Category Archives: Projection

When do I ask for feelings toward me?

“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.]

Pt: Yes.

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.

How to Handle Three Kinds of Projection

Thanks for this question. And the answer is: it depends. For simplicity’s sake I’ll discuss projection as it occurs in three kinds of patients: fragile, depressed, and detached/uninvolved.

Fragile patients experience their anxiety in the form of cognitive/perceptual disruption. When they project upon you, they lose sight of the difference between you and the projection. Thus, they become scared of you or angry with you. This is a loss of reality testing: the inability to differentiate you from the fantasy they have of you.

Since their anxiety is in cognitive/perceptual disruption, and they suffer from a loss of reality testing, we have to restructure the projection so they can have an alliance with you rather than a misalliance with their projection.

Th: You seem anxious. Are you aware of that?

Pt: Yes. I’m scared of you. This room seems really intimidating. [projection and loss of reality testing.]

Th: Thank you for letting me know. What thoughts do you have about me? [Explore the content of the projection.]

Pt: I’m afraid you want to hurt me. [projection]

Th: I’m not aware of any wish to do so. Is there any evidence you have that I want to hurt you?

Pt: No.

Th: So although there is a thought about hurting [symbol] there is no evidence for that thought. [reality] [Now the therapist watches to see if the patient can bear the anxiety that rises when she takes back what she projected.]

Pt: [tenses up] No. But it feels that way.

Th: That’s why it is important for us to check to see if the feeling fits the facts. Is there any evidence that I want to hurt you? [Contrast her fantasy with reality.]

Pt: No. [Alliance restored.]

Th: So I wonder what feelings you might have here toward me that are underneath that thought?

Depressed patients also use projection but it takes a different form and requires a different strategy. When they experience feelings toward you, their anxiety rises and moves into the smooth muscles. They turn anger they feel toward you onto themselves. That makes them depressed. As a second step, they may project that you are angry or critical toward them. They may start to become a little afraid or sad, somewhat convinced that you are critical of them.

Pt: You think I am fat. [Projection]

Th: Is there any evidence I think you are fat?

Pt: No.

Th: So there is a thought about criticism. Is there any evidence I am criticizing you?

Pt: No. I’m such an idiot. [Now she shifts from projection to self-attack.]

Th: Could that be a critical thought? [Identify the defense]

Pt: Yes.

Th: Could that make you depressed? [Clarify the price of the defense]

Pt: Yes.

Th: I wonder what feelings are coming up here toward me if we look underneath the self-criticism? What feelings are coming up here toward me?

Pt: What?

Th: What feelings are coming up here toward me?

Pt: I don’t know. [weepiness stops]

Th: Wouldn’t it be nice to know what you feel, so you wouldn’t have to feel depressed instead?

Pt: Yes.

Th: So can we take a look? What feelings are coming up here toward me?

The patient’s primary form of resistance is repression: she turns rage toward the therapist upon herself. When she projects her reality testing is only slightly compromised. Quickly clarify the defense, then immediately ask for feelings toward you. When you invite feelings toward yourself, the patient does not have to turn them onto herself. This unconsciously restructures the resistance of repression.

Exploring feelings with the highly resistant patient, who uses isolation of affect as his resistance, triggers feelings toward you because you are becoming emotionally intimate. To detach from his feelings toward you, he detaches from you. His anxiety is in the striated muscles. He uses projection as a tactic to keep you at a distance.

Pt: You seem to think I should take a look at this. [Projection of will. No anxiety.]

Th: Only you can know if this is something you want to look at. So what is the problem you would like me to help you with? [Block the projection and continue to ask for the problem.]

At higher levels of feeling, the highly resistant patient with isolation of affect can use another form of projection.

Pt: I think you are arrogant. [Anxiety in striated. Patient is detached and distancing from the therapist.]

Th: This still doesn’t say what the feeling is here toward me. Notice how you put up this wall of thoughts between us? What is the feeling here toward me that makes you put up this wall?

In his case, we treat his projection as a barrier he puts up between the two of you to keep his distance. It’s usually the same wall he maintains with others.

Let’s compare these three patients.

Overwhelmed

Anxiety: cognitive perceptual disruption

Form of resistance: projection

Loss of reality testing

Spectrum: fragile

Function: Since I cannot tolerate the anxiety rising due to conflict within myself, I project part of myself onto to you to eliminate internal conflict.

Result: fear of therapist

Intervention: restructure the projection, and then ask for feelings

Depressed

Anxiety: smooth muscles

Form of resistance: repression

Mild impairment of reality testing

Spectrum: highly resistant with repression

Function: Since I cannot tolerate the anger toward you, I protect you by turning it upon myself.

Result: weepiness and depression

Intervention: light restructuring, restructure repression, and then ask for feelings

Detached

Anxiety: striated muscles

Form of resistance: isolation of affect

No loss of reality testing

Spectrum: highly resistant with isolation of affect

Function: Since I feel mixed feelings toward you, I avoid them by detaching from you.

Result: detached from the therapist

Intervention: address the interpersonal wall, and then ask for feelings

Take home point: how we address projection depends on the pathway of anxiety, system of resistance, and level of reality testing. Once you understand these, you can tailor your intervention to the patient’s specific capacity. We restructure the fragile patient’s projection to establish reality testing and then we ask about feelings toward the therapist. We can quickly clarify the depressed patient’s projection, and then we ask about feelings toward the therapist to restructure the resistance of repression. We treat the highly resistant, detached patient’s projection as a wall he puts up to distance from the therapist. We identify his wall and its function, and then we ask for feelings toward us that make him put up that wall. So when the patient projects, is he: 1) afraid of you (fragile); 2) getting depressed (repression); or 3) detached (highly resistant with isolation of affect)?