Monthly Archives: January 2015

ISTDP for Aspbergers?

“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.



What is the feeling times infinity!

“I had an interesting discussion with someone whose friend had been through ISTDP therapy. The friend said it was very valuable, but she found the relentless focus on anger to be repetitive, grasping, even coercive.


I sense that some ISTDP therapists practice a crude version of it, in which they use these questions to hammer their patients into complying with them and emptily name a feeling “anger”. “What’s the feeling?” can be therapeutic when used with genuine curiosity. But when used in a leading way, it can turn an inherently unpredictable process into a lifeless event. I’m curious to hear any thoughts you have about it.” Thanks to Kent for this important question!


Any intervention used mindlessly can make a living therapy lifeless. Alas, if someone doesn’t understand where to focus, how the patient responds, and how to intervene, mechanicality can replace sensitivity.


Even though “what’s the feeling?” has an iconic significance in ISTDP, many times you should not use that intervention, e.g., if the patient has not declared a problem, his will to look at the problem, or a specific example of the problem; when anxiety is too high, when the patient has gone over the threshold of repression, or when the patient is projecting and has lost a sense of reality testing.


Inviting feeling is not a mechanical intervention to be repeated ad nauseam. We use it to mobilize the patient’s unconscious. Then we watch the patient’s responses. If his anxiety is too high, we regulate it and then ask for feelings. If he uses defenses, we address them and ask for feelings.


If he doesn’t understand the process, we don’t just keep barreling along. We pause and summarize our joint understanding of what causes his problems, how we can address them, and the goals he hopes to achieve. Once we have this joint understanding, the patient understands why we do what we do, and we can go forward as partners.


If he is repressing and has trouble knowing what he feels, we don’t just repeat the question. We mobilize him to the task:

Pt: “I don’t know what I’m feeling.”

Th: “Wouldn’t it be nice to know what you feel, so you wouldn’t have to be depressed instead? So could we take a look at the feelings underneath and see if we can help you overcome this depression?”

Th: “That makes sense. If you don’t know what you feel, you go through life without a compass. And it sounds like that happened in your marriage. Would you like us to help you get to those feelings, so you know what you want? So what feelings do you notice coming up here toward me?”


If the patient criticizes himself for not knowing what he feels:

Th: “Could that be a form of self-criticism? Could that be hurting you? If you don’t hurt yourself, and if you don’t protect me, could we take a look at the feeling here toward me underneath that self-criticism? Could we see what’s under the self-criticism?”


These additional comments help the patient understand what we do and why we do it. They mobilize his will to the task so we can do the job together. If we don’t do that, the patient can be mystified by the process, not know why we are doing this, and the best he can do is compliantly go along for the ride. And that is a misalliance.


But let’s suppose that the patient is at a mid-rise of feelings and the therapist is correctly asking the patient, “What is the feeling here toward me?” This can seem puzzling to the patient as well. “Why are you asking about feelings toward you?” All of a sudden, the patient can think you are a uniquely narcissistic therapist!


Again, you can avoid this misalliance by starting off this way:

Th: “Notice how you are distancing a bit here with me? Notice how you are going up in your head and having a conversation in your head instead of with me? Since you are distancing here with me, could we take a look and see what feelings are coming up here toward me that would make you distance?”


Here you identify the transference resistance in terms the patient can see and understand. You identify how it happens in the relationship. And you ask not out of anger, but out of curiosity. So it makes sense to her why you ask about feelings in the relationship.


With very highly resistant patients, of course, the role of the conscious therapeutic alliance may be small initially. However, with all patients we need to cultivate the conscious alliance as much as we can to mobilize the patient to the task, so we go forward as partners.


When we ask the question in this way, with genuine curiosity, and with respect for the patient’s wish to understand what we do and why, he realizes we simply want to help him. Meanwhile, we will also pay attention to the sighs and other indicators of the unconscious therapeutic alliance, so that every part of the patient is engaged in the task.


Therapy is so hard to do and to learn, isn’t it? Naturally, sometimes we don’t understand the patient’s response and don’t know how to respond. When anxious, we can resort to repeating the same question. Every one of us has made that mistake out of anxiety and a lack of knowledge whether doing ISTDP, CBT, or psychoanalysis!


The mechanical quality Kent mentioned is not an element of ISTDP. Rather, it is a result of therapists’ anxiety when learning any new approach, not understanding the patient’s response, and not knowing what to do. It’s a learning problem encountered in every model of therapy.


That’s where supervision can be so helpful. Once we understand the patient’s response and need, our intervention can be based on knowledge rather than anxiety. We can respond rather than react. And we can be sensitive instead of mechanical.


“What’s the feeling?” is a technique. But what is a technique in therapy? It’s just a way to form a more intimate healing relationship. If we remember our goal, to form a more healing relationship, that goal will inform everything we do and say in therapy. Keep that goal in your mind and heart. For a patient will always forgive a mistake of the head, not one of the heart.