What should I do when I see no signs of anxiety?

Hello, I am reading these posts with extreme curiosity! I have been trying to learn ISTDP by means of supervision and reading your excellent book. I wonder how you work with patients who present problems like “I am too passive, I do not do what I plan to do, and therefore do not achieve my goals. This in turn makes me depressed.

They show no smooth muscle or cognitive-perceptual disturbances, but they are NOT signaling with striated muscles when they describe their problems! You wrote earlier that signaling means we can ask for feelings towards me. How do you find a way towards the unconscious when they present behavioral problems that cause suffering?”

Great question! When the patient responds with sighing, we ask for feelings. But what do we do when the patient does not sigh?

Lack of sighing can occur because we are not exploring feelings or a conflictual area. For instance, if we chit-chat, no anxiety will rise. In my book, Co-Creating Change, I list nearly twenty reasons we might not see sighing occur. But, now, let me offer a central technical principle that simplifies the process of assessment.

Assuming you are exploring a conflictual area, sighing occurs because mixed feelings and anxiety are rising. When there is no sighing, resistance is operating. So our question becomes: which resistance system is preventing a rise of complex feelings?

Not sighing is just as important for assessment as sighing! When you intervene and there is no sigh, assess the next verbal response to find out what resistance system is preventing a rise of complex mixed feelings.

Th: “What’s the feeling toward her for leaving you?”

Pt: [no sigh] “She’s just a lying bitch.” [Splitting and devaluation]

Th: “You call her a bitch and at the same time loved her and wanted to marry her. What happens inside as we notice these two facts together at the same time in you? [Pressure to consciousness to block splitting so feelings can rise.]

Rather than face his mixed feelings toward his girlfriend, he splits off his loving feelings and feels only rage toward her. Since he feels only rage, not mixed feelings, no guilt is triggered and, thus, no anxiety. This explains why anxiety does not rise when patients use the resistance system of projection, based on splitting. Here’s another example.

Th: “What’s the feeling toward her?”

Pt: [no sigh] “I feel only positive feelings toward her. I didn’t deserve someone like her.” [denial and self-attack]

Th: “Could that be a critical thought? Could that thought be hurting you? If we look under the thoughts, I wonder what other feelings are coming up toward her?” [Inviting the feelings by blocking turning on the self.]

Rather than face his mixed feelings toward his girlfriend, he feels only positive feelings toward her and turns the rage upon himself and becomes depressed. Since he feels only love, not mixed feelings, no guilt is triggered and, thus, no anxiety. This explains why anxiety does not rise when patients use the resistance system of repression, based on turning on the self. Here’s another example.

Th: “What’s the feeling toward her?”

Pt: [no sigh, looks away out the window] “No feelings really.” [Detaching from the therapist and from feelings]

Th: “Notice how you look out the window instead of at me? Notice how you relate to the window instead me and avoid my eyes? What feelings are coming up here toward me that make you avoid my eyes?” [Since he is detaching from the therapist, address his distancing and then ask for the feelings toward you that lead him to distance.]

Rather than face his mixed feelings toward his girlfriend, he detaches from his feelings and from the therapist, becoming distant and uninvolved. Since he detaches from mixed feelings, no guilt is triggered and, thus, no anxiety. This explains why anxiety does not rise when patients use the resistance system of isolation of affect, based on detaching.

If you see no sighs, pay attention to the patient’s verbal and non-verbal responses to find out which resistance system is preventing a rise of mixed feelings. Then you will know which resistance system to address. In our next post, I’ll talk about the different ways we invite feelings to address these three different systems of resistance.

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