Monthly Archives: April 2016

I can’t afford therapy!

Sometimes people cannot afford therapy. Other times, this concern may be a defense to avoid the feelings and anxiety triggered by depending on someone else. For instance, a patient says he cannot afford therapy but just returned from an expensive vacation. Or a woman says the therapy fee is too high, yet she just bought some Gucci shoes.

Pt: This is too expensive.

Th: Yet your shoes were not too expensive.

Pt: Are you criticizing me for buying shoes?!

Th: Not at all. They’re beautiful. It’s just that you are willing to spend money on shoes but not on yourself, your depression. Is this part of a pattern of valuing things more than yourself? Are you having trouble valuing yourself sufficiently?

Perhaps the patient spends money readily on others but not on herself, feeling guilty about making her inner life a priority. She may say that therapy is self-indulgent.

Pt: I can’t afford to pay for therapy.

Th: Yet you were able to afford an expensive vacation for your niece and nephew. Is it hard for you to treat yourself as well as you treat others? Could delaying treatment for your depression be a form of self-neglect?

Often patients feel angry about having to pay to have someone listen or care for them. Rather than explore their anger over depending, they may want to quit, claiming therapy costs too much.

Pt: I just resent the fact that I have to pay to have someone listen.

Th: I wonder how that could be happening here.

Pt: Definitely. I hate having to pay you to listen.

Th: What is the feeling here toward me?

Sometimes when you have explored the patient’s difficulties, the patient will still say:

Pt: I can’t afford to pay for therapy.

Th: Can you afford not to?

Pt: It just costs too much.

Th: You’re right. Therapy does cost a lot. And to calculate these costs accurately, how much will it cost you not to be in therapy, if we factor in your anxiety, depression, separation from your husband, and job probation?

Sometimes the patient complains about how much the therapy costs but then resists collaborating with the therapist.

Pt: How much is this going to cost?

Th: It depends on how long you want to wait until you collaborate with me. The longer you wait, the more expensive the therapy will be. Why make it more expensive for yourself?

In this example, we help the patient see that therapy is not costly, his defenses are.

Or the patient may have described a number of ways that she puts herself down and devalues herself.

Pt: I can’t afford therapy. It’s very expensive.

Th: Are you worth it? Are you worth this investment in yourself?

I know therapy is expensive, having been in therapy for many years myself. But, in the end, my defenses cost me much more.

Pt: I don’t know if I can afford therapy.

Th: Can you afford more suffering?




“I am working with a patient who presents with histrionic personality features. She goes to tears easily but the emotion is very thin and fleeting. In the past she ignored her body and feelings, and her expressions take on a performance quality at times. I invite her to notice feeling in her body rather than engage in discharge, but she gestures toward her body in a somewhat sensual manner. She has begun to observe her feelings instead of ignoring them and pushing herself beyond what her body can handle, as she also is diagnosed with Lupus. How do you conceptualize and intervene with this unique personality style from an ISTDP perspective?” Thanks to one of our California members for this question.

Although early psychoanalytic writers referred to the “hysteric” patient as if such patients took one form, ever since Zetzel’s classic paper on the so-called good hysteric we realize that this personality style can be expressed either within a neurotic or borderline level of character structure. Thus, to assess such a patient always find out which defenses she uses.

From an ISTDP point of view, we would explore her problems and feelings to discover whether we need to restructure her pathway of anxiety discharge and to assess which system of resistance she uses: isolation of affect, repression, or projection. If she uses repression or projection as her primary form of resistance, we need to restructure her defenses until she is able to use isolation of affect consistently.

The fact that this patient goes to tears easily and has physical problems suggests that repression is her primary form of resistance. When she goes to tears, address her use of repression.

Pt: teariness

Th: Notice how these tears come in right now?

Pt: Yes.

Th: I wonder what feelings might be coming up here toward me that could be underneath the tears. What do you notice feeling here toward me, if we look under the tears?

This intervention blocks her repression and provides an outward pathway for her anger so she does not have to become depressed instead. This intervention, when done systematically, will also help reduce her physical symptoms.

The “performance quality” of her expressions suggests a transference resistance. When she “performs”, she acts out a role with you rather than engage in authentic contact. That is a barrier to forming a healthy therapeutic alliance.

Pt: [Performs in some way with the therapist.]

Th: I notice you act a kind of role here with me. [Imitate her gesture] Do you notice that?

Pt: It’s just how I am. I’m expressive. [Identification with the resistance]

Th: It’s not how you are. It’s how you present yourself. You present a kind of image here for me to relate to.

Pt: What if that is me? [Identification with the resistance]

Th: The problem is: it doesn’t feel real. It feels fake. I’m not saying you are fake. You are real. But you put up this image that feels fake. And that prevents us from having real contact between us. I would keep getting to know this image, but I’d never get to know who you really are on the other side. That’s why I’m wondering what feelings are coming up here toward me that lead you to put up this barrier of fakeness between us? What feelings are coming up here toward me?

Always address the enacted transference resistance the patient erects as a barrier to genuine emotional closeness. After all, this is the barrier she uses with everyone. And it keeps her chronically lonely in relationships.

When she gestures in sensual ways, acting seductively, don’t remain silent. This is also a transference resistance. Although it makes us therapists anxious to comment on these behaviors, the patient needs realistic feedback from someone. And you have been nominated! This requires honesty and tact.

Pt: Strokes her body in a seductive manner. [defense of acting out]

Th: Do you notice how you are rubbing your body?

Pt: I like my body. [identification with the defense]

Th: Do you notice though how you stroke your body here in front of me?

Pt: Do you have a problem with that doctor? [projection]

Th: Now it is as if you are in relation to someone who has a problem when you rub your body.

Pt: Smiles and says, Yes. Do you? [projection]

Th: Now it is as if you are in relation to someone who has a problem when you rub your body. And since you continue to rub your body, you apparently want that person to continue to have a problem.

Pt: Yes!

Th: So let’s suppose you were to continue to rub your body and that person kept having more and more of a problem. How would that person be able to do therapy with you?

Pt: He couldn’t.

Th: Exactly. So we have to ask why you would want to destroy your therapy in this way? You could seduce a therapist, if you find the right one. But then you would have only converted him into a sexual partner. And then he’d be useless to you as a therapist.

Pt: That’s what happened with Dr. X. He couldn’t keep his hands off me.

Th: So then this is a barrier you put up between us. If you could corrupt me so that I treat you as a sexual object, then you could prove to yourself that I would be worthless as a therapist.

Pt: Well, isn’t that what all men want?

Th: So what is the feeling here toward this man that makes you put up this wall of seductiveness? What is the feeling here toward me?

This patient engages in a kind of enactment which the therapist must block. Then you must explore the underlying feelings which the enactments are designed to keep out of awareness. When you feel judgmental of the patient, notice that urge. Rather than give in to it, notice that you are holding the patient’s disavowed conscience which she is likely projecting onto you.

Take home point: when exploring feelings stalls, most likely the patient is putting up a barrier with you: the transference resistance. Start describing the ways she distances from you, and then ask about the feelings toward you which her enactments are warding off.