“Parts” of the Patient

“Would you write a post that clarifies how ‘sometimes therapists mistakenly refer to defensive behaviors as parts of the self’” (p.287 in Co-Creating Change)?

Thanks to Kerry for this question!

First of all, behaviors are things we do, not who we are. Actions are not “part” of me but what I do. I will brush my teeth tonight, but that action is not a part of me. In philosophy this is known as conflating the person or subject with its hypostases. If we don’t make this distinction between the person and the actions he makes, every decision becomes another self or “part” leading to infinite fragmentation that is not real but merely the artificial result of a form of conceptualization.

However, in ISTDP we sometimes use “part” language to help patients observe and intellectualize about their inner conflict so they can begin to bear it internally. Take for instance a fragile patient who projects that it is your will to do therapy. Unable to tolerate his internal conflict (he both wants do therapy and avoid it) he projects onto you his wish for therapy.

Pt: You think I should do this.

Th: Who came here?

Pt: I did. [looks anxious]

Th: How are you feeling now?

Pt: A little dizzy. [cognitive/perceptual disruption]

Th: Notice how you got a little dizzy and anxious as soon as we noticed that it was your decision to come here? [Point out causality]

Pt: Yeah.

Th: So we see that although your feet brought you here, another part of you gets anxious about that. [Pointing out his internal conflict]

Pt: I’m not sure I want to come to therapy.

Th: Although you’re not sure you want to come, you find that you are here anyway. It’s as if you have two parts of you at war with each other: coming and wanting to come to therapy. [Pointing out conflict]

Pt: [sigh] Yes. This makes me uncomfortable.

Here we use “parts” language to help a patient see and bear his internal conflict without using projection to get rid of it.

With severely depressed patients we do something similar.

Pt: I’m such an idiot.

Th: Could that be a critical mechanism in your mind?

Pt: I guess so.

Th: Could that critical part of your mind be making you depressed?

Pt: Definitely.

Th: So could we take a look at the feeling underneath here toward me that could be under that critical mechanism?

Here “parts” language helps the patient differentiate himself from the defense with which he was identified. Then we help him explore the feeling toward the therapist underneath that defense. Patients who engage in self-attack can benefit a lot from this kind of intervention. Let’s look at a common therapist error.

Pt: I’m such an idiot.

Th: Do you notice how you criticize yourself?

Pt: [cries] I know. I just can’t seem to do therapy right.

The therapist accurately points out the patient’s self-attack. However, this triggers more self-attack. Thus, differentiating the patient from her defense through using “part” language will help her see the defense, dis-identify from it, and intellectualize rather than engage in repression.

Once fragile and depressed patients are able to intellectualize about their inner life and defenses, we no longer use “parts” language. Why?

Th: Could this be a critical mechanism in your mind again?

Pt: Oh gosh doc, you are so right! I mean that critical mechanism has really been doing a number to me this week.

This patient uses “parts” language to intellectualize and deny his agency. He refers to “parts” of himself to deny that defenses are choices he makes.

Pt: [sigh] But I can’t help it. This mechanism keeps hurting me.

Th: But now that you see it, it’s not just a mechanism. You hurt yourself. I wonder what the feeling is here toward me?

Block the defense of denial of agency and return to feelings toward the therapist because the patient’s use of denial of agency is a resistance to genuine engagement.

We use “parts” language to build capacity with depressed and fragile patients but not with highly resistant patients. Let’s examine another reason to be careful about “parts” language.

Some therapists refer to “healthy” and “unhealthy parts” of the patient. This splitting by the therapist encourages the patient to split off and judge aspects of himself in order get the approval of the “superego therapist.” But our task as therapists and patients is not to judge the tragic forms of adaptation we call defenses. Instead, our task is to recognize that every defense is a compromise  between the expression of the true self and taboo against doing so. Rather than refer to “bad parts of the self”, help the patient see and embrace all of his humanity.

 

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