by Martha Stark, MD / Faculty, Harvard Medical School



What follows are excerpts from a short piece that I had written (for a small publication) many years ago and prior to my developing the concept of “relentless hope.”


It will be easy to see how the concept of relentless hope was simply waiting to be found – although, at that point, I had not quite yet let myself appreciate that!


Let me start by making brief reference to a model of the mind that takes into consideration both structural deficit and structural conflict – in other words, a model of the mind that takes into account both the absence of good (deficit) and the presence of bad (conflict).


From this it will follow that if something good is missing inside, then add it – structural growth. If something bad is already there inside, then change it – structural modification.



Self Psychology vs. Object Relations Theory


But how exactly do we add new good? And how do we change old bad?


To understand how it is that new good structure is added, we must look to self psychology.


Self psychology is all about illusion, disillusionment, and grieving.


Self psychology spells out in exquisite detail the relationship between working through the loss of illusions and the laying down of new good structure – structural growth.


Self psychology provides an excellent model for the addition of new healthy structure but does not deal at all with the modification of existent pathological structure.


After all, self psychology is a theory about deficit not conflict, absence of good not presence of bad, the filling in of deficit not the resolution of conflict.


It is therefore a theory about structural growth, not structural change.


There are no internal bad objects or pathogenic introjects in self theory – only impaired or absent capacity.


To understand how it is that old bad structures are modified we must look to object relations theory, the building blocks of which are internal bad objects or pathogenic introjects.


Object relations theory offers us a way to conceptualize the process by which bad objects get inside to begin with and how, once inside, they are reworked, rendered less bad – structural change.


In another post, I will be writing more about structural modification (whereby old bad is rendered less toxic).


For now, however, I will be focusing on structural growth (whereby new good is added).



Transmuting Internalization


Self psychology conceptualizes a model for development of self structure in which empathic failure (against a backdrop of gratification) provides the impetus for growth. If such a failure can be worked through and mastered, that is, grieved, then it will be the occasion for transmuting internalization, that is, the building of self structure.


In other words, a nontraumatic frustration, or an optimal disillusionment, provides the impetus for internalizing a good object and for laying down new structure.


In sum, a loss properly grieved gives rise to healthy psychic structure.


More specifically, the regulatory functions that the selfobject had been performing prior to its failure of the child/patient will be internalized.


Taking in the good that had been is part of the grieving process and is the way the child/patient masters her experience of the parent's/therapist's failure of her.


Internalizing the good is the process by which capacity (or structure) develops. 



Psychic Structure


What exactly do we mean when we speak of psychic structure?


Well, structures are thought to perform functions.


The drive structures of drive theory (the drive‑regulating introjects in the ego and superego) perform the function of drive regulation.


The self structures of self theory (the ambitions and purposes of the ego, the goals and aspirations of the ego ideal) perform the function of self‑esteem (or self) regulation.



From Need to Capacity


We are speaking here to the difference between needing external reinforcement of one's self‑esteem and having the capacity to provide such reinforcement internally. 


Structures allow for capacity. Where once there was need, now there is capacity – where once energy, now structure.


Classical psychoanalysis is about transforming (id) energy into (ego) structure, need into capacity – where id was, there shall ego be.  …transformation, say, of the need for immediate gratification into the capacity to tolerate delay.


So, too, self psychology is about transforming need into capacity.  …transformation, say, of the need for perfection into the capacity to tolerate imperfection.


More generally, in self psychology transformation is of the need for external regulation of the self‑esteem (or self) into the capacity to provide such regulation internally.


Where once the patient needed to rely upon her objects for reinforcement, now she has the capacity to rely upon herself for such reinforcement.


The need for external reinforcement will have become transformed into the capacity for internal reinforcement.


In what follows, we will be speaking also about transformation of the need to experience reality as it isn't into the capacity to experience reality as it is, uncontaminated by need.


Self psychology, then, informs us that it is the experience of properly grieved frustration, against a backdrop of gratification, that provides the impetus for internalization and the laying down of (self) structures that will enable the patient to regulate internally her self‑esteem.



Optimal Disillusionment


With respect to both child and patient: When the parent/therapist has been good and is then bad, the child/patient will deal with her disappointment in the frustrating parent/therapist by taking in the good that had been there prior to the introduction of the bad.


The child/patient will adaptively internalize the good parent/therapist as part of the grieving process, so that she can preserve internally a piece of the original experience of external goodness.


Such internalizations will enable the child/patient, ultimately, to separate from her infantile objects and to relinquish her infantile attachments.


Note that, according to self theory, good gets inside not so much as a result of experiencing gratification but more as a result of working through frustration, against a backdrop of gratification.


More specifically, self structure develops not so much as a result of the experience of an empathically responsive parent but more as a result of working through disappointment in an otherwise empathically responsive parent, working through a positive transference disrupted.



The Impetus for Internalization


In other words, the impetus for internalization is the failure itself.


And as long as the child/patient is having her needs met, there will be no impetus for internalization because there will be nothing that needs to be mastered.  …a positive (selfobject) transference.


It is only in the aftermath of a failure (positive transference disrupted) that there will be impetus for internalization. 



Positive Transference Disrupted vs. Negative Transference


Is a positive transference disrupted the same thing as a negative transference? No!


What is the difference between a positive transference disrupted and a negative transference?


On the one hand, a positive transference disrupted describes the situation in which an object turns out to be not as good as the child/patient had hoped the object would be.


On the other hand, a negative transference describes the situation in which an object is experienced as a bad object when it is not.





Self psychology, then, is all about grieving, grieving the loss of illusions, illusions about the perfection (or perfectibility) of the self and/or the object.


What exactly do we mean by grieving?


I would like to suggest that we think of the patient’s grieving as involving the facing, head‑on, of certain intolerably painful realities about her objects, past and present.


It means recognizing that her objects have certain very real limitations.


It means accepting the fact that she is ultimately powerless to do anything to make those painful realities different. 


Grieving means feeling, to the very depths of the patient’s soul, her anguish and her outrage that her therapist is as she is, her parent was as she was, and the people in her life are as they are.


The patient must feel all that needs to be felt in order, ultimately, to make her peace with the reality of just how imperfect, just how disappointing her world really was and is.


Such grieving does not mean being depressed, feeling sorry for herself, blaming herself, blaming others, feeling victimized.


The patient who faults, blames, and accuses is still fighting it.


The patient who holds out for things being different is refusing to accept the reality of how things actually are – and is not really grieving.


The patient who tries to make her objects be other than who they are is a patient who is not able to sit with the pain of her disappointment.


The patient who insists that her objects be different is refusing to grieve.


Grieving means confronting the reality of just how bad it really was and is; and it means accepting this, knowing that there is nothing now that can be done to make it any different.


It means coming to terms with the fact that neither she nor the objects in her world will ever be exactly the way she would have wanted them to be.


…and her life will never be exactly what she would have wanted it to be.


Grieving means being able to sit with her disappointment about all this, accepting her ultimate powerlessness in the face of all this, and moving on.


In relation to the illusions that the patient brings to the treatment situation: Over time, the patient must come to understand that her therapist will not be able to make her all better, will not be able to fill her up inside, will not be able to make up the difference and make right the wrong, much as both patient and therapist might have wished this to be possible.


The patient needs to grieve this; she needs to feel her disappointment, her heartache, and her outrage about what she's not getting from the therapist (a stand‑in, of course, for the parent).


She needs to face, head‑on, the intolerably painful reality of the therapist's limitations, namely, the therapist's inability to make up entirely for the bad parenting the patient had as a child.


And it is only as the patient grieves the reality of what the therapist doesn't give her, that she can begin to appreciate, to take in, and to profit from all those things that the therapist does give her.


It is only as the patient grieves the reality of what's bad that she can have what's good.


But as long as the patient refuses to face reality as it is and clings, instead, to illusions about what might be, then she will not be able to internalize the good that there is – and she will continue to feel empty.


It is by means of grieving that new good stuff is added, structural deficits are filled in, and the self is consolidated.


It is by means of grieving the intolerably painful realities of past and present that the patient, over time, will come to feel a little more full, a little less internally impoverished.


It is by means of grieving that new healthy structure will be laid down.


In other words, it is by means of working through disillusionment, working through positive transference disrupted, that structural growth occurs and psychic structure accretes.


Self psychology is about this process of grieving the loss of illusions, loss of the illusion that the therapist will be able to make up the difference to her, loss of the illusion that the therapist will be the perfect parent the patient never had.


When a selfobject transference is in place, we do not interpret.


We only interpret disruptions of it – because it is only in the context of our disappointment of the patient that there will be need for intervention.


The therapist's failure of the patient will recreate for the patient the early‑on failure situation.


All the old hurts, the old pain, the old grievances will get revived.


In the associative material, the patient may recover significant childhood memories and genetic reconstructions may be possible.


It is in the context of being "held" that the patient can now let herself feel, in the present, in the therapeutic setting, the unspeakable dread, the pain, and the anger she feels about her therapist's (nontraumatic) disappointment of her and her parent's early‑on (traumatic) disappointment of her.


She must rage, scream, rant, rave, wring her hands, pound her fists, bemoan her fate, and cry her heart out.


It is this work of grieving, the constant, repetitive raging, screaming, ranting, raving, and despairing, that is the process whereby the patient will gradually let go of her illusions.


The patient will gradually replace her illusion that the therapist will be for her the good parent she never had with a reality – namely, that she will have to become for herself the good parent she never had.


Her need for illusion is being replaced by the capacity to tolerate reality.


Self psychology is about having something good, losing it, and then recovering from its loss. 


It is the working through (and mastering) of one's disappointment in the object that provides the impetus for internalizing the good that was and for laying down healthy psychic structure.


Such internalizations are part of the grieving process and are the way the patient masters her experience of being failed. 


In essence, when the object (be it the parent or the therapist) has been good and is then bad, the child/patient deals with her disappointment in the frustrating object by taking in the good that had been there prior to the introduction of the bad.


Grieving – grieving the loss of illusions about the perfection, or the perfectibility, of the object is the way in which structural growth occurs.


It involves working through disruptions of the positive transference. Optimal disillusionment. Transmuting internalization. Structural growth.





Although the patient may contend that her pain will not go away until her needs have been gratified, my belief is that the patient's pain will not go away until she has worked through the disappointment she feels when it turns out that her needs will not always be gratified.


The patient must have the experience of working through optimal disillusionment; she must be able to tolerate the devastation and outrage she feels as she begins to confront, head-on, the object’s limitations (whether the object is the infantile object, a contemporary object, or the transference object).


She must face such limitations, grieve them, and master them.


Ultimately, she must move beyond the need to have reality be a certain way, transforming such a need into the capacity to know and to accept reality as it is, a hallmark of mental health.


Growing up (the task of the child) and getting better (the task of the patient) have to do with learning to master the disenchantment that comes with the recognition of just how imperfect the world really is – optimal disillusionment.


I am here reminded of The New Yorker cartoon in which a gentleman, seated at a table in a restaurant by the name of The Disillusionment Café, is awaiting the arrival of his order. His waiter returns to the table and announces, "Your order is not ready, nor will it ever be."

PS Only later did I realize that I was – here and elsewhere – really speaking to the concept of "relentless hope"!