“I have a patient. Unable to depend on his father, he began to rely on a cousin five years older who abused this patient sexually, physically, and verbally from ages seven to twelve. Now he suffers from OCD, which began after a girl friend left him. He imagines having intercourse with men to see if it would be pleasant for him. Yet he is afraid of getting close to men, especially if they are five or six years older.
Afraid of being alone, he spends most of his time with friends whom he relies upon for encouragement to finish projects he takes on. To maintain relationships with them, he is “pleasing” and “helpless”. When I point out those character defenses, he says: “I can see it but I can’t get over it.”
He never experiences his anger physically. Instead, he experiences anxiety, his body shakes, and he feels numb. For some reason, anxiety regulation has not worked. I try to block his defenses, and when resistance is crystalized in the transference I do a “head on collision”, but he gets confused and says, “Yes I want to talk to you very clearly about myself and I want to get out of these sufferings but I don’t know how!” How can I help him?” Thanks to one of our anonymous members for this question!
His OCD symptoms occurred just after his girlfriend left him. So we can hypothesize that his symptoms are psychogenic, defenses against facing rage toward her. Why would a breakup trigger so much feeling and defense? It probably evoked the earlier rage toward the cousin who abused him. Obsessional thinking about sex with men who are five to sex years older symbolically re-enacts the rapes by his cousin. Triangle of conflict: mixed feelings, especially rage; anxiety; obsessional thoughts about the girlfriend and older males (abuser).
In his relationships, feelings rise. To ward off his feelings and anxiety, he distances from people and the therapist. Triangle of conflict: rage/power; anxiety; defenses: adopting a pleasing stance (reaction formation), going helpless, taking a one-down position, passively waiting for his rage or initiative to be encouraged or approved of by others.
When the therapist points out defenses, the patient responds with helplessness: “I can see it, but I can’t get over it.” That is a transference resistance.
Th: “Notice how you go helpless now? Notice how you put up a wall of “I can’t”? I wonder what feelings are coming up here toward me that make you put up this wall of helplessness?”
When the therapist explores the patient’s anger, the patient never experiences his anger. Instead, he reports feeling anxious.
Th: “But anxiety is not your anger. Anxiety is how you hide your anger. It is your wall. Can we look underneath the anxiety and see what feelings are coming up here toward me that make you put up this wall?” [Since the patient is anxious with you, focus on the feelings toward you that make the patient anxious.]
Bodily shaking expresses a conflict in the body between the wish to enact an impulse and the prohibition against doing so. Help the patient face his feeling and let go of the defense, so that the anger can move through the body.
Th: “Notice this anger here toward me? And then you hold it back. If you don’t protect me by holding it back, how do you experience that anger if you let it go through your body here toward me?” [Offer this intervention several times until the patient realizes that he does not need to protect you from his feeling.]
Or he goes numb.
Since he uses a transference resistance of helplessness, he is not fragile. Thus, deal with his numbness as a “wall” of detachment.
Th: “I ask about your anger, but then you put up this wall of numbness. This is how you detach and how you distance here from me. How do you experience this anger here toward me that makes you put up this wall of detachment?”
When the resistance is crystallized, the therapist confronted the patient who responds, “Yes I want to talk to you very clearly about myself and I want to get out of these sufferings but I don’t know how!” This is not confusion. It is the transference resistance of helplessness.
Th: “Notice how you take this helpless position here with me? As long as you put up this helpless façade, we won’t find out who you really are underneath. What is the feeling toward me underneath the helplessness?”
Helplessness is the major resistance to facing his rage. With friends he becomes helpless. When the therapist points out a defense, he becomes helpless. This is not to fault the patient. Perhaps he survived by hiding his rage toward the abuser underneath this helplessness! No wonder this defense is so strong. Address it constantly.
Whenever you explore feelings, the patient will put up the wall of helplessness (“I’m not able to share feelings with you.”) Point out the resistance of helplessness and ask about feelings toward you. Keep doing this until a breakthrough to feelings occurs. Why? As long as the patient resists contact with you, feelings in current or past relationships are not available. That’s why you work on the patient’s relationship with you first.
Take home point: helplessness is a resistance to emotional closeness with you. Focus on the patient’s helpless behaviors, label them as a wall, and then ask for the feelings toward you that make the patient put up this wall of helplessness. Maintain this focus until his feelings break through and his resistance dissolves.