Why is my patient talking so softly while hunched over?

“A young man with severe depression has a history of self-harm since he was 5 and severe neglect by parents, who told him to man up when he showed them the cuts he did to himself. We worked on his fear of opening up to me, and
how he hides behind vagueness. He speaks very, very softly while hunched over. In our last session, we talked about his stress at university. He talked about a lecturer who didn’t show up to 10 of their 12 lectures, and how because of that he now struggles in class. (Is this a strange person to work on, given that we
worked on more important people in past sessions?) He said anger quite clearly without defenses, and when I asked him how he felt it, he was able to say heat in the stomach, and the impulse to hit. But it was weird because he said this still
hunched over (elbows on knees), and with that soft voice. So I asked him
about it, and he said he has weekly episodes of derealization – where he
seems like he is a few meters behind his head and when he watches his
body, the body isn’t his. I asked if that was happening now, and he said he wasn’t sure, but maybe. This is very weird, any ideas? He does sigh once in
a while, but not much, maybe every 7-8 minutes, and his hands are limp.” Great question!
The fact that the patient speaks “very, very softly while hunched over” suggests that he is responding to a projection he has placed upon you. Perhaps he views you as a father who will tell him to “man up” as soon as he reveals himself. We don’t know. What we can be sure of is that if he was in relation to you, he would look at you, talk in a normal voice, and sit up.
When he appears to be relating to a projection, explore his thoughts and ideas about the therapy to find out what projections are in the room. “I notice you are talking very softly. I wonder what thoughts and ideas you might be having about the therapy?” When he tells you about his thoughts, you will learn what projections he is placing upon you. Then you can help him see the difference between you and his projections.
1) “So these are some thoughts your mind creates. What is that like to notice these thoughts your mind creates?”
2) “Are these the kinds of thoughts your mind often creates?”
3) “I wonder what reactions you are having to the therapy that might be under those thoughts?”
In this way, you first help the patient see his thoughts, then intellectualize about his projections. Once he can do that, then you can ask about “reactions” he is having. This is a very graded way of asking about feelings toward you.
Unable to tolerate the rise of feelings within himself, he projects those feelings upon you, and then he fears you.
When you asked about the anger toward the teacher, he reported that he felt anger. But there were no defenses! Why? Because anger toward the teacher was not mobilizing unconscious anxiety. It was not the path to follow. Instead, he was having feelings toward you, but rather than tolerate the feelings inside him, he projected onto you. Then he sat in fear, talking softly, hunched over in front of a supposedly angry therapist. He was projecting. And, to his credit, he revealed his cognitive/perceptual disruption: his derealization. And his limp hands reveal that his anxiety is not going into tension (striated muscles) but into smooth muscles or cognitive/perceptual disruption.
Take home point: when the patient talks in an extremely soft, submissive manner, ask about the thoughts he is having about the therapy to find out what projection he is reacting to. Then help him intellectualize about his projections to re-establish reality testing. Then you can explore the reactions (feelings) that triggered his projection. In this way, you build his capacity to bear feelings inside without projecting them outside.

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