I hate therapists!

“I’ve been thinking about when to ask for feelings towards me. But I am still unclear when a feeling is based on a projection (in which case we clear it up) or a transference (which we explore). A client comes to mind. At his first session he raged at his previous therapist, whom he believed judged him. Security then removed him from her offices. Then he told me he hated my profession because of his last therapist. I didn’t address this in detail as I didn’t know what to do.” Great question!
The patient believed his previous therapist was judging him and then raged at her based on that projection. His loss of reality testing was so profound, security personnel had to remove him from her office!
Let’s take a look at the triangle of conflict. He comes to a therapist who invites him to look at his inner life. In response. like all patients, he experiences a mixture of feelings toward her for this offer of a relationship. The question is how he deals with those feelings. Moderate resistant patients can tolerate the feelings and still collaborate. Highly resistant patients with isolation of affect distance and detach from the therapist. Highly resistant patients with repression become depressed and somatize turn the anger inward and protect the therapist. Fragile patients cannot tolerate feelings internally, so they project those feelings onto others.
This patient projects his anger onto therapists, believes they want to judge him, and then he rages at the projection he places on the therapist. If you explored his rage, you would only reinforce his projection, making him regress.
Th: “Is there any evidence I am judging you?”
Pt: No. It just seems that way.
Th: “So although there is a thought about judgment, we don’t see any judgment here in me. Sometimes people who fear judgment tend to judge themselves too much. Is that something you have suffered from?”
This deactivates the projection onto you. Step one.
Th: “So coming here to let me know about yourself stirs up some feelings. They make you anxious, and then there is some self-judgment that comes up. Any ideas what feelings might be coming up here with me in the therapy?”
Why focus on feelings toward you? Feelings toward you mobilize anxiety and then he projects. Once we clear up the projection, we explore feelings toward us, building his capacity to bear feelings internally, so he doesn’t have to project them onto others. He learns to feel rather than project his feelings. This is the first step in integrating the personality of the fragile patient.

Premature Challenge II

“Thanks for your post. I probably should have been more clear about what I meant about this ‘apparent change in ISTDP.’ I was referring to things that I heard from Maury Joseph and Tom Brod. Maury said: “with depressed and fragile patients, we use almost exclusively pressure to lift them up, recaps when they pop a threshold, and challenge only when the rise is high. Challenge triggers anger towards the therapist, and in somebody who’s in repression that will make them more depressed in an instant.” Tom said: “Challenge used to be one of the stages of the Central Dynamic Sequence. Davanloo wants to avoid the word and make it all Pressure, so as not to feed the resistance. He emphasizes the importance of using Head On Collision as the pressure to “unlock the unconscious.” The proper intensity cannot really be defined a priori, and so what is the now-forbidden “challenge” is also not defined.”

So I’m getting the impression that we should hold off on challenge and use it much more sparingly.” Thanks to Jeremy for this request for more on premature challenge!

We use systematic challenge only with highly resistant patients with isolation of affect. Low and moderately resistant patients relinquish their defenses without needing their defenses challenged. Fragile and depressed patients cannot tolerate a high rise of feeling without becoming overwhelmed with anxiety, depression, or somatization. Challenging defenses causes a sharp rise of reactive anger which will overwhelm their capacities. As a result, challenge will make them flatten out, get depressed, or overwhelmed with anxiety and projection. So never use systematic challenge with depressed or fragile patients.

Although ISTDP gained some of its notoriety for the use of challenge, this intervention is used with only about 25% of patients (highly resistant with isolation of affect) and only after the defenses have formed a transference resistance.

When therapists do not realize the importance of helping the patient see the defenses and their price and function (restructuring of defenses), they often use challenge prematurely, resulting in misalliances. Also, if therapists have not been through their own therapy, their affect tolerance may not be high enough to identify and clarify the resistances in the highly resistant patient. As a result, when feelings rise, therapists may use challenge prematurely.

To deal with this problem some trainers avoid talking about challenge, relying only on pressure to feelings instead. Some avoid pressure to feelings, fearing that could be dangerous! Instead, they emphasize exclusively restructuring.

The truth is that in any complex model of therapy, we must see how all the parts fit together. Simplistic solutions will not do.

Challenge is a useful intervention, but at the right time, right place, and with the right person. I would urge you not to challenge defenses at all! If you are challenging a defense against a feeling instead of a resistance to emotional closeness, you are engaging in premature challenge. Wait until the defenses begin to work as a system to form a pathological relationship, the transference resistance.

Once the defenses coalesce into the transference resistance, identify and clarify the resistance. Once the patient can see his transference resistance, its price and function, THEN you can challenge the resistance and you won’t have to worry about a misalliance.

Having asked you not to be simplistic, I’ll be simplistic for a moment.

Fragile patients: invite feeling and regulate anxiety, identify and restructure projection and splitting. No challenge

Moderate resistance: invite feelings, block, identify, and clarify defenses. No challenge.

High resistance with repression: invite feelings, identify and clarify defenses and then ask for feelings toward you. No challenge.

High resistance with isolation of affect: invite feelings and identify and clarify defenses. When defenses coalesce into a transference resistance, identify the resistance and invite feelings toward you. Clarify the resistance and ask for feelings toward you. When the patient sees the resistance and its price, then you can challenge the resistance.