Monthly Archives: September 2013

Why does my patient shut down?

A patient is disturbed to see herself on videotape expressing feelings and fantasies that she is “normally” ashamed of. When she experiences anger towards her abusive and neglectful parents she shuts down and becomes disconnected and “cold”. She does not preserve the emotional openness and warm feelings toward me as therapist between sessions. Is this dissociation or a negative therapeutic reaction? What is the ISTDP perspective on these issues? Thanks to Jonatan for this important question!

No matter how good a job we do exploring feelings, if we don’t identify and clarify the defenses sufficiently, they will undo our work during and after the session. No matter how beautiful an essay your student writes upon the blackboard, if she erases it after class, there is nothing to show for all of your work. So let’s take a look at some of the defenses at work that would prevent a patient from having the progress she yearns for.

When the patient views the videotape at home, she does not have Jonatan there to observe her defenses, block them, point them out, and help the patient get free of them. Instead, without Jonatan, she judges herself and her feelings. This is a way to turn rage upon herself. And it is also probably a character defense: she verbally criticizes and abuses herself for her feelings as her abusive parents may have done to her.

Th: “Do you notice how you judge yourself and your feelings? Could that be a way you reject yourself? Could that be a form of verbal abuse to yourself?” [identifying character defenses]

When she feels anger toward her parents, she shuts down herself and her anger. Again, we see a character defense: she rejects and dismisses her anger, shutting herself down.

Th: “Do you notice how you shut down yourself and your anger? Could this be a way you reject yourself and your feelings? Could this be a form of self neglect?” [identifying a character defense]

When she feels anger toward her parents, she disconnects from Jonatan and from herself and her anger.

Th: “Do you notice how you disconnect from yourself and your anger? Could this be a way you reject yourself and your feelings? Could this be a cruel way to treat yourself…to disconnect from yourself and reject yourself?” [identify the character defense of self-rejection and clarify its price: the cruelty to self.]

When she feels anger toward her parents, she goes “cold.” This is another character defense: rejecting herself and her feeling.

Th: “Do you notice how you freeze your anger now? Do you notice how you reject your anger, freeze it, and become a cold, dead woman instead?” [identify the character defense and clarify the price]

You could also approach this last defense as a transference resistance: inviting the therapist to have a cold, dead relationship with a cold, dead woman.

Th: “Do you notice how you freeze your anger now? Do you notice how you put on this façade of ice to cover your anger? See, as long as you do that, we’ll just have a dead, frozen relationship with you as a dead, frozen woman. And your loneliness will continue. What can we do about this façade of deadness you put up here with me?” [identify the transference resistance, clarify its price, and invite the patient to let go of this destructive mode of relatedness.]

Jonatan points out that the patient does not hold onto the warm feelings of a previous session. This is not simply a defense; it’s a type of relationship. “I know we were close last time, but now that’s over and I am going to reject you today and detach from any emotional connection with you. Meanwhile, I expect you to heal my while I remain emotionally uninvolved with you.” This is the transference resistance.

In other words, she does to Jonatan what her neglectful parents did to her. She neglects him as if to say, “See what it is like to be neglected and abandoned? See what it is like to feel what I had to feel? See what it is like to try to form a relationship with someone who refuses to hold onto a connection with you? Now you know what my history was like!” As Freud pointed out, the patient enacts the past relationship with you so you can feel the feelings so she doesn’t have to. In other words, by acting like the neglectful parent, she can avoid having feelings toward the neglectful parent.

Th: “Do you notice how you say you have no warm feelings here toward me? It’s as if you wiped away the feelings from last time and we are supposed to start all over again. Do you notice how this barrier of detaching and uninvolvement is coming up here between you and me? As long as you maintain this barrier of non-involvement here with me, I’ll be on one side of the wall and you will be on the other. And then I’ll be just another useless man in your life, unable to help you. What can we do about this destructive wall you are putting up here between you and me?”

In my book, Co-Creating Change, http://www.istdpinstitute.com/co-creating-change you will find a chapter on superego pathology. There you will see the theory that will help you understand this patient more deeply.

In her character defenses she neglects and abuses herself the way her parents did to her. In the transference resistance, she neglects Jonatan the way her parents did to her. When she presents with character defenses, point out how she treats herself. When she enacts the transference resistance, Jonatan must address the way she wards off contact with him.

Given the defenses she uses in these examples, I doubt she dissociates because her anxiety does not appear to be in cognitive/perceptual disruption. Her use of a transference resistance that we see here suggests she is a highly resistant patient, not a fragile one. But only viewing a videotape would let us know for sure.

The negative therapeutic reaction refers to the patient’s tendency to punish herself for any positive movement in order to satisfy an unconscious desire for punishment. While we could certainly view this as a negative therapeutic reaction, that doesn’t tell us much. Much more important is the moment to moment assessment of each character defense the patient uses to avoid feeling and transference resistance she uses to avoid feelings and contact with the therapist.

Since Jonatan successfully made emotional contact with the patient in the previous session, the patient rejects him emotionally. She enacts the past relationship to avoid the feelings that arose in that relationship. Thus, Jonatan must address the ways the patient rejects contact with him. As that defensive enactment weakens, the patient’s unconscious feelings will rise again.

Why does she shut down? To keep Jonatan at a distance from her feelings……toward him!! “How dare you get close to my inner life! Don’t you realize how much people close to me have hurt me? I am going to reject you before you can reject me and hurt me!! Otherwise, you will discover how much rage I feel toward you (as the representative of all the people who hurt me before!).”

 

“I don’t see what you are talking about!” Mobilizing Self-Observing Capacity

How do we strengthen a patient’s self-observing capacities? Another great question from our master question asker, Johannes! Thank you!!

Ever since Freud brought up the idea of the observing ego in 1923, through the focus on observation in behavior and cognitive therapies, on up to the present day emphasis on mindfulness, therapists have recognized the central role of observation and attention. After all, if a patient doesn’t observe his bodily sensations, he won’t know what he feels. If he can’t pay attention to his anxiety, he can’t regulate it. If he can’t see a defense, he can’t do anything about it. If he doesn’t see how a defense hurts him, he may think his defense helps him. If he cannot see the difference between himself as a person and a defense he uses, he will think you are attacking him as a person rather than describing his defense. Thus, mobilizing self-observing capacity is central to every psychotherapy effort.

Techniques to do this are well known in every model of therapy. In ISTDP we will use any technique that will help mobilize the patient’s self-observing capacity, however, we tend to mobilize these capacities in a particular sequence. This idea of a sequence of capacities to be mobilized came from Josette ten Have de Labije.

Let’s start with self-observing capacities as they relate to anxiety. Can the patient observe that he anxious? If not, draw his attention to the bodily signals. “Notice your dizziness? That’s a sign of anxiety.” Can the patient pay attention to his anxiety so it can get regulated? If not, help him see the defense that prevents him from paying attention to his anxiety and mobilize his capacity to pay attention to his anxiety. “Do you notice how you are talking over and ignoring your anxiety right now? See, that will prevent us from regulating your anxiety and you will become sick. If you don’t talk over your anxiety, could you say where you notice feeling this anxiety right now physically in your body?”

Now that the patient can see and pay attention to his anxiety, can he see the triangle of conflict? If not, help him see the sequence in the session. “Do you notice that when you felt this anger here toward me, you became anxious, and then talked over your anger and anxiety so they could be hidden by words. Do you see that too?”

Now that the patient can see the triangle of conflict, can he see causality (how defenses cause his problems and symptoms)? If not, point out in session how defenses make the patient feel worse. “When you criticize yourself and turn the anger back onto you, could that be making you depressed right now?”

Now that the patient can see causality, can the patient see the difference between himself and the defense he uses? If not, help him differentiate himself from the defense. Otherwise, the patient will feel attacked by your defense work. The patient has just said, “Maybe I’m just a self-critical person.” “No. That’s not the way you are. Self-criticism is the way you deal with anger. Rather than feel it toward me, you protect me by turning the anger onto yourself. This self-criticism has as little to do with you as a vine has to do with the tree it is strangling. Could we pull this vine of self-criticism off of you so we could see who you really are underneath it?”

Now let’s take a look at self-observing capacities regarding defenses. Can the patient observe a defense? If not, point it out. The patient has just called himself an idiot. “Could that be a form of self-attack?” If the patient can observe the defense, can he pay attention to it and what you said, or does he shift rapidly away? If he cannot pay attention to his defense, he will just shift from one defense to another to another. “Before we go off to another topic, when you call yourself names, could that be a form of self-attack?” Block the defense against paying attention and redirect his attention to his defense. Once the patient can see his defense, can he see the triangle of conflict? If not, point it out. “Do you notice that when you felt angry with me, you became anxious, and then called yourself a name. Do you see how you turned the anger toward me back onto yourself?” If the patient can see the triangle of conflict, can he see causality? If not, point out how his defense causes his problems and symptoms. “When you turn this anger back onto yourself, could this be hurting you?”

So let’s recap:

Can the patient observe his feeling, anxiety, or defense?

Can the patient pay attention to his feeling, anxiety, or defense?

Can the patient see the triangle of conflict?

Can the patient see causality (defenses cause his problems)?

Can the patient see the difference between him and his defense?

Once you have mobilized these capacities for self-observation, most patients will let go of their defenses. And for those highly resistant patients who do not, it will now be safe to confront their defenses. Why? Because now the patient will realize you are confronting his defenses, not him as a person.

Key point: defenses prevent the patient from observing and paying attention to his inner life. Thus, to mobilize self-observing capacity, invite it, and then address the defenses that interfere with self-awareness. One problem often comes up. We can get so carried away with mobilizing self-observing capacity that we forget to keep inviting feeling, mobilizing the unconscious. Remember our twofold task: reduce resistance and mobilize the patient’s unconscious wish to become well.

 

In my book, Co-Creating Change, you’ll find an entire chapter devoted to mobilizing these self-observing capacities, an entire chapter devoted to mobilizing self-observing capacity regarding anxiety, and several chapters on how to mobilize self-observing capacity regarding defenses.