Each year we open submissions for our Annual Wise Therapy Spotlight, where we ask a question of particular importance to our wider therapist community. We are always moved by the depth and generosity of our community voices.
This year, we asked our community, What Is the Soul of Therapy? Read more about our inspiration for this, our 5th edition, in the letter from the editors and Academy of Therapy Wisdom founders, Brian and Ian.
Continue here to read the submission by Martha Stark MD / Harvard Medical School. We hope you enjoy it as much as we all did.
Empathic Grunts ~ A Clinical Vignette
This vignette is about a patient who was relentless in his pursuit of that which, at least on some level, he knew he could never have but to which he nonetheless felt entitled – a man who had not yet confronted the pain of his early-on heartbreak in relation to his father.
The patient, Mark, is a man who sought me out for a consultation several years ago.
He is a psychiatrist, had been in analysis for some eight years with a well-known and highly respected local training analyst, and was feeling very stuck in his treatment. He explained to me that he was becoming increasingly dissatisfied with his analyst because he was not getting the kind of support he wanted and felt he deserved.
By way of illustration, Mark cited a time when he had gone to his analyst’s office, had lain down on the couch, and had told his analyst in some detail about the very difficult day he had been having – he had had three admissions to write up, he had been reprimanded by the attending, when it came time to leave for his analytic hour he had found that his car had been blocked in by other cars so that he had had to take a cab in order to be on time, in the confusion he had lost his wallet and had therefore needed to beg his cab driver to accept a check, and so on and so forth.
In his consultation with me, Mark expressed his outrage and his bitterness, protesting that all he had wanted from his analyst was an “empathic grunt,” some acknowledgment by the analyst of how frustrated and angry he (the patient) must have been feeling because of the horrid day he was having. The patient demanded to know, “Was that too much to ask? All I wanted was a little kindness, a little compassion!”
Mark went on to talk about how his colleagues had confirmed his belief that if his analyst could not give him even this, then he (the patient) had no business remaining in such a disappointing relationship, that it was masochistic for him to be continuing the treatment.
But as Mark’s story unfolded, I came to see things in a somewhat different light. Admittedly, it does not seem unreasonable to be asking for a bit of support, understanding, and comfort at a time when you are feeling overwhelmed and agitated. But for the patient to be looking for such support from someone whom he knew did not give that kind of support (although the analyst did offer many other good things), for the patient to be looking still, even after these eight years, for support from someone whom he knew had never given that kind of support – this is what caught my attention! This is what seemed to me to be masochistic.
So whereas Mark was thinking that it was masochistic for him to be staying in a relationship with someone who was not giving him what he so desperately wanted, I was beginning to think that it was masochistic for the patient to be wanting still that which he was clearly never going to get – and that the solution lay not necessarily in severing the relationship with his analyst but, first, in confronting the reality that he was never going to get exactly what he would want from his analyst (probably a stand-in for an earlier caregiver) and, then, in grieving that disillusioning reality. The patient would get other good things from his analyst (and, in fact, over the course of the previous eight years, had gotten all sorts of good things from his analyst) – but never the empathic grunts.
Admittedly, I did also wonder a bit about the analyst’s seeming refusal to relent, refusal to allow himself to be influenced even a little by the patient’s impassioned entreaties; but, in this instance, I decided not to focus on what I suspected was the analyst’s contribution to the stalemated situation between them. My fear was that were I to speak too much to the part I sensed his analyst might be playing, the patient could use this to reinforce his own rather entrenched position, which would then obscure the more important issue of the patient’s accountability for his own relentlessness, fueled by his refusal to confront the reality of his analyst’s limitations.
And so I said that, at this point, I believed the work of the analysis involved Mark’s confronting, head on, the excruciatingly painful reality that his analyst was never going to give him exactly what he wanted. I shared with him that I suspected the analyst was a stand-in for one or both of his parents and that his experience of thwarted longing in relation to his analyst was the recapitulation of an early-on (and never grieved) heartbreakingly painful relationship with a parent.
Although in the first of his three consultation sessions with me Mark had said that (as a result of the work he had done over the course of the previous eight years) he felt he had pretty much made his peace with his parents’ very real limitations, when I now framed the stalemated situation in his analysis as speaking perhaps to frustrated desire and unrequited longing with respect to at least one of his parents, he began to resonate with this.
Somewhat shaken, Mark now (in the third and final session of our consultation) finally acknowledged that, indeed, he had always been frustrated in his desire to get recognition from his father, a narcissistic man who was chronically depressed and totally unavailable for support and comfort. As Mark now talked about his father, he began to express what he said he had always known (on some level) but had never really been able to let himself think or feel – namely, that his heart had been broken by his father’s failure of him, his father’s inability to respond to his desperate pleas for attention and love.
As our session continued, it became very clear that although Mark had given lip service over the course of the eight years of his analysis to acknowledging how devastated he had been by his father’s emotional remoteness, the patient had never really let himself feel just how traumatizing his father’s inaccessibility had actually been for him.
Furthermore, Mark’s refusal to grieve that early-on failure was forcing him to relive it in the here and now of the transference and intensifying that early pain – but now in relation to his analyst.
As we explored other areas of Mark’s life, we came to see that it was a recurring theme for the patient to be ever wanting from his objects the one thing they would never be able to give, a recurring pattern for the patient to be ever in a state of frustrated longing and thwarted desire in relation to the significant people in his life.
I suggested to Mark that before he made a decision about whether or not to continue with his analyst, he should use the analysis to make his peace with just how disappointed he was in his analyst. I told him I thought that in the process he would also be doing some important, even if belated, grief work around the emotional unavailability of his father.
So I suggested that instead of immediately rushing off to another analyst in order to pursue elsewhere his relentless search for gratification, Mark should stay in the relationship with his current analyst at least long enough to gain insight into why he was always in the position of trying to extract the right thing from the wrong person, that is, why he was ever in relentless pursuit of the unattainable.
In essence, I told Mark I thought he would need to take some responsibility for the part he was playing in the unfolding of his life’s drama, that he would need to take some ownership of his relentless hoping against hope that his analyst might someday turn out to be someone whom the patient knew (in his heart of hearts) the analyst would never – and could never – be, and that the patient would need, eventually, to confront the pain of his grief about his father and those he had then chosen to be parent substitutes.
In sum: It could probably be said that a patient’s relentless pursuit of the right things from the wrong people is the hallmark of a patient who, refusing to grieve, clings to his relentless hope.
As a follow-up – Several years later, I ran into Mark at a professional event. We had only a few moments to exchange words, but just before we parted, Mark leaned in and whispered that he had indeed returned to his analyst and had finally confronted – and truly grieved – his analyst’s emotional unavailability (and, before that, his father’s). It had not been easy, and it had taken time, but he had gotten the job done.
With a twinkle in his eye and a broad smile, Mark then confided that once he had made his peace with his analyst’s “limitations” – and, in the process, adaptively internalized much of what his analyst had, in fact, been able to offer him over the years – he discovered something unexpected, namely, that every now and then his analyst would actually offer him an “empathic grunt.”
I think both Mark and I understood that once he had let go of his relentless desire to shape his analyst into being the person he needed him to be, he was able to appreciate – and make use of – what his analyst was able to offer. In turn, it is also possible that, no longer feeling so pressured, Mark’s analyst had been able to relent a bit and had then become more comfortable with exposing his “more human” – and “less neutral” – side.
“To grieve is to confront the reality of what was never ours – so that we can be liberated from relentless pursuits in the present and embrace authentic possibilities for the future.” Martha Stark (2024)
The views expressed in this essay are not necessarily the opinions of Academy of Therapy Wisdom, its presenters or its staff. This is part of a series featuring the unedited voices of our community in conversation. All content is used with permission and is copyright 2024 by Academy of Therapy Wisdom. Only the author may reproduce their content.
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