“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.






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