1. THE TRANSFORMATIVE POWER
OF OPTIMAL STRESS
PRECIPITATING DISRUPTION TO TRIGGER REPAIR
NO PAIN / NO GAIN 
FROM DEFENSE TO ADAPTATION
THE EVER – EVOLVING PSYCHODYNAMIC PROCESS
MARTHA STARK MD
MarthaStarkMD @ HMS.Harvard.edu
Friday, October 8, 2021
IPI’s eBook Project
© 2021 Martha Stark MD
1

2. OVERVIEW
OPTIMALLY STRESSFUL
THERAPEUTIC INTERVENTIONS
OFFER JUST THE RIGHT BALANCE
OF ANXIETY – PROVOKING CHALLENGE
AND ANXIETY – ASSUAGING SUPPORT
THEREBY PROVIDING BOTH IMPETUS AND OPPORTUNITY
FOR THE PATIENT TO ADVANCE
THROUGH HEALING CYCLES OF
DISRUPTION (IN REACTION TO THE CHALLENGE)
AND REPAIR (IN RESPONSE TO THE SUPPORT)
HEALING CYCLES OF
DESTABILIZATION AND RESTABILIZATION
AT EVER – HIGHER LEVELS
OF ADAPTABILITY, RESILIENCE,
AND MENTAL HEALTH 2

3. OVERVIEW
MODEL 1 CONFLICT STATEMENTS
“OPTIMALLY STRESSFUL” INTERVENTIONS
DESIGNED TO ADVANCE THE “CONFLICTED” PATIENT
FROM “RESISTANCE”
– WHICH IS THE DEFENSE –
TO “INSIGHT OR AWARENESS”
– WHICH IS THE ADAPTATION –
FROM BEING JAMMED UP, STUCK, AND “UNCONSCIOUS”
TO BEING MORE AWARE OF THE INTERNAL FORCES AND
COUNTERFORCES GENERATING THOSE (NEUROTIC) CONFLICTS
PATIENTS THEMSELVES WILL EVENTUALLY START
TO CRAFT THEIR OWN CONFLICT STATEMENTS TO GIVE
VOICE TO THEIR INTERNAL CONFLICTEDNESS
ONCE THEY DEVELOP “DUAL AWARENESS” AND THE
SELF – REFLECTIVE CAPACITY TO STEP BACK FROM THE
IMMEDIACY OF THEIR EXPERIENCE IN ORDER TO OBSERVE IT
3

4. OVERVIEW
THE “SANDPILE MODEL OF CHAOS THEORY”
AN ELEGANT VISUAL METAPHOR
FOR THE THERAPEUTIC IMPACT
– OVER TIME –
OF “OPTIMALLY STRESSFUL”
CLINICAL INTERVENTIONS
DESIGNED TO REINFORCE
THE PATIENT’S RESILIENCE
JUST AS THE GRAINS OF SAND
BEING STEADILY ADDED TO A
GRADUALLY EVOLVING AND CONTINUOUSLY
COLLAPSING – AND – THEN – RECONSTITUTING
SANDPILE WILL REINFORCE ITS INFRASTRUCTURE
4

5. 1

6. THE ART OF PRECIOUS SCARS
6

7. LONG INTRIGUING TO ME
HAS BEEN THE CONCEPT
THAT SUPERIMPOSING
AN ACUTE PHYSICAL INJURY
ON TOP OF A CHRONIC ONE
IS SOMETIMES EXACTLY
WHAT THE BODY NEEDS
IN ORDER TO HEAL
7

8. FOR EXAMPLE
THE PRACTICE OF WOUND DEBRIDEMENT
TO ACCELERATE HEALING
SPEAKS DIRECTLY TO THIS CONCEPT
OF “CONTROLLED DAMAGE”
TO “TRIGGER REPAIR”
NOT ONLY DOES DEBRIDEMENT
PREVENT INFECTION BY REMOVING
FOREIGN MATERIAL AND DAMAGED TISSUE
FROM THE SITE OF THE WOUND
BUT IT ALSO PROMOTES HEALING
BY MILDLY AGGRAVATING THE AREA,
WHICH WILL IN TURN
JUMPSTART THE BODY’S INNATE ABILITY
TO SELF – REPAIR
IN THE FACE OF OPTIMAL STRESS
8

9. OTHER OPTIMAL STRESSORS THAT WILL TRIGGER
THE BODY’S INBORN CAPACITY TO SELF – CORRECT
IN THE FACE OF OPTIMAL CHALLENGE
INTERMITTENT FASTING
HIGH – INTENSITY INTERVAL TRAINING
ACUPUNCTURE / ACUPRESSURE
RED LIGHT THERAPY / INFRARED SAUNAS / CRYOTHERAPY
HOMEOPATHIC REMEDIES
PROLOTHERAPY (INSTEAD OF CORTISONE INJECTIONS)
PLATELET – RICH PLASMA / PLATELET – RICH FIBRIN
DERMABRASION / FRAXEL LASER TREATMENTS
CARDIAC DEFIBRILLATION
BRAIN STIMULATION THERAPIES (ECT / TCM)
BRAIN TEASERS / MENTAL EXERCISES
TENS UNIT / SCENAR DEVICE / PEMF THERAPY / FSM / CHI MACHINE
HYPERBARIC OXYGEN
ALL OF WHICH, AFTER INITIALLY DESTABILIZING THE
BODY’S STATUS QUO, WILL EVENTUALLY PROVOKE
ADAPTIVE RECONSTITUTION AT A HEALTHIER LEVEL
THEREBY STRENGTHENING THE BODY’S UNDERLYING RESILIENCE 9

10. VACCINES
WHICH OPTIMALLY STRESS THE BODY
BY INTRODUCING SOME FORM
OF THE INFECTIOUS AGENT
WHETHER LIVE BUT ATTENUATED, DEAD, OR
SYNTHETICALLY CREATED mRNA FRAGMENTS
SUCH THAT THE BODY’S IMMUNE SYSTEM
WILL LEARN TO PROTECT ITSELF AGAINST
SUBSEQUENT EXPOSURES TO THE AGENT
IN OTHER WORDS
“ACQUIRED OR ADAPTIVE IMMUNITY”
AGAIN, THE CONCEPT OF CONTROLLED DAMAGE
TO REINFORCE RESILIENCE
BY ELICITING AN ADAPTIVE RESPONSE TO THE STRESSOR
10

11. DEPRIVING YOURSELF OF HALF A NIGHT’S SLEEP
PREFERABLY THE SECOND HALF OF THE NIGHT
CAN PRODUCE A RAPID, EVEN IF TEMPORARY,
RESTABILIZATION OF MOOD
AND RECOVERY FROM DEPRESSION
(LEIBENLUFT and WEHR 1992)
A 36 – HOUR WATER FAST ONCE A WEEK
WILL SO SIGNIFICANTLY REDUCE THE TOTAL
BODY BURDEN THAT YOUR MENTAL CLARITY
AND FOCUS CAN BE IMPROVED DRAMATICALLY
DUKE UNIVERSITY MEDICAL CENTER
DISCOVERED THAT IF YOU DO 40 MINUTES OF
AEROBIC EXERCISE DURING THE DAY,
YOU CAN THEN GET BY ON 40 MINUTES
LESS SLEEP THAT NIGHT
(BLUMENTHAL et al. 1999)
11

12. JUST AS WITH THE BODY
WHERE A CONDITION MIGHT NOT
HEAL UNTIL IT IS MADE ACUTE
SO TOO WITH THE MIND
INDEED
OVER TIME I HAVE COME
TO APPRECIATE THAT
THE THERAPEUTIC PROVISION
OF OPTIMAL STRESS
AGAINST THE BACKDROP OF
AN EMPATHICALLY ATTUNED
AND AUTHENTICALLY ENGAGED
THERAPY RELATIONSHIP …
12

13. … WILL SOMETIMES PROVE TO BE
THE MAGIC INGREDIENT NEEDED TO CONFRONT
THE SEEMINGLY INTRACTABLE PSYCHIC INERTIA
AND RESISTANCE TO CHANGE
SO OFTEN ENCOUNTERED IN OUR THERAPY PATIENTS
OVER TIME
THE THERAPEUTIC PROVISION OF OPTIMAL STRESS
WILL ACCELERATE THE TRANSFORMATION OF THEIR
RIGID AND GROWTH – DISRUPTING DEFENSES INTO
MORE FLEXIBLE AND GROWTH – PROMOTING ADAPTATIONS
AGAIN
THE OVERARCHING GOAL IS TRANSFORMATION OF
PSYCHOLOGICAL RIGIDITY INTO PSYCHOLOGICAL FLEXIBILITY
AS DEFENSIVE REACTIONS BECOME ADAPTIVE RESPONSES
AS RELENTLESS HOPE (THE MODEL 2 DEFENSE)
IS TRANSFORMED INTO ACCEPTANCE
AS RELATIONAL ABSENCE (THE MODEL 4 DEFENSE)
IS TRANSFORMED INTO AUTHENTIC PRESENCE 13

14. AFTER ALL
IN THE PROPHETIC WORDS OF
THE NEUROSCIENTIST CHARLES KREBS
WHETHER FUNCTIONAL OR DYSFUNCTIONAL
“SELF – ORGANIZING
(CHAOTIC)
SYSTEMS
– INCLUDING US! –
RESIST
PERTURBATION”
PEOPLE RESIST CHANGE
(CHARLES KREBS 2006)
14

15. AND SO IT IS THAT WE KEEP PLAYING OUT
– ON THE STAGE OF OUR LIVES –
THE SAME SCENARIOS
AGAIN AND AGAIN
EVEN WHEN WE KNOW
THAT THE OUTCOME WILL BE JUST
AS DISAPPOINTING THIS NEXT TIME
AS IT HAD BEEN SO MANY TIMES BEFORE
ALBERT EINSTEIN CAPTURES
THE ESSENCE OF THESE
RELENTLESS PURSUITS AND
COMPULSIVE RE – ENACTMENTS WITH –
“INSANITY IS DOING THE SAME THING
OVER AND OVER AGAIN
AND EXPECTING DIFFERENT RESULTS”
15

16. A SATURDAY NIGHT LIVE SKIT IN WHICH
TWO MEN ARE SEATED AROUND A CAMPFIRE
CHATTING AND ONE SAYS TO THE OTHER –
“YOU KNOW HOW WHEN YOU
STICK A POKER IN THE FIRE
AND LEAVE IT IN FOR A LONG TIME,
IT GETS REALLY, REALLY HOT?
AND THEN YOU STICK IT IN YOUR EYE,
AND IT REALLY, REALLY HURTS?
I HATE IT WHEN THAT HAPPENS!
I JUST HATE IT WHEN THAT HAPPENS!”
16

17. BAD STUFF HAPPENS
BUT IT WILL BE HOW WELL THE PATIENT
IS ABLE TO PROCESS, INTEGRATE,
AND ADAPT TO ITS IMPACT
– PSYCHOLOGICALLY, PHYSIOLOGICALLY, AND ENERGETICALLY –
THAT WILL MAKE OF IT
EITHER A GROWTH – DISRUPTING TRAUMA
THAT OVERWHELMS BECAUSE IT IS “TOO MUCH”
“TRAUMATIC STRESS”
OR A GROWTH – PROMOTING OPPORTUNITY
THAT MAKES POSSIBLE TRANSFORMATION AND RENEWAL
“OPTIMAL STRESS”
17

18. MORE SPECIFICALLY
THE GOLDILOCKS PRINCIPLE
TOO MUCH CHALLENGE WILL BE
TOO OVERWHELMING FOR THE PATIENT
TO PROCESS AND INTEGRATE
TRAUMATIC STRESS
TOO LITTLE CHALLENGE, HOWEVER, WILL
PROVIDE TOO LITTLE IMPETUS
FOR TRANSFORMATION AND GROWTH
BECAUSE THERE WILL BE NOTHING
THAT NEEDS TO BE MASTERED
18

19. THE GOLDILOCKS PRINCIPLE
BUT JUST THE RIGHT
AMOUNT OF CHALLENGE
– JUST THE RIGHT AMOUNT OF STRESS –
HANS SELYE’S EUSTRESS (1974)
AND MY “OPTIMAL STRESS”
WILL OFFER JUST THE RIGHT MIX
OF CHALLENGE AND SUPPORT
NEEDED TO OPTIMIZE
THE POTENTIAL FOR
DEEP CHARACTEROLOGICAL CHANGE
19

20. IN ORDER TO GET IT JUST RIGHT
THE THERAPIST MUST THEREFORE
ALWAYS KEEP HER FINGER ON THE
PULSE OF THE PATIENT’S ANXIETY AND
CAPACITY TO TOLERATE FURTHER STRESS
CHALLENGING WHENEVER POSSIBLE
WHICH WILL INCREASE THE PATIENT’S ANXIETY
AND SUPPORTING WHENEVER NECESSARY
WHICH WILL DECREASE THE PATIENT’S ANXIETY
ALL WITH AN EYE
TO GENERATING
AN OPTIMAL LEVEL
OF “INCENTIVIZING ANXIETY”
AND “DESTABILIZING STRESS”
20

21. IT TOOK ME YEARS TO APPRECIATE SOMETHING THAT
IS AT ONCE BOTH OBVIOUS AND QUITE PROFOUND
NAMELY, IT WILL BE
INPUT FROM THE OUTSIDE
AND THE PATIENT’S CAPACITY TO
PROCESS, INTEGRATE, AND ADAPT
TO THE IMPACT OF THIS INPUT
THAT WILL ULTIMATELY ENABLE
THE PATIENT TO GET BETTER
21

22. BUT EVEN MORE IMPORTANTLY
IT WILL BE “OPTIMALLY STRESSFUL”
INPUT FROM THE OUTSIDE
AND THE PATIENT’S CAPACITY TO
PROCESS, INTEGRATE, AND ADAPT
TO THE IMPACT OF THIS “STRESS”
THAT WILL ULTIMATELY TRIGGER
THE PATIENT’S RECOVERY …
22

23. … BY TAPPING INTO
THE PATIENT’S
UNDERLYING RESILIENCE,
INNATE STRIVING
TOWARDS HEALTH,
AND INTRINSIC CAPACITY
TO SELF – CORRECT
IN THE FACE OF
OPTIMAL CHALLENGE
23

24. WITH RESPECT THEREFORE TO THE THERAPEUTIC ACTION
IT IS NOT SO MUCH GRATIFICATION AS
FRUSTRATION AGAINST A BACKDROP OF GRATIFICATION
OPTIMAL FRUSTRATION
IT IS NOT SO MUCH EMPATHY AS
EMPATHIC FAILURE AGAINST A BACKDROP OF EMPATHY
OPTIMAL DISILLUSIONMENT
IT IS NOT SO MUCH SUPPORT AS
CHALLENGE AGAINST A BACKDROP OF SUPPORT
OPTIMAL STRESS
THAT WILL PROVIDE THE THERAPEUTIC
LEVERAGE NEEDED TO INCENTIVIZE
AFTER INITIAL DESTABILIZATION
EVENTUAL RESTABILIZATION
AT A HIGHER LEVEL OF RESILIENCE,
ADAPTIVE CAPACITY, AND MENTAL HEALTH 24

25. AGAIN
BECAUSE “SELF – ORGANIZING
(CHAOTIC) SYSTEMS
RESIST PERTURBATION”
THE PSYCHOTHERAPEUTIC INTERVENTIONS
THAT WE OFFER OUR PATIENTS MUST
ULTIMATELY PROVIDE ENOUGH “STRESS”
THAT THERE WILL BE
BOTH “IMPETUS” FOR “DESTABILIZATION”
OF DEFENSE
AND “OPPORTUNITY” FOR ITS “RESTABILIZATION”
AT A HIGHER LEVEL OF
ADAPTABILITY AND FUNCTIONALITY
25

26. IN ESSENCE
JUDICIOUS AND ONGOING USE OF OPTIMALLY
STRESSFUL INTERVENTIONS WILL GENERATE
HEALING CYCLES OF DISRUPTION AND REPAIR
ULTIMATELY EVOLVING THE PATIENT
FROM RIGID DEFENSE TO MORE FLEXIBLE ADAPTATION
MODEL 1 – FROM RESISTANCE TO AWARENESS
MODEL 2 – FROM RELENTLESS HOPE TO ACCEPTANCE
MODEL 3 – FROM RE – ENACTMENT TO ACCOUNTABILITY
MODEL 4 – FROM RELATIONAL ABSENCE TO AUTHENTIC PRESENCE
NOT IN SPITE OF THE STRESS BUT
BY WORKING THROUGH THE STRESS
IN OTHER WORDS
BY PROCESSING, INTEGRATING, AND ADAPTING TO
THE IMPACT OF THE “OPTIMAL STRESS”
26

27. MY PSYCHODYNAMIC SYNERGY PARADIGM FEATURES FIVE MODELS
THE FIRST OF WHICH IS MODEL 1
WHICH IS MY VERSION OF THE STRUCTURAL CONFLICT
– OR DRIVE – DEFENSE –
MODEL OF CLASSICAL PSYCHOANALYSIS
OPTIMALLY STRESSFUL “CONFLICT STATEMENTS”
ARE AT THE HEART OF MY MODEL 1
THEIR FORMAT
“YOU KNOW THAT … , BUT YOU FIND YOURSELF … ”
FIRST THE THERAPIST CHALLENGES
BY SPEAKING TO A PAINFUL REALITY THAT THE PATIENT
REALLY DOES KNOW – BUT WOULD RATHER NOT
– A PAINFUL TRUTH THAT THE PATIENT
WILL ULTIMATELY NEED TO CONFRONT –
THEN THE THERAPIST SUPPORTS
BY RESONATING EMPATHICALLY WITH WHAT THE PATIENT,
MADE ANXIOUS, FINDS HERSELF THINKING, FEELING, OR DOING
IN ORDER NOT TO HAVE TO CONFRONT THAT PAINFUL TRUTH 27

28. MODEL 1 CONFLICT STATEMENTS
“YOU KNOW THAT … , BUT YOU FIND YOURSELF … ”
“YOU KNOW THAT EVENTUALLY YOU’LL NEED TO FACE THE REALITY
THAT YOUR FATHER WAS NEVER REALLY THERE FOR YOU
AND THAT YOU WON’T GET BETTER UNTIL
YOU LET GO OF YOUR HOPE THAT MAYBE SOMEDAY
YOU’LL BE ABLE TO MAKE HIM CHANGE;
BUT YOU’RE NOT QUITE YET READY TO DEAL WITH ALL THAT
RIGHT NOW BECAUSE YOU’RE AFRAID THAT WERE YOU
TO FACE THAT DEVASTATING REALITY YOU MIGHT NEVER SURVIVE
THE HEARTBREAK AND DESPAIR YOU WOULD THEN FEEL.”
“YOU KNOW THAT IF YOU’RE EVER TO GET ON WITH YOUR LIFE,
YOU’LL HAVE TO LET GO OF YOUR CONVICTION
THAT YOUR CHILDHOOD SCARRED YOU FOREVER;
BUT IT’S HARD NOT TO FEEL LIKE DAMAGED GOODS
WHEN YOU GREW UP IN A HORRIBLY ABUSIVE HOUSEHOLD
WITH A MEAN AND NASTY MOTHER
WHO WAS ALWAYS CALLING YOU A LOSER.”
28

29. MORE SPECIFICALLY
WHEN THE THERAPIST INTRODUCES A CONFLICT STATEMENT WITH
“YOU KNOW THAT … ”
SHE IS INDIRECTLY INSISTING THAT THE PATIENT TAKE
RESPONSIBILITY FOR WHAT THE PATIENT REALLY DOES KNOW
IF INSTEAD THE THERAPIST
– IN A MISGUIDED ATTEMPT TO URGE THE PATIENT FORWARD –
RESORTS SIMPLY TO TELLING THE PATIENT
WHAT THE THERAPIST THINKS
THEN NOT ONLY DOES THE THERAPIST RUN
THE RISK OF DRIVING THE PATIENT
TO BECOME EVER – MORE ENTRENCHED
IN HER DEFENSIVE STANCE OF PROTEST
BUT THE THERAPIST ALSO WILL BE
ROBBING THE PATIENT OF ANY INCENTIVE
TO TAKE RESPONSIBILITY
FOR HER OWN DESIRE TO GET BETTER 29

30. FURTHERMORE
BY LOCATING THE CONFLICT
SQUARELY WITHIN THE PATIENT
AND NOT IN THE INTERSUBJECTIVE FIELD
BETWEEN PATIENT AND THERAPIST,
CONFLICT STATEMENTS AVERT
THE POTENTIAL FOR A POWER STRUGGLE
BETWEEN THE TWO OF THEM
BECAUSE THE STATEMENTS FORCE
THE PATIENT TO TAKE OWNERSHIP
OF BOTH SIDES OF HER AMBIVALENCE
ABOUT GETTING BETTER
BOTH THE GROWTH – PROMOTING BUT
ANXIETY – PROVOKING FORCES PRESSING “YES!”
AND THE GROWTH – DISRUPTING BUT
ANXIETY – ASSUAGING COUNTERFORCES PROTESTING “NO!”
30

31. “YOU’RE COMING TO UNDERSTAND
THAT YOUR ANGER CAN PUT PEOPLE OFF;
BUT YOU TELL YOURSELF THAT YOU’VE GOT A RIGHT
TO BE AS ANGRY AS YOU WANT BECAUSE OF HOW MUCH
YOU’VE HAD TO SUFFER OVER THE COURSE OF THE YEARS.”
“YOU KNOW THAT SOMEDAY YOU’LL HAVE TO LET SOMEBODY IN
IF YOU’RE EVER TO HAVE A MEANINGFUL RELATIONSHIP;
BUT, IN THE MOMENT, THE THOUGHT OF MAKING YOURSELF
THAT VULNERABLE IS SIMPLY OUT OF THE QUESTION.
THERE’S ABSOLUTELY NO WAY YOU’RE WILLING TO RUN
THE RISK OF HAVING YOUR HEART BROKEN EVER AGAIN.”
“YOU KNOW THAT YOU WON’T FEEL TRULY FULFILLED UNTIL YOU’RE
ABLE TO GET YOUR THESIS DONE; BUT YOU CONTINUE TO STRUGGLE,
FEARING THAT WHATEVER YOU MIGHT WRITE JUST WOULDN’T
BE GOOD ENOUGH OR CAPTURE WELL ENOUGH
THE ESSENCE OF WHAT YOU WANT TO BE CONVEYING.”
“YOU KNOW THAT IF YOUR RELATIONSHP WITH ELANA IS TO SURVIVE,
YOU’LL NEED TO TAKE AT LEAST SOME RESPONSIBILITY FOR THE
PART YOU’RE PLAYING IN THE INCREDIBLY ABUSIVE FIGHTS THAT YOU
AND SHE ARE HAVING; BUT YOU TELL YOURSELF THAT IT ISN’T
REALLY YOUR FAULT BECAUSE IF SHE WEREN’T SO PROVOCATIVE,
THEN YOU WOULDN’T HAVE TO GET SO VINDICTIVE!” 31

32. PLEASE NOTE THE IMPLICIT MESSAGE DELIVERED
IN THE SECOND PART OF A CONFLICT STATEMENT
WHEN TEMPORAL EXPRESSIONS ARE USED
“FOR NOW” – “RIGHT NOW”
“AT THE MOMENT” – “IN THE MOMENT”
“AT THIS POINT IN TIME”
WHICH THE THERAPIST WILL OFFER WHEN SHE IS
ADDRESSING THE PATIENT’S INVESTMENT IN THE DEFENSE
“YOU KNOW YOU’RE PAYING A STEEP PRICE FOR YOUR REFUSAL TO STOP
SMOKING, OF PARTICULAR CONCERN BECAUSE OF YOUR RECURRING LUNG
INFECTIONS; BUT, IN THE MOMENT, YOU FIND YOURSELF FEELING THAT
YOU SIMPLY MUST HAVE THE CIGARETTES IN ORDER TO RELIEVE THE
MASSIVE ANXIETY YOU’RE FEELING BECAUSE OF THE IMPENDING LAWSUIT.”
THE THERAPIST IS ATTEMPTING TO HIGHLIGHT THE FACT
THAT EVEN IF, FOR NOW, THE PATIENT WOULD SEEM
TO BE INVESTED IN MAINTAINING
THE DYSFUNCTIONAL STATUS QUO OF THINGS,
AT ANOTHER POINT IN TIME THAT MIGHT CHANGE
32

33. IN ESSENCE
MODEL 1 CONFLICT STATEMENTS
ENCOURAGE THE PATIENT TO STEP BACK
FROM THE IMMEDIACY OF THE MOMENT IN ORDER
TO FOCUS HER ATTENTION ON THE UNDERLYING
FORCES AND COUNTERFORCES WITHIN HER
THAT ARE CREATING CONFLICT FOR HER
AND IMPEDING HER FORWARD MOMENTUM
THEY ARE DESIGNED TO TEASE OUT AND ARTICULATE
– ON THE PATIENT’S BEHALF –
THE INTERNAL CONFLICT THAT THE THERAPIST
SENSES THE PATIENT IS HAVING BETWEEN
WHAT THE PATIENT REALLY DOES KNOW
AND WHAT THE PATIENT IS DOING IN ORDER
TO AVOID HAVING TO CONFRONT IT
33

34. IN SUM
MODEL 1 CONFLICT STATEMENTS
STRIVE TO CREATE INCENTIVIZING TENSION
WITHIN THE PATIENT BETWEEN HER DAWNING AWARENESS
OF JUST HOW COSTLY HER DEFENSES HAVE BECOME
– WITH AN EYE TO MAKING THEM MORE EGO – DYSTONIC –
AND HER NEW – FOUND UNDERSTANDING OF JUST HOW
INVESTED SHE HAS BEEN IN HOLDING ON TO THEM EVEN SO
– WITH AN EYE TO HIGHLIGHTING HOW EGO – SYNTONIC THEY HAVE BEEN –
ULTIMATELY
THE DISEQUILIBRIUM AND
EVER – INCREASING INTERNAL DISSONANCE
– BOTH COGNITIVE AND AFFECTIVE –
RESULTING FROM THE PATIENT’S
EVER – EVOLVING AWARENESS
OF BOTH THE COST AND THE BENEFIT
OF MAINTAINING THE DEFENSE
WILL FORCE HER TO RELINQUISH IT
THEREBY RESTORING HER HOMEOSTATIC BALANCE
AND INTERNAL HARMONY 34

35. THE SANDPILE MODEL
OF CHAOS THEORY
AND THE PARADOXICAL
IMPACT OF STRESS
35

36. THE “SANDPILE MODEL OF CHAOS THEORY”
SPEAKS TO THE CUMULATIVE IMPACT
– OVER TIME –
OF ENVIRONMENTAL STRESSORS
ON OPEN SYSTEMS
MORE SPECIFICALLY
THIS SIMULATION MODEL PROVIDES
AN ELEGANT VISUAL METAPHOR
FOR HOW ALL OF US
– BY CONTINUOUSLY ADAPTING TO OPTIMALLY STRESSFUL INPUT –
ARE CONSTANTLY ABLE
TO REFASHION OURSELVES
AT EVER – HIGHER LEVELS OF
COMPLEXITY AND DYNAMIC BALANCE …
36

37. … NOT JUST
“IN SPITE OF”
STRESSFUL INPUT
FROM THE OUTSIDE
BUT
“BY WAY OF”
THAT INPUT 
37

38. AMAZINGLY ENOUGH
THE GRAINS OF SAND BEING STEADILY ADDED
TO A GRADUALLY EVOLVING SANDPILE
ARE THE OCCASION FOR BOTH
ITS DISRUPTION AND ITS REPAIR
NOT ONLY DO THE GRAINS OF SAND BEING ADDED
PRECIPITATE PARTIAL COLLAPSE OF THE SANDPILE
BUT THEY ALSO BECOME THE MEANS BY WHICH
THE SANDPILE WILL THEN BE ABLE
TO BUILD ITSELF BACK UP –
EACH TIME AT A NEW LEVEL OF HOMEOSTASIS
THE SYSTEM WILL THEREFORE HAVE BEEN ABLE
NOT ONLY TO “MANAGE” THE IMPACT
OF THE STRESSFUL INPUT
BUT ALSO TO “BENEFIT FROM” THAT IMPACT
38

39. AS IS TRUE FOR ALL SUCH
SELF – ORGANIZING (CHAOTIC) SYSTEMS
– OVER TIME –
AN UNDERLYING ROBUST PATTERN WILL BEGIN
TO EMERGE AS THE SANDPILE EVOLVES
A PATTERN
CHARACTERIZED BY
ITERATIVE CYCLES OF
DEFENSIVE DESTABILIZATION
FOLLOWED BY
ADAPTIVE RESTABILIZATION
AT EVER – HIGHER LEVELS
OF COMPLEXITY
AND DYNAMIC BALANCE
39

40. SO, TOO, OUR PATIENTS
– OVER TIME –
WILL BE ABLE TO EVOLVE FROM
RIGID DEFENSE TO FLEXIBLE ADAPTATION
IF WE BUT HAVE THE COURAGE TO OFFER THEM
OPTIMALLY STRESSFUL INTERVENTIONS
THAT WILL PROVIDE BOTH “IMPETUS” AND “OPPORTUNITY”
FOR THEM TO ADVANCE THROUGH HEALING CYCLES
OF DISRUPTION
– A REACTION TO OUR CHALLENGE –
AND REPAIR
– A RESPONSE TO OUR SUPPORT
AND BY TAPPING INTO THEIR INNATE ABILITY
TO SELF – CORRECT IN THE FACE OF OPTIMAL CHALLENGE –
SUCH THAT THEY NEED NO LONGER DEFENSIVELY
CURSE THE DARKNESS BECAUSE NOW THEY HAVE
THE ADAPTIVE CAPACITY TO LIGHT A CANDLE 
40

41. OPTIMAL STRESS
STRONGER AT THE BROKEN PLACES
IS THERE NOT A CERTAIN BEAUTY IN BROKENNESS,
A BEAUTY NEVER ACHIEVED BY THINGS UNBROKEN?
IF A BONE IS FRACTURED AND THEN HEALS,
THE AREA OF THE BREAK WILL BE STRONGER
THAN THE SURROUNDING BONE
AND WILL NOT AGAIN EASILY FRACTURE
ARE WE, TOO, NOT STRONGER AT OUR BROKEN PLACES?
AND IS THERE NOT A CERTAIN BEAUTY IN BROKENNESS,
A QUIET STRENGTH WE ACQUIRE
FROM SURVIVING ADVERSITY AND HARDSHIP
AND MASTERING THE EXPERIENCE OF
DISAPPOINTMENT, HEARTBREAK, AND DEVASTATION?
AND, THEN, WHEN WE FINALLY RISE ABOVE IT,
DON’T WE RISE UP IN QUIET TRIUMPH,
EVEN IF ONLY WE NOTICE … 41

42. 42

43. 43

44. 44

45. 45
THANK YOU!
STUART AND HIS BROTHER STEWART

46. IF YOU WOULD LIKE
COPIES OF THESE SLIDES,
HAVE ANY QUESTIONS,
OR WOULD LIKE TO BE
ON MY MAILING LIST,
PLEASE EMAIL ME AT
MarthaStarkMD @
HMS.Harvard.edu
46

47. REFERENCES
Bak, P. 1999. How nature works: The science of self-organized
criticality. Gottingen, Germany: Copernicus Publications.
Blumenthal, J. A., et al. Effects of exercise training on older patients with
major depression. Arch Intern Med 1999;159(19):2349-2356.
Krebs, C. 1998. A revolutionary way of thinking: From a near fatal accident
to a new science of healing. Melbourne, Australia: Hill of Content.
Leibenluft, E., and T. A. Wehr. Is sleep deprivation useful in the treatment
of depression? Am J Psychiatry 1992;149(2):159-168.
Nelson, P. 2012. There’s a hole in my sidewalk: The romance of
self-discovery. New York: Atria Books.
Selye, H. 1974. Stress without distress. New York: Harper & Row.
Stark, M. Hormesis, adaptation, and the sandpile model. Crit Rev
Toxicol 2008;38(7):641-644.
Stark, M. The sandpile model: Optimal stress and hormesis. Dose
Response 2012;10(1):66-74.
Zevon, W. 1996. I’ll sleep when I’m dead. Burbank, CA: Elektra Records. 47