Monthly Archives: July 2018

Guilt or self-punishment?

“A client separated from his wife, but left his kids with her, and they suffered when she neglected them, often leaving them alone at home. He began to lead the life of a hermit, throwing himself into work, and detaching himself from everyone but his kids whom he met on weekends. Now that he is getting old, and his business is in crisis, he feels guilty for immersing himself in work as a defense against his feelings of anger, loss, grief and guilt. We have done a lot of work and he is far better today. But he ruminates about his son who is not married, nor settled professionally, and he blames himself for leaving his son with his mother at age five. Or he worries about his unmarried daughter—what if she falls ill or gets into an accident and is alone with nobody to care for her? When he ruminates about other close family members, he often calls them to ensure they are safe.
What are the interventions to make to help him face his guilt over leaving his children? And how do we address his obsessive rumination over the safety of others? Is the rumination a projection of anger or is it rooted in his guilt too?” Thank you for this important question!
While divorce may be the right thing to do, it always causes pain for others. In this case, there is the additional pain this man suffered because his ex-wife neglected their children. Thus, he inevitably feels guilt about his choice and its consequences for his children. However, as we look more closely, the picture is more complicated.
He ruminates (defense) about a son who is not married or settled professionally. This raises the possibility that he may be angry with his son for not living up to his expectations, and that rumination may be a form of self-punishment. The only way to test that hypothesis is to explore feelings toward the son and see if those feelings trigger anxiety and defense. Then you will find out whether the rumination is a form of self-punishment, not guilt.
He ruminates (defense) about his daughter, worrying about her falling ill with nobody to take care of her. Again, we would want to explore feelings toward his daughter who had moved far away. Is his rumination a defense against his anger toward his daughter for leaving him and moving far away? Or is he projecting upon her his own worries about being ill, alone, without someone to take care of him? Only exploring feelings toward the daughter will allow us to test these hypotheses.
He ruminates about family members, and then he calls them to put his fantasies to rest. Since the ruminations make him suffer, they are defenses. Thus, we might explore feelings toward each family member he ruminates about to find out what feelings are underneath his ruminations.
If you can help him face his feelings and feel them, he won’t have to ruminate as a form of self-punishment for having those feelings.
In other words, there is a lot of exploring of feelings necessary here in order to get clear about the triangle of conflict in each example. However, here is a big hint. When we talk about guilt in ISTDP, we are usually referring to UNCONSCIOUS guilt, buried under defenses.
The conscious guilt that patients report almost always has a defensive function. For instance, a patient might report feeling conscious guilt about leaving his son as a child, but this may ward off unconscious guilt due to his current rage with his son for failing to meet his expectations.
Just as conscious guilt can ward off unconscious guilt, the conscious crime may distract us from the real one. A person might say she feels guilty about snubbing a colleague at a work party, but exploration may show she actually feels much more guilt over having stolen the credit for a report written by her colleague who now will not get a promotion.
Remember that whatever guilt patients report is what the defenses allow to come to the surface. Conscious guilt distracts us from other deeper feelings. For instance, doesn’t it sound better to say, “I’m worried about my daughter’s health,” than to say, “I’m furious with my daughter for leaving me here all alone when she should have stayed nearby to take care of me!”
If you can help him face his rage and complex mixed feelings toward his children, he will no longer have to punish himself through his rumination, and then he can accept the loss of a child he always has loved and always will, even if from afar.

No wonder the patient gets angry with you! You are irritating!!

“A colleague said, ‘No wonder the patient gets angry at you. Your constant pressure for feeling can come across as irritating!”  How would you respond?

My own inclination (based on your book and Allan Abbass’ book) is to say that: 1) pressure to feeling and defense work are key to healing; 2) if we do not persist we will never reach through the resistance which defeats both us and the patient; and 3) the patient’s unconscious communication (e.g., negation ‘I’m not angry.”) signals a rise in the unconscious therapeutic alliance, suggesting we are on the right track. Without this, irritation can be a sign of a misalliance due to a mistake by the therapist.” Great question and great answer!

Obviously, it is never our intent to irritate a patient. After all, that would not be therapy but sadism! If you act like a jerk, the patient will rightly feel angry toward you, without mixed feelings, and without any therapeutic result.

So why do we ask for feelings? To form a healing relationship. In this bond, together with the patient, we embrace the formerly unembraceable: his complex mixed feelings under the anxiety and defenses.

When we invite the patient to form a healing relationship, feelings arise. These feelings trigger anxiety and defenses. As we regulate anxiety and point out defenses, we implicitly welcome and accept his entire inner life.

In response, the patient’s forbidden anger rises. If it is accompanied by sighs, we know that the anger is simultaneously connected to love, complex feelings that cause the anxiety. That is our unconscious signal to continue exploring. When the patient says he does not have feelings, he does not feel irritated, he does not feel anger toward you, these negations are further unconscious signals: feelings can emerge as long as they are negated—another sign to continue to explore feelings. Even the patient’s defenses are signs that we are going in the right direction! After all, if there is no treasure, there is no lock on the door.

Let’s suppose, however, that the patient believes you really are trying to irritate him. Then we have a conscious misalliance, which must be corrected. “Thanks so much for letting me know. It’s not my intent at all to irritate you. So let’s back track for a moment to make sure we’re on the same page.” Then remind the patient of the triangle of conflict causing his problems. Then remind him of causality: how his defenses are causing his problems. Then remind him of the task you two agreed upon: to face the feelings under the defenses so that he can feel and deal instead of avoid and suffer. It’s just as important for patients as it is for colleagues who view our videos to understand what we do and why we do it. Otherwise, both patients and colleagues will suffer from a misconception about the work.

Sometimes a misalliance will occur later in the work, even when the two of you agree on the conflict, causality, and task. If you point out defenses constantly without inviting feelings toward you, the patient will experience you as a critical superego, leading to a misalliance. If you challenge defenses before the patient has begun to resist closeness with you, you will get a misalliance. If you challenge or confront the resistance to emotional closeness prematurely, you will get a misalliance. If you challenge a fragile patient, unable to tolerate the sharp rise of feelings, he will project his anger onto you, and then you will have a very bad misalliance.

And, to be absolutely honest, a good therapist will sometimes be very irritating. Why? We are supposed to be honest, telling patients what they do that hurts and sabotages themselves. There is no reason for patients to be ecstatic when we tell the truth. As the ancient Roman theologian Tertullian said, “The first response to the truth is hatred.” So when we point out defenses and the destructive impacts those defenses have, patients will become angry with us. And, if we look honestly within ourselves, who among us hasn’t felt a flash of anger internally when someone has pointed out the truth about us? So in response to their anger when we point out the truth, we ask: “So what feelings are coming up here toward me?” Even if they are angry when we tell the truth, we don’t ask them to lie about their anger. Instead, we invite them to explore and feel it as fully as possible.

After all, that’s what we do in a healing relationship: face the truth and our feelings about it.