“When do you process anger toward the therapist? I understand that doing so can be very helpful and lead to breakthroughs, but I have also read that when patients are experiencing projective anger we should not process the anger but deactivate the projection. Then some patients get angry with us because of misunderstandings. Should we process their anger then or should we clear up the misunderstanding. For example, if a patient says they are angry with me for interrupting their long, detailed story because they perceived that I was bored or annoyed would it be better to process those feelings of anger or clarify that I wasn’t bored, but rather trying to interrupt what I perceived as the defense of story telling. I guess if I had some rules of thumb about when it is effective to process anger in the T that would be very helpful.” Great question!
You are not alone. As you rightly point out, this is a complex topic that does not yield a single answer. Anger can arise for many reasons.
Anger arising as a result of exploration.
When you explore the patient’s feelings and help him see defenses, this will cause emotional intimacy to increase in the therapeutic relationship. This rise in intimacy will trigger mixed feelings toward the therapist. On the one hand, the patient is glad. On the other hand, the he feels angry. This anger, a transference feeling, arises organically as a result of the therapy process. We explore it.
Th: You seem to be having a reaction to what I’m saying. What feelings are coming up here toward me?
Anger resulting from a misunderstanding where you could lose a conscious alliance.
A patient says he is angry because he doesn’t think the therapy is working. When he does so, we see no sighing. If the patient really believes the therapy is not working, the anger is the result of a misalliance. “I want you to help me. I don’t think the way you work with me is helping.”
We don’t explore this anger because it would worsen the alliance. After all, he just said the way you are working is not working. Why do more of it? Instead, check in with the patient and see if the two you can get consensus on what is causing his problems and how the two of you should work together.
Pt: “I don’t think the way you work with me is helping.”
Th: “Thank you for letting me know that. Obviously, you came here because you want to feel better, overcome your depression, and improve your marriage. We share that goal in common. Let me know what I’m doing here that is not helping you so we can see how we can make sure we get on the same page.”
He doesn’t think the therapy is working and believes it. Take him seriously. Find out what he thinks is not working. Then make sure you have consensus on the problems and what causes them. Then make sure you get consensus on the task. If you don’t have those forms of consensus, you will get a misalliance and lose a patient.
Anger arising from projection, leading to loss of reality testing.
If a patient projects that you are judging him and he believes that projection, he will be angry at you, as if you are a judge. Don’t explore his anger at you as the judge because that will only strengthen his projection. Instead, restructure the projection and re-establish reality testing so he can differentiate you from his projection. Then he will have an alliance with you instead of a misalliance with his projection. Examples of this can be seen in my book and in other blogs.
Anger due to interrupting the patient’s train of thought. No sighing.
Pt: “I’m getting angry at you. You keep interrupting me. I don’t like this at all.”
Here the patient does not understand the process or therapeutic task and is at risk of leaving therapy. The lack of sighing tells us that there is no unconscious anxiety. Thus this is not unconscious rage based on earlier figures in his life. Instead, it is conscious anger toward a therapist she really believes is not listening to her.
Th: Thanks for letting me know. Let me just check in with you. It’s true. I have been interrupting you when you criticized yourself. [Validate her.] When you criticize yourself, is that making you depressed? [Help her see the price of the defense.]
Th: Do I have your permission to interrupt any self-criticism that I think might be hurting you and making you depressed? [Show her why you intervene when you do: to interrupt harmful defenses, not her.]
Pt: Now that you put it that way yes. Thanks for asking permission. Now I understand.
Anger due to interrupting their train of thought.
The patient says he is angry because you interrupt his train of thought, but he sighs and is detached. Since he sighs, we can explore feeling. And since he detaches, we can address his wall of detachment.
Pt: You keep interrupting me! [sighs]
Th: And you are having a reaction to that. What is the feeling here toward me?
Take home point: when anger arises in the session, assess what causes it: growing intimacy in the therapeutic alliance, misunderstanding, projection, or therapist error. Once you know the source, you can help the patient.