Monthly Archives: November 2013

How can anger be a feeling and a defense?

“I have worked with many who ‘know’ their anger very well. They bring anger stories to the here and now almost every session, although they are not always conscious of feeling angry with me too. Not being aware of anger is not their problem (the ‘preoccupied attachment ‘ trait). So are you saying that in those cases ISTDP would regard the ‘forever raging patient’ as warding off other feelings with anger? I am a bit confused about how anger can be a feeling and a defence. How can a feeling be the expression of self and a defence at the same time?” Thanks for this important question!

Anger is a feeling, an expression of self. However, under certain conditions, a feeling can function as a defense to ward off another feeling. That’s why we always ask: what is the function of the patient’s statement? Does this patient statement function as a feeling, anxiety, or a defense? It is this issue of function to which we need to direct our attention.

Let’s suppose a patient is feeling grief over the loss of her husband. Then she suddenly shifts and says, “I hate the bastard. Look what he has done to me!” At this point we have to ask ourselves: does her anger at this moment help her to express her feelings of grief and sadness, or does this anger at this moment block the expression of her grief? In other words, what function does the feeling of anger serve at that moment?

This is not to diminish or deny the fact that she probably also does feel angry toward her dead husband. As in any complex relationship, she will have complex feelings. Our question is this: can she tolerate her complex feelings or is there one feeling that gets expressed and another set of feelings which gets repressed? For instance, a patient who cannot tolerate her grief may come into her session for weeks on end expressing anger toward her dead husband. But the anger leads nowhere, nor does it trigger any anxiety, nor does it bring any relief. Why? In her case, her anger has the function of covering up her grief. Our goal is to help her accept and experience all of her complex feelings so she doesn’t have to use any feeling to ward off another feeling.

Sometimes a patient uses anger to cover over grief. However, most frequently anger is enlisted in a sneaky way to cover up externalization. This type of patient spends sessions complaining about other people and blaming them for her suffering. When you explore their anger, they will explore it with you but it does not lead to an unlocking of complex feelings. Why? Their anger is toward an “all-bad” person whom they blame for their suffering. Since they view the other person as “all-bad”, they have no complex feelings toward that person.

Is it true the other person causes their suffering? Not usually. The other person causes some pain. But the patient, by continuing that relationship as it is perpetuates her suffering. She often focuses on what the other person did, not how she made things worse by hurting herself.


Let’s take an example. A patient expresses her anger toward a boyfriend who did not pay back a loan. This seems straightforward, doesn’t it? But then we learn that she had given a number of loans in the past which he also had not paid back. So what is the triangle of conflict? She is angry with him for not paying back the past loans. The anger makes her anxious. As a defense, she punishes herself for being angry by loaning him money again. And now for the interesting point: then she gets angry with him for mistreating her! In fact, the first time he did not pay her back he mistreated her. After the first time, however, she mistreated herself every time she loaned him money! She just blames him for how she has hurt herself. “He hurts me!” is a projection. Now she hurts herself. But she blames him and then gets angry at him for the ways she perpetuates her own suffering. She would be happy to blame him and be angry with him forever rather than face how she hurts herself. That’s why we have to undo the externalization so she can face her defense of self-punishment. Once she can face her defense, and face her responsibility for how she has mistreated herself, then she can face the underlying anger for his offence to her the first time.

Pt: He hurt me.

Th: Who loaned him the money.

Pt: I did, but he needed it.

Th: You loaned him money when he had not paid it before.

Pt: He said he would.

Th: And he didn’t before. So you trusted his words instead of your experience.

Pt: He lied to me.

Th: And when you didn’t listen to your experience you lied to yourself.

Pt: Hmm.
Th: So when you loaned the money to someone you knew was a liar, who hurt you?

Pt: I see what you’re saying.

A third pattern is one where the patient regales you with stories of people she is angry with. But as soon as the therapist asks how the patient experiences that anger physically in the body, the patient uses defenses. Here, the issue is not the anger toward other people. The issue is that the patient begins to resist contact as soon as you explore feelings. Here, the therapist again needs to address the barrier the patient is putting up in the relationship, and then ask what the feeling is toward the therapist that makes the patient distance.

Ophrah asked, can anger function as an expression of the self and defense at the same time? No. Either a feeling functions as an expression of self or a defensive feeling enters to prevent the expression of self. At one point in a session, anger may function as a defense against sadness. At another point in a session, anger may be the underlying feeling that needs to be expressed. To see the difference between feelings and defensive affects, read the chapters on feelings and defensive affects in my book, Co-Creating Change: Effective Dynamic Therapy Techniques.

Take home point: when you see a feeling, ask yourself what its function is. Does this feeling further the expression of self or inhibit that expression? If it is a feeling, help the patient feel it more deeply. Does the expression of this feeling lead to a sense of inner freedom or does it lead to a sense of despair and paralysis? If the expression of the feeling does not lead to inner freedom, consider that it may have a defensive function. Does the expression of this feeling help a relationship or damage it? If it does not help a relationship, consider the possibility that it is a defensive affect which either functions as or results from a defense. If it is a defensive affect, help the patient see and let go of the defenses upon which that defensive affect is based. Then you can pursue the underlying feelings that were warded off by the defensive affect.

How can you treat drug addition in therapy?

“When doing therapy with a drug-addicted patient, must I know what neurobiological changes have occurred in the brain as a result of addiction?  Can therapy undo permanent brain damage, that would otherwise forever cripple the patient when it comes to the urge for alcohol?” Thanks to Rikke for these interesting questions.

Ordinarily, we don’t do exploratory therapy with any drug-addicted person until he has been in recovery for at least a few months. Why? For many drug addicts, drugs are a defense against experiencing feelings and anxiety. If you explore feelings and anxiety beyond the patient’s capacity to bear them, his defenses against feeling will fail and he will resort to drugs to numb out his feelings because his defenses no longer do the job.

Thus, for many drug-addicts it’s best to begin with supportive therapy using motivational interviewing techniques and the research of the process of change group. Your supportive therapy with an active user will help him begin to see that his drug use is a problem and motivate him over time to reduce his usage of alcohol or drugs. Goals here are complicated.

In the U.S. abstinence is considered the only real practical goal for alcoholics. However, in the U.K a considerable amount of research into harm reduction has found that many alcoholics can be helped to reduce their use of alcohol to levels that are no longer harmful. Given these various positions in the field, I suspect that some patients may benefit from a harm reduction strategy, and that others may need to be abstinent in order to maintain their recovery.

Once the patient is in rehabilitation, a more exploratory therapy can be very helpful for many drug-addicted patients. In my DVDs of the fragile patient and the patient who uses projection, you see how to work with the regressive defenses that often come up with drug-addicted patients.

However, having said that, don’t forget that drug-addicted patients can be anywhere on the spectrum of psychoneurosis. Some are psychotic, some have a borderline level of character pathology, and some have neurotic conflicts. Thus, you need to assess each patient on an individual basis so that you know how to regulate the patient’s anxiety, and which defenses you will need to restructure. I always begin with the graded format with drug-addicted patients because I want to assess the patient’s anxiety and affect tolerance and self-observing capacities first. Then I work to gradually increase the patient’s capacities. If you get too high a rise of feeling, anxiety, or regressive defense, the patient will be at risk of relapse. Thus, ask about feelings, build the capacity for anxiety regulation, and help the patient see and let go of regressive defenses. Go slow.

In the average clinic, we do not have access to good instruments to assess the degree and type of brain damage patients have from drug use. Many patients begin to function better over time as their bodies detox during a period of abstinence. However, we can assess where the patient’s anxiety is discharged. We can also assess the patient’s ability to see his defenses and their price. At this stage of assessment, we may find that the patient’s ability to regulate anxiety is so poor, that his cognition is impaired. On the other hand, we may find a patient whose anxiety is well regulated and his cognition is impaired. In that case, we have probably some brain damage. In that case, proceed very slowly and make sure the patient always understands what you say.

Certainly, with good anxiety regulation, and building of other capacities, we see improvements of neuroplasticity of the brain. With patients who suffer brain damage, their progress will be slower and may be quite limited. However, I have found that some brain-damaged patients benefit from an additional treatment to psychotherapy known as Low Energy Neurofeedback System, or LENS. Many patients who receive this neurofeedback treatment or others report a great drop in anxiety physically which results in a drop in the need for substances to regulate their bodily discomfort and, as a result, they become far less impulsive. The research on this method is fairly limited, however, I have found it very useful for anyone suffering from brain damage to consider this option as an adjunct to psychotherapy.

Take home point: do supportive therapy with active drug users. Once the patient is abstinent, you can use the graded format to gradually build the patient’s affect tolerance, anxiety regulation, and restructure regressive defenses. Always avoid excessive rises of feeling, anxiety, and regressive defenses to avoid precipitating a relapse in the patient.