Monthly Archives: March 2013


“How do we understand somatization on the triangle of conflict?” Patients suffer bodily symptoms in psychotherapy for three reasons: 1) medical causes; 2) anxiety; and 3) the defense of somatization. Assuming the patient has been medically evaluated, we then explore the psychological causes for somatic symptoms.

The most common source of somatic symptoms is anxiety. As you know from our videos and previous blogs, anxiety can be discharged into the somatic and autonomic nervous systems. When anxiety is discharged into the somatic nervous system, the patient’s voluntary muscles tighten up causing back pain, neck pain, tension headaches, vulvadynia, and many other complaints. When the patient’s anxiety is discharged into the voluntary muscles, we pursue the patient’s feelings and help him let go of his defenses. Once he feels his feelings as deeply as possible, his anxiety drops, and his symptoms disappear. Any of you who have followed John Sarno’s work know that he helps patients face their anger so that they can feel their feeling rather than cover with anxiety in the form of tension. That is consistent with the way ISTDP thinks about somatic symptoms that result from tension in the striated muscles.

If anxiety is discharged into the parasympathetic nervous system, the patient will suffer migraines, cognitive problems, immune system problems, and digestive tract problems such as diarrhea, nausea, and irritable bowel syndrome. Here, the therapist must regulate anxiety as soon as these symptoms occur. Bring anxiety back into the striated muscles. Then explore feeling again. As the patient’s feeling tolerance increases, eventually her anxiety will no longer go into the parasympathetic nervous system and her somatic symptoms will disappear. This change is what we call restructuring the pathway of unconscious anxiety discharge.

For some patients somatic symptoms do not result from anxiety but from the defense of somatization itself. In the defense of somatization, the patient unconsciously identifies with the body of another person with whom she has mixed feelings. A patient, unable to bear the loss of her mother who died of lung cancer, was troubled by a chronic cough (identification with her mother’s symptom). Once she could grieve the mother’s death, her cough disappeared. Another patient imagined putting an ax to his father’s head. A moment later he had a “splitting” headache. Due to guilt over his rage toward his father, he identified with his father’s body, as if the murderous blow had gone onto him, not his father. In this case, due to unconscious guilt over the murderous rage, the patient identified with the body as if to say, “Don’t worry father, the rage went onto me instead.” Once we can help the patient face his rage and his guilt, he no longer has to punish himself for his unconscious crime through the defense of somatization.

When patients use the defense of somatization, we help them see the defense, then encourage them to face the feelings the defense wards off. When the patient can bear the warded off feelings, the defense of somatization is no longer necessary.

Thus, when working with somatic problems, assess whether the symptom is caused by the discharge pattern of unconscious anxiety or whether it is caused by the defense of somatization. In my forthcoming book, Co-Creating Change, an entire chapter is devoted to treating the fragile spectrum, including somatizing patients. You can also read the case of the depressed patient on the resources page for a case of somatization that resolved very quickly after a breakthrough to the complex mixed feelings.



Dissociation: Defense or Result of Cognitive/Perceptual Disruption?

The term dissociation has been used to describe so many things it at times appears to mean nothing at all. For instance, it has been used to refer to describe a continuum of experiences of detaching from reality that can range from daydreaming and boredom to the fragmentation of the self into separate streams of consciousness such as we see in dissociative identity disorder.

In ISTDP we make several distinctions when dealing with this class of defenses. First of all, detaching and daydreaming are viewed as tactical or repressive defenses when the patient’s anxiety is in the striated muscles. In this case, we point out how the patient detaches from her feelings (repressive defense or character defense) or detaches from the therapist (tactical defense or transference resistance). We point out the defense, help the patient see its price, and invite her to let go of her defense to have deeper contact with her inner life and to have a deeper connection with others.

However, when we address more pathological forms of dissociation (blanking out, derealization, amnesia, or fragmentation of self experience), the anxiety is discharged into cognitive/perceptual disruption. When anxiety is channeled into cognitive/perceptual disruption, we regulate anxiety before addressing the defense of dissociation. We have to restore proper functioning of the brain. In this case, as soon as a severe form of dissociation occurs, we point out the anxiety and regulate it until the patient’s anxiety returns to the striated muscles. Then we will explore feelings again, building the patient’s capacity step by step so that he can tolerate higher levels of feeling without resorting to the defense of dissociation. Once the patient’s anxiety has been completely restructured into the striated muscles, the dissociation will no longer be necessary as a defense.

ISTDP differs in two ways from many other models of working with dissociation. First, when dissociation results from anxiety in cognitive/perceptual disruption, anxiety regulation takes precedence over defense work. Often, anxiety regulation leads to a drop in the defense of dissociation in the moment. Second, ISTDP does not work with the integration of the “multiple” selves. Why? These multiple selves are the results of the defense of splitting. We regulate anxiety until the defense is not necessary. Then we help the patient face and integrate his complex mixed feelings internally without splitting, so those feelings and experiences do not have to be split apart and represented as “multiple” selves. You can read an interesting case of ISTDP with a dissociative man on our resources page, “The Man Who Awoke from a Coma.”