Monthly Archives: September 2018

I want to avoid my pain!

“I have a patient suffering from severe cancer. In response, she became constantly angry at everything and everyone. When we tried to learn more about what is hiding behind the anger, I told that anger can be a cover for other emotions. And slowly she became aware that she was not only angry, but also scared and sad. She was also aware that it had major negative consequences for her to use anger as a defense. In our second session, she said that she would rather go back to just being angry rather than feel the sadness and fear so clearly. It was easier to bear, she said. How should I intervene?”
First, you might say, “Of course you would rather be angry at life and cancer rather than face your fear and sadness. Who wouldn’t? But if we avoid the sadness and fear, they will still be there for you. Shall we face this together so you don’t have to face it alone?”
Then, you might comment on her invitation: “If we avoid your sadness and fear, I would be abandoning you at the very time you need my help. Do you notice how you invite me to abandon you at the moment you feel most alone?”
Then you might ask about the larger ramifications: “Since you are asking me to abandon you emotionally, is this a pattern in your life, trying to go it alone? Why do you ask me to abandon you?”
It is not uncommon that we use anger as a form of denial: “If I’m angry enough at reality, maybe reality will change!” Yet, who among us is not tempted to use denial under the threat of death? If the patient’s use of denial is stronger, we can mirror and reflect the patient’s denial. “Maybe it’s important to be angry at cancer right now.” “Maybe it’s important to be angry at everyone else who is not facing death yet.” “Can we accept that you don’t want to accept this diagnosis yet?” “Have you noticed that although we don’t accept the cancer, the cancer has already accepted you?”
Often, this mirroring of denial deactivates the will battle the patient anticipates, the one he gets from almost everyone else. And it allows him to see that reality will be here no matter how much he rages. With the collapse of the defense, the grief can pour. And when it pours, who wouldn’t want to fight that off too? “I would want to rage too rather than feel this terrible grief. Do you think you need to rage a little longer before you let yourself cry?”
Notice how I keep avoiding a will battle. If you argue with this patient, he is completely alone facing death. As therapists, we need to place ourselves, at least metaphorically, right by the patient, side by side, facing reality and death. Hopefully, treatment will save him, but, even so, he will suffer, he will be sick, he will be terrified in the meantime. And he will need your support and understanding of every single feeling, bit of anxiety, and defense.
In a certain sense, this is not about how to intervene, but how to be together, living through the fear of dying, the suffering of illness, and the staring of death in the face, the experiences that deepen our sense of being human. Our task is not to run, but to stand still while the truth tears off the false from the patient—and from ourselves.

My patient is afraid she will be poisoned!

“I am treating a young man, 24, who suffers from Lyme Disease and is afraid he will die. He had these fears before he got the Lyme Disease, but since then they have become stronger. He also fears he will be poisoned from food in restaurants or supermarkets, (Delusional thoughts), but those thoughts don’t prevent him from eating. He lives with his girlfriend and seems to have a good relationship with her. He stopped working, watches TV all day, and tries to ignore his thoughts. Since he is afraid of dying he is afraid to sleep. He uses so many defenses that I don’t see his core conflict or who he really is. This is not his first therapy and I hope it will be the last one, because he suffers a lot. We have a good relationship and I hope to help him.” Excellent questions!
Lyme disease, of course, can be a serious condition, but if treated properly it is not life threatening. And, since he had these obsessive thoughts before he got Lyme disease, we are dealing with a pre-existing condition and can leave the Lyme disease to the side. So let’s see if we can help you find out his core conflict.
In terms of defenses, we see that he obsesses about death, which could be the defense of rumination, if the patient is neurotic. But then we learn that he fears that restaurants or supermarkets will poison him. These are paranoid delusions. Thus, his ruminations about death probably are part of his paranoid delusional system and he, most likely, is severely fragile. In response to his delusions, he is not functioning well, no longer working.
All we know so far is this: life events trigger complex feelings; these feelings trigger anxiety; and he uses delusions about death and being poisoned as his primary defenses.
This is what we need to find out:
When did his delusions start? Then we may find the triggering event that evoked the feelings and anxiety that required him to use these psychotic defenses.
In that triggering event, what feelings were triggered?
When feelings are triggered in session, where does his anxiety get discharged? Does he have any access to anxiety being discharged into the striated muscles, or is his anxiety constantly discharged into cognitive/perceptual disruption? This will let us know his degree of fragility.
As you explore feelings, how does he respond? Does he immediately regress into more severe forms of paranoia (psychosis), does he begin to clear up a bit cognitively and have improved reality testing (borderline level of character structure), or does he clear up completely and begin to sigh and intellectualize (neurotic level of character structure)?
As you explore feelings, is he able to have some access to striated muscle tension? If so, what degree of feeling can he tolerate before she crosses the threshold of anxiety tolerance? That is, at what level of feeling does his anxiety shift out of the striated muscles and his resistance shift out of isolation of affect?
These questions will allow you to determine the triangle of conflict, the pathway of anxiety discharge, the system of resistance, and the threshold of anxiety tolerance, so you know what to treat and in what format.
Given the severity of his defenses and the poor level of functioning, my hypothesis is that he is severely fragile and will require the graded format to gradually build her capacity. However, only a careful exploration of the questions above will allow us to know for sure what his genuine capacity is. It’s always possible he is someone with a severe obsessional disorder whose anxiety will go into the striated muscles with sufficient invitation of feeling.
This is an excellent example of a case where we cannot make a determination just from dramatic symptoms we have read. We have to conduct a careful psychodiagnosis of the patient so we know what to treat and how.
To know what to do, you have to know what is going on.