Monthly Archives: May 2018

Why is she becoming more paranoid?

“One of my patients (fragile/depressed/very self-critical) started a new relationship. However, her paranoid ideation increased at the same time. She believes others wish her ill, want to humiliate her, and hope her relationship will fail. She is afraid of being rejected. How does this tally with the increase of projected punitive super-ego? Can unconscious anger be triggered just by getting into a relationship again? Or is she criticizing herself for being afraid? I’m a bit uncertain!” Thanks for a great question!
A new relationship always triggers mixed feelings if our earlier relationships were painful. So the questions for assessment begin. How much trauma did she suffer in the past? How much feelings are mobilized by a new relationship? When these feelings rise, how does the patient deal with them? Can she detach from them (isolation of affect)? Does she turn the anger onto herself and the love toward you (repression)? Or does she project her feelings onto you and other people (projection)?
In this case, the patient experiences mixed feelings toward her new boyfriend. After all, a new love reminds her of the past loves who hurt her. She can split her loving and rageful feelings apart and project the rage onto other people to protect herself as the loving girlfriend and her boyfriend as the all-good boyfriend.
Once the anger is projected onto others, people are viewed as angry: 1) they are angry with me (wish me ill); 2) they want to hurt and humiliate me; 3) they will reject me; and 4) they hope the relationship will end.
Since the patient is also depressed, she either projects anger onto others and fears them (projection), or she turns the rage against herself (repression). Your first task is to help her face mixed feelings inside without projecting them outside. That is known as restructuring the resistance system of projection.
Pt: I’m afraid they wish me ill.
Th: Insofar as you are afraid of how people wish you ill, I wonder what thoughts you might be having about me? [If she projects onto others, she projects onto you too.]
Pt: I wondered if you thought I shouldn’t be in this relationship. [projection]
Th: Is there any evidence for that?
Pt: No. But I wonder about it.
Th: So you are aware of this thought. [cognizing about the projection]
Pt: Yes.
Th: So I wonder what feelings might be coming up here toward me that could be underneath that idea? What feelings are getting stirred up here with me?
Having clarified the projection, ask about feelings. Build the patient’s capacity to bear mixed feelings toward you without projecting those feelings onto you or other people. Building her affect tolerance in this way helps her eventually tolerate 100% of her feelings without projection. This tolerance has to be built initially almost entirely within the therapy relationship. Why? The patient’s projection onto others means that examples in past or current relationships are seen through the lens of projection. Thus, they are nearly always distorted.
With fragile patients we expect that a new relationship will trigger a rise of mixed feelings based on her past. As her feelings rise, they will exceed her integrative capacities, and she will eventually split off and project her feelings onto others. The greater the rise of feelings, the more feelings she has to project onto others. Thus, the more paranoid she will become.
That’s why we focus on feelings in the session to build her capacity to bear them internally without projection. Otherwise, without an internal “storage tank” for her feelings, they will get projected, and she will become increasingly paranoid. And, if we don’t address these feelings with the therapist, her projections in therapy will increase until she acts out and leaves therapy.
Take home point: restructure her projections repeatedly and build her capacity to tolerate ever higher levels of mixed feelings inside her until she no longer needs to project them outside of her.

I don’t know what my problem is

“When I ask, “What’s the emotional problem you’d like my help with today?” sometimes, long-time patients reply, “I don’t know.”
We established goals for treatment earlier and had an unlocking of grief or anger already. Is not the problem clear? I don’t expect my patients to know everything, but I would expect something like, “I’m not sure exactly, but let’s keep working on my anger problems.” Others ask me for advice on how to handle a life situation when we had established earlier that the goal was to get to the bottom of their emotions.
Should I point out this defense?
 Is it resistance in the T?
 Might this be a good intervention? “We have established a clear goal together, and you say you don’t know what you want to work with. Could it be that you’re becoming a little passive/helpless with me right now?”
 Do I need to be clearer about the conscious treatment goals? Or is this repetition just necessary?” Thanks for this important question about a common problem!
When you have established goals for the therapy in the opening session, you go ahead and explore the situations where the patient’s problems arise to determine the feelings, anxiety, and defenses that cause his presenting problems. Then we explore those feelings as deeply as possible, while ensuring that anxiety is regulated, and helping the patient see and let go of defenses.
As you become more intimate with the patient, his complex mixed feelings rise. As a result, you had several breakthroughs to grief and anger. But since he experienced these feelings, he is becoming more emotionally close to you. To distance from his feelings, he eventually begins to distance from you. When he distances from you in the opening of the session, he does so often by saying, “I don’t know what to work on today.” You can bet that when he goes to the car mechanic, he does not say, “I don’t know what I brought the car in here for.”
I use this metaphor to highlight how this behavior is a defense against closeness. To answer your question, yes, this is not a defense against feeling but a resistance to emotional closeness, what we call a transference resistance. You do not need to clarify again the goals of therapy. Instead, you need to point out that he comes to the therapy without a goal or a problem, and that would make you or any other therapist useless.
Start by identifying this treatment destructive behavior. This can be done in many ways.
Th: So a man without a psychological problem finds himself in a therapist’s office. [Pointing out the contradiction between what he says and does.]
Th: If you don’t have a problem to work on, we can’t help you can we. Notice how this is a barrier to us being able to work together? I wonder what feelings might be coming up here toward me that make you put up this barrier? [Resistance identification. Clarification of the price of the resistance. Inviting feeling toward the therapist because the patient is resisting closeness with the therapist.]
Th: You say you have no problem for us to work on. Then you leave it up to me to declare the problem. Notice how this is the same kind of passive behavior that you mentioned comes up with your wife? What feelings are coming up here toward me that make you put up this barrier of passivity? [Identify the resistance of passivity. Invite feelings toward you.]
If you do this in one session and in the next session he again says he has no problem, then:
Th: I wonder what feelings are coming up here toward me?” [His resistance is a sign of feelings rising toward you. So you use his unconscious signal (the resistance) as a sign to invite the feelings toward you he is resisting.]
Take home point: when you are working with a patient whose anxiety is in the striated muscles and he is intellectualizing and detaching from you, he is resisting emotional closeness with you. Identify his resistance, point out the price, and ask for feelings with you. His distancing with you is the central problem you need to address.