Monthly Archives: January 2017

When anxiety regulation does not work

“I have a new patient who dissociates throughout our sessions and gets more anxious when we turn her attention toward her body to try to regulate her anxiety.  This makes sense since she leaves her body for that very reason.  I’ve tried to help her understand what’s going on in the moments she goes away, but much of the time neither she nor I know what just happened that made her leave.  We did identify projections she had that I was judging her and might abandon her, which helped bring her anxiety down a little.  But most of the time, she and I are unaware of what’s going on. It’s hard for me to track since it all (Feeling-Anxiety-Defense) happens so fast.  Any suggestions about what to do here? I did read the section of your book on building ego capacity, which helps give me some direction, but any specific suggestions in this case? Thanks!”

Great question! I’m less worried about what triggers her anxiety than what perpetuates it once it gets going. The fact that she continues to dissociate suggests that she is projecting something onto you. Otherwise, she would not have to get away from you that way.

Once she projects upon you, identifying that projection and establishing reality testing are top priority. Only once we have stopped the feedback loop of anxiety-projection-anxiety-projection-etc., will the patient be calm enough to look back at whatever feeling triggered her anxiety and projection and dissociation.

Keep in mind that when I refer to the defense dissociation, I am referring to a defense that occurs while the patient is suffering from cognitive/perceptual disruption. If her anxiety is in the striated muscles and she is able to intellectualize, her so-called “dissociation” is just a form of detaching which would be handled differently.

When the patient dissociates, several options are available.

Jumpy legs.

Th: Notice how your legs are getting jumpy right now?

Pt: Yes.

Th: If we take a moment to notice your legs, what do the legs want to do?

Pt: They want to jump and run.

Th: Exactly. Although you realize you are sitting here with mild mannered therapist Jon Frederickson, your legs are having some other reaction. You want to sit here with me, but your legs are reacting to someone else, as if there is a need to jump up and run. Do you notice that too?

As you continue to differentiate the present from the past, the room from a past location, and you from a previous figure, the patient’s reality testing will improve, projective anxiety will drop, and dissociation will drop too.

Freeze reaction.

Th: You seem stiff head to toe. Does that sound right to you?

Pt: Yes.

Th: So although you know you are here with Jon Frederickson, your body is kind of frozen here as if someone else is in the room. Do you notice that too?

Pt: Yes. I’m just scared.

Th: Right. That seems like an important memory your body is having. Although you know it is 2014 here with Jon, your body hasn’t quite caught up and it is bringing up a fear memory. You know I’m Jon, but your body is remembering someone else. Does that make sense to you?

Pt: Yes. But how do I know you won’t hurt me?

Th: Well, you have already figured that out. That’s why you are here. But your body has not figured out what you have figured out. So we notice that it’s like your mind and your body are kind operating in stereo. Do you notice that too? It’s like your mind and your body are having two different reactions here.

Pt: [relaxes] Yes.

Remember, the patient freezes, not in front of you but in front of the projection she has placed on you. Once you identify the projection she can relate to you and the freeze reaction can come to an end.

Mind went away.

Pt: My mind just went away.

Th: Good you noticed. So we see that when you were talking about your father just now, some feeling rose, you became anxious, and then your mind went away. Do you see that pattern too?

Notice, I do not infer what feelings were underneath. That would only cause her to dissociate again. Instead, you remind her of the cause, but at a lower level of feeling than what she did so you don’t trigger the same defense. Let’s suppose she was talking about her father’s cruelty to her mother. You would say, “So you were describing the relationship your parents had and this triggered some feeling and anxiety, and then your mind went away. Do you see that too?” Having lowered the dose of feeling slightly, you make it easier for her to look back at causality without disrupting.

With fragile patients, it’s very important to adjust the dosage of your comments so you do not overwhelm their integrative capacities. Start with low dosages. As you increase the dosage of feeling language, you will learn where the patient starts to have trouble and then you can work at that level rather than go higher just yet.

 

Problem During an Unlocking of the Unconscious?

“I am working with a depressed patient who faced his rage toward an abusive brother in a portrayal and experienced his mixed feelings toward him. His anxiety dropped and he became calm and relieved. So I guess we did a good job.

However, there was one point I found very confusing. When I asked him to look in his dead brother’s eyes and pressed for guilt feelings, he suddenly thought of his mother’s eyes when she was dying. So I interpreted that his love for his mother is helping him to express his love for his dead brother. Maybe I should explore his rage toward his mother, even though he really loves her and misses her a lot now. What do you think? And many thanks for your interest and time.”

First of all, bravo on helping this patient face his feelings so deeply that you were able to get a breakthrough of the rage and an unlocking of complex mixed feelings. This is wonderful.

With the rise of complex mixed feelings toward the brother, the unconscious unlocked: the image of his mother appeared. Now we learn that his conscious feelings toward the brother are linked to unconscious mixed feelings toward the mother. This “transfer” or unlocking of an unconscious image is the beginning of the unlocking of the unconscious.

At this point, explore that unconscious image as quickly as possible.

Th: So it is your mother whom you wanted to kill. [Then outline everything that was done to the brother as what he wanted to do to the mother.] What feelings do you have as you look into her dead eyes looking up at you?

This will mobilize his unconscious mixed feelings toward the mother. You will help him face these feelings, especially guilt, as deeply as possible. As a result of these feelings, the patient may start recalling memories with his mother, and spontaneously offer insights as part of the unlocking. You encourage as much to come out as possible as the unconscious unlocks.

Rather than speculate about the links between the brother and mother, we encourage him to experience his unconscious mixed feelings toward the mother. This experiential unlocking of feelings allows images, memories, and insights to arise within him. Those derepressed elements will offer the understanding which you will summarize later during the phase of consolidation.

What you thought was a problem (the image of his mother) was a sign of success: the beginning of the unlocking of the unconscious!