“I’ve had a few really good sessions with a severely depressed woman who has hated herself for years. She started to remember her rage toward her father, a cousin who abused her, and a former partner who raped her. When I focused on her rage and her avoidance of it, she became angry with me.
The next session she said she had not wanted to come, and she became flat again (I think to avoid her anger.). In addition, she started to attack me as a therapist and became passive aggressive. I addressed this defense and asked about her anger again. She then said she had looked up on the internet ways to commit suicide because she did not want to remain so flat and depressed. We explored the murderous rage behind her suicidal wish and she admitted she was angry with me and said she wanted to kill me. We then recapped our work and I became more supportive, but I thought we should still focus on her feelings rather than have her turn the anger onto herself. I felt we were able to repair a lot of the damage in the alliance, but I’m not sure all is good. What do you think I should do now?” Thanks to one of our community members for offering this question!
Triangle of conflict: rage; anxiety (discharge pattern unknown); defenses: self-attack, depression, provoking punishment, and passive aggression.
Process: when the therapist explores rage in a current or past relationship, the patient begins to
When the therapist addressed the patient’s anger and her defensive avoidance, the patient became angry with the therapist. We often think that is a bad sign. In fact, it is a good sign. It means she is able to feel angry toward the therapist rather than turn it against herself and get depressed. In addition, her ability to avoid and detach is also a good sign. It means she has access to isolation of affect. Thus, she probably has high resistance with repression. By highly resistant we mean that she can put up a wall of avoidance and detaching with the therapist. By repression, we see that she turns anger against herself by going flat, getting depressed, criticizing herself, and becoming suicidal.
In the first session mentioned, the therapist correctly asked about feelings toward him. In the next session, the patient tests the therapist, “I didn’t want to come.”
Th: Insofar as you didn’t want to come here today, it suggests there are some feelings coming up here toward me. I wonder what feelings you have here toward me?”
Not wanting to come to therapy is a defense to avoid feelings toward the therapist. Take that invitation and ask about feelings toward the therapist.
The patient then attacked the therapist verbally. This is a way to provoke the therapist to punish her for being angry. Don’t punish the patient by getting angry. Instead, help her face her feelings without provoking punishment.
Th: You say I am useless to you. What is the feeling here toward me underneath that sentence? [Block the defense and invite the feeling.]
She said she had looked up on the internet how to kill herself. Without seeing the video and knowing the exact context, we can’t know for sure what the therapist could say. However, you might try the following.
Th: Insofar as you are thinking of killing yourself, I wonder what feelings are coming up here toward me? If we look underneath this wish to kill yourself, what feelings are coming up here toward me? [Encourage the patient to face her rage toward you so she does not have to turn it onto herself.]
The therapist did this and the patient admitted she was angry. Great success on the part of the therapist! In fact, the patient said she wanted, in fantasy, to kill the therapist. That is great progress as well: she can admit her wish to kill the therapist rather than turn that wish upon herself. Her threat to kill herself wards off her rage toward the therapist and, no doubt, others in her life.
The therapist thought the patient’s anger was a sign of damage to the alliance. In fact, it revealed the patient’s increased freedom to feel her rage toward the therapist rather than turn it upon herself. This is a sign of a much improved alliance. Now his task is to keep asking the patient about her anger toward the therapist so he can help her see the defenses that cause her symptoms, and then let go of those defenses so she can face her rage as deeply as possible toward the therapist.
The resulting unlocking of the unconscious will help the patient see where her rage really belongs so she no longer has to turn it against herself. Once she can face her complex feelings of rage, love, and guilt with the therapist and those who hurt her in the past, she won’t have to punish herself through self-attack and suicidality.
When a suicidal patient can describe and experience her anger toward the therapist, this is a positive sign. Her alliance is so good she can admit her anger toward the therapist. If the alliance is poor, she will protect the therapist and then turn the anger back upon herself. In a research study conducted years ago by Maltsberger, he and his associates found that patients who committed suicide often had therapists who had become angry with the patient. If you feel a flash of anger, let that be a signal that the patient may be angry with you. Then encourage her to face her feelings toward you: “What feelings are coming up here toward me?” Then you send her a powerful communication: “You don’t have to kill yourself to protect me from your feelings.”
Needless to say, without seeing the video, my comments can only be provisional. Getting good supervision with a case like this is essential if you want to do exploratory dynamic therapy of any kind.