Category Archives: Projection

I hate therapists!

“I’ve been thinking about when to ask for feelings towards me. But I am still unclear when a feeling is based on a projection (in which case we clear it up) or a transference (which we explore). A client comes to mind. At his first session he raged at his previous therapist, whom he believed judged him. Security then removed him from her offices. Then he told me he hated my profession because of his last therapist. I didn’t address this in detail as I didn’t know what to do.” Great question!
The patient believed his previous therapist was judging him and then raged at her based on that projection. His loss of reality testing was so profound, security personnel had to remove him from her office!
Let’s take a look at the triangle of conflict. He comes to a therapist who invites him to look at his inner life. In response. like all patients, he experiences a mixture of feelings toward her for this offer of a relationship. The question is how he deals with those feelings. Moderate resistant patients can tolerate the feelings and still collaborate. Highly resistant patients with isolation of affect distance and detach from the therapist. Highly resistant patients with repression become depressed and somatize turn the anger inward and protect the therapist. Fragile patients cannot tolerate feelings internally, so they project those feelings onto others.
This patient projects his anger onto therapists, believes they want to judge him, and then he rages at the projection he places on the therapist. If you explored his rage, you would only reinforce his projection, making him regress.
Th: “Is there any evidence I am judging you?”
Pt: No. It just seems that way.
Th: “So although there is a thought about judgment, we don’t see any judgment here in me. Sometimes people who fear judgment tend to judge themselves too much. Is that something you have suffered from?”
This deactivates the projection onto you. Step one.
Th: “So coming here to let me know about yourself stirs up some feelings. They make you anxious, and then there is some self-judgment that comes up. Any ideas what feelings might be coming up here with me in the therapy?”
Why focus on feelings toward you? Feelings toward you mobilize anxiety and then he projects. Once we clear up the projection, we explore feelings toward us, building his capacity to bear feelings internally, so he doesn’t have to project them onto others. He learns to feel rather than project his feelings. This is the first step in integrating the personality of the fragile patient.

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.