Monthly Archives: May 2013

“I don’t have any feelings.” Denial

“Is denial a regressive defense, indicative of a fragile ego? Or is it a tactical defense?” Thanks to Johannes for this important question!

In his seminal work, Denial and Defense, Theodore Dorpat pointed out that denial is the basis of ALL defenses. Think about that for a minute! I might deny that I have a feeling. Or I might deny that I have a feeling and do one more thing: e.g., relocate it in someone else (projection), cover it with words (intellectualization), or make someone else feel it (projective identification).           What do we deny? Two things: 1) the stimulus (otherwise known as reality); or 2) our feelings and internal responses to that stimulus. If I can deny the reality of a stimulus, I don’t have any feelings about it. “He said he wanted to break up, but I had been thinking of leaving anyway, so I don’t think that’s what my depression is about.” Here, the patient denies the significance of reality to avoid having feelings about it.

Since all defenses are based on denial, all of us use this defense. Thus, we can’t say that it is always a regressive defense or a tactical defense. Instead, new questions arise for us. In a given moment, what impact does the denial have on the patient’s reality testing and what function does the denial serve?

Denial can obviously be a regressive defense in a fragile patient if the other defenses are regressive, the patient’s anxiety is in cognitive/perceptual disruption, and the denial impairs the patient’s reality testing. For instance, a suicidal patient denies the lethality of her suicidal attempt through omnipotent denial. “My suicide will not lead to death but to rebirth in a new life.” Notice in omnipotent denial that the patient not only denies reality but offers the complete opposite of reality as a substitute.

Denial can also function as a tactical defense in a highly resistant patient if he uses tactical, repressive, and character defenses, if his anxiety is discharged into the striated muscles, and if his reality testing is good. For instance, he might say, “I don’t have a problem. You should ask my wife, since she’s the one who thinks there is a problem.” Here we see first the defense of denial. Then we see projection of his awareness (which he denies) onto his wife. This is not a loss of reality testing because, most likely, his wife really does think he has a problem. Here, the defense of denial wards off his awareness of his problem, but it also functions as a tactical defense to keep the therapist at a distance from his inner life.

Of course, the denial of any part of reality or of our feelings in response to it will falsify our picture of reality and ourselves. Thus, denial always impairs our reality testing. But the degree to which our reality testing is impaired occurs on a spectrum from neurotic denial (“I don’t have a problem”) to psychotic denial (“My suicide will lead to my rebirth as a savior of the world”).

In my forthcoming Youtube videos on denial, you’ll learn about the four types of denial: denial per se, denial through fantasy, denial through words, and denial through deeds. And in my book, Co-Creating Change, you’ll find an entire section on denial since it is such an important defense to understand and address if you are to gain access to the patient’s feelings.

ISTDP for Traumatized Patients

“I meet a lot of patients multi-traumatized, highly dissociative with PTSD. After initial stabilization, could these patients benefit from a treatment based on ISTDP principles?” Thanks to Christopher for this important question!

The graded format of ISTDP is a terrific treatment for traumatized patients. I think it may be one of the very best. Why? Because ISTDP is the only treatment model available that understands the pathways of anxiety discharge, has a theory of a threshold for anxiety tolerance, has a theory of differentiating anxiety caused by feeling versus anxiety perpetuated by regressive defenses, and has a theory of anxiety regulation which differentiates anxiety from projective anxiety.

Further, ISTDP is uniquely prepared for these patients because it has a theory for differentiating feelings from defensive affects that result from regressive defenses. And it has a theory that allows it to differentiate regression in the service of the ego from regression of the ego itself.

In the graded format, we help patients face as much feeling as they can as long as their anxiety goes into the striated muscles and the patient does not use regressive defenses. Under those conditions the patient becomes increasingly integrated as the result of experiencing his feelings. If the patient’s anxiety goes into cognitive/perceptual disruption, his prefrontal cortex and hippocampus shut down, preventing higher order thought, understanding, and integration of learning. If the patient uses regressive defenses, the patient’s reality testing continues to worsen, leading to a regression of ego functioning and loss of reality testing.

Thus, as soon as the patient experiences anxiety in the parasympathetic branch of the autonomic nervous system, we regulate anxiety immediately to restore optimal brain functioning. As soon as the patient uses a regressive defense, we restructure the regressive defense to prevent a regression in reality testing and ego functioning. Step by step we increase the patient’s tolerance of affect, we restructure the pathway of anxiety discharge, and we strengthen the ego.

Rather than explore high levels of feeling which would overwhelm and re-traumatize the patient, we build the patient’s capacity to tolerate feelings step by step. Rather than explore the products of the patient’s defense such as the multiples selves of dissociation, we regulate the patient’s anxiety, which makes her brain malfunction. Once her brain is functioning correctly again, we restructure her defense. We do not integrate the “selves” which result from the defenses of splitting and dissociation. Instead, we help the person let go of defenses like splitting and dissociation and then integrate her previously warded off feelings.

When the patient experiences overwhelming dysregulated affects, we address the regressive defenses which create those defensive affects. By restructuring the regressive defenses, the dysregulated affects stop, the patient’s reality testing is restored, and then we can face the underlying feelings which were originally triggered by the traumas, bit by bit gradually.

When the patient experiences a loss of reality testing such as a “flashback”, we regulate her anxiety, help her differentiate the past and present, increase her reality testing, and then from this new position of strength help her face a little bit more feeling.

For examples of how the graded format of ISTDP works with highly traumatized patients, visit the resources page and download the article about the man who awoke from a coma, a case of a dissociative patient. Or download the article about separating the ego and superego in a recovering drug addict. She had been verbally, physically, and sexually abused as a child. Or you might consider buying the DVD of the fragile man who had fourteen previous therapists. He also had been severely traumatized as a child. These examples will help you understand the graded format of ISTDP, a format of treatment tailored to help fragile, traumatized patients. For more information on the graded format, the middle third of my book, Co-Creating Change: Effective Dynamic Therapy Techniques, is devoted to the graded format.