Monthly Archives: November 2017

Premature challenge

“I’ve been hearing a lot of talk about “premature challenge” but I’m having a hard time wrapping my head around this apparent change to ISTDP. I think that part of the problem may stem from the fact that “challenge” means different things depending on who is using it. I was wondering if you might want to do a post on the appropriate timing of challenge.” Thanks to Jeremy for asking this important question!

When the patient presents a specific example of a problem, we invite him to share his feelings in that example so we can find out the triangle of conflict: what feelings, anxiety, and defenses create his presenting problems?

When we explore feelings, defenses arise. At first, we block the defenses by asking for feelings again. That is enough to brush aside tactical defenses, which are lightly held by the patient.

If those defenses remain, however, we identify them and then ask for feelings.

Th: That’s your thought, but what’s the feeling underneath that thought?

If the patient sees the defense as a result of your work but still uses it, clarify the defense.

Th: That’s your thought but your thought is not a feeling. That’s how you cover your feeling. (clarifying the function of the defense) If we look under the thought, what is the feeling toward him?

If the patient sees the function of the defense, clarify the price. “If you cover the feeling with thoughts, you’ll stay confused (price). So can we look under the thoughts and see what the feeling is toward him?”

Once the patient sees the defense and price and it continues, this is usually a sign that the resistance has moved from resistance against feeling to resistance to emotional closeness. The patient is not just distancing from his feelings; he is distancing from you!

Now instead of a defense here and there against feelings, his defenses work together to form a pathological relationship with you called the transference resistance.

Once the patient can see his defenses and their price, we can challenge his defenses.

Th: What can we do about this habit of covering your feelings with thoughts?

If you challenge the patient before he sees the defense, he will believe you are attacking him as a person instead of commenting on his defense. This leads to a misalliance. Or the patient may become confused, unsure what you are talking about. If the patient sees the defense but not the price or function, you are asking him to give up something that he believes is good and helpful. Without seeing the price of the defense, why should he give it up?

Once the defenses coalesce into the transference resistance, likewise, we do the same sequence.

  • identify the resistance and ask for feelings.

Th: Notice how you look away and avoid my eyes. That becomes a barrier between us. I wonder what feelings might be coming up here toward me that make you avoid?

  • Clarify the price of the resistance and ask for feelings

Th: If you keep avoiding me, we won’t get to find out who you really are and then you’ll remain a lonely man. I wonder what feelings are coming up here toward me that make you put up this wall?

Once the patient can see his resistant behavior and its price, THEN you can challenge it.

  • Again we see this wall of avoidance coming up here between us. But this will defeat your efforts here. What do you think we can do about this wall you are putting up here between us?

Just to be clear, we NEVER challenge the patient. We challenge the defense’s usefulness today. We challenge the defense’s punitive effects upon the patient. Then we ask the patient to let go of a defense that hurts him.

When the patient can see his resistance and how it hurts him, he can finally let go of it.

If he can’t see the defense or how it hurts him, there is no reason he should he let go of it. Always do your preliminary steps of identifying the defense/resistance, and clarifying its price and function. Once those two steps are accomplished, then challenge the defense.

Jeremy wondered if this is an “apparent change” in ISTDP. The answer is no. Davanloo was always very clear about the dangers of premature challenge and the preliminary steps of restructuring that are necessary. However, because our feelings get aroused when working with patient resistance, we therapists sometimes go to premature challenge to avoid the rising feelings within ourselves. This is where building affect tolerance within therapists is so important.

Build capacity before portrayals

“A patient while experiencing anger towards his father shared memories of abuse, became highly anxious, and was unable to proceed. Were these genuine memories or a defense?
The patient has been unfaithful in his marriage. His defenses include
identifying with the aggressor ,self attack, identifying with the object of one’s rage, intellectualization, rationalization, acting out, and dissociation. His pathway of anxiety discharge had been smooth muscles and cognitive perceptual disruption. Lately he feels some anxiety in the striated muscles.
In the last session during a portrayal, he became limp, lost eye contact, and bowed down. He said he saw his father and aunt together and a child, who turned its head with an exposed skull. He doubted whether the images were real and said he felt as though he was watching this session as a movie. Previously, when he went limp, I explored his feeling towards me. He felt angry and believed I was just like his aunt, violating his boundaries. When I tried to deactivate his projection, he remained anxious and avoided my gaze.
When I explore rage, he can say the word but he doesn’t experience it in his body. Why?” Thank you for this fascinating question!
Without seeing the video, of course, it is impossible to make an accurate assessment. But I can offer some questions. When you say he feels his anxiety in the striated muscles, is he sighing? Fidgeting or tension aren’t enough. We need to know if he is sighing in response to your interventions to know his anxiety is in the striated muscles. From the clinical material you describe here, it sounds like his anxiety is going into the smooth muscles and cognitive/perceptual disruption.
You mention his defenses, which are in all three systems of resistance. Isolation of affect: intellectualization and rationalization. Repression: self-attack, identification with the object of one’s rage. Projection: projection, dissociation. So the question here is at what level of feeling does his anxiety shift out of striated muscles (isolation of affect) into the smooth muscles (repression) and then cognitive/perceptual disruption (projection).
The portrayal you mention in the last session has him going limp (repression), meaning he has gone over the threshold of anxiety tolerance. Then he says the portrayal is like watching a movie (dissociation, the resistance system of projection). Here, you see that feeling and anxiety were too high, so he shifted from isolation of affect, to repression, and then to projection as his forms of resistance. If we don’t see the signs of anxiety or systems of resistance, we work with patients at levels of feeling that are too high, which will lead to disorganization and regression in the patient. That’s what happened here.
Previously, when you explored his anger toward you, he projected, losing his reality testing. This is a clear example of cognitive/perceptual disruption.
Are these memories that come up? Not necessarily. They could easily be fantasies. But that is the least of our worries. The problem is that this fragile patient needs you to build his capacity to bear feelings within himself before you attempt any portrayals or unlockings of the unconscious.
When he feels anger, he projects it onto you. He cannot bear the experience of anger within himself without relocating it onto others. So our first task is to restructure his pathway of anxiety discharge so it goes into the striated muscles and to restructure his system of resistance, so he can bear feelings internally without projecting them. Without this fundamental structural capacity, no unlockings of the unconscious are possible. Why? His unconscious is not in him to be unlocked. It is relocated everywhere else.
Before you go for portrayals, make sure your patient has the capacities necessary. Otherwise, we will overwhelm him with anxiety, he will regress to more primitive defenses, and he will suffer a regression and increased symptoms. So, if someone is fragile, restructure his anxiety. Then help him feel his feelings inside himself without relocating them onto you or others. Once he can do that, help him feelings toward you without engaging in self-attack.
Allan Abbass’ new book has a chapter on integrating the personality of the fragile patient. This basic work of restructuring projection is essential and must be done systematically before attempting any unlockings or portrayals.
How do we know if the patient’s anxiety is too high?: 1) it shifts out of striated muscles into the smooth muscles or cognitive/perceptual disruption (sighing stops); and 2) the defenses shift out of the resistance system of isolation of affect (intellectualization and rationalization) into repression (self-attack, weepiness, conversion, somatization, depression or projection (projection, dissociation, projective identification, hallucinations, delusions). In this clinical material, the patient was using the resistance systems of repression (thus, anxiety was no longer in the striated muscles) and projection (a sign that the patient is fragile).
If we do not recognize those shifts in anxiety or resistance system, we can easily work at levels of feeling and anxiety that are too high for the patient to integrate. This is where quality supervision can be invaluable so that you can learn to recognize those signals and work with the patient at an optimal level of feeling within his capacities.