Self-Reflective Function in ISTDP

Every kind of therapy tries to help the patient observe her inner life more accurately. Freud referred to this as building an observing ego. In particular, he emphasized the importance of the patient being able to observe his defenses. Today the term mindfulness is often used to describe the ability to observe and reflect on one’s inner life moment by moment. Attachment researchers refer to meta-cognitive self-reflective function. In particular, attachment researchers have been interested in whether patients can learn to observe and reflect on their inner reactions and transference reactions. In other words, if I think you are like my father, do I equate you with him, or can I see the difference and reflect on that difference? The ability to observe and reflect on that difference can allow someone who grew up in an insecure attachment to see reactions from that attachment and yet, through reflection, be able to establish a secure attachment today.

In ISTDP we also help patients develop their capacities for self-observation, what Davanloo called restructuring of the ego. Ten Have de Labije proposed that we need to develop these observing abilities in a specific order. First, can the patient observe her feeling, her anxiety, and her defense? Can the patient pay attention to her anxiety? If not, she won’t be able to regulate her anxiety. All anxiety regulation depends on paying attention to an anxiety symptom. Can the patient pay attention to her defense? If not, she will quickly ignore it and never discover its price: her suffering. Can the patient see the triangle of conflict: that she has a feeling, anxiety, and defense? If she can’t, she may confuse her feeling with anxiety. “How do you experience this anger?” Pt: “I feel tense?” If she confuses her anger with her anxiety, she will not be able to feel her anxiety deeply and the anxiety will continue to inhibit her. Likewise, if she confuses her feeling with defense, “I feel shut down”, she will continue to use her defense without realizing she is shutting down her anger. Next we help the patient see causality: can she see that feeling triggers anxiety, anxiety triggers defenses, and her defenses cause her presenting problems and symptoms? If she does not see causality, she won’t realize her defenses cause her problems. For instance, a man says that his wife over rules him. He does not see that when he is angry, he over rules himself and his anger. That’s the defense that creates his problems. Since he doesn’t see his defense, he thinks his wife’s demand is the problem. In fact, his response to her demand (his defense of over ruling his feeling) causes his problems. Remember: she can over rule him only if he joins her and over rules himself. And finally, we look to see if the patient is able to see he is not the same as his defense, “That’s the way I am.” If he thinks he is the same as his defense, he will think you are criticizing him rather than describing a way he deals with his feelings.

Understanding these steps allows you to develop the patient’s self-observing capacities in a step-by-step fashion so you can develop a consensus on what creates the patient’s problems and a consensus on what to do in therapy to overcome those problems. These steps specify some of the kinds of self-reflective functioning we try to build in patients so that they can observe, pay attention to, and bear their feelings to the fullest extent possible.

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