Restructuring Defenses

Restructuring refers to the ways help the patient learn to observe his defenses in the here and now, see their price and function, and then face the underlying feelings. This takes place in several sequential phases.

1. Identify the defense: “Do you notice how you look away?”

2. Clarify the function of the defense: “When you criticize yourself, could that be a way to turn the anger toward your father back onto you?”

3. Clarify the price of the defense: “When you doubt yourself, could that be making you confused, directionless, and depressed?”

4. Differentiate the patient from the defense: “No, you aren’t detached. That is not how you are; that is how you deal with your feelings. You detach from your feelings. Do you see what I mean?”

5. Now that the patient can see his defense, its function and price, and can differentiate himself from the defense, then we can challenge him to let go of the defense and face the underlying feelings.

Challenge: “If you don’t turn this anger onto yourself and if you don’t protect me, (followed by inviting feeling), how do you experience this anger here toward me?”

We do not challenge defenses until the patient can see them, their price and function, and can differentiate himself from the defenses. Otherwise, he will feel you are attacking him as a person rather than helping him see a way he handles his feelings.

Once we have done this amount of defense work and invite the underlying feelings, several things can happen.

The highly resistant patient will respond with anger toward the therapist and defenses/transference resistance. Thus, the therapist will continue to invite feeling toward the therapist and systematically challenge defenses the patient sees, deactivate the projections upon which the transference resistance is based, and confront it until the patient experiences a breakthrough to feelings.

6. Confronting the transference resistance: When the patient’s defenses come together to form a pathological relationship (the transference resistance), the therapist must not address merely a single defense here and there. Instead, the therapist must address the pathological relationship as a whole, which the defenses create. The therapist facilitates a “head-on collision” between the patient and his resistance. As the patient experiences how his resistance will defeat him, he experiences an intrapsychic crisis, which leads to a breakthrough to feeling. The therapist does not so much confront the patient, but he helps the patient confront his own resistance. The therapist avoids having an interpersonal conflict so the patient can have an intrapsychic conflict instead. “On the one hand you have come here to overcome your problems and get rid of your depression. On the other hand we see this wall of detachment, which will defeat your goals. As long as you maintain this wall with me, you will be on one side and I will be on the other. And I will just become another useless person to you. You can maintain this wall. I cannot stop it. It is yours. And you can keep it as high as you want. But as long as you maintain this wall of detachment and non-involvement here between you and me, this process will end in failure, and this relationship will end up in the graveyard of failed relationships. Yet, you have not come here to fail. You came her to get better. Why defeat yourself? Why perpetuate your suffering. What can we do about this destructive wall? For as long as you keep this wall, this process will end in failure.” Fragile patients do not require a confrontation of the transference resistance initially. Instead, following restructuring and challenge of defenses, they may experience a rise of anxiety over the threshold of anxiety tolerance. Here, regulate anxiety by recapping what happened and describe the triangle of conflict. To further regulate the patient’s anxiety, we may shift from exploring feeling to inviting the patient to describe his symptoms of anxiety, or we may offer the defense of intellectualization through cognizing about the process, or we may offer the defense of displacement by inviting the patient to explore feeling in a different example in a different corner of the triangle of person (therapist, past relationship, current relationship). Once the anxiety is back in the striated muscles, we explore feelings, continue restructuring defenses, and restructure the pathway of unconscious anxiety discharge. We keep building the patient’s anxiety regulation and affect tolerance until she can tolerate an unlocking of the unconscious. This will be signaled by the experience of an impulse in her body.

The highly resistant patient needs help with restructuring of the repressive, tactical, and character defenses as well as the transference resistance. The fragile patient needs help with restructuring character and regressive defenses.

Take home point: make sure to use this sequence in defense work: identify defenses, clarify the function and price of defenses, help the patient differentiate himself from his defenses, and challenge or encourage the patient to let go of his defenses. If a transference resistance emerges, continue with these phases then confront the patient’s transference resistance.






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