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.


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