Monthly Archives: April 2013

Does projection always cause a loss of reality testing?

“Is cognitive/perceptual disruption always a projection? If we distort the other by devaluing, is that always projection, or can we demonize or idealize as defenses in their own rights? Or are they always a form of projection? What’s the surest way to know whether a patient is having cognitive/perceptual distortion and not fully in touch with reality?” Thanks to Johannes for this boatload of questions!!

The term cognitive/perceptual disruption refers to a level of anxiety, discharged in the parasympathetic nervous system, that results in problems with thinking, dizziness, blanking out, ringing in the ears, and blurry vision. If this level of anxiety continues to rise, the patient will begin to project and lose the ability to differentiate the therapist from her projection, thus losing her reality testing.

Anxiety is not the defense of projection. However, anxiety so high that it can disrupt brain functioning can lead the patient to lose reality testing when he projects.

Projection may be a tactical defense without any substantial loss of reality testing or it can be a regressive defense where there is a loss of reality testing. That’s why we need to assess the pathway of anxiety discharge, the type of defenses used, and reality testing to find out if projection is serving as a tactical or regressive defense. Projection as a tactical defense: anxiety in striated muscles’ repressive, tactical, and character defenses; no loss of reality testing. Projection as a regressive defense: anxiety in cognitive/perceptual disruption; regressive defenses; loss of reality testing. Now let’s shift to the defense of devaluation.

Devaluation may or may not involve projection. For instance, suppose a patient becomes aware of flaws in his girlfriend. He may focus on her flaws and ignore her good qualities, leading to devaluation. In this case, devaluation is based on denial. He denies any of her good qualities and is left with only her bad qualities, a devalued image of her. Conflict: rage toward the girlfriend; anxiety; denial and devaluation to avoid the complex mixed feelings toward her.

Let’s suppose this same patient longs for his girlfriend but despises himself for doing so. He projects his longings onto her and judges her as “needy”. Now he can despise her instead of his own neediness. In this case his devaluation of her is based on the denial of his own neediness and the projection of it onto her.

Now for the final question, how can we tell if the patient who projects is losing his reality testing? First of all, if the patient’s anxiety is discharged into the striated muscles and if his other defenses are repressive and tactical, his projection is functioning as a tactical defense and there is no problem with reality testing.

If the patient’s anxiety is discharged into cognitive perceptual disruption, and the other defenses are regressive, then you need to restructure the projection to regulate anxiety and re-establish reality testing.

How can we assess the reality testing? If the patient is projecting onto you and appears fidgety, anxious, and afraid, this anxiety is an indication that he is having trouble differentiating you from a projection. If the patient’s eye gaze is darting around, this can also be a signal that the patient is having trouble differentiating you from the projection. Or if he maintains a flat stare.

But the best way to assess is simply to ask the patient: “How are you perceiving me right now?” Once the patient reports a projection, assess his ability to differentiate you from it.

Th: “What is the evidence that I want to judge you?”

Healthy patient: “I know there isn’t.” [Good reality testing]

Less healthy patient: “I can’t think of any, but I feel that way. I sense it.” [Impaired reality testing: I regard my feelings as the same as reality.]

Least healthy patient: “I can see it in your eyes.” [Loss of reality testing. Positive hallucination.]

Therapist responses:

Pt one: “So what is the feeling toward me?”

Pt two: “So although there is a feeling that I’m judging you, there isn’t any evidence to support that feeling.” [Point out the difference between fantasy and reality.]

Pt three: “I’m not aware of judging you. Let yourself look in these eyes and let’s see what you see in my eyes as you look at them. Do you see judgment in my eyes?” [Experiential restructuring of the projection: Invite the patient to look at reality to see if it helps the patient differentiate your eyes from the ones he hallucinates.] Or, “So we see there is an image of judgmental eyes that comes in here between me and you. And when you see those judgmental eyes it becomes difficult to see mine. It must be very upsetting to you to have these judgmental eyes coming in here to interfere with the relationship you and I are trying to form.” [Cognitive restructuring of the projection.]

Of course, projection can take many forms resulting in loss of reality testing. But hopefully these examples give you a framework for thinking about how to help patients differentiate you from a projection when they lose their reality testing.

Take home point: if there is projection, assess reality testing. If it is fine, explore feelings. If it is impaired, restructure the projection to re-establish reality testing. Otherwise, the patient will have a misalliance with a projection rather than a therapeutic alliance with you. You may want to read the section on projection in Co-Creating Change: Effective Dynamic Therapy Techniques.