Monthly Archives: April 2016

Mirroring Defenses

“I would like to hear you speak more about this intervention of mirroring defenses. I have found myself spontaneously doing this is in an almost exaggerated way to try to make defenses less syntonic with decent results. When do we mirror defenses and when do we invite feelings and invite the patient to let go of his defenses?” Thanks to one of our community members for this question!

Since defenses occur outside of the patient’s awareness, first we help the patient see the defenses that create his presenting problems and symptoms. We do this in three steps: 1) point out and identify the defense; 2) clarify the price and function of the defense; and 3) challenge the defense, i.e., encourage the patient to let go of the defense and face his feelings. This is often enough to help patients let go of their defenses, face their feelings, and have a good therapy result.

For some patients, however, this is not enough. They are identified with the defense. They claim the defense is good and helpful. They say they intend to continue using the defense, knowing full well that the defense is causing their problems. How do we understand this?

At this point, the patient is no longer using a defense to ward off a feeling. The patient is enacting a past relationship to avoid feelings rising toward the therapist that are related to that past relationship. For instance, a patient grew up with a father who sexually abused her. Her mother knew this but did not stop it. In fact, the mother told her daughter to put on a smile when she left the house each morning to go to school.

In therapy, a surprising enactment occurred. The patient reported a self-destructive relationship she had. She knew it was destructive and saw clearly how she set herself up. The therapist pointed this out repeatedly but to no effect. Meanwhile, the therapist felt helpless and frustrated.

The patient was acting out the role of the mother who could have stopped a molesting husband but claimed to be helpless to do so. The therapist was in the daughter’s role, helpless and frustrated. This enactment of a past relationship is known as the transference resistance.

In traditional psychoanalysis, the analyst interprets this enactment so the patient can remember rather than repeat the past relationship. Sometimes, however, interpretation does not help. The patient simply learns to intellectualize about her self-destructive activities rather than change them.

In ISTDP, modern psychoanalysis, and other experiential approaches, the therapist offers a new experience, not an interpretation. The therapist does this with the transference resistance in four ways: blocking the projection of the patient’s healthy wishes, deactivating the patient’s identification with her mother, deactivating the regressive wish, and deactivating the omnipotent transference. That’s a mouthful. Let me explain.

When the patient is destructive, she encourages the therapist to speak up for her health: projection of the patient’s healthy wishes.

When the patient says she is helpless to do anything else she is identified with her mother: identification with the resistance.

When she comes to therapy, consciously acting out destructively, she expects the therapy to help when she is sabotaging it: the regressive wish (I want to be healed without having to do anything.).

When she acts destructively against her goals and therapy, she asks the therapist to take all the responsibility for her recovery: the omnipotent transference.

These are all elements of the patient’s suffering. When the patient’s mother enabled the father’s cruelty and abuse, the patient was left with the sole responsibility for speaking the truth.

When the patient’s mother sabotaged the relationship and asked the patient to smile, this was her regressive wish: to have a perfectly happy daughter while she created a perfectly horrible family.

And when the mother acted so destructively, she asked the daughter to take all the responsibility for stopping the abuse. This was an impossible situation for the patient, and it would be one for the therapist too.

The patient, through enactment, is simply telling the story of her suffering which she has not been able to put into words. Although the enactment, in one sense, is a resistance to putting the past into words, it is also an unconscious act to facilitate the healing the patient needs. So we enter into the enactment, saying to the patient what the daughter was never able to say to the mother.

When the patient enacts her identification with her mother, she expects the therapist to speak up for her health. If the therapist does so, the conflict is between the patient and therapist rather than between the patient and her resistance. When the patient uses a defense (now express my healthy wishes), the therapist mirrors the defense. This blocks the projection and the patient experiences internal conflict within herself rather than between her and the therapist.

Pt: There’s nothing I can do. I can’t help it. [Identification with the mother]

Th: I’m sorry to hear that. [Block projection of responsibility]

Pt: What do you mean?

Th: If you cannot leave your husband who hits you, we have to accept that. [Block projection of responsibility]

Pt: [rise of anxiety] Isn’t there something you can do? [Projection of responsibility]

Th: No. I can’t leave him for you. Only you can do that. [Block projection of responsibility, deactivate omnipotent transference]

Pt: I’m sorry I just can’t do anything about it.

Th: That’s a shame.

Pt: What do you mean?

Th: Then we won’t be able to achieve your goal. [Blocking the regressive wish: I want to take a passive stance and have a great result anyway.]

We mirror the patient’s defenses only when the patient is identified with them, i.e., when we have a character or transference resistance. At other times in therapy, mirroring a defense will cause a misalliance because you would be treating a patient as more resistant than she is. Often, therapists are angry with a resistant patient. So when they mirror the defenses, they do so sarcastically or in an exaggerated manner. This will cause a misalliance. Never try to be sarcastic with a patient. When we mirror defenses, we should do so carefully, tuning in to the exact kind of history the patient is revealing through her enactment.

Take home point: mirror defenses only when the patient is identified with them while enacting a character resistance or the transference resistance. Also, only mirror the level of resistance the patient demonstrates. Otherwise, you will create a misalliance. This requires us to identify with the patient more completely so that by mirroring her resistance, we join her in a way that she begins to see herself, resistance and all.

CBT and ISTDP: how are they related?

“I want to thank you for making ISTDP available to the general public and clinicians across the globe. I wanted to ask how you understand the relationship between ISTDP and CBT. On the surface, CBT is quite compatible with ego psychology, particularly around adaptive functioning. As I understand it, ISTDP considers maladaptive cognitions as defenses. That seems fine to me. However, cognitive theory, a la Beck is all about schemas, implicit cognitions, core beliefs that are triggered via environmental stimuli, which then present as intermediate assumptions, attitudes and automatic thoughts.

So my question is: how are core or implicit core beliefs about self, the world, others or the future, defenses? Which comes first: schemas then affect, or the other way round? Clearly, working with beliefs, or meaning-making, is relevant to our attempts to have meaningful lives. What place do beliefs have in ISTDP?” Thanks to one of our Aussies for sharing this question.

Although CBT and ISTDP differ in terms of their understanding of what causes psychopathology, they share much in common in terms of technique. Allan Kalpin wrote a great article on the ways we can incorporate cognitive therapy techniques into ISTDP.

Causality: in ISTDP we understand that forming a relationship triggers unconscious feelings which evoke anxiety based on past relationships. To ward off those feelings and anxiety, the patient uses defenses which were effective in past relationships. These defenses are understood, according to ego psychology, as healthy forms of adaptation to the environment. The tragedy is that what saved the patient’s life in the past often ruins his life today. Some patients’ defenses come together to form a pathological relationship known as the transference resistance (or schema in CBT). Here, the patient has feelings with you that trigger anxiety. Then the patient forms the kind of relationship he had to live with as a child. It is his unconscious form of relational adaptation to his early environment. Within this early form of relationship, he has many thoughts and perceptions that are congruent with that relationship. We deal with his thoughts, feelings, and relational behaviors as a whole, as transference, and help him face the feelings which this entire complex wards off.

In CBT anxiety is believed to be triggered by conscious or implicit cognitions which are triggered by the environment. Thus, earlier forms of CBT help patients see those thoughts and their irrationality. Later forms of CBT address the transference, the patient’s unconscious mode of relating to you. In CBT, transference is called a schema. Jeffrey Young and others help patients recognize unconscious patterns of relatedness and the related thought patterns. As in transference analysis, they help patients reflect upon patterns of relating that cause problems in their lives. They have great techniques for helping patients see the schema (transference) and the cost/benefits of the schema which are very useful in ISTDP as well. ISTDP differs in that we view the transference (schema) as a defense against unconscious feelings toward the therapist. So in ISTDP, after the schema work, we go one more step and help the patient face and experience the feelings which the schema (transference) wards off.

ISTDP causality: relationships trigger unconscious feelings and anxiety and defenses.

CBT causality: the environment triggers implicit cognitions, beliefs, and schemas which trigger feelings and anxiety.

Neuroscience has buttressed the idea of causality that is proposed by psychoanalysis and ISTDP: non-conscious perception of threat (Damasio, Panksepp) triggers emotions (Damasio) which evokes anxiety (LeDoux) and defenses (Freud). This is why Barlow said that CBT therapists would need to shift their idea of causality to incorporate the findings of neuroscience. And it is why third wave CBT is incorporating emotion, implicit cognition, and schemas much more into their model. It’s important for non-CBT people to realize that CBT is a very different model now from its first iteration.

Even though the theories of causality appear to be different, there is a very interesting overlap. Helping patients see how maladaptive thoughts can trigger anxiety can be an effective intervention. Why?

We have seen that unconscious feelings trigger unconscious anxiety and unconscious defenses which cause the presenting problems and symptoms. However, some defenses, such as projection and maladaptive cognitions, can perpetuate anxiety! A patient is sad over the death of her uncle. The sadness makes her anxious. She tries to distract herself from her sadness by rumination. But the rumination triggers more anxiety. The cognitive therapist would correctly address the rumination, which will bring the patient’s anxiety down. The ISTDP therapist would do that as well. Then the ISTDP therapist would focus on the underlying grief, knowing that if the patient can face her grief, her anxiety will drop further, and her defense will no longer be necessary.

From this point of view, ISTDP sees that the patient feels a feeling, becomes anxious about sharing it, and uses a defense such as maladaptive cognitions. CBT sees that the environment triggers the maladaptive cognitions.

ISTDP: feelings trigger anxiety which evokes defenses which can perpetuate anxiety.

CBT: maladaptive cognitions (defenses) perpetuate anxiety.

So from my point of view, cognitive therapy causality is absolutely correct, at the tail end of the chain of causality. CBT work on maladaptive cognitions (defenses) is an essential step. ISTDP adds one more: facing the underlying feeling that the defenses warded off.

Let’s look at some other similarities between ISTDP and CBT. In ISTDP we use cognitive techniques for defense identification and clarification, and for restructuring projection and other regressive defenses. We promote cognizing with fragile patients who do not have sufficient access to isolation of affect.

We not only share certain techniques in common, but certain intervention strategies.

Let’s translate ISTDP into CBT terms:

ISTDP: exposure therapy with response prevention (exploring feelings while blocking defenses)

Defenses: implicit memory processes, maladaptive behaviors and cognitions

Projection: assumptions or automatic dysfunctional beliefs

Transference resistance: schema

Pressure to feeling: exploring dysfunctional beliefs, schema, and behaviors, exposure to feeling

Clarification of the price of the defense: exploring the relationship between cognitions and behaviors, the cost/benefit analysis

Challenge of defenses: asking the patient to shift thoughts or behaviors, response prevention

Recapitulating links between past and present and the triangle of conflict and the triangle of conflict: behavior analysis

Graded format: graded exposure

As you can see, the two models show much in common. CBT techniques can be very helpful and it’s useful for everyone to know them. At the same time, ISTDP can add to CBT the emphasis on unconscious feelings, new ways of handling resistance, new ways of assessing and working with anxiety, new ways of listening for unconscious material, and new ways of working with the unconscious. Now for your next question!

How could core beliefs be defenses? Let’s suppose a woman is angry with her abusive husband. In therapy she mentions her anger, becomes anxious, and then says, “I’m just worthless. I deserved that slap.” Here her thought/belief has a defensive function. She turns the anger toward her husband back upon herself. It is not just a belief. This thought has a function: to turn anger upon the self. Where cognitive therapy looks at the content of thoughts (their irrationality), ISTDP looks at their function (to ward off feeling). Function: does this thought amplify her ability to face and feel her anger, or does this thought inhibit her ability to do so?

Obviously, beliefs do not always serve defensive functions. Suppose the patient is angry with her husband and then says her religion condemns anger. Now she enlists a thought about religion to inhibit the experience of her anger. Another person might speak about her religion as it relates to the ontology of personhood. This could be a healthy intellectual discussion about the very meaning of what it is to be human. The issue is not whether a belief, per se, is a defense. It is whether a belief is misused in the service of defense. And any thought or belief can be misused for defensive purposes as we read in the papers every dayJ

Until we succeed with 100% of our patients 100% of the time, we have more to learn. What is the relationship between ISTDP and CBT or ISTDP and anything else? Hopefully the relationship of openness and learning from one another. All of us work with the same patients and issues. In spite of grandiose claims, no treatment model has yet been conclusively shown to be markedly more effective than other treatment models across the spectrum of patients. So we’re in no position to idealize our pet theory or devalue others. Those are the games of children, not the scientific work of adults. So let’s keep learning from others. Let’s keep looking at the evidence in our videotapes. Let’s keep relating to other theories and thinkers.