“A man in therapy declares his problem: ‘I’ve been an alcoholic for 24 years (he’s now 42). I’ve managed to stop drinking for an entire year (last year), but this year, I’ve had 3 weekends of complete loss of control and intensive drinking alone. The only thing I know, other than I understand my history and that I’ve been in and out of rehab and different therapies, is that I just don’t feel anything.’” This is a really important question posed by one of our community members.
Interestingly, the patient has not presented an internal emotional problem. We don’t know if his drinking is a problem for him. If it is a problem, we don’t know how it is a problem for him. So we would first have to explore to find out if his alcoholism is a problem for him and how it is.
However, we have also learned some important facts that will lead us to ask questions primarily to psychodiagnose this man’s anxiety regulation and affect tolerance. He has had three weekends of complete relapse, which indicates that his impulse control is still quite poor: a sign of low self-observing capacity. He also tells us that he does not feel anything. This tells us that his self-observing capacity is extremely low: he does not observe or pay attention to his feelings or anxiety. Thus, he probably has no capacity to recognize, much less regulate, his anxiety. That is why his drinking bouts occur for reasons of which he is unaware. If he is unaware of his feelings and anxiety, he will not be aware of why he suddenly uses alcohol to blank out his feelings and anxiety.
Remember that our first session is a trial therapy, a therapy designed to assess the patient and find out what kind of therapy might be optimal for him. Given this patient’s low self-observing capacity, we will explore very cautiously, constantly assessing his pathways of anxiety discharge, to ensure that his anxiety does not become too high, leading to another relapse.
So you would begin by asking, “You mention that you are an alcoholic. Are these drinking bouts a problem for you?” If they are, ask, “How are they a problem for you?” Then when it is clear that it is a problem for him ask, “Could we look at an example where this problem occurred for you?” Then you will explore what emotional triggers were occurring in this man’s life prior to the drinking bout. That would be the beginning of pressure to declaring a problem and pressure to declaring a specific example in the graded format.
As you ask these questions, observe the patient closely. Does he become tense? Does he sigh? Do his hands become tense? In other words, do you see any signs of striated muscle tension? If you see no muscle tension after a few minutes of inquiry into his problems, ask if he is aware of feeling anxious in his body. Then psychodiagnose his pathways of anxiety discharge. Find out if his anxiety is going into the smooth muscles or cognitive/perceptual disruption. If anxiety is going into those channels, begin anxiety regulation. As you observe his responses to your inquiry, notice how many of them are defenses. Now you will see what defenses he uses to avoid his anxiety and feelings. Help him see those defenses. Then you will have the beginnings of the triangle of conflict: feelings toward you for asking about his inner life; anxiety; and defenses. Through this very gradual inquiry, you will be able to help him see the triangle of conflict.
Given that he uses the regressive defense of drinking bouts, you must take care not to evoke excessive feeling or anxiety. Otherwise, he will be at great risk for drinking right after your session. As soon as his anxiety goes out of the striated muscles, begin anxiety regulation right away, then cognize about the triangle of conflict so that he can begin to see how his mind works and his body reacts.
You will notice that I don’t suggest any challenge of defenses with this patient. Why? Challenge with him will cause two problems: 1) too sharp a rise of feeling and anxiety that will lead to relapse; and 2) a misalliance because he will feel personally attacked. Since he doesn’t see his defenses, he will feel as if you are attacking him rather than describing his defenses.
You will also notice that I don’t suggest addressing a transference resistance. When a patient uses such a regressive defense and has such a low level of self-observing capacity, he most likely uses a number of regressive defenses and has little access to repressive defenses. And a patient must have access to a number of repressive defenses which can work together to form a transference resistance.
Further, when a patient’s anxiety regulation is so poor and self-observing capacity is so low, they become our first priorities in treatment. With poor anxiety regulation, exploration of feeling is dangerous. And when self-observing capacity is low, it is not possible for you and the patient to see feelings, anxiety, and defenses clearly, creating the basis for a conscious therapeutic alliance. And remember: an unconscious therapeutic alliance is not possible if we do not have a conscious therapeutic alliance.
Take home point: inquire if his drinking is a problem for him and how it is a problem for him. Then ask for an example where his drinking is a problem. As you ask, assess his anxiety and capacity for regulating his anxiety. Most likely his anxiety goes very high quickly outside his awareness. When you help him see and regulate his anxiety, exploring feelings becomes safer. However, given his use of regressive defenses, you must proceed in a gradual manner, summarizing and cognizing with him a lot so that you can restructure his pathway of anxiety discharge, build his affect tolerance, and develop his capacity for self-observation. Once these restructuring tasks have been completed, a more rapid form of exploring feelings will be possible. And also remember that he will use this regressive defense as long as he is unable to see what triggers his anxiety and as long as he cannot regulate his anxiety in any other way. That’s where you can help him.