top of page


by Martha Stark, MD / Faculty, Harvard Medical School




The process of rendering conscious what had once been unconscious can best be facilitated through the use of optimally stressful conflict statements that alternately challenge and then support.


They first challenge by speaking to the patient’s adaptive capacity to know certain anxiety-provoking realities and then, with compassion and without judgment, support by resonating empathically with the patient’s defensive need to deny knowing those uncomfortable truths.


The patient does know – be it some uncomfortable truth about her internal dynamics, the price she pays for maintaining her dysfunctional status quo, or the sobering reality that there is further therapeutic work to be done – but would rather not and so, made anxious at the reminder of what she really does know to be true, she mobilizes a defense.


Model 1 conflict statements are strategically designed to create destabilizing tension within the patient between her knowledge of anxiety-provoking but ultimately awareness-promoting (and empowering) realities and the defenses she mobilizes in order to ease that anxiety.


Their format is as follows:  “You know that…, but you find yourself…”


First the therapist challenges (by highlighting an anxiety-provoking reality) and then supports (by speaking to the patient’s anxiety-assuaging defense).


Model 1 conflict statements:  YES! (accelerate!) – but (made anxious) – NO! (brake!).


The therapist first challenges by speaking directly to the patient’s observing ego and adaptive capacity to know some uncomfortable truth, which will increase the patient’s anxiety, but then supports by resonating empathically with the patient’s experiencing ego and defensive need to deny such knowing, which will decrease the patient’s anxiety.


The patient does know “but” would rather not and so, made anxious, she defends and “finds herself” thinking, feeling, or doing whatever she must in order to maintain things as they are.


Again, first the anxiety-provoking reality (which is what the patient really does know) and then the anxiety-assuaging defense (which is what fuels her resistance to knowing) –


“You know that ultimately you’ll need to let Jose go because he, like your dad, really isn’t available in the way that you would have wanted him to be; but, for now, all you can think about is how desperately you want to be with him and how horrible it would be to lose him.”


“You know that eventually you’ll need to make your peace with the reality of just how limited your mother is; but your fear is that were you ever to let yourself really feel the pain of that, you would never recover.”


“You know that someday you’ll have to let somebody in if you’re ever to have a meaningful relationship; but, in the moment, the thought of making yourself that vulnerable is absolutely intolerable.  You’ve been hurt too many times in the past to make that a viable option for you now.”


“You know that if we are ever, truly, to get to the bottom of things that it will take time and that coming weekly is probably the better route to go; but you find yourself feeling restless, impatient, and dissatisfied and thinking that, at least for now, you don't want to have to keep coming every week."


“You know that coming every other week will make it a little harder for us to get the work done; but you are tired and, in the moment, feeling that you need a break.”


“You know that things won’t get better until we figure out what is making you feel so desperately lonely and that it will take a lot of work to undo a lifetime of heartbreak and sadness; but, right now, you're feeling so discouraged and so damaged from way back that you have lost faith in our process and feel like giving up.”


Anxiety-provoking but ultimately awareness-promoting interventions are strategically formulated to precipitate disruption in order to trigger repair.  These optimally stressful statements call the patient’s attention to the conflict that exists within her between the objective reality that she knows with her head and the subjective experience that she feels with her heart.


Ultimately, and most importantly, these conflict statements will highlight the price the patient is paying for remaining so deeply entrenched in the (dysfunctional) status quo, even as they will also resonate empathically with her investment in maintaining that status quo even so.


Again, Model 1 conflict statements alternately challenge and then support – as follows:


“You know that ultimately you will need to confront – and grieve – the reality that Tom is not available in the ways that you would have wanted him to be and that until you have made your peace with that painful reality you will continue to be miserable; but, in the moment, all you can think about is how angry you are that he doesn’t tell you more often that he loves you.”


“You know that you won’t feel truly fulfilled until you are able to get your thesis completed; but you continue to struggle, fearing that whatever you might write just wouldn’t be good enough or capture well enough the essence of what you are wanting to say.”


“You know that if your relationship with Elana is to survive, you will 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!”


Model 1 conflict statements strive to create incentivizing tension within the patient between her dawning awareness of just how costly her defenses have become (with an eye to making them more ego-dystonic) and her new-found understanding of just how invested she has been in holding on to them even so (with an eye to highlighting how ego-syntonic they are).


Ultimately, the ever-increasing internal dissonance resulting from her ever-evolving insight into both the cost and the benefit of maintaining her attachment to her (dysfunctional) defenses will galvanize her to take action in order to resolve the inner tension.


“You know that eventually you will need to face the reality that your mother was never really there for you and that you won’t get better until you let go of your hope that maybe someday you’ll be able to make her understand this; but you’re not quite yet ready to deal with it right now because you're afraid that you might never survive the heartbreak and despair you would feel were you to face that devastating reality.”


“You know that your need for your children to understand your perspective might be a bit unrealistic; but you tell yourself that you have a right to their respect – and their forgiveness.”


“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 suffered over the years.”


“You know that if you are ever to get on with your life, you will 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 was always calling you a loser.”


Model 1 conflict statements encourage the patient to step back from the immediacy of the moment in order to focus on the underlying forces and counterforces within her that are tying up her energies and interfering with her forward momentum.


They are designed to tease out and, on the patient’s behalf, to articulate the conflict within her between her voice of reality (which will be anxiety-provoking but ultimately insight-promoting) and the growth-obstructing defensive counterforces (which she mobilizes in an effort to ease her anxiety and silence that voice).


“You know that you’re paying a price for clinging to your anger (a lot of that anger old, from way back); but you find yourself feeling that you don’t really have much of a choice.”


“You would want to be able to forgive me; but the pain and the hurt go so deep that you can’t imagine ever being able truly to trust me – or anyone else.”


“You know that you might well later regret it; but, in the moment, all you can think about is how good it would feel were you to have that ice cream sundae.”


“You know that if you are really serious about finding yourself a partner, then you will need to put yourself out there in a way that you don’t ordinarily do; but you find yourself holding back because you have an underlying conviction that no matter how hard you might try, it wouldn’t really make any difference anyway.”


“You know that eventually, if you are ever to work through your fears of intimacy, you will have to let someone in; but, right now, you’re feeling that you simply cannot afford to be that vulnerable.  In the past, when you were vulnerable, especially in relation to your mother, you always got hurt.”


In essence – recursive cycles of challenge, then support – addressing cognitive, then affective; head, then heart; knowledge, then experience; objective, then subjective; observing ego, then experiencing ego; adult, then child; rational, then irrational; left brain, then right brain; adaptive capacity, then defensive need; and adaptation, then defense.


With the therapist’s finger ever on the pulse of the patient’s level of anxiety and capacity to tolerate further challenge, moment-by-moment the therapist will alternately support (by resonating with where the patient is) and then challenge (by directing the patient’s attention to elsewhere).


Back and forth, back and forth, support then challenge, challenge then support, back and forth, back and forth.


In other words, moment-by-moment the therapist will alternately challenge (by reminding the patient of an anxiety-provoking reality that the patient has the adaptive capacity to realize – albeit reluctantly) and then support (by resonating with the patient’s defensive need to maintain things exactly as they are) – all with an eye to generating an optimal level of incentivizing and therefore growth-promoting stress.


Parenthetically, as we sit with our patients, there is always a dialectical tension within us as well, between, on the one hand, our vision of who we think the patient could be (were she but able to make healthier choices) and, on the other hand, our respect for the reality of who she is (and for the choices, no matter how unhealthy, that she is already making).


We are therefore always struggling to find an optimal balance within ourselves between wanting the patient to change and accepting the reality of who she is.


Importantly, Model 1 conflict statements, by locating within the patient the conflict between her anxiety-provoking knowledge of a distressing reality and her anxiety-assuaging need to dismiss it, the therapist is deftly sidestepping the potential for conflict between therapist and patient.


The therapist who is able to resist the temptation to get bossy by overzealously advocating for the patient to do the “right thing” will be able masterfully to avoid getting deadlocked in a power struggle with the patient.  Such a struggle can easily enough ensue when the therapist takes it upon herself to represent the voice of reality – a stance that then leaves the patient no option but to become the voice of opposition.


When the therapist introduces a conflict statement with “you know that…” she will be forcing the patient to take responsibility for what the patient really does know.  But if the therapist, in a misguided attempt to urge the patient forward, resorts simply to telling the patient what the therapist knows, not only does the therapist run the risk of forcing the patient to become ever more entrenched in her defensive stance of protest but also the therapist will be robbing the patient of any incentive to take responsibility for her own desire to get better.


It really is an untenable situation for the therapist to be the one representing the healthy (adaptive) voice of yes and for the patient, made anxious, to be then stuck in the position of having to counter with the unhealthy (defensive) voice of no.


And so it is that, in the first part of the conflict statement, the therapist highlights what the patient, at least on some level, really does know.


In essence, by locating the conflict squarely within the patient and not in the intersubjective field between therapist and patient, conflict statements force the patient to take ownership of both sides of her ambivalence about getting better – both the yes forces and the no counterforces mobilized in reaction to those yes forces.


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,” and “at this point in time,” which she will do when she is addressing the patient’s investment in her dysfunctional defense.


“You know you’re paying a steep price for your refusal to stop smoking, of particular concern because of your recurrent lung infections; but, in the moment, you find yourself feeling that you simply must have the cigarettes in order to relieve the massive anxiety that you’re feeling because of the lawsuit.”


The therapist is attempting to highlight the fact that even if, for now, the patient would seem to be invested in protesting her right to maintain things as they are, at another point in time that could change.


In sum, optimally stressful conflict statements are designed to provoke the relinquishment of dysfunctional defenses by generating cognitive and affective dissonance.


Importantly, the wisdom of the body is such that it cannot tolerate the distress of disequilibrium for extended periods of time and will therefore be prompted to take action in order to resolve the tension that has been generated and to restore the order.


Ultimately, it will be the patient’s ever-evolving capacity to understand the fundamental conflict between cost and benefit that will simply force her to let go of her dysfunction, that is, to surrender her unhealthy defenses (despite their erstwhile robustness) in favor of healthier adaptations – as she evolves from cursing the darkness to lighting a candle.


To review – In order to increase the patient’s awareness of her ambivalent attachment to her dysfunctional defenses, the Model 1 interpretive therapist alternately challenges by highlighting what the patient is coming to understand as the price she pays for clinging to her dysfunctional defenses (a price that fuels her aggressive cathexis of those defenses) and then supports by addressing what the therapist is coming to understand as the investment the patient has in holding on to her dysfunctional defenses even so (an investment that fuels her libidinal cathexis of those defenses).  Back and forth – back and forth – in an effort to make the ambivalently held defenses ever less ego-syntonic and ever more ego-dystonic.


The goal of these optimally stressful interventions is not only to promote the patient’s detachment such that she will be able to bring to bear her self-reflective capacity but also to give the patient sufficient space to experience – and to express – whatever she might find herself feeling as a reaction to being confronted with anxiety-provoking realities that she can no longer deny – all with an eye to making her ever more acutely aware of the struggle being waged within her between what her head (albeit begrudgingly) knows and what her heart (in desperate protest) feels.


By repeatedly formulating conflict statements that strategically juxtapose the patient’s dawning awareness of just how steep a price she is paying for holding on to her defenses, that is, the pain, with her new-found appreciation for how they have served her, that is, the gain, the therapist will be able to create galvanizing tension within the patient – growth-promoting dissonance that will ultimately become the fulcrum for therapeutic change.


And so it is that the therapist, in order to increase the patient’s level of awareness, will repeatedly juxtapose the “price paid” (pain) with the “investment in” (gain) in order incrementally to make the patient’s ambivalently held dysfunctional defenses ever less ego-syntonic (that is, ever less consonant with who she would want to be) and ever more ego-dystonic or ego alien (that is, ever more dissonant with who she would want to be).


As long as the gain is greater than the pain, the patient will maintain the defense and remain entrenched.


But once the pain becomes greater than the gain, the stress and strain thereby created as a result of the cognitive and affective dissonance between the pain and the gain will provide the impetus needed for the patient – in order to restore her psychological equilibrium – gradually to relinquish her attachment to the defense, thereby resolving the structural conflict between id drive and ego defense.


At this point, the now stronger ego will be better able to regulate the now tamer forces of the id by redirecting those energies into more constructive channels.


In sum, the patient’s neurotic conflictedness – and resultant obstructed progression through life – will become gradually transformed into actualization of potential.


In essence, a weak ego’s need to defend itself against the untamed energies of an id will have become gradually transformed into a stronger ego’s capacity to channel those now better regulated energies into more constructive pursuits.


The defensive need to “put a lid on the id” will have become gradually transformed into the adaptive capacity to “sublimate” – as structural conflict is replaced by structural collaboration.


From structural conflict to structural collaboration – from “defense against” to “adapting to” – truly from "cursing the darkness" to "lighting a candle."

bottom of page