I could use your thoughts on a difficult patient. This man was emotionally and physically abused by both parents and has been diagnosed with countless psychiatric disorders. He abuses marijuana and has acted out. In our first session I asked if he was aware of feeling any anxiety. He said yes so I inquired about physical sensations. He had difficulty answering this question and became guarded and angry. I wondered what was making him anxious. He said meeting me was “like the first day of school.” As I attempted to explore this with him he became enraged and started cursing and yelling. I tried to identify the feeling (angry at me) and manage the behaviors (“I can’t help you if you curse and yell at me”) but was unsuccessful.
I’ve never seen such an angry response to inquiring about a patient’s internal experience, and am not sure how to address this. Thanks to Chantal for asking this important question.
Chantal asked her patient about his anxiety. Excellent intervention! Given his history and impulsivity, it’s always important to know where anxiety is discharged in his body.
In response, he became guarded and angry. These are signs of projection. If he is in relation to a therapist who wants to help him with his anxiety, he will feel relieved. If he is in relation to a projection, he will guard himself against this projection. He will become angry, not at Chantal, but at the projection he places on her.
Why? When Chantal explores his anxiety, she invites him to become closer to her, to depend upon her. This arouses feelings in any patient. The more traumatic his history, the more powerful the feelings her invitation will evoke.
When his feelings arise toward Chantal, his anxiety increases. In his case, his anxiety became so high that it shifted into cognitive perceptual disruption, and then he projected. Then he lost sight of the difference between Chantal and his projection. Once he equated her with his projection, he became enraged at the projection he placed on her.
When she continued to explore with him, his anxiety increased and so did his projection. Now she seemed even more dangerous to him. Feeling even more threatened by her (the projection), he threatened her by cursing and yelling.
Triangle of conflict: complex mixed feelings toward a therapist who invites a closer relationship; anxiety in cognitive perceptual disruption; defense: projection of will and projection of superego. The defenses of cursing and yelling are secondary because they are in response to the projection he places on Chantal.
Focus of treatment: deactivate the projection to bring down projective anxiety and re-establish a therapeutic alliance with the therapist, and then regulate anxiety triggered by feelings until anxiety returns to the striated muscles. Do not explore his rage toward the projection. That will increase his anxiety and reinforce his projection. Instead, deactivate his projection so he no longer rages at the projection he places on Chantal.
Patient becomes guarded.
Th: I notice you seem hesitant to explore. I have no right to explore this anxiety unless it is something you would like to explore with me. So let me check with you: do you want us to explore your anxiety so we can help you with it? [Deactivate the projection of will. If you don’t, the patient will experience you as an invader, trying to get into him by exploring.]
Pt: I’m not sure I can trust you. [Projection]
Th: Thanks for letting me know. That’s important information. It sounds like you have some thoughts about me. Could we take a look at what thoughts you have about me and how you perceive me? [Explore and deactivate his projections]
“I feel like it’s the first day of school.” [Projection of superego]
Th: It sounds like you are having a reaction to the therapy and the questions I’m asking. Could you say a little bit about your reactions to our conversation? [Explore and deactivate the projection of the superego]
Pt: I just feel like you are asking questions and I’m going to fail to give you the answers you are looking for.
Th: So a concern about how your answers might be judged.
Th: It’s not my intent to judge you. If you have trouble answering a question, that just helps me see where I can help you. Since you are concerned about evaluation here, have I done anything here to judge you that I’m not aware of? [Deactivate projection of the superego, then ask if there is any evidence you are judging him.]
Pt: No. It just felt that way.
Th: So, although it felt like I might judge you, we don’t have any evidence for that.
When you see signs of projection such as guardedness and premature anger, deactivate projection quickly to prevent the defensive affect of rage arising in response to those projections.
Patient curses and yells. [Patient threatens the therapist because believes the therapist is threatening him: he equates the therapist with his projection]
Th: I’m sorry, there must be a misunderstanding here. You would not be yelling here, if you didn’t feel I was doing something wrong. Can you tell me what I need to stop doing?
Pt: You keep pushing and pushing and pushing. [Projection of will]
Th: Thank you for letting me know. It’s not my intent to push. I have no right to explore anything here unless it is your wish to explore it. [Deactivate the projection of will] Would you agree? [Once you deactivate the projection, the patient will feel less threatened. Thus, the cursing and yelling will stop.]
Th: Do I have your permission to help you feel more comfortable here? [Mobilize will to the task.]
Th: To help you feel more comfortable, do I have your permission to explore your anxiety?
Pt: I don’t know. I don’t know what you are trying to do. [Projection]
Th: If you give me permission, we can try to make you feel less anxious by paying attention to your anxiety symptoms. Would you like me to help you feel less anxious? [Mobilize will to the task. By asking permission, you deactivate his projection of will. Remind him that he decides what you will explore. Thus, he no longer needs to feel threatened.]
Take home point: when working with a severely fragile patient, assess any signs of projection. Once you see a projection, deactivate it immediately to re-establish a therapeutic alliance and to stop further regression. A patient threatens you because he feels threatened by the projection he has placed on you. Find out what the projection is and deactivate it. Then the cursing, yelling, and acting out will stop. Once you have deactivated the projections and re-established a conscious therapeutic alliance, regulate anxiety until it returns to the striated muscles. Only then is it safe to explore his inner life again.