Monthly Archives: February 2019

You tricked me!

“My patient declined to explore a problem which previously she adamantly wished to do. I respected her position and asked her to identify a different problem that she did want to work on. She revealed something very close to the topic she had wished to avoid. When asked for a detail she became furious and suspicious then cut off communicating convinced that I had tricked her. No effort I tried was able to ‘disarm’ the projection. She insisted on leaving. Of course now I am faced with a misalliance.” What would you advise?” Great question.

When she did not wish to explore something, she was projecting onto you that YOU wanted to explore. Thus, she would be wary of you, fearing your supposed desire to get into her mind. So when you invited her to offer another problem, you unwittingly reinforced her projection. Exploring a problem when the patient projects that You want her to reveal yourself reinforces the patient’s projection, resulting in a loss of reality testing.

Instead of asking for another problem, it’s more important to deactivate the projection. 

Pt: I don’t’ want to look at this.

Th: That’s ok. I have no right to ask you to explore something you don’t want to explore. If there is something you want to explore, I’m happy to help you do that. But if you don’t want to explore anything, I have to respect your wish not to explore anything right now.” 

Full stop. This leaves her with her conflict: a wish to explore and a defense against doing so. And it leaves her with the price: no progress. If she reveals a problem, it has to be her will to do so. Deactivating all projection of will onto you is essential to avoid a paranoid transference: the patient fearing you will make her reveal herself against her will.

The second projection you mentioned is her statement, “You tricked me.” 

She doesn’t realize that she wants to reveal her problem to you. So when it slips out, she assumes you “tricked” her. Thus, she becomes even more paranoid. This projection of omnipotent mind control must be deactivated. Otherwise, the patient will slip into a psychotic transference where she equates you completely with her projection, and fears you as a mind invader.

Pt: You tricked me.

Th: I can’t trick you into revealing something you don’t want to reveal. I can ask if you want to reveal your problem, and in response you can say yes or no. That’s up to you. I can’t make you reveal yourself. Only you can make yourself reveal yourself. And if you don’t want to, I have to respect your right to keep your problems to yourself. You have every right to keep inside what you want inside. Would you be willing to keep inside what you want to keep inside?

Notice here two things: 1) we deactivate the projection of you as a mind invader by reminding her of reality (only she can reveal herself); and 2) we do a counter projective maneuver—we encourage her to keep her inner life secret for now (Would you be willing to keep inside what you want to keep inside?). This deactivates her projection onto you and at the same helps reinforce her boundaries which are “leaky.”

Precisely because her defenses are so weak and primitive, she can’t hold things in like a much healthier patient could. Helping her reinforce her boundaries in this way will help her trust that we are not trying to weaken boundaries which are already weak. 

Patients with severe ego fragility, like this patient, suffer from a dual fear: 1) they are afraid of what will leak out; and 2) they are afraid of what will get in. In other words, they are afraid that they will tell you about themselves and become overwhelmed by feelings and anxiety and then regress. And they are afraid that if they let you in, you will dominate them and they will lose any sense of a separate identity. 

If you keep these primitive fears in mind, you can deactivate the projections accordingly.

Pt: I’m afraid of what I will tell you.

Th: Would you be willing to hold in whatever you want to hold in until you feel it is the right time?

Pt: I’m afraid I might tell you something I regret.

Th: Would you be willing to hold things in until you can be sure that it is your will to tell me and not someone else’s?

Pt: But then I might not tell you anything.

Th: Would you be willing to give yourself the right to say nothing?

Pt: Yes. I think so.

Th: Because unless you are free to hold back what you don’t want to say, you aren’t really free to say what you want to say.

Pt: I hadn’t thought about it that way.

Pt: I’m afraid you want to get in my mind.
Th: The good news is: I can’t. I can only know about your mind only what you reveal. If you tell me nothing, I know nothing about you. If you tell me a little, I know a little. So the good news is, I can’t get in your mind. I can only hear from you about what is in there.

Take home point: when the patient is projecting her will upon you, deactivate the projection thoroughly. Otherwise, your exploration of anything will “feed” the projection and make it worse until there is a loss of reality testing where the patient equates you with the projection.

Why is learning therapy hard?

In supervision, a supervisor lets us know when we made a mistake, so that next time we can make a better intervention that leads to healing. But it hurts to learn we made a mistake. Why? It’s not just because it hurts our self-esteem. When we make a mistake in therapy, we either cause or perpetuate the patient’s suffering. That is, our best attempt at loving the patient (psychotherapy) actually caused harm. The result? We feel guilt. And that’s why it’s hard to receive supervision. We learn that we hurt the patient when we were trying to heal him. 

Our task as supervisors and colleagues is to face reality: all of us make mistakes. We always will. All of us have hurt patients through our mistakes. All of us feel guilt. And this is painful.

Sometimes supervisors avoid this problem by just “being nice” and offering approval rather than genuine supervision. Sometimes as colleagues we sympathize and rationalize and say, “it wasn’t so bad.” We try to avoid the guilt that is inherent in learning psychotherapy.

We do this out of a false sense of compassion. Compassion comes from the Latin: to suffer with. If we try to erase painful reality of the mistake, we hope to erase the guilt, so there is nothing to suffer. But this is pseudo-compassion. Genuine compassion is facing reality together: “You made a mistake that hurt the patient. I have done this too. Let’s face this guilt together because it is a sign of your love for your patient. And let this guilt guide you in the learning so that next time you can do better work and repair the harm you did.”

Unlike in many fields, guilt is inherent in the learning of psychotherapy: our mistakes cause pain. As therapists, supervisors, teachers, and colleagues, our task in learning is to identify with each other as people whose mistakes cause suffering. If we can bear the guilt that comes when learning of our mistakes, that guilt, based on our love, can mobilize us to learn more, work harder, and become the best healers we can be. In other words, just like in life and in our love relationships, facing our guilt over the mistakes we make mobilizes us to engage in the act of repair. In our case, this loving act of repair is known as learning psychotherapy.