Monthly Archives: September 2013

Why Doesn’t my Patient look Anxious?

“How do we understand the absence of unconscious signaling in the patient’s body?” Thanks to Monica for this important question!

There can be many reasons why you won’t see unconscious signaling of anxiety in the striated muscles. In fact, I have an entire section of my book, Co-Creating Change, that addresses this problem in detail. So let’s review a few of the main reasons why your patient may not appear to be anxious.

1. The patient won’t be anxious at all if you are not exploring feelings within a conflict the patient wants to resolve. So, if you are not asking for feelings, you won’t see anxiety in the patient’s body.

2. The patient won’t look anxious if he is using lots of defenses or using a transference resistance. He will look cool, calm, and collected while you are working hard. Since he is uninvolved in the therapy, he is uninvolved with himself and his feelings. His defenses are working so well, his anxiety is not rising.

3. If you don’t address his defenses, feelings and anxiety will not rise within the patient’s body. Or if you address defenses he is NOT using in the moment, feelings and anxiety will not rise within the patient’s body.

4. It may be that the patient is genuinely confused about the process, suffering from a brain injury, on excessive amounts of psychotropic medications, under the influence of illegal drugs, or physically depleted due to illness. Any of those factors could prevent a patient’s anxiety from rising.

5. You might be exploring a feeling but in a conflict the patient is not interested in exploring. Since his will is not engaged, you will be exploring, but he won’t. Thus, no feeling or anxiety will rise.

6. You might be exploring feeling regarding a problem you see, but which the patient does not regard as a problem. Thus, no feelings or anxiety will rise in response to your exploring.

7. You might be exploring a problem which is a problem for the patient’s wife but not for the patient himself. Thus, no feelings or anxiety will rise in response to your exploration.

8. You might be exploring a defensive affect. Since this affect already functions as a defense, exploring it will not trigger deeper feelings and anxiety. For instance, a patient projects that you think she is fat and cries. If you explore her tears (the result of projection), no anxiety will rise. Or a patient is grieving the loss of a boyfriend, and then becomes angry to cover up her grief. If you explore her anger (a defense against her grief), exploring this defense will not trigger the underlying grief or anxiety.

9. You might be exploring a problem for the patient and exploring his feeling in a situation, but the patient’s anxiety has shifted into the smooth muscles or cognitive/perceptual disruption. Now that the anxiety has shifted into the parasympathetic branch of his autonomic nervous system, it is no longer going into his striated muscles. Here you need to regulate his anxiety so it goes into the striated muscles again. Then you can resume exploring feeling again.


Thus, when you don’t see anxiety triggered in the patient’s striated muscles, go through this checklist to see what is preventing a rise of unconscious anxiety in the patient’s body.


It’s his/her fault!! Externalization

How do we help patients who describe themselves as victims of other people’s actions? One patient complains that her ex-husband, who claims he is unable to care for their child due to his difficulties, is strangling her and failing to help her. When the therapist asks about anger, the patient says, “I have too much to deal with. I cannot do this. I am tired.” Thanks Maria for this common problem!

What do we mean by externalization? The patient is angry with her ex-husband for dropping his responsibilities for the care of their child. This is quite understandable. The question becomes, “what does she do with her rage?” It turns out that she strangles her rage and does not assert herself. But she blames her ex-husband for “strangling” her. Let’s unpack this.

Triangle of conflict: Feeling: anger; anxiety: striated; defense: strangle her feelings; second defense (externalization): blame the ex-husband for doing to her what she does to her self, strangles herself. By strangling her own feelings, she hurts and victimizes herself. But, if she blames her ex-husband for strangling her feelings she can imagine that he victimizes her rather than she victimizes herself through her defense.

When patients blame others for their suffering, we must look closely to find out the patients’ defenses which cause the suffering. The therapist might say:

Th: “Did you say something to him?”

Pt: “No.”

Th: “So you didn’t express your anger or set a limit about his failure to abide by the conditions of child care you had set up.”

Pt: “No.”

Th: “So is he strangling you, or did you strangle your own feelings?”


Here, the therapist helps the patient see causality: her actions victimize her and cause her suffering. Once this defense is cleared up, the patient will be able to face her anger toward the husband for his failure to abide by the child care agreement. If we don’t clear up the defense of externalization, the patient’s anger will be toward the ex-husband who supposedly “strangles” her feelings. That is, you would be exploring feelings based on the defense of externalization. That’s why we always clear up externalization. Then we can establish an internal focus for the therapy: “I will focus on my feelings, my anxiety, and my defenses inside me that cause my problems.” Otherwise, the patient will have an external focus: “I will focus on my ex-husband’s feelings and his actions that cause my suffering. He is the cause.”

Some of you observant ones out there may have noticed that I have not yet discussed a delicious defense here that the patient used. Remember that the ex-husband said he was “not able” to take care of the child due to “his difficulties.” In response, the patient says, “I have too much to deal with. I cannot do this. I am too tired.” Rather than face her anger toward the ex-husband, she identifies with his helpless stance.” I call this a “suffer-off”. In this kind of masochistic competition, the one who suffers the most is the winner. What do you win? You win the crown of the one who has suffered the most, the one to whom great reparations must be made by the ex-husband, and perhaps even the universe!

Pt: “I have too much to deal with. I cannot do this. I am too tired.”

Th: “You cannot deal with this conflict with your ex-husband.” [Mirror her denial and helplessness.]

Pt: “No.”

Th: “That’s too bad.”

Pt: “Why do you say that?”

Th: “Well if you cannot deal with this conflict with your ex-husband, you will not be able to resolve it.” [Price of her denial and helpless stance.]


The therapist also shared that she felt an omnipotent responsibility to get the patient to take responsibility for herself. This is a common countertransference response to a patient who uses the defense or transference resistance of helplessness. “If everything is too much for me, I need you to do for me what I refuse to do for myself.”

Pt: “I cannot do this. I am too tired. What do you think I should do?” [Transference resistance: I will take a helpless stance and say I am too tired to do anything. Then I ask you, the therapist, to become active and ask me to do something I am too tired to do.”]

Th: “If you’re too tired, you can’t do anything.”

Pt: “That’s what I think.”

Th: “It’s good you’re aware of that. If you’re too tired, you can’t do anything. And things will just have to stay the same for now.” [Mirror her resistance and point out the price.]

Pt: “But how can things change?”

Th: “They can’t. You’re too tired.” [Price of the resistance.]

Pt: “Isn’t there something more you could do?”

Th: “I can do what I can do, but if you’re too tired, we have to accept we can’t make any progress right now.” [Mirroring her resistance and pointing out the price.]


Take home point: when a patient blames others for her difficulties, notice what defenses she uses that create her difficulties. Then help her see how her defenses, not her ex-husband, create her problems. This new internal focus will also give her an internal locus of control, which can result in greater hope for her future. Then she can leave the competition of who suffered most that I call the “suffer-off.” For more help on this, see the section on regressive defenses in my book, Co-Creating Change: Effective Dynamic Therapy Techniques.