Two Clinical Vignettes by Martha Stark, MD / Faculty, Harvard Medical School


Clinical Vignette:  I Don’t Think I Can Keep Doing This!


I would like now to develop two more examples that demonstrate how the Model 3 therapist can use her "self" to “find” her patient. 


The first is the situation of a female patient, a male therapist.  In the vignette that follows, please consider the two different positions that the therapist takes with respect to his patient's relentless hopelessness. 


The patient, Jennifer, has long struggled with feelings of despair; she speaks repeatedly of her anguish, her desperation, and her outrage that the therapy has done so little to ease her pain.


The therapist hypothesizes to himself that, for whatever the reason, the patient (herself hopeless) needs him to carry, on her behalf, hope that she herself cannot access.


And so it is that even in the face of the patient's unremitting despair and constant threats to terminate, the therapist refuses to be daunted.  He is able to resonate empathically with Jennifer's experience of despair but, on a deeper level, maintains his faith in the patient, his confidence in his own ability to persevere, and his belief in the healing power of their connection; he holds fast to his conviction that if Jennifer can tolerate continuing in therapy, she will eventually get better. 


In essence, the therapist carries the hope, where the patient carries none.  The therapist cares very deeply about his patient, thinks of her as one of his favorite patients, and would like to believe that she will someday be able to find her own hope.


Every now and then, there will be a session in which the therapist begins to feel that he and his patient are actually making some progress; inevitably, however, Jennifer will come to the next session and will say that she thinks the treatment is going nowhere – that perhaps she really should terminate this time. 


Then one day, after several years, the therapist, listening to the patient's anguished cry that no one will ever be able to understand, no one will ever be able to help, becomes aware of feeling (this time) a profound weariness and a heaviness in his heart, which he cannot shake as the patient continues to express her angry dissatisfaction with him, the treatment, her life, everything, everybody.


No longer able to keep the patient's despair at bay, the therapist shakes his head slowly, sighs deeply, and, broken, says finally, "I don't think I can keep doing this."


Initially startled, the patient looks at her therapist intently.  And then she visibly relaxes.  This is something familiar, something deeply familiar.  The therapist is expressing feelings of resignation and hopelessness with which the patient has lived her entire life. 


At first Jennifer is very still; then, after a little while, she chuckles quietly and says, with a soft smile, "Now you know what I've been feeling all these years!" 


The rest of the session is spent in silence – a relaxed, comfortable silence.


To the next session the patient comes with a different energy about her; she appears to be a little lighter, a little more spontaneous.  At one point, she remarks, almost casually, "You know, sometimes I begin to think that maybe things aren't so bad after all." 


Neither patient nor therapist says anything for a while, both exquisitely aware that this is the first time the patient has ever admitted to having any hope whatsoever. 


How do we understand this sequence of events?  For a number of years the therapist had steadfastly refused to be drawn into taking on, as his own, the patient's weariness and despair.  Unflinchingly he had clung to his hope, unwilling to let go of his belief in her and their relationship. 


But then one day that all changed.  Something rather dramatically shifted in the dynamic between the two of them – and the therapist finally allowed himself to be drawn into experiencing Jennifer's resignation and despair (which he signaled by giving voice to his own frustration and sense of futility). 


Where once the therapist had been relentlessly hopeful and the patient relentlessly hopeless, now the therapist was able to join Jennifer in her despair.  Where before the patient could not have known that her therapist truly understood, now Jennifer was able to know that her therapist understood deeply what it was like to feel hopeless, despairing, and resigned.  Her therapist was no longer fighting her; he had finally opened himself up to feeling her pain as his own.  She was no longer alone.


Importantly, once the therapist relinquished his investment in carrying the hope, the patient was then able to access (and to articulate) some of her own hope – which enabled the two of them to share the responsibility for the treatment and for carrying the hope. 


The work that followed was difficult, demanding, and exhausting for both patient and therapist, but neither participant was alone.  The work was done jointly, collaboratively. 


What patient and therapist came to appreciate, over time, was that their relationship was a replay of the relationship the patient had had with her father – although Jennifer's father had loved his daughter as best he could, he had always been somewhat disengaged, distracted, preoccupied with his own concerns.


That dynamic had been recreated in the patient's relationship with her therapist – until something shifted and the therapist, allowing himself to be impacted by the patient, opened himself up to her despair and became, at last, more fully engaged. 


The grieving that the patient was then able to do was done against the backdrop of Jennifer's experience of her therapist as now understanding something fundamental and profoundly important about her experience of being in the world, understanding that turned out to be deeply healing for a patient who had never before had the experience of finding someone willing to go with her into her darkest places.


In finding the therapist, she herself became found.



Clinical Vignette:  I Want My Mommy!


I would like now to present my own work with Isabella, a 30-year-old woman with whom I have been working very intensively for six years now.  This too is a story about a patient's despair – but, as you will soon see, the dynamic between us unfolded in a way that was different from the way it did in the example just cited.


Isabella has a very difficult, demanding mother, breathtakingly narcissistic and scathingly critical, and an ineffectual father, loving, gentle, and kind but passive.  The backdrop of our work together has been Isabella’s profound self-hatred and unrelenting despair.


Nonetheless, over the course of the past several years, Isabella has made some rather significant changes in her life.  Once a poorly paid secretary with few friends and a deep distrust of men, she is now a fairly successful therapist with a number of friends and occasional dates.


But as our work has deepened, Isabella has become increasingly aware of the profound loneliness and anguished despair that never let up.  We have also come to understand just how much she despises herself, deprives herself, punishes herself.  She is relentless in the demands she places upon herself.  There is little pleasure in her life, no real joy.  She lives a life of extreme self-denial, every day experienced as something that must simply be lived through and, somehow, survived.


With time, Isabella and I have developed a very deep connection.  I mean the world to her; and, for that matter, she means the world to me.


Periodically, however, she will come into the session and be on a tear, lashing out at everything and everybody around her.  She will beat on herself, rail against the world, berate me and the therapy, and scream out her anguish, her pain, and her rage.


When she is like this, it feels as if there is nothing I can do to contain her relentlessness. 


Over time, I have responded to such tirades in any number of ways.  Most of my efforts have been fairly ineffectual, although eventually, somehow, Isabella does become less tortured and less torturing and we do get to a calmer place.  Sometimes it has taken hours, sometimes days, sometimes weeks, and several times it took months for her to let up.


But one day I found myself doing something a little different, something that I think enabled Isabella to relent much sooner than she would otherwise have relented.


Isabella had come to the session in a rage at herself, her parents, me, and the world.  I had done my usual, mumbling things like: “I think you are wanting me to feel the same kind of helpless and inadequate that you used to feel in relation to your mother,” and “You want me to know just how desperate and unloved you’re feeling,” and “I think you’re showing me what it was like for you to be at the receiving end of your mother’s relentlessness.”  And so on and so forth.


Even I was tired of these interventions, as I’m sure she was too.


But then as I sat there, feeling with her the pain, the despair, the rage, feeling my own pain, some of it a response to her pain, some of it my own pain from way back and stirred up in me now in response to her pain, I suddenly felt an incredible longing to be held by somebody, to be soothed and comforted, so that I wouldn’t have to feel so desperately alone, disconnected, and lonely.


And so, somewhat to my surprise, I found myself suddenly blurting out, "I want my Mommy."  At that moment, I did want my Mommy.


My sudden outburst stopped Isabella dead in her tracks.  Some of it might have been because of her surprise that I would have said something so unexpected.  But I think that most of it had to do with my having put into words something that, in the moment, Isabella too would have wanted had she but been able to let herself have such yearnings.


I cannot say that Isabella then did a complete about-face, but I can say that, by the end of the session, Isabella had relented and was at last facing, in a way that she had never before done, some of the heartache and devastation she had long felt about just how unavailable, ungiving, and relentlessly hurtful her narcissistic mother had always been. 


Isabella was now able to confront – and grieve – intolerably painful realities against which she had spent a lifetime defending herself.


In retrospect, I believe that it was my ability to be with Isabella in her loneliness and her despair and then, in the midst of that barrenness and bleak desolation, to remember a way out, to remember the possibility of connection and engagement with a comforting other – it was this that was transformative.


In other words, I think it was my capacity to recover hope, even when I was so deeply immersed in my own loneliness and my own despair, that enabled Isabella ultimately to wend her way out of the quagmire of relentlessness and unrelatedness in which she had thought she was destined to spend the rest of her days.


It was this interaction that stands out for us both as the turning point for the recovery of her own hope and the rekindling of her own desire for connection.


There had earlier, and have since, been other powerful moments in which the two of us have connected in a very profound manner, both of us extremely vulnerable to the other – but it is the interaction just recounted that stands out for us both as having marked the turning point for the recovery of her own hope and the rekindling of her own desire for connection.



To conclude:


The Model 3 therapist brings herself, as an authentic subject, to the interaction – which enables her both to find the patient and to be found by the patient.  Intimate without losing the self, separate without losing the other.


The therapist's capacity to use her authentic self is the way she makes meaningful contact with the patient and accesses what is most genuine, personal, and alive in the patient. 


Patient and therapist engage in a collaborative process of discovery.  Each helps to find the other; the process of "we" becomes the recognition of two "I's" (Schwaber, 1995).  There is a paradox involved: It is by way of staying grounded in one's own reality that one can locate another; but it is in locating another that one can become more grounded in one's own reality.


If the therapist does not bring her authentic self into the room, then the patient may end up analyzed but never reached.  If the therapist does not allow herself to become a participant in what unfolds between them, then the patient may end up a lot wiser than when she started – but still not found.  By using her “self,” the therapist is indeed able to find, and to be found by, the patient.


Both vignettes speak directly to the power of a (Model 3) relational approach, wherein there will be an interpenetrating mix-up between the two participants and their mutually constructed realities.  The continuously evolving dynamic demonstrates a process of ongoing self and interactive regulation, resulting ultimately in dyadic expansion of healthy patterns of relatedness and in shared integration at ever-higher levels of organization and complexity.