Monthly Archives: June 2013

Is it weepiness or sadness?

“A depressed patient starts to weep at the beginning of a therapy before I have even asked about her problem. It’s not triggered by a specific example or a question about feeling. It’s just constant weepiness from the start followed by “sorry but I’m a weepy person”. How would you intervene?” Thanks to Liv for this important question!

When a session begins with weepiness, it’s almost always a sign of anxiety. Draw the patient’s attention to her weepiness as a sign of anxiety, assess her anxiety, and regulate it if necessary. Then begin to ask about what feelings she has that the tears could be covering up.

Since the patient says she is a “weepy person”, we can feel comfortable assuming that this is a habitual response to anxiety triggered by her feelings. That’s why you assess her anxiety until it is regulated, and then explore the feelings that trigger her anxiety. In the course of this exploration, you will help her see the triangle of conflict: feelings, anxiety, and the defense of weepiness, washing her feelings away with tears.

At the same time, a patient may begin the therapy immediately crying due to grief. A patient walks into the office, begins to cry, and as she is crying we learn that her husband just died suddenly over the weekend.

How do we differentiate weepiness (a defense) from sadness (a feeling)? Weepiness, since it is a defense, will not trigger anxiety or defenses. The weepiness does not lead to relief or clarity. And the weepiness usually involves thoracic, rather than abdominal, breathing.

Sadness, a feeling, will trigger anxiety and defenses. The experience of sadness leads to relief and clarity. Sadness and crying usually involves abdominal breathing. Weepiness is accompanied by a chronic tension. Sadness, once it is released, leads to a drop in tension throughout the body. The shape of the experience is that weepiness is chronic, shaped like a line. The shape of the experience of grief is that of a wave. It rises and then falls, and the patient is calm again.

In this case, the fact that the patient becomes weepy as soon as she feels a rise of feeling shows that her affect tolerance is quite low. Since her weepiness is a regressive defense, it is important to restructure it immediately in the session to prevent the patient from regressing in therapy. The fact she says she is a “weepy person” suggests that she may ignore this as a problem and take it for granted. Thus, we may find that she uses character defenses of self-dismissal, and self- ignoring.

If you still aren’t sure, notice what the patient’s response to intervention is. If the crying in session leads to relief and clarity, she was feeling grief. If the crying in session leads to more depression and despair, she was feeling defensive weepiness. Now you will know not to explore her weepiness. Instead, you will treat it as a defense, help her let go of the defense, and then help her face the feelings underneath that her tears were washing away.

Take home point: restructure weepiness as soon as it occurs. Explore warded off sadness as deeply as possible.

Complaining

Projection of the superego. And why I love complainers.

“Does projection of the super-ego always go together with cognitive/perceptual disruption? Is it a kind of tactical defense? Is it a way to avoid facing how I mistreat myself?” Thanks to Peter for these important questions!

Everybody projects. (Welcome to my club: homo projectens!) Thus, projection exists on a continuum from the everyday garden variety projections we all do all the way down to the most primitive projections of psychotic patients.

So we have to differentiate when projections are functioning as tactical or regressive defenses. When projection occurs with anxiety in the striated muscles, the other defenses are repressive, and reality testing is intact, projection functions as a tactical defense, to keep you at a distance.

Th: “What is the problem you would like me to help you with?”

Pt: “You should ask my wife.”

This projection onto his wife is just a tactic to keep you at a distance.

In contrast, when projection functions as a regressive defense, the patient’s anxiety is in cognitive/perceptual disruption, his other defenses are regressive, and the patient’s reality testing is impaired. For instance, if he projects the superego onto you, he looks like he is afraid of you (or, more precisely, afraid of the projection he has placed upon you). His eyes will often dart around frantically, fearing your judgment. Perhaps his legs are jumpy too, wanting to run away from your supposed judgment.

When a patient uses projection of the superego as a tactical defense, block it and continue to ask about feeling toward you.

Th: “There is that barrier again. So what is the feeling here toward me?”

When a patient uses projection as a regressive defense, however, we must restructure the defense, improve the patient’s reality testing, bring anxiety back into the striated muscles, and then we can invite feelings toward the therapist again.

Th: “Is there any evidence that I am criticizing you?”

Very often, therapists try to restructure projection of the superego when the patient’s anxiety is in the striated muscles. This just slows down the process. Always assess: 1) pathway of anxiety discharge; 2) other defenses in operation; and 3) reality testing. Then you will know if the projection is a tactical or regressive defense.

Projection of the superego, indeed, can be a way to avoid facing how I mistreat myself. This is the basis of the defense of externalization. When angry, I hurt myself. But rather than face how I hurt myself, I blame others and claim that they hurt me and cause my symptoms.

Listen very carefully to complainers: they are helping you! I’ll say it again: love your complaining patients. Every complaint they make about another person is an x-ray into their character defenses.

Pt: “He is so insensitive to me. He doesn’t listen to me. He doesn’t respect me. He dismisses my feelings.”

Now for the x-ray into the patient’s character defenses:

1)     She is insensitive to herself.

2)     She doesn’t listen to herself and her feelings.

3)     She doesn’t respect herself and her feelings.

4)     She dismisses herself and her feelings.

Now you now know the defenses that create her presenting problems and symptoms. When you explore examples, you can show her how she doesn’t listen to her feelings in session. You can show her how she disrespects her feelings in session. You can show her how she dismisses herself in session. In this way, you be able to show her how she does to herself what she claims other people do to her.

Take home point: always assess the anxiety pathway, defense structure, and reality testing to differentiate projection as a tactical from a regressive defense. And….love those complaining patients. They are being incredibly collaborative…unconsciously!