Category Archives: Anxiety

When do you need to integrate the personality first?

Forming a relationship with another human being always triggers mixed feelings based upon our attachment history. As these mixed feelings rise, patients respond in one of five ways:

  • they tolerate the rise of feelings, sharing with you, and becoming more intimate;
  • they tolerate the rise of feelings, but start to unconsciously detach from the feelings;
  • they tolerate the rise of feelings, but start to detach from their feelings and from you;
  • they tolerate the rise of feelings, but protect you from their anger by turning it upon themselves
  • they cannot tolerate the rise of feelings, so they relocate their feelings and desires in other people.

This last group is known as the fragile group. When mixed feelings rise, they become overwhelmed with anxiety (cognitive/perceptual disruption). If anxiety continues to arise, to get rid of the anxiety, they get rid of their feelings through splitting and projection.

Once they split off and project their feelings onto others, they interact with the projections they place on other people, not with the people themselves. For instance, a fragile patient may project her anger onto others. Then she fears others upon whom she projects. Then she fears going out of her house. Another fragile patient, projects his anger upon others, imagining they are talking behind his back all the time. In response to this imaginary stimulus, he becomes chronically angry at his projection (the supposedly critical people).

Exploring feelings with this group becomes problematic. First of all, as soon as you explore feelings, the patients begin to split off their anger from themselves and project it onto others. Secondly, often, when these patients report being angry, they are reporting anger at a projection, not toward a person. If you explore their anger toward a projection, they merely become better at projecting!

Our first two tasks with this group are restructuring the unconscious pathway of anxiety discharge and restructuring the resistance system of projection. Doing these two things is referred to as “integrating the personality.” That is, we help the patient integrate within himself the feelings, impulses, and desires he formerly located in others.

Maury asked here, “When do we do that?” When patients are fragile. Signs that they need help with integrating what they formerly projected include: cognitive/perceptual disruption, splitting, and projection. Signs that patients are using projection (with loss of reality testing) are rapid speech (to keep a projection on you from criticizing her), speaking loudly (to drown out the projection the patient has placed upon you), urges to run from therapy or leave the session early (to leave the projected feeling in the room and run away from it), severe anxiety or panic in your presence (fear of the projection the patient has placed upon you).

Often, the patient will tell you about problems in her outer life that indicate projection is active in the room: “I’m afraid of people”; “I’m afraid of what people think, so I avoid them”; “I get into fights a lot”; “People are extremely critical”; “You can’t count on anyone at all”. Sometimes, projection emerges clearly in the room: “I’m afraid you will hurt me”; “How do I know you won’t misuse those videos!” “You look angry.”

One sign therapists often miss is the lack of signaling when the patient reports being angry. When the patient is angry at a projection, you will see no sighing or tensing. Why? No unconscious anxiety is mobilized because this is conscious anger toward a projection. Likewise, the patient will use no defenses to interrupt or ward off his anger toward a projection. Why? Because the anger is already toward a defense: the projection he placed on someone else.

Once you realize he is angry with a projection, stop exploring anger toward the projection, and start restructuring the projection.

Another sign is that when you ask if it is his will to do look at an important issue, he may agree, but not sigh. The absence of signaling always tells us that the patient’s will is not on line. But in this group the lack of signaling tells us that the patient is relating to a projection, not to you. There can be no conscious alliance if he is relating to a projection he thinks will hurt him. Thus, you have to differentiate yourself from his projection so he can have an alliance with you instead of misalliance with his projection. He lives in a world of projections, people he fears will hurt him. Once he owns his feelings internally, the world will become a much more benign and less frightening place. This is your first task.


Are some people born with the inability to look in our eyes?

“An adolescent walks into my office and says she has panic attacks every day, coming out of nowhere. She has anxiety in the smooth muscles and no signaling in the striated muscles. She says she has a very mild autism diagnosis, and never has been able to look people in the eyes. If she does, she instantly suffers cognitive/perceptual disruption. When she looks at me in the office, she looks only at my nose or between my eyes.
When I ask if she would like to work on this “problem” so she can look people in the eyes and become emotionally closer, she replies that she will not be able to because she has autism. I would like to challenge that understanding, but I´m no expert in autism. Can it be, that some people are born with the inability to look into another person’s eyes without becoming intensely distressed?”
Of course, without looking at a video we have no way of assessing whether this patient has autism or not. Clearly, feelings rise quickly triggering high anxiety that goes into cognitive/perceptual disruption. So she is fragile and this problem could be treated through regulating her anxiety, and developing her capacity to tolerate feelings without excessive anxiety. Rather than go straight to eye gaze, which arouses too much feeling for her to tolerate, you can ask her about her thoughts about therapy, her reactions to therapy, her thoughts about you, and her reactions to you, until you finally ask about feelings toward you. This graded exploration would build her capacity to tolerate increasing amounts of feeling while anxiety remains regulated.
As for the question of eye gaze, in fact, many autistic people have gained this capacity over time with skilled help. What can be forgotten is that most autistic people suffer from terribly unregulated anxiety. Their autonomic nervous systems are dysregulated. See Porges’ writings for more on this. So the first task is to regulate their anxiety and then build their capacity gradually. In fact, as Stanley Greenspan once pointed out to me, autistic people are always making eye contact. However, they do so fleetingly and out of the corner of the eye. So the issue is not black and white, gaze or no gaze. The issue is the dosage of contact the autistic patient can tolerate before becoming dysregulated. At least that is what I understand from people who have treated them.
So your patient need not despair about being able to look people in the eye. But there is no need to propose this goal to her at this time, since it exceeds her capacity for anxiety tolerance. As you work with her in a graded fashion at much lower levels of feeling, you will build her capacity, and her ability to look people in the eye will increase simply because her ability to tolerate emotions will be increasing.
She is very fragile. So just regulate anxiety and invite her to cognize about the therapy relationship. As you explore her thoughts about the relationship, feelings and anxiety will rise. When it’s too high, regulate it, and then continue. Step by step you will build her capacity for affect tolerance so that relationships will be possible.