Category Archives: General

This is a slap in the face! I quit!

“I work with a patient who works full time and wants her treatment at a specific time when I am not available. I suggested other times we could meet, which she felt was “a slap in the face” since she “has to work” at those times. “We might as well quit!” she said.

Psychodiagnostically, what I see here is externalization (I’m the one slapping her face, when it’s really her superego), passivity (She needs to talk to her employer, not me), resistance, self-punitive superego (she won’t let herself have therapy) and denial of reality (a clinic can’t offer therapy whenever she wants). But I struggle with how to present this to her without coming off as blaming.

Other patients are not as hostile, but I still confront the reality that I can’t offer therapy at times they want. I get paralyzed and depressed, and then overextend myself. How do you help patients confront reality and put agency back into their hands!” Thanks to Arvid for this great question!

Patients often want therapy at times we cannot offer it. Their needs conflict with our limits. This is not their fault nor ours. The question becomes how to face our feelings honestly when reality conflicts with our desires, face the limits of life, and find ways of negotiating gracefully the inevitable conflicts of living.

You did not slap her in the face. Reality did. She wants a time when she can see you because she values you. Doesn’t that make sense? You can’t see her at the time she wants. That’s reality. It doesn’t mean her desire is wrong. Nor does it mean you are wrong for not being able to offer what she wants. It simply means that our desires do not always fit the limits of what other people can offer.

In response, she is angry that you can’t give her what she wants, and she is sad over the prospect of having to lose a valued person in her life. And she is tempted to deal with her mixed feelings by quitting prematurely, a form of self-punishment.

She is hesitant to ask her boss for time off to go to therapy. Perhaps this is passivity on her part. Perhaps she has trouble asserting herself. Perhaps she has trouble valuing herself enough to assert herself to the boss. Perhaps she is afraid to reveal her need for therapy to her boss. Perhaps she has a boss who looks for any excuse to fire people. I can’t know. All I can know is that we must carefully explore to find out what conflict she has, if any, that, if overcome, could enable her to come when you are available.

As far as denial of reality, don’t we all do that? She wishes reality would shift to accommodate her desires so she would not have to feel anger and loss. Even her therapist wishes he could overextend himself so he would not have to feel guilt and loss and so his patient would not have to feel angry with him. We’ve all done that.

How to confront this? 

“I completely understand. You wish we could continue at a time that works for you. I wish we could continue at a time that works for you and for me. And unfortunately, we can’t find a time that works for both of us. I keep wishing reality were the same as our desire, but reality keeps showing up instead. I understand you are angry that reality is showing up instead of the night-time session you wish I could offer. And we both are feeling loss because this has been an important relationship to both of us. If you can’t reschedule with your work, I have to accept that and so do you. But then it means we have to say goodbye when we wish we didn’t have to. Just as there are limits on when you can come, there are limits on when I can come. And there’s nothing wrong with your limits. It’s just that sometimes in life what we want what others can’t give. And you and I are having to face this reality and the sadness we feel over saying goodbye.”

Of course, you probably won’t offer such a lengthy speech, but its tone of accepting her, her limits, and reality may help her accept you, your limits, and reality, leading to new change. Both of you are facing the real limits of what we can offer, grieving the loss this entails, facing the anger that arises, and doing this rather than use the defense of overextending yourselves. Life and therapy require us to accept necessary losses.

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.