Monthly Archives: December 2013

Is it shame or self-condemnation?

“Dear Jon,

I have a question about a client I would like your input on. The client I’m working with has been diagnosed with an autism spectrum disorder, but I doubt it is the main problematic issue in his life.

We have discovered that my client has a very deep shame inside him, and this leads him to project onto others. Then he unconsciously expects everyone else to judge him. Then he reacts with anger towards the perceived judgment.

The issue at hand is that my client wants to form a romantic relationship, and is doing great progress. But every time he meets other couples, it reminds him of what he doesn’t have in his life and he reports feeling very angry (I expect it to be a replacement feeling) so far so good. But it has proven really difficult to work with this issue. I would love your input on how to untangle the underlying dynamics.”  Thanks to one of our anonymous community members for sharing this interesting question!

Whether this patient has an autistic spectrum disorder is impossible to assess from such limited material. However, his capacity to have such a degree of theory of mind would lead me to question the diagnosis. But without more information, we really have to leave that to the side. So let’s look at what we can be clear about.

Here is triangle of conflict number one: When this man wants to reach out and connect to someone (wish), he becomes anxious, and then shames himself (defense). Then he projects, imagining that other people shame him or criticize him for wanting to become close. Thus, rather than react to the person who might want to talk to him, he relates to his image of a rejecting image. Thus, his projection comes between him and the people he wants to meet.

Th: Did she judge you?

Pt: I think she was.

Th: That was your thought. So can we take a look at her and see if she was the same as your thought? Did she say anything judgmental to you? [differentiate the other person from his projection to re-establish reality testing and an intrapsychic perspective]

Pt: No.

Th: So we see you had a thought about judgment, but she did not judge you.

Pt: Yes.

Th: In my experience, people who fear judgment tend to judge themselves too much. Is that something you’ve noticed within yourself? [Establish an internal perspective]

Pt: Yes. I judge myself a lot.

Th: So is it possible that when you want to get close to someone, that you condemn yourself for having that wish? [establish causality: his defenses, not other people, are causing his problems]

Pt: Yes. I think I don’t deserve it.
Th: Would that be a form of self-attack? [defense identification]

Pt: Yes.

Th: And do you think that self-attack may be interfering with you being able to form relationships? [clarify the price of the defense]

Now let’s go on to triangle of conflict number two: When the patient meets couples, he becomes aware of his longings to have their kind of intimacy and closeness. Then, rather than experience this wish and act upon it, he attacks himself. “I’ll never have what they have.” “They have what I’ll never have.” He predicts a future in which he will be eternally deprived, envious of others who receive what he doesn’t. All the while, he would remain unaware of how he deprives himself through his defenses and this very stance. Exploring his anger would do little good since it is the result of defenses: projection, self-deprivation, and envy.

Pt: I’ll never have what they have. [Helpless transference: patient gives up and asks the therapist to hold the hope and desire and the goals for therapy.]

Th: So shall we give up?

Pt: Are you saying I should give up?

Th: No. That’s what you are saying. Obviously, if you want to give up on having relationships, it’s important for me to know so that I’m not pursuing a goal you have already given up on.

Pt: I thought you are supposed to help me find relationships.

Th: I can’t do that if you have already given up on that goal. That’s why I have to ask you. If you want to give up and decide you will never have anyone, you can do that. Then we’ll just have to focus on some other goal.

Pt: Now I’m feeling angry with you!

Th: How do you experience that anger toward me physically in your body?

The patient is angry at other people who supposedly cause his suffering. In fact, his defenses of projection, self-deprivation, and self-attack are causing his suffering. Thus, the therapist must help the patient differentiate his projection from a person he meets, face his self-attack, and then face the underlying feelings which the self-attack is covering up.

The patient also takes a stance where the therapist ostensibly can do nothing: this is a helpless transference resistance, a defense which wards off feelings toward the therapist. Here, the therapist deactivates the patient’s transference resistance by refusing to pick up the omnipotent role of carrying the patient’s hope, desire, and goals. As the therapist maintains this stance, the patient’s defense of helplessness fails, and his mixed feelings toward the therapist rise. Then the therapist can shift to asking about feelings toward the therapist.

These clinical phenomena would suggest to me that the patient is not on the autistic spectrum. Perhaps we will hear more about this example later and develop a more nuanced understanding. After all, our psychodiagnosis of any patient can be based, not on our fantasies but on the patient’s responses to intervention.


Gender and ISTDP?

“Is there a gender difference for how male and female therapists experience ISTDP towards their male and female clients? Personally, this more ‘confrontative’ style works better for me with a male client than with a female client. Between women one should ‘listen and understand’ more, which I do not like anyway in private encounters, this expectation on me and on interaction between women. This is probably something to learn for the therapy room (but in private life, I am happy as I am with my encounters). Is this something that you have noticed in your work with teaching psychotherapy?”

What a fascinating question! First of all, let’s be clear that we never confront a patient until the patient can observe a defense he uses, can see its price and function, and can see that the defense is not him but a way of dealing with feeling. Only at that point, will it be possible for the patient to see that we are confronting a behavior rather than criticizing him as a person. Thus, confrontation only occurs with certain patients under certain conditions.

But our questioner raises another point, how comfortable are we when confronting a patient with his self-destructive behavior? Sometimes not too comfortable. Why? Sometimes confrontation makes us feel anxious because we are afraid of our own aggression and capacity for power. Sometimes we fear confronting others because this evokes anxiety we had in the past over people who confronted us or people whom we wanted to confront but couldn’t due to the dangerous consequences of doing so. As a result, our ways of addressing patients may become constricted by our own defenses of avoidance and reaction formation. Rather than confront patients’ defenses, we may start to intellectualize or justify their defenses. We start to tiptoe around the patient’s defenses which start to dominate the therapy.

On the other hand, another way we can deal with our anxiety is through a counter-phobic reaction: becoming more aggressive. When our feelings and anxiety rise, we may start to confront the patient prematurely, leading to a misalliance. We may rely excessively on confrontation rather than help the patient see his defense and its price. And we may project that the patient is more resistant than he really is, leading to an excessively confrontational stance.

In other words, confronting a patient’s defenses requires the therapist to take a strong stance that can arouse the therapist’s anxiety, arousing defenses of reaction formation or counter-phobic responses. Thus, examining countertransference is essential when therapists either avoid or excessively rely upon confrontation as a technique. These are universal problems shared by male and female therapists.

However, as our questioner alluded to, the socialization of gender roles can lead to different styles in therapy by male and female therapists. Stereotypically, males feel more comfortable confronting patients than females. However, I have found both male and female therapists who engage in premature confrontation. Stereotypically, females tend to avoid confronting patients. However, I have found both male and female therapists who relied upon reaction formation as a defense against confronting destructive defenses in the patient.

We should always “listen and understand” as our questioner described above. But we must take care that “listen and understand” does not mean “agree with me 100%!”

Pt: I thought you understood me.

Th: I do understand your point of view. I don’t agree with it. I think slapping your girlfriend was incredibly destructive to the relationship. You are having to decide whether you want to remain with a girlfriend who loves you or a defense that sabotages you.

Pt: If you understood me, you would agree with me.

Th: No, if you understood how slapping her destroys your relationships, you would no longer agree with your defense of slapping.

Pt: I want you to listen to me.

Th: No, you want me to agree with your self-destructiveness. You want me to lie to you.

This would take some strength to say, wouldn’t it? It takes strength whether you are a man or a woman. And it would take strength in any culture I have encountered. It takes strength to say the truth to a patient who threatens to dislike you, abandon you, or criticize you if you do not agree with his destructiveness. But if you collude with his destructiveness, you abandon him. He loses a therapist. But when you confront his destructiveness, he realizes you regard him as strong enough to bear the truth. I remember a patient who once said he could trust that I cared for him because at one point when he was verbally abusive in the session I had told him I couldn’t stand his guts when he did that. When I was honest about his darkest qualities, he could trust my honesty about his best qualities.

It is said that Plato regarded truth as the food of the soul. It takes emotional courage for us to share this truth, especially when we might be punished in session for doing so. Yet it is a test we are asked to pass daily. Sometimes we will have more trouble being honest with a male or a female patient. Sometimes it is due to our socialization. Sometimes it is due to our own transference. Sometimes it is because we fear the patient’s reaction. Sometimes it is because we are afraid to confront something within ourselves. No matter the cause, our task is the same: facing the truth of others and ourselves, and then speaking from the truth.