“Hello Jon! I just finished course 2 of your skill-building audio exercises, which was a real breakthrough for me professionally. The principle of shifting focus to the patient’s feeling towards me when resistance comes up in the therapeutic relationship was not a principle that was clear to me in the literature of ISTDP!
I have four questions regarding anger towards the therapist:
At what point do you stop exploring anger toward the therapist? I’ve been working through this with patients who could declare anger towards me cognitively and somatically (Declaring “My arms tense up!” for instance, but not aware of sensations of the impulse in the torso) and then felt relief from anger and anxiety. Since their anger didn’t seem to be murderous rage, I didn’t feel it was necessary to keep pushing for awareness of somatic and impulse component.”
First of all, congratulations on doing those skill-building exercises. All the students who do them tell me their skills go up enormously. Now let’s go to your first question. Without seeing the video, it’s impossible for me to know whether the patient would have benefitted from a higher rise of feeling. We always answer this question by asking, “What was the response to intervention?” If the patient felt relief, anxiety dropped, and the patient’s symptoms dropped, then that rise of feeling was healing. If anxiety and symptoms increased, then we need to do more defense work and get a higher rise of feeling to access the unconscious feelings.
“Also, when the patient says “Stop asking me, I can’t give you an answer!” with clarity and determination I felt that was as adaptive as the anger would get and it would be the opposite of a corrective emotional experience to invalidate the patient and keep pushing, so I felt that was a good place to stop challenging. What do you say?”
Again, without seeing the video we can’t be entirely sure here. If the patient is tense and sighing while saying, “I can’t give you an answer,” he may be resisting you through the resistance of helplessness. In that case, you might shift to noting his wall of helplessness and ask about the feelings toward you that make him put up that wall. If tension and sighing stopped, it might have been a sign of a misalliance and then you would need to stop challenging his defense. Instead, you could point out, “You want me to help you overcome your difficulties, your depression, and your anxiety. At the same time we notice how this wall comes up between us, sabotaging your efforts. Obviously, you want to get to the bottom of your problems, so it’s important that we notice how this helpless stance defeats you at the very moment you want to succeed. Do you see what I mean?” Here you could clarify the price of his defenses, so he understands that you are on his side, but that his defenses are not. With this deeper understanding that the defenses are not him and that they are hurting him, he will understand why you challenge the defenses, and you will no longer risk having a misalliance.
“How is it that “irritation” is always a watered down version of the true impulse, anger? Could the patient not, in fact, be just irritated with me rather than angry?”
Obviously, since patients have a range of trauma in their backgrounds (from none to a lot), they will have a range of intense feelings that rise toward the therapist (from none to a lot). So a few patients may feel only a little irritation. But for the vast majority of patients, the word “irritation” is a cover word that covers up the patient’s anger. The patient has usually learned that if he reveals his anger, his relationships can be endangered. So he has learned to “water down” his feelings so that loved ones aren’t frightened of his feelings. That’s why we usually treat “irritated” as a defense, recognizing that on a few occasions it will not be.
“Is it always anger? Can a patient not also withdraw rather than showing sadness or warm feelings/”weakness”?”
Of course, we can use defenses to ward off any feeling. We can ward off grief. We can ward off the joy over winning a victory over a rival. We can ward off the shame over having harmed someone. We can ward off our guilt over having abandoned a loved one.
ISTDP is not just about anger. Our task is to help patients face the complex mixed feelings we all have toward our loved ones. It’s just that when those complex mixed feelings come up, the easy ones come up first. But the anxiety provoking ones are warded off. Thus, anger tends to be the one that is warded off first. Once the patient faces that rage, then the other complex feelings of love, guilt, and grief emerge. And we help the patient experience the full mixture of his inner life. That way he has an integrated sense of himself as a whole person and he has an integrated sense of the other person as a whole as well.