Monthly Archives: February 2013

“I Don’t Know”

A colleague asked, “If I ask someone how they feel and they say, ‘I don’t know,’ and they are just beginning therapy, how should I respond?” This is a great question because this is a very common response. Why don’t patients know what they feel? They use defenses. When you hear the response, “I don’t know”, you have just received really useful information: “Oh, I see. I have to help her see her defenses so she can know what she feels.”

For instance, if a patient intellectualizes, rationalizes, and uses hypothetical speech, her attention will be distracted away from her body so she won’t know what she feels or how she experiences a feeling in her body. Thus, our task is to keep inquiring about the patient’s feelings so her defenses will come up. That way we can help her notice, moment by moment, what defenses prevent her from knowing what her feeling is. When she first says, “I don’t know,” you can simply mobilize her will to engage in the therapeutic task by responding, “That makes sense. If you don’t know what you are feeling, you won’t know what you want in in life. Then it’s like you are going through life without a compass. And that would create the problem you mentioned earlier: feeling a bit lost in life. Would you like to know what you are feeling so you aren’t so lost in life?”

The phrase “I don’t know” can mean many things. It’s not as if there is one right response to fit all patients. That’s why we assess the patient and the context so that we can respond to the problem the patient needs help with in the moment. For instance, you ask a highly resistant patient about his feeling and he might say, “I don’t know” before you even finished your question. This would be an example of instant repression. The patient avoids looking inside. Imagine if I asked you if there were any cookies in the cupboard and you said, “I don’t know” without even bothering to open the cupboard to take a look! When a patient responds with “I don’t know” immediately without looking within himself, you can respond, “Do you notice you say that right away without even looking inside yourself first?”

Another situation calling for a different response might be one where you ask the patient what she is feeling toward you. The patient responds by saying,

“I don’t know. I feel fine with you.” Here, based on the context, you realize the patient is trying to avoid conflicts and feelings toward you. You could open that up by saying, “I’m sure you do. But if fine was the only feeling you had with me, you wouldn’t be anxious. So I wonder what other feelings might be coming here toward me that are making you anxious?”

Or suppose you are working with a highly resistant patient who is detaching. You point out his detaching and ask, “What can we do about that?” The patient responds by saying, “I don’t know” and he has a smirk on his face. Here, the problem is not his lack of knowledge. The problem is his defiance. Rather than address his “I don’t know”, the verbal defense, address his defiance, the non-verbal enactment of a non-collaborative relationship. You could respond by saying, “The good news is, you don’t have to do anything about it. You can detach as much as you think would be helpful to you. [Deactivate the defiance.] It’s just that as long as you detach, we won’t be able to get to the bottom of your difficulties.”

This would contrast with a situation where a fragile patient suffers from cognitive/perceptual disruption and responds to a question with “I don’t know.” At that moment, the patient really does not know. Her brain is not functioning correctly because anxiety has become too high. Thus, her statement of “I don’t know” is not a defense but the result of a malfunctioning brain. Here, you would respond by pointing out her anxiety and regulating it until her cognitive functioning is restored.

When the patient says she does not know the answer to your question, psychodiagnose her response. “I don’t know” can be a defense, the result of defenses, or the result of excessive anxiety. Your psychodiagnosis will allow you to offer a precise intervention that targets the specific problem she is struggling with in the moment.


Treating Panic Attacks: How do we Understand Dizziness?

Patients can experience severe levels of anxiety in many forms. The fragile patient may experience anxiety discharged into the parasympathetic branch of the autonomic nervous system (ANS) and suffer dizziness, blurred vision, ringing in the ears, and problems thinking. But some patients who hyperventilate suffer panic attacks where they get dizzy too. Are they fragile? How can we tell?

A person is fragile if her anxiety is discharged into the parasympathetic branch of the ANS (what Davanloo called cognitive/perceptual disruption), and her defenses are regressive. In her case, her dizziness is due to the drop in blood pressure and blood flow to the brain and dilation of her blood vessels. In her case, we can regulate her anxiety by drawing her attention to it. “This dizziness is a sign of anxiety. Are you aware of feeling anxious right now?” Then we cognize about her anxiety with her, helping her use the defense of intellectualization. “So we see that you were angry with your boyfriend. This triggered some anxiety. Then the anxiety made you dizzy. Do you see that sequence too?” Repeating this a few times is usually enough to bring the patient’s anxiety down and her dizziness stops.

Another patient who has a panic attack may experience her anxiety very differently. She starts to hyperventilate, gasping for air, and then becomes dizzy. Is she fragile? As you observe her, you will notice that she is tense and previously was sighing. Hence, her anxiety is in the striated muscles. However, you also notice that her pupils are dilated, she is hyperventilating, and her pulse rate seems higher. That means her sympathetic nervous system has escalated. When the patient hyperventilates, the blood becomes alkaline due to a drop in carbon dioxide levels, leading blood vessels to constrict. That causes her lightheadedness and sometimes fainting. Do not have the patient breathe into a paper bag. Instead, simply slow the patient’s breathing by having her inhale slowly for five seconds and exhale for five seconds over the course of a minute or two. Or invite her to hold her breath for fifteen seconds. The patient’s carbon dioxide levels will return to normal, vasoconstriction will end, and dizziness will disappear. Then summarize the process for the patient to show causality and regulate the anxiety. “We saw that you were angry with your boyfriend. That made you anxious. And when you became anxious you started to hyperventilate. Then the hyperventilation made you dizzy. Do you see that sequence too?” Then invite her to face the feelings that triggered her anxiety. “Would you like to take a look at this anger so we can help you feel anger instead of having symptoms?”

When assessing dizziness, notice where the patient’s anxiety is discharged in the body (parasympathetic or sympathetic branch of the autonomic nervous system). That will determine how you regulate her anxiety.