Category Archives: Guilt

Problems working with guilt

When patients experience their unconscious rage in therapy, they often do not experience their love and guilt. Why? Also, how do you work on anxiety when it goes too high during guilt work? What defenses do you look out for and how do you work with them? Why doesn’t guilt and love come through?

Thanks to Reza for these questions!

In all therapy relationships, mixed feelings rise toward the therapist, feelings based on the patient’s previous experience. Love arises because the patient wants to connect. Rage arises because previous connections hurt the patient.

Those mixed feelings trigger anxiety and defenses, which create the patient’s presenting problems. So the therapist helps the patient see and let go of those defenses to face the underlying feelings that have been driving a pattern of self-punishment through defenses.

To do this, the therapist explores feelings in a current, past, or therapy relationship. As the therapist helps the patient face and let go of defenses, often anger is the first feeling to break through. Once the anger breaks through to someone we love, however, guilt arises. Why? The rage is felt toward someone we love. That combination of love and rage toward the same person triggers guilt.

To avoid the anxiety triggered by the love and guilt, the patient may use defenses such as denial or devaluation. In my book, Co-Creating Change, (chapter on breakthrough to the unconscious) you will see how I suggest you work with sixteen different defenses that arise at that very moment, defenses that will prevent the breakthrough of the love, guilt, and grief.

However, sometimes the patient begins to experience the love, grief, and guilt, but has trouble bearing these powerful emotions and becomes overwhelmed with anxiety. If so, cognize about the anxiety briefly, make the link to the guilt, and build the patient’s capacity to bear this much guilt without becoming overwhelmed with anxiety.

Th: Notice how you are becoming dizzy? So we see that as soon as we touch on this guilt, you become anxious, and then your mind becomes dizzy. See that?

Pt: [sighs or tenses up] Yes.

Th: So what does you father’s face look like as you see what you did to him? [Explore images that will trigger higher levels of guilt so you help build the patient’s capacity and enable him to have a fuller unlocking of his unconscious.]

We call this a “pocket of fragility”. The patient is temporarily too anxious, but a brief summary is enough to regulate anxiety and we continue to go for as high a rise of feelings as the patient can manage.

Why don’t guilt and love come through after the rage? Defenses or anxiety block the way. Why?

Sometimes the therapist goes for a premature breakthrough before having explored feelings long enough to mobilize the unconscious enough to have a breakthrough. I have seen therapists go for a breakthrough after asking for feelings only three times…instead of after twenty or thirty minutes!

Sometimes the patient has shifted from resisting feelings to resisting emotional closeness. Thus, the patient is distancing from the therapist with a transference resistance. If the therapist does not see this, no breakthrough will be possible. See my earlier blogs on signs of the emerging transference resistance.

Sometimes the patient’s resistance is in the system of projection or repression where further restructuring is necessary before a breakthrough to complex feelings would be possible, or even advisable! Premature breakthroughs with these groups of patients can lead to regression or depression.

Sometimes the therapist does not recognize the defenses which are preventing a rise of unconscious feelings. If we address the wrong defenses, the unseen defenses will block the way. That’s why having an expert look over your videos is essential. He or she can help you see what you need to do to help the patient further.

If love and guilt do not arise after a breakthrough to rage, look for the defenses that are getting in the way. If you help the patient feel only rage, without her love and guilt, we only help her get better at denying her humanity through denial, detaching, projecting, or devaluation. Experience of rage by itself is almost never helpful. Our task is to help the patient embrace the fullness of her humanity: her rage, her love, her guilt, her grief, and her wish to connect.



Should the patient feel guilt over rage toward the therapist?

“Reading Patricia Coughlin’s book, I see that when the patient experiences murderous rage toward the therapist, she encourages the guilt and longing feelings with the therapist and then after that encourages links to past figures. In the immersion with Abbass, he was clear that we do not encourage guilt with the therapist after the murderous rage toward the therapist, but encourages the patient to look at the dead therapist’s eyes to see figures from the past. What are your thoughts on this? I have read a lot of your work but can’t see this point being made anywhere.” Good question!

You can let the unconscious do what it does. Sometimes the patient feels guilt while looking at your face and a genetic figure comes up that way. We ask, “What feelings are coming up as you look into those dead eyes?” This primes the way for the patient to see someone else. Another way to think about this is, “Why would the patient feel guilt about rage toward us?” The patient hasn’t actually done anything except share a fantasy. So the guilt that rises is coming from somewhere else. You are just the vehicle that allows these mixed feelings from the past to rise.

Like Allan, I do not invite the patient to feel lots of guilt vis a vis me. I’ll just ask what feelings come up as he looks at “the dead eyes” or “dead body”. With more feelings mobilized, I’ll ask, “Who comes to mind?” Then we’re on our way. It’s important to realize that the goal of the portrayal is the unlocking of the complex feelings toward people in the past, not toward you. Your imaginary body is just the gateway to the unconscious. Don’t stay at the gateway. Go on in to the unconscious.