Monthly Archives: August 2013

Regression after Recovering Memories of Sexual Abuse

“How would you handle a person severely depressed with suicidal ideation (within a psychiatric unit)?  After a fully functional life she suddenly remembered an early incident of sexual molestation. Her anxiety is very high. She is withdrawn and numb.” Thanks to one of our anonymous readers who sent this question.

Of course, without seeing the patient we can only speculate. So, instead, let’s get clear about the assessment questions we need to keep in mind when working with this patient. Let’s start with the triangle of conflict. We can safely hypothesize that recovering the memory of sexual molestation has triggered a very large rise of complex feelings. These feelings have triggered her anxiety. And her defenses, from what we have heard, include turning rage on the self (suicidal ideation), withdrawing from her feelings, and numbing herself.

Given that the patient is in a psychiatric unit we want to assess her anxiety. Which channels of unconscious anxiety discharge does her anxiety go into? High anxiety could go into purely striated muscles, or it could go into the smooth muscles and cognitive/perceptual disruption. If her anxiety is going into the striated muscles, the therapist can explore feelings freely and hope for a rather quick treatment. However, if the patient’s anxiety goes into cognitive/perceptual disruption, the patient’s pathway of anxiety discharge will have to be restructured. And most likely she suffers from high superego pathology (e.g., character defenses, transference resistance, or projection of the superego). And this superego pathology would have to be addressed quite thoroughly in order for the pathway to feeling to become available.

As the therapist explores the patient’s feelings about the molestation memory, she would assess not only the patient’s anxiety but also what kinds of defenses the patient uses. Does the patient also use repressive defenses such as intellectualization (good sign) or are all of her defenses regressive? (bad sign) This assessment would allow the therapist to see how much affect the patient can tolerate, what risk she has for acting out, her reality testing, and what degree of defense restructuring the patient needs.

As the therapist explores the patient’s feelings, she will see whether the patient becomes more firm and steady with a rise of feeling (good sign) or whether she starts to flatten out (depression), become confused and disorganized (cognitive/perceptual disruption), or suffer physical symptoms (somatization). This will allow the therapist to see what level of feeling the patient can tolerate without regressing, the highest level where the therapist should try to work at with the patient.

As the therapist explores feelings, she should assess whether the patient can observe and pay attention to her feelings, anxiety, and defenses. If she can’t pay attention to her feelings, she won’t be able to access them as deeply as possible. If she can’t pay attention to her anxiety, she won’t be able to regulate it. If she can’t observe her defenses, she will keep using them and suffer the symptoms that result from those defenses. Whatever observing capacities the patient lacks, the therapy must rebuild.

As the therapist explores feelings, she should assess whether the patient can see the triangle of conflict that generates her symptoms. Can the patient differentiate her feelings from her anxiety and defenses? Can the patient let go of the defenses that hurt her? If not, mobilize those missing capacities.

And as the patient is able to tolerate a higher rise in feeling, does she continue to use defenses against feeling, or does she shift into avoiding contact with the therapist. If so, then the therapist must focus on those defenses against contact, what we call the transference resistance.

We can’t know what to do with any patient until we know what is going on. To know what is going on, we explore feelings. The patient’s responses of anxiety, defense, and self-observing capacity show us her strengths and weaknesses. They show us what we need to treat. Gently explore feelings so you can assess the patient’s responses and conduct a thorough psychodiagnosis. Her responses of feeling, anxiety, and defense will tell you what strengths she has and what weaknesses you need to strengthen so you can access her feelings as deeply as possible. In my book, Co-Creating Change, there is an entire chapter on just the topic of psychodiagnosis.

“You Can’t Make Me Do it!” Defiance

“Is defiance always a sign of a transference resistance building up or high resistance? How would you address it? Is it part of a wall?” Thanks to Peter for these great questions!

How we understand defiance depends upon its context. Let’s take a common form of defiance we encounter with fragile patients. You ask what the patient would like to work on. In response to this invitation to form a more intimate relationship, the patient experiences a rise of feelings and anxiety. As a defense, the patient projects his will to explore his inner life onto the therapist.

Now the patient has ‘forgotten’ that it was his will to come to therapy, to talk, to explore his inner life. Now he believes the therapist wants to explore his inner life. Now the patient says things like, “I’m afraid of the questions you want to ask. He is not really afraid of you. He is afraid of the projection he has placed on you (his will to explore). Now he fears your wish to explore.

In response to this projection, the patient may defy you. This is very important to remember. A patient never defies you. He defies the projection he has placed upon you. Defiance is always based upon projection. Thus, to deactivate defiance, we have to deactivate the projection upon which defiance is based.

In this case, the therapist blocks the projection and reminds the patient of his will to deactivate the projection.

Th: “Was it your will to come here to day?” “Was there a problem you want to overcome?” “Do you want to know what is going on inside you so you have better information about yourself?” “Do you want better information about yourself, so you can make better decisions for yourself?”

Notice how each question reminds the patient of his will. Each time he accepts a part of his will, that part is no longer projected onto the therapist. Thus, step by step, the therapist can deactivate the projection of will. Once the patient accepts his will and does not project it onto the therapist, he no longer defies the therapist.

A patient can defy other projections onto the therapist. For instance, a patient who judges himself may project that the therapist is judging him.

Pt: “What are you looking at?”

Th: “It sounds like you are afraid I am looking for something. Is there any evidence for that?” [Help the patient differentiate the therapist from her fantasy.]

The patient who believes the therapist is judging him may defy the supposedly “judging” therapist.

Or the patient may project that the therapist wants her to depend on the therapist.

Pt: “I don’t want to f***ing depend on you!”

Th: “I have no right to ask you to depend on me if that is not something you want to do.” [Deactivate the patient’s projection.]

The patient defies the therapist who supposedly wants her to depend.

In each case the therapist deactivates the projection upon which the defiance is based.

In these examples, we have seen how defiance can result from a single projection and can be relatively easily restructured. Thus, defiance, although quite provocative, is not always a sign of high resistance.

In contrast, we can see a defiant transference resistance that does not deactivate so rapidly. Why? In contrast to the previous examples of defiance (based on a single projection), the transference resistance is a pathological mode of relating where a bunch of defenses work together as a system. For example, you might have an oppositional patient. Remember the line of James Dean:

Man: “What are you against?”

James Dean: “What do you got?”

In the oppositional transference resistance, the patient enacts a relationship from his past. He enacts, for instance, the role of a domineering, questioning, doubting, critical father and you are in the role of a dominated, questioned, doubted, criticized child whose every initiative is opposed by the father. This is the enactment of an internalized object relation, that is, a memory of a past, pathological relationship. You can see that here the enactment is not based on a single defense, but that a large variety of defenses work together to create this enactment.

To deactivate the oppositional transference resistance, therefore, you will need to deactivate the patient’s identification with the oppositional father and deactivate the projection of his healthy desires onto you. Therefore, we psychodiagnose each patient response to see which of the four elements of the transference resistance is in the forefront.

For instance, the patient may be identified with his oppositional parent.

Pt: “I don’t want to look at that.”

Th: “Why look at it if you are fine with how things are going?” [Deactivate the patient’s identification with his father by hinting at the price of the defense.]

Or the patient may be proposing an omnipotent transference for the therapist.

Pt: “I’m not going to look at it.” [Encouraging the therapist to take on the sole responsibility for looking at an issue.]

Th: “Ok. If you don’t want to look at it, we won’t be able to.” [Pointing out reality to deactivate the omnipotent responsibility he proposes for the therapist.]

Or the patient may propose a regressive wish.

Pt: “So how am I supposed to get better?” [I want to get better even though I refuse to collaborate with you.]

Th: “You can’t. If you don’t want to look at this issue, we simply have to agree that we won’t be able to help you with it.” [Point out reality to deactivate the patient’s regressive wish.]

Or the patient may project his healthy wishes onto the therapist.

Pt: “You seem to think I ought to look at this.”

Th: “Why look at something you don’t want to look at?” [Deactivate the projection of the healthy wish onto the therapist.]

These interventions facilitate a “head-on collision” between the patient and his resistance. Up to this point, the patient identifies with his resistance and tries to have a conflict with you, the embodiment of his healthy wishes. When you deactivate the projection of his healthy wishes, his resistance becomes in conflict with his healthy wishes rather than with you. Thus, we try to convert his interpersonal conflict between him and the therapist into an intrapsychic conflict between him and his resistance.

This pathological relationship, the transference resistance, is the “wall” between the patient and therapist. The issue here is not a single defense but an entire enacted relationship. We no longer focus on an isolated defense but on the enacted pathological relationship.

Sometimes the patient will enact this relationship by arguing with everything you say. The only way that can continue is if you argue with the patient. Here is a little secret: the patient’s resistance can work only if YOU resist it. His arguing works ONLY if you argue with him. In other words, the resistance takes two. When there is a tug of war, drop the rope.

Pt: “I don’t believe you.”

Th: “Ok.” [Deactivate the omnipotent transference: you are supposed to make me believe you.]

Pt: “Aren’t you supposed to convince me?”

Th: “No. That’s not my job. If you don’t believe me, why should you believe someone you don’t believe?”

Pt: “I want to argue with you.”

Th: “It’s good you notice that.”

Take home point: defiance is always based on a projection. In a fragile patient, defiance will be based on defying a projection of will, desire, superego, or feeling. Deactivate the projection and the defiance will disappear. In a moderately resistant patient, deactivate the projection upon which defiance is based and feeling will rapidly rise. In a highly resistant patient, defiance enacts a pathological relationship, the transference resistance. Here, deactivating one projection will not make the defiance fall. Instead, the therapist must deactivate all the projections upon which the transference resistance is based. The therapist must assess each patient response to see which element of the transference resistance is being enacted in that moment (identification with the resistance, omnipotent transference, regressive wish, or projection of healthy wishes). The therapist deactivates that element repetitively until the transference resistance drops and feelings finally break through. When the defiance continues, examine the videotape carefully to see what you might be doing to defy his defiance!!