I’m in pain. I don’t have a psychological problem!

“I’m working with a woman who has been hospitalized many times for somatization disorder. Her father brings her because she lies in bed at home, barely eating. Convinced she is dying, she believes her symptoms and pain are due to physical illness. Yet medical examinations found nothing. She insists that our psychiatric institution cannot help her, but agrees to be admitted because “it’s ok to be here.” When here she lies in bed most of the time, explaining that she is sick. She believes her symptoms are not psychologically caused. She refuses to discuss her emotional conflicts with her mother, whom she wishes would die. To her it’s not relevant. Health personnel feel helpless, unable to relieve her of her suffering.


She doesn’t think she needs to talk to me, her psychologist. I have to initiate our talks, so it’s not possible to follow the ISTDP line of inquiry, e.g., “What’s the problem you would like me to help you with?” When we talk she lies in bed. Is it possible to do ISTDP in these circumstances, and if so, how?” Thanks to one of our community members for posing this question.


It is hard to answer this since I don’t know how she responds to your inquiry. For instance, let’s look at a possible session with her and how we would assess her suitability for therapy.

Th: “What is the problem you would like me to help you with?

Pt: “I don’t have a problem.” [Denial]

Th: And yet you are here. [Point out the contradiction between what she says and does.]

Pt: My father sent me. [Projection]

Th: Are you in the habit of following your father’s orders?

Pt: He thinks I need help. [Projection of awareness]

Th: And you? [Block projection]

Pt: I don’t. [Denial]

Th: So a person who thinks she does not need psychological help comes to a psychological hospital. [Mirror splitting and denial.]

Pt: He thinks it’s a problem that I lay around all day. [Unconscious therapeutic alliance. She think’s this is a problem and projects that awareness upon him. Thus, she is a potential patient.]

Th: But that may not be a problem for you. You may like lying around all day. [Mirror denial to block projection onto the therapist.]

Pt: It’s not that I like it. It’s just I have so much pain. [Unconscious therapeutic alliance. She mentions pain.]

Th: Are you in pain now?

Pt: Yes. I’m always in pain.

Th: I wonder what feelings you might be having right now about being here? [Since the patient is in pain while talking to the therapist, he asks about feelings to see if pain changes in response. If pain fluctuates in response to asking about feelings, the patient has a psychological not a medical disorder.]

Pt: I don’t have feelings. [Denial]

Th: Do you have pain instead of feelings?

Pt: I just have a medical problem. [Denial]

Th: So I wonder what feelings you have about being here?


You have to address her denial of a problem. Once she talks about pain, ask about the feelings toward you under the pain. She has complex feelings and, I suspect, represses those feelings into the body to suffer physically.


As you intervene, look for:

1)    a rise of unconscious therapeutic alliance: sighs indicating rising unconscious feelings, whispers of a desire for help or of awareness of her need for help;

2)    pathway of unconscious anxiety discharge: does she start to sigh or does her anxiety go into the smooth muscles or cognitive/perceptual disruption;

3)    changes in pain symptoms: if the pain remains the same, it is medically caused; if the pain increases, she somatizes as a way to deal with her feelings and her primary resistance is repression;

4)    system of resistance: is she using isolation of affect, repression, or projection as her primary system of resistance? If isolation of affect is her primary system of resistance we should see sighing emerge during inquiry; if repression is her primary system of resistance we should see an increase in pain symptoms, depression, conversion, fatigue, and self-attack; if projection is her primary system of resistance, we will not see sighing during the inquiry, her projections will continue, and her defenses will be regressive, e.g., denial, splitting, projection, and projective identification.


You wait for her to tell you a problem in words. Instead, she shows you her problem through enactment: she defiantly neglects herself in front of you.


For instance, her actions say:

“My father needed a break. So I want you and the inpatient unit to do his job for a while: care for me while I neglect herself.”

“I will lay in bed passive, you must be active.”

“I will neglect myself, you must care for me.”

“I will ignore my inner life, you must pay attention to it.”

“I will starve myself of food, you must feed me.”

“I will starve myself of therapy, you must feed it to me.”


This patient may be highly resistant with repression. Why? Her physical pain and her unconscious therapeutic alliance say so.


She wants her mother dead. Then she says she is dying. Triangle of conflict: rage toward mother; anxiety; defense: identify with the dying mother. Due to the guilt over the rage toward her mother, she gives herself a death sentence. She punishes herself and asks her father, the therapist, and the hospital to keep her alive against her will. Thus, she remains faithful to her punitive superego.


She uses a transference resistance with the therapist and inpatient unit by taking a passive, defiant stance. In addition, she uses the resistance of repression to turn the rage back on her body in the form of physical pain.


A patient like this may be treatable with ISTDP. However, you need to know how to work with highly resistant patients who use repression. And you need to focus on feelings toward you for a long time, while recognizing and treating symptoms of anxiety or repression that arise.


Briefly, classic signs of repression are weepiness, physical pain, depression, self-attack, conversion, or getting tired. When those symptoms occur, she has gone over the threshold of repression. Do a recap, and then have her do a recap until the pattern is clear and her energy returns. Then focus on the feelings toward you that those symptoms covered up.


Constantly focus on the feelings toward you so the rage comes toward you rather than back onto her body. Since she has been repressing rage her entire life, she will not know what she feels toward you. You could maintain this focus for twenty minutes without her being able to tell you the feeling. However, if you keep your focus, her weepiness will disappear, depression will lessen, her body will become firmer and more energetic. Those unconscious markers in the body will tell you to keep the focus on feelings toward you. Even when she has not described the feeling toward you, you will have begun to restructure her unconscious.


Now for the alliance. Highly resistant patients often do not present with a conscious alliance. However, in this case there is an unconscious therapeutic alliance. That is your ally. Mobilize the unconscious therapeutic alliance, for that is what will overcome her resistance. To do so, ask about the feelings toward you, block and address defenses, and keep asking about feelings toward you. Regulate anxiety if necessary, and then ask about feelings toward you. Always recap when she represses and ask her to recap, and then ask about feelings toward you. You may not see any improvement in the conscious therapeutic alliance initially, but you will see massive improvements in the unconscious therapeutic alliance. And that will be great progress.


Maybe she starts sighing. Maybe she brings in the defense of negation: “I don’t have a problem.” Take out the “not”, and she has unconsciously told you: “I do have a problem.” That is how the unconscious starts to talk to you. Later she may offer more gifts from the unconscious to inspire you: “I wish my mother would die.” Rather than wait for the conscious alliance, mobilize the unconscious therapeutic alliance.


Take home points: when highly resistant patients do not tell you about a problem, they usually enact it. In the first stage of inquiry, mirror denial and block projection. As her transference resistance emerges (asking you to take omnipotent responsibility for her life while she remains passive), address that resistance while asking for feelings toward you. Rather than wait for the conscious therapeutic alliance, mobilize the unconscious therapeutic alliance.







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