Why Doesn’t my Patient look Anxious?

“How do we understand the absence of unconscious signaling in the patient’s body?” Thanks to Monica for this important question!

There can be many reasons why you won’t see unconscious signaling of anxiety in the striated muscles. In fact, I have an entire section of my book, Co-Creating Change, that addresses this problem in detail. So let’s review a few of the main reasons why your patient may not appear to be anxious.

1. The patient won’t be anxious at all if you are not exploring feelings within a conflict the patient wants to resolve. So, if you are not asking for feelings, you won’t see anxiety in the patient’s body.

2. The patient won’t look anxious if he is using lots of defenses or using a transference resistance. He will look cool, calm, and collected while you are working hard. Since he is uninvolved in the therapy, he is uninvolved with himself and his feelings. His defenses are working so well, his anxiety is not rising.

3. If you don’t address his defenses, feelings and anxiety will not rise within the patient’s body. Or if you address defenses he is NOT using in the moment, feelings and anxiety will not rise within the patient’s body.

4. It may be that the patient is genuinely confused about the process, suffering from a brain injury, on excessive amounts of psychotropic medications, under the influence of illegal drugs, or physically depleted due to illness. Any of those factors could prevent a patient’s anxiety from rising.

5. You might be exploring a feeling but in a conflict the patient is not interested in exploring. Since his will is not engaged, you will be exploring, but he won’t. Thus, no feeling or anxiety will rise.

6. You might be exploring feeling regarding a problem you see, but which the patient does not regard as a problem. Thus, no feelings or anxiety will rise in response to your exploring.

7. You might be exploring a problem which is a problem for the patient’s wife but not for the patient himself. Thus, no feelings or anxiety will rise in response to your exploration.

8. You might be exploring a defensive affect. Since this affect already functions as a defense, exploring it will not trigger deeper feelings and anxiety. For instance, a patient projects that you think she is fat and cries. If you explore her tears (the result of projection), no anxiety will rise. Or a patient is grieving the loss of a boyfriend, and then becomes angry to cover up her grief. If you explore her anger (a defense against her grief), exploring this defense will not trigger the underlying grief or anxiety.

9. You might be exploring a problem for the patient and exploring his feeling in a situation, but the patient’s anxiety has shifted into the smooth muscles or cognitive/perceptual disruption. Now that the anxiety has shifted into the parasympathetic branch of his autonomic nervous system, it is no longer going into his striated muscles. Here you need to regulate his anxiety so it goes into the striated muscles again. Then you can resume exploring feeling again.


Thus, when you don’t see anxiety triggered in the patient’s striated muscles, go through this checklist to see what is preventing a rise of unconscious anxiety in the patient’s body.







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