When do you need to integrate the personality first?

Forming a relationship with another human being always triggers mixed feelings based upon our attachment history. As these mixed feelings rise, patients respond in one of five ways:

  • they tolerate the rise of feelings, sharing with you, and becoming more intimate;
  • they tolerate the rise of feelings, but start to unconsciously detach from the feelings;
  • they tolerate the rise of feelings, but start to detach from their feelings and from you;
  • they tolerate the rise of feelings, but protect you from their anger by turning it upon themselves
  • they cannot tolerate the rise of feelings, so they relocate their feelings and desires in other people.

This last group is known as the fragile group. When mixed feelings rise, they become overwhelmed with anxiety (cognitive/perceptual disruption). If anxiety continues to arise, to get rid of the anxiety, they get rid of their feelings through splitting and projection.

Once they split off and project their feelings onto others, they interact with the projections they place on other people, not with the people themselves. For instance, a fragile patient may project her anger onto others. Then she fears others upon whom she projects. Then she fears going out of her house. Another fragile patient, projects his anger upon others, imagining they are talking behind his back all the time. In response to this imaginary stimulus, he becomes chronically angry at his projection (the supposedly critical people).

Exploring feelings with this group becomes problematic. First of all, as soon as you explore feelings, the patients begin to split off their anger from themselves and project it onto others. Secondly, often, when these patients report being angry, they are reporting anger at a projection, not toward a person. If you explore their anger toward a projection, they merely become better at projecting!

Our first two tasks with this group are restructuring the unconscious pathway of anxiety discharge and restructuring the resistance system of projection. Doing these two things is referred to as “integrating the personality.” That is, we help the patient integrate within himself the feelings, impulses, and desires he formerly located in others.

Maury asked here, “When do we do that?” When patients are fragile. Signs that they need help with integrating what they formerly projected include: cognitive/perceptual disruption, splitting, and projection. Signs that patients are using projection (with loss of reality testing) are rapid speech (to keep a projection on you from criticizing her), speaking loudly (to drown out the projection the patient has placed upon you), urges to run from therapy or leave the session early (to leave the projected feeling in the room and run away from it), severe anxiety or panic in your presence (fear of the projection the patient has placed upon you).

Often, the patient will tell you about problems in her outer life that indicate projection is active in the room: “I’m afraid of people”; “I’m afraid of what people think, so I avoid them”; “I get into fights a lot”; “People are extremely critical”; “You can’t count on anyone at all”. Sometimes, projection emerges clearly in the room: “I’m afraid you will hurt me”; “How do I know you won’t misuse those videos!” “You look angry.”

One sign therapists often miss is the lack of signaling when the patient reports being angry. When the patient is angry at a projection, you will see no sighing or tensing. Why? No unconscious anxiety is mobilized because this is conscious anger toward a projection. Likewise, the patient will use no defenses to interrupt or ward off his anger toward a projection. Why? Because the anger is already toward a defense: the projection he placed on someone else.

Once you realize he is angry with a projection, stop exploring anger toward the projection, and start restructuring the projection.

Another sign is that when you ask if it is his will to do look at an important issue, he may agree, but not sigh. The absence of signaling always tells us that the patient’s will is not on line. But in this group the lack of signaling tells us that the patient is relating to a projection, not to you. There can be no conscious alliance if he is relating to a projection he thinks will hurt him. Thus, you have to differentiate yourself from his projection so he can have an alliance with you instead of misalliance with his projection. He lives in a world of projections, people he fears will hurt him. Once he owns his feelings internally, the world will become a much more benign and less frightening place. This is your first task.

 

One thought on “When do you need to integrate the personality first?

  1. Reyhaneh

    Dear Jon
    I have experienced some challenging situations with BPD patients. I would like to know what your approach will be in such sircumstances below:
    1) She invites you to her birthday party to introduce you to her parents.
    2) she calls you while she is heavily drunk.
    3) her father calls you and asks you to talk to her because she is cutting and doing a suicidal act.
    These situations was realy hard for me and I was not sure what the right decision could be and how should I do that in the best way.
    Thank you so much in advance for your kind consideration.

    Reply

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