Monthly Archives: August 2018

Realistic guilt?

“Can I ask about realistic guilt? I have a patient who was married to an abusive woman, and she won rights to their children. His kids tell him of the abuse they suffer, but he is helpless to win custody of them as she’s good at lying to the system. Facing the anger towards her has eased his depression tremendously but he feels guilt for not being able to help his kids. I felt this was realistic and not self-punishment. Any ideas, please?

Another patient came in with CPD, and I spent the whole session regulating his anxiety with success. Second session he came in crying over his girlfriend who died. After facilitating his grief for 15 minutes, I learned he was 17 when it happened. He has been crying as if it was fresh for the past 30+ years. They were joyriding illegally in a motorcycle, they crashed, and she died. There was some suicidal ideation, so I asked him who the anger was toward if he didn’t turn it back into himself. After some defense he admitted it was towards a friend who goaded her into riding the cycle. When we get close to the anger, even
cognitively, he experiences memories of the war, followed by increased self-attack and guilt. I cognitively gave him awareness of his guilt, which he admitted felt different in a good way, but he just kept crying. Any help much appreciated!”
An important question with two great examples. Thanks for sharing this question!

Of course, there is such a thing as realistic guilt. Every one of us has done something to hurt a loved one, and, hopefully, we feel guilt about the wrong we did and reach out to repair the harm we did to that person and to our relationship. Healthy, realistic guilt mobilizes us to engage in the act of reparation. So let’s look at these two examples.

The first patient divorced his abusive wife and left his children with her. Inevitably, he feels guilt. After all, his freedom came at a price: he is not with them, and they suffer. I am not judging him, by the way. I am just pointing out reality: he was able to leave and the children could not. Understandably, his children are angry with him for leaving, and he feels guilt that he was able to get free but they could not, and they still suffer. Even though the legal system made the decision that the children stay with the ex-wife, he made the decision to leave. This is his painful burden to bear, one based on his love for his children. All he can do is feel his guilt and continue the act of loving his children, supporting them as much as he can, accepting their anger, listening to their pain, and bearing the complex feelings that arise when he has left a painful relationship his children could not leave. If he attacks or punishes himself for leaving, you will address that defense, so that he can bear the burden of guilt, which arises anytime a parent divorces, a decision which always, to some degree, involves pain and loss for the children. This is realistic guilt.

The second patient is a man who rode a motorcycle and had a crash that led to his girlfriend’s death. In effect, he killed her. Feeling enormous guilt, he wishes he could die to punish himself for her death, and, thus, expiate his guilt. Being angry with the man who encouraged the girlfriend to get on the motorcycle is a form of projection to avoid his own guilt. After all, the other fellow did not crash the motorcycle.

Tragically, this man suffers from cognitive/perceptual disruption. As a result, his ability to bear complex feelings and guilt is extremely low—note the use of projection to avoid the internal experience of guilt. Due to this low capacity to bear feelings internally, he has not been able to work through his guilt. He can grieve forever, but this, too, has served a defensive function. If he feels only grief over his loss, he can avoid guilt over his murder. I use this word because in his inner world he killed her. He drove the motorcycle. He crashed the motorcycle. She died because of his actions. Thus, he killed her.

If we therapists can face this kind of causality, responsibility, and guilt, we can help patients like him face the horrific guilt over being the cause of someone’s death. He knows in his heart that if he had not taken her on the motorcycle, she would be alive today. This is realistic guilt, based on a tragic mistake of engaging in illegal joyriding. Glossing it over will do him no good. But facing his guilt and his responsibility will help him heal, end his lifetime of self-punishment, and enable him to find ways of repairing the damage he did, even if those acts of reparation must to be for others, not the poor woman who met her death.

This takes emotional courage on the part of the therapist. We are not here to judge. But we are here to face the truth, even when it is an ugly truth, even when facing that truth will initially trigger a painful wave of feeling within the patient. Without judgment, without condemnation, but with compassion we can reach out to him and say, “Of course you feel guilty. You drove the motorcycle illegally. You crashed the motorcycle. She died because of your actions. That’s why you feel guilt. This is a sign of your humanity. Shall we face this guilt you’ve been carrying the past thirty years?”

These statements are not judgments, but statements of the facts. By stating them, we let the patient know that as two guilty humans, we can face facts together, bear the guilt together, and reclaim our humanity together and rejoin the human race after a long period, thirty years in his case, of personal exile.

Anger management

“A man asks for anger management. He can’t control his rage toward his children when they do not obey him. He is in law enforcement and says he is successful being powerful. He asks for therapy because his wife and his children can’t endure his anger. He agrees. Rage rises within seconds when he does not succeed. He grew up with a father, a military man who was very controlling. My client never contradicted this father he looked up to. How can I work with his problem in the best way?” Great question!

Of course, the feeling is obvious: anger. The problem is that this man channels his anger into acting out toward those he loves: his children. So what do we treat?

First of all, how is this a problem for him? He agreed to go to therapy, but notice that he says he came because he wife and children could not endure his rage: the source of the motivation, as he describes it, is them. Ask about how and why his anger is a problem for him. Unless the therapy is driven by his will, you run the risk of have a half or quarter-hearted patient. Ask him, “How is this a problem for you?” “How is this impacting the relationship with your kids?” How are your kids feeling about you?” “How is that affecting you?” “When you don’t succeed with your kids, like all fathers, this mobilizes a big reaction in you. When you don’t succeed, what do you make that mean?” Questions like these encourage reflection, make his defense less syntonic, and mobilize his will to the task.

Second, as you explore, find out where his anxiety is discharged. Is his anxiety in cognitive/perceptual disruption leading to projection onto his children, so he beats his projections? If so, anxiety regulation will be paramount.

Third, notice his affect tolerance. Clearly, rather than channel his rage into effective assertion and parenting he loses control of his rage. At what level in the therapy office do you notice early signs of problems in affect tolerance: racing speech, impulsive bodily movements, raising his voice, yelling, talking over you, impulsive speech, or a wish to leave. Now you know the level of feeling he can barely tolerate, the level you will work at and not exceed in order to build his capacity. As soon as you see any of these reactions, stop exploring feeling, and do a recap of the process to encourage intellectualization and self-observation. “I notice that you started to talk over me. Did you notice that too? Sometimes, when people do that, it’s a sign of anxiety rising. Where do you notice feeling anxiety in your body right now?” This encourages self-observation and self-regulation as a substitute for losing control of himself.

Fourth, notice his verbal defenses as you explore his problems. Does he intellectualize (offer thoughts instead of feeling) or does he hyper-mentalize (offer elaborate speculations about other peoples’ motivations without having the evidence for their motivations)? If he intellectualizes, you can explore feelings in a graded fashion. If he hyper-mentalizes, you are dealing with projection and may need to begin with anxiety regulation.

If he views his children or wife in all-good or all-bad terms, you will know he is engaging in splitting. Here you may use pressure to consciousness of both sides of the split, monitoring any rise in anxiety and feeling when you block his splitting. “So the boy who makes you angry is the same boy who likes to sit in your lap when you fish.” Reminding him of these split-apart reactions, builds his capacity to tolerate mixed feelings.

How do you help him? First, conduct a careful assessment of the triangle of conflict. Find out where his anxiety is discharged, what system of resistance he uses, what capacity for self-observation he has, and what capacity for thinking about the minds of others. Once you know his strengths and weaknesses, you will be able to tailor the treatment to his needs.