Monthly Archives: June 2014

Personal Lives of Therapists

Dear Jon,

“I have had you on my mind so much this holiday season while I have been working with patients on their family issues.  After helping them for the last several weeks, I went home to my family of origin!  Yikes!  Jon, I recall in the very beginning of my doctoral program we had an open forum where mature therapists shared with students how their lives were about to change.  I recall a few things that were said, but mostly I just wanted to get on with the process of obtaining my degree and getting licensed.  They were trying to prepare us for how we were going to change personally and professionally.

Now, I am wondering more than EVER….WHAT DO YOU DO?  Jon as I learn more and more about ISTDP and become (hopefully) a better practitioner I am also finding that I do not like what it means personally.  There were so many defenses that I employed to not deal with my own reality.  Now I do my best to recognize them, see the reality, and face my feelings.  Check.  However, what do folks do (you and others) when you can so easily see what is happening around you (say in your family) and knowing there is NOTHING you can do about it.  I find this to be a real challenge.  It is like you know what is going on, but nobody else has the information you have, furthermore, nobody wants it. Jon, how do therapists deal with this in their personal lives?  It sure ain’t easy.”

Thanks for one of our community members for sharing this common plight.

I don’t know what others do. I’ve often had the secret belief that my background was more pathological than that of my colleagues. But it turns out there a few of us out there. Thanks for the company.

It makes no sense to bring information to people who are not seeking it. And it takes a great deal of humility and the capacity to bear grief when you see the lives of those you love go inexorably in terrible directions. Sometimes they make terrible decisions and we can’t stop them. And rather than the bear the grief over losses which we can’t control, we try to control them instead! “Please let me control you so I won’t have to feel the feelings I feel while I see your life go down the toilet!” When they are in pain and we are in pain watching them, it is so hard to sit down in the fire next to them. Instead, we ward off the grief through “intervening” or “sharing “insights”, which only provoke rage at worst or puzzlement at best. We think we are putting out their fire. In fact, we are trying to put out the fire within ourselves. That’s why it has been said that the kindest thing you could do for your friends and family is to own your projections. Yet how hard it is for us to sit in the fire of our own feelings when it comes to feelings about our loved ones! So we export.

Sometimes, rather than bear the grief over the loss of the kinds of relationships we want, we try to coerce our loved ones into being different than they are. We judge them, tell them they are wrong, we appoint ourselves as their much-needed guides (without their consent), and then we are surprised when they respond with less than unmitigated delight.

They naturally respond with rage because they realize that we don’t love them the way they are. We are treating them like home renovation projects. Then they say, “You’re not my therapist!” [Uh, that’s right!] We keep giving them the message: “You are almost good enough for me to love, but to get there you need to change x, y, and z.” It’s not their job to become loveable to us. It’s not their job to reject themselves the way we reject them. It’s not their job to judge or doubt themselves the way we judge and doubt them.

Our task is to love them the way they are without trying to change them and to bear the grief that they are not the same as the fantasy family we have in our mind. It’s not their job to live up to our fantasies. It’s their job to be them. It’s our job to accept reality, the way they are, and over time give up our project of changing them so they are the same as our fantasy. For me this took a lot of time and I’m still a work in progress.

You see, every time a family member or friend disappoints you, a door opens up to reality. Reality shows up instead of our fantasies. We can bear those feelings and shed another illusion and have a brighter picture of reality and life as it is, a mysterious gift. Or we can ward off reality, cling to our fantasy, and ward off our feelings, and then resume our project of rejecting the reality of our friends and family. All the while calling it “love.”

What if a disappointment with your family is not a problem? What if it is a portal, a gateway to the new you whom you could become through shedding another illusion, bearing the feelings that could transform you? What if continual disappointments are not a reflection upon your friend or family member? What if continual disappointments are a reflection of your resistance to reality and your feelings about it?

The beautiful thing about friends and family is that they are constantly providing us for opportunities to grow. [And don’t forget, we with our foibles and imperfections are generously giving others the chance to grow all the time too! (Looking back, I can see I have been more generous than I could ever have known at the timeJ.)]

Sometimes there are openings for something new, especially with nieces and nephews. Sometimes not. Although rage is often emphasized when working through issues of the past, I think grief is a major factor in letting go of our project: making families fit our fantasies. Sometimes when we let go of that project and accept family members as they are, they begin to respond in new ways. Then we have this chance to recognize that our closest family members are always, to a degree, a mystery. They will always be people whom we don’t totally understand, even though we share so much in common.

When our friends and family members disappoint us, we experience the crucifixion of fantasy on the cross of reality. Suddenly, we are reminded, “You are not God and the world was not created in your image.” Our false divinity suffers another death (it’s kind of a slow death in my case). We think, “I can’t take this!” But, in fact, you already have taken reality in. That’s why you are experiencing the death throes of your false divinity, the fantasy that life should be your way instead of reality’s way. But, as Byron Katie says, “Who made you God?”

And here’s another joke on us. Did you ever notice how we therapists talk about how much we see that others don’t see and don’t want to see? Isn’t that a comfortable fantasy we have! Here’s a secret: our families see stuff about us that we don’t want to see either! It’s just that if they share their insights, we mysteriously are less than grateful to receive their feedback. Funny how much we share in common with our families, isn’t it?

This much I have learned. I don’t know what the journeys of other therapists are, except in the four walls of my office where I treat some. But these issues I’ve mentioned here seem to be central for them too. Reality is the Great Teacher and one of its greatest instructors is our family. We just get into trouble when we keep resisting what our families are trying to teach us. They have always been faithfully devoted to our growth by reminding us of reality.

 

 

 

 

ISTDP and Addictions II

What do we mean by the superego in drug addiction? Is it just that the patient has an internal judge? Is it that he is too harsh on himself? It’s more complicated. The superego is really a bunch of memories of early relationships. We can enact those memories in three ways.

Let’s suppose the addict had a harsh, rejecting mother who beat him severely. He has a bunch of memories of that relationship. The patient can enact that early relationship with his drug counselor in three ways.

1)    He judges himself harshly in session.

2)    He fears that you, other people in recovery, or the staff will judge him harshly.

3)    He judges you, the other people in recovery, and the staff harshly.

Many addicted people suffer from severely unregulated anxiety that leads to projection and regression. Their drug use may be a form a severe self-punishment. In treatment, they may project that others judge them. Believing these projections, they get into fights and arguments with the supposed “judges.” Or they may shift and judge others harshly as if to say: “I can see you are going to judge me, so I’ll take the initiative and judge you first!”

The frequency of projection on staff and fellow addicts in recovery can make treatment impossible. Thus, any therapist working with this group must identify projections and restructure them. Otherwise, the patient will remain suspicious of fellow addicts and the recovery staff as potential judges. In my book, Co-Creating Change, you can read about how to restructure projections.

Many addicts can look as if they are highly resistant, claiming to have no problem, refusing to engage in therapy, claiming that they were sent by someone else, or asserting that they have no need for therapy of any kind. However, it is important to assess whether the patient is indeed a highly resistant patient with a neurotic character structure or a fragile patient with a fragile character structure. Otherwise, therapists may mistakenly challenge these patients, leading to misalliances and ruptures in treatment.

The highly resistant patient with a neurotic character structure will claim to have no problem and no need for therapy. As you mirror his denial, you will see his anxiety show up in his striated muscles. As you persist, he will move from denial to defenses such as vagueness, intellectualization, and rationalization. In other words, he will use repressive and tactical defenses. As you continue to explore with him, his defenses will form a kind of wall where he remains detached, passive, and uninvolved.

The seemingly high resistant patient with a fragile character structure will also claim to have no problem and no need to therapy. However, as you mirror his denial, you will find that he uses denial, projection, projective identification, and splitting as his primary defenses. In other words, he uses regressive defenses. Since he projects a great deal, you may not see any access to striated muscles. At the slightest rise of feeling and anxiety, he projects, preventing any rise in feeling. As you block his projections, his anxiety will rise, but then he will resort to regressive defenses such as more projection, splitting, projective identification, and acting out. As you continue to deactivate his denial, projection of awareness and will, and projective identification, you will often find an underlying paranoid transference where he fears you will attack him. Then you must restructure that underlying projection to establish finally a therapeutic alliance.

 

In the highly resistant patient with a neurotic character structure, the repressive and tactical defenses function as a “wall” to ward off feelings toward the therapist. In the seemingly high resistant patient with fragile character structure, regressive defenses create a “wall” to ward of an underlying projection.

 

In the highly resistant patient with neurotic character structure, we ask for feelings toward the therapist in order to facilitate a breakthrough to the unconscious. His tolerance of feelings is very high. In the seemingly high resistant patient with fragile character structure, any rise of feelings leads to projection. The patient cannot tolerate a rise of feelings that would lead to breakthrough. Thus, the therapist must restructure the patient’s regressive defenses and build his affect tolerance so he can tolerate his feelings without using regressive defenses. Once he can do that, then the therapist can use the graded format to build the patient’s capacity higher and higher until he can tolerate a breakthrough to unconscious feelings.

 

With the highly resistant patient with neurotic character structure, we can clarify and challenge defenses and confront the destructiveness of his defenses. With the seemingly resistant patient with fragile character structure, challenge is contraindicated because the sharp rise of feelings that would result would lead to more projection and then acting out on the basis of those projections. Instead, the therapist must mirror denial, mirror splitting, and block projections until the underlying projection emerges. Restructure the underlying projection of the paranoid transference, and then establish a conscious therapeutic alliance. Then continue to use the graded format, using inviting feeling and clarifying the function and prices of the defenses to build the patient’s capacity to tolerate the experience of his feelings.

 

The tragedy of much work with addicted patients is that the failure to assess the underlying character structure that creates the picture of “resistance” leads to premature challenge, projection, misalliances, and treatment failures. My next DVD for sale on the ISTDP Institute website will be of such a patient. On that DVD you will be able to see how we work with fragile character structure in a patient with a paranoid personality disorder. In the meantime, always assess the pathways of anxiety discharge and the types of defenses the patient uses so that you can choose the type of treatment most appropriate for the patient in front of you.