“I have a patient who suffers from a lot of anxiety and worries about things that could go wrong in the future, whether or not he will ever find a relationship. He is not objectively alone, but he has difficulty feeling content and safe without other people physically present.
Performing for others and himself is the main way to feel good about himself. When by himself, there is no one around who can confirm his worth as a person, and as a result, he describes a feeling of emptiness. How should I approach his difficulties?” Great question!
Triangle of conflict: mixed feelings; anxiety; defenses: rumination and self-attack.
I would ask if those thoughts are occurring in his mind at this moment.
Then I would ask, “Since those thoughts are coming up here now with me, I wonder what feelings are coming up here with me underneath those thoughts? If we look under the thoughts, what feelings are coming up here toward me?”
Why do I ask about feelings toward me? The patient attacks himself, saying he is not good enough, he should perform better, he will fail in the future. This is the resistance system of repression. He attacks himself.
You have formed a close relationship with him that triggers feelings toward you. As these feelings rise, he protects you from his anger by turning it upon himself. Thus, we ask about feelings toward you to block his self-attack and help him develop an outward pathway for his anger, so he does not have to turn the anger upon himself instead.
Here’s another example of how you could intervene:
Th: “You say you judge yourself according to how well you perform and you are worried about how others think of your performance. How is that in operation right now here with you and me?” “So if we look under these thoughts about performance, what feelings are coming up here toward me?”
Sometimes, of course, the patient’s self-attack and self-doubt is so habitual, he cannot see that it is a defense. If he insists on the wisdom of his self-attack, you might ask,
Th: “When you doubt your worth, could that be a form of self-doubt? Could that be hurting you? So if we look underneath the doubt, what feelings are coming up here with me? What are the feelings here toward me?”
Habitual self-doubt and self-devaluation are destructive defenses that cause depression. Interrupt them as soon as possible to prevent a regression into depression. Then invite feelings toward the therapist to form a new relationship: one based on feelings in a relationship rather than protecting others from feelings by getting depressed.
Oh, and the emptiness? He tries to empty himself of his anger because he believes no one could love him with his anger. Thus, we encourage him to face his feelings with us. Implicitly, he will experience our acceptance of all of him. Experientially, he learns that he does not have to be an empty man to be loved.