“I have worked with many who ‘know’ their anger very well. They bring anger stories to the here and now almost every session, although they are not always conscious of feeling angry with me too. Not being aware of anger is not their problem (the ‘preoccupied attachment ‘ trait). So are you saying that in those cases ISTDP would regard the ‘forever raging patient’ as warding off other feelings with anger? I am a bit confused about how anger can be a feeling and a defence. How can a feeling be the expression of self and a defence at the same time?” Thanks for this important question!
Anger is a feeling, an expression of self. However, under certain conditions, a feeling can function as a defense to ward off another feeling. That’s why we always ask: what is the function of the patient’s statement? Does this patient statement function as a feeling, anxiety, or a defense? It is this issue of function to which we need to direct our attention.
Let’s suppose a patient is feeling grief over the loss of her husband. Then she suddenly shifts and says, “I hate the bastard. Look what he has done to me!” At this point we have to ask ourselves: does her anger at this moment help her to express her feelings of grief and sadness, or does this anger at this moment block the expression of her grief? In other words, what function does the feeling of anger serve at that moment?
This is not to diminish or deny the fact that she probably also does feel angry toward her dead husband. As in any complex relationship, she will have complex feelings. Our question is this: can she tolerate her complex feelings or is there one feeling that gets expressed and another set of feelings which gets repressed? For instance, a patient who cannot tolerate her grief may come into her session for weeks on end expressing anger toward her dead husband. But the anger leads nowhere, nor does it trigger any anxiety, nor does it bring any relief. Why? In her case, her anger has the function of covering up her grief. Our goal is to help her accept and experience all of her complex feelings so she doesn’t have to use any feeling to ward off another feeling.
Sometimes a patient uses anger to cover over grief. However, most frequently anger is enlisted in a sneaky way to cover up externalization. This type of patient spends sessions complaining about other people and blaming them for her suffering. When you explore their anger, they will explore it with you but it does not lead to an unlocking of complex feelings. Why? Their anger is toward an “all-bad” person whom they blame for their suffering. Since they view the other person as “all-bad”, they have no complex feelings toward that person.
Is it true the other person causes their suffering? Not usually. The other person causes some pain. But the patient, by continuing that relationship as it is perpetuates her suffering. She often focuses on what the other person did, not how she made things worse by hurting herself.
Let’s take an example. A patient expresses her anger toward a boyfriend who did not pay back a loan. This seems straightforward, doesn’t it? But then we learn that she had given a number of loans in the past which he also had not paid back. So what is the triangle of conflict? She is angry with him for not paying back the past loans. The anger makes her anxious. As a defense, she punishes herself for being angry by loaning him money again. And now for the interesting point: then she gets angry with him for mistreating her! In fact, the first time he did not pay her back he mistreated her. After the first time, however, she mistreated herself every time she loaned him money! She just blames him for how she has hurt herself. “He hurts me!” is a projection. Now she hurts herself. But she blames him and then gets angry at him for the ways she perpetuates her own suffering. She would be happy to blame him and be angry with him forever rather than face how she hurts herself. That’s why we have to undo the externalization so she can face her defense of self-punishment. Once she can face her defense, and face her responsibility for how she has mistreated herself, then she can face the underlying anger for his offence to her the first time.
Pt: He hurt me.
Th: Who loaned him the money.
Pt: I did, but he needed it.
Th: You loaned him money when he had not paid it before.
Pt: He said he would.
Th: And he didn’t before. So you trusted his words instead of your experience.
Pt: He lied to me.
Th: And when you didn’t listen to your experience you lied to yourself.
Th: So when you loaned the money to someone you knew was a liar, who hurt you?
Pt: I see what you’re saying.
A third pattern is one where the patient regales you with stories of people she is angry with. But as soon as the therapist asks how the patient experiences that anger physically in the body, the patient uses defenses. Here, the issue is not the anger toward other people. The issue is that the patient begins to resist contact as soon as you explore feelings. Here, the therapist again needs to address the barrier the patient is putting up in the relationship, and then ask what the feeling is toward the therapist that makes the patient distance.
Ophrah asked, can anger function as an expression of the self and defense at the same time? No. Either a feeling functions as an expression of self or a defensive feeling enters to prevent the expression of self. At one point in a session, anger may function as a defense against sadness. At another point in a session, anger may be the underlying feeling that needs to be expressed. To see the difference between feelings and defensive affects, read the chapters on feelings and defensive affects in my book, Co-Creating Change: Effective Dynamic Therapy Techniques.
Take home point: when you see a feeling, ask yourself what its function is. Does this feeling further the expression of self or inhibit that expression? If it is a feeling, help the patient feel it more deeply. Does the expression of this feeling lead to a sense of inner freedom or does it lead to a sense of despair and paralysis? If the expression of the feeling does not lead to inner freedom, consider that it may have a defensive function. Does the expression of this feeling help a relationship or damage it? If it does not help a relationship, consider the possibility that it is a defensive affect which either functions as or results from a defense. If it is a defensive affect, help the patient see and let go of the defenses upon which that defensive affect is based. Then you can pursue the underlying feelings that were warded off by the defensive affect.