“My patient is a 22-year old woman with a diagnosis of Asperger’s disorder. She attends college and majors in child development. In session, she presents much younger than she is and seems to be socially underdeveloped. She becomes anxious when she perceives people looking at her and then attempts to hide from them. In session she plays this out by being very still. She admits she feels anxious. In class, she fears if she moves people will look at her and think she is weird. She seems to be paralyzed by this fear of judgment. During session, she rarely makes eye contact and often looks down. She rarely brings up conversation but waits for me to start. How should I approach her in terms of ISTDP? Thank you very much and I look forward to hearing from you.” What a great question!
Ordinarily, we don’t do ISTDP with patients who suffer from diagnoses with a neurological origin such as autism spectrum disorders. However, no matter what diagnoses patients have been given, we still need to do a psychodiagnostic assessment.
To do that, we ask about her problems, get a specific example, and then ask about feelings. Then we find out what her triangle of conflict is, where anxiety is discharged in the body, and what defenses create her presenting problems.
Of course, without videotape we can’t do a thorough psychodiagnosis. However, the information provides us some clues about the questions we should ask to do that psychodiagnosis.
Triangle of conflict: mixed feelings; anxiety (we don’t know what the pathway of anxiety discharge is); defenses: self-attack, intellectualization, projection of the superego, gaze avoidance, and passivity.
She has feelings toward people. The feelings make her anxious. She deals with her feelings and anxiety by intellectualizing about them (they will think I am weird), self-attack (I am weird), projection of the superego (you are judging me), and avoiding the eyes of the therapist (this could be a sign of a transference resistance in a highly resistant patient or a reaction to a projection on the therapist made by a fragile patient).
How should we intervene to get a clearer assessment?
She becomes anxious when she perceives people looking at her.
Th: Since I am looking at you, are you aware of feeling anxious here with me too? Where do you notice feeling that anxiety in your body physically?
If the anxiety is the smooth or striated muscles:
Th: I wonder what feelings are coming up here toward me that could be making you anxious?
Th: Could we look underneath the anxiety and see what feelings are coming up here toward me?
Th: Wouldn’t it be nice to know what feelings are coming up, so you wouldn’t have to feel anxious instead?
She says she hides from people.
Th: How is that in operation here with you and me?
Th: I wonder what feelings are coming up here toward me that make you hide from me?
Th: Could we take a look at the feelings here toward me that make you hide?
She sits very still with the therapist.
Th: Notice how you sit so still here with me? That can be a way to hide from me. I wonder what feelings might be coming up here toward me that are making you hide?
Th: Could we take a look at the feelings here toward me that you are hiding?
She admits she feels anxious.
Th: Since you are feeling anxious here with me, could we take a look and see what feelings are coming up here toward me that make you anxious?
She is paralyzed by fear of judgment.
Th: I wonder how that is in operation here between you and me?
Th: Is there any evidence that I am judging you?
Th: Could we look under that thought and see what feelings are coming up here toward me? Could we look at what the thoughts are covering up? What feelings are coming up here toward me?
She looks away.
Th: Notice how you look away and avoid my eyes? Notice how you retreat behind a veil of silence. I wonder what feelings are coming up here toward me that make you avoid me?
She waits for the therapist to start.
Th: Do you notice how you wait for me to start? Notice how some passivity comes up here between us? I wonder what feelings are coming up here toward me behind this wall of passivity?
Using each of her responses above, we can explore feelings to find out where her anxiety is discharged and what defenses she uses. Then we can discover what causes her problems and what we need to do in therapy.
Does this patient have Asperger’s syndrome? We can’t know for sure without a thorough psychodiagnosis and watching the videotape. However, she is concerned about the thoughts of others. She is socially sensitive. She uses isolation of affect and repression as resistances. So it is possible she does not have Asperger’s and may be treatable with ISTDP. But only further psychodiagnosis will tell. Keep asking for feelings toward you so you can assess her responses.