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.

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Th: “What is the problem you would like me to help you with?”

Pt: “My doctor told me to see you. He says I have an anxiety disorder. My mother died ten years ago. And my sister, she was there. She is really difficult. I just saw her at Thanksgiving. When I saw my mother, she was dead in the chair. She had kidney problems. She didn’t eat right. I have this anxiety.”

What is the sign of excessive anxiety here? Does she make sense, or did you have to fill in the blanks to make her statement make sense? In fact, she is demonstrating thought disorder. When hearing thought disorder we often think “there is something wrong with me that I don’t understand” rather than “there is something wrong with this patient’s thinking.” 

In case you missed it, I will put in asterisk in the text each time her thought is disordered.

Pt: “My doctor told me to see you. He says I have an anxiety disorder. * My mother died ten years ago. And my sister, she was there. * She is really difficult. I just saw her at Thanksgiving. * When I saw my mother, she was dead in the chair. She had kidney problems. She didn’t eat right. * I have this anxiety.”

Notice the sudden shift from her anxiety to a memory. The next shift is from her memory of her sister in the past to her sister now, without any awareness that this might be confusing to the listener. Next she suddenly shifts from Thanksgiving in the present to her traumatic memory. Next she shifts from her memory in the past to her anxiety today, again without any awareness that her thoughts are not linked together into a coherent narrative.

Let’s contrast thought disorder with rumination: “My doctor told me to see you. He says I have an anxiety disorder. I think this probably started ten years ago when my mother died. So my sister was there with me when my mother was dying. And she was really difficult. We had a really hard time getting along then. Although things have gotten better. We even celebrated Thanksgiving together a few weeks ago. Anyway, my sister and I couldn’t reach my mom on the phone. So we went to her house. When she didn’t answer the door, I used my key, went in the house, and saw her dead in the chair. I have felt this anxiety ever since.”

Notice in this example that there are clear links between sentences. It makes a logical flow. This is in contrast to the disjointed quality of thought disorder.

Fragile patients with a traumatic past often present with soft forms of thought disorder like this. When you see it, immediately shift to anxiety regulation. If the thought disorder continues when the patient’s anxiety is regulated, you can comment on it: “I’m sorry. I’m a bit confused. Can you help me out? You are mention your mother’s death now, but a moment ago you were talking about your anxiety. I’m having trouble seeing how those are connected. Could you help me see that?” After intervening like this a number of times, many psychotic or traumatized patients will begin to see when they shift topics suddenly.

Why do patients’ thoughts become disordered? Some propose purely neurological reasons. However, psychoanalysts, following Bion, have proposed that when two thoughts come together, meaning forms, which, in turn, triggers feelings and anxiety. Thus, unconsciously, the patient “attacks the links” between those thoughts so that meaning cannot form. If the thoughts do not come together, they cannot create meaning, feeling, and anxiety. Thus, if you help the patient see the links between those thoughts, feelings and anxiety will rise. So you need to be vigilant when working with more traumatized patients so you can help them bear the rises in feeling and anxiety that will arise when you block psychotic defenses such as thought disorder.

But your first step will be to recognize this defense and regulate anxiety immediately. For thought disorder is a sign of cognitive/perceptual disruption.

            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.

            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.

We reject the experience of being rejected. Could we accept this feeling?

We run away from the frustration we feel. Could we accept this feeling?

We avoid our sadness and make it sad. Could we accept our sadness when rejected by a patient in the moment?

We try to force his closed heart to open, making it close even more. Could we open our hearts to his closed heart by accepting it and the story it is telling?

We fear our fear and try to control it by asking the patient to behave differently. Could we accept our anxiety and let its information heal us?

We try to argue with the patient’s insanity to make him sane. Could we accept our anxiety when seeing insanity so he could feel his anxiety when seeing his insanity?

What if projective identification is how the patient awakens the light and dark parts of ourselves so that we can learn to love them? What if we resist patients to resist what is in ourselves? What if we need to love the light and dark places in ourselves so that through our being that love, the patient experiences that his  dark places are worthy of unconditional love too?

We don’t resist patients. We resist what we fail to love in ourselves. We need to love the darkness within, so we can finally embrace what the patient has brought for our healing. 

Narcissism is a spectrum trait, meaning that some us of have a little narcissism and some of us a lot! Therefore, its implications differ depending where someone is on the spectrum of human difficulties. For instance, we have the common narcissism of preening ourselves a bit in the morning before the mirror. We have the presenter who enjoys showing his work in front of others. [Hmm. This sounds a little too close to home!] And then we have the narcissistic personality who has to be the center of attention, always number one, and devalues other people as “stupid”, “ugly”, and “ignorant.” Sound like any political personality you have heard of? And then we have narcissism in the psychotic patient who, having lost everything following a psychotic break, has a delusion that she is going to give birth to the messiah. In this last example, her brittle grandiosity is a defense against massive loss.

Classically, one way we understand narcissism is that the patient equates himself with his ego ideal. All of us have ideals which guide us through life. We realize that ideals, like the North Star, are ideas which will provide guidance in our lives but which we will never achieve. Why? An ideal is an idea. And we are real. When we fail to live up to our ideals, that tension can help guide us back toward our ideals. The narcissist, unable to tolerate the painful feelings of grief and shame when we fail to live up to our ideals, solves this tension by claiming he is the SAME as his ideal! He projects his weaknesses and failures onto other people whom he devalues, and then idealizes himself and expects others to do the same. Thus, narcissism at this level always involves splitting. The narcissist idealizes his solutions and devalues others who disagree. 

Of course, this results in impoverished relationships. Intimacy means I am real with a real person. The narcissist insists he is unreal (perfect) and that you must be unreal (perfect) as well, or else you will be devalued and thrown away. This is why narcissists tend to choose other narcissists for partners or depressed spouses who accept devaluation and punishment.

As for the anger of the narcissist, narcissistic rage, this is rage split off from mixed feelings toward an all-bad image. The narcissist wants to be idealized by others. If he is not idealized, but is given realistic feedback instead, he will feel massive rage since he experiences reality as a murderous attack upon his fantasy self-image of perfection. In response, he feels murderous rage toward anyone who does not idealize him. This split off rage toward a devalued image does not involve mixed feelings and should not be encouraged, since it only would reinforce his splitting and devaluation.

The split off rage gives the patient a pseudo-experience of organization because he obliterates the other person rather than experiences the obliteration of his self-image of perfection. “If rage enough, painful reality will go away.” However, since reality doesn’t go away, narcissists tend to rage a lot, i.e., every time reality shows up.

From an ISTDP point of view, I view narcissistic personalities as fragile because their primary defenses are splitting, projection, idealization, and devaluation—consistent with patients at a borderline level of character pathology. Unable to tolerate low levels of painful feelings, they use splitting and projection to avoid the internal experience of mixed feelings. The narcissistic structure itself, the image of perfection, is a defense against facing who we really are: real, flawed, imperfect, and guilty.

The narcissist, unable to bear these complex feelings, projects all sense of imperfection onto others whom he judges and idealizes. Although he can be superficially charming, underneath he is paranoid, anticipating attacks from others that he gives out himself. His seeming stability is completely dependent upon receiving idealization. Once the idealization stops, he collapses either into severe depression or elevates himself into an even more manic version of pseudo-greatness.

These patients have a poor prognosis in treatment. This may be because clinicians over-estimate the patient’s capacity based on their superficial achievements. These patients do not show the classic signs of cognitive/perceptual disruption (e.g., dizziness) because they immediately resort to splitting, projection, and narcissistic rage. Premature confrontations will merely trigger massive rage and projection, leading to premature termination. The graded format is called for in these cases with great attention to working on splitting and projection to build the capacity to tolerate painful mixed feelings at very low levels without triggering the regressions into narcissistic rage.

Without seeing the videotape, we can’t say for sure, but both are possibilities. When patients see how they imprisoned themselves, they will feel grief over this loss and guilt over how they harmed themselves. Experiencing grief and guilt is the essential emotional ingredient that makes defenses dystonic.

If the patient is experiencing grief over her loss and guilt over her self-harm, these feelings will trigger anxiety and defenses. For instance, the grief and guilt may be so painful that the patient will misuse a fact (I hurt myself in the past.) to punish herself: “I was so stupid.” “Why should I even try, now that I see how self-destructive I am?” Her she uses self-punishment as a defense against grief and guilt.

Or the patient may use projection to rid herself of her guilt: “You just keep reminding of everything I did wrong.” Now she views you as her judge to avoid her own guilt and internal self-judgment.

Or the patient may use isolation of affect: “I understand it all now and it’s just a matter of childhood issues I didn’t work out.” Here, she detaches from her guilt and grief through intellectualization.

Genuine grief and guilt will trigger anxiety and defense. 

If the patients result from self-attack, the defense of self-attack will not trigger anxiety or defense. Thus, we see weepiness but no rise in anxiety or defense to ward off the tears. Why? The tears are a defense! So we rely on the presence and timing of sighing and the types of defense the patient uses to let us know whether she is experiencing grief and guilt or using the defense of self-attack. 

In my book, Co-Creating Change, the chapter on defensive affects will help you learn the signs that indicate whether a feeling is a genuine feeling or a defensive affect.

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.

Our task as supervisors and colleagues is to face reality: all of us make mistakes. We always will. All of us have hurt patients through our mistakes. All of us feel guilt. And this is painful.

Sometimes supervisors avoid this problem by just “being nice” and offering approval rather than genuine supervision. Sometimes as colleagues we sympathize and rationalize and say, “it wasn’t so bad.” We try to avoid the guilt that is inherent in learning psychotherapy.

We do this out of a false sense of compassion. Compassion comes from the Latin: to suffer with. If we try to erase painful reality of the mistake, we hope to erase the guilt, so there is nothing to suffer. But this is pseudo-compassion. Genuine compassion is facing reality together: “You made a mistake that hurt the patient. I have done this too. Let’s face this guilt together because it is a sign of your love for your patient. And let this guilt guide you in the learning so that next time you can do better work and repair the harm you did.”

Unlike in many fields, guilt is inherent in the learning of psychotherapy: our mistakes cause pain. As therapists, supervisors, teachers, and colleagues, our task in learning is to identify with each other as people whose mistakes cause suffering. If we can bear the guilt that comes when learning of our mistakes, that guilt, based on our love, can mobilize us to learn more, work harder, and become the best healers we can be. In other words, just like in life and in our love relationships, facing our guilt over the mistakes we make mobilizes us to engage in the act of repair. In our case, this loving act of repair is known as learning psychotherapy. 

Of course, many patients avoid happiness. Happiness easily triggers anxiety and defenses. Why? To be happy is a crime because we are breaking the superego’s law that we must suffer. How dare you!!!

In ISTDP the defenses against happiness are covered in the concept: defenses against emotional closeness. To be intimate brings great happiness. Defenses against happiness can be triggered by different dynamic situations. 

If I am happy it may be a crime because I differentiate myself from my mother and our agreement to suffer, be unhappy, and be victims together: the depressive symbiosis.

If I am happy it may be a crime because I will have surpassed my father and achieved an oedipal victory. Therefore, I will become unhappy and deny or minimize my success to avoid my guilt over wanting to surpass him.

If I am happy it may be a crime because my colleagues will become envious. I will deny and minimize my happiness so we will be miserable together. Then they won’t envy me. The problem is that success will aways trigger envy in some people. You cannot avoid it. If you hold yourself back to avoid their envy, you will commit a crime to yourself and to those who would have benefitted from your success.

And finally, if I am happy, I turn against my self-punishment and face my underlying mixed feelings. Otherwise, to avoid guilt over my happiness, success, and pleasure, I will punish myself any time I feel happy to hide my forbidden wishes to succeed, to be happy, and to live a fulfilling life.

We deal with defenses against happy feelings as we would any other defenses.

Mohsen offers some common defenses. 

Pt: “Being happy makes us selfish.” [Self-attack]

Th: “Or is that how you justify punishing yourself?”

Pt: “Being happy makes us immoral.” [I must be unhappy if I am moral = Self-punishment]

Th: “You say you must be unhappy to be moral. Is this how you punish yourself?”

Pt: “Being happy makes bad things happen.” [Self-attack. Possibly a memory being misused for the purpose of self-punishment]

Th: “Being happy doesn’t make bad things happen; self-punishment is making bad things happen in your life.”

Pt: “Being happy makes others jealous. [Self-punishment to avoid envy and competition]

Th: “Yes it does. So are you willing to face that some people will envy your success?”

Pt: “Being happy draws us away from God.” [Being unhappy brings me closer to God = self-punishment + a view of God as someone who wants us to suffer for eternity (the superego masquerading as God]

Th: “So being unhappy will draw you closer to God? What kind of a God would want you to suffer for eternity?”

Pt: “Being happy brings sadness.” [If I am happy I will be sad, so I will become sad right away and beat the rush= Self-punishment]

Pt: “Being happy doesn’t bring sadness. When you are happy, you punish yourself. And this self-punishment makes you sad.”

As you can see, these defenses can develop due to varied conflicts. In ISTDP we deal with these defenses as would deal with any other defenses: identify, clarify, and confront the defenses. Turn the patient against the defenses. Help the patient face his mixed feelings as deeply as possible so he no longer needs to punish himself by avoiding happiness.

Remember that good outcome is not merely the absence of depression or anxiety. It is the presence of genuine happiness that shows the patient has processed his underlying guilt enough that he no longer has to punish himself by avoiding happiness, the birthright of every patient to seek.