Clinical Vignette:  A Provocative Enactment

by Martha Stark, MD / Faculty, Harvard Medical School


Let me now present another example that I believe highlights the difference between empathic attunement (the province of Model 2) and authentic engagement (the province of Model 3).


I owe a debt of gratitude to one of my supervisees (Carole), who gave me permission to share the following vignette.


John, a very handsome 59-year-old man, had been in therapy with Carole (a very attractive 66-year-old woman) for many years.  Although Carole knew that her (characterological) tendency to be hoveringly overprotective – and sometimes, even, a bit intrusive – might have been making John feel somewhat uncomfortable, nonetheless the therapy was progressing well.  Furthermore, John was clearly attached to Carole, as she was to him.


But, in 2008, when Barack Obama was elected to the White House, John made a denigrating racial remark that had a profound impact on how Carole then began to feel toward John – an impact that, although subtle, Carole simply could not shake.  After Obama won the presidential election, John made the following racial slur:  “I hate it that we now have a n***** in the White House!”  Carole (herself white) was understandably taken aback and deeply offended that John would have thought to describe anyone in such an offensive manner.


But, by summoning up every bit of empathy that she could possibly muster, Carole did somehow manage to respond with the following:  “You are concerned about the direction in which our country is going.”  This empathic utterance on Carole’s part enabled the session to continue; and John then went on to talk about his upset, anger, frustration, and despair about the direction in which he felt the country was going and, quite frankly, the direction in which he felt his own life was going.  The session ended up being a very productive one.


A price, however, had been paid.  Although Carole had managed to be empathic (which not only enabled the session to continue but also prompted John to delve more deeply into the heartfelt anguish and despair he was feeling about the course of his own life), Carole had been left with feelings of shock and revulsion; and despite the passage of time and Carole’s efforts to let it go, the souring of her feelings had persisted and Carole now found herself having a little less respect for John, feeling a little less affection for him, and becoming a little more withdrawn from him during their sessions.  Nonetheless, the therapy continued to progress well; and John, in his life on the outside, was making substantial gains.


And so it was that Carole’s empathic remark, although enabling John to feel understood, obviated the need for the two of them to address the dysfunctional relational dynamic (Carole’s overprotectiveness / John’s subsequent need to distance / Carole’s retreat) that was being played out between them and creating tension in their relationship.


In 2012 Carole came to me for supervision (around John and various others in her clinical practice).  In reviewing John’s case with me, Carole acknowledged the horror she still felt about the racial slur John had uttered those years earlier.  In our supervision session, the idea suddenly came to me that perhaps Carole could use the upcoming November 2012 presidential election as an opportunity to re-visit what had happened between the two of them in 2008.


Right after the announcement was made that Obama had indeed been re-elected to the White House, Carole – despite the fact that John had not, this time, commented on the election results – opened the next session by saying that Obama’s re-election was reminding her of what John had said to her the first time Obama had won.  Carole had decided not to share directly with John (at least not initially) what she had felt in response to his provocative remark.  Rather, she simply asked, “When you referred to Obama as a n*****, how were you imagining that I would respond?”


The Rule of Three:  Hoping, Fearing, Imagining


I believe that when a patient says or does something that the therapist experiences as provocative, the therapist has the option of asking the patient any of the following:  (1) “How are you hoping that I will respond?” – which speaks to the patient’s id; (2) “How are you fearing that I might respond?” – which speaks to the patient’s superego; and (3) “How are you imagining that I will respond?” – which speaks to the patient’s ego (the executive functioning of his ego).  All three questions demand of the patient that he make his interpersonal intentions more explicit – in essence, that he take responsibility for his provocative enactment.


In any event, at first John was clearly surprised by Carole’s question; but, to his credit, he did pause to reflect upon what he remembered of that moment between them those four years earlier.  Interestingly, John did then go on to acknowledge that he had known all along that Carole would probably be offended by his remark.


As Carole and John continued to explore at the intimate edge of their relationship, it became clear that Carole’s hovering overprotectiveness (during their earlier years and prior to John’s off-putting 2008 remark) had indeed been experienced by John as somewhat intrusive and was probably at least in part responsible for what had then prompted him to make what he knew, in his heart of hearts, was a provocative and offensive remark about Obama to Carole.


John also acknowledged that, in retrospect, he had felt a complex mixture of feelings after his distancing of Carole:  some relief that he had actually succeeded in getting the distance he felt he needed; some shame about having said what he had in order to get that distance; and some sadness that the two of them were indeed no longer as close.  It was in the context of their negotiating at their intimate edge that Carole also now admitted to having felt distanced and somewhat put-off by John’s offensive remark about Obama.  She also went on to acknowledge her own sadness that the two of them had then become less connected.


As John and Carole continued to examine the mutual enactment that had taken place between them and together, with shared mind and shared heart, grieved the loss of the special connection that they had enjoyed during the earlier years of their relationship, they discovered a newer connection – one that was ultimately much more solid, honest, and genuine.  John apologized to Carole for his insulting comment about Obama (adding that he was still no Obama fan!); and Carole graciously accepted the apology.  Carole, in her turn, also apologized for having been too maternal in her approach to John during their earlier years and for not having found a way to share with him how taken aback she had been by his derogatory 2008 remark about Obama.


At the end of the day, both John and Carole felt much better and much closer for having put more explicitly into words what each had been experiencing in relation to the other – both during the years prior to 2008 and during the four years between 2008 and 2012.