“When a patient of mine started to believe that therapy might help her, she became sad because of all the time that had gone to waste when anxiety made her stay in her house for years. I can understand grieving over her wasted life, but could it also be self-attack?” Great question from Anders!
Without seeing the videotape, we can’t say for sure, but both are possibilities. When patients see how they imprisoned themselves, they will feel grief over this loss and guilt over how they harmed themselves. Experiencing grief and guilt is the essential emotional ingredient that makes defenses dystonic.
If the patient is experiencing grief over her loss and guilt over her self-harm, these feelings will trigger anxiety and defenses. For instance, the grief and guilt may be so painful that the patient will misuse a fact (I hurt myself in the past.) to punish herself: “I was so stupid.” “Why should I even try, now that I see how self-destructive I am?” Her she uses self-punishment as a defense against grief and guilt.
Or the patient may use projection to rid herself of her guilt: “You just keep reminding of everything I did wrong.” Now she views you as her judge to avoid her own guilt and internal self-judgment.
Or the patient may use isolation of affect: “I understand it all now and it’s just a matter of childhood issues I didn’t work out.” Here, she detaches from her guilt and grief through intellectualization.
Genuine grief and guilt will trigger anxiety and defense.
If the patients result from self-attack, the defense of self-attack will not trigger anxiety or defense. Thus, we see weepiness but no rise in anxiety or defense to ward off the tears. Why? The tears are a defense! So we rely on the presence and timing of sighing and the types of defense the patient uses to let us know whether she is experiencing grief and guilt or using the defense of self-attack.
In my book, Co-Creating Change, the chapter on defensive affects will help you learn the signs that indicate whether a feeling is a genuine feeling or a defensive affect.