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.







6 responses to “When anxiety regulation does not work”

  1. Kevin Avatar

    Hi Jon. How would you work with dreams in the ISTDP model. I mean if a patient introduced a dream, would you ask them how they felt about parts of the dream, could the dream be viewed as a defense depending on when the patient brought up the dream during a session, or if the dream elicited anxiety which was discharged in the striated muscles, would you then ask about what the patient felt towards such a dream? Thanks

    1. istdpadmin Avatar

      In general, I would invite the patient to describe his thoughts, feelings, and reactions to the dream. Then I let the patient’s response of feeling, anxiety, and defense guide how the exploration should go.

    2. istdpadmin Avatar

      Asking the patient about the parts of the dream can be very useful, of course. However, it’s also possible that a dream has a defensive function, to avoid what just came up in the session. That’s why we have to pay attention to the process: why did that dream come up just now?

  2. Sepide Avatar

    Hi Jon,
    When the patient reports feeling scared, if she says, “but I know you won’t hurt me,” does it necessarily mean that there is no projection engaged? If not, what kind of defense is that?

    1. istdpadmin Avatar

      It means that her projection is just a tactical defense, not a primitive defense. Her reality testing is fine. It’s typical with healthier patients.

  3. Jon Frederickson Avatar
    Jon Frederickson

    Of course, this is projection, but without the loss of reality testing. The patient consciously realizes you won’t hurt her. Thus, it can be dealt with rather easily: “If we look under the fear, what feelings are coming up here toward me?” All people project. It’s just that for some, there is no loss of reality testing and it functions as a tactic to keep the therapist at a distance. At the other end of the spectrum, patients project and lose reality testing temporarily. And patients at a psychotic level of character structure project and lose their reality testing permanently.

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