”I work in an outpatient clinic for people suffering with drug abuse/addiction and comorbid psychiatric illness. Many of our patients have aggressive outbursts where they yell, threaten family members or therapists, and punch walls and tables. Since we therapists get scared, we have trouble confronting this defense.
For instance, a patient begins sessions calmly, but after five minutes, he starts ranting about people and institutions who’ve done him wrong. He raises his voice and waves his arms while ranting. Then after 20 minutes, he deflates and calms down again. Due to his threatening behavior, he has been excluded from other public services, so his behavior obviously causes trouble. I have feared for my own safety even though he has never threatened me, so my fear may be unfounded. But, as a result, I avoid trying to regulate him when he starts ranting. He has a history of violence, both ‘blind’ street violence and other crime-related violence, but never within the health services. The patient uses cannabis daily because it calms him. Thanks to Pal for this extremely important question!
First of all, we must differentiate the feeling of anger from the defense of discharge. Let’s suppose a man is angry because a neighbor tried to molest his daughter. Feeling his anger, he then becomes depressed. Here is a classic therapy situation: the patient feels angry, becomes anxious, uses the defense of self-attack, and then suffers the symptom of depression. The therapist will help the patient let go of his defense of self-attack, and then help the patient face his rage as deeply as possible. Then the patient will be able to channel his rage into effective legal action rather than become depressed instead. That is how we deal with the feeling of anger.
Pal is talking about a very different kind of clinical situation. Discharge is not the experience of feeling. It is the attempt to get rid of the experience of a feeling through action. The patient, unable to tolerate feeling within himself, may blow it out of his mouth through yelling, try to shake it out of his body through movement, or pound it out of his body through punching a wall. Each of these defenses we call discharge: the attempt to rid oneself of the experience of a feeling.
Discharge is a regressive defense and a sign that we must use the graded format. These patients try to get rid of their feeling rather than tolerate a high rise of it. Since they act out, our first step is to build their capacity to tolerate feeling without using the defense of discharge.
If you mistakenly pursue high levels of feeling, you will exceed the threshold of feeling tolerance. Then these patients will regress and act out in session and out of session. If you allow ranting and discharge in the session, you encourage regression and the patient will become worse. Thus, always interrupt discharge as soon as you can so you can help the patient develop the capacity to tolerate his inner experience.
To assess in session, always notice what triggers the patient’s rants and discharge. Then help the patient see the triangle of conflict: feeling, anxiety, and the defense of discharge. This cognitive work of pointing out the triangle of conflict helps the patient see the process that creates his problems. Then we gradually help him observe and tolerate feelings inside of him without resorting to discharge. Simple, right? Not quite. Let’s go on to the complexity.
Discharge can occur in several situations involving various defenses. These situations can require different forms of work. Here are a few:
1) The patient who has trouble tolerating a rise of feelings;
2) the patient who projects and then discharges upon the person he projects upon; and
3) the patient who uses discharge in the service of denial of reality.
Here is one way to work with situation one:
Pt: Ranting and shaking his arms. [Defense of discharge]
Th: Do you notice you are yelling right now and shaking your arms?
Th: That’s often a way to get rid of feeling. See, any feeling you yell away or shake away is feeling we won’t be able to help you with. [Price of the defense in therapy] Would you be willing to speak quietly right now and put your arms on the arm rests? [Block the defense] Let’s see what you feel in your body now that you aren’t getting rid of the feeling. [Encourage the patient to experience his feeling rather get rid of it through acting out in the session.]
Pal’s patient sounds like the second type. This kind of patient has feelings, becomes anxious, and then he projects, accusing others of doing things they never did. Then he becomes enraged toward them and acts out.
Here, the patient uses discharge to get rid of a defensive affect: rage triggered by his projections. As long as he projects, he is enraged. Pal’s patient most likely projects onto people, equates them with his projections, and then beats them up.
But why does he yell, or threaten, or punch? If he projects onto someone, he believes they will never listen. Thus, he yells out of despair, hoping the loudness of his voice will penetrate their supposed “stupidity.”
If he projects that people want to threaten him, he will threaten them first. It’s important to remember: the patient never threatens you; he threatens the projection he has placed upon you. He threatens you because he has projected upon you and views you as a threatening figure.
If he punches things, it is because he wants to punch someone, possibly you. If he projects that you want to attack him, he may attack you first. Since Pal’s patient has violently attacked people, Pal’s caution is very well founded. Rather than explore feeling with this patient, we want to restructure the projections which create his defensive affect of rage.
With this second kind of patient, find out what the patient is projecting onto others that leads him to want to attack them. If he projects his superego, he believes others are criticizing him, putting him down.
Pt: What are you looking at!
Th: I’m just looking at you. How are you perceiving me right now? [Explore the patient’s projection so it is out in the open where you can talk about it, rather than implicit and silent where it could soon become acted out.]
Pt: I can see you are looking down on me. [Projection of the superego]
Th: I’m not aware of doing that. What is the evidence that I am looking down on you. [Explore the projection to promote reality testing.]
Pt: You could be looking down on me. [Projection and failure to explore reality.]
Th: That’s true. That’s why we have to check to see if I really am looking down on you. After all, if I was judging you, I would not be doing the right thing here as your therapist. So could you help me see the evidence that I’m rejecting you? [Validate reality: it’s always possible a therapist is judging. Then explore reality.]
When patients project upon others, they remain chronically afraid of others or chronically angry. Since their projection continues, so does their rage. When they express their rage toward a projection, there is no relief. Why? The projection still exists. Thus, their hopelessness about the world still exists.
When patients express rage which they previously kept out of awareness, they will feel the relief of finally facing their anger and finally facing the reality stimulus that triggered their rage.
When patients express rage toward a projection, there is no relief because the rage was never repressed out of awareness. They are aware of their rage toward someone. They just don’t realize their rage is toward the projection they placed on another person. Instead, they feel chronic rage toward a projection.
It makes complete sense that Pal does not explore the patient’s rage because the patient is extremely impulsive, having been violent on the streets and in criminal life. These symptoms suggest that the patient has feelings but then begins to project rapidly, losing any distinction between people and his projections, so that he then can beat people up violently. When patients chronically project, they are chronically anxious. Thus, he uses cannabis to calm himself down.
Pal is afraid to interrupt the patient’s ranting, for fear the patient might become angry with Pal. Several options are available:
Pt: [Beginning to yell.]
Th: When you yell, I find it hard to think. And when I find it hard to think, I’ll be less useful to you. Would you be willing to talk in a lower voice so I can be more helpful to you?
Pt: [Begins a rant.]
Th: May I ask a question? [Block the defense of ranting.]
Th: You mention that you are angry at people who you feel are really critical of you.
Pt: That’s for sure.
Th: Given that think that many people have been critical of you, I wonder how that may be in operation here with me.
Pt: I don’t know if you will help me or not.
Th: That’s true. We can’t know yet if I will helpful to you or not. So given that you think a lot of people are critical of you, how is that in operation here with me?
With Pal’s patient, projection is his major defense, which drives his acting out. Thus, the main focus should be restructuring his projections and increasing his reality testing so he no longer projects onto people and then attacks them. The best way to do this is to focus on any hints of projection happening in therapy.
Since this kind of patient projects most of the time, we can’t explore current or past examples of relationships. Why? Because his perception of other people and events is distorted by his projections. As a result, the therapist cannot get a clear picture. Instead, it is most useful to keep the focus on feelings between the patient and the therapist. Then if the patient projects, both therapist and patient can look at what has occurred in the session and restructure the patient’s projections. As you restructure the patient’s projections over a series of sessions, his projections will drop, his capacity to acknowledge and bear his feelings will increase, and his acting out will decrease as well.
Another situation involves rage, ranting, and discharges as defenses against facing reality.
Th: Do I have your permission to help you for a moment?
Th: I know how frustrated you are with the lack of help you have gotten with this. So I want to share a concern: you have yelled about your boss many times. But it doesn’t look like that has led to any change for you. Does that sound right?
Pt: Yes. It just feels good.
Th: In the short term it feels good to yell, but in the long term it doesn’t lead to change. And you keep suffering. [Price of the defense]
Th: Could we try something different to see if we can find out what is going on underneath this yelling? [Invitation to the therapeutic task]
Th: You mention your boss has never promoted you.
Pt: Yes. And it pisses me off.
Th: Could we accept that as a fact? He has not promoted you. [Encouraging the patient to face reality rather than deny it.]
Pt: I hate it!! [Defense]
Th: I didn’t ask you to like it. I’m just asking. You accept that this chair is real. You accept that my eyes are brown. Can we accept that he has not promoted you? Can we accept that as a fact?
Pt: Well, when you put it that way, yes. [Becomes anxious]
Th: What do you notice feeling as we accept that he has not promoted you? As we make room for that fact.
Pt: I feel hopeless, and I can’t stand it.
Th: Since you are feeling hopeless, can we accept that feeling right now?
Pt: [Begins to tear up.] I can’t give up.
Th: It sounds like the hopelessness is trying to tell you something, to give you some information. Could we make some room for your hopelessness and find out what you need to give up on?
Pt: Cries. I complain to everyone about the boss.
Th: Is it possible that your strategy of complaining is hopeless?
Th: So can we accept this feeling of hopelessness that has been trying to heal you?
Here the patient rages as a defense against facing his grief over the loss of not being promoted and the hopelessness of his strategy of complaining. But the sooner he faces his loss and reality, the sooner he will be able to adapt to reality.
Th: I notice you are beginning to raise your voice. In my experience, when we start yelling, we are trying to make something go away. And you are letting me know: something is not going away. Could we look under the yelling and see what you wish would go away?
Some patients have trouble tolerating the inevitable limits of reality. Someone doesn’t want what you want. A spouse doesn’t behave the want you want him to behave. A friend doesn’t want the kind of friendship you want. A child doesn’t make you look good the way you wish she would. These situations share one thing in common: reality is not the same thing as our fantasy.
Rather than face that reality is not the same as our fantasy, we rage at reality. A patient might try to bully his wife to behave the way he wants her to behave. You might judge and condemn your friend for not wanting to form the kind of friendship you want. A patient might punish and yell at a child so she will make the parent look good. We rage at reality with the hope that reality will change. But no matter how many years we rage at the world, reality keeps showing up instead of our fantasy.
We might yell and curse at someone with the hope that our loudness and force will make the other person change into the “right way”, meaning our fantasy. We might judge and offer “insights” to our spouse so they will become the same as our fantasy. Then we can remain in love with our fantasy rather than let go of our affair with the fantasy and love our spouse instead.
The father who hits his son hopes he can “beat it into him.” What is trying to beat into his son? His fantasy of what he thinks the son should think, feel, and do. And he hopes to beat out what he cannot accept in his son. Thus, much of discharge is in fact a defense against facing a terrible loss: the loss of our fantasy son, spouse, or friend, and the acceptance of the person who is in front of us.
Reality has always accepted the person who disappoints our fantasy. But we say that the reality of this person is wrong or pathological. Then we find friends who support our rejection of reality by joining us in the judgment of our spouses, children, and friends. And if our rage is high enough, some of us will yell, hit, judge, or accuse them of failing us. Yet they did not fail us. They just were the way they are. They only failed to live up to our fantasy of how we think they should be.
Take home points: discharge is always a regressive defense. For some patients, simple restructuring of discharge is enough. Some patients use discharge once they have projected onto someone. Here we must help them restructure their projections. Once they no longer project, discharge will no longer be necessary. Some patients use discharge as a defense against facing reality. Here we must clarify what aspect of reality they are trying to deny or obliterate and then invite them to face the element of reality they have been denying.