Monthly Archives: January 2019

How do I understand the anxiety symptoms in this patient?

“I have a question about the level of anxiety of one of my patients. He had a traumatic childhood, with a father who beat him regularly. He has had some jobs, but nothing stable, and he has lived a good part of his life in the criminal world. He abused various drugs, which triggered some psychotic episodes.
In therapy he has stopped using drugs while we have been building his capacity and confronting self-destructive defenses. We used to see dissociation, disturbed thinking and visual disturbance with just a low level of emotional focus. Now there is only a slight tendency to dissociation (which he is able to stop) and no disturbed thinking. He sighs and seems more solid with no regressive defenses like projection and splitting.
But he still reports visual problems at low levels of feeling, similar to what he experienced when he was beaten by his father (together with dissociation). So, I see signs of striated anxiety (sighs, tension) on the one hand and signs of C/P-disruption (the visual disturbance) on the other.
This apparent mixture of anxiety-levels confuses me. Could you could comment on that?” Great question!
Clearly, this patient has been fragile, given the dissociation, projection, visual disturbances, and disturbed thinking you saw in the initial phase of therapy. Working gradually to build his capacity, you have helped him improve. Now at low to moderate levels of feeling he sighs and, presumable, can also intellectualize.
However, when you go to higher levels of feeling you will cross the threshold of anxiety tolerance and at that moment he will begin to disrupt cognitively and resume the use of dissociation and other regressive defenses such as splitting and projection. It is not that he has these signs of striated and cognitive perceptual disruption at the same time. It is that his anxiety will move out of the striated muscles back into cognitive perceptual disruption when he crosses the threshold of anxiety tolerance. It’s just that this threshold is higher now than it used to be, and the words and feeling levels that trigger him to go over threshold are different than what they were earlier in treatment.
As an analogy, think about your work this way. Before, at 5% of feeling he would disrupt and dissociate. You regulated his anxiety, and you helped him bear 5% of feelings without dissociate. Bravo! But now, when you up to 10% or 20% of feeling, he will disrupt again and use dissociation again. Again, you will regulate anxiety and help him bear mixed feelings inside without dissociating. You will keep repeating this process at successively higher levels of feeling until he can bear 100% of his feelings without dissociating or projecting or disrupting. At that point, the resistance system of projection and the anxiety pathway of cognitive/perceptual disruption will be completely restructured.
Until that point, each time the patient crosses the threshold of anxiety tolerance, you will see the anxiety shift back into cognitive/perceptual disruption and the defenses of dissociation, projection, and splitting will occur again.
When reviewing your videos, examine the thirty seconds of video before the patient dissociates or has visual problems. Then you will learn either what you said or what the patient said that pushed him over the threshold. Now you will know the precise words or descriptions of feeling that he has to bear now without dissociating. Use bracing using those specific words until he sighs again.
When we are confused in these matters, it is because we don’t notice when the patient went over threshold and what triggered that shift. Study of your videos will allow you to analyze this in detail so that you become more attuned to the specific “dosage” of feeling he is able to manage and the “dosage” where he starts to have trouble. Then you can work at the edge of his capacity, while building it gradually.
He still has a fragile character structure, most likely. And that will remain so until he can bear 100% of his feelings without c/p or projection. Keep up the good work! Keep working slowly. Given the severity of his past symptoms and his past behaviors, I would guess that this will take a while. Be patient. Keep building capacity. He has a long way to go.
Take home point: the issue is not whether he is “in” striated or “in” cognitive/perceptual disruption. The issue is at what level of feeling does he cross the threshold of anxiety tolerance and shift into cognitive/perceptual disruption. This threshold is higher than it was, but it needs to be raised a great deal until he is able to bear 100% of his feelings.


“Can you say more about specific interventions to deal with projections for fragile patients? One is to help them notice the thoughts and see if they see any evidence for that. Most say they don’t see any evidence but as you point out some don’t immediately tense up, still look afraid or say something like “but you can be critical of me inside of you anyway.” What interventions can we use if the evidence-intervention doesn’t work immediately? When do you use experiential deactivation?” Great question!

When fragile patients project, they experience complex mixed feelings toward the therapist. Unable to bear the experience of anger and love toward the same person, they project one of those feelings: usually anger. Now the patient imagines you are angry with him, and, thus, he fears you as the projection: what we call projective anxiety.

Fearing you, he is no longer in a therapeutic alliance with you. So you must help him see the difference between you and the projection, and you must build his capacity to bear his feelings inside without projecting them inside.

Pt: I’m afraid of you. [patient looks afraid, thus loss of reality testing]

Here is a series of questions you can ask to grade the amount of feeling the patient feels.

“That’s really good to know. Thanks for telling me.” Then follow up with:
1. What thoughts do you notice having about the therapy?
2. What reactions are you having about the therapy?
3. What thoughts do you notice having about the questions?
4. What reactions are you having to the questions?
5. What thoughts are you having about me?
6. What reactions are you having to me?
7. What feelings do you notice coming up here with me?
8. What thoughts do you have about those feelings?
9. What is it like to notice those feelings inside you?
10. What feelings are you having here toward me?

Often beginning with a low level of invitation here will clear things up and as you go up the ladder slowly, you will discover the level of invitation the patient has trouble with. That is the level of invitation you will work with and build up his tolerance from there.

We can grade our invitations to the patient to build step by step his capacity to bear his feelings even without asking about his feelings. In other words, you can tailor the dose of your invitation to the patient’s capacity to bear feelings. Often projection occurs because we started to invite feeling at a level that exceeded the patient’s level of affect tolerance. So if you bring the dose of invitation down, feelings will drop, projection will drop, and then you can gradually increase the level of invitation until the patient just starts to get a little dizzy (the moment before he starts to project). Then you can engage in bracing to build his capacity to tolerate mixed feelings at the level that he starts having trouble regulating his anxiety.

This is a key issue in working with fragile patients. Once you discover the threshold where projection occurs, we need to work at a level of feeling just below that threshold. Then we build capacity until the patient goes into repression or slight dizziness and then do bracing. That way you can avoid sessions that are flooded with projection. Of course, if you are working with severely borderline or psychotic patients, this is not always possible. But it is the aim. So if you start analyzing the level of invitation you are using and the patient’s response, you will have a much more finely tuned therapy.

If you try to do the usual cognitive strategy of restructuring projection and the patient sees his thoughts but still “fears” you, you need to do more restructuring. “So there’s a thought about the future. Is this a pattern for you that you have thoughts about the future? If we go to the future, we would bypass what your body is feeling now. So if we return to this moment, what sensations do you notice in your body that could be under these thoughts?” In this way, you block his rumination about the future and you return his attention to his body and regulating his anxiety.

If he is able to intellectualize about his fear of you in the future, and he holds onto it while seeming afraid, then you can say something like this: “Can we make room for this thought?” “As you make room for this thought here, what do you notice feeling as you just let this thought be here without having to do anything about it?” This can be very helpful with patients who think you are trying to take their projection away from them. (This often happens with patients who have had many therapies.) As they learn to tolerate their thought without doing anything about it, then I might ask, “So if you let that thought grow, how might you expand it? And if you let that thought become really big, how might you grow it even bigger? And if you really let go, how could you really let it grow?” After doing this with me, one patient said, “Wow! I’m really paranoid!” I replied, “Join my club. I’m a recovering paranoid myself.” She smiled.

Two take home points: when patients project, look at your interventions for the minute before projection occurs. See the level of invitation that is triggering the projection. Then you will see how to lower the level of invitation and build his capacity from there. When restructuring projection, help the patient intellectualize more and, if that doesn’t work, assess what other projections might be operating. For instance, in the last case I described here, she was not only projecting anger onto me, but she was projecting that I was trying to make her give up her projection. So when I encouraged her to elaborate on it, I deactivated the second projection and then we saw a large increase in self-reflective functioning.