Monthly Archives: April 2018

Why does my love make her worse!

“As I spoke to a patient about her anxiety, she became quite disturbed, teary eyed and agitated. She found my gaze intruding and invading her body. I deactivated the projections, and encouraged her to pay attention to her anxiety again.
But when we did so and she felt relief, she suddenly became disturbed, shaking all over, said she shouldn’t be relieved, and said her own name in the third person: ‘L. is getting so mad! I shouldn’t be looking at myself with such attention’.
I summarized what happened. She said that a voice in her, like a small creature, always yells at her when she pays attention to herself, telling her she shouldn’t, and she should break things in the room and leave therapy. She flooded with anxiety again, regretting having told me about the voice.
She tells herself she shouldn’t help herself and should avoid any human contact. Until the end of the session I was afraid to help her assess her anxiety. Is she psychotic and not suitable for the graded format? Do such interventions help or cause more splitting and psychotic reactions? I would greatly appreciate any comment and insight from you.” Thank you for this important question!
Traumatized patients have learned that love leads to pain. And what is anxiety regulation but the most basic form of love? A startled infant cries, the mother bends over, picks her up, and holds her in a loving embrace.
Exploring the problem, trying to help, regulating anxiety, exploring feelings, these are forms of love. As therapists, you know you love. You care for the person before you. But we forget: love led to pain.
As soon as you explore a problem or a feeling or regulate anxiety, you don’t say you love the patient; you show it. This triggers feelings in all homo sapiens. When these feelings rise, based on earlier relationships, anxiety rises too. That’s why we always need to assess the fragile patient’s response to anxiety regulation: our act of love.
In this patient’s case, feelings rose, anxiety rose, and she began to split and project. Overwhelmed by the mixed feelings of love and rage from her past, she projected her rage onto the therapist: ‘you want to intrude, invade, and hurt me!’ Then she became terrified of the projection she placed on the therapist.
When the therapist regulated her anxiety again, this act of love triggered another rise of feelings and anxiety in the patient. This time she projected the rage onto a hallucinated voice that told her not to accept the therapist’s care and not to care for herself. However, a little bit of the rage toward the therapist was not projected, just displaced onto the objects of the office…a positive sign.
Does our love make patients worse? No. But we must move in quickly to help patients with the rise of feelings and anxiety our love evokes. For those reactions are the history of her suffering. And those reactions rule her life, creating her suffering, increasing her isolation.
As soon as you regulate her anxiety, move in quickly and ask what she is feeling in that moment. Catch the feeling and help her be aware of it and cognize about it before it becomes so amplified by anxiety that she has to project.
Th: “What feelings do you notice here with me as your anxiety comes down?”
Pt: “I’m feeling scared.” [projection]
Th: “Let’s take a moment. Before you got scared, what feelings came up, just for a split second?”
Pt: “I don’t know.”
Th: “Wouldn’t it be nice to know what feelings are getting stirred up so you wouldn’t have to get scared?”
Pt: “Yes, it would.”
Th: “So let’s take a moment and see what feelings were coming up here with me, just before you got scared.”
You want to build her capacity to know what she feels inside her before she projects it outside of her onto you or others. To do so, cognize about the process.
Th: “Something about helping you with your anxiety makes some feelings come up in you. But then it’s like the feelings travel over here. And for a moment you wondered if those feelings were in me.”
Cognizing about the projection may help, or she may become dizzy for moment, in which case you will repeat the cognizing until she is able to cognize too.
You may need to deactivate the projection of gazing and invading her.
Th: “Was it your wish to look into these problems?”
Pt: “Yes.”
Th: “And do you want to see into those problems so you have the information you want?”
Pt: “Yes.”
Th: “Since I can’t see into you, would you be willing to look into yourself to find the information you need?”
Continue until she tenses up a bit and can cognize. Then, you must ask about her feelings: “Something about making this choice to look into your problems stirs up feelings and anxiety here. Do you have any idea what feelings might be coming up here about the therapy that could be making you anxious?”
You must provide a pathway for her to see and feel feelings inside herself toward you. Otherwise, she will project onto you: ‘my feelings aren’t in me; they’re in you.’ If you don’t explore those feelings and deactivate the projection, the patient takes a second step: ‘my feelings aren’t in me; they’re in a hallucinated voice, or they are in the people at my apartment building.’ Projection onto you is the patient’s attempt to begin to look at feelings in her. If we don’t explore her feelings toward us, her feelings will travel into the environment and other people.
As you work this way with a severely fragile patient, you will begin to see how she responds to treatment. Many patients respond well, but it requires a rapid capacity for recognizing splitting and projection, and knowing how to address it. Get the best supervision you can get. This is not a case to work with if you are a beginning therapist. On Allan Abbass’s website there is a lovely paper he and some Australian colleagues wrote on working with eating disordered patients. It’s essentially a primer on how to work with severe fragility. You can also find some excellent hints on how to work with this kind of patient in Allan’s recent book, Reaching through the Resistance. Buy it!
Take home point: when regulating the anxiety with a severely fragile patient, assess the resulting rise of feelings immediately before the patient goes to splitting and projection. Otherwise, she will suddenly regress. Cognize about the mixed feelings to block splitting and cognize about projection to increase the capacity to bear feelings internally without relocating them externally. These are among the first steps we take when integrating the personality of the severely fragile patient.

This therapy will fail!

“Some patient called me and asked me about fearing pigeons. In my opinion, this is the best way to ignore herself. She is forcing me to talk about pigeons instead of herself. As a result, I think the therapy will be failed just before beginning. What do you think?” Thanks to one of our community members for asking this question!
How can we know if the therapy will fail? We have not met her yet. If we do not sit with her and explore, how can we know her capacity, her degree of motivation, even her other difficulties. If we give up before we have met her, we are responding to our own projections (She is hopeless.), not to her.
Instead, we need to be the welcoming openness in which the unknown of this woman may be revealed to us and to her. Due to our fear of the unknown, the patient as mystery, we are often tempted to “predict” [fancy word for therapist projection]. Instead, we must let go of our desire to “know” her before we have had the chance to come to know her. And we must let go of our desire that she be a certain way. Otherwise, we will be relating to our desire, not to her.
She will “force” you talk about pigeons? She must have very great powers to do such a thing! In my experience, no patient can “force” me to do anything. She can ask me to do something. I can say yes to her and no to myself, and then blame her for my choice. Or I can say no to her and yes to myself. Or it may be saying yes to her feels like a yes to me too, and then I’ll do it. If she insists on talking about pigeons rather than her inner life, this can be dealt with as we would with any defense involving self-neglect.
And let’s not forget. No matter how much I know a patient even after a therapy, she is always something other and greater than any idea I can have about her. Can we accept that we do not know the future of this patient? Can we let go of our ideas which are a substitute for living with, being with, another person? Can we bear this unknown we enter into each day? The challenge of therapy: how to be the welcoming openness to the mystery that is another person.