Monthly Archives: June 2018

Why do ISTDP teachers say different things about projection?

“In your book you have said we don’t ask for feelings if someone is projecting onto us. But in Allan Abbass’s new book and one of Patricia’s videos people ask for feelings when the patient is projecting onto the therapist. This is confusing. Does the difference lie in whether the patient’s anxiety is in striated or not? What if the patient isn’t showing any anxiety?” Thanks to Albert for this very important question!

First of all, everybody projects, even you and me! Projection can range from the psychotic man who claims that space aliens are communicating to him through the fillings in his teeth to the daily blatherings of politicians onto each other. So, to deal with projections, we must understand where the patient is on the spectrum of resistance.

As you know from earlier blogs, in ISTDP we see patients handling their mixed feelings through three strategies: 1) projection: I split off my feelings and project them onto other people; 2) repression: I split apart my feelings and turn the love onto you and the rage onto me; and 3) isolation of affect: I detach from you to detach from my feelings.

Patients who use projection as their primary form of resistance suffer from cognitive/perceptual disruption, losing a sense of reality testing when they project. As a result, they become afraid of you, since they equate you with the projection. This is known as symbolic equation: equating you (reality) with the projection (symbol). Thus, the first task is to differentiate you from the projection and re-establish reality testing. As soon as reality testing is established, then we ask for the feelings toward the therapist. Why? We must build the patient’s capacity to identify and bear mixed feelings toward the therapist at higher levels without projection to restructure his system of resistance and pathway of anxiety discharge.

Patients who use projection in the system of resistance project that you will be critical of them and they become depressed in response to this projection. Again, you help them see the difference between you and the projection. Then you ask for the feelings toward you, so they can bear their mixed feelings internally without attacking themselves. These patient’s projections restructure very quickly because there is not a marked loss of reality testing. In fact, most of the time, if we simply ask patients who repress about the feelings toward us, providing an outward pathway for the feelings, the weepiness will decrease, sighing will increase, and the patient’s depression will diminish in the following minutes.

Patients who use projection in the resistance system of isolation of affect suffer no loss of reality testing, their anxiety remains in the striated muscles, and their other defenses serve isolation of affect. In this case, projection serves as a tactical defense, a tactic to diversify away from your focus on the feelings toward you. Projection in this case requires no restructuring at all.

To compare these kinds of projection according to systems of resistance, let’s review their differences:

 

Projection

Defenses:  Splitting, projection

Result:  scared of therapist

Anxiety: c/p disruption

Reality testing:  impaired

Intervention: restructure projection until sighing, tension, or intellectualization returns, then invite feelings INSIDE the patient

 

Repression

Defenses:  Self-attack, weepiness, tiredness, somatization, conversion

Result: depressed

Anxiety:  smooth

Reality testing:  easily corrected

Intervention:  Identify defense, invite feelings TOWARD the therapist

 

Isolation of Affect

Defenses:  Intellectualization, rationalization, detaching

Result:  detached

Reality testing:  no problem

Intervention:  ignore the defense, invite feelings toward the therapist

 

 

In my book, due to limitations of space, I focused on how to address projections when patients are fragile, using the resistance system of projection. Allan’s book shows how to use pressure to feelings once the fragile patient sighs again, and how to use pressure when the highly resistant patient uses projection as a tactical defense. Patricia’s video also shows how to press for feelings when a highly resistant patient uses projection as a tactical defense. In future blogs, I’ll take you through this spectrum of projection, showing how we intervene differently and how we invite feelings differently to block systems of resistance while mobilizing complex mixed feelings.

On Failure

“This is a personal question, Jon. Through your book and your facebook page, I get to read about succesful interventions and the path forward. But do you still get patients whose resistance is too strong for you to help them? Or who, for some reason or other, just won’t benefit from ISTDP? How do you learn from and carry your failed therapies, if you can call them that, gracefully?” Thanks to Arvid for this important question.

According to psychotherapy research, no therapist succeeds with all patients all the time. Not me, not you, no one succeeds all the time. No therapy succeeds 100% of the time with all patients. Anyone who claims differently is just lying.

Sure I fail at times, even after practicing for thirty years! I can console myself that I sometimes get patients who failed with many other therapists. But still, I fail. Everybody does. So the question becomes, how can we learn from our failures?

When I fail, I study my videotapes to see what I can learn. I show my videotapes to colleagues to see if they can help me see what I don’t see. I read more widely. I think about the case. I write out transcripts of the session to see if my analysis of it helps me see a pattern I didn’t see before.

I make a note of the specific problems the patient has that are are not resolving and I consider what other approaches I could use. Sometimes a stalemate resolves after I have tried four or five different approaches until something works. And sometimes, I never figure out how to help the patient get better. Sometimes I send a patient to colleague to get a second opinion.

You mention “failed therapies, if you can call them that.” We must call them that. We fail. We have failed therapies. We do our best, and sometimes our best is not enough. If you read psychotherapy research studies carefully, you will notice that EVERY single psychotherapy research study involves patients who did not respond to treatment. Psychotherapy research shows that about 50% of patients improve in therapy and 10-15% of them get worse! Fortunately, ISTDP is getting better results than that in our studies. But, ISTDP is still a therapy model, not magic. We do not and cannot claim perfection without failures.

Forgive my repetition about this, but I do it for a reason. All of us have a deep longing to heal those who suffer. Sometimes we even harbor a longing to save others. But therapy requires two people. Results in therapy are a form of addition: what I can do plus what the patient can do. Sometimes we can do a lot, sometimes a little, sometimes nothing at all.

Sometimes people will make magical claims for a therapy model, but we do not practice magic, we do not save people, we do not achieve the impossible. We do what we can in the time we have with the abilities we have with the abilities the patient can bring to the task. That means sometimes we succeed and sometimes we fail. And when we fail, we have the chance to learn from our failures so that future patients may be able to have results that we couldn’t have before.

That’s why the path of the therapist involves humility, the acknowledgement of our strengths and weaknesses, and guilt. When we fail, we feel guilt over not being able to do more. But the productive bearing of our guilt can mobilize us to study our work, analyze our videos, get some supervision and consultation, and then do better with our future patients. Admitting failure and bearing our guilt is part of the path for all therapists who love their patients enough to face the truth and the feelings it provokes. Sometimes, the truth is, we fail……like everybody else.