- Moderate resistant: ask for problem and then example
- High resistant: inquiry not possible, he demonstrates the problem
- High resistant with repression: inquiry until depression, then inquiry within the problem in here and now
- Fragile: inquiry until disrupt, then inquiry
“A patient is addressing a situation that has come up in the recent past and then says, “I was angry at the time, but I don’t feel it anymore.” In a lot of examples, this clearly posed a problem for them (anxiety for example), but they state that the feeling is no longer accessible. Just defense? Curious…” Thanks to one of our community members for offering this common clinical problem.
Suppose you had a wonderful meal at a restaurant last week and the bottle of wine was delicious. If I asked you, “How do you feel when you think of that meal?” a smile will cross your face and you will feel happy. If you asked me how I felt last week when I learned that a dear friend is having chemotherapy, I would say I feel sad.
Every day we have feelings from the moment we wake up in the morning and hear the birds singing, when we read the tragic news about Syria in the newspaper, when we sit with our 10 am patient, and when we get a call from a friend inviting us for dinner. We feel all day long and those feelings give us the information we need for living life.
You may have noticed that feelings are very “accessible” for babies. That’s us. We have to learn to use defenses to make our defenses “no longer accessible.”
When the patient can’t tell you what his feeling is, he goes through life without a compass. He does not know what he feels, so he does not know what his passions are. He is directionless. All due to defenses.
When the patient says, “I don’t feel it now,” that is unconscious therapeutic alliance: “I need help with the defenses I am using in this moment.”
When he says, “My feelings are no longer accessible,” that is also unconscious therapeutic alliance: “I need help with the defenses that make my feelings inaccessible in this moment.”
Pt: “I don’t feel it now.”
Th: “And the feeling toward her?”
Pt: “It’s not accessible.”
Th: “Would you like it to be accessible?”
Th: “Wouldn’t it be nice to know what you feel so you wouldn’t be going through life in the dark?”
Th: “So can we see what the feeling is toward her?”
Now, having explored feeling this much, we will have mobilized complex feelings. These feelings will trigger anxiety and defenses. We watch the patient’s responses now to find out his pathway of anxiety and system of resistance. Then we know what to treat.
For instance, let’s look at two possible responses the patient might offer.
Pt: [teary] “Maybe I just can’t do this kind of therapy.” [self-attack]
Th: “Could that be a critical thought? Could that thought be getting you down?”
Th: “If we look underneath that thought could we see what feelings are coming up here toward me?”
Here, the patient’s teariness and self-attack reveal that she is using the resistance system of repression and her anxiety is channeled into the smooth muscles. So you would use the graded format to build her affect tolerance, so she could eventually feel her full feelings without having to use self-attack as a defense.
A second response might look like this.
Pt: [sigh. Looking away.] “I told you I don’t have a feeling.”
Th: “Notice how you look away? Notice how you avoid my eyes? I wonder what feelings might be coming up here toward me that make you put up this barrier of avoidance?”
Here, the patient’s sigh indicates anxiety is in the striated muscles. The verbal statement is the defense of intellectualization, so the patient uses the resistance system of isolation of affect. The use of gaze avoidance indicates that the resistance has shifted from resistance against feeling to resistance against emotional closeness. Therefore, the therapist addresses the gaze avoidance, a sign of mid-rise of transference feelings, and then asks for feelings toward him to mobilize complex feelings and to bring the transference resistance out into the open.
In other words, the patient’s first response is not a problem, “I don’t feel it now.” It’s an opportunity to explore feelings to find out where anxiety is discharged and which resistance system is operating. Then the therapist knows what to treat and why.