Why is my patient talking so softly while hunched over?

“A young man with severe depression has a history of self-harm since he was 5 and severe neglect by parents, who told him to man up when he showed them the cuts he did to himself. We worked on his fear of opening up to me, and
how he hides behind vagueness. He speaks very, very softly while hunched over. In our last session, we talked about his stress at university. He talked about a lecturer who didn’t show up to 10 of their 12 lectures, and how because of that he now struggles in class. (Is this a strange person to work on, given that we
worked on more important people in past sessions?) He said anger quite clearly without defenses, and when I asked him how he felt it, he was able to say heat in the stomach, and the impulse to hit. But it was weird because he said this still
hunched over (elbows on knees), and with that soft voice. So I asked him
about it, and he said he has weekly episodes of derealization – where he
seems like he is a few meters behind his head and when he watches his
body, the body isn’t his. I asked if that was happening now, and he said he wasn’t sure, but maybe. This is very weird, any ideas? He does sigh once in
a while, but not much, maybe every 7-8 minutes, and his hands are limp.” Great question!
The fact that the patient speaks “very, very softly while hunched over” suggests that he is responding to a projection he has placed upon you. Perhaps he views you as a father who will tell him to “man up” as soon as he reveals himself. We don’t know. What we can be sure of is that if he was in relation to you, he would look at you, talk in a normal voice, and sit up.
When he appears to be relating to a projection, explore his thoughts and ideas about the therapy to find out what projections are in the room. “I notice you are talking very softly. I wonder what thoughts and ideas you might be having about the therapy?” When he tells you about his thoughts, you will learn what projections he is placing upon you. Then you can help him see the difference between you and his projections.
1) “So these are some thoughts your mind creates. What is that like to notice these thoughts your mind creates?”
2) “Are these the kinds of thoughts your mind often creates?”
3) “I wonder what reactions you are having to the therapy that might be under those thoughts?”
In this way, you first help the patient see his thoughts, then intellectualize about his projections. Once he can do that, then you can ask about “reactions” he is having. This is a very graded way of asking about feelings toward you.
Unable to tolerate the rise of feelings within himself, he projects those feelings upon you, and then he fears you.
When you asked about the anger toward the teacher, he reported that he felt anger. But there were no defenses! Why? Because anger toward the teacher was not mobilizing unconscious anxiety. It was not the path to follow. Instead, he was having feelings toward you, but rather than tolerate the feelings inside him, he projected onto you. Then he sat in fear, talking softly, hunched over in front of a supposedly angry therapist. He was projecting. And, to his credit, he revealed his cognitive/perceptual disruption: his derealization. And his limp hands reveal that his anxiety is not going into tension (striated muscles) but into smooth muscles or cognitive/perceptual disruption.
Take home point: when the patient talks in an extremely soft, submissive manner, ask about the thoughts he is having about the therapy to find out what projection he is reacting to. Then help him intellectualize about his projections to re-establish reality testing. Then you can explore the reactions (feelings) that triggered his projection. In this way, you build his capacity to bear feelings inside without projecting them outside.

My patient terminated therapy prematurely!

And, of course I am feeling low and have been wondering what I did wrong. She was a great candidate for ISTDP, but highly resistant. She asked to reschedule a session, but I refused because I had rescheduled once a few sessions back due to extremely poor weather conditions, and I didn’t want to make this a practice. But I felt bad that she had to miss her session, so I wrote back to her offering some available slots to make up for her lost session. She became angry and said she would come as scheduled for her next appointment and hoped that I would not charge for her missed session. She also added that coming every week did not suit her. I said we would discuss it when we meet. Then the day before her next session, she terminated therapy over an sms saying that this form of therapy does not suit her and she would like to go back to her previous therapist. I offered to keep the slot open so she could come and explore her issues about therapy and about me, but she wrote back saying she would like to close the chapter. She had difficulty facing rage against her husband (who cheated on her) and her father (who controlled and berated her). She is a highly controlling individual, and I feel she was trying to control me by dismissing my cancellation policy and creating one of her own. 
Is it possible some patients don’t feel comfortable facing their rage and drop out, or do they drop out because we therapists have failed to handle their anxieties appropriately? How does one handle premature terminations?
We can help you become competent, but we can never help you become omnipotent! Sometimes patients act out rage with therapists to avoid the rage going onto family members. I doubt your back and forth about your cancellation policy was the issue. She had already cancelled a session. She had already proposed a different policy, hoping to control you. She had already opposed looking at feelings toward her husband from what you told me earlier. Thus, she had already felt rage toward you and was resisting you before your policy was even part of the picture.
This kind of patient is hard for everyone because we have trouble seeing the rage in the transference. This kind of patient rarely says she is feeling angry with you. She is not even aware of it initially. We see her anger toward you because she starts to resist closeness with you. For instance, you asked about anger toward the husband, and she resisted. Or you addressed her self attack while she remained detached, and she probably disagreed with you or argued or dismissed what you said = resistance in the T. Or she talked about people she was angry with and said she didn’t dare tell them about = I am angry with you and dare not tell you.
In other words, we fail with this kind of patient until we learn to recognize the signs of resistance toward the therapist. Once we see the resistance, we start asking for feelings toward us that make them put up a wall with us. And by keeping that consistent focus, we help them feel their rage toward us so they don’t have to act it out by quitting therapy.
Sadly, this is part of every therapist’s learning curve. All of us have a hard time picking up when the patient is feeling unconscious anger toward us as we begin our work as therapists. As a result, when we don’t see their anger in the early phase, it builds up, and then the patient acts out by dropping out of therapy. The sooner we pick up on the resistance and the underlying mixed feelings, the sooner we describe their resistance and ask about feelings toward us, the more we keep patients from acting out their rage in this way.
This is part of the learning curve for all therapists. The issue was not what you did or said. The issue was that you didn’t see the early signs of resistance, so it built up and built up until she blasted out of your office. 
Here are signs that the patient is resisting you and not just resisting feelings: looking away, pausing, going silent, going up in the head, avoiding contact, refusing to explore important issues with you, arguing with you, going helpless, going passive, describing relationships where she hides what she feels and thinks. When those actions occur, describe those actions, label them as a wall against contact, and then ask about feelings toward you that make the patient withdraw. Keep that focus exclusively until there is a breakthrough to feeling. In the meantime, her feelings toward you will rise so that she does not have to channel them into acting out.