Working With Resistance (Book Review)
Author: Stark, Martha
Publisher: Jason Aronson, 2002
Reviewed By: Lawrence E. Hedges, Fall 2003, pp. 47-50
Freud once remarked that psychoanalysis is like the game of chess, in that the opening moves and the closing moves can be taught, but the middle game is difficult to learn. Martha Stark teaches the middle-game in a book of extraordinary depth that is marked by disarmingly simple and remarkably understandable principles and moves. Taking the position that the central project of psychoanalytic psychotherapy revolves around the resistive forces that oppose the work of treatment, Stark speaks to all those resistive forces within the patient that interfere with the analytic progress toward mental health, i.e., toward developing the capacity to experience one’s love objects as they really are, uncontaminated by the need to have them be other than they are. The patient defends against accepting reality by clinging to illusions and distortions that constitute the resistance. While Stark does not directly address countertransference and counter-resistance, she writes in a direct, no-nonsense style about how two people can work together to cut through forces that limit the lives of both in the relationship of the treatment process.
The patient experiences a tension between “his recognition of the reality that his therapist is not as good as he had hoped and his need to see his therapist as the good parent he never had, [as well as a tension between] his recognition of the reality that his therapist is not as bad as he had feared and his need to see his therapist as the bad parent he did have” (p. 8). In working with these tensions, Stark sees the patient’s knowledge of the therapist informed by the present and his experience of the therapist informed by the past.
The central tenet of Stark’s approach to studying resistance is the patient’s refusal to grieve. Drawing upon classical, object-relations, self-psychology, and relational theories, she presents a model of the mind that “takes into consideration the relationship between unmourned losses and how such losses are internally recorded—as both the absence of good (structural deficit) and the presence of bad (structural conflict)” (p. xi). Maintaining these internalized records in personality functioning allows the illusions and distortions resulting from traumatic childhood disappointment to interfere with the movement toward mental health in adulthood and constitutes the resistance to treatment. The patient feels the tension between what he should let himself feel or do and what he actually feels and does instead. Both sets of forces must be named so that the patient can come to appreciate his investment in his defenses and the price he pays for holding on to them. “Ultimately, the force defended against is that healthy (but anxiety-provoking) force within each of us that wills us to change, that force that wills us to let go of the old and to get on with the new, that force that wills us to get better” (p. 3). The compulsive repetitions of childhood trauma fuel the resistance and transference, but they are also the forces that make possible belated mastery of the early environmental failures—the working through of resistances and transferences. Intrinsic to the relentless pursuit of childhood gratifications is the wish to be contained, the wish to be able to repeat in the here-and-now of the therapeutic relationship the traumatic failures with the hope that this time the outcomes will be better.
Building on Sheldon Kopp’s thesis that in genuine grief we express with sobbing and wailing the acceptance of our helplessness to do anything about our losses—while in denial we whine and complain, insist that this cannot be, and demand compensation for our pain—Stark maintains that defensive pathology or resistance arises from our refusal and/or our failure to fully mourn the past and to live realistically in the present. When patients sustain depression, feel sorry for themselves, blame oneself or others, or feel victimized and accusatory, they are not accepting present reality. They are “not confronting reality and doing what they must do to come to terms with it. They are refusing to grieve” (p. 122),
Genuine grief involves confronting the reality of just how bad it really was and is; and it means accepting that, 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 the objects in one’s world nor one’s self will ever be exactly the way one would have wanted them to be. Nor will life ever be exactly the way one would have wanted it to be. It means knowing that one may well be psychically scarred in the here and now because of things that happened early on but that one must live with that, knowing that there is no way to undo the original damage done…Grieving means being able to sit with the horror of it all, the outrage, the pain, the despair, the hurt, the sense of betrayal, the woundedness; it means accepting one’s ultimate powerlessness in the face of all of this; and it means deciding to move on as best one can with what one has—sadder, perhaps, but wiser too. There is a kind of peace that comes with recognizing that things were as they were and are as they are. (p. 123)
Stark reviews Freud’s five types of resistance:
1. Repression resistance designates the barrier erected by ego to keep out of consciousness the forbidden libidinal and aggressive drives threatening to break through.
2. Transference resistance involves enactments that are repetitions of the past, a re-experiencing without conscious recall.
2. Secondary gain resistance includes gratification of dependency needs, needs for attention, needs to be taken care of, and the need not to have to take responsibility for one’s life.
4. Id resistance occurs when the libido unswervingly adheres to its objects, so that the person is reluctant to give up internalized attachments to infantile objects—regardless of their quality.
5. Superego resistance arises from the person’s sense of unconscious guilt that the ego experiences as it is failing to perform as it should by keeping id instincts successfully out of consciousness or from constantly threatening the repressive barrier. The harsher the superego, the more formidable the guilt; and the need for punishment to assuage that guilt.
Stark deals with two-person forms of guilt that derive from the interpersonal perspective: depressive guilt that the person’s aggression is hurting someone loved; and Arnold Modell’s separating and individuating guilt, in which the person is reluctant to achieve emotional distance from the internalized parental objects, hesitant to become a person in one’s own right and unable to carve out an existence for oneself. Suggested interventions include: “You want desperately to find a wonderful woman with whom you can have a close relationship, but you are not sure that you have the right to such happiness” and “You want to be able to excel in your work, but you tell yourself that you are not entitled to find such success” (p. 101).
The most extraordinary feature of the book is the number of rich suggestions for actual clinical interventions—something rarely found in psychoanalytic texts. Stark’s many suggestions revolve around various categories of conflict statements, in which both desire and resistance are highlighted. In order to capture the unusual technical venue of this book, I have chosen a rather extensive sampling of suggested clinical interventions to demonstrate how very helpful and thought provoking this book truly is at a practical level.
When we go with the patient’s resistance, we are careful not to challenge it. We are not interpreting the patient’s defensive posture; we are naming it, highlighting it, defining it. It is his way of constructing his world, and we are respectful of it. We frame our interventions in such a fashion that the patient will feel understood and may even gain further understanding as well. We do what we can to use verbs that emphasize the element of choice in what the patient is doing/feeling; we want the patient, over time, to recognize and to own the power he has to decide how he wants to experience his world. When we suggest, for example, that the patient is determined not to be angry, or when we suggest that the patient does not want to be someone who is dependent, we are attempting to name the power he has and to make him aware of the choices he is making….When the therapist names the defense, the therapist is encouraging the patient to articulate some of the basic assumptions he has about himself and his objects…in an effort to get the patient to be ever more aware of how he structures his world. (p. 23)
Examples of statements supporting defenses are: “You feel that you must have guarantees” and “You are not entirely sure that it feels safe in here” (p. 24). Examples of damaged-for-life statements that uncover underlying distortions are: “Deep down inside you feel so damaged, because of things that happened to you early on, that you cannot really imagine being able to do anything now to correct it” and “You feel so incapacitated, so impaired, so handicapped, that you have trouble imagining how things could ever be any different” (p. 28). Compensation statements include: “You wish that I could do something to make the pain go away” and “Because you feel so confused and so lacking, you find yourself looking to people on the outside for direction and guidance” (p. 29). Entitlement statements read: “Because you feel that it was so unfair, what your father did to you, deep down inside you are convinced that the world now owes you” and “Your sisters treated you terribly, and now you’re not interested in maintaining a relationship with them unless they are willing to go more than halfway.”
Conflict statements as illustrated by Stark are often framed with constructions that include: “although…nonetheless…”; a part of you…while another part of you…”; “on some level…but on another level…”; “on the one hand…but on the other…” (p. 40). A conflict intervention might be: “Although there must be times when you wonder why you don’t just leave her, you can’t bear the thought of not having her in your life because she makes you feel special and loved in a way that you have never before felt” (p. 41). A path-of-least-resistance conflict statement might be: “Although on some level you know that there are some things you could choose to do, you tell yourself that none of those things would make a real difference” (p. 43). A price-paid conflict statement might be: “You recognize that as long as you refuse to deal with just how disappointed you are with your marriage, you will continue to feel depressed, but it is easier for you to feel depressed than to think about the terror of being alone again” (p. 46). A confrontation conflict statement might be: “Even though you know that someday you will need to deal with these issues before you can have the quality of life that you seek, for now you are feeling that you have done the work that you set out to do and are therefore looking ahead to termination in the near future” (p. 47).
Stark contrasts conflict statements as those that first direct attention elsewhere and then resonate with where the patient actually is in the present with containing statements that first resonate with where the patient is now (in order to engage) and then direct attention to something that will serve to deter acting out. Examples of containing statements might be: “You just can’t get rid of this conviction that if you feel hurt by me, then you get to do anything you want, including breaking the rules, which you and I both know we need to have in order for our relationship to continue” and “I know you’re hating me right now…and I know you want to walk out this minute; but you and I both know that someday you’re going to have to figure out why it’s so much easier for you to get rid of people in your life, even people who care about you, than to forgive them” (p. 78).
Stark borrows heavily from the work of Kohut and self psychology for her understanding of how good gets internalized through non-traumatic frustrations. She relies heavily on Fairbairn and object-relations theorists to understand how bad becomes internalized through traumatic frustrations. Stark calls upon a two-person relational or intersubjective model for understanding how personality integration is achieved through encouraging the patient to look outward in order to experience the reality of who the therapist actually is in the here-and-now—namely, that he is a new good object, not the old bad one.
Working With Resistance demonstrates through theory and extended case illustration how structural deficits give rise to illusion and positive transference and how structural conflicts give rise to distortion and negative transference. Further, it shows how the patient’s transferential need to experience love objects as other than they are can be systematically worked through so that the structural configurations of the patient’s internal world are gradually altered. If something good is missing inside, the goal of therapy is to add it; if something bad is already there inside, the goal is to change it. In the deficit-compensation model, the therapist is experienced as the new good object (i.e., through the positive transference); while in the relational-conflict model, the therapist is experienced as the old bad object (i.e., through the negative transference).
Stark devotes considerable attention to the defense of affective non-relatedness to the therapist: “You are determined not to let me matter that much”; “It feels safer, somehow, not to let anyone get that close”; “Perhaps it feels safer right now to be keeping parts of yourself hidden” (p. 189). In the facilitation-conflict statement, the therapist juxtaposes the healthy wish to change and the unhealthy fears about changing: “You wish that you could find the answer, but you are not convinced that you will be able to” or “You would like to understand why you are so sensitive to criticism, but you are not sure that such understanding will make any real difference in terms of your actual vulnerability to it” or “A part of you wants to be known and understood but another part of you wants to remain unknown, unfound, hidden” (pp. 191-4). Stark also finds a place for work-to-be-done conflict statements: “Although you know that coming twice a week enables us to do more in-depth work, there’s a way in which (at this point in time) you are feeling that it takes too much out of you to be investing so much time and effort and money in our work together” or “Even though you know that you are someday going to have to recognize that your mother was never there for you in the ways that you would have wanted her to be, you find yourself thinking that if she could but admit that she was wrong, then it would make things so much easier” (pp. 196-7).
To aid with the working-through, grieving process of psychotherapy, several other kinds of statements are offered. Examples of the disillusionment statement would be: “You had so hoped that I would be able to give you answers, and it angers you that I haven’t done that”; “You were so hoping that I would not make the same kinds of mistakes that everyone else has made, and it makes you very sad that I too have now let you down”; and “Sometimes you wish I knew what you were thinking without your having to say it, and so it’s annoying when you find yourself having to explain it to me” (p. 218). As other examples of working though, Stark offers integration statements: “When your heart is breaking, as it is now, you can’t imagine that you could ever dare to trust me again”; “When you are feeling this despairing, you can’t remember ever having had any hope whatsoever” (p. 219).
Stark’s defense of relentless entitlement features the patient’s conviction that the therapist has “it” or knows “it” but is somehow refusing to cooperate—i.e., that the therapist is not the perfect parent that the patient wanted him to be. Relentless entitlement defends against disillusionment that the bad object never will become good, that the patient never will attain the love that she wanted in the way that she wanted it and from those whom she most wanted it. Relentless entitlement is a part of the resistance to working through the positive transference disruptions, as well as the negative transference realities. The feeling is that it should not have happened the way it did or been the way, it was and so the patient feels she is entitled to have it different now.
As a child, to have confronted and acknowledged the horrid truth about his infantile objects would have been tantamount to psychic suicide. Now, in the context of being “held” by the therapist, the patient dares finally to face the horror of just how bad it was. As he confronts the truth, he feels the pain of his devastation, no longer needing to deny its existence. Belatedly, he grieves for the wounded child he once was and the damaged adult he has now become. (p. 266)
Through experiencing disillusionment in the historical past, as well as in the therapeutic present, and grieving the loss of how the person would have wanted relationships to be, the mature hope that comes from mastering disillusionment arises from working to attain something in current and future relationships that is fully realizable. In the context of being held by the therapist, the patient can let herself feel (in the present interpersonal context) the pain and outrage she feels about her therapist’s (non-traumatic) disappointment of her, as well as her parents’ (traumatic) disappointments of her. By facing these disappointments with discouragement and despair and finding that she survives them, the patient is able to find her way to a healthy capacity for hope based on realistic aspirations, not unrealistic, unattainable dreams and goals.
I have personally used Martha Stark’s Working With Resistance in fifteen small study groups of practicing psychotherapists, with excellent results. Therapists in early phases of practice find the book gives them practical help with extremely difficult situations, while seasoned therapists and psychoanalysts find many of their assumptions and ways of approaching patients to be seriously challenged. All find this relationship-centered book revealing, permission-giving, extremely practical, and personally inspiring.
Lawrence E. Hedges is a psychologist-psychoanalyst in private practice in Orange, California. He is director of the Listening Perspectives Study Center and the founding director of the Newport Psychoanalytic Institute. He is author of numerous papers and books on the practice of psychoanalytic psychotherapy.
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