Monthly Archives: December 2013

What do we know and what do we not know?

In response to a recent post, Timothy proposed the following ideas about a woman who was angry that a boyfriend who habitually did not pay back his loans to her, once again did not pay back a loan.

Timothy proposes: “The reason that she is hiding her true concerns from the therapist is that she still wants to keep a man that cannot support her financially, and her dilemma and frustration on how to handle such a weird problem creates great restriction that she expresses through anger on the man.”

Jon: Staying with a man who cannot support her is a fact. Since it is self-destructive, it is a defense. I would propose that she feels some anger toward the man and punishes herself through her self-destructive behavior. However, insofar as she blames him for her continual choice to loan him money, her anger is also based on externalization. She can be angry with him rather than at her self-destructive behavior. We don’t know if she came to the therapist because he is a man. That is a hypothesis. We also don’t know if “she unconsciously wants your male opinion on what you think about the character of her bf and whether you think she should stay with him any longer.” That is also a hypothesis.

Timothy proposes: “I don’t see her anger as just a defense. She is not being totally truthful and maybe not wanting to get to the point of her real problem.”

Jon: This is a really important point. To a certain extent, every defense represents a moment of dishonesty about one’s inner life. But we must differentiate the conscious lie of the sociopath from the unconscious defense of the usual patient. Our unconscious defenses prevent us from being in touch with the inner Truth of our feelings. The idea that she does not want to get to the point of her real problem is only half of the truth. Every one of us resists the truth. AND every one of us seeks the truth. We must never forget the nature of conflict: we both seek and resist the truth of our inner lives and external reality. When we relate only to the patient’s resistance, we forget the patient’s unconscious longing to be healed. And that is our resistance to facing the complex, conflicted person who is seeking our help.

Timothy proposes: “The woman’s anger is an expression of the restrictions she is feeling from the problem. And she has been focusing the cause of the restrictions she felt on the only logical source she knows that is her bf.

Jon: I agree that her anger is in response to his failure to pay the loans, and it is a response to her self-destructive defenses which cause her more suffering. But she blames him for her choice.

Timothy proposes: “She is also angry at herself for allowing the problem to prolong, because she is desperate to keep her bf, holds fear of losing him, and maybe has low self-confidence of getting another one.”

Jon: I suspect that continuing to loan money to her boyfriend is a way to turn anger upon herself. If she is desperate to keep her boyfriend (something we don’t know), this is maladaptive and, thus, a defense. Desperation to keep a boyfriend is a way to hide anger toward the boyfriend! If she fears losing the boyfriend (something we don’t know), that would also be maladaptive and a defense. I would hypothesize that the conscious fear of the boyfriend is a defense covering up the anger toward him that she really fears. Her low self-confidence I would see not as a feeling but as the result of a defense. Turning anger onto herself and devaluing herself are defenses that would create the state of low self-confidence.

Timothy proposes: “At the end of the day, she came to you because you are a guy and she wants your male opinion on whether or not her bf is really a good man that she should continue to keep.”

Jon: We can’t know this for sure. It’s a plausible hypothesis. But we need evidence from her words, actions, and feelings before we can make such a claim.

Timothy proposes: “For the first example you mentioned, the woman calls her dead husband a bastard because she is expressing restrictions and sadness from no longer being able to be a normal wife with a living husband. She is putting the blame on the only logical source she knows. She didn’t blame God or something else. She is confused. She needs to release her traumatic feelings through Tension/Trauma Release Exercise(TRE) therapy maybe?

Jon: Certainly she is angry with her husband for leaving her and she needs to release her feelings. However, insofar as she calls him a bastard and devalues him, we are looking not just at rage but at devaluation. When she devalues someone, it is usually a way of dealing with grief over the loss of a VALUED person.

Timothy proposes: The more expressive the patient is expressing their anger reflects how justified they are perceiving themselves as the victim of being faced with such restrictions imposed by their unfortunate circumstances. They have been putting up various defenses by great exaggerated expressions of anger and frustration in order to make others feel that they are the justified victims rather than be perceived as the ones who got themselves into their misery.

Jon: This is an excellent way of posing the problem. If I can angrily pose as the victim, I do not have to face how I victimized myself.

Timothy says: “Sorry if what I say is quite conflicting to your ideas.”

Jon: Thank you for sharing your ideas. It is wonderful when we can clarify the differences between feelings, defenses, and the problems created by defenses. Here, the feeling is anger toward an exploitive boyfriend or a dead husband. The woman with the exploitive boyfriend, continues to make loans to him, thereby exploiting herself. Then she blames him for her choice to hurt herself. The woman whose husband died is struggling with grief which she can avoid through defensive anger or devaluation.

But Timothy raises a larger question that we must face as therapists, something larger than any school of therapy: What do we know and what do we not know?

I remember a colleague of mine years ago who taught at a local psychoanalytic institute. He was very upset because he said students would hear a case and they weren’t taught how to analyze a case. They were taught how to speculate about case. They would share their fantasies about the case. But they weren’t taught how to look at the material and see what the evidence was and what the evidence would support.

In other words, they weren’t taught about the scientific method. Our task as listeners is to pay attention to the material and see what hypotheses the material supports and what hypotheses the material does not support.

All of us reading about cases can come with our personal theories and hypotheses based on books we’ve read, our personal experience, or people we have known. But unless we have evidence from the patient, these ideas are merely……….drumroll…… our projections! Yes. You heard it here. We therapists often project a lot onto our patients.

Why? It is hard to bear not knowing what is going on. The hard work is to explore, to ask about feelings, to learn what defenses are operating, to learn gradually the relationships between different conflicts. The hard work is: psychodiagnosis. Through that moment-by-moment work we build a mutual understanding of what is going on in the patient’s life by understanding what is going on here and now in the session.

I applaud Timothy for sharing his thoughts and hypotheses. He is doing what we all do. It is so easy for us to have assumptions about our patients even though we don’t have the evidence to support them. This is our great temptation as therapists. I feel relieved that Timothy has joined me in my group PA (projectors anonymous). We are a large group and contain many therapists. Membership is open to any of you, by the wayJ

If anything, this post is a plea for a measure of humility. Let us always remember that a plausible hypothesis we hold dearly may not be the truth. Our task is to embrace the patient tightly but hold our hypotheses very lightly. Go forth and embrace!

Neutrality? Does it have a role in ISTDP?

“I was just reading a book on transference-focused therapy and their description of “technical neutrality” and came to think how differently I would approach certain situations in therapy now that I´m trying to do ISTDP. Of course neutrality (as well as abstinence) is a debated concept within psychoanalysis and psychodynamic therapy but I believe I´ve read in several texts that it is not  relevant in ISTDP. We are NOT neutral in relation to the patient’s struggle with the punitive superego. At the same time there are aspects of neutrality that I think still apply in ISTDP – like not giving advice, being “supportive” in a general sense of the word or over-identifying with the patient. I wonder if you would consider reflecting on the concept of neutrality from an ISTDP-perspective?” Thanks Peter for this great question!

We can easily misunderstand the concept of neutrality as if the therapist is somehow “neutered”! God forbid! It would have to be a very dishonest or uncaring therapist who claims not to care whether a patient gets well or not. Otherwise, why do therapy? Just for intellectual interest?!

Obviously, we engage in this work so we can help patients face their feelings, face what makes them anxious, and let go of self-destructive defenses. That’s the therapeutic task that makes patients become healthier. And that task is really the same, no matter what kind of therapy people do. It’s nothing unique to ISTDP. Everybody is trying to help patients improve. Everybody is helping patients regulate their anxiety, let go of self-defeating patterns, and face feelings and truths they usually avoid. It’s just that different schools of therapy use different terms for these elements of the therapeutic task.

Anna Freud proposed an interesting way to look at neutrality. She said that the therapist must take an “equidistant” position: neither being only an advocate for the feelings, an advocate for avoiding what makes you anxious, nor only an advocate for the defenses. She said that we need to take stance where we encourage the patient to face feelings while acknowledging that those feelings arouse anxiety, and while acknowledging the temptation to use defenses. Leston Havens took this further by proposing that we offer “complex empathy”: empathy for the feelings, for the anxiety, and for the defense.

So is neutrality relevant in ISTDP? Absolutely, the question is how. Obviously, the ISTDP therapist is aligned with the patient’s wish to become well and aligned against the patient’s punitive superego. The therapist does take this stance. However, the therapist’s stance may have to shift because of the patient’s own stance regarding his conflict.

Let’s take Peter’s first example, advice. Why does the ISTDP therapist usually not offer advice?

Th: What is the feeling toward your boyfriend for throwing the glass of water in your face?

Pt: What do you think I should do doctor?  [defense]

Th: That still doesn’t say what the feeling is toward your boyfriend. What is the feeling toward him?

 

Almost always, the patient asks for advice to avoid a feeling or to adopt a one-down position with the therapist, a regressive transference resistance. We do not give advice in this example because we want to help her face rather than avoid her feeling, and we want to avoid reinforcing a regressive transference that she probably uses in the rest of her life.

This is often thought of in terms of “abstinence.” Here, the therapist responds optimally to the patient’s forward strivings but abstains from reinforcing her regressive defenses. This is why Paul Wachtel, in his book on psychoanalysis and behavior therapy, pointed out that psychoanalysis has its own forms of reinforcement. Behavior therapy’s brilliance lay in its clarity about what to reinforce and what not to reinforce. All therapy reinforces some things and not others. We might as well be clear about it. In ISTDP, we reinforce forward strivings by asking for feeling and we do not reinforce defenses, especially regressive ones.

Peter’s second point concerned “being supportive.” In fact, all therapy is supportive. Therapists constantly support certain activities and do not support others. Irwin Hoffman pointed out that analysis of sessions reveals both conscious and unconscious forms of support. Every time you explore one thing, you are not exploring something else. Every intervention reveals what you support and do not support. It is inherent in the very act of intervening. So, again, the question is not whether we support, but what do we support? In ISTDP we support the experience of feelings as deeply as possible. With fragile patients, we support them in this task by regulating their anxiety, and adjusting the dosage of feeling to work within their capacities.

“Being supportive” is only a problem when you are supporting defenses that cause the presenting problems. Then we unwittingly just support the pathology creation system. For example, a patient takes a helpless stance in therapy and the therapist supports the patient’s defense by agreeing there is nothing the patient can do but wait for his wife to change. A patient says he is not ready to face a conflict, and the therapist agrees that the patient should wait until he is ready, thereby supporting the patient’s passivity and denial that time and life are passing.

Peter’s third example concerns “over-identifying” with the patient. Freud recognized that our own desires for the patient’s growth can never be a substitute for the patient’s desire. We want the patient to have a better life, but, in the end, only the patient can give himself that life by facing his feelings and conflicts. We take a stand against the patient’s pathology, but we cannot take the patient’s stand against his own pathology. When we forget that basic fact, we try to fight the patient’s fight (losing neutrality), rather than help the patient see his fight and his task (maintaining neutrality). When we identify with the patient’s struggle but forget our own identity as a separate person, we fight the patient’s fight and lose. Only the patient can see and let go of his defenses. That is something you cannot do for him. In the transference resistance, the patient plays out a relationship where you (in the child role) are asked to take responsibility for the patient’s defenses (parent role). Since many of us did that as children, we fall into that trap temporarily.

That is why we need to confront the patient’s stance when he asks us to identify with his healthy strivings while he remains identified with his unhealthy defenses. Here, the concept of neutrality becomes clear. We hope the patient will choose health. However, the struggle between his yearnings for health and his unhealthy defenses is HIS struggle. Only he can turn against his defenses, not you. This is his fight, not yours. In that sense, you must regain your position as a neutral observer of a conflict in him, not in you. You empathize with his struggle, but you recognize as a neutral observer, that this is his struggle, his responsibility, and his task. You cannot fight his fight. You cannot take on a responsibility that is his alone. And you cannot do his job. This understanding, both emotionally and intellectually, constitutes the essence of a neutral stance when dealing with the transference resistance.

Of course we care when we see the patient suffer in a transference resistance. But we also have to recognize what our work is and what the patient’s work is. What his task is and what our task is. What he must do and what we can do. Where his responsibility begins and ours ends.

In ISTDP neutrality can be thought of as an outgrowth of an existential truth: overcoming the patient’s internal conflicts is the patient’s job and responsibility. The therapist can only point out those conflicts and the price the patient pays for handling his conflicts the way he does. The truth is powerful but we are not omnipotent. Only the patient has the power to face his truth and let go of his defenses. We are not neutral in terms of what we support. But we have to take a position of the neutral (if pained) observer when the patient hesitates to fight for himself and let go of his defenses. It is his life, his choice, and his responsibility, not yours.

The patient may accuse you of not caring, being detached, or uninvolved. But this is projection. The patient’s stance of self-neglect and helplessness reveals that he does not care for himself, detaches from himself, and is uninvolved in the fight for his own life. If he makes such a destructive choice, we have to accept his choice and part ways while he continues on his path toward self-destruction. For that is not a path we can take together in therapy.

For those of you who don’t have enough to readJ, the noted analyst Jay Greenberg wrote a nice article on the concept of neutrality, illustrating the problems of its definition:

 

http://www.wawhite.org/uploads/PDF/E1f_10%20Greenberg_J_Analytic_Neutrality.pdf

 

Enjoy!