Why am I not getting a Breakthrough to The Feeling? “Hello Jon, I am new to practicing ISTDP. Recently, two patients, after experiencing rage and visualizing the beating and/or killing of the targeted figure, had little or no feeling of guilt and remorse. In one case, a patient felt rage towards the woman with whom her husband had an affair. But then she felt sad and regretted beating her in her fantasy. In the other case, the patient felt her rage but experienced only sadistic pleasure afterward, saying, I am watching her die and I am enjoying it. Did my lack of skill cause them not to experience their rage to the full extent, or was the expression of rage itself a defense? What would be the right approach?” Thanks to one of our new practitioners for this great question! Problem: the patients experienced rage but there was no unlocking of the unconscious leading to the experience of mixed feelings of rage, love, guilt, grief, and longing. We never want patients to experience only rage because they would be engaging in splitting; they end up viewing themselves as feeling only hate and view others as all bad. They disavow their own complex humanity and that of the people toward whom they feel rage. This is precisely the problem we want to help patients overcome. So the million-dollar question is this: why did this problem occur? Without seeing the videotape we can only speculate. But we can examine some of the most common reasons. Patient number one felt rage toward the woman who had an affair with her husband. This is the defense of displacement: feeling rage toward the woman rather than toward her husband. It would have been better to help the patient see how she protects her husband from her rage by putting it on the other woman. Then the therapist could encourage the patient to face the anger toward her husband. After all, it was he who betrayed the marital vows! Even so, with the therapist’s work on inviting feeling toward the woman, we find something else very informative. The patient became sad. This suggests that the patient’s sadness comes in to cover up the rage and complex feelings. Then the patient punishes herself for having felt this anger toward the woman. Now we see a regressive defense (weepiness/sadness to cover the anger) and her superego pathology (punishing herself for the “crime” of being angry at the woman). This means that the therapist needs to block the patient’s use of displacement onto the woman so she no longer protects her husband in therapy. Then the therapist must restructure the patient’s regressive defense of weepiness. Then the therapist needs to restructure the patient’s defense of self-punishment. No breakthrough to the unconscious will be possible as long as this regressive defense of weepiness and the self-punishment are operating. Let’s look at how he might address the self-punishment. Pt: I feel so bad for feeling this anger toward her. Th: Could this be a form of self-criticism or self-punishment right now? [defense identification] Pt: But isn’t it terrible what I did? [defense] Th: Could this be a form of self-criticism and self-attack? [defense identification] Pt: Yes. Th: So notice how as soon as you feel this criticism and anger toward her, that you turn it on yourself instead? [clarify the function of the defense] Pt: I didn’t before. Th: If you don’t turn it on yourself, could we have an uncensored look at how you experience that anger toward her? Here’s another way to work with it. Pt: I feel so bad for feeling this anger toward her. Th: Could this be a form of self-criticism or self-punishment right now? [defense identification] Pt: But isn’t it terrible what I did? [defense] Th: Could this be a form of self-criticism and self-attack? [defense identification] Pt: Yes. Th: So notice how as soon as you feel this criticism and anger toward her, that you turn it on yourself? [clarify the function of the defense] Pt: I didn’t before. Th: So we notice that you began to criticize yourself here with me and you invited me to judge you too. I wonder what feelings might be coming here toward me that are underneath the self-criticism and self-judgment? Didn’t anticipate that did you! Here is the reasoning according to ISTDP. When you invite feelings in a current relationship, you are inviting the patient to form an emotionally intimate relationship with you. Since patients have usually been hurt in previous relationships, feelings rise when you invite them to take the risk of being emotionally intimate with you. When these feelings rise toward you, one of the signals is self-attack. Rather than let those mixed feelings come up toward you, the patient protects you in the here and now by criticizing herself. All of this is unconscious. But if you invite her to look underneath the self-attack and see what feelings are coming up toward you, if you are right, the patient will begin to sigh or get tense and she will use defenses. When we are learning ISTDP we often don’t recognize how self-attack is a signal to explore feelings with you. You don’t want her to hurt herself in session to protect you from her feelings. That’s why you invite her to share her feelings toward you so she can learn to face her feelings directly with you and no longer have to use the defense of self-attack. Patient number two faced her rage but no complex feelings were experienced. We don’t know more about her or the session, so we can’t comment on any specific defenses that would have interfered earlier. But let me comment in general. We will assume the patient has declared a problem, that it is her will to look at her problem with the therapist, that they have a specific example of her problem, and that the therapist and patient are looking at feelings toward someone who actually did something to the patient. In that case, when a patient does not experience a breakthrough to the unconscious, it is due to two reasons: 1) an insufficient rise of unconscious feelings; and 2) an insufficient drop in the defenses and resistance. It may be that the patient declared what she felt, but she did not declare how she experienced her feelings physically in her body. It may be that she declared how she experienced her feelings in the body, but had no physical impulse. If the patient has no impulse viscerally in the body that we can see, the rise of feelings is not high enough to access the unconscious. It may be that the patient is using certain defenses, which the therapist needs to address in order for the feelings to become available to the work. It may be that while the therapist explored feelings the patient began to resist contact with him and he didn’t notice. This is the most common problem when therapists explore feelings in a current or past relationship. You get stuck or the patient does not seem activated because the patient is now distancing from you. I suspect this happened. Take home point: if the patient does not experience a breakthrough into the unconscious, either the rise of feelings was too low and/or the defenses and resistance did not come down. Review your videotape. Examine each patient response: was it feeling, anxiety, or defense? If defense, which one? Examine your interventions. Were you addressing feeling, anxiety, defense, or were you reflecting? Now you know which defenses to address next time. And now you know which interventions you need to use instead of reflection. Take home point number two: if you are a beginning ISTDP clinician, don’t worry about getting to a breakthrough. Make sure you are focusing on feelings, restructuring defenses, and reducing the resistance. These are the preconditions for getting a breakthrough. If the patient is unable to get to a breakthrough in a current or past relationship, almost certainly the patient is resisting forming a closer relationship to you. Start pointing out the ways he is avoiding forming a closer relationship and then ask about the feelings toward you that make him distance. If you can do these things alone, your patient will start getting better even without an unlocking.
Posted on: Tue, 11 Feb 2014 17:17:16 +0000
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