMILITY, AND POSITIVE IDENTIFICATIONS
13

14. RATHER
I DEFINE DEFENSES “MORE BROADLY”
AS SPEAKING TO ANY OF THE
“SELF – PROTECTIVE MECHANISMS”
THAT WE MOBILIZE WHEN MADE ANXIOUS
IN THE FACE OF STRESSORS
– PSYCHOLOGICAL, PHYSIOLOGICAL, AND ENERGETIC –
AT ONE END OF THE CONTINUUM
WHAT HAPPENS “REFLEXIVELY”
WHEN WE ARE CONFRONTED WITH STRESSORS
THAT “OVERWHELM” US WITH ANXIETY
TO WHICH I REFER AS “LOW – LEVEL DEFENSES”
OR “RIGID DEFENSES”
AT THE OTHER END
WHAT HAPPENS “MORE REFLECTIVELY”
WHEN WE ARE CONFRONTED WITH STRESSORS
THAT WE ARE MORE EASILY ABLE TO “TAKE IN OUR STRIDE”
TO WHICH I REFER AS “HIGHER – LEVEL DEFENSES”
OR “MORE FLEXIBLE ADAPTATIONS”
AT ONE END OF THE CONTINUUM – “DEFENSIVE / CONDITIONED REACTIONS”
AT THE OTHER END – “ADAPTIVE / RESILIENT RESPONSES”
14

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

16. THE RELATIONSHIP BETWEEN DEFENSE AND ADAPTATION
IS A YIN – YANG RELATIONSHIP
THESE SELF – PROTECTIVE MECHANISMS
ARE COMPLEMENTARY – NOT OPPOSING – FORCES
FURTHERMORE
ALL DEFENSES HAVE AN ADAPTIVE COMPONENT
JUST AS ALL ADAPTATIONS SERVE A DEFENSIVE FUNCTION
NONETHELESS AND MORE GENERALLY
ALTHOUGH DEFENSES MIGHT ONCE
HAVE BEEN NECESSARY
FOR THE PATIENT TO “SURVIVE,”
AS RIGID DEFENSES BECOME UPGRADED
TO MORE FLEXIBLE ADAPTATIONS,
THE PATIENT BECOMES
EVER BETTER ABLE TO “THRIVE”
THE THERAPEUTIC ACTION
IS INDEED DESIGNED
TO TRANSFORM “RIGIDITY” INTO “FLEXIBILITY”
AND “SURVIVING” INTO “THRIVING”
16

18. THE
WORKING
THROUGH
PROCESS
IN
PSYCHODYNAMIC
PSYCHOTHERAPY
18

19. THE WORKING THROUGH PROCESS
IN PSYCHODYNAMIC PSYCHOTHERAPY
THREE STAGES THAT ARE BOTH REPETITIOUS AND PROGRESSIVE
– “ASCENDING SPIRAL STAIRCASE” –
THE BEGINNING GAME
“MINIMALLY STRESSFUL” INTERVENTIONS
THAT TEASE OUT THE VARIOUS DEFENSES
– THE RECURRING AND PROBLEMATIC THEMES, PATTERNS, AND REPETITIONS –
IN ORDER TO IDENTIFY THE PLAYERS AND SET THE STAGE
FOR THE THERAPEUTIC ACTION THAT WILL FOLLOW
THE MIDDLE GAME
“OPTIMALLY STRESSFUL” INTERVENTIONS
THAT ALTERNATELY CHALLENGE AND THEN SUPPORT THE DEFENSE
IN ORDER TO CREATE
GROWTH – INCENTIVIZING “MISMATCH EXPERIENCES”
THE END GAME
“NO STRESS” INTERVENTIONS
THAT CELEBRATE AND APPLAUD “ADAPTIVE RESOLUTION”
– EVEN IF ONLY TEMPORARY AND / OR MAKESHIFT –
BECAUSE THE SEQUENCE WILL PROBABLY NEED
TO BE REPEATED AGAIN AND AGAIN
UNTIL THE PROBLEMATIC ISSUE HAS BEEN
MORE THOROUGHLY PROCESSED, INTEGRATED, AND ADAPTED TO

20. MINIMAL
STRESS
OPTIMAL
STRESS
AND
REPEAT

21. THE WORKING THROUGH PROCESS
– THE MIDDLE GAME –
WITH THE STAGE HAVING BEEN ALREADY SET DURING THE BEGINNING GAME
AND AGAINST THE BACKDROP OF EMPATHIC RESONANCE BETWEEN PATIENT AND THERAPIST
THE THERAPIST WILL REPEATEDLY OFFER THE PATIENT
OPTIMALLY STRESSFUL INTERVENTIONS
– JUST THE RIGHT COMBINATION OF CHALLENGE AND SUPPORT –
STRATEGICALLY DESIGNED TO GENERATE
DESTABILIZING INTERNAL DISSONANCE
AND HOMEOSTATIC IMBALANCE
ACCOMPLISHED BY JUXTAPOSING
ANXIETY – PROVOKING CHALLENGE OF THE DEFENSE
WITH ANXIETY – ASSUAGING SUPPORT OF IT
THEREBY CREATING GROWTH – INCENTIVIZING
“MISMATCH EXPERIENCES”
THE ONGOING WORKING THROUGH OF WHICH
– IN ORDER TO RESOLVE THE INTERNAL TENSION
AND RESTORE THE HOMEOSTATIC BALANCE –
WILL INCREMENTALLY ADVANCE THE PATIENT
TO EVER – HIGHER AND EVER – MORE EVOLVED LEVELS
OF RESILIENCE AND ADAPTIVE CAPACITY
21

22. STRATEGIC LEVERAGING OF THE PATIENT’S ANXIETY
ALTERNATELY INCREASING IT BY CHALLENGING THE DEFENSE
AND THEN DECREASING IT BY SUPPORTING (JOINING) THE DEFENSE
TO GENERATE GROWTH – INCENTIVIZING “MISMATCH EXPERIENCES”

23. A MISMATCH EXPERIENCE 

24. THE WORKING THROUGH PROCES IS NEVER ABOUT A SIMPLE
STRAIGHT – LINE PROGRESSION FROM DEFENSE TO ADAPTATION
– FROM LESS EVOLVED TO MORE EVOLVED –
RATHER, WORKING THROUGH IS ABOUT THE EMERGENCE OF
ITERATIVE HEALING CYCLES OF DESTABILIZATION AND RESTABILIZATION
AT EVER – MORE EVOLVED LEVELS OF
RESILIENCE, COMPLEXITY, AND ADAPTIVE CAPACITY

25. NUANCED
PHRASEOLOGY
– RELEVANT THROUGHOUT –
AS A PRELUDE
TO LEARNING
ABOUT
MINIMALLY
AND OPTIMALLY
STRESSFUL
INTERVENTIONS
25

26. 94

27. NUANCED PHRASEOLOGY
“YOU FIND YOURSELF”
WHEN THE PATIENT IS
HAVING AN “ANXIETY – PROVOKING” FEELING
BUT HAVING TROUBLE “ACKNOWLEDGING” IT
“YOU FIND YOURSELF FEELING PRETTY ANGRY RIGHT NOW.”
INSTEAD OF
“YOU ARE FEELING PRETTY ANGRY RIGHT NOW.”
THE THERAPIST IS INDIRECTLY
LETTING THE PATIENT “OFF THE HOOK” A BIT
BY INTIMATING THAT THE PATIENT’S ANGER
MIGHT WELL BE SOMETHING THAT HAS
COME UPON HER (AS IF TAKEN HER BY SURPRISE)
AND, THEREFORE, SOMETHING FOR WHICH
SHE IS NOT ENTIRELY RESPONSIBLE
PARADOXICALLY
THE PATIENT MIGHT WELL THEN
BE MORE EASILY ABLE TO “ACKNOWLEDGE”
THE “ANXIETY – PROVOKING” FEELING
27

28. NUANCED PHRASEOLOGY
“YOU WOULD PROBABLY RATHER NOT”
WHEN THE THERAPIST SAYS
SHE KNOWS THAT THE PATIENT
“WOULD PROBABLY RATHER NOT”
BE FEELING WHAT SHE IS FEELING,
THE THERAPIST, HERE TOO, IS INDIRECTLY
LETTING THE PATIENT “OFF THE HOOK” A BIT
THEREBY PERHAPS MAKING IT
A LITTLE EASIER FOR THE PATIENT
THEN TO “ACKNOWLEDGE”
THE “ANXIETY – PROVOKING” FEELING
“YOU WOULD PROBABLY RATHER NOT
BE FEELING ANGRY
BUT, EVEN SO, FIND YOURSELF
FEELING PRETTY ANGRY RIGHT NOW.”
INSTEAD OF
“YOU ARE FEELING
PRETTY ANGRY RIGHT NOW.”
28

29. NUANCED PHRASEOLOGY
“I AM REALIZING”
INSTEAD OF
“I REALIZE”
“I AM REALIZING”
IS MORE “DYNAMIC”
AND SUGGESTS
AN “ONGOING PROCESS”
OF “EVOLVING AWARENESS”
“I REALIZE”
IS MORE “STATIC”
29

30. NUANCED PHRASEOLOGY
“FOR NOW” / “AT THIS POINT IN TIME”
“RIGHT NOW” / “AT THIS MOMENT”
HERE THE THERAPIST IS USING
A LITTLE BIT OF
“SUBLIMINAL STIMULATION”
TO HIGHLIGHT THE FACT THAT PERHAPS,
AT SOME LATER POINT IN TIME,
THE PATIENT MIGHT WELL BE ABLE
TO TAKE HEALTHIER (MORE ADAPTIVE) ACTION
INSTEAD OF REMAINING (DEFENSIVELY) STUCK
“EVEN THOUGH YOU STOPPED LOVING
YOUR WIFE YEARS AGO,
AT THIS POINT IN TIME
YOU CAN’T IMAGINE EVER LEAVING HER.”
INSTEAD OF
“EVEN THOUGH YOU STOPPED LOVING
YOUR WIFE YEARS AGO,
YOU CAN’T IMAGINE EVER LEAVING HER.”
30

31. NUANCED PHRASEOLOGY
“EVERY NOW AND THEN” / “SOMETIMES”
“PERHAPS” / “ON SOME LEVEL” / “A LITTLE”
“MAYBE” / “POSSIBLY” / “AT TIMES”
“A PART OF YOU” / “SOME PART OF YOU”
THE THERAPIST CAN USE “QUALIFIERS”
TO “LIMIT” THE “INTENSITY” OF SOMETHING
THAT IS “ANXIETY – PROVOKING,”
THEREBY “PERHAPS” MAKING IT EASIER
FOR THE PATIENT THEN TO “ACKNOWLEDGE” IT
“SOMETIMES YOU FIND YOURSELF FEELING A LITTLE ANGRY.”
INSTEAD OF “YOU ARE FEELING ANGRY.”
“A PART OF YOU IS ENRAGED.”
INSTEAD OF “YOU ARE ENRAGED.”
“EVERY NOW AND THEN PERHAPS
YOU FIND YOURSELF FEELING A LITTLE ANGRY.”
INSTEAD OF “YOU ARE FEELING ANGRY.”
31

32. NUANCED PHRASEOLOGY
“I SEE” INSTEAD OF “I HEAR”
THE THERAPIST MAKES EXPLICIT THAT
SHE IS A WITNESS TO WHAT THE PATIENT IS FEELING
“I SEE HOW MUCH PAIN YOU ARE IN.”
“I SEE HOW DESPERATELY YOU WANT TO GET BETTER.”
NOTE THE SUBTLE DISTINCTION BETWEEN
“I SEE HOW LONELY YOU ARE FEELING.”
AND “I HEAR HOW LONELY YOU ARE FEELING.”
“I SEE HOW SAD YOU BECOME WHEN YOU TALK ABOUT
YOUR MOTHER AND HOW SHE NEVER UNDERSTOOD.”
AND “I HEAR HOW SAD YOU BECOME WHEN YOU TALK ABOUT
YOUR MOTHER AND HOW SHE NEVER UNDERSTOOD.”
IT FEELS GREAT TO BE ABLE TO KNOW
THAT HOW LONELY AND SAD YOU ARE IS BEING “HEARD”
BUT SOMETIMES IT IS EVEN MORE VALIDATING
AND REASSURING TO BE ABLE TO KNOW
THAT HOW LONELY AND SAD YOU ARE IS BEING “SEEN”
32

33. NUANCED PHRASEOLOGY
THE “ACT” CONCEPT OF “COGNITIVE DEFUSION” CAN BE VERY USEFUL
ONE OF THE GOALS OF WHICH IS TO CHANGE THE WAY
THE PATIENT RELATES TO HER THOUGHTS
– THAT IS, HOW SHE POSITIONS HERSELF IN RELATION TO THEM –
COGNITIVE DEFUSION PROMOTES “NOTICING” THE THOUGHT
RATHER THAN “GETTING CAUGHT UP IN” OR “BUYING INTO” THE THOUGHT
– LETTING THOUGHTS COME AND GO RATHER THAN HOLDING ONTO THEM –
DEFUSION INVITES THE PATIENT TO “THINK ABOUT THINKING”
AND TO REALIZE THAT SHE IS
CONTINUOUSLY “VERBALLY CONSTRUCTING” HER WORLD
IT IS ABOUT NOT CHANGING THE THOUGHT BUT RELATING DIFFERENTLY TO IT
“YOU ARE HAVING THE THOUGHT THAT YOU ARE BROKEN.”
“YOU ARE NOTICING THAT YOU ARE HAVING THE THOUGHT
THAT YOU ARE BROKEN.”
“YOU FIND YOURSELF THINKING THAT YOU ARE BROKEN.”
ALL OF WHICH ARE DESIGNED TO ENCOURAGE DEVELOPMENT
OF THE PATIENT’S “REFLECTING SELF” OR “OBSERVING EGO”
33

34. MORE SPECIFICALLY
“DUAL AWARENESS” IS BEING FOSTERED
WHEN THE PATIENT IS BEING ASKED
TO DIRECT HER ATTENTION
TO WHAT SHE IS EXPERIENCING IN THE MOMENT
AT THE SAME TIME THAT SHE IS BEING ENCOURAGED
TO STEP BACK FROM THAT EXPERIENCE
IN ORDER TO DETACH HERSELF FROM IT,
RECOVER PERSPECTIVE, AND REFLECT UPON IT
IN THE PSYCHOANALYTIC LITERATURE
THIS DISTINCTION
BETWEEN “EXPERIENCING” SOMETHING AND “OBSERVING” IT
IS DESCRIBED AS A “SPLIT IN THE EGO”
BETWEEN THE EXPERIENCING
– OR PARTICIPATING –
EGO
AND THE OBSERVING
– OR REFLECTING –
EGO
RICHARD STERBA (1934) / LESTON HAVENS (1976)
“DUAL AWARENESS” IS ONE OF THE GOALS OF ANY TREATMENT
34

35. NUANCED PHRASEOLOGY
AS WE SHALL LATER SEE
RELEVANT FOR OPTIMALLY STRESSFUL INTERVENTIONS
DESIGNED TO “PROMOTE AWARENESS”
ARE THE IMPACTFUL WORDS “YOU KNOW THAT … ”
WHICH HIGHLIGHT “ANXIETY – PROVOKING REALITIES”
THAT THE PATIENT REALLY DOES KNOW
– EVEN IF SHE WOULD RATHER NOT –
“YOU KNOW THAT I DON’T ANSWER THOSE KINDS OF QUESTIONS,
BUT YOU FIND YOURSELF WISHING THAT I DID.”
INSTEAD OF
“I DON’T ANSWER THOSE KINDS OF QUESTIONS … ”
“YOU KNOW THAT YOU COULD ASK YOUR NEIGHBOR
TO KEEP HIS BARKING DOG INSIDE,
BUT YOU FIND YOURSELF HESITATING FOR FEAR OF GETTING HIM ANGRY.”
INSTEAD OF
“YOU COULD ASK YOUR NEIGHBOR TO KEEP HIS BARKING DOG INSIDE … ”
YOU ARE NOT TELLING THE PATIENT WHAT “YOU” KNOW
RATHER, YOU ARE INSISTING THAT THE PATIENT
“TAKE OWNERSHIP” OF WHAT “SHE” KNOWS!
– EVEN IF IT MAKES HER ANXIOUS –
35

36. NUANCED PHRASEOLOGY
ALSO AS WE SHALL LATER SEE
RELEVANT FOR OPTIMALLY STRESSFUL INTERVENTIONS
DESIGNED TO FACILITATE THE “GRIEVING OF DISILLUSIONMENT”
ARE THE IMPACTFUL WORDS “YOU HAD HOPED THAT … ”
STRATEGIC USE OF THE “PAST PERFECT (PLUPERFECT) TENSE”
HIGHLIGHTS THE REALITY THAT SOMETHING THE PATIENT
“HAD BEEN HOPING FOR” IS BECOMING NO LONGER A VIABLE OPTION
“YOU HAD HOPED THAT I WOULD TELL YOU WHAT YOU SHOULD DO
BUT YOU ARE BEGINNING TO REALIZE
THAT I DON’T SIMPLY OFFER ADVICE
AND THAT ANGERS AND UPSETS YOU TERRIBLY.”
“YOU HAD HOPED THAT YOUR MOTHER MIGHT SOMEDAY APOLOGIZE
BUT YOU ARE BEGINNING TO REALIZE
THAT PROBABLY SHE NEVER WILL
AND THAT BREAKS YOUR HEART.”
“YOU HAD HOPED THAT YOUR HUSBAND WOULD ASK YOU
HOW YOUR DAY HAD GONE
BUT YOU ARE STARTING TO REALIZE THAT HE NEVER DOES ASK
AND PROBABLY NEVER WILL
AND THAT REALIZATION IS ABSOLUTELY DEVASTATING.”
THESE KINDS OF STATEMENTS ARE DESIGNED TO HELP THE PATIENT
ADVANCE ULTIMATELY FROM “RELENTLESS HOPE” TO “ACCEPTANCE”
36

37. 37

38. MINIMALLY
STRESSFUL
INTERVENTIONS
– THE BEGINNING GAME –
“BE WITH THE PATIENT WHERE SHE IS”
– “HOMEOSTATIC ATTUNEMENT” –
SALMAN AKHTAR (2012)
38

39. MINIMALLY STRESSFUL INTERVENTIONS
ARE DESIGNED TO ELICIT “LITTLE OR NO” ANXIETY
NOT ONLY DO THEY SUPPORT THE PATIENT
BUT THEY ALSO ADVANCE THE BALL A BIT
BY GENTLY TEASING OUT AND BRINGING INTO FOCUS
SOME OF THE “DEFENSIVE” AND “LESS – THAN – HEALTHY”
RECURRING THEMES, HABITUAL PATTERNS,
AND CONDITIONED REPETITIONS
IN THE PATIENT’S LIFE
INTEGRATION STATEMENTS
2 “PARTS” – BOTH / AND STATEMENTS
PATH – OF – LEAST – RESISTANCE STATEMENTS
DAMAGED – FOR – LIFE STATEMENTS
COMPENSATION STATEMENTS
ENTITLEMENT STATEMENTS
MASOCHISM STATEMENTS
SADISM STATEMENTS
PARADOXICAL INTERVENTIONS
YOU – WOULD – WISH STATEMENTS
EMPATHIC STATEMENTS
39

40. IN OTHER WORDS
MINIMALLY STRESSFUL
“CLARIFYING” INTERVENTIONS
SUPPORT BY SPOTLIGHTING
– ALWAYS WITH COMPASSION AND NEVER WITH JUDGMENT –
SOME OF THE
“PAINFUL AND DIFFICULT TRUTHS”
IN THE PATIENT’S LIFE
“JOINING THROUGH THE TRUTH”
TERRY REAL (2020)
40

41. MINIMALLY STRESSFUL INTERVENTIONS
INTEGRATION STATEMENTS
FOR THOSE PATIENTS WHO ARE HAVING TROUBLE
HOLDING IN MIND SIMULTANEOUSLY BOTH
THE “GOOD” AND THE “BAD” ASPECTS OF THEIR EXPERIENCE
IN OTHER WORDS
PATIENTS WITH TENUOUSLY ESTABLISHED
“LIBIDINAL OBJECT CONSTANCY” / “EVOCATIVE MEMORY CAPACITY”
“HARD TO REMEMBER” / “HARD TO IMAGINE”
“WHEN YOU’RE FEELING THIS BAD,
IT’S HARD TO REMEMBER THAT YOU HAD EVER FELT GOOD
AND IT’S HARD TO IMAGINE THAT YOU COULD EVER FEEL GOOD AGAIN.”
“WHEN YOUR HEART IS BREAKING AS IT IS NOW,
YOU CAN’T IMAGINE THAT YOU COULD EVER DARE TO TRUST AGAIN.”
“WHEN YOU’RE FEELING THIS ANGRY AT ME,
IT’S HARD TO REMEMBER THAT YOU USED TO FEEL GOOD ABOUT ME
AND EVEN LOOKED FORWARD TO OUR SESSIONS.”
“WHEN YOU FEEL THIS DESPAIRING,
YOU CAN’T REMEMBER EVER HAVING HAD ANY HOPE WHATSOEVER.”
41

42. MINIMALLY STRESSFUL INTERVENTIONS
2 “PARTS” – BOTH / AND STATEMENTS
FOR THOSE PATIENTS WHO ARE ABLE TO HOLD IN MIND
BOTH THE “GOOD” AND THE “BAD” ASPECTS OF THEIR EXPERIENCE
BUT ARE “AMBIVALENT” / “CONFLICTED” ABOUT SOMEONE OR SOMETHING
AND ARE STRUGGLING EITHER TO MAKE A DECISION
OR TO COME TO TERMS WITH SIMPLY “BEING AMBIVALENT”
IN OTHER WORDS
PATIENTS WHO ARE FEELING “TWO WAYS” ABOUT AN ISSUE
– WHEN BOTH “SIDES” ARE “REASONABLE ENOUGH OPTIONS” –
“A PART OF YOU” / “ANOTHER PART OF YOU”
“A PART OF YOU THINKS ALL THE TIME ABOUT STOPPING THE AFFAIR,
BUT ANOTHER PART OF YOU IS STILL ENJOYING EVERY MINUTE OF IT.”
“A PART OF YOU IS PROFOUNDLY DISAPPOINTED, HURT, AND ANGRY
AT YOUR HUSBAND, BUT ANOTHER PART OF YOU DOES KNOW
THAT HE IS A MAN WHOM YOU DEEPLY CHERISH, ADORE, AND LOVE.”
“A PART OF YOU IS TEMPTED TO STOP TREATMENT BECAUSE
IT COSTS SO MUCH, BUT ANOTHER PART OF YOU KNOWS THAT
YOUR THERAPY HAS BEEN VERY HELPFUL AND THAT YOU MIGHT
BE MAKING A HUGE MISTAKE WERE YOU SIMPLY TO QUIT RIGHT NOW.”
“A PART OF YOU REMAINS HURT, DISAPPOINTED, AND UNFORGIVING,
BUT ANOTHER PART OF YOU IS WANTING TO FIND A WAY TO FORGIVE ME.”
42

43. MINIMALLY STRESSFUL INTERVENTIONS
PATH – OF – LEAST – RESISTANCE STATEMENTS
FOR THOSE PATIENTS WHO ARE
“REACTING DEFENSIVELY”
RATHER THAN
“RESPONDING ADAPTIVELY”
EASIER TO “REACT DEFENSIVELY”
THAN TO “RESPOND ADAPTIVELY”
“IT’S EASIER TO GIVE UP
THAN TO KEEP FIGHTING FOR WHAT YOU REALLY BELIEVE IN.”
“IT’S EASIER TO EXPERIENCE YOURSELF AS DISEMPOWERED
THAN TO TAKE OWNERSHIP OF THE POWER
AND AGENCY THAT YOU ACTUALLY DO HAVE.”
“IT’S EASIER TO EXPERIENCE YOURSELF AS HAVING NO ACCOUNTABILITY
THAN TO TAKE RESPONSIBILITY FOR YOUR LIFE.”
“IT’S EASIER TO HOLD ON TO THE HOPE
THAT YOUR HUSBAND MIGHT SOMEDAY CHANGE
THAN TO CONFRONT THE REALITY THAT HE PROBABLY NEVER WILL.”
43

44. THE “I CAN’T, YOU CAN, AND YOU SHOULD” DYNAMIC
FOR THOSE PATIENTS WHO EXPERIENCE THEMSELVES AS
SO “DAMAGED” FROM WAY BACK THAT THEY CAN’T
IMAGINE BEING HELD ACCOUNTABLE FOR THEIR LIVES NOW
DAMAGED – FOR – LIFE – AND – THEREFORE
– NOT – RESPONSIBLE – NOW STATEMENTS
WHO FIND THEMSELVES THEREFORE LOOKING TO OTHERS
TO “COMPENSATE” THEM FOR THE EARLY – ON “DAMAGE”
COMPENSATION STATEMENTS
AND WHO
– QUITE FRANKLY –
FEEL THAT THIS “COMPENSATION” IS THEIR DUE
ENTITLEMENT STATEMENTS
DISTORTION – DISTORTED SENSE OF SELF AS “NOT HAVING”
ILLUSION – ILLUSORY SENSE OF OBJECT AS “HAVING”
ENTITLEMENT – ENTITLED SENSE THAT “GETTING” IS THEIR “RIGHT”
ALL OF WHICH ARE DEFENSIVE REACTIONS
44

45. MINIMALLY STRESSFUL INTERVENTIONS
DAMAGED – FOR – LIFE – AND – THEREFORE
– NOT – RESPONSIBLE – NOW STATEMENTS
“YOU FEEL SO DAMAGED BECAUSE OF ALL
THE ABUSE YOU SUFFERED AS A CHILD THAT
YOU CANNOT IMAGINE EVER BEING ABLE TO DO
ANYTHING NOW TO MAKE YOUR LIFE BETTER.”
COMPENSATION STATEMENTS
“WHEN YOU ARE FEELING DESPERATE, AS YOU
ARE RIGHT NOW, YOU FIND YOURSELF WISHING THAT
SOMEONE WOULD UNDERSTAND JUST HOW BAD YOU FEEL
AND WOULD DO SOMETHING TO HELP EASE YOUR PAIN.”
ENTITLEMENT STATEMENTS
“BECAUSE YOU FEEL THAT WHAT YOUR FATHER DID TO YOU
WAS SO UNFAIR, DEEP DOWN YOU HARBOR
THE CONVICTION THAT THE WORLD NOW OWES YOU.”
“BECAUSE YOUR MOTHER NEVER UNDERSTOOD YOU AND
LEFT YOU SO MUCH ON YOUR OWN, YOU’RE NOW FEELING
THAT UNLESS SOMEONE IS WILLING TO GO MORE THAN
HALFWAY, THEN YOU’RE SIMPLY NOT INTERESTED.”
45

46. MINIMALLY STRESSFUL INTERVENTIONS
MASOCHISM STATEMENTS
FOR THOSE PATIENTS WHO
– BECAUSE IT SIMPLY “HURTS TOO MUCH” –
REFUSE TO “CONFRONT” – AND “GRIEVE” – THE REALITY
THAT THE OBJECT OF THEIR DESIRE WILL NEVER CHANGE
INSTEAD, THEY HOLD ON TO THEIR
DEFENSIVE – AND RELENTLESS – “HOPING AGAINST HOPE”
“BECAUSE IT IS SO PAINFUL EVEN TO THINK ABOUT CONFRONTING
THE TRUTH ABOUT YOUR HUSBAND AND HIS ONGOING INSENSITIVITY
TO YOU AND YOUR FEELINGS, YOU FIND YOURSELF CONTINUING
TO HOPE THAT PERHAPS, IF YOU TRY HARD ENOUGH, ARE PERSUASIVE
ENOUGH, PERSIST LONG ENOUGH, AND SUFFER DEEPLY ENOUGH,
THEN YOU MIGHT YET BE ABLE TO COMPEL HIM TO CHANGE.”
“BECAUSE IT HURTS TOO MUCH TO CONFRONT THE REALITY THAT
YOUR FATHER WILL NEVER BE WILLING TO APOLOGIZE FOR ALL THAT
HE DID TO YOU WHEN YOU WERE GROWING UP, YOU KEEP HOPING
THAT IF YOU TRY HARD ENOUGH, PERSIST LONG ENOUGH, AND
SUFFER DEEPLY ENOUGH, THEN HE MIGHT YET RELENT AND BE WILLING
TO ACKNOWLEDGE THAT HE KNOWS HE CAUSED YOU TERRIBLE
HEARTBREAK DURING ALL THOSE YEARS OF HIS DRINKING.”
46

47. MINIMALLY STRESSFUL INTERVENTIONS
SADISM STATEMENTS
FOR THOSE PATIENTS WHO
– IN THOSE MOMENTS OF DAWNING RECOGNTION THAT WHAT THEY
HAD SO DESPERATELY WANTED AND FELT THEY NEEDED TO HAVE
IN ORDER TO SURVIVE IS SIMPLY NOT GOING TO HAPPEN –
ARE DEFENSIVELY PRONE TO EXPERIENCING THEMSELVES
AS HAVING BEEN “MISTREATED” AND / OR “VICTIMIZED”
THEY WILL OFTEN THEN FIND THEMSELVES FEELING THAT THEY
EITHER HAVE NO CHOICE BUT TO RETALIATE
OR ARE ENTITLED TO RETALIATE
“WHEN YOU FEEL THAT YOU HAVE BEEN WRONGED,
YOU CAN GET PRETTY UGLY IF YOU HAVE TO!”
“WHEN YOU FEEL THAT YOU ARE BEING MISTREATED,
IT MAKES YOU SO ENRAGED THAT YOU FEEL
YOU HAVE NO CHOICE BUT TO LASH BACK.”
“WHEN YOUR MOTHER IS DOING HER ‘USUAL,’
IT HURTS SO MUCH TO BE FEELING SO MISUNDERSTOOD
THAT YOU FIND YOURSELF THINKING ABOUT
WHAT YOU CAN DO TO HURT HER BACK.
SHE SHOULD HAVE TO GET A TASTE OF HER OWN MEDICINE.”
47

48. MINIMALLY STRESSFUL INTERVENTIONS
PARADOXICAL INTERVENTIONS
FOR THOSE PATIENTS WHO ARE DEEPLY ENTRENCHED
IN MAINTAINING “SAME OLD, SAME OLD”
ALTHOUGH THE PATIENT HAS BEEN GIVING “LIP SERVICE” TO WANTING
TO CHANGE, IT IS CLEAR FROM WHAT THE PATIENT IS ACTUALLY DOING
THAT THE PATIENT IS NOT, IN FACT, PREPARED TO CHANGE
THE THERAPIST THEREFORE “LETS GO” OF HER OWN “NEED”
FOR THE PATIENT TO CHANGE AND “ACCEPTS” THE REALITY THAT
THE PATIENT IS NOT PREPARED TO CHANGE – AT LEAST “NOT FOR NOW”
IN ESSENCE, THE THERAPIST “GOES WITH THE RESISTANCE” BY
“PRESCRIBING THE SYMPTOM”
“I THINK I AM BEGINNING TO SEE WHY YOU FEEL THAT YOU
CANNOT AFFORD TO TRUST ANYONE. BASED UPON WHAT YOU
HAVE BEEN TELLING ME ABOUT THE NUMBERS OF TIMES
YOUR TRUST HAS BEEN BETRAYED AND YOUR HEART BROKEN
IN THE PAST, I CAN NOW UNDERSTAND WHY YOU FEEL THAT YOU
SIMPLY MIGHT NEVER WANT TO OPEN YOUR HEART AGAIN. ALTHOUGH
IT MIGHT MEAN BEING ALONE FOREVER, AT LEAST YOU WILL
KNOW THAT NO ONE WILL BE ABLE TO HURT YOU EVER AGAIN.”
48

49. MINIMALLY STRESSFUL INTERVENTIONS
PARADOXICAL INTERVENTIONS
IN ESSENCE, THE THERAPIST USES HER “EMPATHIC UNDERSTANDING”
OF THE PATIENT TO OFFER HER A PARADOX
TO THE PATIENT WHO, EVEN AFTER A YEAR, HAS NOT BEEN ABLE TO MOBILIZE
HIMSELF TO UPDATE HIS RESUME – DESPITE HIS PROCLAIMED INTENTION TO DO SO
“YES, EVERY SINGLE DAY YOU DREAD GOING TO WORK, YOU HATE YOUR
BOSS, AND YOUR JOB IS INCREDIBLY TEDIOUS. BUT, AS YOU HAVE SAID
REPEATEDLY, IT DOES PROVIDE YOU WITH FINANCIAL SECURITY AND A SENSE
OF BELONGING. SO I THINK I AM BEGINNING TO APPRECIATE THAT,
AT THIS POINT IN YOUR LIFE, PERHAPS IT DOES NOT REALLY MAKE SENSE
FOR YOU TO BE MOVING FORWARD WITH APPLYING FOR A NEW JOB.
PERHAPS AT SOME POINT IN THE FUTURE, BUT NOT RIGHT NOW.”
TO A DESPERATELY UNHAPPY 45 – YEAR – OLD MAN MARRIED FOR 20 YEARS
“YOU HATE IT THAT YOUR WIFE ABUSES YOU IN ALL THE
WAYS THAT SHE DOES. AND YOU STOPPED LOVING HER YEARS AGO.
BUT, AS YOU HAVE OFTEN EXPLAINED, WHEN YOU START
TO THINK ABOUT HOW OLD AND TIRED YOU FEEL, YOU FIND YOURSELF
THINKING THAT PERHAPS IT IS SIMPLY TOO LATE – THAT THE TIME
TO HAVE LEFT HER MIGHT ALREADY HAVE COME AND GONE. UNDERSTOOD.”
IF THE PATIENT IS MADE ANGRY BY THE THERAPIST’S PARADOXICAL INTERVENTIONS,
THEN THE PATIENT’S ANGER MIGHT WELL EMPOWER HER –
MIGHT WELL PROVIDE THE NECESSARY MOTIVATION (OR IMPETUS)
FOR HER TO TAKE ACTION – IF ONLY TO PROVE THE THERAPIST WRONG!
49

50. MINIMALLY STRESSFUL INTERVENTIONS
YOU – WOULD – WANT / YOU – WOULD – WISH STATEMENTS
HERE THE THERAPIST IS GIVING THE PATIENT THE “BENEFIT OF THE DOUBT”
USING A LITTLE BIT OF “SUBLIMINAL STIMULATION”
TO HIGHLIGHT THE FACT THAT THE THERAPIST THINKS THERE IS INDEED
A HEALTHY PART OF THE PATIENT THAT “WOULD WANT” TO BE ABLE
TO DO A BETTER JOB OF MANAGING THINGS IN HER LIFE
INSTEAD OF ALWAYS SABOTAGING HERSELF
ADMITTEDLY, THE THERAPIST IS “LEADING THE WITNESS” A BIT
BY “PUTTNG HEALTHY WORDS IN THE PATIENT’S MOUTH”
BUT IT IS ALL BEING DONE WITH AN EYE
TO HELPING THE PATIENT ACCESS HER “LEADING EDGE”
“YOU WOULD WANT TO BE ABLE TO FORGIVE YOUR HUSBAND
BUT ARE JUST NOT QUITE YET PREPARED TO DO THAT.”
“YOU WOULD WANT TO BE ABLE TO GET YOUR TAXES DONE
BUT FIND YOURSELF FIGHTING IT EVERY STEP OF THE WAY.”
“YOU WOULD WANT TO BE ABLE TO HAVE A RICHER, MORE FULFILLING LIFE
BUT HOLD BACK FROM VENTURING OUT
FOR FEAR OF BEING TERRIBLY DISAPPOINTED.”
“YOU WOULD WISH THAT YOU COULD BE MORE ON TOP OF YOUR GAME
BUT FIND YOURSELF CONTINUALLY FEELING OVERWHELMED
AND LOSING YOUR WAY.”
50

51. MINIMALLY STRESSFUL INTERVENTIONS
EMPATHIC STATEMENTS
ARE ALSO DESIGNED TO ELICIT “LITTLE OR NO” ANXIETY
BUT THEY ARE IN A CLASS OF THEIR OWN
THEY ARE MY “DEFAULT MODE” AND WHERE I SPEND MUCH OF MY TIME
THEY “TEASE OUT” AND “BRING INTO FOCUS”
– MOMENT – TO – MOMENT –
BOTH THE PATIENT’S “AFFECT”
AND THE “NARRATIVE”
WITH WHICH THAT AFFECT IS ASSOCIATED
FORMULATING THESE EMPATHIC STATEMENTS
REQUIRES OF THE THERAPIST THAT SHE BE
“ATTENTIVELY LISTENING” AND “EMPATHICALLY ATTUNED”
TO WHATEVER THE PATIENT IS “EXPERIENCING” IN THE MOMENT
THE THERAPIST’S STANCE HERE IS PROBABLY BEST DESCRIBED
AS ONE OF HAVING AN “AGENDALESS PRESENCE”
– IN THE WORDS OF DANIEL GOLEMAN (2007) –
AND OF BEING A “MINDFUL WITNESS”
– IN THE WORDS OF TARA BRACH (2004) –
THESE EMPATHIC STATEMENTS REASSURE THE PATIENT
THAT SHE IS BEING UNDERSTOOD AND THAT SHE IS NOT ALONE
51

52. EMPATHIC STATEMENTS
“EXPERIENCE – NEAR” NOT “EXPERIENCE – DISTANT”
WHAT’S IN THE PATIENT’S CONSCIOUSNESS NOT HER UNCONSCIOUS
THE GOAL OF THESE STATEMENTS IS
TO HELP THE PATIENT “FEEL UNDERSTOOD”
NOT TO HELP THE PATIENT “UNDERSTAND”
BUT THESE STATEMENTS
WILL START TO GIVE SHAPE
TO THE “FILTERS” THROUGH WHICH
THE PATIENT IS INTERPRETING HER WORLD
“OLD BAD” DISEMPOWERING NARRATIVES THAT WILL ULTIMATELY
NEED TO BE UPDATED TO “NEW GOOD” EMPOWERING NARRATIVES
“IT’S HARD TO KNOW WHERE TO BEGIN
WHEN EVERYTHING FEELS SO OVERWHELMING.”
“IT’S UNCOMFORTABLE TO BE HERE WHEN YOU’RE NOT SURE
THE THERAPY IS REALLY HELPING ANYWAY.”
“YOU’RE TERRIFIED OF BEING DISAPPOINTED AGAIN.”
“IT’S UPSETTING TO BE FEELING THIS OUT OF CONTROL.”
“YOU’RE CONFUSED ABOUT HOW BEST TO USE YOUR SESSION.”
52

53. I TAKE MY CUES FROM THE PATIENT
AND AM THEREFORE GENERALLY ONE STEP BEHIND HER – NOT AHEAD
LISTENING ALWAYS WITH COMPASSION AND NEVER JUDGMENT
– WITH BOTH “HEAD” AND “HEART” –
TO EVERYTHING THE PATIENT IS TELLING ME
– NO MATTER HOW SEEMINGLY IRRELEVANT IT MIGHT APPEAR TO BE –
– NO DETAIL TOO TRIVIAL TO BE IGNORED OR FORGOTTEN –
I WILL THEN OFFER THESE EMPATHIC STATEMENTS
THAT HIGHLIGHT
“WHAT THE PATIENT IS ACTUALLY FEELING RIGHT THEN”
AND “ABOUT WHAT”
STATEMENTS THAT OFTEN END WITH AN IMPLIED QUESTION MARK
WHEREBY I AM SIGNALING THAT I AM VERY OPEN TO HAVING
MY RENDERING OF THINGS EDITED, CORRECTED, OR REVISED
IN ORDER TO MAKE IT A MORE ACCURATE REFLECTION OF WHAT
THE PATIENT IS ACTUALLY SAYING AND WANTING ME TO KNOW
THE “AFFECT” DOES NOT NEED TO BE A “BIG DRAMATIC EMOTION” LIKE
ANGER / OUTRAGE – FEAR / PANIC / DESPERATION
SADNESS / DESPAIR – DISGUST / HORROR – SHAME / GUILT / REGRET
IT CAN BE SOMETHING “MORE UNDERSTATED” LIKE
CONFUSED / NOT KNOWING FOR SURE / LOST – UPSET / CONCERNED / WORRIED
UNCOMFORTABLE / WEARY / BURDENED – DISAPPOINTED / FRUSTRATED
WOULD RATHER NOT / WOULD WISH
53

54. WITH RESPECT TO THE “FRAMING” OF AN EMPATHIC STATEMENT
PLEASE NOTE THAT INSTEAD OF
“I WONDER IF IT IS PAINFUL TO BE FEELING SO MISUNDERSTOOD.”
OR “IT SOUNDS AS IF IT IS PAINFUL TO BE FEELING SO MISUNDERSTOOD.”
OR “IT SEEMS AS IF IT IS PAINFUL TO BE FEELING SO MISUNDERSTOOD.”
OR “IT MUST BE PAINFUL TO BE FEELING SO MISUNDERSTOOD.”
YOU COULD SIMPLY SAY
“IT IS PAINFUL TO BE FEELING SO MISUNDERSTOOD.”
FOLLOWED BY THE IMPLIED QUESTION MARK
AGAIN, THEREBY SIGNALING THAT YOU ARE VERY OPEN
TO HAVING YOUR STATEMENT AMENDED
I DO MY BEST TO ELIMINATE EXTRA WORDS AT THE BEGINNING
OF THE STATEMENT SO THAT I CAN CUT RIGHT TO THE CHASE
“IT BREAKS YOUR HEART THAT SHE DOESN’T SEEM TO CARE.”
EXTRA WORDS RUN THE RISK OF PUTTING TOO MUCH DISTANCE
BETWEEN THE PATIENT AND THE THERAPIST
54

55. OPTIMALLY
STRESSFUL
INTERVENTIONS
– THE MIDDLE GAME –
ALTERNATELY AND REPEATEDLY
“BE WITH THE PATIENT WHERE SHE IS”
– “HOMEOSTATIC ATTUNEMENT” –
“DIRECT HER ATTENTION TO
WHERE YOU WOULD WANT HER TO GO”
– “DISRUPTIVE ATTUNEMENT” –
SALMAN AKHTAR (2012)
55

56. OPTIMALLY STRESSFUL INTERVENTIONS
ARE DESIGNED TO GENERATE
“DESTABILIZING STRESS”
BY JUXTAPOSING
– WHETHER DIRECTLY OR INDIRECTLY AND WHETHER EXPLICITLY OR IMPLICITLY –
ANXIETY – PROVOKING CHALLENGE OF THE DEFENSE
WITH ANXIETY – ASSUAGING SUPPORT OF THE DEFENSE
TO CREATE GROWTH – INCENTIVIZING
“MISMATCH EXPERIENCES”
MODEL 1 CONFLICT STATEMENTS
– CLASSICAL PSYCHOANALYTIC –
MODEL 2 DISILLUSIONMENT STATEMENTS
– SELF PSYCHOLOGICAL –
MODEL 3 ACCOUNTABILITY STATEMENTS
– CONTEMPORARY RELATIONAL –
MODEL 4 FACILITATION STATEMENTS
– EXISTENTIAL – HUMANISTIC –
56

57. MODEL 1 CONFLICT STATEMENTS (COGNITIVE)
“YOU KNOW THAT ... , BUT YOU FIND YOURSELF THINKING,
FEELING, OR DOING IN ORDER NOT TO HAVE TO ... ”
GOAL – TO FACILITATE RESOLUTION OF INTRAPSYCHIC CONFLICT
BY CREATING “INCENTIVIZING” TENSION
BETWEEN “ADAPTIVE CAPACITY” FOR “AWARENESS”
AND “DEFENSIVE NEED” TO “RESIST”
“YOU KNOW THAT YOUR MOTHER WILL NEVER APOLOGIZE,
BUT YOU FIND YOURSELF CONTINUING TO WISH THAT SHE WOULD.”
“YOU KNOW THAT IF YOU ARE EVER TO GET ON WITH YOUR LIFE,
THEN YOU WILL NEED TO LET GO OF YOUR CONVICTION THAT YOUR
CHILDHOOD SCARRED YOU FOR LIFE. BUT IT’S HARD NOT TO FEEL
LIKE DAMAGED GOODS WHEN YOU GREW UP IN A HORRIBLY ABUSIVE
HOUSEHOLD WITH A NASTY MOTHER WHO KEPT CALLING YOU A LOSER.”
“YOU KNOW THAT ULTIMATELY YOU WILL NEED TO CONFRONT AND
GRIEVE THE REALITY THAT JUAN, 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.”
57

58. MODEL 1 CONFLICT STATEMENTS (COGNITIVE)
“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 ARE
HAVING. BUT YOU TELL YOURSELF THAT IT ISN’T REALLY
YOUR FAULT BECAUSE IF SHE WEREN’T SO PROVOCATIVE,
THEN YOU WOULDN’T HAVE TO BE SO VINDICTIVE!”
“YOU KNOW THAT I DON’T ANSWER THOSE KINDS OF QUESTIONS.
BUT YOU FIND YOURSELF CONTINUING TO HOPE THAT I WILL.”
“YOU KNOW THAT, ULTIMATELY, YOU’LL NEED TO LEAVE MIGUEL
BECAUSE HE KEEPS BREAKING YOUR HEART.
BUT YOUR FEAR IS THAT WERE YOU TO LET HIM GO,
YOU WOULD SIMPLY NOT SURVIVE.”
“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 SOMEDAY YOU’LL 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.”
58

59. MODEL 2 DISILLUSIONMENT STATEMENTS (AFFECTIVE)
“YOU HAD SO HOPED THAT … ,
BUT YOU ARE BEGINNING TO REALIZE THAT … ,
AND IT DEVASTATES / ENRAGES YOU … ”
GOAL – TO FACILITATE GRIEVING
BY CREATING “INCENTIVIZING” TENSION
BETWEEN “DEFENSIVE NEED” TO “AVOID CONFRONTING”
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” THE “REALITY” –
AND THEN “RESONATE EMPATHICALLY”
WITH THE PAIN OF THE PATIENT’S “GRIEF”
– “ADAPTIVE CAPACITY” TO “FEEL” THE ACTUAL “HEARTBREAK” –
59

60. MODEL 2 DISILLUSIONMENT STATEMENTS (AFFECTIVE)
“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 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 UPSETS AND SADDENS YOU.”
“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.”
60

61. MODEL 2 DISILLUSIONMENT STATEMENTS (AFFECTVE)
“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 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 THAT WAY; AND THAT MAKES YOU VERY SAD.”
“YOU WERE SO HOPING THAT I WOULD NOT MAKE THE SAME KINDS OF
MISTAKES THAT EVERYONE ELSE IN YOUR LIFE HAS MADE, WHICH IS WHY
IT MAKES YOU VERY SAD THAT I TOO HAVE NOW LET YOU DOWN.”
“YOU HAD WANTED SO MUCH FOR ME TO BE ABLE TO MAKE
IT ALL BETTER, AND IT UPSETS YOU TERRIBLY THAT I DON’T
SEEM TO BE ABLE TO MAKE YOUR PAIN GO AWAY.”
61

62. MODEL 2 DISILLUSIONMENT STATEMENTS (AFFECTIVE)
“YOU KNOW THAT EVENTUALLY YOU WILL NEED TO FACE THE
REALITY THAT YOUR FATHER WILL NEVER CHANGE, AND THAT
BREAKS YOUR HEART 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’S ABSOLUTELY
DEVASTATING BECAUSE YOU HAD SO HOPED THAT SOMEDAY
SHE MIGHT ACTUALLY COME TO UNDERSTAND – AND APOLOGIZE.”
“AS YOU BEGIN TO ADMIT TO YOURSELF THAT PROBABLY
JUANITA 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.”
62

63. MODEL 3 ACCOUNTABILITY STATEMENTS (RELATIONAL)
TRANSFERENCE / COUNTERTRANSFERENCE ENTANGLEMENTS
PROJECTIVE IDENTIFICATIONS – MUTUAL ENACTMENTS
CO – CREATION OF THERAPEUTIC IMPASSES
GOAL – TO BRING THE FOCUS INTO THE HERE – AND – NOW OF
WHAT’S GETTING RE – ENACTED BY THE PATIENT IN THE TRANSFERENCE
– TO WHICH THE THERAPIST, IN HER TURN, IS
COUNTERTRANSFERENTIALLY REACTING / RESPONDING –
THE THERAPIST MAY CHOOSE TO SHARE –
SOMETHING ABOUT HER EXPERIENCE
OF BEING IN THE ROOM WITH THE PATIENT
HER OWN STATE OF INTERNAL CONFLICTEDNESS
AS A RESULT OF SOMETHING HAPPENING BETWEEN THEM
HER SENSE THAT SHE HAS BEEN MADE TO FEEL
– IN RELATION TO THE PATIENT IN THE HERE – AND – NOW –
SOME VERSION OF WHAT THE PARENT MUST HAVE FELT
IN RELATION TO THE PATIENT IN THE THERE – AND – THEN
HER SENSE THAT SHE HAS BEEN MADE TO FEEL
– IN RELATION TO THE PATIENT IN THE HERE – AND – NOW –
SOME VERSION OF WHAT THE PATIENT MUST HAVE FELT
IN RELATION TO THE PARENT IN THE THERE – AND – THEN
63

64. MODEL 3 ACCOUNTABILITY STATEMENTS
CAN BE INTRODUCED IN ANY OF THE FOLLOWING WAYS
“IT OCCURS TO ME THAT, BY WAY OF YOUR
BEHAVIOR IN HERE WITH ME, YOU ARE HELPING
ME TO UNDERSTAND SOMETHING THAT
I HAD NEVER BEFORE ENTIRELY UNDERSTOOD … ”
“I THINK THAT YOU HAVE BEEN TRYING TO
COMMUNICATE SOMETHING IMPORTANT TO ME
THAT I HAD BEEN REFUSING TO SEE … ”
“I WONDER IF MY DIFFICULTY APPRECIATING
JUST HOW DESPERATE YOU WERE MADE
YOU FEEL THAT YOU HAD TO DO SOMETHING
DRAMATIC IN ORDER TO GET MY ATTENTION … ”
64

65. AS ADDITIONAL EXAMPLES
MODEL 3 ACCOUNTABILITY STATEMENTS (RELATIONAL)
THE THERAPIST MAY CHOOSE TO SHARE SOMETHING ABOUT
HER EXPERIENCE OF BEING IN THE ROOM WITH THE PATIENT
“IT WOULD SEEM THAT 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 THAT YOU HAVE
SPOKEN OF HAVING FELT 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)
65

66. MODEL 3 ACCOUNTABILITY STATEMENTS (RELATIONAL)
AS IRWIN HOFFMAN (2001) HAS SUGGESTED
IF THE THERAPIST IS AWARE OF FEELING CONFLICTED IN
RELATION TO THE PATIENT, SHE COULD 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 STATE OF INTERNAL 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.”
66

67. MODEL 3 ACCOUNTABILITY STATEMENTS (RELATIONAL)
“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.”
67

68. MODEL 3 ACCOUNTABILITY STATEMENTS (RELATIONAL)
“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 MORE
A STORY ABOUT FEELINGS THAT 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 CHARACTERIZED YOUR
RELATIONSHIP WITH YOUR DOUBLE – BINDING FATHER –
THE FEELING THAT NO MATTER WHAT EITHER OF US MIGHT DO,
IT WOULDN’T GET THE OTHER’S APPROVAL!
BUT ALL OF THIS 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!”
68

69. MODEL 3
THE “RULE OF THREE”
FOR THE PATIENT WHO HAS DONE
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 MIGHT ASK THE PATIENT ANY OF THE FOLLOWING
“HOW ARE YOU HOPING THAT I WILL RESPOND?”
WHICH SPEAKS TO THE ID
“HOW ARE YOU FEARING THAT I MIGHT RESPOND?”
WHICH SPEAKS TO THE SUPEREGO
“HOW DO YOU IMAGINE THAT I WILL RESPOND?”
WHICH SPEAKS TO THE EXECUTIVE FUNCTIONING OF THE EGO
– THE DORSOLATERAL PREFRONTAL CORTEX OF THE BRAIN –
ALL THREE DEMAND OF THE PATIENT THAT SHE MAKE
HER “INTERPERSONAL INTENTIONS” MORE EXPLICIT
ACCOUNTABILITY AND EMPOWERMENT
69

70. MODEL 4 FACILITATION STATEMENTS (EXISTENTIAL)
ARE SPECIFICALLY DESIGNED TO HIGHLIGHT
– WITH COMPASSION AND NEVER JUDGMENT –
THE INTENSE AMBIVALENCE THE PATIENT HAS
ABOUT BEING “AUTHENTICALLY ENGAGED” WITH PEOPLE
THEY EXPRESS AN APPRECIATION FOR THE COMPLEXITY
OF THE PATIENT’S EXPERIENCE OF “BEING – IN – THE – WORLD”
AND, IN SPEAKING TO DIFFERENT PARTS OF THE
PATIENT’S SELF – EXPERIENCE, HONOR THE “COLLAGE”
OF SELVES THAT CONSTITUTE THE WHOLE
“A PART OF YOU WOULD WANT DESPERATELY
TO BE SEEN AND UNDERSTOOD.
BUT ANOTHER PART OF YOU IS TERRIFIED OF BEING FOUND.”
“A PART OF YOU WOULD WANT TO BE ABLE TO TRUST ME.
BUT ANOTHER PART OF YOU HOLDS BACK
FOR FEAR OF BEING BETRAYED.
TOO MANY PEOPLE HAVE ALREADY BROKEN YOUR HEART.”
70

71. MODEL 4 FACILITATION STATEMENTS (EXISTENTIAL)
“A PART OF YOU IS DESPERATE TO BE ABLE TO FEEL
THAT YOU BELONG SOMEWHERE. BUT ANOTHER PART
OF YOU IS AFRAID EVEN TO HOPE THAT
YOU MIGHT SOMEDAY FEEL AT HOME IN THE WORLD.”
“A PART OF YOU LONGS TO FIND A SOULMATE WITH WHOM YOU
WOULD BE ABLE TO SHARE WHAT MOST MATTERS TO YOU AND
WITH WHOM YOU WOULD BE ABLE TO SPEND THE REST OF
YOUR LIFE. BUT ANOTHER PART OF YOU IS CONVINCED THAT
YOU WILL ALWAYS BE LIVING IN ISOLATION
AND THAT YOU HAVE NO CHOICE BUT TO GROW OLD ALONE.”
“A PART OF YOU WOULD WANT TO BE ABLE TO FIND SOMETHING
THAT WOULD MAKE YOUR LIFE FEEL MORE MEANINGFUL.
BUT ANOTHER PART OF YOU FEARS THAT IT IS SIMPLY NOT
IN THE CARDS FOR YOU EVER TO FIND ANY REAL PLEASURE
IN LIFE OR ANY REAL JOY IN RELATIONSHIPS.”
“A PART OF YOU WANTS VERY MUCH TO GET BETTER AND
REALIZES THAT COMING IN EVERY WEEK PROBABLY
GIVES YOU THE BEST CHANCE OF MAKING THAT HAPPEN.
BUT ANOTHER PART OF YOU IS EXHAUSTED, DISCOURAGED, AND
NOT AT ALL SURE THAT YOU HAVE IT IN YOU TO KEEP TRYING.”
71

72. PSYCHODYNAMIC
PSYCHOTHERAPY
OFFERS THE PATIENT
AN OPPORTUNITY
TO REVISIT
TRAUMATIC EXPERIENCES
THAT HAD ONCE CREATED
THE NEED FOR DEFENSE
BUT THAT CAN NOW
BE REWORKED
SUCH THAT THERE CAN BE
A DIFFERENT ENDING THIS TIME
– AN ADAPTIVE RESOLUTION –
72

73. IN ESSENCE
PSYCHODYNAMIC PSYCHOTHERAPY
AFFORDS THE PATIENT
BOTH IMPETUS AND OPPORTUNITY
– ALBEIT BELATEDLY –
TO MASTER TRAUMATIC EXPERIENCES
THAT HAD ONCE BEEN OVERWHELMING
– AND, THEREFORE, DEFENDED AGAINST –
BUT THAT CAN NOW
– BY VIRTUE OF THE SYNERGY BETWEEN
THE THERAPIST’S LOVING SUPPORT AND
THE PATIENT’S INNATE CAPACITY TO ADAPT TO STRESS –
BE REVISITED, REPROCESSED, AND REFRAMED
SUCH THAT GROWTH – IMPEDING DEFENSES
– ONCE NECESSARY FOR SURVIVAL –
CAN BE GRADUALLY TRANSFORMED
INTO GROWTH – PROMOTING ADAPTATIONS
STRONGER AT THE BROKEN PLACES
73

76. THE ART OF PRECIOUS SCARS

77. 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

78. THANK YOU!
STUART AND HIS BROTHER STEWART

79. IF YOU WOULD
LIKE TO BE ON
MY MAILING LIST
(AND ARE NOT YET)
PLEASE EMAIL ME AT
MarthaStarkMD @
HMS.Harvard.edu
79

80.  REFERENCES
 Akhtar, S. 2012. Psychoanalytic listening: Methods, limitations, and
innovations. New York, NY: Routledge / Taylor & Francis Group.
 Bollas, C. 1989. The shadow of the object: Psychoanalysis of the
unthought known. New York: Columbia University Press.
 Brach, T. 2004. Radical acceptance: Embracing your life with the heart
of a Buddha. New York: Random House.
 Ehrenberg, D. 1992. The intimate edge: Extending the reach of
psychoanalytic interaction. New York: W. W. Norton & Co.
 Freud, A. 1979. The ego and the mechanisms of defense: The writings
of Anna Freud. Madison, CT: International Universities Press.
 Freud, S. 1914. Remembering, repeating and working through (Further
recommendations on the technique of psycho-analysis II). Standard
Edition of the Complete Psychological Works of Sigmund Freud,
Volume XII (1911-1913). London, UK: Hogarth Press.
 Goleman, D. 2007. Social intelligence: The new science of human
relationships. New York: Bantam Books.
80

81.  Havens, L. 1976. Participant observation. Northvale, NJ: Jason
Aronson.
 Hemingway, E. 1929. A farewell to arms. New York: Charles Scribner’s
Sons.
 Hoffman, I. 2001. Ritual and spontaneity in the psychoanalytic
process. Abingdon-on-Thames, UK: Routledge / Taylor & Francis.
 Mitchell, S. 1988. Relational concepts in psychoanalysis: An
integration. Cambridge, MA: Harvard University Press.
 Real, T. 2022. Us: Getting past you and me to build a more loving
relationship. Santa Monica, CA: Goop Press.
 Stark, M. 1994a. Working with resistance. Northvale, NJ: Jason
Aronson.
 ----- 1994b. A primer on working with resistance. Northvale, NJ: Jason
Aronson.
 ----- 1999. Modes of therapeutic action: Enhancement of knowledge,
provision of experience, and engagement in relationship. Northvale,
NJ: Jason Aronson.
 Sterba, R. 1934. The fate of the ego in analytic therapy. International
Journal of Psychoanalysis 64:321-32. 81