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President,

Co-Creating

Effective
Jon

Change

Dynamic

Frederickson

Seven

Leaves

Kansas

City,

Press
MO

Therapy

Techniques

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16

15

14

13

12

10

9 8 7 6 5 4 3 2 1

In

memory

taught

me

of
the

my

father,

meaning

Laurence
of art

and

Frederickson,
craft

at the

a blacksmith
anvil

and

forge

who
.

Acknowledgments

A book

of this

helped

me

scope

along

Joe

Maureen

Lyon,

Nyqvist,

Monroe

for

Braun,

Marup,

the

thanks

are

critiqued
Ammons,
book.

And

have

made

have

always

entire

of

course,
me

been

very

Washington

School

supervisors

there.

keeps

the

intellectual

Martin

to Anne

Stephansky,

who

this

would

supervision
intensive

book

and
short-term

for

and

thanks
Maurice
also

this

like
And

book

Gilbert,

and

Carolyn

critiqued

the

entire

trainees

whose

questions

precisely.

Their

questions

forgotten

have

has

training

an
and

Buber

and

and

as

course,

and

anyone

intellectual
I thank

once

In particular,

friend,

support

Of

to

open.

a mentor

my

If I have

Psychiatry,

As

curiosity

thank

and

videotapes.

to Linda

read

reading

who

helped

gratitude.

of

mentor,

research

also

Monica

I would
of

go

Tobias

research.

assistance.

thanks

Larsen,

deserves

library

did

deeply

grow.

fortunate

questions

Kirschner,

more

my

who

to

for

transcriptions

who

I want

me

accept

her

Allan

F.

Silberstein,

Blackmon

research

Special

Byster,

think

helped

his

Joal

Meerson,

Wennerberg

and

many

Campbell,

Kuhn,

Michael

Rowan

Burt,

book.

Diane

Tor

for

Penelope

and

please

I have

Kunkel

due

the

for

Nat

so

Ammons,

Linda

Maggie

videotapes

thanks

Suzanne

Brod,

and

since

Bruce

Isaaksen,

book.

of

thank

Russell,

and

of

to

Olga

Ollie

Warshow,

of a community

Thomas

Jeanne

Pray,

deserves

thank

me,

like

transcriptions

Joseph
to

Id

Gorin,

chapters

her

way.

Tom

Susan

critiquing

work

Jean

Evans,

Urru,

the

the

Bennet-Stenzel,
Barton

is truly

dynamic

and

a model

not

have

received

said,

who

integrity,

introduced

all

like

for

within

me.

is

to this

to thank

been

written

from

the

the

Habib

Gordon
ideal

of

must

go

of treatment.

were
man

that

whose

thanks

model

and

place

Kainer,

And

the

teachers

exemplifies

Rochelle

me

psychotherapy,

my
It

I would

colleague,

been

home

it not

who
Davanloo.

for

the

developed
I have

also

benefitted

colleagues
and

immensely

and

Josette

friends

Allan

Ten

Have

moment-to-moment
today

were

it not
My

supervisor,

and

years

whom

finally,
none

for

training

Abbass,

Allen

de
would

thanks

go

Patricia

supervision

Kalpin,

Robert

have
Terry

to

Coughlin,

transformed

work

become

on

what
and

dear

friend,

whose

work

my

my

Neborsky,

my

Sheldon

my

of

vision

it

is

Beatriz
mentor,
with

of

me
what

be.

profound

of this

presentations

And

never
with

must

and

Labije.

relationships

colleague,

could
my

my

biggest

of

psychotherapy
And

the

processing

Winstanley.

over

from

would

gratitude
have

been

goes

to

possible.

my

wife,

Kath,

without

Contents

Acknowledgments
Introduction:

Part

Dynamic

One

Establishing
Chapter
Feelings:

an

Effective

Where
Two

Anxiety:

The

Chapter

Three

Defenses:

Four

Tactical

and

Chapter

Five

We

First

The

Chapter

Inquiry:

Focus

Detour

Second

Repressive

Psychodiagnosis:
Chapter

Focus

One

Chapter

Part

Psychotherapy

in Therapy

from

Feelings

Detour

from

Feelings

Defenses

Co-Creating

an

Effective

Focus

Six
Co-Creating

a Conscious

Therapeutic

Two

Building

Capacity

Chapter

Seven

Treating

Fragility,

Chapter

Eight

Building

Self-Observing

Chapter

Nine

Regressive
Chapter
Defensive

in Fragile

Defenses
Ten
Affects

Patients

Depression,

Capacity

and

Somatization

Alliance

Part

Three

Helping

the

Chapter

Highly

Patient

Eleven

Superego

Pathology

Chapter

Twelve

Superego

Pathology:

Chapter

Addressing

Character

Thirteen

Superego

Pathology:

Chapter

Transference

Fourteen

Breakthrough
Chapter

to the

Fifteen

Consolidation
Chapter

Sixteen

Conclusion
References
Index
About

Resistant

the

Author

Unconscious

Resistance

Defenses

INTRODUCTION

Dynamic

Psychotherapy

I walked

into

the

the

The

analyst

wall.

interview.

He

application

to

only

one

amount
I was
the

in your
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later

traumas

in

get

you
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only

first

what

they
time

past.

acts

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of will

1944)

and

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end,

the

Patients

in self-creation.
of which
in

their

they
lives

are
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had

given

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done

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paying

to

me

done

location

because
have

unable

the

analysts

no

one

asked,

in

to

where

me
bad

attention

to

the

what

I had

these

difficulties

you

about

which

we

lives

(Frankl

they

the
get

to
and

what

new

create

did,

for

the

what

spite

of
my

that
life

appreciation

ourselves

to
for

(Berdyaev

1959).

lost

their

determined,

see

in

me,

throughout

freedom

know

to

done

It highlighted

have

become

done

choices

between

to

did

been

I had

a gift.

They

about

How

question

had

Now

by

asked

overcome

to make

was

unaware.
are

been

had

of

of

I had

field

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had

were

what

proud

experience

to us

but

my

to me.

on

to our

psychotherapy
come

our

by

analyzable,

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asked

done

1936)

meaning

this

began

delighted

accidental

you

obstacles.

(Rank

give

one

feel

past

did

based

else,

it.

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but

had

to

are

what

analysts

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me

with

most

others

judged

he

on

person.

no

everyone

overcome

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short,

I began

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the

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paintings

and

were

you

on

been

The

today?

far?

about

When

just

background,

are

sure

done

interviews,
my

down,

the

a psychoanalyst,

judged

I had

to me,

become

at

history.

happened.

impersonal,

I sat

colleagues

not

being

I had

glancing

hand.

his
to

of trauma

had

where

and

Were

not

my

institute

impersonal.

During

he

concern:

past,

things

in

the

office,

shook

said

shocked.

was

well-appointed

they

the
and

inhibits

tension

determinism.

freedom
in part,

want

basic

to
by

engage
defenses

something
their

freedom.

different
Our

task

as

therapists

live,

and

and

their

to

create

life

them

that

easy

lives.

But

persons.

determining

help

are

their

living

to

genetics

determine
than

is

matters.
to

Their

we

as

relate

overarching

forces

while

which

we

create

What

we

do

their

mistake

then

Our

recover

love,

to

their

diagnoses,

factors

that

completely

to

dead
is

patients

to

past,

task

mobilizing

freedom

to

concepts

rather

recognize

those

self-creative

capacity

to

act.
The

acts

of this

by

book.

a desperate

life

a choice:
the

face

therapeutic

create
we

to

full

may

task

can

inner
or

Usually,

is to

stop

life

we

To

each

or

run

not
in

patients

suffering.

At

do

that,

from

thousands

of

to

that

we

life

how

full

from

they

our

create

hurt

focus
or

we

to

have

engage

inner

pursue

that

the

of meaning

ourselves,
run

must

be

in therapy

consciously

we

will

moment

actions

see

do

meaning

a beautiful

it. When

engage

help

and

create

avoid

automatically

therapists

can

lives

of suffering.
our

suffering.

our

in

life,

we

suffering,
it.

Our

task

themselves

understand

but

so

what

as
they

causes

suffering.
From

the

people
we

Buddha

have

tried

suffer

because

therapists
say

say

we

we

suffer

reactions

in

Behavior

therapists

pay

we

said

We

all

these

have

Now

we

that

psychotherapy

is
widely

to

which

have

suffer

because

suffer

answers
its

first

our

undergoing
recognize

a
the

at

we

years
scientific
need

suffer

because

frozen
all

in

these

of

the

body.

maladaptive

because

we

are

each

moment.

And

the

reality.

each

of which

has

have

passed,

the

revolution
for

transference

suffer

resist

therapies,

hundred

we

of

we

experience

and

and

become

say

because

Psychoanalysts

conflicts
say

say

Emotion-focused

feelings.

workers

today,

therapists

cognitions.

unresolved

therapists

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2003).

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to 150

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embrace

compassion
a letter

for
to

Carl

Jung,

Sigmund

love

(S.

faith.

As

the

our

once

wrote,

and

Jung,

1994).

Freud
one

chaos

found.

Freud

patient

and

our

blockage

encourage

her

you

often

and
of

feelings
free

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being

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up

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path

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alliance

task,
needs

identify

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patients.
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of doing
the

right

patients

to

become

suffering.

Then

personality

itself

must

explore

consensus

to

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us

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assess
to

begin

the

resolve

and
able

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on

understand

be
let

for

the

develop
by

learning

feelings.

RECOMMENDED

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A.,

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Town,

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Harvard

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http://www.istdpinstitute.com/resources/
Coughlin

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effectively.

life

help

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that

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to

demonstrating

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to

the

all

psychotherapy

the

we

this,

tools

has

psychotherapy,

therapeutic

there

an

attention

perpetuated

the

those

to

, of

develop

of

embrace

contrast,

self-creation

anxiety,

we

merely

she

and

regulate
with

to explore

have

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not

act

same.

patient

that

problems

causes,
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the

an

inner

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constant

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it,

through

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In

are

belief

that

presenting

problem,

to

Our

our

we

itself

a me

techniques

wood.

Techniques

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this

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relating

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the

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To

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demonstrates
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love
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A revolutionary

and

of

D.

1653).

for

method

of

intensive

Solomon,
and

support

Karnac.

method

In

change

Theory

Wiley.

Davanloos

F.

psychotherapy.

psychotherapy:

transformed:

(pp.

(2001).

RECOMMENDED

by

York:

psychotherapy.

McCullough,

For

New

In

short-term

dynamic

psychotherapy

Neborsky,

therapy

intensive

R.

Malan
New

short-term
Neborsky,

(Eds.),
York:

L.

Short-term

W.

W.

Norton.

MATERIALS
on

Frederickson,
short-term

forming
visit

a therapeutic
the

dynamic

URLs

alliance

presented

in

videos

below.

psychotherapy

part

(October

5,

part

(October

5,

http://www.youtube.com/watch?v=cKzmk2-xnzY
short-term

dynamic

psychotherapy

http://www.youtube.com/watch?v=dK2x906ptWA
short-term

dynamic

psychotherapy

http://www.youtube.com/watch?v=sDmVgoKPVkw

.
part

(January
.

18,

PART

ONE

Establishing

an

Effective

Focus

CHAPTER

ONE

Feelings:

L izards,

Where

We

and

humans

lions,

known

as

emotions

emotions

organize

however,

we

the

body

our

feelings

the

basis

others

and

feelings
laws,

our

identity.

be

religions,

transmission

of

consciousness

tell

what

and

what

own

behalf,

unit,

feelings

get

have
art.

we

want

and
pain.

pursue

tell

where

we

we

for

make
do

we

in life

are,

to

to

the

we

culturally,
through

accumulated

of the

world.

gives

act

(Tomkins

where

know

57).

what

us

to

intergenerational

sense

not,

us

And

of

1999),

express

the

connect

mobilize

goals

allow

we

in

aware

1994,

1996).

2009,

we

mammals,

activations

(Damasio

which

allow

These

becoming

feelings

values,

way

and

physical

self

(Trevarthen

They

our

us

those

activations

1998).

reptiles

Nathanson

which

what

bodily

Subjectively,

1996;

by

fundamental

to

of

Feelings

the

us

Unlike

a core

shared

the

Panksepp

Intersubjectively,

culture

gives

by

us

pleasure

adaptively
1962).

want

on

Like

to go,

They

and

our
GPS

how

to

there.

HOW

TO

When

we

emotional
provided

FOCUS
do

not

ON
know

compass
us

adaptively.
the

of

of humankind

are

us

a sense

and

moved

feelings.

(Kelly

to

Therapy

1872/1998;

as

intimate
us

all

conscious

them
us

in

behavior.

become

gives

allow

Feelings

(Darwin

label

for

are

animal

can

and

Focus

with

information

what

(P.

which

who

use

feelings

mobilize

their

actions;

Therapy

helps

patients

feelings.

By

learning

we

Coughlin,

feelings,

Patients

FEELINGS
feel,

let
to

go
feel

go

through

life

personal

communication).

organize

the

defenses

provide.
anxiety

we

to

ignore

Feelings
and

of their
and

body,

defenses
defenses
deal

so

(Fosha

so

we

can

feelings

desire
do

no

(Schore

they

an

Evolution

their

and

without

can

2000),

act
lose

longer
2009).

face
they

their
can

channel

their

defenses.

Thus,

avoided

into

we

adaptive

intervene

actions

to

help

rather

patients

than

maladaptive

experience

previously

feelings.

Seemingly

everyone

patient,
the

feelings

What

is the

face?

She

descriptions

knows

what

feelings

feeling

toward

your

might

of her

offer

one

are.

Suppose

boyfriend

of

the

for

you

ask

slapping

following

you

in

comments

as

feeling:
I feel

he

feel

shouldnt
he

have

did

that

done

that.

because

of

his

upbringing.

Only

the

last

examine

statement

these

is

responses

I feel

betrayed.

I feel

detached.

I feel

like

I feel

tense.

I feel

sad.

I feel

angry.

the

feeling

in detail

is

not

defense
her

feeling

but

the

of intellectualization

feeling.

feeling

She

toward

her

thats

your

thought,

cover

your

feeling

slapping

you

not

way

but
with

in the

a thought,

what

This

is

not

The

tries

to

explain

describe

differentiate
respond,

the
her

Well,

is the

that.

feeling:

the

rather

than

thought

might

not

done

a thought
her

therapist
is

have

are.

and

respond,

feeling.

feeling

If

her
Well,

you

toward

dont
him

for

of

his

face?

upbringing.

than

offers

Lets

feelings

avoids

between

patient

what

patient

thought

boyfriend.

shouldnt

patient

The

your

he

the

distinguish

boyfriend.

her

to understand

. The

does

him.

toward

I feel
This

leaving

a feeling

feeling
explanation

thats

the

the
toward
from
reason

feel

but
reason
him
her
he

he

the

did

that

defense
her

for

of

rationalization

boyfriend
doing

feeling.
slapped

because

so.
The

you,

hit

her

She
therapist
but

that

.
rather

does

not
might

doesnt

say

what

the

to reasons,

feeling
what

is toward

is the

him

feeling

for

slapping

toward

him

I feel
but

the

stimulus

Naturally,

she

difference
her

from

how

for

she

patient

wards

the

feeling

how

you
look

feeling
he

betraying

not

the

The

at the

your

but

differentiate
therapist
What

is the

She

(the

slap,

The

therapist

anxiety

feeling

action

her

feeling

from
not
and

the

detached.

using

the

feeling

tension,

might

her

the

reactive

therapist

detach.

him

for

betrayal)

and

differentiate

the

of

He
is

betrayed

the

feeling

like

that

her

feeling

The

therapist

him.

dont

is the

feeling

want

This

could

is not

the
that

. She

feeling

toward

him

from

sadness

The

leave

him.

a feeling

the
but

feeling

her
anxiety

you

not

that

tense?
but

differentiate

covers

between

is

anxiety

is a feeling,

does

but

anxiety

with

makes

is a feeling

not

differentiate

Sadness

boyfriend

action.
to

anxiety,

the

sadness

is

to leave?

not

toward

This

from

does

differentiate

cover

the

way

is not

She

want

does

sad.

This

intended

you

him

the

detach,

him.

you

your

toward

The

Detaching

dont

her

might

toward

defense

feeling.

feeling

tense.

Thats

If we

her

makes

responding,

feeling

you?

sense

by

and

the

leaving

. She

detaching

feeling

your

impulse,

makes

him

her

slapping

is not

of

If you

by

the

It

defense

is not

You

from

by

respond,

the

This

feeling

might

feeling

recognize

what

differentiate

I feel
it is not

off

(stimulus).

course!

So

between

mobilized

anxiety.

what

act

Of

the

Detached

toward

feeling

not

might

I feel

difference

respond,

her

the

you.

toward

triggered

from

her

does

slapping

I feel
the

slapping

by

feeling.

the

feeling

is not

responding,

therapist

feeling

might

This

by

I feel
feeling

betrayed.

by

feeling

responding,

avoid

you?

go

you?

her

see

it off.
by

did

dont

slapping

in response.

boyfriend.

If we

for

her

stimulus

her

avoids

does

she

the

what

him

betrayed

a feeling

the

Thats

toward

we

has

toward

stimulus

but

He

between

feeling

you.

you.

it.

The

you

and

you.

If we

look

at

would
as

dont

the

cover

feeling

consider

this

toward

the

a defense

other
him

sadness

to cover

feeling

up

for

a defensive
her

her.

toward
She

anger

someone

might

would

clinical

be

reactive

In these

become

the

the

stimulus,

help

patients

conscious

patient

express,

1995,

1996).

to the

emotions

We

must

to label

and

they

feel

We

used

two

the

limbic

as

emotions

bodily
Emotion
disgust,
Tomkins
identified

the

know

what

and

by

specific

we

it

functions

the

patients

that

in the

he

hit

future,

who

sadness

hit

but

her.

In

or anxiety,

differentiate

not

feelings,
into

we

from
affect.

they

than

use

can

they

Patients

pay

et

do

long
not

al.

attention

to avoid

body

who

them.
enough

know

what

The

brain

want.
emotions

and

environment.

Humans

can

them

as

feelings

found
and

six

happiness

feelings
expressions

are

feelings

This

1999).

have

must

in the

reflect

(Monsen

a defense

of emotion

feelings.

perceive,

actions
we

the

facial

so

can

healthy

mobilizing

These

feeling

a defensive

differentiations

brain,

surprise,

her

or

self-knowledge,

the

label

researchers

1962).

our

above:

in the

sadness,

case,

sad

someone

impulse,

these

rather

our

(Damasio

emotions

is

feel

again

their

not

an

experience

assesses
system

him

toward

them

body

words

nonconsciously

FEELINGS

this

in the

not

this

take

feelings.

channel

understand

do

This

might

to

could

of

acquire

tolerate

close

make

of their

and
To

her . She

anxiety,

conscious

upon,

In

because

angry.

describe

OF

becoming

affect

feel

feeling

often

CONSCIOUSNESS
By

you?

we

of anger.

examples,

must

be

reactive

feeling

a defense,

hit

to

patients

can

anger.

who

afraid

the

practice,

their

We

be

sadness,

slapping

I
feeling

with

message

bodily

goes

reactions

to

known

become

conscious

of

feelings:

anger,

fear,

Izard

1994;

.
basic

(Ekman
unique
recognized

2003;
because
around

they
the

are
world

(Ekman

1992,

2003;

system

(ANS)
Levenson

(Frijda

1986),

no

plus

generators
Based

emotions

and

Ekman

adaptive

activated

markers.

guilt

2004;

will

shame

and

the

more

focus

Davidson
tendencies

feelings.

Other

cognition

and

have

on

six

basic

only

because

nervous

action

by

, involve
We

autonomic

they

the

are

the

primary

of conflict.
on

pay

social

specific

specific

routines

biological

feelings

and

motoric
as

2003),

(Davidson

2003),

known

specific

et al.

activation

1994;

feelings,

Keltner

what

we

attention

to

experience
of

anxiety

her

her

tendency

learned

so

feelings,

feelings

her

and

have

in

feelings.

defenses,

(2)
the

To

we

label

body,
do

which

far,

must

her

and

so,

she

prevent

her

help

the

feelings

(4)

patient:

accurately,

experience

must
from

(1)

see

(3)

the

and

turn

becoming

action
against

aware

of her

feelings.
INVITING
We

FEELINGS:

feel

feelings

anxiety

based

on

dangerous

in

dangerous.

The

may

do

now

it

so

so

they

To

do

out

Suppose

We

must

the

he

Thus

we

as

detours.

body

to

may

patients

patient

has
a

hide
have

and

focus
This

us

we

explore

who

feeling
up

while
a

can

sharing

her

as

if

feelings

been

adaptive

go

of

problems

then,

their

still
past
but
the

defenses

for

which

he

example

to

uses

to avoid

him.

To

toward

is

Thus,

a specific
he

it

was

in the

symptoms.
let

trigger

feelings

reacts

feeling

of inviting

FOCUS

feelings

humiliated

is the

brings

the

defenses

phase
on

and

tell

the

What
the

and
see

to

boss

ask,

begins

constantly

the

permission,

mentions

situation,
that?

defenses

feelings.

his

If

problems

their
ask

experiences.

feelings

help

face

these

learned

is to

feelings

he

specific
doing

Hiding

With

the

who

THE

Sometimes

relationship,

presenting

we

help.

long.

previous

patient

task

this,

day

past

creates

can

seeks

today.

therapeutic

find

all

MAINTAINING

explore

your

boss

them.
a
for

feeling.
addressing

common

anxiety

misunderstanding

and

about

free

feelings
But

association.

would

he

discovered

patients

often

Freud

if he

invited

that,

rather

associate

1923/1961c).

patients
The

and

must

a session.

fifty-minute
and

no

insecure
show

compassion

possibility

of

outpouring
inner

resistant
so

of

his

life.

mind.

using

issues,

defenses

systematically

(S.

point

out

the

do

not

can

be

use

once

or

single

create
We

that

patients

interrupt

feelings

problems.

the

in

to

Defenses

defense

interrupt

defenses

access

presenting

every

only

150

no

possible.

and

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occur

defenses

an
must

destroys

the

feelings,

the

that

block

his

help

him

life.
soon

see

as

the

invite

the

patient

difference

the

feeling,

(2)

or

Always

address

the

usually

respond

either

point

out

feeling

(3)

his

paying

close

a moderately
fit of rage

By

with

her

that?

[ Invite

didnt

rationalization

want

to

go

and

and

then

then

invite

anxiety

or

defense.

To

help

or defense,
we

co-create

to his

inner

has

just
ring

(Th):

then

invite

a better
life.

into
Whats

the

then

invite

the

feeling.
Patients

the

him

patient,

to face

his

relationship,

In the

reported

and

the

feeling.

engagement

feeling

anxiety,

stimulus,

the

patient

the

explore

following

that

his

both
vignette,

fiance

in

gutter.

the

feeling

toward

her

for

.]

Patient
I

and

and

defense,

then

Therapist
doing

feeling

or

and

so,

attention

anxiety

a defense,

to anxiety

resistant
threw

and

doing

feeling

detour,

detour

with

(1)

a feeling

instead.

of us

responds

between

feeling,

that

to

to difficult

by

defenses,

will

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inner

must

many

blocking

treatment.

them

patient

symptoms,
by

comes

associate

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alliance

attachment,

what

unconscious

them.

active.

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therapeutic

freely

we

that

to say

from

is why

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thought

a patient
than

block

be

session.

initially

away

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defenses

therapist

twice

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rise

Freud

to

(Pt):
the

I think
restaurant

the

reason
she

she

wanted.

did

it

was

[ Defense:

.]
Th:

Thats

the

reason,

but

the

reason

she

did

it

is not

the

the

side,

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ring

feeling
can

you

we

in

have

take

the

a look

gutter?

from

the

feeling,

defense,

and

then

invite

the

the

feeling

she

out

the

invite

did.

What

stimulus,

the

is

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the

to go,

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is the

the

feeling

is

from

hypothetical

defense,

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dont

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feeling

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negation,

stimulus

then

we

your

take

it

and

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you

for

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in

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turn

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against

confusing

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you.

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that?

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her

for

from

know?

doing

the

feeling,

vague.

throwing
out

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invite

about

the

and

then

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[ Defense:

is

[ Point

the

vagueness

ring

in

us

gutter.

differentiate

feeling

be

.]

tell

the

defense,

the

whole

It doesnt

the

I could

.]

irritated.

[ Defense:

for

say
we

anger.
you

dont

throwing

invite

the

toward

in

feeling

irritated

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out

and

block

or
the

[ Defense:
feel
what

ring

negation

anger.
you

in the

.]

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do

gutter?

feel.

tells

us

What

[ Point

is
out

.]

his

eyes

.] I feel

sad.

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her .]
you

her?

are

know
the

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you

dont

feeling

toward

Either

.]

feel

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still

opinion?

feeling

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at the

suppose?

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her

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uncomfortable

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cover

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invite

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toward

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her

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tears

course!

her?

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you

to

for

to

.]

feeling,

Pt:

what

her

off

.]

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and

patient

Uncomfortable

toward

speech

not.

the

to do,

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youre

defense,

toward

toward

feeling

defense

the

feeling

what
Th:

the

toward

reason

.]

where

what

out

the

.]

Pt:
situation,

feeling

disappointed.

differentiate

feeling

leave

the

feeling

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what

at

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encourage

Pt:
with

her.

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defense

stimulus

toward

notice

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toward

put
her

how
the
for

these
tears
throwing

tears
to

the
the

come

in

side,

could

engagement

to

ring

away?

against

[ Point

the

out

defense,

the

and

then

Pt:
broke.

[ Defense:

defense,

displacement

the

my

the

feeling

glasses

patient

to

turn

.]
on

the

ground

didnt

do

the

feeling

and

they

.]
But

the

glasses

anything

to

you,

they?
Pt:

No.

Th:
glasses,

what

defense

of

defense

and

is

the

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feeling

displacement
face

his

feeling,
that

so

we

anger

go

feeling

physically

Each

time,

focus

on

we

the

responses

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the

so

review

we

know

some

FAILURES
a

feeling

toward

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how

focus

her
and

for

why

patient

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onto

[ Point

to

turn

your

out

the

against

the

patient

ask,

can

describe

his

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do

you

experience

inviting

defense
the

feeling

feeling

allows

us

or

anxiety

is not

an

to

and

then

indiscriminate

assess

the

patients

to treat.
mistakes

therapists

make

in this

phase.

FEELING
on

the

throwing
the

fiance?

[ The

patients

INVITE

clear

angry.

body?

what

out

.]

stage

common

TO

keep

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the

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instead

in your

address

put
your

invite

next

feeling.

intervention.

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toward

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invite

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did

encourage

reactive
the

following

feeling,

ask,

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effective

ring?
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youve

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anger,

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of

body).

defenses.

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cover

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.] I think

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in unconscious

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and

.]

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emotions

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Pt:
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his

anger,

suicide

you
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defenses,

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and

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in

a position

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patients

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task.]
to fight.
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Pt:

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into

intellectualization,

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focus

doctor.

on

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as

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his

body,

a series

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impulse

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of

turned

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patient

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patient

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in his

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against

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occurred

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immobilized

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defenses,

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experienced

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patient

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murderous

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I addressed

I asked

defense

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patients

interview.

time,

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patients

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the

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displacement.
to

is all about.

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breakthrough

thirty-six

this

his

failed

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displacement,

and

he

body.

Questions
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case

therapists

wonder,

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experiences
hurt

the

of the
the

these

patients
fall

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suffering;

apart,

his

anxiety
patients

can

the

patient

his

came

capacity.
to

your

suffering
focus
Lastly,

His
office.

through
on

his
in

feelings
learning

the

defenses
do

defenses,
and
any

it possible

do.

feelings
were
not
which

help

him

treatment

hurt

the

quickly
creating

cause

do

cause

address

his

do
not

suffering.
see.

not

the

hurt
the

patient
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we

before
causes

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task

make

we

according

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against
we

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defenses,

suffering

turn

will

regress.

his

and

he

cause

make

gradually,

see

do

not

to

if

patient?

or

not

apart
feelings

regressive

does

videotaped

feelings

him

he

method,

fall

these

Feelings

Feelings

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that

is this:

can

and

will

I could

patient.

defenses

his

or see

patient

to remember

anxiety

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the

a danger

defenses

face

transcript

danger

there

and

this

Isnt

hurt
his

the

help

points

defenses

regulate

to

there

important

patient;

read

feelings?

patient?

most

who

his

he
his
is

defenses.
mistakes.

to

Patients

will

of the

nearly

what

question
he

cannot

know

feelings.

If we

getting

a mistake

use

his

giving

the

best

keep

ball

dropping

of the

while

your

catch
repetition

new

head,

your
kept

ball.
we

connections

so

just

he

gain

will
his

not

one

child.

You

forming

new

neural

same

at

what

he

feelings,

to

the

or

ball

after

time

you

could

here.

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form

is feeling

is

learning

time

to

wont

prefrontal

until

chance

is

patient

of

work

cortex

the

his

ball

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he

missing

the

is

brain

recognize

kept

to

for

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his

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asking

connections

principle

patients

that

brain.

patient

access

prefrontal

keep

know

seeing

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his

not
the

system.

connections

throwing

can

practice

if we

kept

he

needs

understand

of

does

to defenses,

limbic

father

the

that

Yet

regions

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give

his
We

can.

were

patient

metaphor,

at first.

subcortical

brain

before

neural

you

He

from

he

the

Due

yet.

them

are

answers

But

that

of

If

persist?

feeling

go

when

it.

is

feelings

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you

information

building

and

is this:

a neuroscience

much

what

ask

do

he

letting

know

catch

why

what

and

cortex

therapists

is feeling,

defenses

we

forgive

heart.

Another

not

always

the

neural

in his

body.

SUMMARY
This
for

case

illustrates

patients

with

perspective,
the

how

low

and

emotions

environment.

become
mobilizes

to

feelings

focus

an

to

the

body.

one

another.

relationships.

They

have

healing

of social

strengthen

our

perspective,

feelings

They

propel

us

learning
reveal

toward

life
and

an

(Trevarthen

2009,

memories.

want.

From

glue
they

55).

From
needs

in

brain

are
the

us

met

to

of

are
Feelings

we

the

allow

the

because

of our

in

feelings

power

changes

whenever

appraisal

are

defenses
evolutionary

to

perspective,

They

we

identify

From

These

which
what

and

automatically

nonconscious

with

mediators

react

interpersonal

communicate

primary

feelings

resistance.

us

others,
in

on

moderate

allow

From

close

to

our

the
also

motivational
or unfulfilled.

perspective

of

neuroscience

(Damasio

consciousness.
feelings
from

From

is the
an

of

We
close

feelings

again,

feelings
from

trigger
being

the

and

How

do

we

and

This

book

those

into

anxiety

and

we

D.

7494).

London:
D.,

theory

and

and

patient

action

rather

explore

emotionally

to

his

pain.

sense

the

patient

points

face

than

the

major

therapy

and

the

science

of

of

out

instead.

that
his

his

these

strengths

suffer

two

self,

avoids.

feelings

vignettes
can

patient
of

meaning

patients

These

the

the

his

78).

and
illustrate

feelings
from

and
anxiety

detours

from

defenses.

The

dialogue
and

of
the

two

triangles.

psychodynamics

In
(pp.

Butterworths.
Coughlin

technique

revolutionary

face

the

the

will

psychotherapy

Malan,

to

our

READINGS

(1979).

Individual

therapist

and

1990,

prevent

the

numerous

so

value

become

even

And

shape

led

feelings

to

contains

adaptively

to

the

patient

according

RECOMMENDED
Malan,

the

detours

Now

on

the

(Gaylin

with

and

core

exchanging

us

human

Defenses

arise,

invites

to

interfering

focuses

varies

them

feelings,

our

development.

closeness

defenses.

with

profoundly

dare

development,

this

symptoms.

feeling:

his

patient
which

defense

then

to handle

in

reveal

to being

the

and

of

and

weaknesses.

channel

life

therapist

anxiety

detours

how

motivation,

Thus,

When

help

cultural

most

central

to

anxiety

aware

feelings

us

development,

and

Feelings

most

after

relationships,
life.

lives.
are

provide
of

intellectual

perspective,

and

invite

feelings

perspective

of our

our

personhood

the

basis

existential

meaning

1999),

method

Della
of

Selva,

Davanloos

of dynamic

P.

(2006).

ISTDP.

In

psychotherapy

Introduction
Lives
(pp.

to

the

transformed:
1033).

London:

Karnac.
RECOMMENDED
If you
effective

would
focus,

MATERIALS
like

to
you

learn

how

can

receive

to

address
a free

defenses
audio

and

skill-building

maintain
course

an
by

subscribing

at http://www.istdpinstitute.com

CHAPTER

TWO

Anxiety:

The

A nxiety

is

First

term

misunderstood.
its

function,

that
first

its

causes.

describe

how

body,

and

regulation.

In

to

assess

the

to

Then

anxiety.

In

patients

where

to work

with

the

anxiety

of

that

will

of

of

the

into

show

work.

anxiety

biological
we

the

will

patients

high,

requiring

for

regulating

techniques

not

from

chapter

too

we

anxiety,

anxiety

this

is

chapter

prevent

define

describe

anxiety

of

does

will

universally

differentiate

anxiety

this

almost

we

part

variety

regulation

defenses

we

second

part

will

discharge

show

third

we

when

yet

chapter

finally,

assess

we

the

of this

And

anxiety.

how

used

Then

of

Feelings

widely

part

misconceptions.

underpinnings

from

is

In the
and

common

Detour

how

Here

to

we

assess

show

how

regulation.

DEFINITIONS
What

do

the
of

we

mean

nonconscious
fear

to

and

systems

create

palms.

call

or

call

anxiety

a session.

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emotional

responses

such

1998,
(Damasio

2009),

nonconscious
Panksepp

the

1999).
of

the

(Damasio

pounding
to

of fear

our

consists

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emotion

body

by

1999).

heart

and

conscious

of

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sweating

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of

1999).
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when

they
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focuses

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are

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on

activation

fight/flight

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1999;

systems

refers

fear

affect

activation

(Damasio

Therapy

must

(Damasio

of

anxiety

1936).

we

threat

of

symptoms

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? The

symptoms
of

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term

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feeling

bodily

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autonomic

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by

triggered

anxiety
of

the

body

threat

mobilization

of
and

by
by

triggered

objective

our
by

supports

immobilization

nonconscious

1998);

triggered

feelings

feelings
defensive

(Porges
detection

emotion
defensive

in

1995).
(Panksepp

in

the

body

responses

(fight/flight

and

Porges

and

immobilization)

Bazhenova

feeling

of anxiety

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signals

away

from

them;

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the

whereas

anxiety

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can

body

from

inside
only

to

mobilizes

us

2001b,

2011;

awareness

of

the

1999).
us

hide

protect

2001a,

conscious

(Damasio

feelings

we

Function

of

Anxiety

has

prepare

the

body

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are
them

itself

a threat.

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by

defenses.

using

physically

to defend

cannot

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(Panksepp

ourselves

run

1998),

psychologically

(S.

somatic

system

or

with,

autonomic
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threats

that

(Porges
Kennard

bodily

symptoms

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with,

2001a,

1947).

has

we

so

can

label

them

as

prepare

the

body

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can

run

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engage

to

and

the

(LeDoux

objective

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conscious
of

from,

externally,

we

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feeling

somatic

internally

become

the

we

act

the

the

or surrender

2011;

sends

activates

activated,

from,

2001b,

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and

flee

mammals

2006),

them

been

steps.

and

Briefly,

muscles

support

body

to fight

amygdala

1999).

and

four

danger

muscles

those

must

the

1995,

(Damasio

signal

the

(Goldstein

voluntary

system

actions

2006;

the

attacker.

now

systems

body

from

assesses
the

to

involves

inherited

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nervous

in the

nervous

brain,

feelings:
This

nonconsciously

activates
an

other

danger.

the

amygdala.

of fear

nervous

to

in

2012),
the

from

respond

autonomic

emotion

fight

function

prewired

to
and

1998).

to

1998,

message

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different

system

(Panksepp

the

body

1995,

1926/1961d).

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2006)

in the
that

(Porges

of

anxiety

these

(Damasio

1999).
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does

mobilizes

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sympathetic
blood

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pressure,

of

the

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large

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and

get

feet

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raises
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muscles
cold.

act?

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hands

and

to

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so

we

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nervous
our

pulse,

from

the

can

symptoms

run

the

amygdala

systems,
breath

rate,

extremities
or fight.

include

dry

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mouth,

the
and
and
is why
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and

rate,

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brain.

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warm

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animals

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escape

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if

fear

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and

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and

the

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of relationships

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weeks

survive.

old.

relationship

anxiety
anxiety

enough

for

lifetime.

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cause

so

Causation

of

constricted

2004;

and
McEwen,

and

enables
sometimes

nervous

think

systems
2006)

about

avoid

or

in

see

such

threat

or

predators;
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cannot.

the

safety

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when

on
of

others
primary
1980),

1973,

Sullivan

1953a,

1953b).

feeling

single
to

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trigger
and

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experience
anxiety
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a
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system

relationships.

independently
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permanent

like

humans

threatening

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emotion

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dangers

1996;

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in

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fear

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to an

today

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to

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us

to

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ears,

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have

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eyes,

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migraines.

Shapiro

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jungle

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and

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to

for

and

breath

flow

ringing

bodily

pulse,

2003).

an

reaction

designed

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Hamill

blood

teary

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anxiety

before

our

vision,

and

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drop

diarrhea,

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anxiety

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tigers,

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The

arrhythmia,

1999).

eaten.

(Ohman

does

2006;

lowers

salivation,

Hamill

when

nausea,

2006;

limp

being

blurry

cardiac

Stewart

ANS

of

increased

(Goldstein

Bulloch,

the

in

dizziness,

include

limpness

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(Goldstein

resulting

symptoms

thinking,

pupils,

of

pressure,

creates

symptoms

create

branch

blood

problems

Yet

pupils

2004).

parasympathetic

less

dilated

is
for

2003).

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after

amygdala

anxiety

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responsible

for
feedback.

detection

of

hypothalamus,

goes

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symptoms

cortex,

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reacts

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visible

cue:

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safe.

tiger.
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the

to

evaluate

patient

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conscious

threat
an

are

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(1998),

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thinking

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symptoms

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anxiety.
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patient

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internal

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it

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test.

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for

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speculate
example

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how

feelings,

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triggers
as

feelings

will

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and

made

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it, she

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experiences

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weeks

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patient

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her

her
anxiety

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any

made

expression

of feelings.
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a

right

hemisphere

childs

(Schore
and

relationships,
2002,

14).

regulates

regulates
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trigger

her

herself

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reject

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her

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brain

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insecurely
and

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person
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feelings

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as

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of anxiety
third

or

(Schore

fourth

year

experiencesthe
and

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2010,

bodily
anxiety

was

bodily

states

are

future

experience
clarified

Anxiety

Is

to

to your

body

values;

annihilation

on

the

quality

Nadel

(De

1978).

of

Rijk,

primordial
all

early
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attachment,

which

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growth

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of

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related

to

to

belief

that

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these

are

genitals,

clear

up

or

separation

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related

to

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feel

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and

hurt

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persecutory
you

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anxiety

in your

the

damage

destroyed;

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to

anxiety.

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to

to transgressing

being

others

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related

self-disintegration;

stimuli,

you

a stimulus

described

one;

anxiety,

your

causality,

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or genitals;

is

immature

behaviors

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psychotherapy

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1960).

only

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regulated.

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concept

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the

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literature

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misconceptions

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The

sensations

142;

not

21).

life,

memories

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Kloet

anxiety:

2002,

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body.

resulting

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anxiety.
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front

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attack

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class.

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the

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him.

experience)

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vision,

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ears,

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professor

is

nausea.
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me.

with

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The

patient

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an

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the

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in the

body

bodily

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2.2.

he

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mind

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professor.
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2004).

symptoms
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symptoms

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hands

shoulders,

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anxiety

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arms,

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of

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and

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not

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(anxiety).

2006;

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neck.

in the

intercostal

muscles,

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muscles
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and

legs

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tensing

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sensations,

painful

irregularity,

and

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mouth

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eyes

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Cold

muscles,

menstruation,

resulting

painful

in painful

intercourse,

menstrual

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symptoms

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pelvic

caused

by

the

sympathetic

nervous

pupils
hands

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heart

rate,

blood

pressure,

and

respiration

system

the

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motility

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of the

bladder

gastrointestinal

sphincter:

tract:

urinary

retention)

due

to muscle

constipation

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(hair

stands

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and

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symptoms

system

Salivation

Teary

on

end

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by

the

parasympathetic

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eyes

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pupils

hands

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heart

rate,

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motility

blood

of the

pressure,

and

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respiration

tract:

nausea,

vomiting,

diarrhea
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bladder

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sphincter:

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urge

to urinate

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arrhythmia

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body

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muscles,

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by

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the

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symptoms

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in the

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of

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headaches

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neck,

anxiety

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of the
legs,

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and

clenching

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and

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and

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in

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systems.

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20022004),

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symptoms

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smooth

muscles

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urgency

and

frequency
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symptoms:

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legs:

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gait

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blurring,

due

to lack

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tunnel
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nausea,

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of tension

in Cognitive/Perceptual

confusion,

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syndrome,

asthma

unsteady

dissociation,

bowel

migraine,

symptoms:

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irritable

vision,
loss

freezing,

track

access)

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of thoughts,

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poor

memory

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of feeling

fugue

(striated

states,

in areas

of the

body

dizziness

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in the

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ears

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summary,

nonconscious

biophysiological
Fear
is

bodily

bodily
the

external

dangers.

body

to

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activation

is the

the

identification

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feeling

mind

danger.

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Freud

to

1936).
in

use

perceived

a
1999).

behaviors

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feelings

(A.

produces

(Damasio

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by

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ward

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detection

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response

to

psychological
dangerous

in

relationship.
ASSESSMENT

OF

UNCONSCIOUS
Every
form
on

time

PATHWAYS

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you

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relationships.

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during

alliance.

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smooth
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muscles,

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or

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patients

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striated

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attention

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can

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regulate

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patient

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feeling

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regulate

her

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the
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regulation,

her

stomach

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fast

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does

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to

feelings.

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her

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childhood

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in therapy.

frequency,

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1999)

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2006).

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1996).

2004).

2007),
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Prinz

2007)

et

consciousness

103;

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2004),

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1997,

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experience,

cortex

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1999),

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idiot.

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and

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will

the

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drop.

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correctly
(Beck

patient

steps

in

out

points
et

al 1979;

Beck

and

Emery

1985).

psychotherapy
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in response

to feelings

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self-attack,

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regressive

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regulation

2002).

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than

remembers

equation
fantasy)

memory

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with

reality.

in

the

past

with

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1981).
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patient

patient
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and

a
Im

And

relationship

with

you

want

therapeutic

on

got

relationship.
a

the

Weve

the

past

to

protect
alliance

(Bateman

.]

Right.
Th:

And

thats

getting

in

the

way

because

youve

been

making

love.

is coming

talking
Its

up

about

hard

in bed,

how

if this

youre

what

here

in just
his

to

here

wanting

to listen

have
me,

Pt:

Okay.

Th:

Then

to

imitates

hands

are

I want

to

when

and

trouble

jumping

got

Were

to

me,

you

theres

protect

urge

trying

really

but

jumpy.

to

listen

your

to what

this

you.

More

because

body

is

happens

[ His

help

doing

because

anxiety

drops

in

urge

How

to jump

are

the

and

arms

then

the

wanting

to

doing

the

attention.

theyre

like

any
and

therapist

that

is that

choke

the

holds

his
his

this.

[ Crosses

life

out

father

hands
Th:
Pt:

thing
to
of

What

that
put

him.

that

evoked

in front

of his

],
the

grabbing

I want

then

gestures

that?

[ in the
The

and

imitates

Whats

sense

toward

like

this

defensive

[ the

pay

more

Theres

two

this

like,

his

arms

.]

Pt:

patient

us

we

of himselfdefense

therapist

impulse

I want
with

Th:

neck

have

you?

in front

make

running

right?

connect

with

Pt:

do

wife

.]

are

protect

and

impossible,

does.

And

connecting

your

true.

Its

body

different.

body

arms

your
wanting

something

protecting

Thats

Th:
with

and

right?
Pt:

you

you

but

the

position

]?

my

to

hands

[ Emergence
the
face

this

[ the

I also

saw

your

impulse

are

comes

theres

gesture

arms

wanting

to

mind

that

doesnt

around

my

fathers

of

the

unconscious
as

], and

murderous
anxiety.

if strangling

his

The
father

.]

Okay.
But
Th:

thats
Do

with

I have

my
your

hands

in this

permission

position.
for

us

to

go

there?
Pt:
In

this

example,

the

[ Nods

patients

.]
jumpy

legs

reveal

his

anxiety

and

his

projection:

he

mistakes

He

is not

conscious

in

danger

with

impulsively,

the

urge

to

run,

therapist
here
alliance
to

the

him

there,

the

Vignette

anxiety

toward

Three:

Some

his

reality.

Their

triggers

anxiety,

which

becomes

of the

difference

In

this

vignette,

hysterically,

twenty

she

got

recently
fears

lost

into

daughter

her
legal

get

into

rehab.

her

right

now

fantasy

from

Im

[ Speech
to

find

reality

agree?

to her

out

your

eyes

to

the

Next

the

and

the

past,

therapeutic

become

clear

Suddenly,

disorder,

often

involve

on

the

therapists

her

way.

to

She

pouring

appointment.

due

they

which
lose

sight

reality.

the

but

their

rage,

because
and

called

equate

office

crying

arrives

to her

out

Her

alcoholism,

a story

daughter

and

of
has

the

patient

job.
afraid

she

Anxiety
is

could

rises

still

alive?

die

.] Do

if she

you

[ Failure

does

mind
to

not

if I

call

distinguish

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are

defense

obviously

anxious

of rumination

right

to draw

now.
her

Would
attention

.]
Yes,

Th:
anxiety?

just

if she

her

Pt:

this

acting

.]

[ Interrupt

anxiety

her

races.

Th:
you

to

lose

Pt:

panic

fantasies

trouble

could

urge.

relaxes.

hyperventilating,

way

that

is

Reality

perpetuated

is lost

late,

on

with
with

has

she

minutes

gotten
her

that

attention

present

body

conflicts

their

patient

saying

session
how

between

his

pay

else,

if he

emerges.

those

with

father.

as

of

distinctions

his

Fantasy

especially

risk

to

those

and

father

Equating

patients,

fantasies

drops,

the

someone

As

reacts

between

and

abusive

body

describe

difference

therapist

his

patient

and

relationship.

his

rage

the

violently

reduce

the

watch,

his

but

To

invites

see

a past

patient,

murderous

therapist.

notice,

for

projection,

therapist

to

and

therapist

of this
the

helps
and

the

You
were

were
blurry.

do

Before
so

anxious

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you

mind

you

do
before

if I call?

that,
you

can
got

we

pay

here

attention
that

you

to
said

Pt:

Yes.

Th:
got

lost,

which

working

right.

means

Thats

your

Would

you

Yes,

Th:

in

so

your

torturous

body.

Invite

to

her

attention
Then

or

disappears.

symptom.

Five

minutes

like

your
difficult,

your

breathing

is

when

you

anxious

but

you

that

Pt:

Much

could

that
end

you

notice

that

feeling
of

anxiety

until

has

tension
in

the

her

symptom

attention

to

.] How

is your

vision

another
now?

now.
thinking?

betterits
Thats

anxiety

not

racing

another

so

sign

much.

your

anxiety

has

Its

much

better

now.

I was

having

trouble

choking.
Th:

But

now,

in this

Pt:

Now

the

breathing

We

blurry,

now
easy.

are

No,

is fine.
your

thinking
is

here

anxiety

was

fine,

calm

driving

moment?

that

vision

You

began

see

your

your

extremely

your

breathing

racing,

your

now.

was

thinking

is

I assume

you

fine,

and

were

not

forward

to

today.

I was

fine.

I was

looking

today.

triggered

so

my
up

daughter
in jail.

I wonder

much

Pt:
me

wasnt

to pay

is your

Th:
office

mind

her

how

Pt:
seeing

invite

this

symptom

is fine

And

was

was

you

breathing?

I was

vision

Then

your

symptoms

one

vision

Th:
high,

to

My

Pt:
breathing,

to

is calmer

Th:

is your

anxiety.

high,

to

do

she

Th:
How

Where

later
Pt:

dropped.

of

anxious.

attention

attention

pay

decreases

so

terribly

pay

today.

[ Mobilize
her

was

I was

Lets

to you

body?

anxiety

sign

agree?

Pt:

been

a serious

did

happened

I talked

to my

on

the

way

to

my

and

he

told

anxiety?

Nothing.
not

what

follow

the

judges

husband,
instructions,

so

she

Th:
you

had

told

sabotaging

herself

What

like
Pt:

made

you

a horrible

To

[ Help
her

the

client

fantasies,
Pt:

she

her

daughter,

day

long,

Your

Its

Right.

Of

punishes

herself

Regulate

the

In the

explore

daughter

in the

patients

daughter.

The

attack,

became

anxious.

punishing

yourself

point.

The

anger

by
her

a way

imagining

attacks

If a friend

her
is

have
dead.

triggering

.]

myself.

of

by

is you

daughter

to hurt

her

point

yours

had

whispering

problem

in her

ear

all

die!

Why

not.

not?

Because

it would

the

same

I see.

distinguish

her

Four:
face

your

attack.

You

to panic

course

And

the

torture

could

your

a panic

toward

I see.

Pt:

Vignette

and

die.

your

lead

Th:

clearly

not

anger

daughter

Pt:

Then

her,

could.

which

Th:

can

she

you

had

angry.

would

real

would

Pt:

toward

with

a panic

for

Th:
with

with

times

that

angry

were

Thats

many
see

imaginary

she

told

myself.

You

But

Th:
yourself

feeling

you

punish

that
Pt:

punished

then

yourself

fantasy

your

were

and

Th:

with

had

angry.

You

anxious,

punished

was

I was

Pt:

you

judge

that?

Th:

Then

the

Yes!

Th:

anger

though

her.
Pt:

for

Even

[ Now

fantasy

session

.]

anxiety

so

her

be

cruel

is true
she
from

mind

is

and

not

if you

do

much

calmer

reality

can

and

function

true.

it to yourself.
because
no

longer

effectively.

feelings.
Transient

of rising

feeling

Delusion
and

anxiety,

a fragile

patient

may

suffer

transient

delusion,

which

address

it.

following

attacks

and

explores
her

In

the

will

frequent

her

heighten
vignette,

problems

anxiety

her

after

a
in

she

anxiety

unless

patient

reality

becomes

you

suffered

from

testing.

aware

The

of

rapidly
panic
therapist

feeling

angry

with

son.
Th:

belly?

[ Explore

attention

her

to her

Where

do

you

parasympathetic

anxiety

notice

this

symptoms

anxiety

and

in

your

mobilize

her

.]
Pt:

Right

Th:

here,

Where

like

acid

else

do

in my

you

stomach.

notice

anxiety

in

anxious

.] I

your

body?
Pt:
like

maybe

The

I have

feeling

effect,

of rage

she

children;

I am

To

increase

the

I am

not

belly.

the

mother

wants

boundary

and

more

feel

Pregnant.

and

the

who

patients

facts

anxiety.

Then

it made

you

defense
who

only

of a delusion.

feels

to give

between

that
point

that

out

you

[ Rise

between

reality

in

So

you

only

rage

birth

reality

and

reality,

draw

attention

and

her

In

toward

to them.
fantasy

to reality

As

you

rage

my
This

triggers

your

your

babies

are

I am

trying

. She

attention

to

regulate

toward

pregnant

weepiness

her

Then

to be

and

delusion

your

rage

toward

with

him.

in your

son,
your

her
and
son

belly.

to

keep

does

not

them

from

distinguish

.]
look

at your

belly,

are

you

pregnant?

.]
Pt:

[ Cries

like

felt

to hide

Uh-huh,

Th:
[ Draw

tried

Its

delusion.

You

want

anxiety

and

the

causality:

Pt:
being

to

contradict

anxious.

imagining

orientation

Th:

way.

in my
anxiety

mother

the

weepy

anxiety.

concrete

by

the

of

babies

triggers

is saying,

breakdown
more

my

[ Becomes

[ Looks

at

her

belly

.]

No,

but

it feels

.]
Th:

But

are

you

pregnant,

as

you

look

there?

that

Pt:

[ Looks

Th:
right

Are

Jim

and

belly

.] No.

[ Cries

.]

Jane

[her

children]

in your

belly

now?
Pt:

differentiate

reality

and

takes

and

delusion,

off

from

But

notice

feeling

But

are

Pt:

No,

they

her

coat.

her

anxiety

in your

With

signals

before

a drop

Jim

and

are

the

drops

belly

me

of

Jim.

[ Still

does

not

.]

Th:

Pt:
sighing

it reminds

fantasy

Th:

clear

Theyre

Jane

not.

in your

belly?

[ Immediately

calms

differentiation

quickly

down

between

reality

.]

not

in

your

belly.

What

do

you

now?
[ Sighs

in her

.] A little

anxiety

better

from

there.

the

high

[ The

levels

return

of

of moments

.]
Th:

Are

Pt:

Are

Pt:

in your

belly

. Now

drops

further

able

to

regulate

there?

Jane

in your

belly?

] No.

They

are

here.

you

agree

and

differentiate

not

they

smiles

reality

How
The

and

is your
pain

are

.] Yes.

from

losses

anxiety.
anxiety,

defense.

patients

anxiety

properly.

She

First,

and
Do

then

not
is

probably

[ Her

delusion,

too

big

children
her

are
anxiety

of

cannot

now?

there,

reality

but

testing

address
point

high

distinguish

the
out

the
for

the

her
between

Poor

reality

testing

causality

content

it is smaller.
occur

disruption.

explore

too

belly

is still

cognitive/perceptual

perpetuates

look

.]

delusions
into

you

and

[ Laughs

Pt:

goes

as

now?

Th:

Transient

Jim

Would

Pt:
adults

pregnant
.] No.

[ Calmly

Th:
to be

you

[ Calmly

Th:

and

at her

of

prefrontal
reality

of

when
reality

testing

problems,
feeling,

delusions
cortex
and

anxiety

then
anxiety,

when
to

fantasy,

the

function
reflect

on

her

delusion,

cannot
The

look

at the

delusions

feelings.

symbolically,

raging

river

content

Pay

hidden

to

think

because

is not

attention

not

or

as

to

integrate

she

important

the

is drowning
as

delusion

deficits

Principle:

To

anxiety.

If this

the

or projections,

deactivate

address

which

a delusion:

deactivate

As

a projection:

eyes

reality

does

not

to

: to ward

the

testing

help,

perpetuate

the

person

of judgment?

you

you

What

do

realities

to

husband

block

and

before

at

he

died.

response

to

Regulate

her

recognizing

therapy

anxiety

and

and

off

who

is

first

try

are

Remind

the

patient

at

eyes

now,

look
you

my

see

in these

with

your

him

facing
defenses

and
will

you

patient

feel

remember

show

patient

her

causality:

dead

husband

and

violently,
and

in

patient
she

need

to

pregnant?

do

reality

to

these

look

contradictory

angry

with
him

lovingly

dizzy.

Something
some
at

the

at

about

anxiety.

You

same

time

regresses,

your

become

is probably
of

reality

of

may

triggers

the

you

nursing

in you

If

of

of

only

the

ego

eyes?

feelings

structure

(Kernberg

the

you

more

becomes
a

supportive

psychotic
form

of

1975).

Principle:
regulate

time

lovingly.

projects

character

say

the

the

belly,

You

then

address

anxiety

at your

interventions,

complex

nursing

paranoid,

same

these

angry

remember

of

the

these

both

level

splitting:

then

patient

look

As

problems,

the

Remind

feel

in it.

function

but

Remind

In

its

She

underneath.

regulate

like

information.

anxiety,

When

and

experiencing
decrease

then
those

unconscious
help

the

feelings

feelings

patient
deeply,

face

cause
the
her

anxiety,

feelings.
anxiety

By
and

Following
prevent

are
anxiety

that

perpetuate

from

defenses

The

some

ways

regulation:
anxiety.

list

defenses

Restructure
Once

drops,

following

to address

then

projective

regulate

summarizes

the

causality,

and

then

anxiety

how

explore

defenses

anxiety

to do
Ego

show

or ego

herself

the

she

feelings

from

warded

and
off

the

Then

resulting

explore

projective

deficits:

against

using

this

anxiety.

contradictory

feelings
For
2.3 .

while

a summary

resulting

from

Regulate

this

feelings.

the

anxiety,

Help
defense.

the

patient

Then

explore

defense.
Deactivate

Regulate

the

anxiety

projection

due

to feelings.

patients

attention

feelings.
Splitting:

to

deficits

this:

Projection:
and

ego

anxiety

resulting

which

feelings.

turn
by

or

or

Self-attack:
differentiate

deficits,

realities,
anxiety
of the

building

the

Draw
capacity

the
to

bear

these

split-off

is regulated.
decision

tree

for

anxiety

regulation,

see

figure

Figure

2.3

Decision

tree

for

regulating

anxiety

SUMMARY
Assess

anxiety

symptoms

anxiety

tolerance.

Once

his

capacities

his

feelings

the

for
more

regressive

anxiety

and

feeling

deeply.

If you

it. Address

The

ability

to

how

well

will

your

help

you

anxiety

become

more

you

can

attune

are

also

must

become
aware

be

able

To

help

Have

the

forefront.

(pp.

3780).

your

assess

in

you

others.

To

consider

using

Rhythms

monitor

your

in your

Meditation
you

and

must

deepest

heart

It will

of anxiety

their

Personal

of

regulated.

face

on

recognizing

anxiety

others,

part

own.

levels,

that

possible.

large

Healing

patients.

regulate

rate

help

you

body

so

exercise

be

able

feelings,

to
you

own.

de

Labije,

J.

In The
Del

would
and

(2006).

When

Collected

Mar,

CA:

session,

patients

Writings

Unlocking

enter

of Josette

with

ten

anxiety

Have

de

in

Labije

Press.

MATERIALS
like

to

study

regulate

a videotaped
anxiety

http://www.istdpinstitute.com/DVD
actual

help

deficits

READINGS

RECOMMENDED
If you

as

your

others

the

highest

fluctuations

RECOMMENDED
Ten

the

of subtle
and

depends

to

address

anxiety

therapist:

physiologically

To

to bear

will

ego

practicing

better

to yourself

yourself.

It

or

up

experience

anxiety,

your

such
).

recommended.

regulate

to

device

the

for

build

can

regulate

sensitive

regulation

http://www.wilddivine.com
and

be

he

regulating

anxiety

any

anxiety,

so

regulate

to make

for

threshold

patients

defenses,

therapist,

essential

biofeedback

variability

cannot

first

patients

tolerance,

a patients

as
is

anxiety

develop

them

the

the

character

regulate

psychotherapy

out

regulate

defenses,

you,

find

you

perpetuate

your

to

teaching

DVD

session

in

and

you

on

that

fragile
will

fragility,

shows

patient,
find
and

DVD
an

how

to

go

to

of
analyzed

an

transcript
If

you

and
URLs
Anxiety

of the
would

regulation

session

like

to
on

on

review
videos

the

DVD.

the
by

basic
Jon

points

of

anxiety

Frederickson,

you

assessment

part

visit

the

(May

assessment

part

assessment

part

3: Anxiety

http://www.youtube.com/watch?v=Vo62ZMGl6ew

24,

2012).

24,

2012).

.
2

http://www.youtube.com/watch?v=FBZF-Ni4rNo
Anxiety

can

below.

http://www.youtube.com/watch?v=22yLR49VUeM
Anxiety

assessment

(May
.

regulation

(November
.

12,

2012).

CHAPTER

THREE

Defenses:

W hen

The

we

explore

presenting
off

Second

feelings,

problems.

aspects
us

and

from

adaptively.

experience

increased

mechanisms

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cause

us

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1991,

2006).
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1977).
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1995).

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of feeling

(see

and

the

patient

and

let

go

chapters

9 ).
Highly

not

toward

feelings.

and

anxiety,

his

by

of resistance.

Fragile
tactical,

feelings

with

Moderately
repressive

inflicted

the

about

feelings

about

suffering

preparing

resist

talk

cost

benefit

patients

from
use

distance

to form

themselves
distances

begins

to

Address

from

against
defense

inviting

as

feelings

a breakthrough

experience
himself

grief
through

complex
breakthrough
SUMMARY

in
the

and
his

feelings
to the

wall,
a wall

guilt

ask

Once
about

unconscious

defenses
toward
unconscious.

or he
the

the
will

the

patient

his

feeling
therapist

the

transference

occurs.

Either

suffering

he

experience

therapist.

This

do
These

relationship)

out

the

the

addressing

alone.

a past
Point

between

however,

clarification

therapist.

over

patients,

(enacting

therapy.

and

to the

and

a wall
the

himself

turn
each

Continue

identification

defenses

patient

until

defense

resistant

to

ways

the

sees

and

toward

you.

and

patient.
resistance

the
has

patient
inflicted

a breakthrough
ushers

in

will
on
of
the

First

identify

and

price.

the

defense.

If the

the

defense

still

If

defense

persists,

defense

or

most

or transference
persists,
Then
In

confront

the

a breakthrough

summary,

Help

them

all

let

and

symptoms.

the

and

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will

use
go

clarify

to

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defenses

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resistance.

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defenses

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feelings

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end

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self-observation
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patients

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and

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for

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of his

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the
should

as

patients
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fashion.

capacity
Figure

self-observing

mobilized.

Figure

3.1

Decision

tree

RECOMMENDED
Blackman,
York:

J. (2004).

New

Cramer,

P.

Cramer,
Social
article
defense.

101

. New
P.
and

work

Selva,

York:

P.

How

York:

(1996).

the

Working

psychotherapy:

mind

shields

itself

. New

with
Theory

defenses.
and

In

Intensive

technique

(pp.

Wiley.

(2006).

Protecting
Guilford

(2008).

the

pillars

Psychology
all

self:

Defense

mechanisms

in

Press.

Seven

Personality

summarizes

defenses:

Francis.

dynamic

5378).

action

and

Della

short-term

defense

READINGS

Taylor

Coughlin

for

the

current

of

defense

Compass
research

mechanism

theory.

, 2 , 19631981.
supporting

the

concept

This
of

Frederickson,
analysis
from
Francis.
patient

J.

studies.
multiple

Theory

of

In Psychodynamic
perspectives

These
uses

(1999).

chapters

a defense.

analysis

psychotherapy:

(pp.
will

defense

165204).

teach

you

Learning

New
how

and

to

York:
recognize

defense
to listen

Taylor
when

and
a

CHAPTER

FOUR

Tactical

and

P atients

Repressive

can

defenses
different

Defenses

use

tactical,

(Davanloo

2000,

purposes

intervention.

and

Thus,

repressive,
111181).

Since

structures,

we

character,

devote

they

and

these

require

separate

regressive

defenses

have

different

chapters

to

types

these

of

defense

groups.
Repressive

defenses

defenses

(Davanloo

primarily

as

repressive

resistant

patients

distance

themselves

patient

Since

will

defenses.

Here,

can

the

but

show
their

at

to

feelings,

fail
be

to

their

tactical

from

the

these

keep

the

patients

defenses

to

defenses

or

try

to

keep

therapist

at

from

tactical

that

avoid

feelings

The

who

alliance.

them

defenses
therapist.

let

Highly

a therapeutic

differentiate

on

feelings.

Address

to

reveal

patients

character

to form

function

They

resistant

and

used

Tactical
but

a distance.

face

tactical

and

difficult
focus

repress

therapist.

can

awareness.

Moderately

use

the

of

therapist

easily
to

distance

avoid

TACTICAL

later

to

examples

connect

of

to

the

feelings.

DEFENSES

Tactical

defenses

distance.

Among

words,

function
the

distancing,

indirect

or

vagueness.
remain

the

he

let

can

we

also

the

distant

be

out

closeness.

from

defenses

therapist

keep

defenses

it

repressive

2000)

continue

repressive

increase

feelings

defenses

remain

distance,

and

to

to emotional

of

the

1990,

a tactic

a resistance
go

keep

most

as

tactics

common

diversification,

hypothetical

speech,

following

vignettes,

same:

help

patient

of his

the

defense

and

therapist

defenses

evasiveness,

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go

tactical

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retraction,
the
see

face

principle

the
his

defense

problems

at

are

cover

generalization,
rumination,

and

of intervention
and
and

its

price

feelings.

will
so

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When

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111181.

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patients

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2004).

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patient

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patient.

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truth.

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but

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(Davanloo
depressive,

describes

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repress
1990,

awareness
2000).

functional,
argument

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with

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of
This

occurs

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wife

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patients
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impulse.

what

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feeling

anxious.

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you

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de

about

Neborsky

2005

following
Instant

on

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ask

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somatic
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Labije

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Ten

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summarizes

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articles.)

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stimulus:
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time

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lap.

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patients

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patient

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and

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impulse.
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stimulus

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or

feeling

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cannot

an

intrapsychic

anxiety,

be

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how

life.

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help

create

her

from

instant

or causality.

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establish

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becoming

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aware

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feeling.

see

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from

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of conflict

therapist

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Labije

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her

feeling,

create
and

see

result,

instant

attentive

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let

before

exploratory

outline

how

go

to
of her

therapy

(2005)

to awaken

the

capacities:
1.

experiences

her

Explore
problems.

current
When

situations
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so,

in
the

which

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patient

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help

defenses.
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the

experiences

triangle

patient

patient

possible.

patients

use

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causality.

the

Thus,

which

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patient

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and

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prevents

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defenses,
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her

defenses

patient

see

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function,

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and

time,
then

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continue

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to

defense
explore

the

current

situation.
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Each

time

the

patient

uses

this

defense

in

the
its

therapeutic
impact

relationship

on

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identify

therapy,

and

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then

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help

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patient

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see
current

situation.
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triggered

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ability

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for

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do

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split-second
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patient

feelings).
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did,

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experience,

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her

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patient

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feelings.
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might
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view

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time,

as

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patient

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it will

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right

to look

now.

at this,

[ Point

out

wants
the

Pt:
emptying

his

mind

conflict

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blocks

the

find

out

way

you

want

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have

no

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you

the

therapeutic

defense

see

what
to

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you

mean?
task

want

why
can

is driving

go,

idea
how

Pt:

you

to

[ Does

not

our

see

the

bottom

how

.]

get

to

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that

you

or

here.

ignore

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of

have

no

idea.

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to do,

we

have

no

his

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or we

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obstacle?

use

anxiety,

anxiety.

want

is an

task

Im

this

say

the

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when

out

defenses?

I ask

Point

which

a problem.
what

choice:

out

face

you

idea

his

can

If

to

do.

engage

the

price

of

in
the

.]
Pt:

against

his

defense

want

to

address

this

anxiety.

[ Turns

feeling

this

anxiety

does

not

.]
Th:

Where

do

you

notice

in

body?
Pt:

attention

to his

anxiety

and

anxiety.

[ Not

pay

attention

to

anxiety?
task?

[ Point

Of

know.

course,

knowing
your

out

dont

[ Defense:

pay

.]
Th:

is

body

his

because

the

result

instead

choice:

of

and

engage

you

ignore

defenses

help

.]

you

your
So

with

in defenses

this

or the

feelings
could

we

crippling
therapeutic

]
Pt:

this

is dominating

.]

do

You

and

right?

it and

your

out,

therapeutic

Th:
anxiety,

to tune

I want

to

do

whatever

it takes

to

get

you

of

rid

of

anxiety.
Th:

anxiety

our

goal

the

same:

to

rid

these

problems?
Pt:

Yes.
Th:

anxiety

Is

and

tension

in your

Where
body?

else

do

you

notice

feeling

this

attention.

this

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Pt:

In my

chest

in the

striated

my

muscles

Th:

Whats

the

Pt:

[ Silence

Th:

Whats

stomach.

[ Now

underneath

that

he

pays

.]

feeling

is driving

anxiety?

ignoringinstant

as

bottom

we

of

look

happen

here

against

the

as

at

Its

these

them.

wander

by

or

anxiety.

What

we

[ Point

is your

The

not

so

defenses

have

his

from

him

you

that.

You

.]

it will

anywhere.

.]

want

to

away

as

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feelings?

how

[ Defense:

feeling

wander

conflict

your

see

get

explore
see

internal

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can

find

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toward

the

out

his

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choice:
the

I dont

the

do

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defeat

get
soon

going

to

him

his

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But

what

I want

turn

goal .]
the

to

ignoring,

patients

or

is your
find
the

price

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that

is

driving

therapeutic

task?

the

[ Turns

can

defense

]
.]

against

the

.]

choice?
out

what

the

therapeutic

rationalizing,

attention

is

against

wander.

task

yourself?

feeling

to turn

want

toward

to

defense

patient

to

that

the

therapeutic

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of denial,

aware

we

then

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anxious.

distracted

is not

away.

can

Th:

Pt:
me

his

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makes

but

helping

out

choice?

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you

away

Pt:
defense

as

wandered

.]

away,

your

great

wander

defense

defense

soon

[ Outline

if you

mind

feelings,

Pt:
of the

My

repression
Th:

the

.]
happening?

Pt:

to

and

away

and
from

feeling
task

that

.]

emptying
his

is

feelings,

his

head
so

he

of them.

Intellectualization
When

the

patient

feelings.

Help

help

face

her

intellectualizes,

the

patient

her

feelings

see

she
that

instead.

thoughts

uses

thoughts
are

not

to

feelings,

cover
and

up
then

Th:
father

dying

in the

a religious

man,

Defense:

What

was

the

Pt:

I realized

that

it was

he

was

and

intellectualization

what

cover

you

your

felt

him

from

with

yet

you

cover

notice

how

you

offer

thoughts?
in the

Isolation

not
in

patient
how

It was

Do

the

forward

to

meeting

your

thought,

best.
his

He

was

maker.

but

out

the

defense

what

do

you

it doesnt

.]

feel

If

tell

you

now

dont

as

you

that

he

would

intellectualization

you

your

fact

longer

be

notice
is

some

feeling

thoughts

you

instead

of

instead

.]

offer

thoughts

feeling

with

all
of

no

about

these

your

your

fathers

thoughts.

feeling?

Do

[ Point

you

out

the

Pt:

Now

that

Th:

Can

we

the

be

able

How

experience

mention

it.

out

who

you

are

as

you

remember

underneath
your

all
father

sad.

to tell

the

of defenses.

to isolate

that
does

regard

you

isolation

in his

in

from

Pt:

I was

his

of affect

question

himself

he

happen?

anger

The

what

feeling
that

of

Some

trash.

find

feeling

I feel

experiences

body).

result

you

Affect

defenses.

the

the

there

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may

he

my

use

for

hospice?

of

physical

he

[ Point

[ Defense:

Pt:

The

your

.]

these
dying

all

me

thoughts,

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death,

defense

saw

dying?

cancer.

feeling?

tells

him.

Th:
your

looking

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Pt:
suffering

you

.]

toward

feelings

remember

as

hospice?

Th:
me

feeling

his
angry

feels

body
The
body
as

(I
(I

feel

dont

feel

patient

which

but

anything

ignores

through

a defense.

becomes,

angry),

the

repressive
I regard
defenses

it as
does

feeling?
when

she

threw

my

resume

in

Th:

How

do

you

experience

that

anger

toward

her?
Pt:

I dont.

Th:

You

[ Defense:
know

isolation

you

are

angry,

of affect

.]

but

dont

you

feel

it.

of the

feeling

angry,

Oh,

Th:

You

you

. His

dont

look

nonverbal

[ Defense:

you

retraction

defense

ignore

your

of ignoring

you

remember

patient

no

signs

her

right

angry,

not

but

you

attention
match

in

chair.

just

said

to

his

dont
the

verbal

Sighs

.]

sound
patients

statement

Maybe

.]

Im

not

as

soon

as

you

you

are.

say

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it?

you

notice

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out

the

his

.] If I dont

feel

angry,

maybe

Im

not

.]
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trash.

you

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throwing

do

the

feeling

by

said

you

you

experience

resume

Do

him

forms.
you

are

angry

trash?

of the

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notice

that

that

that

in the

reminding

[ A fist

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anger

do

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Pt:

your

are

[ Draw

you

anger

denial

in the

to face

you

angry.

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Th:
resume

shows

.]

[ Defense:

your

[ Nonverbally

.]

Pt:
angry.

say

[ Fidgets

Th:
how

angry.

defenses
Pt:

angry.

Im

.]

and

defense

Pt:

fist?

she

anger

threw
now

as

[ Encourage

stimulus

.]

rise

of feeling

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do

the

.]

you

feel

there?
Pt:

I feel

Im

getting

hot.

[ Experiences

his

rage

.]

Minimization
Some

patients

they

do,

the

feeling

can

feel

will

however,
was.
her

feeling

admit
they

Point

feeling

get

incorrect

out

the

and
Th:

receive
What

but

information

patients
the
is the

minimize

use

information
feeling

its

impact.

about
of

how

minimization

When
important
so

she

it offers.
toward

him

for

throwing

you

out

of the

car?
Pt:

A little

Th:

A little

Pt:

He

snow,

and

water

down

threw

then

you

your

an

Do

you

out

of

say

you

feel

feelings?

Thats

uncensored

car

out

If we

you

left

.]

did

you

see

in

the

how

you

of minimization

throw

water

your

stranded

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defense

He

minimize

you

peeved.

the

dont

how

and

a little

true.

look
Pt:

notice

his

[ Point

Th:
have

minimization

peeved?

you

Pt:

we

[ Defense:

Yes.
Th:

feelings?

peeved.

me

down

out

your

.]

of the

car.

feelings,

can

at them?

I was

angry!

Rationalization
When

rationalizing,

rather

than

reasons

the

the

from

patient

feelings

describes

themselves.

feelings,

and

then

Th:
employee

tried

to steal

patient

is beginning

Right

toward

her?

happened

thoughts,
Interrupt

my

mother.

He

relates

in reality

but
and

that
identify

[ Defense:

had

If

to

his

patient

his

differentiate

feelings

strong

feelings

instead.

feeling

when

your

she

dont

the

[ Because

signals

that

.]

we

he

for

firm.

go

to

because

rationalization

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what

the

face
a

because

[ Interrupt
Pt:

fantasy.

him

to rationalize
Th:

feeling

help

your

reasons

Help

You

from

Pt:
the

the

hadnt
wish

done
had

, what

is

the

.]
it

[ Defense:

happened

denial

rather

than

in
what

.]

wont

Th:

But

help

you.

the

defense,

Pt:

I think

Now

did.

What
then

my

rationalization
Th:

she

you

is
ask

anger

And
the
for
is due

now

you

feeling
the

toward

feeling

to her

move

to

her?

.]
similarities

to

.]
try

to analyze

your

anger.

But

how

do

you

ask

feel

about

it physically
the

in your

feeling

rationalization

to

cover

with

another

reasons,

the

defense

and

then

But

its

true.

She

is

like

mother.

my

.]
Th:

in

[ Identify

.]
Pt:

Defense:

body?

Im

truth:

how

sure

your

do

it is.

However,

anger.

you

If you

experience

you

dont

this

bring

this

cover

anger

truth

your

anger

toward

your

employee?
Pt:
already

punished

her?

How

can

[ Defense:
Th:

explain
tell

it away

us

how

and

you

experience

I felt.

[ Defense:

your
you
you

feeling
feel

experience
and

anger

experience

invite

and

Im

the

anger
feeling

think

rationalization

its

this
feeling

anger

explain

defense

to

you

do

not

felt

.]
why

you

me

tell

me

shouldnt.

all

Still,

in

in your

how

you
the

we

your

reasons

dont

body.

body?

experience

know

How

[ Point

out

why

the

do

how
you

defense

[ Sighs.

Pounds
[ Rise

of

dont

go

his

fist

on

feeling

the

(fist)

chair

.] I

followed

tell
by

use

If we

right

now

in your

off

to

fist?

because

[ Block

the

, how

do

defense

you
and

.]

because

feelings.
Reaction

you

because

Pt:
Patients

the

you

.]

experience
the

how

.]

Th:

invite

has

explanations

out

tell

physically

Pt:
you

Thats

these

to

than

body,

physically

company

.]

Rather

anger

anger.

[ Point

trying

the

.]

but

anger.

just

why

when

your

it away,

in your

this

this

not

rationalization

physically

your

Thats

your

Th:

angry

rationalization

rationalize

Pt:
what

I feel

Formation

[ Looks
to

at his

rationalize.

fist .] My
Point

out

fists
that

are

tense.

reasons

are

not

Reaction

formation

patient

see

is acting

and

warded-off

let

go

of this

of what

defense,

What

do

you

Th:

Your

feel

toward

Pt:
relationship

with

Defense:

and

his

reaction

boyfriend
him

for

I understand

mother.

So

formation.

one

feels.

Help

the

then

invite

her

to face

her

slapped

you

and

called

you

doing

why

I decided

She

acts

that?

he

did

that.

to

pay

for

the

opposite

He

had

his
of

bad

mortgage.
an

adaptive

.]
Th:

feeling

toward

him

out

defense

.]

the

for

Thats

At

Th:
opposite

instead.

[ Point

your

anger.

Point

out

up

with

An
the

defense

an

angry.

feel

you

look

feel

you

the
[ Point

acted

formation

your

anger

toward

you

acted

the

go

out

formation

.]

got

a point

dont

act

at this

names?

anger,

of reaction

whats

the

.]

mean?

doesnt

If we

but
you

your

Then

Youve

honest

I was

than

of reaction

Th:
have

do

woman

calling

defense

understanding.

angry

and

than

Rather

Pt:

we

time

the

What

Th:
it

the

out

understanding,

you

Rather

Pt:

covered

your

slapping

Pt:

can

opposite

feeling.

names.

feeling

the

and

pay

him,

you

opposite

his

of

mortgage.

there.
the

opposite

of

your

anger,

anger?

Suppression
Suppression
patient
has

involves

see

been

and

let

the
go

conscious

of the

forget

defense

so

she

of
can

a feeling.
face

the

Help

the

feeling

she

avoiding.
Pt:

another

avoidance

woman,
about

but

I just

it. [ Defense:

Its
try

painful
not

to

suppression
Th:

I hear

that
think

he

has

about

it.

just

left

Eventually,

me

for

just

.]
that,

but

if forgetting

your

feelings

worked,

would

you

be

here?

Pt:

[ Point

[ Smiles
Th:

Your

feelings

forget

your

yourself
Why

are

your

its

from

a form

to

of self-neglect

Its

price

where

of the

feelings

we

think

treated

ignore

you

important
to

has

your

is a way

matter

refuse

husband

away

suppression

and

the

defense

.]

.] No.

No

you.

feelings

like
walk

inside

out

he

herself

like

that
them,

Why

did

there

notice

about

you.

like

go,

do

her

are.

when

you

you

his

to you?

you

treat

dirty

[ Point

husband

work?
out

how

ignored

her;

.]

Pt:

[ Tears

.]

SUMMARY
Moderately

and

defenses.
Tactical

highly

resistant

Repressive
defenses

defenses

push

the

how

the

focusing

patient

on

how

RECOMMENDED
Davanloo,

defenses
dynamic
Davanloo,

(2000).

of cover

of

tactical

awareness.

defenses

by

tactical

closeness

H.

words

(2000).

defenses.

In

135182).

New

of

psychotherapy,

psychotherapy

dynamic

and

with

(pp.

the

focusing

defenses

by

therapist

in

intensive

Intensive
York:

short-term

defenses
I:

speech.

111134).

Management

tactical
part

indirect

psychotherapy,

RECOMMENDED
increase

out

Address

Management

dynamic

short-term

To

feelings

and

READINGS

H.

short-term

avoids

repressive

repressive

feelings.

patient

use

away.

Address

avoids

the

push

therapist

Principle:
on

patients

York:

tactical
part

tactical

In Intensive

New
of

Overview,

II:

dynamic

short-term

Wiley.

defenses

in

Spectrum

of

psychotherapy

intensive
tactical
(pp.

Wiley.
MATERIALS

your

skills

at defense

identification

and

intervention,

you

may

want

to

download

the

audio

files

for

defense

skill-building

exercises

at

http://www.istdpinstitute.com/resources/20-skills-to-overcome
defenses/
and
prevent

. These

intervene
the

five
effectively

establishment

hours

of
with

training
over

will
twenty

of a therapeutic

help

you

different
alliance.

learn

to

defenses

identify
that

CHAPTER

FIVE

Psychodiagnosis:

Co-Creating

T o know

what

what

going

is

moment
(H.
by

by

to

on,

we
we

moment.

Davanloo,
the

say,

need

to

need

That

an

know

to

what

assess

on.

To

patients

known

20022004),

Focus

is going

each

assessment,

supervision

Effective

as

know

response

psychodiagnosis

determines

every

intervention

therapist.

In theory,

the

therapeutic

process

appears
You

problem

the

patient

wants

help

simple:
ask

with,

what

internal

and

he

if he

would

like
it.

emotional

gives

you

clear

to

explore

answer.
You
specific

example,

at his

feelings,

and

and

he

he

gives

says

ask

you

one

and

explores

You

ask

if he

would

he

He

answers

you

with

that

feeling?

insights
But

in your

along

therapy

problem,

emotional
to
an

come

(the

He

you

goes

ask,

How

you.

You

ask,

is your

his

this

way.

Why?

or

a feeling,

with

the
He

feeling

when

you

toward

(defense).

Rather

therapeutic

task),

he

the

what

uses

the

he

exploring
the

feels,
his
detours

offering

responds

claims

of

with

achieving

of

patient

that

impulse

deeply,

his

example

than

is

experience

Instead

describes

ask

you

feelings

patient

specific

do

What

faces

(defense).

but

What

tells

Perhaps

up

ask,

and

example,

defenses.

example,

feeling

feelings

way.

problem

unable

no

the
never

and

offers

tells

a specific

anxiety

body?

He

a look

a feeling.
You

anger/sadness

to take

would.
You

X?

like

he

with
has

problem
it

but

(defense).
he

says

no
is
He

he

has

problems

and

of

and

anxiety

defense.
That

is

not

patient

a problem

responds

and

then

help

him

with

explore
see

When

the

return

to the

but

and

an

anxiety

his

feeling.

let

go

patient

opportunity

goes

therapeutic

that

is

If the

defense,

off

task:

too

the

and

defense,

feelings

his

see
he

the

anxiety,

explore

him

If

his

with

then

help

the

patient.

regulate

responds

detour,

facing

help

high,

patient

of the
to

to

it

feeling.

so

usually

he

can

avoids.

PSYCHODIAGNOSIS
Therapists

sometimes

of

or

anxiety

remember:
good

defense.

all

because

assess

that

become
They

want

responseseven

they

you

tell

problem

and

the

anxiety,

intervene,

a patients

feelings

right

anxiety
to

follow

Assess

each

responses

and

treat

away.
defenseare

in this

these

three

patients

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analysis
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studies.
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Francis.
the

J. (1999).

of the

In Psychodynamic
perspectives

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triangle

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readings

will

analysis

of conflict

psychotherapy:

Learning

(pp.

51110).

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help

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to

listen

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J.

(2012).

download

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for

RECOMMENDED
three

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Intensive
2011).
Intensive
2011).
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2012).

and

in terms

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focus

on

http://www.istdpinstitute.com/Maintaininganeffectivefocus/

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to listen

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of conflict.

Frederickson,

private

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of this

. This

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MATERIALS

videos
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purchasers

feeling.

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on

psychodiagnosis

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Jon

below.
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http://www.youtube.com/watch?v=cKzmk2-xnzY
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dynamic

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dynamic

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5,

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18,

CHAPTER

SIX

Inquiry:

Co-Creating

Conscious

Therapeutic

Alliance

T he

first

task

Sometimes
therapy
of

clarify

these

what

task

comes

and

is

therapy

tries

dynamic

conflict

the

the

to

if

mind

and
a

purpose

from

a Greek
person

the

therapeutic

up

alliance.

perspective.

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of

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the

focusing

psychodynamic

resulting
and

us
term

healing

symptoms

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meaning
).

for

listens.

psychotherapy.

anxiety,

change.

shows

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( intrapsyche

feelings,

for

patient

the

word

psychological

among

relationship

the

of

intrapsychic

cure

exists

to

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within

oneself

co-create

constitutes

derives

( psyche

to
one

elements

psychotherapy

inside

is

assume

says

the

soul

therapy

people
and

none

in

from

defenses

the

within

person.
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establish

this

problems

and

therapist

asks

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at

engage
fears,
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in
and

patient

a specific

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example,

work
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in

experiential

insights

co-create

work

life.

feelings

a rise

unconscious

lead
therapeutic

therapist

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about

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help.

of where

those

problems

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let

asks

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task:

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experiences

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focus,

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conflicts

internal

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of

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occur.

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memories,
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discover

defenses,

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to long-lasting

helps

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patient

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patient

face

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does

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she

suffering.

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change.

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mobilize

ingredients

in

order.
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an

2.

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internal

emotional

problem

to

on.
it is the

patients

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work

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the

problem.
3.

to discern

and

get

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consensus
4.

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on
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INGREDIENT:

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relationship,

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INGREDIENT:

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PATIENTS

internal

emotional

WILL

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patient

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internal

right

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minutes,

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patients

verbally
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Once

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parents.

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intrapsychic

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FOURTH

INGREDIENT:

THERAPEUTIC
In

create

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actions,

the

symptoms,
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in

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6.1

Decision

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use

established
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are

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help

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the

get

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consensus

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patient

on

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formulate

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task:

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see

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when

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use

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x feeling,

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c defenses.

create

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defenses

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3.

of those

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up

depressed.

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go

it

you

the

therapeutic

might

boss

anger

] or

1.

that

we

TASK

interventions

use

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with

CONSENSUS

creates

therapeutic

you

you

and

of conflict

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blamed

way

touch

defenses

THERAPEUTIC

on

boss

unmotivated.

ESTABLISHING

Having

what

of

feel

his

also

to the

feeling

is the

your

self-criticism,

by

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the

angry

problem

from

more

leads

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whats

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felt

you

yourself

out

and

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angry,

distance

and

]. You

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you

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yourself,

.]
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crime

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think

problem?

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4.
capacity
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and

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experience

feel

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your

of

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like

you

example,

power;

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of

victim,

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you

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of feeling

feeling
you

an

timid,

depressed,

could

feel

could

you

confident;

assert

yourself

effectively.
5.
like

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that

sound

like

something

you

would

to do?
Therapeutic

defenses

and

face

his

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feelings.

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the

task

patient

achieves

let
his

go

of

his

therapeutic

goal.
Therapeutic
defenses

that

feelings

that

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following

task

during

anxiety,

create

the

you

symptoms
healthy

vignette

and

where

cause

presents
we

the

cant

explore

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with

me

problem

the

patient

adaptive

to

colleagues.

trouble

misperceived

how

with

Pt:
person

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of inquiry.

conflicts

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replace

his

channeling

of

his

a consensus

on

the

functioning.

shows

phase

have

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but

we

establish
patient

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at

suffers

an

from

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depression,

of

situation

in

which

conflicts?
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in

way

in

such

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you

be

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was
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situation

thought

a vague

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unfair.

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manner

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specific?

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specificity

.]
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paper
drawer
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for

a drawer
years,

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office,

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feelings

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of

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girl,

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angry
a

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.]
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us,

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task:

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defenses

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want
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the

defense,

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patient

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out

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her

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problems

under

.]

this

strong,

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does

it

anxious.

back

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anger

standing

about

of

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this

have

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ground,

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from

being

of this

timidity

completely

and

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task

of her

goals

her

choice:

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dont
sound

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in therapy
and
she

her

work

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if you

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girl

faade

here

bottom

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and
hide

something

of

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you

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with

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behavior.

help

like

deal

and

like.

rather

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anxious

to

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depressed;

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and

power
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to feel

able

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anger

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and

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made

you

so

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how

manner

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patients

hold

see

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go

capacities

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me

thought

submissive

dont

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makes

faade

anger

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you

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adult

this
feel

her

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and

creates

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problems

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prevented

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face

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me

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made

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.]

defenses

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causing

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causing

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against

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make

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patient

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problem.

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way

cover

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we
your

yourself

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you

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anxious
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.]
task.

can

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use

her

time

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defenses

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and

continue
her

to suffer,

positive

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the

phase

based

creating

his

of

to

have

take

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establish

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defenses

conscious

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achieve

wants

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into

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and

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manner

have
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history

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leading

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patient,

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defenses

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anxiety

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resistant

says

anxiety

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it is not

disruption.

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on

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past,

detached

work

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his

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reasons.

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feeling

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in

begins

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patients

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in therapy.

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instead

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his

patients

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describes

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initially

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resistant

defenses

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himself.

assessed

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to

to

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patients

right

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problems.

patients

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take

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he

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become

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an

a problem

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to

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experience.
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take

a history

relationship.
patients

defenses

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are

anxiety.

get

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work

on.

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presents

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any

not

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each

regulate
numerous

asking

response
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anxiety

defenses,

anxiety

come
can

an

internal

intervention.

and
help

detached
out

with

emerge

in

problem

to

is regulated.

for

to

past

fragile

information

avoidant,

the

healing

the

feelings

so

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an

patients

while
by

regulating

healing.

defenses

fashion
focus

but

without

creates

Help

intrapsychic

with

information

harmful,

Address

anxiety,

gain

high

integrative

First,

with

be

relationship.

emotionally

floods

to

information

would

nontherapeutic

an

just

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anxiety

while

not

then
him

turn

If the

explore
against

patient

feelings.
them

If
and

then

explore

conflicts
As
is

feelings.

that

the

cause

patient

feelings

of

trigger

present
of

his

his

will

learn

the

and

body,

revealing

reveal

to

how

only

his

The

history

learned

to

fluctuations
history,

or

procedural

defenses

past

his
he

relational

2002).

to

unconscious

moment-to-moment
his

he

him

related

in his
uses

you,

invite

These

et al.

not

we

now.

present

(Fonagy

time

to

and

he

defense

defenses

but

the

memory

the

history

of

suffering.
he

relinquishes

feelings.

THE

his

and
Then

between

his

he

he

past

will

will

and

anxiety

in

the

reveal

her

patient

present

conscious

done

to

life.

evokes

me!

therapist

gently

he

to know

wants

dedicated
love

feelings
inner

and
toward
wish

of

resorts
you

spite

yet

tempt
of

firmly
her

focus

the

freedom

her
from

the

therapist

for

emotional

to

to be

patients

and
inner

the

one

based

on

to you

demonstrating
is willing
life

to face

mobilizes

her

the

in spite

to know

hand,
her

herself

the
past

what

was

and

anger,

the

the

patient

that

feelings.

patients

of

to

intimate

after

accompanied

persists

freedom,

to

and

patient

emotionally
On

close

feelings
the

resistance

suffering,
who

an

defenses

persists,

connections

triggers
invites

reactions.

me

the

deeply
on

therapist

to

unconscious

ALLIANCE

invitation

kinds

emerge

way.

alliance

the

The

two

dare
In

in a new

because

will
to

experience

therapeutic

patient

How

history

breakthroughs

emotionally

unconsciously

suffering.

his

THERAPEUTIC

inner

relationship

defenses,

experience

UNCONSCIOUS

Establishing

This

and

Every

These

reveals

spontaneously,

for

anxiety

others.

unconscious

Once

This

you

feelings

here

defenses

with

relationships

anxiety,
history.

the

The

anxiety,

exploration

unconscious

unconscious

feelings

feeling,

his

in

regulation.

his

feelings,

alliance,
emerge

affect

avoid

his

revealing

closer

this

problems.

reveals

relationships

of

his

simultaneously

form

Through

longings

by
her

positive

resistance.

deeply

and

to

love,

and

constitute
1987).

the

deeply

signs

of

Why

reveal

are

to

relinquish

her

her

The

has

realized

ally.

One

can

Bion

a Truth

instinct

instinct

to

emotional
can

false

truth
lead

the

sense,
both

the

emotional

patient

the
wish

to

the

Never

person
see

unconscious
to

at

epistemophilia,

(Bion

1970).

He

transformed

in the
our

her

We

on

therapist
in

the

long

this

moment.

to

do

patient

the

In
truth
same.

face

to

fact,
of

this

And

the

of

her

truth,

as

inherent
with

the

the

truth

so

in

her

imprisoned

union

and

could

as

an

one

feelings,

alliance

Truth

at

we

with
is

is

form

the

truth.

In

relational.

In

our

become
it

the

always

who

have

remain

for

of the

patient

therapeutic

the

love

for

underneath

the

we

patients

longing

experience

courage

than

the

unconscious

that

and

alliance

with

the

to

which

me,

person

our

help

desire

with

saw

becoming

rather

focus

unconscious

and

by

truth

That

suggests

our

resistance

to

You

one

health

conscious

therapeutic

become

moment.

her

the

said

it myself.

for

Through

faade

me.

and

is underneath.

tragic

wasnt

albeit

longs

the

patient

and

anxiety

mobilize

mistake

the

one

feeling

this.

truly

no

patient,

patient

increase

to our

truth
face

to

refers

Through

this

the

of

a life

with

designed

is merely

almost

of

the

deny

she

As

of

words

who

I could

in this

partnership

courage

(Davanloo

see

signs

of the

reveal

that

become

self.

work,

together

Unconscious

can

herself.

inherent

existence.

patients

we

part

a part

alliance.

before

we

resistance

think

patients

therapist
alliance

bodily

freedom.

that

and

saw

the

freedom,

are

you

underneath

she

inner

covered

that

is our

the

that

is

inner

us

therapeutic

patient.

resistant
but

if the

defenses

unconscious

the

telling

interventions

patient

for
therapeutic

there

for

even

dedication

be

that

longs

signals

wholeness,

our

us

that

so

alliance,

to

unconscious,

the

are

therapeutic

anxiety

All

unconscious

patients

conscious

and

the

feelings

unconscious?

Sometimes

feeling

positive

at
the

moment
sometimes,

one

with

therapists
that
it

gives
is

the

patients

courage

that

gives

us

the

faith

to go

forward.

SUMMARY
During

the

phase

of

for

change.

relationship
therapist

and

ingredients

inquiry,
To

patient

in this

must

patient

and

develop

explore

and

therapist

co-create

therapeutic

alliance,

discover

the

the

following

order:
1.

intrapsychic

the

An

internal

emotional

problem

he

has

(the

focus)
2.

His

3.

A specific

4.

will

to seek

therapy

example

A positive

for

of the

goal

the

this

problem

problem

therapy

is designed

to

achieve
Through

exploring

consensus

the

problem,

the

presenting

We

co-create

run

into

6.2

and

developing

patient

conflicts

creating

develop

The

the

patients

problems
2.

ingredients

and

on
1.

element

therapist

this

problems,
of the
are
6.3
an

The

therapeutic

task

for

step

relationship
refer

therapeutic
a presenting
show
alliance.

the

to

this

change
list

alliance
problem
decision

of

by

step.

ingredients

is missing.
and
trees

to

Often,

a specific
for

those

Anytime
find

the

out
two

example.
two

you
which
missing
Figures

steps

in

Figure

6.2

Inquiry:

Declaring

Figure

6.3

Inquiry:

Getting

RECOMMENDED
Coughlin

2657).
Lebeaux,

York:

D.

Davanloos
Journal

Selva,

dynamic
New

(2000).
intensive

of

internal

a specific

emotional

example

problem

of

the

problem

READINGS

Della

short-term

an

Intensive

P.

(1996).

The

psychotherapy:

trial

therapy.

Theory

and

In

Intensive

technique

(pp.

Wiley.
The

role

of the

short-term

conscious

dynamic

Short-Term

therapeutic

psychotherapy.

Dynamic

alliance

in

International

Psychotherapy,

14

(1),

3948.
RECOMMENDED
If you
forming
Intensive

want

to view

a therapeutic
short-term

MATERIALS
some

video

presentatons

alliance,

visit

the

URLs

dynamic

psychotheapy

by

short-term

dynamic

psychotheapy

http://www.youtube.com/watch?v=DDKEGwXiNsY

Coughlin

on

below.
part

http://www.youtube.com/watch?v=eVOgXhq49ek
Intensive

Patricia

(May

5,

2012).

27,

2012).

.
part

5 (June
.

PART
Building

TWO
Capacity

in

Fragile

Patients

CHAPTER

SEVEN

Treating

O ne

day

smother

Depression,

traumatized

patient

her

interrupted
that

discharged

therapy

Patients

with
with

of inquiry.
into

project.

anxiety,

Their

fragility
anxiety

self-attack,
Severely
and

ringing

begin

and

regressive

therapist
Fragile

before

is

is
said,

out

feeling

during

they

shift

to

the

striated

out,

but

before

muscles.

of the

blank

anxiety

supervision

do

phase
muscles

they

experience

not

necessarily

cognitive/perceptual
such

as

weepiness,

patients

with

weepiness,
shift

cognitive/perceptual

even
very

projections.

restructure

somatic

self-observing

striated

defenses

experience

defenses

their

they

Impulsive

regressive

She

from

a little

defenses

ears,

to use

must

as

the

why,

If there

Davanloo,

of the

They

patients

capacity

with

suffer
low

only

it shifts

fragile

patients

self-observing
others

in

somatization.

fragile

use

until

disruption.

and

and

tolerate

repressive

rises

well.
away.

who

(H.

out

anxiety,

asked

grow

to

eroded.

patients

shifts

use

to

tried

with
she

disruption,

can

mother

washed

I got

to

which

Moderately

disruption

with

patients

mild

vision

be

defenses

cognitive/perceptual

blurry

such

refers

regressive
These

flood

I think

When
rain

can

cognitive/perceptual

and

20022004).

fragility

a little

her

flooded

down.

soil

Somatization

how

she

slow

only

previous

into

capacity,

needs
gardens

of

before

to

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splitting

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1975).
projection,
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in chapter
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hope
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they

others
want)

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about

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adaptively.

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patients

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level

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).

is denial.

betrayals

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about

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many

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( self-punishment

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tried

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self-attack.

SOMATIZATION
Somatization
symptoms
this
some

condition
have

refers
without
has
assumed

to conditions
any

identifiable

been
that

hampered
patients

where

patients

medical
by
are

three

suffer

cause.
main

malingering

from

physical

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problems.
when

they

of
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suffer

from

genuine,

have

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to

symptoms

medical

recognize

and

the

the

precise

activation

of

systems.

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clinicians

resulting

from

anxiety

from

the

patient

conditions.
relationships

the

have

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somatic

between

and

autonomic

to differentiate

bodily

resulting

the

failed
those

therapists

from

bodily
nervous
symptoms

defense

of

somatization.
We

will

which

assume

has

the

found

relations

autonomic

nervous

how

somatization.
treat

treat

These

(Abbass

Frederickson
Patients

care

They
et

Norten

1981),

only

first

side

and

conversion

al.

being

between

to

et al.

the

this

and

we

will

defense

treatment

of
model

a short-term

2008;

show

differentiate

Finally,

from

in

will

somatic

how

allowed

therapy

Abbass

31

In

percent

et al.

recovered

work

of

of psychological

2009;

believed
would

traumatic
that

once

disappear.

psychosomatic

for

stop

the

(1924,

341),

physical

thought

experiences

Later,
symptoms

years.

ancient

Stekel

patients

fifteen

felt

these

F.

Alexander

that

per
and
They

There

is

Egyptians
term

no

referring

somatic
from

to
S.

the
Freud

symptoms
consciousness.

unexpressed

symbolically

(see

somatization

symptoms.

that
hidden

it.

and

disorders.

The

into

the

days

(Coryell

using

review).

states

seven

study

somatizing

from

times

Monson,

to

a brief

(18831895/1974)

from

two

after

and

dates
for

for

nine

(Smith,

longitudinal

medication

2007,

incur

American

one

treatment

the

disorder

bedridden

1991).

from

Allen
in

Breuer

symptoms

the

show

effectively

average

of somatization

appears

Freud

and

resulting
have

evaluation,
We

symptoms.

somatization

pharmacological

resulted

thorough

symptoms.

also

Abbass

of the

effects

diagnosis

and

from

report

(Katon

Woolfolk

will

caused

2007;

expenses

month

The

We

problems

suffer

1986).

effective

the

symptoms

contributions

2005,

2005).
who

suffer

for

symptoms

psychosomatic

format

Ray

bodily

medically

to

received

cause

systems.

from

discuss

health

medical

between

psychogenic

to

no

has

(1950)

emotions,
differentiated

communicate

or

represent

a psychological

conflict

and

those

resulting

from

emotional

arousal.
Symptoms
There

Due
are

anxiety

to

three

Unconscious

patterns

discharged

of

Discharge

somatic

through

the

symptoms

somatic

and

of

Anxiety

that

result

from

autonomic

nervous

systems:
Striated
anxiety

manifests

in

symptoms

hyperventilation.

The

result

headaches

c2,

in

tension

and

joints,
the

c3
limbs,

pelvic

and

painful

when

in

the

tension

and

the

2008).

experiences

an
holds

dry
of

activation:

eyes,

and

Symptoms
sensitivity

consciousness,

response

to

include
light

dizziness,

to excessive

and

heart

rate

to

activation:

striated

tension.

legs),

has

blurry

vision,

disruption.

loss

The

trouble
and

tunnel

of

can

vision

sensation

due
can

of

are

for

the

throat

and

convulsions

result

combined

retention,

with

nervous
constipation,

pupils.

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can

loss

occur

parasympathetic

and

results

from

unsteady

on

ringing

in the

symptoms

of

in

memory

to hypoperfusion

in the

occur.

Nausea,

nervous
the
his

ears,

loss

feet

of
(jelly

blindness,

cognitive/perceptual

consciousness,

also

cause

hyperventilation.

Deafness,

loss
occur

weak

of

palpitations

weakness

patient,

walking.

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or dizziness
or

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tensing

sympathetic

dilated

Excessive
system

back,

impulse.

heart

and

c1,

menstruation,

impulse

urinary

due

in

or

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system

the

chest,

is

lump

unconscious
the

can

painful

fits

back

muscles

Chronic

and

to

and

wall,

sensations,

lead

sighing,

around

abdominal

Psychosomatic

unconsciously

skeletal

irregularity,
can

Unconscious

tension

et al.

in painful

tension

the

muscle

(Abbass

swallowing.

patient

in

tension:
clenching,

of

to

menstrual

Muscle

difficulties

pain

results

intercourse,

vulvadynia.

(due

and

hand

tensing

extremities

muscles

of

chronic

vertebrae),

muscle

loss,
brain.

vomiting,

amnesia,
Anesthesia
diarrhea,

abdominal

bloating,

gastrointestinal

and

tract.

intolerances.

nervous

assessing

which

parasympathetic
cause
defecate,
will

Labije,
The

chronic

pain

of

(Toner

parasympathetic

symptoms.

Chronically

from

who

who

primarily

in

pressure.
defenses

from

food
of

when

several

of

or

Always

discharge
take

the

wall)

stomach).

anxiety

forms,

anxiety

into

the

activation

urges

to

sick

tiredness.

feel

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tired

tired

sensation

(J.

will

urinate

When

use
the

Patients
discharge

et

et

al.

al.

1992).

or

asked,

the

sensation
Ten

like

Have

de

1995),

in

multiple

assume

they

dysregulated

headaches,
who

use
their

and

organ
have

bowel

(Schulkin
pain

blood

pressure.

irritable

to functional

bowel
symptoms

(Schulkin

chronic

for

and

increases

systems
a

irritable

function

causes

Leigh

severity

sympathetic

raises

leads

and

pain

activation

anxiety

and

1990),

activation

with

Schwartz,

immune

nervous

elevated

associated

Elevated

decreases

repressive

is

(Jamner,

activation

somatic

tension

defenses

sympathetic

chronically

Patients

suffer

al.

dysfunction

suffer

the

the

cause

abdominal

sudden

(King

somatic

Elevated

patients

into

activation

Parasympathetic

(Deschields
et

Increased

Many

sick

the

discharge

function

discharge

as

the

doesnt
a

can

headaches

and

pressure

Elevated

well

of

and

system

sensitivity.

as

in

repressive

blood

parasympathetic
2004).

rather

patients

symptoms

(nausea

system.

she

immune

elevated

the

by

frequent

that

use

1988),

from

in

discharged

communication).

chronic

compromised

result

breathing,

but

personal

can

triggered

of

report

exercise

dysfunction

Migraine

nervous

difficulty

patient
after

be

symptoms

of

pathways

pain.

can

forms

system

two

abdominal

of

anxiety

(tension

nervous
these

from

pain

system

parasympathetic
differentiate

result

These

Abdominal

somatic

some

gas

2004).

medical

condition

anxiety.
defenses

discharge

sympathetic
back

nervous
pain,

repressive
anxiety

and
and

into

their
systems.

They

elevated

blood

some
the

anxiety

regressive

somatic

and

parasympathetic

nervous

complaints,

irritable

Patients

who

discharged

dizziness,

negative

feelings,

as

We

the

helping

his

identified

feeling.

the

see

through

symptoms
systems.

of

murderous

the

to

from

Due
this

the

nervous
to

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point

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we

let

of

systems.

person

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whom

pictures

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of

they

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complain

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of

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his

defense

often

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express

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look

like

be

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and

symptoms

somatization

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of

Unconscious

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the
with

patient

patient

with

experiences

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fantasy

regains
identification

Once
he

sensation
with

somatic

symptoms

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can
with

rage.

defense

that

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autonomic

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result

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body

following

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of

the

symptom

of somatization.

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rage

toward

the

police,

the

paralyzed.

identification.

arms.

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symptoms

the

feels

Anesthesia:
unconscious

somatic

somatizationidentifying

consistent

becomes

at
through

Paralysis:

his

from

classical

First,

However,
of

in his

go

Expression
have

discharge

defense

patient

They

reduce

symbolically

person

from

is

rage.

Symptoms
Up

they

can

of

through

Second,

body

and

clues.

discharged

anxiety

suffer

through

We

symptoms
two

whose

walking.

result

symptoms

patient

and

headaches.

projection.

underlying

The

in

gastrointestinal

migraine

disruption

which

and

anxiety

feelings.

the

of

from

and

defenses

problems

most

reduce

inviting
by

and

suffer

syndrome,

regressive

externalization

can

They

cognitive/perceptual

fatigue,

such

bowel

use

into

systems.

he

feels

imagines
in
the

his

Anesthesia

For

instance,

his

murderous

chopping
arms,

murdered

can

also

a patient
rage
her

reports

toward

arms

result

off.

and

the

therapist

figure.

The

patient

his

from
no

feeling

ex-wife,

Afterwards
points

identified

an

in
he

out

the

with

the

wife

as

a punishment

for

feeling

rage

Abdominal
angry

with

someone

imagines
but

hitting

identified

and

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with

then

father

him

pain:
reports

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and

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conflict.

then

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him

gets

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the

disappears.
tension
of

headache.
head

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pain

like

The

has

cut

a knife

patient

went

Principle:
the

striated

When
or

muscles,

somatic

feeling.

the

explore

somatization,
7.2 ) .

Table

7.2

How

to

Psychogenic

How

to

Assess
or

the

result

of

somatic
restructure

table

back

and

the

eliminate

somatic

Whether

Somatic
Caused

from

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stabbing

then

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muscles

format

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explore

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explore

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in patients

Symptom

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defenses.

smooth

graded

from

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in the

discharge,

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form

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by

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from

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fit

ex-fianc

murdering

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can

rage

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wanted

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expresses

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imagines

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He

blow

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with

patient

a pain

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A patient

her.

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stomach.

Headache:
psychological

toward

Is

feeling

Current

self-report

functional
cause

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Rather

than

Watch

the

somatic

measures

symptoms.

In

a symptom,

they

assume,
patients

symptoms

symptoms

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of somatization.

anxiety

and

anxiety

past,

assess.

body

to

observe

rise

and

fall

If the

suffer

(Abbass

when

2005,

do

causes
with

2007;

Abbass

et

medical
cause.

rise

and

by

anxiety

not

shift

do

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somatic

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no

is discharged.

caused

symptoms

from

anxiety

feelings

are

patients

found

from

a psychological

where

psychological
Most

office

it had

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organic

clinicians

assumed

can

feeling,

differentiate

if

we

creation.

therapists

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psychosomatic.

defense

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fall,
or

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in response
play

resulting

from

al.

or

to

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symptoms

2008)

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in

in

unconscious
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defense

of

emerge

in

somatization.
The

following

excerpt

response

to a rise

Vignette

One:

The

patients

the

first

stomach).
past

illustrates

of unconscious

Migraine
anxiety

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After

boyfriend

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and

striated

initial
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abused

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anxiety

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body.

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daughter.

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.]

Pt:

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of

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Headache

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how

boyfriend,

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toward
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feelings

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her

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the

SUMMARY
Psychosomatic
body
a

or

the

symptoms
defense

conflictual

symptoms
psychogenic.
anxiety,

If no

physical

from

of somatization.

situation
increase

result

and
in

change

symptoms

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ask

about

response

to

occurs
are

the

discharge
assess

the
a

most

likely

a symptom,

patients

rise

in response

of anxiety

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anxiety,

the

explore

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to a rise
medically

in

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they

are

of feeling

and

caused.

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have

somatic

conflict

so

anxiety

to drop

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symptom.

the

patient
and

you

a link

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you

became

can

see

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that

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restructure

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intense

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feelings
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explore
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see

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somatization,
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see

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occurs.

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patient

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bear

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unconscious

person

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symptoms

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anxiety

is

toward
the

whom

patient

to

of

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experiences

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ability

into

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patient

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symptom

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whose

patient

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increasing

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point

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time

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at which

patients.

of

severe

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invite

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spectrum

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and

link

causality

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the

impulsive

in your

somatization.

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of

patients

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anxious

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defense

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of

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into

stomach.

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of identifying

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feeling

of

without

toward

to your

defense

experience

defense

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angry

more

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symptoms.

symptom

to

triangle

intervention

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to

her

bodily

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patient

patient

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of

sees

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from

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patient

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felt

sick

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feeling

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defense.

feeling

allows

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angry

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and

patient

summarize

causality.

were

the

too?

somatic

invite

until

to decrease

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anxious

and

see

symptoms

feeling

feelings

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Then

about

anxiety

and

a breakthrough

to

goes

restructure
the

feeling,

drop.

fragile,
patients

depressed,
need

the

somatizating,
graded

approach

and
to

restructure
goes
the

the

into

the

therapist

of these
will

pathway
striated

muscles.

must

have

in the

A.

use

discharge,

regressive

establish

an

so

anxiety

defenses,

intrapsychic

in self-observing

capacity,

which
focus.

All

which

we

chapter.

RECOMMENDED
Abbass,

to

problems

next

anxiety

They

restructure

patients

examine

of unconscious

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dynamic

of

T.

Psychotherapy

Direct

of pathological

short-term

Journal
J.

(2008).

dynamic

Transformation

Treatment

Trunnell,

Short-term

disorders.

of pathological

Psychotherapy,

intensive

Frederickson,

Purdy,

short-term

(1988).

International

and

Transformation

intensive

D.

somatic

(2009).

13051314.

of Short-Term

Davis,

for

K.

78 , 265274.

Lovas,

Davis,

Kroenke,

psychotherapy

Psychosomatics,

Abbass,

and

An

format

Dynamic

overview
of Davanloos
Psychotherapy,

of

RECOMMENDED
You

may

to work

MATERIALS

want
with

to view

fragile

Working

with

the

session,

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the

following

videos

including

fragile
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understand

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transcript

http://www.istdpinstitute.com/DVD/

of

DVDs

analyzed

at http://www.istdpinstitute.com/DVD/
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to better

including

transcript

of

the
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initial
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.
with

borderline

patient

a teaching

video

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the
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CHAPTER

EIGHT

Building

T he

Self-Observing

triangle

defense.

of

Capacity

conflict

tells

Self-observing

patient

can

bear

us

where

capacity

his

feeling,

to

tells

regulate

focus:

us

feeling,

the

his

anxiety,

extent

anxiety,

to

and

or

which

let

go

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of

his

defenses.
Moderately

resistant

defenses
fragile
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with

some

spectrum
attention

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it. If he
more

and

ask

about

or pay

from

If

Therefore,

we

Freud

he

have

to

attention

A.

the

patient

response

see

in the

observe

all

experience
he

anxiety,
If he

or

his

these
to

1936).

The

him

he

become

will

differentiate
when

let

go

from

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of

them.

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patient

you

create

capacities

his

If

regulate

defenses
to

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defensive

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of

them

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no

prevent

order

phases

(Ten

of

inquiry

anxiety,

his

self-observing

Have

de

Labije

and

defenses
2.

feelings,

and

for

1.

his

from

breakthrough

defenses

patients
cannot

anxiety,

become

see

and

the

feelings

is unaware

observing

of

and

his

paying

to them.

During

feeling,

will

Freud

cant

feelings.

mobilize

experience

because

feelings

cannot
will

often

he

to his

about
he

he

1923/1961c;

feelings

this

ask

defenses,

problem,

(S.

you

feelings.

can

his

anxiety,

or defenses.

feelings,

attention

feelings,

However,

patients

anxiety,
his

their

therapist.

resistant

differentiate
when

observe

the

feelings,

observe

presenting

patient

highly

observe

anxious
feelings

can

from

cannot

cannot

his

help

to their

If a patient
he

patients

anxiety,

and
3.

invitation

to

feeling,

capacities

(A.

assess
Freud

each

1936)

in

2006):

Observation

: Can

in the

moment?

Attention
defenses

the

: Can

the

in the

moment?

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: Can

patient

patient

the

pay

patient

observe

attention

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his

to

his

feelings

from

anxiety

and

defense?

4.
feeling

triggers

anxiety

he

how

defenses

see

his

Causality

which

triggers

create
5.

defenses,

or

feelings?

Does

inflicted

on

does

he

he

himself

his

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patient
in

presenting

his

sadness

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defense

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see

feel

: Can

: Does

guilt

the

he
are

over

through

his

each

patient

response

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his

moment?

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problems?

defenses

or

see

defenses

identify

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avoids

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them?
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of

intervention.
express

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prevent

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defenses.

self-observing

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feeling.

anxiety

and

awareness

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capacity.

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from

assess

that

feeling

experiencing

each

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of
patient

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to intervention.

SELF-OBSERVING
observe,

CAPACITY

pay

anxiety.

attention

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feeling

resistance,
of

his

pay

or

defenses

label

and
and

problem

and

cannot

next

so

capacity

attention
First

they
in

to,

or

strengthen

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turn

patients

experience
patients

against
is

capacity

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called

their

defenses.

restructuring

1990).
(1990,
and

separating
(1999,

labeling

to

anxiety

observe

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internal

defenses

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excessive
and

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and

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to

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process

ego

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OF

observation

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anxiety

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patients

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his

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2005)

2000)

patient

described

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from

the

restructuring

the

corners

resistance.
as

in terms

the

of the
Ten

Have

development

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separating

triangle,
de
of

and
Labije
specific

self-observing

capacities.

understand

this

(procedural

memory)

Today

nearly

of the

patients

observing

models

(S.

Freud

theory

emergent
of

complexity

awareness.

the

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case

following

capacities.

They
builds

without

must
on

to

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be

assess

moment.

the

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capacity.

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capacities

until

feelings

of

to address

that

without

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to
she

assess
can

under

in

the

of
and

the

rubric

brain
of ego

different

neuroscience
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to

the

2000)

between
of

role

perspective

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emergence

of the

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of

ego.
self-observing

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build
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anxiety

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self-observing

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central

ones.

problem

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concept

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patient

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defenses

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on

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perspectives

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vignettes

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the

allow

capacities

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Grigsby

of

patient

agree

capacities

psychoanalysts

2000).

today?

1999),

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self-observing

capacity

and

(Palombo

theory

Stevens

psychotherapy

2007;

brain.

the

of

properties

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and

1923/1961c)

ego . Instead,

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the

parts

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attention

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in terms

all

neuroscience

called

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in

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breakthrough

of

self-observing
to

unconscious

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the

present
Vignette
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this

responses

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observe

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feeling,

anxiety,

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of anger?
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mechanism
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difficulties,

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you

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or worse?
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bottom

as

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herself

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depressed?

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of

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you?

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made

her

want?

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yourself

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to overcome?

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making

choices

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experience

aware

defenses

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self-punishment

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it what

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defenses.
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she

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her

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right

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consequences.
fact,

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you

in your
say

this

get

to

way?
to yourself,

is

that

mechanism?
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how

you

are

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give

up

on

yourself?

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like

you

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were

how

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work,

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results?
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to make

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of

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toward

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many

hard

him

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for

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is

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aware

she

says

of
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a fact .]

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to know

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what

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you

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feel,

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you

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relationship.

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you

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car?

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yourself

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each

your

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lover

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what

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choices.

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toward
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fine

with

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tries

to avoid

conflict
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worried

your

feelings

with

the

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here

therapist

some

could

reluctance

make

things

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how

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to get

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patient

you

as

you

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you

just

think

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as

of your

detach

here

about

that?

have

to

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long

be

as

you

difficulties.

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me?

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know

what

if you

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know.

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patient

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wont

not

as

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about

to you.

here

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do

how

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what

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do

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[ Said

healthy

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healthy

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a puzzled

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detaching

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if

the

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.]

unhealthy

alternative?

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with

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feeling

toward

him

for

betraying

you?
Pt:
patient

experiences

the

patient

question,

do

carefully

based

not

goes

cognitive/perceptual
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Yes.

Th:
When

[ Patient

says

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she

assume
on

the

your

total

mind

a sign

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disruption

does

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limp .]

just

go

know.

and

goes

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there?

the

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blank

.]

of anxiety.
not

know

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To

avoid

self-observing
getting

this

to

your

capacity
response,

avoid

asking

Sullivan

questions

1953a).

capacity,

something
from

If you

dont
she

knowing.

that
ask

know

does

be

know,

help

generate

questions
will

not

Then

will

her

far
the

find

see

it

(Mitchell

beyond

result.
out

and

go

her

H.

S.

self-observing

Rather

what

let

2007;

than

defenses

ask

for

prevent

of those

defenses.

capacities

and

her

SUMMARY
We

have

outlined

the

psychodiagnostic
building

the

patients

the

capacity

Self-observing
feeling,

to

from

the

Ten

Have

Davanloos
Josette
Press.

reduce

he

with

mobilized

defense;

pay

and

defense,

patients

the

defense.

certain

order:

to

feeling,

attention

differentiate

assess

the
of

in

and

transference

build

syntonicity

common

assessing

and

Then

the
be

for

defenses,

presents

causality;

defenses

the

patient

as

uses.

READINGS

de

Labije,

road
ten

patient

and

see

RECOMMENDED

principle

anxiety,

must

anxiety,

defense;

same

capacity.

capacities

and

person

time

to

self-observing

self-observing

anxiety,

The

applies

Each

observe

self-observing

problems.

capacity

resistance.

basic

Have

to
de

J.
the

(2001).
unconscious.

Labije

(pp.

Red

and
In

97110).

green

The
Del

traffic

Collected
Mar,

CA:

lights

on

Writings

of

Unlocking

CHAPTER

NINE

Regressive

W hen
the

Defenses

working

with

pathway

of

restructure
more

forms

are

less

parts

1991).
refers

out,

defenses

of themselves
from

Patient

groups

fragile

patients

(weepiness,
somatizing

patients

specific

invite
split-off

the

on

(identifying
(cursing,

the

regressive
patient

feelings

to
.

the

(S.

Freud

of

formal
patients

feelings

through

They

ability

to

earlier

expression

internally,

their

the

self,
the

discharge,

(2)
of

require

relocate
differentiate

it,

of

projection,

and

(4)

defenses);

ones

and

price

integrate

rage);

acting

regressive

its

patients

character

object

clarify

restructuring:

depressed

and

restructure

defense,
go

that

projection);

with

To

let

of

projection.

lose

defenses
and

Principle:
identify

to

examples

of

and

then

modes

to

a projection).

rage

patients

impulsive

and

(splitting

turning

rid

splitting,

(e.g.,

have

get

conscious
mature

feelings

to

restructure

differentiated

are
their

to

in others

a fantasy

to

and

experience

and

from

anxiety

leading

from

regression

defenses

discharge,

identify

regression

and

make

impaired,

regression

structured,

than

verbal

to

formal

complex,

regressive

essential

restructure

capacity,

defenses
more

to

we

self-observing

testing

temporal
and

Rather

use

reality

(Land

Regressive

regression.

acting

it is

functioning;

spectrum,

Regressive

Thus,

processes;

of

fragile
build

reality

regression

1914/1957b).

can

and

defenses

unconscious

the

defenses.

regressions.

term

in

discharge,

regressive

regressive

that

anxiety

dysregulated

severe

The

patients

and

out).

defense,

(1)

function,

(3)

and
the

previously

ACTING

OUT:

PUNCHING

WALLS

OR

THROWING

OBJECTS
Patients

who

feelings
or

unable

externally.

hit

things

than

feel

Acting

out

provokes

get

rid

toward

the

of

internal
one,

off

of

feelings,

experience

himself

they
of

may

out

their

vent,

yell,

feeling.

punch

with

internal

act

Rather

the

wall.

broken

experience

He

knuckles.
of

feeling

or

it.

the

Defense

the
Thus,

internally,

a man

the

having

example,
out.

a rise

punishing

for

acting

feelings

bear

the

Making

following

defense

of

wards

punishment

the

to

while

One:

tolerate

a loved

rage
always

Vignette

to

Unable

to

rage

releases

In

are

patient
he

Dystonic
does

is not

not

yet

see

the

motivated

to

price
let

go

of

his

of

the

defense.
Th:
Jane,

you

punched

the

wall

Pt:

out

the

price

hurt!

By

feelings
face

the

this

pattern

rage

rage

toward

the

defense

.]

then

who

took

the

hit?

Who

this

mechanism

got

hurt?

the
her

and

See

how

Jane,

but

rage

on

the

punished

honestly

in

destructive
then

you

wall,

you

yourself

here

so

we

were

one

avoided

instead.
can

the

you

who

got

facing

Would

help

is?

you

your
like

overcome

to
this

of self-abuse?

possible

the
so

he

maladaptive

Vignette
of

[ Identify

the

Me.

toward

turning

Encourage

than

rage

toward

experience

.]

Th:
felt

instead.

But

Pt:

You

than

Right.

Th:
Point

Rather

Acting

Two:
Out

patient
can

to

feel

channel

his
them

feelings
into

internally
adaptive

as

powerfully

self-assertion

rather

self-destruction.
Differentiating

Feeling

from

the

as

Defense

In

the

following

between
out

example,

experiencing

externally.

and

his

patient

a feeling

That

defense,

the

is,

he

which

does

internally

does

helps

not

him

not

within

see
his

differentiate

avoid

the

the

difference

body

and

between

internal

acting

his

it

feeling

experience

of his

feeling.
Th:

How

Pt:

do

you

I slugged

experience

of anger

with

the

defense

Th:
is how
you

you

try

get

[ differentiate

destructive.
[ The

push

her

of

away,
the

ACTING

and

recovering
Rather

at?

others,

he

judges,

and

punish

him.

.]

his

in

his

ask.
they

acted

he

she

could

you

act

out

Why

his

son

guilt,

do

that

very

feel

for

rage,
to

you

yourself?

it .]

when

he

however,

his

was

he

facility.

He

inside

PROJECTION

to

differentiate

projected

furious
to

on
his

are

you

superego

became
trying

high

Who

cruel

them,

failed

your

against

rehabilitation

toward

Unfortunately,

love

him.

out

the

TO

judged

is

this

turn

projected

it

but

him

He

his

Slugging

feeling

],

you.

abandoned

experience

that

then

When

rage.

from

feeling

to leave

equates

your

keep

off

RESPONSE

would

imagining

kill

patient

is not

to

from

to help

everyone

at Jane?

out.

her

rage,

you

her

addict

than

onto

looking

your

defense

invite

IN

drug

superego

of

self-punishment

OUT

drugs.

slugging

Jane,

the

The

of acting

defense

hitting

price

[ Address

rid

the

By

you.

to

But

rage

her.

Psychodiagnosis:
feeling

this

provoke
them

onto
at

these

them
from

projections.
Acting

out

disruption.
shuts

is
The

down

patients

often

do

anxiety
not

which
is

too

remember

AND
and

accompanied

hippocampus,

when

CONTEMPT
Contempt

frequently

sarcasm,

high.
what

by

cognitive/perceptual

integrates
That
happened

may

short-term

memory,

be

impulsive

when

why
they

act

out.

SARCASM
regressive

defenses

against

emotional

to
his

closeness,

prevent

patients

mistake
and

complex,

nuanced

partial

picture

based

on

the

following

In

a therapeutic

sarcasm
the

fact,

for

other

And

something

could

patient

does

than

always

sarcasm

offers

be

the

never

Some

However,

rather

is

that

alliance.

honesty.

person

contempt

people.

example,

to help

try

you

the

Notice

the

therapists

to take

devalue

other

contempt.

to take

and

view.

of

of

offer

dishonest,
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notice

are

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back

are

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slow

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patient

down

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anxiety.
DISCHARGE:
Patients
hearing
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talk

loudly

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to

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get

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onto

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patient

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feels
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rises,

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with

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access

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end

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rid

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capacity.

to

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tolerance.

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to
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following
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cursing.

simply

making

intervention
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draws

feelings

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patients

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words?

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bother

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therapist
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for
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you

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patients

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defenses

patient.
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cursing

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feelings

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cursing
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as

as

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anxiety.

our

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talk
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chapter,

may

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be

all

willing

your

to

feelings?

way

320323

talk

the

that

impulsively

to

of the

whether

THERAPIST

preventing

also

(projection

deactivate
pp.

capacity

as

they

you

you

THE

anxious,

you

what

help

OVER

become
over

Would

to you?

self-observing

they

work.

I can

TALKING

Patients
soon

here,

sense

DISCHARGE:

for

talk

over

intimate

talk

over

over

you

patient

relationships.

their

feelings

because

superego).

If anxiety

(See

, and

chapter

11 .)

the

patient

talked

and

they

fear

regulation

is projecting

projection.

others

a judge

projection

onto

section

in

Intervention
In

the

following

soon

as

he

from

hearing

patients

example,

started

to

what

the

anxiety

defense

to the

speak.

is

therapist

too

high.

patients

see

that.

prevent

us

better.

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finish

speaking,

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patient

the

next

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from
that

so
says

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that?

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she

Some

anxiety

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to

can

yes,

her

you

you

you
you

sees

comes

intervention

prevent

you

do

see

her
up

as

healing

get

help

to

open

mobilize
notice

or

willing

to

right

anxiety,
say

here

when

show

her

patient

may

other

words,

until

feeling

now

the

to get
I

a defense

to her

you

will

to receive?

trigger

you

good

me

listen

here

as

the

Its

over
need

attention

feeling

me?

you

will

the

of criticism.
over

came

up

her

feeling
soon

you

that
brings

Talking

be

as
patient

signals

sense
talked

you

the

therapist

relationship

the

wish

also

problem.

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therapist

want

in
right

you

say

causality:

to collaborate

that?

does
from

be

you

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prevent

the

any

notice

to

it

how

without

you

would

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sense?

unless

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the

make

second,

me.

going

forming

away.

with

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this

said.

attention
Th:

you

Clearly,

over

not

criticizing

work,
her.

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be

talking
she

is

over

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projecting

the

superego

about

onto

and

section

you.

If

perceiving

on

you

projection

in this

so,

explore

to

deactivate

chapter,

how

the

this

pp.

patient

is

projection.

320323

thinking
(See

, and

chapter

the
11 .)

DISSOCIATION
Dissociation
multiple
This

is

selves.

strategy

person

Many

merely

who

warded-off

malfunctioning
occurs,
patients

has

muscles

of

to

of

his

without

body,

associated

with

Vignette:

products

of

of selves.

a defense,

2003).

of

not

the

Integrate

the

disruption,

anxiety.

As

start

regulating

and

and

soon

tension

but

However,

anxiety

until
stop.

the

Anxiety

also

sighing

a patient

who

may

have

respiration,

dissociation

tension,

of detaching.

brain

as

dissociation

muscle

If

the

so-called

in the

striated

respiration

is tense
a

the

and

throughout

freeze

response

dissociation.

Dissociation
in the

patients
therapist

following
anxiety
should

example
as

soon

be

of dissociation

how
as

he

anxiety

the

therapist

dissociates.

regulation

begins
The

before

to

first

regulate

concern

addressing

of
the

itself.
Th:

beating

symptom

integration

cognitive/perceptual

only

the

of defense.

striated

sighing

the

2000,

results

defense

hands.

creates

on

disruption
to

not

the

the

feeling

is a tactical
involves

focus

excessive

access

clenching

defense

sign

exploring

dissociation

the

the

cognitive/perceptual

patient

the

that

(Frederickson

not

due

stop

therapies

it

feelings,
is

defense

integrates

uses

Dissociation

Notice

regressive

Whats

the

feeling

you

mean?

toward

your

father

for

you?
Pt:

I just

left.

Th:

What

do

Pt:
patients

face

striated

tension

is slack,
.]

his

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like

eyes

are

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blank,

up

on

the

and

his

body

ceiling.
is

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limpno

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Pt:
concentrate,

but

its

not

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blurry?

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getting

the

fuzzy,

better

your

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to

down

bring

anxiety

got
the

his

goes

gone

.]

we

in

my

to

to

you

were

your

to
.]

or

is

your

.]

but

my

vision

is

.]

observe

is

ears,

anxiety

ears,

back

and

hard

disruption

of his

drops

step

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into

striated

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feeling

triggered

triangle

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.] Do
Pt:

so

observe:

your

having

and

thinking

some

label

thinking

Anxiety

may

shift

explore

the

feeling.

If

anxiety,

and

outline

the

returns

to

feelings

tolerance

the
at

back

striated
a

rises,

higher

and

the

now?

trouble

symptoms
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some

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your

see

the

feeling
mind

know

was

the

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the

have

been

cognitive/perceptual

so,

stop

exploring
of

muscles.

conflict

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level

in

is fine.

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disruption

toward

your

conked

why

it did

feeling

feeling

into

triangle

vision

out.

is

father.
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that?

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the

cognitive/perceptual

was

What

anxious?
Pt:

you

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you

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and

anxiety.

of conflict

made

fine

muscles,

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his

really

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now

that

trying

in your

pattern

blurry,

anxiety

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ringing

ringing

patient

Pt:

the

any

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now?

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No

now.

vision

thinking.

fuzzy.

discharge

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was

a little

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blurry.

thinking

working.

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vision

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toward

your

father

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angry.
disruption
the
until

encourage
different

cognitive/perceptual

that.

feeling,
the
the

and

regulate

patients

example.

disruption

when

the
anxiety

patient
As

you

to
his

dissociation

face
affect
will

disappear.
EXTERNALIZATION
Externalization

is

a defense

by

which

the

patient

blames

others

for

the

ways

she

makes

the

hurts

patient

herself.

Unable

others,

blaming

establish

an

she

does

she

can

internal

see

him

her

lead

it was

fine

fist

blames

Out

with

her

her.

help

others

punishing

she

accuses

the

for

patient

doing

see

to

she

to

her.

will

that
Once

have

an

therapy.

as

A few

by

that

externalization

suffering,

in

reports

anus

anger

Undo

her

a stimulus

herself,

Causality

patient
into

her

so,

to effective

masochistic
his

do

cause

Pointing

with

punishes

To

she

off

suffering.

defenses

will

insert

she

focus.

her

One:

could

for

begins

wards

how

what

that

conflict

She

see

them

that

A depressed,

told

to

herself

focus

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angry.

intrapsychic

to

Vignette

he

herself.

that
part

Externalization

her

husband

of their

minutes

later

asked

lovemaking.

if
She

in the

session

and

it hurt

she

continues.
Pt:

he

did

He

hurt

me

last

night.

Th:

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so?

Pt:

He

put

his

fist

in my

Th:

He

put

his

fist

in your

anus.

Pt:

Yes.

you

did.

anus,

when

it.

I just

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ahead.

told

you

mind

he
if

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you

he

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true?

different

perspective?
Pt:
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in your

anus.

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you

chose

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to say
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saying

yes

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put

his

fist

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but

you

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or no,

asked

to him,

she
Pt:

said
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at

that

point,

you

could

have

said

yes

yes.
he
So
no

didnt
you

want
said

to herself

me
no

.]

to

to say
yourself

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instead.

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your

anus.

him

he

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effect,

could
him

for

your

blame

him

for

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you

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blame

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put

choice.

she

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when

fist

he

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way

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inviting

think

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him

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to put

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with

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defense
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it on

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him

for

fist

you

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then

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you

feel

to yourself,
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face

in

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way.
way,

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what

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anus?

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idea.

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person

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work

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(Winnicott

trauma

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1965).

the

therapist

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who

projection

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impulses

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else

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often

across

the

need

to

who

she

the

(Frosch

(Bateman

and

Have

Fonagy

de

2004;

1983);

2001)

Fonagy

unconscious

the

2004;

Labije

et

anxiety

of

al.

A.
and
2002;

the

A patient

those

(Knight

the

discharge

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a projection

before

S.

335).

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content

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supervision

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function

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1923/1961c;

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capacity

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thinking
1981);

to

occurs

self-observing

Segal

the

1940,

1985).

projection;

symbolic

same

projection

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1936;

[ hoping

projection,

defense,

Freud

you

her

tendencies

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patients

she
to

degrees.

unconscious

primitive

more

].

classical

possesses

her

and

recognizes

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psychoneurosis

function

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to varying
but

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office

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herself.

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projects

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of reality

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instead

filter

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behind

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becomes

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angry

1953b).

projection

therapy

hiding

are

feelings

Sullivan

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pathological

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Deactivating

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9.3

brief

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9.3 .

spectrum

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Level

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Type

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Level

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Psychotic
Loss

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Experiences

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hallucinated

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9.4

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patient
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desires

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Table
or

9.5

regressive

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Table

9.5

regressive

Psychodiagnosis

of

projection

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tactical

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or

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regressive
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See

figure

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Figure
If the
loss

9.1

Psychodiagnosis

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of

reality

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therapist,

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Figure
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9.2

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of

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Figure

9.2

Restructuring

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loss

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reality

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in

patients

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PROVOCATION
Some

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with

hard

on

him,

on

you.

him .]

was

being

hard

reason,

you

were

felt

guilty,
you.

rather

true.

being

angry

she

punishing

Thats

just

on

You

wife

I was

hard

no

you.

her

Pt:

of that.
his

of self-punishment

throwing

projects

guilty

guilt .]

hard

you

felt

punish

Pt:
her

You

out

feel

feel

on

rather

[ Point

than

didnt

but

hard

his

than

how

he

guilt .]

right

about

it

afterward.
Impulsive
guilty

patients
for

person

their

rather

provoke
own

than

misdeeds.

their

Then

defense

punish

them

they

rather

resent

of provoking

the

than

feel

punishing

punishment.

SOMATIZATION
Patients
do

not

defense
sequence:

somatize

in session

usually

see

of

somatization.

rise

the

of feelings,

in response

link

between
Help

anxiety,

the
and

to
a

a rise

rise

of

patient
the

defense

of

feelings.

feelings

see

the
of

They
and

the

following

somatization.

(See

chapter

7 for

examples.)

in

cover

up

depressive

WEEPINESS
Tears

come

intervene

to

patient
her

see

how

action.

to

avoid
how

this

tears

come

defense

(See

anger.

10

for

soon

as

regression

in to

makes

chapter

As

wash

her
more

away

weepiness

in

therapy.

her

anger.

depressed,

unable

information

on

begins,
Help

the

Then

to

take

show
effective

weepiness.)

SUMMARY
Address

regressive

intrapsychic

perspective.

you

could

now

we

still

inside

thought

leave
can

you

have

feel

worse.

news

No

been

no

matter

was

worse.

news

since

office
how

where

you

you

the

one

are

reality:
left

you

run,

your

go,

there

but

The

this:

now

hoped

time,

we

are.
can

be

are
You

see

making

yourself.

it, it could

but

feelings

is making

hurting

doing

last

is not

self-attack

an

You

you

hospital

are

develop

you

you,

and

of

when
far

yourself.

is

you

patient

persecuting

defenses

perpetuate

Restructure

restructure

defenses

and

and

then

regressive

the

capacities

unlocking

of

you
The

how
you
feel
good

entirely

anxiety,

regulate
feelings.

defenses,

help

Observe

under

anxiety,

the

and

making

patient

pay

it

mobilize

sequentially

attention

to

regressive

feelings

2.

See

3.

Differentiate

4.

Let
so

the

unconscious

regression,

to

patients

explore

warded-off

these

misalliances,

the

them

1.

the

my

self-persecution

bad

self-observation,

Build

the

to

control.

Regressive

To

in

persecuting

Your

The

rage

matter

hospital

is that,

your

that

you.

systematically

Remind

your

see

the

worse.

defenses

and

causality

go

reality

from

of regressive

patient

will

feelings.
patient

By
drop

projections

defenses
be

strong
doing

out.

enough
so,

you

to
will

bear
avoid

RECOMMENDED
Coughlin
In

READINGS

Della

Selva,

Intensive
(pp.

Davanloo,

H.

In Unlocking
H.

(1990).

von

Davanloos

with

highly

(pp.

Theory

resistant

127).

technique

unlocking

disorders.
the

depressed

Chichester,

of

Unlocking

and

UK:
the

part

patients.
Wiley.

unconscious

in

1: Restructuring

unconscious

(pp.

the

283306).

Wiley.

(1998).

Early

intensive

International

defenses.

Wiley.

functional

In

UK:

P.

The

from

defenses.

Korff,

ISTDP

regressive

psychotherapy:

York:

unconscious

suffering

Chichester,

New

(1990).

Restructuring

dynamic

79103).

the

Davanloo,

egos

(1996).

short-term

technique

patients

P.

management

short-term

Journal

of

of

unconscious

dynamic

Short-Term

defiance

psychotherapy,

Dynamic

in

part

Psychotherapy

1.
12

183208.
RECOMMENDED
You

may

the

DVD

will

help

different
If

you

want

Projection

to

series
you
ways

would

Frederickson,
examples

MATERIALS
visit

on

see

restructuring

projection,

to help
like

http://www.istdpinstitute.com/DVDs/

to

visit
of projection

projection
what

causes

the

patients

restore
view

the

the

URL

along

video

on

below.
with

(December

http://www.youtube.com/watch?v=pPY2wKhiSWA

specific

and

in a borderline
it,

and

reality

how

patient.

It

intervene

in

testing.

projection
The

to

get

presented
video

offers

interventions

for

20,

by

Jon

several
them.
2012).

CHAPTER

TEN

Defensive

Affects

D efensive

affects

defenses.

Patients

feelings,
them

which
with

with

result

projective

endless

Suppose
him.

the

will

more

point

with

symptoms.
and

few

or

floods
them

paranoid

people

injury.

defensive

important

unable

to see

the

to

Experiencing

hopelessness.

her

deeply

defenses.
turn

against

as

result.

possible,

them

create

she
explore
or

help

affects.

10

of

(Lilienfeld

depression,

According

patients
2007).

strengthens

can
Why?

rage

increases
increases

to

become
Exploring

patients
anxiety,

sadness

defensive

as

boyfriend,

that

defensive

percent

her

Never

to

defensive

from

however,

projection.

therapies.

increased

Expressing

as

expressive

affects

become

result

depressed

all

therapy

defensive

and

onto

and

defenses
from

up

experiential

leading

sad

sadness

for

and

regressive
see

or

differentiate

people,

self-judgment

feels

feelings

from

patient

her

Deactivate

most

of

affects.

her

She

feel

For

the

to

escalate

critical
fearful,

emotions

or result

help

her.

research,
an

as

projects

differentiate

can

or

or

angry,
Unable

dysregulated

those

to

feelings

brain

angry

chronically

patients,

must

are

rejection.

his

depressed,

is

remain

function

her

deepening

defenses,

impulsive

others

imaginary

judge

affects.

patient

will

a patient

psychotherapy

and

encourage

feel

imagining

projection,

generating

he

worse

overwhelms

therapist

instance,

This

weepiness

feelings

defensive
the

Defensive
fills

as

overwhelming

anxiety.

deficits

dysregulated

If we

from

function

Projection

this

In

neurocognitive

believing

suffer

or

defenses.

he

his

catastrophic.

For

spectrum

from

regressive

projects,

about

defenses

result

from

response,

from

Thus,

fragile

Externalization

man

depressed
others

that

rage.
a

In

feelings

in the

depression.

with

will

are

regressive
and

somatic
depression

acting

out,

projection,

and

feelings
in an

from

destruction

defensive

of

affects

emotionfocused

our

crying

and

grief,

though

capacity

to

love.

We

expressive

crying.

nervous

system

But

defenses

Before

breathing

and
more

Levenson

1994;

hormones

110112;

and

feelings.
defensive

Table

10.1

Type

cry

brief,

crying

unsoothable.

Infantile

crying

stereotypical
trauma.

feels

body
and

of

Fogel

off

grief.

increases.
and

her

The
mouth

Fredrickson,

and

Vingerhoets
crying

and

the

calms
1996;
and

common

the

sympathetic

Expressive

sadness

after

sympathetic

this

cries,

Pena

2009,

2007;
flushes

patient

Walter

weepiness
types

of

out
(Fogel

2006).
ward

genuine

off
grief

112113).

countertransference

of ones
most

loud,

angry

rather

bodily

experience

likely

to have

of feeling.
tears.

Patient

than

sobbing,
relieved.

helpless

and

Pateint

feels

apathy,

or guilty.

quivering,

movements.
Patient

patient

loss

affection.

away,
Lip

cries,

our

lighter

wards

activation

2003).

soothed,

Exhausted
pushed

patient

and

Therapist

Intense,

irritation,

grief,

of

crying

easily
and

genuine

Rottenberg,

presents

Awareness

nurturing

Protest

10.1
(see

of

and

patient

Block,

us

relieved

Gross,

affects

Features

crying

Calming,
feels

crying
Types

of

Good

patients

FROM

remind

2009;

the

Sullivan,

Table

the

the

Gotlib
from

defensive

as

(Fogel

and

D.

of

the

Hendriks,

toxic

start

slow,

saliva

Gross,

painful,

parasympathetic

rate

Rottenberg,

contrast,

and

and

pulse

produces

other

harming

CRYING

feel

rises

drop

decreases

stress

the

activation

activation

In

to avoid

differentiating

CRYING

Expressive

2009,

is essential

EXPRESSIVE

DEFENSIVE

as

Thus,

therapy.

DIFFERENTIATING

and

relationships.

trembling,
May

unreachable,

be

related
lost

may

be

tearless,

to infantile
inside

repeated

attachment

of herself.

Unprovoked
thought

or

prolonged

or stimulus,

unacknowledged
for

Dramatic

the

crying

inappropriate,
rejection

based
grief.

explanation

Not

by

imaginary

Therapist

clearly

by

any

stimulus

feels

obvious

or

confused,

connected

feeling

acting

manipulated

on

Unprovoked

unable

to find

an

crying.

dead
and

crying

out

inside.

to get

attention

to an

Possibly

attention.

seeking.

emotion.

linked

to childhood

Therapist

Tries

Socially

feels

to avoid

the

patients

entreaties.
Sources:
1987;

J. Nelson

Protest
the

crying

can

therapist:

you.

seemingly

when

withhold

patient

Alexander

2003;

Mills

projects

the

and

Wooster

occur

You

The

and

2000

T.

from

becomes

withholding

the

me,

lost

in

therapist.

hopelessness,

the

patient
so

sad

Do

result

of

I can

hope

explore

nothing

from

in

her

projection.

onto

for

hopelessness

not

superego

front

feelings

Instead,

of
of

the
rage

address

the

projection.
Infantile

crying

that

therapist

the

cries

with

covering

can

will

fearful
it with

Unprovoked

feeling)

patient

her

superego

she

cries

without

genuine

loss

created

by

crying
suffer

cant
from

or

severe
onto

in
her
stop

Fearing

the

punitive

therapist,

Instead,
(a
her

real

infantile

or

of
calls

finds

no

she

relief.

is

For

ugly,
Im

ugly.

She

These

dysregulating

triggers
a

may
In

is not
an

defense

instance,

she

rejecting

from

while

conditions.

relief,

from

stops.

she

anger

always

defense.

suffers

constantly

but

no

thinks

fears

crying).

imaginary)

herself

He

feel

in neurological

brings

projection

affects

may

except

result

and

projection

patient
like

occur

boyfriend:

stopping
reality.

which
the

her

dysregulated

herself,

looks

superego

until

punishes

(either

crying,

(warding-off

who

Or

not

stimulus

a patient

her.

(which

does

Prolonged

with

punish

anxiety

when

trembling.

crying

Otherwise,
crying.

occur

if

project
response,

grieving

imaginary

loss

boyfriend).
patients
defenses.

The
do

not

For

instance,

attention

rather

she

crying

can

wants,
also

experience

she

be

of her

Sometimes

than

defensive

weepiness.

confuse

defenses.
from

Since

one,

it

emerges
Or

after

it arises

not

anger

a genuine

Defensive

loss,

sadness

with

a history

and

that

that

all

she
men

of
will

choosing

will

be

an

find

bad

the

internal

with

genuine

grief
as

genuine

grief

from

trigger

anxiety

a defense

or

defenses.

and
results

Weepiness

projection

or

imaginary

stimulus:

My

imaginary
abusive

never

Dramatic

feels.
affects

and

example,

involves

of

the

externalization.

it off.

versus

for

she

and

anxiety

to ward

rid

defensive

example,

Real
involves

badly

getting

crying.

get

functions

trigger

not

dramatic
to

Sadness

for

for

differentiate

either

defenses,

after

how

criteria

weepiness
does

it under

these

Process:

rage

discharge

prove

following

her

hide
of

and

therapists
The

may

form

guilt

sadness.

express

a good

to her,

she

husband

loss,

died

for

claims

that

one.

In response
over

of

instance,

men

cries

Grieving

all

cancer.
a

men

to her

imaginary

patient
are

bad

projection

losses

in the

future.
Physiological
involves
the

parasympathetic

activation

patient

sighs,

and

feels

more

deeply

She

Defensive
during
remain

a loose

connected

the

remains

body
the

a deeper

during

with

involves

elevated,

experience

cries

sadness
which

activation:

throat

in

patient

feels

the
the

parasympathetic
tension

continues

form

tense,
is

grief,

tension
anxiety

activation
with

and

herself

continuous

connection

of

belly,

to

the
and

or the

flow

the

striated

therapist.

and

belly

dominates.

In

contrast,

breathing

patient

does

not

therapist.
grief

muscles.

The

sympathetic

rate

freely.

activation

Rising

drops.

heightened

relaxes,

body

tears

the

signaling:
the

the

and

heart

to herself

in

grieving

sympathetic

tight,

Unconscious
anxiety

which

Genuine

and

throat
during

activation.

triggers
Once

the

relax

and

weepiness,

Defense
emerges

more

contrast,

weepiness

it does

not

fully

when

activation:
the

patient

functions

evoke

as

in

the

according
the

patient

of

the

of

wave.

amount

of

In

anger

or

brings

clarity,

woman
after

relief

just
who

she

her
more

therapist

identifies

attention

regressive

In

defenses;

experience:

contrast,

Grief

rises

weepiness
ward

off

and

fluctuates

or

the

projection

experiencing

the

feeling:

Genuine

and

increased

pain.

For

instance,

reject

her

feels

boyfriend

believes
no

as

will
she

is

still

brings

with

no

relief
the

no

an

relief

imaginary

hope.

soon
If the

the

to

the

you

on

(Barrett

Th:
feeling

toward

In this

Emotion

What

Im

begins

to

rapidly

addressed,

example,

notice

how

and

mobilizes

the

regressive

she
the

defense

differentiation

is

essential

2001).

is

the

feeling

toward

your

boyfriend

Day?
upset.

[ Defense:

Clearly

he

him

doing

Pt:

patient

immediately

Once

et al.

Valentines
Pt:

the

is not

weepiness

again.

Th:
dumping

depressed

regression.

feeling

regulation

the

in session.
patients

stop

the

as

weepiness

depressed

explore

to emotion

for
Im

angry.

you

notice

upset

cover
you.

word
Thats

.]
what

he

did.

that?
[ Becomes

tearful.

Defense:

.]
Th:

now?

the

it must

of

her

has

rage.

becomes

weepiness

defenses.

sadness

she

arises

experience

Whats

and

Intervention

Weepiness

for

from

her

Defensive

that

because

in whom

stops,

of

clarity.

exhaustion

Weepiness:

her

and

projects

crying

rejecter

go

defenses

is using.
Result

grieving

triggers

them.

shape

to

lets

or results

Architecture
falls

Grief

[ Mobilize

patients

Do

attention

to the

how

these

defense

tears
.]

come

in right

Pt:

[ Nods

Th:
away

your

anger

as

Notice

soon

as

Pt:

I feel

not

differentiate

her

see

its

to cover

function:

in

to

function

cover

of the

up

up

anger?

depressed?

help

you

so

the

engage

in the

Initially,

she

affects

such

her

observe

the

feeling

its

how

to

defense

the

this

how

this

your

think

anger

she

does

.]

nor

does

sadness

anger?

that

these

these

tears

and

[ Point

tears

might

presenting

you

to get

task

feel

she

tears

out

the

are

be

problem

washing

making

you

.]

to

take

an

with

tears

[ Mobilize

the

honest
and

look

so

we

patients

at

could
will

to

.]

her

anger

and

sadness.

defensive

like

covered

depression?

function.

in

therapist

nor

differentiate
Once

Once

the

self-attack

regression

face

the

for

putting

be

in

this

Response

identifies

it from

defensive

weepiness

begins,

weepiness

stops,

feeling

you

and

to

help
invite

How

In

depression.

covered
do

up

Self-Attack

draws

immediately.
into

Pt:
wouldnt

you

to her

have

anxiety

of

the

patient

boss

her

wash

.]

away

Would

Th:
your

from

to

again.

Notice

the

defense

[ Psychodiagnosis:

see

think

Weepiness

interrupts

the

in

Absolutely.

therapeutic

as

Defensive

the

it wont

cannot

[ Label

come

so.

defense

overcome

anger
you

Do

Th:
anger

it?

now.

wash

you

Pt:

this

her

I think

Do

[ Link

sad

Do

Th:
your

feel

tears

.]
Pt:

away

these

sadness

and

defense

how

you

defensive

Th:
come

.]

the
this

Then
by

the

patients

attention

way,

therapist

the

the
therapist

helps

self-attack.

you

experience

have

finished

such

an

this

rage

toward

down?
I should

situation.

Im

idiot.

college.
[ Cries

If I had,

Defense

self-attack

.]
Th:

notice
the

you

were

defense

freer

You

to describe

Yes,

Th:
dont

like

you

describe
have

feeling

your

therapist

yourself

your

a minute

boss

now,

but

ago?

do

you

[ Point

out

deepen

feel

even

more

time

she

feels

in the

weepiness

[ Interrupt
can

we

the
take

toward

defense

of

self-attack

at

your

boss?

Could

we

a look

your

Pt:

Okay.

Th:

What

Pt:

Anger.

not

block

session.

boss.

blocked

is the

take

.] But
It

if

sounds

a look

at the

see

toward

him?

and

depression

weepiness

will

make

self-attack

will

resume

the

its

self-attack,

.]

weepiness

block

patient

the

feeling

her

Always

the

stops

self-attack,

and

angry.
help

[ Weepiness

Exploring

depressed,

and

have

but

boss?

does

will

will

you,

a feeling

toward

If the

describing

.]
Pt:

we

are

self-attack

defensive

which

the
the

that

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person:

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rage

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possible.

address

us

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are
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as

projection.

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it is proportional,

normal

person

attacked
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persons

goes

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directed

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it

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out

the

rage

toward
a fight;

29).

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patients

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he

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himself

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arrange

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immediately

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world.

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stimulus

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internal

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rage

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and

notice

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husband,
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hard

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has

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to me)

begins

.]

not

have

to realize

the

at

what

happened?

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and

by
by

makes

go

you

on

your

way,

making

yourself

late

cheating

yourself

out

[ Point

out

for

your

the

triangle

choice

anxious.

and
of

punish

you

twenty

of conflict

to

you

.]

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yourself.

.]
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certainly
her

defense

others
to

fits

for

what

to

take

for

what

she

see

her

how

rage

will

start

looking

for

the

Anger

Due

to

Denial
the

victim

she

stance,

how

my

pattern,

was

doesnt

doing

to

it?

myself.

.]

daughter,

notice

look

angry.

her

example,

anger

daughter

her

unable

felt

angry

blamed

the

blames

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to herself)

[ Patient

take

angry

being

leads

daughter,

blames

sees

to

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listen

dont

delaying?

the

externalization

Externalization
about

was

feel

your

how

we

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Pt:
hadnt

on

listen

leave.

doesnt

come

to

you

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therapy

blamed

listen

(She
just

her

doesnt

a problem.

anyway,

and

(not

minutes.

she

just

punished

minutes

for

problem.

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have

to yourself

did

the

.]

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rather

you

yourself

she

twenty

Pt:

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to

wasnt

to yourself!

waiting

daughter

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were

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for

that

then

listen

listen

her
Pt:

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you

what

but

to you,

if you

out

not,
listening

listen
but

as

going

that

course
werent

to you,

were

projects

you

you

a problem.

before

she

that

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stance:

did

to

hurt

externalization

therapist

of

herself.

herself.

escalate.

she

complains

She
As

long

Whenever
that

raged
as

you
sustains

at
she

see

it.

Responsibility
helps

the

patient

see

how

he

blames

see

his

partner

elements

of

choices

he

see

choices

the

his

partner

his

choices.

for

reality.

made

that
he

his
Then

the

caused

his

made

caused

his

choices.

that

decided
and

to

take

I came

sucks,

along.

and

here.

there

I was

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just

move.

this

says

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is no

way

at her
her

last

resent

her

what

about

much

how

another

much

for

to

this

move

her

for

girlfriend.

She

another

year,

here.

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in my

and

job

specialty

I hate

year,

taking

decided

you

It was

this

then

place.

we

can

[ Point

out

job.

with

her?

wouldnt

move.

choice.

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to

have

for

where

your

choice.

choice

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you

focus

live.

choice,

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But

girlfriend,

but

his

defense,

for

chose

decided
now

that

how

he

rage
we

not

her

one

time

to move

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his

the

that

responsible

self-abandonment,
on

was
at

chose

recognizes
his

she

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ways.

choice.

patient

destructive

you

is not

it both

onto

GUILT

But

she

your

than

the

your

you

yell

at

her

for

chose.

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can

better

believe

with

people

something

not

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Pt:

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so

the

last

the

does

will

angry

my

see

he

he

will

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lasts

as

patient

.]

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her

night

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Pt:

try

find

contract

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reality

to

long

with

which

the

patient

suffering,

furious

city.

the

eternally

here,

this

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his
be

so

job

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that

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Im

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yelling

caused

helps

helps

suffering.

and

teaching

therapist

therapist

suffering

Pt:

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you

here
your

to

stay
was

you

are

projects

have
move.

wanted

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with

with
more
here,

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rapidly.
an

said

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her

to move.

have

her.

choice.

she

drops

who

was

are.

and

you

to

resent

intrapsychic

he

you

punish
you

her

for

for

his

responsibility
Once

your

But

important
you

you

admits
focus.

his
We

Misunderstandings

occur

guilt .

(See

Bergler

differ

in the

following

when

1959,

we

7173.)

hurt

someone.

feels

neurotic

guilt

hates

the

So

guy.

to

corresponds

Healthy

matter:

Neurotic

over
she

forgetting

the

to the

the

cannot

be

punishes

need

damage

you

expiated

The

the

Neurotic

elements

on

it is how
limit:

an

guilt

the

grows

deed

form

guilt

criticizing
deed

can

punish
guilt

patient

fact,

she

of healthy

guilt

Neurotic

guilt

be

expiated

by

Neurotic

guilt

ourselves.

disappears
guilt

versus

because

never

you

disappears.

in intensity
herself

and,

is

connected

with

which

in a meeting,
he

feels

guilt:

the

self

misuses

and
more

crimes.

Normal

guilt

exhaustible.
which

for

patient

new

is

realistic

Neurotic

guilt

is

is inexhaustible.

Genuine

guilt

substitute.

which

Normal

compassion

as

therefore,

to

self-aggravation:

and

of self-punishment,

a colleague
over

you

crime.

amount

Neurotic

Battlefronts:
Neurotic

what
A

relationship.

we

reparation

to torment

a real

unrealistic

lesser

guilt

Exhaustibility:
to

for

In

committed.

Normal

caused.

through

of reality

response

guilt

continues.

self-limiting

others.

is

displaced.

the

Normal

Self-limitation
is

neurotic

name.

The

you

inflicted

you

self-punishment

guilt

neurotic

self-punishment.

because

damage

guilt

often

for

factor:
deed

for

is

herself

wrong

Time
repaired

with

and

someones

Expiation:
repairing

guilt

guilt

Healthy

guilt

Quantitative
corresponds

healthy

ways.
Subject

didyou

confuse

is

for

man

a real
feels

deed.

guilt

for

is a substitute

for

the

real

the

to

fire

the

convincing

boss

colleague.
Type
guilt

is an

unrealistic

form

of

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guilt

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guilt

is realistic.

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of self-punishment.

Outcome:
reparation.

guilt:

Normal

is forever.

guilt

rises

and

then

ends

with

THE

STRUCTURE

Greenspan

and

capacities:

her,

self-protective
her

become

depressed,

project
fear

of

her

feelings,

use

her

her
him.

as

represent
acted

and

verbally

their

feelings.

Table

10.2

or

onto

herself,

the

them

is

impaired.

She

feeling

states
states:

if my

Words

have

anger,

anxiety,

body

illustrates

feelings

refer

how

is

experienced

patients

represent

I feel

somatic

into

of intention

in behavioral

Verbalization

of behavior

I grabbed

description

to specific

My

differentiated

disgust,

shame,

guilt

awful.
feelings

somatic

explodes

a combined

sadness,

Verbalization

somatic

feeling

emotion

Examples

and

of global

cannot

states

meaning
Joy,

of

information.

Table

of

she

paralyzed

experience

labeled).

Hierarchy

Or

bodily

is

10.2

to

remain

(the

of disorganized

Organized

to

awareness

Verbalization
as

attention

complete

of organized

its

to

of conscious

it

then

If

set

to

Verbalization

me,

pay

identify

boyfriend

dysregulation.

and

attention

need

(the

out)

states.

boyfriend

her

turn

affect

represent

a source

when

from

pay

to

anger

nonawareness

feeling

Expressions

to

adaptively.

her

unconsciously

her

and

them

to
from

feelings

express

to

(3)

them

or

Unable

express,

and

differentiate

identify

feeling

to

feelings;

to her

to

it.

(2)

from

affective/cognitive
feeling

onto

to

of

a continuum

Representational
Abstracted

suffer

ability

feelings

Feelings

and

Unable

her

able

express
may

of

attention

be

she

anger

able

to

hierarchy

feelings;

range

regulate

not

nor

anger,

be

attention

will

limit,

identify

wide

pay

cannot

regulate

cannot

pay

she

and

with

signal

cannot

criticizes

simply

to

EXPERIENCE

proposed

and

who

they

patient

by

attend
signal

A patient

needs

may

(2006)

representations

reality.

to

and

construct

FEELING

Shanker

(1)

understand,

the

OF

My

feelings
a thousand
terms
her.
heart

hurts.

heart

aches.

When

she

stares

pieces.
I want

to push

you.

at

Disorganized,
vessels

fragmented,

were

Complex

going

primitive

communication

Direct

discharge

of behavior

Simple

gestural

communication

verbal

fragmented

abstract,
his

or gestural

terms

you

he

anger.

Or

in

body

his

anger

so

feeling

as

to

he

first

the

tolerance,

but

of
us

can

he
he

may
has:
of it

represents

his

I feel
be

who

experience

who

of

like

able

to

could

label

his

impulses

to
them

we

in fragile
acted

tolerance,

put

feelings

patients.

out

To

in the

maturity

of

into
assess,

past.

Second,

defenses,

anxiety

symbolization.

label
with

anger.
up

(how

impulsively

affect

Patients

getting

Encourage

patient

feeling

the

wont

somatic

instance,

the

say,

be

or in behavioral

For

know

he

impulsivity

has

affect

control

experience

out

terms

might

But

The

patient

symbolization

to assess

patients

out.

bodies,

state

can

organized

tolerate

feeling

states.

not

and

IMPULSIVITY

Affect

acting

states,

cannot

pieces.

affect

patient

and

impulse

behavioral,
of

impulsive.

instead.

somatic

OF

if the

assess

230 .

anger.

allows
ask

out

1997,

somatic

but

expressions

holding

frowns

feeling

to be

is angry

acts

hugging,

nods,

somatic

someone

a thousand

hierarchy

words)

hit

he

ASSESSMENT
This

blood

facial

representations

likely

a disorganized
into

My

prebehavioral,

in disorganized

is more

says

as

differentiated

feelings

wants
he

as

explode

categorized

intentions,
and

biting,

Greenspan

Verbal

represents

tell

be

or loving

Smiles,

representations.

behavioral
states,

can

Angry
Hitting,

Source:
states

pattern

to explode.

gestural

Feeling

somatic

tolerance:

and

tolerate

poor

Instead,
out

avoid
to tolerate

chair,

the
the

the

impulse
they

of the

Patients

try
and

internal
feeling

rise

of

control
to

get

raising

who
the

feeling

cannot

rid

of
their

it by

resorting

of

good
without

tolerate

the

moving

voices.

experience
without

have

the

their

They

act

feeling.

to discharge.

Blocking

discharge

the

rage,

and

act

body.

thereby
out

The

greater

impulse,

longer

he

affect

he

the

reducing

his

his

sooner

helps

acts

patient

develop

higher

impulsivity.

When

he

wants

ask

can

about

tolerate

the

his

tolerance.

The

acting

project
be

use

their

hostile.

with

out,

poor

into

or superego

they

the

However,

act

striated

out

with

feel

like

hit

him),

after

trigger

feeling

the

as

or as

patient,

unable

the

a feeling;

he

enacts

it. Some

seem

angry.
angry.
will

FEELINGS
feelings

The

reflection

word
(Ekstein

A reflective
An

impulsive

pound

his

fist

air

anger

The

would

patient

for

AND

SYMBOLIC

to become

part

yell,

of our

fist.

Youre

how

they

with

poor
states

(I

want

the

experience

He

does

patients

in the
might

Youre

language

has

goddamn

right

to
of

not

suffer

action

respond,

impulse

somatic

therapist

whom

into

Patients

intention

trigger

control.

good

describe

to tolerate

may

their

frequently.

body.

his

to

project.

discharge

with

impulsive

patient

they

disorganized

with

1966).

and

more

a behavioral

punch

than

For

their

imagine

discharged

and

in their

to

language.

function

impulse

of

They

impulse

Patients

anger

begins

rather

feel

and

of

to explode)

which

projection

symbolization:
feeling

describe

I want

anger,

describe

their

feeling

control

(I

the

label

good
is

out
regressive

they

who

have

good

projection.

whom

Patients

usually

use

and

on

anxiety

disruption

the

impulse

the
the

with

use

whom

people

tolerance:

Affect

experience

the

it out,

anger

control

others

the

whose

cognitive/perceptual

can

in

tolerance,

keep

speech,

onto

muscles

patients

control

about

anger

Patients

that

impulse
racing

Anxiety
anxiety

talk

acting

affect

defenses:

defenses

discharge,

impulses
Then

of

repressive

Patients

defenses:

of

without
the

to

of

out.

control

awareness.

anger
lower

Maturity
impulse

experience

tolerance

just
from

patient

say,

You

right.

trigger

Im

angry!

FUNCTIONING
symbolic

world,

we

must

separate

do

perception
and

from

action,

impulsive

punches
to his

which

adults.

the

wall

feeling

An

without

or think

delay.

about

any

intervening

Such

patients

are

not

these

patients

2006,

467).

For

instance,

group

home
My

with

more

awareness

with

much

higher

for

you

were

feel

saying

Some

might

describes

patient

defense

(projection).

feelings,

he

is not

his

projection,

he

not

a feeling

not

run

second

not

his

patient,
of

his

and
Since

but

must

last

patient

he

observe
or

patient

the

of his

his

act

it,

he

assumes

can

see

feels
to

run

of

his
the

legs

from

cause.

with

you

as

if

This

The

patient

anxiety,

attention

or

to

his

me

so-called
placed

from

impulse
on

me.

is

He

did

defensive

action)

of

projection.

The

third

the

result

his

anger

can

projecting.
he

feeling

away

patient

(the

therapist,

urge

a projection.

defense

not

longer

wanted

his

he

else

impulsive.

pay

His

his
could

to differentiate

me.

from

in

angry

(anger),

or

projection

but

its

Unable

Shanker

Im

office

feeling

from

to the

is afraid

of

his

and

And

away

not

observe

away

a therapist

but

no

to
to

run

can

but

of them.

a reaction

he

of my

symptom

Unable

projection

projection,
Each

says

out

attention

anxiety,

projection,

the

the

pay

patient

who

his

of

ran

feelings,

Someone

you.

act.

their

knives

aware

running

they

office.

Im

like

feeling.

person

of

I felt

the

Another

of the
afraid

attention

when

with

and

becomes

to

about

office.

Im

pay

(Greenspan

reflect,

who

conscious

from

feeling,

past

the

or

away

say,

or

feel

people

out

impulse

attention

abstractly

my

could

me .

quality

of

children

it. Impulse

they

mode

to run

could

with

observe

The

I want

In the

what

threatened

out

capacity

call
the

cannot

like

that.

angry

action

who
ran

or

to think

an

patient

say,

you

in

suddenly

legs

or

an

to channel

of

young

observe

awareness

verbally

in

feels

cannot

best

conscious

remain

separated
adult

He

how

without

to express

not

impulsive

action

Unable

are

Unaware
is

afraid

(anger)

to run
from

observe

away

of
and
from

projection.

of
the
the

but

therapist.
defense

a projection.
The

feeling

of

seems
his

catastrophic
projection,

testing

past

causes

To

regulate

In

the

and

to

observe

anxiety,

and

angry,

he

gets

toward

his

When

Help

impulsive

observe
body

feeling

pay

When

and

2006,
the

words,
represent

feelings
them

as

Rather

projections,

he

can

channel

the

see

reality

impulsivity

the
ability

mobilize

feeling

his

his

triggering

his

he

anger

drops

feels

and

acts

out

because

he

can

see

the

projection.

testing

before

experience

it.

patients

body,

from

causalitywhen

help

to the

These

levels

the

patient

exploring

physical

fast

build

the

the

rise

of

experience

skills

control,

higher

can

meanings.

he

of

feeling.

feeling

of the
the

feeling

in

capacities

construction

of consciousness

to

of

for
internal

(Greenspan

and

467).

patient

the

or

capacities

the

his

projection,

reality
who

in

projects

his

impulse

representations,
Shanker

his

enacting

tolerance,

loss

projection

mobilize

to

to

his

from

attention

without

see

projection,

The

the

anxiety

then

from

patients

and

cannot

self-observing

present,

ability

Then

regain

missing

to

and

result

and

his

present.

attention

his

therapist

impulses

patient

from

separate

and

pay

anxious

the

projection

the

and

projections.

differentiate

the

the

attention

mobilize

therapist

would

past

pay

the

feelings.

we

differentiate

because

from

activate

patient,

observe

his

catastrophic

first

ability

case

experience

emotions,

therapist,

first

differentiate

differentiate

to

in the

pay
no

longer

words,

to

than

those

fantasies

from

feelings

put

unreflective

and

suffer

effective

and

trigger

images,

experiences
into

attention

action.
that

impulses

triggered

feelings

by

into

He

acquire

can
many

resulting

from

stimuli,

which

real

action.

SUMMARY
So-called

dysregulated

defenses

. The

helping

the

issue
patient

affects
is not
see

are

regulation
the

defenses

the
of

result
the
that

of

dysregulating

dysregulated
create

affect
it,

especially

but

projection.

Krystal

alexythemia,

(1974,

proposed

hyposymbolization,
who

ignore

them.
we

the

have

The

term

The

patients

she

is

Any

the

without

be

the

overwhelmed
Defensive

reality

current

affects

testing
and

feelings

due

increasing

(e.g.,

self,

a feeling

bearing

her

feeling

For

the

traumatized

if it were

the

tolerate

remember
The

feeling

past

and

feeling
rises
present.

in

shame

and

feeling
this

because

to

an

of

bear

it

Patients

reason
there

and

is a loss

trauma

from

the

loss

of

observing

to cover

cover

other

grief),

and

for

an

expression

If

the

patient

is

a projection,

she

will

overwhelmed.
experience

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our

inner

life

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2007).
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2001),

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defined

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1952)

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1991).

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adulthood

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2006).

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1940/1963).

death.

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as

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conscience

1961;

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references

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1952,

ego

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1975).

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1990,

2000;

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Freud

identify

(Davanloo
wears
with

enlist

his

fathers

a dangerous

so

that

the

hope

in

(Fairbairn

dangerous
1954;

clothes
person
caretaker
Guntrip

for

after
to

his

become
is

1968).

still
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instance,

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life

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themes

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1990;

murderous

dont

unconscious,

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reveals

suffered

eternally

1993).

loved

themselves

child,

himself.

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(Davanloo

impulses

1975b).

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usually

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1975a,

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child
1980).

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mother.

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we

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1994).

bond

life.

1975b).

1969,

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toward

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early

guilt

childs

self-punishment
1975b).

in

murderous
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to keep

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as

so

1975a,

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1993;

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1975b;

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fantasy

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herself
1970).

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projection).

patient

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operational

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1970).

also

fantasy

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herself

herself.

self-attack).

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Winnicott

concrete

1981)

examine

believes

reliably

reality

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successfully

1950;

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fantasy

1981;

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identifications

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she

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immature

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not

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child

receives.

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the

childs

she

mother

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reality

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projections

toward

preserves

occur

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girl

off

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be

life
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2001).
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patient

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2005)

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1975)

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1968).
acts

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115).

patient

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124).

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reality

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REFLECT

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When

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of

.]

Mirror

the

her

if I would

sounds

why

Pt:

conflict

him

thats

right.

distant

When

and

.]

Th:

the

without

when

with

Pt:

Some

close,

.]

.]

pathological

conflict

be

syntonic

happens

If you

Th:

you

to

knowledge

.]

defense

being

the

relationships

Pt:
the

to

from

Th:
have

want

his

.]
Pt:

Begins

without

dont

goal.

of conflict

secretly

for

identifies

does

not

identifies
a

positive

with

experience.
with

the

purpose,

the

defense,

Mirror
defense,
but

the
mirror

at

the

do

not

defense.

When

conflict
same

mirror

time,

(Part
you

sabotage

yourself.

You

patient

is

against

it: Underestimating

seem

differentiated

self-defeat.

Why

to be

at war

the

defense,

from

do

yourself

that

like

to yourself

with

yourself.).

When

encourage

this

will

her

only

the

to

turn

perpetuate

your

COUNTERTRANSFERENCE

AND

SUPEREGO

PATHOLOGY
The

patient

her

can

project

superego

(Racker

countertransference
wishes.

overwork

in therapy

patients

resistance.

As

her.

the

he

patient

patients
patient

inner

is

project

The

patients

superego

her

As
good

the

the

patients
listening
becomes

we

may

a result,
and

the

begins

to

from

the

the

patients

patient
what

and

aspect

of

empathize

with

the

can

help

the

and

defenses

and
therapist
to

the

then

superego

us

rather

not

and

the

only

(A.

or

persecuted

by

failure

healthy

Freud

like

it

him

to

filter,
or only

who

submits
stance

patients
1936).

fear

wishes

therapist

that
the

but
blinds

masochistically

only

become

criticisms

acts

The

who

patient

feel

seek

patients

calling

the

or

Masochism

resistance,
sees

can

masochism

defenses.

wishes,

unresolved

We

at

therapists

only

therapists

patients

angry

aspects.

to see

healthy

superego

of

the

the

174180).

become

healthy

patients

with

the

with

impulses,

1968,

resistance,

The

of

therapist

trigger

makes

therapist

aggression,

only

also

force

Masochism

patients

enabling
the

can

the
Or

1968).

with

better

the

feelings,

(Racker

disappointment.

the

wishes,

under

patient.

a result,

of

suffering

critical

can

issues

two

therapist

understands

he

or

others.

issues

(Racker

As

the

identifies

therapist

impulses

identifies

depressed,

feels

identifying,

attacks

depressed

the

the

feel

and

to

therapist

therapist

therapist

conflict.

onto

The

to

wishes

leads

advocate,

starts
the

her

This

sole

Or

Once

integrate

than

the

the

pathologizes

therapist

therapists.

and

Now

the

1968).

for

patients

superego.

onto

sees
to

the

empathic
pathology,

The

truth

is

that

the

neurotic

constant

and

from

his

chains

The

masochistic

passive
can

for

himself.

help

frustrate

face

of

bad

in the

To

remember

with

defenses

good

superego

the

difficulties.

for

or only

bad,

pathology

in

therapist,

only

to

we

the

fail

be

and

needs

is to liberate

traps.
fight

himself

patient.

and

him

rather

bad

in
his

ourselves

as

as

(Racker

1968,

to identify

with

179).
the

no

as
If we

entire

ones
see

on

our

and

own

[is]

only

the

to

superego

self

patient.

genius

than

ourselves.

addressing
well

fight

good

while

patient

not

Or

resistance

the

and

remain

does

recognize

good

can

the

who

by

To

the

requires

for

defenses

the

in

He

patient

frustrated

patient

good

patient

the

patients

[E]xperiencing

understanding

the

failing

recognize

in the

remembering

two

resistance.

must

if he

into

for

the
to

and

we

the

fall

fighting

wish

resistances

analyst

resistances,

therapists

his

178).

can

overactive,

patient

of

the

1968,

therapist

his

basis

from

Collaborating

the

means

prisoner

(Racker

become

reveals

the

intense

in the

he

is

the

the
good

To

see

only

part

of

the

projection.

SUMMARY
The

superego

is

encompasses
criticize
our

sense

These
but

judge

on

through
emerges
standards,
attachments
superego

as

and

actions,

system

provide

our

constitute

need

(Barnett

unconscious

conscience,
the

for

parts

of

internal
our

2007).
the

mind

ideals,

capacity

self-punishment,

that

serve

for

and

It

as

guilt

and

provide

our

of morality.

elements
they

our
or

insist

viewed

conscious

voice

remorse,
inner

the

and

inner

best

are

of
formed

childhood
with

our

humanity
in

the

and
capacity

ideals,

and

pathology

early

crucible

adolescent

the

in

are

to

based

of

lead

his

early

life

Some,

trauma,
on

by

culture

defenses,

and

and

religion,

relationships.

development,

values.
life,

shaped

in

the
accord

given
other
which

Ideally,
young

with

adult

his

inner

their

insecure

factors,

develop

enact

pathological

identifications.
The

superego

clear

is

clinically,

focus

identifications

judges

forms

interventions
the

on

must

be

If we

self-doubt.

What

we

others

patients
ignore

projects

to

Defenses

are

such

our

thing

can

put

us

the

person

the

habit

are

forms

of

we

The

has

who

that

be

enact

not

We

our

Who

is always

to
you

here:

we

will

of
reject,

are

the

in

own

defense

of

in others.

If

not

see

the

we

will

and

personal

journey.
In a sense,

only

our

you

push

we
are

away,
is here.

hidden

there

defenses,
but

who

is what

person

result,

ourselves,

defenses,

Acceptance
Trying

judge

mutual

these

the

supervision

are

These

therapists

will

essence.

There
have

them.

ignore

this

As

the

ourselves,

on

judges

him.

recognize
we

needs

patient

judge

is

not

we

patient

a superego.

self-hatred.

discover

hurt

therapist

the

self-rejection.

of

will

Anything

in a trance.
who

To

capacities.

work

we

conditioning,

as

uses

testing.

in ourselves,

how

to help

1984).

The

others

patients

effective

condemn

for

patient

reality

to the

ourselves,

we

(Ryle

forms.

that
of

tailored

doubt

act

the

basic

spectrum

patients.

psychotherapy

to

or

externalizations.
in our

defenses

three

obstacle

problems.

it cannot

superego.

takes

major

blame

the

others,

occur

Often

the

pathology

himself,

Thus,

on

within

Superego

no

a concept.

is

which

can

forget

undermines
or

fix

You

under

oneself
are

the

here
habits

of self-hatred.
RECOMMENDED
Barnett,

B.

READINGS
(2007).

superego

and

Carveth,

D.

You

conscience
(2001).

ought

to!

. London:
The

unconscious

or evasion

3 (1),

http://www.yorku.ca/dcarveth/guilt.html

Carveth,
issues.

D.

(2002).

Canadian

sense

of Psychoanalysis

study

of

for

punishment:

Psychoanalytic

Studies

.
as

the

Books.
need

of guilt?

Self-punishment

Journal

psychoanalytic

Karnac

Expression
921.

of the

guilt

evasion:

, 14 (2),

177198.

Theoretical

Davanloo,

H.

In Unlocking

the

Davanloo,
part

II:

H.
The

paralyzed
York:

(1990).

Clinical

unconscious

(1990).

In

drug

of

Unlocking

J. (2010)

New

manifestations
the

of

superego
the

addict.

Separating

and

unconscious

York:

pathology.
Wiley.

superego
the

pathology,

liberation

(pp.

you

would

borderline
purchase

ego

and

of

193216).

superego

http://www.istdpinstitute.com/resources/

RECOMMENDED

can

(pp.

163192).

superego

the
New

Wiley.

Frederickson,

If

of

Clinical

resistance

ego.

manifestations

in a recovering
.

MATERIALS
like

patient,

more
visit

a DVD

information

on

working

with

http://www.istdpinstitute.com/DVD/
series

that

focuses

on

restructuring

projection
. There
projection.

in

a
you

CHAPTER

TWELVE

Superego

Pathology:

Addressing

Character

Defenses

T he

patient

someone

who
did

to him

1917/1961a;

him,

enacting

a past

in therapy

take

the

form

was

of

done

character

avoid

the
to

are

nonverbal

behavior

211).

more

The

pathological

Kernberg

in

treat

than

severe

the

function

(Kernberg

Thus,

character

defense

every

suffering

(Kernberg

patient

spoke

noted
in

that,

of

although

nonchalant

realized

an

He

problems

in

said

manner.

that

he

noninvolvement
him.

79;

began

to sob.

This

identification

with

the

enactment,

the

patient

to

enacting

the

a
can

therapist

patient

may

treated.

use

Character
traits

(Kernberg

and
1984,

the

more

defenses

the

history

of

1933,

158).

For

was

I focused

on

to

with

his

as

and

how
(A.

mother

character
Freud
dismissed

patients

example,

he

detached
his

his

the

his

important,

tolerate

just

simultaneously

rising

210211).

issue

aggressor

or
By

enactment

character

relationship

illustrates

to

pathology,

as

Reich

complaint,

feelings

character

character

me

Freud

desires

shift

was

associations

1984,

this

As

expected

without

he

his

his

and

the

patients

reveals

1976,

he

as

S.

himself.

This

Or

simultaneously

resistance

his

doing

past.

patients

transference

ignored

then

in the
in

114;

feelings.

himself

demonstrated

1954,

what

156157).

and

the

himself

devalues

resistance,

patient

rather

traits

defenses

to

feelings

1980,

transference

the

or
off

experiencing

and

often

If a parent

wards

repressive

does

1945,

feelings

he

1967;

defenses

defenses

(Fenichel

his

relationship

to

defense

1984).

ignores

use

relationship

past

1975,

(Greenson

past

character

in the

he

patients

what

Kernberg

devalued

Some

uses

girlfriend.

described

it

stance,
distance

he
and

expected
defenses
1936).
his

of
enact

In

this

feelings

(character

defense)

and

his

character

defense

functioned

therapist

(transference

resistance).

simultaneously

as

His

transference

resistance.
A character
he

defense

acts,

says
the

behaves,

than

how

forms

such

manner

The

indicates

He

wants

to look

a detached

The

posture,

words

involved

are
but

detached.

right

acts

not

but

his

his

not

avoids

with

the

music.

not

He

words

words.

dont
on

is

in therapy.

is
his

what

he

tone
he

he

of

voice.
to

but

behavior,
does,

sits

wants

angry,

he

says

uninvolved,

a dismissive

he

but

He

looks

says

continually

something,

He

of

indifference,

nonverbally.

match

Comment

do

or

use

a resistance

gaze,

says

take
typical

constant

feeling

will

eye

speaks

uninvolved.

When

behavior,

but
and

The

becomes

but

he

can

politeness,

he

what

expressions,

repressed

verbally,

in

how

overcorrectness,

47).

says

you :

defenses

facial

excessive

patient

at a feeling,

character

1933,

114)

is with

interested

haughtiness,

that

1954,

collaborates

patient

less

gait,

rudeness,

(Fenichel

are

talking,

(Reich

patients

the

instance,

derision,

character-disordered

doesnt.

in

of

politeness

or criticalness

We

it. For

smiling,

attitude

present.

The

says

as

in how

relates.

manner

of

defensive

and

he

of

attitudes
the

is revealed

be

sounds
trust

not

on

his

what

he

says.
An

exclusive

importance
more

focus
of his

to

defense

defense,

from

Character
because

your

Therapists
his

defenses

if you

out
and

you

interpret

from

yourself

genuine

our

believe
how

may

enactment

any

mistakenly

he

the

be

they

underestimates

the

closeness,

must

and

words

interpret,

I suppose

feelings

prevent

often

If you

instance,

point

defenses
they

patients

emotional

of detaching:

detach

sees

For

avoid

a character

the

behavior.

enactment.

detaches

on

first

to
will

have

right
priority

create

responds

a patient

enact

his

a point.

(Reich

emotional
the

patient

the

1933,

now
when

here

with

that

he

character
To

address
27).

You

with

me.

they

occur

connection.

character-disordered
his

presenting

patient
problems.

When

the

it. Thus,

patient
no

enacts

a character

interpretation

or confrontation

Principle:
defense,
how

In

point

he

out

relates

the

First

the

behaviors

and

behaviors:

he

does

not

observe

is possible.

the

enactment

behaviors,

and

of

then

the

character

invite

him

to

see

example
then

block

patients

to himself

following

defense,

the

invites

therapist

the

pathological

points

patient

way

of

to

out

the

see

the

to

herself,

the

toward

him

relating

patients

pattern

of

those

character

defenses.
Th:

What

is

the

Pt:

I just

forget

feeling

for

hitting

you?

she

enacts

doing

her

identification

to herself

the

bruised

Do

you

lip.

notice
the

relates

to herself

first.
which

her

parent

Th:

You

forget
you

patient

Sometimes

that

You
how

[ Invite

yourself

what

to

she

ignores

Then

she

is the

about

the

how

you

then

the

Once

the

dismiss
pattern
patient

and

about

the

pain.

[ Point

ignore

the

ask

prematurely,

patient

pattern

does

herself.
will

parent

herself
hit.

You
out

yourself
of

by

.]

forget

the

and

these

easily

defense
Its

deal.

about

behaviors

your

.]

feelings?

behaviors:

and
of how
can

no

say

say

the

ignore

your

she

relates

see

see

point

out

see

big

how

she

you

yet

the

itself:

You

You

Do

not

Always

more

character

big

the

defense:

dismissive

to herignores

see

Th:
is no

did

[ Character

forgetful,

forget

forget

Pt:

bruise

it.

how

she

.]

therapists
? But

with

about

how

see

her

how

you

behavior,

the

much

patients

pattern

of

she

treats

is no

big

dismiss
less

behaviors

the

behaviors,

herself.

deal.
the
pain

hit

is no

feelings?
to herself
relates

big

deal.

deal.

[ Describe

You
Do
the

say

you
facts

the

notice
and

.]
to

herself

(the

character

defense),

help

her

see

the

price

of those

defenses.

When
onto

yourself,

does

this

mobilize

you

you

yourself,

does

it make

you

this

or paralyze

When
onto

turn

you

criticism

back

criticism

back

you?

turn

this

feel

good

or

does

When

you

say

his

it make

you

feel

depressed?

does

that

help

you

create

the

kind

of relationship

hit

is no

big

deal,

you

want

with

your

boyfriend?
Once
her

the

patient

presenting

with

the

begins

to see

problems

and

that

her

symptoms,

or could

it be

your

or is this

Then

we

can

what

you

mobilize

turning

a stand

want

like

her

will

to the

against

this

interrupt
disrespecting

you

your

what

you

want

that
this

sense

has

been

self-attack

to

you

hurting

that

we

you?

something

you

and

of defense

might

have

be

your

permission

dismissing

CHARACTER

defenses

are

since

they

work

before
1.

are

character

based
usually

they

Point
2.

of the

to

yourself

or

ADDRESSING

character

enactment

yourself

task.

it make

self-dismissal

sense

yourself
IN

identification
steps

disidentify

to overcome?

anytime

STEPS

onto

yourself

therapeutic

Do

Since

her

causing

to change?

Is
would

help

anger

dismissing

Would
take

can

is

enemy?
Is

to do,

we

defense

defense.
Is

friend,

character

Point

on

out

defense).

the

enactment

syntonic,

become

out

DEFENSES

the

require

an

several

dystonic.

patients

how

they

of

she

concrete
relates

behaviors.
to

herself

(the

3.
creates

her

presenting

Help

problems
4.

and
As

engage
soon

within

in the

as
a

she

split

Intervene

see

and

you

Mobilize

against

second,

want

you

notice

against

her

next

anxiety

to

defense

take

stand

when

right

punitive

instead

you

Intervening

side

defense

turn

against

the

defense

so

she

you

new

can

do

want

it occurs.

feeling

when

mechanism?
the

two

rise

defense.

when

notice

that

will

character

see

you

against

say

feelings

you

What

of us

do

to join

forces

for

saying

As

how

you

if its

that

comes

in

want

against

anxiety

to take
the

law

a stand
to

take

to

against
your

side

of self-attack?
before

herself
randomly

from
but

it.

the

defense

She

predictably:

helps

learns

that

anytime

she

her

recognize

self-attack

and

does

expresses

her

not

feelings

desires.

Every

time

moment

we

we

from

how

what

we

you
are

for

the

patients

Focus

herself
emerging
can

Mobilizing

against

what

the
we

do

defenses.

let

will

helps

will
go

defense

feel,

and

which

Help

patient

defenses

.
her

be
we

to

want

becomes

and

herself

essence,
the

the

should

perception,

between

differentiates

in

You

judgment

attacking

easily

not

direct

her

and

said,
character

parents

feelings,

these

experience

who

Through

a space

feelings

the

someone

create

these

more

feel

emotional

self-awareness,

her

underneath

to

our

dismissive

patient
on

now.

not,

want.

the

with

are

not

Help

reject

identify

do

she

just

immediately

differentiate

and

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relationship

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2001).
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1996;

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1990,

2000,

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Lebeaux

2000;

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Labije

2001).
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psychodiagnosis

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Aspergers

hard

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you

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in

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of

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13.2

patient
But

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pathological

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in

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Table

13.2

Differentiating

transference

projection

of

will

passive

resistance

Elements

for

psychodiagnosis

transference
Anxiety

Projection

of

will

Passive

resistance
Cognitive/perceptual

Defense

structure

disruption

Regressive

Striated

defenses

muscles

Repressive

and

tactical

defenses
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testing

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to

Extent

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Response

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of

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Patient
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feelings

C.

Davanloos
Journal

let

his

experience

him

to

let

go

to

cues

from

his

resistance.

to

(1990).

Management

of

short-term

dynamic

Psychotherapy,

complex

for

of

the

punish

unconscious
freedom

maximize

while

the

an

tension

unlocking

of

resistance

in

short-term

dynamic

International

Journal

of Short-Term

H.

(2000).

short-term

dynamic

transference

resistance

psychotherapy,

Psychotherapy,

Head-on

International

5 , 277296.

intensive

collision

with

psychotherapy

in

part

II.

6 , 145161.
the
(pp.

resistance.
235253).

In
New

Wiley.
A.

International
1936.

he

you

psychotherapy.

Davanloos

Kalpin,

when

questions

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York:

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transference

the

Eventually,

he

of

makes

longings

defenses

life

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that

Management

Intensive

of

crime

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his

do,

(1991).

Davanloo,

on

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on

forces

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READINGS

of Short-Term
C.

is

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resistance,

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goals.

positive

outcome.

his

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Benoit,

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self-destructive

RECOMMENDED
Benoit,

his

Focus

and

he

you

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alliance.

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What

way?

with

destructive

of

as,

and

establishes

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him

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factor

you
for.

to

goals.

goals

longs

continue

his
potent

Instead,

closeness

resistance.

most

his

patient

feelings

achieve

(1994).
Journal

Effective
of

use
Short-Term

of

Davanloos
Dynamic

head-on
Psychotherapy,

collision.
9 ,

CHAPTER

FOURTEEN

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(minutes

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minutes

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84104

her

abandoned

death

him.

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imagines

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and

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And

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allowed
death,

potential.

He

feeling

and

too.

SUMMARY
This

transcript

defense
rise.
can

illustrates

work

During

the

occur.

deeply

loved

ones.

world

is

embracing

And

by

the

part

Part

II:

unconscious

patients

addressing

patient

to
his

defenses

feel

his

experiencing

his

complex

humanity.

not

comprehensible,
of its

For,
but

it

is

an

guilt,

feelings
and

as

feelings

so

grief,

complex
for

own

of the

unconscious

feeling

his

unlocking

and
as

love

Martin

he

Buber

embraceable:

as

deeply

understanding
feelings,

to

as
of

his

becomes
said,

The

through

the

beings.
READINGS

H.

(1990).

I: In Unlocking

Davanloo,

invitation

a complex

RECOMMENDED
Davanloo,

the

facing

with

of one

for

keep

By

regains

systematic

way

portrayal,

possible.
he

reunited

the

Encourage

as

possible,

clears

how

H.

the

(1990).

Partial
(pp.

The

technique

unconscious
The

unlocking
125162).

of
(pp.

technique
of
New

the

of

unlocking

the

101124).

New

unlocking

the

unconscious.

York:

Wiley.

In

unconscious,
York:

Wiley.

unconscious,
Unlocking

the

CHAPTER

FIFTEEN

Consolidation

A ll interventions

help

breakthrough

to
a

the

interprets

Summarize
the
the

caused.

Then

session

to

the

link

conscious

from

the

past

feelings
the

unconscious

guilt

to

Link

symptoms

other

the

in his
during

in

the

ways

he

his

mixed

out

develops

a more

himself.

Then

the

of

two

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co-created

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can

face

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following

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patient

to

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patient

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suffered.

emotions

in a consolidation

link

inflicted

task.

buried

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ingredients

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the

breakthrough.

person

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of

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body

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TREATMENT
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SUMMARY
Rather

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inner

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and

therapists

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life

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trust

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what

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develop

an

unconscious
present,

and

CHAPTER

SIXTEEN

Conclusion

I n intensive
see

the

short-term

triangle

creates

her

of

on

consensus
therapeutic

The

patients

task

her,

to

rather

face

her

therapeutic

task

as

is

patient.

1944).

No

(Frankl
meaning
chance

if,

have
at

worst,

1959).
of our
to make

emotional

can

we

our

get

must

have

help

and

consensus

on

point

rather

face

of

the

patients

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love

service
to

as
own

against

choice
our

Each
lives.

only

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choice

choice,
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a different

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the
face

face
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of

growth

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takes

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our

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to

(defenses)

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therapist

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patients
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potentials
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it

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189190).

stress
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(Eds.),

and

the

Primer

Amsterdam:

autonomic
on

the

Elsevier

nervous
autonomic
Academic

Index

Abbass,

A.,

65 , 70 , 245 , 246 , 250

abdominal

pain,

abstracted

feeling

abstract

states,

language,

abused
acting

247 , 248

dog

344

287

example,

269 , 413

out
after

sessions,

240 241

misrepresentation
pathological

relationships,

punching

state

objects

to a projection

anxiety

and,

leading

to,

345

390

walls/throwing

in response
adrenaline,

of feeling

(vignettes),

(vignette),

293 295

295

57

affect
building

tolerance

defensive

( see

of,

50

defensive

affects)

differentiation

of feelings

from,

differentiation

of genuine

from

hierarchy
isolation

of affect

by

learned,

affect

symbolization,

affect

tolerance,

aggressors,
Ainslie,

184

42

of,

344 , 348

92

348
hierarchy

of,

345 346

345

identification
G.,

nonconscious,

165 166

dysregulation

regression,

345

of
dyadic,

affect

331 332

132

of emotion

regulation

defensive,

symbolization,

of (vignette),

production

15 16 , 294 295

enactment

with,

358 359 , 361

Albus,

K.,

92

Alexander,

F.,

246

Alexander,

T.,

331

alexythemia,
Allen,

L.,

348
246

alliance.

See

Almaas,

H.,

amnesia,
Andersen,
anger,

therapeutic
384

217 218
S.,

413

16 . See

also

capacity

rage

for

defensive,

tolerating,

237

340 343

expression

of,

physical

30 31

experience

projection

of,

to parts

repression

of,

tolerance
ANS

alliance

for

(autonomic

19 , 132

of oneself

(vignette),

320 321

67
experience

nervous

of,

system),

345

16 , 35 , 36 37 , 41 , 57

anxiety
ability

to observe

addressing,
adrenal

function

and,
of,

annihilation,

57

215

39

assessment,

causation

261 262

17 , 20 21

anesthetization

avoidance

(vignette),

42 43 , 89
by
of,

therapist

of arousing,

69

5 , 37 39

definitions

of,

discharge

of

35 36

for
with

fragile
no

patients,
signaling

in patients

body,

214
(reasons

for),

45 47 , 49

66

in projection,
sighing,
effects

of ignoring,

feeling

as

feelings
forms

of,

of,

highly

52
39
of,

36 37

anxious

ignoring
during

patients,

of,

by

inviting

pathways

of,

physical

173 , 174

patient,

215

feelings

phase,

assessment

experience

projective,

278 279

272

fragmentation,
functions

26
165

trigger

versus,

322 323

mistakes,

of,

of,

regulation

234 235

272

of,

43 , 59 , 89

addressing

defenses,

decision

tree
of,

before

focusing

fragile

graded
with

88

on

declared

patients,
format

for,

with

69 70

techniques

147 148

for,

therapeutic

to intervention,

60 62 , 61 62

64 65

projection,

63
task,

165 166

43 44

374 376

symptoms,

39 , 40 41 , 41 42 , 45 46 , 70
headaches

and,

254

172 173

50 52

of (vignettes),
for,

problem,

215

nausea/fainting,

principles

as

70

71 87

prevention

response

for,

failure

for

tension

68

226 , 323

purposes

social,

21 24

therapists

assumption

therapists

response

as

threat

signal,

of no,
to,

of tolerance

toleration

of,

as

of,

138

36

threshold

triggers

68

(vignettes),

48 50 , 57 59 , 233

22 , 346

49 50

unconscious

biophysiological

activation

pattern

in

body,

40
unconscious

signaling

willingness
anxiety

detours

anxiety

tolerance

Arnsten,

A.,

of,

44 45

to experience,

(examples

and

threshold

443
vignettes),

(vignette),

149 , 151 152 , 155 156

57 59

47 , 57

assessment.

See

psychodiagnosis

association,

16 , 111 112 , 262

attachment,

39 , 92 , 166 , 356

attention
assessment

of capacity

building
central

capacity
role

of,

to feelings,
lack

selective,
withdrawal
J.,

68 , 142 , 259

226

260 261

215

of attention

mutual,

Austin,

for,

for,

(vignettes),

265 266 , 266 269 , 269 271

165 166
122 123
of,

119

47

autonomic

nervous

avoidance

defense
of

system

closeness

(ANS),

with

16 , 35 , 36 37 , 41 , 57

therapist,

444

( see

also

transference

resistance)
with
people

nonproblems,
pleasing

182 184
by

not

having

(vignette),

183 184

avoiding

the

present

moment

(vignette),

61 62

awareness
anxiety,

59 60 , 129

avoidance

of,

129

of causality/triggers,
central

role

of,

of feelings,

260 261

13 , 93 , 126 , 344

of healthy

desires,

ignoring,

of feelings,

of projection,
projection

of,

repression

320
232

of ( see

of splitting,

J.,

Barnett,

M.,

353 , 395

272
A.,

80 , 316

Bazhenova,

O.,

Beauchaine,

T.,

A.,

Begley,

task,

333

Bateman,

Beck,

of therapeutic

92

L.,

Basch

defenses)

480

B.,

Barrett,

repressive

224

unawareness

Bargh,

347

224 , 321 , 438 439

of reactions,

M.,

425

129

nonawareness

Bakhtin,

96

36 , 57
57

73

S.,

185

behaviors
defensive,
direct

287 , 347

discharge

nonconscious
nonverbal,
patterns

of,

344

guidance

of,

415 416
of,

410 , 424 425

354

230

pointing

out,

104 , 402

verbalization
Benjamin,

L.,

Benoit,

C.,

92 , 355

N.,
E.,

1 , 8 , 479 , 480

336 , 337 , 338 , 343 , 354

Berntson,

G.,

Bion,

6 , 207 , 481

W.,

Birnbaum,
L.,

C.,

47

72 , 413

Blackman,
Blair,

70

S.,

Biven,

J.,

119 , 373

48

blame/blaming
Block,
blocking
bodily

344

417

Berdyaev,
Bergler,

of,

L.,

defense,

177 178 , 310

330
of defenses.

See

symptoms,

specific

39 ,

somatization/somaticizing
level

of character

borderline

level

of superego,

borderline

personality
J.,

Bradley,

S.,

40 41 ,

e.g.,
217 ,

rumination
245 .

patients

borderline

Bowlby,

defense,

structure,

319 , 320 , 377 378

361 362

disorder,

372

5 , 37 , 92 , 355
93

brain
blood

flow

to,

36 37

causes

of malfunctions,

effects

of anxiety

formation
to,

limbic

system,

nonconscious

21 , 48

connections,

32

66

neuroendocrine

response

on,

of neural

injury

57

16
discharge
appraisal

to anxiety,

of adrenaline,
of,

36 37

33

57

See

also

Brandt,

L.,

390 , 391

breakthroughs

to feelings,

breakthrough

to the

106 , 256 257 , 471

unconscious

defenses

against

experience

of complex

defenses

against

experiencing

defenses

against

picturing

mistakes

in focusing

portrayal

phase

mixed

feelings,

456

460

mistakes

on

an
the

impulse,

defense

step

of

452 454
454 456

(vignette),

in focusing

skipping

impulse,

on

451

feeling,

447 448

experiencing

the

feeling,

448

449 , 450 451

Stage
(vignette),

Bremner,

J.,

Brenner,

C.,

Stage

Two:

Stage

Three:

of the

to

portray

impulse

facing

complex

unlocking

unconscious,

feelings,

of unconscious,

446 447
447

445

353

J.,

246

Britton,

R.,

354 , 357 , 379

Martin,
K.,

468 , 480
37

Cacioppo,

J.,

capacity,

313 ,

70
429 .

psychodiagnosis;

See

also

self-observing

Carveth,

D.,

Carveth,

J.,

383

Cassidy,

J.,

92

castration

patient

48

Breuer,

Bulloch,

inviting

446

unlocking

Buber,

One:

observation/observing
capacity

383 , 384

anxiety,

39

causality/triggers
ability

of patient

to see,

142

capacities;

anxiety,

39 , 40 , 227
correct/incorrect

causality,

expression

of positive

feeling

as,

feelings
assessment

of capacity

deactivation

therapist

for

seeing,

disruption,

of projection

defenses

( see

goals,

198

278 279

toward

cognitive/perceptual

38

as,

as,

49 50

260

320
320

defenses)

errors

of (vignettes),

277 278 , 278 279 , 279 280 , 280 281

during

establishment

of conscious

, 281 282

external,

308 310

failure

to see

feelings
grief,

(vignette),

( see

feelings)

patient

instant

to see,

repression,

mistaken

sense

mixed/complex
for

problems
rage,

57 , 65 , 223

128
of,

276

feelings,

patient
of,

355

to see,

103

276 277

337 339

reminding
resistance
sequence
somatization,
suffering,
syntonicity,
unconscious
centration/decentration,
character

194 195

332

helping

need

therapeutic

defenses,

the

patient

of,

identification,
of,

289 290
439

227 , 275
251 , 252

4 6 , 7 , 275
282 283
feelings,

198

403 404
67 , 89 , 109 , 241 243 , 361

alliance,

206

clarification

of,

disidentifying
as

97 98 , 404 412
with,

enacted

401

identification
clarification

of price

of defense

(vignettes),

404

405 , 407 409

differentiating
(vignette),

from

projection

406
differentiation

of patient

pathological
enactment

of,

exhibition

of,

habitual
introject,

therapist

way

for

defense,

of relating

to oneself,

404

with

pathological

400
415 416

enactment

of

identification

368 369
handling
as

of,

history

415

of patients

suffering,

identification

as

enacted,

identification

of,

106

letting

go

of,

mirroring,

patients
role

of will
who

use,

self-judgment,

types

of,

primitive

disorders/pathology,

character

structure,
T.,

Chasseguet-Smirgel,

402

241 242 , 399

in,

356

402 403
thinking

in,

403

320 , 377 , 380 381 , 400

92 , 156 157 , 319 320 , 354

92
J.,

359

choices,

289 , 424 425 , 479 480

Clyman,

R.,

92

task,

140

character

Chartrand,

to therapeutic

357

in addressing,

structurally

404 412

391

of identifications

steps

399 400

411

mobilization

405

cognitive

functioning,

impaired,

cognitive/perceptual

217

disruption,

anxiety

and,

48 , 346

deactivation
effect

of projection

of anxiety

during

on,

exploration

in fragile

See

with

also

complaining
complex
compliance,
concrete

250 251
usage

patients,

400

344

390

defense,
feelings.

(vignette),

244 , 428

gestural,
of,

308

language/word

metacommunication,

styles

320

47 48

of character-disordered

simple

trigger,

185 187 , 214 , 223

symptoms

communication.

as

of feeling,

patients,

somatic

46 , 66 , 68

310 , 376

See

mixed/complex

feelings

67 , 455
operational

conditioned

thought,

responses,

conflict/tension,

357

48 , 479

15 , 367 . See

also

transference

conflict
as

cause

of anxiety,

components
creation

of,

defiant

with

ego

ideal,

generators

of,

intolerance
intrapsychic,

275

of interpersonal,

with

internal,

40

patients,

420
297 298

360
16

370 , 424 , 438 439

of,

417

facilitation

mirroring,

388 390 , 394

observing

inner,

Oedipal,

465 466

310

of,

424

resistance;

triangle

of

reflecting
with

degree

therapist

rather

unconscious,
of will

than

of (vignette),

resistance,

391 394

438

248 249

to share

confrontation,

feelings,

297

98 100 , 177 , 224 225 , 417 , 442 443

confusion

state,

conscience,

causes

of,

116 117

319 320 , 373

conscious

guilt,

383

consciousness

of feelings,

consensus,

16 . See

also

awareness

199 202 , 203 206

consolidation,

471 477

contempt,

295 297

contradictions,
control,

pointing

internal

Cooper,
coping

of syntonicity

S.,

locus

of,

Cornelissen,

K.,

cortisol,

47 48

Coryell,

W.,
P.,

Coughlin

Della

defenses

versus,

91 92

317

6 , 13 , 436
Selva,

P.,

countertransference,

138 , 424 , 425

100

irritation

with

obstacle

superego

counterwill,

194

245

Coughlin,

with

177

92

mechanisms,

as

out,

types

patients,

177

to effective
pathology
of crying,

work,
and,

396

394 395

330 331

297

Cowley,

A.,

50

Cramer,

P.,

91 , 92 , 93 , 120

crying/weepiness,
defensive,
differentiation

30 , 239 , 326
329
of genuine

from

defensive

affect,

331 332

intervention

(vignette),

in response

to projection

in response

to self-attack

types
cursing,

of,

of superego

(vignette),

(vignette),

334 336

334

330 , 331

305 306

cutting/self-mutilation,
daimonium,
Dale,

333 334

G.,

Damasio.
Darwin,

7 , 240 241 , 245 , 287 , 288

354
37
A.,
C.,

4 , 13 , 35 , 36 , 42

13

Davanloo,

H.,

44 , 50 , 72 , 75 , 109 , 118 , 126 , 137 , 206 , 213 , 218

260 , 315 , 316 , 354 , 355 , 361 , 382 , 383 , 414 , 424 , 425 , 436 , 442

443
Davidson,

R.,

16

decentration/centration,
deCharms,
decision

R.,
trees.

403 404

185
See

anxiety

also

questions/inquiry

regulation,

declaring

88

internal

defense

work,

developing

emotional

feelings,

of transference

dedifferentiation,

348

defense

(examples

defenses.
e.g.,

See

also

therapeutic

alliance,

167 , 168 170

23

psychodiagnosis

detours

208 , 209

107

conscious

inviting

problems,

and

vignettes

resistance,

vignettes),

424

149 150 , 155

for

examples

out;

regression/

and

specific

defense,

rumination
acting

out

activation
addressing,
attention
for

avoiding

( see
of,

acting

332 , 337
20 21 , 70 , 372

to ( see
reality

attention)
and

feelings,

3 4

regressive

defenses)

blindness

to,

blocking

381

of,

191 , 195 196

( see

also

specific

defense,

e.g.,

rumination)
causality,

reminding

as

of problems/symptoms,

cause

challenging,

patient

( see

clarification

character

of,

96

45

confronting,

98 100 , 417
of,

315

deactivation

of,

( see

314

of,

disidentification

from

( see

diversification,

16

283

dissociation)

identification

285 , 285 286 , 286 287

( see

with

also

the

syntonic

and

function

anxiety

mistakes
of,

identifying,

in,

challenge

triggers

(vignettes),

of,

of,

287

279 280

451

96 98 , 236 237

resistant

identification

as

defense

defenses/syntonicity)

to differentiate/premature

on

27

syntonic,

feeling

defense

31 , 39

dissociation

highly

specific

feelings,

from,

displacement,

focus

also

15 , 98 99 , 284

differentiation

failure

( see

denial)

detachment,

ego

280 281 , 282

defenses)

compliance,

denial

289 290

224

character

creation

of,

patients
( see

responses

identification;

with,

174

identification

enactment)

95 96 , 105 106 , 173 , 410 411

anxiety,
for

56

awakening

observing

causality/triggers,
character

defenses,

173
106

capacities,

128

284

creation

of

instant

repression

(vignette),

129

131
example,

25

feelings,

32

transference
ignoring,

resistance,

60 62 , 120 , 127

intellectualization

( see

interpersonal

origins

interpreting,

intellectualization)

of,

92 94

386

interruption/relinquishment
letting

106

go

maturity

of,

noticing

17

of,

necessity

of,

345

of,

93 94

patterns

observation

of anxiety

of ( see

overexaggeration,

and,

64

self-observing

capacity)

120

patterns

of,

64

pointing

out

choices

preventing

for

using/not

breakthroughs

using,
( see

205
breakthrough

to

unconscious)
price

of,

96 , 98 , 104 , 236 237 , 295 , 404

projection

( see

purposes

of,

projection[s])

91 92 , 269

rationalization,

4 , 134

regressive

( see

relational

impacts

repression
resistant

( see
( see

responding
reversal,

regression/regressive
of,

defenses)

101

repressive

defenses)

resistance)

with,

versus

describing

internal

problem,

120

ridicule,

120

somatic

( see

somatization/somaticizing

patients)

177

the

syntonic

( see

tactical

syntonic

( see

therapists

tactical

of,

transference

transient

tree

shifting

( see

transference

resistance)

84 85

for,

of defenses,

focus

affects,

107

from,

95

95 96

16 , 225 , 274 275

differentiation
exploration
rage

of defenses,

100

definition/description,

329
of expressive

and

( see

weepiness
rage,

defensive

responses,

from

deepening

under

of,

defensive

crying,

330 332

329 330

rage)

( see

defensive

crying/weepiness)

336
fight/flight/immobilization,

defiance,

67 , 217 , 301 , 422 , 430 433 , 443

De

E.,

denial,

94

356

of recognition

identification

delusions,

of,

128 129 , 478

encouragement

Kloet,

problems

94

decision

defensive

therapeutic

138

resistance

against,

work,

to,

delusions,

turning
defense

defenses)

response

transference
as

defenses/syntonicity)

35 , 36

39

84 85 , 86 , 319
67 , 91 , 118 124
in borderline

patients,

362

of capacity,

313

clarification

of (vignette),

compared
in deed

to splitting
(vignette),

examples,

244

in fantasy

(vignette),

hopelessness

when

97
and

projection,

316

123 124

121 122
denial

breaks

down

(vignette),

314

in instant

repression

mirroring

patients,

omnipotent,
per

se

300 301

(vignette),

121

118 120 , 360

in words

(vignette),

122 123

pathological,

depersonalization,

312

217 218

depression/depressed

patients

ability

to observe

capacity

and

to bear

let

go

feelings,

character

defenses

defenses

against

in,

of defenses,

141

141
241 242

experiencing

differentiation
(vignette),

127

218

of reality,

dependency,

of feeling,

of

an

impulse

depressed

(vignette)

patients

in,

from

454

defenses

287 289 , 288

fragile

patients,

graded

format

192 , 213
for

( see

fragile

also

patients

fragile

patients)

(vignettes),

231 233 , 236

237 , 238 243

hopelessness

in,

243 245

inviting

feelings

inviting

intellectualization,

presentation

in,

of

238
240

negative

goals

for

therapy

(vignette),

199
psychotic,
rage

in,

365 367
240

regressive

defenses

restructuring

responses

somatization

using
De

Rijk,

R.,

39

cause

of,

244 245

of regression/regressive

self-attack

spectrum

as

( see
of ability

graded

in,

defenses

367

somatization/somaticizing
to observe

approach

in,

(vignette),

a defense

patients)
in,

236 237

264

293

195

Deschields,
detached

T.,

247

transference

detachment

resistance,

defense,

422 , 423 424 , 434

98 99 , 284

detours
from

feeling

( see

interventions

anxiety)

for
anxiety

detours

(examples

and

vignettes),

144

defense

detours

(examples

and

vignettes),

146

146

148 , 152 155

when

inviting

when

feelings

inviting

(vignettes),

specific

problem

151 155
example,

148

150
psychodiagnosis
reasons
using
diagnosis.

of typical

for

avoiding,

psychodiagnosis)

5 6

psychodiagnosis

See

( see

to manage,

137 138

psychodiagnosis

differentiation
ability

of patient

for,

anxiety/projective

anxiety,

assessment

of capacity

of corners

of the

defensive

of

patients

versus

patient

for,

rage,

from

95 , 260 , 271 275

336

defenses

(vignettes),

287 299

287

neurotic

from

260

of conflict,

genuine

to differentiate,

healthy

226

triangle

versus

depressed
failure

142

guilt,

defense,

343

character

defenses,

98 99 , 405

406
of patient

from

projection

of will

therapist
therapists,

from

transference
from

passive

projection,

of patient

resistance,

424 425

transference

319 320 , 406

from

defenses,

480

resistance,

429

discharge

of feelings
blocking,

345

cursing,
loud

305 306

speech/yelling

rapid

speech,

talking
disgust,

disorganized

301 302

over

the

from

defenses,

somatic

displacement,

therapist,

306 307

defense,

dizziness,

250 251
M.,

Duffy,

C.,

dyadic

222

101 , 111

92
92

affect

regulation,

dysregulated

165 166

affect/feelings,

dystonicity.

See
ability

also

syntonic

mirroring
with

observing,

ego

ideal,

Eigen,

261

359 361 , 367

6

297

Ekman,

P.,

Ekstein,

R.,

with,

self-criticism,

16
346

142

379

388 390

to syntonicity,

86 , 89 , 222

M.,
H.,

of,

of defenses,

402

regression/regressive

70

deficits,

price

dystonic

conflict

spectrum

ego

defenses/syntonicity

to see

defenses,

consciousness

J.,

329 , 344 , 348

of patient

character

Egan,

344

47 , 216 , 217 218 , 307 308

distancing

Dozier,

283

feelings/patterns,

offering,

dissociation,

Eist,

302 305

16

disidentification

ego,

(vignettes),

defenses,
283 284

294 , 305

Elster,
Emery,

J.,

184

G.,

73

emotional

closeness,

33 , 311

emotions,

13 , 16 , 25 , 333 , 347 . See

also

feelings

empathy
attunement
healthy

to presence
guilt

patients

and,

feel

or absence

of,

391 392

382

for

your,

98

enactment
of character

defenses,

identification

( see

of

past

400

identification

relationships,

enactment)

372 , 399 400 , 414 415 , 419 , 444

451
sadomasochistic

enactment

of superego
epistemophilia

(love

Erickson,
Evans,

S.,
F.,

of truth),

121

369 370
207

93

37

evasiveness,

112 114

examples.
vignettes

pathology,

(vignette),

See
and

under

specific

therapy.

of ambivalence,
awakening

supportive

observing

versus,

externalization,

capacities,

resistance,

45 , 67

problems,

334

to decrease,

therapies,

vignettes

for,

128
174 , 177

224

presenting

of weepiness,
when

also

of permission

of transference
of vague

See

66

permission/lack

expressive

intervention,

or

disorder

examples

exploration/exploratory

for

defense,

233 234

329 330

442
180 181

for

examples

for

attribution

of suffering

blaming,

to,

194

177 178 , 376

deactivating

projection

defensive

anger

in (vignette),

based

on,

definition/description,

340 342

308

impulsive/paranoid
obstacles

310 311

patients,

to declaring

329

internal

emotional

problem

(vignette),

177 180
pointing

out

causality

unconscious
fainting,

causality

in,

308 310

310

69 70

Fairbairn,
false

W.,

354

causality,

Fanselow,
Farrelly,
fear,

in (vignette),

281

M.,
F.,

37

387

16 , 35 , 164 165 . See

feedback
feelings,

loops,

anxiety

315

286 287 . See

anxiety

( see

anxiety

versus,

avoidance
basic,

also

also

emotions

anxiety)
272

of,

4, 6

16

building

capacity

for,

causality/triggers

of,

consciousness
definitions,

of,

226 , 231
4 , 21 22 , 277 278

16

16
differentiation

of

defenses/stimuli/anxiety/impulse/defensive
dysregulated,
exploration
expressions

affect,

329
of,

sequence

of global,

feeling-anxiety-defense

of,

65

344
triangle,

feelings
15 16 , 294 295

from

focusing

on,

healing

power

indicators

5 6 , 13 16 , 447 448
of,

of experience

internal

experience

inviting

( see

lack

of ability

observation

of ( see

264 265
by,

identification

reasons

versus,

self-observing

of,

of,

50 52 , 347

of,

67
332 , 337

structure

of experience

symbolic

functioning

thoughts

versus,

states,

of,

344 345

and,

346 348

26 , 131

of pursuing,

unconscious

32

133 134

of experiencing,

timing

15

348

patients

results

294

to observe,
of actions

repression

69

signaling

of,

44 45

344 345

Feldman,

S.,

93

Fenichel,

O.,

92 , 399 , 400 , 413 , 416

Ferenczi,

S.,

356

focus.

See

also

vignettes

externalizing,

mistakes
resistance
A.,

for

examples

315

maintaining,

Fogel,

152 , 228 229

in,

447 448

to ( see

resistance)

330

Folkow,

B.,

70

Fonagy,

P.,

46 , 80 , 206 , 316

Fosha,

D.,

44

feelings)

mobilization

regulation

of,

of,

inviting

overwhelming,

feeling

33

14

capacity)

fragile

patients,
ability

22
to observe

and

let

go

of defenses,

141

assessment
anxiety

(vignettes),

of impulsivity
low

in,

breakthroughs
to bear

conflict

will

against

effects

in ( see

on

formation

to share

of,

of,

defense

format

for

297

429

414

depression/depressed

with,

451
alliance

treating

conditions

patients)

229 230

of therapeutic

graded

feelings,

of will,

feelings

of defenses

focusing

234

141

of projection

depression

215

205

regarding

defenses

capacity,

216 218

unconscious,

feelings,

of,

deactivation

adaptive

defenses,

to the

collaboration

345 346

self-observing

regressive

capacity

214 215

166

spectrum

requiring,

implications

by,

for

integrating

of
218 219

technique,

splitting

224 226

and

projections

(vignette),

223 224
responses

and

restructuring

symptoms

anxiety

restructuring

requiring,

(vignette),

cognitive

219

220 221

recapitulation

(vignette),

221 222
restructuring

regressive

defenses

(vignette),

224

mildly

fragile

moderately

sequence

of interventions

threshold

of anxiety

patients,
fragile

tolerance,

213

patients,

for,

213 , 222

219 220
220

222

projection

in,

216 , 222 223

addressing,

177

blocking,

66

causes/bases
chronic,

of,

216 217

deactivation

of,

of desire

for

feelings
go

as

of,

others,
from,

184

215

(vignette),

225

54
to

declaring

internal

emotional

181 182
to anxiety,

restructuring,
signs

of,

46

therapeutic

218
misalliance

in unconscious
of will
rage

in response

recognizing
regressive

somatic

67
(vignette),

185 187

339

52 56

226 227

of regression/regressive

restructuring

severely

of (vignette),

in,

46 , 323 324

172 174 , 191 192

restructuring

of steps

to,

a problem

to a projection

transferences,

resistance,

due

transference,

to declare

signs

40

71

of superego,

pathway
for,

of

defenses,

unconscious

anxiety

293
discharge,

234 235

fragile

patients,

symptoms

spectrum

of,

structure

of sessions

( see

213 , 222 , 231

somatization/somaticizing

patients)

157 , 213 , 257 , 349

decreasing
234

with

obstacle

relationship

sequence

onto

of therapist

exploring
letting

66 , 173 , 227

treatment

differentiation

problems,

69

invitation

to

explore

feelings,

233

inviting

feelings

resuming
use
Franchini,
Frank,

K.,
S.,

Frankl,

of projection

A.,

322

57
69

Frederickson,

J.,

Fredrickson,

B.,
(will

307
245

to seek

, 299 , 437 . See

therapy),

also

concept

will

56 , 147 , 161 , 184 185 , 207 , 229 230

(intention)

of free

will,

184

emphasizing/mobilizing,
engagement
freeze

response,

Freud,

234

50

Institute,

will

by,

to feeling,

231 233

1 , 479

Frederick,

free

invitation

format,

480

V.,

Franklin

in graded

A.,

301

in therapeutic

task,

230

47

5 , 35 , 42 , 72 , 119 , 259 , 316 , 355 , 357 , 358 , 379 , 380

381 , 384 , 395 , 399

Freud,

S.,

4 , 5 , 7 , 16 , 36 , 72 , 91 , 246 , 259 , 261 , 284 , 293 , 316 , 353

, 354 , 357 , 361 , 383 , 399 , 413 , 414

Frijda,

N.,

16

Fromm-Reichmann,
Frosch,
fugue

J.,

functions

481

316

states,

functional

Frieda,

217 218

versus

organic

of defenses,

symptoms,

96 98 , 236 237

anxiety,

36 37

content

versus

guilty

feelings,

intrapsychic,
projection
tactical,

249 254

function

of delusions,

384
118

(vignette),
118

316 317

85

transference
Gado,
gait

M.,

43

gastrointestinal

complaints,

W.,

Gaynor,
Gellhorn,

247 248

33

D.,

70

E.,

70

gestural

communication,

Gill,

357

M.,

103

48

assessment,

Gaylin,

resistance,

344

goals
achievement
of inviting

of positive,
feelings,

presentation
resistance

D.,

Gotlib,

G.,

graded

format,

195 199

for

positive,

establishing

192 199

consensus

on,

203

36 , 37 , 47 , 48 , 57

214
50 52 , 231 233 , 236 237 , 238 243 . See

also

under

patients

Granger,

D.,

Grawe,
Gray,

of negative,

I., 330

Gottwik,

fragile

22 23

to declaring

structure
Goldstein,

166

K.,
P.,

Greenson,
Greenspan,

48
47 , 185 , 196 , 261

94 , 357 , 361
R.,

399

S.,

344 , 346 , 347

grief
architecture
avoidance
breakthrough
compared
defenses
differentiation

of experience
of healthy,
of,

332

382

466 467

to defensive
triggered

of,

by,

of genuine

weepiness,
rage,
from

335

338 339
defensive

affect,

331 332

projection

to parts

somatization

as,

to turning
types

J.,

Gross,

J.,

of genuine,

also

self-punishment
of,

defensive

healthy,

of healthy

defenses

projection

of,

self-attack
treatment
types

of,

for

neurotic,

R.,

to avoid

(vignette),

avoiding,

367
384 385

343
381 385 , 445 446

negative,

120

36 , 37

identifications,
H.,
R.,

357

4 , 93 , 354

354 , 413

297 , 360

Havens,

L.,

headaches,

443
248 249 , 250 , 254 255 , 255 256

superego,

helplessness,

343

370 371

91

Hartmann,

healthy

and

354

hallucinations,

hate,

384

324 325 , 337 338 , 355

of neurotic,

unconscious,

Hassin,

against,

of superego

provocation

N.,

of,

343 , 381 , 382

manic

H.,

458

function

exhaustibility

harsh

330

216 , 354 , 456

16 . See

Hamill,

30

467

avoidance

Haan,

resistance,

92 , 260 , 261 , 354

J.,

Guntrip,

321

93 , 330

Grotstein,
guilt,

(vignette),

251 252

against

unresolved,
Grigsby,

of oneself

361

67 , 311 314 , 427

376 377

helpless

transference

Hendriks,

M.,

hierarchy

of affect

hierarchy

of feeling

resistance,

330
symbolization,
states,

39 , 48

hopelessness,

67 , 243 244

K.,

Hornstein,

378
G.,

481

hyperventilation,

management

hypervigilance,

hypothetical

69

348
speech,

vignette,

114 115

412

idealization,
ideals,

of,

59 , 316

hyposymbolization,

Henrik,

345

344 345

hippocampus,

Horney,

422 , 423 , 425 429

216 , 222

360 , 361

identification
with

abuser

(vignette),

with

aggressors,

124 125

in character

defenses,

deactivation

of,

with

the

(vignettes),

( see

differentiation

also

enacted

from,

from
character

harshness

of superego,

ideals,

mirroring
with
as
with

part
past

283
404 412

362
357 359

360 361
toxic,

object

379 380

defense,

of pathological,

syntonicity

defenses/syntonicity)

defenses,

enactment

with

ego

syntonic

of self

disidentification
as

356

370

defense

285 286 , 286 287

241 242 , 421 422

390

of rage

of survival
figures,

(vignette),
system,
451

125 126
354 355

with,

284 285

with

pathological

introject

with

pathological

superego

projective,
reason
with

forming,

resistance,

369 370

of,

355

patients

identification

with

defenses,

282 283

356

spectrum

of,

378

structuring

of,

syntonicity

and

of therapist

357 358
self-observing

with

patients

capacity
superego,

with,

380

394 395

391

in transference

resistance

unconscious,
identification

(vignette),

300

restructuring

toxic,

363 367

67 , 216
for

roles

(vignettes),

somatization

enactment,
with

with,

101 102 , 104

251

362

aggressors,

character

(vignette),

358 359 , 361

defenses

as

clarification

of price

of defense

(vignettes),

404

405 , 407 409

differentiating
(vignette),

of patient

pathological

immobility,

from

from

defense,

projection

406
differentiation

ignoring

therapist

way

habitual,

with

defense,

60 62 , 120 , 127

127 . See

pathological

also

freeze

of relating

introject,

368 369

response

impulses
differentiation

of feelings

experiencing,

19 20 , 455 456

exploration
versus
inability

of,
feelings,

from,

446
15 , 336

to experience,

449 450

to oneself,

15 16

405
404

murderous,

446

projection

of forbidden,

362

impulsivity
assessment

of,

in fragile
lack

patients,

mirroring,
speech,

inquiry.

See

instant

body,

450 451

388 390
329

325

of projection,

of poor

in the

externalization,

with,

result

indirect

with,

patients,

provocation

signs

feeling

defenses

in paranoid

incongruity,

218

of experiencing

mirroring

as

345 346

347

control,

235 236

390

vignette,

114 115

questions/inquiry

repression,

127 131

intellectualization
avoiding,

231

encouraging,

222

high

of,

degrees

inviting,

240

vignette,
intention.

See

interactional
internal

131

will

(intention)

defenses,

67 68

focus
establishment
with

problems,

interpersonal

of,

origin

defenses

See
anxiety

177 178
against,

283

157 , 181 182 , 208 , 209

of defenses,

interpretive/noninterpretive
interventions.

159 , 359

externalization,

syntonic
internal

67

focus
also
detours

vignettes

92
on

resistance,

for

examples

(examples

and

443

vignettes),

149 , 151 152

155 156
anxiety

response

assessment

to,

43 44

of response

to,

143

blocking
bodily

projection,

sequence

responses

clarification

to,

of,

( see

under

graded

format

for

mobilizing

detours)
( see

responses

for

tailoring,

spectrum

intrapsychic

focus,

42 43

consensus,

of syntonicity,
the

therapist,

202 203
283 284

306 307

205 206 , 214 , 315

pathological,

invitation

to therapeutic

363 367
task,

20 . See

anxiety

during,

decision

tree

decreasing

164 , 220 , 232

also

for

examples

23

invitation

examples,

vignettes

21 24
for,

in depressed

to explore

patients,

feelings,

233 234

238

26

failures

to invite,

19 , 20

patients,
and

226

principle
format

interventions
inviting

298 300

420 , 424

introjects,

feelings,

with,

establishing

over

conflict,

(vignette),

psychodiagnosis)

of alliance

structure

intrapsychic

63 64

232

strengthening

graded

capacity,

142 , 158 , 421 424

of,

talking

format)

defiance

( see

to,

sequence

goal

graded

will/deactivating

psychodiagnostic

fragile

148

self-observing

mobilizing

inviting

333 334

of projection,

detours

for

139

(vignette),

deactivation

323

102 103

crying/weepiness

for

for,

feelings

of,

22 23

(vignette),
for

238 243

detours

(vignettes),

in graded

format,

151 155 , 157

231 233

phases

in,

physical

experience

resuming

invitation
(labeling

Stage

Two

(experience

Stage

Three

toward

the

mirroring,
versus

isolation,

as
C.,

19 20

feeling),
the

19

impulse),

19 , 20

104

157

223

rational

defense,

responses,

hopelessness,

244

45

16

Jacobson,

E.,

364

W.,

185

L.,

247

Jamner,

the

therapist,

vignettes),

234

feeling),

(experiencing

examples,

irrational

the

and

17 19 , 26 30

specific

James,

to feeling,

One

irrationality,

Izard,

of (examples

Stage

vignettes,
inviting

24

Janig,

W.,

70

Joels,

M.,

57

judgments
failing
by

to live

others,

of others
projection
self-,
Jung,

C.,

Kaloupek,
Kalpin,
Karst,

A.,
H.,

Katon,

W.,

Keane,

245

Kelly,

H.,
T.,

V.,

of the

57 , 383

57

57
13

47

359

(vignettes),
judge

223 , 362 371

424

Kaufmann,

to,

perception

7
D.,

up

of,

357

370 372
(vignettes),

372 378

152 155

Keltner,

D.,

Kennard,

16

M.,

Kenny,

A.,

36

184

Kernberg,

O.,

86 , 91 , 225 , 354 , 357 , 358 , 362 , 369 , 370 , 378 , 380

399 , 415 , 416 , 419

King,

A.,

Kitraki,
Klein,

E.,

39

M.,

Knight,

353 , 354 , 355 , 356 , 369 , 382 , 383 , 456

R.,

Kohut,
Korff,

247

316

H.,
P.

91 , 92

von,

Kraemer,

298

H.,

Krystal,

H.,

48
348

Kuhn,

N.,

442

Kuhn,

T.,

LAbate,

L.,

387

labeling

feelings,

labeling

of defenses,

Land,

J.,

25 , 448
191

293

language/word

usage

abstract,
for

287 , 346

acting

out

demoralizing,
using

tactical

E.,

73

Leahy,

R.,

357 , 403
D.,

LeDoux,
Leigh,

J.,
H.,

Levenson,

400 , 409 410

436 437

Lasley,

Lebeaux,

defenses,

424
4 , 36 , 37 , 72

247
R.,

relationships,

383

patients,

vague,
verbal

pathological

93 , 330

140

390

Levine,
lies,

P.,

412

Lilienfeld,
loss,

S.,

329

3 , 251 252 . See

Lovas,
love

69

D.,

S.,

Main,

M.,

Malan,

grief

65

of truth

Lupien,

also

(epistemophilia),

207

48
92

D.,

McCullough,

J.,

McEwen,

B.,

403

37 , 48 , 73

medications,

effects

meditation,

of overmedication,

68

Meissner,

W.,

362

memory(ies)
conscious/unconscious,
fear/anxiety,
formation

37
of,

354

procedural,

92 93 , 289

short-term,

57

Merzenich,

M.,

as

185

metacommunication,

244 , 428

migraine

250 , 254 255

headaches,

Miller,
Mills,

W.,
C.,

65
331

minimization
Minton,
mirroring,

defense,

K.,

120

69
174

defenses,

388 390 , 438

degree/lack
denial,
irrationality

of conflict,

394

300 301
(vignette),

223

defense

triggers,

92

level

of resistance,

resistance

to blocking

superego

pathology,

transference
misalliance,

C.,

projection,

See

436
therapeutic

292
feelings

accessing

unconscious/buried,

defenses

for

avoiding,

defenses

for

avoiding

emergence

(vignettes),

457

identification

with

of,

out,

response

Monson,

R.,

moral

of,

rage

447

471 472
to,

with,

355

216

16
245

anxiety,

39

motoric

procedures,

motoric

retardation/immobility,

muscle

responses
by

414

accessing,

triggers

split-off

458

446

for

pointing

superego,

459 460

227

experiences

picturing,

451 , 456

of experiencing,

devaluation,

experiencing,
past

251 , 361 , 465

413

avoidance

J.,

misalliance

357

mixed/complex

Monsen,

433

385 391

resistance,

therapeutic.

misperceptions,
Mitchell,

177

93

to anxiety,

capacity

freeze
jelly

127

for

response,
legs,

41 42

tolerance

to anxiety,

69

43 , 247

smooth

muscles,

striated

muscles

45 46 , 56

45 47

effect

of stress

hormones

manifestation

of unconscious

response
shift

to anxiety

of anxiety

mutilation/cutting,
Nadel,

L.,

anxiety

in,

246

45

to smooth

muscles

from,

50

39
D.,

13

69 70

Neborsky,

R.,

127 , 128

negation

defense,

negative

hallucinations,

Nelson,

J.,

331

Nelson,

M.

C.,

120

deficit,

neuroendocrine
neurosis,

120

387 , 390

neurocognitive

329

discharge,

transference,
disorders,

neurotic

guilt,

343 , 381

neurotic

level

of character

neurotic

superego,

Newcomer,

J.,

47 48
215

neurotic

spectrum

nonconscious

procedural

nonconscious

responses,

noninterpretive/interpretive

structure,

nonpsychological
nonverbal

tactical

Norcross,

J.,
rage,

Norton,

S.,

65
338

245

H.,

319 , 320 , 377

344
memory,

380

93

35 , 36 , 41 42
focus

182 183 , 183 184

normal

170

361

of feelings,

nonproblems,

of,

47

nonawareness

Nunberg,

by,

48

7 , 240 241 , 245 , 287 , 288

Nathanson,
nausea,

on,

problems,

183

defenses,

100

on

resistance,

443

object

relations,

419

object-representation,

357

observation/observing

capacities

ability

of patient

attention

ego,

impaired,

365

261

conflict,

Ogden,

P.,

69 , 70

Ogden,

T.,

100 , 216 , 419

A.,

OKeefe,

465 466

37

J.,

39

omnipotent

transference

operational

thought,

oppositional

(vignettes),

transference
factors

in lack

organic

versus

functional

organized

somatic

oscillation

of projection,

resistance,
of signaling,

422 , 423 , 430 433

66

symptoms,

feelings,

249 254

344

377 378

407

outcomes

of normal

overexaggeration
Pain,

423 , 431 , 434 , 439 , 440 , 443

357

organic

Osho,

141 142

215 , 226

Oedipal

Ohman,

C.,

Palombo,

and

neurotic

defense,

guilt,

343

120

69
S.,

Panksepp,

capacity)

128 129

severely
observing

self-observing

60

patients,

mobilizing,

also

to observe,

versus,

fragile

( see

J.,

261
13 , 35 , 36 , 72 , 413

paralysis

(psychological),

paranoid

patients,

parasympathetic
activation
anxiety

248 , 272

329 , 362
nervous
of,

system
330 , 332

symptoms

caused

by,

41 , 57

effect

on

blood

symptoms
passive

of anxiety

of excessive

transference

passivity,

flow

by,

activation

resistance,

47
of,

246 247

422 , 423 , 425 429 , 443

67 , 229 , 311 314

pathological

superego.

See

superego

pathology

pathways
anxiety,

68

anxiety

discharge,

139 , 322 323

unconscious

anxiety,

unconscious

anxiety

139 140
discharge,

assessment

of,

restructuring
Pena,

J.,

people

pleasing,

See

anxiety,

phases

of inquiry,

phobias,

social,

71 , 234 235 , 317 318

cognitive/perceptual

in psychodiagnosis,

nervous
J.,

disruption

39

activation.

155 156

See

system;

parasympathetic

sympathetic

nervous

nervous
system

356 , 357 , 403

Porges,

S.,

positive

goals,

35 , 36 , 50 , 57

prebehavioral

196 199
feeling

states,

premature

breakthroughs

premature

confrontation,

preoperational

level

345
to the

unconscious,

of thought,

403 404

problems

creation
defenses
moment,

235

177 , 224 225 , 442 443

clarification

present

of,

217

physiological

presenting

pathway

183 184

disruption.

persecutory

Piaget,

42 43 , 52 59

330

perceptual

somatic

41 42 , 45 , 70

of,
and
as

114

maintenance
cause

61 62 , 64

of,

of,

93

280 281 , 282

system;

price

of defenses,

96 , 98 , 104 , 236 237 , 295 , 404

ability

of patient

clarification

primitive

to see,

of,

404 405 , 407 409

pathological

relationships,

idealization,

222

Prins,

A.,

57

Prinz,

S.,

47

142

102 103

problems
declaring,

157 , 161 , 170 172

in getting

specific

nonproblems,

examples,

182 183 , 183 184

nonpsychological,

183

representation,
role
Prochaska,

286

of defenses
J.,

projection(s),

191 , 209

in creating,

177

65
40 , 222

acting
for

out

in response

avoidance

of feelings,

avoidance

of internal

blocking,

295
413 414

conflict

with,

370

376 377 , 433

compared
content

to,

to denial,
of,

parts

deactivation
defensive
defiance

of,
anger
of,

316

of oneself

(vignette),

320 324

86 , 300 301 , 312 314

in response

to,

336 , 339 340

297 298

definition/description,
differentiating

314 316
therapist

dispelling,

382

in fragile

patients,

from,

character

215 , 222 223

addressing,
blocking,
causes/bases

177
66 , 181 182
of,

69

defenses,

406

chronic,

216 217

deactivation

of,

of desire

for

treatment

differentiation

feelings
go

as
problems,

onto

of therapist

exploring
letting

66 , 173 , 227

of,

others,
from,

with

184

215

(vignette),

225

54

obstacle

to

declaring

internal

emotional

181 182
relationship

to anxiety,

restructuring,

71

of superego,

218

therapeutic

misalliance

in unconscious
of will
function

onto

with

therapist

oscillation
pathway

( see

of

46 , 323 324

67

a problem

onto

splitting,

onto

to,

(vignette),

185 187

316 317

conscience

integration

due

transference,

to declare

of (vignette),

of integrated

40

others,

223 224

transference

therapist

373

of,

unconscious

resistance)
377 378

anxiety

discharge

in (vignette),

317

318
in patients

with

self-observing
severely

fragile

of,

patients,

state

of superego,

of patient

control,

versus

projective

anxiety,

projective

identification,

318 319

215
by

regressive

type

of,

defense,

75 77 , 226 , 315 , 323 , 329

67 , 216

429

psychodiagnosis
anxiety,

345

321

319 320 , 356 , 357 , 376

tactical

pseudoincapacity,

impulse

capacity

subjective

as

poor

42 43 , 89 , 139 140

322

of will,

229 , 429

anxiety

without

signaling

activation

of transference

ambivalence,

assessment

hiding

involuntary
for

repression
weaknesses
attention,

capacity

for

differentiation,

capacity

for

seeing

67

defenses,

170

259
260

causality,

260

to observe

and

143

defenses,

140 150
ability
capacity

to bear

character
description

and

of

let

feelings,

structure,

process

differentiation
(vignette),

68

and

for

of,

66

of feelings,

capacity

cycle

66

factors,

overmedication,

67

65

therapy,

or brain

68 70

transference,

referral,

organic

assessing

mistakes,

of unconscious

need

67 68

66

common

no

resistance,

of,

go

of,

141

141

140 150

137 138

depressed

patients

from

defenses

288
discharge
fragile

of unconscious

52 59

patients
anxiety

(vignettes),

impulsivity,
low

inability

inability

self-observing

of patient
patients

the

response
gait,

43

adaptive

defenses,

to observe

to see

214 215

345 346

regressive
with

anxiety,

feeling,

capacity,

216 218

a defense,

264

281

to self-observation,

260

215

phases

of inquiry,

principles

for

projection,

155 156

assessment

using,

302 , 322 324 , 323

response

to interventions,

self-observing

142 , 143 , 158

capacity,

superego

pathology,

symptom

assessment,

syntonicity,

141 142 , 259 260 , 261 , 290 292

362
160 161

260

of triangle
typical

138 139

of conflict,

detours

psychosis/psychotic

139

( see

detours)

patients,

215 , 320

psychotherapy
origin

of word,

supportive

versus

psychotic

depression,

psychotic

level

psychotic

patients,

Purdy,

A.,

purpose

of character

testing

versus

defensive

in healthy

decision
for

for

K.,

and

neurotic

decision

trees

for

developing

on

know

positive
response

trees;

responses

transference
to,

resistance,

143 , 161 162

100 , 394 , 395 , 419

anger

architecture

vignettes

for
alliance,

examples
208 , 209

290 292

262

also

343

196 199

70

speech,

guilt,

therapeutic

goals,
to,

338

19 20

passive/helpless

patients

See

362

rage,

also

ineffective,

rage.

224 , 319 , 320

in,

See

focusing

I dont

H.,

structure,

reality

factors

questions/inquiry.

Racker,

224

65

quantitative

racing

exploratory,

365 367

of normal

Quigley,

159

of experience

of,

337

428 429

based

on

projection,

breakthrough

69

of murderous,

462 463 , 463 465

defensive
activation
for

of,

covering

criteria

337
grief

for

differentiation

differentiating
due

to

(vignette),

338 339
from

normal

from,

of

responsibility

denial

genuine,

336

337 338
(vignette),

343
due

to projection

in response
in depressed

patients,

displacement

of,

due

of,

external
guilt

iatrogenic,
object

Rank,

of,
with,
216

turning

toward

impulses,

O.,

versus

irrational

Rauch,

S.,

reaction

defensive,

337

338 , 355
364

self,

236 237

1 , 297

rational

Razza,

and

275

use

D.,

451

322

rationalization,

Ray,

of,

of normal

split-off,

L.,

412

442

self-attack

Rangell,

381 382

255 256

provocation

rageful

(vignette),

240

guilt,

venting

over,

to projection

339 340

31

to unconscious

exploration

of superego,

of because

in,

responses,

47

245
R.,

48

formation,

example,

244

134
hopelessness,

244

339

342

reactive

feelings,

realities,
reality.

15 16 , 274 275

contradicting,
See

also

86

denial

avoiding,

3 4 , 6 , 380

defenses

for

denial

of,

fantasy

denial

perception

123 124

of,
out

versus

120 , 316

(vignettes),

projections,

of regressive

wishes,
of,

as

source

of harsh

for

warding

orientation,

reality

testing

312 , 340 342 , 436

362

reminders

reality

118 120

360

versus,

pointing

of,

423

313 314 , 423

off

identifications,

feelings,

reinforcement

borderline

defenses
loss

on

of,

85
character

spectrum

pathology,
of,

for

enhancing,

390

of discharge

of,

spectrum

of projection

and,

feelings
A.,

versus,

322

320

133 134

defenses,

projection(s);
acting

out,

affect

regression,

as

in projection,

92

regression/regressive
idealization;

378

358 359

pathways

reasons,

225 226

85 , 213 , 217 , 323

mirroring

Reber,

454
of (vignette),

addressing/assessing,
with

357

cause

compared

89 ,

105 ,

109 ,

splitting

293 295
348

of depression,
to repression,

contempt/sarcasm

244 245
315

(vignettes),

295 297

301 .

See

also

crying,

239

defense/description,
defiance,
denial

293

297 301
( see

discharge

denial)
( see

dissociation

( see

externalization
formal

discharge
dissociation)

( see

regression,

helplessness
impulse

control

passivity

and

( see

of,

of,

somatization

( see

regressive

transferences,

regressive

wish

provocation,

324 325

somatization/somaticizing
by,

of self-attack

defenses,

215

216 , 326

created

regressive

311 314

345

projection[s])

restructuring

symptoms

(vignettes),

use

regression,

projection

use

externalization)
293

and

pathological

of feelings)

216 218

and,

blocking

patients)

357
of,

302 303

226 227

expression

(vignette),

422 423

regulation
anxiety

( see

under

emotion

differentiation

feelings

( see

Reiner,

W.,

relating

333

feelings)

39

358 , 389 , 400 , 404 , 416 , 443

A.,

relapses,

as,

under

self-regulation,
Reich,

anxiety)

354
prevention

of,

241

to oneself
in character

disorders,

pathological

ways

for
relationships.

turning
See

against
also

of,

320 , 377 , 380 381 , 400

404

character

defenses,

countertransference;

409
therapeutic

alliance;

transference
enactment

of past,

parent-child,

355 , 357 358 , 421 422

past

painful,

pathological,
Reller,

M.,

390

216

representation
repressive

372 , 399 , 414 415 , 419

problems,
defenses,

286 287

45 , 109

avoidance

(vignette),

compared

to regression,

de-repression
discharge

of anxiety

guilt

of,
( see

315

of Oedipal

displacement
failure

118 119

conflict,

and,

(vignette),

247
124

59
guilt)

identification

with

aggressors,

identification

with

object

indicators
instant

465 466

of,

124 125

of rage

(vignette),

125 126

400

repression
of feeling,

127 129

identifying

defenses

that

create

(vignette),

129

131
of stimulus
intellectualization
intrapsychic
in

function
to

of,

127

131
118

exploration

of

internal

emotional

problem

190
shift

to character

suppression,
types
resistance,

(vignette),

resistance

(vignettes),

(vignette),

of,

defenses

from,

135
132 135 , 140

105 , 135 , 141 , 166 . See

to conscious

399

therapeutic

also

alliance,

transference
206 207

resistance

to declaring

a positive

to declaring

a problem

to declaring

will

defenses

for,

diagnosing

( see

character

problems

also

tactical

structure

of

192 199
170 182 , 185 187

on

closeness,

exploration

(vignettes),

(vignettes),

to work

105

to emotional
to

goal

in,

(vignettes),

184 189

defenses)
156 157

99 100

internal

emotional

problem

(vignettes),

189

192
head-on
highly

collision
resistant

with,

424

patients,

156 157

enactment

of past

principles

for

reasons

for

resistance

relationships

working

with,

by,

443

177

resistance,

413 415

to declaring

a problem

(vignette),

173

177
resistance
problem

(vignettes),

to

of,

invitation
levels
low

internal

emotional

of resistance

of,

415 416

400

to let
of,

of

190 191
spectrum

indicators

exploration

go

of,

104

105

resistance

patients,

156 157

formation

of therapeutic

alliance

by,

resistance

to declaring

a problem

166

(vignette),

170

172
resistance
problem

(vignettes),
mirroring,
moderately

to

exploration

of

internal

emotional

189
deactivation
resistant

of projection
patients,

breakthrough
collaboration
de-repression

by,

300

156 157

of grief
of,

(vignettes),

467 468

205
of

Oedipal

conflict

(vignette),

465

 466
focusing
grief

on

defense

(vignettes),

inviting

problem

(vignettes),

(vignette),

to

460 462

exploration

of

internal

emotional

190
second

(vignettes),

451

466 467

feelings

resistance

with,

breakthrough

of

murderous

462 465
spectrum

of resistance

transference
siding

with,

turning

of,

resistance

415 416

in,

372

390

against,

willingness

30

to work

on

problem,

184 185

restructuring
anxiety

(vignette),

cognitive

220 221

recapitulation

(vignette),

definition/description,
of ego

deficit,

graded

format

reversal

Roth,

regressive

defenses,

separation

of ego

J.,
P.,

of,
120
120

65

57
354

Rothschild,

B.,

Rottenberg,

J.,

rumination,

somatization,

identification

S.,

Rosen,

for,

patients

defense,

Rollnick,

86

of unconscious

defense,

ridicule

260

pathway

sequence

70 , 80
330

196 , 409

221 222

anxiety
with

249
discharge,

defenses,

282 283

71 , 216 , 222 224 , 315

and

233 234

superego,

260

71 , 234 235

rage

Ryle,

G.,

396

sadness,

16 , 330 331 , 331 332

sadomasochistic

enactment

Safa-Gerard,
Safran,

D.,

J.,

Sandler,
Sapolsky,

Scaer,

383

357 , 379 , 380 , 381 , 384

R.,

48

295 297
R.,

Schore,

47 , 69 , 70

A.,

Schulkin,

13 , 39 , 60 , 72 , 166 , 354 , 355

J.,

57 , 184 , 247

Schwartz,

G.,

Schwartz,

J.,

Segal,

121

J.,

sarcasm,

vignette,

H.,

247
185

46 , 77 , 316 , 318 , 349 , 356

self-attacks

defense,

86 , 263 , 287

causality,

363

common

forms

defensive
loss

of symbolic

with,

thinking

334
with,

of after-session

at severe

levels

self-destructiveness,
self-dismissal,

364 365

weepiness

prevention

self-hatred,

of,

356 357

attacks

of superego

(vignette),

pathology,

240 241

379

369 370 , 387 388 , 390

241 242

360

self-mutilation/cutting,
self-observing

7 , 240 241 , 245 , 287 , 288

capacity.

assessment

See
and

also

observation/observing

mobilization

of,

capacities

43 , 59 60 , 63 64 , 106

259 260 , 261 262 , 292

differentiating
differentiation
(vignette),

corners
of

287 289
effects

of low,

275 276

of the

triangle

depressed

(vignettes),
patients

271 275
from

defenses

elements

of,

in fragile

overview,

patients,

identification

as

lack

of ability

to observe

a feeling

the

patient
of

(vignette),
(vignette),

of causality,

ability

to

263
264 265

289 290

observe

defense,

depressed

264

when

( see

patient

self-punishment,

syntonic

says

defenses/syntonicity)

I dont

know

(vignette),

240 241 , 244 , 383 , 413 , 458 . See

effects
fear

of chronic,
of,

living

to others

up

to punish,

to standards

provocation

as,

unconscious
separation

383

406

invitations

anxiety,

and,

382 383

359

324 325

guilt

versus,

381 385

39

16 , 384

Shanker,

S.,

Shapiro,

R.,

Sheldon,

A.,
Y.,

Sherman,

344 , 346 , 347

36 , 37
74
48

M.,

390

21 , 26 , 40 , 41 , 85 , 140 , 246

signaling,

unconscious,
G.,

22 , 44 45 , 65 , 332 , 336

245

social

anxiety

social

emotions,

social

engagement

social

phobias,

somatic

356

a defense

syntonicity

Smith,

of,

to observe

patients,

sighing,

problem

of ability

spectrum

Sheline,

226 227 , 235 236

lack

reminding

shame,

260 261

nervous

(vignette),

374 376

16
system,

50 52

217
system,

35 , 40 41

290 292
also

guilt

somatization/somaticizing
ability

patients

to observe

asking

about

diagnosis

and

let

feelings

of,

go

until

of defenses,

symptoms

141
appear

(vignette),

246

differentiation

of psychogenic

or

medical

causes

(vignettes),

249 254 , 254 255

fragile

patients

graded

format

with,
for

214 , 217

restructuring,

organized/disorganized
restructuring
rising

somatic

symptoms

in session,

of,

feelings,

headaches,

symptoms,

defenses,

252

255 256

245 , 246 248 , 248 249 , 249 250

tension

headaches,

therapists

254

understanding

unconscious

of,

identification

vignettes,

245 246

with,

251

24 32 , 252 253 , 253 254

Southwick,

S.,

57

speculation

defense,

116 117

patterns/rate,

262 , 301 302 , 302 305

splitting
addressing,
blocking

87 , 177
the,

in borderline
compared
effects

Spotnitz,
Sroufe,
standards,

86
patients,

to denial
of,

patients,

integration

with

L.,

362
and

projection,

216 , 222
projections,

387

92
violation

316

217

in fragile

H.,

344

325

somatization

speech

249

of regression/regressive

sequence

256

of our

own,

360

223 224

293

Steiner,
Stekel,

H.,

93

W.,

246

Sternberg,

E.,

Stevens,

D.,

Stewart,

184
92 , 260 , 261 , 354

J.,

37

stimulus
addressing,
feeling

versus,

26 , 271 272 , 277

of normal

or defensive

picturing,

for

real

versus

as
Stovall,

17

trigger

K.,

rage,

awakening

338

observing

imaginary,

capacities,

128

332 , 336

of feeling,

277 278

92

Strachey,

J.,

414

suffering,

275
attribution

of,

causes

of,

choices

to external

of,

relationship

194

2 , 4 6 , 32

leading

nature

forces,

to,

342

2 4
between

Sullivan,

D.,

Sullivan,

H.

S.,

for

breakthrough

therapeutic

task

and,

6 8

330
37 , 59 , 91 , 92 , 292 , 316

summarizing

cognitive,

to unconscious,

221 , 222 , 223

in cognitive/perceptual
to show
triangle
superego,

causality,

being
healthy

of,

also

disruption,

70 , 222 , 243 , 256

269

of conflict,

260 . See
aspects

235

182 , 255 , 256

identification

353 354

a superego
versus

to others,
unhealthy,

371 372
360 361

pathological

( see

superego

pathology)

projection

of,

218

302 , 306 307 , 317 , 319 320 , 334 336 , 339 , 356 , 357 , 376
punitive,
as
superego

357 , 373 374

system,

395 396

pathology,

322 , 390

character
countertransference

defenses

and,

deactivation

of,

of,

judging

oneself
of,

and,

359 361

(vignettes),

362 371

361 362
(vignettes),

projection

of the

projection

to avoid

385 391
judge

(vignette),

guilt,
of,

reflecting

of syntonicity

degree

362

resistance

resistance,

372

376 377

psychodiagnosis

transference

( see

of,

391 394

transference

resistance)

413

135

symbolic

equation,

symbolic

functioning,

symbolic

thinking,

sympathetic

354 355

357 359

standards

mirroring

suppression,

369 370

internal

levels

superego

354 , 359

of identifications,

harshness

defenses)

369

of,

formation

character

394 395

definition/description,
enactment

( see

318 319 , 356 357

320 , 346 348
356

nervous

system,

41 , 246 , 330 , 332

symptoms
anxiety,
assessment
bodily,
somatization/somaticizing

36 37 , 41 42 , 45 46
of,
39 ,

160 161
40 41 ,
patients)

( see
217 ,

also

psychodiagnosis)

245 ,

249 250

( see

also

causes

of,

57 , 216 218 , 246 247 , 282

cognitive/perceptual
functional
graded

versus
format

impulsivity
labeling,
links
with
syntonic

disruption
organic,
for

as

of,

assessment

of,

mirroring

with,

Ten

Have

capacity,

of,

of,

with

of conflict,

spectrum

of dystonicity

380 381

defenses,

for

in superego

spectrum

282 283

identification,

pathology,

380

358

391 394
to syntonicity,

283 284 , 378

109 118 , 140 , 322

crying/weepiness
de

388 390
failure

identification

self-observing

See

254

282

causality,

defenses,

unconscious,

260

conflict

observing

and

67 , 98 , 284 , 402

definition/description,

tears.

219

217

defenses/syntonicity,

tactical

of,

347

conscious

splitting,

severity

spectrum

56

between

patients

250 251

249 254

treating

quality

(vignette),

Labije,

temporal

J.,

regression,

293

60 , 110 , 126 , 128 , 247 , 259 , 260 , 316 , 370

379 , 424 , 425

tension

tension
therapeutic

(bodily)
conscious

hiding

symptoms

of,

(conflict).
alliance.
co-creation
common
conscious,

See

of,

66 67

46 47
conflict/tension

See
of,

also

therapeutic

misalliance

6 7

nonproblems

(vignettes),

182 184

205
decision
order

tree
of steps

for
for,

developing,
166

167 , 168 170

defenses
with

used

each

intervention,

identifying

and

indicators

of,

ingredients
inquiry

to prevent,

42 43

regulating

for,
phase,

unconscious,

obstacles

to declaring

of ingredients

437

internal

emotional

problem,

177 182

for
declared

internal

emotional

problem

160 161
Second:

patients

Third:
(vignette),

will

to do

consensus

on

therapy,

161

intrapsychic

conflict

161 162
Fourth:

(vignette),

consensus

on

therapeutic

162 164
phases

of inquiry

resistance

therapeutic

causes

therapeutic

of,

of,

156 157

a problem

(vignettes),

170 182

206 207 , 444

misalliance,

effects

in developing,

to declaring

unconscious,

55
69
premature

confrontation,

projection,

46 , 323 324

417

67

task
establishing
for

consensus

fragile

patients

patients,

detection,

202 203

(examples

between

understanding
versus

on,

and

vignettes),

479

relationship

threat

56

207 208

First:

thoughts

for,

159

the

(vignette),

anxiety

30

mobilizing

order

94

feelings,
35 , 38

as

suffering
purpose

131

of,

and,
165

6 8

230 231

task

tolerance

for

anxiety,

Tomkins,

S.,

6 , 13

Toner,

B.,

45 47 , 56

247

transference
causality

of,

104 105

of defense,

role

regressive,

226 227

resistance

of identifications

to ( see

transference

in superego

pathology,

unconscious,

hiding

transference

neurosis,

transference

resistance,
avoidance

in,

356

resistance)

361
of,

67

215
67 68 , 100 101 . See

of intrapsychic

deactivating,

conflict,

also

resistance

420

425 429 , 436 437

description,

141 , 413 415

enactment

of past

evolution

relationships,

372 , 399 400 , 444

of
creation

of pathological

defenses

against

relationship,
offering

416 418

presenting

problem,

416
distancing

from

intolerance
steps
handling

of,

of conflict,

in addressing,

and

identification

of,

passivity

443

417
418 419

feelings

312 , 422 , 423

focus

toward

judgment

of others,

mirroring,

439 440
when

as,

106

interpretive/noninterpretive

problems

416

415

helplessness

inviting

therapist,

the

on,

therapist,

443
104

357

addressing,

premature

confrontation,

442

psychodiagnosis

of
decision

tree

elements

and

sequence

role

for,

presenting

stages

in,

of resistance,
of,

C.,

triangle

the

282

inability

to explore,

inability

to recognize,

of,

language,

unconscious

corners

formulating,

T.,

101 102 , 104

234

consensus

purpose

Trunnell,

(vignette),

70

establishing

of,
on

95

(vignette),

199 202

190
127
interventions

for,

139

259

346

causality/triggers

causality,

102 104

422 , 423 424 , 434

psychodiagnostic

true

Troendle,

P.,

216 , 234 , 419

281 , 380 381

236
anxiety,

discharge
meaning

of (vignette),

419

to patient,

differentiating

See

part

5 , 46 , 117 , 479

description,

triggers.

as

297 , 315 , 349

describing

trigger

goals

13

of conflict,

21 22 , 86
of,
of,

41 43 , 45 , 52 59 , 139 140
207

421 424

420 421

(vignette),

uninvolved/detached,

Trevarthen,

interventions,

100

of,

patients,

421

356

identification

traumatized

patient,

415 416

clarification

structure

by

therapist

positive

of identifications

spectrum

424

expressed

responses

resisting

for,

193

patterns

of,

triggers

64

of,

unconscious

defenses,

unconscious

feelings,

198
93 , 225
16

breaking
breakthrough

through

to the

of,

triggering,
guilt,

unconscious

procedural

unconscious

signaling,

the

Vaillant,

G.,

memory,

representation
See

vignettes

under

and

A.,
R.,

445 , 447 , 451 . See

19 , 50 . See

R.,
C.,

sites.

to

evasiveness

344
of feeling

states,

specific

defense,

345
intervention,

or

disorder

for

330

93

7 , 404 , 405 , 406

See

recommended

chapter
G.,

387

weeping.

See

Wegner,

D.,

M.,

breakthrough

330
S.,

Wehrenberg,

also

also

39

Wallerstein,

Warshow,

422 , 423 424 , 434

examples

Vingerhoets,
Waelder,

resistance,

93
of feelings,

vignettes.

Wexler,

92 93

22 , 44 45 , 65 , 332 , 336

vagueness,

verbalization

Weeks,

also

381 382 , 383

unconscious,

unconscious

Web

( see

224

transference

unlocking

Walter,

234 235

115 116

uninvolved

verbal

214 ,

21 22

unconscious

the

105 ,

unconscious)

emergence

undoing,

to,

crying/weepiness
184
M.,
390

47

materials

section

at

the

end

of

each

Whittemore,
Wiens,
will

J.,

S.,

50 , 218

37

(intention).

See

also

free

acknowledgment
avoiding

of will

battle

conscious

of,

will

effects

will

to seek

to work

on

therapy)
problem,

184 189

433

versus

unconscious

of declaring,

to explore,

(will

habits

(vignette),

172

maintaining

focus

mobilization

of,

on

will/deactivating

(vignette),

298 300

projection

of,

(vignettes),

229 231

31 , 402 , 403

mobilizing

defiance

55 , 77 , 186 , 187 189 , 224 , 324 , 429 , 430

433 , 455
projection

to parts

resistance
verbalization

Willick,

M.,

of,

on

specific

D.

Winstanley,

W.,
B.,

344
problems,

Woolfolk,

R.,

246

Wooster,

A.,

331

Worchel,

J.,

Wurmser,

418

L.,
M.,

297 , 315 , 319 , 356

74

55

349 , 378

(vignette),

184 185

222 , 316

Winnicott,

Ziegler,

of oneself

to declaring,

to work

289

170

321

About

the

J on
is

Author

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cochair

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