Monthly Archives: February 2019

Can happiness trigger anxiety?

“What do you think about fear of positive feelings? Do you notice an aversion to feeling positively in your clients? How do you think this develops, and how would ISTDP handle it? By fear of happiness, I mean avoiding happy feelings to escape negative consequences (such as being happy makes us selfish or immoral, being happy makes bad things happen, being happy makes others jealous of us, being happy draws us away from god, being happy brings sadness, etc.).” Great question! Thanks to Mohsen for posing this.

Of course, many patients avoid happiness. Happiness easily triggers anxiety and defenses. Why? To be happy is a crime because we are breaking the superego’s law that we must suffer. How dare you!!!

In ISTDP the defenses against happiness are covered in the concept: defenses against emotional closeness. To be intimate brings great happiness. Defenses against happiness can be triggered by different dynamic situations. 

If I am happy it may be a crime because I differentiate myself from my mother and our agreement to suffer, be unhappy, and be victims together: the depressive symbiosis.

If I am happy it may be a crime because I will have surpassed my father and achieved an oedipal victory. Therefore, I will become unhappy and deny or minimize my success to avoid my guilt over wanting to surpass him.

If I am happy it may be a crime because my colleagues will become envious. I will deny and minimize my happiness so we will be miserable together. Then they won’t envy me. The problem is that success will aways trigger envy in some people. You cannot avoid it. If you hold yourself back to avoid their envy, you will commit a crime to yourself and to those who would have benefitted from your success.

And finally, if I am happy, I turn against my self-punishment and face my underlying mixed feelings. Otherwise, to avoid guilt over my happiness, success, and pleasure, I will punish myself any time I feel happy to hide my forbidden wishes to succeed, to be happy, and to live a fulfilling life.

We deal with defenses against happy feelings as we would any other defenses.

Mohsen offers some common defenses. 

Pt: “Being happy makes us selfish.” [Self-attack]

Th: “Or is that how you justify punishing yourself?”

Pt: “Being happy makes us immoral.” [I must be unhappy if I am moral = Self-punishment]

Th: “You say you must be unhappy to be moral. Is this how you punish yourself?”

Pt: “Being happy makes bad things happen.” [Self-attack. Possibly a memory being misused for the purpose of self-punishment]

Th: “Being happy doesn’t make bad things happen; self-punishment is making bad things happen in your life.”

Pt: “Being happy makes others jealous. [Self-punishment to avoid envy and competition]

Th: “Yes it does. So are you willing to face that some people will envy your success?”

Pt: “Being happy draws us away from God.” [Being unhappy brings me closer to God = self-punishment + a view of God as someone who wants us to suffer for eternity (the superego masquerading as God]

Th: “So being unhappy will draw you closer to God? What kind of a God would want you to suffer for eternity?”

Pt: “Being happy brings sadness.” [If I am happy I will be sad, so I will become sad right away and beat the rush= Self-punishment]

Pt: “Being happy doesn’t bring sadness. When you are happy, you punish yourself. And this self-punishment makes you sad.”

As you can see, these defenses can develop due to varied conflicts. In ISTDP we deal with these defenses as would deal with any other defenses: identify, clarify, and confront the defenses. Turn the patient against the defenses. Help the patient face his mixed feelings as deeply as possible so he no longer needs to punish himself by avoiding happiness.

Remember that good outcome is not merely the absence of depression or anxiety. It is the presence of genuine happiness that shows the patient has processed his underlying guilt enough that he no longer has to punish himself by avoiding happiness, the birthright of every patient to seek.

Borderline Personality Disorder

Hi! We are two Norwegian students writing our thesis on ISTDP and therapy with patients suffering from Borderline personality organization. How do you work with these patients? And where do these patients belong, on the spectrum of psychoneurotic disorders or the spectrum of fragile character structure? Are they highly resistant or fragile?

 We want to emphasize the defenses of splitting, projection and projective identification with this patient group. We want to understand the therapy methods of ISTDP with these patients compared to the therapy methods of Transference focused therapy. How does ISTDP understand the personality structure and defense pattern of patients with Borderline personality organization? We appreciate it a lot if you take your time! Emilie & Katrina

First of all, as you know, patients who have the diagnosis of borderline personality disorder share only a set of symptoms, not a common character structure. That is why Kernberg has proposed that we differentiate the DSM-V diagnosis of borderline personality structure (a set of symptoms which can be found in people with psychotic, borderline, or neurotic levels of character structure) from borderline level of character structure itself.

Patients with a borderline level of character structure use projection, projective identification, and splitting as their primary defenses. Thus, they have what we call in ISTDP a fragile character structure. Their anxiety is discharged into cognitive/perceptual disruption and they can tolerate only a low level of mixed feelings before they use primitive defenses based on projection and splitting (e.g. acting out, discharge, dissociation, projective identification).

Patients with a fragile character structure require the graded format. A gradual exposure to mixed feelings to build the capacity to bear feelings without anxiety moving into cognitive/perceptual disruption and without using the defenses of splitting and projection. This graded format requires the therapist to use only very low levels of feeling in the session tailored to the patient’s very low level of affect tolerance.

When fragile patients split, we use pressure to consciousness of splitting to build the patient’s capacity to bear mixed thoughts, urges, and feelings internally without splitting them apart.

When fragile patients project, we restructure the projection to re-establish reality testing with the therapist, then we invite the patient to experience the feeling internally that he previously projected externally. After all, if he cannot build the capacity to bear the feeling inside, he will project it outside next time.

Thus, we cognitively restructure the projection first. Then we use pressure to help the patient experience internally what he projected externally. As he bears the feeling internally, as soon as he starts to get dizzy or disrupt we do bracing. That is, we remind him of the internal feeling while cognizing. This builds his capacity to bear that level of feeling while cognizing and without projecting. As we do the bracing, we watch the patient. We continue bracing until he sighs or intellectualizes. That shows us he can now tolerate that level of feeling without projecting. Thus, we have built a new level of unconscious affect tolerance.

In contrast to transference focused therapy, we rely less on interpretation. We rely more on building the capacity to bear feelings internally without projecting or splitting. We have two primary tasks we focus on: 1) restructuring the unconscious pathway of anxiety discharge so the patient can tolerate 100% of his feelings while anxiety remains in the striated muscles; and 2) restructuring the system of resistance so the patient can tolerate 100% of his feelings without the use of splitting and projection.

Another distinction from transference focused therapy is that ISTDP has a theory of anxiety based upon the somatic and autonomic nervous systems that allows us to determine what is the optimal level of anxiety for learning in therapy. Patients with a borderline level of character structure have a very low capacity for affect tolerance or anxiety tolerance. As a result, many of these patients suffer because therapists are working at levels of feeling and anxiety are far too high for the patient, leading to the regressive phenomena for which these patients are famous. Thus, if the therapist can recognize the physical signs of anxiety and the resistance systems with which they are correlated, it is much more possible to work with these patients in an effective manner that does not lead to regression.