Monthly Archives: October 2013

Who challenges the patient?

“I noticed your substitution of “invitation” for “pressure”, and I think that clarifies the purpose of the intervention: to encourage collaboration and deepening the emotional connection. Why did you substitute the term “confrontation” for “challenge” and “head-on collision” in the new book?” Thanks to Maury for this question.

It is easy to forget that the patient is never in conflict with you. It may FEEL that way. But that occurs when the patient forgets that his defenses are in conflict with himself, not with you. The patient’s defenses are always in conflict with his desires or with reality. For instance, a patient who sabotages his therapy is not in conflict with you. His self-sabotaging defenses are always in conflict with his healthy goals. If he wants a healthy relationship with his girl friend but dismisses her feelings, his defense, dismissal, is in conflict with the demands of reality.

The patient, unable to see his defenses, may mistakenly think you or other people cause his difficulties. So he will imagine he is in conflict with you or them. In fact, he is in conflict with himself. That is why we have to differentiate the patient from his resistance.

When we mistakenly think the patient is in conflict with us, we are caught up in the transference resistance. The patient is passive, for instance, and we become active. When active, we may mistakenly become more active to make a passive patient more active. Then what is really an intrapsychic conflict (between the patient and his resistance) becomes an interpersonal conflict (between you and the patient). When we are caught up in that enactment, we often think we need to “challenge” the patient and end up in a “head-on collision” with the patient’s resistance. And we fail.

The true purpose of our defense interventions initially is to help the patient confront reality, to see how his resistance (challenging reality) is doomed to fail. This facilitates a “head-on collision” between the patient and his resistance. He begins to see that he is not resisting you. He is resisting the inner reality of his feelings and the external reality of life, its demands, and limitations.

In this sense, we never challenge, confront, or “collide” with the patient. Reality does that. Reality is The Great Teacher.

Pt: “I’m not sure I’m ready to face this.”

Th: “That’s ok. You don’t have to face reality now. Reality is very patient. It will still be here whenever you decide to face it.”

We are simply the messengers from reality. Let the truth do its work and get out of the way. Often, therapists operate mistakenly from the belief that they have to “confront” the patient with reality, adding their anger and outrage over what the patient is doing. All too often, however, the patient ends up reacting to your anger and not to the truth. We need to get out of the way so the patient can experience the truth directly. Then he will experience how he resists the truth, how his defenses challenge reality, and how reality persists in spite of his resistance to it.

When we “challenge” or “collide” with the patient, we mistakenly identify with the patient’s projection. We act as if there is no healthy desire within the patient to be in contact with the truth. Then we enact the patient’s conflict: he embodies the resistance and you embody his healthy wish to become well. This can look dramatic and heroic, but this merely reinforces the interpersonal defense of the transference resistance. This is why I don’t use the term challenge or ‘head-on collision’: students often mistakenly believe they need to adopt an adversarial stance with the patient. This just enacts the transference resistance at best or leads to a misalliance at worst.

Our task is to help the patient see how he is engaging in an adversarial relationship with inner reality (his longings for love and freedom) and external reality (the demands and limitations of life). Once you let go of your conflict with the patient, he can begin to experience his inner conflict, the ‘collision’ between his longing for freedom and his resistance to it. Then he will challenge himself to fulfill his higher potential. Then he will confront reality and his defenses.

When we let go of this urge to have a conflict with the patient, we express our faith in his longing to become free of his defenses. When we no longer act as if we must “challenge” the patient, we express our faith that the patient can bear the experience of reality challenging his defenses. It really comes down to our faith in the patient’s unconscious therapeutic alliance, his inner wish to become reunited with the emotional Truth of this moment.

How do you work with the feeling of loneliness?

“How do you work with the feeling of loneliness (or more precisely, the core feelings of sadness and longing due to loneliness). My patient feels lonely and feels sadness and longing, but her life is still not changing. Her relationships with others are somewhat better but not as much as she would like. Since she can’t ultimately control when the right people/persons comes into her life, I’m not sure whether we need to work on acceptance of what is (being single) or addressing possible defenses against closeness.

In the session I don’t feel close to her. She does not take in my caring during the session. I felt that especially in the last session where my countertransference was that I felt neglected and not acknowledged by her. I would say things to her, but then she would continue with her ruminations about loneliness without actually responding to what I said. Any ideas?” Thanks to Jackie for this question.

What creates emotional closeness? Sharing our feelings with others while feeling them. Is loneliness a feeling? No. Most of the time, loneliness is the state that results when our defenses isolate us from others. If we distance from others, we will feel emotionally distant from others. If we ward off our feelings, we feel isolated even from ourselves. And if hold our feelings in, we will feel lonely, emotionally unconnected to others.

Thus, loneliness, by and large, is not a feeling. It is the result of defenses against emotional closeness. Since it is the result of defenses, we don’t want to explore it. We want to help the patient see her defenses, let go of them, and explore the feelings her defenses ward off. When we explore her loneliness and her sadness about being lonely, she does not feel better. She just feels more lonely and sad. We merely deepen the feelings (sadness and loneliness) that result from her defenses (dismissal and detaching).

Instead, we need to help her see the defenses she uses to ward off emotional closeness. What does she do to make herself lonely? How can we find that out? The best way is to focus on the ways she wards off closeness with the therapist in the here and now.

This is a leap of faith here, but I’ll take the leap: I think all of you care for your patients. That’s why you entered the field. I suspect Jackie cares for her patient very much. Yet her patient does not take in Jackie’s caring. That refusal to take in caring is one defense that makes the patient feel lonely now and here with Jackie.

Th: “Do you notice how you don’t take in my caring right now?”

Pt: “Well, you’re a therapist. You’re supposed to care.”

Th: “When you say it’s just because I’m a therapist, do you notice how you dismiss me and my caring right now?” [point out the defense against emotional closeness]

Pt: “Isn’t it true?” [defense]

Th: “It’s true I’m a therapist. And it’s also true that you are dismissing me and my caring. This is how you distance from me right now. Do you see what I mean?” [point out the defense of dismissal.]

Pt: “I see what you mean.”

Th: “And that’s why you are lonely. You don’t let me get close to you. You deprive yourself of my caring. Although I am here for you, you distance from me and make yourself lonely in my presence. Then I just become another useless person to you.” [pointing out the price of the defense]

Pt: “How do I know you won’t hurt me?”

Th: “The issue isn’t whether I will hurt you. The issue is that you hurt yourself by distancing from me and everyone else. You thought the enemy was me. But do you see how the distancing is hurting you, making you a lonely woman?” [clarifying the causality and the price: defenses hurt her.]

We can also focus on rumination about loneliness as a defense in and of itself. For instance, Jackie says something. The patient, rather than respond to Jackie’s statement, ruminates again.

Th: “Do you notice that you ignored what I said?”

Pt: “What do you mean?”

Th: “When I mentioned how you distance from me, you ignored what I said and how you distance, and then began to ruminate about loneliness again. Do you see how your rumination is a barrier here between you and me?” [point out the defense against emotional closeness]

Sometimes therapists become angry with a patient who ignores and dismisses them. Remember that this transference resistance (ignoring and dismissing you) almost always functions simultaneously as a character defense (ignoring and dismissing herself). Thus, if the patient dismisses you, keep an eye out for the ways she dismisses herself in session.

Does she need to accept being single? I think the question is different. Does she want to keep using the defenses that keep her isolated? Does she want to continue to divorce herself and her inner life, or does she want to stop being “single” and finally become married to her inner life? Only when we have achieved the inner marriage with our desires and feelings is it possible to have the outer marriage with another person. The inner marriage with yourself is the precondition for the outer marriage with another person. If you do not know what you feel, how can you share feelings with others to have emotional closeness? If you reject yourself and your feelings, your inner divorce will prevent the mutual outer marriage to you. Help your patients form the inner marriage with their inner life. Only then will the outer marriage be possible.

Take home point: when a patient says she feels lonely, look for the defenses she uses that create her loneliness. And in session look for the ways she makes herself lonely with you. If you feel lonely with her, notice what she does to reject contact with you. Does she ignore what you say by talking over you, interrupting, going off on another topic? Does she dismiss what you say (“We’ve talked about that before.” “I know that already.” “I want to talk about something else.”)? Does she refuse to collaborate? All these responses are good. They tell you what to work on: the patient’s defenses against closeness that create her lonely life.