Transference Resistance: A Case Example

High Resistant Patient who presents with a Transference Resistance in the Forefront
By Jon Frederickson, MSW

Male client (Slouches down in the chair holding hands.)

 

Th: What is the internal emotional problem you would like me to help you with?

 

Pt: Um, (Looking up and avoiding eye contact with therapist, rolling head back and forth on back of chair: non-verbal defenses against emotional closeness.) let’s see the immediate issue is I have a really hard time, um, controlling my temper.  Um and ah, I get into arguments with my wife and I get very angry and it is very unpleasant, unpleasant for me, unpleasant for her.  And uh.

 

Th: Uh hum.

 

Pt: This is, has been something that I’ve had for a long time.  It’s not, I, you know (gestures), I don’t hurt anyone (gestures) or whatever but there is yelling and it is almost frankly like at times, (smacks his lips: dry mouth, sympathetic nervous system discharge of anxiety) it is almost like a different person (gestures) you know, something that is very hard for me to control.

 

Th: Uh huh.

 

Pt: And uh, some of it is (looking up and away, rolling head back and forth, gestures) you know, almost like some of its triggered by a certain kind of situation, or certain kind of pattern, or certain kinds of interaction will trigger it, I know that.  But it is also, well, it is disproportionate to the situation, if you will.

 

Th: Uh huh.

 

Pt: I’m looking (chuckles), uh,  for a way, you know,  to try to kind of either figure out a way to spot it before it comes, figure out what is triggering it and how to control it before it comes out or somehow to modify that (looking up and away).

The patient gives a fairly clear description of his presenting problem: angry outbursts with his wife which he realizes are disproportionate.  However, non-verbally, the patient reveals that he is uninvolved and detached, signs of defenses against becoming emotionally close with the therapist.  His anxiety so far is discharged into the somatic nervous system (striated muscles), and the sympathetic branch of the autonomic nervous system (dry mouth).  Although the patient has declared a fairly clear internal emotional problem, the non-verbal defenses reveal that his will to engage in the therapeutic task is not yet available.  Non-verbally he is letting us know we do not really have permission to begin exploration of his internal problem.  Thus, our first task is to get his will online.

 

 

Th: So the main problem you are having here is that there is a tendency to have angry outbursts.  It is not involving hitting but more of a sense of feeling really angry inside and taking the form of yelling and arguing.  You are saying that this predates the relationship with your wife but it comes up with your wife and it obviously has its source before then.  You are concerned about the anger and the way that it comes out and that you can see that there are different triggers and when it does come out.  You say that you are concerned about the way that it comes out.  You can notice that there are different triggers for it and when anger comes out it is disproportionate to the situation and you are concerned about it.

 

Pt: Right.  I have two kids, two girls.  I don’t want to be behaving this way in front of them.  [His defense of outbursts is somewhat dystonic.]

 

Th: Don’t want them seeing this kind of disproportional reaction.  Yeah.

 

Pt: So, that is the immediate issue.  That is the immediate issue.

 

Th: Yeah, and that is what you would like me to help you with?

 

Pt: Yeah.  [His diffident tone of voice reveals his resistance to emotional closeness.  But since his will to engage in the therapeutic task is not yet online, I don’t have permission to comment on his behavior yet.]

 

Th: Okay, good.  Yeah.  As we begin, I will be inviting you to pay really close attention to anything that you are feeling inside, any kind of anxiety that comes up or any kind of reaction, any feelings inside, any kind of reactions.  Any kinds of shifts in our connections in here because what you are saying is that there is feeling that takes you by surprise that comes up quickly that you would like to control.  We want to pay really close attention moment by moment to any feeling you have, any anxiety, any shifts or reactions you are feeling that you are having with me so that we can have.  [I invite the patient to engage in the therapeutic task.]

 

Pt: I won’t explode up front.

 

Th: Listen, if that urge comes up it will be a wonderful opportunity for us to see what got triggered.  And, as you say, you do not want to explode.  You say that you have some kind of reaction pattern happening inside and you say you would like to have a better handle on it and you would like to know.

 

Pt: Right.

 

Th: So if you have a big reaction like that, it gives us the opportunity to look what is happening and see what got triggered because you are saying somehow something is happening and this gives us an opportunity to think in a microscopic way to see what is going on underneath that leads to the kind of behaviors that you are not liking that you are not feeling so comfortable with yourself.  So as we are beginning what are you noticing here today?

 

Pt: Um (sighs: rise in complex emotions and anxiety when I invite him to reveal what he is feeling.)  I don’t know [Defense] it feels, you know, a little awkward I guess.  [He has a slight awareness of his anxiety.]

 

Th: Yeah.  How do you experience that awkwardness as we begin?  [I assess whether he is able to pay attention to his anxiety.]

 

Pt: Ayyyyyyyyy, I don’t know.  [Defense.] It, it feels, it feels (gestures) I don’t know [Defense], it feels, I don’t know [Defense], it feel slightly funny I guess [‘I guess = the defense of vagueness.], you know (gestures), and the situation seems kind of artificial. [Defense: he ignores the anxiety in his body and focuses on the therapy instead.  This tiny invitation to emotional closeness has triggered five defenses in short order.]

 

Th: It is. It is isn’t it?

 

Pt: Yeah.

 

Th: It is artificial.  Let’s face it.  It is an artificial situation.  You come here to an artificial conversation to have a look at certain situations that you have with no one else, to have a look at things you don’t look at anywhere else.  You are letting me know that it feels a little awkward to begin this, sort of artificial.  I mean it’s for a purpose.

 

Pt: Yeah.

 

Th: So it is important for us to notice that.  I appreciate your willingness to be so collaborative.  How do you notice it?

 

Pt: Well (smiling), I do that in awkward situations.

 

Th: Yeah, the way that you deal with meaning…?

 

Pt: I mean it is when I don’t, when I don’t feel like (Looking up and away still slumped: non-verbal defenses.) you know, the, you know.  It is an artificial situation and you are a very intelligent guy and yet it is a very sort of structured, sort of formal interaction.

 

Th: Exactly.  Yeah.

 

Pt: It just seems weird to me that’s all.  Which I understand.  I understand but it seems weird.

 

Th: Yeah. This is a weird relationship.  You come here to ask me to help you look at your feelings [I point out the stimulus to his feeling and anxiety: our joint decision to form a therapeutic alliance and to become emotionally close.] and we are here to look at your feelings in this weird situation and it is weird.  Do you want to do this weird thing?  [Mobilize his will to the therapeutic task.]

 

Pt: Yeah. Oh definitely.

 

Th: So you want to do this weird thing.  You want to look at your feelings in this weird situation and you say that you feel a little awkward.   [Point out causality: becoming emotionally close in therapy triggers his anxiety (awkwardness).]

 

Pt: Yeah.

 

Th: How do you experience this awkwardness, this weird feeling inside as we start to do this artificial weird thing?  [I invite him to pay attention to the anxiety which is triggered by his wish to engage in therapy.]

 

Pt: I don’t know right now.  I don’t feel any great anxiety.  [Defense: he ignores his anxiety and minimizes it.]

 

Th: Any little anxiety, do you notice?  [I invite him to notice his anxiety again.]

 

Pt: No. Actually I actually, I didn’t.  I didn’t actually have any.  [Defense: rather than pay attention to what he feels now, he pays attention to what he felt before he came to therapy today.]  I was thinking on my way over here that it was actually kind of nice to come here and have, um, to sort of have the time for myself, if you will.

 

Th: Yeah.

 

Pt: Um.

 

Th: Is that something that you want to give yourself?  [Mobilize his will to the task.]

 

Pt: Right, right, right.  You know, it would be nice to sort of make progress on this.  [His will is more mobilized, but the ‘sort of’ indicates his resistance at the same time.]

 

Th: Uh huh.

 

7.38

 

Pt: This is something I’ve been kind of dealing with for a long time and, you know, I’ve, (sighs, rise in complex feelings) I’m and when it happens that I always sort of have this feeling of you know, I feel very angry and having this feeling of sort of initially sort of justifying myself and then I get depressed because I realize this, you know, this whole proportion and I made a fool out of myself.

 

Th: Yeah, you are saying that you want to make some progress.   [Remind him of his will and his positive goal.]

 

Pt: Right.

 

Th: You want to do something different.  [I remind him of his will.]

 

Pt: Right.

 

Th: And you are also saying you want to make some time for yourself to do precisely this.  [Remind him of his will to engage in the therapeutic task.]

 

Pt: Right.

 

Th: What do you notice feeling as you say you want to make time for yourself here?  [I ask about his feeling because expressing his wish to engage in the therapeutic task (forming an emotionally close relationship) will trigger feelings, anxiety, or defense.]

 

Pt: I, I, I don’t know, I feel good about it I guess [He responds with both feeling and defense.] (Slight nodding-therapeutic alliance starting to build).

 

Th: That this is what you want? [Mobilize his will to the task.]

 

Pt: Right.

 

Th: How do you know that inside that this is what you want?  How do you know that this is what you desire?  [As I ask about his will to engage in the therapeutic task, feelings, anxiety, and defense will arise which will help him become aware of his non-verbal resistance to the therapy.]

 

Pt: Umm (licks his lips: dry mouth = rise in anxiety), because it is a drag to be, you know, to be sort of bummed out, you know depressed may be too strong of a word.  [Defense: he describes his depression but not how he experiences his desire to engage in the therapy.]

 

Th: Uh huh.

 

Pt: You know, feeling kind of stuck, feeling like, that, you know, that you are repeating this same kind of behavior again and again. And not really able to get, can’t get some kind of resolve.

 

Th: Uh hum. Feeling sort of stuck. What do you want instead?  [Mobilize his awareness of the positive goal he wants to achieve through therapy.]

 

Pt: Um, I don’t know [Defense]. I mean.

 

Th: Uh hum. How will we know we’ve been successful here?  [Mobilize his awareness of the positive goal he wants to achieve through therapy.]

 

Pt: One change, modified behavior will be one thing (Still slouching in chair with minimal eye contact.). To not be in a situation to, to when I feel like when I’m in a comparable kind of situation, in an argument with my wife or whomever or getting frustrated about something that I’m not, where I can say to myself that there is a trigger here that I need to either like train myself to step outside for 10 seconds to take a breath or maybe there is a different strategy that I can use when it comes to interacting that I can take with my wife or whomever.  Um, so that would be one thing.  [He finally declares a positive goal.]

 

Th: Uh huh.  So you would like your behavior to be different.  Yeah.

 

Pt: Yeah change the behavior.

 

Th: What would that look like?  [I invite him to envision his positive goal to activate his wish to engage in the therapeutic task.]

 

Pt: Umm.  Ideally, it would be where on the one hand I feel like I can express, I feel like I can get my point or views across and be heard and understood and at the same time not feel like, umm, you know, not get, be sort of consumed with anger.

 

Th: Uh huh.  You would like to be able to feel anger and be able to channel it so that you could communicate effectively and you can make yourself understood.  [Clarifying the positive goal he wants to achieve through therapy.]

 

8:03

 

Pt: Right.

 

Th: Yeah, just to be able to communicate effectively, to make yourself understood and that you feel that you can channel it in a way that is effective and feels good to you.

 

Pt: Right, right that would be nice.  That would be really nice.

 

Th: That would be a goal you would like me to help you with here, to help you be able to feel it and channel it in a healthy way.  [Clarify that he wants me to help him achieve this positive goal.]

 

Pt: Yeah, definitely, definitely.  [Less resistant non-verbally.]

 

Th: What do you notice feeling when you say that?   [Check to see whether feeling, anxiety, or defense is mobilized when he consciously declares that he wants to engage in the therapeutic task.]

 

Pt: When I say definitely?

 

Th: Yeah.

 

Pt: Well, (sighs, rise in complex feeling) I guess I’m feeling like um (chuckles and gestures: anxiety) I feel like there is so much more, what can I say. Yeah, I mean, you know.  I mean.  Um.

 

Th: There is so much more.

 

Pt: Well (Looking up at the ceiling, then some minimal eye contact: impaired attachment response.), aaaaay in a sense, I don’t want to [Defense], I guess [Defense of vagueness], I, I don’t know [Defense] if I am willing to commit or able [Defense] to spend a lot of time dealing with all the other issues that I have [Defense of not committing to himself, his goal, and his therapeutic task to achieve his goal.]

Every therapy involves an agreement to form an emotionally close relationship, the therapeutic alliance, in order to achieve the patient’s healthy positive goals.  In this case, the patient’s resistance to emotional closeness initially showed up in non-verbal defenses such as slouching in the chair, gaze avoidance, and an uninvolved tone of voice.  Although he declared a clear internal emotional problem verbally, non-verbally he communicated his resistance to the therapy.  The constant focus on what he wants, his positive goal, and our relationship to achieve that goal involves the formation of an emotionally close relationship.  This focus has triggered a constant rise of unconscious mixed emotions and anxiety, which has triggered defenses which are emerging verbally where we can finally address them directly.

 

Th: Uh hum. And you are not sure how committed you want to be.  [Clarifying his defense.]

 

Pt: Yeah.

 

Th: I appreciate you being so straight forward.  Because you can be as committed or uncommitted as you want to be.  [Point out his choice: to commit to his goals or not commit to his goals, to engage in the therapeutic task or not.]

 

Pt: I guess my concern is that I want to make sure.  I’m not sure, I feel like I have, I know that, I’ve got, you know um, you know.  I know that there is sort of a hole, you know, and I’ve got my past and there are things in my past that would be, you know, fruit for years of therapy potentially.

 

Th: Uh huh.

 

Pt: And I’m guess my concern is, I want to make sure, I guess I’m not sure that I am committed to, that I want to spend that much time in therapy [Defense] but I do want to make sure, I guess, that I come out of this with a tangible improvement in this area of behavior [Healthy wish].

 

Th: Uh huh, yeah and naturally in as much as we are combining forces together we need to find out how committed you are to you.  Yeah.  [I clarify that the issue is whether he wants to commit to himself and his positive goals, not whether he commits to me and therapy.]

 

Pt: Yeah. How (looking up at the ceiling and smiling) committed to me, yeah, I guess you, that is interesting, yeah.

 

Th: Are you worth it?  [Address the superego which treats him as if he is not worth committing to.]

 

Pt: (Chuckles [anxiety], looking away at ceiling: anxiety.). Ummmm, (pause, slight eye contact) sure I’m worth it, I mean. [Turns against the self dismissal.]

 

Th: What do you notice feeling as you say that?  [I ask what he feels as soon as he turns against a defense in order to help him notice the momentary rise of feeling and anxiety that arises.  If we intervene quickly before the next defense, he has a chance to find out what he feels when he commits to himself: the feeling that triggers anxiety and defense.]

 

Pt: It seems like (smiling, looking up at the ceiling) a form of marketing, a very sort of marketing. [Defense: he dismisses me like he dismisses his own feelings and goals.]

 

Th: Right, but what do you notice feeling, what are you feeling when you say that you are worth it; what gets triggered inside when you say that?

 

Pt: Um, part of me, of course, says that I should immediately say, yes I am worth it (Lightly pounds the chair with his fists.) [Rise of the healthy part of him.]. Why, why is there, this I mean?

 

Th: That is the should, but what do you actually notice feeling when you say ‘yeah’ that you are worth it?

 

Pt: Iiiii, ambivalence whether I want to spend a huge time and money on it.  [Defense: rather than commit to his goal, he adopts the position of ambivalence, sitting on the fence, not taking the side of his own goals.]

 

Th: I want to encourage you to shift your thinking.  I want to shift your thinking to how committed you want to be to yourself.  It sounds like there is some ambivalence about being committed; about how committed you are to you.  It is important for us to notice that there is some ambivalence to committing to you.  There is sort of one foot in and one foot out about committing to you.  Let’s just notice that.  [Point out the conflict and the defense: he wants me to help him achieve a goal; he becomes anxious; as a defense he no longer commits to his goal. I also remind him that the issue is not between him and me, e.g. whether he commits to me and therapy, the issue is whether he wants to commit to himself and his positive goals.]

 

Pt: Yeah. I think there is some truth to that. [He sees the defense.]

 

Th: There is some ambivalence on how committed to be to you and to what you want. It is important for us to notice this and pay close attention to this ambivalence about how committed to be to you. [Encourage the patient to pay attention to the defense.]

 

Pt: Yeah, I think you are right.

 

Th: Yeah, so let’s just notice that.

 

Pt: Yeah.

 

Th: How do you notice this ambivalence physically inside both wanting to commit to you and not wanting to commit to you?  [Invite the patient to notice how he experiences his internal conflict in his body.]

 

Pt: Aaaay, I. I guess what I (looking away), I don’t know [Defense of vagueness.] whether this is the same thing. I don’t know whether there is what I perceive it as but there is a lot of self-editing that goes on. [He sees another defense: how he edits and censors himself.]   A lot of sort of internal.

 

Th: Uh hum. Are you worth being listened to?  [Self editing, not listening to oneself is a character defense: identification with a parent who did not listen to the patient.  When I ask whether he is worth being listened to, I point out how he does not listen to himself, how he ignores himself, and how he treats himself as if he is not worth being listened to. I begin to help him see and turn against this identification and this cruel self-treatment.]

 

Pt: Aaaay I guess, it’s, it’s funny [Defense of self dismissal.]. I don’t interpret it as, it’s not, maybe it’s not, maybe that’s the issue. I don’t feel it in that way. I mean I guess [Defense], you know, it is a want of confidence sometimes in terms of expressing my, my views and also just in terms of expressing doing what I want to do and that sort of thing. [When he says there is a ‘want of confidence’ he reveals another character defense: identification with a parent who does not express faith in him.]

 

15.58

 

Th: Yeah, yeah exactly. So something about it is one foot in and one foot out and another one whether you want to commit to you and whether you want to edit you or to listen to you and another thing whether to go for what you want or not let yourself have what you want. [Clarify again his conflict: whether to commit to his goals or not to.]

 

Pt: Yeah.

 

Th: Yeah. How much would you like to hold yourself back?  [Point out the character defense: identification with a parent who doubts and holds him back.]

 

Pt: (Sigh: rise in complex emotion), well my first thought when you said that was (hands up and drop), you know, (hands lift and drop) you know you construct a life, so you know, I cannot, I’m not totally free actor. I cannot just jettison everything.

 

Th: Nope.

 

Pt: That I want or, you know, (drops hand, lifts, drops looks further away toward ceiling) so it’s kind of, I guess the question is how do you, how do you sort of, um, how do you get to the point of where you can be sort of honest with other people without feeling like you are going to sort of destroy the, you know, things that matter to you. [Unconscious therapeutic alliance: he is letting us know that he fears if he does not hold back his feelings and desires, others will be hurt. This indicates that there is probably some harmful feelings he feels toward others and guilt about hurting others.]

 

Th: Yeah. Yeah. Lots of feelings like you are going to sort of destroy the things that matter to you basically.

 

Pt: Yeah, yeah.

 

Th: A lot of feeling comes up about that.

 

Pt: Yeah. [The patient can observe his feeling.]

 

Th: Just notice that. [I encourage him to pay attention to the feeling.]

 

Pt: Yeah (smiles).

 

Th: Just notice; just let yourself have some information here.

 

Pt: Yeah, ok (smiling).

 

Th: Something about really being honest and fearing the impact that would have on others. That is important for us to notice because for us to operate well, you know, we do need to be as honest as possible and obviously if there is that fear that I would be harmed in some way or others be harmed in some way we need to pay attention to that.

 

14.52

 

Pt: No, it’s not. Well it’s not; again, I’m just free associating here. It’s the other, its honesty and the other feeling I have is, um (sighs, lips smack: rise of anxiety). It’s just a desire, a kind of wish that you could be more self-confident, that I could be more self-confident. [He is revealing a defense: his lack of self confidence is the result of self-doubt. Just as he doubts the validity of his commitment to therapy, and just as he doubts the validity of his thoughts, so he edits them. This is another character defense: identification with a parent who doubted the validity of his thoughts, feelings, and desires.]  Why does it matter, why does it matter to me or why does it matter so much what other people think or feel or whatever?  [When patients doubt themselves, they hope the faith of others will compensate for the lack of faith they feel for themselves. But the problem is not other people. The problem is that the patient’s chronic defense of self-doubt results in chronic lack of confidence and an inability to follow through on commitments.]

 

Th: Yeah. Is there a wish that you would have more faith in yourself?  [Point out the healthy alternative to the destructive defense of self-doubt.]

 

Pt: (Deeper sigh: rise of feelings and anxiety.)  Sure, sure (looks away: impaired attachment response).

 

Th: Is there a tendency to self-doubt that kind of gets in your way? [Point out the defense of self-doubt and how the defense hurts him.]

 

Pt: Yeah. [Patient can observe the defense of self-doubt.]

 

Th: So in a way it is useful for us, because we are seeing that it is your wish, I assume you came here on your own free will. I assume you weren’t dragged here by anybody, right?

 

Pt: Right.

 

Th: So you came on your own free will and as soon as you say you want to commit to you and to commit some time to you and to get to the bottom of your difficulties as quickly as you can to get the bottom of your goal, we see that there is some self-doubt about what you want. [Point out the conflict: his healthy wish to overcome his difficulties versus this defense of self-doubt which blocks him from pursuing his positive goals.]

 

Pt: Yeah.

 

Th: So there’s kind of this war within yourself. You are saying that there is this kind of mechanism that doubts whether you should listen to yourself or listen to these doubts, about whether you should listen to you and doubts whether you should go for you. [Point out the difference between the patient and the defense of self-doubt.]

 

Pt: I’m not sure what part of the problem is, it is hard for me to always know, you know, to even know, you know, if even that impulse that I’m experiencing is the real one. [He is unable to distinguish his genuine internal desire from the defense of self-doubt.]

 

Th: It sounds as if this doubting has gone on for so long that you’ve doubted yourself for so long that it is hard to even know which is the real you, the impulse or the one that is being doubted.  [Differentiate the patient from the defense of self-doubt.]

 

Pt: That is a scary thought.

 

Th: What do you notice feeling? [Ask about the feeling now to assess what happens as he differentiates himself from the defense.]

 

Pt: (Smiles, rolls his head: rise of anxiety indicates a rise of unconscious emotion.)  I don’t know. [Defense: He says he does not know immediately without taking a moment to look inside.  If he says he does not know right away, he cannot know because he doesn’t let himself look inside himself.]

 

Th: Just take your time to let yourself notice because this is stirring up a lot of emotion for some reason. [Encourage the patient to pay attention to his feelings.]

 

Pt: It is funny. It’s not, yes it is. I mean it’s not. I mean, um. I’ve, I’ve certainly talked with enough people who are self aware and empathic enough that they have, you know…I’m aware that I have some of these issues. So, on the one hand and I’m aware that I have some of these issues so it’s not like some horrible revelation. [My intervention did not focus his attention precisely on his feelings. As a result, his response is a little scattered.]

 

Th: No.

 

Pt: Um. But it is, it is I guess [Defense of vagueness], you know, the issue is, sort of you know [Defense of vagueness], what is my real identity what do I really want to do [The defenses of vagueness, ignoring, and self-doubt result in the loss of clear sense of what he feels and wants: his identity.]. That is kind of you know and that’s, that’s some of, you know.

 

Th: Exactly. That is why it is so important for us to look at that here because if it turns out that this is not what you want to do I have no right to ask you. [Deactivating his defiance. Since he easily gets into yelling arguments with his wife, he easily gets into defiant relationships. So we need to deactivate defiance to avoid any possible misalliance.]  So that is why we have to pay attention to find out what the real impulse is in you and if you doubt the utility of this, if you really doubt the utility to you I have no right to ask you. [Point out the conflict between his genuine wish and his self-doubt and the impact on our therapy.]

 

Pt: No, I don’t doubt. I don’t doubt the utility of therapy. I don’t doubt the utility of this it’s, um.

 

Th: There is something here about committing to you, committing to what you want and we are seeing there is some kind of struggle. You are at some kind of war with yourself and wanting to commit to you and at the same time some kind of doubting about committing to you. Some kind of war with yourself here with you as we as we are entertaining the idea of whether the two of us should join forces and commit to you. [Point out the conflict between committing to himself and not committing to himself and its impact on our relationship: shall we form a therapeutic alliance where both of us will commit to him?]

 

Pt: Yeah (smiles).

 

Th: Yeah.

 

Pt: You are right, it’s, it’s, I’m just thinking, God, this could be a long. I don’t know [Defense of non-committal.], I, you know. I just don’t [Defense], you know. [He believes his problem is whether to commit to a therapy that could be very long. But this is because he fails to see causality. He thinks committing to therapy means he will have a long therapy. In fact, if he uses the defenses of self-doubt, non-committal, distancing, vagueness, and ignoring, those defenses will create a very long therapy. So his commitment to himself won’t create the problem, his defenses will.]

 

Th: Well, you know, if you doubt the utility of committing to you and if you hold out on committing to you, I can guarantee you can make this therapy as long as possible and there are people who do that, who drag it out for 20-30-40 years, decades if you work it out right. Yeah (patient laughs) so obviously if there is anything you could do to make your therapy unnecessarily long I think both of us have an obligation to make sure that doesn’t happen right? [Point out that defenses will prolong his therapy, not his commitment. Also point out our therapeutic task: to join forces against any defenses that would hurt him.]

 

Pt: Right.

 

Th: So obviously, if there is anything you could do to make your therapy unnecessarily long I think both of us have an obligation to make sure that doesn’t happen.

 

Pt: Right.

 

Th: Because you know if you do not want to commit to you or to your therapy full tilt because we could prolong this and gosh it is nice for me to make money but it is not going to be nice for you to pay more money than you need to and making it longer than you need to. [Point out the price to him if he uses those defenses.]

 

Pt: No it’s I, I, no, I mean, I’m trying that’s, so I don’t know [Defense]. I don’t know what [Defense]. I definite, I want to be as [Healthy wish], I guess [Defense] um, I certainly want to get there, um, as much as I can. [Clearest statement of his wish to engage in the therapeutic task yet.]

 

Th: Absolutely, I hear that and how do experience that you want to get there? You want to get to your goal as much as you can. [As he moves even closer toward a collaborative relationship, I ask what feelings get triggered. Now we can assess whether feeling, anxiety, or defense gets mobilized by this stronger wish to engage with me.]

 

Pt: I actually feel good about that. I do feel good about that.

 

Th: How do you experience that inside that you want to get there, to get to your goal in as short of time as possible?

 

Pt: That feels good, that feels good.

 

Th: Yeah. What’s happening now?

 

Pt: Um, (smiling) I’m just remembering I went to a psychoanalyst, he was a Freudian, when I was in my early 20’s, I was 25 maybe at the time, and um that was hard, I mean, you know, it was, um (looks up at the ceiling), and the challenge then was the same, kind of the question about how much do you want to invest and you know. Um (looking away).

 

Th: Uh huh. Are you worth investing in, do you think? Should we make that kind of investment? Are you worth it, making that kind of investment do you think? [Point out his character defense: identification with a parent who did not think he was worth investing in. Invite him to invest in himself.]

 

Pt: I wouldn’t be here if I didn’t believe that I was at some level. [Positive move forward.]

 

Th: Uh hum. Uh hum.

 

Pt: Yeah. Um. Yeah.

 

Th: What do you notice feeling when you say that?

 

Pt: Again, Well, it is this sort of feeling, of course, (chuckles) part of me is saying you should me emphatic but the fact that I don’t say it emphatically must, you know. [He now is able to experience his internal conflict: wanting to invest in himself and form a therapeutic alliance, and not wanting to invest in himself fully.]

 

25.26

 

Th: So it is fascinating. You think about it, it is fascinating to see this conflict playing out.

 

Pt: No. I, I, I, I mean believe me (voice rising: rise of feeling and anxiety as he observes and pays attention to his internal conflict.]. I see this playing out all the time. I play this game all the time. The same thing goes on in my head all the time.

 

Th: We’ve got this artificial environment where we can look at, wow, what an interesting conflict. On the one hand, it makes obvious sense that you and I should invest 100% in you (the therapeutic alliance). It makes total sense but you are aware of this other person that says, ‘Why don’t you go for 20, 30%? Don’t throw all your chips on the table,’ and just noticing. ‘What is this?’ Yeah. ; What is this?’  [Differentiate the patient from his superego: the mechanism or ‘person’ that says he should not invest in himself. Since he has not been able to tell the difference between himself and his superego, it is useful to portray the superego as a ‘mechanism’, ‘person’, ‘voice,’ etc. so that the patient can learn to picture and represent this punitive process and then be able to stand back, look at it, and take a stand regarding these self punitive habits.]

 

Pt: Yeah, good question. I don’t know. I don’t know, um.

 

Th: What is it like just noticing this conflict inside, because that has got to be kind of wild in a way to see it at work, eh? [Invite him to observe and experience his conflict physically. Observing the conflict helps him differentiate from the superego.]

 

Pt: Yes, but I’ve, I’ve seen it go on for so long and I guess, again, that is part of the frustration and why I wanted to come here because I feel like I am sort of sophisticated enough to sort of see this going on. It’s not like this is, you know. I can tell there is this issue here.

 

Th: Yeah.

 

Pt: But it’s, um,  but it’s not knowing how to break out of it or feel, um, brave enough to kind of make the choices that would get me out of this and deal with the consequences and so on. [Rise in the unconscious therapeutic alliance. He realizes now that he must have the courage to make choices that go against his habits of self-punishment and self-doubt.]

 

Th: Uh huh. So, how would you say, in so far as you’ve seen this pattern, would it be too much to say that it has been this kind of habit to withhold from yourself and deprive from yourself in this way, to withhold your full investment and full commitment to yourself? [Invite him to notice his character defenses.]

 

Pt: Yeah and there is also this, I had this thought as soon as you said that I withhold from other people. [This is certainly true. However, before we focus on his relationships with other people, we must improve his relationship with himself. His character defenses involve a number of ways that he withholds from himself: faith, effort, respect, attention, etc. Only when we have improved his relationship with himself, will it make sense to focus on his relationships with others.]

 

Th: Right. Sure. But for right now I’m really more concerned about how you withhold from you [The patient suddenly sits up in his chair at this moment, indicating a sharp rise in feeling and anxiety.] because, in a sense, this is your goal and I’ll be glad to help you achieve your goal. But in so far as you withhold from you your commitment, that is kind of cruel. [Point out the conflict between committing and not committing to himself. Point out the superego function: this defense of not committing to himself is a way he is cruel to himself.]

 

Pt: Yes but I mean I don’t know what it would mean to fully commit. [Defense: helplessness.]

 

Th: Yeah. Right.

 

Pt: You know. I don’t know how to evidence that. [Defense: helplessness. By taking a helpless stance, he withholds from the therapy the knowledge and capacity he has. At the same time, he withholds from me what is necessary for us to have a mutual and collaborative therapeutic alliance.]

 

Th: Yeah. It sounds like that would be an important thing to find out because you are saying that you don’t know what it would look like for you to actually commit 100% to you. [Point out how he does not commit 100% to himself. He withholds from himself.]

 

Pt: I think that is true. [He observes this defense, but he does not turn against it.]

 

Th: Yeah. I think that is real important information.

 

Pt: Yeah. (Sitting up and looking at the therapist: a rise of feeling and anxiety when I point out his conflict and do not accept his helpless stance.)  I think you are right.

 

Th: Obviously, you can commit 20% and you’ll get 20% results. And it is no wonder you are feeling furious because you are getting 20% results. [Point out causality: 20% involvement leads to 20% results which leads to the chronic feelings of rage and frustration he reported at the beginning of the session. In other words, 20% involvement creates his presenting problems.]  I’d be furious all the time. I’d probably be doing more than yelling. That would be enough to make anyone furious. So, yeah. So, you are saying that it is so habitual that you don’t know what it would be like to go 100% for you, full tilt for your goal. Because you are saying that this is your goal but I can say let’s go to the top of the mountain but if you only give 20%, that is how far we will get.

 

Pt: I guess [Defense of not committing.] that is true [He is beginning to see causality.].

 

Th: What do you notice feeling right now?

 

Pt: Um. I mean, I thought it was a good. I mean I think, I think that was, you know, I think that was a good insight, I guess [Defense of non-committal]. I feel like, yeah, I think that is something.

 

Th: What was the insight that caught hold for you?

 

Pt: (looking away) I, I guess thinking about it more in terms of thinking about it as a commitment to me, which still strikes me as a very selfish [Superego injunction: ‘How dare you commit to yourself!’].

 

Th: Oh God knows you shouldn’t do it. Oh God forbid that you commit to yourself. Oh God!  [Mirror the superego injunction so that he can see its irrationality.] Do you think if you commit to you, it would be a sign that you are some kind of selfish asshole or something like that? [Poor intervention. Better: ‘Do you notice how a policeman comes into the room and punishes you right now as if it is against the law to commit to your goals?’]

 

Pt: No, well. It’s partly that. It’s partly. It also strikes me as impractical  [Superego injunction: ‘It’s very impractical to commit to yourself!’]. It also strikes me.

 

Th: Very impractical to commit to yourself. Very practical to commit just 20% to your goals. At least it’s such a practical result. Never underestimate the value of having a 10% result. At least it is always practical to commit to a 20% result. [Mirror the pathological superego so the patient can observe it and differentiate himself from it.]

 

Pt: I guess when you say selfish I equate that with always getting my way. [Superego injunction: ‘You should never get your way or advocate for it.’]

 

Th: Oh. Might be kind of nice to get your way more than 20% of the time. I don’t know, but isn’t it interesting though that as soon as we have this idea of you committing to your goals, your respecting your goal and pursuing your goal with 100% of your energy, isn’t it interesting, isn’t it sort of like this policeman comes in and slaps you around a little bit and says how selfish of you and says get back into your place. ‘You know you aren’t supposed to be devoted to you. We’ve got someone else’s goals, listen to theirs.’  [Differentiating the patient from his superego: representing it as a policeman with the self-doubting statements that paralyze the patient’s will.]

 

Pt: Right. I think, yeah, I think there is some [Defense: not fully committing to what he thinks.] truth to that. [Patient can observe the superego a little now.]

 

Th: Yeah. It is very important that we notice that there is some kind of internal punitive element, kind of like a policeman or whatever you want to call it that comes in to punish you. [Point out the superego.]

 

Pt: No, I do, I do. I think that is true and I think often a lot of my anger is self-directed. [Notice in this previous sentence how the patient declares what he thinks without any qualifiers like ‘sort of’, ‘some’, or ‘kind of’. He is beginning to commit himself to what he says and thinks.]  Or you could say when I get frustrated a lot of my anger can be sort of self-directed. [With this work on clarifying his superego and self punishment, the patient is able to see it quite readily.]

 

Th: Exactly. So it is important here because if you give less than 100% to you here, you will have a very frustrating result. [Point out how the defense of not committing to himself is a form of self punishment.]

 

Pt: Uh hum.

 

Th: Do you know what I mean? Because, if you don’t commit 100% to the result, if you don’t give 100% here to you, you are going to be frustrating you. Because you won’t be giving you the full result that you could give you, I can give 100% and you can give 10 or 20 or 50 or whatever, but you are going to be very frustrated because you will be depriving you. So, there is something about this automatic self-depriving mechanism that has been causing a lot of frustration in your life, it sounds like. [Point out how he is frustrated in life because he frustrates himself by not committing to himself. Not committing to himself is a form of self deprivation.]

 

Pt: Yeah. Yeah.

 

Th: Yeah, yeah. And we are seeing that there is this punitive element that almost says it is as if is against the law for you to commit 100% to some goal that you really value. [Differentiating the superego from him.]

 

Pt: Yeah. I’m not even sure, the problem scaring me is that I’m not even sure I know what goals I really 100% value. [Now he is somewhat differentiated from the superego but not fully.]

32.05

 

Th: Right, right because you are saying that your habit is not to value anything you say 100%. [Causality: he cannot know what goals he values 100% because he does not value any of his goals 100%.]

 

Pt: Yeah.

 

Th: Do you know what I mean?

 

Pt: Yeah. Yeah. I think you are right.

 

Th: That there is somehow. Do you think that is a very respectful way to treat yourself? [Separate the ego and superego by inviting him to take a stand and notice the cruelty of his self-dismissal.]

 

Pt: (Chuckles: anxiety indicates a rise of unconscious emotion.). That is a very leading question [Defense: dismissal of my question just as he dismisses his own feelings.]. Um. I. I.

 

Th: It is at the risk of asking the obvious. But you know.

 

Pt: I mean, I mean. I wouldn’t, of course, you know like I said, I wouldn’t be here if I felt like, ‘Gee it’s great!’ like I was happy with the way I treated myself 100% of the time. [Although he sees that his self-dismissal is not a ‘great’ way to treat himself, he does not call it disrespectful.]

 

Th: Absolutely, we know that. So, it is just another way of looking at the struggle going on in you because there is this healthy side of you and you’ve got some goals and maybe you aren’t always clear about goals but you stated some today. You would like to be able to communicate effectively and clearly about important things that you value. And you would like to be able to communicate in a way where you can communicate effectively that you are 100% behind them with your wife and kids so that they can see someone who values what he says 100%, and stands behind it and states it clearly effectively 100%, and that they know that you mean business and that you respect what you say. [Summarize his positive goals and desires that he wants the therapy to achieve.]  And at the same time you have this punitive element that comes in and says, ‘How dare you respect yourself!  How dare you value yourself!  How dare you commit to any goal of yours!’  It says something like, ‘Hold back!  Deprive yourself of the full result.’  [Summarize the punitive side of his personality that is frustrating and paralyzing him.]  And we saw that this therapy could go on for eons, right, and then that holding back would simply deprive you and leave you frustrated and leave you very enraged. That would be very infuriating, right?  [Point out the price of the defenses so that he can turn against them.]  [A shift in feeling occurs within the patient: unconscious signaling.]  What’s do you notice happening inside?

 

Pt: I, I, I, you know, I have some sense of relief or whatever. I, you know, I think what you are saying is true. There is a lot of truth to it. [He experiences some relief as he is more differentiated from the superego and can see it more clearly. The patient declares himself even more directly now.]

 

Th: What do you notice feeling right now as you are aware of this truth because there is some kind of shift?

 

Pt: I don’t know. It felt good, it felt good, um, to be talking about that, um you know. Um, (pauses, smacks lips: rise of anxiety indicates a rise of emotion.) you know, I felt like it was, you know, I’m, it was like a, ah, it felt good and it was almost like a relief, you know. Okay, it’s almost like you brought out a value, you know, like to me. Like, ‘Okay he’s brought out something like a value, this is like getting somewhere.’

 

Th: Yeah. Yeah and what is that you are valuing right now?

 

Pt: (Looking away: impaired attachment response)  It’s like you are getting below or thinking about it in a different way and feeling like there might, um, be a way out, um. [Once he can see what the defenses have been doing to him, he can make different choices.]

 

Th: Uh huh.

 

Pt: And I guess feeling. It is nice to be in a situation where, um, you can talk about, you know, what you, what I want and what is important to me (looks at therapist), respecting you, respecting myself. [He is getting a clear picture of the therapeutic alliance: both of us together respecting his feelings and desires, taking a stand against any defenses that interfere with that task.]

 

Th: Uh hum.

 

Pt: Yeah.

 

Th: Respecting yourself and respecting your desire without disrespecting it and without holding it back and tamping it down but simply let yourself know your desires, to sit here and explore your desires. (Pt. looking more serious and scratching hands: sign of anxiety and rising feeling.) What do you notice feeling right now?

 

Pt: Now, (Chuckles: anxiety) I’m thinking about all the tasks, sort of a sense of regret. I’m sitting here and thinking about all the times I’ve withheld from myself. [Now that he can see how he has withheld from himself, feelings of guilt and grief will arise. After all, he has unwittingly hurt himself worst of all.]

 

Th: So, there is some sadness and regret, some sadness and regret that when you think, ‘Oh, I withheld from myself’, and that led to sadness, regret, frustration, and depriving yourself. That there is this habit of self withholding, depriving and cheating yourself of what you could give to yourself, yeah.

 

Pt: Right, right, yeah.

 

Th: Because you know another thing that occurs to me in so far as you were saying here that you are not sure you are committed to you and 100% committed to this goal. In so far as you are taking a position of not being sure if you are 100% committed to you, you are also inviting me to not be committed to you either. You are inviting me not to take you that seriously either. [Now that he is clear about how he has related to himself, now we can explore the implications of these defenses for our relationship too.]

 

Pt: (Slight smile, some satisfaction in the defense.) I guess [Defense] that is true.

 

Th: You guess? I mean either it is or it isn’t. [Blocking the defense of sitting on the fence.]

 

Pt: Well, I mean I wouldn’t think of this kind of environment as being one that I need to enlist your commitment. [Denial: of course he needs to enlist my commitment. The therapeutic alliance involves the commitment of both the patient and the therapist.]

 

Th: But you do.

 

Pt: But isn’t that your job, isn’t that your profession to help me and to be committed to me?

 

Th: On the one hand, sure that is true. But, on the other hand, if you are saying that ‘I’m not sure I am committed to myself’ then you are inviting the other person to not be committed, right?

 

Pt: It feels like a paradox. Like I said, if I were healthy enough to enlist, if I were healthy enough to enlist your commitment from day one I probably wouldn’t be here. And if I were able to enlist people and if I had the wherewithal to enlist people and I didn’t have any issues I would do that by myself. [Defense and failure of causality: he does not see that he is unable to enlist people to get behind his goals because he is not behind his goals.]

 

Th: Well obviously you can’t because if you aren’t committed to you, you won’t be able to enlist people to be committed to you because you are not committed to you. You won’t be able to commit people to you if you yourself are not 100% committed to you. [Point out causality.]

 

Pt: That is a sad thought.

 

Th: Because if you are not committed to you and if you don’t believe and value that and you are not willing to put yourself 100% behind that, then why would anyone else be willing to go where you aren’t willing to go? [Point out causality.]

 

39.03

 

Pt: (Looks away and at ceiling [impaired attachment response] and then back at therapist) I guess [Defense], but I mean at some point you have to start by asking for help. [Defense of helplessness. “I need you, Jon, to value my goal 100%. I am able to value my goal only 20% right now. So I need your help to offer the other 80% that I can’t offer right now. So, Jon, would you be willing to offer 180% to this therapy?”  This is not just a defense, but a mode of relatedness: the transference resistance. Through a passive, uninvolved, and helpless stance he tries to establish an insecure attachment that would prevent us from achieving his goals. Thus, this insecure attachment must be blocked and deactivated so that the patient can form a secure attachment with the therapist.]

 

Th: Yeah absolutely.

 

Pt: So that is why I’m here.

 

Th: Absolutely and I’m aware that if I put 100% and you put 100% [Therapeutic alliance] then we can at least have the best result possible. But I’m aware that if I put 100% and you make a choice to you hold back from yourself then you and I simply have to be honest.

 

Pt: Well, what, what do you see, what, what, what is, what is the holding back, what do you, what, what does holding back mean? [Defense of helplessness. Just a few minutes earlier he described very clearly how he holds back from himself and from other people. Now he is doing that with me.]

 

Th: You tell me. [Block the defense.]

 

Pt: (Chuckles: rise of feeling and anxiety when I block the defense.)

 

Th: Because you yourself said that you can see a number of ways that you have held back over the years.

 

Pt: Well it’s not expressing what you are feeling at the time. [Clear answer but he leaves himself out of the sentence.]

 

Th: Is there a personal pronoun in the house? [Point out the defense of denying his agency.]

 

40.28

 

Pt: (Chuckles: rise of feeling and anxiety when I block the defense.)  Um, you know, I don’t express my personal feelings about myself. Um, I don’t do things that are going to get people angry necessarily or take chances. I worry too much about hurting other people’s feelings. Um. I’m very…I can be very risk adverse. Um, so, I mean, I guess [Defense] that is what I mean by commitment or that to me would be the sign. But for me in this situation…[He now clearly describes how he holds himself back.]

 

Th: Uh huh.

 

Pt: I’m having a hard time figuring out what would be, how to be more, how to show more commitment. [Defense of helplessness just after he described very clearly how he withholds commitment.]

 

Th: Yeah

 

Pt: So (chuckles: anxiety) um, I don’t know. [Defense]

 

Th: Uh huh. How committed is your posture if you were to describe it?

 

Pt: I, I was, I, I, I  was, I’m being comfortable but I don’t feel it is uncommitted. [He is a bit slumped in the chair.]

 

Th: Would you say it is demonstrating 100% commitment 20, 50, in your opinion? If someone were sitting with you like this what level of commitment would you feel they were putting into the deal?

 

Pt: I, I feel like it is an appropriate posture for the circumstance. [Defenses of denial and ignoring.]

 

Th: Hmm.

 

Pt: Um. (Shallow breathing: the attention on his non-verbal defenses is causing a rise of unconscious emotion and anxiety.)   I suppose [Defense: non-committal] if I were in the work environment or whatever or totally focused on problem solving,

 

Th: Uh hum.

 

Pt: In the office, working on an analytic problem or work probably I would say I would probably [Defense: vagueness] be hunched over and the back straight. [He acknowledges that his posture is not the kind he would show if he was working hard in the office.]

 

Th: Uh huh.

 

Pt: But, I guess I want to, to sort of (chuckles: anxiety) relax. I want, I want, it would be nice to relax sort of have this happen to me. [Passive/uninvolved transference resistance: ‘I want to relax while you do the work. I’ll be healed by letting ‘this happen to me’ without my active participation or involvement. This is an insecure attachment which would prevent us from achieving his positive goals. Thus, it must be blocked and deactivated so we can establish a healthy therapeutic alliance.]

 

Th: Exactly.

 

Pt: Relax and enjoy this experience and let this happen to me without having to work at it.

 

Th: How many years will that take? [Point out the price of forming a passive uninvolved relationship in therapy.]

 

Pt: (chuckles: blocking the transference resistance causes a rise of feeling and anxiety.)  Um, um. I take your point.

 

Th: I mean this can last as long as you want, don’t get me wrong, I’m not going to get in your way. [Deactivate his possible defiance.]

 

Pt: I see what you are saying. I see what you are saying.

 

Th: Why would you want to prolong your suffering? [Ask the healthy part of the patient why he colludes with this destructiveness. This will mobilize the healthy part of the patient to rise up against the superego.]

 

Pt: (Chuckles: the question to the healthy part of the patient evokes emotion and anxiety.)  It’s nice to come in here and have someone get, to share what you are feeling.

 

Th: Yeah. Oh absolutely, absolutely. Uh huh.

 

Pt: (Chuckle, sigh, pause, and chuckle: rise of complex emotions and anxiety.)  When I had my, ah, when I had my therapist, my guy I used to see in, um, Chicago, he would, it was almost like he would make me this, I remember he would make these, he would move his face and make facial gestures and so on.

 

Th: Uh huh. Uh huh.

 

Pt: No, I mean, I take your point. I mean if uh.

 

Th: How passive do you think it would be in your interest to be here? [By paradoxically inviting the patient to be passive, I invite him to take a stand against this destructive defense.]

 

Pt: Passive, um I, I mean

 

Th: Because you said you would like to be kind of sit here and be healed.

 

Pt: I mean it’s.

 

Th: No, I appreciate your honesty and you are so incredibly collaborative. I mean you can be as passive as you want. I mean, I just wonder how passive you would like to be in your best interest. How passive do you think it would be to be in your best interest?

 

Pt: (Sits up and leans forward in the chair: the paradoxical invitation to be passive triggers a high rise of complex emotion and anxiety.)  I mean, that is a hard question. I mean, I wish, I guess some part of me just wishes I could just change (chuckle: anxiety). Just being kind of lazy about it, I guess. [Defense of passivity.]

 

Th: Sure. How lazy would you like to be? [Paradoxical invitation to be lazy to help him take a stand against this destructive defense.]

 

Pt: (Sigh: rise in complex emotion and anxiety.)  I don’t know. [Defense of vagueness. He does not take a stand against the defense of passivity.]

 

Th: Fair enough. You can be as lazy as you want to be because, it is always an option. You can be as work as much on your behalf as you want or you can withhold as much from yourself as you want. It is really your call. [Point out reality. Undo the omnipotent transference: since it is his choice, I have no control over his decision to be lazy and passive in therapy.]

 

Pt: I guess, it’s hard for me when you say I can withhold.

 

Th: Uh hum.

 

Pt: I mean does my posture really affect how much I withhold from myself? [Defense of helplessness.]

 

Th: Uh hum.

 

Pt: I don’t know [Defense]. I mean maybe [Defense]. Maybe [Defense] it does. Maybe [Defense], maybe [Defense] that’s. [The patient retreats into a position of vagueness and non-committal.]

 

Th: Well, as you said you can be as lazy on your behalf as you want. [I avoid any argument. Instead, I point out it is his choice and continue to deactivate the omnipotent transference.]

 

Pt: I mean I don’t know what work on my behalf would be. [Defense of helplessness.]

 

Th: I hear that, I hear that it sounds like you haven’t felt that you deserve your total effort for you. [Point out his character defense: he treats himself as non-deserving.]  You felt that you deserve only a kind of a lazy effort for you. You haven’t felt like you deserved that full effort that you could give you. I don’t know why you would withhold from yourself, but you are just letting me know. Because it is important because you would like me to give 100% but we notice that you have come in here and that it sounds like you are going to go on strike on yourself. [Point out his intrapsychic conflict: he is not on strike with the therapist. He is on strike on himself; he refuses to work hard for his goals.]

 

46.40

 

Pt: I feel like I’m a hard worker. [Splitting: He sees he is a hard worker, but he does not see that he does not work hard for his goals.]

 

Th: Right I hear that. But it sounds like you don’t feel you deserve that hard work. You believe others deserve it; but when you come in here for you, you don’t deserve the results; but why would you want to do that in here? [Question to the healthy part of the patient.]  I can guarantee if you want a long therapy, I can guarantee if we work it out right we, we could work it out for decades if we work it out right and you got lazy enough you could buy me a vacation house. [Point out the price of laziness and non-commitment to his therapy.]

 

Pt: I (rubs forehead), I suppose [Defense] that is true.

 

Th: You suppose? Do you think we could drop the ‘suppose’? [Invite him to drop the defense of not committing to what he thinks.]

 

Pt: I could try. [Defense: He still does not commit himself.]

 

Th: Do you want to commit to a statement?

 

Pt: Chuckles. [Rise of emotion and anxiety in response to challenging his defense of non-committal.]

 

Th: Do you want to commit to a statement? Do you want to commit to what you know?

 

47.48

 

Pt: It is very hard for me.

 

Th: What I’m hearing is that it is very hard for you to stand behind what you know. [Point out his character defense: he identifies with someone who did not stand behind him. Thus, he does not stand up for what he thinks, feels, or desires.]

 

Pt: Yes, I think that is true.

 

Th: It seems to me if we can help you stand behind what you know you will never have to yell again. [Point out how engaging in the therapeutic task to achieve his goal (stand behind what he knows) will end his symptoms.]

 

Pt: Yeah, that would be great (chuckle: anxiety) to get there. It would be great to get there (nods). Boy that would be great to get there. [Rise of positive feeling as he joins me in the therapeutic task.]

 

Th: Yeah, yeah. To stand behind what you know, to stand behind what you want and to treat what you know and what you want as worthy of your respect. [Restate the therapeutic task.]

 

Pt: Yes, I think, no, that definitely a big issue for me. I think you are right.

 

Th: What do you notice feeling as we clarify that?

 

Pt: It is a tough issue for me, a tough issue for me

 

Th: Very tough, Very hard to stand behind what you know and to take a stand and make a statement with it.

 

Pt: It’s tough for me. Very tough for me and I know that I should have more self-confidence and conviction and so on and I know.

 

Th: I don’t know how much this is really about self-confidence. I’m not sure that the issue is self confidence if I may offer a different point of view. What I’m noticing is that when you stand up for what you know or want you want it seems like there is this punitive mechanism that comes in to chop you down, a punitive mechanism that comes in to doubt you, this punitive mechanism that comes in to question or this punitive mechanism that comes in to withhold from you. That is very different from self-confidence because it seems like there is some very powerful, self kindred mechanism that treats you as if it is against the law for you to know what you know or want what you want as if it is against the law. [Point out how the lack of self confidence is due to the character defense of chronic self-doubt.]

 

Pt: That, I, I hadn’t thought about it, honestly, in those terms. [He has not seen it in these terms before because he did not see causality: his feelings trigger anxiety which trigger the defense of self-doubt which creates the presenting problems of poor self confidence.]

 

Th: Uh hum. What happens now as you think as you think about it in those terms?

 

Pt: I mean, I immediately want to think, ‘What is this punitive mechanism?’ or ‘What caused it?’ or whatever. [With clarity about causality, now he is mobilized to take a stand against his self-doubt.]

 

Th: My question is a little different, ‘Why would someone obviously as bright as yourself be punishing yourself so much and disrespecting yourself so much, treating yourself as if you don’t even deserve your own commitment and as if you don’t even deserve to work for what you want?’  [Question the healthy part of his personality: ‘Why do you collude with this destructive part of your personality?’]

 

Pt: Deep breath (Rise in complex feelings and anxiety in response to my question.).

 

Th: What is it, why would someone as intelligent as you treat yourself as if you are not worth as if you are not worth your own effort, as if you don’t deserve your effort? [Since the question to the healthy part of the patient aroused so much feeling, I asked this question again to further mobilize the healthy part of the patient.]

 

Pt: I’m hearing what you are saying.

 

Th: I’m wondering where in the world did you learn to treat yourself in such a cruel and depriving way. Where did you learn to treat yourself in such a cruel and abusive way and in such a withholding kind of way? [Question to the unconscious.]

 

Pt: I mean, all I can say is that I’ve been.

 

Th: Because you are obviously suffering.

 

Pt: This is something. When I would get very frustrated at myself when I was a little kid I would get very angry at myself so it has been going on for a very long time. [The unconscious therapeutic alliance comes up. He lets us know that very early in childhood he felt tremendous rage at someone, but turned the rage onto himself.]

 

In this first phase I have helped the patient see his defenses of ignoring and dismissing himself and his feelings. As we looked at his defenses together, it became clear that his defenses were working together as a system (the transference resistance) to form an insecure attachment where I would be kept at a distance. Then, I shifted focus to help him see the kind of relationship he was forming with me and the price he would pay if he related to me and to himself in this pathological manner. At this point, he is able to see his defenses much more easily and he is recognizing the pathological helpless relationship he tries to form with me. As I continue to ask about the healthy part of him that has colluded with these destructive defenses, feeling and anxiety rises.

The continuous moment to moment work on his defenses prevents the therapy from becoming paralyzed and dominated by an insecure attachment. Instead, the disruption of the defenses, his attention to them, his turning against them, and his turning against the transference resistance, loosens up the defenses and resistance so much that the unconscious can come through more easily. He not only mentions his parents, but he mentions his tremendous rage as a child.  This is a cue that we can shift from our emphasis on defense to his feelings.

 

Th: If you hadn’t been directing it all the anger toward you where would it have gone instead?

 

Pt: Probably my parents (chuckles: anxiety.)  Probably [Defense of non-committal.].

 

Th: Yeah most likely.

 

Pt: Yeah.

 

Th: Yeah. So already being angry at them and turning this self punishing toward you as a child. So the self punishment started pretty early. So you are saying that it started pretty young?

 

Pt: Well that is because my parents got divorced when I was very young.

 

Th: How old were you? Uh huh.

 

Pt: Five and it was very painful, you know, it was very painful ah.

 

Th: What happened?

 

Pt: I mean I was 5. I don’t remember a whole lot about it other than that. I remember my parents were very unhappy with each other. I, I don’t really remember but according to my older sister they had very violent arguments and so they so, there was one period when my father was out of the house and then they got divorced. So they were kind of quasi-separated and whatever from whenever I was 4 or 5 and they got divorced when I was 5 or 6 years old. You know, the positive thing was that they were, you know, they were very loving toward me but it was not like he was physically abusive toward me but it was very painful.

 

Th: How so?

 

Pt: I, um, it was just very upsetting, very upsetting.

 

Th: Uh hum.

 

Pt: It was, it was, you know, I mean my father moved out. You know we didn’t see him as much and he remarried shortly afterwards and my mother dated frequently.

 

 

 

DVD 2

 

Th: So it felt like you were being abandoned. By your dad?

 

Pt: Well, yeah, and certainly by my mother as well.

 

Th: By both. Tell me about that.

 

Pt: (looking away: impaired attachment response)  It is funny [Defense of dismissal], my father, I mean, it was physically almost painful for him to be absent but when I would see him, visit with him it was so great. My mother it was, um, it was just tough. I mean, she was you know, she was dating other men and, uh, economically we didn’t have that much money; and it felt like it was bleak (looks at therapist) and bleak in a way.

 

Th: Bleak

 

Pt: Bleak, (chuckles: anxiety, looks away [impaired attachment response] and back) yeah, it sounds terrible and it was, you know, she was a school teacher and we weren’t impoverished or anything but it was.

 

Th: But mostly it felt bleak.

 

Pt: Um yeah (looks away and back then down).

 

Th: What you just said. Yeah. Tell me about that.

 

Pt: (looking down, sigh, rise in complex emotion)  Emotionally, it was hard, you know. Um, you know my sister and my mother fought a lot. Um, I (looking away), remember my mother, um, being out a lot  and uh, (fighting back emotion) it was, it was um, it was very kind of, um, lonely, scary (looks at the therapist momentarily).

 

Th: Say more about it.

 

Pt: What?

 

Th: Say more about that.

 

Pt: Well (looks away) part of me is sort of embarrassed about it [Defense: identification with a parent show shames the child and tells him he should be embarrassed for having brought up his sadness. Superego activity.]. I guess.

 

Th: Embarrassed.

 

Pt: Well part of me (chuckles: anxiety) is sort of embarrassed and saying, ‘Who am I to feel this way?’, it sounds so trite in a way. [Self attack.]

 

Th: So the policeman.

 

Pt: Exactly. Yeah I’m seeing that. [Now he sees how the self punishment comes in just for revealing his sadness.]

 

Th: (Pt looks at therapist)  So it is important that we see that there is this habit of sort of self dismissal, putting yourself down for having an emotion, a sort of under the radar contempt for yourself and for your suffering and the kind of pain you suffered.

 

Pt: Yeah, yeah (looks away).

 

Th: And it is important because, in a sense, because it was not your fault you felt what you felt because you were going through what you went though as a little kid of 6 or 4 to 8 or whatever. You are going to feel what you feel as you go through it as a kid. What we see is that there is this temptation to treat this little kid as if he doesn’t deserve our empathy. [Point out to the patient the pattern of self dismissal.]

 

Pt: Yeah.

 

Th: And there is this temptation to ignore and withdraw from him and treat him as if he doesn’t deserve your compassion and empathy. As if we should ignore and not stand up for his right to have his feelings. And, as you said, your dad left you and your mom left you and you left you too. You got in the habit. It was like, ‘I will abandon me too, I will abandon my emotions. I won’t stand up for me when I have a feeling. I will dismiss it and ignore my emotions too.’  [Point out how he identified with parents who abandoned him by abandoning his feelings, thoughts, desires, and goals.]

 

Pt: I guess it felt like kind of survival for me.

 

Th: I think it probably was at the time to ignore and abandon your feelings and treat them as worthless and ditch them. It was probably very adaptive. It probably saved your life; and you are right: it probably was some kind of survival mechanism as you said as a kid but we see that now it is a disaster.  It was probably very adaptive, this trivializing and abandoning you while it helped you survive and just kind of survive. But what we are seeing now is that while it helped you survive then, it has become a disaster as an adult. We are seeing that as an adult it has become a habit of self neglect and self dismissal. [Always empathize with the origins of the defense in the past then point out the destructiveness of perpetuating it in the present.]

 

Pt: Hmm.

 

Th: Which you know, it helped you then but what was your solution then has become your problem today. So that while we have to admire your ability to do that and applaud you for finding that survival mechanism because you have to do what you have to do because your father is gone and your mother is gone. The only way you’ve got to deal with your emotions was to trivialize them. But what we are trying to do is recognize and thank your mechanisms for doing their job. But it may be time for you to say goodbye to those mechanisms so that we can help you overcome that learned pattern of self loathing, self dismissal, self contempt that was truly adaptive then but it is just terrible to you now. [Point out the therapeutic task: turn against destructive defenses.]

 

Pt: Yeah. That is right.

 

Th: What do you notice feeling?

 

Pt: I’m just very sad (looks up at therapist, tension in chest, looks down and rubs fingers: sharp rise in feeling and anxiety as he faces the pain he suffered in the past through being dismissed by others and the pain he inflicted on himself through his own self dismissal.).

 

Th: Just let yourself feel it. Just let yourself feel it. We don’t have to, we don’t have to dismiss your pain anymore. We don’t have to dismiss your suffering. We don’t have to cover it up; we can actually respect your feelings. We can make this mutual commitment, you and I, to stand up for you and respect whatever feelings you have. And no longer abandon you and your feelings like you and your parents did then. We can make a different choice. Just notice them. [Invite the patient to engage in the therapeutic task.]

 

Pt: (Long pause looking down, shallow breath, motionless).

 

Th: What’s happening inside?

 

Pt: Um, just you know, it’s kind of random thoughts about.

 

Th: Uh hum.

 

Pt: Um (long pause continuing to look down and then rubs forehead) just trying to think where the punitive, the punitive back to your question where the punitive mechanism um (looking up and to the side).

 

Th: Well, you let me know that you sort of identified with your mom and your dad. And when they left, you left; and when they abandoned your feelings, you left your feelings. When they didn’t pay attention to them, you didn’t pay attention to them. When they pulled away, you pulled away. And when they withheld or at least you experienced them withholding, you withheld too. It became sort of an automatic self deprivation, self withholding. It became automatic. It saved your life then but it became automatic and it wasn’t your intent. But it was just what happened and then it became automatic and then it became an automatic wreckage causing all this sadness and loss for you later on. What is happening inside?

 

Pt: (Chuckles: the emphasis on his identification with his parents causes a rise in feelings and anxiety.) I’m thinking of an ex-girlfriend of mine, um, just, you know. [A rise of feeling occurs within him.]

 

The repeated emphasis on how he abandoned himself as his parents abandoned him and the price he paid for it has led him to turn even further against his destructive defenses. As a result, the unconscious therapeutic alliance offers another cue for exploration, his ex-girlfriend, and a large rise of feeling which is visible in his face.

 

Th: The deeper you feel your feelings now the more you will be giving to yourself and the faster your therapy will go. So if you are wondering how to commit to you, the deeper you feel the feelings that come up: it is a gift you could give to you and a commitment to you and it will make this as quick as effectively as possible. So every time these feelings come you can hold back which will prolong your therapy or you can feel as deeply as you want even though it is scary. [Point out his choice: use destructive defenses and prolong his suffering or face his feelings as deeply as possible and gain his emotional freedom.]

 

Pt: I don’t know if it’s. [Feelings continue to rise.]

 

Th: Give yourself a bit of time. Give yourself this gift. Give yourself this gift. Give yourself this gift. It’s time to be kind to you. [Encourage him to engage in the therapeutic task: to feel his feelings as deeply as possible.]

 

Pt: (chuckle: anxiety as he is fighting back tears.).

 

Th: Give yourself this gift. Let yourself be in touch with you. The yeller has just been the façade that has covered this. Let’s get in touch with this gift so you don’t have to yell anymore. Very painful feelings. You’ve got the capacity to face it.

 

Pt: (Chuckles: anxiety in the face of rising feelings.) You are right.

 

Th: You’ve got the capacity to feel. It might have been too much back then, but you’ve got the capacity now. We can do it together. It’s like the anxiety comes in to attack you (Pt. laughs) as if it is against the law for you to have contact with tender feelings. [Point out how the anxiety attacks the patient as if it is against the law for him to share his feelings here with me.]

 

Pt: Well it is. It’s.

 

Th: As if it is against the law for you to have contact with the inner you.

 

Pt: Well, it’s, I don’t even know if this is a woman I was very much in love with (Fighting the tears, smiling.). [Negation: I do not know if this is a woman I was very much in love with = I do know this is a woman I was very much in love with. Since negation simultaneously denies and reveals the repressed, the repressed is very close to the surface. Hence, my next comment.]

 

Th: Let your love go through. Let your love go through. Don’t ignore your love. The time for ignoring love has come to an end now. The time for ignoring love has to come to an end. [Encouraging him to turn against the defense of ignoring his feelings and his love.]

 

Pt: But what if you want this person still that is the problem?

 

Th: You may not be able to have her but at least we can reclaim your capacity to love. That is what we are here to do. [Refocus the patient on his internal life. Whether he can have the former girlfriend back is outside of our control. What is inside our control is whether he lets himself have his heart back, his love, and his grief.]

 

Pt: Uh hum. (Long pause looking at floor, shallow breathing, and takes tissue and wipes nose continues looking at floor sitting very still. (Dry mouth, licks lips; turns sits back in chair, sighs, and chuckles: signs of anxiety discharged in the sympathetic and somatic nervous systems.).

 

Th: Tell me about her.

 

Pt: (smacks lips; looks away, rubs forehead. Sighs, fights tears: rise of feeling and anxiety.).

 

Th: Just let it go. Don’t hold your breath.

 

Pt: (Sobs, covers his mouth.).

 

Th: That’s it. That’s it. Let it all out.

 

Pt: (Continues sobbing, sighs.).

 

Th: Let your suffering come out.

 

Pt: (Sighs.).

 

Th: Let your suffering come out. Don’t hold your pain in. Let your pain come out. [Patient cries with his mouth held shut, stressing his body with the buildup of pressure.]  Open your mouth, let the pain come out.

 

Pt: (He opens his mouth, sobs, and continues to hide his eyes.).

 

Th: That’s it, just let it out. Don’t hold it in. The deeper you feel it the more you will be healed.

 

Pt: (Tension in chest, holding breath, scrunches face: rise of anxiety with the rise of deeper, more intense feelings.).

 

Th: The deeper you feel it the more you will heal. This is your love.

 

Pt: (He covers his mouth, sobs, sighs [Anxiety], inhales, holds his breath [Defense], licks his lips, and sighs [Anxiety].). Um. (Sniffs). Um, she was fantastic. Um

 

Th: Uh hum.

 

Pt: Um. (Looking away: impaired attachment response.). We um, I met her in college. We basically lived together a couple of years, (smacks lips) and uh, it was the uh, it was just one of these things like you just bonded totally with someone. She had come from a similar kind of wounded family or whatever and we connected (sigh-rise in complex feeling) strongly and she was really, really fantastic. Um and, she was not easy person. She was prone to get depressed very moody but um very needy. Um and, she very much wanted (smacks lips: anxiety) to get married, you know. We got engaged. She wanted to get married.

 

Th: She loved you. Let it go. Don’t hold back. Let her love go through you. The deeper you feel it the more you will be healed. Don’t hold back. The deeper you feel that, the more you will be healed.

 

Pt: I just feel so much shame.

 

Th: Let yourself feel that too. The deeper you feel that the more you will be healed. Yeah. She loved you too. She loved you so much she wanted to marry you. Wanted to spend the rest of her life with you and you loved her.

 

Pt: (nods)  Yeah. (Wipes nose). Yeah. (Still looking away. Deep sigh, rise of complex emotion). And um, (Sigh, gestures, sigh, pause: rise of feeling and anxiety.) and there was part of me that was very um. I was, she was, she loved me and I was so intense. I was so and I, you know, that I was afraid of getting married I felt like, god you know, I was 21 years old and it was a huge step and I don’t know if I’m ready to make this commitment. [Now we see the same conflict in the therapy as it occurred with his fiancé: committing to an emotionally close relationship; anxiety; and the defense of doubt and non-committal.]

 

Th: You had a hard time making a commitment. Yeah.

 

Pt: Yeah.

 

Th: To her.

 

Pt: Yeah.

 

Th: To her and to you.

 

Pt: Yeah. [Rise of painful feelings as he realizes the terrible price he paid for his defense of non-committal.]

 

Th: It’s all right. Yeah. A lot of painful feelings. Let it go through. The deeper you feel this the more you are going to heal. You can feel as much as you want. You don’t have to carry the suffering anymore. Hmm. So what happened?

 

Pt: (Sigh: rise in complex feelings and anxiety.). Well, you know, I think in the back of my mind I thought you know we will sort of you know, have time to basically, time to get my act together. And that is what I told her: can we take this more slowly? Do we have to get married right away, etc? And you know eventually she, you know, for a while we were still hooked up emotionally but eventually I think she decided she’d had enough and she moved on. And uh, (lips smack: rise of feeling and anxiety.), um (sighs) and, you know, I spoke to her and we, you know, and 15 years ago or 1995 or something like that.

 

Th: Uh huh.

 

Pt: So it was almost 10 years after we had broken up. And I spoke to her and it was, you know, but I was married and already had one daughter and, um, and when I spoke to her at least it was, it was great on one hand. She was obviously very happy to hear from me and on the other hand it was like, I wasn’t willing to sort of walk away from my marriage or take the chance that, I, I so.

 

Th: But obviously a lot of regret.

 

Pt: (Nodding) Yeah.

 

Th: Over saying no to what you wanted. [Point out how non-committal is saying no to himself, his feelings, his desires, and his goals.]

 

Pt: Yeah. (Still covering face). Yeah.

 

Th: So in a way we are learning that you weren’t actually saying no to her but you were saying no to what you want, you were doubting what you wanted, and you withheld from you the partner you wanted. [Make the link between the conflict in therapy and the conflict with his former fiancé. Clarify that this was an internal conflict: he not only rejected her—he rejected his own heart and desires.]

 

Pt: Right, right. Yeah that is true.

 

Th: And feeling a lot of regret over depriving yourself over what you want and this fear that you have and you deprive yourself of what you want. So, we see how that punitive mechanism really stole something very precious from you. [Differentiating him from his defense and helping him see how the defense deprived him.]

 

Pt: Uh hum. (Nodding, still rubbing forehead and looking away). Yeah it did.

 

Th: How sad.

 

Pt: (silence and pause).

 

Th: What’s happening inside?

 

Pt: Thinking about my wife.

 

Th: Uh hum. And, what about her?

 

Pt: I’m thinking that when she asks me about how therapy goes, um, whether I should tell her I thought about my ex-girlfriend.

 

Th: Because she knows this is a very big wound for you.

 

Pt: Yeah (nodding).

 

Th: What’s happening inside?

 

Pt: (Lips dry and smacking: rise of feeling and anxiety.). I mean I guess it’s great to be able to talk about this, um, because I really can’t, I really feel like I can’t, it’s not something I can talk about with my wife.

 

Th: Uh hum.

 

Pt: Uh. So, no that feels good, very good.

 

Th: It feels like it is a real relief.

 

Pt: Right.

 

Th: You haven’t said so but I sense that you have some feelings about having pushed her away, your girlfriend about not making a commitment; about saying no to her. [The continued anxiety indicates that feeling is still rising. Inquire about his guilt over the pain his defenses caused the woman he loved.]

 

Pt: Sure (Chuckle: anxiety in response to my question indicates that guilt is rising…), I mean (rise in feelings).

 

Th: Uh hum. See if we can lance that wound to let some of the pus out.

 

Pt: No, it’s I mean, I mean I feel terrible that I hurt her so badly (trembling voice). [Rise of powerful guilt.]

 

Th: So it’s tremendous guilt. Let yourself feel that as deeply as you can. Tremendous guilt about hurting her, guilt about rejecting her. It is important to feel that as deeply as you can. Tell me about this guilt.

 

Pt: (Deep sigh and chuckle: rise of guilt and anxiety, long pause [Defense].). It is hard to (sighs) she was so (gestures) (sighs) so supportive of me.

 

Th: Hmm. She believed in you.

 

Pt: And uh (sigh) and one of the, one of the things that was she would stick up for me

 

Th: Hmm.

 

Pt: She would stick up for me with her parents and her family.

 

Th: Wow, so she really fought for you.

 

Pt: I, on the other hand, I, on the other hand was not so brave.

 

Th: I’m sorry to hear that. So there is a lot of guilt that you didn’t reciprocate by standing up for her.

 

Pt: Yeah.

 

Th; How do you experience that guilt inside physically in your body?

 

Pt: (sigh, rise in complex feelings).

 

Th: Notice what is in your chest.

 

Pt: Well it’s funny. It kind of comes and goes.

 

Th: Yeah, but do you notice it in your chest?

 

Pt: I don’t know if it is the guilt per say, the guilt. [Denial and ignoring his guilt.]

 

Th: Oh yes, oh yes it is guilt. Don’t run away. [Brush the defense away.]

 

Pt: Yeah.

 

Th: It is a good reason you’ve been punishing yourself for so many years.

 

Pt: (Chuckles: anxiety indicating a rise of guilt.). Yeah.

 

Th: You feel a tremendous guilt about what you did. Yeah. She stood up for you and you didn’t reciprocate by standing up for her. You have tremendous guilt for hurting her and guilt for rejecting her.

 

Pt: So basically when I met her we bonded very quickly (smacks lips) and basically I moved in with her. I was in college and we went back and I was in Chicago with her family in Chicago (lips smack) and that was, I found, this great thing. It gets worse. So her um.

 

Th: Take your time. We don’t want to avoid anything here.

 

Pt: (Sighs)  And she, her family… (Sobs).

 

Th: That’s it, just let it out. Take your time. Just let it out. Don’t hold back. Take your time. Let all your pain out. Just let more out. Take your time.

 

Pt: Um, you know, so her family embraced me as this like the best thing that ever happened to her kind of thing.

 

Th: Hmm. They really had faith in you.

 

Pt: Yeah.

 

Th: They believed in you.

 

Pt: (Wipes nose.)

 

Th: They committed to you.

 

Pt: So uh and, her mother really liked me and so on (sniffs and sighs), um (smacks lips). Her mother was not friendly in my face particularly. She had her issues. She was not, she was somebody who had a conflicted relationship with Josephine, um, but so (deep sigh). My father and step mother, um, who were living in Chicago did not; they certainly liked Josephine a lot. They certainly did not like her mother and I think they thought it was weird or that they were, or maybe they felt guilty because I was basically adopted by them, by her family.

 

Th: That you were adopted, these people took you in as if you were their own son.

 

Pt: So.

 

Th: Just let it go through.

 

Pt: (Chuckles: rise of anxiety.)

 

Th: Don’t talk over the feelings. They adopted you as if you were their very own son so for the first time in 15 years there was a mother and dad together who wanted you in the same house.

 

Pt: Yeah. Well actually there was no father because Josephine’s parents had divorced and she had gone through a very painful hard divorce.

 

Th: But she took you in.

 

Pt: She took me in and her family took me in and they sort of…[His speech starts to race: a defense against being present to and  experiencing his feelings.]

 

Th: So slow down and don’t talk over your feelings. We are not here to talk over and ignore your feelings. We are here with kind attention. [Interrupt the defense of racing speech.]  They took you in as one of their own. They adopted you for yourself, this adopted son. Now, how does this adopted son continue?

 

Pt: So, um, my, um, my junior year of college, um, Josephine’s mother was diagnosed with breast cancer. Um, and uh (sighs) um, it was very hard for her and that was I was supportive of her and so on. But then, (smacks lips) by my, that would have been the second summer we were together, so the second summer (looking away) that we were together. I was, I don’t know if I was feeling sort of claustrophobic or, you know, or too sort of closed in by this relationship feeling like too much the embrace by the family or whatever or like it was too intense of a situation. We, uh, we didn’t spend the entire summer together the way we had before and, um, and that was kind of when by the end of the summer that’s when things sort of fell apart. Um, because she decided not to go back to college, um and um uh and you know, I could have taken time off from college. I could have helped her, you know, take care of her mother, and you know and I know you know, um, that is what she wanted me to do and I know that is what her mother and brothers and sisters wanted me to do. But I went back to college.

 

Th: But there is some guilt.

 

Pt: There is a lot of guilt.

 

Th: About not staying there to help her.

 

Pt: Oh yeah.

 

Th: Not staying there to help take care of her.

 

Pt: I mean she was, it was humiliating for you.

 

Th: That you weren’t willing to commit to her.

 

Pt: Yeah.

 

Th: So some guilt.

 

Pt: Oh yeah, a lot of guilt

 

Th: That you abandoned her.

 

Pt: Yeah.

 

Th: Yeah. Let yourself feel that. How do you experience that guilt over abandoning her?

 

Pt: (continues looking away).

 

Th: How do you experience that in your body?

 

Pt: Well, I don’t know if it is the guilt but obviously. [Defense: denial and ignoring his feeling.]

 

Th: It is the guilt.

 

Pt: I feel a weight on my heart.

 

Th: That is guilt. Just pay attention to that weight on your heart. Just notice this very intense feeling here, this weight on your heart, this guilt. You feel very intense guilt about abandoning her the way you were abandoned. [Point out that he abandoned his fiancé the way his parents abandoned him.]

 

Pt: Yeah. I guess that is right.

 

Th: Yeah. It is very important to feel that guilt as intensely as you can so that you can go through it.

 

Pt: So, yeah (deep sigh) um, so since then, like I said I’ve had one.

 

Th: Slow down.

 

Pt: I’ve had one interaction with her. I had one phone conversation with her and tried to tell her.

 

Th: Uh hum.

 

Pt: Tell her you know how much she meant to me and so on.

 

Th: So if she were here now what would you say? [Encourage a portrayal of the apology so that he can access and face the full depth of his guilt over abandoning her, the guilt which has been a partial determinant of his self punishment.]

 

Pt: (Deep sigh: rise of anxiety due to rising guilt. Looking away: defense.)  Um, I’d say (shaking head) um; I loved her more than anything (sobbing).

 

Th: Just let it go through you. That’s it. Just let it go through. Just let it go through. Just let it go through. And what else would you say to her?

 

Pt: I’m sorry.

 

Th: Tell her what you are sorry for. [Encourage the patient to face the full extent of his guilt by recounting what he did for which he seeks forgiveness.]

 

Pt: (sighs) Letting her down.

 

Th: I’m sorry I let you down.

 

Pt: I’m sorry I took her for granted.

 

Th: I’m sorry I took you for granted. Speak to her. I’m sorry I took you for granted. [Encourage the patient to speak as if she is there in order to access his feelings more deeply.]

 

Pt: I’m sorry I took you for granted. (Still looking away.)  I’m sorry I didn’t stand up for you.

 

Th: Uh hum. And what else?

 

Pt: (sigh)  It would mean a lot to me if you could forgive me.

 

Th: Please forgive me. [It would have been better if I had said, “How do you ask for her forgiveness?”]  And if she could speak to you what would she say to heal your heart?

 

Pt: (still looking away, sigh long pause, fighting emotion)  Funny I would, I would give a lot to just have, to just talk about the stuff

we talked about.

 

Th: What would you say to her?

 

Pt: I don’t know, just talk about our (long pause) you know we can talk about anything.

 

Th: Hmm.

 

Pt: She you know was, it sounds corny but you know the feeling that kind where you found a, there were times when I felt like I had found my other half, that person.

 

Th: Yeah. Uh huh.

 

Pt: So.

 

Th: If she were here and she could speak to you to heal your heart what would she say to you to heal your heart?

 

Pt: I’m not sure. I’m not sure. I mean anything literally being able to talk to her I mean, part of it would just be.

 

Th: But what would she say?

 

Pt: (sighs).

 

Th: What is it you need to hear?

43.40

 

Pt: (Smiles, still looking away.)  I’m honestly not 100% sure. I mean I was thinking what I would want her to say is, ‘I love you. I love you.’ Uh hum. ‘I love you even in spite of all that you did. You’ve hurt me (Chuckles: anxiety.), you abandoned me, but I still love you and…’

 

Th: I forgive you.

 

Pt: Yeah.

 

Th: How do you imagine saying goodbye to her?

 

Pt: I, I don’t know (lifts hand and drops). I don’t know. Um.

 

Th: You never have.

 

Pt: Yeah that is true.

 

Th: So how do you imagine saying goodbye?

 

Pt: (sigh, pause) I, I have so many different thoughts. I mean part of me thinks, I don’t know if I want to say goodbye. [Due to his guilt over the ways he hurt her, he has punished himself and has not let himself say goodbye to her. We have to help him grieve this loss in order to truly be free to love others, such as his wife and daughters.]

 

Th: Tell her how you want to hang onto her.

 

Pt: (Smiles, raises eyebrows, gestures, pauses.)  I, I want to hang on to the feeling that we had.

 

Th: I want to hang on to my other half. Ever since you left, I feel like half of me has been missing.

 

Pt: (Nods)  Yeah. Yeah. Yeah. I don’t know if that is saying goodbye (deep breath) but.

 

Th: Tell her how you want to hang on to her and why.

 

Pt: (Sigh) I just want to be able to talk to you.

 

Th: Tell her what you want to say.

 

Pt: (Lifts hand and drops it, still looking away.)  I, I, (Lifts his hand and drops it, long pause, lifts his hand and drops it, lifts both his hands.) I just want to talk about everything I guess. Talk about, you know, what I’m feeling, about (Pause, gestures, drops his hand.) about our families, everything you know.

 

Th: You wished you had told her.

 

Pt: Well I definitely wish I could tell her. I wish I could tell you how badly I feel about how I treated you. Um.

 

Th: Tell her.

 

Pt: I wish I could tell you how bad I feel about how I treated you. I’m really sorry about your mom.

 

Th: Uh huh. Her mom died and you weren’t there.

 

Pt: (Nodding)  Yep.

 

Th: Go ahead and feel it. Apologize to her for it.

 

Pt: I’m sorry I wasn’t there when your mother died. (Long pause, still looking away, takes glasses off and wipes eyes, continues to look away.)

 

Th: Anything you would say about her or that you would like her to hold onto forever?

 

Pt: (Inhales, hesitates, gestures, and stops.)  I mean I could spend so much time (chuckle, sigh) I guess you know, I would, I want to tell her, ‘I want you to know that, that no matter what I’ll, you’ll you know, you gave me (smacks lips) everything.’

 

Th: Uh huh.

 

Pt: And the time we had together was really precious. You know: no matter what, I will always be forever in your debt for that.

 

Th: For teaching me how to love.

 

Pt: (Nods). Yeah. Yeah  (Looks at the therapist and away.)  Yeah. I don’t, if she, I don’t know if I learned that well.

 

Th: She gave you a lot and taught you a lot.

 

Pt: Yeah.

 

Th: And how do you say goodbye to her?

 

Pt: (smacks lips, sigh) I, (Shrugs, lifts and drops his hands twice.) goodbye. I mean I don’t know. (Looks at the therapist, purses his lips, looks away.)  Part of me doesn’t, I don’t know how much I want to say goodbye. Part of me would love to say goodbye to her.

 

Th: Yeah. Part of you wishes you could hold onto her because then it would deny the fact that you cheated yourself and pushed her away and said no to her and no to your desire. Because to say goodbye to her is to acknowledge that you said goodbye to your desire that day because you said goodbye to not only to her but your own desire. [Point out the defensive function of not saying goodbye: to avoid facing his guilt over abandoning her.]

 

Pt: Yeah. Yeah.

 

Th: And this tremendous guilt you feel about hurting her and abandoning her as you were abandoned and tremendous guilt about how you abandoned your own heart, threw away your heart, ignored your heart and paid this terrible price. And we see that you feel such tremendous guilt over pushing her away and making her wait, rejecting her, abandoning her, leaving her to deal with her mother alone dying of cancer at the point when she needed you most. And then you left and feeling just overwhelming guilt about that. And we see that one way that you dealt with this guilt was really to punish yourself ever since. That, since you felt such guilt about walking away from yourself, you punished yourself by walking away from yourself. Since you felt such tremendous guilt about not standing up for her with your parents you punished yourself by no longer standing up for yourself. [Point out how he has punished himself by doing to himself what he did to her.]

 

Pt: Nods.

 

Th: And that you felt such guilt about not valuing what she wanted and what you wanted that you punished yourself by no longer valuing what you wanted.

 

Pt; (Blinks and slight nod.)

 

Th: And you felt such guilt about not committing to her that you punished yourself by never committing to yourself again. That you have, in a way, punished yourself by not committing to what you want. You punished yourself by not standing up for yourself, just like you felt such guilt about not standing up to your parents on her behalf that you punished yourself by acting as if you didn’t deserve to stand up to your wife for what you want. Then we see that you felt such guilt about how you had hurt this girl that you punished yourself by having the outbursts with your wife when you were angry and needing to stand up for yourself.  And when you yell at your wife, you actually invite her to punish you and reject you. And you actually invite her to kill off her love for you by rejecting you. So we see that the yelling was just a way for you to be punished because you have been treating yourself as if you are a man who doesn’t deserve to be loved by anyone again.

 

It’s as if because of this crime you committed with this woman and abandoning and hurting her that you treated yourself as if you don’t deserve to be loved by your wife. It is as if you have imagined in your mind that how dare you let yourself be loved by that woman when you didn’t allow yourself to have what you could have had there with her? How dare you let yourself have this embrace when you were unwilling to embrace you? And we see that you felt, you’ve been carrying this enormous burden of guilt.

 

And another way that you have been punishing yourself is that you are coming here. And it is as if this punitive part of your mind and says, ‘Well it is okay if you come here to see Frederickson as long as you don’t commit to yourself and let yourself have the full result.’  And the terrible thing here is that the punitive part of you says that because you have punished her and did not let her have the full result, it’s as if you don’t deserve to have the full consummation of this marriage and it’s as if this is just another relationship that you are allowed to start but you have to end it and not allow it to reach full fulfillment. It is as if just as you were not wanting to make a full commitment to her, you’ve been doing to yourself in every relationship what you did to her as if it is an eternal punishment for this crime. Do you see what I mean? [Showing the link between the guilt over abandoning his fiancé, his attempt to abandon himself in therapy and with his wife. However, I leave out an important link in the summary: how he did to his fiancé what his parents did to him—they abandoned him.]

 

Pt: Yeah I do.

 

Th: Yeah, so that is why it is so important for us to face this guilt because rather than just feel the overwhelming guilt we see you were punishing and torturing yourself. And you are having such guilt about withholding what she wanted and you felt such guilt about depriving her. And sadly, rather than just feeling the guilt you punished yourself by withholding and depriving yourself here and you can see now in a number of ways in the past that you have done the same thing by withholding and depriving yourself which was a way of continuing to punish yourself and do it to yourself repeatedly what you’ve done to her. As if you should be imprisoned and continuing this suffering because of this overwhelming guilt. And then we see further, that this is such a crime that we see how you really murdered this relationship that you buried half of yourself with her because you felt that she completed you so that means that you left half of you buried with her.

 

Pt: Uh huh.

 

Th: And you’ve been living sort of a half life since then.

 

Pt: Yeah.

 

Th: That you felt such guilt about what you did to her desire that you buried your desire with her as if it didn’t deserve to be listened to; as if it should be abandoned; and as if it should buried with her for punishment for your crime. That is why it was so hard to say goodbye to her because if you say goodbye to her you might be saying goodbye to your desire for her as punishment. So while we are having to find a way to say goodbye to her, but we are also trying to bring your desire back which you’ve felt you didn’t have a right to. ‘That I really don’t have the right to be decent to my desire after the way that I treated hers. I should ignore and dismiss, I should treat my desire as selfish to punish myself for a time when I was selfish. That rather than face my guilt for my selfishness then I will accuse myself of being selfish all the time now.’ Because there was a time that you are aware that you were selfish and you feel tremendous guilt about it. But rather than face your guilt about selfishness then you accuse yourself of being selfish all the time now which is a way of avoiding facing the guilt over a time, that regrettably you were selfish and that you felt terrible guilt about that. Does that make sense?

 

Pt: Yeah it does. It does. Um.

 

Th: Just let the feeling go through. You have capacity to face it. The deeper you feel the feeling the more you will be healed. You need to let this guilt go through and let yourself feel it so this self punishment, self deprivation, self withholding can finally come to an end and finally come out of this self imposed prison that has caused this frustration, such rage.

During the remainder of the initial session we continued to make the links between the abandonment by his parents, his reactive rage, and then, as a defense, his identification with them. He abandoned his own feelings and desires. But then by abandoning his feelings and desires, he ended up abandoning his fiancé who had to suffer at his hands as he had suffered at his parent’s hands. Then we repeatedly addressed his guilt over his treatment of his fiancé and the ways he avoided his guilt and punished himself instead. Then we linked this to his relationship with his wife. By yelling at her and pushing her away, he punished himself, as if he did not deserve his wife’s love after the way he had treated his former fiancé. These links came as a surprise to the patient but they also led to a lot of relief and a considerable drop in anxiety.

 

After eight weeks of therapy he terminated, reporting great improvements in his relationships at home and at work. At two year follow-up his gains had maintained and he continued to do well.