EMPATHIC GRUNTS ~ A Clinical Vignette

by Martha Stark, MD / Faculty, Harvard Medical School


This vignette is about a patient who was relentless in his pursuit of that which, at least on some level, he knew he could never have but to which he nonetheless felt entitled – a man who had not yet confronted the pain of his early-on heartache in relation to his father. 


The patient, Mark, is a man who sought me out for a consultation several years ago.


He is a psychiatrist, had been in analysis for some eight years with a well‑known and highly respected local training analyst, and was feeling very stuck in his treatment.  He explained to me that he was becoming increasingly dissatisfied with his analyst because he was not getting the kind of support he wanted and felt he deserved.


By way of illustration, Mark cited a time when he had gone to his analyst's office, had lain down on the couch, and had told his analyst in some detail about the very difficult day he had been having – he had had three admissions to write up, he had been reprimanded by the attending, when it came time to leave for his analytic hour he had found that his car had been blocked in by other cars so that he had had to take a taxi in order to be on time, in the confusion he had lost his wallet and therefore had had to beg the cab driver to accept a check, and so on and so forth.


In his consultation with me, Mark expressed his outrage and his bitterness, protesting that all he had wanted from his analyst was an empathic grunt, some acknowledgment by the analyst of how frustrated and angry he (the patient) must have been feeling because of the horrid day he was having.  The patient demanded to know:  "Was that too much to ask?  All I wanted was a little kindness, a little compassion!"


Mark went on to talk about how his colleagues had confirmed his belief that if his analyst could not give him even this, then he (the patient) had no business remaining in such a disappointing relationship, that it was masochistic for him to be continuing the treatment.


But as Mark’s story unfolded, I came to see things in a somewhat different light.  Admittedly, it does not seem unreasonable to be asking for a bit of support, understanding, and comfort at a time when you are feeling overwhelmed and agitated.  But for the patient to be looking for such support from someone whom he knew did not give that kind of support (although the analyst did offer many other good things), for the patient to be looking still, even after these eight years, for support from someone whom he knew had never given that kind of support – this is what caught my attention!  This is what seemed to me to be masochistic. 


So whereas Mark was thinking that it was masochistic for him to be staying in a relationship with someone who was not giving him what he so desperately wanted, I was beginning to think that it was masochistic for the patient to be wanting still that which he was clearly never going to get – and that the solution lay not necessarily in severing the relationship with his analyst but, first, in facing the reality that he was never going to get exactly what he would have wanted and, then, in grieving that.  The patient would get other good things from his analyst (and, in fact, over the course of the previous eight years, had gotten all sorts of good things from his analyst) – but never the empathic grunts. 


Admittedly, I did also wonder a bit about the analyst's seeming refusal to relent, refusal to allow himself to be influenced even a little by the patient's impassioned entreaties; but, in this particular instance, I decided not to focus on what I suspected was the analyst's contribution to the stalemated situation between them.  My fear was that were I to speak too much to the part I sensed his analyst might be playing, the patient might use this to reinforce his own rather entrenched position, which would then obscure the more important issue of the patient's accountability for his own relentlessness, fueled by his refusal to confront the reality of his analyst’s limitations.


And so I said that, at this point, I believed the work of the analysis involved Mark’s confronting, head-on, the excruciatingly painful reality that his analyst was never going to give him exactly what he wanted.  I also said I suspected that the analyst was a stand‑in for one or both of his parents and that his experience of thwarted longing in relation to his analyst was the recapitulation of an early‑on (and never grieved) heartbreakingly painful relationship with a parent. 


Although in the first of his three consultation sessions with me Mark had said that (as a result of the work he had done over the course of the previous eight years) he felt he had pretty much made his peace with his parents' very real limitations, when I now framed the stalemated situation in his analysis as speaking perhaps to frustrated desire and unrequited longing with respect to a parent, he began to resonate with this. 


Somewhat shaken, Mark now (in the third and final session of our consultation) finally acknowledged that, indeed, he had always been frustrated in his desire to get recognition from his father, a narcissistic man who was chronically depressed and totally unavailable for support or comfort.  As the patient now talked about his father, he began to express what he said he had always known (on some level) but had never really been able to let himself think or feel – namely, that his heart had been broken by his father's failure of him, his father's inability to respond to his desperate pleas for attention and love.


As our session continued, it became very clear that although Mark had given lip service during the eight years of his analysis to acknowledging how devastated he had been by his father's emotional remoteness, the patient had never really let himself feel just how traumatizing his father's inaccessibility had actually been for him.


Furthermore, the patient’s refusal to grieve that early-on failure was forcing him to relive it in the here-and-now of the transference, and intensifying that early pain – but now in relation to his analyst.


As we explored other areas of Mark’s life, we came to see that it was a recurring theme for the patient to be ever wanting from his objects the one thing they would never be able to give, a recurring pattern for the patient to be ever in a state of frustrated longing and thwarted desire in relation to the significant people in his life.


I suggested to Mark that before he made a decision about whether or not to continue with his analyst, he should use the analysis to make his peace with just how disappointed he was in his analyst.  I told him I thought that in the process he would also be doing some important, even if belated, grief work around the emotional unavailability of his father.


So I suggested that instead of immediately rushing off to another analyst in order to pursue elsewhere his relentless search for gratification, Mark should stay in the relationship with his current analyst at least long enough to gain insight into why he was always in the position of trying to extract the right thing from the wrong person, that is, why he was ever in relentless pursuit of the unattainable. 


In essence, I told Mark I thought he would need to take some responsibility for the part he was playing in the unfolding of his life's drama, that he would need to take some ownership of his relentless hoping against hope that his analyst might someday turn out to be someone whom the patient knew (in his heart of hearts) the analyst would never – and could never – be, and that the patient would need, eventually, to confront the pain of his grief about his father and those he had chosen to be parent substitutes.


To summarize:  It could probably be said that a patient's relentless pursuit of the right things from the wrong people is the hallmark of a patient with relentless hope and sadomasochistic defenses.