by Martha Stark, MD / Faculty, Harvard Medical School


A patient's beloved grandmother has just died.  The patient, unable to feel his sadness because it hurts too much, recounts in a monotone the details of his grandmother's death.  As the therapist listens, she feels herself becoming intensely sad.  As the patient continues, the therapist finds herself uttering, almost inaudibly, an occasional "Oh, no!" or "That's awful!"  As the hour progresses, the patient himself becomes increasingly sad.


In this example, the patient is initially unable to feel the depths of his grief about his grandmother's death.  By reporting the details of her death in the way that he does, the patient is able to get the therapist to feel what he cannot himself feel; in essence, the patient exerts interpersonal pressure on the therapist to take on as the therapist's own what the patient does not yet have the capacity to experience.  This is clearly an instance of the patient's impact on the therapist.


As the therapist sits with the patient and listens to his story, she finds herself becoming very sad, which signals the therapist's quiet acceptance of the patient's disavowed grief.  We could say of the patient's sadness that it has found its way into the therapist, who has taken it on as her own.  The therapist's sadness is therefore co-created – it is in part a story about the patient (and his disavowed grief) and in part a story about the therapist (in whom a resonant chord has been struck). 


The therapist, with her greater capacity (in this instance, to experience affect without needing to defend against it), is able both to tolerate the sadness that the patient finds intolerable and to process it psychologically.  It is the therapist's ability to tolerate the intolerable that makes the patient's previously unmanageable feelings more manageable for him.  The patient's grief becomes less terrifying by virtue of the fact that the therapist has been able to carry that grief on the patient's behalf. 


A more assimilable version of the patient's sadness is then returned to the patient in the form of the therapist's heartfelt utterances – and the patient finds himself now able to feel the pain of his grief, now able to carry that pain on his own behalf. This is clearly an instance of the therapist's impact on the patient. 


For the relational therapist, the locus of the therapeutic action always involves mutual influence; both patient and therapist are continuously changing by virtue of being in relationship with each other.