Monthly Archives: August 2016

How to Work with Self-Deprecation

“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]

Pt: Me.

Th: And who had the thought you were a joke right here?

Pt: Me.

Th: So who is thinking about you being a joke? [Restructure projection]

Pt: Me?

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]

Pt: Yes.

Th: Would that be something you would like to overcome? [Mobilization to the task]

Pt: Yes.

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.





Shouldn’t there be contempt for the defenses?

Some have said so, but I disagree. Gottman’s studies of couples resulted in one of the most powerful findings in psychotherapy research: when one member of a couple expresses contempt for the spouse, 94% of those couples will divorce. Contempt is one of the most destructive emotions for relationships. If it has no place in marriage, how can it have a place in therapy? If it is destructive for a patient to have contempt for the therapist, how can it be healthy for the therapist to have contempt?

I know, some of you might say, “Hey, it’s not contempt for the patient, but for his defenses.” But do we really want to model contempt? Do we want the patient to join us in a relationship of mutual contempt for his historical adaptations, known as defenses?

When we show contempt for the defenses, we invite the patient to show contempt for his defenses as well. We treat his defenses as contemptible, as not-me. But who among us has not used defenses……today? If we treat his defenses as not-me, we treat him as alien. Yet, we are all too human. We are all defense users. Contempt for his defenses shows contempt for his humanity and our own.

Sadly, the patient may show contempt for his defenses in order to form a closer relationship with us. Just as his parents showed contempt for him and asked him to join them in a contemptuous symbiosis. But this would be a pathological relationship rather than a therapeutic alliance.

There is no need for us to show any contempt for the patient’s defenses. We can block them and direct the patient’s attention to his inner life. We can point out his defenses so he can see them. We can point out the price and function of his defenses. We can point out how defenses that saved his life in the past destroy his life today. We can trust his longing for the truth rather than our contempt.

What are defenses after all? The lies we tell ourselves, the façade or false self we erect around ourselves. And this façade? It is not real. It is a false image behind which we hide. Why show contempt for this façade? Why treat it as if it is real, when we need to reach out to the real person who is hidden underneath? When we show contempt for the façade, we treat it as if it has being, we give it life as if it is real. We end up fighting an idea or image rather than relate to the real person behind it.

ISTDP is not a therapy based on self-rejection but on self-acceptance, accepting all of the feelings, ideas, and impulses that flow through us so that we no longer identify with the defenses that hide the flowing of you. We help the patient no longer show contempt for himself through using defenses or for using them. None of his inner life is excluded. Instead of helping him treat aspects of his inner life as not-me, we help him embrace everything as all-me. We feel all feelings. We use all defenses. We have all impulses. As the poet Terentius said, “Nothing human is alien to me.”

Patients come to us showing contempt for their inner life through using defenses. They show contempt for their inner potential, settling for lives crippled by self-hatred and self-doubt. They project, imagining that we will show contempt for them. By underestimating themselves, they invite us to do the same, showing contempt for them. They are already burdened by learned self-contempt. They do not need more from us.

Should there be contempt for the defenses? No. There cannot be room for contempt in any loving relationship. Why get distracted relating to the patient’s resistance, when our task is to reach out to the patient trapped underneath? Why treat the resistance as real when it is merely the imaginary that hides the real? Why form a relationship of contempt when that opposes the relationship we are trying to form?

In showing contempt for the patient’s defenses, we show contempt for our own defenses, our inner life. In judging the patient’s defenses as not-me, we alienate ourselves from our humanity. In that sense, we ask patients to live up to an ideal none of us can live up to: having no defenses.

Then therapy becomes a way to narcissistically exploit the patient. By judging patients for failing to live up to impossible ideals, we place ourselves on a pedestal as if we have achieved an impossible ideal. We ask patients to hold the flawed humanity we cannot tolerate within ourselves. Then we can judge it or “analyze” it “over there.”

By the way, there is no form of therapy that has a monopoly over this danger. Any kind of therapy can be misused to exploit the patient and artificially elevate the therapist. But when we “elevate” ourselves this way, we lower ourselves to a grandiose position. We betray our human potential by living a lie. And we ask the patient to do the same. No, I don’t think there should be contempt for the defenses. It’s a distraction. Reach through the resistance to the person underneath. Love for the person, not contempt for the defenses, is the pathway to healing.