Category Archives: Transference

How do I know if the Patient is Fragile and Projecting his Will or Highly Resistant and Engaging in a Transference Resistance?

If the patient is fragile and projecting his will onto the therapist, his anxiety will be discharged in cognitive/perceptual disruption. His other defenses will be regressive, like splitting, weepiness, and externalization. He will lose some of his reality testing, now beginning to fear the therapist’s will and where the therapist is going to “make” him go in therapy.

If the patient is highly resistant, his use of projection will be a tactical defense, a mechanism to keep the therapist at a distance. The patient’s anxiety will be in the striated muscles and we will see sighing. The patient’s other defenses will be repressive and tactical. Since the patient’s reality testing is good, he does not equate the therapist with the projection. As a result, he is calm and dismissive with the therapist. Whereas the fragile patient is afraid of the therapist upon whom she projects her will, the highly resistant patient is quite comfortable projecting his will onto the therapist. He sits passively while waiting for the therapist to work. The fragile patient who projects is afraid of where the therapist wants to explore. The highly resistant patient looks forward to watching the therapist try to explore.

If you deactivate the fragile patient’s projection of will, his projective anxiety will drop, he will calm down and he will engage in the therapeutic task. If you deactivate the highly resistant patient’s projection of will, he may readily agree with you that it was his will to come to therapy but he will remain uninvolved, passive, and unengaged in the therapeutic task. His anxiety will not drop because he did not have any projective anxiety. His anxiety will not rise because he will remain uninvolved. These responses simply tell you that his problem is not fragility or projection of will but resistance to contact with the therapist. Thus, the therapist can begin to address the resistance to contact with the therapist, “Do you notice how you look away right now?”

When differentiating fragility and projection of the will from transference resistance, assess the pathway of anxiety discharge, the types of defenses used, the patient’s reality testing, and presence or absence of projective anxiety.

 

 

How Do I know when to Ask about Feelings toward the Therapist?

It’s so easy to ask the patient about feelings toward parents in the past and spouses in the present. But asking about feelings toward the therapist? When do we do that? In a previous blog I talked about non-verbal signals that tell you when to ask about feelings toward the therapist. Now we’ll talk about verbal signals.

Signals. That’s the key. Often a therapist says to me, “should I shift into the transference?” No. The therapist never shifts into the transference. The patient does. We simply follow the patient’s shift. The problem becomes one of recognizing when the patient has shifted from defending against feelings to resisting contact with you.

Suppose the therapist asks the patient about his feelings toward a girlfriend. The patient looks down at the floor then says, “I shut down.” His gaze away from the therapist is a non-verbal signal that he is resisting contact with you. So when he says, “I shut down,” he not only shuts down on his feeling. He shuts down with you. Your response could be something like, “You shut down on your feelings. And you look away. So there is a wall of shutting down coming in here between you and me. What is the feeling here toward me that makes you shut down?”

Suppose the therapist didn’t notice that signal and said to the patient, “If you don’t shut down, what is the feeling toward your girlfriend?” In response, we would see no sighing. Why? The patient is not defending against feeling. He is warding off contact. If the therapist asks about feeling, no anxiety will rise. If the therapist notes how the patient distances, the patient’s anxiety will rise. In response, to the therapist’s question, the patient sighs and says, “You seem to want me to look at these feelings.” This is projection. But it is projection as a tactical defense, a tactic to keep the therapist at a distance. The patient is calm, not frozen with fear in front of a therapist whom he equates with a projection. In response to the patient’s statement, “You seem to want me to look at these feelings,” the therapist can simply say, “So what is the feeling toward me?” Here, asking about the feelings toward the therapist blocks the patient’s distancing tactic and maintains an effective focus: the feelings toward the therapist that lead the patient to distance from the therapist. When the patient refers to what the therapist wants, this is a verbal signal that the patient is having a reaction to the therapist. That’s why the therapist will focus on that reaction and the feelings which are getting stirred up.

Let’s suppose the therapist asked again about feelings toward the girlfriend. This time the patient again resists contact with the therapist by replying, “You are reaching a point where I want to close you down.” This is another signal that the patient is resisting contact with the therapist. The patient’s reference to the therapist is a signal to ask about the patient’s reaction and feelings. “So what is the feeling here toward me that makes you want to close down?”

We don’t shift into the feelings toward the therapist. We simply follow the patient’s lead. When the patient shifts from warding off feelings to warding off contact with you, he has shifted. When we see that shift, we acknowledge it by asking about the feelings toward the therapist that lead the patient to begin to avoid contact.