Monthly Archives: August 2014

I want to die! The suicidal patient.

“How do I overcome my patient’s urge to die?”

We don’t overcome her urge to die. We accept it. We make room for it. We explore it.

As therapists, we can make the mistake of trying to “fix” the patient. We try to drug away her suicidal thoughts. We argue with her, try to convince her not to kill herself, offer all the reasons she should live. Then the conflict is between you and her: you want her to live and she wants to die. Meanwhile, no one listens to her.

The urge to die is double-sided. On the one hand, wanting to die is almost always how we turn rage toward others upon ourselves. In fact, the suicidal urge can be an opportunity to help the patient feel her rage where it really belongs.

 

At the same time, the urge to die affirms her life: “I don’t want to live this way. I don’t want to pretend I feel something I don’t feel. I don’t want to keep putting up this façade. This life of the false self is not worth living.”

 

We can agree. A life of lying to oneself, of being a false self, is not worth living.

 

Underneath her wish to kill the false self that traps her, is the urge to come out of prison. Underneath her wish to die is a wish to be reborn. Suicidal thoughts keep saying to her, “This is not enough! You shouldn’t have to live this way.” Her despair is not wrong. She should despair. Living with a façade is hopeless. Lying to herself is hopeless. She does not need to give up hope on herself, but she does need to give up hope on hopeless strategies: defenses.

 

She is right. Something does need to die. Not her. But her way of dying, the defenses that are killing her.

 

 

 

Why should I ask about the feelings toward me?

“Isn’t that narcissistic? What makes you think she has feelings toward me? She was talking about her father!”

Imagine an abused dog in a shelter. If you approach that dog and invite him to eat from your hand, he will bark and bite or whine and whimper. You approach with love; he recoils in fear. He doesn’t know you, but he has feelings toward you anyway. Why? Someone hurt him. You approach, he withdraws. You could call these dog transference feelings. People hurt him, so he avoids people. It’s adaptive evolutionary learning at work.

Most of our patients have also been badly hurt. They want to bark and bite or whine and whimper, but they were rejected when they revealed those feelings. So they hide those feelings through defenses. Yet in spite of their disastrous histories, they take a courageous step. A patient tries to connect to us. And we try to connect to her.

 

You ask about her problem, her will to look at the problem, a specific example of her problem, her feeling in the situation. These invitations to declare a problem to specificity, to will, or to feelings say one thing: “Are you willing to form an emotionally intimate relationship with me so we can heal you?”

 

In response, some patients say yes. They were accepted when they shared their feelings. Most patients, however, were rejected, so they become scared or say no.

 

You keep asking about feelings. You address defenses against sharing feelings. As the patient shares more, she becomes closer to you. Your persistent invitation to closeness (love) awakens her longings and fears of rejection. These complex transference feelings toward you are based on her past experience.

 

You think she is telling you about her feelings toward her father. But she shares with you what she has never told anyone. She never told her father! At this moment, the therapy relationship becomes the most emotionally intimate relationship in her life. This stirs up powerful feelings and reactions. “I am becoming more intimate than I was with my father! What will happen now? At what level of feeling will you reject me? Should I punish myself first for having these feelings before you do?”

 

Now the danger is not her feelings toward her father but emotional closeness with you. To avoid these feelings rising toward you, she avoids you.

How does she do that? Let’s take a look.

 

Th: “What’s the feeling toward your father for beating you?

 

Pt: [looks away or gazes at the floor or ceiling] [Gaze avoidance]

Pt: pauses a long time before answering [slowing down]

Pt: Goes up in her head and has a dialogue with herself instead of with you. [Detaching and withdrawing]

Pt: I don’t know. [She says this right away without looking inside herself.] [Instant repression]

Pt: I don’t know what I feel. Do you have a list of feelings? [Helplessness/passivity]

Pt: I don’t know if I have any feelings. [Detaching]

Pt: Irritation. [Said without any emotion in her voice] [Detaching]

Pt: I had a feeling a moment ago but I forget what it was. [Forgetting]

Pt: It’s an unpleasant feeling. [Vagueness]

Pt: crosses arms or legs [Non-verbal distancing]

Pt: I don’t know. I could throw out something. [Presenting a façade]

 

These signs indicate that her feelings toward you have become high enough that she no longer distances just from feelings toward her father. She distances from you. In response, label her relational behavior, point out the wall, and then ask for feelings toward you.

Pt: I said I felt angry but I don’t know if I feel anything.

Th: You say it and unsay it. Notice how you disappear here with me. But then neither I nor anyone else would get to know you. [Relational behavior] This is a barrier you put up here between us. What is the feeling here toward me that makes you put up this wall of the disappearing woman?

 

Why ask about the feelings toward you? She is avoiding you. Why focus on your relationship with her? When she distances from you, she will not share feelings about anything with you. If she doesn’t let you in the front door of the house (your relationship), you won’t be able to enter the living room (current relationships) or the basement (past relationships).

 

Think of it. If your beloved distanced from you, wouldn’t you ask what feelings your beloved was struggling with that led her/him to distance from you? Wouldn’t you want to know?

 

With our patients we explore feelings in current and past relationships. When the patient uses the signs of resistance above, she resists emotional closeness with you. In response, describe her relational behavior so she sees it, note how this is a wall in your relationship, and then ask about feelings toward you that make her put up that relational wall.

 

Another sign of rising feelings toward you: the patient refers to you or the way you do therapy.

Pt: You keep asking about feelings.

Pt: You are a tough therapist.

Pt: You said that before.

Pt: You sure aren’t like my previous therapist.

Pt: I don’t think this kind of therapy is helping.

 

Response: “It sounds like you have a reaction to the way I’m working with you. What feelings are coming up here toward me?”

 

Every patient will have reactions to our interventions. That is natural and expectable. In response, accept her reactions and ask what her feelings are toward you.

 

Another sign of rising feelings toward you when you explore feelings in a current or past relationship: self-attack.

Pt: Maybe I just can’t do this kind of therapy.

Pt: I was so stupid to deal with my husband that way.

Pt: I’m hopeless at this.

Pt: Maybe I can’t get better in therapy.

 

Response: “Notice how this critical mechanism comes up right now to hurt you? If you don’t criticize or hurt yourself, could we take a look at the feelings here toward me just before you criticized yourself? Can we look underneath the self-criticism and see what feelings are coming up here toward me?”

 

Becoming more intimate stirs up complex feelings. As these feelings rise, the patient protects you by turning these feelings onto herself. Then she becomes depressed. Instead, invite her to face the feelings toward you. This stops the depressive process. Now her anger can go outward rather than back onto her. Keep asking about the feelings toward you. Her weepiness and depression will stop, and you will see her perk up and become firmer. Your metacommunication? “You don’t have to protect me from your feelings. I am strong enough to embrace them and you at the same time.”

Why do I ask for the feelings toward me? Because she has feelings that lead her to distance from me. She deserves a relationship where we care about her feelings and are open to them no matter what. She deserves a relationship where she doesn’t have to distance herself to protect us from her feelings. Am I being narcissistic? No. It is not about me; it’s about her. Are we willing to surrender our egos so we can be the person who accepts her feelings, no matter what they are? She was wounded when her feelings were rejected in the past. Can we let her feelings in so her wounds can be healed today?