Monthly Archives: January 2018

Problems working with guilt

When patients experience their unconscious rage in therapy, they often do not experience their love and guilt. Why? Also, how do you work on anxiety when it goes too high during guilt work? What defenses do you look out for and how do you work with them? Why doesn’t guilt and love come through?

Thanks to Reza for these questions!

In all therapy relationships, mixed feelings rise toward the therapist, feelings based on the patient’s previous experience. Love arises because the patient wants to connect. Rage arises because previous connections hurt the patient.

Those mixed feelings trigger anxiety and defenses, which create the patient’s presenting problems. So the therapist helps the patient see and let go of those defenses to face the underlying feelings that have been driving a pattern of self-punishment through defenses.

To do this, the therapist explores feelings in a current, past, or therapy relationship. As the therapist helps the patient face and let go of defenses, often anger is the first feeling to break through. Once the anger breaks through to someone we love, however, guilt arises. Why? The rage is felt toward someone we love. That combination of love and rage toward the same person triggers guilt.

To avoid the anxiety triggered by the love and guilt, the patient may use defenses such as denial or devaluation. In my book, Co-Creating Change, (chapter on breakthrough to the unconscious) you will see how I suggest you work with sixteen different defenses that arise at that very moment, defenses that will prevent the breakthrough of the love, guilt, and grief.

However, sometimes the patient begins to experience the love, grief, and guilt, but has trouble bearing these powerful emotions and becomes overwhelmed with anxiety. If so, cognize about the anxiety briefly, make the link to the guilt, and build the patient’s capacity to bear this much guilt without becoming overwhelmed with anxiety.

Th: Notice how you are becoming dizzy? So we see that as soon as we touch on this guilt, you become anxious, and then your mind becomes dizzy. See that?

Pt: [sighs or tenses up] Yes.

Th: So what does you father’s face look like as you see what you did to him? [Explore images that will trigger higher levels of guilt so you help build the patient’s capacity and enable him to have a fuller unlocking of his unconscious.]

We call this a “pocket of fragility”. The patient is temporarily too anxious, but a brief summary is enough to regulate anxiety and we continue to go for as high a rise of feelings as the patient can manage.

Why don’t guilt and love come through after the rage? Defenses or anxiety block the way. Why?

Sometimes the therapist goes for a premature breakthrough before having explored feelings long enough to mobilize the unconscious enough to have a breakthrough. I have seen therapists go for a breakthrough after asking for feelings only three times…instead of after twenty or thirty minutes!

Sometimes the patient has shifted from resisting feelings to resisting emotional closeness. Thus, the patient is distancing from the therapist with a transference resistance. If the therapist does not see this, no breakthrough will be possible. See my earlier blogs on signs of the emerging transference resistance.

Sometimes the patient’s resistance is in the system of projection or repression where further restructuring is necessary before a breakthrough to complex feelings would be possible, or even advisable! Premature breakthroughs with these groups of patients can lead to regression or depression.

Sometimes the therapist does not recognize the defenses which are preventing a rise of unconscious feelings. If we address the wrong defenses, the unseen defenses will block the way. That’s why having an expert look over your videos is essential. He or she can help you see what you need to do to help the patient further.

If love and guilt do not arise after a breakthrough to rage, look for the defenses that are getting in the way. If you help the patient feel only rage, without her love and guilt, we only help her get better at denying her humanity through denial, detaching, projecting, or devaluation. Experience of rage by itself is almost never helpful. Our task is to help the patient embrace the fullness of her humanity: her rage, her love, her guilt, her grief, and her wish to connect.



When do you need to integrate the personality first?

Forming a relationship with another human being always triggers mixed feelings based upon our attachment history. As these mixed feelings rise, patients respond in one of five ways:

  • they tolerate the rise of feelings, sharing with you, and becoming more intimate;
  • they tolerate the rise of feelings, but start to unconsciously detach from the feelings;
  • they tolerate the rise of feelings, but start to detach from their feelings and from you;
  • they tolerate the rise of feelings, but protect you from their anger by turning it upon themselves
  • they cannot tolerate the rise of feelings, so they relocate their feelings and desires in other people.

This last group is known as the fragile group. When mixed feelings rise, they become overwhelmed with anxiety (cognitive/perceptual disruption). If anxiety continues to arise, to get rid of the anxiety, they get rid of their feelings through splitting and projection.

Once they split off and project their feelings onto others, they interact with the projections they place on other people, not with the people themselves. For instance, a fragile patient may project her anger onto others. Then she fears others upon whom she projects. Then she fears going out of her house. Another fragile patient, projects his anger upon others, imagining they are talking behind his back all the time. In response to this imaginary stimulus, he becomes chronically angry at his projection (the supposedly critical people).

Exploring feelings with this group becomes problematic. First of all, as soon as you explore feelings, the patients begin to split off their anger from themselves and project it onto others. Secondly, often, when these patients report being angry, they are reporting anger at a projection, not toward a person. If you explore their anger toward a projection, they merely become better at projecting!

Our first two tasks with this group are restructuring the unconscious pathway of anxiety discharge and restructuring the resistance system of projection. Doing these two things is referred to as “integrating the personality.” That is, we help the patient integrate within himself the feelings, impulses, and desires he formerly located in others.

Maury asked here, “When do we do that?” When patients are fragile. Signs that they need help with integrating what they formerly projected include: cognitive/perceptual disruption, splitting, and projection. Signs that patients are using projection (with loss of reality testing) are rapid speech (to keep a projection on you from criticizing her), speaking loudly (to drown out the projection the patient has placed upon you), urges to run from therapy or leave the session early (to leave the projected feeling in the room and run away from it), severe anxiety or panic in your presence (fear of the projection the patient has placed upon you).

Often, the patient will tell you about problems in her outer life that indicate projection is active in the room: “I’m afraid of people”; “I’m afraid of what people think, so I avoid them”; “I get into fights a lot”; “People are extremely critical”; “You can’t count on anyone at all”. Sometimes, projection emerges clearly in the room: “I’m afraid you will hurt me”; “How do I know you won’t misuse those videos!” “You look angry.”

One sign therapists often miss is the lack of signaling when the patient reports being angry. When the patient is angry at a projection, you will see no sighing or tensing. Why? No unconscious anxiety is mobilized because this is conscious anger toward a projection. Likewise, the patient will use no defenses to interrupt or ward off his anger toward a projection. Why? Because the anger is already toward a defense: the projection he placed on someone else.

Once you realize he is angry with a projection, stop exploring anger toward the projection, and start restructuring the projection.

Another sign is that when you ask if it is his will to do look at an important issue, he may agree, but not sigh. The absence of signaling always tells us that the patient’s will is not on line. But in this group the lack of signaling tells us that the patient is relating to a projection, not to you. There can be no conscious alliance if he is relating to a projection he thinks will hurt him. Thus, you have to differentiate yourself from his projection so he can have an alliance with you instead of misalliance with his projection. He lives in a world of projections, people he fears will hurt him. Once he owns his feelings internally, the world will become a much more benign and less frightening place. This is your first task.