I don’t know what my problem is

“When I ask, “What’s the emotional problem you’d like my help with today?” sometimes, long-time patients reply, “I don’t know.”
We established goals for treatment earlier and had an unlocking of grief or anger already. Is not the problem clear? I don’t expect my patients to know everything, but I would expect something like, “I’m not sure exactly, but let’s keep working on my anger problems.” Others ask me for advice on how to handle a life situation when we had established earlier that the goal was to get to the bottom of their emotions.
Should I point out this defense?
 Is it resistance in the T?
 Might this be a good intervention? “We have established a clear goal together, and you say you don’t know what you want to work with. Could it be that you’re becoming a little passive/helpless with me right now?”
 Do I need to be clearer about the conscious treatment goals? Or is this repetition just necessary?” Thanks for this important question about a common problem!
When you have established goals for the therapy in the opening session, you go ahead and explore the situations where the patient’s problems arise to determine the feelings, anxiety, and defenses that cause his presenting problems. Then we explore those feelings as deeply as possible, while ensuring that anxiety is regulated, and helping the patient see and let go of defenses.
As you become more intimate with the patient, his complex mixed feelings rise. As a result, you had several breakthroughs to grief and anger. But since he experienced these feelings, he is becoming more emotionally close to you. To distance from his feelings, he eventually begins to distance from you. When he distances from you in the opening of the session, he does so often by saying, “I don’t know what to work on today.” You can bet that when he goes to the car mechanic, he does not say, “I don’t know what I brought the car in here for.”
I use this metaphor to highlight how this behavior is a defense against closeness. To answer your question, yes, this is not a defense against feeling but a resistance to emotional closeness, what we call a transference resistance. You do not need to clarify again the goals of therapy. Instead, you need to point out that he comes to the therapy without a goal or a problem, and that would make you or any other therapist useless.
Start by identifying this treatment destructive behavior. This can be done in many ways.
Th: So a man without a psychological problem finds himself in a therapist’s office. [Pointing out the contradiction between what he says and does.]
Th: If you don’t have a problem to work on, we can’t help you can we. Notice how this is a barrier to us being able to work together? I wonder what feelings might be coming up here toward me that make you put up this barrier? [Resistance identification. Clarification of the price of the resistance. Inviting feeling toward the therapist because the patient is resisting closeness with the therapist.]
Th: You say you have no problem for us to work on. Then you leave it up to me to declare the problem. Notice how this is the same kind of passive behavior that you mentioned comes up with your wife? What feelings are coming up here toward me that make you put up this barrier of passivity? [Identify the resistance of passivity. Invite feelings toward you.]
If you do this in one session and in the next session he again says he has no problem, then:
Th: I wonder what feelings are coming up here toward me?” [His resistance is a sign of feelings rising toward you. So you use his unconscious signal (the resistance) as a sign to invite the feelings toward you he is resisting.]
Take home point: when you are working with a patient whose anxiety is in the striated muscles and he is intellectualizing and detaching from you, he is resisting emotional closeness with you. Identify his resistance, point out the price, and ask for feelings with you. His distancing with you is the central problem you need to address.






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