Category Archives: Projection

You tricked me!

“My patient declined to explore a problem which previously she adamantly wished to do. I respected her position and asked her to identify a different problem that she did want to work on. She revealed something very close to the topic she had wished to avoid. When asked for a detail she became furious and suspicious then cut off communicating convinced that I had tricked her. No effort I tried was able to ‘disarm’ the projection. She insisted on leaving. Of course now I am faced with a misalliance.” What would you advise?” Great question.

When she did not wish to explore something, she was projecting onto you that YOU wanted to explore. Thus, she would be wary of you, fearing your supposed desire to get into her mind. So when you invited her to offer another problem, you unwittingly reinforced her projection. Exploring a problem when the patient projects that You want her to reveal yourself reinforces the patient’s projection, resulting in a loss of reality testing.

Instead of asking for another problem, it’s more important to deactivate the projection. 

Pt: I don’t’ want to look at this.

Th: That’s ok. I have no right to ask you to explore something you don’t want to explore. If there is something you want to explore, I’m happy to help you do that. But if you don’t want to explore anything, I have to respect your wish not to explore anything right now.” 

Full stop. This leaves her with her conflict: a wish to explore and a defense against doing so. And it leaves her with the price: no progress. If she reveals a problem, it has to be her will to do so. Deactivating all projection of will onto you is essential to avoid a paranoid transference: the patient fearing you will make her reveal herself against her will.

The second projection you mentioned is her statement, “You tricked me.” 

She doesn’t realize that she wants to reveal her problem to you. So when it slips out, she assumes you “tricked” her. Thus, she becomes even more paranoid. This projection of omnipotent mind control must be deactivated. Otherwise, the patient will slip into a psychotic transference where she equates you completely with her projection, and fears you as a mind invader.

Pt: You tricked me.

Th: I can’t trick you into revealing something you don’t want to reveal. I can ask if you want to reveal your problem, and in response you can say yes or no. That’s up to you. I can’t make you reveal yourself. Only you can make yourself reveal yourself. And if you don’t want to, I have to respect your right to keep your problems to yourself. You have every right to keep inside what you want inside. Would you be willing to keep inside what you want to keep inside?

Notice here two things: 1) we deactivate the projection of you as a mind invader by reminding her of reality (only she can reveal herself); and 2) we do a counter projective maneuver—we encourage her to keep her inner life secret for now (Would you be willing to keep inside what you want to keep inside?). This deactivates her projection onto you and at the same helps reinforce her boundaries which are “leaky.”

Precisely because her defenses are so weak and primitive, she can’t hold things in like a much healthier patient could. Helping her reinforce her boundaries in this way will help her trust that we are not trying to weaken boundaries which are already weak. 

Patients with severe ego fragility, like this patient, suffer from a dual fear: 1) they are afraid of what will leak out; and 2) they are afraid of what will get in. In other words, they are afraid that they will tell you about themselves and become overwhelmed by feelings and anxiety and then regress. And they are afraid that if they let you in, you will dominate them and they will lose any sense of a separate identity. 

If you keep these primitive fears in mind, you can deactivate the projections accordingly.

Pt: I’m afraid of what I will tell you.

Th: Would you be willing to hold in whatever you want to hold in until you feel it is the right time?

Pt: I’m afraid I might tell you something I regret.

Th: Would you be willing to hold things in until you can be sure that it is your will to tell me and not someone else’s?

Pt: But then I might not tell you anything.

Th: Would you be willing to give yourself the right to say nothing?

Pt: Yes. I think so.

Th: Because unless you are free to hold back what you don’t want to say, you aren’t really free to say what you want to say.

Pt: I hadn’t thought about it that way.

Pt: I’m afraid you want to get in my mind.
Th: The good news is: I can’t. I can only know about your mind only what you reveal. If you tell me nothing, I know nothing about you. If you tell me a little, I know a little. So the good news is, I can’t get in your mind. I can only hear from you about what is in there.

Take home point: when the patient is projecting her will upon you, deactivate the projection thoroughly. Otherwise, your exploration of anything will “feed” the projection and make it worse until there is a loss of reality testing where the patient equates you with the projection.

Borderline personality disorder

Hi! We are two Norwegian students writing our thesis on ISTDP and therapy with patients suffering from Borderline personality organization. How do you work with these patients? And where do these patients belong, on the spectrum of psychoneurotic disorders or the spectrum of fragile character structure? Are they highly resistant or fragile?
We want to emphasize the defenses of splitting, projection and projective identification with this patient group. We want to understand the therapy methods of ISTDP with these patients compared to the therapy methods of Transference focused therapy. How does ISTDP understand the personality structure and defense pattern of patients with Borderline personality organization? We appreciate it a lot if you take your time! Emilie & Katrina
First of all, as you know, patients who have the diagnosis of borderline personality disorder share only a set of symptoms, not a common character structure. That is why Kernberg has proposed that we differentiate the DSM-V diagnosis of borderline personality structure (a set of symptoms which can be found in people with psychotic, borderline, or neurotic levels of character structure) from borderline level of character structure itself.
Patients with a borderline level of character structure use projection, projective identification, and splitting as their primary defenses. Thus, they have what we call in ISTDP a fragile character structure. Their anxiety is discharged into cognitive/perceptual disruption and they can tolerate only a low level of mixed feelings before they use primitive defenses based on projection and splitting (e.g. acting out, discharge, dissociation, projective identification).
Patients with a fragile character structure require the graded format. A gradual exposure to mixed feelings to build the capacity to bear feelings without anxiety moving into cognitive/perceptual disruption and without using the defenses of splitting and projection. This graded format requires the therapist to use only very low levels of feeling in the session tailored to the patient’s very low level of affect tolerance.
When fragile patients split, we use pressure to consciousness of splitting to build the patient’s capacity to bear mixed thoughts, urges, and feelings internally without splitting them apart.
When fragile patients project, we restructure the projection to re-establish reality testing with the therapist, then we invite the patient to experience the feeling internally that he previously projected externally. After all, if he cannot build the capacity to bear the feeling inside, he will project it outside next time.
Thus, we cognitively restructure the projection first. Then we use pressure to help the patient experience internally what he projected externally. As he bears the feeling internally, as soon as he starts to get dizzy or disrupt we do bracing. That is, we remind him of the internal feeling while cognizing. This builds his capacity to bear that level of feeling while cognizing and without projecting. As we do the bracing, we watch the patient. We continue bracing until he sighs or intellectualizes. That shows us he can now tolerate that level of feeling without projecting. Thus, we have built a new level of unconscious affect tolerance.
In contrast to transference focused therapy, we rely less on interpretation. We rely more on building the capacity to bear feelings internally without projecting or splitting. We have two primary tasks we focus on: 1) restructuring the unconscious pathway of anxiety discharge so the patient can tolerate 100% of his feelings while anxiety remains in the striated muscles; and 2) restructuring the system of resistance so the patient can tolerate 100% of his feelings without the use of splitting and projection.
Another distinction from transference focused therapy is that ISTDP has a theory of anxiety based upon the somatic and autonomic nervous systems that allows us to determine what is the optimal level of anxiety for learning in therapy. Patients with a borderline level of character structure have a very low capacity for affect tolerance or anxiety tolerance. As a result, many of these patients suffer because therapists are working at levels of feeling and anxiety are far too high for the patient, leading to the regressive phenomena for which these patients are famous. Thus, if the therapist can recognize the physical signs of anxiety and the resistance systems with which they are correlated, it is much more possible to work with these patients in an effective manner that does not lead to regression.