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.