by Martha Stark, MD / Faculty, Harvard Medical School


Repetition Compulsion


As with every repetition compulsion, the patient's need to recreate the early-on traumatic failure situation in the therapy relationship has both unhealthy and healthy aspects. 


(1) The unhealthy component has to do with the patient's need to have more of same, no matter how pathological, because that's all the patient has ever known.  Having something different would create anxiety because it would highlight the fact that things could be, and could therefore have been, different; in essence, having something different would challenge the patient's attachment to the infantile (parental) object. 


(2) But the healthy piece of the patient's need to be now failed as she was once failed has to do with her need to have the opportunity to achieve belated mastery of the parental failures – the hope being that perhaps this time there will be a different outcome, a different resolution.


And so it is that in a relational model, the therapist's failures of her patient are thought to be co-constructed – both a story about the therapist (and what she gives/brings to the therapeutic interaction) and a story about the patient (and what she gives/brings to the therapeutic interaction).


Clinical Vignette:  My Refusal to Believe


I would like to offer a vignette that speaks to the power of the patient's (unconscious) need to be failed – and its impact on the therapist.


My patient, Celeste, had been telling me for years that her mother did not love her.  Again and again she would complain bitterly about all the attention her mother showered on Celeste’s sisters.  Celeste claimed that she, on the other hand, was treated by mother with either indifference or actual disdain.


Of course I believed her; that is, of course I believed that this was her experience of what had happened as she was growing up.  I wanted to be very careful not to condemn Celeste's mother as unloving.  My fear was that were I to agree with her that her mother did not love her, I would be reinforcing a distorted perception, which might then make it much more difficult for Celeste to reconcile with her mother at some later point, were she ever to decide to do that. 


And so I was always very careful never to say things like:  "Your mother clearly did not love you," "Your mother obviously favored your sisters over you," or "Your mother had very little to give you."


Instead, I would frame my empathic interventions in the following way:  "And so your experience was that your mother did not love you – and that broke your heart."  Or I would say something like, "How painful it must have been to have had the experience of wanting your mother's love so desperately and then feeling that you got so little of it."


In retrospect, it makes me sad to think that I said these things and that Celeste let me.  Part of her problem was that she allowed people to say these kinds of things to her.


But one day she came to the session bearing a letter from her mother.  She began to read it to me, and I was horrified.  It was totally clear, beyond a shadow of a doubt, that for whatever the reason, her mother really did not love her in the way that she loved her other daughters.  It was a horrible letter and my heart ached for Celeste; now I really understood what she had meant all those years.  And I felt awful that I had thought my patient's perceptions of her mother might be distortions of reality.


When Celeste had finished reading one of the saddest letters I have ever heard, I said, "Oh, my God, your mother really doesn't love you as much as she loves the others, does she?  I'm so sorry that it took me so long to get that."


Celeste then hung her head and said quietly, with a mixture of anguish and relief, "You're right.  My mother really doesn't love me very much."  She began to sob in a way that I had never before heard her sob.  I am sure that she was crying both about how unloved she had always been by her mother and about how disappointed she was now in me, that it had taken me so long to understand something so important.


On some level, unconsciously I had been defending her mother.  I think I was having trouble believing that her mother would have been so heartless as to favor her other daughters over my patient; I was so fond of my patient that I could not imagine any mother not loving her.


The reality is that I had not really taken Celeste seriously when she had told me that her mother did not love her.  I understood that she had felt unloved as a child, but I could not bear to think that she had actually been unloved.  And so I did her a grave disservice in assuming that she was inaccurately perceiving the reality of the situation.  In doing this, I was blocking some of the grieving that she needed to do about her mother.


By the way, as Celeste grieved the reality of how unloved she had actually been by her mother, she and I came to discover something else:  Although she had not been loved by her mother, she had in fact been deeply loved and cherished by her father, a man who, although severely alcoholic and often absent from home, was nonetheless very deeply attached to Celeste and proud of her.  We might never have gained access to the special connection with her father had I persisted in my belief that Celeste's mother had to have loved her.  


Let me add, at this point, that another way to understand what happened between Celeste and me is to think in terms of my patient as having needed me to fail her as she had been failed in the past, so that she would have the opportunity to achieve belated mastery of her old pain about not being taken seriously. 


Such a perspective (a relational or interactive perspective) would see the therapist's failure of her patient as not just a story about the therapist (and the therapist's limitations) but also a story about the patient (and the patient's need to be failed). 


More generally, relational theorists believe that there are times when the patient needs not only to find a new good object but also to re-find the old bad one, needs not only to create a new good object but also to re-create the old bad one – so that there can be an opportunity for the patient to revisit the early-on traumatic failure situation and perhaps, this time, to achieve mastery of it.