I’m stuck with my patient

“I’m stuck with my patient. She does not feel her anger in her body. Instead, she becomes anxious in the smooth muscles or cognitive/perceptual disruption

(dizzyness and ringing in her ears).

When I encourage to her to imagine what she would do with her anger, she can do it for only a few seconds. For some reason, she becomes angry with me instead. Or she gets a headache or has weakness in her whole body and numbness in her hands). Outside the session, when she is angry her body becomes paralyzed.

Sometimes she will clench her fists, but when I ask about her anger, she says her anger disappears. I ask how she experiences the anger in her body, and she keeps saying she does not feel anything in her body. As I keep asking, she gets angry with me and starts to distance and detach. We don’t seem to be progressing. Is it ok if she imagines her rage without feeling murderous anger in her body?” Thank you for sharing such great questions!

First of all, without seeing the video it’s impossible for us to precisely assess the patient. However, there are a few recommendations we can make. First of all, the patient is fragile: her anxiety goes into cognitive/perceptual disruption. At those times, she uses the resistance system of projection. In addition, when she experiences a rise in feeling she experiences conversion (becoming paralyzed, weakness in the body, numbness in her hands). That means that she is using the resistance system of repression.

This means that the therapist must use the graded format, building this patient’s capacity for affect tolerance slowly, restructuring her pathway of anxiety into the striated muscles, and restructuring her resistance system into isolation of affect. This takes time.

We should not rush into portrayals of her rage because of the risk of excessive anxiety or increased somatic symptoms. Instead, our focus should be on building capacity. This is where therapist focus and patience are essential.

When she experiences conversion, she has gone over the threshold of repression. That is, her level of feeling and anxiety is too high. Pause and recap the process to bring her anxiety down until the symptoms remit.

Th: Your arm is going numb? Thanks for letting me know. So as you experience this anger, you become anxious, and then your arm becomes numb. Do you notice that sequence too?

Invite the patient to cognize about this pattern. Once the symptom drops, explore feeling again, but in a different corner of the triangle of conflict. If you keep exploring in that example, her symptoms will worsen and the therapy will get stuck.

When her fists are clenched, this is a sign of important progress in her ability to tolerate the experience of anger. When you ask about her anger, you say she no longer experiences it. Most likely, she is using the resistance of repression. When you listen to what she says, you will learn which repressive mechanism she is using (self-attack, weepiness, character defense, conversion, getting tired, depression). Point out the mechanism and note how it makes her depressed. Then ask, “I wonder what feelings might be coming up here toward me that are underneath that self-critical thought? What feelings are coming up here toward me?”

This shift into feelings toward you is essential to restructure her pattern of self-attack. Now, a really important point: given her degree of repression she may not be able to identify what she feels toward you for some minutes. That is ok. That is expectable. As you keep asking about what she feels, notice signs of unconscious progress in restructuring: does she begin to tense up? Does she begin to sigh a little? Does she begin to intellectualize? In other words, do you see small changes in the pathway of anxiety discharge and system of resistance? If you see those changes, the patient is improving before your eyes EVEN THOUGH SHE CANNOT SAY WHAT SHE IS FEELING.

Going back to the clenched fists. Sometimes we ask for a dose of feeling that is higher than what the patient can tolerate. For instance, if she has symptoms when you ask “How do you experience that anger in your fists?”, try another intervention. For example, “Just notice your fists.” “This is a new level of feeling you are experiencing. What is it like to let yourself have this new sense of power?” “Would you like to hold onto this power inside you?” “What do you notice feeling as you let yourself hold onto your power?”

All of these seemingly cognitive interventions are graded ways to help the patient tolerate the rise of feeling while increasing it very slowly. That way you build her capacity gradually rather than make it rise too quickly so that she goes into repression instead.

You ask if it’s ok for her to picture her rage without experiencing it directly in her body. Short answer, yes. Long answer, it depends. My guess is that you are trying too hard to get a portrayal rather than build her capacity to tolerate the complex mixed feelings involved in a portrayal.






4 responses to “I’m stuck with my patient”

  1. Sepide Avatar

    Hi Jon
    In the last paragraph you said sometimes it is OK to portrait rage without mobilizing it whole in the body. what does it depend on?

  2. Jon Frederickson Avatar
    Jon Frederickson

    With fragile patients, visualizations of a portrayal may be helpful initially to desensitize the patient and to build affect tolerance.

    1. Sepide Avatar

      How can we make sure that it doesn’t lead to act out mostly outsdie the session?

      1. istdpadmin Avatar

        Make sure you are regulating anxiety and deactivating projections in session. Then you will know you are not promoting acting out. However, keep in mind that the patient may have stressors outside the session that may trigger acting out.

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