Is this Affair a Breakthrough or a Defense?

A fragile patient sees his defenses of self-judgment and self-attack (“I am hopeless. I am useless.”). He made one suicide attempt during therapy with me. I have a good therapeutic alliance with him after many months of work. However he does not feel his feelings in sessions with me, only when he was suicidal or on the phone with me. He becomes anxious when I ask about feelings. (“You will not like me, you are judging me, I am hopeless and you will throw me out…”) I help him differentiate the superego and the ego; he gets it.  But later, he uses those same defenses again. He understands his grief and his need for love. He says his wife is cold and hates him, so he has started an affair with another woman.

He has made some progress: he feels less alone and is now able to feel sad and angry at times. His father was a bully, mother detached and fearful of father. He was bullied at school. In the past he was suicidal because he was worried his wife would leave him or be unfaithful to him (he knows it was a projection.) Now he threatens suicide because he is worried that I will tell him to stop his affair, judge him for it, or not like him. Is the affair a breakthrough or a defense? Thanks to one of our community members for sharing this vignette.

The patient sees that he attacks himself, but he still does it. Thus, his defense is syntonic. When he is not attacking himself, he imagines that his wife would attack him by leaving (projection of the superego), or that his therapist would judge him (projection of the superego).

Then he claims that his wife is cold. We don’t know. But we can be certain that he is cold and rejecting of himself through his vicious self-attacks. After all: he, not his wife, tried to kill him.

He projects that the therapist will judge him. Then he gets angry at the therapist as the “supposed” judge. Then he threatens to kill himself as a way to paralyze the therapist and control what he will say. Then the patient torments the therapist the way his superego torments him. This is the defense of projective identification.

Conflict: mixed feelings, especially rage; anxiety (pathway of discharge unknown); defenses of self-attack, projection of the superego, and projective identification.

Without seeing the videotape, it is impossible to accurately assess this patient, especially his pathway of anxiety discharge. So my comments must be taken very lightly since there is much information we don’t have. However, there are a few things we can keep in mind.

“I am hopeless.”

Intervention: “ Notice how you criticize yourself right now? Could that be making you depressed? If you don’t hurt yourself, what feelings were coming up here toward me just before you criticized yourself?” [When this patient experiences complex feelings toward you, he protects you through criticizing himself instead. Identify the defense, block self-harm, and then invite him to face the feelings toward you. This gives his rage an external outlet toward you so he doesn’t have to turn it on himself. This is an essential intervention with depressed patients and highly resistant patients with repression.]

“You will throw me out.”

Intervention: [assuming he has lost reality testing] “What is the evidence for that?” Once he realizes there is no evidence. “So we see there is a thought that I would throw you out, but there is no evidence for it. In fact, we see that you tried to throw yourself out of therapy through suicide. I wonder what feelings are coming up here toward me that are underneath this thought?”  [Restructure the projection to establish reality testing, then explore the feeling underneath the defense. The more he can experience his rage in therapy, the less he has to project it or act it out.]

 

Notice that the restructuring of projection is not done cognitively. It must be done experientially with the therapist in the here and now. And part of that restructuring is facing the feelings being avoided through the projection. Once he can face his rage, he does not need to project it onto others. The more deeply he can feel his rage, the more thoroughly his need for projection disappears. Projection is restructured because the patient can bear his feelings internally toward the therapist, not because he “sees” his projection.

He projects his rage and his superego upon the therapist and his wife. “She is cold”. In fact, he is extremely cold to himself. Once he equates her with his cold and hateful superego, he leaves her to have an affair. Is it a breakthrough? No. He avoids his wife to avoid the projection he has placed upon her: the rejecting superego. Some have serial relationships because they are serial projectors. Each partner becomes the rejecting superego and must be left. Then the “geographical cure” continues.

Likewise, if the therapist does not quickly address the projection on him, the patient will leave therapy too to have an “affair” with a warmer therapist. That is, a therapist upon whom he has not yet projected his superego.

“I’m afraid you will disapprove of my affair.”

Intervention:

Th: Who is having that thought?

Pt: Me.

Th: Notice how you put that thought over here onto me, when it’s a thought in your mind? [identify the projection.]

Pt: Do you disapprove? [projection]

Th: It’s not my job to approve or disapprove. You already are having thoughts of disapproval in your mind, but you attribute them to me. Do you see what I mean?

Pt: Do you think I should stop it? [projection]

Th: Only you can know if you should stop it for you. [block projection]

Pt: I would kill myself if you disapprove. [He is not saying he will kill himself. He is saying he will IF you disapprove. Thus, he knows that you are not disapproving.]

Th: I wonder what the feeling is toward me that makes you want to kill yourself? [Explore his feeling toward the therapist so his rage does not have to go back onto himself.]

Pt: Do you think I should kill myself? [projection]

Th: You said you would kill yourself. So I wonder what feeling is coming up here toward me? If we look under the suicidal thoughts, can we see what feelings are coming up here toward me?

Insofar as he fears the therapist’s disapproval, the patient judges his affair  (projection of the superego onto the therapist). Insofar as he views his wife as cold and hateful (projection of the superego onto the wife), he is cold and hateful as evidenced through his self-attacks. Thus, his affair is not a breakthrough. It is based upon his defenses of splitting and projection.

Take home point: superego pathology must be restructured within the relationship with the therapist. Help the patient see his self-attack and then invite him to look at the feelings toward you his self-attack covers. Help the patient see his projection of the superego onto you. Then invite him to look at the feelings toward you that he thought you were going to judge. Cognitive restructuring is not enough. Restructure defenses by helping the patient experience the feelings toward you that his self-attacks cover up.


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One response to “Is this Affair a Breakthrough or a Defense?”

  1. bill Avatar

    I find these vignettes extremely helpful. Thank you, and please keep them coming!

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