Is it weepiness or sadness?

“A depressed patient starts to weep at the beginning of a therapy before I have even asked about her problem. It’s not triggered by a specific example or a question about feeling. It’s just constant weepiness from the start followed by “sorry but I’m a weepy person”. How would you intervene?” Thanks to Liv for this important question!

When a session begins with weepiness, it’s almost always a sign of anxiety. Draw the patient’s attention to her weepiness as a sign of anxiety, assess her anxiety, and regulate it if necessary. Then begin to ask about what feelings she has that the tears could be covering up.

Since the patient says she is a “weepy person”, we can feel comfortable assuming that this is a habitual response to anxiety triggered by her feelings. That’s why you assess her anxiety until it is regulated, and then explore the feelings that trigger her anxiety. In the course of this exploration, you will help her see the triangle of conflict: feelings, anxiety, and the defense of weepiness, washing her feelings away with tears.

At the same time, a patient may begin the therapy immediately crying due to grief. A patient walks into the office, begins to cry, and as she is crying we learn that her husband just died suddenly over the weekend.

How do we differentiate weepiness (a defense) from sadness (a feeling)? Weepiness, since it is a defense, will not trigger anxiety or defenses. The weepiness does not lead to relief or clarity. And the weepiness usually involves thoracic, rather than abdominal, breathing.

Sadness, a feeling, will trigger anxiety and defenses. The experience of sadness leads to relief and clarity. Sadness and crying usually involves abdominal breathing. Weepiness is accompanied by a chronic tension. Sadness, once it is released, leads to a drop in tension throughout the body. The shape of the experience is that weepiness is chronic, shaped like a line. The shape of the experience of grief is that of a wave. It rises and then falls, and the patient is calm again.

In this case, the fact that the patient becomes weepy as soon as she feels a rise of feeling shows that her affect tolerance is quite low. Since her weepiness is a regressive defense, it is important to restructure it immediately in the session to prevent the patient from regressing in therapy. The fact she says she is a “weepy person” suggests that she may ignore this as a problem and take it for granted. Thus, we may find that she uses character defenses of self-dismissal, and self- ignoring.

If you still aren’t sure, notice what the patient’s response to intervention is. If the crying in session leads to relief and clarity, she was feeling grief. If the crying in session leads to more depression and despair, she was feeling defensive weepiness. Now you will know not to explore her weepiness. Instead, you will treat it as a defense, help her let go of the defense, and then help her face the feelings underneath that her tears were washing away.

Take home point: restructure weepiness as soon as it occurs. Explore warded off sadness as deeply as possible.

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