Category Archives: Projection

Projection

“Can you say more about specific interventions to deal with projections for fragile patients? One is to help them notice the thoughts and see if they see any evidence for that. Most say they don’t see any evidence but as you point out some don’t immediately tense up, still look afraid or say something like “but you can be critical of me inside of you anyway.” What interventions can we use if the evidence-intervention doesn’t work immediately? When do you use experiential deactivation?” Great question!

When fragile patients project, they experience complex mixed feelings toward the therapist. Unable to bear the experience of anger and love toward the same person, they project one of those feelings: usually anger. Now the patient imagines you are angry with him, and, thus, he fears you as the projection: what we call projective anxiety.

Fearing you, he is no longer in a therapeutic alliance with you. So you must help him see the difference between you and the projection, and you must build his capacity to bear his feelings inside without projecting them inside.

Pt: I’m afraid of you. [patient looks afraid, thus loss of reality testing]

Here is a series of questions you can ask to grade the amount of feeling the patient feels.

“That’s really good to know. Thanks for telling me.” Then follow up with:
1. What thoughts do you notice having about the therapy?
2. What reactions are you having about the therapy?
3. What thoughts do you notice having about the questions?
4. What reactions are you having to the questions?
5. What thoughts are you having about me?
6. What reactions are you having to me?
7. What feelings do you notice coming up here with me?
8. What thoughts do you have about those feelings?
9. What is it like to notice those feelings inside you?
10. What feelings are you having here toward me?

Often beginning with a low level of invitation here will clear things up and as you go up the ladder slowly, you will discover the level of invitation the patient has trouble with. That is the level of invitation you will work with and build up his tolerance from there.

We can grade our invitations to the patient to build step by step his capacity to bear his feelings even without asking about his feelings. In other words, you can tailor the dose of your invitation to the patient’s capacity to bear feelings. Often projection occurs because we started to invite feeling at a level that exceeded the patient’s level of affect tolerance. So if you bring the dose of invitation down, feelings will drop, projection will drop, and then you can gradually increase the level of invitation until the patient just starts to get a little dizzy (the moment before he starts to project). Then you can engage in bracing to build his capacity to tolerate mixed feelings at the level that he starts having trouble regulating his anxiety.

This is a key issue in working with fragile patients. Once you discover the threshold where projection occurs, we need to work at a level of feeling just below that threshold. Then we build capacity until the patient goes into repression or slight dizziness and then do bracing. That way you can avoid sessions that are flooded with projection. Of course, if you are working with severely borderline or psychotic patients, this is not always possible. But it is the aim. So if you start analyzing the level of invitation you are using and the patient’s response, you will have a much more finely tuned therapy.

If you try to do the usual cognitive strategy of restructuring projection and the patient sees his thoughts but still “fears” you, you need to do more restructuring. “So there’s a thought about the future. Is this a pattern for you that you have thoughts about the future? If we go to the future, we would bypass what your body is feeling now. So if we return to this moment, what sensations do you notice in your body that could be under these thoughts?” In this way, you block his rumination about the future and you return his attention to his body and regulating his anxiety.

If he is able to intellectualize about his fear of you in the future, and he holds onto it while seeming afraid, then you can say something like this: “Can we make room for this thought?” “As you make room for this thought here, what do you notice feeling as you just let this thought be here without having to do anything about it?” This can be very helpful with patients who think you are trying to take their projection away from them. (This often happens with patients who have had many therapies.) As they learn to tolerate their thought without doing anything about it, then I might ask, “So if you let that thought grow, how might you expand it? And if you let that thought become really big, how might you grow it even bigger? And if you really let go, how could you really let it grow?” After doing this with me, one patient said, “Wow! I’m really paranoid!” I replied, “Join my club. I’m a recovering paranoid myself.” She smiled.

Two take home points: when patients project, look at your interventions for the minute before projection occurs. See the level of invitation that is triggering the projection. Then you will see how to lower the level of invitation and build his capacity from there. When restructuring projection, help the patient intellectualize more and, if that doesn’t work, assess what other projections might be operating. For instance, in the last case I described here, she was not only projecting anger onto me, but she was projecting that I was trying to make her give up her projection. So when I encouraged her to elaborate on it, I deactivated the second projection and then we saw a large increase in self-reflective functioning.

Why is my patient talking so softly while hunched over?

“A young man with severe depression has a history of self-harm since he was 5 and severe neglect by parents, who told him to man up when he showed them the cuts he did to himself. We worked on his fear of opening up to me, and
how he hides behind vagueness. He speaks very, very softly while hunched over. In our last session, we talked about his stress at university. He talked about a lecturer who didn’t show up to 10 of their 12 lectures, and how because of that he now struggles in class. (Is this a strange person to work on, given that we
worked on more important people in past sessions?) He said anger quite clearly without defenses, and when I asked him how he felt it, he was able to say heat in the stomach, and the impulse to hit. But it was weird because he said this still
hunched over (elbows on knees), and with that soft voice. So I asked him
about it, and he said he has weekly episodes of derealization – where he
seems like he is a few meters behind his head and when he watches his
body, the body isn’t his. I asked if that was happening now, and he said he wasn’t sure, but maybe. This is very weird, any ideas? He does sigh once in
a while, but not much, maybe every 7-8 minutes, and his hands are limp.” Great question!
The fact that the patient speaks “very, very softly while hunched over” suggests that he is responding to a projection he has placed upon you. Perhaps he views you as a father who will tell him to “man up” as soon as he reveals himself. We don’t know. What we can be sure of is that if he was in relation to you, he would look at you, talk in a normal voice, and sit up.
When he appears to be relating to a projection, explore his thoughts and ideas about the therapy to find out what projections are in the room. “I notice you are talking very softly. I wonder what thoughts and ideas you might be having about the therapy?” When he tells you about his thoughts, you will learn what projections he is placing upon you. Then you can help him see the difference between you and his projections.
1) “So these are some thoughts your mind creates. What is that like to notice these thoughts your mind creates?”
2) “Are these the kinds of thoughts your mind often creates?”
3) “I wonder what reactions you are having to the therapy that might be under those thoughts?”
In this way, you first help the patient see his thoughts, then intellectualize about his projections. Once he can do that, then you can ask about “reactions” he is having. This is a very graded way of asking about feelings toward you.
Unable to tolerate the rise of feelings within himself, he projects those feelings upon you, and then he fears you.
When you asked about the anger toward the teacher, he reported that he felt anger. But there were no defenses! Why? Because anger toward the teacher was not mobilizing unconscious anxiety. It was not the path to follow. Instead, he was having feelings toward you, but rather than tolerate the feelings inside him, he projected onto you. Then he sat in fear, talking softly, hunched over in front of a supposedly angry therapist. He was projecting. And, to his credit, he revealed his cognitive/perceptual disruption: his derealization. And his limp hands reveal that his anxiety is not going into tension (striated muscles) but into smooth muscles or cognitive/perceptual disruption.
Take home point: when the patient talks in an extremely soft, submissive manner, ask about the thoughts he is having about the therapy to find out what projection he is reacting to. Then help him intellectualize about his projections to re-establish reality testing. Then you can explore the reactions (feelings) that triggered his projection. In this way, you build his capacity to bear feelings inside without projecting them outside.