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A HOW–TO 'PLAYBOOK' FOR THE MIDDLE GAME

IN PSYCHODYNAMIC PSYCHOTHERAPY

by Martha Stark, MD

Faculty, Harvard Medical School

 

Peter Giovacchini (1986) once wrote – “The poorest understood and two most enigmatic words in psychoanalysis are working through.”

 

And Patricia Coughlin (2022) recently wrote – “Like the middle game in chess, there is no playbook to guide us.”

 

 

Friday / February 17, 2023 – 5:00 - 7:00 pm (ET)

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"A How-To 'Playbook' for the Middle Game in Psychodynamic Psychotherapy" – Part 1

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"A How-To 'Playbook' for the Middle Game in Psychodynamic Psychotherapy" – Part 2

Hosted by The International Association for Relational Psychoanalysis and Psychotherapy (IARPP) Australia Inc.

A FUND-RAISING BENEFIT FOR UKRAINIAN PSYCHOTHERAPISTS

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It took me 48 years to get here and a lot of encouragement from my students, but what follows represents the rather bold effort on my part to conceptualize a broad strokes framework for this “middle game” in psychodynamic psychotherapy – in essence, a “how-to playbook” detailing the progressive working through of longstanding, deeply entrenched defensive reactions and their eventual transformation into adaptive responses.

 

So here we go.

 

When deep and enduring psychodynamic change is our ultimate therapeutic goal, in the evocative words of Acceptance and Commitment Therapy (ACT), the process of working through involves transforming psychological rigidity into psychological flexibility.

 

In the more traditional words of psychoanalysis and ego psychology, the process of working through involves transforming, on the one hand, low-level defenses into higher-level defenses and, on the other hand, rigid defenses into more flexible adaptations...
 

...such that the patient (whatever her diagnosis / whatever her level of functionality / whatever her starting point) will, over time, become ever better able to manage the myriad stressors in her life – ever more adept at “respond adaptively” instead of “reacting defensively” to the various stressors to which she will be continuously exposed.

 

Please note that I do not limit defenses to the well-known and more traditional ones. At one end of the continuum would be low-level defenses (like repression, regression, denial, dissociation, displacement, projection, isolation of affect, intellectualization, reaction formation). And at the other end would be higher-level or more mature defenses that would be more adaptive and socially acceptable (like sublimation, humor, altruism, and positive identifications).

 

Rather, I define defenses more broadly as speaking to any of the self-protective mechanisms that patients mobilize when made anxious in the face of stressors (external and internal, past and present). At one end of the continuum is what happens reflexively when patients are confronted with stressors that they are unable to process and integrate – to which I refer as low-level defenses or rigid defenses. And at the other end is what happens more reflectively when patients are confronted with stressors that they can more easily “take in their stride” – to which I refer as higher-level defenses or more flexible adaptations.

 

So, in what follows, I will be talking about transforming defenses into adaptations – defensive reactions that impede growth into adaptive responses that promote growth – “same old, same old” / “mindless knee-jerk reactivity” into “something new, different, and better / “something more mindful, considered, and intentioned.”

 

First a brief overview: The process of advancing from psychological rigidity to psychological flexibility is never a straight-line progression. Rather, evolving from rigid defense to more flexible adaptation will involve the therapist’s strategic provision of not just support but also an artfully conceived combination of challenge and support – namely, optimal stress.

 

And the ongoing therapeutic provision of this optimal stress will generate healing cycles of disruption (in reaction to the challenge) and repair (in response to the support) – and, eventually, progression from less-healthy defense to more-healthy adaptation.

 

Of course, nobody said it would be easy. In fact, Freud (1914) himself once wrote, “This working-through of the resistances <defenses> may in practice turn out to be an arduous task for the subject of the analysis and a trial of patience for the analyst.” Amen.

 

In any event, the following four things are at the heart of what is required of any therapist whose goal is to effect profound and sustained psychological growth.

 

(1) staying ever attuned to the level of the patient’s anxiety and understanding that it is OK to leverage this anxiety by alternately increasing it and then decreasing it;

 

(2) developing comfort with both challenging and supporting the patient’s defenses –always done mindfully, of course, with compassion and never judgment;

 

(3) against the backdrop of empathic attunement and a solid therapeutic alliance, periodically offering optimally stressful interventions designed first to destabilize defenses and then to restabilize them at ever higher levels of functionality and adaptive capacity; and

 

(4) appreciating the importance of supporting (and celebrating) the patient’s hard-earned adaptations.

 

The generation of ongoing healing cycles of destabilization and restabilization – disruption and repair – will create states of homeostatic imbalance. But these states of disequilibrium cannot be tolerated for long. The imbalance will, therefore, prompt restoration of equilibrium – re-equilibration – but each time at a new, more-evolved level of homeostasis and adaptive capacity.

 

How is this possible? Well, the restabilization at a new, more-evolved level of homeostasis and adaptive capacity will be possible because of the synergy of the therapist’s external provision and the patient’s internal resources – in other words, the synergy of, on the one hand, the therapist’s interventions that offer support and, on the other hand, the patient’s underlying resilience – whether described as the wisdom of her body, her innate striving towards health, or her intrinsic capacity to adapt to (optimal) stress.

 

I believe that, fundamentally, all patients, no matter what their starting point, have some degree of innate resilience – such that therapeutic interventions thoughtfully designed to offer both challenge and support will be able to tap into their internal reserves – resulting, ultimately, in reinforced resilience – in essence, transformation of innate resilience into adaptive resilience – innate immunity into adaptive immunity.

 

So – big picture overview – the working through process involves –

 

(1) supporting the patient’s defenses (to create the backdrop and set the stage);

 

(2) alternately challenging and then supporting the patient’s defenses (to create destabilizing anxiety and incentivizing dissonance); and then

 

(3) supporting (and celebrating) the patient’s adaptations.

 

...not always in that order – but often.

 

Certainly, it could be said that, on the one hand, “Without support, therapy never begins; but without challenge, it never ends” and that, on the other hand, “Without challenge, therapy never begins; but without support, therapy never ends.”

 

Similarly, “Without empathy, therapy never begins; but without empathic failure, it never ends.” So, too, “Without empathic failure, therapy never begins; but without empathy, therapy never ends.”

 

In any event, it will be critically important for the therapist to be keeping her finger ever on the pulse of the level of the patient’s anxiety – using that level as a barometer to guide her interventions – supporting whenever necessary but challenging whenever possible – all with an eye to precipitating disruption to jump-start repair – thereby facilitating advancement of the patient from psychological rigidity to more flexible adaptation.

 

To the point here is the Japanese adage – “Fall down seven times, stand up eight.”

Coughlin, P. 2022. Facilitating the process of working through in psychotherapy: Mastering the middle game. London and New York: Routledge (Taylor & Francis Group). 

Freud, S. 1914. Remembering, repeating and working through (Further recommendations on the technique of psycho-analysis II). Standard Edition of the Complete Psychological Works of Sigmund Freud, Volume XII (1911-1913). London, UK: Hogarth Press.

Giovacchini, P. 1986. Developmental disorders: The transitional space in mental breakdown and creative imagination. Northvale, NJ: Jason Aronson.

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