Will my patient die as a result of our work?

“I have been going slow with a patient who became seriously ill with an infection. Then I learned about multiple strokes in the past and bouts of irregular heart rhythm. The patient is getting a lot from the work and is quite committed but has suggested coming every other week to have more time to integrate for health reasons. We did some deep work on fears and resistance to dependency. The patient shared a traumatic memory of a woman giving birth during which her care was grossly inadequate. We decided to go slow and monitor the physical responses carefully. I’m quite concerned about possibly precipitating a stroke due to the intensity of the work. What do you think?”

Without seeing the patient or knowing the doctor reports, we cannot know realistically how severe the illness is. Is the level of anxiety too high for this patient? The person who wrote this is very skilled, so I can be sure that the patient’s anxiety is being monitored and it’s not too high. So how might we look at this?

As the patient explores deeper feelings, unconscious fears can rise to the surface. For instance, a memory of a pregnancy that nearly ended in death. The therapist, listening and feeling with the patient, starts to feel similarly. This is a concordant countertransference: the therapist feels what the patient feels. When we can sit with this feeling the patient has and experience the fear, we can develop a deeper, feeling understanding of the patient.

“You mention wanting to reduce the number of the sessions to integrate for health reasons. In mentioning this near death experience, I wonder if you are afraid if you will die if you allow yourself to be born here? Clearly, if you allow yourself to be born, your false self will die. And I suspect your false self is afraid, knowing when you are born, it will die.”

Does this mean I don’t think there are genuine health issues? That’s not something I can know. I would certainly encourage any patient to seek a medical evaluation when there is a health concern. However, insofar as he is in therapy, we also should offer whatever understanding we have of the possible psychological meanings of his plight. There is always reality to be explored and known, and the unconscious fantasy meanings attributed to reality, based on our inner world. Both are important in the work. It’s rarely either/or.

4 thoughts on “Will my patient die as a result of our work?

  1. Ellie

    I’ve really enjoyed reading your blogs thus far, and have really learned a lot. Previously, you mention that anxiety is discharged into the SNS and PNS when it gets really high. If a patient predisposed to arrhythmias has undue either vagal tone or vagal withdrawal from the pacing system of the heart, that could absolutely cause an arrhythmia, which may or may not result in a subsequent stroke. If psychotherapy is really as physiologically active as ISTDP supposes, then the decision to pursue therapy needs to be made with a similar risk/benefit decision that any other medical procedure merits. How do you explore this issue with your patients? Do you refer them out to a physician to be medically cleared, like one might get medical clearance prior to engaging in an exercise program? Do you discuss it yourself with your patients? If so, how do you suggest non physician practitioners adequately learn the risk/benefit profile of engaging a physiologically active treatment with a diverse set of underlying physical pathophysiology?

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    1. istdpadmin

      The issue is not so much whether to let such a patient be in an emotion focused therapy, but whether the practitioner (regardless of his or perspective) is able to assess anxiety symptoms to ensure that the patient’s level of anxiety and activation is at a safe level. In my book, Co-Creating Change, I go into great depth into this issue, showing how to assess the physical signs of anxiety, how to address them, and what to do when traditional anxiety regulation methods don’t work. Without this kind of information, therapists from many perspectives often work with patients at levels of anxiety that are too high, resulting in the kinds of risk that you outline above.

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    2. istdpadmin

      I have not seen any evidence that exploring feelings leads patients to suffer attacks of arrhythmias. In fact, the reason we explore anxiety in the initial session is to conduct an assessment of the patient’s ability to identify and regulate his anxiety, as a precondition for any exploration of feelings. If the patient’s anxiety is too high in the session, the therapist begins to identify and regulate anxiety, so that once anxiety is back in the somatic nervous system, exploration of feelings can be done safely.

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    3. istdpadmin

      Before assessing the patient, we really have idea what difficulties the patient will have. Our job is to assess where the patient experiences their anxiety and physical symptoms, and the level of feeling where those symptoms occur. Then, together, we can design a treatment that is constantly building the patient’s capacity for self-regulation. That’s why supervision and training are so important. Otherwise, therapists in any modality can easily trigger excessive anxiety in patients. This is a problem we see across all therapy modalities.

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