Monthly Archives: July 2016

Is it a medical or a psychological condition?

“Sometimes patients believe their physical condition explains psychological symptoms such as depression or anxiety. The diagnosis can, e.g., be hypothyroidism. The patient then believes this is why she has been depressed, sad, without energy and joie de vivre. The physical diagnosis becomes used as another defense, making psychological treatment very difficult. How I can intervene with this type of patient?” Thanks to John Page for this question!

It is well known that people suffering from psychosomatic conditions often believe their problems are purely medical and not psychological. And, to be fair, this is sometimes the case. So we cannot be doctrinaire about this but must take a scientific approach to the problem.

When someone comes for a psychological assessment for a psychosomatic condition we cannot assume that his physical problems are psychological in origin. Instead, we have to explore and find out. Find a specific example where he has psychological problems and then explore his feelings.

As we explore feelings, feelings and anxiety will rise. If the patient’s symptoms emerge or worsen with a rise of feelings and anxiety, the symptoms have a psychological cause. If his symptoms do not emerge or worsen while feelings and anxiety rise, then we refer him back to the physician for further workup and medical evaluation.

Therapists often get into trouble trying to convince the patient that his symptoms are psychological in origin. In ISTDP we don’t do that. After all, we can’t know that in advance! Our job is not to convince a patient of anything, but to jointly explore and learn IF there is a psychological cause for his symptoms.

Pt: I don’t think there is any psychological cause for my problems.

Th: You may very well be right. There is no way for me to know that at this point. Could we explore a situation where you have some emotional conflicts so we can rule that out?

Pt: I don’t want to hear again that this is all in my head!

Th: Good, because it’s not all in your head. You are suffering genuine physical pain. The doctors sent you here so we can rule out whether there is a psychological cause. If we look at a situation where you have emotional conflicts, we can rule out this possibility and ensure you get the further evaluation you need. If there is any psychological element, you and I can eliminate that factor and, if there are still remaining symptoms, we can refer you back so you get the further evaluation and treatment you need. Does that sound like a reasonable plan for us to take?

Pt: Do you think this is all psychological doctor?

Th: I can’t make that assumption. This is too serious a problem for us to operate on the basis of guesses. What we can do, if you like, is do an assessment here so we get accurate information about what is causing your physical problems. If there is a psychological factor, we can remove it. If there is no psychological component, we can make sure the doctors focus on finding the medical cause instead. Shall we go ahead and find out together?

Avoid arguments with the patient over what is a scientific question. Then you will avoid will battles and misalliances. Your job is not to convince or argue with the patient, but to engage in scientific exploration of his feelings, anxiety, defenses, and symptoms. Together you can examine the pattern of responses that arise and jointly come to a conclusion based on the evidence of the session rather than on the basis of guesses or assumptions. If the patient makes his assumption and you make yours, you both make the same mistake: “Don’t confuse me with the facts. I’ve got an assumption going here!”

Portrayal or Acting out?

“I explored a patient’s feeling toward me and this led her to resist closer contact. As I continued, her rage rose toward me. She pictured an impulse toward me then something surprising happened! She stood up from her chair, approached me and took an intimidating posture toward me, standing really close. I reached out my hand, signaling her to stop and asked her to sit down in her chair again.

We kept exploring her angry impulse but my intervention to have her sit down contributed to a significant cool down of her feeling and impulse. What would you have done? Where do you draw the line from portrayal to acting out in the session?” Thanks for this important question!

When we invite patients to explore their feelings as deeply as possible a moment occurs when the patient experiences her impulse. At this moment we invite her to experience her impulse physically in the body and then picture what would happen if that impulse came out in FANTASY: “If that impulse came out onto me, how do you picture that in your IMAGINATION, in THOUGHTS, WORDS, and IDEAS?”

We never encourage the patient to act out rage in reality, for that defense leads to destructive results. Acting out rage is always a defense against tolerating the internal experience of it. In therapy we help patients experience the full extent of their rage so: 1) they can channel their rage into healthy self-asserting; and 2) they can access the complex mixed unconscious feelings linked to the rage. As a result of facing the previously avoided unconscious feelings, their anxiety and defenses will drop. They will now be able to feel and deal rather than avoid and be symptomatic.

In this case, the patient suddenly stood up, a sign of having difficulty tolerating the rise of rage internally. The therapist correctly asked her to sit down and then invited her to experience her rage internally rather than act it out externally. Did he do anything wrong beforehand? We can’t know without the data. However, one mistake therapists often make is one of timing. As soon as the patient has the impulse, intervene: “If that impulse came out onto me, how do you picture that in your imagination, in thoughts, words, and ideas?” If you say it right away, the patient understands that she is not to act out her impulse, but to channel it into her imagination. This immediate support will help her avoid acting out.

Sometimes a patient has no history of acting out and we don’t see any evidence of acting out until this point in the therapy. Thus, this simple intervention of helping her tolerate her feelings while sitting down will be enough for her. Other patients show signs of impulsivity earlier in the session: rapid speech, interrupting the therapist, rapidly changing topics, fidgeting and bodily movements, loud speech, yelling, cursing, rapid projection, pounding movements with the arms, and stamping of the feet. These signals tell us the patient has a low capacity for feeling tolerance requiring the graded format. Explore feeling until each regressive defense occurs and then restructure repeatedly to build structure in the patient. As we block and restructure each regressive defense, the patient gains the capacity for feeling tolerance so that when we get to portrayal, he will be able to bear his feelings rather than act out.

Portrayal or acting out?

Acting out: the patient acts out an angry impulse physically in reality.

Portrayal: the patient imagines acting out an angry impulse in fantasy.

Acting out in reality versus imagining in fantasy.

Acting out must always be blocked. Otherwise, we reinforce the patient’s defense of acting out and increase his burden of guilt over any damage he causes.

Take home point: as soon as the patient experiences the impulse, immediately intervene: “If that impulse came out onto me, how do you picture that in your imagination, in thoughts, words, and ideas?” That provides her with the support she needs and will block any tendencies to acting out.