Why did he drop out?

“How do you ease people into the emotional side of ISTDP? I’ve had patients come in with different problems, and with some focusing in the first session they got in touch with their feelings. One had grief over a suicide years ago and never cried except in our session. Another externalized. I kept returning him to an internal focus and he eventually cried about childhood trauma.  

            They all said it was fantastic to be able to cry even though it was embarrassing and strange. But some of them stopped coming after that. Should I have eased them into it? Did they have sort of transference resistance or anger towards me I didn’t pick up?” Thanks to Albert for this great question!

Without seeing the video, it’s hard to know. So let’s think about our checklist:

1) Was there consensus on the triangle of conflict?

2) Was there consensus on the therapeutic task?

3) Was the patient’s will online?

4) Once you accessed feelings, did you assess what that experience was like for the patient? 

5) When they felt deep feelings, did you help them notice the relief they now experienced? Did you show them that this demonstrated that they had more capacity than they imagined?

6) Did you assess any hesitation or anxiety that was triggered by the experience?

That helps you assess whether you got resistances out of the way in advance or whether resistances emerged as a result of experiencing their feelings. 

When you review the video, here is one other clue: write down a one-sentence statement about each relationship they mention. For instance:

“I am thinking about leaving my girlfriend.”

“I feel like my boss is pushing me to do things I don’t want to do, so I’m looking for another job.”

“The violinist in my string quartet is so irritating, I’m thinking of joining a different quartet.”

In each example he is thinking of leaving. That is his unconscious view of therapy: He is thinking about dropping out. These cues in the “latent content” are an early warning system alerting you to possible dropout. In 99% of sessions where a patient drops out, I hear these cues in the therapists’ transcripts. If you catch these unconscious cues, you can address the patient’s resistance right away in session and dramatically reduce your drop out rate.

How do I work with jealousy?

“I have a client who struggles with jealousy. Her caring boyfriend gives her no reason to doubt his fidelity. However, her father left her mother for another woman when the client was only six months old, and she has no contact with him today. Her former boyfriend cheated on her. The client realizes that her feelings toward her present boyfriend might be old feelings toward her father and ex-boyfriend. How do you deal with jealousy in ISTDP since this client’s feelings towards her boyfriend are actually out of proportion, considering what he does— for instance participating in a Christmas dinner with co-workers. Should we focus on her old relationship with her ex-boyfriend and her non-existing relationship with her father?” Great question!

            Since her boyfriend is faithful, her jealousy is based on projection. She accuses him of a crime he did not commit. Then she punishes him for the crimes committed by her father and former boyfriend. Thus, exploring feelings toward the projection on the boyfriend would only increase her projection. Not a good idea!

            First identify and clarify her projection onto her boyfriend. 
Th: Is there any evidence your boyfriend is unfaithful?

Pt: No.

Th: So who was unfaithful? Who deserves your anger?

Pt: My ex-boyfriend.

Th: So shall we take a look at your feelings toward him, since he really was unfaithful? 

            Now let’s go on to the second defense.

Th: What is the feeling toward him for betraying you?

Pt: I’m so jealous of her for taking him away.

Th: That’s your feeling toward her, but he made the choice to leave you. So what is the feeling toward him?

            Notice that her jealousy of the other woman is a defense against the rage toward him. She can be jealous/angry with her, and thereby protect him from her rage.

            So let’s look at the triangle of conflict: rage toward the unfaithful ex-boyfriend; anxiety; defenses: rage and jealousy toward the other woman, projection onto the current boyfriend. Either way, the ex-boyfriend is protected from her rage. And, either way, she is punished for feeling rage toward him.