Monthly Archives: July 2018

How can I keep from being boring by focusing on feelings?

I am a beginning therapist in ISTDP with a question that is probably due to my lack of experience with the approach. When I’m with patients, I can’t stop worrying about how they might find my sessions repetitive as I keep working with their feelings, anxiety, and defenses every session, starting from revealing the feeling, to trying for showing an impulse and going for a breakthrough. This concern sometimes leads me to get a little distanced from the approach, as if it will bore the patient if I go on with the same process (although the content is different every time). Am I totally misunderstanding something here?

Things are already getting clearer in my mind as I’m going further with your book, Co-Creating Change, and hopefully I will soon get more comfortable with this very interesting approach. Thank you very much for your time.” Thanks for an excellent question!

Of course, the last thing we want to do is “bore” the patient with our obsessional disorder masquerading as therapy:-)

An important way to avoid this problem is to make sure you and the patient agree on the problem she wants help with. Second, make sure the two of you develop a consensus on what is causing the patient’s problems. If you don’t have this consensus, the patient won’t understand why you focus on feelings. Third, make sure you get consensus on the therapeutic task.

If you get consensus on these three things, the patient knows what the problem is, what causes it, and why a focus on feelings will help. Then she will not feel bored, but, in fact, encouraged by your systematic focus on what she has trouble focusing on. Another thing you can do is continually mobilize her will to the task: “would you like to take a look at the feelings so you don’t have to feeling anxious instead?” Frequent mobilizations of will to the task remind the patient of what we are here to do and why we do it. Then, neither she nor you will be bored.

Often, when we are afraid the patient will be bored, we are ourselves unsure of where we are on the triangle of conflict. As a result, we can’t feel confident we are exploring the right area of the triangle. This is a normal phase in learning ISTDP or any therapy, really. To get better on that, in your self supervision, examine each patient response to see if it is feeling, anxiety, or defense. Then say out loud to the videotape how you would respond to the patient now, given your better information. When you go through your videotape this way, you can improve the speed of your psychodiagnosis and the speed of your response.


Projection and fragility

When mildly or moderately fragile patients experience a low rise of mixed feelings, they can still intellectualize and exhibit tiny sighs. However, as those mixed feelings rise, they are no longer able to bear the rising feelings. In response, sighing stops and anxiety shifts into cognitive perceptual disruption. To stop the worst of those symptoms, patients split feelings off from themselves and project them onto others.

They no longer fear their feelings; they fear the people onto whom they have projected their feelings. They no longer relate to people; they interact with the projects placed upon those people. They are no longer anxious due to internal feelings; they are afraid of those feelings they perceive in other people.

Projection of anger

“You look angry.”

“You wanted to kick me out of therapy.”

Projection of will/desire/love

“I’m afraid of the questions you want to ask.”

“I feel like you are trying to get into my head.”

Projection of disowned parts of self

“You think I’m psychotic and want to put me in a hospital.”

Notice that projection involves qualities, feelings, or wishes of oneself. This is different from transference.


Transference involves projection, not of a part of himself, but of an image of another person.

“My boss treats me like an incompetent boy.”

Here, the patient projects, not a feeling or desire within himself, but an image of a person, his father, onto his boss. This is transference, not the kind of projection we see in fragility.