“I have helped a patient see his defenses and their price. But now he asks, ‘When I no longer have all these ways to hide myself and my feelings, who am I?’ I said, ‘Then you are your real and original self.’ He responded, ‘But who am I when I do not have my old way to be me. Because I do not know what you call my real and original self.’ I did not know what to say. What do you suggest?” Thanks to Iben for this interesting question!
When a patient uses defenses habitually for a lifetime, they seem as if they are his being rather than the way he hides it. The patient, identified with his defenses, cannot differentiate who he is from the ways he deals with his feelings.
If you challenge his defenses when he is identified with them, he will experience you as attacking him as a person rather than inviting him to let go of his defenses. Thus, we must help highly resistant patients differentiate themselves from their defenses.
For this patient, we might say, “These defenses are not you. They are the way you hide your feelings and yourself from others. They are like a grimy coat you put on. We see the coat. But we never get to meet who you really are underneath. Would you be willing to take off that coat so we can see who you really are underneath?”
If he asks, “Who am I if I don’t have my old way to be?” we can’t answer that question. We don’t know the answer for it will be revealed only in the living reality of becoming himself without his crippling defenses. Rather than respond to the content, you can respond to his unconscious therapeutic alliance:
Th: “Would you like to find out?”
Th: “Would you be willing to let go of this old way so you can find the new you underneath?”
Th: “The caterpillar wonders what he will look like as a butterfly when he comes out of this cocoon of defenses. Would you like to find out?”
If his questions remain, you could address the transference resistance dimension.
Th: “Do you notice how you ask what will happen if you let the wall down rather than let it down now here with me? What is the feeling here toward me that makes you put up this wall of questions?”
Th: “You invite me to relate to a hypothetical man who might appear in the future. But then we will just have a hypothetical relationship and hypothetical therapy. What is the feeling here toward me that makes you put up this wall of the hypothetical man?”
This patient is only somewhat identified with his defenses. He sees his defenses and their price, and he can intellectualize about them. Thus, his identification is fairly weak and can be countered by mobilizing the unconscious therapeutic alliance and some challenge:
Th: “Would you like to find out who you really are underneath this cocoon? So what can we do about this façade you are putting up here with me?”
In his case, identification serves as a defense. In fragile patients, identification often results from a failure of defense.
Fragile patients require more extensive restructuring work. Let’s look at how to build self-observing capacity so they can dis-identify with the defense.
A patient with bipolar mood disorder.
Pt: “I hate myself.” [She is identified with the defense of self-hatred.]
Th: “You are aware of something in you that wants to hate.” [This helps her observe and be with her defense rather than act it out.]
A patient projects onto her therapist and suddenly says,
Pt: “I have to leave.” [She is identified with the impulse and identifies the therapist with a projection from which she must run.]
Th: “You are aware of an impulse in your body. Where do you notice that impulse in your body, if you were to describe it in words.” [This encourages the patient to observe and describe an impulse rather than identify with it.]
A patient floods with anxiety.
Pt: “I feel terrified.” [She shifts from describing her anxiety to identifying with it. If you say, “you are feeling afraid”, she will flood with anxiety because you are encouraging identification.]
Th: “You’re aware of something inside you that gets terrified of this feeling of anger.” [This shifts her from identifying with to observing her experience. Help her be with rather than drown in her experience.]
Shift the fragile patient from identifying to observing her experience. Use phrases like:
“There’s an awareness…of sensations in your body…of an urge within…of something inside you.” Help the patient be in relation to a defense such as self-hatred rather than overwhelmed by it. When the patient appears to be overwhelmed by a feeling, most likely she is overwhelmed by a defense.
To help the patient observe her defense you could say:
Th: “Can we acknowledge that there is something inside that has a hating urge?” [Saying, “Do you notice how you want to hate yourself?” would only deepen her identification with the defense.]
Th: “You’re aware of an urge inside you that wants to hate.” [We don’t say it’s an urge “to hate you.” By saying “an urge to hate”, we leave an opening for the rage to go other places.]
Th: “You’re aware of something inside you that wants to hate.”
Th: “You’re aware of something inside you that hates anxiety.” [Help the patient see that the hate is directed toward some aspect of her (a feeling, anxiety, or defense). Now she can see herself in a less global fashion. She sees a relationship (something within her hating something else: the implicit object relation being enacted).]
Help the patient compassionately witness her defense rather than identify with it. Before she can observe the defense, any comments on it or its price will not help. Once she can witness the defense, then ask, “I wonder what feelings are coming up here toward me underneath that thought?”
Take home point: we can never know who the patient will become without his defenses. We can never know in advance the mysterious potential of the person hidden underneath impersonal defenses. That is what is exciting and frightening about therapy.