Monthly Archives: December 2012

Working with Projection

What do we mean by projection? Projection occurs when we attribute to someone else a feeling, thought, or impulse that belongs to ourselves or someone else. Although projection is often thought of as a “primitive” defense, that is not always true. In fact, everybody uses projection at one time or another. Remember a few years ago when President George W. Bush referred to the “Axis of Evil”? He was projecting onto several countries. It happens all the time. So let’s take a look at some of the most common forms of projection and how to deal with them.

Highly resistant patients often use projection as a tactical defense, that is, as a tactic to keep you at a distance. For instance, you ask the patient what problem he would like you to help him with. The patient responds, “You should ask my wife. She’s the one who thinks I have a problem.” This is a projection. Don’t forget: the patient came to your office. His wife did not carry him in on her shoulders. But he projects his awareness of a problem onto his wife. His anxiety is in striated muscles and he has no loss of reality testing. He sits in your office looking cool and collected, detached and uninvolved. Thus, he uses projection as a tactic to keep you at a distance.

Since the patient has not yet declared a problem for therapy, you don’t have the right to interpret his projection. Instead, you must block his projection and return to the focus: the internal problem for which he seeks therapy. “Well, since you wife is not here, I can’t help her. So what is the problem you would like me to help you with?”

When anxiety is in the striated muscles, the patient’s reality testing is good, and the patient’s defenses are tactical and repressive, the projection is merely a tactical defense. You block it and return to the focus.

In contrast, projection can also function as a regressive defense. What do we mean by regressive? It means that the patient’s reality testing regresses. For instance, the patient becomes unable to differentiate the reality of you from his projection.

For instance, a fragile patient enters the office and begins the session with racing speech, looking at you in a frightened manner. Naturally, seeing the sharp rise in anxiety, you quickly intervene to help the patient see and regulate his anxiety. As you assess his anxiety, you discover it is discharged into symptoms of cognitive/perceptual disruption (parasympathetic activation). But you find that it is very hard to regulate the patient’s anxiety. Then the patient says he is afraid you are judging him. Now you see the problem: he is projecting his superego onto you. Unable to differentiate you from his projection, he fears you as a judge. Naturally, if he believes you are a judge, he cannot trust you to regulate his anxiety. Thus, you have to restructure his projection, so he can have a therapeutic alliance with you rather than a misalliance with his projection.

To do this you might say: “This is really important what you are saying. So let’s check this out carefully. Is there any evidence that I am judging you?” Encourage the patient to look at your face to find out if there is any evidence in what you have said or in your face that you are judging him. As he takes in the evidence of your face and contrasts it with his projection, he will eventually see you, the projection will drop, and then his fear of the projection will drop too.

Keep in mind that feeling triggers anxiety which triggers the defense of projection. The problem is that projection only makes his anxiety worse because now he is afraid not only of his feeling; he is afraid of you too! So you must restructure the projection to get rid of the projective anxiety: anxiety that results from a projection. Then you can resume anxiety regulation.

Another common form of projection is projection of the will. The fragile patient says, “I’m just afraid of the questions you are going to ask.” And she looks at you with a frightened face. In this case, the patient, with rising anxiety, forgets that it is her will to ask questions and learn about her inner life. Instead, she projects that you want to get into her inner life. As a result, she will fear you as a persecutor whom she must avoid.

To deactivate this projection, remind the patient of what she has projected. “Was it your will to come here today?” “Was it your will to overcome this problem?” “And do you want to know what is going on underneath so you have better information about yourself?” “And do you want better information about yourself so you can make better decisions?” Each time you ask a question and the patient answers “yes”, she takes in part of her projection, bit by bit. Once she has taken the projection entirely back, she will relax because she no longer fears the projection on you.

So let’s take a minute to review. If projection is a regressive defense, the patient’s anxiety will be in cognitive/perceptual disruption. Her other defenses will be regressive such as externalization, splitting, and dissociation. And, having lost her reality testing, she will equate you with the projection and become afraid of you. In this case, you must restructure her defense to re-establish reality testing.

When projection is a tactical defense, the patent’s anxiety will be in the striated muscles. Her other defenses will be tactical and repressive. And her reality testing will be fine. In this case, we just block the projection and return to our focus.

Sometimes projection occurs in a gentle way with fairly healthy patients. For instance, the patient who reports a misdeed, then says, “You might not think that was a good idea.” In response, you could say, “Is that me or your conscience talking?” Why can we respond differently in this case? Notice that the patient said, “You might not think…” That might tells us that the patient realizes this is just her thought about you and it might not be true. In other words, she can tell the difference between you and her projection. Her reality testing is good. Thus, you can directly offer the projection back to her for her consideration. With the fragile patient, however, we often have to re-establish reality testing.

In my forthcoming book, Co-Creating Change, you’ll find lots of material on projection. But you don’t have to wait so long. A new DVD on projection is available on our website. It features a two-hour session where you’ll see me working with several different projections in several different ways. It comes with a teaching video on working on projections. And it contains a cd with the complete transcript analyzed in depth.

And, in case you haven’t bought it yet, the DVD of the fragile patient also involves some restructuring of projection. Be sure to check that out if you want to see another way of working with projection.

Exploring Feelings Toward the Therapist

When do we explore feelings toward the therapist? For most of us who were initially trained in other models of therapy, it can be a bit scary to ask patients about their feelings toward us. We are comfortable asking patients about feelings they have toward people in their current relationships or toward their parents. But when it comes to asking about feelings toward the therapist? Gulp. Ahem. Cough. Cough. It’s hard at first.

Of course, some of this has to do with our anxiety about facing such feelings. And this can be dealt with in our own therapy and supervision. However, it is useful to have some guidelines to know when and how to ask about feelings toward you. So we’ll look at the two most common cues that tell you to ask about feelings toward the therapist.

The first cue is when anxiety is in the forefront and it is discharged in the striated muscles. For instance, suppose the patient comes in, sits down, sighs heavily, crosses her arms and legs, and wiggles her foot. You haven’t done anything. You just invited the patient in the room and sat in your chair. Yet the patient has a rise of feelings and anxiety. Why?

If we take the analogy of the abused dog in a dog pound, if you approach it or I approach it, the same thing happens. The dog either barks or withdraws. Having been abused by one human, it feels anger and fear regarding all humans. We could call them dog ‘transference feelings.’ Likewise, the patient who has been hurt in previous relationships feels those same feelings when she approaches another human being. See the youtube video The Child of Rage to see the tragic consequences of these transference feelings in an abused child and how she acts out those feelings toward others.

Thus, when the patient presents with this anxiety in the striated muscles, this is a cue that she is having feelings toward you. In response, you can say, “You seem anxious. Do you notice that too? So some anxiety comes up as you come here to see me. So can we take a look at what feelings are coming up here toward me that are making you anxious?” Since the patient is having feelings, we want to offer a pathway for those feelings. Ideally, we can help her feel those feelings, so she won’t have to feel anxious instead.

Another important cue to ask about feelings toward you is when you notice the patient resisting contact with you. For instance, suppose you are exploring feelings the patient has toward her husband. Initially, she describes her anger, but as you ask about how she experiences her anger, she intellectualizes and rationalizes. But as you continue to point out her repressive defenses, something very interesting occurs. You will notice that she stops looking at you and starts looking out the window or at the floor. She starts to hesitate when you explore feelings. She withdraws. She becomes vague and hard to reach. Gradually, you realize that she is not avoiding feeling so much. She is avoiding you!

When this happens, it is fruitless to keep exploring feeling. The issue is no longer her avoidance of feeling, but her avoidance of genuine contact with you. So you need to shift your focus from her defenses against feeling to her resistance to emotional closeness with you. To do this, point out the defenses by which she distances from you.

“Do you notice how you are becoming vague?” “Do you notice how you look at the floor now?” “Do you notice how you go up in your head?” Having drawn her attention to these tactical defenses (tactics to avoid contact with you), you can point out the pattern. “Do you notice how you are avoiding my eyes?” “Do you notice how there is a barrier coming up here between us?” Having drawn her attention to the “wall”, you can ask, “I wonder what the feeling is here toward me that is making you pull back?” Then keep that focus on the feelings toward you and keep addressing the defenses against emotional closeness.

Sometimes therapists ask, “Is that the only thing you do? Ask about feelings toward the therapist?” No, of course not. There is no one intervention that we do “all the time.” To do any intervention all the time would not be therapy but an obsessive-compulsive disorder on the loose 😉 The only thing we do all the time is monitor the patient’s response to intervention. If exploring a feeling in a past or current relationship mobilizes unconscious anxiety and defense, we know we are in the right place. If exploring the patient’s feelings toward us mobilizes unconscious anxiety and defense, we explore there. Thus, no intervention or formula is our guide. Instead, the patient’s unconscious anxiety and defense always let us know where the unconscious feelings are. And that’s where we go.