“In your book you have said we don’t ask for feelings if someone is projecting onto us. But in Allan Abbass’s new book and one of Patricia’s videos people ask for feelings when the patient is projecting onto the therapist. This is confusing. Does the difference lie in whether the patient’s anxiety is in striated or not? What if the patient isn’t showing any anxiety?” Thanks to Albert for this very important question!
First of all, everybody projects, even you and me! Projection can range from the psychotic man who claims that space aliens are communicating to him through the fillings in his teeth to the daily blatherings of politicians onto each other. So, to deal with projections, we must understand where the patient is on the spectrum of resistance.
As you know from earlier blogs, in ISTDP we see patients handling their mixed feelings through three strategies: 1) projection: I split off my feelings and project them onto other people; 2) repression: I split apart my feelings and turn the love onto you and the rage onto me; and 3) isolation of affect: I detach from you to detach from my feelings.
Patients who use projection as their primary form of resistance suffer from cognitive/perceptual disruption, losing a sense of reality testing when they project. As a result, they become afraid of you, since they equate you with the projection. This is known as symbolic equation: equating you (reality) with the projection (symbol). Thus, the first task is to differentiate you from the projection and re-establish reality testing. As soon as reality testing is established, then we ask for the feelings toward the therapist. Why? We must build the patient’s capacity to identify and bear mixed feelings toward the therapist at higher levels without projection to restructure his system of resistance and pathway of anxiety discharge.
Patients who use projection in the system of resistance project that you will be critical of them and they become depressed in response to this projection. Again, you help them see the difference between you and the projection. Then you ask for the feelings toward you, so they can bear their mixed feelings internally without attacking themselves. These patient’s projections restructure very quickly because there is not a marked loss of reality testing. In fact, most of the time, if we simply ask patients who repress about the feelings toward us, providing an outward pathway for the feelings, the weepiness will decrease, sighing will increase, and the patient’s depression will diminish in the following minutes.
Patients who use projection in the resistance system of isolation of affect suffer no loss of reality testing, their anxiety remains in the striated muscles, and their other defenses serve isolation of affect. In this case, projection serves as a tactical defense, a tactic to diversify away from your focus on the feelings toward you. Projection in this case requires no restructuring at all.
To compare these kinds of projection according to systems of resistance, let’s review their differences:
Defenses: Splitting, projection
Result: scared of therapist
Anxiety: c/p disruption
Reality testing: impaired
Intervention: restructure projection until sighing, tension, or intellectualization returns, then invite feelings INSIDE the patient
Defenses: Self-attack, weepiness, tiredness, somatization, conversion
Reality testing: easily corrected
Intervention: Identify defense, invite feelings TOWARD the therapist
Isolation of Affect
Defenses: Intellectualization, rationalization, detaching
Reality testing: no problem
Intervention: ignore the defense, invite feelings toward the therapist
In my book, due to limitations of space, I focused on how to address projections when patients are fragile, using the resistance system of projection. Allan’s book shows how to use pressure to feelings once the fragile patient sighs again, and how to use pressure when the highly resistant patient uses projection as a tactical defense. Patricia’s video also shows how to press for feelings when a highly resistant patient uses projection as a tactical defense. In future blogs, I’ll take you through this spectrum of projection, showing how we intervene differently and how we invite feelings differently to block systems of resistance while mobilizing complex mixed feelings.