“I’m glad she’s dead!”

“I’ve gotten to the point in my training where I can start helping patients with murderous rage. However, some patients switch to a cold, hateful position toward the object, with no signs of anxiety. My thinking is that they’re splitting or shutting down their mixed loving feelings, and that portrayal of this black-and-white rage would only be destructive. I’ve tried reminding them that they are angry with someone they love. But some patients lose the anger and become anxious instead. How can I help these patients tolerate and experience their full mixed emotions?” Thanks for this important question!
In life our loved ones can only deliver, delay, or disappoint. Thus, the experience of love and anger toward the same person is inevitable. The question becomes: how do we deal with those mixed feelings? Some people detach from their feelings. Some people feel love toward us and turn the rage upon themselves, becoming depressed, suffering somatic problems. And others, unable to tolerate these mixed feelings, split them apart, and project them onto other people.
The patient feels rage toward a neglectful parent. Yet this neglectful parent almost always was at times kind and loving. The patient, when facing his feelings, feels both rage for the harm she did and love for the good she did. But if he cannot tolerate the grief, pain, and guilt aroused by these mixed feelings, he will split his love apart from his rage. He will claim, “She was never any good to me.” He will devalue her, calling her a “bitch” or worse. If he admits loving feelings toward her in the past, he will maintain that, “It was only because she fooled me.” Typical comments that indicate splitting are: “I’m glad she’s dead.” “I would just burn him up.” “I would spit on his body.” These are not expressions of guilt but of contempt and devaluation, the results of splitting.
Now he views her as “all-bad” and feels only rage toward her; no love, no grief, no guilt. Thus, no anxiety. Remember: anxiety is not triggered by rage; it is triggered by the mixed feelings of love and rage. If the patient splits his love off, and feels only rage toward this “all-bad” person, he will feel no anxiety over expressing his rage.
If we mistakenly encourage the patient to feel and express this split-off rage, we will only help him get better at splitting and devaluation! That would be destructive. Rather than explore his split-off rage, we need to address the splitting of his rage from his love. That way he will be able to face the love and rage within himself and the good and bad of the other person.
When we remind him of his love toward the person toward whom he feels rage, these mixed feelings will trigger guilt and anxiety. This is a positive sign, building his capacity to tolerate mixed feelings without splitting or projection. In the example, the patient stops being angry and feels “anxious” instead. In fact, the patient is feeling anger, plus love, thus anxiety. At that moment, simply remind the patient, “So you feel this anger toward your mother whom you love, and this mobilizes some guilt and anxiety.” Later, you can point out how he devalued his mother to avoid his love, rage, guilt, and anxiety.
Take home point: therapy is not about rage, it is about embracing the fullness of our humanity (our love and rage) and embracing the fullness of the other person, who has both good and bad qualities. If we encourage splitting, the patient never learns to embrace his humanity nor the humanity of those he loved.

How to Build Capacity

Ever try to help a patient feel his feelings and get stuck? Did he keep saying he didn’t know where he felt his feelings? Or did he get depressed and feel worse? Or did he begin to accuse you of trying to control him? Inviting feelings is supposed to help, but in these examples it didn’t. Why?

Inviting feelings does two things: 1) it mobilizes feelings toward you because the patient senses your genuine wish for connection; and 2) it mobilizes the resistance system (defenses), which causes his presenting problems. And we discussed before the three resistance systems patients use: projection, repression, and isolation of affect. So let’s see how to invite feelings to build the different capacities necessary in each group.

Patients who use projection cannot tolerate feelings inside, so they project them outside. You meet them. Feelings and anxiety rise. To avoid the rise of anxiety, they project the feelings onto you and others.

Capacity to be built: ability to tolerate feelings inside without projecting them outside. So how do you invite feelings: “What feelings do you notice having here toward me, if you let the feelings be inside you for a moment?” Notice that we not only invite feelings, but we encourage the capacity to be built (experiencing feelings inside) while blocking the defense (projecting feelings outside).

Patients who use repression can tolerate feelings inside, but they cannot tolerate anger toward you. So they feel love toward you and turn the anger upon themselves. You explore feelings with them. Feelings and anxiety rise. Then they turn the anger toward you upon themselves through self-attack, depression, getting tired, weepiness, somatization, or character defenses.

Capacity to be built: the ability to tolerate anger toward you without turning it upon oneself. So how do you invite feelings: “What feelings do you notice having here toward me, if you let them come here?” “If you don’t protect me and don’t hurt yourself, what feelings are coming up here toward me?” Notice that we not only invite feelings, but we encourage the capacity to be built (experiencing the mixed feelings toward you), while blocking the defense (turning anger upon the self).

Highly resistant patients who use isolation of affect can tolerate feelings inside without engaging in self-attack, but they detach from their feelings by detaching from you.

Capacity to be built: the ability to feel mixed feelings toward you without detaching. So how do you invite feelings: “What feelings are coming up here toward me right now?” As the resistance rises, we point out the resistance and ask for feelings toward us. “Notice how you look away and avoid my eyes? Notice how this avoidance is coming up as a barrier between us? What feelings are coming up here toward me that make you put up this barrier?” As the patient lets go of the resistances by which he distances from people, his character resistance drops, and his essence emerges. Emotional closeness now becomes possible.

Take home point: inviting feelings takes many forms and is tailored according to the specific capacities we are trying to build and the defenses we are trying to block.