Monthly Archives: December 2018

ISTDP with violent offenders

“I´m working with men who batter their wives and am trying to motivate perpetrators to change their behavior and to seek therapy. I am trying to create a brief intervention method (no more than 15 minutes) that social workers, police and others can use to assess and motivate batterers to seek treatment. Motivational Interviewing is one method. But I would like to base the method on ISTDP. I imagine that working with projections is essential. Any thoughts would be helpful.” Thanks for this very interesting and important question.
First of all, while we can assess, for instance, somatization in about fifteen to thirty minutes, we cannot usually help a batterer see his defense, see that it hurts him, and motivate him to seek therapy in fifteen minutes. So if we leave this kind of unreasonable time limit to the side, let’s take a look at how to help this kind of patient.
First of all, to motivate this group we first have to find out if it is a problem for them and, if so, why it is a problem. Often these patients deny that their impulsivity is a problem. As in motivational interviewing, we will spend our time mirroring his denial and splitting until he can bear the rise of feelings that will allow him to admit that this is a problem. This process can take some time and requires patience on the part of the therapist.
Pt: I don’t have a problem. [denial]
Th: Wonderful. [mirror denial]
Pt: So what do you want? [projection]
Th: Nothing. I’m just wondering what the problem is you would like me to help you with. [block projection]
Pt: I don’t have one. [denial]
Th: So a man without a problem finds himself in a therapist’s office. [mirror contradiction between his words and actions]
Pt: The probation officer said I need to come here. [projection]
Th: Since I can’t help him, I have to ask you what the problem is. [block projection]
Pt: Everything is going well. [denial]
Th: You’re a lucky man. [mirror denial]
Pt: [fidgets] Well I don’t have a problem I can’t handle. [Beginning acknowledgement of a problem with denial of a need for help]
Th: That’s the best position to be in: to have a problem and know how to handle it. [mirror denial]
As a result of this process of mirroring denial and splitting while blocking projection, over time many of these patients will eventually admit to a problem.
Next, draw his attention to the price of the defense for HIM:
“What impact does it have on you when she fears you rather than loves you?” “What impact does it have on you when your son/daughter is afraid of you?” “What impact does it have on you when you have departed from your strongest self?”
“What impact does it have on you when you let the rage be in charge instead of you being in charge of the rage?”
“Would you like to be the one with the power instead of the rage taking the power away from you?”
You could also deactivate the gratification of losing control.
“I get the sense that it feels like a relief to let it out, but would it be fair to say that the rage gets its way but then leaves you to pay the price?”
“Do you notice how the rage is happy that it got its way, but then you are the one who gets punished? You must be angry at how the rage tricks you and sets you up this way.”
Help the perpetrator see how the impulse does not solve his problems but creates them, and remove the gratification he receives for his impulsivity.
Then you can mobilize his will to the therapeutic task:
“Would you like me to help you regain your power, so the power is in you rather than the rage taking the power away from you?”
“Would you like me to help you become in charge, so the rage is no longer in charge of you?”
“Would you like me to help you become more powerful, even more powerful than the impulse? Is that the kind of power you would like your children to admire?”
Thus, once he has agreed there is a problem, and that it is a problem for him, we can begin therapy.
Usually, people with this kind of impulse problem really have a projection problem. They feel powerful mixed feelings. As a result of splitting, they feel only split-off rage and no love toward their spouse. Since the spouse is now viewed as “all-bad”, there is no guilt or anxiety to inhibit the impulse. So the perpetrator directs all his rage at the all-bad projection he has placed on his spouse.
In the therapy, we will need to build his capacity to bear feelings inside him so he doesn’t project those feelings outside of him onto others, where he beats those feelings and projections. This process of building the capacity to bear feelings inside without projecting them outside is called restructuring the resistance system of projection.
Hopefully, this gives you a place to start.

My supervisor doubted whether I should be a therapist!

“Dear Jon, My past supervisor doubted whether I should do therapy. Now as I begin a new placement, I doubt myself and I’m afraid of how I will make mistakes and that I will become anxious with patients. What if I stutter to death? What if I mess up?”
All of us have had doubters in our lives. Their opinions mattered to us. I have had doubters in the past say that I had “shit for brains” and that I was a “dumb shit”. I had a music teacher who said that I sounded “like hogs rooting in the mud in a barnyard in Iowa.” Doubters doubt all of us.
Even though they are gone, we can always bring them and their opinions into the room to torture us. We can always misuse our memories for the purpose of self-punishment. This will be true no matter how much further training you or any trainee seeks. Let’s face it: you have decided to break the law of the doubters and discover your potential instead. When we break their law, our anger rises. When our anger rises, we might protect them by continuing to doubt ourselves, punishing ourselves for having broken their law. But we must leave their prison if we are to become free.
When you start seeing patients, your anger will rise toward previous doubters. You may protect those doubters by letting the anger go back onto you in the form of self-doubt. That will probably happen for a while. You will not always know what to do (like all therapists at all stages). And at those moments, you might punish yourself for not knowing what to do (the failure to be omniscient). You might stutter with your first patients. That will be a sign that you are anxious in front of your former therapist, when in front of you will be a patient even more anxious than you are! And for some patients your anxiety will be a relief: “Oh. Thank heavens. My therapist knows what it is like to be anxious. She will understand me because she is a suffering human too!”
Now, as for stuttering to death, what will die? You? No. What will die will be a perfect image, an image of a supremely calm figure, an image without flaws, an image that is omniscient, an image that every mind creates but no one has ever become. As you begin to treat humans in therapy, you will begin to accept yourself as a human, someone who gets nervous, who hates herself at times, who can have irrational ideas, who stutters, who….you name it.
Patients don’t need ideal therapists; they need real people. They need you: your compassion, your understanding as a fellow sufferer, another imperfect person who messes up—your humility. If we needed to be “cured” before doing therapy, no one would be able to do therapy. The more you embrace your flaws, your neurosis, and your humanity, the more you will be able to embrace the flaws, neurosis, and humanity of your patients. They don’t need you to be ideal; they need you to be real. They don’t need someone who sits up above them on some throne; they need someone who can sit next to them on the ground.
You worry you will mess up. I guarantee it! I have messed up many times. I still do. And I am sure I will mess up in the future. In life, we mess up. We mess up in friendships, in love, and in therapy. That’s what we humans do. And through our mistakes, we learn, we apologize, and we try again. There is no other way. We don’t become perfect and then magically go through life handling everything just fine. We make mistakes, learn, make more mistakes, learn, and repeat the cycle. That’s how we learn: through living.
You worry you will mess yourself up. I guarantee that too! Therapy messes us up. We get stirred up. And that’s also how we learn: through living. But, to be clear, we don’t get messed up in therapy. Our illusions get messed up. When emotions and the truth mess up our illusions, we might think we are getting messed up, when our former illusions, ideas, and lies are getting messed up. And, as a result of this messy experience, we grow. This happens repeatedly through the life cycle of therapists. Countless times I have been overwhelmed with some feelings, some puzzling experience, some mess with a patient. And over time, by living through it, I learn something more deeply about myself and my patients or my supervisees.
So I invite you to join the rank of humans who do therapy: people who don’t always know what to do, people who make messes and learn from them, people who get messed up by these experiences, people who get scared: therapists.
Thanks for sharing your concerns about being human,