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!).”

 

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