Category Archives: Guilt

Guilt or self-punishment?

“A client separated from his wife, but left his kids with her, and they suffered when she neglected them, often leaving them alone at home. He began to lead the life of a hermit, throwing himself into work, and detaching himself from everyone but his kids whom he met on weekends. Now that he is getting old, and his business is in crisis, he feels guilty for immersing himself in work as a defense against his feelings of anger, loss, grief and guilt. We have done a lot of work and he is far better today. But he ruminates about his son who is not married, nor settled professionally, and he blames himself for leaving his son with his mother at age five. Or he worries about his unmarried daughter—what if she falls ill or gets into an accident and is alone with nobody to care for her? When he ruminates about other close family members, he often calls them to ensure they are safe.
What are the interventions to make to help him face his guilt over leaving his children? And how do we address his obsessive rumination over the safety of others? Is the rumination a projection of anger or is it rooted in his guilt too?” Thank you for this important question!
While divorce may be the right thing to do, it always causes pain for others. In this case, there is the additional pain this man suffered because his ex-wife neglected their children. Thus, he inevitably feels guilt about his choice and its consequences for his children. However, as we look more closely, the picture is more complicated.
He ruminates (defense) about a son who is not married or settled professionally. This raises the possibility that he may be angry with his son for not living up to his expectations, and that rumination may be a form of self-punishment. The only way to test that hypothesis is to explore feelings toward the son and see if those feelings trigger anxiety and defense. Then you will find out whether the rumination is a form of self-punishment, not guilt.
He ruminates (defense) about his daughter, worrying about her falling ill with nobody to take care of her. Again, we would want to explore feelings toward his daughter who had moved far away. Is his rumination a defense against his anger toward his daughter for leaving him and moving far away? Or is he projecting upon her his own worries about being ill, alone, without someone to take care of him? Only exploring feelings toward the daughter will allow us to test these hypotheses.
He ruminates about family members, and then he calls them to put his fantasies to rest. Since the ruminations make him suffer, they are defenses. Thus, we might explore feelings toward each family member he ruminates about to find out what feelings are underneath his ruminations.
If you can help him face his feelings and feel them, he won’t have to ruminate as a form of self-punishment for having those feelings.
In other words, there is a lot of exploring of feelings necessary here in order to get clear about the triangle of conflict in each example. However, here is a big hint. When we talk about guilt in ISTDP, we are usually referring to UNCONSCIOUS guilt, buried under defenses.
The conscious guilt that patients report almost always has a defensive function. For instance, a patient might report feeling conscious guilt about leaving his son as a child, but this may ward off unconscious guilt due to his current rage with his son for failing to meet his expectations.
Just as conscious guilt can ward off unconscious guilt, the conscious crime may distract us from the real one. A person might say she feels guilty about snubbing a colleague at a work party, but exploration may show she actually feels much more guilt over having stolen the credit for a report written by her colleague who now will not get a promotion.
Remember that whatever guilt patients report is what the defenses allow to come to the surface. Conscious guilt distracts us from other deeper feelings. For instance, doesn’t it sound better to say, “I’m worried about my daughter’s health,” than to say, “I’m furious with my daughter for leaving me here all alone when she should have stayed nearby to take care of me!”
If you can help him face his rage and complex mixed feelings toward his children, he will no longer have to punish himself through his rumination, and then he can accept the loss of a child he always has loved and always will, even if from afar.

Problems working with guilt

When patients experience their unconscious rage in therapy, they often do not experience their love and guilt. Why? Also, how do you work on anxiety when it goes too high during guilt work? What defenses do you look out for and how do you work with them? Why doesn’t guilt and love come through?

Thanks to Reza for these questions!

In all therapy relationships, mixed feelings rise toward the therapist, feelings based on the patient’s previous experience. Love arises because the patient wants to connect. Rage arises because previous connections hurt the patient.

Those mixed feelings trigger anxiety and defenses, which create the patient’s presenting problems. So the therapist helps the patient see and let go of those defenses to face the underlying feelings that have been driving a pattern of self-punishment through defenses.

To do this, the therapist explores feelings in a current, past, or therapy relationship. As the therapist helps the patient face and let go of defenses, often anger is the first feeling to break through. Once the anger breaks through to someone we love, however, guilt arises. Why? The rage is felt toward someone we love. That combination of love and rage toward the same person triggers guilt.

To avoid the anxiety triggered by the love and guilt, the patient may use defenses such as denial or devaluation. In my book, Co-Creating Change, (chapter on breakthrough to the unconscious) you will see how I suggest you work with sixteen different defenses that arise at that very moment, defenses that will prevent the breakthrough of the love, guilt, and grief.

However, sometimes the patient begins to experience the love, grief, and guilt, but has trouble bearing these powerful emotions and becomes overwhelmed with anxiety. If so, cognize about the anxiety briefly, make the link to the guilt, and build the patient’s capacity to bear this much guilt without becoming overwhelmed with anxiety.

Th: Notice how you are becoming dizzy? So we see that as soon as we touch on this guilt, you become anxious, and then your mind becomes dizzy. See that?

Pt: [sighs or tenses up] Yes.

Th: So what does you father’s face look like as you see what you did to him? [Explore images that will trigger higher levels of guilt so you help build the patient’s capacity and enable him to have a fuller unlocking of his unconscious.]

We call this a “pocket of fragility”. The patient is temporarily too anxious, but a brief summary is enough to regulate anxiety and we continue to go for as high a rise of feelings as the patient can manage.

Why don’t guilt and love come through after the rage? Defenses or anxiety block the way. Why?

Sometimes the therapist goes for a premature breakthrough before having explored feelings long enough to mobilize the unconscious enough to have a breakthrough. I have seen therapists go for a breakthrough after asking for feelings only three times…instead of after twenty or thirty minutes!

Sometimes the patient has shifted from resisting feelings to resisting emotional closeness. Thus, the patient is distancing from the therapist with a transference resistance. If the therapist does not see this, no breakthrough will be possible. See my earlier blogs on signs of the emerging transference resistance.

Sometimes the patient’s resistance is in the system of projection or repression where further restructuring is necessary before a breakthrough to complex feelings would be possible, or even advisable! Premature breakthroughs with these groups of patients can lead to regression or depression.

Sometimes the therapist does not recognize the defenses which are preventing a rise of unconscious feelings. If we address the wrong defenses, the unseen defenses will block the way. That’s why having an expert look over your videos is essential. He or she can help you see what you need to do to help the patient further.

If love and guilt do not arise after a breakthrough to rage, look for the defenses that are getting in the way. If you help the patient feel only rage, without her love and guilt, we only help her get better at denying her humanity through denial, detaching, projecting, or devaluation. Experience of rage by itself is almost never helpful. Our task is to help the patient embrace the fullness of her humanity: her rage, her love, her guilt, her grief, and her wish to connect.