Monthly Archives: March 2018

What should I do when I see no signs of anxiety?

Hello, I am reading these posts with extreme curiosity! I have been trying to learn ISTDP by means of supervision and reading your excellent book. I wonder how you work with patients who present problems like “I am too passive, I do not do what I plan to do, and therefore do not achieve my goals. This in turn makes me depressed.

They show no smooth muscle or cognitive-perceptual disturbances, but they are NOT signaling with striated muscles when they describe their problems! You wrote earlier that signaling means we can ask for feelings towards me. How do you find a way towards the unconscious when they present behavioral problems that cause suffering?”

Great question! When the patient responds with sighing, we ask for feelings. But what do we do when the patient does not sigh?

Lack of sighing can occur because we are not exploring feelings or a conflictual area. For instance, if we chit-chat, no anxiety will rise. In my book, Co-Creating Change, I list nearly twenty reasons we might not see sighing occur. But, now, let me offer a central technical principle that simplifies the process of assessment.

Assuming you are exploring a conflictual area, sighing occurs because mixed feelings and anxiety are rising. When there is no sighing, resistance is operating. So our question becomes: which resistance system is preventing a rise of complex feelings?

Not sighing is just as important for assessment as sighing! When you intervene and there is no sigh, assess the next verbal response to find out what resistance system is preventing a rise of complex mixed feelings.

Th: “What’s the feeling toward her for leaving you?”

Pt: [no sigh] “She’s just a lying bitch.” [Splitting and devaluation]

Th: “You call her a bitch and at the same time loved her and wanted to marry her. What happens inside as we notice these two facts together at the same time in you? [Pressure to consciousness to block splitting so feelings can rise.]

Rather than face his mixed feelings toward his girlfriend, he splits off his loving feelings and feels only rage toward her. Since he feels only rage, not mixed feelings, no guilt is triggered and, thus, no anxiety. This explains why anxiety does not rise when patients use the resistance system of projection, based on splitting. Here’s another example.

Th: “What’s the feeling toward her?”

Pt: [no sigh] “I feel only positive feelings toward her. I didn’t deserve someone like her.” [denial and self-attack]

Th: “Could that be a critical thought? Could that thought be hurting you? If we look under the thoughts, I wonder what other feelings are coming up toward her?” [Inviting the feelings by blocking turning on the self.]

Rather than face his mixed feelings toward his girlfriend, he feels only positive feelings toward her and turns the rage upon himself and becomes depressed. Since he feels only love, not mixed feelings, no guilt is triggered and, thus, no anxiety. This explains why anxiety does not rise when patients use the resistance system of repression, based on turning on the self. Here’s another example.

Th: “What’s the feeling toward her?”

Pt: [no sigh, looks away out the window] “No feelings really.” [Detaching from the therapist and from feelings]

Th: “Notice how you look out the window instead of at me? Notice how you relate to the window instead me and avoid my eyes? What feelings are coming up here toward me that make you avoid my eyes?” [Since he is detaching from the therapist, address his distancing and then ask for the feelings toward you that lead him to distance.]

Rather than face his mixed feelings toward his girlfriend, he detaches from his feelings and from the therapist, becoming distant and uninvolved. Since he detaches from mixed feelings, no guilt is triggered and, thus, no anxiety. This explains why anxiety does not rise when patients use the resistance system of isolation of affect, based on detaching.

If you see no sighs, pay attention to the patient’s verbal and non-verbal responses to find out which resistance system is preventing a rise of mixed feelings. Then you will know which resistance system to address. In our next post, I’ll talk about the different ways we invite feelings to address these three different systems of resistance.

Shame

“Hi Jon. How do you differentiate shame from guilt and how do you work with a client who has suffered abuse and feels shame?” Thanks to Florence for this question which many therapist ask!

Guilt: “I hurt you and feel remorse, so I want to reach out to you to repair the damage to our relationship.”

Healthy shame: “My behavior fell short of my ideals. Shame reflects the tension between me and how I want to be. Thus, healthy shame orients back me toward my ideals.” It’s easy to forget that there is such a thing as healthy shame. But all we have to do is remember a “shameless” celebrity who acted badly. The term “shameless” is not a compliment. It reflects on the person’s failure to re-orient himself to his healthy ideals. Don’t forget, if a loved one did something bad, you would hope s/he would feel ashamed. Guilt = “I did something bad to you.” Healthy shame= “I am bad and should be better.” It’s important to remember that we have a healthy superego: the ideals, values, and morals which guide our lives.

Pathological shame, the kind of shame we most often treat in therapy, is a form of self-attack. The patient reports a feeling and then suffers a “shame-attack” which punishes the patient. I don’t think of pathological shame as a “state” but as an attack, a defense. There is nothing healthy about pathological shame; it cripples the patient. Thus, we deal with it as a form of self-attack or character defense.

Pt: “And then he began to rape me. I feel so ashamed telling you this.”

Th: “Notice how this shame attacks you right now? Do you think this shame could be making you depressed?”

Pt: “Yes.”

Th: “Could we look underneath the shame and see what the feeling is toward the rapist? If we look under the shame, what is the feeling toward him?”

As Florence points out, often, abused patients feel shame. In part, this shame is a form of self-attack. However, Nathanson and others have found another way to look at this: borrowed shame. The patient “borrows” the shame that belongs to the perpetrator: the defense of identifying with the aggressor. However, once the patient faces the rage toward the perpetrator, this defense usually falls away.

Some perpetrators project their shame into the victim, telling her that she “likes” the abuse. If she “likes” it, he need feel no guilt or shame.

Pt: “He said I liked it.”

Th: “So he not only molested your genitals; he molested your mind. He put his penis in you and then shoved his shame in too. Can we take a look at the rage toward him for doing that?”

Pt: “Maybe I did like it.”

Th: “If you did, you wouldn’t be here. He molested your mind too. So can we take a look at the rage toward him for doing that?”

In victims of abuse, shame is usually a defense against facing the massive rage toward someone the victim loved. These complex feelings of rage and love generate guilt. Unable to bear the mixed feelings, the victim protects the perpetrator by turning the rage upon herself and feeling only love toward the victimizer. Our task is to help her face not just her rage but her mixed feelings toward him.

Therapists, outraged by the abuse, often mistakenly try to help the patient face only her rage. This encourages splitting. The patient will oppose you. Instead, our task is more complex: helping her face the mixed feelings toward the person she loved and hated, the person who was kind and cruel to her. Horrified by her love for the victimizer, we act out the split by pointing out how awful he was. Instead, we need to embrace both her love and rage toward the victimizer. If we can embrace her complexity, she can do the same, and then she can cast off the mantle of shame, which has always hidden the truth: who she really is. Shame is the grimy coat that hides her essence.