ISTDP Institute

No wonder the patient gets angry with you! You are irritating!!

“A colleague said, ‘No wonder the patient gets angry at you. Your constant pressure for feeling can come across as irritating!”  How would you respond?

My own inclination (based on your book and Allan Abbass’ book) is to say that: 1) pressure to feeling and defense work are key to healing; 2) if we do not persist we will never reach through the resistance which defeats both us and the patient; and 3) the patient’s unconscious communication (e.g., negation ‘I’m not angry.”) signals a rise in the unconscious therapeutic alliance, suggesting we are on the right track. Without this, irritation can be a sign of a misalliance due to a mistake by the therapist.” Great question and great answer!

Obviously, it is never our intent to irritate a patient. After all, that would not be therapy but sadism! If you act like a jerk, the patient will rightly feel angry toward you, without mixed feelings, and without any therapeutic result.

So why do we ask for feelings? To form a healing relationship. In this bond, together with the patient, we embrace the formerly unembraceable: his complex mixed feelings under the anxiety and defenses.

When we invite the patient to form a healing relationship, feelings arise. These feelings trigger anxiety and defenses. As we regulate anxiety and point out defenses, we implicitly welcome and accept his entire inner life.

In response, the patient’s forbidden anger rises. If it is accompanied by sighs, we know that the anger is simultaneously connected to love, complex feelings that cause the anxiety. That is our unconscious signal to continue exploring. When the patient says he does not have feelings, he does not feel irritated, he does not feel anger toward you, these negations are further unconscious signals: feelings can emerge as long as they are negated—another sign to continue to explore feelings. Even the patient’s defenses are signs that we are going in the right direction! After all, if there is no treasure, there is no lock on the door.

Let’s suppose, however, that the patient believes you really are trying to irritate him. Then we have a conscious misalliance, which must be corrected. “Thanks so much for letting me know. It’s not my intent at all to irritate you. So let’s back track for a moment to make sure we’re on the same page.” Then remind the patient of the triangle of conflict causing his problems. Then remind him of causality: how his defenses are causing his problems. Then remind him of the task you two agreed upon: to face the feelings under the defenses so that he can feel and deal instead of avoid and suffer. It’s just as important for patients as it is for colleagues who view our videos to understand what we do and why we do it. Otherwise, both patients and colleagues will suffer from a misconception about the work.

Sometimes a misalliance will occur later in the work, even when the two of you agree on the conflict, causality, and task. If you point out defenses constantly without inviting feelings toward you, the patient will experience you as a critical superego, leading to a misalliance. If you challenge defenses before the patient has begun to resist closeness with you, you will get a misalliance. If you challenge or confront the resistance to emotional closeness prematurely, you will get a misalliance. If you challenge a fragile patient, unable to tolerate the sharp rise of feelings, he will project his anger onto you, and then you will have a very bad misalliance.

And, to be absolutely honest, a good therapist will sometimes be very irritating. Why? We are supposed to be honest, telling patients what they do that hurts and sabotages themselves. There is no reason for patients to be ecstatic when we tell the truth. As the ancient Roman theologian Tertullian said, “The first response to the truth is hatred.” So when we point out defenses and the destructive impacts those defenses have, patients will become angry with us. And, if we look honestly within ourselves, who among us hasn’t felt a flash of anger internally when someone has pointed out the truth about us? So in response to their anger when we point out the truth, we ask: “So what feelings are coming up here toward me?” Even if they are angry when we tell the truth, we don’t ask them to lie about their anger. Instead, we invite them to explore and feel it as fully as possible.

After all, that’s what we do in a healing relationship: face the truth and our feelings about it.

 

 

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Jon Frederickson

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One response to “No wonder the patient gets angry with you! You are irritating!!”

  1. George Williams Avatar
    George Williams

    “A colleague said, ‘No wonder the patient gets angry at you. Your constant pressure for feeling can come across as irritating!” How would you respond?
    My own inclination (based on your book and Allan Abbass’ book) is to say that: 1) pressure to feeling and defense work are key to healing; 2) if we do not persist we will never reach through the resistance which defeats both us and the patient; and 3) the patient’s unconscious communication (e.g., negation ‘I’m not angry.”) signals a rise in the unconscious therapeutic alliance, suggesting we are on the right track. Without this, irritation can be a sign of a misalliance due to a mistake by the therapist.” Great question and great answer!
    First I would like to comment about your comment regarding “my own inclination” and then reply to the question that you have asked.
    So my first question is “How do you feel about your colleague’s comment?””
    What strikes me is that your colleague may be correct. Possibly you do have some irritating or provoking character. In fact we can say that your colleague who I assume spends some time around you professionally finds you irritating. Maybe you need to look at that first, instead of looking for some technical response or justification for why your colleague would say that.
    However, it is clear that your colleague is irritated with you and is using this as an opportunity to express his feeling about your character. So possibly you and he have a transference neurosis with each other and that is why he is over reacting towards you. Also how does he know what you do in a session? Where does he get the idea that you pressure towards feeling and that the client gets irritated with you? None of this makes sense to me. So I find it very difficult to respond to any of your concerns without knowing much more information so I will have to make some assumptions.
    I will assume that this colleague has seen some of your video tape and that he is not practicing ISTDP and does not understand Dr. Davanloo’s metapsychology. It is clear from your comments that you are practicing his ISTDP as you refer to Dr. Abbass’s new book.
    So if this is the case, your colleague’s unconscious may be reacting to ‘the pressure of hearing your interventions’ as it is stirring up his unconscious feelings as it always does in most participants. If this is the case he wants to reject the technique because it is stirring up too much emotionally for him and so he is trying to find fault with you that somehow you are the cause of his anger. Dr. Davanloo experienced this all the time. I myself have witnessed colleagues ask provoking questions of Dr. Davanloo as they are stirred up by Dr. Davanloo’s presentation. It happened to me in a huge way during my first experience of his technique. If this is the case, then it has nothing to do with you (your character) or the technique other than supporting the idea that it is effective in stirring up all the complex transference feelings in any human unconscious.
    In the event that he truly finds you irritating, possibly you have some character qualities that are irritating to people and drive them away. Just because we are therapists does not mean that we are free from destructive character unless your unconscious is completely clean and clear. Dr. Davanloo would frequently comment that Health professionals and especially psychiatrists have the most resistant and complex unconscious of all human beings and it is loaded with murderous rage and guilt. He was referring to psychiatrists, psychologists, medical doctors who are long-standing character neurotics. So it is quite possible you have some character problems that he is referring to. However, even if this is true, I am certain his reaction relates to his issues either about his reaction to the technique or his transference with you (transference neurosis) or both.
    Now you ask a good question. Your question was this: “A colleague said, ‘No wonder the patient gets angry at you. Your constant pressure for feeling can come across as irritating!” How would you respond?
    This is my response to your question. I would suggest you speak to your colleague and something like this:
    “Hi Dr. Smith, would you have a few minutes to chat sometime. I was very interested in your comment that you made the other day about me irritating my patient. I would really appreciate if you could elaborate more on it so I could have some insight into your concerns. Could you tell me where you got the idea that I am irritating to my patient? Are you saying that my character is irritating to patient? Or, are you saying that my technical intervention is irritating to the client? Or are you saying that in your opinion the “repetition” of the question is too often or too much? Dr. Smith, how well do you understand Dr. Davanloo’s technique? Are you interested in learning about it more? (or) Dr. Smith are you saying with your clients that you use different forms of pressure or are you saying I use too much pressure or poorly timed pressure? Could you give me an example Dr. Smith of where the problem is that I have? Possibly we could look at some of your tape and you could show me how you approach this issue of pressure with your ISTDP clients?”

    I will respond to your “inclination” one point at a time as you nicely numbered them.
    My own inclination (based on your book and Allan Abbass’ book) is to say that:
    1) pressure to feeling and defense work are key to healing;

    Yes, pressure is essential to create rise in the Complex Transference Feelings. Please remember that these feelings are all the feelings. Dr. Abbass clearly reminds the reader that we should not focus on only anger or even one feeling at a time. Dr. Davanloo has concurred with this. Dr. Davanloo in core training frequently suggested that we focus on the word “feeling” to encompass all feelings including rage, guilt, grief, loving or positive affectionate feelings and sexualized feelings (that may be fused with the rage). Dr. Davanloo suggested switching to the word “anger” or “rage” or “irritation” after the client uses the word or when there are clear signs of the somatic pathway of the rage. Dr. Abbass even builds on this point remarking that it is not good to focus on only one feeling. So your colleague friend is mistaken and it actually makes me think he does not know much about ISTDP. Dr. Davanloo’s technique is not about focusing on anger and rage. He has made this crystal clear. It is about helping the client to face all their mixed feelings (rage, love, guilt, grief) in relation to their parents/genetic figures/caregivers and putting them all in the right perspective. Too much emphasis is put on the unlocking to the rage. But without love the rage is nothing. Then you only have a psychopath, killing his parents. The guilt is the key to the feeling that must be removed from the client. “Healing” comes from actual physical experience of the somatic pathway of the guilt as well as the multi-dimensional structural changes that are necessary for successful treatment. I have had many clients stop their therapy immediately after a Major Unlocking with excellent access to the guilt. They found the process to disturbing and they quit therapy. Up to that moment they were working with me or otherwise I could not have had access to their unconscious.
    Dr. Abbass inidicates that the two key factors to healing are pressure and recapitualation. The pressure can be applied to many areas but he mainly is focusing on the feeling as you make reference to. Again, too many therapists focus on feeling and are “fishing for the anger” (as Dr. Davanloo referred to it). What does this mean? They focus on anger because often that is the first feeling they identify in the client. This approach is dangerous with other types of clients such as psychosomatics or fragile. Most of my clients present sexual feelings or positive affectionate feelings in the first or second session. (It is easily explained when later they tell you that their father had sexual intercourse with them for 7 years) So this is why you must be careful when dealing with this question “how do you feel?” (towards me, towards him/her) Most therapists are so impressed by seeing a major unlocking and the changes afterwards that they aim for that. But they do not see the thousands of hours of hard work that went into the persistence with observation of detail and the intracacies of the unconscious communications. It is like watching an expert play the French horn. They make it look easy. No one appreciates the countless hours the put in practicing that instrument to make it look effortless. It is only another expert in horns who can truly appreciate the quality, effort and persistence of that horn player. So in some ways this word anger or rage is a four letter word.
    I see so many therapists trying so hard to be successful during the therapy session. They have a demanding voice in their head thinking about what to do next to get to that unlocking. That thinking destroys therapies. They need to be thinking how can I get in tune with this persons unconscious so I really can connect with them. It is this very demanding pattern in their head that blinds them to see that the client feels all that pressure and is unable to produce what you want. Just forget about the unlocking. Focus on listening. Even Dr. Abbass and Dr. Frederickson makes clear communications about the importance of mirroring the client. What does this mean? It means unconsciously feeling the client’s feelings before you realize what is consciously happening. It is this “mirroring” that guides the therapist in making some of his decisions. I tell the client that the UTA is our friend on the inside helping us out. He lives in the dungeon and we need to get him out. He is our man on the inside who sends us important information.
    2) if we do not persist we will never reach through the resistance which defeats both us and the patient;

    Yes, you are correct that Dr. Abbass makes it clear that pressure is the most important element as it is the lifeline to the person behind the resistance. However, you need to be persisting with the correct intervention in the correct direction. Far too many therapists are hammering away with persistence towards feeling when that is not the front that is sitting in front of them.
    I think the therapist projects too many of their problems on to the client when it is some technical or metapsychological misunderstanding that the therapist has at that moment with that particular client.

    3) the patient’s unconscious communication (e.g., negation ‘I’m not angry.”) signals a rise in the unconscious therapeutic alliance, suggesting we are on the right track. Without this, irritation can be a sign of a misalliance due to a mistake by the therapist.”

    Yes, this is correct. If we are sure we are getting unconscious communications from the UTA, then this means we have a Rise in the Transference. But remember Dr. Abbass refers to them as “whispers” from the UTA. He is suggesting that the UTA is not a dominant force yet. This means that although you may be getting whispers from the UTA, your mistakes or the Resistance could wipe the process out of operation within minutes of that whisper that you received. There needs to be many parameters that you measure to determine exactly where the patient’s unconscious is at that present moment.
    George Williams

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