“A client thinks of himself as a “joke”, so he interprets other people’s actions poorly and then gets mad at them. For instance, a relative who hasn’t called him for a while called him up and asked him for work. He got mad, thinking his cousin thinks he’s a joke. He does this so much, almost every session is like this. This is linked to his parents, of course, who neglected and used him. But I am not sure what to do, because in your section on defensive affect, you have mentioned that we don’t explore defensive rage (which is what I think this is). So what do I do?” Thank you for sharing this question!
First, let’s look at the triangle of conflict.
Stimulus: a relative asks for a job
Feeling: we don’t know, but presumably this triggered mixed feelings
Anxiety: we don’t know where it is discharged in the patient’s body yet
Defense: He thinks of himself as a joke (self-deprecation)
Next defense: he projects that others think of him as a joke. (projection of the superego or externalization: he accuses others of doing what he does to himself)
When the patient projects that others regard him as a joke he will get angry with them. But this is a defensive affect: anger that results from a projection. We don’t explore anger that results from an imaginary stimulus.
- help the patient see how he projects onto others;
- help him see how he engages in self-deprecation;
- help him see the feeling he wards off through self-deprecation. Let’s take a look at an example of how to do that.
Pt: He thinks I am a joke.
Th: What’s the evidence for that?
Pt: Well, I don’t know for sure but I think so.
Th: Who had the thought you are a joke? [Restructure projection]
Th: And who had the thought you were a joke right here?
Th: So who is thinking about you being a joke? [Restructure projection]
Th: Yes. You are thinking about you being a joke. That we know. Whether your cousin does, we can’t be sure of. But we can be certain now that you think about you being a joke. [Restructuring the projection] Do you see what I mean?
Pt: I hadn’t seen that. But what if he is thinking that?
Th: Well, if he does, he would be agreeing with you because you call yourself a joke. So can we take a look at that? Do you think calling yourself a joke might be hurting you? [Clarifying the price of the defense of self-deprecation]
Pt: Yes. Definitely.
Th: Could it be making you depressed? [Clarifying the price of the defense]
Th: Would that be something you would like to overcome? [Mobilization to the task]
Th: So I wonder what feelings are coming up here toward me that could be under that self-criticism? What feelings are coming up here toward me? [Help the patient face his feeling outward toward the therapist rather than turn it upon himself through self-deprecation.]
You may have wondered how we could be sure calling himself a joke is a defense. Any behavior that is maladaptive is a defense. Anytime you see a patient do something that hurts himself, that is a defense. Don’t worry about what the label of the defense is. Just notice what feelings the patient wards off through hurting himself. Once you have this triangle of conflict (feelings, anxiety, and the defense of self-harm), you will be able to maintain an effective focus that will lead to healing.
You also may have wondered why I shifted to a focus on feelings toward the therapist. When a patient hurts himself in front of you, he is turning feelings toward you back upon himself. If we don’t interrupt that defense, he will become more depressed. The fact that he turns anger upon himself doesn’t mean you did anything wrong. It’s just that forming a more intimate connection with you triggers feelings within himself based on his past suffering and longings. As those feelings rise, he has learned to hide them. But the way he hides his feelings is to turn them on himself. Recognizing his unconscious strategy, we just ask what feelings he has toward you. As you do so, his self-attack will lift, his depression will lessen, and eventually he will be able to tell you what he feels. Even if it takes twenty minutes before he can identify his feeling, you will have helped him become less depressed through this shift in focus.