Monthly Archives: December 2016

Anorexia and ISTDP

“I have a question about a young woman I am working with. She is suffering from a severe case of anorexia and is in inpatient treatment, due to bodily damage due to the anorexia. During the first consultation she said, “I wish I could just get rid of my emotions. They are just in the way.” We have been working with her emotion and her need for control, but if possible I would really like some aid on how to diagnose the dynamic behind anorexia as we would see it in ISTDP.”

There is an abundant literature on the dynamics of anorexia. But the problem is that in any diagnostic group, patients will have similarities, but also significant differences. That’s why we have to tailor the treatment to the specific person.

First, self-starvation and self-harm are primary defenses for this woman. Second, given the physical damage to her body, these defenses must be very syntonic. Third, she does not want to face and experience her feelings. She wants to get rid of them (and herself). That’s what we can glean from what you have shared so far. So how do we proceed?

You didn’t mention what the problem is for which she is seeking therapy. That would let us know what, if any, leverage you have for therapy. It may be that she denies having any problem that requires therapy. That would be typical.

Just as she starves herself of food, she may try to starve herself of therapy by claiming she has nothing she wants to work on (no hunger for therapy). Likewise, by offering no problem for you to work on she can starve you! Thus, she enacts the internal dynamic of anorexia in therapy. She can act like a cruel, depriving mother with herself and with you.

Often, the best place to start is right there: her claim to have no problem requiring therapy. This is her defense against depending on you. If she can claim she needs no food, no people, and no therapy, she can have omnipotent control over the anxieties of depending upon another human being.

Th: What would you like me to help you with?

Pt: I don’t need any help. I have to be here because the doctors say I have some health problems.

Th: And the psychological problems you would like me to help you with?

Pt: I don’t have any. I don’t need any help. I wish people would just leave me alone. [Unconscious therapeutic alliance: “Don’t leave me alone.”]

Th: I hear that you wish people would leave you alone, but I’m still wondering what the problem is you would like me to help you with? [Each time, the therapist talks to the unconscious therapeutic alliance in the patient to form the unconscious bond for health and then asks again for the problem.]

Pt: Didn’t you hear me! I told you. I don’t have a problem! [Unconscious therapeutic alliance: rise of feeling and negation.]

Th: I hear that you don’t have a problem, but I’m still wondering what the problem is you would like me to help you with.

Pt: [sigh] Look. I told you. I don’t have a problem. I’m here just because my parents think I have a problem with anorexia. Ok? [Unconscious therapeutic alliance: she acknowledges she has a problem with anorexia through the projection onto her parents. With more severely disturbed patients, their underlying longing for help often emerges initially through projections before they acknowledge these wishes as their own.]

Th: So your parents think you have a problem with anorexia. And the problem you would like me to help you with?

Pt: I told you. I don’t have a problem. I just want to get rid of my emotions. [Unconscious therapeutic alliance: she has let us know she has a problem with emotions.]

Th: You want to get rid of your emotions. And how are your emotions a problem for you?

Pt: [Sigh] I told you I don’t have a problem. [Unconscious therapeutic alliance: “I do have a problem” can enter the room when preceded by a “not.”

Th: Right. You say you don’t have a problem and you also say you want to get rid of your emotions. So how are your emotions a problem for you?

Pt: They’re just useless. [Defense: self-dismissal]

Th: You say your emotions are useless. How are they a problem for you?

Pt: [Sigh] Like right now, this is useless. Why are you asking these questions?

Th: Just to find out what the problem is you would like me to help you with. I notice you are having a reaction as I ask you about the problem you would like me to help you with. What feelings are coming up here toward me?

Pt: [Sigh] I don’t have any feelings! [Unconscious therapeutic alliance: the patient uses negation and her voice rises, belying her claim to feel nothing.

Th: And the feeling here toward me?

Pt: Angry.

Th: How do you experience this anger here toward me?

When a patient denies having any problem and has feelings rising toward you, keep asking about her problem so her feelings can come into consciousness. Then she can express and feel her anger rather than act it out through an oppositional stance in therapy. As you continue to explore feelings, you will find out what defenses she uses that create her problems and how she resists contact with you that creates her impoverished relationships. The process of exploring feelings and identifying defenses and transferences will help you develop a clear picture of her dynamics.

If the patient suffers from cognitive/perceptual disruption, work on regulating anxiety, and keep exploring what the problem is, meanwhile restructuring her pathway of anxiety discharge.

If she projects her will upon you and becomes defiant, then deactivate her projection to undo the defiance and then return to your focus on the problem.

Remember: don’t shift from this focus on the problem until she declares one. Anorexic patients usually resist depending upon you at this first step. Our most common mistake is exploring without having a declared problem, declared will, and agreement on the task. Take your time and focus on her declaring a problem to work on and her defenses against doing so. That phase alone should help develop a clear psychodiagnosis of her dynamics.


On Being Present

Listening to a case recently, I heard the therapist ask, “Are you willing to be present here with me?” What if this is presence? “Being present” often implies that we should be different from how we are in this moment. That’s being “absent” in the pursuit of “presence.” “I need to get a life.” What if you are life? What if how you are now is the perfect expression of your life as it is unfolding in this moment? What if you don’t need to get a life, but are living it right now? What if this is your life right now?

Yeah, your attention wandered. What if that is the expression of who and how you are now. We regard presence as something we need to find in some other place or time else. But your presence isn’t anywhere else. You didn’t lose your presence. Presence is how you are now, here.

When we think of “being” present, we are wanting ourselves to be some other way, feel some other feeling, thinking some other thought. The reality of me right now is wrong, so I need to some other way and I’ll call it “being present.” Now is present. What’s wrong with this moment if you don’t ask yourself to be in some other moment?

Presence isn’t something you put on or turn on. It is how you are in this moment. All these states and feelings go through: inattention, scattered, angry, attentive, happy, and sad. “I don’t want to feel this way.” Yet that is how you are present: feeling this way and not wanting to. The weather systems keep moving through the sky. Deep down, you are like the sky through which everything passes. The sky doesn’t have to do something to be there. It’s just there. Present. So are you.