Superimposing an acute injury on top of a chronic one is sometimes exactly what the body needs in order to heal.
But just as with the body, where a condition might not heal until it is made acute, so too with the mind. The therapeutic provision of "optimal stress" – against the backdrop of empathic attunement and authentic engagement – can be the magic ingredient needed to overcome the inherent resistance to change so frequently encountered in patients with longstanding emotional injuries.
Too much challenge (traumatic stress) will overwhelm. Too little challenge (minimal stress) will reinforce the dysfunctional status quo. But just the right combination of challenge and support (optimal stress) will galvanize the patient to action and provoke healing.
With my finger ever on the pulse of my patient's level of anxiety and capacity to tolerate further challenge, I will formulate "incentivizing statements" strategically designed "to precipitate disruption in order to trigger repair." Ongoing use of these optimally stressful interventions will induce healing cycles of defensive destabilization followed by adaptive restabilization at ever-higher levels of integration, dynamic balance, and functional capacity.
Behind this "no pain, no gain" approach is my firm belief in the underlying resilience patients will inevitably discover within themselves once forced to tap into their inborn ability to self-correct in the face of environmental challenge – an innate capacity that will enable them to advance, over time, from less-evolved defensive reaction to more-evolved adaptive response.
The health of a system is therefore a story about its capacity to adapt, that is, its ability to self-regulate and to restore its homeostatic balance in the face of challenge. At the end of the day, the goal of any holistic treatment – be its focus psychological or physical – must be to restore the intrinsic orderedness and fluidity to the MindBodyMatrix so that stressful challenges can be more effectively mastered.
THE ULTIMATE GOAL
Targeting Complex Chronic Conditions and Persistent Problems
Comprehensive Consultation and Strategic Solutions
Integration of Traditional and Nontraditional Approaches
Customized Interventions to Optimize MindBodyHealth
Lightening the Load to Correct for Toxicities
and Replenishing the Reserves to Correct for Deficiencies
In Order to Facilitate the Flow of Information
and Energy Throughout the MindBodyMatrix
Restoring Resilience, Adaptability,
and the Capacity to Cope with the "Stress of Life"
SARA ~ An Unforgivable Mistake
A Clinical Vignette by Martha Stark, MD
I have been seeing Sara, an exceptionally gifted 55-year-old therapist, four times a week for the past five years.
Five years ago, at the very beginning of our work together, I said something to Sara that made her feel I did not want to work with her. (I apologize for not being able to share with you the specifics of what I actually said, but Sara asked me, please, not to. She did, however, give me permission to share the rest.)
Sara considers what I said to her in our third session those five years ago to have been a mistake for which she will never be able to forgive me, although she desperately wishes that she could.
At the time, I was horrified that Sara would have so "misunderstood" what I was saying; but given what I have since come to know about her, I can now appreciate why what I said was indeed deeply hurtful to her.
Over the course of our years together, Sara has spent much time trying to decide whether or not she feels safe enough to continue our work. But because of the unforgivable mistake that I made those five years ago, she fears she may never be able to trust me.
Although periodically I have attempted to clarify (rather defensively I'm sure) what I had thought I was trying to say in our third session those five years ago, understandably Sara has not been all that interested in listening and has held fast to her experience of me as untrustworthy and of the therapy as a place that is not safe, certainly not safe enough to bring her pain, her tears, her anger, her loneliness.
Over time, what Sara and I have come to understand about our dynamic is that we have unwittingly recreated (between us) the mutually torturing relationship that she had with her toxic mother. At times, Sara is her bad mother and I am Sara who, as a little girl, was tormented by her double-binding mother. At other times, I am her bad mother and Sara is tormented by me as she was once tormented by her mother.
In my work with Sara, it has been extremely important to her that I be able to confirm her experience of things, not just that I validate her perceptions as "plausible constructions" of reality (Hoffman 1983) but that I actually confirm them. In other words, Sara needs me to agree that her reality is "the truth." Otherwise, she begins to feel crazy.
Almost without fail I have been able to confirm Sara's perceptions, most of which have seemed to me to be uncannily on target.
Unfortunately, some of her uncannily accurate perceptions have been about me. Although it is more difficult when the focus is on me and my vulnerabilities, ultimately (with the one exception noted above) I have been able -- and willing -- to confirm these perceptions as well.
As an example of how Sara will zero in on me: When recently she came to a session and asked to schedule a number of extra sessions, I was obviously very pleased (I actually said something to the effect of, "Yes! Yes! Yes!"). Indeed it meant a great deal to me that she would want the extra time, particularly in light of her experience of me as having failed her so unforgivably early-on in our relationship.
So we spent some time scheduling the extra sessions and then I said, gently: "You know I am so pleased to be scheduling additional appointments, but it occurs to me that I should be asking you how you feel about having these extra sessions."
Sara did not answer for a long time. After what seemed like an eternity to me, she said finally, sadly, that she was now not sure the extra sessions were such a good idea after all; she said that she was suddenly feeling that maybe I did not really want her to be coming for the additional appointments.
Although I was initially stunned by her response, in time she helped me to understand something that I had not previously understood: By asking Sara to share with me how she felt about having the extra sessions, I was, in a way, humiliating her. Obviously she would not have asked for this extra time if a part of her had not wanted the additional contact with me. So my asking of her that she admit to wanting more time with me was, in a way, tantamount to my forcing her to acknowledge having desire in relation to me. Indeed, had I, in advance, thought more about my somewhat formulaic question, then I would probably have known not to ask it.
What I now understood was that by asking her to tell me how she was feeling about getting the extra time, I really was more "going by the book" than "coming from my heart." I had been taught that it is always important to explore whatever underlying expectations, hopes, or fears the patient might have whenever she asks for something from her therapist. So I really was more going by the book than by what I did know (deep inside of me), namely, that despite Sara's deep reservations about me, a part of her was beginning to trust me a little more and was wanting me to know this without her having to say it outright.
Indeed, I came to see that Sara's experience of me as having humiliated her was not just a story about her but also a story about me. I was able to understand that I really was shaming her by asking of her that she acknowledge wanting to have the extra time with me.
Sara has been a wonderful teacher – she has devoted considerable time and energy to teaching me to be a better therapist to her and, in all honesty, a better therapist period. I am so much wiser for my time with her. I am increasingly coming to see how often I will unconsciously fall back on going by the book instead of coming from my heart – not always in the big ways, but in the little ways (some of the rituals, some of the routines that I will do without really thinking them through).
This we have accomplished.
But there has been between us the ongoing issue that we have not yet been able to resolve, namely, what to do with respect to the unforgivable mistake I made those numbers of years ago – about which I feel absolutely terrible and for which I have apologized many times over from the bottom of my soul.
Periodically Sara will turn to me and ask, point-blank, that I confirm her perception of me as having failed her unforgivably in that third session those five years ago. And, over the years, she has made it very clear that were I to confirm that perception, she would have no choice but to terminate her treatment with me. On the other hand, when I do not confirm that perception, then she feels she has no choice but to continue to feel unsafe.
When Sara and I get into this place, as we have many times over the course of our years together, my mind almost snaps from the pressure of how crazy-making the whole thing is. By asking of me that I confirm her perception of me as untrustworthy and of my early-on mistake as unforgivable, Sara puts me in an untenable position. But by holding on to my wish that Sara would someday both trust me and forgive me, I too put Sara in an untenable position. Sara asks of me something that I cannot possibly do; and I ask of her something that she cannot possibly do.
It is indeed agony for us both, yes – but it is also telling, telling us a great deal about the toxic relationship she had with her mother. I believe we are doing the work that needs to be done, namely, attempting to negotiate our way through and out of this convoluted, mutually torturing, hopelessly enmeshed relationship that is, in fact, a recreation of the double-binding, no-win relationship she had with her mother. It is a mutual enactment – in which both of us are participating.
But by way of the drama that is being re-enacted between us, Sara is enabling me to experience, firsthand, what the experience must have been like for her in relation to her mother. We will need someday to find our way out of this Catch-22 situation – but, for now, we must both sit with the uncertainty of not knowing what will ultimately unfold.
The other day, however, something different did happen. Sara was once again begging me to admit that what I had said to her those numbers of years earlier was unforgivable. As I listened, I found myself feeling so sad, so trapped, so anguished, and so tormented that I suddenly burst into tears. I rested my head in my hands and just sobbed. Sara sat there very still, barely breathing, watching, waiting. Eventually I stopped, and we continued our talking. This time I knew not to ask her the pat question: "How was it for you, my crying?"
But later in the session, I think she showed me what it must have been like for her. She herself began to cry – she put her head in her hands and wept. Now I sat there very still, barely breathing, watching, waiting. What made it particularly poignant for me was my knowing that she (as an adult) had never before cried in front of anyone.
Our work continues.
TRAUMATIC LOSS, HEARTBREAK, AND RELENTLESS HOPE
Alicia’s Poignant Story
A Clinical Vignette by Martha Stark, MD
In the words of Roberta Beckmann,
“Grieving is nature’s way of mending a broken heart.”
I think that all of us have experienced one or more “traumatic losses” over the course of our lives – whether a single, devastating trauma or a series of smaller, incremental traumas – whether the trauma involved abuse and violence (“presence of bad”) or deprivation and neglect (“absence of good”).
People we have loved and trusted will violate, betray, and disappoint us. Our hearts will get broken. People will let us down. Our dreams will get crushed. We will suffer defeat. We will let ourselves down. We will periodically lose our way. We will make bad financial decisions. People will die on us. We will get sick, develop chronic illnesses. We will get old, become infirm, experience pain in our bodies. None of us has an entirely charmed existence; none of us gets through life unscathed.
Admittedly, the FACT of a traumatic loss can never be changed, but how we position ourselves in relation to it can. In other words, the REALITY of an overwhelmingly devastating loss can never be altered, but the narrative we create in an effort to understand it, to make sense of it, and to put it into perspective can make a difference.
Indeed, how we position ourselves in relation to our heartbreak will determine whether we are able to move forward in our lives (perhaps even stronger for having mastered the challenge) or whether we remain defeated, stuck, and broken.
Perhaps it could be said that maturity is achieved once we have transformed our need to have the world (and ourselves) be a certain way into the capacity to accept things as they are – once we have transformed our defensive need to deny painful truths into the adaptive capacity to confront them, grieve them, and ultimately accept them. It could therefore be said that maturity is a hard-earned adaptation to the impact of devastating truths – it requires the acceptance of heartbreaking realities that sober and sadden.
In what follows, my contention will be that if we are ever to evolve beyond the devastation and paralysis of the heartbreak we experience in the aftermath of our losses, then we must ultimately be able to confront – and grieve – the reality of the losses that we have sustained.
I present now one of the most heartrending consultations I have ever done. It is a story about Alicia, who came to see me many years ago because she was haunted by a tragic event that had occurred half a century earlier.
Alicia presented as a strikingly attractive, elegantly refined, and immaculately dressed 58-year-old woman who held herself with grace and dignity. By dint of her razor-sharp intelligence and extraordinary hard work, she had established herself in a highly successful career but had no life partner and no family and suffered from multiple health problems, most notably malignant hypertension.
At the age of seven, Alicia had been involved in a horrific accident. She had been vacationing with her family at their summer cottage and was out slalom water skiing on the lake. In the water ahead and to the right, she had seen something breaking the surface. Was it a rock? …the end of a log? …a clump of seaweed? She couldn’t quite make out what it was. Next thing she knew, she had run over it. Tragically, it had been a little boy out swimming – whom she had decapitated with her ski, instantaneously killing him.
Alicia had then spent every single day of the next five decades brutally punishing herself, wracked with guilt, haunted by her shame – her blood pressure inching up year after year. She couldn’t live with the knowing that she had done what she had.
Every one of the many therapists with whom she had consulted over the course of those years had done their best to reassure her – telling her that she had not been at fault; how could she have known; my God, she had been only seven at the time, a mere child; it was an accident; she had not tried to kill the little boy; she had to forgive herself.
But in her heart of hearts, Alicia knew that, although she had been only seven at the time, she was an experienced water skier and, had she chosen to do so, she could have steered clear of, and thereby avoided, that mysterious object in the water.
And so Alicia had spent a lifetime wrestling with her shameful secret, her inner demons, and her intense self-loathing – the knowing that she had been responsible for the death of that little boy, who, as it happened, lived only several doors down from her family’s cottage and had been her friend.
As I listened, my heart was breaking – for this devastated, broken, guilt-ridden, tormented soul who lived every single day of her life with unspeakable grief and unbearable pain. I said very little as her story unfolded; but, with hand on my heart and tears in my eyes, I nodded my understanding. The horror of it. Her decades of guilt, shame, private grief, and relentless self-punishment.
When I finally spoke, I said, softly, that I got it, why she felt responsible for his death. I told her I understood why she was having such trouble forgiving herself, such trouble figuring out a way to live with herself, what with her knowing that she could have chosen to do something different – but that she had not. I went on to say that it broke my heart to think that she had had to carry inside of her (all these years) her crippling guilt, her secret shame, and her unrelenting grief.
And then Alicia began to reveal more and more of the horrific – and incriminating – details about what had actually happened that fateful summer day on the lake… that as she had approached the object in the water ahead of her and to the right, she had found herself wanting to know what exactly it was. She, always one for a challenge, had decided to test her skills as a slalom water skier by seeing how close she could get to the object without actually running it over – and so, even when she had gotten close enough to see that the thing in the water ahead of her was moving and possibly alive and even with her knowing that she could and should veer away from it, she, as if driven by some uncontrollable inner compulsion, had made a split-second decision to jump the wake behind the boat so that she could get closer to it – instead of staying inside the wake and carefully steering clear of that unknown object bobbing in the water ahead…
While Alicia – with unflinching honesty and raw vulnerability – was recounting these more specific and revealing details, I sat very still, barely moving, barely breathing, just quietly taking it in and occasionally nodding. I knew that it was for me to be able, simply, to listen, to be present, to be there to help her bear the pain of it, the horror of it, the guilt of it, the shame of it – and not to withdraw, not to recoil in horror. It was for me, simply, to listen with compassion and without judgment.
Alicia alternately wept, raged, wailed, howled, fell silent – decades of pent-up anguish, heartbreak, guilt, shame, fear, anger, torment, despair, loneliness, isolation, regret, and high blood pressure. My heart was breaking for that spirited little girl Alicia had once been and the solemnly dignified but privately broken woman who now sat before me – surrendering, at last, her long-held secret guilt and searing shame.
Alicia explained that she had (robotically) recounted her story to many over the course of the years – but that it had always been an abridged version. She said she had held back for fear that people would not be able to bear the horror of it – that they would offer her pat reassurances that would make her feel even more misunderstood, disconnected, isolated, alone, and alienated.
As she wept, sobbed, and wailed, she and I both knew that she was releasing, at long last, the reservoir of tears, pain, heartbreak, and anguish that had been accumulating inside of her for decades. She had so needed to be able to tell her truth – and she had finally found someone who was willing to listen – and to bear witness.
At the end of Alicia’s harrowing narrative, exhausted from the effort of remembering but visibly relaxing as she revealed the devastatingly painful details, blow-by-blow, she said she suddenly felt a tremendous rush of relief, at having shared, finally, what had really happened those years earlier – a wondrous release followed by an exhilarating inner calm, sense of gentle peace, and serene acceptance. Alicia said she no longer felt quite as alone – because now someone else knew the real story and the incriminating details about what she had never before dared to share with anyone – now someone else knew the truth about what had happened that day on the lake.
And then Alicia was done and, although she came back to see me a number of additional times, at the end of the tenth session, she said she was ready to go. I told her she would always be welcome to return, were she ever to want to. She said that meant a great deal to her. At the end of our last session, as Alicia was leaving, she lingered at the door for a moment to give me a heart-felt hug.
Alicia did not ever come back but, in the interim, has referred me at least 15 of her friends and colleagues. And, periodically, she will drop me a little note, reiterating her gratitude that I was able to bear the horror of what she had done and, in that way, had helped her to make her peace with the crime that she knew she had committed, albeit with no malice or ill-intent, those 50 years earlier. And in one of her notes she told me, with much pride, about the nonprofit organization that she had set up, shortly after we met, to help people who had survived the tragic loss of a loved one to deal with their heartbreak and grief. There also came a time when she informed me that her malignant hypertension was now gone and that her blood pressure had returned to normal!
I think of Alicia often and of how she was finally able, with incredible courage and integrity, to confront – and grieve – the haunting reality of her past, which allowed her not only to evolve to a place of self-forgiveness, humble acceptance, and inner peace but also to channel all that now freed-up energy into the creation of her nonprofit! I believe that, in Alicia’s case, an important part of what enabled her to find absolution was the opportunity she had to confess to someone who listened with compassion and without judgment – to someone who was able to be present with her as she dared to remember, dared to confront, dared to relive, and, finally, dared to relent and to forgive herself.
In truth, the Serenity Prayer – “God grant me the serenity to accept the things I cannot change; courage to change the things I can; and wisdom to know the difference” is very apt here. I had always mistakenly assumed that the Serenity Prayer spoke primarily to the importance of our capacity to accept disappointing realities about the people in our world and to relinquish our relentless hope with respect to them – I had, rather naively, not fully appreciated that perhaps equally relevant is the importance of our capacity to accept disappointing realities about ourselves.