Monthly Archives: November 2018

My patient terminated therapy prematurely!

And, of course I am feeling low and have been wondering what I did wrong. She was a great candidate for ISTDP, but highly resistant. She asked to reschedule a session, but I refused because I had rescheduled once a few sessions back due to extremely poor weather conditions, and I didn’t want to make this a practice. But I felt bad that she had to miss her session, so I wrote back to her offering some available slots to make up for her lost session. She became angry and said she would come as scheduled for her next appointment and hoped that I would not charge for her missed session. She also added that coming every week did not suit her. I said we would discuss it when we meet. Then the day before her next session, she terminated therapy over an sms saying that this form of therapy does not suit her and she would like to go back to her previous therapist. I offered to keep the slot open so she could come and explore her issues about therapy and about me, but she wrote back saying she would like to close the chapter. She had difficulty facing rage against her husband (who cheated on her) and her father (who controlled and berated her). She is a highly controlling individual, and I feel she was trying to control me by dismissing my cancellation policy and creating one of her own. 
Is it possible some patients don’t feel comfortable facing their rage and drop out, or do they drop out because we therapists have failed to handle their anxieties appropriately? How does one handle premature terminations?
We can help you become competent, but we can never help you become omnipotent! Sometimes patients act out rage with therapists to avoid the rage going onto family members. I doubt your back and forth about your cancellation policy was the issue. She had already cancelled a session. She had already proposed a different policy, hoping to control you. She had already opposed looking at feelings toward her husband from what you told me earlier. Thus, she had already felt rage toward you and was resisting you before your policy was even part of the picture.
This kind of patient is hard for everyone because we have trouble seeing the rage in the transference. This kind of patient rarely says she is feeling angry with you. She is not even aware of it initially. We see her anger toward you because she starts to resist closeness with you. For instance, you asked about anger toward the husband, and she resisted. Or you addressed her self attack while she remained detached, and she probably disagreed with you or argued or dismissed what you said = resistance in the T. Or she talked about people she was angry with and said she didn’t dare tell them about = I am angry with you and dare not tell you.
In other words, we fail with this kind of patient until we learn to recognize the signs of resistance toward the therapist. Once we see the resistance, we start asking for feelings toward us that make them put up a wall with us. And by keeping that consistent focus, we help them feel their rage toward us so they don’t have to act it out by quitting therapy.
Sadly, this is part of every therapist’s learning curve. All of us have a hard time picking up when the patient is feeling unconscious anger toward us as we begin our work as therapists. As a result, when we don’t see their anger in the early phase, it builds up, and then the patient acts out by dropping out of therapy. The sooner we pick up on the resistance and the underlying mixed feelings, the sooner we describe their resistance and ask about feelings toward us, the more we keep patients from acting out their rage in this way.
This is part of the learning curve for all therapists. The issue was not what you did or said. The issue was that you didn’t see the early signs of resistance, so it built up and built up until she blasted out of your office. 
Here are signs that the patient is resisting you and not just resisting feelings: looking away, pausing, going silent, going up in the head, avoiding contact, refusing to explore important issues with you, arguing with you, going helpless, going passive, describing relationships where she hides what she feels and thinks. When those actions occur, describe those actions, label them as a wall against contact, and then ask about feelings toward you that make the patient withdraw. Keep that focus exclusively until there is a breakthrough to feeling. In the meantime, her feelings toward you will rise so that she does not have to channel them into acting out.

Should I restructure projection or ask for feeling?

“I’m sometimes struggling when it comes to differentiating transference resistance from projection. For example, a patient says, “You’re criticizing me,” when the patient knows in reality I’m not. In this example, I’m often torn between exploring the anger coming toward me or do I treat it as a projection and differentiate myself from the projection? When I focus on the anger toward me it often works, but I’ve had a few unsatisfactory experiences when I get iatrogenic anger.
I recently brushed aside the projection and asked what comes up if the patient doesn’t turn my good feelings into something critical. I get breakthroughs of deeply painful feelings when I do this with patients who reject themselves and their feelings. Any thoughts would be helpful.” Thanks to Ange for these great questions!
If the patient thinks you are critical but is able to see this is a perception and not reality, then the projection is a tactic to keep you at a distance, and you can ask for feelings toward you. If the patient is in cognitive/perceptual disruption, the projection will lead to some loss of reality testing, and asking for feelings will not trigger sighing. In such a case, we need to restructure the projection, so the patient can see the difference between you and the projection first before exploring feelings.
In the case Ange describes, the patient has what the psychoanalysts would call a “superego transference.” The patient transfers the superego onto the therapist and cannot see the difference between the therapist and her superego. Exploring the anger toward the therapist would lead to a misalliance since the patient would only become more convinced that you are a critical superego to her.
Ange’s intervention is very effective: “Notice how you take my good feelings and turn them into criticism? Then you would lose me as your ally, and end up alone with a critic. Then you would be lonely here with me, like with your husband.” This would clarify the price of her projection of the superego. She could then elaborate, “Notice how this image of a critic comes in here between you and me? Then you would be in relationship to this critic and then lose all contact with me? And then I couldn’t reach out to you, because I would be unable to reach you from behind this barrier of the critic. Then you would be alone. Why do that to yourself?”
Other variations of this you can find in my book, “Notice how the critical part of your mind takes my caring comments and tries to convert them into a way to punish yourself? Could this be a form of self-punishment? Do I have your permission to interrupt anytime this critical part of your mind tries to come between us to torture you?” “Could you and I join forces against that punitive part of your mind, so it would be cornered instead of you being cornered?”
What Ange touches on here is that projection can show up in different ways in the three systems of resistance: 1) isolation of affect: anxiety in striated muscles, excellent reality testing, projection as a tactic to distance; 2) repression: anxiety in smooth muscles, less reality testing, projection of the superego; 3) projection: anxiety in cognitive/perceptual disruption, projection of a split off feeling of anger usually, loss of reality testing.
In isolation of affect, we can brush aside the projection and ask for feeling. In repression, we must address the projection of the superego to re-establish reality testing and to establish an intrapsychic focus. In cognitive/perceptual disruption, we must restructure the projection to establish reality testing, so the patient can tolerate the emotion of anger inside without projecting it outside. Only then is pressure to feeling advisable.
If the patient is projecting the superego, pressure to feeling will worsen the patient’s reality testing, with the patient experiencing the therapist either as more critical or the patient will become more depressed. If the patient is in cognitive/perceptual disruption, the more feelings invited, the more feelings the patient has to project, and thus, the worse the reality testing and resulting misalliance.
When wondering about what to do with a projection, see what is projected, which resistance system is operating, and which pathway of anxiety is in place. When you invite feelings and signaling stops, pay attention to the defenses to find out which resistance system is operating. That will help guide you on how to proceed.