Thanks for this question. And the answer is: it depends. For simplicity’s sake I’ll discuss projection as it occurs in three kinds of patients: fragile, depressed, and detached/uninvolved.
Fragile patients experience their anxiety in the form of cognitive/perceptual disruption. When they project upon you, they lose sight of the difference between you and the projection. Thus, they become scared of you or angry with you. This is a loss of reality testing: the inability to differentiate you from the fantasy they have of you.
Since their anxiety is in cognitive/perceptual disruption, and they suffer from a loss of reality testing, we have to restructure the projection so they can have an alliance with you rather than a misalliance with their projection.
Th: You seem anxious. Are you aware of that?
Pt: Yes. I’m scared of you. This room seems really intimidating. [projection and loss of reality testing.]
Th: Thank you for letting me know. What thoughts do you have about me? [Explore the content of the projection.]
Pt: I’m afraid you want to hurt me. [projection]
Th: I’m not aware of any wish to do so. Is there any evidence you have that I want to hurt you?
Th: So although there is a thought about hurting [symbol] there is no evidence for that thought. [reality] [Now the therapist watches to see if the patient can bear the anxiety that rises when she takes back what she projected.]
Pt: [tenses up] No. But it feels that way.
Th: That’s why it is important for us to check to see if the feeling fits the facts. Is there any evidence that I want to hurt you? [Contrast her fantasy with reality.]
Pt: No. [Alliance restored.]
Th: So I wonder what feelings you might have here toward me that are underneath that thought?
Depressed patients also use projection but it takes a different form and requires a different strategy. When they experience feelings toward you, their anxiety rises and moves into the smooth muscles. They turn anger they feel toward you onto themselves. That makes them depressed. As a second step, they may project that you are angry or critical toward them. They may start to become a little afraid or sad, somewhat convinced that you are critical of them.
Pt: You think I am fat. [Projection]
Th: Is there any evidence I think you are fat?
Th: So there is a thought about criticism. Is there any evidence I am criticizing you?
Pt: No. I’m such an idiot. [Now she shifts from projection to self-attack.]
Th: Could that be a critical thought? [Identify the defense]
Th: Could that make you depressed? [Clarify the price of the defense]
Th: I wonder what feelings are coming up here toward me if we look underneath the self-criticism? What feelings are coming up here toward me?
Th: What feelings are coming up here toward me?
Pt: I don’t know. [weepiness stops]
Th: Wouldn’t it be nice to know what you feel, so you wouldn’t have to feel depressed instead?
Th: So can we take a look? What feelings are coming up here toward me?
The patient’s primary form of resistance is repression: she turns rage toward the therapist upon herself. When she projects her reality testing is only slightly compromised. Quickly clarify the defense, then immediately ask for feelings toward you. When you invite feelings toward yourself, the patient does not have to turn them onto herself. This unconsciously restructures the resistance of repression.
Exploring feelings with the highly resistant patient, who uses isolation of affect as his resistance, triggers feelings toward you because you are becoming emotionally intimate. To detach from his feelings toward you, he detaches from you. His anxiety is in the striated muscles. He uses projection as a tactic to keep you at a distance.
Pt: You seem to think I should take a look at this. [Projection of will. No anxiety.]
Th: Only you can know if this is something you want to look at. So what is the problem you would like me to help you with? [Block the projection and continue to ask for the problem.]
At higher levels of feeling, the highly resistant patient with isolation of affect can use another form of projection.
Pt: I think you are arrogant. [Anxiety in striated. Patient is detached and distancing from the therapist.]
Th: This still doesn’t say what the feeling is here toward me. Notice how you put up this wall of thoughts between us? What is the feeling here toward me that makes you put up this wall?
In his case, we treat his projection as a barrier he puts up between the two of you to keep his distance. It’s usually the same wall he maintains with others.
Let’s compare these three patients.
Anxiety: cognitive perceptual disruption
Form of resistance: projection
Loss of reality testing
Function: Since I cannot tolerate the anxiety rising due to conflict within myself, I project part of myself onto to you to eliminate internal conflict.
Result: fear of therapist
Intervention: restructure the projection, and then ask for feelings
Anxiety: smooth muscles
Form of resistance: repression
Mild impairment of reality testing
Spectrum: highly resistant with repression
Function: Since I cannot tolerate the anger toward you, I protect you by turning it upon myself.
Result: weepiness and depression
Intervention: light restructuring, restructure repression, and then ask for feelings
Anxiety: striated muscles
Form of resistance: isolation of affect
No loss of reality testing
Spectrum: highly resistant with isolation of affect
Function: Since I feel mixed feelings toward you, I avoid them by detaching from you.
Result: detached from the therapist
Intervention: address the interpersonal wall, and then ask for feelings
Take home point: how we address projection depends on the pathway of anxiety, system of resistance, and level of reality testing. Once you understand these, you can tailor your intervention to the patient’s specific capacity. We restructure the fragile patient’s projection to establish reality testing and then we ask about feelings toward the therapist. We can quickly clarify the depressed patient’s projection, and then we ask about feelings toward the therapist to restructure the resistance of repression. We treat the highly resistant, detached patient’s projection as a wall he puts up to distance from the therapist. We identify his wall and its function, and then we ask for feelings toward us that make him put up that wall. So when the patient projects, is he: 1) afraid of you (fragile); 2) getting depressed (repression); or 3) detached (highly resistant with isolation of affect)?