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for
Co-Creating
There
are
many
Co-Creating
thought
inspiring,
and
job
and
or
Co-Creating
on
and
when
deserves
the
Davanloos
to
clearest
chock-full
of compelling
into
session
the
Practitioners
by
delving
in
and
most
Dynamic
clinical
a
vignettes
wonderfully
Professor,
the
client
into
therapist
an
feelings.
The
therapist
can
by
enabling
Rutgers
is
awareness
book
is a road
client
how
and
to
Center
for
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and
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market.
reader
It
directly
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will
is
way.
profit
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Messer,
PhD,
School
of
Dean
and
Applied
and
an
the
map
and
effective
guide
collaboration
to
biobehavioral
shifts
with
examples
excellent
a therapeutic
to become
well-written
alliance
aware
W.
to
that
stop
that
lead
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constitute
of how
the
the
suffering
of feelings.
Porges,
PhD,
author
of
The
Theory
Frederickson
feelings
and
University
Stephen
Polyvagal
the
volume.
B.
insightful
build
of
co-create
the
an
useful
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Graduate
to
novice
founder,
therapy
Stanley
enables
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emotion.
both
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of this
Change
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by
that
pages
Co-Creating
emotions,
Psychotherapy
the
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of psychodynamic
Professional
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forms
Distinguished
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focus
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Short-Term
transcripts
alike.
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clinical
moving.
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Fredericksons
attachment,
Stephen
This
of
psychotherapeutic
psychotherapists
Therapeutic
clarity
multiple
neurobiology,
Change
experienced
the
psychotherapy,
tremendously
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research
The
and
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Change
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skilled
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therapeutic
our
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harmonious
of
weaknesses
will
Well-Being
author
of Affective
This
book
to
way,
developmental
theories.
knowledge
about
exactly
what
change
through
the
with
experience
the
toward
breadth
exceptional
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guide
Change
to
to
confront
chains
War
in Intimate
Co-Creating
wanting
do
a solid
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from
the
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well-equipped
and
It
and
is
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practical
integrated
of
This
is
guide
for
to
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model
suffering.
Solomon,
theory
of
can
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PhD,
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source
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spectrum
Mexico,
anxiety
therapists
for
and
Jon
outlining
of
Love
deeply
therapists
affecting.
Frederickson
treatment
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all
deals
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their
and
effectiveness
of patients.
Patricia
New
clear
Relationships
Change
to
communication,
relationshipan
of their
in
ideas
offers.
and
of Mind
theory
modern
Professor
University,
Archaeology
requires
Change
dyadic
Endowed
interpersonal
Marion
of
to
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Co-Creating
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across
an
Baily
The
research
ways
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with
be
in
Washington
Neuroscience
neuroscience,
From
be
Panksepp,
Science,
synthesizes
straightforward
and
can
interested
this
led
brought
progress.
Animal
people
are
clients
Anyone
find
processes,
we
of
Jaak
of
emotional
engagements,
living.
life
brains
and
author
Coughlin,
of
PhD,
Intensive
faculty,
University
Short-Term
Dynamic
Psychotherapy
Jon
Fredericksons
Techniques
This
the
may
technical
is
very
Co-Creating
a must-read
well
be
processes
Change:
for
the
of
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and
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psychotherapy.
distillation
Clearly
written,
of
with
abundant
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Frederickson
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descriptions
excellent
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theoretical
the
and
process
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for
any
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Association,
and
Co-Creating
of
and
guide.
especially
work
J.
serve
I
numerous
attunement,
with
of Presence
concrete
concise
up
terms
and
the
as
as
of
ABPP,
and
Past
Psychological
University
scholarly
text
Fredericksons
and
as
integration
with
moment-to-moment
highly
resistant
intervention!
patients
to
be
on
Washington
therapists
of
accessible
psychotherapy
Lab,
Therapy
This
indispensable
I only
to
rapidly
style
therapist
Id
had
occurring
is warm,
with
and
psychotherapy.
putting
Written
book
for
the
theory,
orientations.
this
is
in
chock-full
Complex
of
reader
into
fresh
to
a
do
available
defenses
and
interventions
Windsor,
dazzling
Clin
and
sweep
profoundly
as
and
PhD,
Psych,
coauthor
Trauma
covers
hoping
this
of
I was
significant
exceedingly
to
moment-by-moment
curious
University
book
personal,
detailed
in
Pascual-Leone,
for
a clinician
wish
Psychiatry,
integration.
Change
force.
all
style,
invites
of Emotion-Focused
de
emotion
illustrations
volume
Emotion
of
International
psychodynamic
Antonio
Director,
faculty,
School
with
contemporary
for
PhD,
Present
practical
This
Stadter,
to working
highly
and
dialogues
and
and
opens
personable
the
Yale
interchanges,
fragile
contribution
Frederickson
Jons
PhD,
American
found
clinical
Institute
fascinating
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serve
valuable.
Psychotherapy
work.
with
regardless
Magnavita,
both
Michael
tour
which
psychotherapist,
in Psychiatry,
can
clinical
neuroscience,
in
psychotherapy
trees,
Psychotherapy,
Lecturer
Change
remarkable
it
vignettes,
orientation.
President,
dynamic
decision
Jeffrey
author
patient-therapist
handle
of
topics
transformational
struggling
anxiety
clear,
every
and
to manage
reactions.
he
equips
confounding
defense,
in
manifestation
of
therapists
office.
all-inclusive
treatment
unlike
scholarly
many
anxiety,
or
This
manual
is
problem
the
I have
texts,
this
most
had
one
that
present
detailed,
the
Warshow,
itself
clear,
pleasure
is enjoyable
Susan
can
to
and
read.
And
to read!
MSW,
founder,
DEFT
Institute
From
the
brilliant
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and
the
process
to know
need
into
centers
to
obstacles
up
most
modern
do
He
by
Change
to
the
to
shows
He
he
convert
and
, Frederickson
carries
tells
but
us
keen
paragraphs
Frederickson
of technique,
what
of growth.
put
Jon
opening
psychotherapy.
theory
know
Co-Creating
the
the
beautiful
suffering,
of effective
about
our
and
us
never
our
to keep
hurt
minds
of psychotherapies,
right
into
what
we
want
we
touch
sticky
going
created
us
loses
patients
how
has
just
with
places
in the
face
encounter.
a classic
Intensive
on
of
With
resource
Short-Term
on
Dynamic
Psychotherapy.
Thomas
Professor
This
of Psychiatry,
valuable
knowledge
format.
illustrated
It
University
resource
and
by
presents
applied
captures
material
the
for
practitioners
who
both
wish
aspiring
to hone
Association
blend
masterful
a
clear,
the
scenarios
of Counseling
skills
therapy
and
to effect
DiNuzzo,
Clinical
Angeles
of
theoretical
accessible
therapists-in-training
their
Associate
Los
of
Theresa
International
MD,
of California,
in
essence
therapist-patient
must-have
Brod,
PhD,
Services
style
process,
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and
lasting
Former
and
deftly
tools.
seasoned
change.
President,
Co-Creating
Effective
Jon
Change
Dynamic
Frederickson
Seven
Leaves
Kansas
City,
Press
MO
Therapy
Techniques
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2013
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2013901623
978-0-9883788-4-1
1. Psychodynamic
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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
I was
what
not
later
traumas
in
get
you
this
only
first
what
they
time
past.
acts
those
of will
1944)
and
In the
end,
the
Patients
in self-creation.
of which
in
their
they
lives
are
but
they
had
given
the
done
been
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
They
had
were
what
proud
experience
to us
but
my
to me.
on
to our
psychotherapy
come
our
by
analyzable,
What
asked
done
1936)
meaning
this
began
delighted
accidental
you
obstacles.
(Rank
give
one
feel
past
did
based
else,
it.
the
but
had
to
are
what
analysts
How
me
with
most
others
judged
he
on
person.
no
everyone
overcome
the
short,
I began
Like
the
In
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
neuroscientists
Cognitive
of avoided
Body
say
attention
He
Clinicians
of
to
question.
because
tendencies,
Buddha?
patients.
suffer
Mindfulness
to
ago
maladaptive
relationships.
action
behaviors.
of
because
adaptive
unable
answer
years
an
integrative
(Kuhn
helped
field
of
1970).
model
of
treatment.
of
This
book
intervention
patients
based
NATURE
begin,
we
coherent
must
for
the
inevitable
pain
broken
and
of life
gives
up
that
everyone
we
there
hearts.
of it all,
reality
Each
of
loved
ones
can
they
want
The
conflict
existence.
to
do
deal
to
have,
what
bump
they
cannot
from
we
reality.
love
the
death
inevitable
open
is
the
reality
not
exist
reality,
always
give
life
we
us
may
what
loving
in spite
using
we
the
delay,
And
even
us
not
ability.
in
human
it,
which
no
said
and
longer
that
our
what
we
suffer.
want
our
if
the
desiring
do
our
defenses,
avoid
makes
want,
Yet
deliver,
have
Buddha
people
we
life.
inherent
suffering:
in reality,
realize
That
relationship.
want.
not
is
reality,
of
knowing
yet,
our
can
we
by
is why
in
They
what
and
source
person
and
every
person
want
That
been
abandonment.
into
things.
face
The
and
will
to the
has
hearts
is
to life.
every
of
we
heart,
losses
is built
pain
heart
a full
or
pain
have
heart.
empty
they
than
has
life,
must
respond
whose
empty
we
In
can
do
develop
we
We
an
want,
desire
does
into
the
of three
what
suffering.
hearts:
being
it effectively.
desire
of
always
Rather
with
to
from
one
avoid
suffering.
desires
different
why
we
everything
with
disappointment
between
relationship
want,
model
of
suffering,
person
through
and
cannot
we
up
to face
only
us
The
kinds
something
give
So
us
two
and
They
to
lose
loving
wants
disappoint.
we
can
of death.
continues
courage
of loss
us
ends
and
and
moment
loving
who
on
die,
ways.
only
to keep
The
our
question:
understand
pain
will
in two
love
are
It takes
love
or at the
heart
cannot
and
assessment
fundamental
to
between
we
a broken
able
theory
suffering
it. And
difference
with
why
treating
before
the
understanding
Everyone
either
bring
integrative
moment-to-moment
address
by
model
inevitable.
or
an
SUFFERING
first
Only
understand
is
on
OF
we
suffer?
lose,
present
needs.
THE
To
will
When
what
we
fantasy
is
In response,
feelings
we
and
adaptively.
anxiety
Or
avoidance
do
and
can
we
our
mean
feelings
therapy),
relational
therapy),
or inattention
use
effectively.
Buddha
to
our
symptoms
defenses
can
can
face
all
deal
the
with
it
However,
and
is optionalif
death
we
learn
we
use
an
that
we
resist
reality
feelings
through
behaviors
(behavior
cognitive
we
and
cannot
with
life
our
to
behavior
and
from
who
with
we
reality
and
ourselves.
tormenting
her
It
to
avoid
The
man
relationships
excuses
resistance
If we
fail.
marriage.
reality
thoughts,
avoid
relationships
abusive
our
deal
self-critical
defenses
housewife
in
ways
avoid
through
suffers
Defenses,
seen
We
reality,
feelings
The
presenting
the
therapy).
avoid
people
and
are
it.
behaviors,
herself
right.
We
therapy),
of touch
other
of loneliness.
was
our
(psychoanalysis,
avoidant
traps
illness,
(mindfulness
become
her
loss,
(cognitive
out
hitting
of
pain
to
we
a life
feelings.
response
feelings,
and
our
in
avoid
onto
and
? They
When
projects
reality
defenses
depressed.
who
we
by
a defense
through
so
The
anxiety.
them.
become
feelings
reality
facing
patterns
If we
by
from
thoughts
we
and
suffering.
against
maladaptive
When
avoid
suffering
turn
feelings
evoked
our
but
and
What
we
creates
is inevitable,
to see
experience
what
husband
turns
is,
for
out
the
create
our
problems.
CAUSALITY
We
have
defenses
First,
is
a
Those
optional.
stimulus
feelings
1961,
1926;
deal
with
feelings
So
in
reality
and
presenting
man
verbally
in
let
us
We
abuses
his
can
Freud
fiance
but
face
Or
which
1923a,
(stimulus).
S.
feelings
1964).
we
create
1961).
In
of
from
suffering.
(Damasio
1999;
our
suffering
causality
feelings
(Damasio
defenses,
(S.
the
our
(Hartmann
through
inevitable,
examine
anxious
1998).
problems
is
triggers
effectively
anxiety
life
us
reality
make
LeDoux
and
pain
1999).
Freud
1923a,
and
anxiety
can
avoid
our
symptoms
For
response,
to
our
instance,
she
a
feels
angry.
However,
expressions
of
becomes
his
boss.
was
no
she
He
She
big
deal.
what
defenses
create
minimizing
what
abusive
abuse
How
do
We
do
Then
so
readily.
with
answer
to
surveyed
we
comes
us.
us
what
for
example
of
will
surprising
Freud
patients
They
1973,
as
who
in
soon
A.
all!
and
her
Once
we
will
to explore
have
it,
a clear
picture
The
patient
you
ask
the
Freud
her
at
with
therapy.
example,
with.
questions
problem
get
as
her
about
her
patient
often
and
uses
1936)
Why?
seek
learned
1980).
to
from.
shares
help
her
verbal
our
no
declares
series
history.
she
change.
occurs
1926/1961
1923a/1961).
have
and
to help
their
as
she
suffers
answers
problem
Yet
she
and
These
fiancs
us
It
saying,
with
her
needs
it, or a specific
Freud
have
her
help.
to explore
(S.
she
pattern
seeking
to
saying,
feelings
stuck
soon
she
relationship
a specific
anxious
(Bowlby
It tells
as
from
herself,
her
wants
she
claim
and
office
relationships.
even
on
what
origin,
anxiety
problem
to your
most
could
she
by
anger
that
his
She
stupid.
herself
out
to
by
felt
away
find
limit
she
defenses.
herself
the
herself
she
something
Perhaps
with
set
fianc,
a raise
what
did
her
her
receive
their
deal.
floods
didnt
and
problem
patients
(S.
what
difficulties,
She
explore,
defenses
pain
she
it.
becomes
must
a great
us
causes
her
we
tell
with
keeps
First,
her
off
onto
she
tells
about
to
turning
she
her
anger
rationalizing
did,
at
anger
by
all,
is good.
the
problem,
Sadly,
asking
co-create
explore
of what
As
by
ask
life
ability
we
her?
did
the
by
fianc
help
he
because
and
deal.
Maybe
Every
symptoms:
big
answers
inner
her
After
we
we
Her
said
men.
is no
turns
he
her
her
condemned
angry
anger
he
who
feeling
because
what
depressed,
people
use
her
angry
She
of
than
wards
was
with
instead
minimizes
deserved
becomes
So
up
Rather
abuse,
rationalizes,
grew
anger.
anxious.
verbal
of
she
therapy
that
Patients
have
been
closeness
want
hurt
and
help,
but
in
sharing
their
previous
lead
anxiety
to
signals
that
this
relationship,
patients
use
desires.
We
conflict
(Malan
triangle
of conflict.)
Every
patient
emotional
are
patients
deeply
Every
his
defense,
we
of
face
it and
focus
on
of
the
be
Here
is
drive
into
we
his
the
lack
personal
an
with
we
identify
each
and
us
and
he
he
we
uses
let
go
of
all
can
simple,
will
focus
to
do
not
the
on
follow
patient
feelings
learn.
is
Feelings
1962).
want
their
illustrate.
invite
(Tomkins
we
anxious,
are
and
of
more
principles
we
therapists
history
feeling
so
book
detour
where
anxiety
If
basic
defense,
drives
the
is too
cost
a consistent
for
a defense,
that
principles
of the
or
skills
to show
its
the
to heal.
feeling.
three
the
anxiety
motivations
Without
to go
in life
(P.
drive
and
you
communication).
analogy.
a ditch.
the
rest
Maintaining
a compass
and
are
the
If he
his
Although
important
primary
difficulties.
defense
as
to feel
patient
on
the
you
and
based
are
is asking
ward
feeling,
His
They
him
to
change
sharing
therapist.
the
the
relationship.
(1)
symptoms
sharing
or
the
anxious
invites
for
explore
These
complex,
feeling.
By
encourage
then
feeling.
Instead,
past
of his
see
respond
most
our
Coughlin,
implicitly
him
his
detours.
we
he
and
patients
them,
the
anxiety
can
express
for
interventions.
application
these
a problem
what
make
anxious
his
of
on
form:
a defense
creates
and
triangle
becomes
relationship
creates
bottom
psychotherapy
When
this
uses
So
hopes,
elaboration
has
he
change.
painful.
the
an
you
becoming
to the
help
later
statement
co-create
for
defense
for
a feeling,
to get
regulate
one
that
suffering,
be
feelings,
automatically
(4)
relationship
expresses
he
and
not
their
could
symptoms
a moment
unwittingly
defenses
(2)
By
sharing
patients
(3)
to
ones,
chapter
body,
closeness.
patient
to
feeling,
dares
If he
the
earlier
of feeling-anxiety-defense
(See
problems.
co-create
avoid
pattern
creating
feeling,
presenting
the
this
in his
that
to
1979).
has
physically
to
call
conflict
patient
off
defenses
like
Suppose
Ill
say,
I was
Could
you
teaching
turn
you
the
wheel
to
so
we
can
get
back
on
want
to
as
the
drive
long
as
tell
me
Its
not
the
say
you
ocean.
New
driving
If the
and
to
focusing
defense,
he
will
THE
THERAPEUTIC
mindfulness
suffering.
this
life
by
his
feeling.
1998).
moment
To
his
by
the
lets
go
in this
this,
feelings
patient
let
have
into
the
up
goes
of
detour
in
his
patient
go
it,
to
and
anxiety
in therapy.
of
day
the
AND
his
patient
defenses,
moment,
becomes
at
one
with
he
with
pay
attention
no
himself.
the
and
of
his
guided
to reality
ignores
and
longer
Each
by
create
form
defense
they
becomes
that
his
our
moment
as
he
or
suffering
Thus,
time
see
reality
our
defenses
Each
in touch
avoid
long .
the
him
not
create
therapy
help
of
do
We
see
help
we
to reality
do
defense,
to
You
regulate
the
we
experience.
becomes
(Bion
anxiety,
car.
end
SUFFERING
patient
We
internal
he
he
to
If
say,
you
wont
If the
goals
all
think
he
And
you
but
Ill
and
feeling.
2003).
moment
a defense,
and
but
and
continues
shown,
(Safran
might
As
suffering,
attention
have
meditation.
using
his
are,
his
BETWEEN
help
One
moment,
see
right,
your
beach,
TASK
must
mindfulness
on
drive
the
me,
destination.
you
York,
a detour
If he
achieve
in a while
we
him
feeling.
not
moment
moment
stuck,
your
you
tell
your
way
New
get
focus
help
way
onto
on
to the
the
ditch,
well
goes
his
the
toward
the
way,
practices
once
symptoms
into
that
on
RELATIONSHIP
feelings
car
reach
is just
it is
might
is certainly
wont
ditch
north
You
That
you
but
defense,
THE
As
drive
return
to
ditch,
patient
then
a detour
return
to
drive
York.
and
are,
the
reply,
in the
you
us
destination?
Ill
in the
driving
way
If you
anxiety
on
that
your
ditch!
drive
want
of
toward
in the
you
you
habit
road
his
inner
return
cause
time
more
present
emotional
truth
in
he
to
his
pays
(Eigen
of
this
face
the
1970).
the
patient
he
fears
and
joins
the
therapist
must
has
relinquish
avoided.
to
co-create
his
Through
defenses
these
a relationship
and
two
for
choices,
the
change:
the
therapeutic
With
alliance.
this
clear:
understanding
help
the
suffering.
of
patient
By
see
feeling
to
channel
them
into
the
reasons
he
In
every
therapy
therapist
invites
patient
has
defense,
This
and
sequence
anywhere
a patient
his
depression
This
an
he
of
me
she
might
be
she
was,
sitting
him
an
we
see
From
an
had
not
hallway.
on
and
brought
If these
herself
by
(1)
the
(2)
the
uses
problem.
relationship,
we
create
the
the
her
patient
patient
inner
demonstrating
defense
them,
do
and
the
that
his
of view,
patient
her
not
sustain
hurts
(S.
the
symptoms
defense
will
interruption
Warshow,
patients
for
out
cutting
onto
into
personal
defenses
In
against
In
our
her
hurts
the
on
her.
In
floor.
I did
knife
is
away
a cut
take
to
die
the
firm
suffering.
help
have
knife
may
her
we
for
the
we
cause
her
the
if
there
X-Acto
patient
therapy,
defenses,
compassion
an
defense
the
of
help
enough,
I took
Every
that
we
with
wrist.
model
I wondered
sure
of napkins
blocked,
her
short,
and
wrist
office.
defenses
relinquish
session.
there
a pile
not
this
her
her
my
are
cuts.
life.
up
cutting
defenses
a thousand
the
I went
defense,
and
he
perspective,
every
point
shown
her
herself
insight
presenting
defenses
be
example.
watch
helping
this
with
drip
with
(4)
a closer
this
relinquish
toward
blood
stand
gain
relationship,
invite
From
stop
and
the
of
hour!
can
floor,
soul.
you
will
sequence:
or
his
place.
anxious,
Instead,
the
death
By
give
in the
watching
the
time
cause
he
will
first
closer
becomes
that
he
following
a
becomes
possible,
and
a symptom
every
If
a patient
her
as
in the
form
experiences
compassion
day
from
he
Collaboration
Let
just
(3)
disappear.
One
not
to
hope.
communication).
while
deeply
the
task
defenses
action,
see
depression.
help
and
patient.
the
defenses
patient
times
therapeutic
all day.
us
act
we
to 150
and
diminish
session
has
gives
patient
those
happens
up
say
is
(5)
as
adaptive
used
feeling,
the
relinquish
feelings
into
the
and
his
able
causality,
her
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
from
she
can
are
being
take
up
the
path
its
problem.
But
journey
explore
feeling,
patient.
Only
do
therapeutic
alliance
task,
needs
identify
will
the
the
patients.
object,
but
is
of doing
the
right
patients
to
become
suffering.
Then
personality
itself
must
explore
consensus
to
will
us
the
how
to
assess
to
begin
the
resolve
and
able
the
on
understand
be
let
for
the
develop
by
learning
feelings.
RECOMMENDED
READINGS
Abbass,
A.,
dynamic
psychotherapy:
Town,
research.
J.,
and
Driessen,
A
Harvard
E.
systematic
Review
Della
Selva,
P.
(2012).
review
of
http://www.istdpinstitute.com/resources/
Coughlin
and
ways
which
therapist
So
be
our
defenses,
effectively.
life
help
to
that
therapist
to
demonstrating
her
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
of
not
act
same.
patient
that
problems
causes,
to
the
an
inner
manipulate
constant
of
it,
through
underneath
patients
the
In
are
belief
that
presenting
problem,
to
Our
our
we
itself
a me
techniques
wood.
Techniques
defenses
this
begin
outcome
relating
was
the
to do
is
I was
strangle
way
of
together.
To
how
of
demonstrates
the
the
love
who
to
many
piece
compassion.
1944).
conscious
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ways
(Berdyaev
patients
learn
refers
sculpting
techniques
ways
will
is a cure
there
attention
and
book
love
constant
that
In
saw
I knew
defenses
life
example,
before
the
inner
that
You
of
patients
Technique
And
to me,
defenses
Through
this
said
Psychoanalysis
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and
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Jon
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M.
Shapiro,
(pp.
Empirical
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
Always
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
Never
inner
must
many
blocking
treatment.
them
patient
symptoms,
by
comes
associate
Defenses
alliance
attachment,
what
unconscious
them.
active.
With
therapeutic
freely
we
that
to say
from
is why
A highly
thought
a patient
than
block
be
session.
initially
away
That
defenses
therapist
twice
As
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,
the
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
Of
the
to go,
What
is the
the
feeling
is
from
hypothetical
defense,
the
dont
the
feeling
the
negation,
stimulus
then
we
your
take
it
and
then
feeling
you
for
You
in
differentiate
the
turn
the
against
confusing
disappointed
you.
Thats
that?
[ Point
her
for
from
know?
doing
the
feeling,
vague.
throwing
out
then
invite
about
the
and
then
the
[ 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
[ Point
out
and
block
or
the
[ Defense:
feel
what
ring
negation
anger.
you
in the
.]
That
do
gutter?
feel.
tells
us
What
[ Point
is
out
.]
his
eyes
.] I feel
sad.
[ Defense:
her .]
you
her?
are
know
the
[ Tears
Do
you
dont
feeling
toward
Either
.]
feel
You
still
opinion?
feeling
I dont
anger
at the
suppose?
your
the
But
her
a look
throwing
[ Defense:
uncomfortable
I suppose
Th:
cover
feel
Pt:
invite
feel.
the
and
is
toward
covering
She
the
her
Pt:
tears
course!
her?
Th:
you
to
for
to
.]
feeling,
Pt:
what
her
off
.]
Which
and
patient
Uncomfortable
toward
speech
not.
the
to do,
Th:
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
I feel
Th:
what
at
If we
encourage
Pt:
with
her.
[ Point
defense
stimulus
toward
notice
If we
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
If you
feeling
displacement
face
his
feeling,
that
so
we
anger
go
feeling
physically
Each
time,
focus
on
we
the
responses
Inviting
the
so
review
we
know
some
FAILURES
a
feeling
toward
Notice
how
focus
her
and
for
why
patient
and
onto
[ Point
to
turn
your
out
the
against
the
patient
ask,
can
describe
his
How
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
Im
the
Thus,
the
instead
in your
address
put
your
invite
next
feeling.
intervention.
Lets
to the
dont
toward
and
Pt:
To
invite
I threw
Th:
did
encourage
reactive
the
following
feeling,
ask,
What
is
the
an
effective
ring?
questions
fail
to
keep
focus.
What
The
therapist
sad
sadness
vague
throwing
or
didnt
anxious.
covers
(about
the
focus
But
the
in the
a specific
the
reactive
that)
ring
on
are
therapist
feeling
rather
than
your
feelings
feeling.
cannot
of anger.
specific
The
show
The
about
about
patient
the
could
patient
therapist
the
that?
say
how
becomes
stimulus
(for
gutter).
Whats
the
feeling?
This
question
is
not
specific.
each
of
would
The
which
be,
gutter?
patient
would
Whats
Focus
say
answer
the
on
can
the
feeling
the
anger,
therapists
toward
reactive
her
patient
could
has
a feeling.
ring
in the
say
Ask,
no.
Of
What
question.
for
you
course,
anxiety,
Much
throwing
is the
have
he
has
feeling
the
better
ring
in
the
a feeling
a feeling.
about
Dont
toward
her
for
your
thoughts
that?
ask
if he
throwing
the
gutter?
What
This
or
feeling.
Do
The
sadness,
question
invites
intellectualization
by
the
are
patient
sharing
his
to
thoughts,
Why
invites
the
patient
to
invites
the
patient
to
speculate
not
did
about
project
onto
use
the
his
she
about
that?
defense
of
feelings.
do
that?
The
therapist
else.
This
question
someone
others
rather
than
focus
What
is
like?
on
his
feelings.
question
invites
thinking,
not
is vague.
or
a defense,
he
avoids.
The
but
you
patient
would
do
could
not
about
invites
the
past.
Remind
him
feeling
toward
INVITING
Do
not
the
of
patient
be
Focus
the
her
to
on
able
stimulus
for
to
throwing
trigger
ring
about
with
was
vague
him
the
in
anxiety,
feeling
then?
This
and
think
this
now:
This
the
present
feeling
in the
face
feeling
feeling
the
that?
a feeling,
the
from
patients
the
feel
to help
detach
the
you
respond
What
question
This
feeling.
How
question
that
moment.
What
is
the
gutter?
FEELINGS
be
discouraged
defenses.
Those
excessive
defense.
then
the
invite
when
responses
feeling
Each
the
tell
time,
again.
The
us
patient
what
address
patient
responds
to treat:
the
with
excessive
anxiety
comes
anxiety
or
to you
anxiety
and
or
defense,
and
suffering
from
presenting
problems
defenses.
can
So
help
and
their
the
symptoms
appearance
patient
caused
in the
by
therapy
immediately
excessive
anxiety
is wonderful!
Now
overcome
the
causes
or
you
of
his
problems.
Inviting
by
the
feeling
anxiety
patient
or
(1)
has
defense.
label
experience
the
three
the
feeling,
the
his
what
he
him?
feeling.
feeling.
you
body?
After
feels.
he
Then
One
may
Each
time,
address
defense
work,
arrive
at the
experience
work,
then
that
the
physically
anger
may
use
in his
is
the
experience
invite
the
off
each
defense,
impulse
in
FEELINGS
the
and
(3)
that
and
your
physically
goes
your
the
impulse
then
ask,
body?
with
in his
How
body,
he
do
the
DURING
THE
Each
then
invite
feeling):
How
body?
After
he
next
body?
goes
with
for
OF
How
do
more
the
you
defense
his
the
anger
his
can
impulse):
How
The
experience
patient
out
stage.
rage?
your
your
how
point
experiences
that
you
in
declaring
time,
feeling:
is ready
PHASE
avoid
says
avoid
(experiencing
that
Once
to
at the
in
to
physically
his
how
physically
the
eventually
the
feeling)
of
Three
is
stage.
body.
arrive
What
and
INVITING
do
feeling.
that
you
patient
may
Address
impulse
experience
a breakthrough
unconscious.
ANXIETY
blocked
help
defenses
patient
defenses
in
we
feeling):
defense,
the
other
declares
Then
impulse
experiencing
physically
be
feeling,
many
the
experience
eventually
body.
use
in his
physically
impulse
that
ward
the
(experiencing
many
Stage
What
can
sequence:
the
next
(or
physically
rage
patient
Two
that
anger
and
the
(labeling
patient
we
patient
experiences
defense,
which
experience
The
some
experience
The
follow
(2)
Stage
do
of
impulse.
toward
declaring
each
Always
Stage
feeling
stages,
his
to
the
Addressing
defenses
deserves
brief
unconscious
tolerate
is
striated
what
muscles.
When
anxiety
not
the
he
what
of
anxiety-provoking
work
at
help
the
sign,
sake
ideal
and
2 on
anxiety.)
our
us
new
for
learning,
the
in
feelings.
rather
He
who
than
If
learning
anxiety
his
to
growth.
Therapists
avoid
that
and
experiences
anxiety.
anxiety
requires
level
is avoiding
of
signaling
of
properly,
an
patients
topic
in therapy
avoids
his
topics
the
good
learning
patient
triggers
but
cannot
is
the
is
for
chapter
low,
work,
anxiety
usually
(See
our
All
anxiety
is too
learn
rising.
brain
When
faces
of
Anxiety
level
high,
impossible.
patient
are
optimal
is too
most
comment.
feelings
an
anxiety
is
his
does
avoid
master
their
difficulties.
Inviting
feelings
and
feelings,
triggering
muscles.
Sighing
unconscious
in
the
addressing
unconscious
and
concern.
the
Treat
the
of
patient
muscles
is
anxiety
a
as
Th:
mobilizes
anxiety
tensing
feelings
striated
defenses
in
the
muscles
usually
avoids.
sign
of
is
voluntary
and
the
(striated)
signal
the
This
progress
a defense,
What
the
unconscious
rise
and
then
feeling
of
no
invite
of
anxiety
cause
the
toward
rise
him
for
feeling.
for
hitting
you?
Pt:
I feel
Th:
anxiety
off,
anxiety
as
Each
anxiety
in
the
wrong
unconscious
Patients
the
an
the
right
your
a look
at the
then
invite
body,
intervention
did
defense.
are
willing
feelings.
focus
useful
We
signaling
on
take
.]
that
lid
of
[ Address
.]
anxiety
did
muscles
underneath?
feeling
unconscious
not
If we
feeling
intervention
Every
and
anxiety.
the
toward
as
the
in striated
unconscious
track:
intervention
feelings
who
and
[ Anxiety
Thats
triggering
after
rise
take
a defense,
is on
Perhaps
the
we
intervention
muscles
not
could
tense.
not
in
the
refer
to
intervention
a rise
. If anxiety
mobilize
feelings,
striated
or
it
should
of
did
feelings.
addressed
mobilize
anxiety.
to tolerate
anxiety
to achieve
their
goals
will
improve
in
improve.
We
them
therapy.
and
Patients
must
show
defeats
unwilling
them
their
how
goals.
to
tolerate
avoiding
their
Then
they
anxiety
will
anxiety
will
turn
not
imprisons
against
their
defenses.
Pt:
This
is too
Th:
uncomfortable.
you
keep
will
happen
Otherwise,
avoiding
makes
face
goals.
you
what
What
do
you
you
think
this
right
to do
like
this
for
twenty
and
you
can
keep
when
inviting
does
no
go
doing
ago.
But
uncomfortable,
if
what
use
problems
principles:
But
feeling,
(2)
anxiety
and
If
the
then
choice.
these
so
best
have
can
can
avoid
or
you
achieve
your
interest?
at this
to.
you
You
symptoms,
you
to look
makes
I cant
Thats
Its
anger.
a choice.
uncomfortable,
not
Thats
just
let
goal
and
defenses
explore
true.
what
go
it. Its
the
patient
responds
feeling,
have
makes
you
the
not
review
of
inviting
You
can
and
you
the
to
(3)
avoid
achieve
this
with
excessive
If
the
patient
on
want.
anymore.
and
is
principles
to
feelings
his
with
you
goal
feeling,
responds
going
uncomfortable,
results
feelings
defenses
this.
been
working
avoided
To
like
You
us
against
away.
on
you
previously
anxiety
patient
going
if it is giving
The
If
keep
avoiding
that
will
(1)
this
in your
dont
that
transcript,
his
better.
have
I have
You
experience
to
uses
presenting
and
have
longer
three
to
be
I guess
years,
feelings.
face
not
you
so.
Pt:
we
get
have
and
would
Th:
patient
makes
it years
you
uncomfortable
anger
Pt:
Before
We
uncomfortable
makes
avoiding
the
anger
faced
makes
I wont
Right.
Th:
have
have
that
I guess
Pt:
keep
this
here?
Th:
can
would
anger
Pt:
what
Obviously
you
this
uncomfortable.
them.
help
so
that
he
Once
he
symptoms
goal,
the
we
feeling,
anxiety,
responds
and
follow
explore
regulate
with
defense,
help
the
explore
feeling.
anxiety,
or
patient
Assess
see
each
defense.
and
let
patient
This
go
of
the
response
response
will
respond
with
defense
to see
and
then
if it is a feeling,
determine
your
next
intervention.
Patients
with
low
resistance
feelings.
Explore
their
feelings.
Fragile
patients
anxiety,
and
resistant
and
1.1
let
respond
then
focus
patients
go
of
their
We
1.1
invite
patient
the
so
in
he
experiences
that
feeling
experiences
the
impulse
anxiety
the
patient
explore
Table
feeling,
Table
or
defenses
see
feelings
1.1
Phases
and
that
his
in his
with
a detour.
until
he
excessive
these
on
when
and
highly
patients
feelings.
see
See
figure
intervening.
feeling
feeling.
comes
cause
Help
First,
physically
defenses
the
stages.
label
may
at that
illustrates
anxiety,
1.1
his
the
Regulate
Moderately
focus
choices
inviting
three
can
feelings.
then
basic
tree:
anxiety.
defenses.
and
three
Decision
their
with
defenses
feelings
has
excessive
on
respond
to understand
Figure
with
can
we
ask
what
Second,
body.
that
we
ask
we
ask
feeling.
At
each
to the
anxiety
next
the
how
Third,
Regulate
go
feeling
how
and
stage.
he
he
stage,
help
Then
level.
first
two
defense.
in inviting
feeling
stages
and
sample
responses
of
SESSION
ILLUSTRATING
FOCUS
The
ON
He
unable
a
transcript
called
complaints
local
sleep
clinic
suffered
elsewhere.
so
much
he
business
took
a caretaker
intimate
with
The
patient
and
saw
through
his
male
and
no
longer
and
He
A recent
the
bowel
home.
His
wife,
who
had
feared
job,
sharing
and
coworkers
had
these
been
He
crippled
and
Besides
without
work
condition
bed.
at
evening!
at
his
regularly
been
headaches,
collapses
his
he
entire
at
had
patient,
complaints,
collapse
somatic
examination
the
during
to work
from
his
a neurologist.
physical
go
with
various
because
him
fifty-two-year-old
from
years.
physical
took
to
him
conduct
conflicts,
diagnosed
anything
he
with
emotionally
her.
regarded
all
At
had
he
realized
left
a mentally
his
his
psychological
symptoms
managing
and
disorder,
treatment.
boss
thirteen
attacks,
phone
role
and
minutes
and
with
suffering
inconclusive
sudden
a car
by
no
sessions
for
panic
could
office
mood
MAINTAIN
session
internist
trembling,
into
bipolar
his
twenty-six
After
him
initial
appointment,
was
from
and
helped
an
by
slept
shaking
is the
regularly
sleep
medications,
also
for
treated
to
TO
FEELINGS
following
man.
HOW
his
complaints
precipitants.
the
beginning
his
organization
This
first
and
were
therapy
worsened.
symptoms
biological
became
he
had
appeared
no
the
of physical
joint
still
only
idea
when
after
after
further
in origin
clear
However,
worsened
assigned
worsening
as
Those
of
dramatically
ill coworker
division.
somatic
beloved
when
responsibility
symptoms
few
led
he
of
him
to seek
treatment.
Doctors
had
treated
medications
inability
for
to
to
meet,
The
able
worker.
he
medications.
and
me
of
him
interview
to
he
by
had
suggested
The
all
my
of
doctors
possibility
that
he
was
spoke
his
range
The
he
We
wide
disorders.
the
fearing
going
on
health
the
to die
soon
phone
before
We
agreed
issues.
office
had
because
he
was
no
distances.
her
She
with
seizure
worsened.
drove
the
told
and
patient
told
long
begins
He
the
wife
to drive
doctor.
social
his
years
condition
had
and
and
patient
his
left
condition
appointment
longer
on
his
several
sleep,
his
disease
because
for
anxiety,
diagnose
Parkinsons
our
him
describing
made
he
transcript
a recent
an
see
appointment
a psychiatrist
begins
meeting
about
with
me,
instead
three
with
a
and
minutes
go
into
the
session.
Vignette
I start
One
the
(minutes
interview
by
35)
inviting
Th:
the
emotion
patient
you
to label
felt
his
When
toward
feeling
the
enough.
fact
that
You
patient
does
need
not
it
feeling
Well,
was
defense
feeling
of
as
you
I think
the
felt
unhappy,
[ Stage
what
one:
was
invite
the
Well,
That
Your
his
was
from
toward
her
not
good
Intellectualization.
and
thought,
toward
his
I felt
workers
feeling
your
emotion
intellectualization
social
[ Defense:
between
her?
emotion
her?
feeling,
and
The
a defense
.]
presumably,
but
[ Differentiate
his
then
invite
the
.]
down
I
say
doctor]?
a psychiatrist.
Pt:
came
feelings.
[the
like,
differentiate
toward
you
her
Th:
your
patients
.]
Pt:
was
the
would
rationalization.
to
the
have
The
fact
liked
I think
that
I had
during
patient
my
this
cannot
emotion
not
had
toward
as
process,
differentiate
hera
much
you
contact
know?
his
feeling
lot
of
that
with
her
[ Defense:
from
defense
.]
Th:
Thats
Pt:
difference
between
his
it was
a hot
button.
Pt:
questioning
the
psychiatrist.
[ Defense:
from
a defense
fact
thought.
a thought
But
your
The
emotion
that,
[ Identify
emotion
well,
to
her?
Because
her?
[ Invite
toward
her
know,
rationalization.
[ Begins
toward
emotion
you
defense
.]
see
the
.]
toward
the
the
you
Cannot
the
feeling
was
need
.]
that
to
differentiate
you
her
see
his
feeling
.]
emotion,
but
Differentiate
my
and
I think
Th:
an
thought.
Thats
feeling
Th:
said
your
It sounds
what
feeling
was
from
like
the
the
that
emotion
defense,
and
was
the
you
had
then
reason
ask
you
toward
about
had
her?
the
feeling
.]
Pt:
think
it was
(she
frustrated
like,
I have
issue.
The
home
and
her
was,
it was
him)
what
last
had
Do
What
frustration.
with
the
I believe
time
I had
called
her
you
need
out
the
stimulus
the
angry
at her
allows
the
understood
Vignette
[ The
physical
event
that
And
Two
with
her,
the
[ Defense:
was
obviously
stimulus
that .] It was
had
raised
and
first
had
thing
gone
out
rationalization
frustrating
this
from
.]
you,
right?
to
your
emotion
toward
her
for
frustrating
.]
defense
she
talked
the
doing
Right.
of anxiety
anger
for
the
bad
her?
.]
feeling
pathway
her
You
last
toward
confusing
problem.
Pt:
muscle
toward
I had
is a physical
She
Th:
[ Invite
emotion
[ Defense:
a psychiatrist?
Pt:
you?
the
feeling
and
Th:
Point
was
[ Sighs.
discharge
(minutes
.] I was
of negation
emerge
was
Indication
.],
[hand
614)
but
opens
of
access
notI
dont
simultaneously
I
think
up].
it
to
think
represses
was
case
striated
I
was
and
ofI
I continue
to invite
the
patients
Th:
But
Pt:
believing
what
Im
the
saying.
defense
the
The
emotion
Well,
Sighs
.] That
.] Like
of the
she
could
Im
an
was
Th:
Yeah.
Pt:
Whats
the
I mad?
Yeah,
now?
Uh-huh,
Pt:
I was
You
need
the
ourselves
that
anger
patient
anger
you
had.
position
and
becomes
emotion?
[ Invite
emotion?
I think,
I was
mad,
the
feeling
at that
sure.
.]
time
[ Emergence
so
you
were
angry
with
her.
I had
a perception
with
say,
This
is
her
then.
psychiatrist
that
territory.
that
anger?
invite
in his
the
body
Im
How
patient
do
you
to
experience
describe
it
how
he
.]
in
much
more
control,
I think,
of
the
.]
have
But
a look
toward
to turn
thought
a psychiatrist.
two:
[ Defense
the
and
And
Th:
let
not
know.
angry
off
Pt:
situation.
Youre
.]
the
leg
you
But
Th:
this
[ Stage
experiences
was,
.]
Th:
even
her
[ Switches
thought,
close
internist.
toward
certainly
the
was
anger
just
her?
.]
I said,
patients
toward
intellectualization
thats
Pt:
animated
feeling
[ Defense:
Th:
Identify
feeling.
her
against
at
if we
that
dont
control
right
right
now?
it, and
then
now,
how
[ Identify
invite
the
do
the
the
anger
now,
you
we
experience
defense,
experience
if
invite
of the
the
feeling
.]
Pt:
.] I really
there
was
just
didnt
know
[ Defense:
feeling
now?
.]
[ Block
the
.] How
exactly
But
defense,
the
do
what
rationalization
Th:
right
[ Sighs
I experience
to
do
at
it now?
that
point.
[ Sighs
I
mean
.]
anger?
and
then
How
invite
do
you
the
experience
experience
that
of
the
Pt:
vagueness
How
[ Invite
the
How
experience
in a little
bit
different
patient
briefly
drops
because
the
rather
than
This
focuses
on
feeling
psychiatrist,
the
right
focus
now?
frustrated
a cover
with
to his
feeling
Pt:
Right.
is
who
she
discharge,
is.
Identify
of
experience
the
to let
She
and
ways
clarify
do
discusses
follows
come
going
his
to
go
difficulties
the
His
anxiety
patients
defense
backbecause
for
you
saying,
you
you
and
need
were
to
dismissive
experience
of the
[ Sighs
.]
stimulus
see
manner.
Im
feeling
still
and
that
anger
.]
frustrated,
his
toward
feeling.
I
We
mean
could
call
.]
But
the
the
[ Sighs
off
steam.
is
anger?
How
experience
Pt:
trying
rationalization
the
.] Im
.]
the
of the
.] I have
I just
to
do
do
her
experience
feeling
not
try
you
.]
made,
to say,
job,
you
look,
you
the
knowI
you
know.
go
know,
she
[ Defenses:
.]
Th:
One
toward
.]
in a clipped
How
[ Invite
I try
anger
of diversification.
her
Th:
Th:
I walk.
[ Sighs
doctor
if we
to you
word
physically?
I?
[ Defense
defense
But,
angry
[ Invite
confusing
do
the
this
later.
speaking
Defense:
out.
[ Defense:
feeling.
Pt:
anger
now?
.]
mistakenly
his
quite
for
.] How
is the
therapist
a minute
obviously
her
it right
experience
feeling
how
Th:
[ Return
about
you
here.
describes
way.
return
[ Sighs
direction
in a dismissive
We
do
of the
Pt:
The
I feel
.]
Th:
her?
do
you
Lets
try
the
to
deal
patients
Pt:
back
up
with
here.
anger
defenses
You
feel
is you
try
angry
with
to
walk
you
try
her.
it off.
.]
Yeah.
Th:
And
you
say
another
way
to
deal
with
anger
is to kind
of steam
Pt:
Yeah.
Th:
is to come
up
with
And
all kinds
Pt:
to deal
with
this
And
very
do
you
have
drop
his
anger
.]
that
defense
these
If we
honest
look
emotion
Pt:
[ Sighs
Th:
Yeah,
anger
of
up
As
here,
of the
Im
you
defenses
he
it up
bananas
uses
Th:
Pt:
Th:
of
this
room,
powerful
Invite
as
emotion
the
experience
her?
up
against
and
were
that
youre
up
inside
you.
away
emotion
toward
anger,
right
her?
describe
am
the
the
if
we
now,
[ Invite
how
him
experience
to
of his
I experiencing?
Physically,
[ Sighs
how
am
.]
.] I have
difficulty
these
mechanisms.
Im
saying
[ Becomes
and
Im
anger
.]
saying
because
throwing
it
aware
Yeah.
Im
not
say
going
In reality,
But
do
of the
Pt:
to,
[ Defense:
In reality,
trying
how
coming
Physically?
here,
Pt:
or go
anger
physically.
I put
Th:
lady
anger
.] How
[ Sighs
said,
throwing
with
Yeah.
Pt:
Im
to deal
mechanisms
at that
and
toward
Th:
think
try
rationalize
of rationalization
that
all
emotion
dont
Pt:
experiencing
are
powerful
a more
experience
you
Right.
Th:
ourselves
way
Yeah.
Pt:
let
another
of rationalizations.
Th:
using
it off.
obviously
Im
you
feeling
know,
negation
swear
at
the
.]
youre
not.
not.
physically,
to
you
if we
understand
experience
just
look,
this
emotionthis
this
emotion
in the
privacy
is
physically?
.]
[ Sighs
.]
think
Id
go
back
to
this
abandonment
thing
sense,
and
this
anger,
how
do
defense
from
of,
you
know.
Th:
Clearly
makes
you
his
you
feeling
truth.
the
[ Defense
hard
toI
just
kind
of
Pt:
[ Sighs
Th:
You
this
woman,
your
just
cut
you
in
toward
physically?
her.
certain
And
the
[ Differentiate
experience
how
do
of his
you
feeling
the
feeling
.]
experience
that
direct
.]
.] I hardly
the
feel
anything,
and
thats
the
feel
feel
right
anything
now,
emotional
anything?
right
between
stuff
this
off.
now.
whole
[ He
sees
I mean,
its
process,
his
Ive
defense
of
.]
is
one
with
way
emotions.
his
hardly
I hardly
really,
all
shows
between
.]
I physically?
of the
Th:
this
angry
the
Yeah,
experience
feelings
what
do
word
.]
just
off
very
invite
cover
abandoned
that
How
Pt:
cutting
feel
and
Th:
[ Invite
she
experience
Pt:
anger?
[ Defense:
Its
the
you
You
defense
great
youre
tremendous
deal
try
to
and
his
with
honest
anger
the
deaden
so
collapses,
that
anger
the
here
you
is you
rage.
i.e.,
feel
toward
almost
[ Point
his
because
deaden
out
defenses
the
are
link
killing
him .]
Pt:
Yes.
Th:
youre
tempted
emotion,
right?
to
go
And
to
[ Point
tears
out
Pt:
how
his
yourself
defenses,
or
and
to
be
wash
it away
with
as
we
a way
the
But
him
tears
see
to
that
another
cover
cover
up
up
way
this
his
is
very
anger
that
heated
.]
obviously,
right?
of his
youve
[ Help
the
underlying
not
come
patient
wish
here
turn
to become
to
against
well .]
No.
Th:
dont
then
dead,
remind
Pt:
.]
Yes.
Th:
deaden
[ Tears
If we
tears.
dont
[ Encourage
deaden
the
this
patient
anger,
and
to turn
if
we
against
his
defenses
.]
Pt:
Yes.
Th:
anger,
how
do
experience
you
of the
[ Sighs
.]
feeling
questions
please.
answers.
Im
just
more
anger
honest
toward
look
her?
at
that
[ Invite
the
[ Sighs
trying.
to
talk.
Tell
think
shes
.]
not
.] Im
confident
I guess
me
if
its
Im
hard
not
searching
that
shes
to dig
in
there.
Ask
the
right
for
there.
[ Defense:
.]
the
anger
the
defense
toward
That
her?
from
describes
How
his
do
feeling,
her,
you
and
but
if we
experience
then
take
that?
invite
the
a look
at
[ Differentiate
experience
of
his
.]
Pt:
The
phrase
speech.
I guess
Block
that
What
is the
defense
experience
of the
.]
patient
I feel
feeling
says
alliance.
he
is
that
of
asking
do
out
the
this?
defense
about
you
of
his
of
feeling
experience
I guess
hypothetical
again
this
anger?
this
anger
.]
[ Invite
.]
What
Im
Im
fighting
fighting
Unconsciously,
I feeling
beginning
How
Pt:
Sighs
am
by
Th:
the
this
[ Sighs
Th:
anger
have
.]
want
just
rationalization
we
experience
Pt:
here.
If
out
of
to
stay
stay
alive:
rise
in
indicates
that
he
has
been
to
he
feeling
alive
right
is
now.
the
that
[ The
therapeutic
killing
himself
.]
Th:
you
feel
like
stay
alive
.]
The
patient
Grief
cry
youre
as
several
summary
he
alone
begins
emerges
as
to
of his
to
defenses
fighting
that
and
turns
aware
later
in
cry
he
becomes
minutes
Hmm,
fight.
tries
against
of
invite
how
his
against
to
[ Mirror
to
the
he
stay
say
experience
It sounds
patients
something
himself
experience
the
the
resistance.
kills
alive.
of
wish
but
continues
slowly.
We
followed
of anger,
to
cannot.
He
anger
like
to
return
by
especially
his
use
of immobility
Vignette
Three
I invite
that
(deadening
the
(minutes
patient
[ Sighs
Rise
want
to turn
against
Pt:
[ Sighs
Th:
The
to live.
to wait
two
physically,
right
question
word
anger
want
now?
[ Invite
Im
conflict
upset.
your
mobilize
the
Ah,
Pt:
I am
Th:
And
feeling
like
I said,
is
.]
is clearly,
I want
something
six
you
know
done
weeks,
you
do
experience
now.
know
.]
How
experience
of the
right
now?
cover
but
Im
word
youre
you
feeling
it,
.]
upset.
Theres
no
.]
angry,
right?
[ Point
out
the
you
with
any
all
the
got
in your
to really
fight
in the
very
important
because
we
you
need
fight
for
help
access
your
to
life.
Absolutely.
It
Because
could
right?
patient
its
bodyright?to
right?
anger,
angry.
anger
to let
go
Pt:
Right.
for
Th:
be
out
I have
If we
life.
the
deaden
a
youre
[ Mobilize
your
form
of
of
his
price
defenses
Because
your
you
almost
of his
therapeutic
Pt:
if
[ Point
Th:
engage
on,
anger
anger?
[ Defense:
around
dead,
deaden
him
the
the
weeks,
alliance
the
Th:
having
to die.
Physically,
Pt:
be
going
upset.]
youve
could
the
four
And
Th:
your
whats
[ Invite
anger,
therapeutic
Pt:
of
body).
defenses.
anger?
weeks,
Th:
cover
his
.] I think
The
I dont
in unconscious
damn
and
.]
.] I want
I dont
emotions
1620)
Pt:
Sighs
his
anger,
suicide
you
if
defenses,
you
and
.]
in
a position
that
patients
will
and
help
anger,
lets
see
if we
the
you
are
task.]
to fight.
dont
deaden
the
can
get
to the
bottom
of what
Pt:
The
first
minutes
of
into
intellectualization,
the
Each
focus
doctor.
on
After
as
anger.
his
body,
a series
the
and
rage
Once
of
impulse
onto
stuff
the
of
how
the
the
feeling
he
.]
of
turned
the
patient
When
patient
Then
the
in his
hands
turned
in
the
against
it,
displaced
had
of
feeling
addressed
who
defense
his
the
physically
patient
doctor
the
to grab
anger
returned
toward
label
the
of
and
then
feeling
could
the
the
against
impulse
and
defense
himself.
toward
defenses
the
about
body.
the
occurred
immobility,
and
in his
used
experienced
immobilization
rage
negation,
the
immobilized
instead
patient
I asked
defenses,
rose
patient
experienced
First,
patient
[ Invite
murderous
The
I addressed
I asked
defense
feeling
patients
interview.
time,
feeling.
When
patients
the
the
rationalization,
displacement.
to
is all about.
Yeah.
breakthrough
thirty-six
this
his
failed
him.
displacement,
and
he
body.
Questions
Sometimes,
case
therapists
wonder,
Isnt
experiences
hurt
the
of the
the
these
patients
fall
Isnt
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
If
we
before
causes
Your
task
make
we
according
He
against
we
One
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
the
that
is this:
can
and
will
I could
patient.
defenses
his
or see
patient
to remember
anxiety
You
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.
Through
form
is feeling
is
learning
time
to
wont
prefrontal
until
chance
is
patient
of
work
cortex
the
his
ball
his
he
missing
the
is
brain
recognize
kept
to
for
Think
his
So
asking
connections
principle
patients
that
brain.
patient
access
prefrontal
keep
know
seeing
between
his
not
the
system.
connections
throwing
can
practice
if we
kept
he
needs
understand
of
does
to defenses,
limbic
father
the
that
Yet
regions
The
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
the
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.
This
emotional
responses
such
1998,
(Damasio
2009),
nonconscious
Panksepp
the
1999).
of
the
(Damasio
pounding
to
of fear
our
consists
The
emotion
body
by
1999).
heart
and
conscious
of
the
These
sweating
awareness
of
1999).
when
when
they
they
focuses
and
are
are
on
activation
fight/flight
differentiate
1999;
systems
refers
fear
affect
activation
(Damasio
Therapy
must
(Damasio
of
anxiety
1936).
we
threat
of
symptoms
as
? The
symptoms
of
them
anxiety
nervous
Freud
Thus,
term
unconscious
sensations
these
threats
the
feeling
bodily
We
the
autonomic
The
these
the
detection
refers
somatic
(A.
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
Anxiety
signals
away
from
them;
mobilizes
the
whereas
anxiety
Freud
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
First,
are
them
itself
a threat.
We
by
defenses.
using
physically
to defend
cannot
Fear
(Panksepp
ourselves
run
1998),
psychologically
(S.
somatic
system
or
with,
autonomic
Third,
in defensive
threats
that
(Porges
Kennard
bodily
symptoms
For
with,
2001a,
1947).
has
we
so
can
label
them
as
prepare
the
body
to
creating
can
run
can
engage
to
and
the
(LeDoux
objective
Bazhenova
conscious
of
from,
externally,
we
Porges
feeling
somatic
internally
become
the
we
act
the
the
or surrender
2011;
sends
activates
activated,
from,
2001b,
Fourth,
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
Second,
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
Anxiety
different
system
(Panksepp
the
body
1995,
1926/1961d).
The
2006)
in the
that
(Porges
of
anxiety
these
(Damasio
1999).
How
does
mobilizes
the
sympathetic
blood
anxiety
somatic
branch
pressure,
of
the
it to the
large
our
and
get
feet
ANS
raises
blood
muscles
cold.
act?
autonomic
withdrawing
redirecting
hands
and
to
Other
so
we
When
nervous
our
pulse,
from
the
can
symptoms
run
the
amygdala
systems,
breath
rate,
extremities
or fight.
include
dry
That
mouth,
the
and
and
is why
dry
eyes,
constipation,
Shapiro
The
and
rate,
and
brain.
This
warm
hands,
and
animals
to
escape
go
the
than
threat
if
fear
problem?
symptoms
of
second,
and
and
Fear
can
and
the
However,
we
no
the
occasional
just
survive,
loss
of relationships
few
weeks
survive.
old.
relationship
anxiety
anxiety
enough
for
lifetime.
Fear
cause
so
Causation
of
constricted
2004;
and
McEwen,
and
enables
sometimes
nervous
think
systems
2006)
about
avoid
or
in
see
such
threat
or
predators;
live
cannot.
the
safety
avoid
when
on
of
others
primary
1980),
1973,
Sullivan
1953a,
1953b).
feeling
single
to
(Fanselow
trigger
and
Why
experience
anxiety
Dale
a
to
our
1969,
problems?
the
only
(Bowlby
many
Anxiety
saber-toothed
must
rely
system
relationships.
independently
Children
H.
permanent
like
humans
threatening
S.
emotion
human
dangers
1996;
are
in
they
objective
cue . The
fear
survival
are
to an
today
mammals
feeling
why
response
a relationship-threatening
memories
Other
(Goldstein
survive,
driver.
our
(Evans
to
crazy
however,
endangers
triggering
us
to
. Many
any
ears,
anesthesia,
predator
bodies
the
the
reaction
consciously
have
must
Therefore,
eyes,
autonomic
our
operates
longer
We,
in
in
to
migraines.
Shapiro
a misperceived
jungle
animals
and
adaptive
to
for
and
breath
flow
ringing
bodily
pulse,
2003).
an
reaction
designed
The
Hamill
blood
teary
by
we
allow
be
of
parasympathetic
anxiety
before
our
vision,
and
somatic
Wiens
drop
diarrhea,
attacked
anxiety
a maladaptive
tigers,
This
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
To
(Goldstein
resulting
symptoms
thinking,
pupils,
of
pressure,
creates
symptoms
create
branch
blood
problems
Yet
pupils
2004).
parasympathetic
less
dilated
is
for
2003).
Milliseconds
after
amygdala
anxiety
sends
responsible
for
feedback.
detection
of
hypothalamus,
goes
anxiety
symptoms
cortex,
already
reacts
before
visible
cue:
Those
Youre
safe.
tiger.
In
the
to
evaluate
patient
what
anxious
because
and
remains
The
of
falls
the
death,
in
a test
she
the
a tiger
and
running
have
then
thought,
about
me.
She
in three
weeks.
supposed
Hmm.
of
not
are
I ask
she
is
Her
anxiety
(the
exam)
trigger.
her
more
thinks
reptiles
our
looks
large
Then
of her
she
fathers
trigger.
bodily
That
has
the
prefrontal
if one
sticks,
cue
reminds
with
anxious
Imagine
be
is the
share
It certainly
of
was
triggering
the
take
body
regarding
instance,
She
human
are
For
it
cortex
and
before
we
ancestors
like
teeth.
and
mammals
operates
know
had
it
seen
a furry
quadruped
Crunch!
He
would
dinner.
beginning
sadness.
the
We
adaptive!
become
feeling
it.
How
toward
the
of
we
after
the
emotions)
anxiety.
death
message
amygdala
her
the
some
as
cannot
His
just
invisible.
Sadness
system
of
cognitively.
test
Then
feedback
(such
yet
died.
rises.
evolution
independently
will
the
just
anxiety
are
and
system,
Therefore,
grass
are
session,
Thus,
threat-detection
predates
At
triggering
uncle
her
they
is
the
same.
her
and
the
to
amygdala
to the
provide
threats
because
feeling
remembers:
in
unconscious
nervous
body.
can
send
According
the
symptoms.
cortex
stripes
the
is
can
body.
autonomic
feedback
anxiety
unconscious
difficult
rises
the
the
the
which
after
triggers
the
provides
prefrontal
relationships,
cue
throughout
which
triggered
of
body,
and
occurs
mobilization
the
cortex,
making,
thought
activate
in
prefrontal
decision
unconscious
which
to the
has
and
mobilized
the
conscious
threat
an
are
to
and
So
(1998),
creating
message
thinking
corrective
LeDoux
symptoms
trigger
the
unable
her
and
session,
to
anxiety.
decided
scan
As
the
patient
her
internal
a result,
it
must
she
be
the
had
forgotten
savannah
could
test.
only
This
her
for
the
speculate
example
shows
how
feelings,
often
do
not
they
learned
anxious.
be
to
our
an
triggers
as
feelings
will
When
a
and
made
nervous.
we
no
enters
the
consciously
do
in
caretakers
it, she
ignoring
wont
feelings
longer
know
room,
our
not
life
know
what
bodies
why.
Lets
of causality.
Correct
experiences
their
Once
habit,
Patients
early
If I ignore
secure.)
feeling
anxiety.
because
that
be
we
cause
feelings
automatic
a tiger,
issue
Mom
relationship
if it were
at the
the
makes
anxiety.
invisible,
invisible
unconscious,
our
react
are
these
ignore
sadness
and
becomes
look
recognize
(My
upset,
which
a feeling
anxiety
(racing
triggers
a defense
(sadness
heart,
about
sweating
(rumination
her
fathers
palms,
about
causality:
and
the
The
death)
tense
test)
patient
that
triggers
muscles)
distracting
her
that
from
her
sadness.
Incorrect
a test
her
she
will
anxiety
The
take
providing
of
(defense
displacement
a reasonable
avoided
weeks
The
patient
thinks
of displacement)
triggers
today.
defense
her
anxiety.
grief,
Once
lessened,
her
in three
causality:
as
anxious
distracted
explanation
however,
she
her
defense
because
her
was
her
for
it pushed
faced
her
her
As
expression,
and
longer
abusive
her
anxiety.
for
sadness
no
from
long
necessary.
condemned
stores
an
as
she
triggering
grieved,
family
sadness,
her
her
anxiety
Sadness
any
made
expression
of feelings.
The
a
right
hemisphere
childs
(Schore
and
relationships,
2002,
14).
regulates
regulates
In
trigger
her
herself
contrast,
reject
of the
her
an
feelings
unconscious
as
brain
determining
A securely
anxiety
others
insecurely
and
how
attached
by
memories
she
careful
regulated
her.
attached
person
Feelings,
of
early
working
handles
person
paying
anxiety.
internal
feelings
her
feelings
attention
perceived
relationships,
to
as
of
her
accepts
reacts
model
if
as
which
it.
She
others
will
dangerous,
take
the
form
the
of anxiety
third
or
(Schore
fourth
year
experiencesthe
and
De
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
Kitraki,
Feelings
attachment,
which
until
trigger
sensations
representations
emotional
of
growth
and
of
has
lets
castration
moral
anxiety,
anxiety,
related
related
to
to
belief
that
the
these
are
genitals,
clear
up
or
separation
anxiety,
related
to
few
not
will
feel
fantasy,
invaded
want
and
hurt
ones
persecutory
you
If someone
anxiety
in your
the
damage
destroyed;
and
to
anxiety.
not
to
to transgressing
being
others
anxiety,
related
self-disintegration;
stimuli,
you
a stimulus
described
one;
anxiety,
your
causality,
Stimulus
or genitals;
is
immature
behaviors
insecure
foundation
a loved
However,
castration
an
psychotherapy
losing
to mutilate
and
These
anxiety.
related
1960).
only
and
regulated.
about
a
related
anxiety,
of
concept
on
fragmentation
remembers
OKeefe
the
Not
literature
hippocampus,
proceeds.
misconceptions
The
the
The
sensations
142;
not
21).
life,
memories
when
Having
of
somatic
Kloet
anxiety:
2002,
threatens
body.
resulting
(Waelder
However,
bodily
state
of
anxiety.
Anxiety
Is
A patient
is angry
paper
in
front
wants
to
attack
projects
makes
from
him
Sequence
a
him
a professor
class.
not
Anger
who
Afterward
physically.
onto
anxious,
( table
Thought
with
rage
projection.
2.1
of
his
thought
Table
Not
his
he
Anger
the
causes
he
This
his
is
afraid
triggers
professor,
anger.
contemptuously
that
his
(I
The
causality
in time
of
Element
anxiety
of
conflict
fear
Description
his
professor
Once
the
projection
2.1 ).
the
anxiety.
believes
thought
anxiety;
criticized
he
professor
him)
creates
results
his
1 Feeling
I am
2 Anxiety
(bodily
angry
with
him.
experience)
Blurry
vision,
ringing
in the
ears,
and
angry.
My
professor
is
nausea.
3 Defense
of projection
angry
me.
with
4 Consequence
The
patient
(thought)
fears
Anxiety
Is
an
Pattern
in
the
Always
the
in the
body
bodily
symptoms
Table
2.2.
he
has
and
in
make
the
placed
mind
this
on
the
professor.
Activation
Shapiro
(defense)
easier
created
by
parasympathetic)
to
the
from
see,
table
somatic
nervous
the
2.2
and
systems
feeling
lists
autonomic
(Goldstein
2004).
symptoms
caused
thumbs
Tension
him.
Biophysiological
anxiety
symptoms
Clenched
and
hands
shoulders,
and
of
anxiety
by
the
somatic
nervous
system
headaches
Tense
arms,
Sighing:
Tight
To
of
Bodily
Anxiety
projection
thoughts
and
Hamill
I fear
not
Body
(anxiety).
2006;
I am
Unconscious
differentiate
(sympathetic
(thought)
tension
stomach
neck.
in the
intercostal
muscles,
tension
muscles
in feet
and
legs
Fibromyalgia
Chronic
tensing
of the
sensations,
painful
irregularity,
and
Anxiety
mouth
Dry
eyes
Dilated
Cold
muscles,
menstruation,
resulting
painful
in painful
intercourse,
menstrual
vulvadynia
symptoms
Dry
pelvic
caused
by
the
sympathetic
nervous
pupils
hands
Increased
heart
rate,
blood
pressure,
and
respiration
system
the
Blushing
Decreased
motility
Constricted
of the
bladder
gastrointestinal
sphincter:
tract:
urinary
retention)
due
to muscle
constipation
Shivering
Piloerection
(hair
stands
Hyperventilation
and
Anxiety
symptoms
system
Salivation
Teary
on
end
contraction)
fainting
caused
by
the
parasympathetic
nervous
eyes
Constricted
Warm
pupils
hands
Decreased
heart
rate,
Increased
motility
blood
of the
pressure,
and
gastrointestinal
respiration
tract:
nausea,
vomiting,
diarrhea
Relaxed
bladder
Migraines
sphincter:
(due
Cardiac
urge
to urinate
to vasodilation)
arrhythmia
Dizziness
Foggy
thinking
Bodily
anesthesia
Limpness
Well
refer
body
to
three
( table
patterns
2.3 ):
nervous
muscles,
disruption
each
of which
anxiety
is created
discharge
smooth
(H.
by
Davanloo,
the
2.3
Pathways
Anxiety
symptoms
Tension
in the
Tension
in arms,
clenching,
Tension
of
unconscious
in the
intercostal
shoulders,
biting
headaches
striated
muscles
neck,
anxiety
somatic
of the
legs,
Hand
and
clenching
chestsighing
and
feet
the
and
supervision
discharge
muscles
in
muscles,
systems.
Table
Jaw
unconscious
striated
cognitive/perceptual
20022004),
of
autonomic
Anxiety
symptoms
in the
smooth
muscles
Bladder
urgency
and
frequency
Gastrointestinal
Vascular
spasm:
symptoms:
Bronchi
legs:
Anxiety
gait
Symptoms
Visual
blurring,
due
to lack
losing
tunnel
sudden
Fainting,
nausea,
vomiting
hypertension
of tension
in Cognitive/Perceptual
confusion,
Anesthesia:
syndrome,
asthma
unsteady
dissociation,
bowel
migraine,
symptoms:
Jelly
irritable
vision,
loss
freezing,
track
access)
Disruption
of thoughts,
Drifting,
poor
memory
blindness
of feeling
fugue
(striated
states,
in areas
of the
body
dizziness
Hallucinations
Ringing
in the
Projection,
In
ears
projective
summary,
nonconscious
biophysiological
Fear
is
bodily
bodily
the
external
dangers.
body
to
in
reaction
reaction
prepares
defenses
threat
activation
is the
the
identification
in
internal
an
feeling
mind
danger.
Anxiety
Freud
to
1936).
in
use
perceived
a
1999).
behaviors
the
feelings
(A.
produces
(Damasio
objective
defensive
triggers
(affect)
(emotion)
by
by
engage
off
body
triggered
Anxiety
ward
the
triggered
to
detection
as
Fear
response
to
psychological
dangerous
in
relationship.
ASSESSMENT
OF
UNCONSCIOUS
Every
form
on
time
PATHWAYS
ANXIETY
you
intervene
a therapeutic
past
THE
relationships.
DISCHARGE
during
alliance.
This
After
each
1.
anxiety
discharge?
defenses.
regulate
If
the
If striated
smooth
anxiety
a session,
triggers
is
muscles,
it returns
you
invite
feelings
and
intervention,
What
muscles
until
OF
or
the
assess
pathway
explore
the
anxiety
the
striated
to
based
the
following:
of
unconscious
feelings
cognitive/perceptual
to
patient
and
address
disruption,
muscles,
and
then
explore
feelings.
2.
If
patients
anxiety
explore
feelings
and
patient
regulates
her
rapid
rise
possible
and
or
project
rise
at
the
striated
her
help
defenses,
and
muscles,
the
attention
If
a patient
and
anxiety
you
can
the
pay
explore
poor
anxiety
lingering
effects
become
session.
regulate
sick
the
patient
observe
the
feeling
under
regulate
her
4.
Does
preventing
regulating
Anxiety
regulation
it,
the
A
regulation,
her
stomach
reveal
until
fast
it returns
to
and
the
pay
attention
anxiety.
If
not,
work?
If
not,
anxiety.
anxiety
regulation
patient
from
observing,
paying
anxiety.
and
does
Self-Observing
not
Anxiety
2.
to
feelings.
the
her
you
feelings.
to
anxiety
Can
explore
when
signs
3.
fall?
of neuroendocrine
These
the
and
attention
safely
indicate
may
rise
session
explore
1.
regulate
You
the
then
so,
of
when
anxiety
and
defenses
to,
of
a case,
and
Assessment
When
anxiety
In such
observe
identify
of
beginning
anxiety?
her
well.
the
during
quickly
anxiety
fall
does
slowly
drops
instance,
of anxiety.
the
to
For
rapidly
rises
slow
regressive
discharge.
How
Ability
work,
assess
in her
body
to
Capacity
observe,
the
patients
pay
attention
to,
and
it
3.
observing,
When
paying
the
anxiety,
patient
she
Assessing
attention
these
to,
cannot
uses
Defenses,
and
regulating
observe,
defenses,
defenses
is
which
pay
prevent
her
prevent
essential
to
from
anxiety
attention,
which
her
or
her
regulate
from
make
her
doing
anxiety
so.
regulation
possible.
How
the
Patient
We
can
begin
the
room
by
Walks
assessing
noticing
In
the
his
gait.
patients
A patient
anxiety
with
as
soon
striated
as
muscle
he
enters
tension
walks
energetically,
face.
In
contrast,
muscles
bit
with
or
wobbly
legs).
on
his
in
assess
Response
to
will
look
pathway
transcript
is
at
some
expressive
goes
into
enters
tension
and
or tense
his
slowly,
in his
tired
evoke
of
transcripts
smooth
perhaps
muscles
posture,
no
that
unconscious
example
a
(jelly
his
tension
or
face
sighing,
show
anxiety
of
striated
how
to
assess
the
The
first
discharge.
muscle
discharge
created
system.
Could
we
look
at an
example
of when
this
is
you?
Pt:
she
of
an
anxiety.
Th:
me
a lack
slumped
nervous
for
to
interventions
a clinical
somatic
a problem
anxiety
disruption
his
and
Intervention
patients
the
posture
whose
due
When
immediately
by
patient
feet
sits
expressionless.
we
erect
cognitive/perceptual
He
Now
an
wanted
to dump
[ Sighs
.] Well,
a couple
days
ago
she
told
me.
Th:
What
is your
feeling
toward
her
[ Sighs.
Shifts
in chair
.] Well,
for
saying
that?
Pt:
Defense:
intellectualization
it. [
Of
course,
what
is the
feeling
toward
her
.] I was
angry.
material,
the
for
that?
Pt:
Each
time
the
asks
tense,
fidgeting
indicate
that
muscles.
Patients
whose
striated
pursue
sighs,
muscles
what
they
high
Unconscious
[ Sighs.
therapist
becomes
you
like
.]
Th:
saying
I didnt
use
feel
levels
and
about
shifts
his
of feeling
Signaling
emotional
of
how
(H.
chair.
is
unconscious
not
fingers
in his
anxiety
isolation
but
Wiggles
The
discharged
anxiety
affect
they
patients
as
sighs
the
is discharged
a defense.
experience
Davanloo,
into
the
supervision
patient
They
feeling.
and
striated
only
can
You
20022004).
into
tell
can
After
the
therapist
signal
2002
2004)
when
rise
the
of
feelings.
effectively
muscles
or
operating.
If you
you
are
anxiety
When
goes
into
him
signaling
him
patient
he
supervision
occurs
intervention
topic
unconscious
anxiety
to
triggers
explore
or
to
is discharged
the
into
anxiety
which
to
unconscious
or
it returns
defenses,
the
are
not
the
smooth
are
patient
sighs,
feelings.
If
cognitive/perceptual
to the
help
you
defenses
and
muscles
until
to
or
feeling
closer
smooth
due
signaling,
disruption,
getting
of
Genuine
feelings
As
it
anger.
says
he
Unconscious
the
striated
patient
muscles.
see
and
let
will
about
if
rise
wants
girlfriend,
you
if
to
his
you
face
that
his
to
point
out
grief
his
of unconscious
wish
than
anxiety;
with
of
defense
the
and
loss
of
his
signaling.
to
signaling
rather
it
defense
his
over
dumped
covers
unconscious
genuine
unconscious
he
listen
his
cruelly
anger,
his
Assess
who
grieve
shows
triggers
defenses
triggers
that
this
feelings.
such
as
not.
anxiety
continuum
Anxiety
ask
represses
trigger
signaling
unconscious
his
drop
A lack
compliance
do
you
shows
anxiety.
compliance
with
compliant?
anxiety
defense
angry
his
being
signaling
the
what
anxiety
signaling
therapists
know
focus
will
but
to feel
Is
the
is
man.
and
How
feeling,
the
patient
feelings
review
on
Signaling
Another
sigh
trigger
the
intellectualization,
wife.
not
stops
another
thoughts.
invite
do
Davanloo,
unconscious
the
of
defenses.
a
for
you
track,
regulate
Suppose
or
Now
shift
on
of those
This
cognitive/perceptual
back
disruption,
second.
(H.
signs
on.
interventions
focusing
bodily
feelings
statement
to focus
When
one
patients
obstacle
unconscious
unconscious
within
unconscious
go
intervenes,
Is
allows
discharge.
us
Since
of unconscious
Discharged
to
assess
anxiety
anxiety
in
the
the
can
get
pathways
too
discharge.
Patients
Body
high,
of
lets
Since
the
pathway
treatment
to
illustrate
of
offer
the
and
range
anxiety
where
of
discharge
we
should
responses
assess
a patients
pathway
Patients
with
a High
Capacity
with
capacity
tells
focus
patients
for
our
offer
of unconscious
us
work,
so
form
we
you
anxiety
Anxiety
what
will
can
of
now
correctly
discharge.
Tolerance:
Striated
Muscles
A
patient
high
presenting
problem
clearly
difficulties,
she
sigh,
shift
positions
She
licks
Invite
Patients
her
example
Exceed
the
describes
She
first
and
breathing
her
exhibits
for
beginning
of
stops,
and
When
her
her
into
anxiety
a
mouth,
As
muscles
threshold
the
for
migraine
she
nervous
her
feelings:
Anxiety
anxiety
Could
we
Tolerance:
defenses
of
intellectualization
regressive
defenses
on
her
anxiety,
of
such
bodily
and
Now
anxiety.
elevated
anxiety
heart
shifts
she
experiences
her
To
she
tension
from
exceeds
nausea
drops,
becomes
anxiety
as
the
or
her
regulate
symptoms.
defense)
and
her
the
the
sighing
her
of
affect
has
anxiety
patients
times.
the
just
repressive
shift
externalization.
Describe
several
she
Now
isolation
projection
regulate
limp,
tolerance.
and
problem,
regression.
an
her
muscles.
She
elevated
and
intensify,
smooth
and
threshold
with
limp.
drops
her
but
tension,
headache,
becomes
tension
explore
some
tolerance.
the
(feeling,
muscles.
while
her
or
problem?
clearly
feelings
exceeded
attention
striated
clearly
her
tense,
(sympathetic
and
Threshold
problems
a dry
rate.
striated
prevent
explore
become
in the
thinks
of this
you
her
Muscles
patient
than
hands,
mouth
problem
describes
As
anxiety
dry
and
explore
her
of
a
tolerance
anxiety.
with
indicating
at a specific
Who
Smooth
the
to
anxiety
little
fidget
intellectualizes
her
a look
with
chairsigns
lips,
She
rises.
in her
her
system).
take
will
for
to
Rather
immediately
to
anxiety,
focus
triangle
of
Do
you
notice
her
conflict
how
your
anxiety
just
your
boyfriend,
Do
she
explore
feeling
see
Once
enters
face
in
were
feeling
and
your
anxiety
Then
anxiety
invite
returns
to
her
the
Already
Tolerance:
angry
with
caused
to
repeat
striated
a
back
muscles,
Exceeding
Smooth
a session
sits
does
difficulties
you
the
Muscles
and
Disruption
who
She
too?
Session
Anxiety
tolerance
body.
that
the
Cognitive/Perceptual
anxiety
see
anxious,
her
Enter
for
A patient
we
again.
Who
Threshold
So
became
you
heard.
Patients
up?
you
stomachache.
what
shot
not
slumped
sigh
She
in
or
a disorganized
is affectless.
already
has
exceeding
the
chair
her
hands.
fashion,
her
vocal
access
threshold
without
clench
no
the
for
tension
She
in
her
describes
tone
is
to striated
muscle
anxious,
she
say
nausea,
blurry
flat,
her
and
her
discharge
of
anxiety.
When
not
asked
whether
realize
that
confusion
are
she
her
limpness,
symptoms
her
look
superficially
the
smooth
muscles
her
anxiety
immediately.
defenses
her
such
most
from
(What
with
project
are
therapy
(What
you
anxious
do
a
the
you
desire
want
to
this
me
therapeutic
projection
enter
therapy
find
therapy
to
do?).
dropped,
to
projection.
(or
They
angry
their
Or
First,
deactivate
the
regulate
they
you
suffering
equate
with)
the
project
on
anxiety
from
1981).
desire
the
example
the
regressive
onto
project
going?).
(See
use
They
feeling
into
Regulate
already
themselves
out?).
discharged
Segal
patients
to understand
(making
differentiate
2002;
fearing
of tension
to
et al.
alliance.
has
ability
begin
does
cognitive
disruption.
will
and
She
and
anxiety
(Fonagy
projections,
is
her
disruption
trying
(Where
develop
Once
their
high
she
and
no.
vision,
absence
of
Otherwise,
disappear
their
may
cognitive/perceptual
projection,
severely
The
is a sign
and
cognitive/perceptual
therapist
They
will
of anxiety.
calm)
as
projection
The
feels
the
him.
therapist
for
the
their
will
projection
to
pp.
5356
triggered
.)
by
the
underlying
Some
feeling.
severely
without
anxious
sighing
striated
or
muscle
thoracic
(See
discharge
rather
fear
fearful
than
who
have
slacking
cause
(Scaer
2001,
17,
(see
(see
When
Anxiety
Once
the
clenching
when
2005;
when
adults
cannot
differentiate
flee
2004).
relive
memories
Does
High
from
Anxiety
Work,
as
body)
endorphins
impair
memory
deactivate
7882
from
the
traumas,
).
projection,
and
reptiles
hand
become
still
hypothesize
from
freeze
the
distortion
pp.
some
escape
of
of the
respiration
Just
same
blood
time/space
predator,
The
They
in
of
anxiety,
therapist
feelings.
the
response.
and
sighing
cannot
Schulkin
past
and
from
they
Not
the
explore
of projection.
levels
restructure
Does
drops,
when
the
and
the
and
patients
(drop
High
amnesia
regulate
The
immobilization
heart).
from
image
2001).
a freeze
and
in
suffer
a frightening
signs
not
engage
and
are
Tension
reaction,
patients
dominance
and
to toe.
freeze
(Scaer
glare
differentiate
Then
freeze
2001,
limp
Regulation
response
they
or go
(racing
7577
can
return.
children
Why
pp.
patient
freeze
project
experience
To
breathing
muscles,
2005).
head
These
They
dissociation,
projections
the
anxiety.
parasympathetic
activation
numbness,
is
of
usually
of tense
sympathetic
hands
the
or angry
dissociate
of
from
of
freeze,
gaze,
symptoms
pressure,
plus
shifting
tense
abdominal
therapist,
look,
6 .)
are
disruption.
the
Patients
patients
wringing
cognitive/perceptual
then
chapter
an
that
abuser
response
losing
(Scaer
can
the
occur
ability
to
present.
Create
Cognitive/Perceptual
Disruption?
The
autonomic
decreasing
blood
nervous
flow
system
to
the
brain
impairs
cognitive
while
increasing
functioning
the
release
neurohormones.
Blood
nervous
system
causes
a sudden
drop
flow:
in blood
The
flow
parasympathetic
to the
brainstem
by
of
(Goldstein
2006),
Birnbaum
et
response,
the
to
describe
tone
in
lobe
and
patient
faints
loses
2004,
(Grawe
of executive
has
and
functioning
endorphins
prevent
(Newcomer
et al.
levels
damage
size,
which
the
the
and
and
hippocampus
divert
muscles.
memories
(Lupien
blood
This
prevents
or retrieving
response,
long-term
experience
cortisol
releases
hippocampus.
to
Sapolsky
al.
1998),
and
from
anxious
182;
2003),
neurological
the
compromising
basis
for
capacity
2004)
the
fear
functioning
decreases,
a drop
may
in
even
storing
the
ability
responses
symptoms
blood
flow
stop
beating
et
al.
1996;
Sheline,
development
This
retrieving
the
for
brain,
a few
and
new
seconds),
the
and
Gado,
and
creating
the
in therapy
The
patients
and
more
cognitive
difficult.
disruption
in
the
and
learning
stronger,
a fall
causes
development
amygdala.
regulation
The
McEwen
altered
of cognitive/perceptual
to
forming
shrinks
2000;
the
to
damaging
1995,
anxiety
from
further
al.
become
making
hippocampus
et
to inhibit
2005).
childhood
hippocampus
and
executive
physiology:
during
disorders.
its
in therapy.
frequency,
brain
anxiety
for
and
conditioned
In summary,
Sheline
cortisol
Razza
patient
memories
the
(Bremner
2000,
(Sapolsky
in
forming
reducing
anxiety
increase
enlarges
Kraemer
severe
Physiologically,
amygdala
impairs
of
from
levels
1990),
al.
Developmental
repeated
High
et
away
the
to
becomes
High
Granger,
glucose
the
able
2001).
et
(Blair,
Now
(Scaer
(Sapolsky
learning
postural
longer
memory
consolidating
words
and
discharge:
declarative
self-regulation
hormones
striated
new
1999)
impairs
functioning,
Stress
explicit,
In
2006).
Neuroendocrine
of
finding
no
fear
(Austin
1996).
2004).
2007),
the
1998b;
al.
trouble
Kaufmann
Prinz
2007)
et
consciousness
103;
and
1998a,
(Rauch
2004),
and
(Wehrenberg
1997,
area
(Ziegler
(Goldstein
amygdala
(Arnsten
Brocas
experience,
cortex
capable
frontal
1999),
sessions
the
less
al.
his
prefrontal
inhibit
the
the
heart
rate
and
increased
result
from
(the
heart
releases
of
adrenaline
and
Excessive
anxiety
and
retrieve
patients
can
suffer
The
we
help
into
the
is discharged
into
striated
tolerance.
When
patients
the
When
over
or
that
some
as
as
soon
and
goes
regulation
brain
deficits.
it goes
over
possible
That
out
and
of
is the
the
the
as
What
is
while
threshold
striated
muscles
disruption,
needs
anxiety
anxiety
Th:
as
cognitive/perceptual
their
treat
feeling
muscles.
threshold
experience
feelings
anxious
anxiety
reversing
much
anxiety
muscles
gone
why
Tolerance
as
smooth
explore
Anxiety
experience
has
encode,
tolerance.
of
patient
2006).
store,
explain
However,
anxiety
patients
anxiety
to
causes
difficulties.
regulating
2004,
capacity
these
functioning,
begin
of anxiety
anxiety
of
neurological
(Goldstein
patients
All
cognitive
Threshold
We
the
information.
from
is why
threshold
neurohormones
impairs
new
restore
That
other
in
anxiety
the
the
regulation.
striated
muscles,
a defense.
the
feeling
toward
him
for
hitting
you?
Pt:
discharged
feeling
into
from
her
anxiety
striated
from
anxiety,
anxiety
what
is the
feelings
feeling
the
toward
Tension
feeling
patients
cannot
your
cover
toward
anxiety
is
differentiate
her
him
anxiety.
[ Differentiate
the
your
for
feeling
hitting
toward
him
with
you?
angry.
enters
the
session
with
anxiety
triggered
by
therapist.
Pt:
I feel
Th:
Its
anxious
good
you
today.
notice
that.
When
did
you
start
anxious?
Pt:
feeling
[ The
She
is
dont
Im
patient
the
tense.
muscles.
.] If you
Pt:
Sometimes
feel
.]
Th:
feeling
anxious
when
I felt
I thought
fine
about
when
I woke
coming
here
up,
but
and
I
as
started
I
was
driving
here.
triggering
[ This
her
suggests
anxiety
that
about
having
here
coming
toward
indicates
anxiety
didnt
.]
I feel
me
that
feelings
fine,
but
therapist
are
be
making
toward
the
was
when
you
feelings
you
anxious?
of
unconscious
therapist
are
something
were
you
are
anxiety
triggering
you
said
last
my
relationship
her
time
like.
boyfriend.
What
[ After
is the
Facing
feeling
What
was
that?
You
said
I sabotaged
exploring
here
Events
and
the
patient
the
the
therapy
stimulus
triggered
your
some
You
professor
reservations
I have
with
trigger
the
a reaction
to
corrective
her
.]
that.
emotional
feelings
to
talk
about
it.
though
to do
patients
anxious.
it started
What
I dont
adaptively
in
anxiety.
When
did
that
begin?
Thursday.
happened
that
know.
about
Would
Pt:
even
is
deal
seem
I think
Th:
wrong,
have
feelings
on
Thursday
that
could
anxiety?
Pt:
my
to
also
Th:
visited
you
the
.]
Pt:
have
explore
now.
outside
out
like
therapist
learns
Th:
Find
happened,
with
me?
toward
The
what
It sounds
toward
feelings
experience.
I had
section
Th:
that?
the
what
. Discharge
there
Th:
said
anxious
I wonder
could
[ Sighs
Pt:
the
became
today.
that
Th:
my
You
here
Pt:
(sigh)
toward
.]
Th:
thinking
feelings
my
you
He
said
followed
is
a regular
dissertation
like
to take
the
his
all over
What
It was
I got
because
he
a look
statistics
instructions
day.
up.
had
at that?
were
exactly.
completely
Then
he
again.
the
feeling
toward
him
for
doing
Pt:
the
striated
muscles:
[ Sighs
explore
Th:
feeling
the
with
from
the
what
you
vague.
Do
In
example,
this
anxious.
you
However,
smooth
over
her
20022004).
anxiety
until
gradually
called
the
deal
with
that
too?
or
and
regulate
you
can
this
occurs,
to
the
stop
striated
the
patients
(Whittemore
The
In
Graded
the
patients
anxiety
feelings
graded
format,
anxiety
and
the
(H.
anger
being
little
striated
muscles.
muscles
into
the
feelings.
muscles.
Then
the
patient
Davanloo,
exploring
affect
this
.]
disruption,
goes
supervision
Regulate
explore
tolerance.
anxiety
it returns
the
feelings
This
method
is
goes
into
stop
to the
the
smooth
exploring
striated
feelings
muscles.
Then
the
into
disruption.
anxiety
explores
feelings
again.
regulating
anxiety,
the
muscles,
therapist
shifts
patients
striated
the
the
Format
cognitive/perceptual
until
cover
[ Differentiate
by
striated
disruption,
again
in
1996).
When
until
him,
anger
in
the
tolerance
cognitive/perceptual
explore
was
from
anxiety
format
the
with
cognitive/perceptual
of
dont
him?
of conflict
anxiety
shifts
If you
the
[ Triangle
patients
is
him.
you
Principle:
muscles
with
Then
building
graded
angry
[ Anxiety
.]
angry
it returns
again,
Im
off.
toward
feel
and
When
feeling
of vagueness
anxiety
threshold
is vague.
You
the
muscles
off
ticked
.]
Th:
notice
when
really
feeling
is the
defense
Pt:
makes
the
Ticked
vagueness,
feeling
.] Im
builds
The
returns
By
therapist
the
explores
the
smooth
therapist
to
patients
feeling
the
patients
tolerance,
or
the
muscles
exploring
the
until
muscles
regulates
striated
alternately
shifts
feelings
anxiety
and
feelings
anxiety
and
then
and
into
the
reduces
the
use
of regressive
When
the
defenses.
patients
cognitive/perceptual
anxiety
goes
into
disruption,
follow
these
1.
exploring
Stop
2.
Draw
the
the
smooth
muscles
or
steps:
feelings.
patients
attention
to
her
anxiety
symptoms.
3.
feeling,
anxiety,
and
Help
see
the
sequence:
stimulus,
symptoms.
4.
symptoms
her
Describe
the
sequence
until
the
patients
different
disappear.
5.
Then
explore
feelings
in
relationship.
The
Graded
The
following
high,
how
and
how
described
about
her
Format
in
vignette
to
use
the
Action
shows
how
graded
format
to
explore
feelings
his
conflicts
with
drug
to
assess
to
regulate
again.
a
verbally
when
anxiety
the
patients
depressed
abusive
is
too
anxiety,
patient
daughter
has
who
lied
use.
Th:
What
is
the
feeling
toward
her
for
doing
that?
Pt:
threshold
the
for
anxiety
anxiety
Im
tolerance.
of
attention
anxiety.
to the
Are
you
[ He
exploring
anxiety
[ He
is not
stomach
right
good
aware
has
the
exceeded
feeling;
his
regulate
of
you
notice.
feeling
This
anxious
headache
right
is
now?
[ Draw
.]
Not
aware
Th:
in your
Stop
Its
Pt:
headache.
a migraine.
.]
Th:
sign
getting
Pt:
Th:
of his
You
now?
really.
anxiety
notice
[ Help
A little
Thats
Im
the
him
just
aware
of
feeling
this
do
feel
.]
headache.
see
other
What
anxiety
you
symptoms
.]
queasy.
another
sign
of
anxiety.
Youve
got
this
headache
anxiety.
and
[ Draw
his
sick
stomach,
attention
to his
Pt:
I didnt
Th:
You
and
anxiety
know
those
are
two
signs
of
.]
that
was
anxiety.
I feel
that
lot.
So
its
important
daughter
which
for
took
see
anxiety
you
lying
the
that
to
notice
to
form
now?
[ Draw
his
you
symptoms
had
that
some
feeling
headache
and
attention
to
of anxiety
feeling
toward
triggered
this
queasy
stomach.
causality:
feeling
lot.
your
anxiety,
Do
you
triggers
.]
felt
something
Pt:
I see
Th:
You
toward
anxiety,
which
stomach.
[ Causality
.]
Assess
if his
anxiety
okay.
[ His
again
anxiety
it now,
just
has
are
see
it before.
headache,
for
your
your
dropped
has
the
into
The
I didnt
daughter
went
How
but
saw
your
Pt:
but
lying
to
now
you,
headache
and
and
stomach
headache
we
see
and
that
in
your
now?
.]
headache
dropped
is gone
quickly,
so
and
ask
the
about
stomach
is
the
feeling
at this
feeling
feel
your
feeling
your
daughter
.]
Th:
had
instead
toward
your
of anxiety?
lying
Would
you
daughter
[ Mobilize
Pt:
his
these
Then
your
triggered
you
that
you.
of
have
so
the
like
we
to take
can
patient
help
to the
a look
you
task
.]
Yes.
Th:
What
is the
Pt:
Frustrated.
feeling
toward
for
to you?
daughter
What
stimulus
is
did)
your
from
with
feeling
his
his
feeling
Th:
Sure.
toward
reactive
Pt:
Explore
feelings
as
deeply
toward
She
her
feeling
I feel
as
[ He
for
confuses
the
stimulus
(what
her .]
frustrated
doing
you
that?
by
lying
to
[ Differentiate
you.
the
.]
angry.
possible
while
the
anxiety
goes
into
the
striated
muscles.
muscles
or
returns
to the
Some
patients
during
which
facial
soon
striated
remain
social
vocal
tone,
of
invite
her
muscles
or
body
chronic
control
(feeling,
to
(Franchini
what
she
Assessing
the
the
Cowley
Pathway
anxiety
ear,
orienting
gesture,
2001b,
body.
defense)
2011).
several
drops
reflex)
To
Describe
Anxiety
disruption
tension
gaze,
her
heard.
Once
(eye
2001a,
on
smooth
free-floating
middle
and
metabolize
and
of
(Porges
anxiety,
back
time
the
it.
the
again.
system
focus
into
regulate
state
of
cognitive/perceptual
needs
released
anxiety,
repeat
shifts
feelings
engagement
patients
to
explore
unavailable
conflict
anxiety
disruption,
in
the
the
triangle
the
muscles,
neurologically
regulate
as
cognitive/perceptual
affect,
remains
As
times,
in
slowly
the
the
and
smooth
because
neurohormones
that
the
were
just
2004).
of
Unconscious
Anxiety
Discharge
We
must
where
his
in the
turn
assess
each
anxiety
is discharged
striated
against
anxiety
may
returns
The
muscles,
his
disruption.
At
to
the
defenses.
into
this
point,
use
the
Vignette
One:
Fragile
patients
example
work
shows
within
middle-aged
the
man
intervention
shift
help
feeling
the
and
or
we
how
will
to
how
out
is
discharged
patient
see
anxiety
the
use
the
assess
to
find
and
rise,
the
cognitive/perceptual
to regulating
Then
to
If anxiety
muscles
and
anxiety
until
graded
the
recognize
it
format.
pathways
signs
that
of
you
format.
Patient
suffer
from
disruption
how
as
illustrate
A Fragile
cognitive/perceptual
and
must
discharge
graded
feelings
muscles.
examples
anxiety
body.
smooth
we
to
in the
However,
the
striated
unconscious
response
explore
shift
following
must
patient
to
patients
slowly
and
recognize
from
signs
capacity
walks
anxiety
into
regressive
of
without
the
in
room
fragility
triggering
without
the
form
defenses.
so
that
of
This
you
regressions.
maintaining
can
A
eye
gaze,
falls
tension
help
you
into
the
chair,
and
limp.
[ No
signs
of striated
muscle
.]
you
years
Th:
Whats
old.
Pt:
[ Pauses
.] I first
[ Patient
it may
[ Block
therapeutic
also
the
task
problem
you
[ Immediately
answer
I would
would
like
assess
[ Assess
in
me
I have
Th:
Are
prevents
the
defense
in this
moment,
you
[ Ability
All
do
need
to
I was
is
tell
thirteen
to the
defense
therapist.
.]
more
about
him
to
helpful
your
history
engage
to
you,
in
the
whats
the
with?
with
anxiety.
of feeling
But
to observe
anxious
you
notice
[ Vague
right
Im
often
the
anxiety
feeling
now?
pattern
where
sick
present
my
.]
body?
stomach.
moment,
in your
.]
in your
in
.]
anxious
generalization
specifically
of
his
discharge
over.
[ Smooth
defense
that
now .]
Are
of moving
moment
Anxiety
be
aware
Where
regulation
you
feeling
sick
out
of the
present
in your
stomach
moment.
now?
Assess
[
his
.]
Pt:
present
me
I should
This
his
invite
problems
Yes.
out
Th:
the
thing
question.
to
biophysiological
moves
anxiety
first
when
to hear
order
you
Pt:
muscles.
like
.]
Th:
anxiety
would
in thinking
then
to help
Pt:
Pt:
He
like
and
first,
Th:
muscles.
the
a problem
defense
.] But
the
revealing
indicate
Pt:
Block
you
psychoanalysis
closenessnot
Th:
body?
problem
.] Well,
entered
doesnt
emotional
However,
later.
the
with?
[ Pauses
against
anxiety
looks
Yes,
regulation
which
I threw
is
shows
up
before
imperative.
he
is
the
He
unable
to
session.
moves
pay
[ Smooth
out
attention
of
to
the
his
now .]
Th:
Are
you
feeling
like
throwing
up
now?
[ Draw
attention
to this
a couple
moment
of weeks.
.]
Pt:
Yes,
but
not
Th:
You
are
feeling
Pt:
Not
[ Since
he
Th:
and
call
you
have
to my
been
just
feeling
are
at
and
this
observe
develop
it
is
coming
anxiety
and
in
pay
Where
up
your
else
do
anxious
here
with
me
ever
since
you
made
anxiety
for
.]
today,
the
see
that
to
you
with
to
his
me.
help
have
Can
you
anxiety,
a
we
with
to
problem
take
it?
help
with
careful
[ Invite
him
regulate
to
it
and
.]
[ Tears
Th:
You
you
notice
Pt:
Th:
Thats
up .]
mention
feeling
feeling
have
anxious
anxiety
migraine
in
in your
your
body?
right
now.
[ Smooth
of
anxiety.
Whats
with
hearing.
.]
sign
of anxiety
that
sign
Are
you
another
notice
What
did
you
having
Pt:
.]
else
your
hearing
you
notice
right
this
now?
so.
any
ringing
in your
[ Cognitive/perceptual
Thats
another
sign
ears?
disruption
of anxiety.
How
.]
is
your
or blurry?
Pt:
Cognitive/perceptual
[ Problem
where
with
think
Is there
Th:
Is it clear
trouble
Yes.
say?
wondering
I dont
Th:
body?
disruption
I was
some
sign
in your
you
of cognitive/perceptual
Pt:
vision?
way
feeling
body
Yes.
Th:
anxiety.
this
therapist
here
alliance
Pt:
Possible
We
attention
a therapeutic
stomach.
another
feeling
today.
Yes.
Pt:
muscles
been
here
the
intense
Th:
look
Ive
anxiety
office.
Pt:
anxiety,
much.
intense
today.
called
You
as
disruption
I can
.]
see
you,
but
its
little
blurry.
Th:
thinking
right
now?
Thats
another
Is it clear,
or are
sign
you
of anxiety.
having
How
trouble
is
your
forming
your
thoughts?
Pt:
seem
slow.
notice.
[ His
I think
speech
and
Cognitive/perceptual
Th:
have
anxiety
difficulty
with
in
forming
coming
feeling
is
me
projectionanother
his
wants
that.
off
persecutory
feelings,
misalliance
Yes.
you
as
You
and
it has
his
to
of
do
feeling
attention
to
sign
of
fragility.
through
of what
He
projection
therapist
of
who
tears
come
up,
theres
that?
afraid
projection
.]
these
notice
Im
his
doesnt
ears,
a lot
you
wants
to
he
will.
wants
want.
tell
[ Defense:
the
therapist
assumes
the
therapist
Otherwise,
he
something
will
ward
from
him:
called
me
which
he
has
with
this
.]
meeting?
located
of tears
I notice
Yes.
Deactivate
be
[ Direct
that
anxious.
and
must
me
he
ringing
anxiety,
there
tell
.]
Pt:
but
very
are
anxiety.
[ Wave
Do
you
is
So
do
although
vision,
this
this
people
slowed,
blurred
all
Pt:
but
that
today.
anxiety
Th:
this
see
All
his
of anxiety.
about
.]
triggering
triggering
wave
disruption
We
Th:
another
are
thoughts.
to see
that
thinking
stomach,
your
here
underneath
the
your
it is clear,
in the
[ Remind
Lets
him
therapist.
clarify
of
This
Pt:
I did.
Th:
And
Pt:
his
something.
desire
deactivates
who
thought
Who
for
therapy,
his
projection
he
had
for
.]
a problem?
Me.
Th:
And
who
asked
me
to
help
him
problem?
Pt:
Me.
Th:
So
Pt:
who
Me,
wants
but
Im
something
wondering
out
of this?
what
you
want.
Projection
still
in place
.]
Th:
But
Pt:
Me.
Th:
about.
You
are
the
one
who
himself
is triggered
projects
here.
a feeling
the
past.
onto
He
the
cannot
an
and
me.
can
lose
image
And
touch
Thats
instead?
when
[ Address
on
anxiety
up
the
The
the
that
projection
.]
patients
Once
therapy.
Once
what
the
(e.g.,
revealing
experiencing
lets
he
problem
his
it scary
how
much
focus.
not
Ive
I sit
past
His
in the
you
anxiety
therapist
been
hurt
who
this
here
together,
.]
before.
hurt
from
that
comes
comes
its
more
in
touch
with
[ Relaxes
in
his
and
in
.]
like
between
you
him
projection
between
you
me,
this
you
image
.]
Yes.
the
further
patient
discharged
go
chair.
anxiety.
and
into
He
of his
declares
his
which
problem,
feeling
reveal
Fear
The
therapist
the
it
drop
have
smooth
observes
of
the
in
his
cleared
muscles
and
cannot
pay
but
it.
is for
his
to
of someone
the
feel
disruption.
patient
think
Right?
wants
him,
and
evoked
is
to or regulate
the
to
who
internal
therapist
image
together
cognitive/perceptual
attention
in
projection
anxiety
one
an
image
you
and
therapist
signals
of this.
because
the
this
Pt:
projection
an
As
me
his
out
find
inside
true
someone
with
something
Right?
if you
differentiate
then
the
therapist.
desire
therapist
of
are
[ Establish
and
Th:
theres
of this?
you
something
I wonder
Pt:
He
offer
out
Right.
yourself
by
me
you
to this
Th:
to reveal
wants
And
Pt:
want
Let
something
Yeah.
Th:
about
wants
Right.
Pt:
something
who
projection,
desire
he
giving
in that
wants
remind
to
do
therapy,
help.
With
a specific
situation),
him
the
example,
fragile
of his
ask
each
will
him
new
declaring
patients
to do
again
phase
and
anxiety
will
rise
again,
Monitor
for
and
anxiety
soon
as
from
his
perhaps
regulate
his
tolerance.
If
it goes
going
and
for
what
him
in
sense
predictable
regulate.
Identifying
of
the
When
anxiety
goes
might
imagine
immediate
by
The
remember
al.
cortex
influence
his
his
you
it
build
his
anxiety
the
and
help
feelings
symptoms
he
anxiety
orient
anxiety,
how
bodily
trigger
of
can
anxiety
observe
is essential
and
to co-create
the
Mobilize
before
patient
the
Adrenal
gland
brain:
missile
chemical
cortisol
internal
defenses.
Launch
hippocampus
by
is hammered
2006;
for
several
(Joels
and
inappropriately,
impulsive,
and
4).
His
adrenal
Rosen
and
gland
Schulkin
The
adrenaline
hours,
so
Karst
2010;
Southwick
the
prefrontal
discharge
acts
thought.
the
hyperexcitable.
in therapy
2006,
and
inside
one
released
norepinephrine
neuroendocrine
patient
all
tolerance,
2004).
memory
Bazhenova
behavior
just
(Goldstein
the
say
Urgent.
have
of
symptoms
anxiety
announcement
Institute
you
of
forces.
disorganized,
and
as
prevent
way,
observe
see
which
hormones
Once
off-line,
often
explanations
threshold
kidneys
short-term
2005).
anxiety
patient.
the
discharge
what
can
patient
can
His
loudspeaker
making
inattentive,
Porges
over
(Franklin
his
his
In this
lower
he
regulating
destruction.
anxiety
impairs
et
brain
176),
the
symptoms,
parasympathetic
continued
2004,
you
small-scale
pattern.
counter-calm
sustains
regulate
threshold
tolerance.
reactions,
atop
cortisol
his
Adrenals
mounted
of
and
helps
a fragile
disruption.
it exceeds
disruption.
Now
with
Attack
time
muscles,
anxiety
his
and
alliance
weapons
of
understandable
silos
smooth
These
self-regulate.
all
each
symptom
it.
become
Attention
cognitive/perceptual
intervene
and
to
therapeutic
you
feeling
bodily
make
anxiety
anxiety
the
triggers
learn
into
cognitive/perceptual
each
patient,
into
into
capacities
Labeling
going
hyperactive
reasoning
takes
is easily
he
distractible,
(Arnsten
is
cannot
less
1998b;
able
to
Patients
and
with
depression,
autism
suffer
functioning
from
1995).
levels
malfunction,
impulsivity,
intrusive
ability
Vignette
to
Two:
Going
of
Kaloupek,
the
distractibility,
other
emerge
and
make
inattention,
and
Defenses
them
Prins,
system
discharge
memories,
disruption.
on
2011;
problems
disorders,
nervous
neuroendocrine
aversive
to reflect
personality
autonomic
Porges
of
leading
cognitive/perceptual
the
2001;
High
disorders,
disturbed
(Beauchaine
Keane
brain
anxiety
symptoms
of
automatically,
while
disappears.
over
the
Threshold
of
Anxiety
Tolerance
In
this
anxiety
the
example,
we
show
shifts
the
threshold
over
anxiety,
Earlier
and
in the
bowel
how
to help
session
the
recognize
of anxiety
the
patient
when
the
tolerance,
see
how
causality
mentioned
she
patients
to regulate
in the
suffers
moment.
from
irritable
syndrome.
to take
a look
You
mentally
such
ill for
a
would
some
problem
have
drinking,
but
describes
then
for
years,
if
son
have
freer
I should
[ Clear
access
anxious.
Rather
ruminates
because
(I
it
problem.
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my
Hes
you
an
with
drinking.
empty
not
son.
alcoholic.
living
kept
with
me,
He
and
told
bottles
how
This
this
wouldnt
I told
me
in the
been
be
him
he
stopped
cabinets.
poses
he
an
[ She
emotional
her .]
say
go.
hes
does,
How
Pt:
would
hes
finding
Th:
friends
a family
a conflict
and
he
I keep
her
got
that
leave
what
problem
Ive
except
to
mentioned
at that?
Pt:
her
to
patient
Th:
like
how
dont
keeps
I just
kick
him
statement
to
know
her
of
their
than
is that
dont
out,
the
anger
feel
where
stuck,
a problem
know
but
would
unable
do
her
but
son,
she
Worrying
channel
about
know
realizes
out),
go).
to
to
She
him
toward
you?
I dont
problem.
angry
he
what
then
(kick
for
her
it.
My
where
her
friends
anger
makes
worries
is a
feelings
he
and
defense
into
effective
action
.]
Th:
toward
your
dont
son,
know
but
what
Theres
then
to do
you
with
Pt:
regarding
Mobilize
her
to the
Clear
wish
about
his
on
just
feel
he
intellectualization
tell
toward
him?
[ Separate
her
us
feeling
toward
Her
you,
the
Point
anger.
your
as
him
triangle
son,
do
against
the
function
Differentiate
these
], as
if
you
to do.
a
look
you
at
get
these
unstuck?
to
task
feeling
striated
muscles
.]
toward
your
son
who
lied
handsstriated
told
me
muscles
the
truth.
think
[ describe
.]
[ Defense:
That
says
you
the
feeling
cramps
what
feel
you
toward
from
him.
the
What
defense
is the
defense,
feeling
and
then
invite
but
whats
.]
Upset.
for
[ Defense:
Clearly
lying
anxiety
As
law
of the
her
are
upset
.]
you,
from
tolerance
soon
how
for
the
as
we
touch
anxiety
have
to attack
thought
to my
has
anxiety
to
anxiety
to
her
this
you
anxiety:
I hadnt
related
is starting
to bring
notice
the
he
stomach
of conflict
you
vagueness
the
to you?
My
for
Pt:
think
take
help
therapeutic
what
threshold
if its
out
what
[ Access
Clenched
Th:
toward
.] Yes.
[ Sighs.
Pt:
out
have
.]
the
Th:
Point
to
could
task
have
Pt:
muscles.
you
.]
it doesnt
emotion
we
the
should
], but
to face
[ defense
know
like
Whats
Th:
her
feeling
drinking?
Pt:
so
[ Sighs
Th:
to you
you
therapeutic
to collaborate
I dont
Would
Pt:
paralyzed
true.
son
some
feelings.
Thats
your
will
seem
your
Th:
feelings
obviously
cramp.
just
been
down
on
crossed.
.]
these
comes
in to
feelings
and
[ Smooth
toward
punish
her
feelings
attack
him?
for
her
Do
you
.]
of it that
anxiety?
way
before.
Th:
Feelings
to
toward
causality:
and
your
anger
turning
on
son,
this
briefly
the
self)
example,
the
until
anxiety
smooth
her
muscles.
anxiety
by
anxiety
When
the
the
defense,
exhibit
face
without
one,
as
her
here?
attention
(intellectualization
of
the
a rise
striated
anxiety
and
of
feelings
muscles
begins
the
her
to
causal
into
the
regulate
sequence:
the
feelings
as
into
striated
warded-off
they
arise.
such
with
the
as
feeling.
Often,
sitting
voice
not
and
patients
uninvolved
expressionless
behaviors
regarded
on
each
resistant
in a slouched,
nonverbal
defenses,
focus
Interrupt
highly
detached
These
muscles,
should
be
signs
of
as
disruption.
contrast,
the
fragile
cognitive/perceptual
patients
disruption.
becomes
flooded
therapist.
Then
with
he
rather
Mobilizing
tolerate
immediately
goes
anxiety.
cognitive/perceptual
feelings
[ Draw
defenses
to
out
the
speaking
addressed
In
the
defenses
and
saw
true.
therapist
access
nonverbal
manner,
cramps.
and
is able
anxiety
by
we
symptoms.
to
one
Thats
shifts
out
patients
defenses
stomach
sequence
.]
The
and
the
anxiety
patient
pointing
trigger
then
triggers
Pt:
In
Whats
than
When
anxiety
becomes
and
anxiety
his
is
repressive
projects
of his
Self-Observing
into
defenses
his
hypervigilant
observant
discharged
feelings
fail,
he
onto
about
the
the
Anxious
the
therapists
own.
Capacity
in
high
anxiety
Patient
Interestingly,
children,
anxious
many
they
(H.
patients
learned
S.
to
Sullivan
adaptive
in
the
past
ensures
that
it
remains
regulate
her
anxiety
ignore
their
1953b).
but
so
with
is
Ignoring
maladaptive
unregulated.
therapy
anxiety
can
Help
become
do
not
if it made
feelings
the
anxiety
was
anxiety
observe
Focus
As
parents
Ignoring
patient
useful.
it.
their
and
today.
see
on
and
what
the
patient
says
and
moment-to-moment
the
following
patient
may
patient
can
it.
not
extended
be
she
patient
does
to
regulation
alliance
provide
of her
(Schore
2002)
her
regulate
it.
her
from
Defenses
healthy
anxiety
body
and
is
any
Have
defenses
the
Anxiety
de
that
attention
to
pay
attention
anxiety
in the
IgnoringA
Thus,
go
to
third
over
an
help
the
defenses
Then
that
she
anxiety
habitually
can
teaches
ignore
unregulated.
in the
or the
That
Always
in the
future,
their
Interrupt
moment.
experience
Defense
first
of
their
it remains
past
attention
Regulation
patients
bodily
pay
anxiety
anxiety.
regulation
to her
regulated
let
her
Anxiety
2006),
attention
be
One:
Labije
it.
Another
anxiety.
her
her
with
When
prevent
patients
cannot
Vignette
help
not
her
to
attention.
anxious.
but
regulate
Then
from
is
regulate
can
self-regulation.
(Ten
to
she
and
she
a moment
attention
anxiety.
observe
for
pay
Interfere
patients
that
able
so
paying
That
Helping
be
time
observation
observe
anxiety
and
of
distinguish
to
not
observe
observe
distract
we
her
will
period
return
This
therapeutic
able
observe
can
them
body
regulation.
material,
Thus,
patient
any
for
her
therapy.
In the
to
anxiety
precondition
successful
what
only
Prevents
moment.
now.
Anxiety
Regulation
This
vignette
regulation
shows
and
compassionate
co-creating
any
how
how
to
interrupt
to
help
the
patient
attention
to
her
relationship
for
change.
Th:
feeling
defenses
You
that
develop
anxietya
appear
prevent
a
No.
[ No
observing
anxious.
Th:
Do
you
notice
Pt:
Yes.
ability
your
foot
capacity
precondition
Are
anxious?
Pt:
anxiety
.]
tapping?
you
for
for
aware
of
Th:
tension
in your
Thats
observes
away
all
the
time
normal.
[ The
Address
the
anxiety
of
you
You
say,
patient
syntonicity
helps
her,
of
she
see
will
if
ignores
tension
say
it
her
you
notice
like
that.
the
it and
[ The
explains
is
no
I dont
it
shoulders.
Its
consider
that
as
if you
normal
to
ignore
her
thinks
ignoring
If
reason
know
in your
that
defense.
see
she
to address
if its
normal,
isnt
normal
anxiety.
her
it .]
but
Im
like
this
all
time.
just
that
you
are
You
anxious
wanted
to
talk
something
about.
else,
access
her
[ She
but
feelings
then
other
defense
than
Right,
but
theres
some
ignores
her
anxiety
now
she
does
knows
your
if I ignored
see
its
cruel
anxiety.
your
she
Th:
yourself?
to
neither
other
by
regulate
things
talking
her
about
anxiety
that
anxiety
right
now?
[ Draw
attention
I have
other
things
talk
[ Help
Yes,
because
wants
away
her
if we
the
what
talk
you
want
kind
nor
to
talk
about
to
the
I want
to
something
talk
about
effect
of therapist
else,
her
would
but
.]
something
of ignoring
else,
we
will
.]
But
[ Point
out
anxiety
I be?
.]
a very
Exactly.
from
about
or harmful
defense
invites
Not
to
function
But
[ Clarify
anxiety,
relationship
try
anxious.
time.
notice
defensive
Pt:
and
so
you
she
Th:
ignore
can
be
.]
[ She
not
Do
your
Pt:
about.
to
.]
of ignoring
talk
this
of the
she
Th:
something
see
most
Pt:
treat
Do
always
but
this
you
as
Th:
way
theyre
anxiety
but
talks
Pt:
the
anxiety.
.]
there
Its
but
Yes,
a symptom
Th:
the
of
shoulders?
Pt:
patient
a sign
it,
differentiate
good
one.
When
you
is this
a helpful
therapeutic
ignore
your
or
from
anxiety
harmful
way
nontherapeutic
this
to
activity
.]
Pt:
see
it is not
helpful,
She
is identified
but
with
Its
not
helpful,
she
has
not
defense
your
to it. [ She
sees
that
from
what
[ Encourage
come
here
to get
of
have
to
that.
bottom
help
pay
If you
you
her
Two:
Avoiding
Anxiety
that
[ She
her
can
defense.
want
to
to
keep
turn
against
her
I generally
dont
pay
now .]
important
your
for
anxiety,
to
your
difficulties.
just
defense
attention
ignore
Its
Thats
with
of your
Vignette
No.
the
Th:
it,
see
out
the
Present
to
to get
whats
anxiety,
[ Point
but
us
notice.
help
with
triggering
we
wont
be
the
task
to the
able
it,
and
to
get
patient
Moment
Youve
it,
both
focus
to
the
.]
Prevents
Regulation
Regulating
this
I do.
.]
attention
on
what
differentiated
Is
anxiety?
Pt:
us
its
it .]
Th:
doingignoring
but
anxiety
moment.
in the
This
vignette
capacity
for
life.
moment-to-moment
This
between
moment
requires
shows
how
moment-to-moment
this
model
attention
to
help
attention
focus
of therapy
Th:
on
and
to experience
the
to
her
now
patient
develop
anxiety
reveals
in
and
the
a
inner
intersection
mindfulness.
I notice
you
are
anxious.
Do
you
notice
that?
Pt:
into
here,
anxiety
her
and
now
anxiety
Im
and
afraid
focuses
prevents
her
Th:
the
moment
put
her
anxiety
this
in
[ block
a
right
moment
state
now
.]
Yes,
her
Im
Ill
on
afraid
feel
worse.
a fantasy
from
If we
of
defense
of
hyperarousal
in your
body?
of
we
[ The
patient
in the
regulating
leave
what
future
are
going
to
ignores
instead.
get
her
Ignoring
it .]
the
going
],
[ Mobilize
future
out
of
off
the
future,
how
to
do
you
attention
the
picture
for
which
will
experience
to
her
anxiety
this
in
Pt:
good
this
patient
By
will
do.
focuses
doing
suffering
a past
she
in this
moving
treats
experience
of
this
the
Just
me.
anxiety
in this
out
defenses
her
ignores
the
regulation
Then
moment
.] Do
present
go
to
them
to some
moment.
Pt:
But
now
than
her
[ block
her
defense
now,
how
do
right
like
are
you
off
you
I said.
feeling
are
the
future
you
do
that?
are
but
not
really
tempted
to
those
Those
but
other
or
tense
right
to ignore
your
the
important.
how
ignore
we
in your
keep
our
past.
[ She
that
[ Point
sees
prevents
body?
experience
[ Orient
at this
her
moment
Principle:
back
to
of
the
past
anxiety
regulation.
she
anxiety
patient.
Once
you
If we
dont
how
you
to the
will
anxious
ignoring
that
important,
with
your
help
you
behavior
and
me.
If
we
anxiety
in
this
or
hurt
you?
or
the
future,
.]
go
off
to
the
experience
task:
paying
past
this
anxiety
attention
right
to her
now
internal
.]
To
regulate
anxiety,
moment.
Fantasies
trigger
increasing
traumas
regulate
be
are
helpful.
current
Focus
will
are
nontherapeutic
Not
on
moments
you
anxiety,
from
focus
now
we
your
therapeutic
other
right
moment,
Th:
memories
[ The
regulation
important
later
but
you
how
moment
Pt:
patient
],
that
going
see
later,
If we
Differentiate
can
time
.]
get
off
to that
tense,
see
see
you
Th:
well
more
what
body?
We
by
one
see
.]
get
really
we
I dont
anxiety
as
moment
in your
but
therapy
preventing
can
present
anxiety
with
past
events
We
Th:
here
my
tense,
self-devaluation
Pt:
now
in
other
moment:
out
really
event,
Th:
of
feel
I remember
on
so,
I just
on
her
experience
anxiety,
in this
explore
continually
of
future
bring
the
dangers
or
anxiety,
moment
her
feelings
preventing
to
calm
again
the
.
Interventions
To
to
regulate
observe
the
and
conflict
her
defenses.
are
the
Self-Observing
patients
pay
and
Mobilize
anxiety
attention
causality:
And
to
feelings
defenses
self-observing
her
before
see
exploring
Intervene
as
the
tolerance
into
Point
her
patients
the
anxiety:
anxiety.
Ask
while
anxiety
is
the
help
stomachache
ignore
you
these
so
of
triggers
patient
aware
it
triangle
problems.
the
not
can
These
develop.
of
her
anxiety,
become
regulated
bring
in her
your
anxiety.
Do
defenses,
she
threshold
trigger
right
pay
Inquiry
to
now?
attention
into
worsened
attention
anxiety
disruption.
and
anxiety.
and
of
anxious
observe
of her
is not
body
of anxiety.
her
problem
feeling
anxiety
and
your
anxiety
and
see
of her
anxiety,
point
out
it down?
of anxiety
you
patient
pay
If she
address
the
of feeling
will
3.
is a sign
how
the
we
presenting
or cognitive/perceptual
is aware
Can
the
over
aware
Help
if she
it,
notice
you
unregulated
you
symptoms
ignores
is
goes
muscles
Are
defenses.
can
help
to
Anxiety
presenting
into
anxiety
smooth
to her
if we
the
ability
Inquire
2.
regressive
see
anxiety.
must
it
her
follows:
until
out
her
mobilize
her
her
to
further
1.
feeling
help
patient
attention
feelings
Then
we
If the
pay
must
trigger
capacities
and
you
create
Principle:
help
it.
Capacity
talk
will
until
If she
defenses.
you
If
notice
over
to
she
you
shift
topics
Once
attention
them.
of her
ignore
anxiety?
pay
recognizes
is aware
you
how
your
learn
aware
to
anxiety
now,
we
your
anxiety?
she
turns
and
The
but
will
Do
against
regulate
her
anxiety.
4.
her
anxiety
and
her
defenses
Once
she
against
observes
doing
and
so,
ask,
pays
attention
Would
you
to
like
to
take
look
at
the
feeling
underneath
that
is
triggering
your
anxious
patient
about
anxiety?
5.
her
feelings,
Help
her
How
so
will
almost
differentiate
anxiety.
you
she
do
When
her
you
always
feeling
triangle
anxious
of
[ anxiety
defense
confuse
the
her
feeling
anxiety.
with
That
sadness
anxiety.
tension
underneath
is
that
your
makes
When
conflict:
], so
you
the
patient
This
cover
sees
sadness
the
her
feeling,
[ feeling
sadness
by
point
makes
explaining
you
it away
].
Principles
for
regulate
anxiety
and
Anxiety
the
Regulation
patients
from
anxiety,
defense
in the
1.
triggers
anxiety
future.
Punitive
feeling
triggers
anxiety
now.
weeks
caused
Ruminating
now,
not
thoughts
it.
In an
her
find
earlier
the
unconscious
anxiety,
was
feeling
defense
makes
the
of
loss
voicing
approaching
her
her
anger,
grief,
in
patterns
For
who
moment
or
but
: A
an
in
the
unconscious
the
thought
feeling
events
triggers
sadness
her
triggered
her
unconscious
present
the
past
anxiety
instance,
died
the
patients
test
in three
her
anxiety.
moment
or future
of unconscious
unconscious
fall.
a boyfriend
her
from
so,
past
feeling
about
Notice
anxiety
the
feeling
a defense.
thoughts
makes
do
present
a patient
Feelings
not
her
anxiety,
what
In fact,
2.
unconscious
the
perpetuate
example,
test
To
about
out
anxiety.
about
moment.
thoughts
may
So
differentiate
Emphasize
Principle:
and
the
anxious?
the
To
ask
from
experience
6.
out
you
in
but
wards
anxiety
will
anxiety
it off
drop.
will
rise
anxiety
the
if a patient
body
feels
by
cause
An
rise.
grief
devaluing
However,
in her
body.
over
him
when
Principle:
anxiety
in the
body.
Unconscious
Defenses
do
3.
occurs
her
first,
anxiety
defense.
her
then
anxiety,
rises,
and
Then
anxiety
anxiety
her
will
will
moment
tension
drops.
rise.
When
unconscious
of
defense
a defense.
later
she
A patient
she
When
distracts
the
uses
: The
feeling
feels
grief,
herself
patient
faces
repressive
with
a
feeling,
defense,
her
drop.
Principle:
anxiety
patterns
then
trigger
not .
Notice
and
feelings
Defenses
occur
after
a rise
of feelings
and
4.
Pay
attention
to the
a.
The
process
therapist
b.
intervenes.
The
feeling
rises
immediately.
c.
Anxiety
rises
in
split
second.
d.
next
split
This
sequence
and
occurs
are
not
repeatedly
by
patients
a defense
draw
a feeling,
anxiety
triggering
her
occurs
in
the
this
If not,
the
patient
feelings
trigger
anxiety
Help
ask,
rises,
anxiety?
attention
session.
feelings.
Unconscious
5.
has
in every
exploring
Principle:
patient
defense
second.
therapist
followed
to the
the
What
triggered
ask,
What
When
the
defense
patient
are
patient
she
just
see
this
you
causality
the
When
the
feeling?
feeling
experiences
used,
: When
which
now
a
that
is
symptom,
is creating
the
symptom.
you
Do
turned
you
the
notice
anger
how
toward
Principle:
triggering
and
her
the
seeing
she
the
which
causality,
suffers
she
became
your
Draw
feeling,
defenses,
you
depressed
teacher
the
back
patients
onto
triggering
her
create
her
symptoms
what
causes
her
now
yourself
attention
feeling
sees
just
to the
anxiety
in
in
the
suffering
after
stimulus
the
body,
session.
at the
By
moment
Psychodiagnosis
of
Anxiety:
When
No
Signaling
Occurs
Sometimes,
muscles
signaling
results
feelings.
the
of
because
However,
feelings,
other
no
if
lack
reasons
the
of
unconscious
therapist
the
is not
therapist
is
unconscious
(Abbass
2004;
anxiety
of
want
trigger
to
do
anxiety.
that
you
want
it.
different
have
Leave
therapy
Solution:
and
share
right
to
the
door
open
the
change
of
his
Accept
no
stage
Prochaska
or
Norcross
do
for
to
in
feelings
and
one
foot
or anxiety
Clarify
presenting
hurt
her,
causality
She
rise.
she
to
occur
patient
so
no
lack
feeling
later
and
does
to
Point
who
when
for
rises
of desire.
someone
(Miller
does
not
Solution:
will
reach
not
a
The
want
Explore
defenses
can
out
does
he
not
is in
Rollnick
2002;
2007).
out.
will
patients
The
Ambivalence:
foot
the
referral:
return
process
patients
2008):
with
him
the
Purdy
patients
therapy
on
striated
and
feelings,
the
the
on
anxiety
Lovas,
Involuntary
not
focusing
focusing
signaling
Abbass,
in
her
If she
see
how
to
consensus
be
on
has
involved,
one
so
no
ambivalence.
does
therapy
patient
not
see
could
what
how
help
causes
her
her.
her
problems.
If
she
says
she
is
doing
therapy
to
obey
projection
reach
and
someone
clarify
a consensus
else,
what
on
is
this
an
is
internal
a problem
she
therapist,
deactivate
that
projection.
problem
wants
the
projection
for
to work
If she
until
Block
her
until
you
will
onto
on.
projects
she
this
her
owns
her
desire
for
therapy.
but
does
not
believe
underestimating
she
can
do
it,
come
to the
Solution:
Refer
For
example,
but
we
the
office
patient
patient
learned
he
He
brain
did
need
while
the
due
experience
to brain
exhaustion.
for
patients
referred
to
a
not
me
need
below-average
Solution:
Explain
with
below-average
or
of
Do
the
calm
and
may
professional.
or
nontreatment.
short-term
head
injury
and
therapy,
in
recent
but
he
psychoeducation
because
the
brain
did
about
task
of
anxiety
get
conscious
into
patient
is discharged
into
instead
until
simply
physically
The
anxiety
and
ill
therapy.
anxiety
disruption
illness
and
while
exploratory
patient
process
clearly
to
disruption:
patients
therapeutic
psychotherapy
an
The
or physical
intelligence
to do
her
factors:
the
therapeutic
supportive
strength
or
about
cognitive/perceptual
Regulate
patient
for
intelligence,
the
cognitive/perceptual
superficially
The
psychotherapy,
Discharge
Solution:
defense
a different
severe
confusion
injury,
recover
muscles
task
trauma.
alliance.
muscles
the
the
treatment
neurofeedback,
genuine
patients
therapeutic
see
therapy:
seeking
Organic
may
her
for
correct
suffered
therapy,
from
to
was
had
accident.
physical
recovery
wrong
automobile
need
help
understands
herself.
No
have
If she
it returns
the
smooth
may
the
of
to
look
smooth
tension.
the
striated
muscles.
Discharge
tensing
or
hiding
the
tension
consciously:
of
The
anxiety
patient
through
can
subtle
get
rid
of
his
anxiety
body.
by
chewing
Solution:
appear
and
in
Ask
the
more
will
the
body
visible
anxiety
gum
to
the
take
therapist.
stiff.
feelings
to
not
His
He
through
compliance,
high
projection
Rather
or
rise,
These
Unaware
triggering
her
her
syntonic
striated
muscles
depressed,
anger,
the
she
and
in the
the
drop.
perhaps
suicidal
plans.
anxiety
from
the
on
defense.
self
no
Feelings
and
consistently
present,
rise
enough,
or
himself
attacked.
unconscious
This
them.
12
under
Solution:
Help
will
turns
The
makes
anger
the
on
the
defense
of self-attack
the
anxiety
patient
will
focuses
on
the
them.
will
through
and
patient
in technique:
defenses
defenses
In this
develops
of
be
his
will
prevent
turn
against
rise.
does
will
see
signaling
himself
self-attack
defense
not
unconscious
focus
or on
feelings
before
the
last
trigger
No
instance,
feelings
that
are
patient
the
conscious
on
patient
anger
an
of
oppositional
the
not
has
but
anxiety.
If
.)
it
Feelings
feelings:
of
Help
misalliance
of
Activation
resistance:
hide
defense
therapist
from
can
against
and
4 , 9 , and
this
the
challenges
differentiated
feel
if
denial,
anxiety.
anger)
who
a case,
Solution:
defiance,
helplessness,
patient
turn
(repressing
revealing
rising.
will
avoid
body.
Someone
In such
include
chapters
feels
Errors
anxiety
lacking
transference
defenses,
(See
anger,
defenses
anxiety
anger
hides
to
unconscious
Repression
of turning
patient
mask,
hopelessness,
identification.
of her
see
will
the
body
defenses
intellectualization,
experience
patient
his
of
passivity,
projective
than
defenses.
the
defenses:
of
to
the
Anxiety
consciously
like
immobilizes
in
in it.
externalization,
degrees
gum.
who
seem
Hiding
feelings
elsewhere
obvious
patient
will
up
the
more
face
show
out
becoming
expression.
experiencing
it does
patient
instead,
look
spontaneous
so
transference
transference
will
not
resistance
and
defense
will
the
patient
out
the
the
repress
of
the
therapist
unconscious
and
a passive,
role
the
argues
feelings,
adopts
active
When
therapist
the
helpless
helper,
enacts
anxiety
will
with
rise.
this
interactional
patient
will
feel
no
stance
and
the
therapist
the
the
her,
patient
will
feel
transference
Solution:
anxiety.
If
acts
no
anxiety.
resistance,
Deactivate
no
the
transference
Patients
on
resistance.
Overmedication:
medications
patients
or
show
illegal
no
patient
appears
or pain
medications.
the
patients
aware
tension,
emotionally
Psychodiagnosis
make
flat,
Solution:
anxiety
unable
mistakes
appear
fidgeting,
medications.
of his
Therapists
substances
Consult
with
feelings.
of
Anxiety:
In
striated
therapists
fact,
and
assessment
has
no
smooth
of anxiety
limp
anxiety.
discharge
patients
muscles
will
tolerance
will
or
help
fail
the
rather
in
and
As
calm,
therapists
to
reduce
patient
become
in the
body
a result,
they
than
miss
and
has
smooth
muscle
the
therapist
avoids
calm,
discharge
focusing
three
work
go
can
symptoms
anxiety
in
both
Careful
within
the
patients
it.
with
of
patient
with
assume
feelings
the
smooth
are
cognitive/perceptual
unconscious
anxiety
pathways.
which
working
striated
the
assume
sometimes
or
on
over
working
disruption,
therapists
all
experience
all
some
assess
sometimes
or cognitive/perceptual
limp
psychotropic
exhibits
to
therapist
When
appears
the
of anxiety
When
appears
any
If
Mistakes
a patient
sometimes
some
of anxiety
threshold
helps
discharge
chair.
psychiatrist
Common
the
the
These
in assessment:
tension,
pathways.
the
flat.
in
is taking
sometimes
When
muscle
shifting
if he
and
to assess
or
ask
This
emotionally
many
not
a
who
patient
muscle
visible.
patient
the
who
patient
disruption.
or relinquishing
If
defenses,
no
anxiety,
some
patient
can
observe
Until
unconscious
the
therapists
pay
her
anxiety
her
to
but
lets
inviting
experience
rush
attention
patient
anxiety,
anxiety
of
a patient
is able
to observe
her
ahead
without
assessing
whether
the
regulate
ignore
defense
will
fail.
if she
goes
into
the
disruption.
This
depression,
dissociation,
excessive
anxiety.
while
paralyzed
while
anxiety
Some
goes
muscle
hypervigilant
chest,
patients
and
therapists
defenses,
is
the
patient
and
her
suffering
based
on
projection,
The
first.
patients
patients
trembling
rage
immediate
rather
regulation.
hyperventilation
anxiety.
Then
When
with
patients
will
explore
feelings
feelings
deeply
and
response
has
in the
Frederick
2005).
Do
and
upper
1997;
not
muscles
P.
assume
unless
you
sighing.
avoiding
capacity
When
for
to
therapists
develops.
feelings
face
and
and
bear
explore
Clear
rage
up
the
feelings.
as
misinterpreted
a
Some
fainting
ones
breathing
by
misalliance
is often
than
the
continue.
a
this
breathing,
gain
from
response
striated
anxiety
not
suffers
2001,
the
arousing
them,
projection
into
face
ones
(Levine
Scaer
when
increasing
patient
to
noticeable
abdominal
will
is not
with
fog
feelings
cognitive/perceptual
the
patient
going
avoid
Now
2006;
hands,
pursue
freeze/immobilization
brain
Pain
anxiety
clenched
When
or
anxiety.
headaches,
muscles
barely
and
and
stare,
face
feelings
experience
striated
mistake
thoughts,
to
and
her
goal
regulation.
feelings
cannot
or
may
her
patient
projection.
activation.
Minton,
observe
the
anxiety
muscles
but
A patient
ignoring
stomachaches,
anxiety
into
anxiety.
therapists
therapeutic
or vacant
racing
Ogden,
the
with
in
and
The
therapists
striated
smooth
results
of
ignores
Some
anxiety
her
it, preventing
the
feelings
feelings
rise.
When
and
then
go
will
sign
of
to the
hyperventilate,
a discharge
of
anxiety
requiring
excessive
therapists
due
as
mistake
fainting
parasympathetic
the
blood
becomes
the
due
to
discharge
of
alkaline,
leading
blood
vessels
sometimes
bag.
for
fainting.
Instead,
five
simply
or
The
Do
seconds
minute
two.
Or
patients
the
Help
her
muscle
the
nausea,
as
soon
lightheadedness
describe
the
the
she
will
any
fainting
paper
her
inhale
course
return
of
normal,
disappear.
causality
seconds.
to
Then
and
triggered
regulate
anxiety,
of
occurs,
which
arms
to
stand
patient
position
position
for
the
of
bent
a minute,
the
and
process
Egan
then
knees
(Rothschild
sympathetic
to
tense
Or
descend
to
2003).
disappear.
explore
you
into
As
system
activation.
will
begin
of
happened,
nervous
parasympathetic
and
levels
2011).
and
disruption
prevent
patient
slowly
her
to
has
the
in
patients
higher
what
(Gaynor
smooth
the
nausea
at
after
pressure
Regulate
encourage
up
with
blood
occurring
and
and
occurs
With
reducing
summarize
conflict,
hands
of anxiety
signs
from
of cognitive/perceptual
The
Then
the
you
patients
again.
patients
same
can
time.
nervous
system
system
(Gellhorn
However,
142,
and
a
fifteen
will
hypoperfusion.
balancing
summarize
Some
the
the
lightheadedness.
dilate,
see
still
the
this
symptoms
feelings
you
in her
activate,
can
as
squatting
holds
will
feelings
and
vessels
cerebral
triangle
encourage
slightly
having
for
discharge
legs,
to
faintness
muscles
can
jelly
and
If
breath
to show
her
into
over
dizziness
patient
that
blood
leading
anxiety.
her
parasympathetic
activation,
anxiety
see
by
seconds
levels
the
breathe
breathing
hold
and
for
patient
five
to
end,
her
to the
of
brain,
for
lightheadedness
symptoms.
due
symptoms
the
dioxide
process
causes
patients
her
carbon
anxiety.
Fainting
the
invite
which
have
exhale
will
summarize
triggered
not
slow
and
vasoconstriction
the
to constrict,
2007).
recent
experience
Traditionally,
had
going
many
believed
a braking
1967;
research
Symptoms
anxiety
P.
effect
Ogden
has
of anxiety
et
shown
vary
on
al.
this
into
the
2006;
several
the
pathways
parasympathetic
sympathetic
Scaer
not
to be
because
the
at
true
nervous
2001,
(Janig
sympathetic
2005).
2003,
and
parasympathetic
branches
antagonistically
rather
Cacioppo,
and
of
symptoms
anxiety
can
than
Quigley
in
1991,
activate
homeostatic
1994).
described
independently
This
by
balance
helps
Abbass
(Berntson,
explain
(2004,
and
the
2007)
spectrum
and
Folkow
(2000).
When
see
regulating
his
anxiety.
symptom
Then
anxiety.
return
the
With
to the
defenses
we
which
covers
discharge
disruption.
of
help
the
striated
muscles.
when
prevent
to
first
pay
attention
patient
self-observing
go
anxiety,
anxiety,
these
that
Before
patients
the
anxiety
next
restructuring
it goes
see
When
it does
sure
to
causality:
capacities
it,
the
and
feelings
in place,
not,
we
patient
label
it
trigger
anxiety
have
can
as
his
should
to address
regulation.
section,
the
into
make
smooth
let
us
pathway
muscles
take
of
and
a look
at
unconscious
figure
2.1
anxiety
cognitive/perceptual
Figure
2.1
Restructuring
discharge
the
when
it
pathway
goes
into
cognitive/perceptual
disruption
WHEN
REGULATION
ANXIETY
THE
CAUSES
of
VERSUS
unconscious
smooth
muscles
DOES
THE
anxiety
NOT
and
WORK:
PERPETUATORS
OF
ANXIETY
When
the
patients
anxiety
cognitive/perceptual
disruption
certain
conditions
assess
and
of anxiety
anxiety
in
the
into
we
first
regulation
differentiate
in the
Anxiety
goes
the
the
regulate
does
causes
smooth
not
of anxiety
it.
muscles
or
However,
work.
under
Then
from
the
we
must
perpetuators
patient.
somatic
and
autonomic
nervous
systems
is
triggered
by
Objective
dangers
(A.
Unconscious
1926/1961d;
with
A.
ANS
1998,
arousal
2000,
2003a,
1936),
(H.
2002;
deficits
once
or
anxiety
Davanloo,
Panksepp
triggered
regressive
are
cues
paired
Biven
(S.
through
supervision
and
by
identify
and
and
anxiety.
Freud
conditioning
20022004;
1998;
feels
can
do
anger
not
must
from
the
2012;
be
LeDoux
Schore
1994,
regulate
by
the
cannot
ego
anxiety
be
ego
causes
perpetuators
and
the
perpetuated
differentiate
anxiety
defenses
of
(regressive
regulated,
deficits
first
perpetuating
triggered
by
feelings.
Anxiety
repress
toward
can
We
Perpetuate
Th:
father?
feeling,
When
the
you
That
defenses
a patient
deficits).
restructure
Defenses
Some
cues)
ego
Then
defenses.
(unconscious
defenses
your
which
1936)
2003b)
Anxiety,
the
Freud
Freud
but
his
How
perpetuate
critical
do
you
the
anxiety
Suppose
father.
experience
this
anger
toward
Pt:
him.
I was
than
be
angry
criticizes
The
a stupid
defense
more
critical
by
anxiety
in
to
toward
a critical
himself.
how
he
himself.
is
I feel
down?
observe
and
No.
relationship
and
patient
feels
2.4 ).
anxiety
stop
regulation.
between
has
the
rather
identify
him,
but
does
with
the
face
him
his
does
work
Interrupt
and
father.
patient
he
not
called
than
with
a habit,
anxiety.
been
feels
not
see
when
the
and
point
nonjudgmental
out
way.
a failure.
Did
you
just
see
what
happened?
What?
that
system
you,
patients
examination
anxiety
father
table
identification
regulation
Wow!
mind
Is it hurting
the
This
your
critical
Interrupt
Rather
versus
may
attacking
like
Th:
this
to
.]
Pt:
When
his
The
(see
in a compassionate,
Th:
in
price.
instance,
become
perpetuates
defense
For
an
Anxiety
Pt:
mechanism
son
father.
with
feeling
a patient
self-attack
statements
the
critical
identifications
enacts
else
of self-attack
Interrupt
55).
father,
if someone
self-attacking
himself
by
1936,
he
and
attacks
defense
at
attacks
these
Freud
Thus,
self-criticism
as
he
relation
his
anxious,
the
good
a defense
(A.
When
a very
identifies
but
triggered
anxiety
criticize
he
anger
realizing
superego
anger
with
father,
the
Anxiety
perpetuated
I wasnt
.]
not
2.4
The
his
.] I think
[ Identification
represses
anxious,
Table
idiot.
with
himself
[ Sighs
Do
you
self-attacks
his
self-attacks,
of
causality
Cognitive
rumination
notice
comes
in your
do
you
in
mind
how
here
comes
theres
and
up,
puts
does
critical
you
down?
that
get
you
think?
immediately.
his
allows
anxiety
us
to
therapy
and
anxiety
Once
will
the
can
drop.
understand
the
correctly
(Beck
patient
steps
in
out
points
et
al 1979;
Beck
and
Emery
1985).
psychotherapy
Defenses
arise
However,
in response
to feelings
(rumination,
self-attack,
2.2
shown
of
in figure
loop
that
(McEwen
Interrupt
to
triggering
the
feeling.
the
trigger
In
anxiety.
Cognitive
with
therapy
the
that
regulation
see
can
When
risk
and
become
Anxiety
aggressor
perpetuates
let
the
Focusing
the
patients
regulate
anxiety
deficits,
character
anxiety,
preventing
or
the
defense
most
loop.
defenses
of
these
identification
with
explore
patients
the
capacity
perpetuate
defenses
Ego
the
the
feeling
to
anxiety,
first
bear
help
so
anxiety
on
or
its
regulation.
first.
The
his
bodily
In
following
of
symptoms
When
regressive
regressive
Deficits,
Perpetuation
feelings.
defenses,
system
drop.
Fails:
by
creating
attention
common
the
When
and
caused
anxiety,
nervous
Then
will
Defenses,
the
from
of relapse
possible
regulation
2002).
Build
go
anxiety
autonomic
resulting
Regulation
Regressive
the
anxiety.
the
for
perpetuates
feedback
patients
patient
broken
Lasley
Principle:
address
relationship.
anxiety.
etc.)
defense
cognitions
stop
Then
be
activates
and
destructive
aggressor
deficit
and
identification
to
2.2 , the
loop
indefinitely
the
causal
feelings
catastro-phizing,
Feedback
feedback
the
defense
anxiety.
Figure
not
unconscious
the
As
is
sessions,
addresses
preexisting
it
it
does
defenses
these
defenses
will
not
usually
work,
perpetuate
cases,
section
Anxiety
the
restructure
will
and
show
ego
ego
that
how
deficits
to
that
perpetuate
Lack
anxiety.
of
the
Differentiation
Experiencing
Some
feel
functioning
they
as
cannot
if they
they
can
from
the
whats
the
pushing
shoulders
Use
notice
moment
side
of
the
where
his
anxiety
Projective
your
step
get
for
bodily
himself
your
down
as
to
head
and
see
if you
are
below
his
head
to
strengthen
your
above
a moment
symptoms.
notic
Lets
put
the
anxiety
hand
can
This
than
from
the
take
visual
be
chest
look
by
out
at
metaphor
flooded
If
out
it
helps
the
and
we
symptoms
your
take
of
for
the
(A.
if
anxiety
here
to
see
other
Sheldon,
the
patient
it.
Anxiety
the
patients
of herself
feelings
onto
make
the
her
anxious,
I think
you
are
judges
herself
angry
says,
she
may
project
any
therapist.
of feeling:
An
angry
patient
at me.
Projection
who
head
back
Projection
says,
They
symptom
bring
hands,
you
we
rather
look
where
your
communication).
observe
aspect
with
can
observation
some
is a
can
to
anxiety.
differentiate
your
how
anxiety
communication).
Lets
see
body
room]
patient
observe
your
[gesturing
personal
When
and
in
above
their
if we
we
with
emphasizes
look , lets
happening
the
abilities:
see
Motion
personal
that
we
to
and
with
anxiety
patient
together
from
for
Winstanley,
observing
moment
down
their
the
Lets
so
from
that
Help
there.
illustrate
patients
not
body.
water,
down
language
can
Ego
flooded
themselves
experiences:
water
to
(B.
he
on
the
Observing
become
anxiety,
the
anxiety
going
anxiety
their
in
anxiety
patients
distinguish
are
observe
above
the
Self
lower
because
up
between
I think
you
are
Projection
of
the
judging
of will:
superego:
patient
me.
A patient
who
wants
to
understand
Im
afraid
The
of the
patient
fears
of
herself
the
Projection
of
will
rather
cannot
the
patient
anxiety
his
anger
patients
the
so
Failure
Its
I am
angry
it.
at
me.
you
When
are
the
angry,
he
vignette,
the
therapist
helping
him
see
the
it,
that
by
projection.
for
way
that?
I feel.
[ If
I feel
.]
the
way
that
is
to ask
in reality
you,
I dont
testing
.]
with
Its
you
with
the
the
Pt:
you
you
really
what
and
think
Given
you
feel.
So
we
need
to ask,
are.
think
and
case.
have
just
Im
dont
have
need
to
of
feeling
feeling.
of
feeling
see.
Its
not
we
aware
you
evidence.
a feeling.
that,
not
is that
any
you
feel
Im
evidence
mention
just
aware
any
evidence
that
you.
So
Th:
angry
the
testing
I just
Pt:
being
2002
evidence?
I need
toward
In this
evidence
just
Thats
Th:
angry
fear
perpetuates
believes
the
the
of reality
whether
[ Progress
The
regulation.
angry
anxiety
and
Whats
Th:
angry,
then
supervision
anxiety
and
anxiety.
therapist
Pt:
out
says,
and
of herself.
projection
are
you
projective
Th:
check
and
therapist
Davanloo,
when
you
onto
is projective
between
is the
the
aspect
attempting
think
Pt:
What
(H.
therapist
me.
onto
internal
anxiety
says,
the
it so.
this
the
to ask
herself
before
Th:
makes
onto
Feeling
This
deactivates
difference
than
projection
projects
you.
wish
want
of
regulate
patient
fear
part
is projective
We
angry
her
you
therapist
Deactivate
An
questions
projects
a projection
2004).
projects
me
for
My
taking
that?
Pt:
what
Yes.
is your
point?
point
is
this:
vacation
you
next
were
month.
talking
about
Remember
Th:
you
got
anxious,
because
it felt
and
risky
As
its
just
as
.] Yes,
I think
as
if
to feel
Pt:
anxiety
soon
you
you
asked
it toward
[ Relaxes
it did
Th:
risky.
Can
we
this
anger
me
to
toward
hold
me,
your
anger
me.
in
feel
felt
his
take
chair:
drop
a look
at
of
the
projective
anger
toward
me?
Projection
A
of
patient
When
who
the
will
her
differentiate
own
internal
in
fear
Superego
judges
patient
she
internal
the
judges
you
a judge.
the
therapist
judgment.
mind
Differentiate
tries
and
projection
then
place
of her
and
superego
is
to help
you
words
judging
judgment
anxiety.
then
We
help
helped
onto
you,
must
help
her
her
me.
see
her
develop
an
the
projection
your
are
this
punitive
of
onto
me?
just
judging
me.
intent.
internal
judge
.]
judging
my
mechanism
You
judge
onto
were
me.
[ Point
out
the
.]
And
so
Wow!
you
right
turn
now
Do
of concern
you
now?
[ Tears
Do
you
are
saying
that
Im
really
against
Th:
my
image
[ Projection
Pt:
takes
the
not
put
sicko?
her
how
Thats
superego
to
notice
you
Th:
mechanism
have
I sense
Pt:
pathological
you
from
you
this
and
will
are
problems.
to
Th:
you
projects
a judge
we
Do
therapist
think
is projective
from
Th:
Pt:
yourself,
This
her
and
Then
on
the
says,
herself
as
perspective
your
herself
see
[ Point
how
out
cruel
the
that
cruelty
punitive
of
the
it .]
in her
you
eyes
see
and
twists
But
you
.]
how
the
punitive
mechanism
them
into
something
to torture
with?
Pt:
Projection
.]
are
saying
I am
pathological.
Th:
treating
And
you
Im
words
in an
also
of
saying
you.
unfair
abusive
to
into
Would
you
mechanism
this
you
right
she
projects
agree
of
A patient
To
he
notices
says,
the
his
the
anxiety
just
At
difference
be
by
See
projection,
trusted
twist
my
abuses
and
is
the
being
punitive
anxiety
the
.] Yes.
judgment
of others.
herself.
(if
patients
is
on
patient
you
want
of
what
with
5356
patient
you
anxiety
to
ask
and
projection
he
his
feels
will
or
so
rather
regulate
explore
the
cannot
projection
the
will
drops,
necessary)
onto
his
the
anxiety
pp.
views
will
drops,
connecting
this
the
patient
the
his
patient
anxiety
projective
the
deactivate
the
is
example
When
to regulate
questions
the
ask
he
feeling
the
projects
the
his
point,
the
If the
first
as
an
differentiate
before
ogre,
you
trying
to
will
not
you
Equation
traumatized
reality
of
Once
anxiety.
Symbolic
The
from
judges
remind
when
projection.
feeling.
the
fears
himself
When
that
Principle:
regulate
to
it
in projective
she
afraid
in therapy.
caused
underlying
ways
projection,
deactivated.
with
the
to you.
mechanism
her
she
understand
Im
the
engage
than
from
punitive
Drop
to the
to
deactivate
to
been
then
is
Will
wants
and
has
unfair
tries
and
[ Differentiate
mechanism
it is very
mechanism
this
conscience,
blind
the
who
therapist
desire
that
punitive
I think
horrible,
[ Relaxes.
her
becomes
Projection
me.
and
punitive
now?
this
.]
she
Then
saying
something
Pt:
When
I am
manner,
that
concern
accuses
No.
today
patient
relives
himself.
This
equates
a symbol
the
problem
who
past
equates
rather
is symbolic
(memory
or
than
remembers
equation
fantasy)
memory
(Segal
with
reality.
in
the
past
with
it, retraumatizing
1981).
The
The
patient
patient
may
equate
feeling
memory,
having
projection.
form
The
with
or
becomes
in
equate
afraid
the
past
the
of
(reliving
therapist
the
with
therapist,
unable
to
Equating
a Memory
of
the
Past
with
Reality
in
Present
the
the
patient
past,
she
trauma
the
through
the
feelings
mother.
The
happening
with
figure.
is
the
from
what
that,
feeling
You
seem
this
the
must
help
is
and
be
bracing
How
do
work
the
the
toward
patient
therapist
her
braces
patient
and
vignette,
freezes,
to
have
relives
remember
we
the
Th:
to
to
In
hands,
not
and
in
abusive
herself.
yourself.
What
is
inside?
anxiety
in your
I feel
about
my
reality
in the
it
feeling,
mother,
today,
your
is
years
Im
forget
therapeutic
you
experience
the
task
to
to
Its
And
relive
deactivate
the
from
the
past
you
are
afraid.
it.
it is,
and
you
and
this
that
important
task
Does
the
feeling
between
.]
Even
though
we
once
you
your
body
feels
it
today.
that
know
have
is
a
as
.]
.] Yes,
our
I feel
distinction
DC,
day
present
[ Relaxes
a memory.
not
which
when
loses
Washington,
though
from
because
[ She
wonder
in
Th:
but
real.
No
even
past
afraid
Th:
Pt:
past
just
a memory
can
ago,
the
is just
that.
and
Friday,
body
Differentiate
I see
it becomes
present
is
anxious.
body?
Pt:
feeling
is
do
experience
therapist
past.
her
Th:
it
helpful
but
To
the
a traumatic
task
hides
Pt:
know
Our
past.
patient
patient
with
traumatic,
of the
present
asked
therapy
contact
which
the
just
the
harmful
past,
differentiate
has
equates
loses
with
relive
the
experience
alliance.
One:
When
if
an
flashback)
patient
a therapeutic
Vignette
the
today
for
here
that
projection.
is it exactly.
us
to
remember
is to help
make
sense?
Sometimes
you
remember
[ Clarify
the
the
patient
believes
the
therapist
Deactivating
that
wants
projection
Pt:
Vignette
Two:
her
to
brings
That
Equating
down
makes
an
relive
the
projective
sense.
Image
trauma
anxiety
[ Relaxes
from
in
the
.]
more
Past
therapy.
.]
with
the
Therapist
When
the
patient
To
patient
can
relive
prevent
this
differentiate
in
his
the
the
trauma
past
from
the
session
dissociates
As
anxiety
in your
from
his
touched
an
on
before
me
in
know
we
even
more
because
blip
the
you
feeling
what
body
right
now?
Pt:
In my
chest
Th:
What
to
do
run
[ dissociation
and
last
and
time
you
as
that
he
do
you
notice
legs.
jumpy.
legs?
[ The
a
patient
topic
that
was
had
been
are
jumpy.
we
see
about
how
were
trying
that
theres
You
have
anxiety
connection
come
up.
And
we
can
be
you
and
your
wife
to
help
you
with
connection,
anxiety,
anxiety
and
then
Yes.
are
This
feeling
a jumpiness
is
progress
anxiety
without
because
youre
present
a blip.
Yes.
Th:
anxiety
patient
] right?
Pt:
this
patient
now?
in your
room,
the
rises.
Where
in my
anxiety.
learning
right
notice
the
then
talking
Th:
me,
anxiety
Theyre
They
and
Pt:
with
you
from
to
I thought.
and
help
the
.]
been
saw
reactions
are
Thats
connected,
we
A dissociative
What
Th:
present,
have
the
his
Th:
with
must
past.
past,
with
therapist
so,
Anxious.
in the
overwhelmed
does
Pt:
urge
a figure
he
Pt:
experiencing
be
the
describes
in therapy.
with
and
image
Th:
that
therapist
retraumatization,
him
third
equates
Thats
in your
progress.
legs?
Right
now
youre
feeling
Pt:
Yeah.
Th:
your
How
you
experience
the
jumpiness
in
legs?
Pt:
felt
do
that
didnt
same
feel
thing,
Its
and
comfortable
I had
your
legs
to run?
wanting
If they
just
want
to jump
right
Pt:
Move.
Th:
Are
did
legs.
legs
feel
to jump?
Are
keptthey
say
the
jumpy.
What
If they
and
then
wanted
were
to do,
doing
what
like
they
wanting
would
last
they
time
do?
I was
here,
run.
Theyd
want
to
jump.
What
do
you
notice
now?
you
that?
my
Yesterday
them.
wanting
they
Tension.
Th:
Whats
you
they
what
Pt:
Because
I put
legs.
to do?
Th:
feeling
in my
moving
position
When
Pt:
theyd
a pressure
to keep
in any
Th:
are
like
notice
What
What
your
are
arms
those
Pt:
do
are
arms
Not
you
sure.
notice
like
feeling
this.
in
your
[ Grabbing
wanting
to do?
Theyre,
theyre
kind
into
position.
arms?
position
.]
of locked
into
What
are
position.
Th:
those
arms
wanting
[ Places
werent
What
arms
they?
do
you
to his
There
notice
this
in those
[ crosses
the
most
comfortable
at restdefense
was
Pt:
this
side
Yes,
Th:
like
Well,
Th:
Pt:
myself
locking
to do?
Pt:
this.
Theyre
but
they
is
like
.]
were
jumpiness
position
in
doing
the
something
legs
and
else,
the
arms.
arms?
They
What
Protect
arms
want
to do
is that?
myself.
across
something.
What
is it they
I felt
his
comfortable
chest
],
and
want
to do?
protecting
I think
was
saying
to
forward,
myself,
and
I dont
if I protect
want
myself,
Th:
at some
point
to
in your
But
life
protect
Im
you
you
not
know
had
myself.
I want
going
to be
what?
Your
to protect
able
move
to.
body
yourself,
to
is telling
or you
us
couldnt,
right?
Pt:
Mm-hmm.
Th:
to
listen
to
not
listen
out,
but
have
your
to
it.
right
this
body
Im
connection
mild-mannered
body
is having
me.
Your
body
where
youre
seeing
your
and
run.
past
(Rothschild
on
with
2003).
Differentiate
here
jump
and
the
is
real
with
with
we
me,
seeing
not
here
with
somebody
protect
The
as
were
bodys
body
that
yourself
present
or
is not
the
from
the
relationship
connection.
wanting
So
its
sort
of
like
were
having
in stereo.
Okay.
Th:
to
now
connect
here
Fonagy
or
and
2004;
you
is
two
tracks
to
in
telling
apparently
me
away
from.
now
from
Fonagy
now.
with
psychotherapy
youre
having
whom
[ Distinguish
a projection
et al.
right
connect
dangerous,
run
Pt:
got
wanting
with
body
whos
from
Weve
Youre
your
someone
and
sitting
to
Okay.
Pt:
in the
reaction,
Your
distortion.
figure
this
Your
to
had
youll
But
us
.]
relationship
yourself
got
I want
apparently
Avenue.
experience.
Th:
right
youre
else.
now.
Maybe
having
know
time-space
Pt:
good
bodys
right
you
was.
Connecticut
youve
[ Address
that
point
that
someone
like
me
some
you
a different
feeling
jump
projection
when
because
is
telling
at
know
therapist
your
its
because
I dont
now
And
2002)
based
me,
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
You
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
Right?
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
are
problem.
function,
so
1997,
1998,
Defenses
can
2003,
reality,
but
adolescent
girl
uses
to
her
reality:
but
she
it
perception
could
we
they
we
respond
and
contrast,
we
coping
to
feelings,
our
defenses
goals,
flexibly
negative
manage
Since
our
use
ward
cannot
In
solve
an
helping
problem
by
altering
not
change
reality
when
she
do
denial
feel
state
get
a
of
we
feelings.
their
unconsciously
anxiety.
achieve
decrease
way
internal
creates
to
cause
us
(Cramer
1991,
2006).
the
change
fail
or
and
trigger
strategies
solve
which
accurately,
negative
They
alter
interpret
we
conscious
we
that
Feelings
defenses,
automatically
reality
result,
from
use
feelings
seeing
As
external
patients
Defenses
of reality
prevent
Detour
of
pregnant.
new
itself.
rather
Denial
in
we
For
her
or
an
She
face
tries
external
anxiety
internally,
Defenses
pathological
see
instance,
sex.
than
avoids
externally.
resulting
way
unprotected
anxiety
problem
reality,
has
the
distort
our
functioning
(Haan
1977).
Defenses
(S.
also
Freud
feels
was
anger
she
unacceptable
thoughts,
For
if you
boyfriend
thing
cannot
also
others
Winnicott
her
immature
Defenses
with
off
1894/1958).
toward
an
ward
example,
for
he
hitting
did.
her,
She
impulses,
ask
she
and
a woman
might
what
answer,
intellectualizes
to
wishes
she
I think
ward
off
it
the
accept.
function
interpersonally
(Kernberg
1965).
replies,
Well,
Im
certainly
have
grown
1975;
woman
not
Kohut
asks
sure
accustomed
what
to
1977,
her
prevent
H.
S.
Sullivan
boyfriend
if
he
loves
mean
by
you
to your
1984;
emotional
face.
He
the
intimacy
1953b;
her.
word
intellectualizes
He
love .
I
to
keep
her
and
his
feelings
self-esteem
and
1945;
1977).
Kohut
Its
no
big
to avoid
THE
ward
deal.
a loss
off
a distance.
negative
A medical
I didnt
learn
want
to be
anxiety,
anxious
so
Bowlby
1973,
This
can
ignoring
looks
man!
defenses
Having
feelings
2)
learned
in
repetitions
implicit
which
effort.
Patients
Imagine
consciously
that
with
them
(Benjamin
1953b).
Wipe
The
that
1993;
physically
smile
to preserve
off
an
your
insecure
1998).
but
affect
dissociation
Avoiding
through
feelings
attachment
Dozier,
feelings
Stovall,
make
defenses
(Cramer
by
using
style
and
and
Albus
and
1999;
persons
automatically
hopping
on
shift
your
feelings
rise.
The
emotions
triggers
anxiety
(see
2000),
defenses
use
the
2008).
These
defenses,
through
countless
character
creating
rigid
1995).
of
not
anxious,
when
strengthened
Stevens
(Main
a caretaker
2006,
become
triggers
do
caretakers
1996).
out
occur
our
between
1994;
defenses
occurs
make
feelings
of threatening
adulthood
memory
1993),
denial
that
does.
link
childhood,
this
uses
(stimulus,
Cooper
father
uses
and
by
He
says,
reality
says,
his
1995;
his
implicitly
(Grigsby
structure
of school
of
Sullivan
regulation
1989,
perception
chapter
S.
and
hides
the
automatically
of
boy
like
Sroufe
unconscious
out
Fenichel
DEFENSES
elements
bond
H.
son
(Cassidy
learned
child
his
affect
explains
1995;
our
1993,
not
psychopathology
Main
maintain
1998;
anyway.
OF
any
1995;
at
The
learns
his
flunks
a doctor
problems)
Main
(Benjamin
child
ignore
preserve
1980;
father
attachment
to
defenses,
we
young
also
(Cooper
who
ORIGIN
children
feeling,
face,
feelings
can
of self-esteem.
as
abusive
Defenses
student
INTERPERSONAL
We
All
at
(Clyman
and
defenses
bicycle
balance
awareness.
Unconscious
1992;
habitually
Duffy
without
or
1997;
Reber
awareness
or
consciously.
to
go
to begin
for
pedaling.
ride.
You
It would
would
just
not
happen
automatically.
encoded
shift
Bicycle
in
your
riding
language.
body
is
You
for
balance.
of
our
are
set
not
This
of
motoric
conscious
procedures
of
cues
is unconscious
never
telling
you
procedural
to
memory
at work.
In
fact,
most
through
most
procedural
efficient
is
not
allows
children
(Bradley
memory
way
feeling
to
precisely
pay
you
so
the
They
Since
defenses
happen
all
create
and
create
But
It
is
the
of
automaticity
and
adaptively
reveal
how
we
thousand
his
sees
from
the
can
need
to
That
concentrate
think
for
how
runs
tasks
why
on
about
memory
other
is
he
phone
to
form
automatically,
. You
do
scratching
not
have
to
an
itch
or
automatically.
So
times
first
we
patient
decisions,
day
he
presenting
interrupt
them.
You
for
defenses
patient
help
the
will
identify
uses
become
become
problems.
and
patient
who
will
see
them
observe
the
and
defense
depressed.
is why
patients
of
If
confused.
That
the
cannot
he
Defenses
it is an
act
defenses.
of
They
symptoms.
you
may
of
ask,
The
my
intellectualize.
bring
This
triggers
unconsciously,
defenses.
to
defenses?
out
happen
his
maintain
compassion
awareness
procedures
to
of
not
is free
help.
attention
doubts
Conscious
quickly
Procedural
therapists
1999).
resistances
never
motoric
a defense.
self-attack
automatically
Chartrand
emotions
and
place
defense.
memory
do
talking.
using
pay
I am.
you
attention
to
the
to
is how
are
your
attention
without
activate
patient
because
while
work.
Defenses
the
a defense
words
and
to
procedural
life,
conversation
to
take
a relationship.
of
assumes
brain
respond
nonconscious
beginning
the
148).
to ride
Since
for
actions
(Bargh
necessary
2000,
learned
everyday
defenses
Isnt
good
pocket,
the
a danger
news
but
Defenses
to
there
is,
you
are
patients
you
if you
cannot.
cannot
behaviors
awareness,
take
You
take
can
the
take
away
(Wallerstein
they
away
patients
the
wallet
my
ability
to
1985).
Once
we
become
choices
the
patient
makes.
how
she
avoids
feelings
to
Others
her
essential
are
problems
generalized
problems.
We
adapt
their
maladaptive
and
may
herself
? Without
parent
disrupted
denial,
for
instance,
is unable
Thus,
the
defense
that
When
But
by
engage
in the
Table
shows
3.1
What
problem
Is
go
functioning
They
create
2006;
Erickson,
1997).
Children
1964).
When
maladaptive,
of
creating
destructive
them
into
defenses,
adaptive
actions
how
could
feeling.
can
not
defend
However,
reality
the
symptoms.
an
clearly
child
harms
We
the
and
say
defend
herself
from
adult
who
adult,
to
causing
that
the
childs
we
cannot
attackers.
defenses
task.
to
We
avoid
her
must
feelings,
address
them
defenses
patients
use
to refuse
you
would
like
me
to help
you
to
co-create
an
invitation
with?
I dont
a problem.
there
a specific
example
we
could
look
at?
I cant
think
uses
respond
the
might
patient
defenses
Defense
have
take
alliance.
Intervention
is the
let
to see
adults
typical
Typical
ever
alliance.
a therapeutic
3.1
not.
become
a child
helped
therapeutic
therapeutic
the
functioning?
(Hartmann
channel
childs
and
uses
a healing,
Table
the
the
patient
can
our
Levenson
a defense,
a defense,
become
the
to form
without
problems
defenses
have
defenses.
Others
presenting
out
avoiding
healthy
are
environment
patients
feelings,
ask,
point
price:
one
for
and
defenses
help
rather
than
to
must
their
can
always
(Cramer
Gross
people,
experience
will
for
essential
symptoms
1997;
other
the
No
defenses
and
Steiner
to
She
defenses
Maladaptive
to
out
Arent
1993).
defenses
We
her.
(Vaillant
use
point
a defense.
defenses
and
can
feelings.
use
from
ask,
her
problems.
or
mature
Feldman,
We
presenting
Healthy,
presenting
or avoid
feelings
away
may
face
feelings.
her
face
choice
can
her
causes
choice
that
She
of
it.
one.
What
is the
Could
we
How
do
feeling
take
you
toward
a look
him?
at this?
experience
I dont
have
Anything
this
feeling
a feeling.
else
but
physically
this.
in your
body?
dont.
Is
this
a problem
problem
Why
for
does
used
a patient
defense
whom
this
would
past.
As
This
is not
of
patient
in
perceives
defenses,
the
which
patient
fears.
Every
to
with
adapt
listener
past.
For
instance,
therapist
as
someone
originally
a fit
originated
maladaptive
fit
defense
reestablished
the
need
to
his
the
every
It
their
tries
risky
Thus,
a child,
and
2005)
the
effect.
become
ways?
someone
her.
However,
as
with
had
someone
adaptive
perpetuators
of the
in
regulators
past.
WORK
defenses
procedural
have
memory,
the
see
(2)
so
showing
the
him
its
function
the
as
same
confront
the
his
patient
them.
can
unconscious
aware
price,
let
us
he
recognizes
the
go
clarify
the
sure
just
First,
Once
to
way
the
implicit,
Thus,
three
confrontation.
price.
(Thats
Now
has
it. Second,
make
as
of them.
work
(3)
observe
and
defense
defense.
is not
and
function
and
been
Defense
clarification;
patient
defenses
always
the
patient
identification;
defense
No.
caretakers
herself
positive
DEFENSE
help
as
these
(Gray
adult,
criticizes
of relationships,
Since
an
criticize
self-affirming,
the
to overcome?
his
history
As
who
in
to
misperceives
patient
who
adapt
1964).
he
like
respond
to
enacts
(Hartmann
would
me.
defenses
the
you
we
stages:
(1)
identify
the
the
defense
patient
first
sees
that
I am).
Then
stage
must
of
he
you
by
the
is
not
can
defense
work.
Defense
As
soon
the
defense
Identification
as
a defense
so
he
can
occurs,
see
how
help
he
the
patient
is avoiding
identify
feeling
it.
in the
Point
out
moment.
Remember:
it. The
if the
following
patient
are
cannot
see
examples
his
of defense
Thats
is
not
feeling.
thought?
Do
[ Point
out
you
see
out
self-doubt
from
your
you
notice
you
want
are
is
right
you
having
help
with?
Sometimes,
to
differentiate
the
differentiating
the
let
go
of
but
your
your
thought
feeling
with
how
you
doubt
yourself
how
you
distance
.]
feelings
problem
cover
notice
you
now?
would
trouble
[ Point
out
point
out
like
distancing
clear
what
help
clear
.]
the
you
internal
with.
example
Do
of
what
you
you
.]
from
What
out
to
defense,
of the
Th:
not
me
vagueness
defense
corners
is
giving
notice
[ Point
It
emotional
cannot
.]
Do
yourself
thought,
you
intellectualization
he
identification:
your
how
Do
? [ Point
defense,
we
must
feelings.
triangle
help
This
of conflict
is the
feeling
the
is
patient
known
as
toward
him
for
slapping
you?
Pt:
differentiate
the
defense
Th:
how
you
feeling
the
deal
from
feeling
is
your
defense
cannot
therapeutic
stuck,
him
down
Shut
is not
step
.] If you
dont
slapping
assess
function
of
the
defense:
it causes
in
down
You
her
your
feeling
feeling.
it down.
shut
down
does
.]
Shut
down
[ Differentiate
your
not
is
her
feeling,
what
is
she
defenses
does
not
see.
Anytime
she
uses
that
the
patient
prevent
forming.
defense
her
from
[ Patient
you?
The
defense.
down.
shut
a defense
what
Clarification:
second
shut
of shutting
against
from
feel
feeling.
for
turn
alliance
Defense
The
her
toward
A patient
therapy
with
Price
work
Help
symptoms
shows
the
and
patient
see
presenting
the
the
price
problems.
price
of
and
the
Always
help
the
patient
defenses,
The
which
patient
and
see
will
patient
create
who
not
onto
on
must
: feelings
presenting
does
hold
consensus
causality
see
rather
trigger
problems
causality
than
go
therapeutic
task,
let
go
defenses
her
patient
begins
to
examples
show
how
and
so
of
triggers
a defense
it.
Thus,
therapy
to
which
symptoms.
believes
let
the
of
anxiety,
helps
her
have
no
we
cannot
succeed.
co-create
The
therapeutic
its
price.
alliance.
When
the
following
see
the
defense,
to clarify
the
When
this,
does
that
make
you
that
be
keeping
feelings
your
difficulties.
causing
your
now,
you
You
your
confused
so
Do
yourself
will
say
we
you
you
want
but
now
wont
see
how
be
able
you
are
anxious
out
rather
what
is
going
on
would
Defense
than
find
out
what
like
me
to help
Clarification:
the
function.
a feeling,
us
from
to
get
like
like
this,
yourself
to
in life?
distance
getting
to
are
the
yourself
to
working
the
from
bottom
bottom
distancing
get
patient
For
sees
example,
denies
the
you
reality,
father
physically
you
we
with,
of
what
yourself
to
the
at
cross-purposes
of
is
from
bottom
of
your
with
of
might
over
and
your
feelings,
youll
keep
we
feeling
is underneath.
dont
we
find
out
what
wont
be
able
the
show
protects
in your
talk
the
problem
to help
you.
Function
price
How
you
feeling
The
Th:
your
you
underneath,
If
Once
yourself
find
is you
doubt
directionless
you
If
wont
defense.
underestimate
you
and
prevent
depression,
feelings,
difficulties.
that
of the
The
depressed?
When
your
price
you
When
could
clarify
someone
do
body?
you
defense,
her
that
else,
experience
help
her
a defense
or punishes
this
anger
see
wards
its
off
her.
toward
Pt:
takes
to go
I think
you
own?
see
how
[ Identify
you
the
When
look
the
him
defense
Oh,
by
criticizing
the
of
a patient
critical
eyes
like
he
see
how
instead?
what
like
instead
it
this,
of your
does?
you
deal
[ Clarify
with
the
your
function
of
father
defenses,
in
must
at it that
up
your
before.
way,
do
anger
you
see
toward
him?
.]
defenses
in
a different
a character
the
criticizes
we
to cover
way
Defenses
have
uses
at it that
a look
defense
character
treated
take
is a way
Character
defenses
was
you
looked
If we
of the
clarify
character
she
yourself
his
myself
do
I hadnt
yourself
function
must
When
have
.]
Clarification
We
through
yourself
Th:
[ Clarify
underestimate
I criticize
Yeah,
criticizing
Pt:
how
I dont
.]
Th:
with
you
at yourself
defense
Pt:
anger
rightmaybe
to college.
Th:
do
hes
For
herself.
structure
from
she
to
patient
the
way
clarify
price
defenses.
herself
patient
the
of
because
other
treats
instance,
Thus,
the
different
defense,
past.
show
who
price
how
the
of
way
had
character
she
relates
to
herself.
Th:
Whats
the
feeling
toward
him
for
slapping
it.
[ Ignores
you?
Pt:
and
minimizes
slapping
You
try
how
you
defense
her
you.
not
You
to make
ignore
and
feeling
try
I try
not
to
too
try
not
to
too
much
much
of
.]
Th:
You
not
to make
too
make
much
dismiss
out
of him
yourself
and
make
too
out
of him
hurting
your
much
you.
feelings?
out
bruising
Do
you
[ Identify
of
him
you.
notice
the
.]
Pt:
Th:
Yes,
but
So
lets
I do
check
it all the
in on
time.
your
goal.
Is that
what
you
want
if the
the
to keep
reason
doingdismissing
for
the
antitherapeutic
session
task
is to
you
invite
of
you
dont
me
to
relationship
when
want
your
to
we
boyfriend
will
does
slap
you?
Point
out
value
in
the
the
defenses
compassion
past.
When
Th:
over
your
feelings.
laughed
at
him
avoid
and
your
your
being
problem
dismiss
your
with
hit
much
and
say
out
its
of
no
agreed
to
the
price
[ Clarify
him
or
big
deal.
ignore
your
or less
likely
to choose
today
while
empathizing
price
kind
feelings
.]
feelings
more
you,
What
your
you
feelings
slapping
ignore
over
being
guys
who
.]
defense
the
patient
more
feels
easily
your
let
go
with
empathy
of
it
for
today,
its
the
feeling
suffering.
We
How
your
feelings
task
your
If
Youve
pain.
too
dismiss
Th:
can
past
you
one.
the
she
her
[ Ask
therapeutic
a good
the
of
for
feelings?
Not
you
price
origin,
in the
when
if we
you?
make
[ Clarify
too
have
slaps
that
all,
make
you
Pt:
slapped,
After
dismiss
would
engage
your
No.
Th:
say
and
.]
Pt:
and
yourself
can
certainly
told
me
wonderful
more,
in
your
father
you
but
father
understand
would
the
found
you
hit
that
agree
past
invites
why
you
you
and
solution
that
your
laugh
then
to
what
join
solved
boyfriend
to
today?
Pt:
When
Th:
I laugh
Shall
off
we
my
anger,
take
he
stand
does
too.
against
that
self-dismissal?
Pt:
Confronting
If
the
uses
the
patient
it,
defense.
we
sees
must
Often,
Yes.
Defense
the
address
patients
defense,
one
cannot
its
more
price,
problem
differentiate
and
its
before
function
and
confronting
themselves
from
still
the
the
defense:
Thats
herself
with
attacking
hurts
just
her
her
her.
way
defense,
as
do
(See
To
differentiate
the
difference
with
patient
confront
it.
from
the
She
patient
will
than
confronting
defense
is
her
herself
feelings,
When
identifies
believe
a
you
are
behavior
central
we
must
that
feature
of
8 .)
between
her
am.
rather
chapter
the
not
person
Identification
syntonicity.
handles
the
defense,
as
between
a person
her
as
an
and
agent
help
the
ways
and
the
are
detached
her
see
that
she
choices
she
makes.
defense
Th:
Do
Pt:
Thats
you
deal
defense
do,
of
but
kind
as
of
with
Once
long
as
out
patient
can
it my
invite
whole
to do
the
I am.
now?
[ Identifies
with
the
are,
it is
the
Th:
The
first
this
detaching
me,
this
habit
have.
had
with
to
have
want
could
[ Point
detach,
this
this
me,
we
here
do
go
but
patient
feelings.
will
you
that
herself
to let
but
with
you
you
the
your
with
.] Why
Yes,
here
said
way
from
her
It is what
you
have
had
to yourself
from
of the
her
the
same
with
your
defenses,
the
from
feelings.
Ive
is this:
what
do
her
task:
defense.
I always
detach
question
for
life.
about
you
price
Pt:
detached
one
the
from
here
patient
let
about
way
[ Differentiate
differentiated
must
you
you
relationship
the
has
not
detach
detached
[ Point
the
its
detach
she
to
how
the
feelings.
you
progress,
the
just
No,
.] You
distant,
therapist
want
your
detaching
ex-husband.
done
notice
.]
Th:
way
you
sabotage
out
will
destructive
how
be
go
here
of
this
your
her
will
her
defense
be
me?
.]
As
defense
a crippled
mechanism
out
relationship
therapy.
here
you
the
now
here
her
What
with
as
that
like
.]
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see
you
goal .] As
do
me?
you
to
just
price
we
you
remain
relationship
and
obstructs
out
long
[ Point
relationships,
healthy
[ Point
a detached
ex-husband.
healthier
the
with
us
want
[ Confront
how
came
long
to
as
do
the
patient
with
her
When
we
let
go
of her
as
a person.
task:
confront
to let
the
underneath
her
of the
patients
defense
We
go
but,
defense,
more
encourage
aspire
her
to
her
to reach
who
her
she
not
full
really
just
to
potential
is,
hidden
defenses.
this
want
the
optimal
level
of functioning
want
this
an
example
of
the
kind
of
to become?
Is
you
challenge
to?
you
what
we
reveal
Is
person
.]
importantly,
Is
you
defense
this
behavior
your
goal,
or
is
this
to
win
to overcome?
Do
you
want
self-doubt
or
you?
Do
self-devaluation
or your
highest
self
yourself
In
sense,
this
to
face
reach
self-creation
In
that
by
the
not
just
emotional
to
defense
let
some
put
yourself
so
is always
she
can
itself.
down,
are
choice
to
encouraging
resume
Every
explore
identification,
go
do
from
of
not.
to
shift
but
Now
avoid
from
their
the
time
her
you
she
patient
journey
lets
of
go
of
potentials
that
and
confrontation,
they
also
the
the
enacts
toward
defense
and
begin
from
patient
feelings
doing
clarification,
defenses
Instead,
feelings
closeness.
transference,
happens,
follow
were
defense.
patients
However,
the
to
potential?
personality
makes
response
many
fears
is
you
a defense
she
she
hidden
full
confronting
what
defense,
your
want
When
letting
you
work
the
to
to
face
their
distance
therapist
a past
feelings.
themselves
They
resist
relationship,
therapist.
the
When
transference
this
resistance
work.
Shift
defenses
from
defense
persist,
work
the
patient
to
transference
becomes
resistance
more
distant,
work
the
if
the
defense
work
no
patient
longer
triggers
becomes
less
unconscious
you
RESISTANCE
draw
attention
to
the
response,
highly
closeness
by
using
nonverbal
your
eyes,
assumes
and
legs,
to
avoid
his
arms
fails
to
answer
problem,
He
fails
to give
resistance
Ogden
the
Now
patients
focus
how
resistance
and
(3)
much
why
you
are
your
relationship.
the
So
Rather
you
we
to
(1)
the
follow
patients
(T.
become
angry
with
ignore
the
may
(3)
transference
resistance
When
how
the
work
to
defenses,
Transference
(2)
clarification,
resistance
sequence:
will
(1)
go
defense
confrontation,
transference
(4)
resistance
transference
resistance.
clearly
and
The
understand
effects.
work
defenses
patient
defense
single
defense
defense
individual
from
therapist.
(5)
destructive
relationship,
address
this
his
on
task.
therapist
transference
of the
Focus
the
identification,
identification,
its
shift
the
confrontation
from
of
The
pathological
than
(6)
focus
He
therapeutic
therapist
clarification,
Principle:
shift
may
chair.
existence
a feeling.
in
crosses
the
the
or declare
Or
stages:
defense
confronting
on
in the
create
when
resistance
see
agree
begins
voice,
in
In
emotional
patient
of
position
therapist
Confronting
smoothly
resist
to engage
relates
three
transference
will
the
harder.
patient
has
and
rise.
The
feelings
The
work.
(2)
patient
to
at a distance.
identification,
clarification,
feelings
tone
slouched
will
defenses
confrontation.
more
his
defenses.
fails
his
even
the
work
example
resistance
on
or
to
uninvolved
resistance.
therapist
transference
an
1968).
his
working
the
tactical
questions,
Racker
resistance,
keeping
begins
countertransference
and
the
defenses,
patient
takes
a specific
1982;
patient
and
to declare
triggers
anxiety,
WORK
patients
resistant
your
or fails
of
collaborative.
TRANSFERENCE
As
signaling
avoids
yields
to
the
you
and
little
benefit,
therapeutic
the
price:
crippled
relationship
and
Transference
First
it.
therapy
Resistance
identify
Then
the
its
he
Once
he
resistance
price
is not
and
the
Identification
transference
clarify
recognizes
I am.
a failed
function.
same
as
can
see
the
transference
so
those
his
the
patient
Then
assess
resistance:
elements,
can
whether
Thats
confront
observe
just
the
he
the
way
transference
resistance.
Start
identifying
patient
the
defenses
he
uses
resistance
to distance
himself
Notice
how
Notice
head
me
and
right
having
a conversation
of
with
your
employees
would
Identify
defenses
the
following
way
he
you
sat
say
to
point
vignette
relates
he
to the
therapist.
looking
away?
going
up
in
the
your
how
you
are
pulling
Notice
how
you
are
detaching
instead
of
closeness
me?
the
how
back
from
how
you
like
you
this
are
in
an
again?
sitting
here?
interview,
If
how
relationship
to help
the
patient
a patient
see
is
and
creating.
reflect
on
at
the
therapist.
I dont
Do
[ Point
with
Pt:
the
think
you
Im
distancing.
notice
out
the
therapist
how
you
defense
by
are
looking
which
he
resists
.]
Yes.
Th:
what
the
are
to
is?
shows
Th:
emotional
from
Notice
with
out
Pt:
carpet
out
are
you
yourself
pointing
now?
involved
The
you
how
Notice
one
by
Thats
sign
of
distancing.
Do
you
see
I mean?
Pt:
Th:
Yes.
You
see
this
wall
of
distancing
that
comes
up
between
head?
us.
[ Identify
Do
you
the
notice
resistance
Pt:
here
with
First
you
form
comes
up
me.
Yes,
between
closeness
of
you
What
and
will
distancing
Its
just
Th:
Its
price
just
happen
and
the
me,
achieve
silence
wall
of
think
we
can
patient
sees
patient
of the
the
in
your
.]
rather
now
the
for
than
talk
you
wall
resistance
you
you
me
for
wall
if
resistance
silencing
do
his
out
and
of
me.
silence
to
emotional
that
you
up
this
wall
you
with
your
and
to
say
keep
way.
you
up
me?
put
have
the
same
[ Invite
wall
the
of
patient
to
.]
Nothing.
And
obviously
you
have
not
come
here
to
No.
see
it. Any
the
patient.
relational
and
about
turn
time
Is he
involved
You
or
impact:
Transference
want
this
wall
of
step
the
Maintaining
is
up
transference
a pathological
you.
to turn
resistance
Does
your
he
each
join
here,
but
do
you
What
us?
him
[ Once
the
against
it .]
if
he
does
relationship
you
or
defense
to a collaborative
clarification,
goals
between
assess
Describe
Resistance
second
defeating
transference
passive?
a barrier
your
invite
is stuck,
uninvolved?
as
is
coming
a therapy
or
achieve
resistance,
against
active
to
distancing
transference
cannot
not
effects.
up
nothing.
your
function
go
between
and
easier
like
Th:
The
yourself
a barrier
easier
between
Pt:
he
by
[ Identify
here
Th:
Is
and
closeness
distancing,
me.
Pt:
silent
.]
between
see
are
thinking.
think
and
Pt:
wife.
Im
becoming
wall
you
but
You
Thats
this
you
to emotional
Th:
loud
how
resist
in terms
with
you?
of
its
relationship.
Clarification
showing
resistance.
the
Point
relationship
patient
out
with
the
the
the
price
and
destructive
therapist
will
result
in the
defeat
patients
of the
The
continual
therapy,
following
and
suffering
failure
interventions
transference
to achieve
show
how
symptoms,
his
to
loneliness,
healthy
clarify
goals.
the
price
of
the
you,
but
resistance:
You
hasnt
from
it
destroyed
your
three
say
this
marriages
wall
protects
and
left
you
lonely
woman?
yours.
And
keep
just
up
how
this
like
wall
your
Havent
you
wonderful
with
other
can
keep
this
you
can
keep
it,
that
me,
it will
therapies.
suffered
You
cause
Why
set
at
that.
but
the
same
I have
as
what
long
will
time
no
as
you
right
we
we
to
here
to
tell
ask
dont
ask
me
say
to
will
failure.
have
No
between
from
getting
says
you
your
up
you
stop
long
end
like
it
as
in
is
you
failure
that
again?
want
asking
me
to
help
questions.
you,
I can
do
you
questions
you
dont
want
to
answer,
the
questions
you
came
here
to
answer,
keep
up
you
only
good
and
to
have
this
the
to
can
result
wall,
but
this
wall
of
that
will
be
relationship
if you
keep
this
destructive
me.
bottom
of
reveal
you
crippled
This
maintain
to
all,
happen?
devaluation,
wall
as
therapy
yourself
If
doomed
but
After
enough?
You
but
the
wall.
your
yourself
then
wall
difficulties.
to
I will
of distancing
There
me.
remain
will
You
is
have
another
prevent
no
law
every
useless
us
that
right
to
person
in
life.
If
wont
find
anxious
out
and
that
wall?
The
following
transference
who
you
depressed.
interventions
resistance:
are
Can
behind
we
show
you
put
that
find
how
up
wall,
out
to
this
wall
and
who
clarify
of
youll
you
the
really
words,
keep
are
function
we
feeling
behind
of
the
will
be
help
on
one
side,
you
will
This
wall
keeps
As
long
as
be
on
the
Notice
other,
with
how
thoughts,
and
you
yourself
put
up
in
this
how
head
rather
your
barrier
to avoid
but
me.
As
who
these
thoughts
long
you
as
really
you
are
are
a wall
between
to our
me
and
working
no
be
wall,
unable
to
up
this
put
behind
this
talk
Letting
continues
as
patient
relationship,
wall
is
the
his
Use
following
the
you
see
avoid
behaviors:
up
our
your
to
me?
feelings
here
with
between
we
up
this
therapy
here
but
does
merely
you
wont
wall
find
of
doubt
or is it a barrier
the
wall
nothing
a brick
clearly.
task.
will
creates
He
fail.
his
instead.
in
the
if
defense
the
patient
In
the
transference
the
wall.
So
address
Now
Otherwise,
will
continue
When
the
suffering,
he
can
we
to
patient
he
enact
turn
the
no
sees
can
co-create
have
past
how
his
against
it
therapeutic
therapist.
steps
when
it: Do
my
Do
you
gaze?
you
between
identifying
Point
2.
coming
put
pathologically.
therapy
1.
how
you
defense
therapeutic
feelings
the
can
to me?
thoughts,
defense
causality
resistance
with
patient
have
talk
here
up
to
relationship.
see
the
alliance
the
of
advance
you
defense
and
transference
one
to
must
on
face
this
than
cover
put
try
wall.
a specific
of
a whole:
agreement
and
about
relate
each
wall
does
go
to
resistance,
The
you,
you
together?
longer
creates.
the
this
I will
relating
you
When
the
maintain
and
Notice
You
We
you
at a distance.
you.
conversation
out
us
notice
Do
you
Point
notice
you
and
out
and
clarifying
a behavior
how
you
notice
out
how
me?
the
several
look
how
times
Do
look
at the
when
is
resistance:
away?
you
wall
there
the
the
wall
so
you
notice
floor?
patient
of
the
sees
avoidance
put
up
a wall
3.
Point
of avoidance
here
4.
this
wall
side,
of
and
able
to help
What
the
and
confront
the
Do
you
you
and
me?
price:
As
long
you
other
side
5.
Invite
think
we
the
and
of
me,
the
the
notice
as
you
I will
wall,
can
patient
do
you
put
be
and
it. (See
chapter
to
about
transference
Resistance
up
on
one
I wont
be
let
this
go
of
the
wall?
resistance
and
its
function
13 .)
and
Inviting
Feelings
Toward
Therapist
reduce
the
therapist
resistance
needs
resistance
to
and
transference
long
as
the
feeling
toward
This
is
of
here,
one
always
The
resists
up
toward
patient
them.
that
by
put
the
which
is
on
in
is
by
will
lead
conflict.
Mobilize
his
past
he
he
up
this
we
can
has
will
wants
to
to
As
What
make.
When
he
is
the
experiences
the
The
the
transference
toward
toward
to the
become
us.
experiencing
experience
face
words
experience.
continue
to a breakthrough
of
the
wall?
feelings
will
can
wall
difficulties.
address
he
which
between
against
feelings
until
this
relational
avoids
we
up
the
transference
therapist,
because
we
And
He
his
is
feelings,
the
at your
to put
it
of
distance
look
you,
which
wall.
therapist
put
points
when
what
this
you
a resistance
Thus,
asking
up
you
important
based
the
creates
a clear
rise
confront
toward
wall
with
the
and
how
leads
most
behavior
him
possible,
get
you.
(the
follow
feelings
cant
behavior)
toward
make
Notice
This
you
(his
resistance
feelings
closeness
transference
that
the
increase
clarify,
us?
me
toward
feelings
off:
we
resists
feelings
identify,
between
its
and
invite
wards
stories
patient
(1)
(2)
and
as
out
between
the
you
sees
Transference
To
on
do
patient
price,
the
be
agency:
you.
resistance:
When
will
here
his
between
Point
avoidance
you
out
you),
the
asking
them
we
therapist
about
as
the
deeply
unconscious.
his
feelings,
well
(inviting
and
he
feeling,
mobilize
the
him
to the
transference
the
In
his
breakthrough
Although
way,
the
and
then
you
will
feelings,
to unconscious
feelings.
have
in
defenses.
this
out
unconscious
we
resistance,
point
resistance,
therapist.
mobilize
task),
just
fact,
Thus,
been
patients
we
can
ask
and
about
decrease
talking
levels
access
and
their
tactical
defenses.
resorts
of these
and
character
repressive
to
Identify
resistance
and
the
way
the
transference
different
resistant
and
for
kinds
of
patients
clarify
defenses,
defenses
regressive
but
with
eventually
defenses.
defenses
patients
the
use
defenses
Help
to tolerate
the
higher
may
use
rise
of
fail.
In
to
repressive,
feeling
response,
patient
levels
observe
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
now
so
will
use
go
clarify
to
function
If
the
character
character
function
defense
and
price.
transference
avoid
defenses
Address
the
defense.
enacting
the
its
or
the
its
If it
resistance.
occur.
defenses
of the
is
Identify
defense
to feeling
and
patient
then
character
problems
here
and
patients
see
the
clarify
confront
resistance.
resistance,
persists,
persists,
likely
a transference
defense
that
create
defenses
patients
feelings
and
their
moment
suffering
can
by
end
anxiety.
presenting
moment
as
in
soon
as
soon
as
possible.
Principle:
she
uses
When
for
3.1
it. That
helping
the
self-observation
shows
capacities
promotes
patient
steps
the
order
the
patients
experiential
see
should
the
and
Address
and
be
for
let
mobilized
mobilizing
in which
they
defense
learning
go
of his
defenses,
in a stepwise
the
should
as
patients
be
his
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,
In the
go
tactical
the
retraction,
the
see
face
principle
the
his
defense
problems
at
are
cover
generalization,
rumination,
and
of intervention
and
and
its
price
feelings.
will
so
Cover
Words
When
we
invite
watered-down
say
say
he
feels
he
patient
word
rather
angry
feels
words
the
with
to describe
than
the
frustrated,
cover
his
the
boss
he
feeling.
who
upset,
true
what
For
publicly
irritated,
feeling,
anger.
feels,
he
instance,
offer
rather
humiliated
or
may
him,
than
he
uncomfortable.
Here
we
look
may
These
at
different
example.
Pt:
wife
died
As
your
wifes
Im
What
is your
had
upset.
over
Im
the
What
phone
call
feeling
Of
I left,
my
are
you
having
I agree.
Pt:
I feel
death
word
upset
.]
your
entire
her?
it came
is the
terrible.
Th:
cover
in shock.
What
Its
her
course,
cancer.
Pt:
[ Defense:
losing
still
Th:
she
sorry.
Obviously,
feeling
Pt:
know
so
I feel
Th:
didnt
from
death?
Pt:
world.
know
yesterday.
Th:
over
you
as
feeling
over
[ Defense:
What
lost
you
you
her?
word
feeling
her.
since
losing
Cover
are
without
a shock
.]
over
[ Defense:
her
loss?
Cover
word
.]
Th:
obviously
hand
this
while
she
triggers
died,
out
and
block
are
of
feelings
a lot
and
making
Pt:
[ Tears
Th:
What
Pt:
Point
You
Im
without
over
the
form
are
her.
losing
funeral
in his
you
You
lost
her,
her,
and
holding
her
arrangements.
eyes
feeling
.]
now?
sad.
tactical
defenses
so
feelings
can
rise
to
the
words
to
surface.
Distancing
Some
patients
will
use
gestures,
tone
of
voice,
and
maintain
interpersonal
imagine
knocking
personal
communication).
not
it to let
open
this
defense
distance
on
someones
He
you
of
from
in the
therapist.
door
talks
to
(J.
to you
house.
distancing
the
Ten
the
any
an
Have
through
Thus,
have
As
the
de
Labije,
door,
therapist
genuine
analogy,
but
must
does
address
contact
with
the
patient.
Th:
anger
you
feel
toward
You
this
Pt:
voice
want
doctor
Sure.
to help
you
with
this
whose
malpractice
left
[ Defense:
Said
a diffident
in
powerful
you
in pain?
tone
of
.]
Th:
nonverbal
distancing
No,
Th:
look
out
the
window?
me
dont
right
sure.
you
sound
sure.
[ Point
Yeah,
what
now?
Pt:
out
Do
Looks
how
turn
the
out
the
[ Point
you
behavior
away
away
.]
right
now
.]
of it?
you
[ Looks
[ Defense:
notice
[ Point
Th:
from
Im
Do
Pt:
yourself
You
.]
Pt:
and
me
notice
out
back
how
the
you
defense
at the
are
distancing
.]
therapist
.] Yeah,
notice
that.
Th:
in our
way
distance
defense
here.
What
yourself
from
to get
better
If you
do
you
me?
distance
think
[ The
yourself,
we
can
patient
do
must
thats
about
see
going
this
and
to
get
tendency
to
let
go
of
the
.]
Diversification
The
patient
association
feeling.
may
to
Block
change
the
the
topics
feeling.
defense
your
husband.
were
in conflict
Can
with
we
him?
Rather,
and
Th:
take
to
You
avoid
it
return
at
This
associating
to the
mention
a look
is
feelings.
that
is
away
not
free
from
the
focus.
you
a specific
have
example
conflicts
where
with
you
Pt:
aunt.
[ Defense:
First
diversification
example
Block
the
Before
where
you
diversification
sale
I really
at Filenes.
me
like
example
of
diversification
some
your
to
give
you
go
off
notice
how
other
topics
all over
you
to
at the
me
to
with
you
of
the
we
your
going
but
but
with
to
my
look
at
husband?
the
then
are
doing
can
we
your
mall
there
to
go
was
this
a beautiful
hear
husband?
you
job
specific
[ Block
the
of
Filenes,
and
avoid
a dress
that
I wanted
to
I had
seen
in
the
this
conflict
[ Point
out
.] Do
that
when
ask
I know.
then
with
to
your
your
your
husband,
shoes?
husband
pattern
My
notice
a conflict
with
the
you
Do
by
going
of diversification
.]
always
me
husband
tells
you
off
to
how
place.
away
out
you
Do
from
defense
Pt:
I do
that
is very
conflicts
Pt:
Yes.
Th:
Its
but
then
want.
see
and
now
This
your
you
talking
the
with
conflicts,
help
just
.]
example
to
Its
I bought
a specific
instead?
the
after
there.
[ Interrupts
in dealing
these
could
with
.] You
Th:
shopping,
[ Point
help
about
.]
getting
store
Th:
my
conflict
trip,
diversification
move
husband?
that,
Macys,
had
Im
Th:
topics
at
shopping
Pt:
talk
to
I were
[ Interrupts
conflict
[ Defense:
you
you
.]
shoes
window.
diversification
Pt:
get
get
and
shopping
[ Defense:
about
we
have
He
Th:
telling
tell
.]
Pt:
shopping.
probably
.]
Th:
specific
I should
You
see
ignore
right
about
clarify
you
the
now
function
point
it out.
your
because
you
conflict
its
important.
with
important
we
how
with
your
.]
You
have
husband,
you
change
asked
for
right?
want
that
changing
topics
your
problems
here
to get
help
deprives
by
talking
about
Filenes
Filenes
last
and
instead
thing
mean?
to
of
your
which
we
[ Point
effects
shoes.
out
the
Then
problems.
of
the
line?
You
department
you
[ Tears
as
if
to
your
attention.
pay
attention
problems
Do
diversification
deprive
same
invite
this
me
to
of our
ignores
be
to
than
yourself
she
.] I hadnt
Could
store
diversification:
the
of
me
you
and
to
are
see
its
the
what
destructive
.]
Filenes
of
pay
defense
Th:
way
invite
Its
should
Pt:
end
you
thought
a way
give
Do
attention
her
you
more
you?
about
put
that.
yourself
at
attention
you
life
to
think
to you?
inner
it like
and
shoes
that
and
might
[ Point
out
invites
the
be
the
price
others
to
defense
.]
do
.]
Pt:
I do
put
myself
last.
[ Sees
the
Evasiveness
Some
patients
cannot
get
pointing
avoid
a
out
the
clear
giving
clear,
picture
defense
of
concise
their
answers,
difficulties.
so
Help
the
the
therapist
patient
by
of evasiveness.
Th:
You
mentioned
that
you
had
a conflict
at
work.
Pt:
conflictmaybe
more
evasiveness
of
notice
its
First
a disagreement,
how
to describe
you
avoid
and
giving
it. [ Defense:
Its
but
you
happened
keep
you
if
or
now
a clear
said
you
would
say
a discussion.
at work?
Pt:
it
was
[ Defense:
Do
out
trying
its
a conflict,
then
a discussion.
[ Point
situation.
out
the
you
Do
you
defense
I dont
know
.]
how
.]
Actually,
[ Point
Im
say
a complicated
shifting.
it was
answer?
evasiveness
Th:
what
know
.]
Pt:
ways,
dont
a disagreement
Th:
said
you
you
the
to.
have
notice
defense
described
how
.]
you
it
avoid
in
three
saying
Th:
not
in a clear
way.
You
[ Point
out
the
Pt:
self-awareness
a clear
answer
picture,
we
out
what
defense
My
boss
happened
at
work
but
.]
says
Im
not
clear.
[ Rise
in
.]
Th:
Point
describe
about
this
be
able
wont
the
And
price
of the
now
we
problem
to
at
help
defense
Pt:
Okay,
see
here
work.
you
how
If we
with
this
you
avoid
dont
giving
get
problem
at
clear
work.
.]
it was
a conflict
I had
with
my
boss.
Generalization
A
patient
Point
may
out
and
describe
block
himself
this
in
defense
general
and
terms
help
the
with
the
patient
therapist.
become
more
specific.
Th:
help
you
What
problem.
Perhaps
generalization
its
Its
an
not
encourage
would
the
like
patient
therapist
generalization
called
would
like
me
to
is
[ Block
emotional
the
emotional
the
me
to
I dont
specifically,
help
specific
Like
you
of a general
know.
[ Defense:
it
what
with?
is
the
[ Block
emotional
the
defense:
.]
I said,
problem
If we
its
not
a specific
personality
leave
problem
defense,
problem.
disorder
My
[ Defense:
and
your
you
return
previous
would
the
therapist
like
me
focus
to
to
out
help
an
of
you
internal
.]
Pt:
generalization
More
.]
Th:
what
problem.
problem.
But
to be
Pt:
with?
you
.]
you
previous
a specific
emotional
Th:
this,
problem
with?
Pt:
problem
is the
There
is
a behavioral
problem.
[ Defense:
.]
Th:
What
is the
behavioral
problem
you
would
like
me
to help
you
with?
Pt:
avoid
intimacy.
Theres
[ Defense:
a tendency
generalization
Th:
generalities:
here
certain
with
me?
[ Point
out
the
Pt:
this
will
about
the
just
this
we
wont
get
be
another
tendency
price
of the
to
therapy.
speak
in
and
Pt:
Th:
whats
the
problem
you
something
that
My
girlfriend
we
defense
work
has
problem.
We
would
girlfriend
and
work
Indirect
or
Rather
than
patients
dont
know
helped
his
make
a
it.
sad.
you
speak
are
in
vague
talk
in
internal
do
you
not
off
to help
think
we
to be
to
these
you
with?
and
can
do
[ Point
to let
I should
vague
difficulties,
here?
to try
go
these
go
out
of it .]
vague.
generalities,
come
because
of
us.
internal
shift
our
tactical
to
emotional
inquiry
clearer
about
problem,
the
description
the
incident
of
his
with
his
defenses.
Speech
clear
statement
They
I guess
how
patient
said
the
him
continue
on
me
between
Hypothetical
qualify
suppose,
feeling
still
you
the
dont
like
happened
Although
you
how
generalities
I need
would
Pt:
What
encourage
If
we
of your
vague
I guess
to
vague.
as
idea
failed
defense,
notice
Im
long
a clear
situations
.]
Yes,
As
notice
you
defense
Th:
generalities,
you
Do
Vague?
certain
.]
Do
situations?
in
so,
Through
say
you
probably,
may
these
about
be
terms
an
anxiety-laden
maybe,
right,
they
sort
topic,
could
of,
turn
fact
have
problems
or
be,
I must
into
be
mere
hypothesis.
Th:
with
your
wife.
Is
this
You
the
mention
problem
you
you
would
like
me
of intimacy
to
help
you
with?
Pt:
I suppose.
[ Defense:
hypothetical
speech
.]
Th:
the
defense
You
suppose?
It could
be.
Th:
you
want
me
Again
to help
Pt:
hypothetical
speech
say
leave
Defense:
air?
out
[ Point
out
dont.
since
patient
uses
possibility.
it is
in this
the
it is
the
the
defense
it isnt.
fence.
Do
block
the
.]
[ Defense:
You
you
notice
notice
defense
problem
sort
of.
block
the
so.
Do
how
how
you
.]
in
so?
is it?
[ Block
guess
you
defense
[ Defense:
guess
Th:
But
the
more
moment
[ Defense:
feet
my
opinion.
notice
Either
you
the
defense
could
speech
and
how
you
speech
.]
.]
hypothetical
you
firmly
and
[ Point
on
the
see
that
you
are
.]
say
leave
projection
things
onto
the
indefinite
his
stance
I leave
of
things
the
the
two
Do
you
the
Now
defense
of
defenses
the
of never
Do
you
defense
you
it
out
declaring
I think
thats
.]
see
refuse
that
point
indefinite.
speech
A possibility?
block
speech,
[ Block
.]
How
and
opinion?
pathological
fence?
vague?
out
in your
hypothetical
Pt:
question
on
of
hypothetical
Th:
Block
and
You
Pt:
stand?
Either
.]
.]
projection
indefinite
speech
[ Block
maybe
maybe?
say
Which
[ Defenses:
sit
sort
I guess
Pt:
both
[ Block
.]
You
Th:
therapist
and
and
Its
Th:
Pt:
indefinite.
be.
it is,
and
speech
down?
or you
could
or it isnt.
be,
[ Point
hypothetical
indefinite
say
hypothetical
with
you
could
in the
things
you
Again
Pt:
water
it isnt.
.]
suppose,
things
[ Defense:
you
Maybe
Th:
you
it is or
.]
Pt:
problem
Either
you
notice
how
you
to
say
how
you
leave
clearly
keep
everything
where
you
.]
mention
to
the
himself
it.
patient,
clearly.
and
call
into
Retraction
Retraction
is
then
it back.
takes
form
of
undoing.
Th:
What
The
is
patient
the
says
something
feeling
toward
him
you
experience
and
for
saying
that
anger
anger,
more
that?
Pt:
I was
angry.
Th:
physically
in your
[ Defense:
anger?
retraction
[ Point
out
Do
the
unsay
it. Do
you
see
you
notice
it
was
how
you
move
away
from
.]
wouldnt
were
angry,
out
the
You
you
I mean?
But
try
defense
to
say
was
angry.
[ Defense:
you
were
[ Point
I wasnt
you
said
angry.
out
the
angry.
you
it back.
Do
Maybe
I didnt
feel
defense
As
you
try
to
retraction
soon
see
you
.]
[ Defense:
were.
take
Now
as
what
you
.]
say
I mean?
.]
Pt:
retraction
said
Maybe
Th:
say
what
Pt:
Point
that
.]
Th:
you
know
defense
Pt:
retraction
dont
.]
Th:
your
do
body?
Pt:
irritation.
How
angry
at
all.
[ Defense:
.]
you
erase
were
it.
defense
Do
angry,
you
Th:
Now
then
you
see
how
you
try
you
try
to
to take
avoid
erase
your
it back,
your
anger.
and
anger?
then
[ Point
First
you
you
try
out
to
the
.]
Pt:
I do
now.
Rumination
Wondering,
but
avoid
they
the
speculating,
are
defenses.
experience
and
The
of
his
ruminating
patient
feelings.
can
ends
up
Interrupt
look
like
in a state
collaboration,
of confusion
rumination.
Help
to
the
patient
see
and
turn
against
it.
Pt:
tendency
to
be
projection
onto
Other
passive-aggressive.
other
therapists
passive-aggressive?
have
And
[ Block
the
[ Block
the
you?
projection
go
off
about
that.
Several
ruminate
about
what
others
stock
market
fell
look
we
get
at what
Some
the
could
the
patients
are
previous
projection
.]
But
.]
in
your
you
would
could
say
be
am
due
[ Defense:
rumination
rumination
.] But
are
to
.]
if we
dont
passive-aggressive?
that
resolved,
is
so
an
area
am
of
my
disappointed
.]
deserve
might
feel
the
mention.
or think,
reason
When
block
he
did
patients
it.
that
was
because
day.
Th:
but
been
I think
that
I suppose
rumination
Pt:
the
Yes,
not
of
the
say
rumination
forms
you
of
and
rumination
that
[ Interrupts
has
and
that
a number
yes,
said
you
[ Defense:
other
Uh,
psychiatrist
Pt:
that
.]
to neurotransmitters,
psychotherapy
that
the
course,
Th:
opinion
[ Interrupts
Of
my
I have
.]
given
Pt:
neurotransmitters,
that
rumination
it your
rumination
projection
passive-aggressive.
Is
[ Defenses:
Th:
opinion?
said
[ Defenses:
I guess,
indicated
have
.]
Th:
Pt:
therapists
therapists
We
absolutely
can
only
clear
feeling
is toward
ruminate
about
speculate
about
him
the
what
for
past.
about
what
he
feel.
Can
we
you
firing
feels,
take
you?
When
this
happens,
block
rumination.
Pt:
I wonder
Th:
what
never
look
at the
Patients
happened.
feeling
may
toward
ruminate
what
[ Interrupts
If we
him
about
dont
for
the
would
.] We
go
firing
future.
off
have
can
to
you?
only
fantasy,
happened
if
speculate
can
we
about
take
Pt:
him
to the
top
of the
If that
to avoid
side,
A
what
your
is the
patient
may
feeling
you
not
patients
will
to engage
right
him
the
you
now?
rather
explore
I wont
notice
toward
ruminate
Do
that
Do
feelings
therapy.
myself
again,
I can
imagine
taking
tower
Th:
future
happens
If we
for
firing
than
off
to a fantasy
leave
the
of
fantasy
the
to the
you?
declare
rumination.
in the
go
his
will
to
it
and
focus
Block
engage
in
on
the
task.
Pt:
Im
afraid
Th:
You
I will
find
out
something
about
like.
probably
will.
Are
you
willing
to
face
that?
If the
patient
the
therapy,
are
afraid
never
can
says
rather
of
find
this
difficulties.
he
about
you
will
discover.
is
going
together
Which
what
ask
what
fear
dreads
than
what
out
face
he
way
do
on
and
you
his
will
find
rumination,
You
out
think
will
about
the
be
say,
this
been
for
in
You
fear
symptoms.
has
best
himself
can
avoid
your
what
about
you
can
underneath
find
out
and
Or
we
causing
your
you?
Vagueness
When
your
two
patients
help
of
patient
clear
remain
or
about
you
to
see
and
an
get
let
understanding
vague
example
clear
go
Th:
help
you
they
of
defense
What
for
make
the
which
they
it impossible
problem.
so
you
seek
for
Always
of vagueness
triangle
the
help
can
the
get
of conflict.
is the
problem
you
would
like
me
to
with?
Pt:
Defense:
vagueness
about
your
Its
relationship
problem
of
sorts.
.]
Th:
I ask
it,
picture
of the
of the
of
problem
problem?
Pt:
Do
you
[ Point
It is kind
notice
out
of
how
the
you
defense
vague.
Im
become
vague
when
sure
there
.]
not
really
is a specific
problem
really.
[ Defense:
Th:
vague?
[ Point
out
the
vagueness
we
get
a clear
you.
[ Point
out
get
picture
at
Now
the
For
more
2000,
my
the
But
but
the
that
problem
problem
picture
your
the
I see
of
your
you
are
is vague
what
more
being
I think.
an
commentary
on
as
be
The
you
And
wont
mean.
clearly
long
difficulties.
therapy
you
into
as
I wont
price:
getting
emerges
is that
difficulties,
and
after
extensive
the
clear
defense
workplace
problem
vague,
of
Pt:
fired
though
.]
wont
dont
notice
.]
.]
Im
Th:
vague,
you
defense
Pt:
Defense:
Do
vagueness
if
we
able
to
help
him .]
problem
argument
are
with
help
is I
my
got
boss.
.]
tactical
defenses,
see
function:
to
Davanloo
111181.
REPRESSIVE
DEFENSES
Tactical
defenses
therapist
at
function:
to
keep
have
distance.
defenses
identification
with
instant
at
the
principle
aggressor,
see
and
let
in these
go
of his
have
Among
avoidance,
intellectualization,
reaction
vignettes
defense,
he
most
the
can
face
object
same,
of ones
of
and
his
common
displacement,
the
formation,
the
intrapsychic
isolation
is always
so
the
with
keep
an
denial,
identification
rationalization,
The
defenses
a distance.
are
repression,
minimization,
interpersonal
Repressive
feelings
repressive
rage,
an
affect,
suppression.
help
the
patient
warded-off
feeling.
Avoidance
All
defenses
patient
admits
patient
that
feelings
we
serve
she
avoiding
usually
to
avoid
avoids
her
feelings
avoid
feelings.
In
feelings.
is
is the
the
the
The
following
therapist
must
antitherapeutic
task
that
example,
task.
accomplishes
remind
Facing
the
goals
the
the
the
of
therapy.
Th:
How
do
you
experience
this
sadness
over
your
husbands
avoidance
you
out
death?
Pt:
I try
to
Th:
To
avoid
are
trying
the
to
defense
avoidance
avoid
your
in the
so
and
can
able
the
Im
avoid
her
your
and
put
about
defense
can
and
remain
rest
we
an
end
to this
your
Do
now
to
you
here
with
it.
[ The
face
must
do
that
help
to
two
life
face
wont
the
notice
how
me?
[ Point
defense
patient
to yourself
the
sadness.
Th:
We
of
let
go
of
want.
to
As
long
he
You
died,
and
[ Deactivate
.] But
help
continue.
to
face
depression,
But
since
feelings
able
sadness.
as
you
as
long
as
mourn
you
[ Point
the
avoid
out
his
these
the
price
of
want
can
this
years
her
be
will
face
if you
depression.
I dont
depressed.
suffer
that
or
obviously
anymore.
fear
you
you
and
Its
master
can
avoid
have
not
just
that
it so
that
this
sadness
come
here
to
suffering.
completely.
her
past
to
Pt:
this
have
your
suffering
Pt:
to explore
of
sadness,
him,
your
the
desire
overcome
down
want
dont
it for
the
of feeling
you
continue
sadness.
therapist
healthy
.] Why
scared
shut
it. [ Defense:
now .]
You
avoid
it for
of
feelings
the
to
avoid
projection
death
of
.]
been
you
reminders
right
I dont
Th:
you
your
sadness
here
is syntonic,
defense
have
any
.]
Pt:
the
avoid
No.
[ With
sadness
and
I remember
this
the
memory,
grief
she
day
I heard
signals
her
he
died.
willingness
.]
Denial
Denial
following
is
a way
four
to
ways
ignore
to deny
reality.
the
Anna
existence
Denial
in reality
does
not
exist
Freud
(1936)
proposed
of reality:
per
se:
Saying
that
something
the
Denial
a fantasy
rather
than
in fantasy:
Paying
attention
to
in words:
Paying
attention
to
reality
Denial
false
words
rather
than
reality
Denial
something
All
in reality
of us
the
use
denial
patients
of psychotic
avoid
internal
due
emotional
2004).
Defenses
That
can
the
or
another,
inability
does
the
conflict?
Deny
defenses
time
Or
deed:
so
we
or
uses
internal
sees
as
if
must
it.
Is
assess
to test
reality?
patient
see
reality
sign
of
neurotic
illness
of
denying
reality,
That
is
That
would
but
be
deny
it to
Reality
be
enlisted
for
the
purpose
following:
Withdrawal
patient
Behaving
exist
to an
illness.
(Blackman
including
not
at one
denial
sign
Many
does
in
denial,
she
withdraws
that
would
stimulus
nor
feelings
neither
the
her
attention
cause
her
of
pain
feeling
attention:
from
and
external
anxiety.
because
When
stimuli
The
she
patient
does
not
look
at them.
Negative
sees
what
is not
there
to avoid
He
asked
me
to set
the
just
ended
the
engagement.
what
wedding
hallucination:
is there
date,
denial
patients
see
because
ignore
essential
reality
the
can
stimulus
aspects
of
to
be
reality
This
is a less
back
or
and
She
in fact,
brought
feeling
in reality.
when
Ignoring:
of
The
their
her
may
say,
fianc
had
extreme
into
form
focus.
feelings,
misperceive
patient
When
they
the
fail
to
meaning
of
events.
Negation:
feeling
been
but
cruelly
negates
rejected
its
meaning.
by
her
For
ex-fianc
The
example,
may
Minimization:
patient
perceives
a patient
say,
I do
The
who
not
patient
feel
her
has
just
angry.
perceives
the
stimulus
(the
For
example,
rejection)
she
may
but
say,
minimizes
I feel
her
maybe
emotional
a little
reaction
bothered.
Overexaggeration:
only
denies
this
exaggerated
For
example,
ever.
reality
I can
exaggerates
the
fantasy
to
avoid
facing
the
reality
I am
even
more
in
may
hardly
say,
wait
to make
love
opposite
to him
of
anger
into
its
feeling.
She
of
love
The
opposite.
patient
not
believes
his
rejection.
with
him
than
again.
Reversal:
experience
The
but
she
to it.
She
patient
may
changes
say,
her
feel
quite
happy.
Ridicule:
stimulus
reality
(the
rejection)
any
feeling
of
nothing.
Ive
had
but
denies
response.
many
men
its
She
before.
The
perception
fantasy.
her
She
fantasy.
of
get
reality
relates
only
Her
perception
hell
of
it
over
but
to
fantasy
thus,
the
say,
that?
That
was
may
(see
it.
Cramer
He
really
it
2006,
loves
less
threatening
consistent
precedence
She
just
may
future.
acknowledges
reality
takes
Its
in the
patient
of
4446).
me.
men
into
portions
reality
Oh
many
The
changes
about
the
and,
Ill have
those
perceives
importance
Fantasy:
her
patient
phase
with
over
her
say,
know
he
is
going
through.
All
forms
does
of denial
not
see,
threatening
Denial
With
avoids,
Per
to
per
se , the
the
contrary.
reality
he
denies.
reality
do
the
visit
she
work
Do
for
the
woman
who
sadomasochistic
distorts
does
perception
what
not
patient
of reality.
she
perceive
denies
Remind
not
mourning
a
the
perceives.
The
patient
Reality
is
not
it.
Se
denial
A patient
with
or
because
evidence
to
interfere
argue
reality
the
with
the
patient
patient.
despite
of
overwhelming
his
Let
denial
the
and
reminders
the
of
you.
recent
enactment.
enjoys
death
of his
bondage
wife
and
reports
discipline,
that
he
a
form
plans
of
Pt:
feel
guilty
for
going
I know
or shell
Th:
feel
guilty
and
shitty.
he
[ Mirror
is meeting
and
feel
guilty
and
worse
about
shitty.
will
either
me
me.
[ Mirror
over
Annes
face
out
the
the
her
a woman
that
either
Ill
who
makes
me
.]
interesting.
interested
the
[ Defense:
worse
[ Mirror
the
denial
makes
myself.
who
will
make
me
I know
she
.]
it sounds
crazy.
me.
a woman
contradiction
about
contradiction
from
who
.]
a woman
.] I know
away
in a woman
contradiction
Ill feel
I want
to
reject
me
or
run
away
.]
Hmm.
It is a distraction
from
all this
sadness
death.
Th:
to
very
[ Laughs
Pt:
very
to meet
or run
the
visit
I want
Th:
from
her
I know
myself.
reject
go
see
shitty.
contradiction
[ Mirror
Pt:
feel
to
why .]
Th:
feel
the
I am
Pt:
I go
me
to
I find
Th:
me
make
I want
Pt:
of who
when
sadness
function
of
I want
over
the
a woman
Annes
denial:
to
to reject
leaving
avoid
me
the
me
so
through
grief
I dont
death.
over
his
have
[ Point
wifes
death
.]
Pt:
grief
as
he
Denial
in
With
to
her
denial
cries
Its
so
painful.
[ Face
contorted
in pain
and
.]
Fantasy
in fantasy
a fantasy.
Help
, the
the
patient
patient
denies
see
the
reality
contrast
by
paying
between
attention
reality
and
fantasy.
A patients
son
has
recently
been
arrested
said
he
and
has
a history
of
lying
to her.
Pt:
was
shocked
fantasy
.]
to learn
that
He
he
was
was
drinking
not
drinking
again.
anymore,
[ Defense:
denial
so
I
in
Th:
truth.
[ Point
she
out
wishes
the
she
I expect
defense:
had
she
rather
than
Pt:
fantasy
then
deny
[ Shocked
is
shows
up
it, you
the
anyway
Of
will
when
up
I was
who
lies
attention
real
to
to
the
tell
me
fantasy
the
son
son .]
shocked!
he
lies
result
[ Defense:
denial
in
the
The
whole
if you
she
had
hurt
you
liar.
Instead,
again
yourself
If you
the
truth
up
again.
once,
but
[ Point
denying
his
denies
the
Th:
see
the
you.
When
You
hurts
But
he
denial
.]
Th:
May
Pt:
Yes.
faced
shows
reality
truth,
testing
and
reality
then
I am
surprised
.]
truth.
You
you
denial
deny
deny
it.
Then
it again,
you
you
set
out
lying,
the
but
I would
you
blames
she
lying
could
that
hurts
the
you.
have
to deal
he
lies,
he
times.
with
set
hurt
you
you
herself
her
you
Would
punishes
way
to
never
that
of
she
for
he
by
propose
hundreds
him
you
prepared
reality
externalization:
she
hurt
been
the
[ Projection:
perspective?
time,
have
hurt.
hurt
me.
he
first
denied
and
has
time
that
would
you
shocked
hurts
another
first
truth
you
time
really
I offer
The
the
because
your
If I deny
reality
uses
to be
agree?
truth
see
of self-harm.
each
up
the
patient
[ Improved
Th:
But
were.
when
the
I see.
denial
cycle
when
shocked
when
Pt:
herself
you
.]
again.
shocked.
course,
be
Pt:
are
pays
her
But
son
.]
Th:
and
my
denial
by
hurts
her .]
Denial
With
in
Words
denial
in words
, the
someones
words,
not
difference
between
because
the
intervention
what
patient
his
denies
deeds.
someone
does
not
reality
Reminding
by
paying
the
says
and
does
address
her
denial.
attention
patient
may
Point
of
not
out
to
the
help
that
she
listens
denial
to
the
through
A patient
other
words
in an
persons
or selective
abusive
in the
face
this
he
his
wont
deeds.
do
out
denial
attention
words
what
talked
he
You
pay
the
denial
.]
her.
toward
him
for
hitting
it,
But
and
in words
attention
he
he
to
said
he
said
hes
sorry,
.]
his
words
rather
wouldnt
do
it
than
again.
.]
Th:
That
said
but
not
what
Pt:
But
he
said
he
Th:
But
do
you
notice
he
says
and
ignore
is what
what
not
what
Th:
believe
denial
his
words
and
he
he
said.
he
Do
did?
you
[ Point
notice
out
you
the
pay
denial
in
was
sorry.
[ Defense:
denial
My
mom
I think;
not
that
you
pay
attention
to
does?
says
thats
Whats
try
your
to
that
what
my
opinion?
believe
too.
mom
Do
his
[ Defense:
thinks.
you
fists?
notice
[ Point
]
you
out
the
.]
Pt:
Denial
in
With
the
Hmm.
in deed
fantasy.
, the
patient
Remind
fantasy
upon
the
which
Pt:
I thought
I could
come
even
I hadnt
thought
of it that
way.
Deed
denial
his
Dont
hit
.]
projectionThats
her
about
denial
Th:
Pt:
and
This
key.
husband
feeling
deeds.
.]
in words
of
his
is the
her
you
[ Defense:
in words
to what
are
We
Pt:
Defense:
ignores
week?
it again.
[ Point
says
What
Pt:
and
and
inattention
marriage
Th:
you
words
we
could
over
think
to
of
it.
denies
patient
his
of
actions
I talked
to
still
work
things
her
place
and
I dont
ever
reality
the
are
talk
want
acting
difference
on
the
between
basis
reality
based.
Jennifer
out
by
on
between
things
to
see
the
phone
us.
out,
you
and
I asked
but
she
again.
told
her
if
said,
But
figured,
Hey,
out.
So
pushed
if we
I drove
the
over
doorbell.
me,
throws
a glass
out
of
life.
her
Rather
than
reality
dont
to
She
this
her
place
comes
on
you
believe
this
sad
want
and
me,
up
work
this
the
door
and
opens
tells
me
[ Defense:
patient
ever
to
door,
then
that?
the
cant
went
front
and
reality,
to see
you
again.
You
Denial
per
it, curses
to get
the
denial
acts
as
in
if
at
hell
deed.
this
is
not
want
fantasy
out
But
a woman
the
how
denial
are
who
said
in fantasy
we
going
she
didnt
.]
to
work
this
out?
se .]
Th:
doesnt
visited
[ Point
Pt:
to
work
I want
things
to work
out
with
things
me.
out
with
a woman
[ Point
out
the
who
denial
in
.]
Pt:
[ Defense:
denial
But
in fantasy
reality
is?
[ Mirror
the
when
yourself
you
up
acting
when
to work
for
as
reality
act
as
more
if
shows
No.
able
if you
it?
out
can
to work
things
out?
Dont
doesnt
denial
is what
when
exist,
it is,
in reality
reality,
get
but
from
what
in fantasy
but
she
you
me
we
different
.]
[ Defense:
ignore
punishment.
be
in fantasy
Reality
things
reality
be
reality
denial
Shouldnt
Th:
wants
we
Shouldnt
patients
Pt:
Jennifer
shouldnt
.]
Th:
on
we
.]
Th:
And
through,
to the
of water
Can
face
talk
you
act
doesnt
get
You
shouldnt
be
as
want
hurt
wrong.
.]
to.
and
can
if
set
keep
surprised
up.
Pt:
[ Chuckles
.] Thats
expressing
true.
Displacement
Displacement
something
belongs.
colleagues
involves
else
A patient
during
rather
than
describes
a business
toward
how
feeling
the
his
meeting.
boss
toward
person
humiliated
someone
where
the
him
or
feeling
in front
of
Pt:
down.
I was
displaces
so
the
furious,
rage
he
And
then
I slammed
felt
toward
Th:
But
I went
back
my
on
his
the
fist
boss
desk
to
the
onto
didnt
the
office
desk.
his
do
and
sat
[ Defense:
desk
he
instead
anything
to
.]
you,
did
it?
Pt:
No.
Th:
desk,
was
Obviously
No,
Th:
toward
your
desk
Identification
The
the
may
anger
other
person
You
the
ridiculed
front
of you?
agree
out
of view
the
defense
defense
call
your
but
it
came
may
hurt
take
the
for
her
point
to
of
avoid
view
instance.
Help
of
her
the
feeling
threw
he
was
with
toward
it into
right.
the
the
your
trash
It probably
aggressor.
professor
can
was
She
right
in
dumb
adopts
her
.]
Do
you
notice
you
put
yourself
down
now?
What?
Do
paper
you
dumb
notice
? Do
you
how
you
put
yourself
down
notice
that?
[ Point
out
patients
likely
continuation
her
.]
Pt:
Yes,
Th:
self-attack
who
criticisms,
then
I think
Th:
and
Alex,
.]
Pt:
now
the
Alex.
toward
person
his
Whats
and
Th:
Point
for
aggressor.
identification
point
toward
rage
patient
with
the
paper
Pt:
[ Defense:
the
the
The
from
your
furious
felt
with
Th:
professors
intended
Aggressor
him.
and
herself
who
I was
identify
toward
differentiate
paper.
wasnt
instead.
with
patient
feeling
anger
it?
Pt:
out
this
.] Do
you
notice
but
[ Interrupts
how
the
you
put
yourself
down
now
just
of
like
your
professor
did?
[ Point
out
Pt:
right?
[ Defense:
call
identification
yourself
yourself?
dumb
[ Point
out
you
? Do
how
she
down
just
the
aggressor
.]
it is right
to put
think
treats
before.
that
But
is the
herself
what
if he
yourself
optimal
is
down
way
to
treat
.]
No.
Th:
yourself
that
think
you
.]
see
with
Do
Pt:
defense
I didnt
Th:
and
the
after
Do
you
you
described
Pt:
I see
notice
how
how
what
you
your
you
began
professor
mean,
to
did
but
put
that?
why
is
that
important?
Th:
depressed.
the
If you
professor
dont
for
Because
put
by
Then
criticizing
to you.
Do
Pt:
angry.
I was
yourself.
Identification
see
patients
with
they
toward
someone,
thing.
They
rage
toward
what
felt
are
and
angry
your
anger
you
what
with
toward
did
down
is the
him
him
feeling
for
you
toward
criticizing
back
to yourself
makes
onto
what
you
yourself
he
had
done
I mean?
the
ward
identify
You
In effect,
with
Sometimes
whom
turned
yourself
down,
you?
you
you
yourself
disrespecting
Th:
unfairly.
putting
Object
off
their
enraged.
the
next
with
the
of
rage
One
by
Rage
identifying
moment
moment
other
Ones
they
they
person,
say,
no
with
the
person
experience
But
longer
anger
I do
the
aware
same
of
their
him.
Pt:
I feel
like
you
werent
so
helpful
in the
last
session.
Th:
about
And
it sounds
like
you
have
some
feeling
it.
Pt:
Yes.
Th:
So
whats
the
feeling
toward
me
for
not
helping
you
more?
Pt:
Im
Th:
me
for
not
helping
you
angry.
How
Im
Th:
me
in your
back.
he
that
said
around
and
says
just
angry.
And
how
Im
[ Defense:
the
hardly
identifying
therapist
did
he
helping
is not
Th:
behavior
that
now?
I didnt
you,
how
do
you
you
helpful.
last
can
help
experience
[ Defense
we
you
take
last
with
me.
[ Point
feeling
Instant
yourself,
out
toward
can
resulting
feeling
suffering
from
patient
toward
this
anger
I have
object
him.
been
of
Now
his
he
holding
rage.
First
the
roles
turns
.]
notice
you
were
are
freer
to
turn
the
dont
not
being
fair.
describing
talk
your
about
the
camera
fact
back
onto
me?
After
all,
you
have
been
If we
dont
toward
he
criticizes
If
see
defense
see
see
turn
anger
I didnt
therapist
we
you
the
feel
angry
criticism
me?
because
back
[ Point
out
onto
the
I
you,
defense
.]
that.
you
dont
how
you
and
then
turn
the
criticism
experience
this
encourage
and
anger
anger
him
to
toward
face
his
.]
Repression
Defenses
the
the
toward
person
lets
the
with
anger
yet
Th:
onto
anger
experience
talk.
this
And
this
Pt:
back
this
.]
at
the
to
himself
If we
Im
time.
a look
of identifying
you
one
help
you
time.
Th:
didnt
do
you
ago
Pt:
really
not
Do
A moment
help
experience
body?
Pt:
feelings
you
more?
Pt:
toward
do
immediately
(Davanloo
depressive,
describes
an
repress
1990,
awareness
2000).
functional,
argument
and
with
his
of
This
occurs
psychosomatic
wife
stimulus
while
in
or
the
patients
disorders.
clenching
his
fists,
then
of the
angry
If asked
say
drops
is
cannot
his
impulse.
what
he
his
feeling
anxious.
the
you
suffer
his
de
about
Neborsky
2005
following
Instant
on
you
these
feelings
create
instant
following
the
ask
about
and
or
wont
know,
know.
or he
feeling,
the
will
patient
Ten
Otherwise,
instant
somatic
Have
each
repression
complaints.
of
de
Labije
instant
and
(See
Ten
2005,
and
repression.
summarizes
their
The
articles.)
Stimulus
stimulus:
A
of
the
What
happened
patient
who
stimulus
will
that
uses
triggered
defenses
respond
in
one
that
of
the
ways:
Denial:
Nothing
Ignoring:
what
his
use
study
symptoms?
repression
wont
repression.
will
repression
the
he
he
repression
anxiety.
patient
the
instant
was,
of
instant
detailed
of
wife,
2005,
instant
Repression
Suppose
from
limp:
impulse
awareness
Neborsky
for
material
his
depression
and
his
create
rage,
of
Labije
an
that
become
what
feeling
defenses
ask
which
is toward
Without
symptoms
Have
hands,
If asked
differentiate
Address
time
he
is bothering
We
happened.
broke
up,
but
I dont
think
thats
me.
Making
ones
head
empty:
Gosh!
I have
no
idea.
Selective
restaurant,
but
I dont
account
for
Instant
Repression
Suppose
you
breaking
up
create
following
remember
memory
anything
loss:
We
happening
went
there
that
to
would
this.
ask
with
instant
of
about
you
the
the
feeling:
that
repression
Feeling
way?
of
the
What
A
do
patient
feeling
you
who
will
feel
uses
toward
him
defenses
respond
in
one
for
that
of
the
no
big
ways:
Denial:
Ignoring:
I dont
Im
feel
not
anything
happy
about
about
it.
it, but
its
deal.
After
all,
I havent
been
so
Making
say.
Nothing
occurs
to
pleased
ones
me.
with
head
Im
him
empty:
empty.
myself.
I dont
Maybe
know
I dont
what
to
have
any
feelings.
Selective
wanted
to
rethink
his
the
break
up,
position,
and
but
memory
we
loss:
talked
I dont
I remember
about
remember
it.
I tried
feeling
to
he
said
he
get
him
to
anything
about
it
at
time.
Motoric
body
movements
her
anger
at
frustration
as
remain
slow
her
retardation/immobility:
down
boyfriend
she
talks
immobile
on
about
her
or
stop.
in
the
him.
lap.
The
patients
has
not
declared
her
arms
patient
session,
Then
The
but
her
arms
Immobilization
suddenly
instantly
rise
drop
in
and
represses
the
impulse.
Each
of
stimulus
these
or
feeling
she
cannot
an
intrapsychic
anxiety,
be
Ten
how
life.
the
help
create
her
from
instant
or causality.
To
establish
the
becoming
stimulus,
repression
that
aware
help
the
As
defenses
must
seeing
feeling.
see
The
from
her
of conflict
therapist
de
Labije
observing
and
Neborsky
her
feeling,
create
and
see
result,
instant
attentive
and
let
before
exploratory
outline
how
go
to
of her
therapy
(2005)
to awaken
the
capacities:
1.
experiences
her
Explore
problems.
current
When
situations
doing
so,
in
the
which
the
patient
will
and
help
defenses.
2.
the
experiences
triangle
patient
patient
possible.
patients
use
the
causality.
the
Thus,
which
Have
patient
she
the
and
prevent
inner
prevents
perspective,
defense,
defenses,
will
or
recognize
repression
her
defenses
patient
see
its
function,
Each
and
time,
then
identify
continue
the
to
defense
explore
the
current
situation.
3.
Each
time
the
patient
uses
this
defense
in
the
its
therapeutic
impact
relationship
on
the
identify
therapy,
and
the
then
defense,
help
continue
to
the
patient
explore
the
see
current
situation.
4.
which
interferes
picture
the
triggered
with
her
stimulus
her
Once
ability
in detail
she
will
repress
have
it.
from
her
in this
steps
2,
triggered
time
her
anxiety
which
go
she
and
can
uses
her
and
give
complex
and
turns
Instant
she
she
nothing.
her
said
to
that
instantly
notice
feeling
her
that
from
the
repression.
instant
repression,
the
for
stimuli
longer
her
(feeling
her
person
differentiate
distinguish
causality
that
then
describe
feelings
cause
to
see
nothing,
Research
her
how
forming
that
periods
feelings
triggers
presenting
the
the
of
from
anxiety,
problems).
the
Then
label
is
patient
about.
to
get
defenses
to
turn
the
feeling
This
will
therapeutic
against
her
bottom
of
her
suffering
perpetuate
will
her
defenses.
and
she
to
feeling
and
feeling
her
patient
a healing
defenses,
can
what
Encourage
complex
repression
the
feelings
face
from
her
her
feels
then
uses
can
can
Invite
words
can
her
against
understand
her
or
patient
the
patient
her
and
instant
she
see
transference
Help
prevent
the
bear
which
8.
difficulties.
defense,
step.
and
so
did
what
the
and
the
until
can
help
differentiate
defenses,
defenses,
next
defenses
person
second
feeling,
When
7.
mobilize
the
encourage
pictures
split
creates
5 again
defense,
evokes
correctly
see
stimulus,
other
to
and
that
feelings,
and
to the
can
patient
the
anxiety,
4,
the
for
of
moment
3,
before
the
the
immediately
6.
do
(what
feeling
experience
defense
to see
When
Intervene
split-second
feeling
patient
feelings).
5.
did,
the
alliance.
experience,
As
her
she
explore,
and
patient
says
feelings.
be
hard
therapist
shows
we
to
recognize.
might
feel
all
When
view
this
the
time,
as
a fact:
but
She
defenses
feels
limit
self-awareness
by
When
a patient
head,
or immobilizes
Nothing
denies,
to
anything.
The
keep
from
defenses
she
Identifying
vignette
that
prevent
describes
me,
Defenses
show
how
from
a situation
and
to
where
looks
Th:
Do
Pt:
Yes.
the
the
we
pay
defense
defense
attention
driving
this
to
the
terrible
of
her
anything,
remember
feeling
means
Defenses
assess
which
angry
the
patient
anxiety.
with
aware
Repression
his
his
uses
The
patient
girlfriend.
of feeling
anxious?
denial.
The
patient
is
tense
.]
Thats
a sign
of
in the
patients
you
like
So
this
in your
anxiety.
body
most
you
Theres
shoulders?
[ Continue
for
a minute
of the
ignore
no
the
Now
.] But
your
sense
defense
you
if we
to your
of ignoring
get
feel
defenses
tension
time,
to
point
.]
but
its
no
big
anxiety
most
of
the
try
ignore
anxiety?
making
a big
of ignoring
to justify
your
of
it.
.]
ignoring
anxiety,
[ Invite
deal
the
your
it will
patient
anxiety.
get
worse.
to let
go
of
his
head
.]
.]
I have
Th:
to
the
notice
using
Pt:
wants
empties
.]
Th:
Shall
feelings.
.]
defense
rationalizes
the
dont
Instant
[ Defense:
Im
ignoring
was
you
terrified
Pt:
[ Identify
I dont
Therefore,
aware
No.
Th:
Defense:
our
feeling,
a feeling
feel.
assess
he
Are
of anxiety
[ Defense:
[ Identify
be
I
Create
being
Pt:
time.
That
Th:
deal.
have
what
her
will
or
from
uses.
him
symptoms
result
dont
away
forgets
empty,
Pt:
out
the
knowing
will
to toe
or
Im
Th:
head
attention
ignores,
statement
the
This
our
herself,
occurs
me
distracting
bottom
anxiety.
no
Weve
of
idea.
got
this
[ Defense:
a problem
anxiety
[ Healthy
wish
and
.]
empties
here.
find
Another
A
out
part
of
whats
part
you
been
of
you
doesnt
want
work
right
to look
now.
at this,
[ Point
out
wants
the
Pt:
emptying
his
mind
conflict
What
blocks
the
find
out
way
you
want
you
have
no
Do
you
the
therapeutic
defense
see
what
to
Thats
Th:
We
you
mean?
task
want
why
can
is driving
go,
idea
how
Pt:
you
to
[ Does
not
our
see
the
bottom
how
.]
get
to
what
that
you
or
here.
ignore
your
of
have
no
idea.
Thats
to do,
we
have
no
his
But
or we
you
obstacle?
use
anxiety,
anxiety.
want
is an
task
Im
this
say
the
[ Point
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
Anxiety
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
Whats
feelings?
how
[ Defense:
feeling
wander
conflict
your
see
get
explore
see
internal
Why
can
find
what
toward
the
out
his
[ Invite
choice:
the
I dont
the
do
[ Help
defeat
get
soon
going
to
him
his
[ Recognizes
But
what
I want
turn
goal .]
the
to
ignoring,
patients
or
is your
find
the
price
We
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
[ Turns
of denial,
aware
we
then
Exactly.
anxious.
distracted
is not
away.
can
Th:
Pt:
me
his
I wont
Th:
makes
but
helping
out
choice?
but
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
Whats
may
he
my
use
for
hospice?
of
physical
he
[ Point
[ Defense:
Pt:
The
your
.]
these
dying
all
me
thoughts,
Obviously,
death,
defense
saw
dying?
cancer.
feeling?
tells
him.
Th:
your
looking
That
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
Do
it?
you
notice
[ Point
out
the
his
.] If I dont
feel
angry,
maybe
Im
not
.]
But
trash.
you
How
throwing
do
the
feeling
by
said
you
you
experience
resume
Do
him
forms.
you
are
angry
trash?
of the
Unconscious
notice
that
that
that
in the
reminding
[ A fist
Th:
anger
do
[ Sighs
Pt:
your
are
[ Draw
you
anger
denial
in the
to face
you
angry.
But
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
How
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
Do
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
If she
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
But
moment.
To
principles:
response
(Is
it
or a defense?)
self-observation
in this
Assess
the
patients
capacity
for
moment.
3.
This
see
problem
2.
specific
with
to
patients
1.
feeling,
frustrated
Intervene
to
help
the
patient
with
that
problem.
process
of
assessment
psychotherapy
usually
patients
directly
diagnosis
tells
causes
them
four
depressed
by
heart
mourning,
different
moment,
of
the
the
call
to
observable
us
or
what
how
to
assesses
symptoms
For
instance,
depressions
recent
loss,
These
same
the
in
phenomenological
has
could
the
but
not
suppose
have
we
been
longstanding
what
had
triggered
pathological
patients
would
responses
to
need
four
discover
the
diagnosis.
patients
(Coughlin
assesses
A
patient
Their
the
. Diagnosis
assessing
the
them.
self-attack.
for
therapist
symptoms.
treat
chronic
psychodiagnosis
phenomenology:
symptoms
patients.
treatments
Psychodiagnosis
cause
refers
surgery,
or
we
Della
the
Selva
patients
2001).
responses
Moment
of
feeling,
to
anxiety,
and
discovers
defense.
the
feelings
discharge
pattern
symptoms,
and
what
feelings
to
restructure,
the
patient
his
and
the
body,
on,
recover.
treatmoment
to
by
To
occurs,
and
presenting
comprise
the
triangle
symptom,
causes
that
problem
Each
response
time
how
the
we
conflict
we
of
feel
And
or
symptom.
To
the
can
out
intervene,
which
patient
deepens
patient
the
responds
the
patient
the
therapist
must
the
defense,
and
patients
need
patients
time
patients
This
triggers
symptoms
defense
has
together
presenting
triangle
that,
(or
we
of
conflict
examine
usually
the
each
of
the
patient
to
assess
three
answer
weakens
which
we
responds
patients
intervene
in only
a clear
which
feeling,
psychodiagnose
and
body
to
ways:
to
your
alliance.
with
Psychodiagnosis
Each
what
respond
Defense,
However,
and
do
Anxiety,
the
each
cause
a patient
Feeling
If
how
in therapy.
you
question),
the
and
feeling.
defenses
find
causes
Conflict
anxiety,
to
so
of conflict.
a reactive
. Anytime
try
analyze
defenses
strengthen
what
to
knows
what
us
treat,
the
therapist
to
to
anxiety
create
anxiety,
triangle
Triangle
Feeling,
of
or
know
defenses.
problems.
problem
patient
the
triggers
the
the
therapist
the
that
Now
what
understand
Whenever
a stimulus
defenses
tells
on,
the
struggles,
Psychodiagnosis
of
Anxiety
the
to address
focus
first
patient
capacities
Psychodiagnosis
anxiety.
the
self-observing
moment.
must
assessment,
capacity.
how
which
what
we
which
self-observing
to focus
symptoms,
this
with
in
can
response,
Through
with
the
the
weakens
can
pathway
self-observing
the
explore
anxiety
or
alliance.
the
feeling.
defense.
of anxiety
capacity
alliance.
to
Now
discharge,
assess
the
watch
the
effectively.
Anxiety
responds
the
to
pathways
an
intervention,
of
unconscious
anxiety
discharge.
Striated
muscles
Smooth
muscles
Cognitive/perceptual
The
patients
pathway
capacity
to
is,
his
when
muscles
not
the
other
learn
to
hand,
integrate
shifts
patient
conflictual
will
is
the
feeling
the
the
striated
and
defenses
to
observe
and
must
find
go
Structure
The
of
Highly
character
defenses,
types
of
you
will
for
choice
avoided.
remain
low,
issues
he
usually
avoids.
the
patient
Work
his
is
It
If
we
but
he
On
cannot
at the
anxiety
highest
discharged
and
enacted
and
regressive
defenses
the
that
use
the
defenses.
fall
under
character
and
tactical
and
resistance
therapist
list
Later
those
(a
at a distance).
use
following
category.
to
repressive,
patients
implications
ability
repressive
the
assess
feeling.
transference
The
each
We
with
tactical,
to keep
presenting
structure,
correlate
use
somatizing
psychodiagnostic
of treatment.
as
uses.
to bear
uses
patients
well
he
capacity
patients
as
and
character
patient
resistant
resistant
symptoms
defenses
and
the
relationship
learn
sign.
will
while
patients
of defenses,
depressed,
character,
the
the
defenses
defenses.
Fragile,
smooth
anxiety
patients
identify
Moderately
pathological
that
Defense
the
out
Character
structure.
the
is a good
previously
to regress.
bear
into
high,
his
tolerance,
muscles
too
begin
can
causes
let
types
will
us
muscles.
what
we
and
tells
anxiety
Anxiety
becomes
patient
of
problems
of
he
patients
anxiety
discharge
striated
feelings
feelings
of
threshold
disruption.
face
if his
anxiety
the
the
learning
learn
from
facing
Psychodiagnosis
To
his
feelings,
new
level
and
cognitive/perceptual
the
avoid
unconscious
feelings
anxiety
or
means
into
bear
of
disruption
repressive,
shows
in
the
defenses
the
book
have
Nonverbal
sighing,
bodily
of eye
contact,
tactical
posture
and
defenses:
(such
as
Laughter,
crossed
cover
rumination,
and
hypothetical
racing
legs
and
tactical
words,
arguing,
speech,
evasiveness,
repression,
down,
passivity,
and
negation,
reaction
weepiness,
projection,
hallucinations,
and
rambling,
neglecting,
dismissed
by
others
to
see
their
somatization,
turning
in the
Observe
and
therapists
help,
of
and
Let
Go
as
let
go
their
defenses
are
who
they
are
go
of their
testing,
and
somatizing
and
establish
defenses,
let
defenses.
projection.
to
and
some
These
an
not
patients
intrapsychic
other
of
of
people,
the
patient
was
fairly
patients
focus
create
quickly.
These
defenses
need
the
patients
of
therapist
not
defenses
their
their
lead
to
to let
go
of their
in therapy.
their
the
Then
symptoms.
resistant
their
require
much
feelings.
see
differentiate
usually
believing
patients
to face
do
can
Highly
mistakenly
people.
cannot
toward
resistant
defenses,
as
Enacting
Defenses
them
Regressive
patients
Ignoring,
resistance:
feelings
moderately
see
regressive
self,
dissociation,
defenses:
oneself
experiencing
not
depressed,
the
past
do
to see
on
externalization,
dismissal
patients
help
Helplessness,
delusions
to resist
defenses
of
rationalization,
defenses:
Transference
relationship
Isolation
formation
splitting,
forgetting,
the
indecision,
defenses:
Character
With
minimizing,
intellectualization,
compliance,
depression,
Ability
Vagueness,
forgetting,
Regressive
a past
avoidance
speech
denial,
slowing
arms),
defenses:
Repressive
affect,
dismissive
gestures
Verbal
generalization,
mimicry,
Fragile,
character
a
loss
therapist
regressive
they
and
in
reality
from
defenses
will
see
that
Capacity
to
Moderately
feeling
and
Feelings
highly
because
Fragile,
of
Bear
their
depressed,
feeling
before
and
The
To
disruption.
defenses
her
they
such
as
attention
able
to
to
observe
a
them
the
observe
patient
and
moment
capacities
them.
and
defenses,
and
deeply,
we
must
suffering
pay
to
pay
attention
get
need
well.
can
bear
to get
to mobilize
of their
and
able
to
cause.
it.
anxiety,
see
The
low
to
or
levels
of
through
and
patient
in the
of
and
must
turn
against
pay
attention
must
and
a list
observe
patient
and
anxiety,
in patients
Ability
able
To
is
muscles
feelings
be
observe
following
levels
externalization.
must
to
low
Capacity
her
to feelings,
The
rid
of
muscles.
only
only
Self-Observing
attention
they
smooth
Some
levels
striated
bear
the
try
high
can
into
regulate
be
the
shifts
a patient
To
bear
into
patients
projection
of
feelings
pay
by
anxiety
before
can
is discharged
Psychodiagnosis
feel
patients
somatizing
their
conflict
regressive
anxiety
and
cognitive/perceptual
feeling
resistant
be
defenses
be
her
to
able
to
moment
the
self-observing
following
order:
to observe
Feelings
Unconscious
anxiety
in
the
body
Defenses
observing
ego
and
experiencing
and
difference
between
the
self
people
The
The
difference
between
other
projections
Ability
to pay
attention
Feelings
Anxiety
Defenses
The
relations
to
among
feeling,
anxiety,
and
defenses
The
Ability
Stimuli
Feelings
from
anxiety
Feelings
from
defenses
to see
defenses,
feeling,
the
which
feeling
create
the
relationship
to differentiate
Ability
triggers
therapeutic
from
causality
Process
triggers
in which
anxiety,
presenting
feelings
and
stimulus
anxiety
triggers
problems
Dystonicity
from
the
defenses
one
Ability
to differentiate
Ability
to see
the
Ability
to
oneself
uses
price
of
the
defenses
grief/guilt
over
the
ASSESSING
price
THE
paid
for
the
experience
defenses
PATIENTS
RESPONSE
TO
INTERVENTION
After
each
or
defense?
patient
patient
response,
If
the
responds
patient
with
cognitive/perceptual
feeling.
keep
the
If the
exploring
patient
These
are
sequence
THE
To
patient
the
and
let
three
anxiety
intervene,
OF
the
regulate
it,
If the
patient
of the
basic
and
a
the
with
go
Is
in
responds
of assessment
CYCLE
yourself:
expresses
disruption,
feeling.
see
ask
this
feeling,
and
in
interventions.
intervention
then
Now
that
focus
striated
with
and
it.
If
the
muscles
then
the
responds
anxiety,
explore
smooth
anxiety
defense,
a feeling,
or
on
muscles,
a defense,
invite
let
guides
the
the
us
review
our
work.
help
feeling.
the
PSYCHODIAGNOSIS
therapist
must
know
what
problem
the
patient
needs
the
help
with
patients
a feeling
(which
therapist
or
a defense
of
so
assesses
patients
the
patient
Psychodiagnosis
go
the
This
and
of
Now
OF
we
will
their
address
them.
go
The
of his
patient
offers
effective
Psychodiagnosis
On
the
let
go
therapist
Should
you
What
seeing
Where
is
explore
problem
a feeling,
of
regulating
so
answer
the
therapist
to address
the
moment.
by
to intervention.
the
therapist.
assessment
progression
of
of the
the
response,
session.
DETOURS
time,
defenses
of
the
help
the
can
any
face
question
When
he
him
patient
his
common
responses
by
and
interventions
to
with
If he
see
regulate
his
warded-off
answers
exploring.
help
most
implications,
he
continue
defense,
the
therapist.
response
response,
some
Each
therapeutic
Interventions
Work
5.
or a defense.
or
patients
psychodiagnostic
a feeling,
anxiety
The
TYPICAL
can
to anxiety
in this
4.
review
patients,
by
problem
determines
OUTLINE
let
Intervention
intervention,
intervention
and
of a defense?
psychodiagnostic
cycle
the
a defense?
from
see
to intervention.
of conflict?
patient
feeling),
intervention
by
address
be
(which
patients
Thus,
an
will
anxiety
patient
response
triangle
or
3.
specific
to develop
patients
the
the
assesses
response
the
feeling).
2.
on
explore
patients
therapist
excessive
help
The
prevents
or letting
will
1.
anxiety,
self-observation
can
response
response
regulate
they
the
patients
explore),
therapist
explore
this,
The
will
so
the
learn
intervention.
regulate
can
To
therapist
(which
each
a feeling,
to
the
will
they
anxiety,
moment.
response
the
the
in this
the
or
therapists
responds
detour
and
feelings.
a feeling,
the
anxiety
with
and
with
detour
question
or
a detour
to
return
to
an
focus.
for
Detours
When
Asking
for
Problem
to
To
co-create
a therapeutic
motivates
the
asking
the
Since
many
they
fear
patient
patient
to
seek
about
of our
on
the
us.
Thus,
may
would
like
me
to help
offer
I am
with
in conflict
hurt
know
we
what
problem
always
he
begin
seeks
in previous
than
offer
by
our
help.
relationships,
a clear
example
a detour.
What
is
the
problem
with
which
you?
with
my
There
fiance,
are
and
lot
I dont
of
situations
know
how
in
to
deal
her.
Psychodiagnosis:
answer
to your
The
example
where
Anxiety
Detours
Sometimes
this
the
present
with
to anxiety,
problem
patient,
anxiety
how
comes
rather
instead.
to assess
Could
like
than
This
them,
offer
me
to help
muscle
tension
and
of
anxiety
in
clear
look
at
specific
show
problem,
common
will
detours
to intervene.
What
is
the
problem
with
which
you?
and
the
will
how
One:
begins
Im
talking
Psychodiagnosis:
rise
we
a presenting
section
Response
shows
gives
up?
Intervention:
would
patient
question.
Intervention:
you
to
which
rather
Response:
which
for
been
Intervention:
you
need
Thus,
problem
have
patient
we
therapy.
the
patients
depending
of a problem,
alliance,
rapidly
The
striated
nervous.
muscles
[ The
patient
.]
patient
experiences
and
uses
a fast
regressive
defense.
Intervention:
assess
and
it, and
ignoring
point
the
out
the
too?
you
are
destructive
attention
to
consequences
the
anxiety,
of talking
over
anxiety.
Th:
notice
Mobilize
talking
rapidly
This
nervousness
over
your
is
anxiety.
sign
Do
you
of
anxiety.
notice
I
that
Pt:
[ Defense:
Th:
way
to ignore
When
it. [ Identify
the
Pt:
Defense:
rationalization
and
denial
speech
talk
over
.] I always
your
do.
anxiety,
thats
.]
I ignore
But
my
anxiety,
it
will
go
away.
.]
has
it ever
gone
away?
[ Confront
the
.]
Pt:
No.
Th:
aware
of it, but
your
Ignoring
body
is still
Pt:
Could
it down?
we
pay
[ Help
anxiety
may
make
anxiety
actually
you
less
anxious.
Ignoring
attention
the
the
Yes.
Th:
you.
you
defense
If
Th:
denial
rushing
to
patient
let
your
your
go
anxiety
of the
Response
and
defense
Two:
see
isnt
if we
helping
can
bring
.]
Im
feeling
pain
in
my
stomach.
Psychodiagnosis:
rise
of anxiety
in the
smooth
The
mobilize
then
invite
sign
of
anxiety.
else
do
you
Go
attention
feeling.
You
Are
notice
through
the
unconscious
to
the
in your
complete
anxiety
Stop
anxiety
are
you
aware
list
such
as
here
of
help;
this
you
see
muscles
of anxiety,
isolation
your
own
makes
that
and
of
free
you
sequence?
is in the
a fast
anxious
right
Once
it by
to
that
is a sign
to assess
it,
and
Thats
now?
What
of anxiety?
her
patient
promoting
me
and
[ Once
the
can
pathways
of
about
the
anxiety
muscles
observe
higher-level
intellectualization.
tell
anxious,
striated
regulate
feeling
now
problem
.]
and
will
to
the
stomach.
right
regulate
affect
into
in your
of symptoms
discharge
inquiry
of pain
of
body
the
immediately
aware
Intervention:
symptoms
experiences
muscles.
Intervention:
and
patient
your
is
longer
instead,
have
problem.
goes
no
defenses,
You
anxiety
ask
her
to
You
your
in
about
come
the
her
want
gut.
Do
smooth
feeling
again
.]
Response
Three:
Im
sorry.
What
did
you
say?
Psychodiagnosis:
tension
anywhere
experiencing
in
her
body.
what
you
mobilizing
into
that,
to
is your
thinking
feeling
a little
confused?
Okay.
I noticed
that
help
you
out.
Did
with,
you
triangle
of
symptoms
of
me
as
conflict
and
is unable
Regulate
the
anxiety
right
is your
as
went
How
and
you
she
is
to think
or
Are
what
straight
up,
is your
your
and
thinking
would
get
you
ringing?
like
me
mind
to
blanked
now?
[ Talk
about
the
the
body
until
the
Is
this
disruption
disappear
out
Are
ears
your
to
blanking
we
cloudy?
you
attention
mind
Before
Is it a little
vision?
immediately
.]
something
you
would
with?
Detours
Sometimes
present
the
with
detours
patient,
rather
defense
to defense,
than
instead.
how
to assess
Intervention:
you
anxiety.
I asked
mobilize
your
of
now?
cognitive/perceptual
anxiety
that
she
experience
soon
anxiety
that?
to help
Defense
the
How
notice
of
problem
like
your
reveals
no
said.
attention
how
exhibits
disruption;
Intervention:
by
patient
Assessment
cognitive/perceptual
remember
The
would
like
me
to help
offer
This
them,
What
a presenting
section
and
will
how
is
problem,
the
show
will
common
to intervene.
problem
with
which
you?
Response
One:
Let
me
first
tell
you
than
answer
my
history.
Psychodiagnosis:
question
have
directly,
no
agreement
the
patient
to
do
uses
therapy
Rather
diversification
yet,
as
so
we
the
defense
the
a defense.
We
interpret
the
cannot
defense.
Intervention:
question.
I look
forward
to hearing
Block
your
history,
but
and
first,
restate
the
can
tell
you
me
the
problem
you
would
like
me
to help
Response
cant
think
of anything
specific
Two:
right
of vagueness
to keep
be
to declare
more
an
The
the
specific
internal
about
patient
therapist
lot
of
things.
the
defense
Thats
problem
uses
the
tactical
at a distance.
Block
problem.
the
now.
Intervention:
patient
with?
Probably
Psychodiagnosis:
defense
you
you
and
a bit
would
vague.
like
me
invite
the
Could
you
help
you
to
with?
Response
Three:
Im
not
sure
have
problem.
Psychodiagnosis:
resistance.
She
denies
she
has
a problem
Intervention:
says
he
have
has
no
to
between
what
sitting
problem,
you
permission
interventions
in
here
no
to
for
no
problem,
your
have
her
says
a therapists
(she
at
feet
brought
no
all
you
my
problem
the
agreement
yet
Im
Four:
patient
therapy.
You
contradiction
does
(she
wouldnt
say
you
you
could
is
come
have
no
tell
me
is.
onto
the
therapist
and
The
then
Intervention:
responsibility.
you
you
one.
noninterpretive
and
sure
high
the
the
I thought
Psychodiagnosis:
responsibility
out
problem)
anyway.
Since
make
no
here
share
to do
Point
although
exhibits
than
inquiry.
So
Response
what
rather
denial.
And
or
patient
Instead,
has
office).
reason
Stop
interpret.
address
she
The
Only
you
can
know
patient
becomes
sure
this
what
her
passive.
Deactivate
for
projects
your
projection
problem
of
might
be.
Response
and
the
way
he
handles
our
Five:
money.
The
The
Psychodiagnosis:
anxiety
in
the
striated
muscles
accompanied
problem
patient
is my
husband
is fidgeting.
The
patient
by
experiences
externalization
and
projection.
her
If we
blame
agree
others
intrapsychic
that
for
her
her
husband
problems.
We
internal
focus.
what
would
Since
internal
hes
Block
not
problem
here,
you
would
Response
looking
problem,
fail
we
to
just
help
establish
an
focus.
Intervention:
with
is the
the
projection
I cant
help
like
to help
Six:
me
I
dont
and
him.
ask
for
wonder
So
an
you?
know
what
you
are
for.
Psychodiagnosis:
reveal
herself
that.
onto
If
no
you:
dont
anxiety
cognitive/perceptual
The
want
goes
disruption
patient
to
reveal
into
is the
projects
the
her
myself.
You
striated
pathway
of
will
to
want
muscles,
unconscious
anxiety
discharge.
Intervention:
to
avoid
which
a misalliance.
she
has
Remind
Was
Pt:
you
to come
Yes.
Th:
Did
To
the
for
asking
explore
anxiety
will
regulate
something
about
will
there
anything
drop
and
of
of
you
No
to
to come
a problem
come
look
inside
herself,
here
today?
you
wanted
me
to
forced
who
own
free
will,
or
were
me.
is looking
until
until
her
can
she
for
anxiety:
(1)
and
help?
Who
is
actually
projecting
drops.
it onto
Then
her
you.
Do
projective
explore.
rise
(4)
stops
projection
accompanied
projection,
of your
of this?
will
you
one
So
out
her
anxiety
causality
defense
will
will
here?
Th:
not
it your
Was
Pt:
Pt:
Keep
her
of her
with?
forced
looking
of
projection
Yes.
Th:
you
her
the
forgotten.
Th:
help
Deactivate
by
projection,
of
feeling,
projective
we
(2)
anxiety
must
rise
due
of
to
understand
anxiety,
fear
(3)
of
the
projection
on
the
perpetuates
it.
regulation
this
be
order:
anxiety
therapist.
Only
by
possible.
Step
Feelings
deactivating
Thus,
One:
trigger
we
the
need
Deactivate
anxiety,
to
the
but
projection
use
the
projection
will
anxiety
following
projection
until
steps
in
the
projective
until
it
drops.
Step
to the
striated
muscles
Two:
and
Regulate
cognition
Step
the
anxiety
becomes
Three:
returns
clear.
Explore
feelings
in
another
relationship.
because
I dont
want
Response
Seven:
I dont
you
into
stuff.
to get
my
Psychodiagnosis:
striated
muscles,
speaking
part
in
of
though
and
she
detached,
reveal
uses
the
myself
Point
choice
up
into
your
you
out
control.
If
you
pay
yourself.
Focus
first
on
how
with
must
inner
the
have
only
you
to
for
of
the
therapist.
a good
Detours
Problem
it
the
defense
of
defense
is
help
me
but
You
is
for
can
So
even
to look
a good
with
When
Inviting
to
to
the
bodily
stuff.
focusing
Specific
[
your
at your
paying
your
under
and
therapeutic
get
yourself.
allow
the
question
will
herself,
leave
me
entirely
before
her
only
listen
feelings
and
reveal
the
feelings
herself
have
relationship
choice,
and
your
to
To
.]
to
those
projection
impossible
issues
choose
relates
it is
that
them,
can
her
And
attention
you
and
is yours.
your
.]
her
projection
control
into
task
she
is in
This
life.
Interventions
Example
go
accompany
But
relationship
The
close
is,
the
them.
to
voice.
want
task
news
[ Deactivate
want
that
first
good
therapeutic
know
to her
The
of
about
anxiety
nonverbal
Deactivate
therapeutic
the
sensations
she
the
or conceal
whether
Point
her.
issues.
emotions
is
to
out
talk
to you.
Intervention:
defiance.
tone
resistance:
to
patients
tactical
uninvolved
transference
I dont
The
want
you
on
to
the
alliance,
attention
Once
the
ask
for
patient
describes
a specific
example
example,
the
we
can
patients
find
the
of
out
problems
problems
the
what
and
for
problem.
the
which
he
seeks
By
exploring
of
conflict
triangle
help,
we
that
specific
is that
creates
at
specific
symptoms.
Intervention:
Can
we
take
a look
example?
Response:
she
suddenly
me.
She
the
ring
turned,
said
she
and
spit
found
threw
on
me
it into
I asked
me,
and
said
despicable
the
her
and
He
Anxiety
exhibits
no
marry
she
me,
would
worthless.
but
never
then
marry
Then
she
took
gives
clear
street.
Psychodiagnosis:
answer.
to
resistance
The
patient
yet.
Detours
When
the
patient
therapist
may
before
asks
offer
for
a detour
exploring
a specific
of
a specific
example
anxiety
that
of
requires
the
problem,
anxiety
the
regulation
example.
Intervention:
Can
we
take
a look
at
specific
to my
stomach
example?
Response:
thinking
about
Im
getting
sick
it.
Psychodiagnosis:
discharged
in the
smooth
anxiety
before
anxious
right
The
exploring
Th:
feeling
The
patients
anxiety
is
muscles.
Intervention:
patients
just
a specific
Thats
now?
therapist
a sign
[ Identify
of
and
must
example
of the
anxiety.
label
regulate
Are
you
the
symptom
you
to look
the
problem.
aware
as
of
anxiety
.]
example
you
stimulus,
of
this
Yes.
Th:
As
conflict,
stomachache.
anxiety,
Pt:
you
Do
and
soon
you
symptom
as
became
see
.]
I invited
anxious,
that
too?
and
[ Point
the
at a specific
anxiety
out
gave
causality:
conflict
so
we
can
Pt:
Yes.
Th:
Im
help
you
Pt:
[ The
patients
anxiety
safe
to resume
the
you
and
Defense
When
is
patient
I have
the
we
you
to get
striated
take
like
to face
this
anxiety?
rid
of this
muscles
of a specific
Can
were
therapist
may
now
example
a look
anxiety.
so
of the
at a specific
it
is
problem
.]
example
of
in conflict?
that
than
address
asks
for
experience
dependency
the
in
at this.
Would
your
.] Yes.
back
to look
it does.
overcome
exploration
she
scary
Detours
the
rather
sure
[ Sighs
Th:
where
It feels
will
anxiety
result.
a specific
those
a specific
As
over
of
until
the
a result,
example
defenses
example
the
of
the
increased
some
problem,
the
closeness
patients
offer
their
problem.
The
patient
offers
a specific
and
defenses
therapist
must
example
of
problem.
Intervention:
Can
we
take
a look
at
specific
example?
Response
of forgetting,
One:
I cant
Psychodiagnosis:
The
This
defense
repression.
tactical
remember
patient
one.
uses
keeps
the
the
defense
therapist
at
a distance.
Intervention:
to
help
example,
and
we
specific
the
patient
we
wont
turn
wont
be
example
be
against
able
able
to
to
of where
Point
it.
get
help
this
If
you
I cant
think
picture
it.
Two:
of
So
have
of
Its
for
defense
your
could
up
the
we
specific
problem,
look
at
you?
more
of
general
tactical
specific.
The
patient
uses
the
the
defense
and
then
of vagueness.
Intervention:
specific
price
dont
comes
Psychodiagnosis:
defense
we
with
problem
of anything
the
clear
Response
problem.
out
example.
Ask
for
Block
a
specific
example
until
the
invite
patient
presents
one.
vague,
we
able
to
where
general
wont
help
this
get
you
problem
a clear
with
problem
is vague.
picture
it.
comes
think
of a place
defense
we
up
you?
for
at
have
of your
The
Intervention:
Block
the
price
Notice
how
example?
a specific
Thats
What
difficult
topics
lots
the
you
example,
difficulties.
of
are
going
we
can
we
giving
the
patient
we
look
wont
be
many,
of
cant
uses
the
tactical
to share
the
his
causes
of anxiety
patient
in which
Detours
When
a
in that
problems.
defense,
her
and
for
then
time
coming
able
a clear
to get
the
invite
because
up
if
we
picture
that?
My
fiance
likes
patient
to
bring
up
generalizes
example
ring
defense,
this
to
the
than
She
into
the
invite
for
Could
you?
Feelings
of
out
the
patient
describe
then
general.
is a problem
Inviting
to find
and
is a bit
example
However,
the
the
That
specific
rather
threw
doing
Block
example
Intervention:
names,
draw
a problem
The
example.
offers
feelings
and
and
a hard
be
about
a specific
for
his
defense,
example.
at a specific
explore
toward
we
of times.
a specific
Interventions
the
to be
Four:
Intervention:
you
remains
example
so
patient
having
Psychodiagnosis:
that
are
defense,
wont
do
Response
Once
and
specific
There
Psychodiagnosis:
to
example.
a specific
avoid
this
to start.
attention
specific
dont
as
problem,
look
Three:
long
of avoidance.
patients
with
of your
Could
Response
As
the
problem,
triangle
usually
his
yelled
street.
we
of
offers
conflict
detours
feeling.
and
spit
What
at you,
is
called
your
feeling
that?
Response:
I was
Psychodiagnosis:
angry.
The
patient
gives
clear
answer
to the
question.
Intervention:
experiences
anger
his
right
Anxiety
When
be
feeling
now,
in
his
physically
body.
in your
How
the
therapist
invites
the
The
pathway
of
therapists
do
you
the
patient
experience
that
body?
interventions
as
patient
names,
toward
and
her
for
threw
doing
to label
anxiety
the
in the
She
ring
into
feeling
from
will
the
will
the
examples.
and
street.
anxiety
determine
following
yelled
One:
I feel
Psychodiagnosis:
striated
feeling,
spit
at you,
What
is
called
your
feeling
that?
Response
the
his
discharge
illustrated
Intervention:
into
how
Detours
aroused.
you
Explore
muscles.
anxiety,
Since
he
The
the
cannot
tense.
patients
patient
observe
anxiety
cannot
the
goes
distinguish
feeling,
only
his
symptoms
of anxiety.
Intervention:
feeling.
with
The
tension
anxiety,
what
is your
is the
Differentiate
anxiety.
feeling
that
Response
If you
dont
makes
Two:
you
I feel
into
distinguish
feeling,
his
only
the
smooth
feeling
from
symptoms
anxiety,
that
of
and
symptom
anxiety
about
your
then
in your
in
your
Regulate
point
stomach?
body
feeling,
is
feeling
anxious?
to my
stomach.
patients
Since
he
your
the
the
anxiety
patient
unable
to
is
cannot
observe
the
of anxiety.
Intervention:
self-observation,
so
The
muscles.
from
cover
sick
Psychodiagnosis:
discharged
anxiety
you
right
out
causality.
Do
you
now?
became
the
So
anxious
anxiety
Where
notice
we
by
any
notice
and
do
you
other
that
then
mobilizing
symptoms
when
got
notice
sick
asked
to
your
stomach.
Differentiate
looked
at
his
your
feeling
from
feeling
toward
anxiety
and
Melanie,
point
this
out
anxiety
causality:
comes
As
you
in
and
attacks
your
After
gut.
drawing
Do
the
regulate
the
another
relationship.
your
anger
you
anxiety
by
attention
to
the
focus
switching
Does
anxiety
the
to
attack
relationships?
therapist
invites
defenses
are
triggered.
and
help
the
patient
sees
the
defenses
feelings
Could
he
the
Thus,
see
he
has
patient
the
names,
toward
and
her
the
we
for
uses,
he
previously
threw
doing
feeling
with
what
cannot
see
his
can
make
stimulus
from
stimulus
soon
also
feeling
as
at an
you
in
face
example?
the
ring
other
feeling
into
that?
street.
his
But
mobilize
avoid
defensive
anger.
what
or
she
did.
the
did
his
function
complex
function.
Help
affect.
spit
the
patient
and
face
at you,
is
patient
called
your
feeling
confuses
stimulus).
does
the
is
That
affect.
his
is why
he
It covers
his
Right.
You
feel
the
That
is,
the
patient,
serve
his
the
out
the
toward
her
for
.]
cannot
sadness
distinguish
comes
the
patient
now?
Does
sadness
help
patients
the
[ Point
feeling
patient
sadness
Here,
feeling
The
the
differentiate
you!
sad.
hurt
Does
hurt
I feel
has
emotions?
patient
your
from
Two:
patient?
the
She
What
Intervention:
defensive
out,
hurt.
(the
stimulus
defensive
If someone
paralyze
point
choice
What
The
Absolutely!
[ Differentiate
Once
and
of anger.
what
from
uses.
and
I feel
Psychodiagnosis:
feeling
identify,
yelled
the
One:
person
feeling.
.] Thats
must
anxiety
that?
the
the
feeling,
a different
She
Response
sad.
can
avoided.
Intervention:
cover
as
his
he
Psychodiagnosis:
his
you
patients
look
to label
defenses
Response
doing
the
you
therapist
Intervention:
you
causality,
Detours
When
the
that?
patients
in other
Defense
see
him
in
will
to
feel
sadness
face
or
sadness
has
feeling
from
anger.
Differentiate
sadness.
This
the
sadness
is
between
you
and
feeling
you,
but
toward
Im
her
asking
for
you
hurting
something
different:
what
is
the
you?
Response
Three:
I think
she
was
wrong
to
do
that.
Psychodiagnosis:
distinguish
his
feeling
from
the
The
defense
the
Thats
you
your
dont
doing
feeling
and
the
thought,
but
your
cover
it with
Help
defense,
and
thought
a thought,
is not
whats
not
the
patient
then
invite
the
your
distinguish
the
same
as
feeling
feeling.
a feeling.
toward
If
her
for
that?
Response
Four:
I wonder
Psychodiagnosis:
distinguish
his
feeling
from
the
between
his
can
speculate
only
about
feeling
and
the
about
defense
how
you
Help
feel.
she
and
did
Whats
she
did
patient
that?
does
not
of rumination.
defense,
why
why
The
Intervention:
clear
does
of intellectualization.
Intervention:
between
patient
the
then
it, but
the
patient
invite
we
feeling
distinguish
the
could
feeling.
get
toward
We
absolutely
her
for
doing
that?
Response
Five:
I was
Psychodiagnosis:
of
self-attack.
self-attack
Address
will
make
this
him
The
defense
depressed
observing
Lets
you
capacity:
pause
what
your
mind
must
be
for
you
doing
feeling,
Does
that
to
make
like
you.
on
Do
you.
critic
comes
Continue
until
As
the
the
patient
defense
his
happened
critical
you
that?
So
soon
as
the
you
room
asked
system
that
pay
to
low
self-attack.
here.
this
see
with
of
instead,
into
defense
session.
at what
and
her.
Otherwise,
a depressed
see
look
her,
criticize
this
patient
to trust
uses
immediately.
for
and
toward
a number
its
the
a moment
feel
began
your
Help
stupid
patient
in the
Intervention
so
in
criticism
attention
interrupt
to
you.
sense?
the
patient
sees
the
difference
between
his
self-attack
feeling
must
and
the
become
defense
dystonic
of
self-attack.
before
he
can
The
fully
defense
access
his
of
rage
.
Response
Six:
[ Sighs
Psychodiagnosis:
into
the
striated
muscles,
so
this
The
Confusion
thought,
whats
the
feeling
If we
toward
did
you
say?
has
into
become
Seven:
I feel
the
[ The
patients
The
patients
disruption.
from
feeling
the
with
body
goes
The
anxiety
patients
is
anxiety
high.
Intervention:
causality
feeling
confused.
cognitive/perceptual
too
the
cover
Psychodiagnosis:
discharged
goes
her?
Response
limp .] What
dont
anxiety
defense.
Differentiate
is a thought.
confused.
patients
is a repressive
Intervention:
defense.
.] I feel
of feeling,
anxiety,
Regulate
and
Th:
the
anxiety
and
show
the
symptoms.
You
are
confused?
How
is
your
thinking
now?
Pt:
Not
Th:
good.
Is it cloudy?
Pt:
Yes.
Th:
Thats
a sign
of
anxiety.
Did
you
just
blank
out?
Pt:
Its
Th:
vision
and
Thats
My
Th:
faint
Th:
up
mind
another
emptied.
sign
of anxiety.
How
is
your
vision
is a bit
Thats
another
Are
you
blurry.
sign
of
anxiety.
your
feeling,
or dizzy?
Pt:
goes
my
hearing?
Pt:
feeling
like
rapidly,
your
No.
When
mind
starts
I ask
not
about
working
right,
and
your
you
anxiety
become
confused.
Do
you
see
that
sequence?
Response
feel
Eight:
[ The
patient
sighs
.] I
dont
anything.
Psychodiagnosis
in the
striated
muscles,
so
this
One:
is the
Intervention:
the
patient
time
you
turn
dont
ground,
what
to
and
against
have
youre
is the
not
feeling
defense
right
and
then
invite
feeling
is
when
you
If you
dont
toward
away,
yet.
you
this
is the
what
you
asked
said
that
right
feel?
To
better
a friend
dont
know.
didnt
know
if she
You
is
encourage
feeling.
are
six
The
feet
deaden
Point
before
any
be
only
under
your
the
feelings,
you
open
bit
perturbed
door
looked
his
Do
you
inside
imagine
pantry
and
pantry
to see
that
she
because
to her
denied
defense.
defense,
in her
the
the
even
this
patient
repression.
out
flour
a
If the
of instant
understand
had
than
defense,
the
Two:
defense
away,
would
rather
anxiety
her?
Intervention:
notice
the
it,
dead
patients
of denial.
Identify
Psychodiagnosis
feelings
The
you
replied,
she
said
she
to see
what
was
in there.
Response
Nine:
Im
embarrassed.
I feel
so
bad.
Psychodiagnosis:
toward
his
toward
fiance
himself.
identifying
shame
who
hurt
In effect,
with
her,
functions
as
he
rather
Rather
him,
borrows
than
a defensive
face
affect
Intervention:
shame.
affect
just
police
her.
Differentiate
of
shame.
when
Do
Do
I ask
come
you
the
you
in to
see
you
see
Taser
that?
you
feel
before
Could
describes
(Nathanson
his
feeling
toward
his
his
the
feeling
her?
you
me
a
tell
take
feeling
1992),
her.
Here,
anger.
defensive
from
function
the
embarrassment
toward
we
a feeling
shame
out
this
describe
her
to hide
and
how
you
patient
Point
patient
what
the
than
Its
of
defensive
attacks
you
like
the
shame
how
you
feel
toward
look
at
the
feeling
underneath,
the
feeling
Interventions
for
Experience
Once
of
the
patient
vignettes
correctly
feeling
use
has
how
therapeutic
experience
labeled
his
feeling,
his
body.
of
to
in
anxiety
address
belly,
my
anger
hands
of his
You
physically
your
want
Anxiety
in his
what
felt
I feel
to grab
describe
patient
may
report
differentiate
anxiety
if it is too
triggered
his
experience
If
comes
body
some
the
following
and
maintain
an
with
her.
do
right
heat
The
How
now?
coming
patient
how
is
let
with
that
he
up
from
aware
of
experiences
heat
that
the
come
that
up
through
rage?
how
he
experiences
the
experience
the
patients
feeling
and
invite
high,
of
then
the
anger
anxiety
from
the
differentiate
The
anxiety,
patient
body,
therapist
regulate
to face
the
the
the
feeling
anxiety.
this
his
in his
instead.
anger
You
physically
felt
in your
[ Sighs
angry
anger
from
his
anxiety,
with
How
do
patient
fails
to
is discharged
into
the
from
the
body
.] I feel
Psychodiagnosis:
right
now?
fear.
The
which
her.
muscles.
Intervention:
feeling,
he
something.
you
up
Response:
striated
response,
The
angry
Explore
Intervention:
you
how
Detours
than
that
body.
impulse
Rather
must
him
feeling.
physically
body,
In
defense.
in your
Intervention:
impulse
Physical
ask
detours
Psychodiagnosis:
experience
the
focus.
this
and
and
these
Response:
my
covering?
Inviting
Intervention:
you
been
When
physically
detours
show
effective
Detours
has
that
may
shame
Feeling
patient
experiences
the
and
encourage
the
patient
Differentiate
to
face
the
his
anxiety
anger.
Thats
your
anxiety,
fear,
but
can
anger
fear
we
have
in your
Defense
is not
your
an
anger.
If we
uncensored
look
dont
at
cover
how
this
you
anger
with
experience
this
body?
Detours
Rather
than
body,
the
patient
describe
patient
see
and
let
how
he
experiences
may
use
defenses.
go
of his
defenses
his
The
so
anger
physically
therapist
must
can
the
he
face
in
his
help
the
warded-off
feeling.
Intervention:
you
experience
this
anger
You
physically
Response:
felt
angry
in your
I feel
like
body
wants
his
to walk
feeling
away
of
from
anger
her
and
his
Intervention:
defense
and
and
then
your
anger.
experience
this
invite
If you
the
anger
walk
toward
5.1
each
through
phase
problem,
offering
different
responses
and
types
patients
of
spectrum).
Table
5.1
What
is
problem
from
OF
different
example,
not
it.
feeling
to walk
your
allow
how
the
from
her
do
you
the
(low,
INQUIRY
groups
alliance
(declaring
declaring
pathway
therapist
respond
an
a feeling).
of anxiety
to
moderate,
These
discharge,
psychodiagnose
or
high
which
you
would
like
the
resistance;
me
at
internal
a problem
with
He
from
away
anger,
patient
and
to feeling,
structure
Declaring
the
away
how
(access
defense)
does
against
the
want
a therapeutic
a specific
character
fragile
you?
show
of developing
her.
feelings.
You
PHASE
5.3
do
her?
PSYCHODIAGNOSIS:
Tables
from
patient
defense
Differentiate
feeling.
dont
his
How
now?
away
The
from
her.
right
walking
Psychodiagnosis:
differentiate
with
to
help
or
Table
5.2
Phase
Can
we
look
Table
5.3
Phase
Therapists
of
at
inviting
a specific
a specific
of
example
example?
inviting
feeling
intervention:
Whats
the
feeling
toward
her?
SUMMARY
Each
patients
defense.
response
Psychodiagnosis
responses
moment.
and
so
Next,
we
we
will
offer
take
and
alliance
with
RECOMMENDED
will
address
us
the
concepts
show
you
the
patients
READINGS
a feeling,
anxiety,
assess
the
interventions
of feeling,
different
range
Assess
be
to
targeted
a broad
Principle:
intervention
will
allows
can
psychodiagnosis
therapeutic
to intervention
patients
moment
anxiety,
ways
or a
to
by
defense,
co-create
of patients.
each
need
patient
in this
response,
moment
so
.
your
Frederickson,
analysis
from
studies.
multiple
Francis.
the
J. (1999).
of the
In Psychodynamic
perspectives
These
triangle
Theory
readings
will
analysis
of conflict
psychotherapy:
Learning
(pp.
51110).
New
help
you
to
listen
and
York:
Taylor
a session
J.
(2012).
download
only
Maintaining
for
RECOMMENDED
three
you
can
Intensive
2011).
Intensive
2011).
Intensive
2012).
and
in terms
an
effective
focus
on
http://www.istdpinstitute.com/Maintaininganeffectivefocus/
For
to listen
of
of conflict.
Frederickson,
private
conflict
of this
. This
is
book.
MATERIALS
videos
visit
purchasers
feeling.
the
on
psychodiagnosis
URLs
short-term
presented
by
Jon
below.
dynamic
psychotherapy
part
http://www.youtube.com/watch?v=cKzmk2-xnzY
short-term
dynamic
psychotherapy
dynamic
psychotherapy
http://www.youtube.com/watch?v=sDmVgoKPVkw
(October
5,
(October
5,
.
part
http://www.youtube.com/watch?v=dK2x906ptWA
short-term
Frederickson,
.
part
(January
.
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.
Let
of
Hence,
the
focusing
psychodynamic
resulting
and
us
term
healing
symptoms
Yet
The
meaning
).
for
listens.
psychotherapy.
anxiety,
change.
shows
therapist
( intrapsyche
feelings,
for
patient
the
word
psychological
among
relationship
the
of
intrapsychic
cure
exists
to
the
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.
To
establish
this
problems
and
therapist
asks
By
at
engage
fears,
the
in
and
patient
a specific
that
example,
work
the
in
experiential
insights
co-create
work
life.
feelings
a rise
unconscious
lead
therapeutic
therapist
the
about
seeks
help.
of where
those
problems
and
the
let
asks
patient
therapist
Now
task:
the
experiences
which
the
her
experience
the
example
therapeutic
the
specific
for
for
experience
To
focus,
symptoms
exploring
conflicts
internal
therapist
go
she
of
and
Next,
As
occur.
the
she
memories,
her
the
discover
defenses,
avoided.
driving
to long-lasting
helps
her
has
in emotions
forces
patient
the
so
the
patient
face
her
does
so,
she
suffering.
can
These
change.
alliance,
we
mobilize
ingredients
in
order.
1.
Establish
an
2.
Establish
that
internal
emotional
problem
to
on.
it is the
patients
will
to
work
on
the
problem.
3.
to discern
and
get
Look
consensus
4.
FIRST
We
on
Get
INGREDIENT:
EMOTIONAL
by
with?
focuses
asking,
What
Choose
on
you
her
The
not
with
problem
vegetative
me
and
to help
because
the
would
to
problem
you
I didnt
the
relationship,
but
I was
like
show
me
to
that
you
would
depressed
ago.
the
severity
of
He
help
therapy
like
ever
[ Clear
no
me
since
declaration
to
my
of
an
there
depression
and
she
had
no
inquiry.
you
any
symptoms,
The
signs,
the
problem
patients
episodes.
vegetative
with
One
Are
the
depressive
continues
would
other
like
me
problems
you
to help
you
would
like
with?
see
this
I think
coming
engagement.
I just
I have
at all.
He
wrote
that
problem
I was
said
off
as
in
shocked
we
had
a little
relationships
that
my
fianc
problems
anxiety.
in
I dont
our
know
missing.
Th:
were
missing.
when
you
wrote
saying.
consequences.
feeling
months
were
depression.
off
was
you
two
Pt:
he
task.
elses.
been
previous
there
episodes.
is your
what
someone
Ive
Th:
broke
therapeutic
INTERNAL
carefully
Whats
assesses
severe,
previous
me
the
.]
signs,
not
with
on
problem
wording
problem,
up
therapist
was
problem
with?
broke
internal
of the
of conflict.
DECLARED
is the
your
Pt:
fianc
triangle
consensus
Th:
help
the
example
PROBLEM
begin
you
at a specific
He
felt
it off
He
Does
It
you
as
told
sounds
had
anxiety,
you.
that
fit?
like
problems
you
You
you
missed
wrote
[ Point
in
out
it off.
how
just
told
your
the
what
relationship,
importance
Then
her
us
you
defenses
but
of
suffered
of
you
what
the
denial
and
ignoring
blinded
herthe
Pt:
hadnt
seen
anyway,
that
and
cost
I hate
I paid
this
your
breakup.
Th:
Seen
Pt:
That
the
anxiety
[ The
in
your
another
heartbreak?
she
when
It
but,
I ignored
price
sounds
short
of the
yes,
that
a problem,
like
term,
ignoring
but
defense
does
fit.
it
happened
him
it set
you
might
up
have
horribly
for
with
this
.]
Right.
you
Th:
You
like
me
to
so
your
relationships
seeks
[ Get
want
me
help
to
you
denial
consensus
on
help
deal
better
doesnt
the
you
with
set
presenting
you
the
up
for
problems
for
help .]
Pt:
SECOND
it,
what?
in the
Would
feelings
which
say
price.
Pt:
depression.
to
before.
Th:
alleviated
.]
Yes.
INGREDIENT:
THE
PATIENTS
internal
emotional
WILL
TO
DO
THERAPY
Once
the
her
will
their
patient
to
will
seek
or
authorities.
desire
and
to be
required
to
do
want
under
Did
therapy,
not
right
you
no
therapy,
do
not
her
from
seeking
THIRD
INGREDIENT:
here
internal
right
to
explore
help
minutes,
CONSENSUS
own
if it
the
court
patients
verbally
ask,
free
will?
is
against
even
expresses
Is
or
it
your
Are
you
decision?
emotional
work
with
further.
to achieve
or
without
of your
your
ask
referred
boss,
therapy
opening
an
have
do
the
this
been
spouse,
patient
or was
problem,
have
the
come
declare
to
in
you
prevents
by
If
here,
does
do
no
reluctance
here?
patients
threat
permission.
to come
to
Often,
have
any
If a patient
an
therapy.
We
nonverbally
will
declares
problem
her.
If she
Instead,
her
goals
ON
find
for
THE
her
or her
will
does
not
out
what
benefit.
INTRAPSYCHIC
Once
the
CONFLICT
patient
therapists
help,
this
problem
her
to
my
intrapsychic
can
show
let
help.
of
symptoms
that
The
attention
to
anxiety,
and
conflict
defense.
too?
little
her
vague
[ Point
out
and
the
one
Moment
by
moment,
When
became
vague
blamed
yourself
when
visiting
yourself
and
depressed?
Show
Now
parents.
turn
the
With
we
that
makes
consensus
can
take
session,
we
will
specific
her
feeling
toward
the
patient
can
see
she
you
reveal
hold
Do
in
defenses
create
her
I hadnt
Do
point
and
it out,
if
that
feeling,
the
pay
feelings,
will
understand
your
anger,
you
angry
your
feelings
defense
with
yourself
therapy
seen
that
with
him,
for
Then
you
outburst
blame
making
other
problems
you
to
be
your
but
his
tendency
might
and
presenting
.]
directly.
this
that
yes.
responsible
think
you
notice
happened
were
you
conflicts
about
anxiety,
him
the
talk
instead.
wonder
on
next
the
intrapsychic
step.
conflict
.]
connection
causing
you
relationships.
before,
sense.
on
the
the
you
anger
Pt:
yes,
she
ways:
help
patient
when
that
than
your
her
you
create
is the
three
the
of feeling,
than
rather
of
yourself
mention
rather
[ Link
how
in
I notice
triangle
You
Explore
If
problems.
Th:
too.
into
suffer.
defenses
What
in
criticize
Pt:
boyfriend
asking,
operating
causing
which
motivates
suffering,
task.
respond
Th:
get
by
reactions.
defenses
her
where
insight
they
create
the
problems.
will
these
for
of
deeper
because
out
desire
declares
me
therapeutic
find
her
example
patient
Give
defenses
example
patient
or
come
and
a specific
the
They
to
presenting
at
say,
in the
problem
specific
look
never
her
engage
her
and
anxiety,
the
and
problem
problem
Patients
how
internal
we
The
a patient
example
Explore
Can
conflicts.
of them
him?
ask,
an
occurs?
seek
go
declares
her
difficulties,
but
FOURTH
INGREDIENT:
THERAPEUTIC
In
create
must
learn
feel
to
actions,
the
symptoms,
her
into
as
her
in
yourself,
which
feelings
or
consensus
on
internal
yourself
because
agreement
on
and
find
self-punishment.
will
task
to the
here,
result?
but
[ Help
avoid
so,
she
into
it,
will
adaptive
symptoms.
here.
and
When
you
feel
the
anger
on
turn
distant
and
fair
summary?
that
dont
express
your
lose
the
[ Get
.]
that
makes
like,
you
task
sense.
our
of
make
out
what
task
here
self-blame
would
and
depressed.
be
to
turning
Does
that
help
anger
fit?
[ Get
.]
And
once
we
turn
against
those
this
anger,
get
to the
bottom
of your
has
something
Yes,
. Point
been
you
but
out
Im
the
driving
would
afraid
like
of my
patients
choice
this
pattern
of
[ Obstacle
to
to do?
anger.
and
mobilize
her
.]
Th:
be
doing
more
is to face
Pt:
in therapy
presenting
than
them
conflict
Is
patient
Yes.
Is that
engaging
rather
By
vague
mechanisms
task
her
become
therapeutic
our
the
you
Th:
mechanisms,
and
So
fears
channel
defenses
When
If you
they
the
and
conflict
Pt:
feelings,
and
depressed.
Yes,
these
possible.
want.
Th:
against
as
become
you
Pt:
on
anxiety
create
she
Theres
you
the
that
defenses
you
concerns,
closeness
turn
THE
symptoms.
what
feelings
you
makes
emotional
you
face
maladaptive
relationships,
and
deeply
Th:
angry
triggers
defenses
(2)
feelings
experience
not
feeling
problems
against
and
(3)
patients
presenting
turn
problems
and
the
her
(1)
ON
TASK
relationships,
that
CONSENSUS
if
her
you
see
Of
course,
continue
the
Pt:
to
price
Ill
you
avoid
of the
probably
are.
your
defense
just
stay
Otherwise,
anger,
what
you
will
wouldnt
be
the
.]
the
same.
[ She
begins
to see
how
her
defense
creates
Th:
control,
or would
Mobilize
her
you
Do
like
[ We
awareness
must
Id
the
and
based
on
anger
and
in
feel
.] Instead
into
you
sense
you
could
choice
anger,
or
charge?
would
[ Point
choice
of the
would
like
like
to
out
the
to
look
indication
desire
at
of
can
avoid
feel
face
[ The
of
you
hiding
channel
be
could
your
this
Shall
fear
the
patient
intimate
alliance
we
so
clear
feelings,
therapeutic
today?
it
have
emotionally
the
and
therapeutic
could
yourself,
this
powerful
you
to make
your
choice
could
vague,
versus
put
know
avoid
you
can
to
declare
this
be
in
her
my
anger.
[ When
projection.
She
you
does
it that
put
not
way,
it that
entirely
Id
be
way
is
own
silly
a
that
not
to
possible
this
is
her
.]
goals,
to achieve
for
the
your
to explore
Defenses
her
therapists
Yes,
and
her
goals.
the
is that
[ The
but
feelings
defeat
Remind
But
purposes?
Pt:
them.
we
more
you
can
control.
instead
invite
I dont
could
being
and
When
Th:
your
.]
Pt:
try
in control?
you
overcome
choice
in
yourself,
have
us
be
[ Unhealthy
you
of
defenses
you
you
so
And
but
You
together,
onto
and
to
.]
of criticizing
them
are
fear,
control.
out
of
anger
you
choices.
Or
anger
self-esteem.
[ Results
my
of
and
Instead
express
two
possible
Instead
want.
of
relationships.
.] What
the
so
of
goal .]
out
anxious
assertion.
what
healthy
than
fear
task
.]
as
fear
master
have
and
deeply
of turning
healthy
about
We
defenses
it as
rather
to
.]
your
your
positive
like
anxious
maladaptive
charge
task
remain
want
therapeutic
Th:
anger
you
of her
clarify
symptoms
to master
Pt:
how.
her
patient
the
conflicts
of
her
you
therapeutic
patients
thats
The
what
I want.
together
therapeutic
goals
yourself,
is not
for
designed
.]
[ Now
she
wants
us
.]
task
so
for
task
goals
what
want
she
will
can
help
see
her
when
achieve
she
is
on
or
off
task.
emotionally
Experiencing
secure
feelings,
we
blocks
insecure
long
for.
defenses
relationship
THE
so
for
Out
can
Life
Only
one
feat
is
help
the
to
allows
contrast,
the
share
to
build
ward
cheat
therapist
their
us
defenses
Defenses
of compassion,
patients
us
off
of
the
interrupts
feelings
and
and
co-create
change.
TASK
Hammarskjld,
said,
In
feelings
attachments.
THERAPEUTIC
Dag
sharing
relationships.
creating
intimacy
and
only
secretary-general
demands
from
of
you
the
is possible:
not
to run
patient
not
run
away
out
the
the
United
strength
away.
that
And
from
his
Nations,
the
you
once
possess.
therapeutic
feelings
that
task
make
him
anxious.
Yet
if we
do
do
in therapy:
in
my
(2)
Talking,
patient
as
Remind
her
well.
of
that
self-defeating
First,
can
offer
to pay
you
feel
understand
in
better?
what
logging
hours,
from
her
that
goals.
kind
Help
goals.
defenses,
and
face
achieve
her
your
what
to
attention
body,
is
letting
not
because
a
relationships,
she
will
behavior
see
what
results
defenses
Then
invite
she
her
passive,
do
in
and
her
has
her
enough.
adopts
of
go
so
in
failure.
relational
to
let
previously
go
of
avoided
goals.
invitation
careful
(1)
The
experiencing
are
to
can
work.
she
her
her
not
problems
If
what
is happening
by
(3)
up
relationship
know
psychotherapy
does
and
showing
in other
However,
what
courage
closeness.
stance
you
Passivity
fears,
and
not
No
emotional
she
does
telling
alone.
sabotage
an
you
getting
facing
uninvolved
patient
Im
some
emotional
the
talking.
ingredients
prevent
therapy
she
not
suffers
or
patterns
usually
defiant,
task,
Im
demonstrate
defenses,
defenses
so
am
those
must
feelings.
here.
Why
with
patient
spell
Im
life.
succeed
of
not
and
going
the
therapeutic
to the
any
on
task.
feelings
shifts
underneath
in
Im
in your
our
to
going
body,
connection
create
these
to
any
so
invite
anxiety
we
can
problems
that
are
willing
its
mobilize
afraid
slave.
As
Does
that
and
so
long
and
help
patients
of
Why
feelings
do
you
will
Pt:
Im
Th:
Of
you
can
as
you
that
have
mobilize
ignore
your
these
terrible
anxiety,
the
to face
afraid
like
something
but
master
avoid
to
what
you
would
be
these
of
our
task
You
these
here
anxiety
feelings,
problems,
fears.
feelings.
your
yourself?
free
she
of those
course,
same
become
that
we
them?
face
to
it just
is to face
rather
youll
can
or we
can
than
have
run
what
remain
symptoms
away
face
symptoms.
rid
that
of
builds,
be
from
those
your
feelings
What
would
attention
to her
anxiety.
then
end
up
suffering
from
If
you
ignore
your
you
like
pay
careful
symptoms
for
you,
attention
and
find
to
out
If
and
you
dont
your
anxiety
is
causing
what
to you?
patients
will
to
turn
against
the
defenses
and
feelings.
Pt:
I dont
want
to take
Th:
Thats
going
a look
at those
feelings.
.]
been
How
avoiding
your
depressed,
come?
depressed
instead
grief
dont
if you
dont,
your
grief
over
Pt:
Five.
[ price
want
course,
this
to.
has
By
of the
After
depression
to be
a problem.
I never
Of
and
Th:
you
experience
these
sense
you
anxiety.
a painful
Th:
became
and
we
Pt:
Youve
and
Could
make
the
to pay
cramps
will
happen.
mobilize
[ Defense
will
stomach
get
Does
her
patients
therapy
can
Finally,
the
anxiety,
the
want
as
sound
to do?
Next,
so
the
are
instead.
us
you.
to do?
Next,
you
bothering
look
but
the
has
loss
been
going
avoiding
the
defense
no
one
will
continue
that
of
on
for
can
you
and
make
the
working?
husband.
how
dont
feelings.
been
your
grief,
]. You
all,
at those
many
have
have
You
years?
become
to face
you.
therapy
But
as
will
this
long
fail
price
of the
defense
[ antitherapeutic
]. You
task
this
depression
The
following
can
], or
we
can
[ therapeutic
list
avoid
face
task
outlines
the
this
grief
and
these
]. What
we
of the
therapist
sequence
pay
of
attention
feelings,
moment
anxiety,
get
moment
defenses
suffer
rid
of
do?
task:
Together
to
and
and
therapeutic
Understanding:
and
to
feelings
shall
purposes
continue
the
to
patient
observe
creating
the
the
patients
difficulties.
Anxiety
therapist
must
patients
anxiety
mutual
pay
attention
and
attention
background
regulates
discover
dyadic
her
preconditions
moment
for
an
and
restores
effective
her
do
defenses
the
to
same,
blocks
the
feelings,
ignore
thereby
patients
her
inner
creating
an
and
decrease
it.
the
This
close,
providing
1994,
cognitive
and
2002).
This
functioning:
the
treatment.
defenses
anxiety,
patient
anxiety,
(Schore
Secure
uses
to
trigger
patients
regulation
The
moment
feelings
the
affect
body
to
what
regulates
of
regulation:
experience
patient
the
attachment.
encourages
to
The
invites
insecure
and
defenses
attachment:
establish
therapist
The
mutual
who
to
therapist
attention
secure
to
autonomous
attachment.
Achievement
Psychotherapy
Since
tries
defenses
therapist
encourages
get
she
what
to
help
the
sabotage
her
the
patient
patient
goals,
of
achieve
her
creating
to let
go
her
of her
positive
healthy
goal:
goals.
difficulties,
defenses
so
the
she
can
wants.
INGREDIENTS
FOR
CONSCIOUS
THERAPEUTIC
ALLIANCE
The
therapist
therapeutic
single
step,
and
patient
must
alliance
in
the
the
conscious
create
following
therapeutic
the
ingredients
steps.
If
alliance
the
for
a conscious
therapist
will
not
skips
be
strong
enough
to achieve
the
patients
1.
goals.
The
patient
2.
The
describes
patient
an
inner
declares
problem.
her
will
to
seek
therapy.
3.
patients
internal
therapeutic
turn
face
she
experience
low
A highly
two.
four.
Wherever
fragile
tree
When
decision
Then
you
from
5.
The
patient
and
therapist
agree
on
the
the
patients
deeply
positive
goals.
a.
The
patient
is willing
to
b.
The
patient
is willing
to
c.
The
patient
is willing
to
quickly.
are
the
forming
occur,
6.1
the
find
that
with
right-hand
may
puts
with
will
therapeutic
to
find
common
for
one
the
one
or
further.
of
steps
in
the
most
common
the
steps.
On
detours
that
therapeutic
see
which
ingredient
see
which
defense
alliance.
step
through
going
sequence
as
after
at steps
steps
before
well
you
most
at
the
as
only
a barrier
them
ingredient
side
emerge
up
illustrates
a patient,
alliance
anxiety
resolve
alliance
will
the
a therapeutic
often
side
stuck
possible.
defenses
flood
figure
of
as
forms
left-hand
you
establishment
to
the
can
in
the
side
look
on
therapeutic
On
you
agree
obstacles
The
the
therapist
patient
patient
TREE
right-hand
and
patients
DECISION
detours.
patient
as
resistant
developing
The
resistance
resistant
five.
example.
defenses.
feelings
with
moderately
a specific
fears.
her
A patient
offers
4.
to achieve
her
what
patient
conflict.
task
against
The
the
prevent
alliance.
is
is
missing.
preventing
Figure
6.1
Decision
OBSTACLES
tree
TO
THERAPEUTIC
Obstacles
for
a conscious
FORMING
therapeutic
alliance
CONSCIOUS
ALLIANCE
to
forming
a conscious
therapeutic
alliance
can
occur
at
any
stage
in
emotional
the
problem,
problem,
to
vignettes
us
fact,
of
Declaring
close
The
where
the
the
can
resistance
feeling.
of
patient
is on
responses
let
ever
been
to
able
us
review
at each
stage
on
that
problem,
or
of
series
of developing
Emotional
and
spectrum
the
if the
first
of
has
anxiety,
type
of
neurotic
questions
patient
Problem
feelings,
discharge
the
to
know
since
cry
[ Clear
[ Defense:
What
my
about
answer
is the
and
defenses
disorders.
during
low,
problem
resistance
mother
her
In
the
phase
moderate,
you
or
would
last
six
months.
its
due
to
my
Moderately
.] Just
Im
moms
clear
not
denial
projection.
.]
My
Defenses
and
no
will
a little
sure
like
high
me
to
of a problem
ask.
[ Defense:
Im
sure
[ Defense:
defenses
resistant
patient:
to explore
.] But
havent
patient:
some
arise
I miss
[ Defense:
thought
reason
feeling
I know
havent
wife
some
been
her
.]
down
why.
Ive
though
I just
Fragile
declaration
even
resistant
with
Highly
For
defenses
death.
answer
patient:
died.
death,
without
vagueness
the
to
work
of the
now
triggering
Moderately
want
to
internal
with?
depressed
problem
will
Internal
anxiety
Low
[ Defense:
will
an
or is fragile.
you
terribly.
ones
resistances
relationship,
Th:
help
declaring
example
We
an
pathway
patients
inquiry
declaring
a specific
these
to
invites
defenses.
to
alliance.
Resistance
Inquiry
illustrate
a therapeutic
to
to offering
labeling
that
resistance
resistance
resistance
resistance
tell
process:
really.
minimization
vagueness
been
the
.]
same
for
Maybe
since.
.]
I dont
have
be
here.
should
immediately
not
with
no
just
really
problem.
[ Defense:
clear
presenting
one .]
patient:
Im
projection.
Im
mostly
Anxiety
afraid
rises
of the
anxious.
[ Initial
questions
rapidly,
leading
you
to
regressive
defenses.
how
the
rapid
her
desire
tolerate
she
rise
to
her
of anxiety
tell
the
internal
projects
Patients
her
wish
we
responses
The
What
patient
respond
we
you
in one
and
first
would
of three
fears
forgets
than
to
talk,
him .]
weaknesses
this
and
process
study
of
series
of
session.
like
me
to help
by
presenting
ways
The
She
wanting
specific
will
reveals
Rather
not
illustrate
in the
problem
and
the
To
question
thinking.
therapist
to assess
answer
difficulties.
wanting
the
treat.
her
her
intervention,
initial
is the
will
us
with
both
onto
to
and
disorganized
about
of
to talk
need
to our
ask,
therapist
allow
psychodiagnosis
or
interferes
conflict
responses
defenses
We
A fragmentary
problem
for
you
which
with?
he
seeks
treatment
High
anxiety
Defenses
Vignette
One:
Notice
in this
defenses.
Low
Resistance
example
We
can
that
begin
you
trouble
problem
in
clearly
out
what
my
the
low
been?
say
other
You
then?
problems:
relationship
resistance
patient
uses
his
problem
right
away.
Whats
the
problem
you
would
Ive
been
feeling
relationship
conflicts
What
life
a problem
very
like
few
me
to
depressed
with
my
lately,
wife.
and
Im
[ Describes
his
.]
depressed?
your
declaring
Patient
Intervention:
find
against
with?
Pt:
having
symptoms
exploring
Th:
help
and
with
create
Explore
his
symptoms
it started
Once
Can
your
problems.
have
three
you
have
you
the
you
How
noticed?
months
ago.
explored
the
tell
me
patients
what
long
How
What
was
problems
have
troubles
you
severe
felt
has
going
depression,
to
on
in
investigate
you
in
the
wife?
Principle:
Once
the
patient
declares
it
his
problems
clearly,
explore
anxiety,
and
and
Vignette
in
her
done
safely.
poor
that
you
the
with
patients
her
eyes
dart
signs
his
symptoms
rather
the
that
problem
There
are
so
than
respond
therapists
exploring
the
forth
and
of anxiety
and
first
feelings
you
rapidly
How
are
many
Patient
as
projection
would
task
can
like
be
me
to
things.
fidgets
she
I dont
in her
avoids
know
chair,
the
and
therapists
.]
you
feeling
right
now?
[ Assess
her
.]
Im
body?
[ Assess
her
cannot
regulate
anxiety
you
anxiety
notice
first
any
anxiety
to regulate
The
into
therapists
feelings
and
the
on
smooth
invitation
overwhelming
the
notice
feeling
the
anxiety
in
over.
[ The
the
rapid
anxiety
notice
of
anxiety
immediately
in your
in your
rise
body
stomach?
shows
.]
where
[ Draw
the
anxiety
attention
to the
it .]
Principle:
focusing
you
.]
Lets
Pt:
discharged
All
do
it. Regulate
Th:
Do
anxious.
Where
Pt:
is.
Thus,
so
back
Th:
she
patient,
anxiety.
vagueness.
Pt:
your
fragile
[ Defense:
Th:
anxiety
wife)
(feeling,
with?
to start.
gaze:
conflict
create
his
Whats
Pt:
where
of
defenses
with
anxiety
Th:
help
which
triangle
Patient
floods
the
the
relationship
example
problem,
regulate
learn
Fragile
this
is to
formulate
to
the
Two:
Notice
to
defense)
(depression
with
them
patients
I feel
nauseous,
muscles
to
like
Ill
throw
up.
[ Anxiety
.]
relationship
immediately
triggered
anxiety.
Regulate
declared
overwhelming
internal
problem.
anxiety
Then
before
show
the
patient
went
bell
what
up
triggered
as
went
up
as
you
as
soon
in order
information
Lets
soon
off
to open
the
you
you
declared
as
this
and
you
Thats
want
another
to
tell
me
comes
in to attack
to
me
tell
from
and
what
the
you
anxiety.
differentiate
you
from
the
law
herself
help
me
to
talk
from
the
experience
you.
it your
will
awareness
therapist
So
let
to
talk
of
me
you
you?
to
scared.
[ Now
therapist
triggers
alarm
will.
You
want
you
have
if
it sad
help
better
as
with,
against
that
good
that
you
if its
her
as
anxiety
law
wish
her
you
soon
this
the
attacks
.] Thats
[ Now
its
her
she
anxiety
against
that
it. Its
that
a question
Is
Its
[ Differentiate
the
that
what
deactivate
she
Yes,
sees
for
you
to
talk
helps
like
her
may
its
against
has
differentiated
drops
.]
law
you
the
anxiety
awareness
of her
will
for
seem
want?
you
to
talk
a bit
odd:
[ Mobilize
projection
of
it
Is
her
onto
the
problem
Inviting
the
talk
about
talking
me.
about
Its
just
herself
I
to
get
the
to do
This
is
therapy
Yes.
[ With
what
you
want?
[ Mobilize
her
.]
her
will
on-line,
we
can
explore
.]
fragile
patient
overwhelming
herself.
to
.]
Pt:
sample
I want
causality:
Th:
revealing
if an
.]
Pt:
and
as
.]
me.
As
ask
will
with.
of anxiety,
about
her
to
As
relaxes
about
Th:
about
me
anxiety
[ Body
for
so
anxiety
risky.
isnt
something
her
Pt:
Its
nauseous.
So
you?
Describing
herself
a little
feeling
want
strangle
want
your
is your
better,
feels
of anxiety.
what
up?
this
yourself
Youre
sign
to open
that
further.
Th:
notice.
notice
that
that
patient
you
want
to know
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anxiety
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desire
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me
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with?
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mirroring
to
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Pt:
problem,
In the
do
by
inquire
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Th:
help
she
two
while
trigger
declares
the
see
video
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wish
http://istdpinstitute.com/dvds/
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you.
her.
together.
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patients
experiences
experiences
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patient
observe
and
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and
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task.
you
projection
to pursue
help
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and
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her
defy
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forces
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you
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back
what
no
have
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permission
contradictions
he
says
and
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[ Defense:
declared
to explore
in
does
a problem.
he
one.
says
internal
Confine
or
denial
.]
emotional
yourself
contradictions
to
Th:
contradiction:
psychologists
man
office
who
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are
here.
psychological
want
out
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out
problems
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but
his
to come
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instead.
you
is
the
in
idea.
.]
projection.
Patients
yet
without
Pt:
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it
desire
for
to therapy
Although
it was
contradiction
was
between
wifes
therapy
wont
your
my
to
his
wife.
.]
wifes
what
idea,
he
you
says
came
and
does
.]
Pt:
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projectionMy
Th:
emotional
problem.
following
Is
her
this
doing
This
idea
instead
something
one
that
thing
contradiction
when
says
lot
of
own?
thought,
not
you
dont
In
your
was
opinion,
your
of your
wifes
own.
in
want
idea,
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your
life?
have
an
you
that
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idea.
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but
does
something
I hadnt
the
thought
time.
you
internal
ended
come
else?
of
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in the
regulation
you.
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may
have
with
her
striated
up
to pass?
find
yourself
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out
the
that.
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go
admission
of
along
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with
internal
of the
his
time
you
problem
[ Fidgets.
muscles.
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go
along
with
her
ideas
.]
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in the
feelings
trigger
muscles
needs
striated
.]
his
resistance
come
ideas
to regard
instead
the
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you
to
this
of your
Pt:
against
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turn
this
had
[ Reflect
Pt:
no
wife
a good
.]
of your
anxiety
it was
you
Th:
instead
thought
.]
she
problem
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happens
Pt:
what
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], but
said,
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as
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normal
and
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defiance
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.] After
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for
you
along
own.
think
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normal,
accepted
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it for
to
speak
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a while.
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he
is willing
to accept
Th:
normal
[ reflect
accepted
your
back
her
own.
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ideas
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gone
his
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defense
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ideas
]. Its
of ignoring
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than
norm.
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just
himself
.]
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up
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Pt:
easier
for
me
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ideas.
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still
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right
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stand
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time
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go
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go
true
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than
to
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along
way.
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it has
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her
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up
for
for
him.
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my
own
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have
no
of his
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own
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ideas
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to go
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her
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ideas.
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peace.
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it .]
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for
know
that
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situation.
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yourself
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act
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his
point
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of
view
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become
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a habit.
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ideas
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on
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defense
.]
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invite
self-neglect
Pt:
for
.]
syntonic
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up
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you
.]
way,
you
is
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acceptable
Pt:
argue.
of
handled
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might
then
it that
for
her
been
up
Pt:
is becoming
with
to deactivate
less
not
that
Its
Th:
over
of
that
seem
own.
this
Pt:
thats
doesnt
it yet .]
acceptable
just
but
himself
to go
this
aware
them
easier
said
Th:
ideas
with
opinion,
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along
not
youre
thought
easier
.]
opinion,
of ignoring
I hadnt
for
],
along
defense
problem
in your
awareness
Pt:
rise
this
so?
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[ If the
patient
therapist
to
agreed,
describe
his
the
own
patient
dawning
.]
It doesnt
sound
good
that
I dont
act
on
my
ideas.
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thats
not
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yourself.
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that
have
you
for
you.
helps
his
gotten
[ Show
differentiate
You
his
himself
and
idea.
[ He
closer
I didnt
do
reveals
habit
from
how
to a consensus
wife.
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it doesnt
defense:
he
is not
his
defense
on
his
I havent
done.
[ More
disappointment.
declares
an
internal
because
I end
up
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leads
of
you
the
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problems
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for
Its
just
not
right
him.
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treats
himself
things
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it wasnt
for
We
him.
.]
good
are
.]
what
you
want
you.
[ Point
may
out
please
the
for
sure.
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There
are
defenses
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price
of
this
defense
.]
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been
Yeah.
problem:
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ignores
with
my
wife
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sounds
[ Reinforce
with
how
the
you
his
dont
wife
Pt:
Thats
for
But
listen
of
to
he
led
things
to
some
problem
[ finally
and
desires
your
feelings
awareness
.]
it sounds
like,
your
arguing
what
has
feelings
ignoring
wife.
of
this.
healthy
defense
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about
like
your
want
his
kinds
.]
of his
price
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all
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[ Point
desires
does
does:
and
And
that
in
spite
or
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act
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ignoring
on
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what
he
.]
her,
to ignoring
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get
he
what
wants
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too.
creates
out
arguments
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thought
what
find
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he
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arguing
out
hurts
some
up
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thats
Th:
you
problem.
with
into
wife
Pt:
problem.
know
himself
been
stand
.]
arguments,
them.
wants
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to
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please
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defenseshow
internal
aware
[ Point
ignoring
Ignoring
pleased
Pt:
of
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always
right
.] You
doing
because
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of
his
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them
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awareness
defense
Pt:
to do
know
healthy
in the
how
right.
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when
you
ignore
I want.
true.
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No
matter
doesnt
yet
how
much
connect
I
this
argue
result
.]
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she
your
desires,
ignores
you
what
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you
get
want,
the
you
results
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want.
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defense,
not
his
wife,
Pt:
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actions
so
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create
you
get
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and
get
of
of
defenses
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rather
patient
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confronting
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by
patient
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[ Invite
with
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the
with
really
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what
patient
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explore
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makes
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see
result,
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therapist
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his
mind,
with
the
challenge
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patient
Obstacle
responded
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when
see
he
man
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with
this
the
working
type
of
mistake
of
and
highly
defenses.
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declares
Do
one
Two:
within
says
not
that
he
not
the
patient
to
the
before
explore
wants
to
one
you
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who
have
will
an
patients
Three:
make
Internal
statements
or
Acknowledge
Four:
Mirror
defenses
you
is before
and
does.
prematurely
is,
splitting
any
collaboration.
challenge
he
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and
toward
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a problem
your
frustrated.
the
before
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you
the
make
contradictions
between
shifts
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against
often
yet
until
turn
change
therapists
principles
not
to
to
problem.
defenses.
following
like
internal
Principle
of
his
this
an
his
patient
noting
contradictions
level
focus:
you.
by
healthy
ignore
.]
Im
Principle
projection
If I
patients,
prematurely
does
task
because
would
him
Principle
problem
before.
intrapsychic
you
therapeutic
therapist,
from
the
want?
describe
patient
.]
that
[ An
something
resistant
the
the
differentiate
should
than
of
I want.
Yeah,
highly
problems
.]
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engage
his
thought
what
Th:
Pt:
Typical
I hadnt
problems
more
causes
or
are
you.
him
he
more
does
assume
relating
Your
the
to
Emotional
not
he
the
resistance
resistant
patients
is
see.
willing
patient
to
dealing
to you.
Problem:
Externalization
Sometimes
patients
believe
other
people,
not
their
defenses,
cause
in
their
suffering.
therapy.
My
For
wife
The
This
example,
is the
patient
believes
does
other
people
The
treat
me.
patient
is impossible!
look
shift
you
the
my
room
he
she
reality.
is
his
causes
to
problem.
help
them
others
Pt:
Im
problems
engage
psychology,
in
looking
by
here.
but
proxy:
Therapy
treating
with
an
an
internal
cannot
do
psychotherapy.
how
to help
his
the
invisible
develop
we
for
own
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not
difficult,
show
to
psychotherapy
is
life,
his
you
than
be
that
his
invites
do
who
inner
Th:
my
wife,
Then
Its
deal
[ Implicit
focus.
externalizing
problems
so
he
can
suffering.
the
problem
hoping
biggest
you
you
can
problem.
not
how
Th:
Since
invite
would
an
he
would
help
[ The
deals
my
wife
with
her.
me
with
a problem
not
like
me
with
patient
his
to help
me
my
to
wife
believes
feelings.
his
He
invites
having
of a problem
help
her.
[ Note
what
the
internal
with?
thing.
problem.
are
I cant
.] I wonder
you
the
the
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here,
focus
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thats
statement
shes
internal
like
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having
creating
rather
you
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Pt:
are
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first
Th:
wife.
have
in
her .]
is you
me
them.
can
Pt:
help
focus
with?
to treat
problem.
internal
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defenses
wife,
examples
from
is
problem
asks
at a patients
how
because
problem
the
at some
recognize
an
say,
the
people,
externalize,
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patient
you
in
patients
Lets
help
is
other
Treat
who
Without
prevents
may
see
create
patient
patient
When
patient
not
observing
himself.
Dont
the
focus
problem.
who
sociology,
into
external
I dont
And
think
Im
trouble
I have
hoping
dealing
you
a
can
with
your
of where
you
.]
Yes.
Can
in dealing
you
give
with
me
your
an
wife?
example
[ Explore
his
problem
to develop
an
intrapsychic
focus
Pt:
time.
She
to
lift
made
the
me
late,
and
see
was
his
hung
Like
over
and
suffer,
defenses
but
patient
can
into
he
blames
see
how
he
made
Pt:
Yes.
was
to
element
of choice:
Yes,
wait.
[ Reflect
She
wait
[ He
chose
his
for
on
wanted
her.
to
choices.
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wait,
He
be
does
not
.]
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back
the
reality
so
the
late .]
she
and
how
he
asked
you
to
wait
and
make
yourself
not
late.
his
wife.
establish
himself
late
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of control
intrapsychic
to
deal
her
for
his
decided
your
that
decision
choice
two
options:
on,
to
and
to make
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Of
to say
patient
wait,
you
include
the
she
course!
no
wait
his
choice,
himself
so,
you
made
him
we
and
will
makes
when
his
wife
is
late.
regain
an
internal
locus
you
to wait.
.]
to!
sense.
late.
making
asked
doing
to
problems
yourself
yourself
by
for
has
makes
himself
her
his
by
choice
he
me
made
and
punishes
solve
asked
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wait,
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the
can
She
Th:
to
blames
feelings
and
to hurt
that.
you
agree
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focus.
he
Pt:
had
he
helps
to wait
does
late .]
decided
as
with
Th:
you
himself
she
asked
can
causality.
long
Pt:
So
You
an
hope
she
we
made
externalization
and
when
when
facts
[ Show
As
I hate
Right.
Th:
made
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the
Pt:
you
late.
her.
here
late.
decided
from
for
come
me
blaming
himself
Th:
not
wife
to
for
made
and
And
wait
argument.
his
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Pt:
late,
an
going
to
she
of externalization
Th:
yourself
me
then
got
Th:
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asked
we
but
today,
and
hairdresser,
late,
.]
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late,
but
Thats
to yourself
then
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himself
me
wanted
you
blamed
her
request
late .]
to!
what
and
she
make
wanted.
yourself
Then
late
or
to
say
yes
yourself,
out
to
yourself
but
his
then
defense:
and
you
blamed
I didnt
defense
rather
than
to
the
of his
price
deprive
blame
sees
her,
his
I dont
behavior
have
together
but
to face
with
not
choice
my
wife
to
you
say
no
made.
punished
before.
pattern
way?
to
[ Point
me .]
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for
you,
[ Invite
her.
her
he
to
can
say
the
patient
the
her
for
when
we
function:
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blame
[ Clarify
a lot
defensive
I cause
see
no
to
to
see
suffering
a lot
defense
If
are
late.
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blame
decide
to
.]
when
you
of externalization
be
.]
Yes.
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self-deprivation?
anxiety,
that
its
You
Th:
of
the
that
blame
how
Pt:
pattern
in
chose
wife .]
that
I do
Th:
late
Is
You
.]
Pt:
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for
seen
his
yourself
defenses
time.
myself;
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Th:
yourself,
on
her
punish
Pt:
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come
you
[ Invite
and
defenses
problemsarguments
and
like
to
him
to
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poor
know
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focus
driving
on
create
the
feelings,
his
relationship
with
that
presenting
himself
and
his
wife .]
that
his
Undo
defenses,
the
patient
wife
my
cannot
his
wife,
create
externalization
to
wont
see
the
internal
that
create
against
reborn
when
create
his
life
and
If
her,
so
of
control:
locus
problems.
these
he
defenses
realizes
he
Its
can
not
therapy
to
for
wife
let
but
sense:
go
he
the
Declaring
an
Internal
Emotional
believes
him
defenses
I can
take
Hope
defenses
Problem:
my
Help
my
suffering.
to
My
problems,
choices.
of
The
control:
therapy.
different
and
of
my
my
sees
focus.
Thus,
makes
make
see
locus
creates
hope
patient
internal
problems.
no
the
.]
an
external
wife
I have
Now
suffering
establish
my
my
focus:
his
an
creates
him.
change
my
stand
creates
help
therapy
Obstacle
[ Intrapsychic
externalizes
controls
therapy
Yes.
not
patients
who
Pt:
a
is
that
Vagueness
In
this
example,
vagueness
as
you
will
see
a defense
against
problem
if the
not
explore
any
the
problem
is vague,
why
it
is
describing
important
to
a presenting
problem
or
example
you
cannot
find
out
what
Th:
Whats
the
problem
address
problem.
Do
is vague.
the
triangle
you
would
When
of conflict
is.
help
you
Defense:
vagueness
vagueness
Ive
Can
you
Pt:
Not
really,
Th:
What
[ Defense:
your
life
in
[ Point
from
be
more
specific?
I just
I dont
bad
mood.
dont
feel
so
hot.
[ Defense:
general,
out
but
the
on
know.
in your
life
I think
its
to trigger
just
that?
my
life
in
.]
I hear
you
have
this
is
defense
a bad
mood,
vague.
and
Could
you
you
think
be
more
.]
Yesterday
Th:
What
I had
crying
jag
when
at work
that
could
got
was
Pt:
I dont
going
on
have
that?
tired
when
I get
home.
Th:
were
tired.
What
know
if it was
[ Defense:
You
anything
vagueness
had
happened
a crying
earlier
just
.]
jag
that
at work.
at
could
home
have
yesterday
triggered
that
jag?
Pt:
that.
in
work.
triggered
crying
feeling
is going
vagueness
Pt:
and
been
.]
specific?
feel
just
Th:
Th:
home
to
.]
Pt:
its
me
with?
Pt:
general.
like
[ Defense:
denial
I talked
to
my
boss,
but
I dont
think
it
was
.]
Th:
Pt:
What
He
did
said
you
he
and
was
your
going
boss
to
talk
have
about?
to
let
me
go
because
they
are
downsizing.
Th:
[ Stimulus
What
.]
is your
feeling
toward
him
for
saying
that?
Pt:
I just
Th:
the
feeling
you?
with
[ Point
out
Feeling
vagueness,
what
the
and
defense
Pt:
Defense:
undoing
start
to take
anger
anger
with
toward
defenses
tear
vagueness
down
is vague.
If you
is the
focus
feeling
on
angry.
dont
toward
the
him
warded-off
Well,
not
.]
cover
for
feeling
angry
firing
.]
exactly.
You
just
said
angry.
Do
you
notice
how
it back?
Well,
Th:
the
[ Defense:
.]
Pt:
cover
down.
I was
Th:
you
feel
your
Im
You
not
say
indecision.
boss
by
sure.
angry;
[ Defense:
then
Do
you
getting
you
notice
bit
indecision
take
how
.]
it back
and
cover
the
[ Point
out
you
indecisive?
.]
Pt:
Yes,
Th:
Do
but
now
I dont
you
notice
how
I feel
sad.
have
a job!
[ Starts
to
up .]
cover
up
your
But
Th:
feel
angry
indecision
cover
with
and
up
tears
come
in
to
anger?
Pt:
you
these
your
your
sadness.
anger
And
you
boss.
feel
Then
I wonder
at your
angry,
boss.
if
you
the
[ Clarify
but
we
cover
crying
the
can
the
jag
function
see
now
anger
was
with
of the
way
to
defense
.]
Pt:
The
patient
get
a clear
of
vagueness
explore
where
the
it fits
presents
idea
on
her
of
her
until
down
the
I think
problem
problem
clear
feeling
triangle
I do
that
in
or
its
picture
would
of conflict.
a lot.
such
trigger.
of
not
a vague
Focus
the
problem
make
sense
way
on
we
the
cannot
defense
emerges.
until
we
To
know
Obstacle
to
Declaring
an
Internal
Emotional
Problem:
Projection
The
highly
problem
resistant
to
work
projections
patient
on
often
in therapy.
to maintain
you
and
my
[ Defense:
but
me
internal
to help
you?
[ Block
whether
and
this
sure
Im
not
how
Defense:
this
it.
problem
argue
with
my
an
The
I see
problem.
would
that
are
like
me
having
you
psychiatrist
to
lots
to deal
of
with
my
.]
was
problem
projection
your
with
psychiatrists
which
you
would
.]
arguments
[ Block
is you
so
are
He
with
my
the
arguments
for
her .]
is always
You
are
going
not
for
husband.
[ Defense:
a problem
on
about
for
you?
wanting
more
interested
in more
sex,
but
Im
you.
I thought
the
projection
want
you
would
think
it is a problem.
me
not
a problem
.] Thats
to help
I dont
you
know.
for
why
you,
Im
I have
no
right
wondering
what
with.
I mean
I would
like
it if
we
much.
externalizing
feelings.
How
If its
Pt:
is
the
Th:
Th:
This
block
.]
Pt:
didnt
the
emotional
is a problem
projection
explore
the
to
interested.
Pt:
to
how
presenting
you
and
suggested
is a problem
Th:
not
the
declaring
.]
Pt:
sex,
on
problem
I understand
is the
Th:
[ Assess
illustrates
husband
onto
what
diffidently
My
projection
Pt:
said
the
psychiatrist
Th:
like
vignette
to avoid
with?
arguments,
idea,
projection
focus
Whats
Pt:
issues.
This
a consistent
Th:
help
uses
How
I just
focus
is that
wish
. The
a problem
he
would
problem
for
you?
just
is
him,
leave
not
me
how
alone.
I
deal
Th:
not
clear
how
the
Thats
what
arguments
are
Pt:
I get
so
Th:
How
is that
Pt:
When
I get
Th:
you
want
a problem
him
for
to do,
but
its
still
you.
angry.
a problem
really
for
angry,
you?
I throw
things.
I yell
at
our
four-year-old
rage
at
your
Mm-hmm.
Pt:
And
sometimes
son.
Th:
directed
at your
Sometimes
four-year-old
Pt:
son
And
declaration
of an
triggers
son.
internal
And
a lot
you
would
rage
Summarize
the
triangle
conflict
and
the
so
case,
her.
the
So
presenting
we
When
want
to
get
have
therapist
it.
[ First
.]
happens
with
it is to yell
you
deal
some
help
in
figuring
son
doesnt
conflict
to
with
out
have
see
your
what
husband
is
at
going
to suffer
the
have
consensus
if we
your
on
results.
[
on
Yes.
presents
right
is
something
to explore
problem
that
the
for
troubles
disputes.
her.
others
Clarify
Otherwise,
but
how
we
the
cannot
alliance.
asks
in therapy,
seen.
a
deserve
NONPROBLEMS
the
for
doesnt
way
no
a therapeutic
COMMON
not
you
.]
patient
have
he
One
of
task
difficulty
establish
help
something
something
your
Pt:
this
So
like
this
not
that
because
problem
of rage.
underneath
In
instead.
is
Yes,
Th:
the
is
on?
Pt:
that
husband
Yes.
Th:
handle
this
problem
But
the
the
patient
sometimes
or
is
not
patient
may
the
what
claim
patient
problem
the
he
may
for
the
problem
has
offer
patient.
no
is
problem,
something
If
the
he
wants
as
that
therapist
we
is
does
not
a dead
recognize
a nonproblem,
One:
Nonpsychological
Patients
can
revealing
something
avoid
problem
outside
to
this
block
the
of
attempt
that
an
an
is either
and
internal
What
into
This
the
patient
vignette
effective
by
or
reveals
therapeutic
without
how
focus
the
problem,
we
have
problem
you
would
on
patients
no
right
to
is the
like
me
to
with?
My
fed
up
with
wife
How
Pt:
problem
for
Im
Its
Pt:
It is.
Th:
How
sure
that
for
you?
it is,
to
be
honest.
Ive
not
clear
if
this
divorce
is
really
money.
so?
Its
psychologically
the
financial
emotional
something
Pt:
Emotional
quite
does
creates
Pt:
to
happen
How
to
cost
but
as
bit.
out
I think
because
its
lot
of
like
a therapist,
the
me
reality
[ For
the
for
my
wife
time,
help
what
with.
I have
he
been
indicates
him .]
a problem
making
you
Well,
first
I cant
.] I wonder
to help
problem?
a problem
is that
me
.]
[ Point
would
Th:
that
course,
is you
daughter
he
Of
problem.
problem
my
going
speaking
Th:
want
a problem
you.
Nonproblem
at
not
a divorce.
her.
Pt:
with
wants
is that
Th:
dont
run
problem
for
Remember:
emotional
Th:
that
to
therapy.
you
yelling
a problem
an
problem.
Pt:
the
it only
emotional
expertise.
maintain
Th:
you
internal
not
therapists
emotional
declaration
been
explore
Problem
revealing
defense
internal
help
may
end.
Vignette
an
he
for
you?
her
afraid
is
moving
of
me,
out
of
and
town
and
shell
have
emotional
custody
problem
Vignette
of
my
daughter.
[ He
declares
an
Having
internal
.]
Two:
People
Pleasing
by
Not
Problem
Sometimes
patients
are
result,
they
may
to
do
have
not
the
can
begin
therapist
Block
this
defense
her
need
to
to help
see
going
well.
fine
I havent
since
my
boyfriend
fine.
defense
has
by
as
to
for
help.
presenting
quickly
as
as
depend
As
if
they
possible
and
her
so
fear
of
patient
the
patients
would
her
defense
problem
his
really
upsets
out
on
of
with
well
this
town
best
and
she
this
week.
on
behavior.
gaze
focus
going
well.
is fine
second
like
could
so
me
and
on
which
you
week.
would
Everythings
Everything
business
So
Im
avoidance
Are
well.
to
the
you
Yet
help
has
trip.
actually
been
And
my
feeling
indicate
you
just
anxiety
your
of
focus
with?
to
racing
speech
feeling
on
a desire
therapist
you
focus
patients
revealing
the
since
the
aware
might
to avoid
sentence,
return
I notice
therapist
and
are
could
what
Here,
the
therapist
the
problem.
racing,
anxious
regulating
right
the
is
glad
problem
the
block
therapist
everything
often
now?
anxiety
Im
could
glad
which
After
is the
Or
Im
help.
say,
here,
speech:
is
for
is
a sign
In
this
ON
a patient
TO
THE
DECLARING
ONES
if it appeared
WILL
TO
PROBLEM
becomes
hesitant
or passive
as
soon
as
you
of
case,
high.
RESISTANCE
WORK
doing
any
speech
going
you
too
Im
is
been
says
are
anxiety.
the
.]
The
things
Whats
had
boss
[ Racing
Often
others
you?
Pt:
be
on
so.
me
the
depend
the
Th:
like
to
please
a problem.
patient
doing
try
afraid
explore
to
the
problem
he
is
he
not.
wants
Mobilize
to
his
resolve
in
will
to
the
his
will
to
therapy.
task
You
to
are
exploring,
co-create
the
but
therapeutic
alliance.
Asking
him
to
emotional
declare
intimacy.
triggers
unconscious
emotional
those
treatment
rather
than
of
experiences
his
triggered
by
for
(Ainslie
1999,
2000).
his
will,
his
will
because
2002).
Yet
2001).
of
dismiss
the
has
both
our
inner
relational
history,
against
decisions.
So
and
will
As
Grawe
and
are
not
emphasis
practice.
on
and
2002,
processes
as
to
to
the
receive
303).
In
then
to
similar
to
Buddha,
the
therapy
that
you
results
part
of
is
still
and
in
your
Buddhism,
lead
all
us
to
Will
aspects
If
myself,
me
that
My
of
any
I regard
of
external
the
precedes
out,
it
illusory
2010).
like
pointed
own
of
is
Sternberg
aspects.
some
(Elster
discard
not
activation
(conscious)
by
achieve
(Wegner
personalityconsists
me
can
will
us
should
brain
106)
upon
is
lead
2007;
(2007,
explicit
will
he
of
dimensions,
experience,
forced
According
it
(Schulkin
Selfmy
so
his
self-control
not
illusions
nonconscious
conscious
(unconscious)
these
defenses
consciousness
do
he
acknowledge
experience
before
how
and
must
for
aware
(2)
anxiety,
He
desire
become
therapy,
1998),
our
unconscious
Obviously,
My
decisions
that
his
must
enhanced
perception
unconscious
my
him
of free
activity.
as
gives
occurs
about
in
task.
(Kenny
own
He
feelings,
goals
activation
concept
preparatory,
Begley
greater
defenses
can
engage
the
propose
conscious
conscious
use
invites
his
and
others.
in the
his
perception.
life.
to
(3)
This
illusions
concept
Our
on
patient
it onto
to engage
and
neural
the
will
and
neuroscientists
much
therapy
anxiety,
until
project
(1)
treatment
them
Some
based
feelings,
defenses
sequentially
wish
invitation,
in
closeness.
Address
to
This
engage
the
just
as
makes
implicit
volitional
agent.
Buddhist
your
mindfulness
will.
efforts
the
You
are
(Schwartz
quality
free
and
of
the
patients
attention
choice
to
James
quoted
The
pay
attention
by
choice
brain.
determines
to
Moment
minds
these
are
(Merzenich
Vignette
the
One:
to
2002,
feelings
we
work,
we
in
and
deCharms
1996,
Patient
rewires
Who
she
wills.
The
of
will
(W.
and
and
choose
embossed
what
317).
choose
left
and
phenomenon
Begley
moment
will
awareness
essential
and
attention
by
ever-changing
selves
is
Schwartz
pay
choices
her
who
physical
changes
sculpt
we
how
will
form
the
be
on
our
our
and
material
77).
Has
Already
Declared
Problem
In this
vignette,
problem
but
to
any
we
does
signs
patients
will
not
that
will
see
want
the
your
patient
to engage
on
is
in the
a patient
it. The
you
who
has
therapist
reluctant,
and
therapeutic
Can
declared
must
then
be
a
alert
mobilize
the
task.
tell
me
more
about
this
problem
wife?
Pt:
minimization.
therapist
to help
to work
Th:
with
how
Lack
of
Im
will
not
to
sure
how
explore
his
important
declared
it is.
[ Defense:
problem
with
the
.]
Th:
Is it your
will
to look
You
at this
mentioned
problem?
this
[ Invite
problem
the
with
patient
your
wife.
to declare
his
will .]
Pt:
and
a detached
Point
out
problem?
or defenses
voice
onto
so.
[ Defense:
hypothetical
speech
.]
Th:
You
seem
Are
you
the
defense
.]
[ Invite
the
patients
will
uncertain.
sure
until
you
he
Do
you
want
to
declares
notice
look
it without
that?
at
this
anxiety
.]
Pt:
of will
I think
others
I know
Im
supposed
to.
[ Defense:
projection
.]
Th:
But
do
you
want
to?
[ Block
the
projection
of
will .]
Pt:
look
at
it.
therapist,
patients
Thats
[ Defense:
defiance.
and
defies
then
problem
with
help
you
with
with
that
problem,
of
will
onto
creates
The
the
your
what
wife
you
the
if you
sure
I really
projects
as
therapist
I have
dont
And
no
his
the
right
to
no
want
if you
deactivates
his
will
you
onto
Hmm.
would
want
will
to
onto
the
of
the
you
with
repository
right
to help
to look
dont
at it. Im
want
try.
[ Deactivating
the
defiance
the
important
to you
this
conflict
ask
about
with
his
will
therapist
his
it was
me
that
to
here
to
help
you
the
projection
the
projection
no
and
if you
dont
your
wife?
[ Deactivate
to engage
you
would
important.
pursue
[ He
sees
this
how
he
.]
I have
right
want
in the
Pt:
declare
I thought
think
Th:
to
to.
So
the
pursue
do
it
is
you
if
want
projection
therapeutic
Well,
this
to
of will
task
its
not
explore
and
then
does
not
it still
may
.]
important.
[ He
still
will .]
Th:
wish
okay.
want.
I have
I thought
projects
his
patient
not
.]
because
be
Im
therapist
Thats
Pt:
not
thing.
will .]
Th:
this
the
something
you
to explore
want
and
his
Pt:
[ Defense:
detached
nonverbally
he
Although
to
explore.
resistance
Id
like
voice.
resists
it is important
to
[ Reflect
to doing
to resolve
you,
the
conflict
between
so .]
this
problem
with
he
moves
forward,
[ Invite
him
Verbally,
my
wife.
but
.]
Th:
Are
you
sure?
to
declare
his
will
.]
Pt:
Yes.
Th:
experience
simply
that
someone
insidethat
elses
[ Defense:
You
you
idea
but
said
dont
know
in a detached
sound
you
yours?
want
How
sure.
this?
do
voice
How
That
you
.]
do
you
this
isnt
experience
inside
that
you
know
his
desire,
experience
cant
go
on
this
nonverbally,
but
this
he
projects
Pt:
[ Sits
way.
we
is what
dont
this
here
with
Pt:
want
to get
to the
do
me?
[ Invite
[ Facial
bottom
his
committed
conflict
Vignette
Two:
once
he
does
and
not
involved
experience
.]
his
will
.]
inside
to declare
and
for
the
that
his
becomes
on
engaging
alert
experience
him
Focus
collaboratively
verbally
as
else .]
him
expression
of this
to
see
you
long
more
We
it yet
[ As
someone
looks
How
Principle:
emotionally
up,
hear
want?
it onto
[ Defense.
Th:
to explore
you
you
want
will .]
more
serious
.] I
all.
patients
in therapy.
will
Then
until
we
he
can
is
explore
Fragile
Patient
Who
Has
Declared
they
reveal
Problem
Often,
and
fragile
suffer
it was
their
example,
of will
from
their
project
you
so
patients
the
become
cognitive/perceptual
will
to
will
look
onto
will
the
learn
patient
owns
your
husband?
her
out
the
to declare
patients
her
Would
Im
not
Pt:
[ Nods
Th:
Was
will .]
Yes.
like
patients
sure.
Some
and
the
problem
forget
that
Instead,
therapist.
deactivate
they
In
the
this
projection
in therapy.
to take
will
a look
to the
[ Defense:
hesitance
can
therapy.
fear
to engage
you
the
defense
Pt:
will
They
in
and
identify
her
Th:
Point
to
[ Mobilize
Pt:
themselves
therapist
how
when
disruption.
inside
Th:
with
anxious
is
at this
task
indecision
here.
Do
conflict
.]
.]
you
notice?
.]
.]
it your
will
to come
here
today?
[ Invite
Th:
Was
there
a problem
that
you
wanted
help
with?
Pt:
Yes.
Th:
Invite
her
to declare
her
And
speech
Declaring
races
her
and
will
Yes,
she
triggers
off
[ Mobilize
regressive
anxiety
her
defenses
that
of
what
problem?
of
well
a sharp
rise
Are
aware
get
in
into.
anxiety.
anxious.
to the
anxiety
arise
in
do
you
you
to regulate
response
to
of feeling
it and
sharp
head
rise
of
.]
trouble
breathing,
anxiety
in the
Yes.
Where
and
comes
up
striated
explore.
in
Do
anxiety,
you
as
Differentiate
herself
your
notice
if its
will
my
muscles
the
and
one
on
how
(trigger)
other
telling
the
law
for
from
feeling
this
my
arms.
feel
too
anxiety?
I have
good.
some
[ Signs
of
.]
hand,
the
just
against
in
doesnt
smooth
On
notice
head,
stomach
and
body,
her
In
my
Th:
the
theres
hand,
this
anxiety
theres
me
what
you
to say
your
you
anxiety,
will
want
what
to
triggers
you
help
that
want?
her
observe
less
anxious.
.]
Pt:
[ Settles
down
into
her
chair,
.]
Th:
just
for
afraid
signs
seem
that
Pt:
what
help
.]
attention
Th:
Nods
want
am
fidgets:
You
Pt:
this
I just
anxiety
Th:
anxious?
you
will .]
Pt:
Her
do
you
for
want,
saying
as
what
Its
if the
you
want
to
wantto
know
what
you
want
Pt:
Thats
come
out
the
in and
Taser
of this
put
this
are
against
law
for
you
you
to
with
say
anxiety
therapy.
it.
If we
explore
you
if its
police
Th:
what
as
that
conflict
feeling
anxiety
with
under
off
your
the
to the
side,
husband?
anxiety
so
is
Do
you
this
you
have
better
information
about
Pt:
you?
[ Mobilize
Yes,
I want
Th:
now?
[ Mobilize
her
reveal
herself
triggers
What
attention
anxiety
Pt:
soon
as
comes
you
you
said,
Yes,
in to
inhibit
you
notice
that?
can
observe
this
automatically
Isnt
as
this
and
observe
her
awareness
and
tolerate
anxiety
of
how
another.
How
do
anxiety,
you
and
two
experiences
to.
the
patients
weird.
Its
got
will
to
anxious
Then
what
saying
this
you
what
with
interesting?
as
anxiety
want.
I want.
anxiety
you
how
in
invite
do
your
her
to
Saying
you.
Whats
your
will
It really
what
that
do.
express
time
once:
Pt:
that
and
build
is,
isnt
or
Do
[ She
resorting
it?
is one
you
experience
pay
to
Its
and
this
her
observe
to
this
want
her
begin
to
anxiety
is
as
will
will
back
[ Mobilize
to
weird
want
step
capacity
thing,
to
you
anxiety?
[ Separate
attention
what
like
this
her
want
body?
[ Defense:
I know
projection
experience
opinion,
invite
I should
of will.
of her
Th:
and
at
.]
feel
her
yours?
from
her
how
she
and
it .]
me
will
that
conflict
back,
you
You
to
flooding
inhibits
Pt:
your
as
a hard
things
go
then
I want
elements:
expressing
If we
causality:
right
.]
Isnt
Th:
notice
in you
.]
two
internal
what
without
that
these
.]
anxious.
soon
sequence
Th:
triggers
anxious
and
interesting?
I have
to defense
goal .]
happening
that
causality
Pt:
notice
anxiety
getting
thats
[ Show
to her
[ Becomes
you
her
will
.]
Im
Th:
to.
do
to
her
this
inside
her
experience
Pt:
[ Sits
about
it. My
the
projection
doctor
and
told
focus
on
will .]
Thats
feel
Block
talk
as
what
your
of her
up
and
he
thinks,
desire?
but
[ Block
how
the
do
you,
projection
will .]
looks
at the
therapist
.] Because
in
of
I want
better
daughter
and
to suffer
her
verbal
declaration
and
relationship
causality
will
to
RESISTANCE
EXAMPLE
OF
the
emotional
this
the
Low
A
Can
body
Each
later
feelings
If
so,
show
.]
PROBLEM
to
explore
at a specific
an
example
internal
of where
you?
to avoid
Resistance
declaring
The
what
a specific
types
type
example
of defense
of
character
and
of
pathway
structure
the
low
Patient
resistance
using
patient
usually
marriage.
I havent
resenting
happened
reveals
Yes.
wanted
me
just
for
last
to go
wanting
to
Its
out
had
with
stay
at
without
his
anxiety
affects
Resistant
moderately
resistant
defenses.
Once
will
offer
readily
readily
we
terrible
my
wife,
home
impact
and
and
I can
not
on
my
tell
she
go
out.
It
patient
gives
clear
or defense.
depression
Moderately
The
Intervention:
where
example
night.
Psychodiagnosis:
answer
specific
defenses.
Pt:
in her
trigger
further
my
SPECIFIC
will
look
want
conflicts.
may
going
his
we
us
of will
EMOTIONAL
for
tell
I dont
disruption.
to explore.
discharge
her
deeply
before
declared
defenses
want
explore
more
anxiety
INTERNAL
use
rise
cognitive/perceptual
is a problem
they
can
had.
has.
without
is
implicit
AN
ask,
patients
patient
this
EXPLORING
problem,
anxiety
[ With
TO
has
problem
of
parents
herself
the
patient
depression
Often,
to
regulate
my
we
reveal
leading
and
Once
I did.
declaration,
of
anxiety,
like
than
point
a specific
his
Explore
specific
example
marriage.
Patient
patient
out
will
those
example
use
repressive
defenses,
of his
problem.
however,
and
the
tactical
patient
of
Pt:
I get
depressed
a lot.
Psychodiagnosis:
clear
example
but
acknowledges
The
he
has
Intervention:
and
maintain
a focus
on
Th:
that
triggered
your
Can
[ Blocking
the
example
.]
Highly
Resistant
A highly
resistant
specific
specific
example
specific
patient
its
example
conflict
to get
we
the
after
my
the
price
so
of
his
of
he
will
the
on
go
we
what
I cant
problem.
He
example?
up
relationship
with
where
withholds
what
of
have
think
wouldnt
defense
be
.]
to
present
on
my
last
clear
the
to
Thats
just
asks
to do
for
therapy
I understand.
example
you
of
with
it.
see
have
without
triangle
of
not
his
a hard
give
an
defense.
time
giving
.]
people
the
ask
therapist
information
me
to
and
the
as
long
things,
have
patient
.]
Its
this
offer
defense.
defense
invites
the
problem.
does
patient
it. When
example.
patient
you
the
[ He
therapist
help
notice
out
nothing.
specific
able
you
patients
his
the
the
with
see
and
explore
the
see
patient
Remember:
The
not
than
defense
of a specific
Help
[ Point
is necessary
example
me
the
the
cannot
causes
does
Do
Th:
dont
vagueness
fired
rather
help
instead.
problem,
Pt:
come
boss
must
let
problem
Th:
just
of
a specific
a defense
We
Intervention:
a specific
at
patient
with
Psychodiagnosis:
me
defense
a look
allowed
problem.
consensus
of his
the
take
responds
Pt:
example
example.
It started
defense
of
and
give
Patient
example
defense
not
depression?
Pt:
job.
does
a problem.
Block
a specific
patient
just
that
problem,
[ Point
then
out
the
as
we
obviously
price
of
I
the
Pt:
example.
[ Defense
Then
we
wont
I wont
be
I really
If you
cant
cant
come
up
with
specific
.]
Th:
though,
But
be
able
able
to
to help
get
you.
come
a
clear
[ Point
Pt:
It happens
Th:
But
a specific
Pt:
Its
something
up
with
a specific
picture
out
all the
the
of
your
price
time.
example
difficulty.
of his
[ Defense:
defense
.]
vagueness
.]
vagueness
specific
Goes
goes
on
a lot.
[ Defense:
on
a lot
is vague.
Can
we
look
at
time
example?
Pt:
[ Defense:
Like
where
you
become
depressed
a specific
until
Fragile
the
mother,
we
take
it happens
when
a look
you
It happened
example
Principle:
defenses,
my
every
.]
Can
Pt:
to describe
with
generalization
Th:
just
a specific
your
example
mother?
yesterday.
[ Patient
begins
and
labeling
.]
Keep
patient
visit
at
your
gives
focus,
a specific
blocking
example
Patient
The
fragile
over
the
begins
must
specific
patient
will
threshold
to
of
suffer
regulate
use
from
the
specific
repressive
anxiety
defenses
tolerance.
At
cognitive/perceptual
patients
anxiety
until
that
her
point,
disruption.
first,
and
anxiety
the
The
then
ask
rises
patient
therapist
again
for
theres
example.
Pt:
feeling
that
.]
Th:
visit.
example?
trigger.
that
[ Sign
It happens
that
is triggered,
the
her
Th:
patient
anxiety,
Can
all the
we
time.
I dont
is unaware
or her
take
of the
defense
a look
think
at
stimulus,
the
.]
an
example
where
you
remember
this
crippling
becoming
depressed
so
we
can
see
what
is triggering
depression?
Pt:
I was
very
depressed
Th:
When
did
Pt:
I think
it start?
it started
Th:
Could
Pt:
Nothing
yesterday.
we
as
look
soon
at
as
what
I woke
up.
happened
the
day
before?
ignoring
of stimuli
revision
of
my
presentation
front
of
seen.
me
Th:
What
happened?
Pt:
I got
up
presentation.
a
afterward.
Then
presents
the
reactive
feelings
of
that
students
worst
him
for
feeling
Pt:
Yeah,
Do
you
that
makes
Pt:
.]
art
art.
did
last-minute
some
school
The
and
and
what
I went
he
to
ignores
my
gave
professor
presentation
by
that
ever
[ Blank
Did
Th:
projection
the
mention
had
Th:
is toward
out.
professor
denial
said
he
said
had
and
importance
the
professor
in
ever
talked
part-time
its
my
job.
to
[ She
and
her
seen.
Whats
the
said
it
feeling
was
toward
that?
Pt:
the
and
worst
then
You
he
Th:
conks
the
school
and
Pt:
mind
[ Defense:
.]
saying
the
to
shocked
after
presentation
what
was
were
Th:
the
usual
performance
it
stimulus
as
I went
form
group
Other
really.
.]
as
the
much
look .] Im
your
mind
that
a sign
your
professor,
Now
that
My
What
out
did
just
you
say?
now?
a lot.
of
anxiety.
you
get
As
soon
anxious,
as
and
ask
your
now?
that
you
It sounds
you
blank
happens
Thats
see
sorry.
point
like
it out.
there
is some
feeling
toward
anxious.
friends
said
they
were
angry.
[ Defense:
Th:
them?
[ Block
the
rationalization
And
projection
her
We
anger
Pt:
I mean
Th:
Are
without
explore
anger
toward
Fragile
and
the
to the
There
that
is a saying
probably
get
goals
the
patients
the
therapeutic
the
on
positive
goals
the
patient
If so,
the
barrier.
Otherwise,
develop
a therapeutic
Patients
can
transference
following
positive
guy.
[ Defense:
goal.
with
him?
[ Progress:
she
disruption
see
how
she
.]
turned
became
her
depressed.
events
know
a rise
that
what
trigger
causes
in symptoms
to
he
will
the
sure
therapy
may
have
therapy
their
discover
motivation
exploring
feelings
and
the
therapist
what
the
and
know
the
to
Without
to
engage
and
patient
declaring
help
you
in
conflicts
have
agreed
to achieve.
assess
and
to go,
therapy.
no
you
want
need
through
have
difficulty
goal
GOAL
you
we
is designed
must
positive
where
achieve
before
make
POSITIVE
know
in
to
therapist
has
not
wants
Thus,
the
examples
now.
ignore
do
goals,
a positive
prevents
patient
patient
will
goal
the
patient
overcome
not
be
for
that
able
to
alliance.
have
that
angry
and
often
preceding
trouble
resistance,
depression
could
dont
Likewise,
patient,
that
herself
they
if you
task.
declaring
she
patients
patient
with
from
see
DECLARING
positive
the
so
result,
there.
deeply
therapy.
with
feelings.
TO
However,
reaction
arrogant
cognitive/perceptual
onto
events
RESISTANCE
the
that
of feeling
I can
example
Explore
positive
share
a really
aware
Yes,
resistant
As
stimulus
you
professor
highly
symptoms.
will
hes
suffering
this
feelings.
the
you
.]
would
their
Do
.]
Pt:
feels
you?
declaring
a
left
the
show
failure
to
patient
how
a
see
feeling
to
help
positive
goal
causality,
depleted
these
due
or
or
patients
to
long-term
hopeless.
declare
The
a
Transference
Resistance
Some
may
patients
transference
may
be
resistance.
inviting
patient
resist
the
presenting
The
patient,
therapist
reluctantly
goes
positive
to
by
present
along
at
best
goals
not
providing
the
positive
or
as
part
of
a positive
goals.
opposes
the
goal,
Then
the
therapist
at
worst.
In this
example,
gives
the
people
patient
what
himself.
Afterward,
blaming
them
they
his
choice
them
so
can
we
Mobilize
the
for
your
help
you
patient
change.
Maybe
resistance:
responsibility
for
up
to the
will
sixty-two
years
and
therapy
by
Th:
transference
resistance
give
up?
[ Defense:
Th:
if we
should
stop
now
things
wont
Failure
to
When
patients
problems,
life,
or
fate.
one
damned
sacrificed
us
him,
yourself
to take
but
a look
exploiting
at that
yourself?
.]
old.
you,
we
cheats
exploiting
Its
too
late
to a passive
breathing
Shall
he
the
for
into
give
up
to
transference
therapist,
hope
me
me.
to
take
[ Block
the
now?
[ Looks
up
projection
.]
said
you
you
can
give
No,
Ive
got
surprised
should
.]
Are
give
you
up.
Im
saying
just
asking
up.
to
turn
this
around.
If I give
up
change.
See
Causality
do
they
ask
so,
he
interests.
of
[ Invitation
You
so
Pt:
now,
own
in which
.]
Pt:
should
for
like
task
up
them
you
therapeutic
up.
doing
you
pattern
give
by
that
this
Im
give
my
see
his
Would
give
I should
with
to abandon
You
a situation
though
angry
choice.
Pt:
described
even
becomes
Th:
blamed
just
want,
he
for
has
not
see
assume
Why
thing
do
how
their
something
bad
after
things
another.
defenses
else
keep
I
does:
create
spouses,
happening
think
their
its
to
just
presenting
other
me?
my
people,
Its
fate.
just
Life
sucks,
what
can
say?
think
its
my
karma
to
suffer
in
this
lifetime.
Since
they
attribute
hopeless.
If
they
hopelessness
cause
causality.
their
problems,
hope
again.
so
them
we
can
see
defense.
If
they
what
about
what
internal
Th:
You
see
you
choice.
give
up
wants
Rather
he
reality
like
so
can
to take
but
a look
yourself
will
does
feel
yourself
They
He
create
and
sacrificed
hopeless.
see
(defenses)
of exploiting
projection.
patients
control
us
fate
at that
?
never
not
care
what
you
care
enough
.]
They
wants
than
should
than
should
what
to
care
care
of denial
about
want.
Is
should.
they
Th:
Is that
(they
want),
he
do
[ Defense:
denial
in
not
relates
care
more
about
to his
fantasy
of how
saying
they
shouldnt
care
care
about
what
want
be .]
true?
Yes.
Are
you
People
who
dont
I want?
about
in fantasy
what
you
Yes.
Th:
his
want.
Is that
true?
you
[ Identify
the
defense
reality
is not.
.]
Pt:
[ Mirror
They
reality
what
Th:
should
Yes.
relate
Pt:
true?
you
or
true?
fantasy.
about
you
It feels
[ Defense:
of
that
pattern
do
feel
their
people
Help
they
they
confront
other
locus
this
not
hopeless.
things
Would
Pt:
what
how
forces,
do
believe
feel
an
Th:
that
should
regain
I want.
he
they
they
your
external
causality,
recognize
Pt:
about
to
they
for
help
suffering
not
problems,
Once
blamed
do
as
their
their
denial
Dont
Reality
you
should
agree?
be
what
Is
that
.]
Pt:
It should!
Th:
You
[ Defense:
say
reality
denial
should
in fantasy
be
your
.]
way,
but
then
this
reality
fight
keeps
with
on
being
always
wins?
Do
[ Point
[ Defense:
denial
but
you
ask
other
attention
But
my
needs
or
you
ignore
your
patient
Yes.
feels
life.
should
you
they
their
job.
having
fight
reality,
care
about
my
They
should
care
his
dont
ask
care
about
you
me
can
blame
others
I hadnt
defenses
about
he
I will
And
for
your
your
if
you
needs.
pay
you
turn
attention
let
me
to
know
choice.
way
before.
externalization
possibility
can
needs,
my
of it this
of
the
No,
needs.
thought
about
care
your
to ignore
say,
but
defenses,
job.
mine.
they?
my
the
about
should
your
should
ignore
uses
You
care
should!
they
And
also
job.
to do
why
But
hopeless
sees
your
I will
needs
who
better
be
.]
they
they
to them,
Pt:
he
to
.]
shouldnt
not
If you
Th:
Once
hard
when
of denial
Thats
people
Pt:
fantasy
how
price
but
Thats
Th:
Yes,
I think
Pt:
pay
the
No.
Th:
dont
be
needs.
Pt:
needs,
notice
in fantasy
Th:
their
you
out
Pt:
about
It must
It is.
Th:
needs?
it is.
reality.
Pt:
reality
what
and
for
against
denial
personal
them
in
change.
and
create
Depression
A depressed
patient
goals
for
some
positive
goals
persist
with
a depressed
can
declare
therapy.
often
a positive
Do
presents
not
for
with
proceed
the
until
therapy.
patient,
negative
the
This
blocking
rather
than
patient
vignette
defenses
has
declared
shows
until
positive
how
the
patient
goal.
Th:
Pt:
What
would
I dont
want
you
to
like
feel
me
to help
depressed.
you
with?
[ Negative
to
goal .]
Th:
the
patients
What
awareness
[ Negative
I just
to
feel
want
to feel
instead?
[ Mobilize
goal .]
dont
want
to
feel
like
constant
goal .]
Th:
want
you
of a positive
Pt:
failure.
do
instead?
If this
therapy
[ Mobilize
the
is
successful,
patients
awareness
what
do
of
positive
you
goal .]
Pt:
one
has
ever
statement
right
felt
illustrates
that
that
how
remembers
the
are
patient
can
depressing
know
we
have
else
will
you
they
(Grawe
goals
remember
his
his
any
This
experiences
depressed
dependent:
life.
state.
This
a depressed
patient
.]
it
sounds
you
want
like
you
want
to
feel
How
therapy.
want
to
2007),
cannot
do
to
be
different?
How
will
Pt:
I wont
Th:
What
Pt:
Ill feel
be
depressed.
will
you
like
Youll
feel
up
like
goal .]
instead?
getting
feel
[ Negative
in the
getting
morning.
up
in
the
morning.
feel?
chronically
the
of
[ No
succeeded?
Pt:
I wont
Th:
What
Pt:
for
But
second
depressed.
Yeah.
Th:
Some
state
memories
Th:
How
cannot
felt
different.
Pt:
we
always
single
with
be
Th:
something
Ive
every
incongruent
memory
only
know.
depressed
reveals
now
I dont
avoid).
the
sad.
they
feel
say
happy
goals
for
but
content.
a positive
negative
mobilize
maybe
formulate
about
defenses,
goal .]
instead?
cannot
ruminate
anxiety,
basis
[ Negative
you
patients
Negative
triggering
be
will
I wouldnt
depressed
Instead,
feel
their
and
therapeutic
goals
avoidance
resistance.
alliance.
goal
(things
system
Negative
Interrupt
depressive
focus
To
rumination
on
do
the
so,
to
positive
ask
prevent
goals
questions
the
such
depression
patient
as
wants
know?
How
will
you
be
this
and
therapy.
unengaged
How
instance,
do
instead
healthy
in
you
of
alternative
That
to
being
be
want
to feel
When
you
us
to be
what
to
to have
ask
the
patient
for
his
to
system.
now
in
as
when
depressed,
we
begin
the
we
end?
For
whats
the
relationships,
said
dont
you
want
positive
1.
Positive
dont
to
want
feel.
What
to
feel
do
you
2.
Anxiety
3.
Defenses
goals,
he
can
respond
with
goals
and
symptoms
One:
Patient
makes
a declaration
of
to feel
happy
instead
of depressed.
goal.
respect
more
myself
I want
instead
intimacy
in my
of
ensure
With
mutual
the
being
Reflect
understanding
patients
down
on
myself,
and
I
want
relationships.
Intervention:
goal
will
instead?
Pt:
want
how
instead?
you
Response
a positive
succeeds,
feeling
different
detached
want
tells
therapy
mention
You
depressed.
Then
to achieve.
relationships
want
you
session.
different?
You
detached,
these:
When
you
in
will
back
the
to
mobilize
and
and
goal
mobilized,
patients
positive
the
approach
explore
specific
example.
Th:
depressed.
yourself,
You
and
want
to
to
be
respect
more
You
want
to
yourself
intimate
feel
instead
in
happy
of
relationships
instead
being
down
instead
detached.
Pt:
Th:
Yes.
Youve
told
me
that
when
you
have
feelings
of
on
of
in
relationship,
intimacy
face
by
you
get
detaching
those
and
feelings
and
detaching
from
your
intimate,
and
instead
becoming
lonely
therapeutic
overcome
you
her
would
to
task
focus
on
Tension
sign
closer
the
Can
we
out
of
anxiety
or does
anxious
of
could
be
against
goals
.] Is
will
[ Outline
the
defenses
to
that
to
and
something
engage
in
the
a look
came
up
conflict
Two:
at
a specific
for
you?
example
[ Invite
her
to
.]
Patient
immediately
is
flooded
occur.
Pt:
I want
the
patients
to
feel
happy
muscles
instead
of
she
becomes
as
depressed.
limp,
.]
Th:
What
Pt:
Tired.
it feel
right
do
you
Does
like
it
a sick
Like
a sick
Thats
notice
feel
feeling
like
right
good
now?
tired
like
after
tired?
tired.
a sign
of
anxiety.
sick
to
Are
you
aware
of
now?
Pt:
I feel
my
stomach,
but
have
problems.
Th:
high
take
of the
Th:
stomach
instead
connections
patients
intimacy
example
Pt:
feeling
that
you
you
Yes.
Th:
exercising,
help
partners
turn
her
and
could
relationships.
and
[ Enlist
or symptoms
of rising
so
emotional
achieve
around
a specific
goes
we
feelings
.]
conflict
anxiety
with
them
your
avoiding
Response
with
like,
of
from
form
deal
you
bottom
and
Th:
this
the
feelings
do?
then
If
and
could
Pt:
where
to
of
symptoms
like
therapeutic
get
face
and
avoiding.
feelings
you
task:
anxious
anxiety.
Did
you
Being
notice
Pt:
Th:
sick
what
to your
triggered
stomach
your
is a sign
anxiety
just
of very
now?
No.
You
mentioned
that
you
want
to feel
happy
and
then
a little
suddenly
scary
observe
to
became
declare
causality
anxious.
a positive
feel
[ Becomes
you,
to take
your
It feels
side.
Pt:
out
you
can
observe
causality
The
or
and
help
the
patient
Yes,
see
expressing
It feels
better
patients
of
positive
the
boyfriends
to
.]
Yes,
it
wanted.
to
body,
how
now,
not
goal
Thus,
sequence
is your
so
stomach?
jumpy.
or
desires
when
it is
it for
were
that
[ Pointing
.]
often
in
goal
will
as
expressing
forefront,
Then
or her
punished
triggers
the
self-regulation.
a positive
and
Three:
I just
I sure
goals
],
their
help
triggers
children
will
for
and
desire
Patient
dont
dont
but
want
want
I dont
uses
to
to
feel
have
know
defenses.
if
depressed
any
that
and
more
is
crappy
possible
for
.]
Th:
When
a positive
anxiety.
[ negative
[ Defense
you
it make
you
would
underestimate
[ Identify
yourself
does
this
make
and
clarify
the
right
you
happy,
defense
.]
Depressed.
like
Pt:
you
yourself,
depressed?
Th:
you
I notice
underestimate
Pt:
something
chair
to form
observe
anxiety
patients
they
anymore,
or does
her
.]
goals
declaring
Pt:
now.
[ Invite
in
can
anxiety
attention
fragile
scary
you
Pt:
pay
unconscious
that
Response
me.
it feel
scary.
in your
causality:
what
a lot
Identify
patient
Many
anxious
.] Does
me?
Shifts
causality
anxiety
the
defenses.
out
Now
expression
the
anxiety.
triggers
with
tense.
the
regulates
patients
anxiety
here
a little
[ Point
Th:
and
causality
scary.
Th:
for
goal
out
.]
Pt:
does
[ Point
Is
this
habit
to overcome
If its
Th:
of
yourself
in therapy?
possible.
I notice
underestimating
[ Defense:
you
doubt
self-doubt
whether
.]
progress
is
possible
your
for
you.
potential?
Does
your
[ Point
out
Pt:
the
hurting
you?
[ Point
Pt:
to
feel
better,
you.
Its
as
your
potential.
its
as
As
if a
you
express
your
that
happened?
Pt:
Yes.
can
work
positive
goal.
should
probably
try
ESTABLISHING
you
and
of
defense
.]
to
declare
have
out
into
faith
I doubt
you
would
the
room
to
and
like
doubt
believe
in
.]
myself
you
life
might
that
in you
causality
like
self-doubt
a lot.
you
a better
I do
a lot.
doubt
here.
yourself
Do
you
as
soon
see
now
to
achieve
as
how
now.
only
patient
not
law
I think
for
habit
comes
[ Point
productively
If the
me
as
It sounds
Pt:
We
of the
policeman
fit?
desire
that
it hurts
the
Th:
think
soon
that
to doubt
.]
price
I think
if it is against
Does
you
the
Th:
a tendency
.] Yes.
Do
out
have
defense
[ Tears
Th:
be
mind
if
has
no
to treat
the
the
patient
positive
goals
problem
CONSENSUS
wants
for
(Grawe
ON
THE
the
therapy,
2007,
a
you
41).
TRIANGLE
OF
CONFLICT
We
explore
patient
on
specific
his
conflict).
This
essential
to get
In
the
example
feelings,
on
a consensus
following
vignette,
constantly
to
sure
defenses.
That
consensus
on
would
like
me
way,
what
to help
develop
anxiety,
consensus
make
to
the
what
on
defenses
causes
the
the
patient
the
Th:
Whats
you
with?
My
and
patients
doctor
the
with
the
triangle
of
problems
is
checks
in
(the
task.
the
sees
consensus
patients
therapeutic
how
therapist
causes
Pt:
and
notice
the
therapist
his
patient
feeling,
jointly
anxiety,
and
co-create
problems.
internal
said
emotional
I should
come
problem
to
see
you
you.
Defense:
projection
onto
the
Th:
whats
the
internal
with?
[ Block
the
doctor
Thats
emotional
projection,
and
the
reality
here
he
(he
for
says
comes
no
(I
Th:
Yet
reason
at
have
no
like
declare
me
an
much
to help
internal
desire
you
Thats
Whats
you
with?
Ive
sleeping,
you
always
onset
of his
opinion,
to
help
you
.]
doctor.
[ Defense:
here.
And
I have
to
ask
you.
been
this
Th:
Pt:
unemployed
Th:
the
sure
you
wouldnt
contradiction
problems)
and
between
what
he
does
.]
the
internal
problem
.]
emotional
little
down
problem
lately.
you
[ Begins
to
down?
Trouble
These
eating
symptoms
out
Im
sleeping,
not
eating
much,
of anything.
not
Pt:
was
here,
[ Point
Yeah.
much
Th:
and
me
question
my
not
been
A little
Pt:
job
your
true.
Th:
emotional
for
are
all.
Th:
trouble
hes
office)
Pt:
the
like
to the
ask
in
know.
to a psychologists
Th:
Have
return
psychological
Pt:
not
would
should
Since
I dont
Pt:
would
but
.]
Pt:
what
said,
.]
out
come
he
you
then
You
Th:
Point
what
problem
Pt:
projection
.]
are
much,
way,
No,
some
not
much
or is this
I havent
When
symptoms
did
desire
a more
always
it start?
you
recent
been
[ Find
for
this
have:
anything.
change?
way.
out
what
triggered
.]
Oh,
What
about
two
was
Not
much
for
a while.
Can
you
years
ago.
happening
around
that
think
tell
me
I can
more
about
that
of.
Oh.
that?
time?
I lost
my
Pt:
Id
been
out
there
that
an
company
Later,
by
the
then
in the
for
twenty
I was
a vice
years
and
accountant
under
accused
me
auditors
discovered
it was
too
company,
of
late.
so
no
from
twenty
this
years
your
own
job,
been
one
You
feelings
will
you
must
trigger
were
have
Pt:
and
detaching
Yeah.
to
take
these
from
your
a look
at
these
symptoms?
[ Defense:
about
the
feeling
feeling
he
I was
didnt
toward
defense,
the
Not
toward
has
we
task
not
about
that.
after
no
the
cause
crime
[ Asking
of
of
about
.]
them.
[ Defenses:
them
tells
defense
can
denial
us
how
.] Would
see
what
you
you
like
triggered
all
called
me
.]
pleased
pleased
him?
handle
No
when
tells
[ Identify
him
if
me
his
you
dont
.]
what
cover
against
hiding
really.
[ Defense:
Thats
to turn
been
feeling
it well.
Pt:
intellectualization
were
the
boss
what
you
defense,
didnt
and
then
feel.
ask
.]
him
invite
defense
you
.]
Th:
feeling
but
management
through
for
his
so
to the
Pt:
thought
[ Identify
[ Invitation
Th:
is the
me,
president
blamed
over
emotions
minimization
What
Getting
emotions.
Pt:
in.
spot.
.]
Th:
detached
fired
over
the
when
vice
or defenses
I got
The
back.
were
it turned
not
new
me
been
on
and
started
feelings
anxiety,
me
was
to ask
wrongly
some
feelings,
There
You
but
funds.
accountant
had
service.
well,
fired
symptoms
you
Company.
embezzling
and
the
XYZ
really
was
going
These
with
done
fired.
was
although
because
subordinate.
me
it was
Id
of excellent
but
had
embezzlement
Th:
fired
president
it, and
[ Defense:
denial
intellectualization
you
it
with
thought,
ask
but
the
fact
for
just
.]
thoughts?
then
.] I
the
whats
the
[ Label
the
feeling
that
.]
I
thought
that
[ Defense:
Th:
thought,
but
if
differentiate
the
you
his
boss
someone
dont
defense
for
firing
elses
you,
crime?
stimulus
and
this
with
his
triggered
do
[ Invite
stimulus
feel
from
the
what
onto
himself
He
depression
toward
brain
you
did
then
I felt
accountant
was
than
feel
Th:
You
it
feeling
toward
you
patient
believe
for
invite
doing.
he
did ,
[ Differentiate
the
I should
[ Defense:
he
boss.
but
.]
because
his
(stimulus),
.]
what
feeling
wrong
toward
anger
that?
the
confuses
him
Thats
doing
I was
the
not
you.
for
thoughts
blaming
probably
disbelieved
and
and
your
.]
patient,
him
Thats
with
the
[ Defense:
in the
feeling,
rather
you,
boss
.]
feeling
], whats
feeling
The
toward
that
the
feeling.
Pt:
known
feeling
Disbelieved.
a feeling
you
his
defense
your
disbelieving
Th:
what
the
cover
from
Pt:
the
[ Interrupts
This
have
turns
anger
would
cause
.]
your
the
feeling
[ Show
it toward
Im
asking
you
about
the
feeling
part
of your
boss?
takes
now?
notice
his
how
boss
Pt:
Yes.
Th:
And
do
toward
he
you
your
turns
the
notice
boss
how
and
a critical
turns
it into
anger
on
himself
that,
but
I can
criticism
on
than
feel
you
see
rather
.]
Pt:
I didnt
Th:
Do
see
see
how
that.
your
see
boss
how
into
the
criticism
defense
of
getting
myself.
him
really
[ Patient
depressed
him
Yes
depressed,
can
think
yourself
makes
Pt:
been
you
Th:
Could
be
depressed
and
causality:
turning
might
I think
see
that
this
hurting
wife
turning
you?
toward
[ Help
him
have
.]
it is hurting
my
feeling
tells
me
me
anger
because
I am
too
hard
on
on
himself
makes
the
feeling
toward
.]
we
take
a look
at
your
boss
without
what
is driving
turning
this
it into
depression?
Pt:
the
feeling
So
[ stimulus
get
are
of
get
you
anger
into
caused
the
touch
to
that
cover
with
out
triangle
gets
the
you
thoughts
and
feel.
with
so
can
task
see
.]
toward
your
for
accountants
that
you
boss?
see
].
us
at
how
causes
you
that
you
and
that
you
turn
onto
yourself,
I mean?
his
angry
[ problems
him
what
Or
are
want,
depressed
see
ON
When
you
and
anger
what
anger.
so
that
showed
you
thats
emotions
you
the
your
], and
[ defense
feel
you
Do
[ feeling
deny
you
makes
turn
can
you
what
the
handle
other
Or
Then
he
patients
the
patients
task.
you
[ Outline
problems
.]
THE
conflicts
difficulties,
Following
can
and
use
established
we
are
to
help
can
the
the
get
consensus
consensus
structures
patient
on
for
the
formulate
the
task:
a, b, and
We
see
that
when
you
use
you
have
x feeling,
you
c defenses.
create
this
defenses
When
presenting
3.
of those
with
up
depressed.
2.
go
it
you
the
therapeutic
might
boss
anger
] or
1.
that
we
TASK
interventions
use
your
with
CONSENSUS
creates
therapeutic
you
you
and
of conflict
explored
what
blamed
way
touch
defenses
THERAPEUTIC
on
boss
unmotivated.
ESTABLISHING
Having
what
of
feel
his
also
to the
feeling
is the
your
self-criticism,
by
will
the
angry
problem
from
more
leads
his
whats
Your
felt
you
yourself
out
and
The
angry,
distance
and
]. You
a problem.
you
[ Mobilize
so
Anger.
Th:
not
yourself,
.]
Pt:
crime
of
Sure.
Th:
Invite
criticism
and
a defense,
do
you
think
problem?
Our
task,
face
the
if you
feelings.
want
to pursue
it, is to
let
4.
capacity
you
instead
could
could
and
happy;
instead
goal
of a symptom.
experience
feel
Our
your
of
For
instead
of feeling
feeling
like
you
example,
power;
instead
is for
of
victim,
have
instead
anxious,
to
you
adaptive
of feeling
feeling
you
an
timid,
depressed,
could
feel
could
you
confident;
assert
yourself
effectively.
5.
like
Does
that
sound
like
something
you
would
to do?
Therapeutic
defenses
and
face
his
Task:
feelings.
Help
This
the
task
patient
achieves
let
his
go
of
his
therapeutic
goal.
Therapeutic
defenses
that
feelings
that
The
following
task
during
anxiety,
create
the
you
symptoms
healthy
vignette
and
where
cause
presents
we
the
cant
explore
The
Th:
Can
with
me
problem
the
patient
adaptive
to
colleagues.
trouble
misperceived
how
with
Pt:
person
with
of inquiry.
conflicts
Help
replace
his
channeling
of
his
a consensus
on
the
functioning.
shows
phase
have
Goal:
but
we
establish
patient
look
at
suffers
an
from
example
depression,
of
situation
in
which
conflicts?
Sure.
There
in
way
in
such
Can
you
be
was
the
was
I
situation
thought
a vague
was
and
unfair.
generalized
[ She
manner
it .]
Th:
more
specific?
[ Invite
specificity
.]
Pt:
paper
drawer
accused
yelled
from
for
a drawer
years,
me
at you?
but
in
her
when
of violating
[ Invite
It
office,
and
I came
company
new
in
bookkeeper.
we
have
there
had
she
I needed
access
started
to
yelling
a
that
and
policy.
Th:
What
was
the
feeling
.]
Pt:
I felt
like
the
a little
feeling
girl.
toward
[ Defense:
her
when
she
takes
she
little
girl
position
rather
than
face
her
feelings
toward
the
bookkeeper
.]
Th:
of
little
Point
out
adult,
what
girl,
even
the
defense
is your
I understand
though
.]
But
feeling
deal
with
defense
girl
her,
Do
defense
the
position
competent
perspective
[ Defense
she
started
think
that
in the
way?
is maladaptive
It definitely
as
adult.
competent
.]
yelling
little
[ Help
girl
her
at you,
you
position
helped
see
the
took
price
a
you
of
the
position
[ invite
feeling
her
to turn
is underneath,
the
If
really
felt
with
was
dont
against
the
I was
Th:
anger
we
feeling
Pt:
your
timidity
you
in the
felt
and
with
go
to
way.
[ She
timidity
defense
have
angry.
You
sees
her
], can
toward
[ Feeling
angry
a
the
little
girl
we
see
what
the
her?
.]
with
little
or
her,
girl
and
then
faade,
but
covered
what
you
anger.
Pt:
Defense
gets
.]
Th:
Thats
true,
but
I feel
timid
right
now.
.]
Th:
the
to take
.]
Pt:
us,
obviously
your
timid.
you
it get
began
her?
When
position.
or did
from
I felt
Th:
little
are
toward
Pt:
timid,
you
you
you
are
defense
Distinguish
tempted
]
the
to
rather
As
soon
cover
your
than
defense
have
from
as
this
anger
us
the
anger
now
face
therapeutic
comes
with
timidity
the
task
up
[ point
anger
.] Do
between
out
together.
you
see
[
what
I mean?
Pt:
Yes.
Th:
you
cover
Draw
difference
her
your
anger
attention
between
What
with
to
using
the
impact
timidity
price
a defense
will
rather
of
and
the
the
that
have
on
than
face
it
defense.
therapeutic
our
in
work
if
therapy?
Point
task:
out
the
turning
against
defenses
you
think
you
mentioned?
.]
that
presenting
is
Pt:
I guess
Th:
When
helping
does
not
Turn
see
faade,
make
does
you
does
that
take
more
make
how
this
you
has
feel
and
depressed
and
conflicts
want
so
in the
we
can
been
driving
can
help
you
power
with
this
effectively
show
so
your
of the
to do?
[ Outline
Remind
the
defense,
your
the
patient
point
can
out
girl.
her
[ The
problems
under
.]
this
strong,
or
little
does
it
anxious.
back
your
without
anger
standing
about
of
under
your
this
have
the
ground,
before,
from
being
of this
timidity
completely
and
but
I can
task
of her
goals
her
choice:
of
dont
sound
have
in therapy
and
she
her
work
task,
if you
little
girl
faade
here
bottom
than
and
hide
something
of
That
you
to
with
Our
behavior.
help
like
deal
and
like.
rather
can
under
anxious
to
to the
depressed;
you
that
and
power
We
to feel
able
get
anger
you
would
pattern
and
your
made
you
so
hiding
has
timidity.
Does
how
manner
anger
patients
hold
see
you
go
capacities
little
me
thought
submissive
dont
adult
makes
faade
anger
faade
you
faade
We
adult
this
feel
her
anger
and
creates
problems.
create
your
problems
or depressed?
prevented
your
has
powerful
work
do
depressed.
it, is to let
face
feel
yelling
girl
powerful
to pursue
hide
this
me
little
has
you
I havent
made
the
.]
defenses
you
good
Th:
timidity
defense
my
timidity,
work
defense
her
When
of
Pt:
see
the
the
causing
It definitely
Th:
and
you
under
anxious?
Pt:
timidity
the
anger.
anger
causing
how
be
to the
your
that
against
When
make
and
is
how
get
hide
see
It could
clearly
this
weak
to
her
Th:
girl
or
her
Pt:
patient
you
you,
[ Invite
problem.
I wouldnt
way
cover
assert
we
we
your
yourself
can
help
in the
you
what
you
anxious
would
like
.]
task.
can
Each
use
her
time
she
defenses
uses
a
and
continue
her
to suffer,
positive
During
the
phase
based
creating
his
of
to
have
take
we
establish
As
her
defenses
conscious
and
achieve
wants
than
the
into
presenting
the
emerges
take
and
with
helped
and
his
the
it in
until
regulate
insight,
is
can
therapy,
you
it. We
manner
have
do
not
because
is not
healing
the
history
until
leading
safe
patient,
patients
defenses
he
anxiety
relive
resistant
says
anxiety
The
history
First
it is not
disruption.
him
on
he
past,
detached
work
until
where
his
with
reasons.
Second,
full
highly
we
feeling
to
in a defensive,
deep
in
begins
not
anxiety
Instead,
with
history
know
traumas
history,
initially
integrative.
we
patients
of exploring.
several
in therapy.
until
Do
history
for
patients
conflicts
overwhelmed
instead
cognitive/perceptual
his
patients
history
the
describes
remember
initially
the
resistant
defenses
to resolve
himself.
assessed
take
history
he
retraumatizing
use
therapeutic
explore
become
history
to
to
Moderately
patients
patients
right
discharged
problems.
patients
discharged.
take
against
willingness
extensive
no
he
the
become
turn
patients
Fragile
an
a problem
or
the
resistant
take
we
rather
inquiry,
easily.
not
all,
has
on
Highly
do
of
presenting
collaborate
anxiety.
can
goals.
alliance
We
or she
to
an
to
form
integrative
experience.
We
take
a history
relationship.
patients
defenses
regulated
are
anxiety.
get
an
work
on.
Then
he
presents
assess
any
not
the
each
regulate
numerous
asking
response
the
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
Getting
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
Getting
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
the
spectrum
they
her
and
described
Just
asked
rain,
in my
The
death.
a garden
much
Well,
to
and
replied
too
Fragility,
before
low.
The
depression
begin
self-attack,
symptoms
often
projection,
to
and
cognitive/perceptual
use
of
use
session
reality
verbal
discharge,
the
alliance.
regressive
defenses
of
superego
disruption.
defense
equate
means
a therapeutic
use
Their
they
testing
projection
the
begins.
important,
to form
into
patients
Most
loss
projections
the
disruption
the
Fragile
patients
of
somatization.
and
acting
out
to
get
rid
of
their
projection,
Before
internal
splitting,
the
capacity
(Gottwik
pathway
muscles
at
Then
physical
While
1998c).
discharge
so
Otherwise,
symptoms,
and
genuine
of
out,
instance,
unconscious
First,
restructure
goes
in
acting
Otherwise,
striated
patient
will
will
not
and
cause
defenses,
no
be
function
which
out,
and
the
the
defenses,
anxiety
fragile
self-observing
brain
cognitive/perceptual
disruption
in
to
and
when
the
ANXIETY
following
the
ears,
think,
inviting
the
feeling,
loss
of
build
intrapsychic
answers
asleep,
therapist
reveal
stare.
are
the
focus
blurry
with
is
vision,
thought
projective
What
What
disruption
falling
dissociation,
equating
Blank
identification,
the
blocking,
projection.
feeling
For
toward
your
fragility.
[ Cognitive/perceptual
did
you
say?
disruption
.]
[ Cognitive/perceptual
.]
I think
looks
projection
frightened,
as
house
you
are
if he
angry
believes
at
you
me.
are
[ Projection:
the
same
the
as
his
.]
A man
the
her
FRAGILITY:
ringing
inability
passing
patient
of
the
regressive
with
and
it
feeling.
restructuring
OF
vision,
wife?
to
possible.
symptoms
tunnel
pathway
defenses,
capacity.
ASSESSMENT
The
the
somatization,
self-observing
resort
feelings
1998b,
her
depression,
testing.
be
of
restructure
states,
patients
1998a,
levels
with
restructure
anxiety
patients
unconscious
regressive
al.
of
high
overwhelmed
reality
the
fragile
identification.
to
must
et
patients
panic
projective
therapist
discharge,
properly.
Severely
a breakthrough
anxiety
will
and
pursuing
patients,
feelings.
but
cognitive/perceptual
cannot
argues
remember
disruption
A
with
what
his
wife
and
he
said
to
stomps
her.
out
[ Possible
.]
woman
speaks
about
her
sadistic
mother,
of
suddenly
feels
murderous
Cognitive/perceptual
As
a result
often
as
disruption,
and
loss
of cognitive/perceptual
cannot
give
hypotonic,
a clear
speaking
Fragile
patients
drugs
to
often
the
out
of orientation
disruption,
account
use
of
impulsive
rather
anxiety
self-observing
jumps
of
to time
severely
recent
her
events,
chair.
and
place
.]
fragile
patients
they
present
or
lifelessly.
anesthetize
outlined
rage,
than
symptoms,
capacity
masturbation,
and
compulsive
regulate
let
us
their
look
regressive
at
sex,
anxiety.
the
defenses,
Having
fragile
and
or
patients
how
to
treat
as
it goes
into
disruption.
Do
not
them.
Principle:
the
smooth
resume
muscles
exploration
muscles.
Regulate
(See
of
chapter
ASSESSMENT
or
cognitive/perceptual
the
feeling
before
suffer
from
fear
the
OF
FRAGILITY:
lost
on
the
appointment
The
severely
observes
prevents
not
his
first
session,
they
see
him
patient
ignores
feelings,
he
such
session
cannot
as
to ignore
the
triangle
from
of
seeing
make
the
him
or
his
stimulus,
conflict
causality
anxious.
their
call
striated
projection.
impairs
times
their
his
it.
as
Instead,
the
may
onto
and
They
may
to
confirm
memory.
anxiety
over
patients
project
several
regulate
talking
fragile
They
with
anxiety
anxiety,
the
the
equate
because
Therefore,
severely
disruption.
hour
fragile
his
in
CAPACITY
to
or projection
ignores
goes
LOW
way
defenses
speech,
cannot
whom
their
it.
regressive
He
at the
cognitive/perceptual
therapist,
soon
anxiety
ADAPTIVE
arriving
get
until
as
2 .)
SELF-OBSERVING
Even
anxiety
soon
he
as
he
resorts
therapist,
to
pressured
anxiety.
and
causing
correctly.
his
feelings.
his
He
As
a result,
difficulties.
thinks
he
Projection
other
people,
We
must
help
feeling,
the
anxiety,
feeling
from
triggers
feelings
the
fragile
and
that
in the
defenses;
(6)
differentiate
defense;
evoke
anxiety
(4)
striated
first,
therapist
so
defenses.
Do
(3)
not
to his
distinguish
a
defenses
the
stimulus
that
the
feeling
see
and
let
his
defenses;
from
cause
while
anxiety
go
regressive
of
is
and
(7)
projections.
the
regulate
his
fragile
patients
anxiety
any
or psychosis
OF
attention
causality:
trigger
(5)
encourage
neurosis,
pay
(2)
see
that
Strengthen
can
and
moment;
tolerate
from
he
ASSESSMENT
the
himself
Principle:
capacities
observe
muscles;
differentiate
the
transference
in
and
problems;
discharged
(1)
defense
anxiety
presenting
patient:
and
observing
let
go
pathological
of
his
regression,
FRAGILITY:
REGRESSIVE
DEFENSES
Severely
other
fragile
patients
defenses
they
habitually
and
project
it onto
I split
of
mine
Ogden
1982).
and
me
and
The
feelings
awareness
make
For
be
splits
My
no
longer
of
severely
by
instance,
unaware
you
feel
anger
boss
off
from
is angry
or
patients
but
separated
resistant
toward
his
me.
boss.
I never
Or
he
I split
I split
fragile
himself.
at
a feeling
instead
it as
a moderately
anger
it
experience
defenses,
of
off
identification:
Dissociation:
not
which
is the
basis
desire
as
of
not
you.
Projective
desire
splitting,
use.
Projection:
me
use
may
off
part
off
a feeling
or
(Grotstein
1985;
T.
desire
as
a feeling
of me.
are
not
repressed
in consciousness
patient
In
feel
split
or
may
contrast,
anger.
off
love,
out
by
splitting.
intellectualize
and
a fragile
Then
so
he
he
of
patient
projects:
feels
only
rage
toward
rapidly
without
2005).
other
but
complex
mixed
grief,
rage
she
love,
feelings
they
typical
Eliminate
physical
feeling
tolerance
explore
the
feeling
Symptoms
any
reality
by
Created
by
her
splitting
by
Troendle
rage
the
Exploring
devaluation.
defenses
as
soon
projection.
somatization.
and
dead
from
restructuring
restructuring
rise
her
and
regressive
chapter
by
relationship.
discharge
(See
can
toward
off
human
testing
restructuring
again.
splits
rage
quoted
rage
encouraging
symptoms
by
2005,
She
of
split-off
only
Restructure
Restore
the
(Reller
guilt.
is destructive,
occur.
Then
feels
or
Principle:
as
one.
feelings
claims
no
split-off
loved
mixed
woman
husband
her
formerly
Increase
acting
out.
Then
9 .)
Regressive
Defenses
in
Fragile
Patients
Chronic
projection
split-apart
or
with
rage
him.
Momentarily
her
of
for
whom
projects.
or
Such
days.
people.
They
others
. Constant
anxiety
chronically
is
she
and
believes
They
do
not
from
projection
repressed
perpetuated
by
fear
makes
by
phobias.
her,
their
from
she
the
projections
them
constantly
which
or
judges
Now
not
afraid
see
for
that
several
fear
they
of
other
place
anxious.
be
to
guru.
her.
testing
was
have
patient
does
character
must
not
the
for
anxiety
claimed
for
anxiety:
love
her
did
judge
reality
social
defenses
projection,
love
others
lose
suffer
and
social
struggling
out,
she
and
judging
can
me,
covers
idealized
but
anger
imagines
are
with
again
onto
that
a woman
blanked
guru
anger
her
then
she
her
create
patients
suffer
not
also
it up
criticism,
her
anxiety
instance,
covered
between
can
a moment
of people
hours
conflict
For
idealized
projecting
projection
herself
guru
of her
She
By
the
Chronic
she
a former
rage.
free-floating
feelings.
aware
him.
experience
in diffuse,
incompatible
toward
covering
critical
results
traits.
restructured.
on
Their
It
is
Splitting
keeps
emotions,
all
the
bad.
By
become
doing
the
the
her
the
not
me.
therapist,
she
becomes
projects,
accuses
a judge.
or
defiance
and
her
denied
projection,
she
desires
within
Splitting
can
somatizing
with
so
no
office
pain
also
an
As
view
on
her
she
anger
and
at
at
her
feelings,
imaginary
the
of
feelings,
him
her
the
she
as
if
he
feelings,
she
then
from
boundary
onto
onto
herself,
fears
want
splits
attributing
judges
you
of himself
vacation,
look
do
existence
reactions.
to
look
projected
the
that
had
cause
his
for
wrist
in a splint
which
bizarre,
patient
medical
a leg
symptoms,
multiple,
One
surgeries
Following
to
or
testing
is projection,
her,
desire
What
now
create
apparent
with
her
been
If
good
reality.
projects
him.
all
reality
distorted
from
complex
either
me?
between
The
herself
therapist.
Through
judgments,
and
herself.
patients.
many
she
avoid
as
panic
and
of judging
as
deny
further
step
of
desire.
desire,
can
to
second
wanting
serves
and
having
If
off
of
functioning
for
afraid
him
his
patients
The
splits
people
fantasy
therapist
To
viewing
shifting,
therapist
If she
defies
prone
else.
the
accuses
fears
cognitive
him
with
separate.
splitting,
differentiate
someone
projects,
his
feelings
a partial,
to
were
on
cannot
as
anger
relies
has
angry
anger
bad
leaving
He
A patient,
and
so,
patient
others.
off
patient
impaired,
result,
and
good
no
and
defied
breakthrough
chronic
somatic
many
arm
in a sling
diagnostic
his
feelings,
to
wrist
had
done
He
entered
due
to
unspecified
of
his
physicians.
skills
the
in
in his
Doctors
functioned.
the
symptoms
symptoms
years.
longer
his
bodily
patients
the
symptoms
disappeared.
Fragile
patients
amnesia,
woman
that
often
leading
sought
frequent
experiences
and
until
she
from
conditions
treatment
concentration,
plummeted
to
suffer
thinking.
began
for
dissociative
such
ADHD.
as
chronic
Instead
of dissociation
As
of ADHD,
Severe
her
fugues,
and
depersonalization.
interfered
a result,
therapy.
reactions,
with
academic
suicidality
we
her
discovered
memory,
performance
often
involves
splitting.
her
A woman
apartment
and
hospitalized,
Her
call
she
she
wish,
raged
Perverse
she
his
but
superego).
kill
sue
me
to
and
wish
she
for
for
having
was
his
onto
children
him
own
police.
on
her
Then
saved
her
life.
defenses.
were
for
her
me.
comfortable
I judged
tolerate
the
regressive
in
had
I acted
to live)
he
than
once
wish
nude
called
her
of
convinced
But
involve
of pills
After
project
photographs
said
hundreds
having
live.
also
He
had
herself.
fantasies
was
Rather
to
off
projected
and
to say
wanted
split
denial).
pornography
not
illegal
with
child
it (projection
judgment,
he
of
the
projected
it
me.
Impulsivity
split
in
apart
fragile
from
hate-filled
letter
discussed
his
but
no
guilt
acting
out
patients
complex
to
letter
or
son
and
feelings
about
him
results
from
For
instance,
feelings.
his
grief
punished
often
and
in
his
by
proudly
killing
read
detail,
acting
off
acting
he
out.
the
love
a
it
felt
Nor
out
man
to
his
Until
split-off
he
son
rage,
sent
me.
only
did
of
rage,
see
could
we
how
the
have
felt
him.
THE
GRADED
FORMAT:
SPECTRUM
We
(her
claimed
to
she
could
at me
(omnipotent
onto
intended
that
behavior
patient
me
threatened
revealed
healthy
for
telephoned
use
OF
the
defenses,
the
graded
low
smooth
THE
for
self-observing
muscles
supervision
conditions
require
the
patients
capacity,
and
and
suffer
anxiety
Whittemore
THE
regressive
discharged
into
disruption
(H.
1996).
The
following
approach:
with
episodes
of
major
depression
Chronic
depression
Depressed
resistance
from
cognitive/perceptual
20022004;
graded
who
Depression
clinical
FOR
FRAGILITY
format
Davanloo,
TREATMENT
and
functional
disturbances,
such
patients
as
migraine
with
high
headaches,
stomachaches,
and
diarrhea
Panic
disorder
Severe
psychosomatic
Fragile
character
Problems
the
graded
format
when
structure
of impulse
Highly
Use
syntonic
you
disorders
see
control
character
the
pathology
following
responses
or
symptoms:
Anxiety
cognitive/perceptual
weepiness,
disruption
conversion,
projection,
and
or the
defenses
syntonic
self-hatred,
patients
needs
to
structure
suffer
shift
from
within
pathway
to
build
anxiety,
and
defenses
feeling
or
format,
until
the
the
capacity
Step
following
at
by
patients
patients
that
step
steps
To
arise.
and
therapist
outline
The
then
the
of
therapist
that
builds
must
change
build
the
them
his
anxiety,
regressive
therapist
builds
uses
the
invites
defenses,
the
patients
feeling
patients
onto
feelings,
gradually
invites
the
patients
therapist
therapist
the
sequence
one
observe
gradually
builds
the
this,
the
the
projecting
to
do
with
to
body,
without
problems
moment
the
patients
whereby
capacity
above,
therapist
capacity
internally.
capacity
listed
the
internally
process
self-observing
self-attack,
somatization,
approach
is,
in the
feelings
and
symptoms
That
discharge
bear
self-observing
exploratory
patient.
others,
graded
the
a purely
of anxiety
capacity
from
the
(e.g.,
ideation)
Low
When
into
muscles
Regressive
ego
suicidal
smooth
discharged
again.
capacities.
interventions
for
The
the
graded
format:
1.
threshold
for
anxiety
Invite
tolerance
2.
summary
of what
just
Stop
happened
feeling
or uses
inviting
so
the
until
the
patient
a regressive
feeling
patient
and
can
goes
over
the
defense.
offer
see
a
the
cognitive
sequence
of feeling,
anxiety,
and
symptom
or defense.
3.
muscles,
and
different
the
repeating
feeling
that
at higher
Even
low-level
into
striated
the
Eventually,
more
building
the
striated
be
of
returns
to
invite
feeling
up,
the
the
striated
again
body
must
anxiety
the
to
in a
without
until
while
while
regressive
patients
anxiety
goes
will
have.
anxiety
goes
she
feelings
the
muscles.
fragile
symptoms
using
metabolize
muscles
it
fragile
to
defenses.
cognitive/perceptual
the
striated
decreases
released
striated
or
returns
patients
the
to the
can
her
smooth
anxiety
returns
the
bear
bear
striated
increase
fewer
bear
in the
to
Tolerance
into
of
capacity
remains
patient
Anxiety
anxiety
patients
feeling
the
and
moves
regulate
However,
of
able
muscles
anxiety
disruption,
anxiety
feeling
will
Threshold
When
while
muscles,
she
the
until
clears
breakthroughs
The
The
thinking
cycle,
levels
capacity.
the
patients
anxiety
relationship.
Keep
into
When
muscles.
slowly
neurohormones.
muscles
and
because
Be
cognitive
patient
functioning
improves.
Patients
with
with
the
therapists
and
let
so
go
they
of
can
Restructure
regulating
mild
patient
pay
attention
the
projections
the
feeling
therapist
then
shifts
ignoring,
to and
of
(See
attention
to
their
fragile
patients
neglecting,
regulate
severely
chapters
need
and
it. (See
fragile
2 and
anxiety
quickly
help
to see
denying
chapters
patients
anxiety
2 and
first,
9 .)
before
9 .)
Anxiety
as
to
of
anxiety.
pay
Moderately
defenses
their
soon
can
help.
Restructuring
As
fragility
pay
anxiety
moves
attention
triggers
regulates
to
anxiety
the
to a different
out
her
of
the
anxiety.
Then
symptoms.
patients
striated
In this
anxiety,
helps
muscles,
help
him
excerpt,
him
invite
see
notice
see
the
causality:
how
causality,
the
and
example.
Th:
What
is
the
feeling
toward
your
wife
for
walking
out
on
you?
Pt:
confuses
the
stimulus
(what
Th:
for
doing
I feel
she
Yes,
picture
of this
feeling
.] What
did
you
My
anxious
right
wife,
you
got
how
that
sequence
irritation
so
of
you
having
[ Point
out
could
irritation
without
feelings
Restructuring:
irritation
Could
her
goes
blank
we
get
her?
thinking
and
right
his
muscles
now?
of blanked
a sign
of
and
out.
anxiety.
Are
you
aware
of
then
your
like
it and
conk
mind
irritated
blanked
Wouldnt
mind
giving
[ Sighs
Can
up?
should
channel
out.
on
Cognitive
help
you
with
it in a healthy
you
when
happens.
it be
out
.] Yes,
we
[ Move
on
My
nice
to
Do
you
this
manner
need
it
the
mind
conks
be
able
at
another
to
out.
feel
your
you?
it would.
take
look
to another
.]
The
feeling
.]
what
Th:
we
out
task
Thats
comes
mentioned
now.
feel
mind
you
happened?
therapeutic
your
as
It sounds
Th:
this
vague.
soon
I do
Pt:
his
toward
a bit
kind
just
just
your
the
mind
anxious,
Pt:
where
feeling
is
is your
As
Th:
most.
is the
her .]
Yes.
Pt:
instead
toward
now?
Th:
see
feeling
[ Defense:
.]
face
Thats
Pt:
you
What
down.
vagueness
toward
How
Th:
your
his
me
say?
Pt:
at
let
[ Defense:
[ Patients
Th:
feeling
with
did.
Irritated
Pt:
slack
she
Irritated.
Th:
go
did)
she
that?
Pt:
clearer
like
Recapitulation
example
situation
to
explore
Once
the
patients
tolerance,
help
the
the
the
therapist
patient
regulate
therapist
patients
will
go
anxiety
of the
anxiety
has
will
cognitively
her
anxiety.
through
before
how
anxiety.
your
mind
blanked
this
of
the
cognitive
following
anxiety
process
to
recapitulation,
steps
again
[ Thats
a sign
causality.
[ You
then
felt
your
mind
If not,
disappear.
this
to
regulate
in a different
the
example
is your
different
example
person.
in which
no
longer
Whenever
the
cognitively
summarize
anxiety
more
high.
tolerance,
the
we
example
assume
of her
by
encouraging
so
we
can
the
continue
to
to build
her
Regressive
and
highly
resistant
got
and
anxious,
symptoms
until
the
have
symptoms
the
up
to
for
feeling
take
you
in
so
an
look
we
example
at
can
cognitive/perceptual
just
the
patient
explore
of
if the
three
like
happened
muscles.
Thus,
a sign
another
help
your
anxiety
problem.
her
Restructuring
Moderately
patients
you
of conflict
you
that?
to see
you
has
when
as
triangle
wife,
see
: Explore
experiences
defense,
the
through
you?
striated
symptom
your
you
comes
on
[ Do
now ?]
Five
what
to the
mature
Since
out
patient
returns
one
anger
out
: Check
[ Would
this
conk
Do
thinking
Step
that
: Point
out.
steps
symptom.
toward
Four
the
.]
Three
blanked
out
: Identify
irritation
repeat
[ How
out?
of anxiety
Step
stopped.
: Point
Two
Step
summarize
feeling
One
Step
mind
threshold
problem.
notice
with
the
In
the
exploring
Step
and
crossed
disruption,
until
Encourage
patients
went
over
has
gone
we
offer
her
feelings
the
the
intellectualization,
anxiety
the
as
patients
becomes
threshold
far
as
defense
of
she
of
in a different
can
too
anxiety
in
this
displacement
relationship
capacity.
Defenses
patients
use
repressive
defenses
to
keep
feelings
defenses,
out
which
physical
anxiety
to keep
anxiety
from
and
regressive
examine
differentiate
deficits
Often,
do
not
ask
obsessive
from
Everyone
uses
projection
However,
fragile
patients
therapist
with
is
this
they
judging
the
anxiety
ability
to
differentiate
In
internal
Help
and
the
the
a misalliance.
Gently
invite
the
fragile
patient
inviting
help
him
see
causality:
when
he
therapeutic
Once
anxiety,
the
observe
grief,
pay
defenses
how
task:
fragile
feeling.
and
his
sees
his
letting
patient
and
to
guilt.
sees
his
create
of his
how
If these
hurt
defenses.
feelings
has
(See
hurt
trigger
difference
the
until
loss
etc.)
Then
emerge.
First,
help
himself,
him
Only
understand
chapter
of
regressive
problems.
he
the
angry
defenses.
presenting
will
from
imagine
the
defenses.
him
1985).
become
see
feelings
his
his
he
or
regressive
to
projection.
reality
splitting,
Restructure
attention
is
Otherwise,
idealization,
defenses
go
face
ego
alliance.
they
fear
patient
projection.
create
primitive
they
the
cannot
(Willick
judgments,
response,
to
Address
address
the
their
He
a therapeutic
lose
will
stop
him.
another
testing
Then
floods
or
judge.
(projection,
that
must
anxiety
anxiety
patient.
time
reality
defenses
put
one
their
beginning
clouds
fragile
we
use
their
the
to form
as
patients
anxiety
to
as
such
at the
at
them.
therapist
first
defense
project
supposed
between
the
or
patient
not
such
triggering
others
but
defenses
regressive
When
the
projecting
fail
results.
defenses
fragile
feeling
onto
feelings,
first
fantasy.
the
it
regressive
the
see
and
defenses
defenses
regressive
splitting
worsened
disruption
Severely
project
his
himself
and
emerge.
and
repressive
regressive
more,
regressive
immediately.
cognitive/perceptual
even
as
can
defenses
to
use
testing
muscles,
shift
such
either
You
and
so
rises
They
they
awareness.
smooth
projection
session.
because
the
patients
in reality
regressive
patients
defenses
Fragile
a regression
rising
If anxiety
splitting
the
to
into
fragile
weepiness.
awareness.
Address
shifts
Moderately
side
lead
symptoms.
Once
of
of their
the
9 .)
he
will
cognitive/perceptual
feel
disruption,
he
feelings.
To
judge:
the
may
avoid
I feel
well
conflict
is,
are
and
his
him
and
internal
me.
therapist.
defenses,
him
he
Now
He
which
he
projection
judgment,
criticizing
himself,
between
remind
splitting
critical
within
that
his
you
supposedly
to get
use
the
of a contradiction
may
he
the
himself,
those
this
internal
or is angry
wish.
conflict
To
of
between
his
therapist.
rid
project
fears
sabotage
within
get
is in conflict
imagines
and
to
is
To
his
wish
avoid
this
outside
address
which
himself,
his
he
toward
defense,
avoids
through
splitting.
In
the
following
that
he
does
half
bottles
it more
example,
his
best
of wine.
readily
and
an
same
bottle
time
and
Notice
through
of
on
splitting
think
wine
said
do
for
that.
you,
your
He
why
do
of his
and
best
you
do
you.
I know
But
striated
experiences
causality.
told
one
so
he
me
and
can
see
drinking
your
best
[ Mirror
the
is a problem,
work
when
you
contradiction
but
at
have
he
avoids
who
am
dont
healthy
think
thats
awareness
end
only
a bottle
and
a half
I to
in the
way?
his
denial
and
not
sure
get
[ Mirror
a good
onto
you
can
[ I
what
is
me .]
know
of wine
allows
If it works
block
idea.
you
for
the
to
you,
projection
.]
Im
it
is
working.
[ Rise
in
others,
he
will
returns
to
the
If
he
.]
Responses
experience
drunk
irrationality
in the
if drinking
different?
awareness
the
this
you
his
Pt:
When
having
just
it.
say
projects
work,
anything
awareness
his
has
.]
Th:
good
man
after
I mirror
You
in
Pt:
never
work
how
reflect
you
half
alcoholic
professional
Th:
the
actively
to
Integrating
patient
a
rise
muscles)
takes
of
and
transient
Cognitively
Splitting
back
anxiety.
reflect
and
what
he
He
may
on
Projections
projected
how
sigh
he
cognitive/perceptual
summarize
what
onto
(anxiety
has
projected.
disruption,
has
just
happened
point
until
out
his
anxiety
bear
returns
to
conflictual
the
striated
feelings
without
Pt:
but
and
now
then
we
anxious,
see
then
recapitulation
you
you
response
project
they
to
more,
Unable
his
capacity
to
or projection.
as
angry
you
feel
said
he
You
with
dizzy.
him,
and
Do
you
your
anger,
was
you
angry
your
anger
see
that?
get
with
you,
makes
you
[ Cognitive
.]
Pt:
In
builds
splitting
soon
dizzy.
get
This
dizzy.
As
get
are
you
using
I feel
Th:
anxious,
muscles.
to
this
work,
and
from
candidates
for
but
some
develop
tolerate
suffer
I didnt,
I do
patients
become
a psychotic
becoming
aware
psychotic
level
supportive
now.
but
more
transference
of
of
not
their
disorganized,
(Kernberg
splitting
and
character
structure.
exploratory
therapy
1975).
projection,
They
are
(Kernberg
1975).
Implications
for
Since
fragile
affect
tolerance,
contrast
to
resistant
Technique
patients
have
we
the
must
ways
we
patients,
mobilization
of
such
a low
tailor
our
can
fragile
their
level
of anxiety
techniques
work
with
low,
patients
to
as
their
outlined
and
capacity.
moderately,
require
capacities
regulation
and
In
highly
careful
stepwise
in
following
the
recommendations.
Do
Not
Challenge
Premature
causing
confrontation
rely
on
superego)
projections.
triggers
is
is
too
with
high
a rapid
the
to help
not
Fragile
disruption,
inviting
clarification
Confrontation
anxiety
in
cognitive/perceptual
Instead,
defense
Defenses
the
usually
or
reality.
he
feeling,
fragile
necessary.
equates
Premature
his
Patients
rise
of
feeling
projection,
and
defense
patient
and
anxiety,
a misalliance.
identification,
let
He
go
resists
projections
confrontation
(of
of his
and
defenses.
because
anger,
confirms
his
will,
or
his
Differentiate
Unconscious
Defensive
feelings
the
with
and
even
though
transferred
to you,
contrast,
the
disruption.
his
angry
with
an
unconscious
in reaction
or
functions
deactivate
the
chapter
to an
earlier
figure
feelings
tolerate
the
the
toward
the
strengthen
projection,
do
the
which
anger,
patients
life.
Now
himself,
the
This
projection
patients
anger
that
is
defensive
the
not
feeling
results
from,
affects,
projection.
generates
can
of a judge.
a feeling
explore
he
patient
It is a conscious
his
not
angry
This
within
therapist.
affect,
We
feels
you
cognitive/perceptual
therapist.
defense,
a defense.
in the
therapist.
is a defensive
he
rising
judgmental
when
why.
trigger
anger
onto
patient
Eventually,
understand
supposedly
only
resistant
not
unconscious
as,
would
Do
Conscious
does
judgment
anger
highly
defenses.
patients
feeling
to an
out
he
to
the
conscious
that
point
fragile
internal
be
in the
belongs
Unable
projects
His
emerge
feeling
you,
In
from
Affects
Unconscious
invite
Feelings
for
Instead,
defensive
we
affect.
(See
10 .)
Not
Explore
Feelings
Resulting
from
the
Defense
of
Projection
Fragile
their
patients
anxiety
resort
to
therapist
Or
can
may
become
project
each
case,
projection,
and
cannot
Therefore,
restructure
experience
that
you
In
can
into
projection.
and
they
them.
goes
tolerate
safely
only
a small
cognitive/perceptual
They
may
defiant,
their
as
their
if the
therapist
is
angry
not
you
the
patients
fragile
of himself
explore
his
Th:
What
Oh,
from
without
feelings
are
I know
you
to
before
Then
explore
therapist
with
you,
chapter
projection
first
onto
it onto
arent
I will
angry
but
with
at
9 .)
so
he
you.
think?
with
the
them.
you.
afraid
they
is angry
it. (See
projecting
toward
you
feelings
is persecuting
the
distinguish
aspect
will
imagining
patient
of
disruption.
project
anger,
the
Pt:
amount
me.
can
Then
Th:
know
that,
Inside,
but
what
in your
are
the
projection.
Distinguish
you
address
gut,
you
Reinforce
Sure.
his
time,
when
we
you
see
have
these
a little
something
anxious
You
this
other
my
gut
Remind
the
triggered
calms
was
his
and
Differentiate
Anxiety
When
as
his
the
patient
Clarify
remaining
Invite
Carefully
Feeling
feeling
can
feeling
with
a clear
picture
the
fragile
of the
Im
not
on.
label
the
anxiety
with
how
angry,
that
head
when
you.
you
At
get
the
dizzy
now.
I know
to attack
yet
your
contradiction,
youre
gut
you
got
not
angry,
but
its
me.
response
to
testing
and
now?
In
the
within
himself
cognitive
that
summary,
he
improves.
by
Feelings
from
Projective
Projection
his
the
His
projections
patient
conflict.
will
to
explore
on
projections
projective
questions
trigger
is going
you?
experiences
triggered
any
angry
split-apart
Gradually
dose
both
then
his
Notice
is your
Caused
until
anxiety
not
noticing
want
therapist.
projections
we
now.
the
projects
a persecuting
Im
see
fine
reality
by
and
Assess
right
inside
How
Anxiety
Caused
else
first,
reaction.
Just
you
anxiety.
down,
know
You
Its
saying
of
head
Yeah.
dizzy.
patient
dizzy
reactions
Pt:
like
something
fantasy.
a little
different.
and
in my
projection.
Th:
two
and
orientation
from
Im
Th:
you
think?
and
Pt:
tells
I will
reality
Pt:
same
feelings,
reality
splitting
head
your
afraid
patients
In your
feeling.
to
Build
that
will
projective
drops.
(See
he
Then
chapter
fear
you
anxiety.
assess
the
2 .)
Capacity
evoke
and
may
create
anxiety
by
you,
feeling.
overwhelming
consist
merely
Too
rapid
anxiety.
of questions
a rise
of
Inviting
to get
Build
Observing
and
Experiencing
patient.
feelings
As
soon
them
to
pause,
they
can
do
them
to feel
feelings
he
and
allow
is
inner
afraid
of
deactivate
afraid
of
deliberate
This
with
me.
he
in chapter
The
Emergence
An
emotionally
experience.
These
response,
the
fragile
anxiety
that
covers
internal
experience
his
on
encourage
feelings
that
by
When
Complex
the
mixed
and
deny
will
As
alliance
to talk
about
show
you
fearful
he
patient
him
of
is
and
causality:
anxious.
part
as
you.
what
Be
Do
long
with
want.
his
others.
have
You
deal
yourself
onto
alliance
and
therapeutic
Does
in chapter
alliance
therapist
feelings
the
he
bear
Not
Work
9 .)
Feelings
therapeutic
patient
onto
Regulation
Projection
can
entrenched.
this
a
he
these
make
Anxiety
on
toward
so
Always
reestablish
section
regulate
or
putting
the
Then
patient
projection.
from
projection.
you,
think
you
cannot.
a therapeutic
you
his
close
feelings
Once
patient
capacity
the
anxiety
of
unconscious
feeling.
fragile
projecting
invite
(See
the
the
places
not
interventions
2 and
the
differentiate
to become
he
see
and
can
from
without
triggers
regression.
to
the
encourage
disruption,
self-observing
believes
can
feelings
prevent
his
you
a projection,
relationship
These
patient
transferences
he
heal
a feeling,
attention
transference,
judgment
what
so
your
the
a projection,
or
not
deeply.
a projection
with
pay
does
Transferences
build
regressive
misalliance
To
more
differentiate
and
experience
then
regressive
patient
anxiety
not
feeling
anxiety
cognitive/perceptual
transference,
In
the
his
and
Regressive
projection.
with
patients
without
the
Capacities
flooded
these
observe,
a neurotic
Help
while
as
so
Managing
In
Attentive
trigger
can
existence
on
the
become
or
powerful
patients
overwhelming
either
feelings
its
based
triggers
past
anxiety.
In
overwhelmed
split
off
or
project
some
part
it onto
with
of
her
others.
Once
she
she
no
denies
longer
conflicts
feels
in the
Table
7.1.
Layer
am
now
Layer
am
internal
of
Thus,
someone
can
see
in table
and
of
the
else,
a layering
of
7.1 .
layers
conflict
triggers
of
what
Experience
feedback
loop.
As
a result,
anxiety.
transference
and
onto
we
illustrated
projective
Regressive
of you
herself
patient
anxiety
with
of
causality
Expression
flooded
afraid
as
fragile
Projective
three
part
conflict.
patient,
the
depth
four
sequence
in
to
projects
fragile
The
experience
Surface
or
you
creates
might
do
projective
to me
anxiety.
[regressive
transference].
Layer
two
Defenses
transference.
of splitting
I am
angry
at me
Layer
one
regressive
relationship
angry
projection
at you
create
[denial
and
the
regressive
splitting],
you
are
[projection].
Complex
feelings
from
defenses.
I feel
anger
with
regressive
not
and
my
father.
the
past
toward
This
trigger
you
triggers
anxiety
related
anxiety
and
to the
in me,
so
I use
defense.
Maintaining
Therapeutic
Focus
with
the
Fragile
Patient
Keep
a steady
focus
it,
(3)
explore
his
feeling
then
in that
Always
focus
active
in
maintaining
on
this
on
(1)
a specific
situation.
his
to help
patients
about
experience
moment.
of
The
a therapeutic
problem,
example
Ask
of
the
feelings
then
problem,
when
feeling,
following
are
good
with
which
for
you?
his
and
he
the
(2)
will
then
avoids
anxiety,
to
or
(4)
them.
defense
examples
of
focus:
What
me
the
is the
problem
you
would
with
me?
like
you?
How
Is
is that
it your
Can
will
we
a problem
to look
take
at this
look
at
here
a
specific
example
where
this
problem
occurs?
What
is the
How
do
How
physically
in your
you
do
The
that
following
are
poor
than
Better:
feelings
What
rather
is the
than
about
yourself
feeling
did
than
face
criticized
the
and
Why
did
than
feel.
the
feeling
flatten
defensive
would
That
avoids:
is
we
What
about
feel
now
as
you
focus:
vague
and
about
that?
invites
patient
to
that
he
the
you
turn
it.
vague
.]
that?
[ Invites
[ Invites
the
patient
to
.]
did
that?
to project.
speculate
triggers
about
patient
[ Too
that?
[ Too
feelings
think
is,
doing
that?
that?
his
make
for
thoughts
that
did
but
would
question
is the
feeling
there
is the
Responses
the
him
you
Why
always
accurate
why
toward
you
others,
What
patient
affect.
be
now,
If we
worse
criticism
about
his
depressed
some
feeling
the
strengthen
.]
the
The
[ Invites
back
onto
defense
patient
rather
will
feel
out .]
Better:
[ The
have
[ Too
feelings
your
do
What
you?
right
a therapeutic
your
experience
Was
always
feeling
you
like?
feel
were
about
[ Invites
you
.]
of projection,
feeling
that
are
feelings
rather
to speculate
defense
that?
.]
Why
the
this
of maintaining
is
What
patient
the
examples
How
speculate
doing
me?
experience
is
What
thoughts
with
for
incident?
rather
vague.
here
him
body?
What
thinking
toward
feel
you
What
remember
feeling
feeling
toward
him
for
the
feelings
you
had
were
has
a feeling,
such
get
about
as
you
anxiety,
I
no
must
focus
toward
him
felt
on
for
doing
and
to the
the
doing
that?
when
or
reactive
feeling
that?
[ We
he
]
hit
sometimes,
anxious
closer
that?
the
]
felt
a
sad
anger.
patient
Maintain
If the
the
a Focus
patient
is
therapist,
on
the
passive
Patients
or
deactivate
is
Will
projecting
his
will
the
projection
of will
that
something
you
to
by
do
therapy
asking
the
upon
following
questions:
Is
Is
that
want
problem
to look
with
which
into?
you
want
my
help?
Is
that
your
Is
that
something
Did
you
Were
Is
come
you
this
wish?
you
of your
brought
your
Would
want
to examine?
free
here
will?
against
your
will?
idea?
you
like
to
get
to
the
bottom
of
this
problem?
this
Would
you
like
to
see
the
feeling
Would
you
like
to
find
out
who
you
this
problem?
anxiety?
underneath
this
you
Do
better
information
your
Some
about
Rather
the
patient
do
you
The
fragile
like
you
to overcome
want
yourself
reveal
than
their
to
to
reveal
help
become
think
patients
projection
support
you
yourself
make
so
you
better
have
decisions
the
of
patients
What
do
you
make
What
do
you
think
Lets
see
How
do
would
will
by
taking
passivity
by
passive
being
active,
active.
We
way
are
patients
stance.
help
behalf
really
self-attack?
Would
on
underneath
what
you
could
be
defenses
most
we
suggest
face
helpful
create
this
of it?
we
ought
will
do.
we
to do?
proceed?
problem
or
avoid
it.
Which
to you?
chaotic,
wandering,
unfocused
sessions
that
yield
disorganized,
Why?
kind,
and
and
anxiety,
are
the
patient,
The
following
can
break
to
it
up
his
in
is
into
therapeutic
task
you
to what
your
with.
you
body,
are
do
creating
our
collaboration.
or to another
distracts
them.
your
you
We
onto
Does
patient
the
focus,
pay
out
do
if
in
he
therapy
offer,
so
you
of
the
is
not
elements
the
patient
Did
I tell
what
you
him
what
make
hesitates,
he
In
so
We
When
and
in here
to
sense
may
response,
feel
understand
need
to
prevent
these
you
shifts
so
in
need
what
close
goes
both
derailed
We
pay
attention
to
anxiety
can
happens,
what
will
you
me
attention
anxiety.
also
that
see
kind
and
we
your
want
and
where
feelings
shifts
attention
out
of us
of
need
you.
Whatever
from
achieving
we
can
achieve
to you?
be
projecting
mobilize
his
his
will
will
to
to
do
therapy
engage
in
the
task.
and
these
shifts
you
so
Do
problems
If
notice
have.
goals
Are
anxiety,
(defenses).
to
careful
Sometimes
that
therapist.
therapeutic
you
your
to
feelings
find
all
know
pay
in your
subject.
our
from
need
goals.
If the
to
are
me
to
internal
problems
back
continuous,
their
I usually
yourself,
let
body,
shifts
the
the
come
pay
task,
know.
ask
need
in your
of these
to
to
what
these
have
we
any
attention
room
You
that,
note
aware
manner.
of
what
is?
feeling
and
to become
is
To
than
task,
Th:
help
this
in
anxiety.
should
therapeutic
you
collaboration
Knowing
But
patient
to
experience
of
it.
to
noncollaborative
of our
longer
parts.
the
the
do
relate
task:
bodily
patient
reducing
task
engaging
willing
statement
therapeutic
the
is
and
degree
fragile
may
therapeutic
the
in the
the
and
the
to
shifts
inform
understands
of
attention
and
Patients
dismissive,
unaware
loving
you
orients
benefit.
inattentive,
They
When
little
so
you
could
be
willing
we
you
more
can
to pay
find
want
attention
out
to
in charge
to your
whats
know
of your
going
what
life?
is
feelings,
on?
driving
your
Is
can
get
Once
free
the
him
see
this
when
has
his
agreed
difficulties
will
we
be
I notice
helping
that
before
her
your
goals
his
you
If we
want
to
explore
therapy,
we
so
you
talk
for
help
goals.
are
starting
about
or helping
can
her
to
describe
problems
your
instead
of
you?
Her.
Th:
needs
his
sabotage
again.
Pt:
her
on
defenses
Th:
yours,
you
of it?
patient
ex-wifes
a problem
Could
this
be
an
example
so.
I hadnt
of
how
you
put
own?
Pt:
Yeah,
I guess
Th:
If we
thought
about
it
way.
would
get
the
most
attention
Pt:
talked
here,
about
her
her
instead
of
you,
who
or you?
Her.
Th:
Does
Pt:
that
No,
Th:
sound
fair
to you?
it doesnt.
Shall
we
focus
on
her
goals
or
yours
right
now?
Pt:
STRUCTURE
OF
FEELINGS
For
IN
severely
someone
What
Start
is the
with
severely
feeling
the
capacity
What
was
shift
to
the
INVITING
GRADED
FORMAT
patients,
too
patient
toward
reaction
present
asking
much
you
What
may
use
you
of
feeling
tense.
How
How
do
feeling
toward
Rather
than
a gradual
think?
of
it encourages
him?
the
quickly.
aware
awareness
to
too
did
become
since
about
anxiety
him?
tense.
patients
your
SESSION:
toward
past
step
higher
Then
THE
activate
fragile
preliminary
THE
fragile
can
Mine.
. Do
approach.
[ This
her
helps
reaction
not
them
to
did
you
feel
you
feel
toward
ask,
do
the
as
this
a
with
intellectualize
toward
him
.]
him?
now?
A sequence
of
of feeling
the
invitation
feeling
patient
like
faces
so
this
her
allows
affect
Build
the
1.
Invitation
you
: Before
to
capacity
inviting
feeling.
to bear
response.
tolerance
patients
feeling,
Asking
feeling
What
your
her
did
mother.
that
to
you
be
can
about
before
did
the
aware
dosage
increase.
using
ask
to
notice
to tolerate
about
feeling
the
that
graded
the
the
stimulus
patient
builds
to
about
the
the
patients
it.
Something
I said
something
about
that
is triggering
you?
just
and
now
I said
labeling
Youre
let
awareness
patients
before
of
stimulus
labeling
I say
2.
her
by
the
caused
I say?
What
like
capacity
Asking
build
can
capacity
Whats
to
to feeling.
stimulus
and
interventions
it sit
of the
Invitation
it. This
be
allows
also
builds
us?
to the
aware
her
I said
between
stimulus
to
reaction
here
right.
of
to
her
you
that.
[ Build
feeling
her
.]
reaction
become
aware
capacity
of
to
tolerate
you
had
feeling.
reaction
to what
I said.
Do
you
It
notice
sounds
notice
and
Let
this
sense
yourself
reaction?
notice
What
this
reaction
is it like
to let
about
what
I said.
What
yourself
are
noticing
this
I said.
How
do
you
notice
that
reaction
is your
sounds
thought
like
about
What
is
you
what
your
had
I said?
reaction
to
I said?
3.
After
to what
It
what
You
it?
thought
that?
reaction.
like
having
intellectualized
explored
way
of
Invitation
the
talking
to
stimulus
about
the
link
her
and
feeling),
reaction
the
we
to
feeling
reaction
have
:
(an
built
the
severely
fragile
directly
about
patients
capacity
enough
that
that
in reaction
goes
with
to what
in reaction
can
ask
more
like
there
feelings.
feeling
we
this
reaction.
It
What
sounds
is that
is
feeling?
What
do
you
notice
feeling
What
do
you
notice
feeling
feeling
toward
I said?
to my
saying
you
are
close
to your
mother?
What
is the
me?
What
do
you
feel
toward
me?
This
sequence
building
the
the
of
patients
threshold
graded
of
only
fragile
allows
capacity
anxiety
approach
severely
interventions
without
patient
running
tolerance
with
too
severely
when
feeling
to
the
rapidly.
risk
Use
fragile
feelings
rise
of
going
this
patients.
overwhelm
gradually,
the
over
extremely
Support
the
capacity
for
self-observation:
Lets
and
observe
step
it like
notice
this
aware
of ?
feeling,
what
are
the
happens
as
Help
bear
her
the
just
as
striated
Continue
When
you
much
to
your
her
toe
feeling
muscles
building
of her
let
capacity
you
be
as
and
pause.
sensations
If
force
notice
this
feeling
to
see
that
feeling
and
it?
Lets
in
and
it.
Whats
notice
back
dont
in the
she
her
step
you
step
back
in your
body
that
you
dive
water
can
thinking
by
When
step
into
for
while
the
her
she
anxiety
the
Invitation
to
Explore
what
remains
are
can
bear
feelings.
Decrease
are
a minute?
capacities
until
feeling,
to
Feelings
intact.
the
full
We
explore
tolerance
feelings
and
discharge,
help
it is
to
following
also
pathway
defenses,
important
restructuring.
know
capacity
of
and
to
Begin
patients
for
unconscious
anxiety
self-observing
when
to
restructuring
affect
capacity.
shift
as
from
soon
as
exploring
you
see
the
responses:
muscles
stops.
The
intercostal
becomes
Unconscious
patient
muscles
suddenly
Isolation
of affect
producing
are
limp
not
with
in
the
Anxiety
shifts
The
chair,
patient
feeling
weak.
into
smooth
muscles
patient
becomes
shifts
confused
into
cognitive/perceptual
or angry
with
you,
equating
a projection;
projection,
dissociation,
signs
anxiety
because
automatically.
slumps
Anxiety
4.
These
breathing
pain;
3.
the
in striated
difficulty
operating
and
of anxiety
disappears;
physical
disruption:
signaling
experiences
2.
you
the
her
1.
the
build
restructure
regressive
However,
feelings
to
to
and
indicate
tolerance.
Defenses
If
acting
that
the
you
continue
become
out
patient
react
with
uncontrolled
anxiety,
other
forms
of severe
regression.
Instead
occur
has
to
rage,
of inviting
regressive:
splitting,
in session.
gone
invite
over
the
feeling,
depression,
feeling,
threshold
the
patient
of
will
somatization,
regulate
the
or
patients
anxiety.
1.
Stop
inviting
feeling.
2.
Offer
a cognitive
summary
3.
Invite
the
to
of
what
just
happened.
symptoms
of anxiety;
ground
4.
her
Help
in her
the
patient
describe
the
bodily
about
other
body.
patient
intellectualize
topics.
5.
If these
anxiety-regulation
techniques
do
not
work,
anxiety
address
(see
ego
chapter
deficits
As
corner
of the
reminder,
it
triangle
of person
can
triggers,
occur:
therapist.
became
triangle
of
not
the
therapist.
boss,
only
the
perpetuate
explore
in
to
to
avoid
feelings
in
past,
the
the
the
patient
to
to
breakthroughs
the
patients
the
the
feeling.
The
in
or
with
his
and
help
the
in
to
where
explore
feeling
and
feeling,
present,
anxiety
relationship
invitation
the
of relationships
a relationship
invite
but
when
used
regulate
Then
defenses,
possible
in
high,
to
refers
kinds
explored
Extended
confronting
defense
relationship
too
patient
conflict
to three
patient
the
of
the
refers
conflict.
with
which
of person.
triangle
and
If the
anxiety
Invite
triangle
the
anxiety
defenses,
2 ).
6.
another
and
his
him
see
the
feelings
the
the
and
past
goes
with
boss
or
again,
with
the
transference,
unconscious
anxiety
conflict
feelings
into
the
are
striated
muscles.
When
to
Invite
feeling
Resume
patient
uses
explore
an
when
and
himself
these
feelings
is
too
anxiety
or
stirs
asks,
up
to
explore
toward
decreases
Stop
uncomfortable,
or
the
striated
When
Why
feelings
motivation.
Feeling
into
affect.
ready
often
to
goes
of
issue
reveal
and
anxiety
isolation
intellectualizing
energy,
Invitation
his
exploring
triggers
the
patient
does
that
feeling.
The
the
gentle
over
we
he
the
is
invitation
A small
when
the
suggests
mobilizing
feeling
or
happen?
therapist.
anxiety,
anxiety
muscles
to
rise
his
hope,
it doesnt
help,
threshold
tolerance.
Restructuring
the
Pathway
of
Unconscious
Anxiety
Discharge
When
anxiety
it. If it does
goes
not
come
over
the
down,
threshold
try
the
of
following
anxiety
steps:
of
tolerance,
regulate
for
1.
differentiate
the
2 ). Encourage
the
body.
to
the
observing
him
Help
him
physical
regulation.
to
step
see
hands
with
Anxiety
is
overcome
not
patients
inner
building
the
patients
it can
ignores
get
his
regulated,
FRAGILE
TO
tear
or
flicker
experiencing
cognitive/perceptual
unremarkable
therapy
breakthroughs
In
the
what
striated
the
of
tiny
may
but
go
away.
regulating
attention
to the
precondition
my
for
translation).
attention
to
defenses
breathing
anxiety
may
his
by
anxiety
which
he
or has
(see
jumpy
chapter
legs,
2 ).
FOR
THE
happened,
last
bit
of
in
for
the
his
quite
involve
isolation
face.
capacity
feelings
and
for
first
experience
of affect
patient
without
small,
As
you
do
visualizations
of
bring
can
multiple
gradually.
The
involving
The
Work
cognitive.
little
second,
complex
disruption.
build
the
rage.
anxiety
of
The
over
time
muscles.
murderous
or have
will
sadness
to
look
increase
response,
project,
kind
for
afraid,
UNCONSCIOUS
feeling
breakthroughs
impulse
Once
the
THE
to
only
into
are
through
character
is barely
perpetuating
experience
the
partnership
necessary
pay
in
attention
anxiety
careful,
not
the
If he
breakthrough
a
the
our
2005,
does
symptoms
PATIENT
first
so,
we
but
close,
(Troendle
address
night
alone,
chapter
Mutual
a
makes
anxiety,
(see
the
forms
at
is the
If he
at
anxiety.
anxiety
pay
with
self
a look
the
forest
floods
anxiety.
projections
merely
be
force
capacity
BREAKTHROUGH
The
take
partnership
3.
address
and
person
of us
2.
so
experiencing
the
by
This
the
of
in
both
life.
and
than
another
where
patient
rather
alone
holding
the
back
experience
When
relationship
ego
If
rage
fragile
has
patients
conversion
and
modulate
emerged,
may
symptoms.
the
guilt
somatize,
When
affective
and
grief
begin
become
this
depressed,
occurs,
experience
to pass.
summarize
to
bring
the
patients
anxiety
Premature
back
into
and
(depressed
(panic
pathways
of anxiety
a breakthrough
Always
assess
capacity
lost
someone!
session.
cursing.
experience
out
the
chair
Help
of
conflict
and
assess
before
the
pursuing
anxiety
and
capacity
the
the
inside
fragile
to
if
outside
over
rid
or
yelling,
of
standing
of
you
voice,
get
she
stabbed
and
talking
wildly,
patient
feeling
up,
or
something.
go
it
goes
of
regressive
to
get
therapeutic
help
once
a raised
around
impulse
asked
had
include
until
let
low
instance,
she
actions
you
self-observing
therapist
control
a sentence,
Patient
means
For
replied
finish
arms
Fragile
A low
the
control
include
see
can
When
she
the
out.
impulse
to show
and
panic
patients),
structure
which
impulse
moving
patients
you
as
rage.
self-observing
capacities,
deeply
signs
restructure
patients
triangle
you
of the
patients),
patient.
acting
anger,
of poor
as
summary,
a fragile
patients
such
suicidality
Always
in
tolerance,
her
of her
Other
with
and
termination.
increased
before
(patients
(impulsive
defense
dissociation,
feelings.
affect
the
Signs
you
muscles.
low
control
out
and
with
explore
Assess
interrupting
In
to
testing
Capacity
means
hesitant
getting
discharge
to
(somatizing
premature
impulsivity
which
ever
or
lead
depression
acting
Self-Observing
means
control,
reality
to unconscious
of
unconscious
somatization
patients),
resistance
Limits
muscles.
disruption),
increased
or
the
of
patients),
attacks
the
to
loss
cognitive/perceptual
had
striated
breakthroughs
projection,
was
the
into
the
striated
defenses.
consensus
Build
on
task.
Once
you
build
patient
face
her
feelings
the
these
as
possible.
DEPRESSION
Depressed
patients
anxiety
goes
into
tactical
defenses.
can
the
Shift
face
striated
to
unconscious
muscles,
the
graded
and
feelings
they
approach
use
when
quickly
when
repressive
and
anxiety
goes
into
smooth
muscles
or cognitive/perceptual
defenses
occur
and
the
regressive
triggers
these
defenses,
returns
to
see
defense,
In
the
and
three
face
the
muscles
and
she
and
how
the
the
its
therapist
price
will
out
defense
telescope
shifts
onto
you
back
not
],
the
Notice
onto
how
you.
you
Then
feel
of
the
let
go
the
anxiety
regressive
patient
the
of
this
toward
first
see
patient
the
anger
your
[ Defense:
I really
him
the
next
back
sees
defense
to
toward
boss,
do
self-attack
am
your
you
notice
.]
a terrible
employee.
on
Pt:
I see
what
Th:
When
function
are
describing
yourself
angry
with
boss
minute,
onto
it stay
a way
you
feeling
let
be
you?
him
How
this
him
defense
how
turn
the
the
focus
back
onto
now.
shift
of protecting
see
[ point
longer?
mean
you
you
you
a minute
you
of the
do
your
right
focus
in this
room
from
your
.]
Maybe.
We
this
suddenly
dropped
you
how
were
then
explored
body
you
maybe
you
and
than
[ Clarify
your
see
you?
Notice
Th:
how
When
Until
to
onto
Th:
from
that
we
(anger
.]
could
As
function.
able
anger
But
Pt:
boss.
go
help
be
this
Pt:
ago,
rather
yourself,
anger?
goes
moment
the
lets
anxiety
causality
depressed).
must
and
We
explored
self-attack
her
her
feelings.
we
anger
Defense:
now?
as
regressive
regulate
show
her
Th:
boss,
Then
make
she
underlying
patient
or
again.
then
things,
the
which
excerpt,
defense,
Help
defense.
feeling
following
those
1987).
striated
explore
the
the
(Trunnell
disruption,
see
anger
went
you
toward
weak
your
feel
power
on
this
your
you?
anger
boss,
feel
real
tired
Th:
You
felt
this
anger
toward
out
causality
[ Point
your
you
notice
conversion
.]
there?
I do
tired.
do
[ Defense:
Pt:
got
toward
now.
him.
.]
It went
Would
you
back
be
willing
to
power
Encourage
feeling
the
instead
The
patient
must
Otherwise,
time
herself,
graded
anxiety
and
the
anger
let
go
anxiety
and
is the
feeling
defenses,
patient
focuses
more
depressed
keep
the
without
turning
from
toward
that
from
face
her
the
self.
rage,
on
she
will
from
We
it
use
flooding
with
overwhelmed
Build
At
turn
her
the
capacity
slightest
immediately
by
to
to
sign
help
of
her
see
makes
for
feeling,
what
is
patient
to turn
Suppose
slapping
I feel
the
feeling
therapist
from
asks,
What
you?
anxious.
Th:
Thats
you
anxious?
your
I feel
from
You
the
shut
[ Inability
anxiety.
down.
shut
Pt:
defense
from
feeling
anger?
[ Clarify
the
.]
down.
toward
her
defense:
Shutting
feeling
feeling
against
tears
differentiating
to
differentiate
What
is
[ Inability
the
to
feeling
differentiate
.]
defense
feeling.
trouble
.]
defense
Differentiate
with
and
becoming
herself.
have
Th:
anger
power?
symptomatic.
defenses.
defense.
him
anxiety
him
Regressive
your
rage
patient
intervene
usually
feeling
from
your
her
and
from
it on
defense,
turn
on
fragile
regressive
Pt:
with
at
defense
which
patient
Pt:
feeling
the
the
by
patients
toward
against
a look
of it.
Depressed
feeling
take
of
depressed
depression-causing
and
could
go
to
caused
tolerate
we
turn
becoming
format
depression
so
to
let
each
against
up
.]
patient
the
back
defense
[ Weepiness
down
is
Shutting
If
you
not
down
dont
him
for
and
face
her
.] Angry.
feeling
Th:
are
not
anger,
are
how
the
tears
come
function
and
longing,
of
the
can
defense
we
I had
in
you
deal
on
your
[ Invite
the
him
back.
[ Differentiate
to
dont
look
.]
they?
.] If we
take
how
you?
I wish
feeling.
down
slapping
.]
.] Notice
is
shut
weepiness
Tears
your
at
cover
your
cover
your
the
anger
underneath?
her
[ Invite
feeling
differentiate
time
with
the
time
become
the
you
or
anxiety,
can
into
using
regressive
the
the
Continue
bear
turning
then
turn
the
faucet
the
two
full
the
full
extent
the
and
face
will
respond
symptomatic.
patient
causes
will
depression.
regressive
defense,
the
again.
feeling
her
Otherwise,
patient
depressed
of
or
feelings
either
Regulate
or
build
Repeat
until
without
cognitive/perceptual
end
basic
anxiety
disruption,
nozzle.
So
again
to
find
the
off
to
identify
to
turn
the
or
hose.
Inviting
level
with
of
of anxiety
capacity.
self-observing
disidentify
and
In
all
capacity,
with
way
plan
regulation,
address
defenses.
the
on
hose
keep
and
turning
one
by
because
one.
it
capacity
highly
So
that
will
are
resistant,
assess
addresses
regressive
of
many
patients.
pathology.
cases
water
building
resistant,
a treatment
the
You
depressed
character
so
leaks
the
Imagine
it has
turn
leak.
all
a moderately
develop
problems
on
depressed.
patch
patch
feeling
to use
have
You
patient
possible.
you
next
and
water
be
to discover
faucet.
to
patient
the
only
the
getting
will
the
can
self-observing
the
to
yard
until
without
unconscious
front
interventions
specific
feeling
off
borderline
build
the
capacity
turn
the
patients
building
her
get
water
of
and
of
and
it is safe
patients
help
invite
in your
and
capacities
and
defense
defenses.
and
that
Then
feeling
cannot
patients
anxiety,
the
the
to
on
on
Depressed
and
feeling,
a defense
extent
a leak,
on
or
from
depressed
muscles
the
water
the
fragile,
the
defenses.
hose
Eventually,
to
feeling
feeling,
the
breakthrough
see
get
use
smooth
the
that
briefly,
against
Feeling
the
leaks
bear
inviting
more
capacity.
going
Then
turn
about
restructure
patient
can
asks
invite
anxious
Invite
to
patients
becoming
self-observing
the
the
therapist
a defense,
Each
patient
.]
Carefully
each
the
depression,
regressive
the
the
defenses,
regulate
defenses,
The
In
Graded
the
Format:
following
described
an
friends.
how
incident
and
when
even
therapist
of weepiness
you
have
of feeling
her
her
the
let
of it before
As
a reaction
to
we
him
reaction
I just
to
that?
her
anger
for
begins
the
for
of
to
Notice
cry.
her
defense
rise.
a moment,
that
just
in front
regressive
can
back
talking
it
way.
[ Graded
thing
happened.
What
the
stimulus
(what
like
it.
feel
A
sounds
inviting
bad.
bad
[ Differentiate
he
did)
is
your
from
her
.]
Pt:
I didnt
Th:
Invite
her
to
about
her
feeling
describe
Of
her
as
wash
we
away
breaths
look
thought.
put
up
tears
her
to
the
turn
it,
and
the
to
against
an
the
the
this
critical
eyes
.]
Th:
So
causality
at this
think
about
before
that?
we
ask
approving
we
.]
tears
as
can
look
thought
A critical
Th:
What
thought
be
.]
tears
come
in
these
tears
come
.]
Lets
shouldnt
come
This
eyes
now
as
in
take
to
few
thought.
he
tears
so
defense
these
out
of the
side
in her
how
a look
function
Pt:
let
thought
stimulus
Notice
[ Point
take
in her
tears
is that
the
how
thought?
thought?
[ Clarify
can
your
Tears
Notice
Pt:
Weepiness:
about
[ Weepiness.
at your
your
to firm
whats
thought
Th:
soon
course,
.]
Pt:
you
see
her
has
.]
Th:
done
she
patient
step
woman
insulted
feeling,
help
go
depressed
boyfriend
must
Pt:
feeling
severely
labeling
Th:
like
Example
vignette,
Without
the
An
in
to
defense
at
thought,
or a critical
your
He
have
done
it.
wash
away
this
see
if we
.] Lets
thought.
shouldnt
[ Invite
have
thought?
thought.
do
you
in your
notice
mind?
sensing
in your
body
as
Pt:
you
let
yourself
I feel
tightness
Th:
Just
critical
hold
in my
notice
that
chest.
sensation
thought.
How
in your
would
body
you
as
label
that
sensation?
Pt:
a
tactical
this
defense:
is a successive
Irritated.
cover
irritating?
gradually,
[ Asking
making
You
her
that
body?
he
it easier
told
[ Invite
me
the
and
what
her
and
Th:
How
do
drop
[ Her
hands
feeling
contrast
to
[ Smiles
level
her
beneath
her
What
label
he
do
evokes
feeling
it correctly
doesnt
you
.]
listen
to
me
another.
experience
that
suddenly
something
do
you
irritation
in your
rise
as
if to
strangle
do
in
your
hands
there.
[ I
irritation?
notice?
.] I dont
How
she
bear
can
capacity,
patients
themselves
afterward,
acting
out
after
before
exploring
relapse.
with
to
Depressed
to prevent
him.
it .]
know.
know.
you
higher
to intellectualize
capacity
of feeling
you
support
stimulus
and
that
we
patient,
I feel
experience
irritated.
that
Anger?
patients
patient
build
did
so
is
.]
to
depressed
me
I notice
did .] What
Pt:
In
the
, this
depressed
toward
on
hands
.] I dont
Th:
the
anger,
patient
.]
Pt:
Invite
toward
It irritates
Th:
mimic
severely
to sense
thing
resistant
irritated
her
one
feeling
then
feel
for
Pt:
someone
In
to elaborate
Pt:
and
word.
approximation
Th:
find
[ In a highly
no
who
rage;
new
face
becoming
sessions
(2)
about
her
tolerate
(1)
clarify
capacity,
her
feeling.
her
capacity.
place.
in
the
session
the
causality;
or the
stimulus
To
patient
and
(3)
at
the
When
take
depressed.
turn
ask
work
will
rage
might
irritation
Always
to build
learning
we
highest
you
may
the
work
punish
prevent
destructive
against
self-attack
predict
self-attack
Th:
deal
with
your
anger
self-criticism.
your
And
anger
have
rage
how
relapse
it as
a guy
it
be
patient
another
onto
Given
are
that
about
in
no
her
the
big
you
form
deal
deal.
And
faced
defenses
we
your
yourself
of
with
dismissing
have
punish
way
you
and
you
to
one
way
yourself
tempted
to think
that
yourself
feelings
anger
you
today
on
that
if your
the
lot
after
of
the
in advance
to
.]
Pt:
call
turn
learned
depressed.
the
learned
you
have
might
[ Invite
have
that
turning
you
today,
prevent
we
that
make
session?
is
is to dismiss
noticed
feelings
We
up
to have
In the
past
I would
binge
on
food,
or I
would
sex.
Th:
And
how
would
Pt:
That
Th:
For
what?
Pt:
For
this
Th:
You
just
as
if you
would
we
be
understand
a way
rage
I just
that
to punish
felt
now?
myself.
toward
my
dad?
you
a whore.
But
why?
go
out
and
a whore
have
sex,
you
said,
like
its
Dad,
Pt:
doing
what
he
said
rather
Oh
now,
than
how
feel
the
would
rage
face
To
prevent
that
is,
does
you
like
but
did
a
not
and
after
the
therapist
help
my
the
to
turn
That
rather
than
feel
rage
this
That
be
him.
If
you
your
anger
to
dad
use
is
so
If
pretend
toward
true.
you
to
be
you.
I would
be
and
to
yourself
dont
punish
yourself
instead
this
myself
and
regressive
let
of
become
patients
go
anger
of
plan
defense.
defense
and
a
punish
treating
anticipate
the
session
way
week?
like
whore
instead.
against
see
stop
patient
explored
her
would
I have
help
temptation
see
I would
to handle
toward
relapse,
herself
instance,
rage
the
not
attack
my
called
say,
God!
toward
Pt:
and
my
he
I was.
Th:
rather
said
her
for
If
a relapse,
the
self-attack,
more
patient
she
depressed.
toward
self-attack.
her
will
For
mother
After
the
session,
the
patient
As
soon
as
the
the
self-attack.
Repeat
they
themselves
young
woman
Rather
than
she
onto
against
herself,
defense,
she
almost
then
can
always
as
rage
her
pause,
explore
experience
her
and
stop
anger
again.
rage
deeply
use
character
others
did
in
herself
just
as
she
identified
toward
him,
through
the
past.
her
with
with
By
her
For
that
is,
instance,
molesting
self-dismissal.
identification
defenses,
father
him
and
turned
dismissing
dismissive
did.
herself,
father.
(See
12 .)
As
soon
as
let
go
the
of
toward
be
the
until
herself
enacted
chapter
see
dismissed
feel
rage
defenses.
patients
rage
her
and
Depressed
the
turns
sequence
anxiety
treat
herself.
patient
Help
this
without
cut
the
him
easily
patient
uses
identification
instead.
a character
with
She
the
must
defense,
abuser
let
go
of
so
this
help
she
can
defense
her
see
face
and
her
before
rage
rage
will
available.
Th:
What
is
the
feeling
toward
him
for
raping
you?
Pt:
voice
I hate
him.
[ Defense:
said
with
detached
.]
Th:
notice
that?
[ Defense
You
say
identification
Pt:
dismissing
herself
that
and
her
with
a detached
voice.
Do
you
.]
Its
behind
feelings
as
me.
her
[ Character
molesting
defense:
father
did
to
her
.]
Th:
the
molestation
feelings
are
detach
from
molester
daughter
You
say
the
of a thirteen-year-old
behind
your
ignores,
you.
Do
girl
you
feelings?
dismisses,
rape
notice
[ Point
and
is
is behind
how
out
you
the
detaches
I didnt
do
it on
you.
ignore,
character
from
.]
Pt:
behind
purpose.
the
you.
You
You
say
say
your
dismiss,
and
defense.
feelings
A
of
his
Th:
but
do
you
see
how
No,
you
of
course,
ignore,
you
didnt
dismiss,
do
and
it on
detach
purpose,
from
your
feelings?
Pt:
Yes.
Th:
Do
you
want
detached
to
from
identification
Is that
how
your
father
imitate
your
[ Help
her
Pt:
dont
want
them,
father
for
of the
defense
If the
patient
Often,
these
I sure
can
we
robbing
you
and
If we
have
an
face
her
continues
to
patients
will
these
the
your
ignored,
turn
feelings?
dismissed,
against
the
ignore
look
use
at
and
defense
of
the
Th:
Do
you
Or
these
Pt:
Maybe
feeling
the
or
detach
toward
patient
your
to let
go
.]
defenses,
people
a bad
him!
feelings
your
feelings
character
had
your
[ Invite
underlying
He
to imitate
innocence?
defend
who
point
abused
them
out.
them.
childhood.
notice
how
you
take
his
side
instead
own?
Th:
Or
dont
honest
of your
Pt:
eyes
to treat
.]
from
the
want
who
feelings?
Th:
of your
you
of his
what
themselves.
just
a slut.
you
like
to
or through
minimize
judge
I was
Would
judgment
patients
patients
the
the
lens
abuser
look
at
yourself
through
of self-compassion?
did,
an
identification
with
abuser.
Pt:
It wasnt
Th:
you,
or is that
Address
extent
each
of
her
what
he
said
character
rage
herself.
When
these
remains
stuck,
or the
Another
problem
can
Is
that
that
what
until
the
occur
felt
the
patient
abuser
defenses
patient
you
when
he
was
raping
afterward?
defense
toward
bad.
are
attacks
if the
can
without
not
herself
therapist
turning
addressed,
after
does
feel
it
the
exploring
not
the
summarize
full
against
therapy
her
rage.
what
the
patient
learned
defense
in
become
the
in
the
moment
depressed
or
after
Th:
father,
you
dealt
him.
Then
we
him.
Then
you
Then
you
began
we
look
back
session.
with
saw
began
As
we
to
been
this
self-attack,
with
your
Yes,
going
on
you
I do
can
That
and
we
are
your
angry
with
You
criticized
his
behavior.
sequence
didnt
need
see
to
awareness.
a different
makes
now
as
choice
it before.
take
care
Once
you
about
how
to
see
can
see
to
deal
session.
Do
you
you
deal
with
we
started
see
that
Now
Th:
sense.
Then
self-judgment
Pt:
saw
how
to make
this
you
self-attack,
depressed
here
too?
I do.
Based
your
anger
Pt:
If the
on
what
toward
weve
your
learned
father
today,
before
how
I see
you
time?
myself
healthy
alternative
To
Th:
make
causality:
father.
is any
indication,
I might
attack
end
of
sure
the
the
punish
you
do
just
What
session,
patient
You
When
When
that
happens,
what
would
be
the
to self-attack?
Pt:
the
past
again.
Th:
At
and
toward
judged
that
it
feelings.
self-criticism,
next
I just
why
your
make
Th:
might
feel
yourself.
see
her
using
You
You
you
now.
Thats
outside
Pt:
in the
Do
you
see
it?
Th:
has
with
yourself.
yourself.
Pt:
what
rage
not
keep
yourself.
angry
criticize
does
will
this
it on
got
patient
she
faced
turning
you
the
price,
session.
to judge
on
its
the
it by
how
If
sees
do
the
you
rage
her
you
what
regressive
for
abuse
toward
my
father?
think?
summarize
yourself
that,
feel
the
you
have
defenses,
rage
yourself
you
as
learned
their
feel
he
did
price,
toward
rather
and
and
your
than
feel
let
the
go
rage
where
of her
it belongs.
self-destructive
This
understanding
defenses,
helps
preventing
the
patient
relapse.
Hopelessness
Depressed
patients
realistic
assessment
transference
hope
In
the
the
following
he
girlfriend
ended
contacts
her
alone.
patients
badly
his
In
her
she
realistic
him.
by
calling
hopeless
her
ones,
and
meaning
therapist
to
transference
with
unreasonable
in her
to
him
create
colleagues
requests
him
His
he
to leave
her
hopeless.
his
The
rage
rage
how
toward
and
loss,
about
how
he
perpetuates
has
about
her
illness
stage
four
to
treatment.
is a realistic
has
no
for
control.
death,
say
that
therapy
why
he
a hopeless
whom
cancer,
is
which
She
has
faces
assessment
The
a
of
therapist
goodbye
can
to
loved
life.
Breathe
of
to
loss,
complains
is
should
hopeless,
have
[Metacommunication:
position.
can
she
prepare
resistance.
passive/hopeless
Defenses
which
loss,
his
feels
face
ignores
responding
declares
prove
he
the
reality.
face
is
He
due
denying
patient
him.
to hold
is
tells
than
hopelessness
over
find
The
hope,
causality.
than
hopelessness
patient
not
Her
the
patient
angry
is
of
angrily
rather
while,
no
repeatedly.
The
grieve
Another
the
seeing
relationship
punish
a patients
and
condition
to
her
prognosis.
medical
but
her
assessment.
she
the
is
is expected
rather
is hopeless.
All
example,
metastasized
that
him,
inviting
treats
another
not
dumped
up,
suffering
help
is
a defense,
hopelessness
but
time,
of
there
strategy
relationship,
of denial
who
patients
Each
result
which
of not
a hopeless
repeatedly.
the
therapist
result
the
in
be
for
the
or the
their
strategy
woman
situation
example,
issue
can
in which
engages
The
calls
relationship,
defense:
he
of
resistance
for
the
hopelessness
life
into
situation.
she
her.
accuses
Rather
asking
hope.
I
the
This
will
is
take
a woman
is
me.]
For
instance,
of
using
her.
They
than
face
her
anger,
made
she
covers
it up
by
overextending
When
Her
life
they
not
want
trustworthy
hoping
venture.
When
situation,
she
they
she
result.
channel
Principle:
is a rational
defenses
response
use
on
the
self,
he
defenses
cutting,
can
and
said
you
defenses
more
life.
and
is
created
hoping
anger
into
what
they
others
want)
be
about
people
Giving
she
or should
hopeless
hopeless
hopeless
adaptively.
the
patients
hopelessness
in reality
or an
irrational
tolerate
a low
level
the
bear
he
result
of
so
and
turn
against
be
able
to face
amount
of his
such
her
soon
can
in
see
the
him
increasing
rage
as
a patient
Offer
the
to
without
any
let
Once
face
uses
cognitive
defense,
amounts
turning
conversion,
moment.
invite
before
as
anger,
feeling.
he
it,
ones
As
exploring
depression
full
of
ideation.
happened
of feeling
depression,
object
into
will
the
stop
cause
slide
defense
time,
can
the
just
the
suicidal
defense,
stop
that
with
and
of what
and
Each
her
patient
Channeling
whether
patients
identifying
regressive
see
felt
what
anger
to a loss
regressive
summary
it,
that
Assess
depressed
weepiness,
a
you
her
In summary,
they
she
a hopeless
see
the
untrustworthy
give
formation
all people
hopeless.
could
could
Not
is
will
( reaction
pattern,
said
Trusting
creates
(while
this
she
hopeless.
self-punishment
ask
).
is denial.
betrayals
become
they
about
This
many
was
will
asked
everyone.
After
what
( self-punishment
therapist
to trust
trusted.
them
herself
the
tried
giving
he
the
go
of
can
feeling.
of feeling
until
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
Understanding
problems.
when
they
of
First,
suffer
from
genuine,
have
failed
undiagnosed
to
symptoms
medical
recognize
and
the
the
precise
activation
of
systems.
Third,
clinicians
resulting
from
anxiety
from
the
patient
conditions.
relationships
the
have
Second,
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.
Fainting,
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.
Fainting,
or dizziness
or
Localized
tensing
sympathetic
dilated
Excessive
system
back,
impulse.
heart
and
c1,
menstruation,
impulse
urinary
due
in
or
Excessive
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
a healthy
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
the
point
to
we
let
of
systems.
person
toward
whom
pictures
are
of
they
the
chronic
complain
regressive
of
defenses
regulating
anxiety
somatizing
his
defense
often
do
and
not
and
express
then
face
can
look
like
be
anxiety
autonomic
the
and
symptoms
somatization
somatic
toward
looked
anxiety
nervous
identification
whom
the
of
Unconscious
somatic
the
with
patient
patient
with
experiences
the
fantasy
regains
identification
Once
he
sensation
with
somatic
symptoms
and
can
with
rage.
defense
that
The
autonomic
also
the
result
occur
body
following
due
of
the
symptom
of somatization.
Feeling
rage
toward
the
police,
the
paralyzed.
identification.
arms.
Conflict
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
his
with
then
father
him
pain:
reports
in the
and
took
and
conflict.
then
hitting
him
gets
on
the
disappears.
tension
of
headache.
head
When
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
like
stabbing
then
anxiety
muscles
format
and
then
explore
the
the
defense
of
explore
the
in patients
Symptom
in
defenses.
smooth
graded
from
symptoms
feel
this
address
and
result
for
defense
feel
in the
discharge,
and
form
head.
anxiety
defense,
the
of the
result
feeling
symptoms
Medically
symptoms
use
anxiety
that
head.
by
headache
symptoms:
of my
from
disruption,
pathway
When
the
If somatic
cognitive/perceptual
restructure
into
him
her
fit
ex-fianc
murdering
not
father
express
her
possibility
unusual
my
also
moment,
does
the
reports
through
symptoms
that
consider
straight
just
At
his
he
himself.
toward
imagines
symptom
headache,
somatization.
she
a shovel.
can
rage
Later
to hit
stomach
headache
being
stomach.
wanted
to the
expresses
a headache
or migraine
something
imagines
in his
He
blow
Later
with
patient
a pain
the
A patient
her.
The
stomach.
Headache:
psychological
toward
Is
feeling
Current
self-report
functional
cause
for
Rather
than
Watch
the
somatic
measures
symptoms.
In
a symptom,
they
assume,
patients
symptoms
symptoms
are
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
not
somatic
symptoms
no
is discharged.
caused
symptoms
from
anxiety
feelings
are
patients
found
from
a psychological
where
psychological
Most
office
it had
They
organic
clinicians
assumed
can
feeling,
differentiate
if
we
creation.
therapists
the
psychosomatic.
defense
symptom
cannot
If
fall,
or
the
in response
play
resulting
from
al.
or
to
role
symptoms
2008)
the
in
in
unconscious
the
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
few
After
boyfriend
who
went
hour
her
the
into
symptoms
and
striated
initial
the
abused
her
anxiety
in the
body.
and
session
session,
smooth
(she
we
muscles
felt
explore
sick
anger
for
to
her
toward
daughter.
What
is the
Pt:
Th:
But
the
Pt:
[ Puts
Th:
What
feeling
should
toward
have
him?
been
there.
[ Defense:
.]
Pt:
Im
Th:
your
feeling
into
of
Th:
self-blame
somatic
Headache
minutes
an
how
boyfriend,
and
feeling
hand
on
toward
her
him?
head
.]
is happening?
getting
Notice
a migraine
how
you
start
to get
Pt:
I get
headaches
this
headache.
feeling
a headache?
comes
up
[ Point
out
toward
causality
.]
Th:
And
right
a lot
now
we
when
see
theres
the
stress
stress.
is
this
feeling
toward
your
boyfriend,
Pt:
Nods.
Th:
how
you
get
Vignette
In
this
due
And
a headache
Two:
right?
then
the
patient
quickly
You
program.
You
put
then
all
a sudden
they
kicked
at
causality
your
Th:
What
Pt:
I feel
feeling
eyes
really
that
you
time
your
What
life
is the
developing
into
this
feeling
and
toward
go
blank
.]
dizzy.
a sign
get
I dont
at the
feeling
you
get
being
dizzy
blurry
Do
feel
you
toward
of
anxiety.
anxious
I do
these
now.
Lets
find
when
you
have
right
anxious,
notice
Th:
Notice
and
dizzy?
when
we
[ Point
out
how
just
dizzy.
you
get
dizzy
as
soon
as
people?
I dont
out.
know
what
If it happens
a feeling.
it means.
again,
Are
you
well
aware
of
know
your
now?
Pt:
Yes.
Th:
Thats
another
Pt:
I must
be
sign
anxious
of anxiety.
a lot
because
I always
get
vision.
Explore
the
muscles
causality:
the
out.
of
this
is happening?
Thats
Pt:
blurry
symptoms
.]
look
vision
all
years
you
Th:
Th:
that
somatic
invested
several
[ Patients
Pt:
you
notice
to you?
Pt:
look
experiences
had
school
that
anger,
Disruption
the
doing
this
disruption.
Th:
for
feel
instead?
to cognitive/perceptual
them
you
Cognitive/Perceptual
vignette,
of
when
therapist
or
patients
difficulties
until
cognitive/perceptual
feeling
and
triggers
patient
disruption.
anxiety
can
anxiety
assess
symptoms.
the
goes
Then
In
the
psychological
into
the
help
here
smooth
her
and
significance
see
now,
of
the
patients
say,
symptoms.
You
may
happens
again,
rise
of
she
can
the
Patients
who
a
of
whom
arms
and
patient
she
then
wanted
to
to
patient
attack
her
without
mixed
feelings
feelings,
she
mother
died
of
saying
When
On
angry
arms
and,
With
it
each
causality
so
symptoms.
This
attack
the
her
face
somatizing
so
she
can
the
longer
hated
need
be
through
the
her
her
fathers
to her
the
in
other
she
her
by
rage
body
body.
turning
as
the
deeply
By
experiencing
as
unconscious
those
of somatization.
loss.
she
health
The
persons
person
defense
body.
person
the
whenever
mother
off
access
against
her
cut
this
a defense
coughed
person
of
the
figure.
to use
the
symptom
other
Help
of
body
on
to a
body
to
painful
often
In response
attached
the
conflict
somatization
the
not
with
protects
psychological
wants
are
cancer
what
inquiry,
husband
constantly.
if
patient.
with
conscious
somatization,
asked
reported
this,
Show
of
the
body.
constant
When
notice
For
dinnertime.
further
hurt
A patient
lung
occur?
around
of
defense
who
unconscious
also
flag
woman
began
problem,
whose
to
grieve.
she
could
goodbye.
assess
symptom
The
can
can
bodily
expression
identifies
no
becoming
avoid
To
if her
toward
will
Somatization
By
as
own
again.
her
identifies
rage.
the
therapist
is a pattern.
rise
The
unconsciously
on
possible
an
feels
attack.
corresponds
The
as
unconsciously
just
the
feelings.
patient
feels
if this
triggers
someone
the
Lets
together
approach.
feeling,
toward
her
toward
wrong.
feeling
somatize
rage
disagrees,
symptoms
how
to face
patient
be
out
patients
different
involves
the
I may
find
recognize
her
need
right.
well
feeling,
mobilizes
rise
be
If
causality.
instance,
Medical
at
however,
she
home
tension
she
left
woman
she
reported
to
nauseous
on
nothing
just
before
abused
her.
His
go
nothing
said
that
verbally
headaches.
home
context
found
dinner,
and
what
felt
assessment
happened
came
In
wife
a
trip,
raged
his
does
and
the
dizzy
unusual.
happened.
dinner
One
at
her
man
him
headaches
stopped.
Principle:
person
an
and
issue,
session
The
suffers
how
the
a somatic
to do
the
other
If somatization
feelings
rise
is
in
the
I punch
I hit
physically
with
the
object
abusive
of
his
rage
this
rage
go
out
onto
him?
him
right
in
the
face
just
he
falls
over.
like
he
right
down
now.
[ Defense:
but
him
again,
And
then
and
I see
an
middle
of his
Th:
Mhmm,
and
what
Ooof.
Ive
really
somatization
who
then?
the
Th:
head,
And
Mhmm.
Pt:
gets
Pt:
Th:
the
his
a result.
does
Mhmm.
Pt:
in the
as
How
Th:
him
toward
to me.
Pt:
Isnt
the
ax,
and
I pick
it up
and
skull.
does
he
got
look
like
a splitting
now?
headache
.]
that
interesting?
headache?
You
[ Point
just
out
chopped
causality
him
.]
What?
You
just
chopped
him
in the
head,
but
who
head,
but
headache?
Pt:
Th:
thats
when
identifies
symptom
Th:
then
toward
Somatization
rage
patient
Pt:
got
is
defense.
rise
of
murderous
Th:
right
feeling
and
will
Defense
is feeling
Notice
chop
the
anxiety,
symptoms
One:
patient
used
what
father.
and
feelings,
somatic
Vignette
The
observe
Ask
you
split
turn
the
instead
rage
of his?
Pt:
I did.
See
how
onto
your
[ Point
Oh,
you
wow!
chopped
head
out
the
I didnt
him
instead
defense
see
so
in the
its
your
of somatization
that.
head
.]
Th:
else
does
against
this
the
Vignette
The
his
Two:
and
The
through
Again,
and
suffers
go
face
Th:
How
put
out
his
I need
the
onto
feeling
you
him
toward
her
son
which
has
drawn
see
act,
someone
a somatic
who
What
to
turn
up.
Somatization
who
identifies
symptom
Th:
him
how
that?
with
illegal
head,
.]
chopping
picture
your
[ Invite
of
rage
on
him?
instead
to finish
do
rage
Defense
an
we
dont
to
Pt:
struggles
career
police.
need
defense
patient
rage
rage
If we
as
is
the
has
the
with
jeopardized
attention
the
of the
object
of
her
a result.
feeling
toward
him
for
doing
that?
Pt:
physically
in your
Im
or legs.
Th:
How
do
I just
feel
limp.
Im
so
tired.
[ Defense:
Th:
the
defense
from
her
But
feeling
Pt:
function
how
do
you
I continue
she
him
of
chop
her
his
that
anger
is
not
is a way
if I cannot
move
my
.]
anger,
is
to cover
.] If we
dont
anger
toward
her
rageful
anger
it?
[ Differentiate
and
cover
your
your
anger.
anger
[ Clarify
with
tired,
him?
addressing
her
defenses
until
impulse.
Th:
And
Pt:
I dont
arms
as
.]
this
on
Its
somatization
tired
Tired
defense
experience
describes
and
the
focusing
experience
No.
Th:
the
you
body?
Pt:
arms
angry.
and
how
does
know
legs
off
this
why,
so
rage
but
he
go
I want
cant
do
out
onto
to take
him?
an
anything
ax
to
wrong
again.
move.
[ Defense:
Th:
And
then?
Pt:
I feel
so
somatization
.]
tired
all of a sudden.
Its
like
cant
Th:
off
his
out
arms
the
and
legs
defense
Isnt
so
he
the
chop
off
exhausted
your
body,
rage
onto
your
what
I mean?
body
fantasy
the
body,
does
how
dead
rest
he
did
the
woman
with
her
without
son.
important
we
have
been
chopping
If
her
Tension
Headaches
somatization,
Tension
headaches
nervous
system,
they
feel
hands
You
Do
face
this
rage
yourself
you
the
see
toward
up
rage
rage
want
to go
out
on
rise .]
all
.]
the
fists
and
body,
put
him.
turn
legs
want
see
that
I pointed
as
soon
the
as
links
guilt,
listed
different
result
creating
patients
pressure
picture
rage,
usually
and
they
you
rage,
three
anxiety,
and
[ Point
in
him
reality,
onto
your
him?
to
hit
him
for
in your
out
how
she
said
she
became
she
between
and
mind?
felt
her
grief
angry
conscious
so
she
can
of somatization.
are
differentiate
anxious,
her
patient
defense
These
move.
chair
his
dont
do
unconscious
headaches
vertebrae.
now?
you
[ Her
and
the
overcome
When
to
Help
and
must
chop
chopped-up
toward
Its
How
arms
symptom
Although
you
to me.
breakthrough
the
it
in the
of your
Th:
After
feeling
off
the
cant
up
Pt:
everything
as
move
chop
become
that
sits
woman.
the
cant
you
you
of
[ She
you
as
body
instead
because
becoming
and
the
Th:
in
soon
own,
Pt:
who
soon
move.
As
and
move,
As
.]
I cant
Th:
you
interesting?
cant
of somatization
Pt:
arms,
that
on
anxiety
of somatization,
according
discharged
affecting
difficulty
tense
the
a form
we
to
their
cause:
into
the
somatic
conditions.
tension
have
become
types
medical
from
as
in the
forehead,
moving
neck,
the
the
the
face,
neck,
c1,
c2,
head
and
scalp,
the
or
sides
c3
neck.
and
of
jaw,
the
head,
or
light,
a tightening
due
to pupils
Tension
dilated
headaches
somatization.
drop,
the
conflictual
the
just
headache
invite
feeling
until
anxiety,
disappear.
you
so,
during
feelings
come
the
of
will
his
anxiety
Always
ask
about
the
the
will
session,
and
the
event
feelings
become
point
to
defense
rage;
patient
out
sensitive
system.
not
Explore
the
the
often
his
headache.
do
are
nervous
experience
the
occurs
They
sympathetic
from
will
As
head.
the
patient
before
situation.
tension
by
headache
occurred
the
result
Help
and
that
around
out
in
the
tense.
If a
causality
patients
and
headache
stops.
Migraine
Many
Headaches
migraine
explore
headaches
only
Migraine
those
nerve
decreasing
the
compensate,
Patients
anxiety
have
You
are
Is
Can
patients
point
there
you
we
your
How
Always
else
on
do
you
regulate
so
anxiety
at
this
this
and
point
anxiety
anger?
have
anger
out
this
anxiety
your
triggered
have
toward
causality
your
Keep
the
Then
boss.
The
migraine.
nice
a headache
at
you
in
the
it be
your
and
makes
body?
toward
As
here
disappears.
Wouldnt
to
flow.
feeling.
in the
your
To
unconscious
of
this
migraine
narrow,
brain.
of
and
when
blood
rise
notice
anger
pain
the
conflict
in
the
the
wouldnt
experience
you
feeling
and
look
you
until
were
anxious,
that
blood
vessels
boss,
sensations
anxiety
You
another
anger
those
the
your
brain,
increasing
to
will
triggers.
with
discharge
summarize
else
throb
to
wider,
response
toward
the
blood
muscle
in
angry
describe
you
take
smooth
anywhere
causality.
made
Shall
feeling
to
We
emotional
oxygen
open
origin.
In
start
and
vessels
appears,
attention
out
anger
feel
a migraine
to
The
blood
migraines
in
headaches.
meninges
of
from
medical
response
activated.
blood
often
now.
body?
other
suffer
as
anxious.
are
who
soon
the
flow
in
vascular
within
fibers
purely
arise
are
traveling
their
that
headaches
vessels
are
just
to
instead?
boss?
the
slightest
sign
of
a migraine
so
raises
the
before
anxiety
amount
for
Explore
feelings
medically
affect
to
suffering
from
medical
the
the
feeling
patient
should
be
tolerate
the
patients
psychogenic
migraines
anxiety.
feeling
of migraines.
differentiate
and
can
Boost
frequency
the
In
appear
any
thoroughly
from
case,
in
patients
evaluated
by
Headaches
headaches
impulse
rises.
usually
Point
headache.
other
out
When
person,
occur
make
how
we
the
you
gave
you
the
this
rage
cognitive
with
the
summary
defense
wanted
Point
of somatization
patients
rage
toward
to
see
chop
headache
rage
just
the
or
before
head
onto
your
out
how
her
person
in
head
guilt
she
causality
him
the
instead.
him
of the
her
the
her
impulse
splitting
body
as
of
the
link.
toward
helps
soon
experienced
the
You
Principle:
to identify
she
cognitive
yourself
turned
as
see
Th:
her
to
to
professional.
These
how
the
Psychogenic
migraines
Somatization
then
the
muscles.
to reduce
session
of
invitation
anxiety
smooth
migraines.
rise
Gentle
and
tolerance
in
worsen.
feeling
into
caused
response
not
of
shifts
capacity
the
it does
and
head,
but
you
see
rage
led
Do
instead?
over
wanted
turns
her
to attack.
her
This
against
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
To
ask
about
response
to
occurs
are
the
discharge
assess
the
a
most
likely
a symptom,
patients
rise
in response
of anxiety
of
anxiety,
the
explore
feeling.
to a rise
medically
in
When
they
are
of feeling
and
caused.
Principle:
have
somatic
conflict
so
anxiety
to drop
Ask
symptom.
the
patient
and
you
a link
between
you
became
can
see
When
that
until
restructure
invite
feeling
intense
the
the
feelings
she
Once
the
explore
tolerate
her
defense
works.
see
until
For
somatization,
When
the
using
striated
allows
your
So
boss.
we
see
stomach.
the
Do
somatization,
occurs.
the
the
the
link
enables
will
symptoms
can
between
with
Immediately
symptoms
patient
drop,
bear
more
breakthrough
her
unconscious
person
the
symptoms
her
anxiety
is
toward
the
whom
patient
to
of
so
that
the
experiences
the
ability
into
from
the
explains
how
the
sequence
and
her
tolerate
her
patient
can
When
feeling
to
discharged
result
somatization.
explore
will
longer
see
disappears,
patients
summary
can
feeling
the
symptoms
cognitive
the
symptom
no
whose
patient
includes
These
the
increasing
muscles,
point
and
time
defense
at which
patients.
of
severe
each
invite
patient
spectrum
defense
and
link
causality
the
the
impulsive
in your
somatization.
this
the
until
fragile
of
patients
defenses
The
anxious
so
defense
again,
disappears,
the
of
of somatization.
feeling
defense
into
stomach.
the
of identifying
can
feeling
of
without
toward
to your
defense
experience
defense
defense
rage
angry
more
the
Understanding
symptoms.
symptom
to
triangle
intervention
somatization
example,
the
to
her
bodily
that
patient
patient
the
of
sees
without
the
from
Otherwise,
patient
rage.
overcome
starts
getting
result
defense
within
and
felt
sick
the
This
feeling
got
and
defense.
feeling
allows
the
the
Once
angry
symptoms
feeling
result.
and
patient
summarize
causality.
were
the
too?
somatic
invite
until
to decrease
You
anxious
and
see
symptoms
feeling
feelings
Pause
Th:
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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RECOMMENDED
You
may
to work
MATERIALS
want
with
to view
fragile
Working
with
the
session,
a teaching
the
following
videos
including
fragile
DVD,
analyzed
projection
the
initial
understand
how
patients.
patient
and
. A
an
set
session,
transcript
http://www.istdpinstitute.com/DVD/
of
DVDs
analyzed
at http://www.istdpinstitute.com/DVD/
Restructuring
to better
including
transcript
of
the
the
initial
session
.
with
borderline
patient
a teaching
video
of
the
.
on
set
projection,
session
of
DVDs
and
an
at
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
the
of
his
defenses.
Moderately
resistant
defenses
fragile
pay
with
some
spectrum
attention
cannot
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
his
of
them.
before
unconscious
patient
you
create
capacities
his
If
regulate
defenses
to
cannot
defensive
reason
of
them
cannot
more
how
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?
Differentiation
: Can
patient
patient
the
pay
patient
observe
attention
differentiate
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
that
patient
in
presenting
his
sadness
the
defense
Syntonicity
see
feel
: Can
: Does
guilt
the
he
are
over
through
his
each
patient
response
patient
cannot
declare
that
his
moment?
Can
problems?
defenses
or
see
defenses
identify
how
with
he
the
suffering
he
can
so
his
avoids
his
he
has
turn
against
them?
Psychodiagnosis
of
intervention.
express
his
prevent
him
experience
doing
the
will
to
from
Assess
defenses
that
his
Before
causality,
and
response,
assess
his
for
next
the
of
differentiate
the
prevent
his
his
defenses.
self-observing
from
to
his
the
feeling.
anxiety
and
awareness
After
capacity.
or
him
attention
from
assess
that
feeling
experiencing
each
Intervene,
of
patient
and
then
to intervention.
SELF-OBSERVING
observe,
CAPACITY
pay
anxiety.
attention
building
that
feeling
resistance,
of
his
pay
or
defenses
label
and
and
problem
and
cannot
next
so
capacity
attention
First
they
in
to,
or
strengthen
can
turn
patients
experience
patients
against
is
capacity
the
called
their
defenses.
restructuring
1990).
(1990,
and
separating
(1999,
labeling
to
anxiety
observe
the
internal
defenses
him
excessive
and
he
and
from
an
the
to
his
cannot
process
ego
If
syntonicity
OF
observation
Davanloo
so.
anxiety
response
without
(Davanloo
assess
capacity
ability
the
patients
This
it,
confronting
ELEMENTS
feelings
the
his
defense.
Many
doing
prevent
assess
assess
explore
it, assess
so.
Also
If
determines
superego,
the
2005)
2000)
patient
described
described
restructuring
differentiating
from
the
restructuring
the
corners
resistance.
as
in terms
the
of the
Ten
Have
development
of
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
The
case
following
capacities.
They
builds
without
must
on
to
the
be
assess
moment.
the
Intervene
response
to
how
capacity.
Continue
capacities
until
feelings
of
to address
that
without
Assess
to
she
assess
can
under
in
the
of
and
the
rubric
brain
of ego
different
neuroscience
the
to
the
2000)
between
of
role
perspective
a thing
and
emergence
of the
mobilize
of
ego.
self-observing
sequence
because
problem
the
and
each
each
response
capacity
and
next
build
a
anxiety
After
self-observing
tolerate
excessive
put
in
central
ones.
problem
intervention.
understand
the
concept
Principle:
patient
not
understand
a reified
previous
we
interactions
mobilized
defenses
the
Stevens
is
we
show
from
on
From
perspectives
us
vignettes
do
and
there
complex
the
allow
capacities
How
Grigsby
of
patient
agree
capacities
psychoanalysts
2000).
today?
1999),
Thus,
self-observing
capacity
and
(Palombo
theory
Stevens
psychotherapy
2007;
brain.
the
of
properties
the
and
1923/1961c)
ego . Instead,
and
differentiating
(Grigsby
(Grawe
the
parts
of
attention
ego
complexity
are
in terms
all
neuroscience
called
Neuroscientists
listen
problem
the
in
to the
of
the
that
patients
self-observing
patients
breakthrough
of
self-observing
to
unconscious
Observation
Can
the
present
Vignette
In
this
responses
patient
observe
her
feeling,
anxiety,
and
defense
in
the
moment?
One:
excerpt
and
Lack
you
of
will
sees
the
Ability
see
how
the
her
inability
to
Observe
therapist
to
observe
Anxiety
assesses
her
the
anxiety.
patients
The
therapist
mobilizes
therapy.
this
Without
highly
anxious
therapeutic
would
capacity
the
ability
to
patient
will
not
me
to help
Th:
Whats
you
with?
Pt:
dont
know
if
since
I met
with
I interrupt
you
read
the
my
you
you
for
me
syntonic
able
that
of racing
to
internal
speech
chart,
No.
in
anxiety,
co-create
an
emotional
problem
the
effective
.] There
and
are
a lot
you
of things.
then
theres
more
racing
speech
.] Do
than
I
that
her
you
mind
if
What?
Th:
[ Speak
you
are
slow
very
talking
speech
slowly
to slow
really
quickly
the
right
patient
now?
down
[ Identify
.]
I talk
rapidly
down.
[ She
all
the
time.
People
the
defense,
observes
are
always
but
it
is
.]
Th:
see
that
way
to
racing
run
But
if you
Our
task
anxiety
speech
over
discharge
its
close
attention
and
invite
any
with
to
races
to avoid
feelings
My
over
anxiety,
If you
head
is full
as
body
What
do
it?
[ Help
just
so
the
function
.]
worse.
your
body,
we
can
therapeutic
dont
race
feeling
we
is often
get
in
the
notice
uses
and
see
task
dont
inside?
wanting
defense
to
of
come
verbal
.]
you
her
you
to
of thoughts
she
in her
defensive
connection
down.
.] And
speech
feelings
her
do
again
it will
to
in our
what
again
speech
[ Mobilize
slow
words,
speech
race
shifts
difficulties.
you
feelings
dont
[ Show
anxiety.
pay
to
Th:
if we
racing
is
Pt:
[ Her
see,
your
your
your
and
You
ignore
is causing
cover
now.
racing
and
body,
to
right
the
over
in your
going
[ Interrupt
feelings
race
here
.] Im
now,
to
[ Interrupt
Pt:
out.
be
regulate
else
a moment?
notice
defense
what
and
anything
doctor.
Pt:
telling
observe
the
[ Racing
Th:
her
doing
alliance.
like
.] Do
before
notice
observe
feeling
her
in
anxiety
your
.]
body
Pt:
anxiety.
body
The
right
therapist
now?
Real
anxious.
intervenes
before
[ Help
Th:
Where
do
the
patient
keep
Pt:
Racing
speech
anxiety.
results
defense
free
association.
patient
true
and
anxiety
in
(2)
anxiety,
and
it is regulated;
(5)
differentiate
Vignette
this
sees
the
long
as
it and
first
Lack
example,
the
the
help
Jim
Two:
patients
patient
the
for
defense
does
depressed
insulting
place.
inability
patient
become
defense
to her
time
to
which
defense
before
not
observe
the
prevent
to
her
the
anxiety
the
anxiety;
the
feeling.
a Defense
patients
a defense.
the
to
in
with
that
invite
Observe
the
present
triggers
(6)
not
or engage
(attention
attention
that
is
makes
anxiety
task
the
observe
speech
defenses
then
to
their
interrupt
patients
block
assesses
Th:
How
Pt:
I was
[ Rather
than
response
The
doing
therapist
anything
defense,
he
and
will
will
else.
keep
As
using
do
you
experience
this
anger
toward
attention
of turning
a stupid
describe
jerk
his
to
anger,
go
the
to
that
bar
patient
in
uses
the
the
.]
Do
to his
Pt:
his
Ability
regulating
Racing
anxiety,
and
.]
Immediately
feeling
your
you?
of self-attack
[ Draw
the
in
in session.
Th:
now?
an
or
therapeutic
anxiety;
therapist
observe
seeing
draw
.]
stomach.
anxiety.
(3)
out
from
of
anxiety
(1)
point
feeling
her
session,
defenses);
(4)
observing
Any
her
defense
anxiety
attention
the
next
this
moment.
present
observe
notice
of unregulated
the
can
patients
to my
to
or pay
that
regulation;
feelings,
until
in
she
symptoms.
attention
to observe
you
from
worsening
mobilize
self-reflection
anxiety
In
in
the
sick
patients
It is a sign
unable
unregulated
feeling
prevents
This
this
Im
[ Now
notice
defense
.]
No.
anger
Th:
you
[ The
on
Do
patient
himself
you
you
put
has
yourself
no
ability
are
calling
down
to
right
observe
.]
notice
you
yourself
name
now?
Pt:
the
defense.
see
the
He
can
function
himself
Yes,
see
that
calls
serves:
to
Jim,
toward
him
defense
theres
back
onto
you
turning
Do
a critical
onto
you
a name,
anger
notice
part
of
I dont
Th:
Do
Jim,
a critical
instead
of
anger
he
on
sees
you
cannot
but
toward
when
your
observe
he
Jim
this
mind
understand.
think
onto
does
not
back
onto
anger
that
comes
turns
up
the
anger
[ He
cannot
observe
his
You
self-attack.
Point
sees
unable
the
it.
Yes,
hurt
[ Help
him
this
turns
anger
the
observe
I criticize
you
I think
this
Otherwise,
comes
criticism
back
the
defense
me
instead
of
rage
of
the
Ability
to
observe
you
create
his
will
make
toward
Jim.
not
from
down?
depression
hurts
does
of
him?
him.
[ See
if
he
.]
observe
his
vantage
depressed,
Observe
of
me.
different
him
instead
feeling
it definitely
initially
to
yourself
get
defense
it
his
criticize
you,
patient
to face
Spectrum
mind
mean
defenses
out
your
when
.]
might
causality:
example,
of
how
.]
Pt:
this
notice
him?
defense
that
you
part
himself
the
observe
he
turn
you
Pt:
Th:
In
himself
[ He
instead?
Pt:
can
true.
.]
toward
Do
its
.]
toward
Now
I think
he
Th:
up
but
in
of
points
and
a Defense
defense
he
until
will
be
Depressed
Patients
The
capacity
complete
where
your
where
awareness
the
patient
interventions
she
defense
of
the
defense
is
on
the
spectrum
to
the
patients
exists
to
none.
of
level
on
If
syntonicity,
of
awareness
spectrum
you
are
you
and
from
aware
can
meet
is.
I
hate
myself.
Psychodiagnosis:
of
target
her
Self-attack
where
with
she
an
directs
boyfriend,
her
implicit
awareness
it. The
anxiety,
patient
of
is not
Psychodiagnosis:
feeling,
but
not
She
of her
aware
anxiety
upset
has
patient
No
is not
aware
self-attack.
Defense:
her
but
feeling,
of her
feeling,
of her
anxiety
Psychodiagnosis:
affect
(she
patient
is
aware
is aware
of
me.
No
of
of her
her
and
[ Fists
feeling,
experiences
Diagnosis
tells
Psychodiagnosis
Vignette
her
In
this
and
defenses.
The
defense
so
out
feeling
her
she
us
about
of the
notice
sees
her
of
but
Im
angry
at
of
her
her
a muted
but
What
Pt:
Th:
No
of
I dont
help
feeling
isolation
experiencing
anxiety
and
of
it).
The
or defense.
I feel
: The
create
a heat
rising
patient
is
up
aware
without
any
defenses,
created
by
defenses.
to
the
to
the
depression.
Observe
therapist
aware
notice
fists.
inability
Th:
The
awareness
Defense:
angry
Ability
the
become
that.
Psychodiagnosis:
has
depression
the
will
done
or defense.
without
defenses
how
have
intellectualization.
physiologically
the
her
therapist
shouldnt
angry,
not
in her
which
Lack
can
toward
awareness
self-attack.
but
rage
impulse
tells
he
.] Psychodiagnosis
the
excerpt,
responses
you
feels
muted
miffed.
feeling
feeling
clenched
Three:
and
or defense.
Im
within
rage
him,
Patient
Im
anything.
with
anxiety,
minimization.
not
of her
Defense:
Im
self-attack.
involved
or defense.
I feel
Psychodiagnosis:
feeling
or defense.
Im
myself.
the
a Feeling
assesses
observe
patient
of the
see
feeling
is your
feeling
I dont
know.
[ Lack
Would
you
the
feeling
and
let
patients
due
go
of
to
each
underneath.
toward
him
for
pushing
ability
to
observe
car?
of
the
.]
like
to know
what
you
are
feeling
so
we
can
observe
find
her
out
whats
feelings
driving
of the
car?
Whats
[ Invite
the
Pt:
him
dont
for
cover
the
pushing
you
feeling
out
dont
him
for
cover
and
your
her
it. [ Defense:
car?
him
for
to
pushing
intellectualization
thought.
[ Identify
whats
[ Invite
he
then
Thats
out
the
.]
difference
to me.
but
Either
the
was
the
the
feeling
wrong
she
this
.]
defense
feeling
.]
toward
.]
to do
that.
feeling
[ Defense:
Im
angry.
Th:
You
guess?
the
or
observe
its
the
], but
feeling
if
toward
feeling
from
the
is
finally
of vagueness
[ Point
out
arent.
It
the
able
to
.]
defense
doesnt
of
make
.]
true.
her
physically
the
[ She
defense
you
defense
No,
whats
defense
.]
the
are
[ identify
[ Differentiate
uses
[ Block
anger
car?
she
you
can
thought
a thought,
I guess
Pt:
[ Now
your
with
of the
invite
feeling,
experience
toward
a thought,
I thought
feeling
you
vagueness
that.
feeling
your
with
Pt:
observe
will
.]
pushing
defense,
the
.]
like
of the
Th:
you
feeling
Thats
Pt:
intellectualization
the
I didnt
Th:
If we
[ Mobilize
Yes.
Th:
out
anxiety?
.]
Pt:
you
this
Im
feeling.
in your
angry
with
Next
body?
him
ask,
for
How
doing
do
you
Attention
First
mobilize
observation
defense
in this
Vignette
One:
Notice
how
that
the
than
a second
on
the
the
patient
defenses
and
then
Ability
to
attention
to
feeling,
anxiety,
or
moment.
Lack
of
therapist
is
before
that
assesses
unable
using
prevent
to
pay
Pay
the
patients
attention
a defense.
the
Attention
patient
to
Thus,
from
to
Feeling
responses
her
the
feelings
therapist
paying
attention
and
sees
for
more
will
focus
to
her
feelings.
Th:
pushed
you
out
of the
What
is
second
this
and
test
then
next
I was
[ Point
ignores
out
the
out
the
you
see
the
that?
sequence
about
function
the
instead.
[ Point
out,
of talking
and
way
to
function
.]
move
still
the
wants
test:
about
yourself
from
ignoring
her
anger
from
her
defenses
for
this
one
feeling
.]
feeling
of
not
observe
her
defense
you
defense
feel
.]
angry
with
angry,
you
.]
soon
as
You
moved
then
test:
you
her
see
how
[ The
patient
anger.
and
your
can
it out,
sequence,
anger?
Is
feel
from
she
point
your
Th:
if
to avoid
do
test
you
away
see
you
the
the
said
anger.
Do
observe,
the
.]
that
But
you
The
and
this
ignoring
but
not
anger
.]
talking
[ Point
sees
defense
ignore
her
habit
it?
but
you
[ Point
I did
the
about
out
the
the
want
defensive
the
feeling
is
of talking
since
she
.]
have
out
test
defensive
function
is syntonic
to
of
distracting
the
defense
your
anger
of
.]
Yes.
Th:
direction
talk
.]
and
sees
her
Pt:
healthy
to
to her
avoid
of feeling
Yes.
about
feeling
you
said
from
to avoid
your
notice
you
and
the
away
to talk
he
feeling
attention
notice
Now
[ She
Pt:
about
when
I want
her
to pay
you
defense
Th:
a
thing
you
As
test
test.
him
Yes.
Pt:
talk
the
does
sequence
of feeling
but
[ She
Do
Th:
about
toward
of diversification
No.
Pt:
talked
feel
observes
ability
Do
defense
Th:
[ Point
[ She
it. No
Pt:
him?
angry,
week.
Th:
anger?
you
car?
Pt:
about
did
or
.]
is
Does
it getting
that
in
help
you
your
way?
channel
[ Separate
the
in
patient
Pt:
the
destructive
effect
I can
of ignoring
Th:
experience
Invite
this
her
anger
to turn
see
her
If we
for
in my
your
and
[ She
feelings,
pushing
defense
way.
sees
.]
ignore
him
the
it gets
feelings
dont
toward
against
how
you
pay
how
out
of
attention
do
the
you
car?
to her
feeling
.]
Vignette
Two:
If the
to
patient
cannot
regulate
it
therapist
is
Lack
or
to
distract
and
let
go
no
longer
explore
the
ignores
anxiety,
her
her
defense
Are
Point
out
right
now?
Yes,
anxiety
for
Th:
You
Pt:
All
anxiety
of denial
but
and
to
will
will
be
unable
how
that
the
the
to
which
patient
anxiety.
able
the
patient
defenses,
help
her
be
Notice
sees
due
ignore
will
see
Once
regulate
she
it
and
aware
but
of feeling
Im
better
at
a moment
and
are
of your
aware
anxious?
getting
then
rid
ignores
of
it now.
it .]
anxiety.
How
do
you
the
patients
[ Invite
her
we
notice
attention
but
cannot
Im
pay
But
denial
your
to her
Pt:
you
.] Do
attention
Th:
As
over,
over
it now.
attention
Im
okay.
to it. Instead,
[ She
she
uses
.]
Pt:
Mobilize
she
you
Pt:
Th:
notice.
her
she
feeling.
therapist
Anxiety
it?
observes
the
anxiety,
anxiety
help
to
feeling.
observes
experience
her
the
which
her
triggering
to
of defenses,
Attention
responses
Thus,
Th:
She
the
attention
her
Pay
to
patients
attention.
her
to
attention
recognize
pay
her
Ability
pay
assesses
unable
of
you
true,
[ Interrupts
anxiety,
anxiety
and
notice
to the
Thats
anxiety
sound
the
quite
anxiety
anxious.
in your
body
.]
but
the
what
defense
do
.] Its
good
you
notice
in your
of
anxiety.
And
that
you
neck?
.]
Tension.
Th:
look
Thats
[ Anxiety
a
sign
.]
in
your
shoulders?
Pt:
Tension.
Th:
Thats
another
sign
of
anxiety.
And
your
arms?
Pt:
Tension.
Th:
And
Pt:
into
patients
the
is too
is discharged
Defense
sick
Are
you
her
anxiety
suffering
in
your
is
of the
time.
but
her
anxiety
if
the
.]
stomach.
[ Smooth
muscles.
the
[ Smooth
your
Thats
I do
right
sign
now?
Well,
[ Cognitive/perceptual
time.
and
You
stomach.
are
[ Label
whether
she
is
that
.]
its
another
anxiety.
[ Assess
blurry,
disruption
Thats
of
legs,
disruption
fine.
of
.]
arms,
cognitive/perceptual
Th:
a lot
another
vision
Its
nauseous?
anxiety
shoulders,
Pt:
lot
my
[ Her
assesses
channels
feeling
Yes,
of ignoring
.] How
from
to
stomach?
therapist
in other
Th:
anxiety
your
The
Im
Pt:
feeling
is
high .]
Th:
muscles.
how
muscles.
Pt:
Anxiety
And
striated
anxiety
legs?
Tension.
Th:
goes
in your
but
its
like
.]
sign
of anxiety.
How
is
your
hearing?
Pt:
Its
Th:
Pt:
is
experiencing
dissociation,
drifting
And
experiencing
bit.
how
any
thoughts,
is your
blanking
Its
dizziness?
[ Cognitive/perceptual
thinking
cognitive/perceptual
Pt:
disruption
you
A little
Th:
if she
Are
fine.
little
disruption
right
disruption
out,
now?
in
or confusion
cloudy.
the
.]
[ Assess
form
of
.]
[ Cognitive/perceptual
.]
Th:
You
are
feeling
anxiety
in
the
form
of
tension
form
in
of
little
your
shoulders,
nausea
problem
arms,
in your
stomach,
thinking.
Do
Pt:
paying
close
your
see
body,
whats
any
driving
task
experience
.] Does
about.
symptoms.
the
feelings
shifts
in
for
You
feel
vision,
anxiety
in
dizziness,
the
and
now?
our
to
and
the
patient:
to
sense
Yes.
But
anxiety,
and
you
join
body,
me
the
pay
in
anxiety
] so
symptoms.
attention
here
in
we
can
[ Clarify
to
her
the
internal
to you?
go
you
to
[ defenses
these
her
we
like
your
theres
of ignoring
If
you
connection
anxiety
make
invite
in
this
that
Would
that
to
[ Defense
your
see
going
Th:
ignoring
blurry
Im
Pt:
to talk
and
Th:
all
therapeutic
legs.
Yes.
attention
and
you
and
something
anxiety
to
me
I would
like
.]
another
would
else
topic,
keep
we
suffering
to
help
you
we
take
would
from
get
be
these
rid
of
these
to
pay
close
symptoms?
Pt:
Yes.
Th:
attention
to
this
anxiety?
task
.]
these
feelings
[ Mobilize
and
the
Pt:
reducing
her
the
A little
patients
attention
experience
see
engage
relaxes
in the
chair
right
now?
more
calm.
[ Mobilizing
onto
you
notice
therapeutic
in the
feeling
will
driving
a bit
notice
her
whats
the
the
therapist,
.]
patients
thereby
.]
How
Im
Th:
bodily
to
can
do
that
calm?
[ Mobilize
the
.]
Pt:
her
we
minute
you
of
anxiety
Th:
will
do
projection
projective
so
[ Patient
What
Pt:
deactivates
anxiety
patients
Yes.
Th:
will
Could
less
How
tense.
is
your
vision?
[ Mobilize
attention
.]
Pt:
Its
fine
now.
[ Cognitive/perceptual
disruption
to
has
disappeared
.]
Th:
And
Pt:
anxiety
has
stopped
Its
the
down?
worse,
the
anxiety
.]
you
Th:
Do
Pt:
Yes.
to
discharge
of
that
pay
see
Would
as
before.
smooth
[ Anxiety
muscles
or
anxiety
to
your
anxiety
regulates
it
it .]
before.
connection
like
to
and
creating
to
ignore
your
attention
that
you
you
attention
that
attention
when
see
the
now?
what
the
these
feelings
feeling
is
symptoms?
triggering
her
Yes.
Th:
What
is the
making
you
so
anxious?
[ Since
anxious
with
the
therapist,
ask
that
are
triggering
Therapists
often
ask,
bad
of
anxiety;
you
pay
this
instead?
as
notice
noticed
this
Pt:
not
we
I hadnt
is driving
patient
its
instead
when
Th:
[ Invite
tension
dysregulate
Pt:
that
notice
muscle
.]
Do
but
[ Defenses
underneath
[ Smooth
but
disruption
it gets
stomach?
now.
muscles
Th:
goes
you
Yes,
striated
cognitive/perceptual
anxiety
fine
Do
Pt:
into
is your
.]
Th:
goes
how
anxiety
feeling
she
about
here
began
toward
the
feelings
me
that
session
toward
the
is
feeling
therapist
.]
Why
do
you
assume
it is a feeling
toward
the
therapist?
Imagine
a dog
approach
the
previous
owner
toward
dog
by
anyone
needs
others
contrast
that
has
dog
behind
abused
who
a fence
have
to a dog,
been
abused
the
him,
fence,
the
approaches
to
these
they
keep
from
not
dog
barks
reacts
Unable
biting
powerful
need
a previous
he
him.
same
do
by
you.
at
with
to hide
Patients
reactions
a fence.
owner.
They
When
you.
Since
powerful
his
the
feelings
feelings,
who
you
were
the
hurt
and
feelings.
In
need
defenses
to
keep
them
Vignette
Notice
from
expressing
Three:
Lack
how
that
the
the
patient
therapist
helps
Otherwise,
would
be
of
assesses
is unable
to pay
patient
patient
unable
ferocious
Attention
therapist
the
the
those
would
to
the
see
Defense
patients
attention
to her
and
attention
not
to co-create
feelings.
pay
let
go
of
What
is your
Pt:
I was
surprised,
describe
her
and
defenses.
Thus,
to
the
a collaborative
Th:
responses
her
the
defenses.
defenses,
and
therapeutic
feeling
sees
she
alliance.
toward
him
for
slapping
you?
Defense.
and
She
her
does
feeling
not
toward
him
Th:
is how
you
dealt
Differentiate
with
her
But
your
feeling
this.
[ She
symptoms
[ She
price
she
is not
your
feeling.
ignored
I just
dont
but
she
You
ignore
Pt:
Yes,
I see
her
how
.]
Th:
observes
him
defense,
or the
ignored
but
defense
but
I just
him.
ignored
him
her .]
You
her
Yes,
her
it causes,
feelings.
for
observes
slapping
feeling.
then
feeling,
ignoring
from
Pt:
at
for
but
your
defense
see
pays
pays
no
it. Do
the
no
for
Ignoring
you
see
that?
point
in
looking
attention
using
to
it,
the
it .]
feelings.
point
but
in getting
points
out
all caught
that
it is
up
in
syntonic
her .]
Th:
feelings.
You
would
how
neither
You
invite
me
I be
her
see
no
to
defense
of us
pays
Oh,
invites
Th:
her
to take
in
we
us
should
to
Not
form
a very
Why
would
against
Its
point
paying
feelings
to her
a stand
Pt:
no
me
your
attention
Pt:
[ Invite
see
point
ignore
if I said,
You
not
attention
attention
to
too!
What
ignore
your
a pathological
inner
nice
to
your
your
feelings.
of
therapist
kind
feelings?
[ Point
relationship
out
where
life .]
one.
you
ignoring
like
in paying
I want
want
to do
that
to
her
feelings
.]
that.
[ She
wants
yourself?
a healthy
relationship
but
does
not
see
Th:
dont
want
feelings,
do
but
just
when
that:
of the
relationship
you
on
had
not
relationships
our
this
Invite
as
long
well
have
Point
out
her
to take
your
your
of
I dont
Th:
What
[ Invite
her
you
to do
Th:
her
to
you
let
to
feeling
go
put
the
of
up
from
the
was
the
the
defense
wall
patient
in
her
defense
Differentiating
the
can
present
feelings,
she
of
ignoring
do
that
to
.] Why
defense
want
to
with
we
do
feelings?
you
see,
ignore
your
them,
mother.
yourself?
[ Invite
.]
to.
we
do
a stand
about
want
to
the
us?
habit
the
ignore
ignore
], whats
this
against
dont
Stimulus
can
your
had
the
your
feeling
of
ignoring
defense
my
.]
feelings,
and
defense
.]
feelings
[ encourage
toward
[ Encourage
her
me
to
that
face
led
the
.]
of
attention
can
from
the
to
Triangle
her
feelings,
she
differentiate
anxiety,
and
uses?
the
effect
pathological
what
you
If you
feelings
this,
invite
against
moment,
her
about
turns
pay
create
me
Corners
to
it before.
and
covering
the
about
feelings
between
us
.]
[ She
defense
this
defense
Differentiating
Once
the
your
I mean?
.] Because
I dont
You
of
out
of ignoring
to take
that.
both
what
thought
had
can
this.
ignore
defense
the
Pt:
to
invite
defenses
think
defense
against
at
[ Point
see
one .]
look
agree
you
you
relationship
her
us
hadnt
youve
terrible
a stand
want
we
to
feelings
.] Do
problems
Pt:
dont
your
unhealthy
have
of
her
As
an
feelings,
I just
her
ignore
price
feelings?
your
habit
same
the
both
Yes,
against
you
the
where
presenting
to turn
as
we
causality:
destructive
her
why
ignore
Th:
about
Thats
relationship
seen
and
invites
and
Pt:
She
she
ignore
to dismiss
defense
how
from
the
Feeling
her
anxiety,
the
feelings
and
stimulus
from
Sometimes
from
how
the
patient
she
feels
differentiate
the
become
aware
cannot
differentiate
toward
that
stimulus
of the
What
feeling
the
stimulus
toward
stimulus
him
for
He
was
with
the
feeling
toward
stimulus
him
feeling
so
her
help
her
she
can
the
feeling
toward
him
for
with
the
.] But
doing
the
you.
[ Stimulus
betrayed.
stimulus
did
the
.] And
stimulus
what
Pt:
I felt
the
is
your
question
did
for
you.
[ Stimulus
triggered
the
is
your
confuses
the
.]
you!
is this:
.] What
[ Patient
abandon
us
confuses
.]
abandoned.
stimulus
He
[ Patient
triggered
betray
that?
what
Thats
what
he
is your
feeling
did.
toward
that?
Pt:
stimulus
confuses
.]
felt
doing
Th:
Stimulus
He
feeling
[ Patient
you?
the
for
hurt.
hurt
hurting
Th:
for
reactive
triggered
Pt:
him
her
I felt
Th:
feeling
response,
to
you?
the
feeling
In
did
feeling.
Pt:
with
someone
person.
from
Th:
slapping
what
(what
he
did
Im
to
angry.
her)
[ Patient
from
can
now
her
feeling
rubbed
some
felt
sandpapered.
distinguish
toward
him
the
for
doing
that .]
Suppose
your
you
I walked
arm.
felt
You
can
we
become
the
ask,
distinguish
triggers.
ring
into
afraid.
the
feeling
Patients
who
say
you
me.
Differentiate
aware
of their
is
I feel
and
Feeling
What
engagement
scared.
not
toward
Differentiating
If
to you
would
angry
patients
up
the
the
I feel
the
harshly
You
stimulus
reactive
from
sandpaper
from
would
on
say
feeling
so
feeling.
Anxiety
feeling
toward
gutter?
the
anxious.
toward
his
fianc
cannot
differentiate
her
patient
I feel
from
their
for
may
throwing
reply,
frightened.
He
the
his
anxiety
feeling
from
the
I
feel
fails
feeling
anxiety
to
remain
his
paralyzed
feeling
the
by
and
then
engagement
anxiety.
invite
him
to face
Th:
What
is the
into
the
gutter?
I feel
afraid.
ring
Pt:
Th:
feeling
with
is making
anxiety,
you
Thats
can
we
Pt:
I feel
shes
throwing
not
that
here.
ring
that
to
anxiety
toward
anxiety.
her
If we
at the
from
for
dont
feeling
throwing
cover
toward
your
her
that
into
the
the
tension?
side,
What
is
of her.
probably
right
now,
were
what
afraid
is the
of
her,
feeling
but
toward
right
her
for
gutter?
I feel
Th:
off
patients
feeling.
feeling
a look
afraid
You
So
Pt:
tension
his
your
take
the
anxious?
Th:
now,
Differentiate
tense.
Tension
is your
can
we
take
the
feeling
anxiety.
If we
at
feeling
a look
toward
the
her
for
put
this
lid
of
underneath
throwing
the
ring
away?
Anxiety
signals
the
example
the
patient
that
above,
underneath
defense,
from
the
the
patient
channel
ask
how
rising
and
the
to
the
with
her.
feeling
was
covered
to
it into
Feeling
the
from
about
side
it
helps
the
Otherwise,
the
Th:
the
anger
so
he
in the
with
can
past.
anxiety.
face
In
Help
the
feeling
action.
the
her
dangerous
his
effective
differentiate
therapist
defense.
angry
anxiety
patient
unable
Notice
the
the
the
we
Im
push
Differentiating
When
Pt:
Defense
feeling,
from
she
her
patient
patients
may
feeling
respond
with
(Basch
1996).
differentiate
feeling
her
will
feeling
not
be
accessible.
you
out
of the
Whats
toward
him
for
throwing
car?
Pt:
differentiate
feeling
feeling
from
defense
feel
.]
worried.
[ Defense.
Does
not
Th:
there
can
are
we
a lot
take
of
thoughts
a look
does
not
I feel
differentiate
Whats
the
off
to
worrying
put
the
thoughts
have
done
now,
to
and
the
side,
underneath?
he
shouldnt
feeling
from
Thats
feeling
goes
If we
feeling
Th:
a feeling.
mind
now.
at the
Pt:
She
Your
defense
your
him
but
for
[ Defense.
.]
thought,
toward
that.
your
thought
throwing
is
not
of
the
you
out
him.
[ Defense.
car?
Pt:
She
does
toward
turn
your
the
might
the
not
differentiate
feeling
Th:
Do
but
then
toward
him
you?
If you
hurting
toward
differentiate
muscles
feeling
her
for
from
you
defense
.]
how
theres
some
critical
part
of your
mind
criticism
dont
with
notice
this
into
being
turn
of
the
you?
Do
criticism
you
onto
feeling
starts
think
you,
to
that
what
is
him?
Pt:
not
stupid
feeling
boyfriend,
feeling
be
I feel
confusion
[ Sighs
.] I feel
from
defense.
is not
a sign
confused.
Since
[ Defense.
anxiety
She
is in the
of cognitive/perceptual
does
striated
disruption
.]
Th:
your
feeling
feeling
with
toward
Confused
confusion,
can
differentiate
feeling
from
how
you
deal
now
you
throw
and
empty
with
your
out
your
yourself,
feel
defense
Th:
have
an
If you
dont
uncensored
cover
look
at
this
empty.
is not
feelings.
we
a feeling.
He
feelings.
can
[ Defense.
She
does
not
.]
Empty
threw
If you
have
an
like
running
defense
.]
Emptying
you
dont
out
throw
honest
yourself
of
the
your
look
at
car,
feelings
your
is
and
out
feelings
him?
Pt:
not
we
a feeling.
him?
Pt:
toward
is not
differentiate
feeling
I feel
from
Th:
You
can
run
away.
away
from
[ Defense.
your
She
feelings,
does
but
no
matter
away
how
is not
you
you
working.
willing
been
far
to
them,
feelings
dont
so
we
run
are
away
can
get
still
from
to
in
you.
these
the
bottom
Running
feelings,
are
of
has
what
you?
Pt:
Differentiating
Some
your
If you
face
troubling
run,
the
I feel
irritated.
Feeling
patients
use
how
therapist
from
[ Feeling
plus
a Defensive
defensive
affect
to
defense
.]
Affect
cover
up
the
underlying
feeling.
Notice
that
the
patient
defensive
patient
the
rather
cannot
affect
make
than
assesses
that
this
covers
from
for
insulting
you
[ She
longing,
does
and
her
How
in front
not
from
I want
formation
defensive
remain
your
feeling
function
stuck
anger
this
feeling
The
therapist
feel
her
sees
from
the
helps
the
reactive
feeling
experience
this
anger
toward
friends?
him
back!
her
I feel
anger
such
from
the
a longing
for
defenses
of
.]
cover
when
confused.
under
you
Longing
.] You
], but
and
do
differentiate
reaction
can
and
affects.
of your
Th:
defense
she
responses
reactive
feeling.
defensive
Pt:
him.
so
her
Th:
him
patients
differentiate
distinction
suffer
the
is
your
you
of
can
your
anger
cover
[ Price
longing,
not
with
your
the
we
anger.
see
longing
[ clarify
the
with
longing,
you
dont
hide
anger
defense
how
[ Differentiate
.] If you
you
experience
this
anger?
Pt:
anger
from
boyfriend,
her
but
insulting
But
I love
of
reaction
defense
she
uses
her
Differentiate
really
[ She
does
formation.
to
cover
She
her
anger
not
differentiate
may
love
toward
her
him
for
her .]
Th:
your
love
him!
anger
feel.
her
with
[ Point
defensive
love,
out
that
the
Im
sure
affect
hides
defensive
you
do.
from
her
the
true
function
But
anger
love
is
.] When
complexity
.]
not
Do
you
of
you
anger.
cover
what
see
what
you
I
mean?
Pt:
feelings
to
defensive
make
You
things
function
your
of her
and
other
to him.
[ Point
out
with
this
how
do
One
might
you
price
this
real
fact)
to
cover
differentiate
does
function.
her
the
the
Feeling
not.
love
insulted
differentiate
Why
(See
that
to
toward
with
begins
positive
to
her
see
this
the
anxiety,
defensive
for
to
you
you.
your
the
anger
defense
so
the
patient
are
her
other
used
fact).
of
a defensive
her
Another
affect
anger.
affect.
affect,
examine
the
A defensive
already
],
you?
and
a defense.
affect
up
real
defensive
that
insults
insulting
defensive
from
then
he
against
(another
affect
from
cover
turn
but
information
dont
case,
the
faade,
when
course,
anger
with
nice
him
him
Of
In
activating
The
chapter
anger
false
love
her
her!
grief
triggers
gives
.] If you
real?
feeling
not?
nicey
you
anger
he
Always
process.
her
cover
this
[ invite
all,
might
[ She
up
defense
experience
patient
To
of this
Isnt
nice?
faade
says
faade
ask,
put
That
nice
After
(a
You
faade
nicey
feelings.
love
the
my
love .]
feelings.
Your
I cover
nicey
Th:
hides
mean
serves
affect
defensive
10 .)
Causality
Feelings
trigger
presenting
suffering
in the
turn
begins
past
Defenses
is
your
patients
of
her
anxiety,
which
symptoms.
the
prevent
patient
feeling
when
toward
awareness
experience
the
us
she
defense,
from
him
this
cause
causality,
the
their
how
defenses
that
As
a result,
patients
present.
seeing
was
for
the
causality.
a child.
abusing
feeling
is aware
and
see
which
helped
can
easily.
she
of her
see
They
in the
more
defenses,
patients
sense.
suffering
defenses
can
triggers
Once
to make
create
against
abused
anxiety,
will
of:
result
therapist
you
as
on
stimulus,
of
father
The
depend
the
The
the
a
how
the
defense.
sexually
asks,
little
many
reactive
See
What
girl?
The
elements
feeling,
figure
8.1
for
the
causal
sequence
Figure
8.1.
Sequence
Every
conflict
has
see
the
stimulus,
her
symptoms.
of
and
whole
At
patient
of
her
not
may
Or
on
deny
it.
about
Or
and
she
When
defenses,
has
Help
may
her
the
patient
she
can
global,
1985)
cannot
see
only
undifferentiated
recognize
(Rangell
see
the
the
one
each
as
we
can
above
anger
an
an
of
these
understandable
result
awful
her
what
say,
of
her
on
the
defense
defense
She
low
does
anxious.
is
not
to
and
Yet
aware
turn
attacks
myself.
of
of
she
of self-attack.
she
about
the
patient
self-attack:
how
it with
examples
I am
person.
honest
of
show
or her
equating
several
might
comment
being
element,
examine
function
If you
just
us
so
I am
or
only
Let
patient
say,
Im
to
her
herself,
Her
of
her
anger
she
will
awareness
self-attack:
feel
is
horrible
myself.
she
might
above,
she
experience
unaware
of
defense
of
experience;
her
In
result,
of her
herself.
limited
causality
components.
relationships
aware
anxiety,
back
The
might
anger,
anxiety,
capacity
be
she
feeling,
being.
see.
not
five
of
herself.
self-observing
does
elements
displeasure.
the
entirety
the
elements.
at least
their
within
first,
of
As
experience
elements
of those
am
is aware
of
only
of
bad
being
the
is
shameful.
the
and
of
the
result
the
of
At
shame
her
five
elements
self-attack:
abused,
her
entirety
of
the
shameful.
being
Thus,
Of
that
her
is
present
not
her
moment,
rage,
the
listed
internal
she
is
anxiety,
entirety
of
or
her
awarenesslimited
by
example,
some
part
sense
of causality.
problems
memory
self-attack.
it
defenses
each
say,
of the
rather
defenses
chain
of causality.
For
than
prevent
instance,
create
them.
she
the
patient
from
As
a result,
she
believes
Address
her
the
being
has
aware
a
defenses
defenses
mistaken
solve
that
of
her
restrict
the
patients
toward
of
awareness
the
abuser,
self-attack,
result,
She
The
will
will
feel
shame
stimulus,
feelings,
The
and
unable
The
following
turn
to him
the
resulting
to deal
the
the
rather
with
their
examples
not
her
therapist
feeling
. He
invites
the
feeling,
her
rage
defense
self-attack.
As
attacking
with
of
and
herself.
his
the
her
shame.
inner
life:
the
resultspresenting
keeps
different
asked
her
patients
confused
effectively.
The
but
feel
belonged.
causality
illustrate
see
of
awareness
feelings
and
identify
it always
defenses,
incorrect
to
without
than
patients
her
defense
abuser
where
anxiety,
help
it triggers,
against
him
with
If we
anxiety
toward
toward
return
interfere
the
rage
rage
Defenses
problems.
can
feel
will
causality.
notice
she
she
of
problems
patient
me
to
the
patient
of causality.
is aware
touch
his
of
the
genitals.
responds,
stimulus
When
the
dont
feel
anything.
The
not
the
make
stimulus
. Im
so
angry,
patient
but
I dont
know
The
patient
is unaware
her
anxiety
. I dont
know
why
The
her
defense
submitted
of
self-attack
I feel
patient
. Im
why.
feeling
It just
but
doesnt
angry
and
the
But
I am
anxious
is aware
with
result
of
it but
shameful.
not
I hate
of
myself
the
patient
the
him,
feeling
now.
of her
stimulus,
feeling,
that
guy
or
anxiety
to use
because
triggering
the
feeling
but,
after
but
all,
feeling,
why
I am
anxiety,
so
her
I think
patient
her
feeling,
or
I deserve
is
defense
of
unaware
. I dont
defense
anxiety
it.
of
know
the
why
me.
The
stimulus,
is aware
stimulus,
The
I asked
of
to him.
The
know
of her
sense.
triggering
not
is aware
or defenses
depressed.
patient
causing
is
her
unaware
symptom
of
. I
the
dont
The
her
defense
trigger
and
to the
her
anxiety,
feeling
but
. I feel
patient
is aware
of
defense,
not
afraid
and
ashamed
The
defenses
cause
people
create
her
her
presenting
problems
make
her
feel
worse
so
people
have
patient
. This
feeling,
Maybe
lives,
do
my
but
depression
without
is create
defenses
do,
same
Vignette
One:
how
triggers
not
help
then
feeling,
but
of
me
her
how
her
worse!
of
the
depression
meaning
causality,
of
all
.
our
we
can
how
her
causality.
does
not
see
. No
she
I can
how
matter
does
not
what
see
I
her
do.
patient
the
has
left
you.
are
Im
what
stimulus
triggers
her
differentiate
the
stimulus
see
the
stimulus
patient
promised
to move
in with
could
together.
Then
Th:
feeling
left.
what
did
and
Sunday
What
feeling
is
Joe
me,
you
someone
Left
Is that
Pt:
that?
her
other
unaware
to make
Since
the
What
Th:
like
is
false
how
how
feeling.
her
live
the
me.
unaware
suffering
see
help
Pt:
someone
her
nothing
does
Th:
describe
patient
or
Error
will
and
The
Theres
patient
therapist
on
create
it in for
of
based
happening.
Causality
feeling
the
keep
need
of
imagines
causing
We
of
is making
understanding
does)
believes,
the
The
the
she
things
she
feeling.
accurate
she
patient
defenses
pseudoexplanations
defenses,
Notice
or
is genetic.
an
(things
the
from
anxiety,
result
feeling,
unaware
is
therapy
The
stimulus,
is
problems
. Other
the
of myself.
patient
The
defenses
her
of
you
are
I had
you
but
this
rented
feel
does
not
it may
be
that
He
had
describing?
me
broke
patient
to her .]
a feeling,
leave
him?
[ The
not
he
do
did
toward
up
this
with
toward
weekend.
apartment
so
we
me.
Joe
for
leaving
you
distinguish
the
stimulus
Pt:
Like
from
the
Th:
feeling
toward
from
the
him
feeling
for
Of
of
I feel
Two:
In this
so
example,
she
patient
sense
is
aware
see
how
and
does
anger
not
so
have
Error
the
does
patient
only
of
feeling
you.
So
does
not
is
your
what
[ Differentiate
the
to be
anxious
you
his
you
not
her
the
leaving
toward
see
you
him.
that
anxiety.
triggers
does
It doesnt
made
left
you?
course,
] in
Causality
her
stimulus
[ stimulus
[ Show
feeling
The
causality:
Then
task:
triggers
therapist
anxiety.
therapeutic
facing
anxiety,
will
her
her
help
anxiety
the
makes
feeling,
so
all
she
instead.
What
do
Tense.
make
Th:
have
[ She
in her .]
Pt:
why.
Of
emotion
Th:
know
left.
.]
he
to
feel
angry.
[ feeling
triggers
Vignette
.]
a lot
stimulus
feeling
that
Th:
the
said,
course,
doing
Pt:
triggers
you
notice
feeling?
Ive
been
anxious
any
sense.
Did
something
happen
day.
today
dont
that
might
after
class
anxious?
Pt:
I dont
think
so.
I was
calm
until
today.
Th:
What
Pt:
the
end
could
due
of
get
to
class
an
the
couldnt
surgery,
get
an
Nothing
I had
extension
to
Im
not
giving
his
a little
to
The
the
paper.
class
professor
Since
behind.
was
I lost
I told
him
the
about
At
whether
a week
that,
usual.
in
school
but
he
said
the
professor
extension.
you
the
business,
What
is your
feeling
toward
extension?
Pt:
thats
my
at class?
much.
speak
on
Th:
for
happened
and
No
he
feeling
has
really.
a right
not
[ Defense:
to
give
denial
one
.] I
if he
mean
doesnt
want
to.
[ Defense:
rationalization
Th:
you
dont
him?
cover
[ Identify
this
the
Thats
feeling
speech
the
defense
if I had
toward
You
received
him?
into
Im
the
behavior.
feeling
If
toward
.]
plus
the
are
or
defense
of
Either
you
you
arent.
course,
the
with
so
feeling
[ Big
to her
anxiety,
angry
him.
It would
have
really
extension.
Of
[ Invite
in response
anger
the
[ Feeling
guess?
No.
Th:
your
his
.]
Pt:
of anxiety
whats
feeling
I guess.
for
.]
Th:
anger
invite
Angry,
Pt:
helped
explanation
a reason,
and
Th:
Block
your
with
defense
Pt:
hypothetical
.]
She
anger
.] Tense.
you
hunches
your
do
do
experience
this
.]
sigh.
Thats
how
how
her
anxiety,
you
but
experience
shoulders.
if you
this
Signs
dont
anger
turn
toward
him?
Pt:
student
who
didnt
Im
deserve
tension
feeling
and
triggers
Do
anxiety
anxiety
in
[ Make
a causal
be
body
.]
Yes,
I hadnt
has
to the
Pt:
you
like
you
get
Vignette
attacks
to
face
to the
Three:
you
just
this
bottom
Do
been
gave
This
for
feeling
one
to this
other
think
anger
[ Point
is
out
triggering
causality:
it before.
this
anger
your
anxiety
problem
toward
all
your
day
long?
.]
it started.
makes
angry
underneath
Error
now?
triggering
anger
of it?
Causality
you
is when
feeling
this
noticed
presenting
That
Th:
anxiety
he
how
in your
what
link
notice
body
Th:
may
you
your
Pt:
professor
I know
it!
Th:
some
furious.
you
toward
the
anxious.
Its
like
a professor.
anxiety
so
we
this
Would
can
help
In
this
example,
trigger
her
Then
herself
this
the
patient
defenses.
they
can
by
using
does
The
explore
her
not
therapist
the
see
will
patients
how
feeling
help
her
see
feeling
so
she
and
this
anxiety
sequence.
does
not
hurt
defense.
Th:
What
is
Pt:
I think
the
feeling
toward
him
for
having
affair?
him.
[ Defense:
self-attack
of
defense
.]
telling
me
your
affect
feeling
of
reactive
your
is
If you
is toward
him?
Pt:
I feel
She
sees
feeling
the
yourself
we
stimulus
see
instead,
Show
the
comes
turning
the
of anger
saw
in to cover
as
that
him?
it was
see
yourself
[ Point
can
painful.
(the
the
affair
for
feeling
feel
out
the
we
see
[ Defensive
affair)
and
but
caused
causing
you
and
invite
then
with
him
angry
with
him,
but
anger
back
onto
you.
the
it now.
If you
not
you
such
the
But
angry
Do
you
I am
to cover
Sure.
all
this,
her
pain.
pain?
feeling
sad.
her
.]
You
criticized
you
see
that?
of self-attack
it before.
you
wouldnt
him
and
the
need
then
not
see
how
to
sadness
sadness
.]
have
many
complex
.]
that?
[ Does
anger
Do
having
you
see
toward
see
for
then
defense
I didnt
saw
feel
anger.
Th:
angry
triggering
you
your
a defense
the
him
I see
Pt:
functions
about
yourself,
stimulus
had
You
felt
Th:
we
to
Anger.
you
causality
Then
talk
criticize
because
the
and
Pt:
here.
you
toward
dont
sad
He
Th:
So
notice
feeling
toward
Pt:
affair.
I was
.]
your
Differentiate
person
Oh.
Th:
What
you
Th:
sadness.
feeling
Do
about
Pt:
what
a stupid
.]
Th:
instead
what
feelings:
be
anger,
guilt,
problem
part
grief,
is
of
how
reality
your
can
keeps
you
in the
angry,
the
sadness
depressed.
this
presenting
her
defenses
she
help
can
the
or
let
from
me
hurts
the
as
to
as
does
it,
[ One
reality
but
.]
when
and
result
the
anger.
of
a substitute,
but
then
of
the
That
you
are
you
get
defense:
now?
Im
in the
on
reason
task.
create
how
your
trying
her
no
defenses
cause
to let
The
her
therapeutic
notice
touch
protects
her
sees
defenses
you
just
that
therapeutic
engage
we
see
she
her
Do
as
not
the
how
and
defense
real,
your
part
feel
and
a result,
in
see
soon
is
cover
you
I mean
engage
of them
to
another
function
As
Pt:
believes
instead
sadness
Error
Th:
here
sad,
patient
patient
go
are
what
problem.
the
cover
the
see
in
to
Causality
example,
her
must
out
The
comes
If you
comes
you
Four:
longing.
enlisted
dark.
.] Do
Vignette
and
sadness
be
[ Point
depression
In
pain,
go
of
therapist
problems
so
task.
you
distance
yourself
sadness?
to protect
because
myself.
she
does
[ The
not
patient
see
how
it
you
or
it
her .]
Th:
keeping
you
lonely?
But
[ Help
is this
the
distancing
patient
see
protecting
how
the
defense
hurts
is
her
.]
Pt:
but
then
I feel
safe.
[ Shifts
[ Failure
Th:
seems
to
came
here
distant
me
to
are
does
have.
how
that
not
create
how
you
rise
the
defense
have
safe?
deprives
from
past
loneliness
now.
[ Correct
her
it creates
Pt:
I see
what
problems
you
you
and
causality
.]
mean.
.]
Lonely,
endangers
You
husband
helped
the
safety;
anxiety
of
look
the
anxious.
but
the
I
can
would
you
that
you
isolation
error:
It
you
created
about.
then,
her .]
support
has
complaining
creates
right
of
you
your
been
in the
with
feeling
now
you
distancing
from
Are
Distancing
distancing
suffering
to see
distancing
relationship
appreciate
agree
that
in chair
her
defense
Empathize
with
maladaptive
today.
Causality
In
Error
the
following
therapist
causes
that
triggers
her.
Her
Due
to
defenses,
the
Inability
example,
her
adaptive
the
anxiety
to
but
that
Im
not
the
afraid
you,
feelings
she
does
not
her
The
trigger
feelings,
are
Feeling
believes
not
see
patient
it. As
cause
causality:
True
the
the
feeling
her
You
causality:
a result,
aware
she
of
her
mistakenly
anxiety.
cause
My
is
my
feelings
anxiety.
toward
you
make
anxious.
Causality
In
Error
the
Due
following
therapist
is
defenses
corner
to
Projection
example,
cornering
of
the
her
the
patient
because
Superego
mistakenly
she
does
Im
feeling
her,
therapist,
now
but
the
believing
patient
he
Th:
talking
about
attacking
how
you,
want,
the
two
it can
no
longer
this
putting
of us
see
how
her
corner
the
interesting
down,
could
superego
because
mechanism
you
patients
superego
onto
the
her.
Thats
punitive
The
projects
corners
together
has
and
telling
corner
that
we
been
you
have
been
cornering
you
to give
punitive
up.
If
you
mechanism
you.
Pt:
[ Cries
Incorrect
Correct
self-attack.
not
the
cornered.
Psychodiagnosis:
corners
believes
her.
Pt:
by
past,
of you.
that
False
me
the
mistakenly
Psychodiagnosis:
thinks
the
it.
Pt:
anxiety
See
patient
because
in
.] I never
thought
causality:
You
causality:
of that.
are
cornering
corner
myself
me.
through
so
Causality:
Defenses
Cause
Presenting
Problems
and
Symptoms
When
formulating
the
defenses
she
instance,
suppose
declare
would
and
uses
and
a
problem,
create
presenting
the
and
the
patient,
note
detaches,
remains
vague,
passive
poor
can
stance.
also
how
with
co-create
the
For
does
not
defenses
office
sabotage
her
all
create.
These
relationships
would
see
she
they
defenses
so
for
problems
takes
patient
problems
conflict
presenting
marriage,
These
Help
of
patient
a failed
loneliness.
alliance.
triangle
mates,
therapeutic
defenses
create
a therapeutic
her
alliance.
Syntonicity
The
final
inability
element
to
days
of
life,
we
Therefore,
defenses
should
or assumes
Syntonicity
is
defenses
or
often
defense,
or
he
refers
fails
impossible
for
Syntonicity:
him
feelings
thats
the
way
in
terms
of
patient
to
see
his
are
cannot
causality.
deeper
Restructure
the
Learned
a patient
habits.
does
not
see
I am.
not
helpful
and
adaptive.
observe
or pay
the
with
Patients
use
inner
his
These
attention
defense.
to
to his
seeing
narrowly
the
continues
access
earliest
automatic
Syntonicity,
he
the
patient
identification
defense,
to gain
when
the
defenses.
become
that
they
syntonicity:
From
through
surprised
that
involves
defense.
defenses
patients
with
the
be
the
to the
disidentify
our
defined
that
from
not
believing
indicate
here,
with
nonverbally,
we
capacity
oneself
deal
and
beliefs
self-observing
differentiate
implicitly
not
of
to his
defined
If he
it,
does
making
it
life.
Identification
with
His
Defenses
Although
patients
mistakenly
their
address
defenses
believe
defenses.
the
defenses
As
patients
result,
tendency
are
actions
are
who
no
they
internal
to
ignore
they
do ,
patients
are . They
focus
his
is
often
identify
with
possible.
defenses
so
First,
he
can
observe
and
anxiety
he
and
does
pay
attention
feeling;
hence,
not
differentiate
see
the
To
help
the
he
is not
his
enemies.
his
dissatisfaction.
following
examples
The
the
and
that
he
satisfied
believes
they
a source
of
the
aware
of
repress
them.
defense,
he
see
defenses,
which
illustrate
he
him
defenses
thought
were
with
defenses,
are
not
help
rather
continuum
cannot
causality.
help
his
Since
the
see
that
create
his
his
friends,
which
create
cause
than
from
of
his
harm.
The
dystonicity
to
of defenses.
Spectrum
from
following
from
defense
solution,
not
can
his
defenses
or
nor
from
been
He
but
The
has
is
anxiety,
Defenses,
He
problems
syntonicity
his
Syntonic
patient
of conflict,
as
problems.
are
the
disidentify
same
them.
feelings,
elements
patient
the
presenting
his
to
no
examples
defense
therapist
Dystonicity
who
to
illustrate
to
the
complete
recognizes
Syntonicity
spectrum
identification
this
of
syntonicity,
with
spectrum
can
the
ranging
defense.
tailor
her
close
to
The
interventions
accordingly.
1.
defenses
reason,
I pull
defense
back,
and
I want
and
does
I dont
not
3.
happen.
the
I dont
ways
wants
know
to
be
to be
close
people.
she
avoids
closeness
get
[ No
see
and
protects
is identified
it
as
that.
I want
to be
close
[ The
patient
does
not
She
feels
conflict
but,
[ The
for
patient
some
sees
it .]
closeness.
to people,
but
see
her
it doesnt
defenses,
because
she
.]
hurt.
not
I do
like
like
to people,
that
why.
4.
could
want
.]
2.
her
[ The
patient
defense.
her,
even
with
her
Im
not
uses
She
I want
a defense
believes
though
defense
sure
it prevents
of
distancing,
her
to be
close
to people.
(rationalization)
rationalization
emotional
but
since
but
is
closeness.
she
says,
does
helpful
She
Im
not
sure,
she
still
feels
a slight
5.
does
to
not
be
see
desire
her
for
as
disidentified
emotional
nor
does
she
She
is
problem
conflict
people
him.
thinking
does
not
away
is
her
reveals
syntonic
are
acceptable
defenses,
refers
is
equate
with
the
result
their
defenses
a result,
criticizing
the
her
You
do!
therapist,
not
lack
of
[ She
believing
see
any
with
her
closeness.
She
feels
it
internal
closeness
identified
or
her
defense
and
no
internal
I can
reveal
only
who
of
as
feelings.
These
against,
defenses
patients
differentiate
the
way
I am.
many
with
(Im
see
This
themselves
choices,
of
the
an
very
their
patient
of pushing
people
but
and
feelings
source
of
myself
act
of
(S.
aware
of
their
If you
note
how
Correct
causality
from
but,
that
self-image
become
make
are
to me
[ The
their
I detach
than
since
with
emotions,
confront
patients
defenses,
patients
part
close
Defenses
with
of their
rather
Her
consistent
tiny
keeping
.]
person.
defense
part
if you
them
they
isnt.
a detached
to get
problem,
defense
just
I enjoy
try
really
values,
Thats
close.
enjoyment
not
these
faced
he
from
or
be
boyfriend
Her
her
Patient
Im
to
when
is
with
reply,
me.
patients
me
patients
When
to
close.
does
see
my
defense
When
they
choose
She
of denial.
respond,
not
onto
want
to behaviors,
to
detach,
choice
to
is identified
they
be:
seeing
her
1923/1961b).
would
I like
the
Ego
they
I dont
defense
Differentiating
Freud
6.
close
that
She
for
be
.]
.]
he
see
pleasure!
As
wish
at a distance.
and
her
to
of projection
of
with
of conflict
want
appraisal
closeness,
defense
I dont
defense
rational
degree
them.
through
That
habit,
emotionally.
defense
unemotional
These
(I
detach)
person).
They
or
see
being.
defenses,
describing
the
no
to
reason
is who
from
I am.
their
they
experience
ways
pay
they
attention
you
handle
to,
Therefore,
we
defenses.
First,
and
must
help
as
their
turn
help
the
patient
observe
and
causality.
Then
Vignette
One:
Notice
how
pay
address
his
the
therapist
patient
identifies
help
the
patient
see
her
is
[ Point
out
emotional
how
the
Do
see
who
what
Thats
your
feelings.
is from
the
you
them.
show
underneath.
are
The
term
under
therapist
is
but
must
how
she
Im
detach
from
your
detached.
defense
the
way
not
.]
you
from
handles
Im
are.
Detaching
your
her
feelings.
feelings
.] Do
you
this
not
like
the
differentiate
Two:
how
the
patient
about
does
dealing
willing
to
emotional
person
she
is from
differentiate
his
defense
.] Right
of the
feelings
me
from
the
the
you
see
from
who
you
woman?
patient
the
but
relationship
let
and
the
her
instead
withdrawal,
with
with
from
unemotional
assesses
not
person.
emotions,
detached
the
Identification
therapist
emotional
have
feelings
you
of the
who
You
uninvolved,
.] Are
hiding
an
of detachment
differentiates
masks,
not
true.
her
faade
faade
Im
.]
intellectualization,
Vignette
makes
this
faade
patient
the
I am.
detach
she
Maybe
Thats
relationship
Detachment,
that
she
you
the
You
[ Differentiate
me
therapeutic
Notice
who
how
is not
how
defense
[ Differentiate
really
the
way
with
Detached
she
with
from
function
the
Th:
Th:
the
the
I mean?
Identification
now,
sees
.]
Pt:
detach
and
responses
Thus,
notice
[ Identification
handle
Differentiate
and
defense.
patients
is not
you
defense
person.
you
the
function,
Defense
defense.
defense
their
feelings.
Pt:
an
the
the
her
the
Th:
feeling?
with
with
with
that
defenses,
identification
assesses
the
with
to his
Identification
how
deals
attention
lack
ways
her
of
defense.
involvement
underneath.
she
hides
Help
herself.
Defense
patients
who
feelings.
responses
he
is from
The
the
therapist
and
choice
uses
sees
he
a
metaphor
to help
turning
off
the
of the
patient
road
see
the
from
your
defense
have
defenses
are
choices,
ways
of
you
keep
distancing
to feeling.
Th:
yourself
how
Do
emotions?
you
notice
[ Point
out
Pt:
But
thats
the
Th:
No,
thats
just
how
the
defense
way
I am.
.]
[ Identification
with
.]
a feeling,
you
deal
with
that
a habit
feeling
you
have.
habitually
by
When
you
detaching.
Its
a habit.
Pt:
habits.
[ Identification
with
I thought
his
Th:
drive.
We
come
Then
we
come
right-hand
we
have
funny
he
the
say
way
makes
park,
but
choice.
we
thats
who
driving
conscious
Vignette
In
this
patient
defense
You
you
you
collection
of
and
you
keeps
are,
car.
I went
make
not
getting
we
would
[ Distinguish
turn.
another
happening
but
for
a right-hand
and
circles,
out
how
.] Thats
until
it
anywhere.
say
who
that
he
you
is
from
know
true.
at
an
backwards,
notice
that
you
or
intersection
even
have
unconscious
just
a habit
defenses
of
limit
you
leave
could
the
making
the
go
car
only
range
in
one
of
our
.]
Pt:
choices
make
you
[ Laughs
right,
would
choices
choices?
and
in
your
.]
left,
[ Point
if
thing
around
Th:
ahead,
same
I am,
Imagine
intersection,
going
of
all
.]
no.
next
Pt:
straight
Oh
the
were
wouldnt
defenses
intersection,
And
clear
choices
an
to
turn.
becomes
Now
to
thats
[ Awareness
You
of himself
mean
there
and
his
is a me
agency
here
as
making
separate
these
from
his
.]
Three:
example,
Identification
the
differentiate
has
as
therapist
a
little
with
defense
to do
with
uses
from
the
Defense
another
his
a persons
metaphor
essence
being
as
as
to
a
a leech
help
person.
has
the
A
to do
with
the
leg
it is sucking
on.
Th:
yourself
and
start
Do
to criticize
Pt:
with
your
I do
defense
anger.
of self-attack
[ Identification
vines.
with
fact,
can
barely
Im
the
you,
but
the
we
have
you
up
that.
Do
you
see
the
patient
defenses
things
of
instance,
how
one
invisible
We
We
do
ask
if
anxiety,
strangles
so
in
to
her.
anger
as
anger,
anxiety,
on
a way
to
and
two
the
represent
patient
Visual
but
after
so
Its
its
way
many
years
are
you
his
this
a visual
defenses
can
see
that
can
from
tree
metaphor
is
have
all
to
help
of
problem
anxiety,
see
reason,
their
visual
life.
can
and
book
For
feeling
bookshelf
another
invisible
inner
one
in
and
provide
how
my
make
you
underneath
cannot
understanding
books
that
that
feelings,
picture
like,
with
healthy
from
patients
For
of
.]
suffer
to
sort
all covered
really
who
can
see
this
Usually,
her,
the
(the
show
feeling)
top.
can
punish
are.
self-attack
affect)
defense.
just
of
form
take
you
vines
unaware.
trouble
Thats
tree,
[ Introduce
has
on
way
Obviously,
patients
that.
these
patients
patient
the
here
See,
from
if this
she
and
metaphors
comes
ask
pattern
underneath.
patients
are
placed
the
large
see
invisible.
(defensive
when
not
can
ask
I will
book
off
its
a large
so
tree
how
if a patient
another,
this
.]
not
himself
help
sure
I mean?
they
to
are
we
what
are
which
metaphors
cover
so
not
see
pull
We
that
you
to
shows
representation.
that
causality:
defense
the
distinguish
example
turn
notice
Thats
vines
see
covered
This
and
even
you
.]
in a jungle
In
how
a lot.
[ Show
Th:
if youre
that
You
Pt:
am.
see
yourself
Th:
deal
you
can
or
how
metaphors
a defense,
sequence
patients
see
of
anxiety
self-attack
the
(like
patient
speaking.
events:
cannot.
how
help
strictly
feeling,
Provide
(like
a
a
vine
picture
visual
policeman)
on
tree)
invisible
processes.
Sometimes
parts
therapists
of
the
the
self
self . Defenses
than
covers
her
part
of
herself
anger
to
Leads
We
patient
not
see
think
way
he
and
are
he
is
his
his
until
can
not
he
see
help
the
patient
Then
help
him
differentiate
with
Then
his
Now
can
knows
challenge
you
Differentiate
Lets
These
or
are
the
helping,
Depressed
the
phase
of
who
identify
with
their
Vignette:
Differentiating
Notice
how
the
therapist
herself
from
her
defense
we
must
take
more
time
its
defense,
his
parts
of
price,
or
he
defense,
than
and
to
anxiety
Then
or confront
the
his
from
causality
your
defenses.
him
defenses
Patient
will
a
his
alliance.
because
Her
identification
from
disidentify
therapeutic
him.
he
describing
and
help
the
not
a misalliance.
attention
from
is
Otherwise,
cause
attacking
the
Defenses
with
depressed
defenses.
the
Patient
helps
the
of cutting.
to
will
see
challenge
those
defense
not
his
establish
not
is
Defenses
defense.
pay
confront
examine
patients
the
causality.
steps
of
who
defense
hides
His
function,
feelings
see
parts
patient
her
she
rather
its
and
his
him
defenses.
we
patient
help
as
never
defense
observe
how
does
person,
from
the
say
confront
defense,
of the
First,
defenses.
his
more
as
Defenses
same
no
from
Therefore,
himself
confrontation
is
defense,
If you
as
feelings.
can
his
behaviors
Take
not
of
the
him
differentiate
premature
would
Patient
see
not
face.
defense
defense.
attacking
handles
defense
her
the
does
from
you
We
say
defensive
are
the
Challenge
that
differentiated
of
sadness.
would
to
identifications
a part
Premature
the
does
is
with
refer
or
Differentiate
to
When
a mask
her.
Failure
mistakenly
help
from
depressed
Since
the
the
patient
Her
Defenses
patient
defense
see
differentiate
is so
the
syntonic,
defense
and
causality.
Th:
you
out
of the
What
is the
feeling
toward
I cut
herself.
If you
punish
anger
and
against
toward
explore
cut
this
the
her
herself
defense
after
to
of
deal
with
self-attack
.]
critical
system
in
defense
] that
takes
defense
system
help
might
her
be
turn
is
this
].
you
against
the
toward
him
thats
mind?
[ Invite
her
you?
depressed?
defense
abstract
language
that
feeling
than
in it. If we
noted
how
herself
again.
Youre
so
I am
terrible.
to
hate
sign
that
to a critical
to
help
when
longer
how
her
she
see
these
sees
and
equating
she
the
hurts
at
in her
defenses
is
herself
to
by
this
again
to
she
what
mind,
in
differentiated
with
self-attack),
That
was
so
the
the
be
patient
feeling
system
herself,
is
in
your
to
help
I hurt
stupid
she
is
myself!
rather
would
just
Instead,
or a thought
from
can
mind
This
from
these
we
herself.
Pt:
and
mind
self-criticism
differentiating
fully
defense
your
your
observe
a habit,
while
critical
.]
doctor.
way
the
that
turn
critical
hurts
right,
the
see
system
defense,
Look
mechanism
like
is a
[ describe
in
to
turn
automatic
the
system
and
theres
think
from
causality
a critical
her
her
may
defense
this
you
you
she
her
but
from
on
Do
critical
out
differentiate
engage
that?
you
her
like
from
turns
covered
to face
him,
cutting
Cutting
from
toward
[ Differentiate
Would
getting
feeling
it
[ Point
.]
a feeling.
and
it .] Could
see
is not
the
see
her
deeply.
her
of
self-attack,
anger
her
you
equates
defense
help
[ differentiate
feeling
Do
against
her
feeling
mind
her
her
yourself
some
patient
First,
[ Differentiate
hurting
making
Use
Cutting
your
mechanism
session.
exploring
feelings.
There
with
or confront
the
before
The
boyfriend
anger
Th:
way
throwing
myself.
Psychodiagnosis:
of
for
car?
Pt:
feeling
him
of me.
begin
another
refer
pattern
them.
defenses
to
begin
talk
Only
(no
about
Th:
You
have
feeling
into
feeling,
aimed
is hurting
Differentiate
the
criticizing
done
and
criticism
mechanism
First,
without
her
to talk
to the
is a critical
mechanism
then
this
critical
back
onto
you.
in your
mechanism
Do
you
mind.
turns
think
that
we
said
that
critical
you?
patient
herself,
so.
This
from
an
automatic
she
might
punish
describe
the
defense
conscious
will.
patient
but
Some
an
habit.
herself
as
immediately
if this
be
happens
a useful
I would
is
having
that
may
description.
she
for
a mechanism
wonder
inaccurate
If
way
suggest
it
is accurate.
Procedural
memory
leading
to
habitual
self-attack.
She
can
sees
it.
operates
modes
Differentiate
outside
of
behavior
such
unconscious
consciously
choose
Pt:
the
habits
not
I really
to
use
messed
part
of your
that
to treat
yourself
policeman
the
You
law
comes
must
trying
I just
feel
really
only
will.
when
theres
be
to hold
comes
in
you
to have
for
in to
upset
you
a perpetrator
you
punish
with
back
comes
have
theres
Is this
she
this
critical
this
habit.
a kind
or
cruel
anxious.
and
Th:
Tasers
this
and
what
from
attack
this
in the
this
room
feeling?
you
you
and
you
with
notice
how
anxiety?
As
its
if
its
of anger?
Th:
anxiety
what
Do
you
emotion
because
So
So
Th:
anxiety
conscious
up.
Th:
against
her
and
?
Pt:
riding
bicycle
mind.
like
as
defense
Th:
way
awareness,
from
a
patients
just
Do
for
is doing
you
see
having
to
how
a
you,
this
feeling?
how
it
is
want.
Th:
strangles
Do
you
see
how
its
you
with
anxiety
like
just
mechanism
Help
comes
the
patient
between
these
in to attack
the
differentiate
driver
questions,
she
could
might
rhetorical,
in
defenses
are
awareness
Help
of
separate
from
the
Patient
patients
and
their
Through
Remind
car
and
Her
agent,
of the
experiences
agency.
see
the
sabotage
herself
she
make
seem
and
Th:
the
you
not
choice,
her
choices
roads
she
takes.
agency.
She
help
the
patient
her;
they
are
choices
becomes
have
you
want
us
effects
their
you
is benefiting
you
be
hurting
of your
difficulties,
have.
or the
impact
self-punishment
you
help
does
this
your
goal,
or is
see
how
this
me
self-punishment
think
this
you
giving
mechanism
think
you
say
this
that,
internal
punitive
mechanism
or is it getting
When
you
an
you
the
might
be
way
of
treating
does
it make
helping
you
you
or worse?
Is this
bottom
as
you?
When
the
herself
her.
depressed?
might
better
of
by
you?
Do
feel
made
her
want?
you
yourself
questions
to overcome?
Do
making
choices
you?
Is this
results
the
experience
aware
defenses
Can
self-punishment
answering
Causality
Is this
it what
By
defenses.
of
on
that
makes,
these
they
she
she
sees
Although
how
now?
the
her
see
right
What
self-punishment
you
from
consequences.
fact,
Do
you
in your
say
this
get
to
way?
to yourself,
is
that
mechanism?
Notice
how
you
are
tempted
to
give
up
on
yourself?
It sounds
like
you
already
tried
that.
What
were
how
you
punish
dirty
work,
the
results?
You
now.
Are
we
to make
to continue
a different
When
the
This
here
choice?
Patient
seemingly
things,
therapist.
We
phrase
requires
will
review
an
her
out
of the
anger
doesnt
because
know
for
incomplete
list
Th:
Whats
the
Pt:
I dont
know.
she
she
uses
is stating
feel
sure
stuck:
what
so
Its
her
can
mean
response
of
the
many
from
meanings
the
of
this
capacity.
One
feeling
toward
you
[ The
many
hard
him
money
want
from
anger
patient
defenses.
for
without
Pt:
admit
here
for
throwing
is
When
not
aware
she
says
of
she
a fact .]
Th:
stolen
we
.]
of self-observing
you
to know
knowing
in this
Whats
what
what
you
you
feel,
feel.
No
you
dont
relationship.
Example
having
father
know,
different
psychodiagnosis
Th:
you
or are
car?
know,
wonder
abusive
dont
Example
you
an
yourself
Know
which
the
had
Dont
phrase,
of
to illustrate
fathers
[ Patient
Says,
simple
each
your
see
Two
the
feeling
toward
your
lover
for
you?
I dont
because
she
know.
[ The
would
have
patient
to
face
does
not
want
to
the
need
to
leave
When
you
do
know
you.
[ The
him .]
Th:
what
you
feel,
you
will
I can
face
Pt:
appreciate
some
That
difficult
Whats
Pt:
choices.
is true.
Example
Th:
that.
the
I dont
Three
feeling
know.
toward
I feel
me?
fine
with
patient
tries
to avoid
conflict
Th:
worried
your
feelings
with
the
I sense
here
therapist
some
could
reluctance
make
things
Example
Th:
Notice
Pt:
defies
the
therapist
anything
helpful
detach,
we
Th:
What
Pt:
I dont
be
alternative,
not
able
you
we
are
fine.
detach
here
about
that?
do
[ Said
the
good
detach
with
with
me?
a smirk.
news
as
.] Its
to the
bottom
Example
Five
Notice
how
is,
much
defiance
to get
The
patient
you
as
you
dont
you
just
think
that
as
of your
detach
here
about
that?
have
to
would
long
be
as
you
difficulties.
with
me?
Yes.
Th:
What
Pt:
I dont
know
what
if you
Four
know.
the
Pt:
does
can
[ Deactivate
Th:
patient
can
Well,
it. You
wont
not
as
.]
about
to you.
here
Yes.
Th:
do
how
.]
what
would
be
can
we
do
know.
the
[ Said
healthy
Th:
Well,
the
healthy
What
is the
a puzzled
look.
alternative
is to detaching
detaching
is
if
the
The
.]
unhealthy
alternative?
Example
Th:
with
Six
feeling
toward
him
for
betraying
you?
Pt:
patient
experiences
the
patient
question,
do
carefully
based
not
goes
cognitive/perceptual
Th:
Did
Pt:
Yes.
Th:
When
[ Patient
says
Thats
she
assume
on
the
your
total
mind
a sign
does.
context.
I dont
disruption
does
she
limp .]
just
go
know.
and
goes
blank
there?
the
answer
[ The
blank
.]
of anxiety.
not
know
Assess
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,
relationship
basis
for
alliance.
defense,
you
sarcasm
disrespect,
therapeutic
establishment
contempt
contempt
In
the
the
patient
see
amount
the
not
of
price
see
time
of his
of
may
his
need
defense.
That
was
a stupid
comment.
pull
that
kind
of
Do
Th:
Do
Pt:
Yes.
Th:
Do
crap.
price
a therapist
Pt:
to
the
I cant
you
really
believe
expect
me
seriously?
you
notice
you
referred
to what
you
notice
you
also
seem
[ Point
out
facts
.]
this
wall
of contempt
I said
as
stupid?
normal
not
to take
me
seriously?
Pt:
Of
Th:
putting
up
here
with
implicitly
Do
answer
not
you
[ Ask
Pt:
patient
reveals
he
it or take
the
up
here
what
I say
crap
This
is very
this
for
wall
this
What
defense
between
. And
of contempt
therapy
do
you
and
to
put
for
us
want
its
price.
help
to do
you
it but
sees
this
problem
asks
you
are
defense
with
.]
that?
a provocative
[ The
question.
bait .]
you.
about
this
wall
of
and
me.
You
put
up
a wall
by
calling
to
look
between
Mobilize
if he
have
Theres
you
here
patient
sees
you
important
notice
the
Do
Th:
putting
it as
course.
Do
me?
to regard
So
this
his
at
you
the
will
up
a wall
what
because
as
and
there
first
wall
contempt
me,
thing
we
of contempt?
to turn
against
you
by
I say
long
will
need
as
calling
stupid
there
is
be
no
to
ask
is,
out
the
[ Point
the
are
defense
way
.]
Pt:
honesty?
[ Psychodiagnosis:
communication
invites
of
a battle
his
talking
contempt.
And
about
this
the
this
We
relationship
will
Right
long
be
doomed
to
thats
youll
what
fail,
contempt,
I will
can
this
make
failed
into
therapies.
may
be
Neither
wall
fail.
Who
pain
contempt.
And
we
You
are
news
is,
as
long
what
wall
of
We
are
up
this
wall
of
do
you
want
to
contempt
here,
useless,
can
therapy
want,
wall
life,
in the
but,
as
this
you
this
in your
continue,
want
what
maintain
person
fails.
you
thats
you
dead
relationship
Perhaps
if
as
useless
in his
eyes
suffering,
Th:
And
you
else
can
help
process
have
help
.] Its
not
and
of
you
graveyard
you
that
accompanied
to
hate
a
his
If
there
with
you
strength
of
say,
that
bad.
[ Partial
by
the
defense
it to
be
any
of
long
as
to
help
you
to each
but
to
reason
like
he
other.
remains
only
maintain
failure
Jim,
maintain
us
this
all
your
didnt
I can
the
for
better.
afford
lonely
this
want
to
man?
wall
of
to meet.
.]
(Winnicott
sadomasochistic
therapist,
no
want
doomed
who
want
be
as
to
then
would
[ Cries
be
goodbye
but
not
you
I tried
to say
suffer?
may
will
say,
everyone,
obviously
co-creates
good
I can
would
continues
his
.]
honesty.
if this
the
[ Tears
Pt:
Meet
care
be.
and
This
Then
I cant
contempt,
I dont
suffering
anyone
relationships.
it.
avoid
He
.]
I nor
of
this
honest
contempt.
putting
is:
my
to you.
of his
minimization
ask
is
of
must
are
may
For
Pt:
recognition
differentiate
about
That
another
acceptable
you
with
to fail.
another
Your
talking
Th:
have.
remain
not
to
problem
defense
therapist
there
Maybe
and
cannot
the
have
as
have
the
now,
we
As
Pt:
relationship
are
question
wall?
from
something
contempt.
you
patient
feelings
of wills,
about
Do
the
Th:
do
What?
1965).
relationship,
not
his
not
toilet
Tolerating
a
(H.
therapeutic
Eist,
contempt
one.
personal
communication).
Standing
help
him
turn
from
position
caught
the
up
against
above
this
of
in the
firm
calm
sarcasm
is
not
defense,
which
rather
anger.
than
defense,
his
free
him
defense.
until
destroys
give
destructive
patients
interventions
contempt
will
the
that
be
effective,
Otherwise,
feels
of
grief
can
speak
will
wills.
over
Expressing
but
you
you
a battle
patient
association,
faith
To
creating
relationships.
sabotages
the
be
Repeat
the
ways
contempt
sadistic
attack.
or
Block
this
therapy.
DEFIANCE
Unconscious
a
defiance
refusal
to
explore
stubbornness,
He
of
an
his
counterwill
time.
He
through
from
feelings,
tone
dismissive
stance,
not
be
of voice,
overt
laughter,
arrogance,
but
or
enacted
through
even
will
develops
traumatized.
worse
triggers
beating
anxiety,
1936)
traits
behaviors
while
if he
so
becomes
character
Imagine
defends
inhibiting
habitual
that
allow
simultaneously
being
himself.
his
and
him
child
will
The
or
using
automatic
to express
triggering
over
his
rage
punishment
others.
his
patient
fear
of
begins
the
so.
their
cannot
I dont
therapist:
do
want
You
will:
wish
that
I reveal
myself.
patient
is
defying
you . For
is not
instance,
wish
he
wish
He
wants
to
this
conflict
defense.
share.
face
the
wish
myself.
the
his
patients
with
the
to share
onto
oppose
the
they
I must
projections
feelings.
and
internally,
Fragile
Then
defies
feelings,
themselves
project
to reveal
you.
his
identify
They
to
to share
bear
They
me
my
wish
and
to share.
therapists
not
the
people
this.
want
It
with
Some
both
sometimes
defense:
therapy
doing
acknowledging
on
may
were
(Rank
defiant
Every
The
and
of a sarcastic
provocative
defiance
patients
gets
experience
his
form
Why?
defiant
beaten.
the
issues
passive,
The
behaviors.
take
key
noninvolvement.
Most
can
But
defy
he
he
your
places
forgets
his
desires
and
projects
desire,
he
defies
conflict
between
conflict
is between
Confronting
his
me.
So
only
he
will
submission
(Korff
defiance
is
experiences
Now
will
you
There
his
shows
that
His
to doing
mistakenly
at
you
a
the
so.
ask
the
want
anger
be
In fact,
resistance
angry
his
to
patient.
If you
become
personify
appears
a resistant
and
you.
that
will.
it stronger.
at
about
projection
on
explore
and
to
toward
this
same
coin:
projection
misalliance.
So
are
I can
to a projection.
defiance
to reveal
angry
and
relates
and
feelings
I am
you.
therapist
he
explore
the
onto
your
makes
you,
you.
to
wish
deepen
Defiance
my
his
toward
to
invade
will
a pushy
Trying
onto
submits
defiance
feeling
you:
or
them
1998)
defy
To
by
sides
or
Remind
his
internally,
of
submit
establish
the
the
to
your
will.
of
will
not
project
Either
way,
alliance,
projection
patient
he
the
a therapeutic
deactivating
based.
will
two
of will
his
reduce
upon
desire.
have
to
defy
which
Once
he
it
his
in
therapist.
Mobilizing
Will
and
Deactivating
Defiance:
Interventions
Since
the
the
therapist
drop.
To
the
his
patient
must
the
the
less
he
of
that?
[ Identify
defense:
projection
Defense:
defiance
the
the
therapist,
for
you.
can
his
],
has
projection
of will,
own
it upon
You
projected
will.
seem
of will
the
for
the
the
therapist
The
the
upon
more
therapist,
defiance
must
the
to
mobilize
patient
owns
therapist.
withdrawn
right
defense
.]
Pt:
You
seem
but
Im
not
so
sure
its
Only
you
can
know
for
to
think
this
is
now.
a big
worth
Do
you
problem
going
into.
.]
Th:
a problem
the
projects
Th:
notice
he
projection
awareness
the
will
deactivate
deactivate
patients
will,
defies
[ Deactivate
determine
the
projection:
if something
sure
only
is a problem
whether
the
.]
patient,
this
is
not
Pt:
about
it. [ Implicit
You
message:
I dont
Th:
can
to
be
your
you.
the
are
He
he
believed
is satisfied
time.
[ Defense:
Th:
force
so.
Projection
.]
your
suffering,
your
life,
do
something
how
not
sure
this
are.
satisfied.
to do
it
is
up
[ Deactivate
The
defenses
I want
and
about
things
of his
something
question
is
about
it at
.]
anything
.]
[ Deactivate
the
projection
that
will
him .]
[ Defense:
I feel
projection
issue,
you
right
not
do,
I have
But
if thats
you
seek,
dont
have
to explore
no
the
yet
to.
to
case,
refuse
I cant.
are
If
trying
to
you
dont
the
defiance
[ Deactivate
these
right
you
push
me
into
doing
.]
Th:
issues.
insist
If this
that
why
are
to do
Pt:
really
think
with
Okay.
Pt:
this.
do
results
not
defiance
I should
was
the
Im
think
you
with
to
is
satisfied
Pt:
this
this
Whether
you
projection.
whether
But
happiness.
Perhaps
seem
you
you
want
is not
do
so.
Why
oppose
telling
you:
That
may
be.
wife
thinks
.] You
Im
out
the
so
every
you
want
to
projection
.]
contradiction:
yourself
not
this
have
[ Deactivate
[ Point
Im
explore
something
here?
therapy.
to
?]
sure
that
this
is
a problem.
Th:
Pt:
projection
it is
of wills .]
a problem.
[ Defense:
Whos
the
one
who
came
here?
[ Deactivate
.]
Pt:
I did.
Th:
And
Pt:
Deactivate
a battle
.]
Th:
projection
My
[ Avoid
projection
My
did
wife
Th:
But
Pt:
Yes,
you
come
said
I should.
did
you
of your
come
own
free
[ Defense:
of
your
will?
projection
own
free
.]
will?
.]
but
that
doesnt
mean
I want
to
get
better.
[ Defense:
defiance
.]
Th:
better.
[ Side
with
the
Thats
resistance
Pt:
defiance
yourself
have
whether
been
living
failed
relationships
been
working
different?
now.
been
attempt
with
not
want
to
get
me
should.
[ Defense:
of
the
at denial
have
working.
to.
keep
as
optional.
[ Undo
his
defenses
you
and
with
his
therapy
devastated
Deactivate
Resistance
.]
],
Why
can
it,
you
a series
and
it
do
of
has
anything
reality
This
projection
and
his
deactivates
to do
I can
shake
hands
was
not
his
it?
[ He
when
his
Projection
do
If this
say
breaks
by
to
our
Mirroring
do
its
you
something,
and
is
you
know
as
completely
want
patient
want
you
to
and
when
you
goodbyes,
life
dont
the
something
you
to do,
will
go
.]
in tears
and
him .]
the
your
you
obviously,
you;
last
.]
to do,
.] You
between
defiance
down
left
you,
for
is not
the
wife
for
feeling
want
resistance
is
down.
say,
something
pretend
[ Deactivate
Pt:
you
is working
conflict
and
you
Like
the
it is working!
to the
necessary
the
we
want
.]
[ Mirror
so
you:
breaks
something
.] Why
should
blessing.
resistance
is not
works.
is
.] I tell
a breakthrough
.] If this
dont
he
with
[ Reflect
eyes
defiance
defiance
.] Why
the
If this
denial
that
my
denial
you
face
reality
resistance.
in his
to prevent
what
the
change?
lets
man
[ reflect
why
Only
And
depressed
his
as
[ Deactivate
[ Deactivate
do?
better.
[ Mirror
[ Tears
doing
I do
in agreement.
get
the
feeling
tries
[ Reflect
should
were
.]
Th:
forth
tell
years
working,
side
further
glad
fifty-three
until
then
Breakthrough
you
cant
of a lonely,
Pt:
know
You
should
life
for
up
and
projection
well
may
.]
Im
you
this
If its
denial,
dont
You
.]
Th:
tell
right.
Patients
describes
how
When
the
patient
resistance,
his
expecting
resistance,
resistance
cannot
to
his
mirror
the
an
upon
onto
you,
to argue
with
his
not
the
argument
get
Without
that
will
conflict
decrease.
to
conflict
conflict
intrapsychic
resistance
the
will
interpersonal
defiance
the
does
him).
have
his
you
he
experiences
and
projects
the
he
mirror
him,
he
a result,
he
feelings
examples
will
show
of
the
his
(your
and
As
his
projection
you
expects
you
and
with
When
defense).
following
deactivate
identified
between
instead,
The
is
position.
(the
rise,
how
to
patients
will
is something
you
to continue
this
you
have
carrying
therapist.
I dont
want
he
to explore.
Perhaps
there
can.
After
all,
if there
isnt.
If
certainly
know
it is your
you
want
life.
You
depression
for
forty
years.
way,
Why
change
If
been
this
now?
this
is
working
for
you,
good
for
you.
You
this,
but
then
we
have
to ask,
Why
have
are
every
you
can
be
yours.
Its
really
up
If
do,
we
wont.
but
then
I have
I wont
Deactivate
When
out
defense
conflict
defense.
following
able
right
patient
reality
to
is
he
denies.
ward
not
This
off
his
between
leads
examples
show
suffering
this
is not
any
Mirroring
having
is
yours,
something
aspect
the
a problem,
Then
your
you
of your
at
and
want
inner
Instead,
you
him,
and
of feelings
how
to
Patients
he
to
life,
and
mirror
you
conflict
mirror
but
Denial
expects
interpersonal
feelings.
to a rise
look
you.
by
denies
to
to you.
to explore
to help
Projection
the
the
be
no
not
here?
Your
happiness
right
his
between
a drop
the
serves
denial.
him
in his
patients
to
point
as
Then
and
denial.
denial
his
The
to
deactivate
the
projection
of
his
healthy
awareness
upon
the
therapist.
This
may
You
not
may
be
be
a problem
getting
for
the
you.
results
you
want.
Your
satisfying
for
you.
Only
you
can
marriage,
know
for
There
wait
as
long
symptoms
as
as
you
think
they
it would
wants
decide
your
continue
to
together
Use
Make
Always
to
do
mobilize
his
his
have
superego.
either
The
defies
deactivate
the
speech
anxiety
and
to
rush.
comfortable
patient
has
as
Defiance
can
submits
to
projection
feelings.
this
an
be
You
can
with
your
deactivate
him
that
his
of the
defense
is
cannot
go
the
from
secretly
imagined
to
work
forward
Aha.
he
from
to
projections.
Interpretation
whom
right
defiance,
task
projection:
result
you
his
our
we
his
and
You
unwittingly
must
defy.
projection
of
projection
criticize
him;
criticisms.
say
In
of
the
the
then
this
he
case,
superego.
SPEECH
the
Her
his
invader
and
deactivate
me.
also
your
will,
a problem
will
you
resulting
imagines
free
to
control
defiance
prevents
Block
need
be
his
Without
on
RAPID
Rapid
the
Remind
to
of you
patient
or
DISCHARGE:
dialogue.
view
will.
sure
it reinforces
want
focused
patients
may
Once
will.
because
you
strengthens
may
helpful.
interventions
fails
because
is no
emphasize
goals.
noninterpretive
this
work
sure.
You
therapy.
his
to achieve
Interpretation
We
help.
whether
and
are.
Principle:
he
be
life,
patient
pressured
immediately
from
paying
speech
and
attention
also
prevents
then
help
her
to
her
genuine
observe,
pay
attention
speech,
you
ignore
her
.] Do
these
you
and
[ Speak
are
talking
so
we
you
your
body
her
feelings
to
session
.]
Im
now?
anxiety
head
see
to
her
Thats
often
Im
what
going
is
for
of
patient
to
going
you
down
a sign
invite
on
moment,
her
defense
of
that
you
to
underneath
what
do
attention
rapid
to,
speech,
Ive
you
and
feeling
toe.
Do
you
And
notice
to
that?
her
will
over
to get
hear
you
in
attention
speech.
the
to
The
in
the
defense
out.
it all.
[ Draw
.]
anxiety
become
[ now
got
speech
how
this
of rapid
all
I need
I want
notice
direct
she
Ive
rapid
experience
defense
tense
stuff
and
down,
her
really
all this
you
do
dysregulated
Just
because
and
down
patient
block
more
got
slow
How
the
anxious,
of rumination
Lets
and
the
really
defenses
Th:
tense
the
[ Mobilize
feeling
[ Slow
anxiety,
races,
], but
see
inside.
Pt:
enters
can
block
her
anxiety
and
she
rapid
rise.
right
longer
her
both
to slow
now?
anxiety.
now?
Th:
this
to
.]
[ Interrupt
experience
listening
wherein
slowly
anything
right
Pt:
to tell
very
and
saying
slowly
will
By
relationship
rapidly
feelings
now
anxiety
speak
anxiety
Th:
inside
her
anxiety.
anxiety.
Without
feeling
regulate,
As
over
words.
notice
and
right
her
a dismissive
you
talking
down
regulate
co-create
notice
are
slow
and
feelings
you
you
to,
I notice
attention
you
back
are
to
her
to
her
.]
Continue
to
slow
the
patient
down
and
draw
her
attention
anxiety.
DISCHARGE:
Patients
hearing
feeling.
LOUD
talk
loudly
impairment)
in
to
SPEECH
the
get
AND
session
rid
of
(assuming
the
internal
YELLING
they
do
experience
not
have
of
a
their
Psychodiagnosis:
attention
to
projecting
feelings,
the
criticisms.
Vignette
One:
the
onto
you.
Blocking
following
example,
defense
of
loud
see
let
go
and
or
superego
imagined
In
anxiety,
of the
defense
he
so
to
or
pay
may
be
yell
over
your
his
regressive
Defense
the
he
patient
tries
does
how
observe
The
Thus,
patient
Notice
to
defenses.
Regressive
the
speech.
Inability
not
see
therapist
can
begin
helps
to face
the
his
patient
underlying
feelings.
Th:
talking
but
quite
any
for
our
now,
are
so
that
you
therapy.
Im
going
can
feeling
Monitor
the
next
defense
inside,
patient
anxiety
rises
second.
Rapidly
can
bear
rise
of the
feels
described
to
me
this
for
the
in
other
talking
to
what
you
are
feeling
if you
dont
you
block
attention
going
more
next
to
you
history
woman.
to
this
build
capacity.
her
loss
of his
where
his
made
Pt:
Yes,
we
girlfriend
other
girl.
recent
you
were
was
So
soon
take
she
as
only
anxiety
relationships
girlfriend
She
My
failed
so
bears
angry,
him
you
at a concert,
drunk
He
them.
made
I started
has
girlfriend.
sabotages
Th:
regressive
as
longer
In
a
she
this
Dystonic
most
and
loudness?
may
and
What
defense.
and
feeling
The
of
all this
. This
right
body.
intervene
defense.
Discharge
relationships
example
defense
feeling,
slowly
a regressive
defense,
are
unavailable
your
rises,
to her
be
and
with
you
some
will
inside
it out
but
of
quietly
anxiety
the
rid
mouth
block
rises,
the
her
you
noticed,
get
talk
drown
when
feeling
the
with
following
an
you
to
Making
man
rage
ask
without
Two:
young
therapy
draw
to
your
before
feeling,
Vignette
A
and
out
if you
of
After
them
a way
closely
the
appears.
usually
blow
notice
second
know
Thats
feeling
you
you
the
loudly.
I dont
and
yelling
entered
repeatedly
He
has
just
angry.
say.
and
I was
started
at
her.
talking
yelling
[ Defense
at
of discharge
.]
Th:
felt
angry
toward
her
She
[ feeling
Pt:
got
home
I hit
her
yelled
]. So
I yelled
back.
at you
how
[ stimulus
did
back
you
at her.
[ Defense:
]. Naturally,
handle
She
discharge
your
hit
me,
.] Then
you
anger?
so
she
when
we
decided
to
leave.
assert
yourself
Differentiate
and
the
Th:
You
set
feeling
[ Defense:
projection
you
yelled
rather
limit
.]
Im
just
at
than
with
her
feel
her.
Im
saying
you
and
see
differentiate
his
feeling
channel
killed
it in a healthy
off
invited
the
her
love
to
she
punish
you
wanted
her
to
you
yell
at
and
hit
you.
Do
you
see
what
and
presenting
another
defense,
problem
relationship?
he
instead.
of discharge
to
have
do
feel
.]
yelled
anything.
your
anger
out
it adaptively
feel
is
at
anger
inside,
your
mouth,
of
by
[ Block
setting
clear
you
than
Im
for
just
you
anger!
feel
yelled.
toward
you
my
[ He
cannot
.]
Rather
her,
girlfriend,
By
you.
being
saying
invite
your
yelling
By
thats
to
and
at her,
you
her,
you
hitting
angry.
her
anger
Im
the
not
saying
effect.
When
punish
and
reject
I mean?
Pt:
rage
with
you.
you
yelling
all!
reject
reject
her
than
.]
the
defense
at
could
and
the
his
way
at
rather
I mean?
But
Not
but
I shouldnt
than
blew
her,
defense
telling
channel
from
Th:
the
rather
what
Pt:
yelled
saying
not
You
it inside
you
conscience
that
instead.
Do
you
of his
Th:
with
from
Are
projection
angry
limit,
of anger
Pt:
her?
felt
But
she
deserved
does
not
see
Th:
But
then
it. [ In the
causality:
his
blindness
defense
causes
of
his
his
.]
Who
Pt:
Th:
gets
who
depressed
gets
rejected?
Who
loses
again?
I do.
When
you
handle
your
anger
by
yelling
and
hitting,
and
you
end
hitting
up
might
lonely.
be
Do
hurting
Pt:
have
an
This
I see
anger
them.
The
hitting
invite
mean?
problem
her
to
how
reminding
him
[ Defense:
price
rage
girlfriend,
leaving
what
but
this
until
series
I mean?
destroying
time
of
[ Point
his
oppose
and
too
you
deeply
as
driving
this
[ The
So
defy
the
therapist
explode,
and
antitherapeutic
to
women
argue
conflict
for
between
already
high,
and
then
you
see
Or,
if we
so
we
if
you
choice
his
Maybe
of my
longings.
longings
do
defense
do?
Just
I
by
your
blows
up,
you
see
Do
to
it
stuff
with
you.
leads
stuff
You
relationship
feelings
so
discharge,
to
do?
[ He
invites
that
he,
the
patient,
is,
you
dont
have
news
.] If you
the
healthy
the
explode
I supposed
good
task
rest
what
can
.]
path
], but
at
and
see
doing.
behind
of
to
this
the
another
am
continue
for
his
are
The
Pt:
avoid
you
what
self-punishment
.]
to
what
what
defiance
task
yells
Yelling
you
from
you
.]
him
therapeutic
Do
.]
denial
and
angry.
the
think
anger.
therapist
explode,
how
tell
possible
the
out
to
[ Deactivate
I dont
your
I supposed
relationships
Th:
anything.
yelling
destroyed
if a girlfriend
anger
wrecked
relationships
therapist
her
but
anger
being
am
Thats
Pt:
the
hitting
with
of
onto
it gets
each
feel
for
What
projection
inside
of
.]
Th:
the
mechanisms
surprise,
deal
feeling
Pt:
inside?
and
will
you
the
of the
her
a
you
punish
[ Differentiate
mean.
like
Anyone
is
you
at
seem
problem.
these
what
Yelling
may
think
you?
Th:
relationship.
you
and
want,
we
can
get
can
bring
want,
of
to
can
the
your
you
destroyed
do
face
this
rage
as
bottom
of
what
is
suffering
can
to
stuff
to an
your
end.
anger,
relationships
[ the
is yours.
I should
life.
[ The
This
his
stop
this
patient
way
resistance
he
therapy
invites
could
.]
the
avoid
and
just
therapist
an
inner
Th:
that
says
avoiding
of
have
women
your
you
you
and
days,
should
to
how
[ Mirror
cruel
internal
conflict,
the
his
he
repeating
rest
of
making
life
fun
and
of yourself.
Right?
lonely
deactivate
the
I want
man.
way
to deal
with
Patients
of
access
but
I be
of
to the
that
If
end
is
what
want
lonely
[ He
than
begins
to
tolerate
his
.]
making
You
me?
rather
therapist
man.
the
have
you
I know
[ Turns
fun
of you
when
to avoid
women
I assume
you
projection
right
agree?
I have
against
feelings
impulsively
than
the
prevents
.]
am
for
the
are
not
.]
to
avoid
women
his
resistance
[ Mirror
and
to
the
so
that
right,
but
resistance
I dont
thats
.] I have
keep
being
not
really
to find
some
rejected.
CURSING
who
rather
law
.]
these
DISCHARGE:
the
You
Would
projection
to do.
no
Right.
Pt:
what
man
obviously
fun
[ Deactivate
Th:
a
is,
said?
remain
you,
is
defiance
a lonely
making
can
have
Pt:
remain
you
onto
There
.]
resistance
you
option.
[ Deactivate
for
resistance
How
an
remaining
option
projects
what
your
therapy.
in
Are
Th:
only
be
healthiest
Pt:
realize
always
relationships,
is the
do.
Thats
experience
avoided
the
act
out
any
feeling
development
their
rise
and
rage
in
build
of affect
frequently
feeling.
curse
Block
this
self-observing
to get
rid
defense
capacity.
to
Cursing
tolerance.
Intervention
The
to
He
following
his
cursing.
simply
making
intervention
Notice
draws
feelings
shows
how
the
patients
unavailable
Th:
words?
It doesnt
the
bother
me
to
therapist
attention
for
Do
how
the
you
draw
the
patients
does
not
judge
to
the
attention
the
defenses
patient.
function:
therapy.
notice
personally.
you
Its
are
just
using
that
some
cursing
curse
makes
some
feelings
refrain
unavailable
from
Does
that
cursing
make
with
as
as
They
can
anxiety.
our
so
low
talk
However,
might
say
does
not
work,
assess
you,
and
then
this
chapter,
may
you
with
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.
Does
finish
speaking,
If the
patient
the
next
Thats
from
that
so
says
What
that?
Once
she
Some
anxiety
If this
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.
Would
therapist
want
in
right
you
say
causality:
to collaborate
that?
does
from
be
you
the
prevent
the
any
notice
to
it
how
without
you
would
But
Notice
sense?
unless
Ask,
Do
the
make
second,
me.
going
forming
away.
with
Do
this
said.
attention
Th:
you
Clearly,
over
not
criticizing
work,
her.
In
be
talking
she
is
over
you
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
Its
like
eyes
are
I went
blank,
up
on
the
and
his
body
ceiling.
is
[ The
limpno
Th:
How
Pt:
concentrate,
but
its
not
Its
blurry?
[ Assess
Its
getting
the
fuzzy,
better
your
[ Encourage
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
.] How
into
striated
Its
This
feeling
triggered
triangle
There
.] 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
[ Assess
some
Then
your
see
the
feeling
mind
know
was
the
[ Inviting
the
have
been
cognitive/perceptual
so,
stop
exploring
of
muscles.
conflict
Then
level
in
is fine.
[ Anxiety
disruption
toward
your
conked
why
it did
feeling
feeling
into
triangle
vision
out.
is
father.
[ Outline
that?
I dont
I must
the
cognitive/perceptual
was
What
anxious?
Pt:
you
Yeah,
Th:
you
now,
and
anxiety.
of conflict
made
fine
muscles,
Th:
his
really
.]
now
that
trying
in your
pattern
blurry,
anxiety
Im
ringing
ringing
patient
Pt:
the
any
[ Anxiety
As
now?
[ Cognitive/perceptual
No
now.
vision
thinking.
fuzzy.
discharge
Th:
was
a little
Is there
Pt:
blurry.
thinking
working.
Th:
vision
is your
toward
your
father
.]
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
The
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:
How
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
Th:
Do
Go
ahead.
told
you
mind
he
if
Is that
I offer
you
he
could
true?
different
perspective?
Pt:
Th:
in your
anus.
He
you
chose
And
to say
Pt:
But
Th:
saying
yes
whether
put
his
fist
Yes.
Th:
but
you
Right?
Pt:
or no,
asked
to him,
she
Pt:
said
Oh.
at
that
point,
you
could
have
said
yes
yes.
he
So
no
didnt
you
want
said
to herself
me
no
.]
to
to say
yourself
no.
instead.
[ By
Th:
your
anus.
him
he
In
effect,
could
him
for
your
blame
him
for
that
punished
you
[ correct
blame
You
put
choice.
she
You
when
fist
he
the
way
by
inviting
think
If we
dealt
him
asked
to put
Th:
But
Pt:
I was
Th:
You
with
were
defense
She
it on
inviting
him
for
fist
you
told
then
you
and
you
how
she
you
feel
to yourself,
than
what
face
in
I mean?
way.
way,
in your
what
did
anus?
like
the
idea.
[ Defense:
was
your
feeling
toward
him?
angry
anger
was
with
to
him.
Then
we
the
anger
on
turn
see
that
yourself
forgotten
that
I had
been
with
him,
angry
with
.]
Right.
You
by
to punish
And
felt
angry
inviting
you
then
for
later
[ Increased
him
to hurt
being
angry
I invited
insight
you.
your
It was
with
him.
to
criticize
him
into
forgot
self-punishment
as
the
as
.]
sees
punishes
her
conflict
no
herself.
understand
table
Table
it that
], but
fist
angry.
yourself
dinner.
self-punishment,
see
see
didnt
were
of repression
turned
I made
I had
Pt:
food
you
his
you.
Th:
if you
herself
no
put
because
rather
of
his
what
your
to hurt
[ Evidence
and
anus
of it that
think
could
.]
you
anger,
your
to say
him .] Do
I didnt
Pt:
him.
He
punished
chose
Pt:
intellectualization
in
yes.
[ Externalization:
Th:
him
him
she
blamed
Pt:
toward
his
causality:
choice.
herself,
told
9.1
the
of
longer
Now
process
she
of
anger,
anxiety,
blaming
has
her
an
unconscious
and
husband
intrapsychic
the
for
Step
one
Stimulus
Step
two
Feeling
causality
Husband
causality
in
Anger
in externalization
asked
to insert
the
focus.
9.1 .
Unconscious
defense
his
fist
of
ways
To
she
better
externalization,
Step
three
Anxiety
Striated
Step
four
Defense
five
Externalization
muscles
Punish
herself
by
saying
yes
and
abusing
herself
Step
Blaming
him
for
her
choice
to punish
herself
We
cannot
anger
explore
anger
is at a projection:
defense
her
of externalization
Then
help
explore
her
face
rage
been
her
his
patient
tired
out.
The
the
at him
defenses
as
an
see
at
first
because
abuser.
how
for
asking
of
blaming
First,
she
her
undo
punished
to insert
of the
up
quite
having
because
to
the
herself.
his
fist.
or
complaining
in
Externalization
Never
have
She
Pt:
you
that
she
broke
your
my
projection.
fantasy.
You
effect,
with
your
story
was
lying
the
story
sense
ignored
affair
do
you
weeks,
another
up
and
up
had
with
you
For
the
man.
had
Now
the
relationship.
arguments,
his
he
so
anger
She
she
moved
toward
her
for
mind
you
than
her
you.
Is that
mean?
Of
if I offer
have
true?
course,
another
You
thought
being
you
and
has
you
all
to
itself,
thought
been
to
you
broken
to
you
listen
words;
already
fantasy.
with
its
true.
me.
weeks,
that
Rather
you
with
broken
broke
some
point
of view?
Okay.
Th:
its
had
about
up
Do
Pt:
Yet
affair
talk
What
Th:
affair.
For
relationship.
Th:
told
an
distrust,
wanted
the
agitated.
she
accusations,
patient
breaking
of
angry
Projection
office
girlfriend
was
had
Now
husband
can
Deactivating
enters
accused
In
she
rage
the
her
husband
so
before
Two:
patient
just
at
restructured.
Vignette
A
her
her,
paid
up
with
she
she
was
having
an
affair
with
listened
to
your
you
attention
her
was
to
and
lying
unfaithful
to
because
you
your
were
to
your
chose
having
an
fantasy.
having
you,
best
but
an
your
interests.
it instead
of
her.
Do
you
Fearing
the
defense
of
distance
see
projection
from
he
with
is having
to emotional
but
at
blamed
her
for
striated
muscles.
To
defense
of
see
projection
ward
projection
his
defense
His
closeness).
and
the
girlfriend
the
having
an
it
of externalization
the
(She,
not
he
triggered
his
a feeling
anxiety
in
he
used
he
did
his
the
not
relationship,
relationship.
my
the
from
Since
his
to
had
anxiety,
damaged
damaging
damaging
that
affair).
the
him
resulting
was
and
used
allowed
of
distress
feeling
he
This
price
feeling
ways
was
affair).
conflict
his
are
girlfriend,
the
This
off
(You
his
an
her
(externalization).
(related
the
(She
Then
assumed
closeness
projection
himself
his
I mean?
emotional
relationship.
own
what
So
projection,
he
he
used
damages
our
relationship).
Therapists
who
mistakes.
They
examining
how
rage
toward
Therapists
he
his
he
he
he
feelings,
can
let
and
make
they
we
uses
patients
are
take
the
less
suffering.
with
go
to
a
patients
of
the
defenses
defense,
adaptive
abilities
the
the
than
explore
the
patients
his
victim
stance.
that
is,
When
punishes
stand
against
for
capable
at
stand
else
AND
a look
take
he
helping
the
his
self-abuse.
self-punishment
choice
own
his
to
the
patient
himself.
against
his
several
without
others.
how
of
victim
solving,
anxiety,
new
lack
see
reinforcing
cruel
one
as
They
problem
not
make
patient
(anger,
HELPLESSNESS
Some
by
take
conflict
the
thereby
needs
than
someone
Then
his
err
does
thinks
internal
blaming
creates
also
rather
his
externalization
with
himself
externalizes,
abusers
see
victimizers,
assert
mistakenly
not
empathize
can
patient
see
do
punish
responsibility,
He
so-called
Help
him
followed
by
himself).
face
his
choices.
PASSIVITY
we
they
feeling
of helplessness
have
to develop.
really
toward
are.
your
and
The
Others
present
as
therapist
asks,
Can
patient
who
father?
passivity
The
responds:
if
I cant.
Im
not
I
feelings.
Do
you
have
a list
of feelings
resistance.
would
[ If I act
you
give
attention,
the
reader
One:
pointing
help
out
not
the
help
the
Point
you
out
make
up
the
motivation
impossible.
depending
from
what
when
the
pathological
the
the
on
patient
patient
cannot
asks
the
withholds.
Reality
use
the
defense
of
that
of helplessness
defense.
by
Helplessness
Im
not
sure
I have
may
be,
the
motivation
for
this.
That
help
you
Pt:
Isnt
get
to
the
but
if
you
bottom
of
dont
your
have
the
difficulties.
.]
for
to accept
mountain.
engagement,
alliance
healthy
consequences
what
I refuse
Th:
have
(will,
relationship,
.]
cant
reality
transference
to this
merely
offers
who
Th:
we
patient.
helplessness
motivation,
I feel?
or
you?
patient
Out
Pt:
Defense:
the
patient
patients
reality
think
something
occurs
Pointing
some
by
you.
therapeutic
therapist
the
mean
at?
defenses
differentiate
the
what
you
you
defenses.
Isnt
must
tell
from
dependency
Vignette
can
I withhold
these
Pathological
be
makes
ask,
do
energy.
what
look
I could
of giving
what
This
Ideally,
to give
does
.]
We
therapist
We
me
may
dependency.
can
incapable
deactivate
therapist?
give.
to
thought)
Therefore,
But,
helplessness
the
know
I could
What
and
I have
dont
I wish
Passivity
sure
that
We
to the
you
will
top
to give
If
you
dont
have
of the
there
you
to this
relationship?
dont
have
to
something
part
mountain.
what
ways,
have
the
we
need
while
[ Point
out
can
do?
[ Could
motivation,
to get
I take
reality
to the
those
.]
we
with
top
will
of
the
Vignette
Two:
Some
Deactivating
patients
onto
the
adopt
therapist.
deactivate
the
Projection
a helpless
In
these
stance
cases,
Whats
the
Pt:
us
what
you
what
what
stance
feel,
can
What
Pt:
What?
Th:
What
we
we
he
Th:
wont
do
helplessness
wants
to project
Only
you
position
[ Block
can
do
what
projection
feeling
unconscious
about
the
could
tell
point
out
toward
and
her?
you.
that?
can
we
do
about
that?
to help
[ Block
[ Defense:
you.
this
you
tell
onto
I nor
[ Block
If you
[ Price
by
defense
what
the
therapist
the
else
tell
defense
asking
I feel?
him
[ Defense:
.]
can
projection
if I cant
tell
.]
me
anyone
cant
of his
helplessness
regarding
what
dont
be
youll
You
know
able
I feel?
Then
.]
Arent
tell
you
what
.]
what
I feel?
No.
a real
me
to
[ Defense:
you
are
you
with
it. [ Price
Only
feeling
supposed
responsibility
you
problem
help
what
you
[ Project
have
want
to help
to
on
your
you
with
your
right
now,
then
of his
stance
be
able
to
what
you
feel.
.]
help
me
.]
can
feel
[ Block
.]
Pt:
of
about
that.
But
Th:
the
capacity
.]
if you
I wont
out
have
do
Neither
Pt:
figure
you
we
responsibility
projection
but
obviously
must
can
that?
Th:
feelings,
wish
Couldnt
Pt:
hands.
feeling
able
to take
Th:
helpless
be
about
Pt:
feel.
therapist
their
.]
.] So
you
the
projecting
projection.
Th:
helplessness
by
and
anxiety.
feeling,
feeling
[ Fidgets
When
and
anxiety
and
the
shifts
patient
rise.
in his
lets
After
this
chair
go
rise
of
of
. Sign
his
of
rise
defense,
anxiety,
ask
.]
Th:
What
do
you
notice
feeling
in
your
body
right
now?
Pt:
Uncomfortable.
Th:
Where
Pt:
Just
Th:
the
anxiety
.]
Whats
do
you
tension
Tension
the
[ Anxiety
feeling
notice
in my
.]
that
in your
back.
in your
back.
toward
me
body?
[ Striated
Thats
thats
muscles
anxiety.
.]
[ Label
triggering
all
this
anxiety?
Some
patients
capacity,
adopt
which
remind
the
they
patient
helpless
have
position
demonstrated
I cant
do
Th:
patient
Are
].
that
Together
you
worth
Separate
agency.
He
incapable
goals
the
the
him
further
this
way?
the
we
can
do
from
to
a stand
take
patient
Vignette
the
who
previously.
In
not
Youve
actual
those
cases,
it.
Thats
these
this,
his
that
takes
his
true.
feelings
if
youll
[ list
give
already
examples
yourself
do
this
crippled
against
Three:
could
ask,
for
a
the
for
the
chance.
Contrast
them.
out
himself
To
his
into
his
perpetuate
an
healthy
differentiate
your
suffering
?
out
that
patientnot
defense
magic
pointing
makes
defeat
Why
pointing
The
he
position.
to yourself
therapist.
by
is helpless;
that
by
waits
helplessness
he
defense,
projections
not
their
effort?
helplessness
Why
patient,
The
face
he
from
Deactivate
can
himself
man;
with
you
patient
tells
denying
of reality.
Pt:
demonstrated
by
or
waits
Hopelessness
the
the
live
defenses
hurt
the
therapistwill
with
the
have
consequences.
forever.
When
Denial
Breaks
Down
Sometimes
hopelessness
However,
hopelessness
a patient
realizes
as
her
fantasy.
is
can
also
it is hopeless
The
hopelessness
way
be
to
to
a sign
expect
of
her
take
helpless
of progress.
the
fantasy
world
For
to
emerges
be
stance.
instance,
the
when
same
her
denial
of reality
breaks
down.
Pt:
I will
just
be
I think
as
well
as
I do
to
get
or
impossible
reality
I think
that
hold
it is progress;
since
a job
me
to look
for
a job.
you
as
are
an
you
not
can
fluent
executive
see
that.
You
in
English,
secretary.
it
is
[ Point
out
.]
Pt:
Cries
But
then
I will
not
be
able
to
buy
a house!
not
be
able
out
that
.]
Th:
house
if you
based
on
apply
denial
for
get
tears
(looking
a job
signal
for
in reality,
that
her
position.
how
to
And
hard
get
how
it is to let
you
cant
jobs
she
I cannot
but
not
her
That
hold.
you
hard
that
is!
go
of that
without
leads
a job.
one
she
true.
wanted
wanted,
This
can
an
fantasy
was
behavior
.]
denial.
get
a job,
executive
so
picture
you
had
very
beautiful
it for
She
Her
but
it
is
secretary
beautiful.
And
in your
mind.
picture.
reality
.]
was
substituting
buy
in fantasy.
down
You
to
to defeat
[ Defense:
is breaking
beautiful
It
[ Point
get)
get
is not
job
will
wont
the
the
fantasy
You
in fantasy
Pt:
observes
is true.
But
denial
Th:
impossible
That
jobs
Pt:
can
for
rejected.
Th:
know
it is hopeless
[ She
.]
Projection
Projection
feeling,
is
impulse,
other
people
imagine
the
or
becomes
other
person
with
example
defenses.
awareness
of feeling,
a functioning
which
the
we
belonging
distorted.
imaginary
a
key
triangle
anxiety
of
to
someone
to
ourselves.
Rather
than
face
our
with
Then
we
become
us.
anger
we
distinction
Repressive
so
attribute
wish
is angry
illustrates
regressive
with
by
quality,
or preoccupied
This
defense
conflict:
on
between
defenses
drops.
place
We
feeling
effectively
associate
evokes
Our
else
view
of
anger,
we
afraid
of
him.
repressive
reduce
these
anxiety,
and
our
defenses
which
triggers
defenses
Regressive
more
projected.
His
(projected
onto)
do
supposedly
others.
This
fear,
adding
projective
by
Restructure
projection
between
9.2
I have
I am
projection.
Goal
that
of
you
on.
versus
has
it
in
therapist,
Thus,
projective
he
he
fears
anxiety
to
(H.
defenses
They
more
regulate
projective
anxiety
who
projects
like
create
triggers
cannot
focus
afraid
of you.
They
trigger
I fear
you.
anxiety
the
projection,
projection
and
anxiety
that
is
as
my
you
and
my
projection.
project
them.
occurred
the
But
in
the
see
difference
table
for
other
9.2 .
therapy
focus
So
problem
is outside
I use
the
is how
image
past
is you.
projection.
I need
Then
and
it is too
the
an
believes
focus
problem
problem
between
anxious
establish
me:
its
Defense
you.
of
I deal
with
must
prove
the
me.
projection.
to get
internal
My
and
understand
focus,
Internal
My
the
same
To
anxiety.
inside
are
not
an
my
already
the
him.
which
externalizing
not
traumatize
with
call
problems.
and
I think
who
with
anxiety.
patient
you,
Patients
sees
Regressive
the
and
therapy
have
we
We
examine
wont
he
leads
anxiety
Then
and
of awareness;
anxiety,
to undo
Externalizing
feelings.
feelings
so
Externalizing
Causality
projects
he
is angry
triggers
intrapsychic
Projection
who
projection.
his
an
patient
anxiety.
whom
free-floating
perspective.
cause
and
upon
if angry
20022004).
and
perpetuated
The
person
out
anxietywhich
anxiety,
intrapsychic
the
projection,
feeling
projective
way.
instance,
continual
loop:
of
therapist
by
trigger
feedback
Table
For
supervision
projection
this
of feeling
therapist.
created
Davanloo,
work
aware
repressed
the
angry
less
afraid
is not
believes
the
us
not
anxious,
anger
and
people
make
defenses
becomes
projects
that
of an
late.
We
to see
I can
project
You
are
the
face
my
here
to me
to
difference
feeling,
so
instead.
aggressor
The
(Winnicott
trauma
fear
they
1965).
the
therapist
fear
in the
Their
will
future
projections
chronically
distort
Denial
involves
seeing
what
within
reality
not
is not
ourselves.
inside
seeing
there
We
and
outside
what
is
in
in someone
project
that
the
myself.
else.
of
deny
onto
anger
session.
Projection
We
element
Denial
therapy
involves
something
exists
others.
through
negation:
Im
not
angry.
Projection
of anger:
Splitting:
me.
Good
When
feelings
the
are
and
the
you
through
you
becomes
suspicious
left
upon
the
Projection
who
projection
and
impulses
attributes
someone
else
Although
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
(H.
a projection
before
S.
335).
Thus,
content
and
of
Assess
of
the
(Bateman
the
Davanloo,
pathway
supervision
Projection
function
of
analyzing
the
1923/1961c;
20022004).
Function
we
capacity
Freud
thinking
1981);
to
occurs
self-observing
Segal
the
1940,
1985).
projection;
symbolic
same
projection
(Willick
1936;
[ hoping
projection,
defense,
Freud
you
her
tendencies
them
patients
she
to
degrees.
unconscious
primitive
more
].
classical
possesses
her
and
recognizes
In
psychoneurosis
function
Fonagy
to varying
but
you,
react
office
believes
of
can
therapists
you
not
projection,
in the
herself.
her
or leaving
unacceptable
considered
spectrum
of
criticizing,
onto
are
of
from,
within
her
assess
projection
Ten
projects
anger
distorted
She
of reality
at me.
instead
filter
hypervigilant.
behind
like
becomes
the
angry
1953b).
projection
therapy
hiding
are
feelings
Sullivan
her
perceptions
generalizes
patient
by
S.
to
and
you
distorts
feelings
(H.
of
Viewing
she
me
relates
negative.
projection
Negative
patient
experience
You
and
interpreting
and
of
its
content.
Projection
discharged
in the
functions
striated
you
Defense:
projection
the
In
regressive,
me
to help
In
contrast,
allows
such
you
.] My
internal
wife
you
would
says
I am
to
remain
patient
functions
like
me
to
a control
freak.
uninvolved
as
in
a tactical,
not
my
avoid
the
conflict
his
The
Pathway
The
interventions
functions
of
capacity.
When
within
Unconscious
for
anxiety
here,
I cant
problem
you
relocation
anxiety
your
is
eyes
inviting
barrier,
also
help
her.
would
like
strategy
for
discharged
in
that
you
hate
me
projection
causes
a loss
the
therapist
(Cornelissen
his
Anxiety
the
therapist
to
anger
toward
his
feeling.
in
There
feeling
and
the
is
to the
that
muscles,
barrier
toward
from
For
testing,
the
from
the
and
some
to
again.
If
disruption.
projection,
head
block
toe
you
me?
restructure
instance,
patients
self-observing
striated
cognitive/perceptual
reality
tension
according
discharge
is the
from
Discharge
vary
channeled
2005).
with
between
anxiety
of
onto
of it.
what
result
superego
projections
is
can
present
from
patient
of
Projection
differentiate
the
judgment
that
see
the
inner
by
up
the
when
I can
unconscious
projection
is
as
relocates
used
pathway
what
is not
mother.
projection
put
.] So
wife
disruption.
the
and
your
experiences
Here,
mother
Since
projection
visiting
projection
is
with?
Pt:
anxiety
problem
projection
defense
cognitive/perceptual
dont
is the
the
a case,
tactical
frightening
the
anxiety
defense.
the
not
What
[ Sighs
Th:
for
when
.]
projection
treatment.
[ Block
tactic
with?
Pt:
Here,
a distancing
muscles.
Th:
help
as
projection,
then
patients
but
When
with
regulate
who
no
use
sighing
or
hand
clenching,
This
is
with
her
then
and
a freeze
reaction
projection.
explore
The
following
therapist
Point
the
the
projection
As
how
projection.
the
absolutely
projection
the
regulate
anxiety,
the
patient
of
therapist
and
experiences
projection
can
have
the
patient
exploration
of
differentiate
other
the
issues
will
be
is deactivated.
Pt:
Im
Th:
Are
projection
must
patients
afraid
you
you
seeing
causing
Yes,
not
assumption
in the
but
up
want
to
hurt
me.
as
an
abuser
reaction
.]
projection
me
freeze
maybe
you
think
to me.
(projection)
[ Defense:
will
I am
hurt
the
me!
a potential
[ Clarify
again?
abuser,
you
consequences
of
the
.]
[ Rise
of anxiety
What
do
in the
patient
in response
to
.]
Th:
Pt:
Defense:
the
If you
open
Pt:
you
I dont
intellectualization.
This
notice
think
feeling
you
repressive
are
inside?
listening
defense
to
reveals
me.
a rise
[
of
.]
Th:
What
do
you
It sounds
notice
feeling
Pt:
[ Sighs
Th:
then
as
to help
No
Th:
said.
equates
projection,
long
breathing.
.]
out
anger
patient
interpretation
shows
Pt:
drop
abdominal
effect.
vignette
until
than
the
the
disruption,
from
useful
which
feeling.
cognitive/perceptual
integrative
in
rather
Deactivate
the
little
thoracic
your
irritated
toward
feelings,
irritation
and
me
traveled
wanted
turned
anxiety,
like
toward
like
you
across
the
room
you.
around
on
you?
Pt:
a reaction
to
what
me?
It sounds
hurt
the
had
.] Irritated.
to
and
you
defense
I didnt
Do
[ Point
got
you
out
of projection
quite
hear
irritated
where
see
the
you
how
with
me,
thought
your
and
I was
irritation
triangle
of
you
said
conflict:
.]
what
there.
Cognitive/perceptual
and
anxiety
tolerance
disruption
rises
so
when
the
patient
Th:
Are
the
goes
projection
over
the
drops,
threshold
feeling,
of
anxiety
.]
you
having
a little
trouble
thinking
right
now?
Pt:
Im
Th:
This
dizziness
miffed
me,
with
your
that
me.
Then,
anxiety
freeze
the
it
the
opinion.
are
(the
projection).
had
done
He
judged
For
himself
the
from
Help
differentiate
order,
the
differentiate
and
(4)
what
bear
he
anxiety
in the
put
that
together.
were
feeling
Do
you
striated
bit
onto
see
summaries
how
of
the
muscles
so
and
the
equates
reality
reported
Step
Then
he
was
therapist
to
(1)
and
fantasy,
feelings
and
can
his
(3)
anxiety
see
with
judging
fantasy
illegal
Step
projected
to
my
symbolic
his
him.
his
he
one
inner
differentiate
the
his
projection
inner
by
attention
the
that
projection,
face
as
something
unable
pay
Restructure
restructure
not
the
1971).
from
see
Thats
known
two : he
(Winnicott
from
patient
is
of
or differentiate
(No.
inability
therapist
crime.
projection
projected.
the
the
projection
project.
a patient
his
ability
the
had
others.
you
there.
their
This
patient
therapist.
reality
discharge,
capacity
onto
his
The
accused
for
therapist
(2)
had
cognitive
is back
this
noticing
dizzy
they
is!)
instance,
then
onto
in this
got
repeated
whom
she
1981).
and
him
you
to observe
upon
how
(Segal
judgment
you
are
put
.]
unable
person
Thats
equation
we
to
Capacity
usually
from
So
anxiety
dizzy.
a moment
noticed
and
[ Offer
drops
Self-Observing
take
we
up,
patients
reaction
Patients
when
here?
until
Lets
a little
of anxiety.
went
happened
process
the
is a sign
feeling
to
price
arise
life
when
build
rather
the
of the
pathway
and
mobilizing,
of
defense,
defense;
integrating
unconscious
self-observing
than
project
it
Projection
of
One
of
This
projection
loss
of reality
to
the
the
the
most
Superego:
common
occurs
and
of
show
how
spectrum
of psychoneurosis.
is
projection
a spectrum
from
severe
examples
Spectrum
projections
along
testing,
projection
the
from
projection
of the
of
pathological
worldloss
of reality
Im
the
mayor
rage
toward
afraid
murderous
between
her
onto
mayor.
the
rage
testing.
her
and
She
level
her
cut
off
boyfriend.
cannot
aware
of
the
himself.
the
of
it,
voices
He
are
becomes
moment
later
he
myself.
He
turns
self-attack
in
angry
says,
the
anger
unethical
good
of
she
She
the
her
head
himself
structure:
patient
is
the
say
while
conflict
fantasy.
he
during
feels
superego
The
that
my
is
punishing
session.
should
kill
attributing
this
voices.
Neurotic
Projection
a delusion:
her
voices.
therapist
onto
outside
of character
disavows
in
the
feel
from
the
structure:
has
projects
onto
voices
across
in
than
level
but
with
The
the
to the
mind
following
head.
reality
superego
his
my
she
differentiate
pathological
figure
Rather
judgment
occur
woman
Borderline
Projection
to
conscience
of character
onto
to
testing
The
can
A schizophrenic
wants
superego.
reality
others.
superego
superego
the
of a mature
onto
Psychotic
Projection
good
projection
aggression
of
healthy
did.
Then
conscience.
she
idea.
The
therapist
patient
can
differentiate
says,
level
A
You
replies,
of
patient
structure:
reports
probably
think
character
dont
thats
something
think
your
this
is
conscience
talking.
This
addition,
notice
the
unhealthy
part
Psychotic
patients
and
fear
Patients
content
of her
it there,
the
superego
project
unable
at a borderline
of the
an
to
level
but
therapist
from
her
projection.
She
does
an
extremely
differentiate
of character
integrated
severe
their
attribution.
not
In
project
an
conscience.
superego
projection
pathology
onto
from
either
others
reality.
project
or
identify
can
with
the
trigger
guilt.
some
Neurotic
difficulty.
Table
pathological
table
The
Deactivating
cognitive/perceptual
patients
See
9.3
brief
superego.
integrate
their
disruption
their
projected
projections
and
conscience
grief
and
with
less
9.3 .
spectrum
of
projection
of
the
superego
and
reality
testing
Level
of
character
symbolic
Type
of
superego
projection
Level
of
functioning
Psychotic
Loss
structure
Experiences
of reality
Borderline
hallucinated
delusions
of persecution
testing
Alternately
Transient
voices,
loss
projects
of distinction
or identifies
between
with
the
the
therapist
superego
and
the
projection
Neurotic
Demonstrates
reality
and
Content
of
the
ProjectionParts
resistant
patients
might
patients
there
others
(My
do
you
will
to
ask
not
may
thinks
me)
disorders
terrible
think
project
is
Ability
said
therapy
and
may
but
work
then
was
to differentiate
project
person)
and
good
of an
you
their
of
superego
then
fear
or
desire
of
you.
(I
become
the
may
Patients
see
angry
onto
(What
project
you
with
you
at
wife
help
therapist
questions
can
(My
for
the
you
resistant
problem
patients
afraid
afraid
onto
Highly
internal
or onto
Fragile
(Im
conscience
idea).
or
come),
on?).
become
may
Oneself
their
I dont),
I should
upon
project
awareness
problem,
I should
of
that
their
doctor
think
do
superego
fantasy
Moderately
(You
integrated
their
want
character
think
your
to
Im
imagined
criticism.
Example
Pt:
with
me,
me?
as
[ Defense:
soon
as
you
[ Angry
projection
with
of anger
Th:
Do
you
are
feeling
notice
Oneanger
the
therapist
.] Are
you
angry
.]
you
it yourself?
put
your
If you
anger
dont
over
relocate
onto
your
anger,
how
do
you
experience
your
anger
here
Example
Pt:
want
to
projects
overwhelm
her
[ Struggling
you.
grief
onto
[ The
the
Th:
projection
her
patient,
But
but
Im
to
help
you?
Pt:
My
Th:
Since
what
[ Block
problem
who
is
feeling
to solve
this
the
your
wife
her
the
loss?
loss,
[ Block
is a problem.
is not
is with
projection
and
the
[ Projection
here,
which
I cant
you
invite
help
would
him
to
her,
like
me
declare
an
.]
his
How
problems
should
I handle
this?
[ Projection
of
his
.]
Only
you
can
know
for
sure.
[ Block
the
.]
Example
Pt:
Psychodiagnosis:
anxiety
Th:
be
dont
Threeawareness
thinks
problem
Th:
the
with
.]
wife
the
Pt:
projection
sorry.
.]
wondering
ability
.] Im
.]
awareness
internal
grief
overwhelmed
Example
of his
me?
Twogrief
with
therapist
toward
projection
from
the
You
probably
in the
striated
Whats
the
therapist
Pt:
Well,
Th:
But
Pt:
Well,
Foursuperego
think
muscles
this
is
stupid.
.]
evidence
for
that?
[ Differentiate
.]
you
havent
said
anything,
but
it
could
true.
Th:
badly
of you,
but
there
head.
Could
this
be
whats
there
Theres
is no
your
the
isnt
any
a thought
evidence
critical
evidence?
yet.
in your
to support
the
conscience
inside
criticizing
myself.
names?
Pt:
Im
always
head
that
thought
you
think
in
your
calling
you
sometimes
been
you
in you
imagine
all the
Th:
Sometimes
you
your
conscience
is out
Pt:
of his
will
what
was
projection
The
driving
of will
patient
placed
by
will
on
the
You
to share
Th:
know
yourself,
here
and
in me,
when
its
my
feelings.
time.
Example
Projection
criticize
his
the
therapist
is
the
a
and
patient
specific
Table
to
came
of his
to
shows
.]
here
anxiety?
way
9.4
share
it who
depression
in
therapist.
me
who
reminding
react
want
onto
But
Fivewill
wanting
to
[ Deactivate
the
will .]
the
these
projection
common
he
has
reactions
to
projections.
Table
9.4
Projection
and
the
resulting
subjective
state
of
the
patient
Content
of
the
Pathological
desires
responsibility
reveal
Rageful
highly
that
at
of
testing.
the
fears
judgment
therapist
the
uses
therapists
therapist
tactical
to take
therapist
will
make
her
and
uses
repressive
Block
His
boundaries
defense
of
as
depends
defenses
projections,
the
equation.
The
defense
remains
and
in
and
return
on
capacities,
symbolic
a tactical
anxiety
or tactical
his
her
self-observing
degree
projection
distance.
violate
regressive
the
the
rage
will
or
discharge,
patient
He
reality
is
is projected,
muscles.
therapists
for
Or
the
the
anxiety
resistant
therapist
therapy.
Fears
of
waits
Fears
projection
pathway
the
life
desires
content
the
inner
the
impulses
Whether
Fears
Passively
for
her
Loving
Result
Superego
Healthy
the
projection
to
the
suffers
to
the
keep
striated
no
loss
focus
feeling.
In
contrast,
defense
into
to
the
relocate
cognitive/perceptual
fragile
patient
internal
uses
experience.
disruption.
projection
Her
She
uses
as
anxiety
regressive
regressive
is
discharged
defenses
on
and
suffers
Unable
from
loss
to differentiate
from
projective
rather
projection,
Now
a therapeutic
regulate
shows
how
reality
between
anxiety.
than
of
reality
she
She
her
becomes
the
then
she
with
therapist.
suffers
projection
Restructure
explore
a projection
terrified.
projection,
a misalliance
with
and
whether
and
has
alliance
anxiety,
to assess
testing.
feeling.
is a tactical
her
Table
or
9.5
regressive
defense.
Table
9.5
regressive
Psychodiagnosis
of
projection
as
tactical
as
or
defense
Qualities
Projection
regressive
Function
parts
tactical
defense
Projection
defense
Keep
of the
Pathway
as
the
therapist
at a distance
Relocate
feelings
or
mind
of
anxiety
discharge
Striated
Cognitive/perceptual
disruption
Reality
testing
Other
Intact
defenses
Regressive
Projective
and
tension
repressive,
character
defenses
No
Block
Restructure
the
returns,
or lost
Tactical,
anxiety?
Intervention
Impaired
the
character
defenses
Yes
projection,
projection
and
and
then
until
and
reality
explore
the
then
return
to the
and
striated
testing
feeling
triggering
focus.
muscle
the
projection
See
figure
when
defense.
9.1 , which
assessing
shows
whether
the
projection
sequence
is
of
a
interventions
tactical
or
to
use
regressive
Figure
If the
loss
9.1
Psychodiagnosis
projection
of
reality
projection.
therapist,
of
is a regressive
testing,
If
the
she
will
unable
patient
be
defense,
to
in a misalliance
alliance
with
the
assessment
and
intervention
therapist.
when
the
differentiate
relates
therapeutic
of projection.
projection
to
a
with
patient
will
the
therapist
from
the
rather
than
the
projection
the
Figure
addressing
experience
projection
rather
9.2
the
shows
three
common
than
steps
a
of
types
Figure
9.2
Restructuring
the
loss
of
reality
testing
in
patients
who
project
PROVOCATION
Some
patients
and
the
have
need
relationship,
them.
others
to
for
therapy.
the
to
they
punish
trouble
repair
the
either
Help
punish
the
him.
My
but
wife
after
asked
I had
me
know
what
it was,
glass
of
water
at
know
is I blew
up,
will
I knew
sex
with
how
my
but
I was
the
sink.
turned
guilt.
they
how
guilt
and
help
establish
an
day
bimbo
was,
so
I dont
doing
at
the
and
pissed
at
know
threw
guilt
on
he
this.
bar,
her.
what
a glass
focus
It didnt
at
her.
I was
she
to
provokes
I came
of
others
intrapsychic
I snapped
off
even
and
be
their
inflicted
provoke
his
that
avoid
or
see
I shouldnt
around,
To
have
themselves
patient
This
their
damage
punish
Pt:
right,
tolerating
feel
home.
dont
getting
said.
water
a
All
in
I
her
face.
She
house
got
all
if I was
to cool
pissed
going
off
to treat
told
her
me
like
to
that.
get
I left
the
the
hell
out
house
of
for
the
while
down.
Th:
about
having
stepping
great
and
sex
out
on
with
their
It sounds
the
woman
Pt:
I felt
wives
like
you
at the
guilty.
and
were
bar.
My
how
great
not
What
feeling
was
friends
have
it was,
but
having
sex
too
that
good
feeling?
talked
about
it didnt
feel
so
to me.
Th:
woman,
but
provoke
your
real
the
wife
reason.
others
way
to avoid
you
to
[ Point
out
his
for
being
yet
his
defense
Yet
by
her,
and
face
your
with
you,
the
on
the
invited
guilt,
his
dealt
the
defense
I hadnt
me.
guilt
was
though
of
to
she
provoking
thought
[ Accuses
Th:
You
water
on
her
you
inner
for
even
with
this
go
home
didnt
other
and
know
the
punishment
was
thought
her
to punish
goaded
judgment
for
into
onto
his
wife
of
from
others
to
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
function.
causes
patient
next
causes
Then
you
regression
into
depression.
Weepiness
In
this
think
in
example,
she
patient
is
fat
patient
he
helps
clear,
see
her
the
patient
and
ugly.
despair
the
the
see
her
of ever
The
to see
I wonder
if she
how
onto
judges
onto
accepted
that
is projecting
onto
the
explores
him.
Then
him
and
the
her
the
feeling
toward
the
therapist,
the
we
find
men
out
will
if
the
therapist
helps
projection.
Then
Once
him.
she
will
this
As
feel
long
a
are
also
therapist
forming
here
.]
with
relationship
me?
is
as
weepy
superego/therapist.
is in operation
the
that
to
internally.
by
Superego
projects
herself
Since
fear
and
therapist
explore
superego
of
herself
between
she
Th:
here,
hates
difference
can
being
Projection
superego
how
therapist
projects
to
the
is projecting
the
she
Response
[ Explore
Pt:
Defensive
affect
Im
resulting
from
Th:
weight?
[ Block
the
afraid
you
her
Whats
projection
are
judging
projection
my
weight.
[ Cries.
.]
the
evidence
evidence
really.
that
Im
judging
your
.]
Pt:
No
But
you
can
see
Im
overweight.
Th:
the
projection
has
that
But
Pt:
I did.
Th:
You
that
judgment
out
the
dont
onto
projection
judge
right
now?
The
patient
that
I judged
Do
I do
now.
herself
and
reject
and
the
will
reject
Once
judged
her
So
who
then
you
happened?
will
loss:
reality.
internal
her
imagines
him
how
rejects
In
rejecting
herself.
me
men,
they
she
would
projection,
that
her
creates
the
stop.
dies.
the
example,
stimulus
if
projected
with
her
side,
toward
then
imagined
projection
the
feeling
Angry
up
.]
to
and
then
cleared
loss:
the
at the
anger,
and
a spouse
first
the
stopped
off
weepiness.
the
In
in
she
but
just
judgment
a look
we
imaginary
to an
of
that
has
take
her
to an
response
date,
me,
weepiness
her.
stimulus
we
that
self-judging,
to real
a response
weight,
how
[ Teariness
Deactivate
is a response
external
aware
[ Block
overweight.
your
see
put
triggered
her.
weepiness,
be
can
through
stopped.
man
yourself
judging
you
If we
with
This
weepiness
can
overweight?
.]
angry
her.
are
me.
yourself,
was
punished
Grief
called
You
Th:
judge
just
you
Me.
Pt:
you
called
thought?
Th:
Point
just
.]
Pt:
put
who
in her
her,
patient
grief
second
Defensive
is
example,
imagination.
and
She
becomes
is
aware
weepiness
fantasizes
in
that
response
to
weepiness
She
sad.
that
she
an
is
projects
She
in
onto
is
not
believes
men
will
these
reject
rejecting
projection.
we
the
she
will
intrapsychic
DEFENSIVE
. Then
rage
externalization
is
or
defensive
explore
rage
from
on
wards
with
off
genuine
defensive
and
defense.
anxiety.
For
instance,
to ward
it off.
results
me.
forms
goes
with
finally
her
rage
with
her
Help
establish
the
an
defense.
stomps
her.
enemy
for
enemy;
a patient
out
Yet
(Bergler
rage
passes,
the
projection
therapists
and
confuse
criteria
of
the
through
of
occurs
differentiate
anger
up
after
reality.
For
not
house.
her
at
and
Then
provocation,
on
criticizes
him.
He
is
Genuine
goes
insults
she
grief
husband
who
disrespect.
rage
of
based
respect
defensive
and
Genuine
My
patient
supposed
yells
feeling
stimuli
before
feeling
example,
instance,
their
after
stimulus:
imaginary
do
occurs
the
imaginary
people
them
real
of
comes
an
For
toward
her
is angry
she
an
husband
with
him
artificially
1961).
Physiological
genuine
onto
stance.
triggering
feeling
involves
other
Suppose
abandoning
created
her
puts
others
to
following
rage
in
projection.
toward
one.
The
versus
anger
that
furious
imaginary
for
she
projections
Sometimes
The
a stimulus
as
projects
he
to
of rage.
defensive
from
such
continually
until
over
projections.
victim
defenses
grief.
Defensive
Defensive
defenses
anger
sad
response
equating
feelings
the
rage.
Real
himself
feel
from
in the
her
the
in
projection
keep
from
based
it
anxiety
hit
entrenched
Process:
anger
are
or
RAGE
Defensive
genuine
toward
people
at,
of projection.
enraged,
more
angry
resulting
defense
rage
become
focus
feelings
the
more
be
feelings
any
clarify
other
fear,
these
patients
differentiate
can
But
become
and
she
explore
and
explore
projections,
her
not
identify
others,
Then
men.
Do
Instead,
If
her.
patient
activation:
relaxes
and
When
feels
the
relief.
impulse
In contrast,
of
the
experience
toward
of
the
a projection,
terrible,
impulse
gives
unchanging
continues,
so
does
the
in
no
defensive
relief.
The
person:
the
defensive
rage.
Unconscious
anxiety
in the
Defensive
not
body.
anger,
trigger
defenses
Once
the
result
anxiety
arising
the
or
signaling:
of
rage
and
functions
defenses.
the
as
defensive
and
due
to
still
to
relating
Since
the
anger,
triggers
anxiety
drops.
projection),
raging
at
projection
anger
(usually
Thus,
activation:
fully
when
defense,
so
projection
or
does
length
without
rage
triggers
Genuine
defenses
it
drop.
doesnt
Defensive
trigger
externalization
repressive
create
and
sustain
rage.
Architecture
rises
rage
anger.
more
a
Instead,
feels
defenses.
emerges
is
expressing
Genuine
defense
Defense
defenses
patient
projection.
patient
is defensive
rage,
falls
in
the
projection
Defensive
shape
and
anger
of
of
remains
remains
the
experience:
a wave.
Defensive
high
long
as
chronically
Genuine
rage
as
the
elevated
rage
rises
patient
rapidly
projects.
because
of
chronic
projection.
Result
experience
leads
of genuine
to
no
chronically
relief,
onto
that
results
projection:
The
I always
experience
more,
develop
increasingly
brings
experiencing
relief
exhaustion
his
feels
is merely
knew
the
she
defensive
rage
more
distorted
Normal
Rage
and
and
wife
of
was
the
clarity.
despair.
perpetual
result
The
rage
the
of
rage
patient
who
or despair.
of a deepened
encourages
The
Defensive
a completely
sense
feeling:
belief
horrible
patient
others,
The
person.
to
and
in
project
become
hopeless.
Differentiating
Normal
rage
hit
Defensive
me.
only
projects
pseudoclarity
the
anger
of
occurs
in response
rage
(based
from
Defensive
to a stimulus
on
projection)
Rage
in external
occurs
reality:
in response
you
to a
wrong
done
become
fantasy:
enraged
explore
the
resulting
an
in
with
rage
genuine
deeply
Let
from
look
Defensive
rage
hurt
class.
you.
He
called
Defensive
rage
distorted
fantasies
visit
on
her
word.
is
rage
so
rage
a piece
toward
an
or projections.
Sunday,
Normal
work
her
is provoked
rage
establish
factors
that
6970).
used
exclusively
toward
a real
of trash
it
in front
for
she
entire
created
by
would
say
I should
she
could
say
before
others.
enemy
the
enemy,
knew
have
by
is
imaginary
I just
I let
to
1959,
is
reality,
explore
projection
(Bergler
then
indiscriminately.
Normal
my
not
in
additional
rage
is used
and
patient
Do
the
rage
me,
the
some
Normal
Object:
who
at
defensive
judging
possible.
address
us
Use:
self-defense.
are
harmed
as
Instead,
focus.
differentiate
you
If someone
as
projection.
intrapsychic
imagine
you.
reactive
from
Defensive
rage
provokes
a fight.
Guilt:
because
The
it is proportional,
normal
person
attacked
because
extent.
persons
goes
The
directed
doesnt
(Bergler
it
1948,
out
the
rage
toward
a fight;
29).
on
patients
pick
does
the
he
Neurotic
the
person
trigger
not
provoke
person
rage
wrong
projections
attacked.
defends
himself
when
always
triggers
guilt
to
his
who
guilt
disproportionate
rage,
not
the
other
actions.
Dose:
to
Normal
provocation.
projection.
small
The
Defensive
slight
amount
rage
plus
of
normal
rage
corresponds
projection
to
corresponds
the
triggers
fantasy
an
or
excessive
response.
Purpose:
stopping
retaliation
an
and
enemy.
Defensive
punishment
rage
from
Normal
Normal
an
rage:
has
rage
has
the
purpose
imaginary
I consciously
the
purpose
of
of
triggering
enemy.
intend
to
harm
the
arrange
to
other.
Defensive
rage:
I unconsciously
harm
myself.
Timing:
rage
when
it is
Defensive
rage
stimulus
an
adaptive
imaginary
healthy
person
his
enemy
is
and
occurs
in the
The
immediately
Normal
world.
Defensive
external
stimulus
in the
internal
Defensive
rage
is
done
as
defensive
rage
it provokes
necessary
as
exciting
punishment
to
person
lose,
even
defeats,
however,
Defensive
and
Sometimes
example,
and
notice
sees
the
husband,
she
therapist
she
the
face
what
of
how
cancer.
hard
How
are
When
Defensive
rage
value
Im
has
you
feeling
based
back,
on
bring
to
easily
pleasure.
experience
even
or
person
wants
to
result
though
and
defeat?:
The
provokes
win.
to cover
If
nothing.
see
this
I look
lost
patient
Pt:
relief!
be
We
success
assesses
at
did
not
job.
neurotic
rage
forever
Th:
know
cannot
does
seek
devaluation.
she
the
she
real
His
aim:
fights
pattern
of
suffering
Grief
therapist
claim
help
a reaction
in advance,
underlying
defensive
enraged
must
can
how
rage
he
Cover
use
can
be
claims
the
defense
she
must
The
reveals
patients
to
end.
to succeed.
to
is often
rage
pleasurable
patient
he
Rage
wait.
to wait.
a reaction
disagreeable
the
though
is
rage
Normal
in the
fights
rage
Normal
but
Does
normal
ability
can
can.
Pleasure:
It
an
He
his
world.
Provocation:
provoked.
to express
vulnerable.
without
Stimulus:
waits
been
and
let
and
to hear
for
the
you
their
grief.
patients
the
patient
But
to
devalued
in him
sorry
up
response
devalues
ward
off
husband.
go
of
has
her
lost
of your
during
In this
the
her
grief,
Thus,
the
devaluation
so
forever.
husbands
this
ordeal
death.
with
I
his
now?
[ Tears
.] Im
glad
I wonder
what
devaluation
.]
the
good
SOB
he
is dead.
ever
was
What
to
me.
a
[
Th:
the
rage
have
instead.
to
bear
defense
If only
this
loss
Its
as
he
had
been
worthless,
what
was
good
of
devaluation
you
no
good
right
He
Defensive
Rage
following
that
other
the
evaluator
was
about.
me
fired.
on
angry
onto
him,
at the
wouldnt
me
now.
[ Defense:
you
then.
But
who
constantly
the
he
[ Point
out
the
the
patient
differentiate
deactivate
with
projects
him
away.
to
boss
my
patient
he
I was
fear
retaliate
criticizing
her,
and
my
was
get
she
her,
she
then
had
to
get
my
she
had
but
now
fired.
projects
angry
was
thought
one
me
that
going
boss,
and
is
what
and
was
and
presentation
know
said
topic
to
my
he
and
the
yesterday
unclear,
afraid
up
have
After
didnt
was
that
for
at work
boss.
said
spoke
to
hurt
Projection
at
Im
[ Having
her
anger
him
as
.]
Due
to
Projection
therapist
assesses
projects
her
him
the
death
her.
topic.
going
will
Anger
how
right
my
for
him
presentation
evaluator
retaliator
Defensive
she
my
is
fears
imaginary
as
you
with
it does
fragile
He
really
been
critical.
I didnt
evaluator
took
to
next
me.
the
the
sit
and
afraid
Notice
in to
clear,
to
alliance
then
tears
him.
a presentation
was
suggested
not
your
in
of good
to hurt
I gave
Fortunately,
presentation
that
cover
.]
Pt:
said
spoken
Death
want
really
He
a lot
concerns
people
came
even
good
Response
example
evaluator
not
of
did
[ Cries
in
the
talking
lot
now.
Pt:
fears
to
.]
Th:
The
want
.]
Pt:
does
if you
from
projection
instead
a superego
of
the
superego
her
so
response
and
sees
onto
therapist
and
does
patient
of a misalliance
onto
him,
Superego
patients
projection.
the
the
the
Thus,
will
with
she
will
the
therapist
have
her
be
therapeutic
projection.
enraged
must
As
with
long
him.
Pt:
are
judging
and
Im
criticizing
me.
Th:
Point
out
reality
What
is the
I just
different.
So
having
evidence
I am
where
that
is
see
you
.]
I am
judging
you?
way.
you
feel
evidence
and
there
way,
to support
criticizing
isnt
that
any
but
your
my
feeling?
you?
evidence
yet.
that
I am
But
there
that
There
thought
it to
Is there
me.
But
patient
self-criticism
angry
Yes.
choices
the
the
coming
example,
she
anger
coming
criticizing
from?
reality
upon
to
help
so
on
caused
see
Who
is
is
hard
a look
at
she
thought
yourself?
is
underneath
therapist
observe
criticizing.
then
time.
what
the
can
critical
on
all the
but
and
her
Then
the
defense
explore
any
therapist.
Externalization
her
the
too
the
myself
therapist
which
thought
that
between
the
the
a critical
to be
take
she
toward
how
that
of reality
of
we
Based
made
you
superego
up
notice
can
difference
of the
Anger
elements
elements
see
having
I criticize
Can
now?
and
feelings
Defensive
this
evidence
criticism
we
for
right
projection
are
now
a tendency
self-criticism
patients
of
You
Th:
the
no
I am.
Pt:
Help
is
thought?
attributed
is in you.
on
evidence
that
judging
Th:
In
the
is the
Well,
Pt:
of
I can
be!
you.
that
because
of superego
I understand
Th:
you
is
feel
What
Pt:
could
you
[ Projection
What
Th:
was
with
.]
Pt:
question
angry
helps
suffering.
they
patient
the
The
agree.
see
patient
see
the
therapist
will
focus
Then
he
use
those
how
she
will
caused
her
suffering.
Pt:
[ Arrives
to the
session
twenty
minutes
late
.]
Im
so
angry
downtown
when
her
we
had
to
was
so
kept
telling
me
with
had
So
my
our
out
we
she
to
patient
her
session
is
the
go
late
Who
But
blame
you
Th:
Who
Pt:
I did,
blame
for
the
She
did,
(daughters
out
the
late)
her
responsibility
angry
told
her
then
she
dressed.
kept
making
she
doesnt
that
to
wait?
[ Point
out
because
she
was
late.
be
choice.
late
But
differentiate
(not
ready
her.
for
her?
yet.
So
to
yourself
she
you
made
you
wait
made
for
late.
Do
her.
you
me
late!
yourself
And
see
you
what
[ Externalization.
differentiate
the
defense
(self-punishment
not
[ Differentiate
her
daughters
could
with
then
Thats
from
her
the
the
to wait
.]
her
her.
you
patient
stimulus
listening
.] She
You
stimulus
through
her
But
didnt
(daughter
.]
leave
to
for
she
listen
not
be
your
to
be
on
time
late
with
from
and
her
late.
Then
you
by
yourself
her.
That
or
was
choice.
wasnt
to
reality
actions,
chose
to
chose
blame
to herself)
true.
daughters
choose
Pt:
Externalization:
for
cannot
from
actions
options:
But
decision
.]
from
to
defense
She
so
decision
patient
lateness)
fantasy,
your
listen.
wasnt
waited
externalization
the
to be
she
to make
Th:
choose
getting
I told
But
then
me
late.
ready.
decision
the
your
decision
Psychodiagnosis:
two
Im
made
but
for
Pt:
had
didnt
with
was
oclock.
and
she
made
You
her
your
[ Point
choosing
wasnt
three
she
ride
.]
her
mean?
she
role .]
Th:
late.
then
at
today.
Pt:
Externalization
But
shower
but
catch
to me.
Th:
to the
to
session.
But
me
or listen
wanted
oclock.
of
had
made
time
my
at two
getting
her
She
to
because
slow
respect
I came
to leave
leave
wait.
Sadie.
listening
herself.
listening
to
to
me!
She
does
not
her)
from
her
Th:
The
problem
listen
she
was
to you
and
doesnt
have
listen
you
what
dont
Its
I mean?
[ Point
to
onto
stewing
there
price
of her
defense
did
you
feel
when
than
yourself
for
punished
yourself
for
of your
then
you
Point
out
the
Can
seen
Patient
now
her
and
being
victim
time.
In
this
time,
I would
you
you
see
and
how
to me)
begins
.]
not
have
to realize
the
at
what
happened?
That
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
.]
And
yourself.
.]
That
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
Defensive
to herself)
[ Patient
take
angry
being
leads
daughter,
blames
sees
to
Do
listen
dont
delaying?
the
externalization
Externalization
about
was
feel
your
how
we
You
Pt:
hadnt
on
listen
leave.
doesnt
come
to
you
If
Anger.
therapy
blamed
listen
(She
just
her
doesnt
a problem.
anyway,
and
(not
minutes.
she
just
punished
minutes
for
problem.
If she
have
to yourself
did
the
.]
Th:
rather
you
yourself
she
twenty
Pt:
Then
to
wasnt
to yourself!
waiting
daughter
Th:
What
were
If I had
for
that
then
listen
listen
her
Pt:
been
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
Of
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
She
just
move.
this
says
But
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.
My
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.
And
to
have
for
where
your
choice.
choice
But
you
focus
live.
choice,
You
But
girlfriend,
but
his
defense,
for
chose
decided
now
that
how
he
rage
we
not
her
one
time
to move
You
his
the
that
responsible
self-abandonment,
on
was
at
chose
recognizes
his
she
And
ways.
choice.
patient
destructive
you
is not
it both
onto
GUILT
But
she
your
than
the
your
you
yell
at
her
for
chose.
Th:
can
better
believe
with
people
something
not
I did.
Pt:
As
so
the
last
the
does
will
angry
my
see
he
he
will
I hate
lasts
as
patient
.]
Th:
her
night
Who
Pt:
try
find
contract
Th:
reality
to
long
with
which
the
patient
suffering,
furious
city.
the
eternally
here,
this
As
his
be
so
job
I hate
that
I just
Im
But
yelling
caused
helps
helps
suffering.
and
teaching
therapist
therapist
suffering
Pt:
The
you
here
your
to
stay
was
you
are
projects
have
move.
wanted
could
with
with
more
here,
the
rapidly.
an
said
That
You
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
Neurotic
guilt
Normal
guilt
is realistic.
Neurotic
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
(Wurmser
a
memory
with
my
the
a trauma,
to
being.
affects
patient
emotional
I was
has
projection,
rage
become
as
reliving
regression
past
self-attack).
experienced
when
flashback
This
between
the
trauma
subsides
When
to
or
of the
way
real,
that
presence
will
every
if it were
when
defensive
punish
and
the
from
patient
for
due
rage
alone
confuse
therapist
human
differentiation
in the
recurrence
and
testing
to
patient
the
differentiate
while
regress.
past.
affects
cover
affects
to
as
the
the
caring
increasing
to
rise
to
of
her
overwhelming
reality
loss
projection,
not
suffering
past,
if
defensive
weepiness
be
can
to
defensive
experiencing
as
of
experiencing
(e.g.,
rage
loss
label
affects.
another
inability
cannot
do
projection
the
bear
become
testingan
reality,
reality
by
leads
remember
to
of
from
Patients
from
Affects
her
to catastrophic
support
therapist
testing
from
much
of
suffer
feelings
Patients
than
too
studies
regression.
their
misnomer.
Fearing
rather
leads
can
present
his
regression.
catastrophe.
relive
feeling
others.
of
genuine
affect
of
reality
projection.
testing
become
is
in
patients
the
and
in
1998),
and
differentiate
regression
her
They
alone
ego
cannot
differentiate
in reality
these
experience
regression
in
abuser.
that
dedifferentiation
with
cannot
of
physical
affect
therapist
1988,
dedifferentiation,
If patients
will
1975,
resonates
2003,
in
uncle
patient
feelings
226).
the
Ed
past.
in
differentiates
do
not
We
I
Iowa.
the
subside
because
(Segal
All
the
1981).
patients
affects.
causing
genuine
unlocking
patient
equates
In his
within
Identify,
the
mind,
the
he
and
defensive
of the
without
affects.
using
unconscious.
present
is with
spectrum
clarify,
feelings
the
feeling
Uncle
of
When
regressive
the
past
trauma
Ed.
fragility
restructure
with
suffer
the
the
from
defensive
regressive
patient
defenses
, she
defenses
tolerates
can
her
bear
an
PART
Helping
THREE
the
Highly
Resistant
Patient
CHAPTER
ELEVEN
Superego
Pathology
I n part
all
1, we
patients.
and
learned
In part
intervention
address
the
These
defenses
they
the
these
of the
we
for
highly
of
defenses
special
group
within
different
on
on
interventions
at
set
which
spectrum
to
defenses,
will
on
defenses
these
discussed
designed
are
to
based.
they
patients
first
the
Since
syntonicity,
help
we
based
defenses
of
will
patients.
interventions
these
designed
those
of
we
resistant
the
to
assessment
Now
superego.
from
special
of
spectrum.
the
structure
a
occur
look
require
see
examine
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them.
a
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the
concept
not
deserve
superego.
A woman
living
anything
ability
interventions
identifications
of
before
and
a
applicable
principles
fragile
require
defenses
spectrum
with
better
to cut
medical
An
additional
the
identifications
have
previously,
learned
of assessment
in
use
of
principles
patients
principles
enactment
basic
2, we
for
patients
address
the
an
abusive
in life.
An
arms
and
feels
enormous
her
school,
out-of-control
internal
husband
adolescent
starve
says
girl
claims
herself.
and
punishes
does
she
A young
shame,
judge
she
man
then
these
is proud
fails
commits
patients
of
her
a test
in
suicide.
continuously.
Why?
We
have
right
a conscience,
and
toward
wrong
which
something.
actions.
values,
have
that
we
We
They
live
(Klein
as
a reward
for
us
to
if they
someone,
caused
or
we
1975a,
living
up
feel
for
guilt,
meaning
an
according
lead
we
gives
strive,
or disapprove
hurt
a capacity
inner
to
a moral
our
voice
lives,
saying
to internalized
approve
are
guilt
1975b).
to our
of
not
and
As
internal
(S.
sense
an
we
a result,
ideals
that
consistent
Freud
reach
ideal
should
standards
deeds
of what
1923/1961).
out
to repair
we
may
(Brenner
the
feel
1955).
is
image
not
do
guide
our
with
our
When
we
damage
self-love
These
aspects
of
our
inner
life
comprise
the
system
superego
(Barnett
2007).
Superego
Roth
originally
2001),
suffering
the
the
defined
(Bergler
1952)
Kernberg
capacity
the
truth
clarity,
guilt
will
linked
memory
(Schore
Each
time
memory
will
be
(Hartmann
et al.
what
to
These
become
habits
Grigsby
guide
and
For
to the
superego
our
drive
the
sake
a
to
to
know
of clinical
collection
defenses.
pathological
form
these
serve
given
and
memories,
of
All
later
superego
to
character
2000).
As
purpose.
nonconscious
respond
frequently
our
in implicit
adaptive
person,
how
nonconsciously
memories
an
enacted
Stevens
the
2003;
FORMED
and
form
daimonium
as
as
memories
that
to
2010).
enact
anticipate
behavior
and
Later
(Britton
of
of
and
1940/1963).
superego
encounters
1964).
to
others
These
child
her
1917/1961a;
continue
imitating
pursuit
1923/1961c),
concept
1975b)
ARE
1991).
the
tells
defenses,
by
the
can
superego
the
identifications
pathological
patients
Freud
1923/1961c;
up-aggression
Reiner
IDENTIFICATIONS
learn
S.
of
1975a,
the
Freud
1923/1961c),
stored
2010;
(S.
1923/1961c;
collection
2004,
to the
Children
structure
implicit
during
adaptively
enough
(S.
as
Freud
memories,
they
adulthood
(Hassin
2006).
imitate
others
purpose
complex
fathers
defense.
feelings
related
1940/1963).
death.
source
someone
unconsciously,
of
1917/1961a;
the
as
(Klein
that
Freud
Freud
have
define
identifications
HOW
conscience
1961;
(S.
Others
(Grotstein
references
(S.
1952,
ego
and
for
we
ideal
superego
1975).
our
to the
1948,
within
thinkers
the
ego
(Bergler
grade
We
referred
We
of
we
can
may
danger
have
but
We
to
we
may
loss
A man
identify
may
identifications
with
others
to
avoid
1990,
2000;
S.
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
For
instance,
a little
dangerous.
We
not
descriptions
tacit
these
identifications?
could
jeopardize
have
WHY
IDENTIFICATIONS
When
fantasy
this
rage
trigger
child
protects
his
feel
guilty
over
rage
rejects
his
Patients
having
inner
who
traumatized
primitive
bond,
feelings,
the
life
bond
well
as
the
impulses
It
may
children,
These
seem
yet
his
on
toward
over
guilt
often
self-sabotage
patients
punish
early
caretakers.
bizarre
their
play
to
turning
constantly
that
hide
the
with.
her
the
onto
triggered
her
gift
and
of
who
rage.
In
response
to
pattern
of
themes
punish
love
he
from
damaged
1990;
murderous
dont
unconscious,
one
reveals
suffered
eternally
1993).
loved
themselves
child,
himself.
the
(Davanloo
impulses
1975b).
powerful
or
may
small
(Benjamin
usually
bond
his
1975a,
this
child
1980).
the
I become
Through
the
1973,
over
(Klein
mother.
with
child,
caretakers
guilt
rage
triggers
attribute
impulses
her
For
a deed
This
that
develop
We
the
themselves
rage
guilt
conscious
we
damage
1994).
bond
life.
1975b).
1969,
arousing
enraged.
and
toward
further
my
early
guilt
childs
self-punishment
1975b).
in
murderous
as
toward
rage
or
could
by
to keep
turn
his
Bowlby
as
so
1975a,
survival.
1993;
guilt
mother
been
with
Schore
much
not
of
or
are
is
feelings
reason
we
boy,
and
just
feelings
for
the
FORMED
times,
1975b;
as
are
Unfortunately,
many
Klein
The
for
rage
(Klein
person
bond
retaliation.
1936;
myself
the
off
main
need
the
(Benjamin
childs
can
with
damages
additional
Freud
sharing
ARE
rage
the
the
he,
kind
ward
These
we
identify
expressing
provoke
(A.
and
reactive
provoke
avoid
as
caretaker
But
relationship
we
parent
the
to
thoughts.
To
feeling
However,
toward
that
father
others
behaviors.
claims
his
with
conscious
of
father
views
identify
wishes
are
feels
a violent
he
may
destructive
These
with
Meanwhile,
dangerous.
over
boy
these
mixed
unconscious
Klein
for
impulses
of
the
1975a,
their
rageful
to
adults
small
being
killed,
eaten,
helpless
with
worse,
the
rage.
on
or
little
and
usually
to rely
defenses
then
autonomy
child
Unable
his
jailed
brought
under
needs
on
his
instead,
the
help
parent
back
especially
power
from
for
life.
of
the
help
the
to
Children
others.
person
with
his
defense
are
What
is
causing
feelings,
the
he
of identifying
relies
with
the
parent.
When
enacting
adult
these
patients
was
an
use
that
see
identifications
deprive,
occasional
hurt,
turn
and
punish
defense
becomes
creates
symptoms.
chronically
and
becomes
against
automatic
themselves
or
a habitual
We
defenses
help
on
habitual,
others.
pattern
must
based
and
of
these
What
defense
patients
identifications
with
aggressors.
HOW
IDENTIFICATIONS
ARE
EXPRESSED
AS
DEFENSES
The
child
can
instance,
and
a child
criticize
and
believe
other
off
three
different
her
do
fear
that
others
what
was
she
imagines
her,
we
(A.
Freud
do
that
to
her,
the
it projection
do
to
therapist
of the
for
with
may
Or
being
mother
did
her
mother
herself
what
it
will
a
do
superego
did
her
she
her
IDENTIFICATION
SELF-OBSERVING
AS
PROBLEM
CAPACITY
Or
mother
to
her
or a transference
1936).
OF
can
mother
mother
her.
and
she
in
did
to
she
can
to
her,
did
the
therapist
resistance
what
her
to her.
does
transference
to
to
mother
project
her
her
For
with
Thus,
with
her
her
may
angry.
what
ways.
identify
she
identification
. When
call
identify
herself
defense
we
three
to
what
does
of
She
anger.
the
what
to her
character
done
call
others
angry.
her
can
one
may
sisters
enacting
patient
is
criticize
She
to
adult
this
will
by
will
little
in
mother
she
her
ways.
can
the
when
anger
She
identification
a critical
people
her.
call
with
criticize
ward
When
an
herself
mother
we
enact
mother
When
did
of defense
to
The
child
wards
aggressors.
distinguish
when
between
occur
when
did,
mothers
loss
or evil.
distinguish
group
of
reality
(herself)
defenses
equates
and
the
1975b;
reality
girl
has
the
child
(Ferenczi
self-attack
here,
(the
fantasy
often
am
1965).
from
like
She
to
innately
occurs
when
(the
her
believes
mother
In
the
little
remains
(Klein
1975a,
must
herself
1970).
operational
good,
early
she
understands
the
distinguish
begins
happens,
concrete
cannot
if
rage
(Piaget
bad,
patients
cannot
her
transient
unlovable,
Naturally,
off
bad
projection).
patient
bad),
thought
regress
show
Self-attack
She
operational
are
the
warded
1970).
also
fantasy
if something
Piaget
also
herself
herself.
self-attack).
(I
Winnicott
concrete
1981)
examine
believes
reliably
reality
they
they
from
successfully
1950;
through
(Segal
fantasy
1981;
cannot
criticizes
the
These
identifications
attacks
think
therapist)
and
and
differentiate
who
she
with
attachment.
These
themselves,
They
we
from
Segal
when
(the
child
identifying
true.
equation
reality
cannot
attack
thinking.
Symbolic
mind
that
by
immature
fantasy.
see
is simply
patients
is
and
The
not
criticism
in symbolic
jeopardized
child
receives.
does
adult
the
childs
she
mother
aggressors
reality
the
projections
toward
preserves
occur
When
feelings
This
defenses
girl
off
in
be
life
bad
and
others
Adults
using
thought
(Leahy
2001).
The
and
patient
who
believes
differentiate
(1940/1963,
she
herself
180)
is bad
from
called
needs
help
self-attacking
this
the
slow
to
see
(Gray
2005)
defenses.
S.
Freud
demolition
of
the
hostile
superego.
Identifications:
Since
the
Why
superego
superego
as
Kernberg
1975)
Harsh
identifications
Superego
is a concept,
a collection
that
the
of
patients
are
not
it cannot
pathological
enact
always
Becomes
So
act.
we
Hence,
identifications
as
defenses
accurate
(A.
Harsh
define
(Britton
Freud
photographs
the
2003;
1936).
of parents.
Their
harshness
stems
from
two
sources:
Reality:
The
parents
Misperceptions:
parents
through
neurocognitive
were
the
deficits,
an
harsh.
child
views
the
brain,
or
immature
projections.
The
a
child
who
child
with
problems,
may
attack.
harsh,
attacking
rage,
angry
his
She
is
views
mother
not
her
(A.
on
How
the
reality
in
manifest
as
memory
mother
is
memory
of
but
any
time
a memory
child).
memory
of
in
as
an
rises
anger
arises,
else,
or projecting
Lets
suppose
of
that
the
Freud
with
image
younger
is
of
boy
1985,
will
Mom
may
siblings.
available.
404)
affect
She
But
he
with
an
can
be
the
between
had
wants
a
her
mother
1975):
anger).
is connected
and
criticizing
father.
mother
(e.g.,
patient
to criticize
judgmental
This
critical
feeling
not
mother.
them
resistant
144).
a memory
(Kernberg
self-criticism,
someone
1963,
form
her
criticizing
highly
will
with
that
1940/1963)
(Gill
relation
in therapy,
(a
Freud
defenses
object
a defense:
patient
say,
identifications
relationship
the
relationship
form
his
(S.
mother.
the
a past
the
for
as
mother,
distorted
Thus,
A.
his
and
less
aggressors
of
and
a feeling
When
cares
identify
four-year-old
(self-presentation),
(object-representation),
Thus,
angry
him
Structured
a critical
herself
this
integration
dress
by
her
contrast,
or both.
primitive
understood
may
he
however,
and
with
had
her,
with
anger.
Sandler
unconscious,
a patient
her
of his
Are
identifications
of
is,
to
onto
In
sensory
attempt
rage
she
or misperceptions
Identifications
Suppose
while
as
frustrated
an
She
lens
Freud
Patients
just
him
harshly.
child,
identifies
instance,
him.
through
his
he
rejects
such
misperceives
project
For
himself
mothers
A normal
Then
rejecting
aggressor
based
he
may
mother.
think
deficits,
mother.
he
judges
his
Because
mean.
depriving
parents
experience
but
and
harsh
neurocognitive
painful
feel
has
to
criticized
enacts
that
someone
her.
In
therapy,
the
patient
can
three
enact
an
identification
with
the
father
who
judged
her
in
ways:
defense)
as
her
father
judged
She
judges
herself
She
judges
you
(character
her.
(transference
resistance).
She
(projection
When
treats
herself
defense
the
treated
the
superego).
she
character
In
of the
the
(Kernberg
her
1984;
(Kernberg
did
solution,
in
child,
the
she
treat
me
a transference
like
ways:
character
of
within
the
Table
11.1
the
(A.
can
Superego
patient
want
if it is
1957).
(reality).
defenses
who
to kill
wonders
He
You
are
such
will
an
with
such
her
father
an
idiot!
her
as
Identified
father:
of the
idiot.
her
judge
idiot.
is
an
as
are
identifications
with
transference
Table
11.1
pathology
In
her
with
You,
the
superego,
or
aggressors
in
resistance,
illustrates
these
(Kernberg
1975).
also
evil
are
patient
I am
view
and
Dad
a spectrum
if you
(reality).
may
You
Im
relationship:
on
Another
correct
this
and
patterns
pathology
occur
him.
past,
her
1936).
enact
of superego
judge
Im
is projection
defense,
Early
These
This
the
you
others
others
Freud
superego.
spectrum
1933):
identical
idiot.
of defense
patients
projection
an
in
1933):
thinks
as
that
treats
imagines
you
summarize,
three
she
Everyone
regards
did
Reich
Reich
she
past:
father
1984;
resistance,
therapist,
To
her
transference
paranoid
father
as
imagines
of reality
critical
may
evil.
his
dont
judges
to
This
his
is
projection
care
testing
a patient
view
about
me.
ranging
who
self-attack
believes
equation
(symbol)
as
To
if
establish
a
you
(symbol)
symbolic
me.
from
as
(Segal
it
is
true
reality
testing
and
people)
The
an
from
to tolerate
healthy
and
criticize
patient
admits
he
others.
They
projecting
onto
at
he
tolerates
but
me.
others
judges
patient
or
other
he
his
healthy
he
have
The
angry
less
denies
The
you
healthy
onto
his
anger,
borderline
judge
constantly
judgment
patient
believes
he
a spectrum.
internal
judges.
Meanwhile,
on
them.
projects
whom
you.
exists
patient
him;
judges
the
next
himself.
STANDARDS
Defenses
based
as
in
on
superego
pathological
pathology
accord
Unfortunately,
with
identifications
. Ideally,
values
however,
of self-punishment.
that
some
The
we
patients
patient
who
standards,
thereby
suffering
fails
herself
from
they
criticize
her.
She
chronic
our
in the
to
lives.
service
to standards
failing
while
live
may
up
to
self-punishment.
her
may
up
for
desires
to
values
to live
symptoms
our
meaning
misuse
Project
believing
create
pursue
give
Judge
her
(the
conflict:
having
A less
moment,
also
internal
for
angry,
like
one
INTERNAL
living
reality
conflict
myself
is
dont
it
alternates:
known
differentiate
internal
patient
feelings
moment
focus,
judgments.
capacity
relatively
internal
inner
even
judge
provoke
onto
them
others,
to
punish
her.
Judge
others
Escape
the
The
same
Ego
as
her
ideal
Ideal:
or by
Who
having
We
than
judgment
immoral
Are
rather
by
herself.
claiming
to
be
standards.
versus
Who
We
Wish
We
Were
None
of
us
is
the
(Chasseguet-Smirgel
our
ideals.
meaning:
as
2003).
They
what
same
are
we
like
value
we
Being
the
and
North
aim
for.
wish
we
were
human,
we
will
Star,
providing
(the
never
a
ego
ideal)
incarnate
framework
of
A patient
this
who
conflict
cannot
in one
bear
not
of four
being
the
my
ideal,
but
I can
be
loyal
hates
to it by
people)
to them
. Since
I know
that
because
rather
Ive
life
hate
learned
Mother
his
than
lacks
was
meaning
hates
. Living
ward
off
were
the
denial.
So
this
his
fear,
ideal
At
he
fears
without
ideals.
that
expulsion
time,
of
his
from
he
paranoid
. He
one
follows
day
from
who
sight
of
When
we
he
the
to
be
to live
group.
as
a fraud.
him
Reality
threatens
for
to
reality
from
now
denying
admire
others
up
results
ideal,
him
(or
flaws,
his
devalues
is
can
will
she
deserves
never
ideal
he
his
or
failing
as
to
To
if
he
his
be
ideal.
threatening
the
forgive
In
we
claims
instructions
with
the
shifts
By
his
attention
doing
so,
we
recognize
these
forms
harsh
self-judgment.
face
ourselves
suffering,
who
were.
can
as
A patient
someone
He
he
against
standards,
perfect.
with
our
guilt
inevitably
superego
and
to
hope
away
he
loses
how
engage
in
flawed
humans
pathology
believes
punishment,
and
An
unhealthy
patient
judgment,
which
perhaps
even
suicide.
Unhealthy?
patient
the
himself.
wishes
a defense
can
idealizes
persons
being.
everlasting
healthy
self-attack,
of
our
be
penalty,
appraisal.
who
be
We
who
through
to
violate
idealized
the
reality
reparation.
Healthy
the
becoming
narcissism
failed
Depression
followers
keep
ideals
character
expose
the
same
denial.
ideal
death
claims
will
the
devalues
of her
a hypocrite.
He
be
handles
not
having
just
others
demands
same
become
leaders
he
or face
the
cults
lie,
ideal,
. Im
and
for
some
He
reality
his
myself.
himself
about
Teresa
himself
hating
He
respected
as
ways:
He
as
same
sees
filter
She
of
sees
ignoring
reality.
harsh
only
her
those
strengths
parts
and
of
herself
for
realistic
substitutes
herself
abilities.
views
consistent
She
insists
with
her
that
she
(a flawed
human
fantasy
(ideals)
identification
not
rage
with
an
innate
worth
as
does
worth.
She
than
a human
not
to
worthy
being.
accept
believes
her
her
herself.
she
must
be
her
critical
value
The
her
for
perfectionism,
toward
regards
enact
criticized
through
be
distinguish
may
a parent
herself
She
cannot
ideal
herself
rather
guidance.
aggressor
intrinsic
attacks
considers
and
her
she
She
patients
Suppose
herself
patient
acceptance
given
Now
ideal.
The
aggressor.
toward
healthy
become
reality.
an
perfect.
directing
should
from
with
being
being)
father.
of
as
constant
unconditional
patient
who
She
believes
perfect
to
identified
she
has
become
no
worthy
of love.
The
healthy
her.
The
inner
In
patient
unhealthy
life,
in
see
S.
Since
Freud
patient
project
that
her
even
can
kill
she
section
to
better
her?
see
will
that
show
or
criteria
for
others.
others,
the
identifications,
create
Thus,
we
character
her
must
help
defenses
feelings
and
(Davanloo
has
she
patient
Does
her
1990,
levels
The
patient
is intrapsychic.
judgment
testing?
of superego
feels
She
assess
guilt
or
to
a
does
judgment
a means
reality
must
her
internal
internal
her
we
bear
her
it become
lost
four
a continuum
the
projects
for
Conflict
on
her?
or
Healthy:
concern
her
2005).
Can
judge
has
suffering.
mixed
exists
she
ignores
PATHOLOGY
action
When
by
These
those
buried
capacities.
others
it to guide
transferences,
her
Gray
pathology
of
aggression
and
against
the
trusting
aggressor,
caretakers.
SUPEREGO
superego
guide
reach
an
experienced
perpetuating
turn
life,
direction.
defenses
1940/1963;
OF
variety
to
inner
with
for
aggressive
and
to
LEVELS
she
response
problems,
transferences
2000;
identified
character
patient
to her
self-doubt
with
as
presenting
the
her
identifies
enacted
attention
patient,
trusting
summary,
child
pays
help
torment
onto
The
or
others,
following
pathology.
guilt,
loves
remorse,
herself
and
and
her
ideals.
She
accepts
herself
while
living
Neurotic:
concern
for
others,
self-shaming,
misuses
and
but
self-attack
ideals
to
of
guilt,
experience
The
attack
a life
patient
defenses
lead
to
herself.
remorse,
and
than
values.
and
self-punishment,
depression
believes
her
guilt,
of
Rather
she
on
feels
her
sometimes
based
anxiety.
tolerate
She
her
it is due
to
internal
criticism
by
bearing
her
others.
Borderline:
guilt,
remorse,
her
or self-concern
superego
(Other
onto
people
projects
her
longer
are
others,
or she
and
trying
forbidden
to
her
denies
me
trouble
self-attack.
afraid
feel
onto
guilty.)
others
and
paranoid,
guilty
projects
their
judgment
Alternatively,
judges
she
them.
but
fearing
to avoid
She
of
intrapsychically,
become
feeling
has
to severe
make
conflicts
to
patient
becomes
impulses
her
leads
due
others
experiences
Projection
The
She
interpersonally.
punishment
severe
no
from
self-punishment.
To
avoid
hold
the
severe
self-attack,
high
values
but
contradiction
short
In
of
ideal,
response,
them
act
between
her
and
anyone
against
her
her
she
she
uses
denial
them
without
values
and
her
self-devaluation
may
who
abandon
has
a life
she
the
falls
mood
swings.
and
devalue
ideals
without
may
by
When
severe
of
She
troubled
actions.
pursuit
living
splitting.
being
creates
the
them,
and
meaning.
The
patient
enacts
tolerates
pathological
them.
during
the
session
Since
his
father
regarded
hitting
For
identifications
instance,
when
called
himself
he
him
a
said
borderline
he
and
as
character
patient
something
names
in session
as
slapped
traits
slapped
regarded
him,
and
himself
as
the
stupid.
patient
normal.
The
borderline
patient
the
of the
reality
transiently
therapist
and
loses
sight
the
projections
Psychotic:
This
of
the
she
patient
difference
places
projects
between
on
him.
primitive,
aggressive
images
she
sight
loses
projections.
onto
of
She
(Meissner
the
as
enact
resistances
closeness
that
from
anxiety,
impoverishment
of the
we
Type
One:
The
examine
experience
she
this
has
about
self-hatred.
self-judgment
someone
who
ones
Some
are
patients
irrational
herself
critical
or
testing
They
function
the
create
emotional
symptoms
of
self-reproach,
sterile
and
offer
relationships.
interventions
for
them.
as
it
she
in
can
with
her
mind
take
the
or
She
critical
form
thought
of
this
healthy
may
conscious
spectrum
of
conscience
to
self-hatred.
superego
of
judged.
show
a relatively
severe
aware
was
as
their
critical
self-criticism,
as
if it is an
internal
voice.
because
we
kids
feeling
her
reality
and
They
vignettes
from
Pt:
The
feelings
and
voice
someone
suffers
Experiencing
and
Oneself
following
from
of
therapy.
them.
defenses
herself
The
of
sharing
judge
as
loss
sabotage
personality,
these
can
because
people
self-destructiveness,
Judging
patient
fear
Pathology
experience
results
constant
other
severe
Superego
the
depression,
Below
identifications
to
in
1975).
of
that
lives
between
from
Kernberg
Psychodiagnosis
She
difference
suffers
1984;
Defenses
others.
would
would
like
I told
have
have
to
to
I shouldnt
I didnt
move.
lose
have
Bill
I would
all
done
want
their
that,
him
to
to
give
have
friends
like
here.
it was
take
that
up
But
selfish
my
job
job.
Ive
been
of me
to say
that.
Th:
the
room
Its
as
her
internal
to
if its
attack
you
against
the
critical
voice
Its
as
law
by
as
if a policeman
soon
as
to do
showing
you
that.
stand
[ superego
up
[ Differentiate
her
how
she
for
] comes
what
the
into
you
want.
patient
from
condemns
herself
after
asserting
herself
Identification
with
Self-attack
a pathological
occurs
attacked
.]
her
when
in the
introject
the
patient
attacks
of
woman
rage:
reported
Self-attack
that
working
clinic
will
too
with
finally
long?
me.
Im
decide
[ Defense:
Im
for
criticizing
What
is
like
that?
you
daughter.
criticizing
Do
you
self-attack
right
you
That
now?
feeling
instance,
unfairly.
I dont
know
why
you
you
think
the
Dont
therapy
the
because
its
taking
Im
you
terrible
have
toward
mother.
your
[ Defense:
this
out
But
you,
the
am
not
your
mechanism
defense
a
feeling
in
your
toward
mind
is
.]
terrible
mother.
[ Defense:
.]
is criticizing
defense,
you
but
Do
right
nowdo
it is syntonic
you
you
think
down?
back
down.
and
but
This
I think
it is right.
mechanism
be
[ Point
out
Pt:
Yes.
observes
how
this
mechanism
in
your
now?
it might
Do
notice
[ Now
she
sees
the
.]
Th:
you
you
Yes,
Th:
steps
the
how
[ Point
Pt:
getting
in
For
her
better.
be
describes
notice
Th:
getting
any
I think
Pt:
mind
mother.
against
.]
Th:
your
someone
.]
Pt:
self-attack
criticized
I shouldnt
Th:
daughter
daughter
getting
self-attack
a defense
a defense.
a terrible
not
as
is always
a teenage
Pt:
keep
as
past.
Self-attack
experience
herself
hurting
you?
causality:
You
think
the
this
you
think
it might
Pt:
Oh,
definitely.
the
defense
that
.]
Do
you
think
defense
critical
be
is criticizing
it might
you
anxiety
right
be
her .]
mechanism
making
[ Her
hurts
you
might
be
depressed?
drops
as
she
Th:
side,
could
feeling
we
shift
is toward
If we
your
see
your
what
the
for
daughter
daughter
feeling
critical
a
mechanism
moment
and
off
see
to
the
what
the
instead?
Okay.
Th:
and
that
perspectives
Pt:
hard,
put
You
mentioned
criticized
is toward
Pt:
you
your
I didnt
Th:
that
in a way
daughter
like
Whats
you
been
trying
was
unfair.
Lets
that
for
being
it. [ Defense:
the
have
unfair
to you.
intellectualization
feeling
toward
toward
her
her
.]
for
doing
that?
Pt:
Anger?
Th:
The
patient
turns
depressed.
Her
her
world
internal
(Jacobson
for
the
Help
judgment.
she
feelings.
90).
pay
Point
can
on
herself
realistic
following
appraisal
to the
fat,
Each
of
and
no
these
critical
defense
are
feelings.
Self-attack
little
cuts
from
report
voice
the
low
in
of self-attack,
common
statements
defends
is
becoming
from
external
world
self-esteem,
look
forms
not
the
her
mind
focus
content,
on
of
attacks
the
the
her.
underlying
of self-attack:
I am
bad,
stupid,
failure,
good.
continue,
Self-esteem
that.
condemnation
function,
ugly,
doing
self-attack,
because
patients
for
it.
how
the
through
plummets
attention
out
see
angry
Whenever
creating
patient
The
rage
replaces
1971,
the
felt
self-esteem
defenses
Once
the
You
against
like
of self-attack.
tree
I am
not
I will
never
I dont
I shouldnt
guarantees
feeling,
creates
a
that
the
and
depression
she
can
good
be
enough.
able
deserve
feel
patients
rejects
the
and
nurture
suffering
patient
low
or
to
chop
and
will
her
self-esteem.
down
with
In
the
following
depression,
She
example,
delusions
had
her
stage,
of
suffered
Because
the
I address
her
could
not
traumas.
I had
syntonic.
She
defense
her,
her
badness
with
this
symbol
see
against
how
her
is
rage
fact,
too.
to her.
How
should
Enact
her
should
not
the
punish
as
child.
so
impaired
at
not
love
not
have
bad.
me.
had
this
[ Her
these
self-attack
She
does
people
who
hurt
She
know
all
herself.
description.
Since
I havent
myself,
[ Surprise
yourself.
cured
do
of self-attack
Pt:
you
treats
hallucinations.
is
not
see
her.
For
equates
herself
.]
I punish
pattern
does
I am
toward
not
of badness
Th:
bad
she
psychotic
way.
I would
because
abuse
are
God
Otherwise,
traumas
cannot
sexual
think
terrible.
from
auditory
in a different
Im
me.
these
this
and
self-attack
love
and
observe
Pt:
he
and
physical
to
suffered
persecution,
from
ability
patient
you
so
and
[ She
think?
she
yet,
see
yet
be
a mirror
it .]
.] What?
not
I must
[ Present
can
a smile
does
you
Oh,
see
her
Dr.
Jon,
self-attack
.]
Th:
fact
that
bad,
I havent
I deserve
myself?
[ Mirror
patient,
which
cured
to
be
the
the
you
you
patient
bad.
punish
superego
And
cured
since
myself,
me
do
Im
But
bad,
you
punished
used
yet.
on
by
I am
bad.
you
think
do
her
you
punitive
herself
the
I
am
punish
used
on
the
.]
much
better
now.
still
arent
cured.
And
are
funny.
to punish
[ Mirror
since
mother
I am
I deserve
and
I should
you
you
now,
And
.] Oh,
think?
the
myself.
punitive
You
cant
that
How
logic
help
means
should
of
I
her
.]
Pt:
yourself
How
[ Laughs
cured
means
logic
just
Th:
am
yet
pathological
havent
have
punished.
Pt:
it that
I should
what
herself
I have
.]
been
[ Laughs
doing
.]
to me.
Now
I see.
[ Now
she
You
are
doing
sees
how
she
to
has
Th:
punish
myself,
relationship
think
she
I am
mad!
and
not
then
had
you
[ Point
feel
we
with
her
[ Laughs
Th:
No,
are
out
the
it toward
mother,
Mobilize
my
so
her
punish
yourself,
suffer
together.
.] Oh,
that
at
she
warded
you
think
Oh,
mother?
Th:
Do
Pt:
Yes.
think
angry
rage
you
to the
would
the
[ Now
you
of
Sometimes
the
himself
rather
patient
can
someone
dont
people
off
her
we
horrible.
could
the
Do
you
use
guilt:
Self-attack
patient
you
are
than
use
toward
to
caused
through
the
a look
turn
it
those
self-attack
anger
on
.]
me
is much
at
on
as
a defense
this
that
rather
higher
anger
yourself
.]
toward
instead?
ward
a defense
that
defense
someone
self-attack
who
.]
is
can
I think
so?
to
task
bad.
awareness
take
have
therapeutic
off
wards
to
else.
off
direct
Here
his
against
genuine
feelings.
rage
we
see
guilt
the
against
how
over
the
hurting
else.
Pt:
Jane
[ Mirror
be
are
I turn
think
Shall
you
Self-attack
experience
and
.]
I dont
really
Th:
your
could
mother
Pt:
Pt:
than
could
bad?
I think
traumas.
You
last
night.
often
because
cried
and
invites
the
rather
than
Im
such
What
Pt:
I told
therapist
by
her
Dont
his
too
you
to be
own
so
terrible
a terrible
Th:
I find
cried.
I feel
Do
Pt:
I do.
Th:
How
way
I talked
to
person.
her
I dont
fat.
I told
that
you?
her
to make
I think
just
so
he
can
love
she
terrible
feel
to her
[ Block
you
the
I was
make
projection
ugly.
She
of
me?
[ He
judged
by
.]
perfectly
awful
it up
to her?
so
is
.]
I think
did
want
was
superego
conscience
Th:
the
happened?
think
his
about
to her.
me
Pt:
What?
Th:
So
Im
wondering
how
You
you
Pt:
awful
her
therapist
to
or
need
her,
not.
Are
her
only
you
[ Block
his
I felt
than
would
you
Given
can
know
awful
to
her.
to her?
thinking
that
I should
you
whether
projection
.]
terrible,
reach
out
I hadnt
that
have?
[ Projection
think
you
That
you
were
want
may
not
to
be
perfectly
make
it up
something
to
you
be
would
You
apologizing
Its
as
substitute
for
your
enough.
reaching
guilt,
the
patient
differentiate
if your
figured
attacks
attacked
actually
if
himself
yourself,
tell
self-attack
out
In
out
of the
uses
her
was
to
engage
(relational
in
that
I was
sorry.
a substitute
for
and
the
to
about
yourself
self-attack
it.
became
a way
repairing
avoid
same
the
When
thing
facing
(narcissistic
their
afterward
to avoid
damage?
.]
reparation).
reparation,
this
her,
thats
self-attack
to her
attacking
Was
defense
I think
back
way,
to her.
reaching
function
come
self-punishment
guilt
I did
his
with
guilt.
Paula.
Always
self-absorption)
patients
so-called
guilty
fail
from
to
apologize
feelings
have
function.
Self-attack
experience
I just
[ He
if you
I didnt
I didnt
Pt:
defensive
that.
to her.
Th:
healthy
be
thought
true.
Its
Pt:
out
about
enough.
Th:
facing
thought
to her .]
Pt:
and
were
.]
Th:
Th:
This
you
to repair.
rather
Point
think
.]
Pt:
told
it up
[ Silence
Pt:
the
made
you
I didnt.
Th:
onto
said
of pride
: A patient
reports
that
as
she
a defense
won
against
a baking
the
contest
at
her
and
church
her
but
puts
pleasure
herself
down
in defeating
to
avoid
the
the
to ward
off
ego
and
grief
the
when
ego
they
must
have
herself:
be
myself
incarnate
may
like
whom
for
image,
experience.
rather
she
herself
fantasy
than
for
the
themselves
ideals.
able
the
ideal.
tensions
to
get
patient
Since
answer
so
that
is
job.
saying
I am
not,
next
time
to
must
I
can
Another
detests
not
being
By
blind
her
the
should
the
like
failing
person
She
herself
truth
be
for
essence.
comparing
to
(I
image,
of
she
severely
herself
ideal
reality
ideal.
a belief
an
when
becomes
punishes
loves
the
becomes
to
she
patient
She
but
relates
Then
excited
of
with
her
someone
a
own
else)
reality.
Character
defenseidentification
introject
friends
to
attack
feeling
ideal.
knows.
she
She
been
swings,
be
fails.
idealizes,
condemns
may
[ Here
my
response
to their
have
as
mood
to
she
someone
she
up
wrong.
same
suffer
when
her
.]
appears
depressed
to live
searching
ideal
momentarily
to be
by
that
patient
the
in
Patients
I should
something
I should
torment
done
ideal:
fail
Pt:
of
them.
Self-attack
between
envy
enacted
with
habitually
(see
a pathological
chapter
12
for
more
examples)
The
treating
herself
patient
wards
herself
what
off
anger
aggressively
others
did
the
[ Talks
Th:
[ Defense
and
feelings.
aggressive
those
figures
figures
did.
She
you
talk
rapidly
of
talking
by
does
to
you
.]
notice
how
right
.]
Yes,
Th:
anxiety
ways
rapidly
Do
identification
Pt:
earlier
to her.
Pt:
now?
toward
If we
I always
Thats
slow
do
often
down
that.
a
for
way
a moment,
are
over
you
your
aware
of
feeling
anxious
defense:
who
she
right
ignores
ignored
her
now
herself,
feelings
You
talking
quickly
over
your
feeling
anxious
right
now?
Pt:
anxious.
it is
Do
no
big
relation
of an
way
her
to
treat
thought
you
might
be
aware
of
before.
about
how
no
deal.
[ Patient
talks
quickly
big
again
.]
say
its
dismiss
of
and
no
big
your
description
the
ignored
When
way
you
to treat
[ Help
deal
that
anxiety
you
right
now
identification:
child
are
as
an
if
object
.]
dismiss
yourself
the
your
anxiety
or might
patient
see
it be
the
as
a
cruelty
no
big
dismissive
of
ignoring
.]
I guess
its
dismissive.
I just
hadnt
thought
it before.
Th:
about
big
of that
you
you
Pt:
about
someone
Yes.
yourself?
feelings
with
identification
Are
mother
a caring
character
anxiety.
how
Th:
is that
the
and
You
[ Implicit
ignoring
[ Address
feelings
Th:
Pt:
deal,
hadnt
Its
notice
deal?
an
thought
of self-dismissal
you
me?
enacting
I hadnt
Th:
defense
with
.]
Pt:
Character
here
it now.
deal.
talking
So
Has
over
you
see
it been
that
a habit
usually
stop
I do
to notice
to it. If you
ignoring
it,
important
for
to
your
anxiety
no
ignore
and
anxiety
by
talk
fast
your
call
feelings
us
to
think
you
could
it could
get
the
anxious
talk
your
all
time.
Thats
true,
and
or not.
over
your
anxiety,
anxiety
rather
than
pay
it just
Escalates.
Th:
so
to
You
ignore
Pt:
anxiety
its
it is dismissive
if Im
Th:
attention
why
them?
Pt:
dont
Thats
Would
get
worse.
it make
handle
[ Invite
sense
on
the
it?
to pay
attention
Otherwise,
patient
to
if
turn
you
against
to this
keep
the
defense
and
pay
attention
to her
Pt:
observes
the
price
of the
That
and
Mobilize
the
anxiety,
are
unconscious
over
past
self-neglect
as
she
Pt:
Im
Th:
choice
Each
to pay
time
against
we
that
identifications
will
This
Complete
This
before
identify
herself.
She
we
with
is especially
in
of
patient
herself
over
an
a
depressed
woman
she
stalemated
in
responded
the
minimally
session,
desires
vignette
onto
she
the
occurred
to
two
into
Th:
she
the
Do
you
it.
and
turn
of
the
part
against
parents.
these
Otherwise,
rage
back
onto
patients.
superego
1975,
for
delighting
121).
envies
She
(Klein
1975b).
at
all
to
She
had
medications.
projecting
could
because
therapy.
not
in
destroys
a consultation
defiant,
whom
of ignore
up
the
twenty-year-long
became
hours
turn
she
and
make
chest.
self-defeat,
presented
consultant,
her
and
(Kernberg
you
up.
turn
pathological
treatment
quickly
toward
therapist
as
.]
defense
and
pursues
ideal
chronically
was
the
grief
comes
depressed
consciously
as
triumph
for
with
self-destructiveness
to
rage
and
in my
character
see
your
opinion?
guilt
deactivated
session
true
identification
type
must
of
instead
have
explore
them
now
to
your
comes
pain
in
defense
feeling
see
attention
Rise
feeling
anxiety
we
superego.
patient
.]
the
some
patient
pay
up.
against
to your
the
tear
painful
identification,
pathological
she
help
to
feeling
attention
[ The
attention
alliance
painful
Some
to
this
turns
Some
sense.
begin
worth
[ Begins
Th:
this
we
therapeutic
Pt:
.]
.]
As
you
instead
makes
defenses
Th:
feelings
feelings
her
oppose.
In
healthy
The
following
interview.
notice
how
you
deaden
defiantly
.]
your
emotions?
Pt:
Th:
I want
to be
Obviously,
dead.
if thats
[ Said
what
you
want,
it can
be
easily
arranged.
you
from
As
killing
you
yourself
omnipotent
transference:
wants
herself
to kill
know,
if
as
Obviously,
helpful
you.
an
if
going
to you,
you
pathological
the
by
emotions,
youll
a dead
helpful
If you
have
your
therapist,
the
destructive
superego
an
see
time.
nor
the
and
In
deprived
this
de
Labije
trait)
that
for
her
pathological
she
hoped
to
helped
her
At
levels
mild
conflict,
severe
you
the
alive
if
emotions
can
she
as
dead
And
as
you
be
able
too.
woman
is
[ Mirror
the
the
pathological
you
your
continue
think
that
.] But
then,
with
help
deaden
to help
identifying
that
will
can
if you
go
yourself
with
long
and
do
yourself.
superego
of
feel
your
identify
would
to
have
would
be
neither
you.
I,
[ Point
her
out
pathological
[ Begins
to
cry .] I guess
grief
and
I deactivated
the
2005,
2009a).
2006,
strivings
1975,
stop
guilt
Ive
over
fed
how
up
she
major
has
hurt
.]
from
123).
ensure
By
its
patients
identification
Her
identification.
while
freedom
(Kernberg
her
years
to yourself
a pathological
healthy
than
therapy.
else
to
herself
enacted
keep
Deadening
then,
result
begins
2001,
I can
emotionally
pathological
impact
example,
[ Deactivate
to deaden
twenty
anyone
do
an
says,
But
another
[ Mirror
[ She
can
want.
woman,
as
rather
it .]
Pt:
big
therapist
you
to deaden
obligation
a dead
for
.] Why
life
which
have
to you.
want
dead
through
mirroring
therapy
your
true.
emotionally
patient
superego
what
believes
Thats
superego,
Help
I nor
.]
Th:
life
thats
she
Pt:
through
neither
she
the
defeat.
defiance
She
opposed
to join
By
(the
invited
by
me
to
speak
She
gained
identifying
with
it
in the
deactivating
Have
character
me
them.
superego
refusing
(Ten
therapeutic
her
task,
identification,
change.
of superego
criticizing
levels
of
herself
superego
pathology,
for
the
patient
forbidden
pathology,
suffers
wishes
the
patient
and
from
internal
feelings.
avoids
internal
At
conflict
by
She
projecting
can
project
therapist
her
her
healthy
her
strivings
for
impulses
loving
or
onto
onto
the
onto
the
so
progress.
fearing
others,
superego.
therapist,
therapys
others,
impulses
pathological
their
fearing
the
She
attacks.
they
can
Or
will
she
violate
boundaries.
Type
Two:
The
Judging
patient
judged.
can
This
Others
enact
the
is a manic
I am
dont
ulcers.
I give
a superego
to
have
Being
This
type
He
of
his
quietly
pathology,
people
guilt)
at,
to
or fearful
the
his
of,
following
girlfriend
betraying
is
his
comes
onto
no
When
the
out
and
with
she
unfaithful
to
someone
you
are
doing
patient,
him.
he
was
suffer
from
who
said,
up.
I got
You
Pt:
Yes.
to your
impulses,
him.
Then
Isnt
wife?
(to
judges
avoid
becomes
his
his
angry
his
frantic
she
it interesting
out
that
over
times
she
stand
was
the
guilt
five
that
I couldnt
believes
deed.
girlfriend)
got
wife,
experience
for
(the
afraid
[ Point
to
than
enraged
were
superego
he
he
he
judges
therapist.
girlfriend
her
of
privately;
his
superior.
He
levels
unfaithful
I really
so
Th:
Pt:
his
and
punishes.
severe
Rather
I called
pick
else.
out
judging
punishes
Th:
what
as
boss
officious,
he
At
judging
the
didnt
bossy,
complains
point
are
Pt:
hour,
the
whom
longer
example,
he
others
I dont
Like
himself.
you
you
as
others
supposedly
wife,
guilt:
others.
across
patient
that
judging
others
judging
claim
against
to
avoid
in person.
by
them!
impulses
the
may
superego
patient
projects
others
identification
defense
superego!
In
wishes
responsible
rageful
project
her
her
becomes
project
can
healthy
was
projection
an
going
it.
betraying
you
in
you.
accuse
her
of
.]
What?
Th:
Isnt
it
interesting
that
you
accuse
your
girlfriend
of doing
to you
what
Pt:
I hadnt
Th:
done.
[ Point
condemn
he
out
how
myself?
can
and
That
Pt:
[ Becomes
argue
what
you
did
him
what
face
I did
his
Sometimes,
not
guilt
feel
bad
the
yourself
worrying
of
his
Only
for
what
you
you
saying
into
a judge,
whom
you
should
therapist
than
ask
about
as
his
and
projection
.]
saying.
the
his
girlfriend
the
pathological
have
should
the
his
it for
you
help
(You
something
and
of
him .]
superego
accuses
pause
her
Next,
Remember:
superego
Now
projection.
done
patient.
content.
I accuse
to bear
have
criticism,
its
whether
see
they
to
know
youre
can
enact
just
the
what
[ He
apologize
criticism
her
.] Are
can
[ Block
assume
therapist,
the
you
wife.
patients
and
of that.
anxious
I see
therapists
accuses
fear
my
wife?
her .]
or not.
rather
when
helpful),
They
to
to your
with .]
Pt:
doing
doing
condemn
to make
Th:
condemn
you
judges
tries
are
thought
he
[ He
oppose
you
are
wrong.
the
patient
him . If you
reflect.
know
find
Notice
how
he
your
criticizes
himself.
In
the
next
disorder
example,
a patient
alternately
therapist
punishes
addresses
this
suffering
himself
from
or the
particular
borderline
therapist.
defense
in
personality
Notice
a
how
the
noninterpretive
fashion.
Pt:
the
most
from
stupid
a book?
hearing
getting
this
any
this
worthless,
say
for
attacks
speak
thing
Dont
better.
from
within
have
I keep
crap
[ The
An
the
ever
from
coming
you,
doesnt
attacks
interpretation
of the
the
heard.
and
that
patient
role
is on
anything
stuff
stupid
himself.
voice
I have
you
worthless
yourself?
[ His
would
attacked
verge
of yelling
Where
useful
and
to say?
it
you
Every
doesnt
nothing
What
letting
trigger
person
do
me
another
.]
get
is
that,
time
Im
Im
not
help.
changes.
help.
me,
did
.] That
All
I hear
is
you
have
to
know
how
he
attack.
So
Th:
what
I say
is off
is useless
that
what
we
he
and
help.
is good
a devaluing
into
argue
[ The
the
with
that.
of the
time
into
is true.
as
the
his
chair
A lot
what
All
I can
, that,
hope
is
end,
shows
without
attacking
patient
usually
.] Gosh.
of
I say
in the
steadiness
patient
depression
say
Sometimes
therapists
by
[ Relaxes
you
stupid.
enough
attack
collapsing
that
in turn
does
.]
could
I wish
that.
Transference
resistance:
Moderately
resistant
contrast,
highly
transference
resistance
parents
resistant
to
avoid
that
the
his
internal
therapist
the
hat
therapist
spectrum
patients
of
him.
has
about
judges
onto
him.
have
past
the
often
feelings.
treats
In
relationship
term
transference
And
has
what
is,
of
they
a
(the
transference
resistance.)
In
the
the
as
his
therapist
Judge
patient
This
the
The
may
projection
project
can
and
range
therapist
to
following
examples
an
integrated
reality
project
conscience
reasonable
imagine
from
a complete
will
mild
conviction
exhibit
this
conscience
testing,
is
they
usually
they
can
are
aware
healthy
acknowledge
of
their
integrated
as
their
judgments.
You
Th:
2004).
the
the
excellent
Pt:
(Blackman
resist
testing.
others
consciencethat
which
on
patient
judges
of reality
projection.
the
enact
relationship
to
hence,
judgment,
patient
Projection
When
13 ,
Projection
thought
the
chapter
a past
defenses
patients
feelings,
of
him.
Three:
To
use
resist
resistance,
treated
Type
enactment
patients
(See
transference
own
I cant
result.
Pt:
say
of what
its
enough,
a good
without
much
Sometimes
doesnt
have
survived
and
target.
I say
can
Well,
probably
I
think
dont
thats
think
your
this
is a good
conscience
idea.
talking
In
the
next
projects
example,
her
inner
the
judge
patient
onto
Pt:
myself
a raise
but
not
to
the
her
location
of
projection
the
I dont
patients
a raise,
you
but
resent
demanding
In
her
and
of
you
true.
And
will
how
like
she
it
if
give
.]
thought?
she
[ point
wont
out
maybe
out
[ Draw
can
instead
like
her
more
of
she
yourself
internal
if you
how
she
Thats
attention
easily
see
if you
give
judgment
could
your
.]
accuse
projects
what
know
true
about
her
them
of
conscience
own
],
conscience
is
patient
believing
they
judge
will
see
her
judge
functions
following
inner
her
of this
projects
her.
already
judging
yet.
her
She
judgment.
for
seeking
in a dangerous
an
I am
superego
the
can
because
any
example,
assignment
accident,
must
The
lacks
see
her
onto
projection
believes
leave
Having
the
judgment
patient
medical
area.
she
inner
to
lost
avoid
many
strength
her
an
physical
necessary
for
assignment.
Pt:
requesting
Defense:
medical
projection
of her
Pt:
severe
enough.
Im
afraid,
leave,
Th:
really
fact,
Thats
a punitive
overseas
am
so
Pt:
dont
colleagues,
colleagues
the
thought,
[ Point
them
they
following
before
see
of you.
Projection
In the
staff
projection
that
them.
Pt:
myself,
my
is having
not
conscience
could
to
I am.
Th:
your
help
.]
Th:
being
think
[ Defense:
Who
Pt:
yourself
more
others.
them.
Th:
needs
theyll
superego
Are
you
Well,
[ Defense:
Th:
if the
What
onto
having
Im
are
they?
office
get
angry
the
office
staff
sure
.]
of my
really
some
not
denial
rest
doubts
my
finds
with
me.
.]
yourself
medical
out
issues
?
are
Pt:
to
the
will
doctors,
cause
and
Ive
got
I cant
problems
carry
with
the
Th:
you
cant
carry
carry
how
more
You
eighty.
And
you
Point
out
denial
.]
the
I cant
have
carry
medical
taking
leave
medical
to do
but
her
you
with
what
projecting
to
now
yourself.
deactivate
it
neck.
lung
function,
and
are
required
to
twenty
but
are
required
to
her
you
we
They
her
like
you
you
qualify
I should
be
you
leave
and
even
try
cannot
do.
[ Smiles
ability
to
If I can
do
this?
carry
only
and
punish
Do
you
that
arent
you,
see
and
onto
You
criticize
denial
I mean?
.] Thats
not
who
[ Point
of
asking
.]
imagine
you
.]
yourself
by
relieved
You
it is
denial
reality
the
defenses
true.
to
they
is
would
critical
out
her
have
and
conflict:
self-punishment
and
.]
I think
Some
are
doing
Pt:
[ Defense:
for
they
would
be
angry.
might
be
in
[ Defense:
.]
you
projection
the
to.
are
going.
what
it.
ignore
you
but
others
But
superego
not
for
cant.
out
yourself
of recognition
like
for
criticizing
able
[ Point
It sounds
are
to
a smile
yourself
superego
see
mean.
when
a leave,
of her
you
Even
Th:
right
else
you
your
what
in fact,
I feel
Pt:
projection
or
when
about
Th:
punish
take
carry
doubts
when,
you
to yourself.
wish
can
I see
Th:
punitive
my
percent
pounds
It sounds
Pt:
angry
pounds,
eighty.
Pt:
be
fifty
according
pounds.
You
Th:
to go,
twenty
have
Eighty
Pt:
yourself
than
on
function,
much?
carry
for
lung
I had
twenty
Th:
taking
percent
more
surgery
than
Pt:
twenty,
fifty
of
them
criticizing
that.
yourself.
[ Point
that
others
That
explains
out
want
why
her
to punish
I have
You
the
future,
are
but
punishing
self-punishment
to
her .]
been
doing
favors
for
other
people.
Th:
As
Pt:
In
the
next
example,
women
will
not
patient
see
his
Notice
how
patient
he
afraid
of the
him
This
find
me
distinguish
his
fails
social
through
places
out
tonight,
Im
out
going
projection
internal
Who
anxiety
how
Socratic
to help
questioning.
causality,
on
fears
showing
women.
the
He
is
not
judgment
that
his
from
but
I dont
think
they
.]
has
distinguish
his
thought?
fantasy
[ The
from
projection
patient,
reality.
of it onto
First
others
.]
Me.
Who
had
the
thought
yesterday
that
you
attractive?
Me.
Th:
you
assignment.
illustrates
he
to
Pt:
that
case
projections
Th:
not
from
others
[ Defense:
Pt:
were
the
themselves.
attractive.
neurotic,
on
points
Th:
although
forgiveness.
then
Pt:
will
their
going
attractive.
onto
of
women
not
suffering
therapist
afraid
for
patient
projection
the
is
Yesfor
a
find
if to ask
were
And
who
had
the
thought
the
day
before
overweight?
Pt:
Me.
Th:
So
Pt:
Me.
who
Th:
has
And
those
who
self-critical
is
accused
thoughts?
of
having
those
thoughts?
Pt:
These
Th:
thoughts
he
can
and
that
you
differentiate
put
his
You
arent
those
see
how
thoughts
from
these
onto
his
are
your
women?
projections
self-critical
[ Determine
if
.]
Yes.
Th:
date.
you
self-criticism
Pt:
you
Do
women.
It is understandable
afraid
of
the
women.
you
You
feel
are
anxious
afraid
when
of
the
critical
mechanism
fear
women
these
that
but
women
the
from
you
not
his
distinguish
wonder
you
you
put
get
that
judge
uncomfortable.
Youre
judgmental
image
anxiety,
projections
he
projections
does
not
Differentiate
the
them
them.
the
[ Point
it
Then,
when
afraid
Differentiate
afraid
out
women,
he
women,
are
Youre
women.
[ But
.]
judge.
you
on
time.
reality
on
internal
women.
judge
the
from
put
an
those
on
[ He
them.
all
women,
of
on
project
then
women
and
of
the
is
that
conflict:
fear
the
from
his
.]
Pt:
the
you
have
afraid
place
places
thoughts
these
not
you
closeness,
You
onto
on
(projections)
when
anxious.
places
those
thoughts
And
women.
.]
I have
his
those
he
projections
Th:
no
on
projections
Pt:
does
place
That
explains
why
I get
so
anxious
before
date.
Th:
are
busy
date.
meeting
That
these
would
make
havent
images
of
anyone
Pt:
Externalization:
You
met
a judge
the
woman
yet,
[ projections
but
you
] before
the
anxious!
[ Laughs
.]
projection
of
the
the
has
superegoblaming
and
complaining
In
externalization,
punishes
herself.
blames
them,
and
Unable
others
she
or
people
myself.
perspective.
Projection
experience
blind
are
do.
I can
(See
of
to
be
a feeling,
her
about
results
Restructure
of
to see
complains
remains
complaining
other
patient
the
defense
how
ways
she
at
them
externalization
chapter
the
guilt
9 on
pathological
restructuring
superego
punish
punishes
. I dont
rather
to
anxious,
and
of self-punishment,
they
of externalization
angry
becomes
than
establish
regressive
to
avoid
her.
Blaming
herself.
Blaming
punish
face
she
myself,
how
an
internal
defenses.)
the
hurt
These
patients
Then
they
they
regard
them.
A
avoid
anticipate
as
woman
believes
wanted
projects
her
is
retaliatory
an
she
her
damaging
her
supposed
judge,
that
In the
she
showing
the
on
patient
not
since
Jon
example,
we
from
her
were
Monday.
marriage.
notice
how
her
others
to
the
toward
at
projection)
the
therapist
of
is
her
hurting
the
causality.
she
all
feels
but
the
proof!
Since
she
guilt,
judge
her.
By
price
of
Attacking
blinds
her
her
blocks
to
the
projections,
affects
result
argument
the
from
her
actions.
We
ratcheting
up,
talk
whom
fact
he
defensive
husbands
judges,
deserves
the
sees
on
others.
I have
he
her
onto
husband.
love
longer
Husband:
Lets
the
her
how
her
to
avoids
(based
is destroying
projections,
And,
rage
now
believes
off
no
provoke
and
blind
she
She
they
me,
she
superego
supposed
onto
is killing
marriage.
following
Or
becomes
superego,
the
these
critical.
judge,
and
her
from
superego
She
loves
projecting
projecting
to punish
unfair
rage.
someone
or
you
he
by
judgment
unfair
I knew
fact
guilt
had
an
I said,
about
this
Lets
then,
hold
and
other
off
see
night.
until
we
if he
see
can
help
telling
you
us.
Th
to wife:
Wife:
how
he
did
so
misrepresenting
well,
and
me,
judges
herself
judges
her .]
as
all
if
he
thought
it
today.
you
said.
would
He
did
all
bad.
as
He
said
be
not
you
good
portray
[ Block
he
says
and
pays
the
the
had
two
as
projection.
It feels
attention
of
an
hes
all
all
Point
that
way.
only
to
nor
out
reality
[ Projection.
the
but
and
good,
feeling
he
to
that
he
did
he
is not
said
me
is
[ She
claiming
heard,
talked
like
good.
projects,
you
you
is
I feel
argument,
of
he
control.
but
what
feeling?
like
and
bad,
be
himself
Wife:
what
if
out
all
notice
I feel
bad,
may
two
you
angry.
all
or
That
do
I was
Im
good
Th:
what
I feel
how
as
What
he
about
he
portray
.]
She
her
ignores
projection
it
creates
.]
Th:
he
is calling
you
assumption.
Thats
[ Her
why
same
all
as
we
husband
bad,
course
you
projection,
have
what
Of
he
actually
of
acts
what
in
happens
here.
him
lower
[ Now
but
functioning,
under
stress,
have
to
that
superego
ability
look
at
lead
at
therapist
to do
different.
This
you
with
the
that
feeling
is
projection
are
not
getting
is much
.]
not
the
from
her
worse
husband
and
realistic
to
me
invites
than
me
to
to sink
to
of
enacts
of
criticized
(Kernberg
shifts
in order
level
of
done
was
him,
at
1975,
that
at
your
top
But
we
see
that
drops
the
the
by
1976).
to make
task:
as
projection
why
you
to
so
face
her
the
punitive
a person
from
the
.]
pathology
what
them,
in the
criticize
then
shift
at one
others
or
thinking
their
to them,
doing
the
pathology
himself,
again
therapist
the
do
and
and
moment
therapist
of the
did
enact
is
past.
moment
The
sense
make
projecting
her
character
next
that
character
done
may
Thats
therapist
to
of
able
precipitously.
therapeutic
from
identification,
child,
know
herself
the
of patient
an
to
onto
level
criticizing
We
Differentiate
was
borderline
are
competent.
to themselves
what
of you
underneath
suffering
doing
both
you.
punish
husband.
type
he
these
to
what
When
parent
her
feelings
her
to them
at
the
He
function
patient
neurotic
by
Patients
accuse
us.
incredibly
the
when
identifications
going
assume
go
assumed
the
you
that
not
to
projections
Patients
sure
the
her
functions
Oscillating
Im
are
your
onto
she
the
that
creates
you
feel
judges
is
both
[ Mobilize
feelings
I just
she
that
you
anxious.
to
what
If you
too .]
levels,
way
feelings
[ Distinguish
between
Th:
we
the
way.
husband,
that
said.
that
.]
picture
judge
feel
her
clarify
Wife:
he
will
not
to
it feels
he
role
must
session.
something
then
criticize
acts
of
the
quickly
shift
and
himself.
out
the
role
criticizing
address
At
one
moment,
superego.
The
therapist.
When
level
the
next
superego
to
156157).
She
them
in
next
Suddenly,
attacks
him
she
not
Why?
placed
She
Her
on
see
how
him
inflicts
superego
defenses
feeling
of splitting
SPECTRUM
is
and
OF
following
to child
Patient
to self
Maybe
I should
I should
today:
criticize
recognizes
tyranny
toward
him
from
shoulds
recommend
punishes
her
compassion
her
and
for
a
her
projection
her
projection.
suffering.
She
does
it onto
symbolic
pathology
identify
with
the
therapist.
thinking
until
the
Their
collapse.
therapist
reality
Thus,
no
restructures
the
SYNTONICITY
You
the
are
spectrum
of syntonicity:
bad.
sometimes
too
critical
of myself.
myself.
myself.
of the
1978,
herself.
or project
past:
criticize
agency:
primitive
punishing
but
all
and
him,
character
illustrate
Im
her
borderline
to
rage
for
IDENTIFICATION:
in the
the
projection.
statements
Parent
only
no
of
on
useful
to
of
has
of
for
the
(Wurmser
rules
distinguish
cause
level
capacity
of
the
has
back
husband
toward
not
superego
position
intense
she
suffering
pathological
and
feels
is not
as
the
and
her
does
a borderline
exploration
The
She
with
testing
She
rage
him.
she
standards
blames
patient
and
Momentarily,
dehumanizes
Patients
the
she
instead.
from
conscience
moment.
like
1975).
rapidly
moral
therapist
like
the
(Kernberg
mature
the
behaves
oscillate,
shifts
denies
herself.
husband.
roles
patient
a
the
he
pathology
experiences
moment,
these
of character
Sometimes
patient
[Some
one
who
(Horney
differentiation
should
1950)
since
criticize
is a sign
the
patient
herself.
The
of superego
pathology.]
I hate
myself.
implicit
awareness
herself.]
[Less
differentiation.
of agency
since
I hate
she
myself
realizes
she
indicates
does
an
this
to
Im
bad.
not
see
Im
[The
how
evil.
patient,
she
[No
says
reality
(who
is).
she
substitutes
for
herself
through
Labije,
personal
healthier
problem.
When
call
myself
realistic
not
fit
the
dystonic
angry
description
of
who
cruel
how
with
not
way
become
2003).
her
She
(J.
Ten
end
fat
Thats
to
punish
anger
from
rather
She
fat.
fact
the
others
Her
to
my
than
views
Have
de
not
my
knows
1985).
myself
anger
by
the
and
hating
angry
with
criticism
is
She
myself.
onto
I am
self-criticism
does
consciousness
does
not
said,
day
Pt:
Th:
say
accept
you
not
grief
like
a feeling.
be
see
an
see
from
that
it
deserves
with
her
accurate
herself
she
a form
telling
would
as
not
her
hurts
it.
me,
suddenly
of shit.
I feel
not
all day
Thats
may
deep
be
a feeling.
Thats
if I spent
may
a piece
this
but
she
shared
Could
Its
she
I am
will
differentiate
self-attack,
her,
patient
herself,
cannot
having
of the
the
treat
She
it hurts
then
all,
that
pathology,
is.
a patient,
After
the
(evil)
is a fact,
I am
I turn
Freud
way
she
sees
to me
is.
A.
Th:
by
image
eyes
that
badly.
she
Pt:
shit,
the
loving
fact
I am
me
Th:
yourself.
identification.]
(Britton
I love,
superego
sees
apologized
does
accurate.
If she
instance,
parent,
self-deprecation
I misuse
say,
who
of
as
For
to
and
as
that
treated
of
self-attack
If she
self-attack
fat . I protect
I used
levels
her.
the
than
is
people
like
who
It
is
with
(Sandler
defense.
equates
and
rather
says,
reality
severe
her
she
self-appraisal
problem
self-devaluation
At
critical
communication).
instead.
boyfriend,
the
from
Self-reproach
names,
my
evil,
believes
devaluing
The
myself
is
She
patient
I am
of herself
she
herself.
with
herself.]
differentiation
a patient
abuses
identified
criticizes
When
she
now
you
feeling
of self-criticism?
shit.
Thats
that
you
shitty,
how
are
you
a piece
treat
of
right?
true.
If you
tell
yourself
that
all
day,
youll
feel
shitty
too.
Do
you
think
this
Pt:
The
patient
cant
she
enacts.
she
could
she
does
she
is attacking
says,
The
she
in effect:
patient
(Kernberg
1975).
Defenses
reject
observe
the
saved
protected
life
you
your
life
The
superego
dismisses
words
as
reality
is
real.
That
protects
with
reject
it,
his
that
thinks
that
father,
good.
denies
feelings.
The
say:
and
we
protected
reality
do
not
awareness.
himself
protect
him
through
or
give
mechanism
thank
in the
his
perceive
at
should
you
feelings,
patients
This
and
defenses
looks
not
his
to
the
does
we
neglecting,
ability
distorting
is why
what
see
devaluing
own
and
identification,
past,
But
her
therapy,
not
she
ignoring,
neglects,
identification
has
148).
that.
then.
your
in
does
father,
Like
for
But
parent,
Capacity
our
the
She
her
which
probably
it
past
him
for
is
how
it
destroying
today.
sensations
to
in
you?
of a punitive
play.
father.
this
and
That
role
is satisfying.
doing
an
appraisal.
your
1955,
They
This
hurting
identification,
in the
like
undermine
reality
eyes.
a realistic
her
acting
ignores,
enacting
dismissive
role
identifications
will
an
the
Self-Observing
truth.
patient,
like
and
just
If he
defenses
The
Im
parents.
character
her
When
her
enacts
be
from
acting
from
is acting
helps
and
denying
in a play,
herself.
Syntonicity
herself
herself
see
self-devaluation
she
were
separate
might
Yes.
differentiate
If she
not
self-berating
if
to
they
Thus,
sanction
are
the
to
be
patient
experience
not
real.
Any
failure
result
of
superego
problem
Paying
the
attention
patient
as
doesnt
from
to
felt
who
his
the
[our]
not
perceptions,
as
in
real (my
identifies
real.
the
with
He
italics)
dismisses
pathology.
You
and
remaining
(Sandler
Oh,
dont
(Nunberg
the
parent
therapists
patient
that
need
in
and
a dismissive
nonpsychotic
exist.
suffering
thoughts,
to
harmony
in Sandler
to
feeling
pay
isnt
attention
with
and
see
A.
reality
Freud
1985,
303).
A patient
it. As
a result,
he
Syntonicity
who
do
satisfying.
not
The
believe
failure
to see
causality
(Why
do
me?),
(2)
circumstantial
have
it
in
examine
patients
with
stance
leading
for
me
Rather
myself,
I accuse
a paranoid
will
never
statements
my
hurt
guilt
only
I punish
the
worse
resulting
rather
course,
myself.
we
assume
my
know
make
my
over
how
sadness,
therapy
and
provoke
defenses
these
yelled
Let
us
causality
out
in
something
I have
and
face
Since
I dont
So
I
of
therapist
is making
When
see
treated
how
how
hurt
causing
worse.
aroused
myself,
therapy
and
keep
are
I punish
the
self-attack
is not
me
feelings
assume
in
I see
makes
me
self-criticism.
the
[ Of
regression
happening
things
True
causality:
When
them
to
me
sabotage
punish
my
at me
by
relationships.
.]
to me,
and
angry,
I lash
leaving.
I dont
So
I dont
out
at
notice
see
how
happen.
I keep
She
(People
why.
boyfriends
how
Its
me.
guilty
Things
dont
me
me).
incorrect
point
causality:
defenses
the
for
to
me.
suffering.
than
out
you
and
This
therapy,
to
stance
When
I feel
of hurting
True
thinking
pathology.
me,
feel
helpful
happening
happen
work
involving
causality:
hurts
you
keep
or (3)
character
than
things
to another),
of
that
myself.
with
are
in several
just
syntonic
myself
results
(Things
True
to
in harmony
defenses
thinking
Things
series
their
bad
You
do
live
Causality
causality
victim
thing
cannot
see
(1)
one
reality
Observing
errors:
just
ignores
suffers.
and
Patients
and
who
again
before
True
I got
causality:
getting
out
blindsided
by
my
wife.
of bed.
When
my
wife
verbally
abuses
me,
ignore
different
paying
attention
result,
we
we
pay
our
Ignoring
inner
reality
or
of
falsifies
turn
neurotic
unconscious
and
engine
and
due
But
the
be
tomorrow,
am
didnt
blindside
abuses
When
others
me
by
do
not
we
cause
instead
of
in
of
it.
the
with
types
bear
As
defenses
that
to
or
so
guilt
reparation
A.
can
healthy
is
awareness
of
1985,
195).
reality.
have
guilt
this
over
a defensive
toward
murderous
1990,
face
overcome
rage
guilt
their
is
ward
it
off
rage
self-punishment,
suffering.
faces
the
(Klein
wrong
1975a,
he
has
1975b).
done
He
to
feels
someone
empathy
suffering.
patient
may
avoid
healthy
guilt
through
his
Acknowledging
reason
to feel
guilt
for
it.
deed.
his
deed,
Patients
murderous
the
and
loved
2000).
unconscious
patients
misdeeds,
function,
rage
unconscious
can
to
defense
Freud
see
(Davanloo
they
their
our
murderous
face
attention
SELF-PUNISHMENT
of guilt:
Help
healthy
they
unconscious
due
guilt
in
and
so
task:
successful
Sandler
psychopathology
to
VERSUS
feelings
to
therapeutic
restricts
Denying
any
will
verbally
either
defenses
guilt
perpetuated
engages
their
she
She
assume
life.
It
Freud
guilty
unconscious
for
she
the
internal
self-punishment.
A patient
fantasy.
people
opposes
three
unable
has
me
to causality.
we
other
ones
Unconscious
which
to
against
guilt
through
my
blindness
GUILT
conscious
are
abuses
time
suffering,
it (A.
differentiate
who
each
dangerous.
can
primary
into
that
fantasy.
experience
UNCONSCIOUS
ones.
fantasy
suffering.
patients
We
wishful
verbally
means
our
something
Help
reality
attention
acceptance
always
bumps
to a wishful
create
creating
and
to
to defenses
how
have
she
she
myself
Blindness
When
because
I blind
see
Then
tomorrow.
blindsided
me.
it.
but
denying
Punishing
himself
to
avoid
guilt
and
reparation.
Projecting
judge
him
solution,
and
he
When
the
patient
may
want
does
him
not
bear
therapist
to
feel
his
guilt
points
avoid
feelings
out
onto
guilty.
In
(Klein
how
of guilt
they
paranoid/schizoid
1975b).
patient
grief
believing
this
1975a,
the
and
others,
hurts
herself,
the
by
Punishing
herself:
know.
Im
terrible.
Punishing
doing
is
this.
Now
was
not
helpful
the
doing
enough.
patient
I cant
criticizes
the
believe
the
you
therapist,
are
me!
you
the
critical
therapist
Therapists
projections.
putting
she
does
therapist
permanently.
If
herself,
patients
her
suffering
invite
others
provoked
felt
toward
a neglectful,
him.
over
Now
something
when
the
The
suffer
his
rage
his
several
patient
the
guilt
wrong
someone
led
to
else
decades
may
pangs
could
(being
will
to
his
for
him
are
doing
what
she
good
see
you
do
herself,
angry
intentions
is
she
at
to
temporarily
how
them.
she
feel
the
dispel
but
not
projects
abusive).
or
He
beat
absent
After
He
and
him
up.
father.
long
He
The
he
had
done
some
relief
severe
than
rather
than
feel
less
attack
himself.
punishment
withdraws
to
could
on
with
people
all,
was
inflicted
provoke
to
and
A beating
had
man
provoke
rational.
him.
verbally
to
guilt.
all
of self-criticism.
repeatedly
himself
punishing
continue.
people
he
like
criticizes
fear
to
of
becomes
their
punish
verbally
own
She
mother
of prison
of
she
alcoholic
punished
punish
I feel
defense
learn
other
him
how
patients
not
history
guilt
paid
therapist
down?
of
the
does
the
her.
patients
criminal
rage
see
at the
reduces
she
not
than
reassure
This
me
criticizes
rather
often
punishes
always
Since
assumes
Some
get
you
to herself.
Why
criticize
What
doing
Accusing
her:
therapist:
narcissistically
into
self-punishment
rather
Self-punishment
than
reach
becomes
out
to
substitute
the
for
person
genuine
he
hurt.
guilt
and
reparation.
Chronic
self-punishment
fragmentation,
these
boredom,
symptoms
wrongdoing
an
and,
(D.
We
Carveth
can
also
stance,
help
it,
than
our
at
the
same
at
rather
than
language
(D.
and
conscious
guilt
Therapists
J.
(D.
to fantasies
from
against
conflate
guilt
love
Klein
guilt
to early
for
1975a,
(Carveth
1998).
Instead
person
reveal
her
may
feels
and
asks
the
Shame
reproaches
other
can
person
also
ward
for
of
to
have
myself
(D.
reaching
out
to
She
than
repair
I hurt
you,
off
Healthy
shame
just
distance
my
wife.
responsibility
wards
1990,
off
guilt
2000).
Healthy
2002;
Self-punishment
S.
It
unconscious
Carveth
182183;
rather
some
and
and
couldnt
fault,
Self-punishment
deeds
victim
from
agency
self-punishment.
her!
the
affair.
was
and
Rather
for
conscious
my
the
(Davanloo
to repair
guilt.
wasnt
There
self-punishment.
herself.
The
need
choices.
traumas
1975b).
2002,
Safa-Gerard
It
3).
others
and
conscious
and
and
patients
2001)
find
unbearable
distanced
2003,
Carveth
our
1923/1961c;
the
Carveth
linked
often
derives
denies
sin
superego
helplessness
chose
Carveth
formation.
the
it happen.
than
of
2).
choice.
I
I made
rather
Demoralizing
due
because
(D.
of
symptom
responsibility,
this
forms
and
evades
through
I made
relationship,
Carveth
guilt
agency,
fault
to
2003,
experience
guilt
narcissism
time,
not
admission
gratifies
J. Carveth
our
than
was
happened
symptoms
healthy
the
resort
our
our
rather
to
do
emptiness,
tormenting
for
to our
in
avoid
as
consider
forced
and
denying
but
insult
of
Patients
substitutes
who
are
entailed
punishment
guilt
us
intolerable
unbearable,
suffering
in
of
are
symptoms
irritability.
deficits
which
Those
guilt
and
as
self-punishment,
2001).
creates
S.
is
Freud
the
so
she
how
the
defense
hurt,
awful
relationship,
comfort
signals
Freud
1923/1961c;
one
says
guilt
that
the
she
she
me.
we
have
failed
to
live
up
to
them.
according
unhealthy
shame
reparation.
We
deed
to others
Guilty
feel
I feel
to
respond
genuine
and
to
guilt,
patient
and
repair
healthy
found
feelings
superego
(A.
Sometimes
therapists
rather
help
than
truth
is
truth
together
not
the
patient,
and
punish
eliminate
able
The
apologize,
Guilty
guilt
yourself
to lead
a life
Compassion
merely
pseudocompassion.
patients
truth
and
closer
to
Help
patient
self-punishment.
guilt,
Treat
the
We
guilty
The
painful
point
to
1987,
92).
the
side
feel
but
The
tolerate
guilt
must
replace
and
reparation
feelings
as
also
to
her
therapists
pain
of
address
Carveth
a defense.
is
412).
feelings
Do
from
the
face
the
to
need
rather
to
ask
escape
is
so
he
it
not
to
will
be
good
not
self-punishment
(D.
feeling
for
the
in developing
truth
of
simply
of
compassion
the
her
a prestage
may
compassion
ideals.
her
of
face
painful
would
person
(Almaas
her
you
for
bad
task
therapist
that
The
lead
patient
face
repentance,
neurotic
painful.
shame,
live
helps
how
can
patients
Our
have
feelings
1985,
these
Protecting
abandonment.
must
and
away
as
substitute
is
Freud
long
guilty
element
A.
say,
I dont
she
wrong
and
but
shameful
As
Feeling
critical
them.
and
who
having
some
analyze
We
guilt,
complexity
for
not
on
pain,
the
are
to
be
or
did
is so
of truth
around
you
bear
but
can
out
to
our
I caused.
responsibility,
in Sandler
guilt
position.
guilty
the
healthy
Patients
damage
sit
act
caused.
irresponsible
so
to
relationship,
reveal
function.
can
instead?
suffering,
than
relationship.
try
matter
Your
feel
us
external
of
the
Freud
compassion,
the
we
the
and
patients
, no
an
guilt
morality.
damage
pain.
mobilizes
experience
to repair
genuine
someone
repair
rather
taking
her
because
and
a defensive
have
reparation.
avoid
the
the
often
her
not
ourselves
have
I dont
do
off
repair
are
standards
we
wards
also
guilty,
own
When
and
guilty,
our
shame
feelings
so
to
is
only
for
the
to
face
the
attention
to
this
wish
seeing
the
the
defense
with
the
2002,
186).
not
explore
truth.
of
capacity
them.
Help
patients
unconscious
ones.
Once
murderous
bond,
face
genuine
guilt
over
the
patient
can
rage,
guilt,
grief,
MIRRORING
with
the
require
a spectrum
of
These
interventions
type
of
Low
Superego
A patient
and
with
can
the
superego
low
superego
helped
readily
In
this
[ Point
out
Moderate
example,
between
against
the
the
the
Do
I hadnt
to
be
the
broken
a defense.
the
ability
As
them
see
to
Now
range
will
differentiate
result,
their
they
defenses.
interventions.
with
we
of
to
enactive
matched
has.
and
think
the
the
degree
show
of
a spectrum
interventions
necessary
turn
against
do
notice
defense
seen
criticize
herself
the
very
gently
defense.
it.
how
you
underestimate
.]
that,
but
I see
it now.
point
out
Pathology
therapist
patients
will
I can
you
Superego
needs
defense
and
only
his
to
goal
for
the
the
patient
conflict
to
turn
defense.
I dont
Th:
Do
think
you
I can
do
notice
it.
how
you
underestimate
?
Pt:
identified
over
enact.
cognitive
to see
character
Pt:
yourself
loved
pathology.
I dont
Pt:
to
their
help
pathology
Th:
Low
to
patient
and
in
they
needs
Pt:
yourself?
toward
of unconscious
pain
as
their
Pathology
with
be
and
necessary
vary
from
capacity
patients
rage
and
PATHOLOGY
range
self-observing
done,
experience
love,
longer
have
murderous
longing,
interventions
capacity
they
deep
identification
intervention
self-observing
to help
the
pathology
from
of
face
is no
superego
what
of
SUPEREGO
themselves
The
over
fantasies
self-punishment
Patients
guilt
with
his
defense
But
.]
what
if I cant
do
it?
[ The
patient
is
Th:
problem
you
others
have
surpass
at
you,
work
declare
of
what
a goal
And
leads
at work,
your
be
goal
defense
focus
see
able
to
to
right?
overcome
yourself
this
back
and
let
goal .]
have
asked
hold
[ Clarify
me
yourself
the
to help
back
as
therapeutic
you
get
soon
task
as
to
you
.]
Yes.
You
do
it.
give
up
Thats
right
now.
Do
you
defeats
his
goal
in
Pt:
Im
his
Th:
When
defense
how
see
on
yourself
you
hold
what
this
and
yourself
mean?
moment.
tell
yourself
back
[ Clarify
Create
an
back
here?
from
how
his
intrapsychic
yourself
back.
On
On
the
other
doubts
you
and
tries
what
I mean?
the
hand,
to
[ Point
get
now,
have
been
feelings
or
shall
driving
or face
against
Moderate
this
therapist
see
first
and
this
punitive
you
to
put
now.
[ Sees
Do
take
this
you
a
[ Begins
defense
the
the
at
the
got
to
to
here,
go
full
in
your
brakes.
conflict
doubt
to
out
yourself
speed
mind
you
see
a little
underneath
the
defense
stop
Do
you
.]
feelings
[ Point
a destructive
Ive
want
on
to
look
capacity
mechanism
want
self-sabotage?
Use
your
you
I do
choice:
or turn
doubting
that
avoid
against
myself.
bit
his
it .]
[ Patient
.]
Pathology
patient
describes
turn
hand,
Pt:
we
the
one
.]
Superego
example,
doubt
conflict
them.
the
you
the
Pt:
turns
myself
out
Th:
more
holding
.]
ahead.
can
hold
to
.]
hold
In
you
you
Th:
wont
his
here
Yes.
Pt:
you
come
you
[ Clarify
Th:
bottom
have
where
right?
Pt:
the
You
against
is more
and
it.
then
identified
mirrors
the
with
defense
the
defense.
so
the
The
patient
Pt:
I dont
Th:
yourself
identified
with
are
her
superego
incapable?
[ Point
its
just
incapable,
I think
she
I am
If the
passivity,
her
can
do?
remains
therapist
wont
percent
and
percent
result.
can
hundred
claims
the
percent.
she
treats
Its
not
that
I want
alliance.
She
think
therapy
have
to help
help
and
feeling
Pt:
[ Becomes
of
pathological
If you
really
we
need
to
only
the
give,
yourself
again.
in
Thats
all
cant
help
me.
[ She
her
passivity
And
[ Mirror
[ Mirror
her
her
had
Actually,
the
succeeded
has
good
pathological
that
she
to
her
something
me
incapable
If
while
she
you
say,
her
as
give
youll
one
just
desires
can
the
hundred
have
healthy
I
had
only
thinks
in
give
ninety
ten
onto
only
one
percent
you
news
you
therapy.
ten
she
just
is,
in
the
.] I just
help
her.
her .]
said
that
you
dont
superego
superego
results
cant
help
may
[ Rise
percent
therapy
cant
pathological
before,
as
.]
Ive
she
herself
rise .]
there
onto
percent,
therapy
will
.]
.]
as
addition,
superego
capacity
.] Isnt
of
her
anxiety
desires
if
that
in response
transference.
to the
that
the
as
myself
portrays
active
projection
omnipotent
see
offer
succeed.
ten
is
.]
with
she
are
[ She
yourself
portray
superego
Th:
give
portray
to
and
healthy
that
to.
hasnt
her
to.
it .]
anxious
admits
her
therapy
to
fail,
give
yourself.
want
therapist
able
herself
Since
will
Th:
dont
underestimate
not
[ Identification
become
Pt:
cant
you
you
she
I cannot
cannot
see
how
[ Deactivate
Deactivate
not
how
[ Silence.
her
what
you
notice
really
not
with
have
you
Im
does
[ Projection
identified
does
the
defense
maybe
incapable.
expects
cannot.
me.
it.
how
out
Th:
we
do
notice
and
Do
Pt:
you
you
But
Th:
way,
Do
I can
?
Pt:
you
think
.]
not
.]
you
think
have
to
After
want
you
if
all,
to
invest
you
since
in
Pt:
before
came
superego
here
Funny
today.
invest
in
yourself
superego
if
that,
since
begins
to
lets
face
I had
see
that
her
thought
pathological
Sure,
and
dont
want
to.
it:
you
[ Mirror
dont
her
have
to
pathological
.]
helplessness
I want
how.
Theres
no
I cant
family.
[ The
more
Do
interpret
not
therapist
more
easily
dont
have
dont
know
how.
[ Defense:
patients
it
to
within
is.
Im
or else
Ill
her
the
yourself
never
and
get
healthy
until
superego
thirty-eight,
you
.]
Im
married
strivings
1974;
build
identification
she
still
not
or have
and
sees
her
so
she
identifies
defense,
So-called
Farrelly
1985)
when
patients
herself.
1968;
Weeks
pathological
invest
pathological
defenses
voice
1962,
1982;
there
to
her
.]
gives
see
But
her
acknowledges
the
Nelson
LAbate
I just
[ Mirror
delaying,
clearly
If the
C.
keep
patient
conflict
You
rush.
Pt:
married.
to!
.]
Th:
the
[ She
you
Pt:
(M.
say
.]
Th:
know
you
the
Spotnitz
see
can
techniques
1985;
Weeks
capacity.
it and
them.
patient
paradoxical
self-observing
can
with
and
Mirror
differentiate
from
it.
Never
mirror
is feeling
create
angry
when
oppose
toward
the
the
Severe
carefully
you,
or if you
Mirroring
the
therapist
Superego
feels
wishes
want
and
to argue
pathological
no
wish
thoughts
with
her.
superego
to
control,
is
argue
if
she
You
will
effective
with,
or
Pathology
is working
abusive
only
the
self-destructive
patient.
therapist
picks
shows
patients
a misalliance.
only
The
the
with
boyfriends.
with
patient
the
an
impulsive
Notice
concrete
causality.
how
facts
In
the
response
patient
the
therapist
patient
to
in her
the
presents
patient
twenties
who
works
very
and
then
identifying
with
her
defense,
help
the
patient
the
see
therapist
and
let
Pt:
dumping
me.
and
got
beat
the
vodka
defense
to the
bar,
up.
I think
it was
because
her
against
her
problems
rage.
your
No
to beat
you
up.
see
how
she
into
up.
a fight,
[ Point
hurt
invited
out
causality:
vodka.
times
to
the
conflict
.]
invite
them
got
got
you
into
fight
blames
a
rather
than
in a fight,
me
feel
and
up.
the
invited
[ She
does
.]
drunk,
to fight
in a
.]
to beat
punishment
for
self-punishment,
And,
out
got
[ Patient
perspective
angry.
boyfriend
then
her
got
getting
and
in a fight,
see
a fight
and,
if they
invited
by
could
others
getting
beat
you
to fight
and
her .]
Pt:
the
I had
drunk,
her
people
and
got
I didnt
my
drunk,
you
You
several
with
than
were
[ Point
Th:
got
intrapsychic
You
arranged
defense
furious
rather
boyfriend,
Pt:
not
really
I went
for
the
of it.
So
toward
people
go
I was
Th:
anger
mirrors
syntonicity
She
sees
she
invited
boyfriend
Oh,
yeah.
Th:
And
Pt:
No,
that
getting
this
may
be
acceptable
Syntonicity
.]
to you.
[ Mirror
thats
beaten
bad.
up
punishment
is
I dont
bad,
to
avoid
Although
you
but
want
she
feelings
to get
does
of
beat
not
rage
up.
see
how
toward
her
.]
find
yourself
beat
up.
drinking
[ Mirror
alcohol
back
what
and
she
Pt:
her
healthy
leads
to
getting
beat
up
is
change
your
drinking.
see
you
onto
I have
no
fights,
and
fights
okay
with
you,
[ Mirror
her
dont
getting
can
Are
awareness
Th:
drinking
that
offhandedly.
.]
Th:
projects
[ Said
want
into
so
fights
right
to
lead
to
pathological
up,
where
I shouldnt
therapist
obviously
beat
you
you
get
far .]
saying
the
to get
drink?
[ She
.]
tell
you
what
to
getting
beat
up,
theres
no
superego.
do.
If
and
reason
This
allows
to
her
to see
it and
the
therapist
.]
blocks
the
Pt:
with
me.
[ The
defense
projection
Except
with
this
the
conflict:
healthy
getting
of self-punishment
Th:
struggles
of her
see.
beat
up
part
becomes
[ Therapist
drinking
capacities
is not
less
waits
creates
results
I shouldnt
drink.
onto
okay
syntonic
as
the
she
.]
patient
does
not
like
of
her
.]
Pt:
healthy
awareness.
I know
Should
implies
Th:
projection
choice
of
her
works
not
get
beat
you
want
her
defenses,
Its
healthy
for
you.
up
[ mirror
to treat
You
can
her
her
more
and
dystonic
Initially,
hurt
feeling
the
her.
results
When
helped
herself.
failed
she
her
patient
experience
guilt
This
in
focus
should.
really
beat
up
the
matter
the
of
or not
end,
.]
[ Block
its
what
drink
and
about
intrapsychic:
getting
beat
her
up
is
how
feelings,
bad.
behavior
an
Her
conflict
herself
grief
will
trigger
patients
between
what
a problem
(syntonicity).
therapists
Mirror
does
She
getting
against
[ Higher
is
becoming
how
degree
of conflict.
she
(dystonicity),
the
her,
will
hurts
people
between
and
says,
she
not
how
want
she
be
she
inflicted
guilt
suggest
does
and
has
She
it may
conflict
her
the
words
she
says
Mirroring
she
against
suggests
a fight.
it
suffering
Her
other
it.
and
the
thought
into
defenses
manner.
manner
and
by
over
offhand
thats
causality.
defense
and
step
see
her
offhand
Often,
get
opinion
of
destructive
sees
in
(dystonicity)
her
turn
problem,
with
this
and
the
although
the
see
mirror
the
But
to
hurt
response,
change.
and
her
.]
indicate
patient
the
Its
], but,
[ Keep
is not
matter
.]
drink
this
.]
In fact,
defense
conflict
Pt:
anxiety
not
awareness
yourself.
and
that
[ Projection
one
what
on
grief.
In
Thats
wants
to
to.
Mirror
says
it.
So
you
can
live
she
says
(syntonicity).
mistakenly
mirror
the
patients
healthy
words,
but
not
the
unhealthy
behavior.
problem,
with
an
offhand
You
see
how
that
can
halfheartedly
not
Yeah.
her
between
no
her
conflict
conflict
at all
the
(Wexler
1975).
repudiate
C.
She
can
strivings),
she
1962,
121).
Nelson
mirror
it.
This
breakthroughs
rather
than
Mirror
the
Part
of
you
wants
and
wants
to
accessible
than
enacts
it.
the
therapist
unconsciously
shown
range
from
to extreme
testing
defense
and
personified
her
with
technique
she
reality
identifications
identifies
her
(M.
defense,
allows
tolerates
her
partial
internal
conflict
it.
patients
conflict.
overcome
these
pathology:
mirror
difficulties
but
pathology:
mirror
be
a problem
to act
out
conflict.
another
part
of
unconscious
explain;
from
the
the
patient
role-playing
enacts
so
she
can
to
on
level
identification
observe
An
and
are
the
therapist
enactive
role
C.
Nelson
(Sherman
the
question
patient
it.
an
interventions.
style
resistances
(M.
less
enacts
enactive
patients
his
patient
identification,
a conscious
the
the
demonstrate.
undercuts
absence
relationship
When
shift
the
you.
a pathological
should
the
not
with
for
communication.
interpret
Do
superego
therapist
communication
is different
patient
superego
words
the
communicates
(who
pathological
Moderate
not
rational
identification,
Rather
may
use
to
can
but
to continue.
That
who
conflict
patients
therapist
her
until
of the
Severe
Patients
self-destructive
the
respond
words
defense)
the
to avoid
degree
This
the
will
herself).
the
guilt
projection
precise
of conflict.
with
ego-strengthening
using
them
1933).
responds,
patients
of
the
resist
When
patient
enhances
resist
can
of grief
you
hurt
see
than
the
degree
identification
Thats
eagerly
to the
the
(Reich
has
says,
therapist
listened
Mirror
she
patient
now,
therapist
identification
Rather
If the
behavior
how
the
a problem
(complete
toxic
it.
healthy
and
over
Mirroring
is
behavior.
words
(guilt
manner.
The
passive
Suppose
of
and
1968).
1968).
acts
This
Here,
out
The
therapist
mirrors
emotional
implications
115).
patient
The
This
is
verbal
not
being
sides
unconsciously
of
the
unconscious
in
part
how
the
lets
patient
are
as
not
himself)
are
committed
out
of
about
goal
defenses
1968,
so
stupid.
that
therapist
she
is
mirrors
mouth,
her
bringing
these
he
appears
as
if he
recognizes
is
1968,
himself
remarks.
enacts
is
This
a function
of
the
124).
Defense
out
the
then
anxiety
long
and
create
not
that
This
patients
mirrors
totally
character
the
defense
defense
as
and
due
the
to
Th:
Its
uncommitted
mirror
his
[ He
to
addressing
about
That
until
the
problema
the
as
you
in his
out
the
Its
good
chair
defense
how
goal,
news
to
and
letting
the
.]
therapy.
your
want
are
perspective
is,
be
superego
and
you
to
you
can
be
yourself.
.]
laughs
.] Im
just
nervously.
concerned
take.
long
sense.
will
prolonged
your
[ Point
about
you.
therapy.
you
intrapsychic
And
makes
how
goal,
you.
it was
his
could
I get
an
to the
your
pathological
shifts
yourself,
Pt:
is
thinking
really
therapy
the
this
establishes
I was
to
committed
committed
Pt:
Th:
your
my
is
implies
patient
(Brandt
to it or to you.
or
reality
how
of
therapist
Although
Pt:
Rise
the
say
resistance-joining
and
Im
not
himself.
committed
Point
So
the
of it.
you
treats
voice
[T]he
points
Th:
know
of
and
(Sherman
to
resistance,
a Character
to
go
the
patient
therapist
content
attention.
the
Pt:
me
out
therapists
of the
committing
patient
words
identification
Mirroring
Notice
honest.
patient.
the
going
tone
just
with
the
Im
her
the
expressions
What
patients
image
Vignette:
say,
the
between
patients
Yet
took
therapist
is because
the
herself,
to the
mirror
(not
to
You
the
the
of
self-abuse.
incongruities
When
incongruity
might
unkind
self-abuse,
the
point.
If you
therapy
therapy
dont
take?
.]
commit
[ Causality:
to
Th:
would
be
in your
best
What
interest?
Pt:
say,
Of
course
I want
[ Laughs.
how
hurts
himself.
With
against
his
self-neglect
ask,
Isnt
you
with
a pathological
agree
identifications
against
in
this
the
his
Rise
stance.
his
final
By
from
mind
so
he
begins
126).
reality
when
No.
You
can
now
.]
to
.]
it in me,
1968,
he
think
.] I want
of alliance
seeing
identification?
you
superego
anxiety
[ Rise
(Brandt
patients
of
statement,
a departure
do
pathological
to myself!
pathological
therapists
noncommitment
Smiles.
to commit
the
stand
of
[ Mirror
I mirror
he
patients
level
he
to
sees
take
Sometimes
you
act
as
reveal
the
toxic
see
and
if
turn
them.
REFLECT
THE
DEGREE
OF
SYNTONICITY
OF
CONFLICT
When
addressing
presence
takes
or absence
place
awareness.
and
conflict,
on
The
some
we
must
also
of awareness
a spectrum
from
following
no
The
awareness
of conflict
illustrate
appropriate
empathically
of conflict.
examples
interventions
attune
for
the
to
degree
of
the
conflict
to complete
spectrum
of
conflict
them.
No
conflict
regarding
desire
for
closeness
Pt:
defense
I want
to be
close
[ No
anxiety
or
.]
Awareness
Pt:
from
to people.
them,
close,
but
and
I pull
I want
I dont
back.
like
that
Dystonic
Th:
interferes
with
your
goal.
avoiding
it, and
not
wanting
Pt:
to be
I do
dont
[ Reflect
Th:
close
that
to people,
that.
is dystonic
but
I pull
[ Conflict:
I want
pull
because
back
to
be
.]
You
it gets
If you
want
her
to avoid
Yes,
of conflict
to
conflict
of
back
wanting
that
closeness,
.]
in my
dont
pull
way.
back
now,
what
are
you
feeling
right
now
here
with
me?
Conflict
Pt:
happen.
I dont
know
wants
closeness
but
patient
.]
I want
why.
[ Said
is unaware
Th:
dont
that
her
know
how
may
not
tone
you
be
of voice
get
close
a distance,
problem.
continue
you
[ Not
unlike
to
doesnt
The
patient
the
previous
people,
[ Mirror
the
it
her
but
you
conflict
syntonicity
.] But
indicated
in
wont
the
because
dont
get
married.
dystonicity:
not
I cant
is becoming
recognize
And
how
you
knowing
get
married
dystonic
you
say
means
if
.]
keep
people
that
would
be
her
problem
a
will
.]
Projection
Do
you
think
I keep
people
at
a distance?
sure.
[ Block
.]
Th:
projection
Only
you
can
know
for
the
.]
[ Projection
Pt:
I must
Th:
But
because
my
last
boyfriend
said
did.
.]
Pt:
engagement
ring
into
the
throwing
the
distance.
engagement
[ Link
her
in your
I did
gutter.
Th:
problem
[ Mirror
but
shrug.
close
close.
knowing
If you
Pt:
to be
be
It is a problem
to people.
[ Mirror
people,
defenses,
to
you.
to
a dismissive
want
for
awareness
.]
Th:
at
close
with
not
a problem
be
of her
You
manage
Pt:
I dont
to
without
yell
at
him
[ Alliance
You
ring
opinion?
think
into
defenses
of
the
projection
and
I threw
the
and
lot,
is improving
that
the
[ Block
yelling
gutter
discharge
.]
.]
at
him
could
have
kept
and
acting
out
lot
him
to
at
the
.]
Pt:
Yes.
I didnt
see
Disavowal
Pt:
Im
not
sure
it at the
time
though.
of conflict
I want
to
be
close
to
people.
The
patient
denies
a wish
for
Th:
Mirror
her
disavowal
closeness
she
has
of
not
closeness
That
.]
may
conflict;
not
do
expressed
be
not
attribute
but
I dont
onto
the
rather
want
therapist.
than
I know
it. [ Patient
bear
tries
it within
Th:
right
to
dont
want.
onto
avoid
the
it.
I have
[ Reflect
therapist
her
to
If you
dont
right
that
to
ask
and
as
I dont
a problem.
Th:
change.
[ Mirror
the
you
with
to
her
to be
projects
the
you
want
therapist
have
every
something
projection
denial
My
not
and
wife
close
denial
may
problem.
[ Block
the
Since
of
with
you
the
desire
my
wife.
And
.]
be
something
stated
absence
thinks
therapist
to state
you,
why
.]
I dont
know
a reason
incompatible
would
realities
shes
projection
Th:
for
She
its
you
want
of conflict
problem.
to
.]
[ Defense:
.]
Pt:
the
for
of conflict
[ Defense:
patients
Th:
her
wish
closeness,
closeness.
closeness,
block
want
That
Pt:
projection
.]
Pt:
see
her
want
conflict
want
Denial
dont
I should
wants
have
.]
denial
think
she
herself
no
to
want.
of conflict
you
denies
She
you
.]
Projection
Pt:
something
so
Neither
you
he
do
come
not
here,
why
I should
can
I cant
oppose
I. I mean,
here
for
be
the
if this
a
help
her
here.
[ Inviting
therapist
is not
with
.]
a problem
nonproblem?
[ State
.]
Pleasure
in the
identification
with
the
it when
he
resistance
Pt:
thinks
and
we
he
are
doesnt
really
know
close,
it.
I dont
and
[ Manic
want
to
be
meanwhile
identification
close.
Im
I enjoy
a million
with
the
miles
rejecting
away,
role.
Pleasure
in rejecting
source
of
Perhaps
her
her
pleasure
that
absence
Th:
You
be
able
to
is your
boyfriend
to
rejecting
move
away
role .] Its
distant
superego
just
be
distant
[ Mirror
her
identification,
I dont
know
what
doesnt
That
superego
sound
feels
right,
say
it,
it sounds
the
knowing
it.
pleasure,
say
its
and
my
identification
I distance
distant
men.
What
goal.
with
[
the
myself.
with
[ Mirror
sick.
makes
Choosing
men,
you
her
pathological
[ Beginning
you
to
have
not?
I have
degree
degree
Mirroring
therapists
should
to turn
say
that?
have
against
[ Mirror
distant
to sound
[ Mirror
actually
her
relationships
her
right
to feel
pathological
thought
[ Greater
of
possible
that,
capacity
the
patient
is
for
right.
If
superego
but
when
tolerating
.]
hear
internal
the
conflict
the
lack
conflict
of,
might
they
want
experiences.
patient
has
conflict
order
patient
seem
counterintuitive.
to
rather
see
Instead,
in
the
we
to
be
than
must
as
the
relate
attuned
to
as
patient.
patient
fully
patient
partially
here
or
of
patient
conflict
to the
the
the
of,
a lack
reflect
of conflict
level
you
remain
It doesnt
crazy.
exact
experiences.
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
now
mechanism?
of the
happen
the
mechanism?
you
that
(how
defense,
and
Notice
attack
to
a character
then
the
feeling
that
price
symptoms).
What
say
the
task.
turns
before
her
and
has
present
different
try
what
from
we
knowledge.
her
defenses.
always
existed
defend
experience
the
be
substitute
consciously
The
to
of
defenses
her
so
of them.
the
patient
differentiate
herself
from
her
identifications.
that
Ask
conflicts
defenses
of
with
emotional
Awareness
Is
of
this
attention
her
Once
and
your
from
the
can
patient
of
must
when
she
faces
her
rage
onto
them
(Leahy
described
Its
all
the
my
consider
other
about
For
himself
using
the
rather
wouldnt
have
Due
observe
character
to
his
intelligence
patient
patient
than
had
the
centration,
thinking
defense
or
(Do
of this
kind
face
her
Otherwise,
identify
with
limited
this
fault
in
mess
will
see
the
them
if
he
cannot
enactment.
notice
of
now,
more
decenter
to
how
you
centration.
cannot
conclusion
Im
he
a shit.
ignores
relationships.
other
(1970)
and
perspective.
been
Thus,
as
global
the
upon
Piaget
dimension
as
using
based
of thinking
preoperational
evil.
himself
himself
I had
am
with
When
in
forms
up
roles
think
1970).
one
on
affair
you
on
he
always
consider
it.
can
or cognitions
Thus,
thought
she
stuck
2000).
focuses
based
past.
often
defenses
process
notices
pay
identifications
children
(Piaget
is
these
he
preoperational
event,
her.
if
in
formed
perspectives.
instance,
qualities
when
or others
to
differentiate
hidden
will
such
her
defenses.
she
Love
ignoring.
help
them,
are
structural
character
now?).
these
character
desire
again.
McCullough
The
from
others,
in
invite
have
against
her
Questions
They
which
THINKING
to observe
fault.
life.
of
habitual
They
PRIMITIVE
2001;
right
herself
toward
of
defenses,
feelings
of her
those
herself
seen
judgment.
defenses,
rage
others
rhetorical.
center
with
her
replaces
replaces
successfully
level
unable
moment
not
disidentify
preoperational
thinking,
are
Remind
of
your
differentiated
defenses
character
this
character
STRUCTURALLY
Character
ignore
at the
has
wants.
desire
reality
herself
She
the
truth
will?
defend
turn
please
the
rage.
and
you
desire
she
enacted
emotional
to the
being
what
the
(Would
the
as
her
The
sole
adult
cause
people.
his
of
My
an
wife
understanding
stand
when
we
call
yourself
of
outside
point
and
out
names?),
his
he
may
But
process
I really
POINT
am
the
intervention
patient
of
her
content
to the
aware
process
of and
notice
as
experiences
it
wants
rid
the
you
put
that
her
of
how
down
her
she
relates
right
her
the
about
now?
Identify
Way
of
each
character
symptom,
1933,
from
with
Help
the
to
Block
become
the
Relating
to
Herself
defense
foreign
body
until
which
she
[she]
50).
do
you
feel
when
you
talk
to
way?
Is that
fair
you
see
feelings.
how
you
minimize
your
to you?
Its
important
argue
on
self-attack.
to
painful
(Reich
not
Defenses:
attention
a
Do
awareness
yourself
Do
feeling?
AN
focused
her
immediately.
Pathological
as
Shift
How
yourself
IS
is
identification:
defense
with
attention
judgment.
Character
patients
to get
how
her
ugly.
out
character
of
the
of her
disidentify
Clarification
Draw
Im
Point
each
Defense
thought.
DEFENSE
herself,
self-attack:
you
label
preoperational
CHARACTER
attacks
attractiveness.
Do
within
IDENTIFICATION
content
herself.
from
idiot!
HOW
TED
When
and
an
OUT
ENAC
her
your
Dont
they
shame
deserve
our
Do
notice
to
talk
over
attention?
your
(Warshow
2008)
yourself
you
how
you
undermine
?
Do
you
see
how
you
devalue
how
you
yourself
?
Do
feelings
Clarification
and
yourself
of
right
the
you
notice
now?
Price
of
the
Defense
reject
your
Help
the
patient
problems.
friend
If
but
see
the
her
how
patient
enemy,
the
defense
can
she
see
can
causes
how
more
avoid
the
deprived
reality
yourself
yourself
now
of my
that
rather
way
than
the
you
here
just
with
feel
now?
deadening
Is
you,
this
killing
Wouldnt
off
Does
of
hating
love
you
for
help
self-condemnation
love
or your
him,
Do
you
your
guilt?
piece
or
to
yourself
self-hatred?
lead
defeat
will
how
this
and
you
to withdraw
be
you
are
Is
it true
Do
you
want
be
helpful
will
Its
feeling
the
best
something
you
from
him
making
you
seeing
you
how
you
condemn
you
or
is
it
self-condemnation
hatred
are
to
an
for
yourself?
told
choice
if you
in this
moment
here
this
give
to
contempt
even
your
worthless?
your
Or
is this
son
your
to him?
for
does
yourself
this
help
contempt
for
more?
me
your
you
desperately
passive
want
with
us
me
self-hatred
want
detached
to
take
(Warshow
the
best
state
look
at
2008).
in you?
Or
in you?
need
to hear
more
feel
this
in yourself
just
called
yourself
an
idiot.
judgment
helping
you,
or
does
judgment
Is
often?
it
is
bad?
What
from
if
hear
Or
Unfortunately,
Is
just
sad
condemn
you
this
You
that
be
deny
you
of
mother?
Is
is it hiding
that
to
how
this
expression
a better
depression.
it.
want
piece?
an
What
out
perpetuate
you
helping
Youve
to
defense.
him?
worthless?
reach
her
notice
you
by
Does
you
longer
me?
Is
expression
presenting
no
of the
how
self-condemnation
you
is
go
notice
Do
yourself
let
compassion?
patients
defense
easily
Do
and
the
that
keep
you
What
make
sure
you
dont
Clarification:
have
defense
is who
patient
from
used
the
character
they
the
are.
Patient
defenses
Hence,
so
the
is the
and
know
and
It is attacking
support
by
yourself.
Would
Vignette
One:
the
that
Defense
they
must
assume
the
differentiate
the
But,
you?
this
you
are
not
problem.
This
the
part
of your
mind
is
not
cloak
of
able
to
you.
embarrassment.
embarrassed
long
punitive
You
shame
to
problem.
That
you.
want
defense.
judgment
protecting
judgment
from
therapist
You
punitive
your
see?
Differentiate
Patients
does
can
hide
if you
do,
Why
natural
should
feeling?
Its
yourself
in this
how
will
we
you
be
ashamed
see
you
sad
agree?
(Warshow
2008)
Differentiating
the
Therapist
to
from
be
or
shaming
the
Projection
In this
example,
defense
and
the
then
therapist
help
the
has
to differentiate
patient
the
differentiate
the
patient
therapist
from
his
from
the
projection.
Pt:
to think
how
[ Character
toward
sick
it was
defense:
me.
punitive
part
fantasy
about
When
That
your
me.
the
problem.
mind
that
out
that
about
with
you
you
I began
and
your
had
wife.
see
two
things:
The
problem
punishes
character
worried
you
is that
you
for
defense
about
your
even
fantasy
theres
this
having
.]
reaction.
[ Defense:
.]
Th:
called
the
I am
fantasy
.]
We
[ Point
that
to think
Th:
Pt:
projection
me
self-contempt
is not
of
for
I shared
yourself
sick . Even
But
even
before
before
you
you
came
came
here
here
you
today
judged
you
your
fantasy.
[ Point
out
her
internal
Pt:
But
this
for
having
of her
yourself
if you
afraid
judge
your
on
of
me
[ Point
superego
you.
[ Point
out
but
The
from
her
patient
to
herself.
She
in
the
danger,
rage
she
her
Notice
share.
need
of
self-attack
the
patient
is
have
If
and
sees
then
the
price
instead
of taking
a stand
harshly
you
will
you
forgot
the
that
you
yourself.
You
put
the
of
But
you
are
internal
only
can
fear
judge
me.
judge
not
that
from
condemns
her
parents
or
.]
her
because
how
parents
see
of
severely
therapist.
Price
of
an
urge
she
her
she
may
anymore.
how
the
refuse
with
You
are
not
is
the
face
the
self-attack
we
is
punish
They
Then
can
for
the
side
an
patient
see
the
price
of
she
begin
to let
this
you
the
character
to
defense
defense.
go
Only
of the
self-attack.
willing
Defense
Are
take
when
defense.
you
willing
stand
for
to
you
self-attack?
I dont
know.
myself
You
of
a Character
the
see
Are
to protect
Th:
of
the
does
it?
Pt:
identification
undo
afraid
herself,
to fear
clarifies
from
instead
this
not
helps
yourself
side
from
the
therapist
defend
and
and
But
judge
were
of
longer
Th:
myself
you
she
me.
would
afraid
Clarifying
the
onto
is covering.
Two:
how
you
judgment
She
no
judge
yourself
self-attack
of how
with
is defending
office.
that
afraid.
afraid
feelings
anxious
doesnt
defense
Vignette
she
internal
therapy
are
thought
becomes
tempted
her
.] I was
yourself
how
put
internal
You
harshly
to defend
you
out
Th:
how
trying
how
judgmentcondemning
[ Tears
then
see
internal
Pt:
your
and
we
.]
share
also
me
Then
own
a fantasy.
projection
were
was
.]
Yes.
Th:
me.
judgment
[ Character
from
dont
know
self-attack.
abandoning
parent
my
defense:
own
rather
abandon
self-attack
whether
[ She
you
takes
than
.]
will
the
take
side
take
your
of
her
her
own
side .]
Pt:
Defense:
projection
of the
Th:
unwilling
to
unable
Im
defend
superego
That
against
yourself
defense:
self-hatred
you
to
will
that
the
continue
to
choose
the
price
[ Identify
is how
freedom,
an
What
are
abandoning
call
to me.
own
attacks
I
self-attack,
If you
you
are
will
be
of others.
dont
dont
love
accept
others.
As
men
myself.
[ Rise
[ Character
Th:
But
love,
as
reject
defense
of
your
long
who
of the
Pt:
parent,
Three:
vignette
defense.
you
you.
you
wont
reject
be
yourself,
Why
do
that
to
.]
feeling.
Tears
whenever
something
I call
the
from
Pt:
[ Sigh.
your
else
in her
eyes
the
goes
.]
Maybe
her
against
name
. [ From
shows
the
love
in
self-hatred
child
But
of
the
your
love
(Osho
perspective
of
love
for
her
of
the
patient,
this
her
.]
perspective
Tears
Clarifying
illustrates
When
the
how
patients
self-attack
of cruelty
appears
mother
by
is
streaming
Price
to persist
so
have
attacked
to
an
be
of
down
face
a Character
the
patient
Defense
can
themselves
obvious
truth
recognize
for
rather
so
than
many
a
form
to oneself.
Pt:
defense:
[ Point
I know
self-denigration
Th:
Wow!
Pt:
What?
Th:
yourself?
sense
me.
.]
Vignette
Character
Maybe
of
love
herself.
self-hatred
years,
love
doing
you
abandoning
This
attack
I love.
you
1977).
perfect
the
If you
accept
yourself?
will
.]
Th:
willing
others
your
against
Pt:
afraid
.]
makes
yourself
to defend
more
out
the
Do
that
was
stupid
of
me
to
say.
.]
Do
you
character
you
see
what
see
how
you
defense
.]
you
just
did?
just
verbally
abused
Pt:
self-devaluation
Well,
it
was
stupid.
[ Character
defense:
.]
Th:
Is that
a kind
or a cruel
thing
to say
yourself
?
Pt:
It was
Th:
know
how
impact
that
you
it has
feel.
on
to yourself
Keep
her
Pt:
It was
Th:
How
attention
to yourself,
to
the
and
defense
let
me
and
the
stupid.
It was
does
that
stupid.
make
you
feel
when
you
say
?
Bad.
feel
bad.
When
Why
Pt:
do
[ Tears
Th:
verbal
that
her .]
Th:
yourself
repeating
[ Draw
Pt:
make
stupid.
you
that
verbally
to yourself
.] I always
You
abuse
refuse
do
to
yourself,
you
?
that
defend
to myself.
yourself
against
this
abuse.
Pt:
defense:
against
ignore
this
verbal
yourself
I hadnt
even
and
your
pain .]
Th:
You
didnt
thought
think
of
of
that.
[ Character
defending
yourself
abuse.
Pt:
But
shouldnt
Th:
How
I think
many
about
times
my
did
mistakes?
you
make
that
mistake?
Pt:
Once.
Th:
yourself
of it and
call
yourself
Pt:
Th:
And
many
times
did
you
remind
stupid?
Probably
So
how
hundreds
is that
thinking
of times.
about
a mistake
or
is
self-torture?
Pt:
I see
Th:
your
You
point.
can
torture
yourself,
or
you
could
it
defend
yourself
Notice
the
against
stepwise
this
torturous
habit.
in which
the
manner
Step
defenses
(how
she
treats
One:
What
shall
therapist
Help
we
helps
the
do?
the
patient
patient:
observe
her
herself).
Step
Two:
Help
the
patient
pay
attention
to
her
defenses.
Step
defenses
from
feeling
Three:
and
Help
the
patient
differentiate
her
anxiety.
Step
Four:
Step
Help
Five:
the
patient
Help
the
see
causality.
patient
turn
against
her
the
feelings
that
defenses.
Step
emerge
As
when
she
turns
as
the
patient
soon
interrupt
her.
she
can
had
an
see
And
it should
often
cannot
the
go
onto
be
labeled
to
show
explore
her
her
how
that
thinking
rage
she
toward
against
levels
relates
she
it
is
times
is
self-torture.
with
the
mistakes?
thinking.
character
misuse
differentiation
of
defenses
their
thinking
is essential.
aggressor
before
immediately
turn
and
these
character
defenses
she
the
has
rage
symptomatic.
turn
her
you
notice
before
against
the
let
back
The
it will
be
defense,
to herself.
how
you
you
laugh
dismiss
?
Do
pain?
correct
Patients
To
we
can
depressed
rage.
case
my
more
of
In this
Once
about
of
will
words.
defense.
thousands
an
herself,
I think
you
Do
yourself
dismisses
concrete
her
from
This
or
her
see
so
way.
defenses,
high
can
mistakes
becoming
turn
using
once
bear
ignores,
Shouldnt
of self-torture.
character
must
she
patient
defenses.
behavior,
differentiate
faces
the
neglects,
mistake
ones
herself,
patient
safe
purpose
of her
her
question,
about
patient
against
behaviors,
about
Ruminating
If the
her
Help
her
interesting
Thinking
for
Label
Six:
you
notice
how
at
your
Do
yourself
and
Only
when
begin
to
notice
how,
you
abandon
the
anxiety
patient
help
her
me
together,
relationship
Use
patients
the
dismisses
deal)
the
she
deeds.
about
in the
describe
Also
the
notice
no
big
see
her
After
the
right
because
she
self-dismissal,
about.
Help
her
see
point
defense.
the
defense,
Do
feelings.
the
You
them
say,
We
she
therapist
and
see
see
out
Pt:
that
and
that
be
use
wont
she
can
pattern
patients
If you
then
ask
dismiss
you
may
not.
of
not
her
can
see
the
I dont
see
how
pattern:
Im
ignoring
pattern
immediately
are
talking
can
see
can
ignore
ward
see
until
the
and
the
can
defense.
my
see
your
defense
Notice
she
the
your
off
the
behaviors.
behaviors
are
them
if she
and
how
pattern.
and
does
things
you
the
it .
it . Always
ask
what
her
pain.
see
patient
patient
patient
cant
of
slapped
at
the
is
of
these
until
you
the
her
recognize
defense
this
and
look
know
use
boyfriend
word
big
and
much
says
can
her
the
she
No
feelings
her
facts.
way
(e.g.,
make
She
the
see
the
if she
her
she
she
how
the
asks
ways
see
not
you
off
precise
Also,
stimulus:
hit,
the
but
them
words
bruise,
the
does
the
the
example,
points
then
this,
Will
dont
behaviors,
not
have?
the
the
notice
will
not
of the
you
feelings
Do
so
Do
may
the
she
out
your
we
we
Do
ignore
a bruise.
facts
price
point
following
because
the
the
Always
feelings?
In
out
the
on
can
laugh
sweeps
deal.
doesnt
herself,
self-dismissal.
self-dismissal.
her
up
and
patients
examples
sees
not
big
show
of
therapist.
the
patient
she
it hides
if she
Do
of
her
to
we
the
pattern
it hides:
pattern
give
relationship?
the
three
you
to
relationship
which
sequence:
recognize
If
repeat
no
word
how
relates
feelings
show
under
gave
facts
deal.
away
to
It s
and
the
your
of
the
rug
it . The
face
relates
same?
kind
she
or a dismissive
can
boyfriends
her
the
Always
it is the
forget
do
words
word
how
she
dismiss
herself.
so
how
what
a healing
see
you
to
notice
can
see
when
invite
yourself
you
feelings.
how
see
Th:
a way
to pay
attention
When
to his
Pt:
attention
is a way
is no
look
big
to
You
not
deal,
look
away
and
your
bruise?
pay
is no
big
deal,
is
that
it?
But
I dont
see,
see
when
attention
a way
from
To
Repeat
the
When
the
bruise,
patients
about.
Establish
ignores
herself
why
I should
pay
to
you
his
to pay
say
hit.
his
When
attention
hit
is no
big
you
say
the
to the
bruise
or to
If
not
she
does
feelings,
and
herself.
Always
function
and
her.
If she
the
After
see
help
price.
evidence
so
function
against
and
it.
presenting
acceptable
You
say
big
deal,
their
could
to
from
wont
her
see
can
see
the
hit
ignore
the
you
defense,
see
her
and
hit
say
will
not
make
no
with
her
ignores
out
its
sense
to
her.
Point
defense.
to
the
patient,
clarify
its
price
herself
from
and
turn
the
defense
creates
the
patients
symptoms.
When
you
ignore
his
show
them
that
hitting
you
No
be
she
pointing
argue
Th:
is
defense.
bruise,
that
before
she
defense
the
evidence
think
how
her
slapping,
do
not
illustrating
differentiate
how
does
observing
defense
what
her
out
and
this
to the
step-by-step
to
the
defense
help
you.
you
she
facts,
enacting
the
the
point
abuse
how
careful,
forgets
she
then
you
see
of
This
she
see
problems
boyfriends,
shift
character
Always
attention
everything
chain
feelings.
she
the
pay
you
show
Otherwise,
not
dont
do
to
how
herself,
identifying
and
her
her
does
you
concrete
and
helps
away.
Yes.
words
a
identification
look
Th:
Pt:
its
it.
hit
away?
you
other
his
or ignore
can
is that
Pt:
out
say
to it.
that
bruise
hit
Ignore
Th:
deal,
you
wonder
no
big
a
deal.
reason
you
stay
When
you
with
you
have
hit
and
is no
the
big
abusive
say
deal,
of
and
boyfriends.
getting
trouble
hits
hit
leaving
is
no
bad
relationships?
The
patient
has
has
trouble
traps
indicated
that
them.
If we
leaving
her,
she
example
will
be
more
of clarifying
the
the
character
show
how
her
motivated
to
let
go
defense
of
it.
and
hurts
Here
is
and
another
defense.
how
you
laugh
over
your
pain?
.]
Is
your
pain
funny?
[ Make
the
defense
.]
No.
Th:
we
sat
the
patients
here
and
What
agreed
attention
protect
patients
you
attention
the
patient
to turn
against
Pt:
Every
time
the
patient
identification
second,
the
self-criticism,
pattern
soon
before
tolerate
lets
go
the
as
the
her
she
why
lets
next
feelings
it?
defense
covering
who
if
[ Draw
.]
of your
molested
defense
you?
feelings,
[ Draw
the
.]
him.
shall
we
protect
her
defense
here:
him
or
of self-dismissal
may
experience
or
these
go
of a character
you?
.]
often
suffer
This
attacking
Within
the
herself.
Lets
notice
feeling
superego.
ask
build
go
of
split
self-hatred,
severe
defense,
helps
lets
self-attack,
of
occurs.
without
new
projection
character
she
superego.
a
patients
of her
defense
defense,
pathological
self-dismissal,
explains
at
have
Me.
within
patient
Who
we
laughed
of her
and
of the
It protects
Th:
would
one.
father
function
and
price
laughter
your
to the
relationship
is funny
a good
This
or
of
relational
Not
Pt:
Invite
pain
to the
Th:
this
kind
your
Pt:
As
can
relationships
Yes.
Pt:
an
bad
Notice
Th:
does
into
defense
Pt:
dystonic
gets
character
Th:
Identify
she
This
regressions.
what
her
she
capacity
continue
feels
to
with
our
take
this
example.
Th:
What
do
you
as
you
stand
for
you
instead
of your
Pt:
Anxiety
attacks
her
for
[ Sadness
taking
Th:
punitive
side
mechanism
instead
defense
your
triggers
rises
in
her
face
.]
Im
afraid.
side .]
wonderful
in now
to
you
Help
notice.
attack
[ Show
anxiety.
you
just
causality:
her
See
for
this
taking
turning
differentiate
how
your
against
herself
the
from
her
.]
I didnt
Th:
comes
Taser
in
here
you
with
you
from
Its
fathers?
Pt:
Do
her
comes
of
identification
father?
notice
her
to
punish
anxiety,
that?
defense
defense
out
Shall
we
break
to
engage
in
face
her
feelings
instead
interventions
Now
without
pointing
the
if
policeman
the
punitive
law
by
causality
mechanism
comes
taking
and
in
your
to
side.
separating
her
can
it onto
the
law
and
therapeutic
take
task:
your
let
go
side?
of
the
.]
Sure.
differentiate
she
turning
this
Yes.
Pt:
defense.
as
broke
patient
and
These
Its
how
.]
Th:
the
now
if you
[ Again
it before.
notice
you?
as
Pt:
[ Invite
But
see
feel
the
the
patient
from
the
rage
toward
her
feeling,
it is a way
character
molesting
father
herself.
SUMMARY
A character
to
defense
oneself.
Point
attention
to
attention
to,
she
begin
The
take
has
out
her
let
of
to explore
playwright
away
the
how
only
wards
the
self-abuse.
and
go
not
patient
This
let
go
the
identification
her
rage
of
off
these
toward
treats
focus
that
Henrik
Ibsen
once
lie
holds
a persons
that
will
forms
with
said
herself
of
an
help
and
the
of
relating
help
patient
her
pay
see,
pay
self-maltreatment.
earlier
Once
aggressor,
we
can
figure.
that
life
we
must
together.
be
But
careful
lies
not
do
to
not
hold
life
together;
You
deserve
to
believe
patient
herself,
self-torture.
our
lies
moment
we
free
they
die.
or
tear
You
the
dont
lies
by
moment
her
from
it
told
see
the
apart.
deserve
to
the
You
anything
us,
we
lies
she
identifications
arent
good
good.
suffer.
has
of her
enough.
By
been
past
When
helping
whispering
and
from
we
the
to
her
CHAPTER
THIRTEEN
Superego
T herapy
life
Pathology:
Transference
an
close
invites
experience,
through
The
the
defenses
resistance
(S.
highly
and
from
punishing
others
to
punish
feelings
resist
unconscious
(Fenichel
We
IS
analogy,
body
can
time
part
(Andersen
et
earlier
she
main
an
to
rise
avoids
strategies
for
al.
2005;
our
lives
several
such
rage
material
as
(secondary
(primary
case,
to
gain),
(superego
defenses
derived
and
from
the
RESISTANCE?
transference
rise
when
described
become
our
for
object
each
and
gratifications
unconscious
any
on
27).
feelings
of
for
In
feelings,
we
rely
therapy
good
over
of
to
resist
external
guilt
1945,
we
wants
to enjoy
1926/1961d).
the
As
any
as
for
due
Unconscious
relationship.
on
which
two
responsibility
differentiate
projection.
she
TRANSFERENCE
should
the
torn:
We
avoiding
Freud
transference
WHAT
Based
feelings,
(repression),
a longing
(S.
is
therapist.
ourselves
resistance)
mixed
transference,
patient
or
to pursue
relationship.
1926/1961d).
the
to avoid
has
the
Freud
reasons:
or
patient
resistant
distance
gain),
emotionally
Resistance
the
earlier,
closer
nonconscious
Hassin
to
resistance,
therapist
using
people,
et
al.
the
of
2006;
tries
to
form
abused
feelings
perception
and
dog
rise
threat
Panksepp
in
the
or
safety
and
Biven
2012).
Some
patients
Instead,
they
angry
at me.
Rather
than
others.
His
but
a defense
cannot
resort
feel
his
projection
against
tolerate
to
the
projection:
feelings,
the
(The
therapist
experiencing
experience
Im
fragile
is
feelings
not
of
angry
patient
angry)
toward
these
at
projects
is
not
the
you.
feelings.
You
them
transference,
therapist.
are
onto
In contrast,
the
therapist
the
by
using
therapist
begin
the
the
1934).
Now
the
defenses
For
instance,
resistance).
patient
began
mind,
whereupon
The
earlier
those
(5)
past.
he
To
summarize,
regressive
functioning.
Then
complex
mixed
withholding
to
experience
with
became
withholding.
the
dissolving
feelings
the
came
toward
his
of
mother
resistance
toward
the
his
her
based
resistance
with
the
to
her.
therapist
had
toward
toward
mother
(2)
of
the
behavior,
the
of rage
feelings
therapist,
feelings
he
patient
(transference
his
mother,
relationship
link
relationship.
the
toward
of feelings
withholding
therapist.
(3)
1926/1961d;
mother
this
toward
patient,
toward
feelings
the
emergence
the
with
therapist,
mother
without
in
the
enacting
others.
patient
experiences
Rather
than
the
experience
highly
relationship.
mixed
The
those
resistant
fragile
feelings
feelings
patient
patient
based
resists
resists
them
on
(based
on
them
by
through
of projection.
in the
help
of
therapist),
of
feelings
withholding
at the
a rise
relationship),
defense
which
the
patient
addressed
enacting
could
a past
his
with
relationships.
enacting
Earlier
(1)
relationship
earlier
like
they
feelings
a pathological
the
avoid
experienced
experiencing
past
the
rage
(4)
the
an
to feel
from
Now
earlier
therapist
by
therapist,
and
the
experience
(withholding
the
act
was
feelings
minutes,
of
resistance
with
As
a relationship
1912/1957a,
form
worked
to
to
he
sequence
on
a few
rise
the
however,
to enact
transference
to
toward
defenses.
feeling,
the
Freud
feelings
character
begins
resist
S.
together
defenses
As
to
term
his
against
patient
therapist
After
began
and
defenses
the
use
tactical,
1990;
work
as
than
avoids
transference,
Hence,
vague.
patient
The
(Davanloo
Strachey
patient
the
a system.
the
therapist
Rather
repressive,
as
past,
became
resistant
addresses
to work
from
highly
book
us
avoid
defenses,
In
this
we
showed
feelings.
which
section
how
to
Then
cause
of
the
address
we
showed
a regression
book
we
are
repressive
how
in reality
addressing
defenses,
to
work
with
testing
and
character
defenses
and
the
relationships.
transference
Since
enactment
of
resistance,
these
a past
forms
of
relationship,
two
ways
resistance
we
have
to
of enacting
are
based
address
past
on
their
the
relational
implications.
We
handle
relates
character
to
himself
the
transference
the
therapist.
chapters,
the
free
of superego
The
transference
need
to
than
we
resistance
his
healthy
and
defenses
desires,
Patients
can
resist
patterns
of
resistance
resistant
and
to
help
and
shows
the
transference
the
separate
and
therapist.
patient
So
become
enables
his
patient
from
to succeed
him
to identify
emotional
experiencing
than
rather
relationship
prevents
encourages
with
him
the
to fail
at the
his
at
pursuit
character
suffering.
Resistance
the
rise
of feelings
across
the
the
in many
spectrum
spectrum
of
ways,
of
but
we
can
psychoneurosis.
resistance
from
see
The
moderately
to
patients.
repressive
defenses
to repress
to relocate
their
feelings,
defenses
to resist
and
the
then
shift
experience
resistant
patients
resort
judgment,
highly
to using
patients
use
feelings.
internal
Some
repressive
to
defenses
anxiety,
Fragile
defenses
handle
relates
in
pathological
Moderately
tactical
patient
the
alliance,
and
wishes
of
list
feelings
patient
We
these
a past
prevents
perpetuates
Spectrum
following
the
character
therapeutic
of unrealistic
defenses,
how
both
them
creates
healing
triggering
of realistic
of
the
relationship).
addressed
use
how
pathology.
pursuit
out
avoid
both
out
a past
have
to
address
pointing
pointing
patients
in relationships,
feelings
highly
by
resistance
will
The
of
resistant
transference
closeness
enactment
Although
highly
rather
by
resistance
you
the
(his
defenses
resistant
character
of feelings.
to
regressive
or defenses.
patients
defenses
use
and
More
therapy
use
using
character
throughout
nonverbal
As
their
to
in
that
exhibit
their
these
resistance)
1945;
more
1984,
defenses,
the
with
the
Kernberg
they
traits
(Kernberg
directly
(Fenichel
begin
pattern
character
character
relationship
patients
a relational
associations
those
past
resistant
enacting
They
addresses
enact
transference
Reich
than
therapist
begins
lives.
behavior
the
defenses,
highly
in
211).
patient
therapist
1984,
(the
218221;
1933).
The
transference
clarifying,
and
therapist
which
resistance
confronting
and
patient;
reveals
The
its
Evolution
The
highly
the
resistant
a presenting
(2)
and
of
dissolved
through
in
the
and
it
and
origin
is
the
here
resulting
patient
the
of
feelings,
starts
against
offering
Resistance
out
using
defenses
problem.
[ Defense:
who
between
breakthrough
Transference
denial
had
the
idea
not
sure
should
ask
I have
an
internal
.]
You
one
now
identifying,
purpose.
Im
problem.
(1)
I should
come
my
to therapy.
wife.
Shes
[ Defense:
the
projection
.]
Address
for
each
which
therapy.
example
seeks
help.
If so,
then
address
where
his
these
distance
or
tone
speech,
from
His
the
He
against
vagueness,
a presenting
he
wants
against
Then
problem
to
engage
offering
explore
that
in
specific
example,
feeling.
shift
changes:
He
if
defenses
therapist.
verbal
out
occurs.
posture
uses
declares
find
his
the
chair.
patient
Then
interventions,
in
voice.
the
problem
defenses
eyes.
slouches
of
his
himself
therapists
until
he
addressing
During
defense
occurs.
He
The
looks
he
away,
crosses
speaks
in
tactical
defenses
generalization,
patient
and
his
dismissive
such
begins
to
avoiding
the
arms
and
and
detached
as
diversification.
legs
hypothetical
These
defenses
not
only
interpersonal
When
do
off
defenses
a patient
not
ward
try
uses
to
someones
defenses
those
defenses,
Since
these
a rise
defenses
to
the
is
feelings
point
will
in the
wall
the
your
focus
from
they
create
(Benoit
individual
[ Defense
Do
identification
Pt:
my
gaze.
eyes.
[ Identify
the
the
window
these
lets
go
of
pathological
becomes
and
others.
a
Shift
relationship
you
are
looking
I supposed
find
if
at
to look
you
the
to think
it easier
to
resistance
at you?
noticed
identification
how
you
.]
when
I look
away.
think
when
you
avoid
.]
[ Sighs,
shifts
in his
Do
notice
how
you
talk
to me?
you
[ Identify
in his
chair
.] I like
the
chair
[ Identify
the
were
.] Yes.
[ Looks
out
like
involved
I think
you
this
say
back
out
the
resistance
at
the
would
resistance
You
look
window
.]
therapist
and
then
are
here
view.
transference
sitting
would
the
you
transference
[ Looks
How
Th:
involved
into
.]
Pt:
intern
Am
it easier
You
Th:
today?
walk
patient
defense
how
resistance
Pt:
slouches
to
pathological
wondered
transference
Th:
when
therapist,
address
himself
the
notice
I just
I find
Pt:
try
create
Each
What?
[ Transference
Th:
my
the
accessible.
between
you
Yeah.
Pt:
therapist.
.]
Th:
avoid
These
1991).
Th:
floor?
with
the
to
to
the
Instead,
more
defenses
therapist.
not
When
together
erects
1990,
contact
relationship.
patient
the
toward
locked.
become
that
off
would
first.
work
out
brick
door
contact
defenses
relationship,
prevent
You
human
ward
of feelings
feelings.
when
against
they
signal
explore
house
feeling,
Im
very
said
in
she
was?
say
you
.]
involved.
youre
your
you
a lawyer.
office
for
[ Identify
If a
an
the
prospective
interview,
transference
how
resistance
.]
Pt:
see
his
transference
Not
resistance
Th:
percent,
twenty
youll
just
He
has
using
here?
have
resistance:
its
yet.
Id
him.
Shift
from
Previous
show
transference
now,
getting
away
and
avoiding
resistance
hundred
about
only
result.
percent,
this
eighty
twenty
[ Clarify
and
conflict
will
to
transform
fifty
percent
percent
the
here,
transference
Do
their
be
book
sharing
his
internal
not
price
between
feelings
conflict
confront
first.
If
the
Transference
of the
how
between
therapist.
them
you
two
have
shown
how
defenses
and
into
an
his
defenses
respond
to
of
you
Resistance
to address
Do
a little
you
notice
distant?
looking
Do
at me?
his
instead
of
Identification
to address
when
they
defenses.
function
as
how
you
you
are
notice
[ Identify
going
up
you
are
how
signs
in
your
pulling
of the
transference
impact
on
work
out
price
.]
Yes.
Th:
withdraw
and
What
become
Pt:
to
withdraw
to let
go
will
be
distant?
so
we
of the
Pt:
What
can
wont
do
you
have
transference
I guess
the
[ Point
I probably
Th:
patient
to
percent.
do
youre
conflict
to
the
Pt:
the
begins
resistance.
head
tendency
if
we
percent
Th:
you
all,
tries
with
Defense
will
One
twenty
can
the
he
see
sections
we
After
So
the
about
What
tolerating
him
within
[ Patient
.]
one
Help
involved?
say
twenty
price
defenses.
provocations,
Now
trouble
interpersonal
I guess.
.]
How
Th:
missing
involved,
percent?
Pt:
thats
too
I need
get
the
better
resistance
not
here
if
.]
anywhere.
think
a
our
we
can
result?
do
about
this
[ Encourage
.]
to withdraw
and
go
up
in
my
head.
Th:
head,
of
what
the
do
you
notice
transference
the
therapist.
about
those
feelings
us
look
working
at
on
you
feeling
When
your
the
wall
Within
two
to
versus
of detachment
transference
of
in
the
on
of the
the
the
defense:
your
emergence
are
rising
resistance,
difference
transference
Do
patient
to
distance
himself
enacting
past
ask
you
between
resistance.
notice
resistance:
now
between
always
Emphasize
you
Do
you
and
emphasize
how
same
the
from
detach
the
you
notice
me?
the
relational
defenses
create
it evolves.
alliance.
on
or
1986a,
The
Then
the
patient
the
invites
starts
patient
those
the
starts
feelings
to
through
Whenever
for
The
past
relationships.
4.
invites
patient
and
transference
The
resistance
to
handling
it
the
always
1986b):
2.
transference)
therapist
sequence
therapist
The
the
transference.
the
at
First,
and
the
arises,
resistance
Then
therapist
relationship:
(Worchel
transference
a close
experiences
patient
enacts
to
avoid
relationship.
feelings
past
toward
relationship
experiencing
those
feelings.
defenses
Resistance
therapist.
the
3.
defense
a therapeutic
1.
based
Transference
Usually,
resistance
therapist
up
enacts
toward
the
put
the
patient
form
feelings
transference
transference
defense.
of a therapy.
(character
[ The
in
relationship.
the
beginning
the
up
feelings
go
illustrate
resistance,
Addressing
Sometimes
remains
that
lets
working
you
treatment-destructive
have
me?
go
feelings?
implications
the
toward
patient
examples
defenses
the
Steps
here
and
.]
Address
this
withdraw
suggests
Address
from
dont
resistance
toward
Let
If
therapist
until
addresses
they
collapse.
the
character
5.
the
The
feelings
toward
patients
past.
Structure
did
him.
to
mother,
feelings
toward
you
1982;
of
as
his
the
links
toward
the
patient
if you
are
between
someone
passive,
to be
warm
what
the
does
doing
nonverbal
Or
in
the
to
what
and
withdrawn
he
may
and
act
giving.
child
felt
like
The
when
you
his
what
his
parent
did
verbal
forms.
For
father,
inviting
you
his
cold,
withholding
therapist
treated
often
in
feels
these
ways
1968).
resistance
object
structure
feelings
takes
Racker
transference
internalized
acts
like
experiences
Resistance
forthcoming.
experiencing
Ogden
The
he
act
and
inviting
angry,
or
may
active
and
resistance,
enactment
he
patient
Transference
him
This
instance,
(T.
the
The
therapist
transference
parent
to be
the
of
the
to
experiences
therapist.
6.
In
patient
has
relation
the
structure
(Kernberg
internalized
1975).
object
(Troendle
Table
relationship
as
2005)
of
13.1
shows
it
enacted
is
an
the
in
therapy.
Table
13.1
Patients
I am
Structure
enactment
passive.
I ignore
my
I oppose
inner
have
hope.
I dont
have
the
not
an
must
life.
therapy.
the
be
Convince
me
energy.
emotional
enact
The
one
the
patient
interpersonal
role
in
must
You
person.
a past
role
active.
must
You
resistance
expected
You
Key
enacting
transference
Therapists
You
I dont
I am
of
pay
attention
to do
it.
have
hope.
must
have
You
insight:
relationship
to it.
it.
must
the
be
emotional
patient
and
avoids
inviting
the
feelings
by
therapist
to
other.
avoids
conflict
an
intrapsychic
conflict
by
creating
an
The
patient
avoid
simultaneously
his
dont
intrapsychic
depend
did.
on
Instead,
me!
wants
This
to
conflict,
anyone
I act
explains
he
who
could
like
my
why
patients
face
mother
did
dont
with
want
an
withhold
from
withholding
me.
to
I dont
withhold
see
any
you
look
think
inside.
[ Projection.
to relate,
[ Projection:
like
my
When
the
patient
unwittingly
speak
therapist
and
enacts
one
I withhold
therapist
to
stuck.
If
she
look
mother
did
know;
do
you
his
healthy
them.
past
the
mother
on
at
you
this.
like
my
role.
the
this
is
important,
at my
inner
life.
to me .]
think
is
know.
my
problem,
I withhold
from
therapist
can
]
desires,
the
conflict
within
relationship,
other
doesnt,
than
you
must
Then
rather
think
like
projects
for
to
to look
me.
in
enact
depend
from
want
from
patient
role
my
you
I should
seem
withheld
up
the
one.
like
and
You
just
I dont
mother
me
To
say
What
doctor?
feelings.
why.
desire
his
interpersonal
mother,
You
but
avoid
creates
You
Projection:
and
occurs
the
between
patient.
The
unconsciously
If she
patients
does,
the
patient
inviting
therapy
resistance
the
fails,
the
becomes
and
change
occurs.
The
patient
long
as
cannot
she
therapeutic
other
view
as
the
other
relationship
off
therapist.
the
and
in other
PSYCHODIAGNOSIS
RESISTANCE
front
the
you
feelings
explore
You
rooms
to
dissolved
feelings
deep
relationship,
relationships.
therapist
to
wards
access
might
door
in
If
first
the
house.
genuine
relationships
will
OF
there
of
THE
the
work
the
contact
be
is
relationships
a
on
the
the
fruitful.
TRANSFERENCE
as
in
the
feelings
relationship
transference
with
problem
exploring
If it is locked,
So
Once
other
before
think
of a house.
therapist.
gain
it
in
in
with
the
there
is no
way
front
door,
the
resistance
patient,
exploring
is
To
intervene,
the
resistance
and
sequence
therapist
the
must
element
of
of psychodiagnosis
assess
the
it
is
that
occurs
as
The
patient
1.
type
in
of
the
transference
forefront.
The
follows:
enacts
the
transference
resistance.
2.
forefront
Psychodiagnosis
of
the
element
in
the
occurs.
3.
The
therapist
intervenes
to
deactivate
the
resistance.
4.
unconscious
feeling
resistance
occurs.
In the
transference
of four
elements:
Decreased
and
anxiety.
5.
The
The
next
sequence
resistance,
resistance
patient
enactment
continues
each
An
as
patient
rise
of
before.
identification
with
of
expresses
one
a parent
healthy
desires
onto
therapist
An
an
to
of transference
response
A projection
the
leads
omnipotent
invitation
for
intervention
interventions
therapist
to
take
stance
A regressive
Each
the
deactivates
will
one
wish
of those
elements,
and
Therapist
as
the
following
illustrate.
Psychodiagnosis
of
Response
Intervention
When
the
assessing
the
transference
parent,
transference
resistance
projection
of
healthy
transference.
Once
you
you
which
intervention
will
Patient
know
Response:
is
resistance,
in
the
Identification
forefront:
desires,
understand
be
element
most
with
which
element
identification
regressive
which
will
note
helpful
a Parent
wish,
with
omnipotent
is in the
in the
forefront,
moment.
of
a
In the
with
the
transference
resistance,
a parents
role
defense.
of an
relationship
patients
In the
avoidant
to
the
child.
identification
who
with
can
the
enact
example,
leaves
Notice
how
all
the
an
the
the
identification
patient
enacts
responsibility
therapist
for
deactivates
the
the
parent.
But
this
makes
me
anxious.
what
makes
I dont
want
to
anxious.
Th:
keeping
calm
and
what
you
should
do.
we
cannot
help
is
you
anxious,
can
avoid
what
charge.
Or
charge.
But
therapy
If
you
that
makes
we
can
as
cannot
giving
face
long
help
mirroring
his
is between
Patient
Response:
as
In this
element
of the
childs
desires
onto
patients
the
experience
anxious,
as
it.
avoid
what
then
avoid
have
then
you
want,
you
We
and
makes
pointing
and
the
the
makes
you
makes
choices.
anxiety
so
is
obviously
what
two
anxious
the
out
his
patients
you
We
will
be
in
can
be
in
anxious,
this
identification
by
realitytherapy
resistance
of
the
will
fail.
The
projects
the
to it .
Patients
resistance
therapist.
parent.
Healthy
how
doing
with
the
Th:
at it.
the
Meanwhile,
Notice
By
intrapsychic
to look
with
Deactivate
Pt:
interest
long
transference
conflict
an
as
you
anxious
Therapist
projection.
interpersonal
But
Projection
onto
with
results
you
and
Desires
identified
the
what
reality
the
you
you
you.
stance
conflict
avoiding
you
you
Principle:
your
patient
following
parent
Pt:
be
the
the
the
patient
therapist
so,
the
patient,
so
conflict
patient
deactivates
therapist
the
remains
patient
the
avoids
an
begins
to
instead.
I know
you
think
Only
you
can
I should
know
take
whether
a look
it would
at this.
be
in
Principle:
wishes.
his
Do
hands
not
Block
advocate
Response:
cannot
deactivate
those
wish
Expression
transference
which
his
projection
of the
to look
patients
inside;
leave
healthy
that
task
in
Patient
The
for
the
of
resistance
be
satisfied
those
always
in reality.
regressive
regressive
the
involves
The
wishes.
wishes,
he
will
Regressive
regressive
therapist
If
fail,
Wish
must
the
therapist
and
the
wishes,
point
out
tries
to
therapy
will
and
satisfy
remain
stuck.
Detached
Heal
me
me
emotionally
while
I hide
or uninvolved
while
from
I remain
me
impact
while
on
our
oppose
or defiant
you.
be
Do
not
passive.
You
gratify
reality:
must
Help
transference
expect
my
resistance:
behavior
to
have
no
helpless
the
wishes
are
transference
activity
I refuse
Instead,
impossible
resistance:
to offer.
remind
to
satisfy,
the
and
patient
of
they
lead
to
this
therapy
therapy.
happen
I was
hoping
I could
just
let
to me.
Th:
Principle:
possible
And
how
Point
long
out
will
that
reality:
the
take?
regressive
wish
is
not
conflict
between
is
reality
self-defeat.
which
or
wishes.
Pt:
The
give
regressive
regressive
a failed
uninvolved.
success.
Passive
will
emotionally
resistance:
you.
Oppositional
Heal
transference
we
not
and
Healthy
violate
between
the
patients
relationships
at
our
peril.
you
and
resistance
operate
Passivity,
the
patient.
The
conflict
to it. Resistance
according
detachment,
to
certain
defiance,
is
leads
to
laws,
and
helplessness
do
not
work.
No
therapy
can
succeed
under
to
an
those
conditions.
Patient
Response:
Omnipotent
To
their
the
the
in any
effort
patient
relationship,
toward
both
a shared
proposes
an
will
give
offer
twenty
one
percent
partners
goal.
In
impossible,
Detached
I
Therapist
Take
Stance
succeed
of
Inviting
must
the
of
omnipotent
my
hundred
percent
of
role
withhold.
The
therapist
for
Then
involvement
cannot
the
therapist.
resistance:
I want
plus
give
percent
resistance,
transference
involvement.
your
100
transference
or uninvolved
percent
put
you
the
what
to
eighty
the
patient
withholds.
Oppositional
I want
you
while
to
I work
put
one
one
hundred
percent
percent
against
the
hundred
one
hundred
percent,
plus
one
hundred
percent
can
give
one
to counter
your
do
have
do
by
how
percent
the
it.
effort
You
percent
to
will
the
therapy
need
I am
opposition.
and
patient
passive
whatever
to
take
your
I deal
Principle:
reminding
or
have
magically
change
hundred
must
I dont
me
to
You
so
Change
one
this.
back
my
your
resistance:
Yet
to
not
no
give
giving,
therapist
percent!
Helpless
cannot
transference
of
hundred
your
300
or defiant
the
my
hundred
I cant
steps
in
resistance:
do.
my
Carry
You
me
on
journey.
interpretation
feelings.
Or,
so
must
give
dont
your
percent.
Deactivate
of reality
I say
omnipotent
with
my
transference
the
omnipotent
patient
disidentify
transference
by
In summary,
1.
Help
2.
desires
onto
the
therapist.
the
Deactivate
the
projection
with
the
of
his
parent.
healthy
3.
Deactivate
4.
Clarify
5.
Help
the
the
omnipotent
regressive
transference.
wish
and
its
realistic
consequences.
These
interventions
put
(Davanloo
2000;
Kalpin
resistance.
His
the
past.
This
his
resistance
crisis,
transference
resistance
Figure
Decision
13.1
defeats
the
him
will
is in the
forefront
for
feeling.
(see
and
defeated
between
assess
collision
patient
someone
of
resistance.
head-on
the
conflict
therapist
of the
as
breakthrough
tree
go
between
of internal
to
let
facilitate
1994)
experience
intrapsychic
patient
together
resistance
leads
the
the
To
figure
13.1
the
in
and
facilitate
element
of
him
patient
which
psychodiagnosis
his
that
of
the
).
transference
resistance
The
We
Process
must
habitual
of
first
help
pattern
relationships.
three
Change
the
patient
of behavior
Changing
so
the
he
and
can
differentiate
make
transference
himself
a different
resistance
from
choice
takes
this
in
his
place
in
stages:
1.
(Coughlin
Labije
see
Della
Selva
Differentiate
1996;
Davanloo
the
patient
2000,
from
2001;
the
resistance
Ten
Have
de
2001).
2.
awareness
of
his
healthy
Mobilize
desires
and
strengthen
(Coughlin
Della
the
Selva
patients
1996;
Davanloo
1990,
2000,
2001;
Lebeaux
2000;
Ten
Have
de
Labije
2001).
3.
(Coughlin
de
Della
Labije
To
Selva
1996;
defenses
the
and
him
see
past
relationship
resistance.
patient
then
help
the
help
price
behavior
so
and
The
patients
resistance
automatic,
To
from
his
his
than
be
his
resistance,
see
the
a healthy
2000,
2001;
choice
Ten
defense,
we
differentiated
not
of
the
you
off.
essence
he
can
his
capacity
help
him
between
his
from
make
Have
drops,
essence
and
self-observing
here
will
focus
have
feelings
aware
as
the
on
is
and
his
and
deactivating
Passive/Helpless
accomplished,
through.
work
the
the
them.
examples
below
illustrate
common
to
see
of
the
the
transference
must
also
defenses,
resistance.
Transference
forms
and
someone
Resistance
The
By
automatic
we
character
transference
remind
resistance.
Although
with
he
choices,
as
a person
break
the
anxiety,
learns
an
Once
defeats
He
he
merely
desires,
them.
his
who
conscious
himself
defenses
conditioning.
observe
been
his
differentiate
of
Then
see
between
feelings,
he
not
out
can
with
capacity
only
his
Now
does
healthy
his
is enacting
must
resistance
observe
become
stages
mobilize
to
you.
It
his
of his
see
him.
different
the
identify
his
three
ways
behaviors.
than
of
We
awareness
the
he
difference
behavior.
his
to
he
point
part
patients
difference
Deactivating
wards
see
the
rather
we
can
of automaticity.
reactions
resistance
he
him
relates
Since
persistently
hostage
and
he
habitually,
the
from
these
must
is
choices,
ways
help
noncollaboration.
pattern
goals
strengthening
Once
the
and
he
resistance,
strengthen
of
how
habitual
see
him
from
him
you
a person
rather
make
1990,
automatically
is as
can
patient
Davanloo
of his
Therefore,
relational
person
the
2001).
differentiate
and
Help
passive/helpless
transference
resistance
pointing
out
reality
and
is key
ways
you
can
to addressing
this
Example
Th:
like
me
to help
Whats
is.
know
[ Invitation
if you
regressive
to form
have
me
wish
with
if I have
you,
reality
or
projection
no
not.
onto
But
idea
and
have
Since
destructive
that
therapist
rise
if
to share
he
me
go
more
you
because
passive
want
this
to
tell
you
of the
faced
insights
about
would
be
transference
do
I do
his
of the
Only
Surely
you
his
you
for
sure.
heard
can
anything
internal
emotional
[ Deactivate
while
The
this
a
about
whats
going
the
the
in
my
resistance
.]
this?
[ The
to
avoid
patient
question
patient,
the
destructive
why
habit
for
our
having
He
feelings
invites
the
is healed.
you
of
faced
painful
passively
isnt
disaster
on
transference
self-destructiveness.
resistance
Th:
out
.]
Two
do
this,
devaluing
relationship.
but
what
yourself
[ Block
the
.]
Example
you
my
[ Confront
I havent
passive
intellectualizes
do
do.
training.
an
collaboratively
Why
Th:
do
what
.]
lets
defense,
would
would
resistance
have
know
Example
me
problem.
all this
you
can
Let
Pt:
tell
I can
emotional
whether
therapist
talks
something
really.
you
patient
could
transference
not
you
Not
Only
the
[ The
momentarily
you
or not.
Pt:
marriage.
which
.]
a problem
I have
problem
with
you
a passive
internal
Th:
from
how
resistance.
problem
hoping
Thats
an
Pt:
tell
Notice
One
the
I was
Th:
can
it.
you?
Pt:
problem
deactivate
Whats
the
Three
feeling
toward
him
for
kicking
to
feel.
house?
Pt:
dont
know
how
Metacommunication:
stance.
Offer
to this
Work
hard
therapy
what
Th:
yourself
right
now?
[ Point
Pt:
Do
out
right
baby
in
the
now?
world
underestimate
defense
Do
say
feels.
her
defense
full
and
yourself
her
transference
to give.
helpless
how
you
underestimate
how
you
underestimate
.]
notice
dont
know
felt.
how
Do
to
you
yourself
I do
put
Th:
Thats
and
Heal
regressive
feelings
feel;
see
yet
every
now
how
you
[ Point
out
the
I know
that.
[ She
down?
cannot
Contrast
her
dont
feel.
resistance
the
for
goal.
But
what
Then
wish
with
we
[ The
if
price
Im
be
you
have
defense
able
able
if
wont
of the
I have
to
.]
feel?
no
feelings.
to
succeed.
[
]
[
.]
indicates
give
we
not
while
reality
because
here,
wont
[ Anxiety
you
here
down
emotionally
you.
the
The
me
issue
is
a list
of
with
reality
Pt:
Isnt
there
Th:
I can
No.
If you
the
on
cannot
capacities
a list.
then
wish
take
consequences
isnt
true,
Please
to deactivate
reality
important
yourself
Th:
If that
regressive
have
a lot.
rise
of
feelings?
complex
[ Another
.]
Metacommunication:
feelings
down
your
me
.] Can
of helplessness
you
myself
put
to achieve
Th:
out
you
put
Pt:
you
.]
capacities
Contrast
your
take
.]
Metacommunication:
say
notice
have
Pt:
form
unable
defense
you
You
yourself
underestimate
your
you
while
What?
You
Pt:
sees
me
I am
the
Th:
yourself
for
feel,
therapy
.]
cannot
something
you
omnipotent
what
then
necessary
projection
issue
is that
help
you
you.
do?
.]
the
do
The
to
onto
transference.
I can
do,
we
have
do
the
could
therapy.
therapist.
but
I cant
to accept
[ Mirror
Then
]
feel
that
her
point
Pt:
of the
me
transference
physically
stance
often
with
covered
it up
resistance
allows
Th:
do
How
No.
with
allows
Im
angry
feelings
you
Wasnt
Every
time
a helpless
the
[ Weakening
to rise .]
that
anger
the
patients
anger
a result
she
became
angry
with
stance.
covered-up
Pt:
Metacommunication:
toward
Focusing
feelings
Im
You
not
will
on
the
of
your
people,
she
transference
to rise.
Four
sure
I have
need
to
the
energy
provide
the
to
do
energy
this.
I
cant
transference
resistance
therapist
to take
on
give
one
therapeutic
and
hundred
alliance
you
can
percent
result.
percent
is all
twenty
percent
resistance
That
will
Isnt
there
something
the
Th:
you
Th:
omnipotent
No.
and
its
we
result
only
[ The
transference
can
give
result
is
resistance
the
transference
rest
if I give
can
the
and
percent
good
hope
[ Invites
here
result
[ The
twenty
.] If
superego
for.
[ The
percent
have
its
and
result.
hundred
just
pathological
can
do?
.]
one
well
resistance
we
you
a very
percent,
and
able
against
But
the
regressive
to achieve
the
what
If you
of
Pt:
Turning
the
twenty
], then
price
of
a
the
if
cant
do
it?
[ Invite
the
you
my
.]
Th:
be
[ Block
.]
transference
wont
problem.
hundred
have
.] But
[ mirror
all
one
can
twenty
Pt:
shoulders
transference
If I give
percent,
give
you
be
.]
Pt:
the
you.
experience
Example
offer.
with
body?
wonder,
her?
.] Now
resistance
in your
Therapists
[ Sigh
your
do
way.
wish
.]
goal.
[ Begins
resistance
cant
.]
I cant
[ Deactivate
Well
[ The
to
it,
have
price
cry .] But
carry
the
to
on
omnipotent
accept
that
you
.]
I cant
go
on
this
way!
Th:
yourself,
this
creates
habit
is
this
of
the
resistance
result
terrible
giving
I hear
on
hoping
you
you
could
help
energy
you
heal
this,
faces
the
as
if
our
while
you
glad
do
they
or
are
or
projection
against
the
up
on
myself.
you.
.]
But
I have
If you
to accept
dont
[ Deactivate
have
the
the
omnipotent
than
passive
respond
they
now?
work?
[ Identify
[ Invite
the
the
patient
because
projection.
The
you
onto
to
ask
is going
patient
will
for
gave
had.
you
[ Now
me
to
have
get
to
dont
know.
passive.
who
will?
his
are
impact
price
what
[ Deactivate
.]
you
going
that
have
will
of
can
in your
end
asks
I remain
therapist
the
So
the
ways:
.] What
him:
with
therapist
I
while
present
working
the
notice
notice
patients
When
dont,
the
resistance
patient
this
said.
I ever
reply:
of these
role
answers,
are.
will
out
in one
the
woman
resistance,
that
omnipotent
fiance
resistance,
patient
Figure
can
best
my
.]
transference
the
of the
passivity
the
myself
what
the
Do
the
on
destructive
turn
giving
yourself.
.] Thats
If
In
up
resistance
this
to
stop
on
transference
capable
helpless
therapist
succeed
give
[ Metacommunication:
myself.
I lost
helpless
less
and
passive
to
up
on
it by
resistance
Metacommunication:
When
about
him
to help
up
[ Cries
and
of his
passive
question
our
do
something.
I give
give
I cant
relationship
price
passive
The
you
.]
the
In
I have
do
Im
Pt:
on
we
as
transference
[ Encourage
could
me
while
to do
transference
up
long
[ The
can
I guess
Th:
cant
What
as
.]
I was
hoped
.]
but,
have.
yourself?
Pt:
But
youll
result
up
you,
his
we
way?
passivity
little
on
resistance
do
about
this
[ Deactivate
for
.]
the
therapy
to
.]
passive/helpless
therapist
to give
transference
what
the
patient
resistance,
withholds.
the
Some
patient
invites
wonder,
What
if he
cannot
children
can
yourself
down
for
the
heart
People
may
answer
these
answer:
What
make
do
not
an
therapy,
require
such
They
people
deficits.
a transference
resistance.
sometimes
the
fragile
highly
the
suffering
For
it can
patient
be
from
resistant
patient.
psychodiagnosis
that
from
Aspergers
hard
to
patients,
Table
you
under
the
of
in
course,
or
projection
other
the
is
of
resistance
differentiate
of
helplessness
transference
to
a faade
syndrome
shows
in
relationship
however,
13.2
patient
But
exceptions,
differentiate
passive
allow
are
The
carpenter.
pathological
There
putting
Questions
day.
abilities
same
Does
head.
skilled
real
questions
you?
every
work.
most
the
it hurt
ask
him?
of the
or
their
enact
neurocognitive
Yet
nurse
at
does
abilities
hide
and
or
We
toward
intelligence
room
friendships,
as
good
and
patients
pseudoincapacity.
feeling
great
skills
helpless
marriage,
feel
emergency
in therapy?
is the
you
demonstrate
be
questions
will
of
in
the
differences
these
two
from
the
in
forms
resistance.
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
Reality
testing
Reaction
to
Extent
with
the
Response
When
the
Fear
therapist
resistance
to
and
the
will
being
of the
therapists
active
while
will
the
patient
passive
of
anxiety
Good
therapists
Comfortable
remains
Impaired
Single
deactivating
patient
therapist
engages
deactivates
defense
projection
in the
The
of
task
projection
will
entire
Drop
Patient
of will,
relationship
in projective
remains
the
fragile
passive
patients
of
projective
task.
anxiety
Her
projection
engaging
in
passive
the
to
form
the
was
passive
readily
the
rest
transference
the
In
many
the
therapeutic
her
the
patient
defenses
that
Thus,
defenses
the
preventing
contrast,
relationship.
of
in
defense
uses
pathological
the
engages
only
task.
resistance
leaves
Deactivating
she
therapeutic
form
defense
and
of will
transference
together
one
drops
from
with
operate
addressing
functioning
so
only
they
can
resistance.
Oppositional
or
Defiant
Transference
Resistance
These
examples
illustrate
transference
resistance
deactivating
the
common
and
forms
ways
projection
of
you
will
of
can
the
oppositional/defiant
deactivate
onto
the
it.
Notice
therapist
is
how
the
key
intervention.
Example
Th:
help
you
Whats
I dont
Th:
not
very
said
to
exactly
brought
you
depend
on
between
fing
therapist
what
help
me.
depend
you
[ Avoid
he
on
but
the
here,
what
the
did
(come
you!)
invites
you
reality
can
.]
obligation
you
would
like
me
to
his
a battle
projection
decide
If
not
not
not
being
The
also
letting
battle
of
to the
has
.]
collaborative.
me
just
let
Point
session)
you
out
and
the
your
know
[ This
response
Although
wills.
you!
patients
response
necessary
so
on
said
therapist
feet
dont
the
(I
was
have
want
to
contradiction
dont
want
to
to.
You
cant
make
me
depend
upon
you.
that.
of wills .]
Thats
.] You
Only
depending
to.
depend
Th:
Deactivate
for
honestly.
is
are
to fing
you
. His
Pt:
Patient
problem
want
Thank
sarcastically
helpful
know
the
with?
Pt:
is
One
[ Deactivate
can
you
on
true.
me
the
Im
depend
can
is
make
glad
upon
that
helpful
projection
to
that
you
me
realize
if you
decision.
you,
you
I want
him
want,
or
[ Point
out
have
an
to depend
on
me .]
Pt:
the
projections,
depend,
the
and
openly
his
[ Tears
patient
in his
eyes.
experiences
resistance
to
doing
so.
deactivation
between
He
his
begins
to
of
wish
talk
to
more
.]
Pt:
transference
resistance.
better.
me
Make
Im
better
if
projection
you
better
dont
of his
not
against
want
desire
to.
resistance
the
[ Invites
dont
want
the
to
get
to
get
law
that
the
onto
I dont
Okay.
says
denial
the
to
you
to
therapist
want
[ Pause
get
have
deactivate
the
.]
better.
[ Invites
the
. Avoiding
battle
of
wills
.]
[ Shifts
to a battle
to get
well
better.
will.
no
defense
Pt:
wanting
to get
.]
patients
[ Invitation
I want
[ Mirror
to get
Th:
deactivates
my
Theres
Pt:
transference
sure
Two
Metacommunication:
Th:
not
this
conflict
Example
Well?
With
in
his
chair
and
becomes
anxious
.]
of wills .]
Th:
Well
what?
Pt:
Arent
you
better?
going
to say
[ Invites
the
therapist
Why
should
I?
something
to get
about
into
my
a battle
of
wills .]
Th:
better,
have
you
have
no
right
transference
.]
every
to
right
tell
you
Pt:
Projection
onto
the
therapist
Th:
to not
else
want
can
Deactivate
to get
stop
the
better.
you
from
omnipotent
to make
what
But
that
to
dont
If
you
choice.
dont
[ Point
do.
[ Deactivate
you
think
thats
want
out
the
to
reality
get
.]
defiant
unhealthy?
.]
Only
[ Point
you
out
making
can
his
know
choice
your
transference
if its
.] Neither
choices.
.]
If
unhealthy
you
I nor
Theyre
dont
want
for
you
anyone
yours.
to
[
get
better,
thats
resistance
the
result
youll
you
resistance
going
to
Pt:
[ Shifts
fight
for
in
chair
out
the
price
of
the
his
with
me?
[ Invitation
should
I fight
a rise
to
of
the
anxiety
.]
transference
.]
Th:
decided
you
resistance
are
not
Why
worth
fighting
for?
for
you
[ Outline
when
the
you
have
transference
.]
Pt:
yourself
as
if you
patient
[ Rise
Th:
You
not
worth
are
Some
patients
desire
so
they
Deactivate
of
the
the
conflict
suffering.
are
.] Thats
aware
fighting
that
for.
a sad
thought.
it is sad
[ Mirror
that
the
you
treat
healthy
desire
you
can
oppose
to
projection
will
the
you
ignore
mirroring
and
to
spokesperson
and
a battle
him
try
be
by
Avoid
between
He
Yes.
invite
price.
is
of anxiety
.]
Pt:
him
[ Point
.]
Arent
of the
have.
of
wills
the
make
his
for
their
the
that
conflict
conflict.
and
you
resistance
healthy
internal
defenses
between
their
reminding
and
is
him.
The
creating
interpersonal.
his
Keep
it
intrapsychic.
Defiant
the
patients
feeling
may
toward
respond
her?
Metacommunication:
you
The
following
response
examples
from
by
Heal
to heal . Omnipotent
four
to
me
the
therapists
saying,
while
.]
show
to
different
dont
I refuse
transference
how
just
question,
to
address
perspectives
share
reveal
this
within
What
feelings.
what
same
the
is
[
want
patient
transference
resistance.
1.
Th:
of your
onto
Then
the
we
omnipotent
wont
be
transference
able
to get
to the
.
bottom
difficulties.
2.
will
Block
the
therapist
Block
the
projection
of the
patients
healthy
Th:
is
no
rule
Reality:
as
he
you
that
says
can
choose
dont
therapist.
share
Why
something
you
transference
you
feelings
that
to
to
or not
with
share
so
the
me
Ill
.] Its
just
[ Reality:
me.
you
think
conflict
to.
that
as
long
useless
help
the
you
price
with
of
the
.]
I should
share
is between
me.
another
cant
suffering
There
with
just
be
Show
his
have
feelings
to share
it perpetuates
I know
dont
your
me,
with
Pt:
is you
share
yourself?
us,
my
feelings.
instead
of
within
your
best
]
Th:
interests
here
to share
idea
about
this.
they
could
have
[ He
invites
a battle
is
your
know
for
of his
healthy
with
her
After
may
what
patient
and
ask,
anxiety
Do
you
me.
[ He
Avoid
the
battle
of wills.
1.
Th:
he
experience
will
passive
argue
is
say
in
.]
You
he
for
begins
tell
must
should
you
your
what
issues.
yourself.
have
an
share
so
you
Only
[ Block
should
you
the
can
projection
.]
in chair.
described
lead
to
and
[ Shifts
feeling
know,
feelings,
Pt:
think
it
projection
to
right
therapist
What
be
no
the
Or,
to
I have
onto
feel?
attempt
therapist
do
may
if
a therapist.
should
has
know
[ Block
youre
the
your
dumping
can
of wills .]
you
desire
for
the
feeling
sure
life,
you
feelings.
But
Th:
This
Only
your
Pt:
do.
news
have
your
dont
Tell
good
to share
resistance:
[ Projection:
me.
do
The
Rise
of anxiety
to share
a conflict
his
with
to a defiant
feelings
his
a problem?
should
I have?
Or,
angry
.]
wife,
transference
I have
.] I was
a rise
of
the
resistance.
What
do
you
He
think
Instead,
Deactivate
Only
you
while
you
with
you
the
can
are
projection
know
the
rather
for
of his
sure.
awareness
[ Deactivate
omniscient
being.
than
to
attend
.
his
If
you
his
inner
suffering
.]
2.
Deactivate
the
projection
of his
Th:
see
how
self-destructive
projection
he
by
can
Is it your
be
defenses
returning
in conflict
the
with
his
to
[ The
his
suffering.
him.
transference
If he
the
patient
fails
to
Block
admits
resistance
Deactivate
the
his
misery,
his
healthy
.]
projection
of
.
Th:
suffering.
If
freedom.
[ Identified
defeating
you
defeat
his
or not?
cause
question
3.
desires
misery
his
our
work
work
succeeds,
with
instead
goals
If our
it will
his
of
fails,
be
defenses,
himself.
it is your
your
the
misery
happiness
patient
Remind
him
and
your
and
your
imagines
how
he
is
his
defenses
to
deactivate
.]
identification
with
4.
Mirror
the
resistance
Th:
You
Th:
If this
the
patients
defense
may
not
have
a problem.
It is for
you
to
decide.
you
should
or not
do.
this
[Deactivate
the
me
for
projection.
you,
He
obviously
must
its
declare
what
whether
is a problem.]
Pt:
Tell
is working
why
I should
Why
change,
Th:
projection.
Now
love
your
Why
change
the
should
so
I can
Perhaps
battle
is
You
have
lived
Mirror
the
resistance.
I change?
argue
you
between
[Metacommunication:
with
you .]
shouldnt.
him
with
and
this
[Deactivate
his
the
resistance.]
crutch
your
You
whole
life.
now?
Principle:
resistance
to block
the
projection
The
as
patient
he
did
relationship
Deactivating
habitually
in
the
rather
the
frustrates
past
than
with
allow
Uninvolved
his
loved
a frustrating
a new
or
ones,
parent.
one
making
He
replicates
to flourish.
Detached
them
Transference
suffer
a
past
Resistance
These
examples
transference
each
of
etc.)
project
his
or enact
common
resistance
form
defiant,
illustrate
the
the
and
forms
how
to
transference
patient
healthy
can
a regressive
deactivate
out
the
engage
She
in
how
(passive,
the
within
uninvolved,
with
omnipotent
the
parent,
transference,
One
dumped
you.
What
are
you
doing
with
feelings?
Pt:
resistance.
dead.
Im
dead
Metacommunication:
to
Heal
my
feelings.
me
while
[ Transference
I
pretend
to
be
of
the
]
Th:
dead.
If
therapy.
you
are
But
this
emotionally
[ Confront
his
cannot
be
then
this
dead,
regressive
wish
with
Example
Th:
dumped
What
is the
psychotherapy
can
reality
be
only
dead
.]
Two
feeling
toward
this
woman
who
you?
Pt:
transference
Theres
resistance.
I present
nothing
to heal.
Pt:
you
with
reality
with
any
there.
going
me
to detached
emotionally
a problem.
Why?
Because
emotional
if you
problems.
have
no
[ Contrast
emotions,
his
we
regressive
cant
wish
.]
Th:
You
Three
mention
a problem
regarding
intimacy
wife.
Pt:
detached
Heal
to be
Example
your
[ Invitation
Thats
Th:
help
nothing
Metacommunication:
Th:
with
Notice
wish.
Th:
while
it.
identification
Example
your
uninvolved/detached
resistance
act
desires,
of the
transference
Theres
resistance.
reluctance.
Metacommunication:
[ Invitation
Relate
to
a
to
me
while
yes
I remain
or no,
the
uninvolved.
Th:
You
Pt:
I guess
patient
It
opinion?
doesnt
his
you
you
the
You
make
[ Block
mean
enacts
Th:
arent.
]
are
could
guess?
Th:
that.
to
[ By
not
resistance
Either
difference
Im
say
transference
detached/uninvolved
Pt:
reluctant?
you
me.
declaring
.]
are
reluctant
Which
is
transference
or
it,
you
in
your
resistance
.]
reluctant.
You
are
reluctant
to
be
intimate
with
your
wife.
This
patient
tried
therapeutic
When
distance
himself
therapist
will
asks
a question
than
co-create
about
a feeling,
healing
Metacommunication:
following
response
the
uninvolved
reply:
Pt:
The
rather
alliance.
the
patient
to
Heal
me
examples
from
four
dont
emotionally
show
different
how
have
when
to
any
I have
no
this
same
address
perspectives
feelings.
within
the
feelings
.]
patient
transference
resistance.
1.
Deactivate
Th:
dont
have
with
your
feelings)
any
feelings,
emotional
and
reflect
Thats
going
then
obviously
difficulties.
the
the
to be
transference
a problem
I wont
[ Mirror
price
Pt:
omnipotent
his
be
because
able
to
resistance
if you
help
(he
you
has
no
.]
But
like
I told
you,
Im
an
unemotional
true,
then
we
wont
person.
Th:
get
to the
root
of your
And
emotional
Pt:
job.
[ Projection
I can
be
able
to
difficulties.
see
that.
But
I cant
get
I thought
that
was
your
bottom
of
your
.]
Th:
emotional
if thats
problems
if that
No.
isnt
something
you
to
the
want.
And
if you
dont
have
for
emotions,
as
to get
to the
me
you
say,
then
bottom
You,
of
the
unemotional
What
can
we
do
Invite
him
to
turn
function:
to
loneliness
the
every
right
if you
As
be
do?
nothing
therapy
will
[ Projection.
.]
long
as
be
position
you
take
this
to
you.
useless
you
Point
relationship
out
and
me
Th:
Okay.
this
this
way,
distancing
yourself
are
its
taking?
price
[
and
perpetuate
of responsibility
patients
onto
onto
this
I feel
the
his
about
role.
end
resistance
unemotional
man.
in defeat.
resistance
of agency
and
it. [
.]
You
Its
just
[ Patient
.]
distant.
detaching
from
your
feelings
and
now.
the
projection
this
therapy
of
the
patients
.
long
the
therapist
Th:
That
will
take?
[ Projection
.]
depends
on
your
motivation.
[ Point
out
.]
I dont
know
Commit
if I should
to me
commit
while
myself
to this
I refuse
to commit
committed
or
.]
Th:
uncommitted
the
will
denial
Deactivate
[ Metacommunication:
to myself
omnipotent
transference
right
How
Pt:
therapy
are
Pt:
responsibility
the
Mirror
detached
therapist
anything
to collaborate.
of the
out
You
to do
I refuse
[ Pause.
Point
3.
desire
while
the
me
on
faade
against
from
I want
take
Heal
turning
sure
to
Th:
or not.
we
something
resistance.
not
to keep
continue
to cry,
Im
Pt:
the
the
another
2.
healthy
do
question.
his
therapist
Metacommunication:
begins
would
.]
Inviting
that
do
unemotional
against
Pt:
have
Good
this
what
therapist,
man,
about
destroy
So
the
Th:
position
there
of.
Pt:
Metacommunication:
obviously
to your
therapy
You
as
you
can
want.
be
as
[ Deactivate
the
projection
as
onto
the
therapist
own
goal?
.] How
[ Mirror
the
uncommitted
resistance
Pt:
to be
committed
begins
to turn
to my
[ Laughs
the
awareness
onto
the
defenses
[ The
patient
healthy
your
awareness
life.
to
emotional
keep
what
the
conflict
how
the
projection
by
Perhaps
your
.]
resistance
him
also
to
your
want
course,
back.
[ The
patient
.]
of
the
patients
be
saying,
are
but
I dont
holding
the
me
think
together.
spokesperson
for
his
and
and
Patients
enacts
the
his
presenting
than
I if this
returning
the
is
marriage.
by
denial
the
he
wants.
thereby
transference
do
him .]
discrepancy
This
keeps
undermining
Transference
to
hurts
the
the
should
him
detaching
see
of
you
encouraging
patient
resistance,
damaging
creating
If it is,
that
results
is
responsibility
detachment
your
his
the
his
better
the
it.
Resistance
resistance
problems.
Help
cannot
him
see
see
it
and
or
turn
it.
therapeutic
alliance
Point
Defense:
vagueness
the
people
optimal
reality
and
mobilize
the
conscious
I have
hard
time
relating
to
people.
.]
Th:
rejecting
out
.
Pt:
Is that
are
resistance
helps
1.
time
in
mirror
the
causes
against
Of
projection
they
to
know
the
behavior
who
I think
want
[ Mirror
between
it
you
the
patient
you
You
patient
Deactivating
A
what
Th:
and
his
I hear
therapist
is doing
between
be
.]
detaching.
Mirroring
to
the
closeness
he
say,
holding
the
me.
[ Deactivate
knowing
like
resistance
hurting
invites
to
like
Deactivate
therapist
are
I feel
transference
Pt:
these
.] I want
but
4.
you
.]
goal,
against
would
and
level
Actually,
pushing
of
functioning
you
them
just
said
away.
you
are
you
[ Confront
looking
have
the
for?
an
easy
denial
[ Mobilize
.]
the
conscious
therapeutic
alliance
Pt:
girl
in
cave
therapeutic
a cave
afraid
[ Tears
of
alliance:
cave
Mobilize
of rejection.
the
(H.
language
highlight
failure,
price
doomed,
perpetuating
the
long
must
therapeutic
[ Burst
in
the
prison,
problems
defeat
the
so
[ Ask
the
the
you
patient
resistance
under
at
goal
[ Unconscious
traps
her
why
in
yourself
in the
darkness?
will
to the
terms
pain,
unconscious
and
phrases
suffering,
loneliness,
your
children
knowing
cancer
of
life .
turn
your
against
the
her
that
you,
Remind
resistance.
unconscious
therapeutic
.
This
is
your
own
time
set.
she
the
Mobilize
same
have
suffer
Use
is
imprisoned
Speak
without
she
self-destructive,
will
you
Why
to
[ the
get
isnt
it?
the
core
to
transference
perpetuate
punishes
your
herself
to
[ the
of
your
resistance
misery
turn
You
this
her
way?
against
the
.]
3.
alliance
little
.]
great
this
resistance
here
and
.]
resistance.
die
suffering
the
] come
theres
cave.
have
alliance
resistance:
Th:
patient
like
resistance
you
20022004).
suffering,
of her
against
her
you
of grief
2.
alliance
the
how
How
of the
your
patient
depicts
that
supervision
the
.] I feel
outside
sad
reinforces
Davanloo,
eyes
How
unconscious
Pt:
Vague
light
2009)
.]
Th:
in that
in her
the
imagery
of defenses
.] (Coughlin
by
reminding
the
Mobilize
patient
the
how
his
unconscious
resistance
therapeutic
defeats
his
goals
.
Th:
overcome
this
your
marriage.
want
to live
in
your
bypassed
depression,
You
a life
work
by
You
no
finally
others.
said
come
anxiety,
work
you
longer
so
have
you
And
no
longer
crippled
can
you
by
here
problems,
want
to
anxiety.
advance
said
of your
rather
you
want
own
and
free
depressed.
You
want
to
to
problems
feel
than
will
You
to succeed
continue
have
in
to
a
be
loving
relationship
now
have.
with
your
wife
Is this
still
true?
Pt:
rather
than
[ Point
out
and
have
self-destructive
with
wife
and
and
end
up
work
me,
and
then
resistance
a better
end
is
up
you
would
your
intent
out
does.
splitting:
patient
what
pathology
long
at
.]
the
want
same
your
your
to
overcome
time
your
a detached
to
.] So
as
what
you
the
avoid
we
goals.
man
You
you
this
detach
detach
detach
here.
like
how
You
You
goals
these
see
therapy.
marriage.
own
here
at
with
[ Transference
want
to do
that
to
the
patient
difference
we
detach,
That
do
we
it is
That
is
doing.
to
what
What
this
have
the
he
he
yourself.
what
between
about
will
you
what
he
says
(healthy)
does
is
detachment
same
are
says
and
but
his
character
here
because,
disastrous
result
you
else?
Projection
of
the
the
causes,
way
his
conflict
the
Patients
he
can
resistance.
must
deactivate
Awareness:
A
her
therapist.
patient
spiritual
between
patient
projects
be
To
the
1.
her
to sabotage
], but
(unhealthy).
experiencing
therapist.
furthering
want
Awareness
Therapist
it
therapist
dont
attention
can
the
problems
with
You
the
does
everywhere
onto
onto
you
intelligent
pays
he
Deactivating
than
you
I dont.
[ validate
his
The
ignores
To
estrangement
Point
have
with
an
Th:
as
goals
sabotaging
sabotage
Pt:
not
life,
unconnected
.] Why
yourself
Although
detachment
your
his
distant
Yes.
Th:
difficulties
the
in
this
projection
and
awareness
with
the
the
onto
therapist
the
rather
conflict,
the
of awareness.
the
her
Then
resistance
interpersonal
Deactivate
described
path.
his
conflict
avoid
his
she
Projection
of
Healthy
self-neglect
as
something
projected
this
awareness
Pt:
Defense:
projection
enough,
reincarnation?
therapist
you
Did
[ Mirror
her
in
projection
end
the
next
of her
because
its
this
that
in
to
healthy
Whats
is
maybe
better
block
between
her
problem.
if you
shape
the
in
neglect
the
projection
self-neglect
next
onto
the
anxiety
rise
have
to
to
block
the
.]
neglect
myself
now
acknowledges
her
healthy
she
the
conflict
as
better
if it leads
to
therapist
afford
[ She
now
resistance
the
I cant
thought.
tolerates
life
and
her
defense
of
.]
patient,
married
awareness
onto
defenses
to
to
the
avoid
experiences
an
conflict
youre
abusive
Notice
interpersonal
within
wrong.
to talk
verbally
therapist.
Pt:
therapist
the
onto
daughter.
to
that
suffering
[ Mirror
Except
and
wish
have
a little
awareness
my
Feeling
did
lifetime?
affecting
awareness.
I know
how
the
conflict.
you
Theres
about
husband,
projects
therapist
As
her
mirrors
a result,
her
the
patient
herself.
the
think
a virtue
price
of her
that
to
this
being
is self-neglect,
patient.
defense
so
but
[ Inviting
they
could
the
have
of wills .]
Th:
solution
to
your
her
resistance
the
therapist
difficulties.
to
block
the
long
projection
Its
her
just
agency
[ Rise
that
I have
that
you
would
you
of
healthy
her
like
have
to
found
wait?
[ Mirror
awareness
onto
toward
of
anxiety
to right
.] Its
now.
not
how
long
[ Defense:
would
helplessness,
.]
Th:
move
wonderful
.]
to wait.
denying
How
How
Pt:
her
think
up
I actually
Pt:
like
think
.]
realization
battle
ever
resistance
Th:
I think
you
might
Pt:
probably
.]
Th:
yourself
You
health
Its
not
that
you
would
.] Its
just
that
waiting
like
is what
to
wait.
you
are
[ Mirror
doing.
You
are
doing
You
can
wait
want.
[ Point
your
best
what
as
you
little
out
as
her
interest.
dont
toward
health
yourself?
[ Mirror
[ Mirror
.]
the
the
marriage
get
out
of
and
the
transference
Th:
Is
by
this
success
[ The
My
You
invite
must
identify
with
] while
you.
But
or
you
wait
is
in
[ She
moves
good
and
and
hurt
I will
I will
A patient,
identified
down
defeat
could
few
.]
I still
of
wait
myself
dont
the
see
defense
stuck
in
how
Ill
of
denial
therapist
to
patient,
my
wish
therapist
his
omnipotent
to
resistance
causality:
protect
assume
omnipotent
am
identified
get
well.
you.
can
transference:
The
Try
omnipotent.
sees
causality
problems
even
to
my
defeat
responsibility
be
My
with
for
incorrectly.
are
by
my
created
by
therapist.
me.
causality:
I use
defenses
that
create
me.
defeat
resistance,
underestimating
I keep
circumstancessometimes
are
respond:
go
to defeat
the
with
hear
protects
causality:
therapist,
Correct
shutting
long
are
you
but
the
Incorrect
may
as
long
way!
projection
lets
the
I try
no
with
you
stuff,
the
I,
identifies
people
resistance,
as
.]
.]
therapy.
with
who
problems
conflict
this
surely
Deactivate
Correct
my
that
it. I realize
this
the
resistance
defenses
internal
wait
going
her
patient
Incorrect
other
be
possible
I get
resistance
patients
for
lies
A patient
her
.]
keep
to block
myself
mess.
responsibility
the
can
you
years,
Okay.
telling
resistant
[ as
or
it may
it
thirty
2.
me
out
resistance
I cant
resistance
the
resistance.
And
But
waited
Pt:
Highly
want,
[ Point
.]
If youve
more.
you
agency
Pt:
like.
my
his
what
causing
causality:
positive
goals,
resistance,
you
me.
If
are
him
If
saying,
identify
myself
defeat
but
[ Metacommunication:
with
my
with
my
to suffer.
causing
can
identify
any
I
to suffer.
therapist.
still
think
Take
He
that
an
omnipotent
position
Mirror
the
resistance
know
better
down,
than
then
And
in
take
end,
lets
out,
Yet
therapist
no
face
or remain
and
assume
can
for
end
argue
with
feel
succeed
otherwise.
patient
to
]
reality
life.
help
you
here
can
be
Its
really
up
the
patient
.]
responsibility
guilty
of
your
me
result
freedom.
omnipotent
and
the
way
the
to do
is damaging
no
and
role
frustrated,
is
me
remind
down
it:
success
who
burned
then
there
omnipotent
Therapists
to convince
I if shutting
or your
the
try
and
obviously
the
suffering,
and
for
for
failing
if the
patient
The
therapist
to
wants
You
If you
shut
with
this.
failure
and
to you.
[ Do
change
become
help
the
not
patient.
to oppose,
detach,
uninvolved.
enacting
the
omnipotent
role
compensate
for
the
patients
passivity
Argues
the
patient
offer
what
the
patient
and
patient
tries
harder
withholds
with
Ignores
instead
or by
by
offering
the
to
patient
signs
asking
to the
of
resistance
the
patient
to
patient
what
the
withholds
engage
in
the
therapeutic
motivation,
desire,
Frustration
in the
The
active
or incapacity
from
Becomes
therapist
succeeding
herself,
taking
therapist
am
the
is often
harbor
because
on
she
I giving
omnipotent
When
resistance,
mobilizes
the
point
the
out
patients
a sign
secret
is
not
good
that
the
patient
emotional
the
will
to
involvement,
of resistance
belief
in the
that
enough.
therapy
She
is withholding?
patient.
is
not
should
How
ask
am
transference?
3.
alliance:
activity,
all
or curiosity
may
What
task,
Provides
Mobilize
patient
how
healthy
does
it
the
not
defeats
wish
unconscious
let
go
his
goals.
This
his
goals,
to achieve
of
therapeutic
his
transference
knowledge
a wish
that
previously
was
therapeutic
unconscious.
alliance
Hence,
the
will
resistance
create
failure)
to
out
causality
mobilize
the
of saying
As
what
long
you
as
you
idea
of your
helpful
transference
to
turn
against
internal
helpless,
vague,
and
feel
we
difficulties
and
will
I wont
be
(the
patient
remain
clear
unconscious
.
Th:
incapable
term
.
Point
resistance
the
be
be
I cannot
unable
able
to
get
to help
understand
you.
you
or
to you.
our
work
will
this
remain
in limbo.
process
will
end
in
defeat.
you
set
of his
for
will
not
reach
the
goal
yourself.
resistance
have
Invite
the
patient
avoid
these
to
assess
the
price
.
Th:
that
you
on
your
If you
goal
to
have
feelings,
more
what
impact
emotionally
will
intimate
relationships?
alliance
by
noting
transference
the
conflict
resistance
cannot
here
to
sabotage
defeat
(Troendle
deserve
arrive
at the
understand
your
yourself,
2005,
to be
As
core
your
own
the
unconscious
between
the
therapeutic
patients
goals
and
his
.
Th:
we
Mobilize
goal
as
of your
problems
and
should
my
translation)
you
. But
yourself
meet
here
Th:
And
now
you
by
your
for
this
You
you
we
wife
have
problems.
defeat
why
punished
long
say
censor
thirty-one
control
to
this
this
You
need
to
interview?
believe
years.
come
yourself.
have
have
you
to
decided
. If you
and
need
that
Yet
we
you
see
that
it
is
not
thirty-one
only
years.
continuously
trying
destructive
part
This
is
And
life
want
way
if you
therapy
your
of your
you
intimate
not
Deactivate
been
able
your
just
the
best
that
have
I will
be
therapy,
The
long
another
and
your
therapy
to
guarantees
and
ensures
relationships
Problems
that
(H.
Resistance:
Do
not
okay.
on
and
at
me
not
that
with
man
we
see
the
therapy
Davanloo,
will
But
me
get
you
what
between
will
misery,
up
in
you
and,
you
and
be
do.
have
if it is
should
will
your
do.
me,
in
Its
then
useless
continue.
healing
out
sets
to
you
relationship,
how
frustrates
man,
end
this
Point
no
have
to
want
years
life,
your
is
You
close
for
wall
there
to.
.] Obviously,
thats
of
you.
have
many
for
make.
on
let
of your
rest
resistance
supervision
Addressing
man.
dont
sabotages
a lonely
the
you
to
isolation
his
cancer
depressed
yourself
in your
perpetuates
this
is the
something
me,
suffering.
remain
This
You
not
this
and
myself.
choice
a distance
useless
the
yourself
so,
on
lonely
be
maintain
Premature
confront
have
profoundly
punishing
do
to depend
Thats
may
you
When
by
for
you
yourself
punish
want
patients
will
And
is
should
hard
is the
resistance
fail,
he
to
I dont
loneliness
the
yourself
her.
This
making
transference
transference
perpetuating
I am
a depressed,
to do
just
you
been
if this
men
as
with
yourself?
continue
That
keep
punished
Now
why
on
depend
interests
as
me
Hard
defiant
to
personality.
remain
feelings.
you.
Th:
succeed
to
punish
see
Th:
right
stayed
I can
Pt:
every
have
You
Pt:
can
and
you
personality.
you
can
to
convince
how
decades.
but
her.
her
in
to
wife,
chose
element
even
life.
You
invited
destructive
and
your
him
the
up
it
dooms
his
own
for
self-defeat,
graveyard
of
the
goal,
failed
20022004).
the
Transference
Confrontation
transference
resistance
until
the
patient
can
observe
and
pay
attention
causalitythe
confrontation
resistance,
he
will
Then
and
confront
rage
(1)
depressed;
(2)
a misalliance.
him
his
ally
against
attacking
from
the
as
see
problems.
Identified
attacking
him
and
presenting
are
of
with
a person.
the
He
defenses.
transference
patients
misalliance.
my
behaviors.
no
First,
resistance.
become
attacking
my
not
project;
not
(3)
very
on
patients
(4)
rage
hear
you
person.
of
become
and
iatrogenic
in
kinds
or
somatization;
I did
misunderstanding,
several
or
Exploring
[ Metacommunication:
results
out
defiant
increased
defiant.
you
creates
flatten
become
suffer
resistance
This
patients
patients
I heard
on
transference
therapist.
depressed
disorders
the
the
the
fragile
functional
based
create
separate
toward
misalliance:
resistant
his
you
as
confrontation
iatrogenic
resistance,
it.
Premature
with
will
you
clarify,
transference
creates
believe
experiences
identify,
his
resistance
Premature
longer
to
highly
deepens
confronting
] This
unconscious
rage
is
transference
feelings.
If a misalliance
the
task,
reaching
his
he
person,
self-sabotaging
deepens
the
higher
rise
you
can
confront
Compassionately
but
of
to
Peter
provides
and
will
our
the
alliance.
them!
up
defense:
Think
taboo
you
from
the
to
the
him
resistance,
free
the
the
the
transference
his
trying
greater
toward
clarify
preventing
confronting
are
for
him
from
transference
differentiation
therapist,
and
the
more
resistance.
the
transference
are
socialized
of
subject.
Okay
are
confronting
feelings
We
are
apologize
Then
that
him
you
The
transference
socialization.
alliance.
defenses
Then,
complex
the
the
that
addressing
reinforce
brings
of
the
recognize
the
confrontation,
differentiate
behaviors.
resistance
face
and
realizes
he
premature
repair
goals,
goals,
Once
his
to
to
his
resistance.
not
due
misunderstanding
therapeutic
from
occurs
the
family
Suddenly
everyone.
Lets
resistance
not
to
flies
interrupt
gathering
Mother
go
into
in
defenses
where
stands
the
the
dining
Uncle
up
and
room
for
dinner.
This
defenses
is
sake
together
and
living
room.
therapy
you
can
co-create
patient
must
be
growth.
so
their
mutual
to
deal
with
compassion
the
the
of
feelings.
involves
fostering
in
in
resistance
therapist
the
valuable
destructive
transference
The
is
To
treat
our
discomfort
colluding
with
Interrupt
the
a therapeutic
to
can
overcoming
adaptive
office.
willing
We
But
experience
anxiety
avoid
anxiety
or
the
patient
with
own
(N.
alliance.
internal
Kuhn
for
face
it
true
resistance
2011,
to
personal
communication).
Noninterpretive
Focus
Interpretation
often
does
not
Reich
1933).
The
lead
supports
to
In
passive
fact,
The
the
attempt
listen
Interpretation
words,
Ill
be
transference
pathological
my
goal
tone
healed
magically
here,
but
of voice
1993)!
the
the
and
Since
Im
uses
must
interventions
not
posture,
he
interventions
For
be
to deactivate
he
his
interpretation
as
patient
can
the
for
If
I listen
to
his
my
own.
In
the
words
might
committed
enacts
not
uses
he
to
to
say,
it.
purpose
Use
enactive,
transference
enact
Yeah,
By
transference
the
enactive.
the
therapists
uninvolved
efforts,
instance,
words
the
transference.
patient
totally
by
resistance.
uninvolved.
omnipotent
by
20022004;
an
The
remaining
enacts
relationship.
cured
him.
This
transference
experiences
control
while
resistance,
be
patient
intellectualization.
the
to
Resistance
supervision
strengthen
defiant
to
of
Davanloo,
waits
to interpretations
Transference
defense
(H.
it can
interpretations.
the
the
change
patient
therapists
on
his
thats
detached
(Havens
of
1986,
enactment,
noninterpretive
resistance.
SUMMARY
When
we
explore
relationship
to
resistance.
Shift
Remind
the
feelings,
keep
patient
the
from
the
therapist
defense
of his
highly
goals
resistant
at
work
and
patient
distancethe
to transference
desires.
Emphasize
enacts
past
transference
resistance
your
work.
role
as
his
ally
to
working
help
him
alliance,
the
the
patient
that
will
defeat
him.
achieve
Help
what
the
avoids
he
healthy
see
the
with
you.
rise.
Remind
unconscious
such
yourself
this
therapeutic
his
between
him
unconscious
his
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
transference
of
York:
can
transference
the
Eventually,
he
of
makes
longings
defenses
life
the
Ask
that
Management
Intensive
of
crime
so
his
do,
(1991).
Davanloo,
on
the
on
forces
which
READINGS
of Short-Term
C.
is
Remind
resistance,
join
goals.
positive
outcome.
his
impact
begins.
intensive
Benoit,
can
positive
self-destructive
RECOMMENDED
Benoit,
his
Focus
and
he
you
Respond
alliance.
confronting
As
What
way?
with
destructive
of
as,
and
establishes
in therapy
conflict
Mobilize
him
This
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
Breakthrough
T hrough
the
to
the
patient
degree
the
develop
the
feelings
rise
The
in
the
therapist
patient
rage.
the
At
this
the
access
the
patient
feelings.
us
that
the
beginning
of what
we
encourage
the
As
patient
memories
toward
the
these
feelings
do
patients
over
her
current
begins
call
people
life.
The
has
impulse
is
in
possible.
as
conflict.
deeply
as
When
the
unconscious
therapist
the
rage
encourages
while
feeling
patients
body
have
Once
figure.
to
the
rage,
this
more
deeply
to
patient
her
relaxes
no
the
of
images
where
feel
these
belonged
in
can
really
patients
feelings
the
others
unconscious
drives
earlier
they
can
is
.
the
the
longer
patient
connected
toward
her
of
is
unconscious
toward
and
of images
into
feel
guilt
of one
see
they
can
guilt
figure
transfer
directed
patient
image
feelings
us
of
transfer
feelings
whom
be
This
of the
these
the
the
This
unlocking
allowing
toward
a wave
a current
powerful
When
feel
to mind.
face
those
to
of feelings,
toward
the
to
life.
unconscious
self-punishment.
often
a past
feels
not
in
imagination
in fantasy,
emerge,
deeply
an
feelings
is
greatest
resistances,
feelings
The
so
passage
patient
unconscious
figure.
the
and
defenses,
in her
rage
the
repressed
without
comes
conscious
toward
belong,
she
caretakers
rage
the
whom
this
unconscious
figure.
with
helps
therapist
experiences
these
patient
to
We
defenses
face
fantasy
to
the
unconscious
this
therapist
feelings
When
patient
to
the
rage.
During
early
the
does
of the
her
enough
killing
this
bear
anxiety.
rage
of
the
to
defense,
patient
figure
this
passage
patients
tells
that
to picture
moment,
painful
the
until
fantasy
When
with
body
experiences
emerges:
the
against
the
and
regulated
turn
helps
toward
patient
capacity
with
signaling
possible
of anxiety
the
patient
body,
Unconscious
restructuring
possible
helped
the
the
experience
past,
in
the
guilt
patients
her
powerful
mixed
embrace
all
integrated
of
IN
When
the
stronger
of
or we
Stage
Once
the
have
see
Invite
the
to portray
Th:
of
going
control
out
like
onto
his
wild
in
Patient
to
your
cause
results
becomes
signaling
At
this
Perhaps
the
point,
her
the
hand
forms
hands.
Portray
impulse
in her
the
Impulse
hands,
her
is accessible.
in her
At
defenses
that
point,
invite
him,
if you
were
imagination.
impulse
animal,
to
went
how
do
out
you
on
picture
that
impulse
body?
Pt:
fantasy,
in her
If that
can
alliance
through,
body.
impulse
impulse
defenses
change
unconscious.
unconscious
the
view
feelings.
break
in her
the
more
realistic
work
character
can
PORTRAYAL
the
impulse
she
a
or
the
therapeutic
of
experiences
and
of
unconscious
OF
and
anxiety
phases
feelings
the
use
more
becomes
integrated
to
unconscious
the
the
she
significant
PHASE
a choking
dropped,
out
needs
earlier
unlocking
patient
patient
longer
resistance,
an
One:
Thereby,
of repressed,
her
caretakers,
a more
change,
THE
than
life.
Although
experiences
a fist
no
patients
beginning
the
She
unlocking
STAGES
her
acquires
symptom
the
patient
inner
and
feelings.
significant
toward
her
people.
her
from
of
person
other
cover
feelings
mind
You
mean
if I really
Th:
Of
course,
how
do
you
did
but
picture
it?
I never
in
thoughts,
that
rage
would.
words,
going
and
out
onto
him?
The
patient
pictures
person
who
hurt
picture
the
image
rage
has
in
her.
passed,
in
her
fantasy
The
her
how
therapist
mind.
body
her
rage
gently
When
the
relax,
and
will
would
go
encourages
impulse
tension
out
the
of
will
her
go
body.
Stage
Two:
Invite
the
Patient
to
Face
the
Complex
onto
patient
the
to
murderous
out
of
her
Feelings
With
the
passage
feelings
may
Encourage
As
the
appears
in her
to
are
patient
from
her
Once
naturally
primary
therapist
inviting
out
the
can
possible.
will
spontaneously
the
prevent
that
occur
failed
The
to
burial
she
does
loving
in
says
picturing
put
readily
her
final
helps
the
them
into
words.
the
current
toward
earlier
her
figure
toward
see
how
behavior
way,
the
her
feelings
that
arise.
We
original
the
as
As
figure,
feelings
only
deeply
therapist.
unlocking.
life.
symptoms.
therapist
occurs,
her
unconscious
and
as
the
the
in
figure
Since
needs
possible
process
to
and
unfolds
However,
therapist
will
address
below
OF
PORTRAYAL
the
occur.
BEFORE
often
what
she
of
and
an
from
how
kind
unconscious
the
picture
flow
Unconscious
recent
the
will
it for
feelings
her
memories
to
feelings
help
assistance
problems
the
that
of
of
little
the
toward
to face
unlocking
feeling.
figure.
as
life
feelings
feelings
of
driven
patient
on
has
painful
unconscious
her
and
This
complex
mind
are
PROBLEMS
Problems
to
have
with
mistakes
of
deeply
the
prepares
holds,
mixed
feelings
those
the
the
wave
murdered
as
in
patient
figure.
how
from
defenses
to elaborate
the
mixed
she
experiences
past
encourage
figure
she
Unlocking
come
the
feelings,
the
how
painful,
experiences
memories
feelings
encourage
service
the
transferred
she
those
complex,
murdered
Three:
The
toward
earlier
the
of
the
access
Stage
arise
painful
an
body,
kind
goodbye
face
impulse,
mind.
murdered
what
patient
of
If not,
the
murderous
those
patients
immediately.
way,
to
image
some
with
patient
experiences
unlock:
With
the
spontaneously
the
she
of
THE
during
properly
following
STAGE
the
state
assess
examples
of
the
portrayal
patients
show
because
responses
common
the
while
errors
in
assessment
while
unconscious
feelings.
Mistakes
in
Patients
those
do
been
feeling,
and
get
have
maintain
the
the
of
rise
of
feeling
Step
of
so
can
label
she
Th:
of the
her
of
feeling,
the
feelings
and
anxiety
sufficient
that
order.
through
and
of
of the
When
patient
in her
resistance
the
feeling,
the
a movement
in defense
have
rise
experience
if
is
body,
enough
the
Feeling
first
feeling
and
is the
feeling
I think
it was
really
help
the
patient
experience
it.
toward
him
let
for
go
of
throwing
The
terrible
patient
of him
has
not
want
to
yet
to do
that.
labeled
her
him?
[ The
cannot
label
.]
mistakenly
feeling,
defenses
What
Th:
therapist
unconscious
get
impulse,
intellectualization.
anger
unlocking
car?
Pt:
her
the
Labeling
patients
feeling:
an
to occur.
the
[ Defense:
or
To
drop
exploring
out
enough
impulse
and
prevent
to
impulsein
experience
the
defenses
you
breakthrough
on
of
will
Feeling
risen
a focus
the
Skipping
that
restructured.
a breakthrough
Before
to
not
experience
reveals
for
not
on
sufficiently
the
feelings
Focusing
feelings
not
inviting
What
jumps
experience
is
it you
to portrayal
when
the
her
impulse
it, or experience
do
to
patient
.]
Solution:
Th:
say
what
feeling
defense,
patient
the
you
with
toward
a thought,
and
must
unconscious
Skipping
feel
the
then
be
I agree
what
invite
able
can
Step
him
to
for
is the
the
terrible,
doing
that.
feeling
feeling
experience
unlock
of
it was
If you
toward
to
her
but
.]
Experiencing
the
Feeling
dont
him?
maintain
feeling
that
the
and
still
doesnt
cover
your
[ Address
the
focus.
impulse
The
before
Before
able
inviting
to
the
label
her
experience
the
impulse
feeling
her
example,
patient
to
and
feeling
the
out
of the
patient
Im
either
right
her
over
her
angry
of
[ The
her
which
she
an
body.
the
to
be
she
the
patient
can
following
portray
anger
toward
first
that
In
the
feeling
her
physically.
him
for
throwing
feelings
jumps
do
you
experience
that
feeling
experiences
with
patient
flat
affect
does
Her
lack
emotion
or
.] I want
not
describe
of affect
reveals
distancing
prevent
her
run
how
that
herself
from
to
she
she
from
getting
is
the
access
to
.]
to
How
do
portrayal
the
insufficient
him.
still
would
Th:
therapist
How
defense.
from
either
deeper
her
with
[ Sitting
him.
anger:
detaching
therapist,
defenses
to experience
is the
must
body?
Pt:
experiences
enough
she
car?
in your
car
impulse,
invites
What
Th:
that
of
in
is able
Pt:
physically
go
mistakenly
Th:
you
let
her
physically
therapist
before
portray
rise
you
when
anger
or
in feeling
picture
the
impulse
for
that
patient
in your
cannot
physically
a portrayal
mind?
[ The
describe
in her
body.
how
This
is
.]
Solution:
Th:
you
notice
defense
so
Skipping
For
have
the
how
you
detach
she
can
begin
the
Step
patient
to
turned
experience
example,
You
of
from
patient
access
and
does
not
in your
in such
rage
the
to
Do
[ Address
and
impulse
feelings,
she
her
do
way.
the
.]
Impulse
that
experience
now?
feeling
unconscious
experience
How
a detached
right
her
defenses
Th:
physically
your
to experience
enough
it physically,
the
that
Experiencing
have
against
say
her
you
can
label
impulse.
she
her
In the
must
feeling,
following
impulse.
experience
that
anger
body
going
body?
Pt:
I feel
a heat
coming
up
from
my
out
to my
arms.
Th:
Whats
the
impulse
that
comes
with
that
feeling?
Pt:
limp.
Defense
against
They
the
Th:
impulse.
that
defense
No
to grab.
experience
of her
How
Pt:
her
want
do
you
I dont.
[ Her
impulse
experience
[ Defense
breakthrough
to
arms
the
lay
in her
lap
.]
that
against
impulse?
the
unconscious
experience
is
of
possible
with
.]
Th:
picture
that
ignores
the
in
your
If
those
mind?
defense
arms
[ The
against
grabbed
therapist
him,
how
to
portrayal
and
but
you
jumps
experiencing
the
impulse
do
you
.]
Solution:
Th:
go
limp.
in the
price
In
Do
face
so
each
rage
you
notice
of your
she
will
of
these
but
turn
her
habitual
skips
address
defenses
address
describe
it.
it.
one
she
impulse
physically
in her
will
mobilize
it
associated
with
of
the
steps
body.
of
feeling
feeling
must
in
her
for
until
be
body,
the
bypass
to
get
able
and
a breakthrough
her
see
the
.]
visualize
to
she
limp
her
rage,
but
from
the
merely
repeats
these
examples,
the
feeling
activation:
(1)
the
feeling
feeling
If you
the
In
of
going
impulse
and
then
detached
so,
until
the
feeling
patient
physically
the
feeling
the
invite
enough
The
experience
two
experiences
and
unconscious.
helpful.
help
breakthrough
doing
not
invite
the
remains
By
keep
and
comply
is
and
defenses
not
feelings.
the
address
not
patient
invite
defenses
how
is
This
or
and
defense
may
him,
if you
experience
patient
The
to grab
happen
the
This
of her
want
will
it and
the
defenses.
therapist
(2)
cases,
experience
What
against
about
you
[ Address
feeling
intellectualizing
say
that?
rage?
without
physical
You
patient
until
in
the
her
patient
any
can
patient
body;
of these
label
experience
to occur.
it;
can
and
experiences
(3)
the
steps,
a breakthrough
to
label
to
you
the
her
feeling,
the
impulse
Skipping
the
Impulsive
patients
out
instead.
build
of
In the
affect
block
the
tolerance
of
use
to
the
when
the
in
their
the
feeling
to
out,
and
of acting
make
the
therapist
Body
it
then
unconscious
mistakenly
patient
act
avoids
explores
the
physical
feeling.
Th:
your
Feeling
experience
example,
impulse,
of his
the
the
must
following
patients
experience
skip
therapist
patients
available.
Experiencing
often
The
the
the
Step
What
is
the
feeling
toward
him
for
taking
girlfriend?
Pt:
discharge.
label
Primitive
his
feeling
I feel
like
somatic
as
an
explode!
representation
abstract
state:
Th:
And
Pt:
Rage.
Th:
I could
what
How
of
anger
is that
do
you
[ Yells.
Defense:
emotion.
Unable
to
.]
feeling?
experience
that
rage
in
your
body?
Pt:
the
floor
with
bypassing
out
his
the
an
to
this
to bear
feet .
Th:
it?
acting
out .]
[ The
his
the
prevents
at higher
punching
patient
of
avoid
phase
feelings
picture
The
experience
impulse
Bypassing
[ Begins
And
therapist
goes
rage.
to
fists
without
acting
mistakenly
stomping
immediately,
patients
from
went
and
impulse
experience
patient
if that
his
Impulsive
internal
the
levels
with
often
of
their
building
his
act
rage.
capacity
out .]
out
on
encourages
him,
how
the
do
you
defense
of
Solution:
to get
inside.
your
[ Block
your
this
rage
If you
feet
stay
out
dont
still
the
defense
body
now?
Th:
I see
of you
by
moving
this
feeling
floor,
and
shake
on
the
thats
what
rather
out
leave
of discharge
.] How
[ Build
capacity
his
you
do
of
want
to do.
than
to let
yourself
your
body,
could
your
arms
you
experience
to
You
pay
on
the
attention
want
feel
you
it
let
armrest?
this
rage
to
in
and
experience
An
his
rage
impulsive
patient
externally
rather
unlocking
of the
in the
same
outside
life.
will
prevent
the
impulse,
toward
moderately
to
problems
the
the
In
highly
has
figure,
who
he
was
angry
the
defense
that
not
to engage
trouble
in his
address
patient
the
an
earlier
from
mixed
feeling
feelings
mistakes
the
feeling
face
his
her
rage
defense
and
and
the
breakthrough
his
toward
detached
occur
defenses
defenses
enacting
due
usually
character
no
is
occur
and
problems
character
patient
can
that
to
the
identification
figure.
father
experienced
an
him.
rage
ignores
prevent
him
into
rage
unlocking.
operating,
the
with
Th:
How
does
Pt:
I just
feel
Th:
the
the
addressing
still
cannot
the
patients,
If
If
do
stop
inviting
trouble
possible.
you
patients,
of
resistance.
toward
does
fragile
are
him
experiencing
having
resistant
therapist
is
impulse
or
will
his
Defense
phase
unconscious
patient
and
and
the
resistance
rage,
of
allows
gets
defenses
can
most
This
visualization
that
.]
vent
internally.
They
on
in
transference
a past
Any
figure
transference
it
later.
resistant
will
discharge
Focusing
identification.
with
and
or discharging
situation
The
helpful.
damaged
In
the
out
unlocking
in
out
experience
portraying
Mistakes
this
unconscious.
It is not
an
acting
in
than
acting
the
because
without
go
out
patients
will
that
go
indifferent.
dont
cover
him?
[ The
therapist
identification
with
a breakthrough
out
onto
[ Character
If you
on
prevent
rage
it with
defense
indifference,
explores
her
him?
of rage
toward
how
feeling
indifferent
.]
but
father,
the
father
a
.]
Solution:
Th:
daughter,
indifferent
you.
But
are
here
to find
we
out
to
here
who
you
Now
you
become
yourself
just
to
yourself
cover
really
are
as
under
your
with
this
the
father
his
faade
emotionally
dead
was
indifferent
faade,
or
are
of indifference?
to
we
Deactivating
breakthroughs
break
with
through,
resistance
role
the
conflict?
highly
from
as
defenses
patient
in.
The
can
just
Instant
is
to
the
feelings
to
patient
play
Experiencing
the
come
If
to
pathway
do
not
transference
playing
avoid
to
and
an
what
intrapsychic
13 .)
against
soon
the
identification
role
you
be
patient.
defense
inviting
chapter
can
resistant
What
patient
Defenses
patient
the
shift
(See
may
defense
identification.
is
As
character
begins
the
to
following
prevent
expressed
Impulse
experience
the
examples
the
patient
from
the
impulse
impulse,
illustrate
how
experiencing
to choke
her
defenses
his
different
impulse.
This
ex-boyfriend.
Repression
In
the
following
go
of the
vignette,
defense
the
therapist
of instant
Th:
helps
the
patient
see
and
let
repression.
How
do
you
experience
just
described
that
impulse
in your
hands?
Pt:
an
ex-boyfriend
circle
as
who
if they
are
[ Having
tried
to
around
his
Th:
hands?
the
Do
defense
you
notice
how
Th:
the
her,
neck
Do
patients
.] I dont.
you
you
the
[ Her
notice
how
just
dropped
but
I do
let
those
wish
to
hands
hands
you
your
strangle
form
drop
.]
dropped
power?
your
[ Point
out
could
we
.]
Pt:
take
rape
her
a look
defense
at
and
that
I didnt,
If you
impulse?
experience
now.
hands
[ Encourage
her
impulse
power
the
patient
instead
.]
up,
to
turn
against
Negation
In the
negation
following
so
vignette,
that
feelings
Th:
the
can
What
therapist
blocks
the
want
to do
patients
defense
rise.
do
you
with
that
fist?
of
denial.
The
patients
Pt:
I dont
fist
drops
Th:
the
fist
your
again,
what
do
you
to do
anything
with
it. [ Defense:
.]
And
yet
there
notice
was
feeling
a fist
there.
when
you
rising
up
what
you
If you
let
form
yourself
feel
power?
Pt:
feeling
I feel
how
some
heat
in me.
[ Return
of
.]
Th:
[I
want
do
you
offer
picture
the
portrayal.
impulse
as
those
patient
During
fists
the
later
her
If those
own
fists
going
defense
out
of
portrayals,
without
did
on
him,
would
in your
displacement
she
will
this
graded
the
therapist
be
never
imagination?
during
able
do,
this
first
to acknowledge
approach
her
.]
Minimization
In
the
following
example,
defense
and
essential
in this
go
defense,
of the
also
the
price:
phase
of
it
the
allowing
Th:
creates
work,
the
How
helps
so
do
you
her
the
feelings
the
patient
see
symptoms.
patient
will
the
This
is
completely
let
to rise.
experience
that
impulse
in your
hands?
Pt:
push
him.
[ The
addressed,
this
unconscious
.]
Its
patient
uses
defense
that
how
has
before
And
rage
now
now,
back?
so
you
it
this
Or
are
have
you
hold
will
in
won
first
just
here
of
prize
in the
back
inhibit
to overcome
your
twin
on
you
that
the
if
you
again,
Are
we
self-destructive
the
Do
you
pattern
back
contest.
at
You
just
held
graduation.
hold
back
and
here
not
to
same
sister
to
If
yourself
karate
But
just
impulse.
this
held
again.
yourself.
your
Isnt
You
him,
breakthrough
down
now?
choke
minimization.
trouble?
back
come
to
water
surpass
yourself
to
prevent
you
you
impulse
defense
back
wouldnt
tendency
we
Now
yourself
getting
would
back
overcome
hold
been
you
yourself
you
an
the
would
Th:
notice
not
we
to
hold
habit?
your
wont
you
[ Label
the
defense,
of the
then
defense,
confront
and
self-destructive
the
then
defense
invite
against
the
defense
how
do
they
with
the
to make
against
Im
here
self-destructive
a choice:
impact
continue
with
it now .]
to
stop
doing
that.
[ The
patient
.]
Th:
fists,
her
or turn
Pt:
turns
patient
come
If you
out
dont
on
him
hold
back
in your
this
rage
and
those
imagination?
Somatization
In
the
following
defense
rage
vignette,
of somatization
to be
felt
the
so
toward
the
therapist
he
can
other
Th:
How
Pt:
[ Hands
let
go
helps
the
patient
of the
defense,
see
the
allowing
the
person.
do
you
experience
that
impulse
in your
hands?
feel
like
having
my
an
throat
is closing
allergic
your
notice
his?
hands
how
[ Point
the
[ The
going
Do
like
impulse
the
to
patient
somatizes
they
were
going
your
throat
on
between
of
murderous
rage
the
patient
vignette,
the
how
the
the
on
get
notice
addressed,
back
having
you
goes
link
.] Im
I need
If not
breakthrough
keeps
looked
out
somatization.
up.
reaction.
Th:
after
drop
my
start
I think
to
choke
instead
Im
choke
him?
of
going
impulse
someone
just
Do
you
onto
and
of somatization
toward
.]
you
to
breathing.
inhaler.
rageful
defense
instead
trouble
the
prevents
else
since
it
.]
Depression
In
the
defense
following
of
addressed,
an
unlocking
self-attack,
that
which
defense
of the
therapist
and
makes
the
identifies
the
resulting
and
patient
blocks
depressed.
depression
the
If
would
not
prevent
unconscious.
Th:
How
do
Pt:
[ Slumps
you
experience
that
impulse
in your
hands?
in chair.
Tension
leaves
the
body
.]
Im
such
you
did
piece
a terrible
for
person
me,
of crap.
here
to
I am
[ Turning
to
onto
hurt
we
you
now?
you?
turn
the
impulse
dont
rage
toward
toward
how
Sometimes
patients
experience
case,
do,
but
then
address
the
wish,
occur.
The
following
examples
to avoid
and
reality:
his
patient
to
are
picture
how
see
everything
an
him
ungrateful
depressed
the
mechanism
and
rage
is
is coming
hurt
yourself
how
you
.]
going
in
here
instead,
can
experience
that
face
an
ever
engage
not
talking
the
in that
this
if in your
Of
reality.
imagination
what
murderous
the
they
wish.
patient
of the
different
I would
to
validate
will
unconscious
defenses
never
ward
the
patient
impulses.
about
their
declare
In
not
will
patients
impulses.
the
impulse,
and
unlocking
reality
must
and
impulse
illustrate
in
encourage
feelings
Impulse
But
bring
Th:
we
I am
Otherwise,
no
their
therapist
then
would
see
portraying
a Defense:
will
the
reality
he
as
often
response,
old
the
and
portraying
Reality
patient
makes
you
defense.
murderous
Using
self
and
off
the
use
the
the
ward
portray
can
you.
After
me?
Picturing
each
you.
hit
me
me
against
to
that
toward
to
Do
protect
Defenses
want
onto
Wow!
See
If you
this
wanting
of rage
Th:
back
feel
to
patient
the
may
course,
in
reality
In fantasy,
that.
feelings.
another
therapist
you
in your
complete
In
perception
respond
in reality.
lost
his
patients
impulse
you
off
explore
When
do
by
never
mind,
control
of
aspect
invites
the
denying
that
would,
how
of
but
do
you
of yourself
?
Projection
If the
may
of
Will
projection
emerge
impulse.
At
(Compliance):
of will
again
this
has
when
point
not
the
in
the
Do
been
therapist
work,
I have
to?
completely
invites
the
restructured
the
therapist
earlier,
patient
to
face
will
confront
it
his
the
patients
the
use
patient
look
of
to
at her
projection
face
inner
and
his
life,
impulse.
the
rage
of will .] But
as
your
you
what
the
will
not.
You
ex-husband.
will
therapist
patient
asks
intervene
course
keep
the
this
happen?
as
follows.
can
avoid
the
out
has
facing
murderous
[ Point
invite
if she
[ Deactivate
avoiding
will
this
projection
rage
the
to
toward
price
of
the
.]
years
Why
if you
toward
him
suffers?
Pt:
Ill just
stay
depressed.
Th:
Right.
And
you
can
stay
depressed
that,
but
then
I have
You
can
want.
perpetuate
I cant
your
in fantasy,
[ Point
out
or
the
or bring
price
we
end?
Bring
Th:
out
of the
Are
it to an
going
it on
way?
yourself
ask
you,
face
this
rage
But
then,
who
in reality.
defense
.]
here
help
another
to
Me.
Pt:
rage
this
turn
Th:
suffering
stop
suffering
Pt:
this
Then
When
Of
your
as
ex-husband,
defense
five
toward
long
price.
therapist
Th:
murderous
its
[ Invite
onto
her
it to an
If we
to
bring
to let
if
that
way.
go
perpetuate
of the
your
defense
.]
end.
it to an
him,
you
you
lost
end,
how
do
total
control
you
picture
like
wild
animal?
Denial:
I just
When
the
therapist
may
suddenly
body.
The
of
the
price
the
therapist
the
patient
the
point
and
therapist
patient
the
impulse
can
denial
the
so
feel
invites
deny
patients
vignette,
dont
out
then
let
go
his
therapist
the
point
challenges
can
to face
the
of
his
you
try
can
evidence
out
impulse,
in the
that
the
flies
price.
patients
denial
see
In
denial
and
the
patients
in the
the
and
face
patient
the
face
following
reveals
its
impulse
he
denied.
Th:
described
her
for
over
harassing
the
past
you
Now
twenty
through
to erase
minutes.
the
courts.
You
You
your
said
feelings
you
said
feel
you
you
have
angry
with
feel
heat
in
your
body.
her
and
Your
hands
silence
defense
formed
her.
Then
who
do
I guess
Th:
you
you
said
silence
you
here?
wanted
to
hit
[ Challenge
the
Exactly.
Pt:
denial
out
onto
comes
identification,
if you
this
the
against
Yet
in your
at
challenge
Defenses
So
her
in
you
me.
[ Projection
say?
[ Block
.]
the
projection
.]
who
is it you
want
to silence?
yourself,
how
Carol.
Th:
go
would
say
Me.
Th:
rage
youd
Who
Pt:
If
Then
.]
Pt:
this
fists.
dont
does
imagination?
point,
after
defense
the
silence
the
phase
of
defense
directly.
Experience
of
Complex
Mixed
Feelings
After
the
patient
ward
off
the
defenses
She
essential.
the
will
view
patient
others
good
and
loveable
guilt
and
grief,
perpetuates
(Grotstein
bearing
the
character
guilt
defense
just
invites
mixed
breakthrough
to
in
splitting
engage
in
them.
terms
of
This
have
driven
herself
1985).
her
her
rage
rage
1975a,
denying
avoid
of
the
1975b).
was
unconscious
It
her
if we
also
images
defenses
is essential
will
what
the
splitting
resolving
unconscious
to
these
self-punishment.
and
Thus,
only
rage,
can
Handling
(Klein
her
helps
defenses
feelings.
within
Continued
patient
beat
complex
fantasy,
Otherwise,
which
over
murderous
of
against
are
to
get
change.
Vignette:
to
in
her
of
only
splitting
others
The
pictured
experience
is
encourage
has
has
the
body
against
portrayed.
the
patient
Rage
killed
after
facing
her
as
father
he
is
the
complex
Notice
to face
how
her
a Defense
off
in her
clearly
the
dead.
This
feelings
therapist
warded-off
imagination
over
blocks
complex
but
continued
the
continues
rage
murder
the
feelings.
defense
she
is
has
and
Pt:
And
then
I take
a baseball
bat
to
his
flattened
it.
You
head
again.
Th:
head
off.
father
that
You
who
you
out
molested
have
attacking
crime
cut
finally
a dead
his
her
He
killed
him
as
and
the
Vignette:
guilt
having
may
envision
feelings.
In
Its
[ Tears
emerges
What
in this
Invite
feelings
you
he
[ Block
dead.
ugly.
genitals
does
picture?
not
do
the
look
the
her
cut
his
of
this
like
now
defense
to
look
of
at
her
.]
[ Vague
.]
see?
form
in her
eyes
as
she
describes
his
.]
the
how
this
the
example,
and
that
obeying
from
your
feelings.
or
your
he?
encourage
feelings
her
to turn
Th:
if you
loved
honor
him
You
Th:
[ Encourage
out
has
I just
walk
Let
now
her
body
points
then
killed
one,
the
and,
thus,
the
defense
off
her
away.
To
patient
from
her
and
its
in
her
father
away
me
you
walk
molest
obey
them?
defense
from
your
you
hell
with
feelings,
while
him,
but
Who
is going
but
you
are
we
walk
here
to win
(identification),
its
him!
isnt
away
to
walk
this
time,
price,
and
it .]
Me.
If you
too
all of your
Pt:
way?
And
a loved
body.
against
Pt:
you
his
or face
out
the
patient
said,
And
[ Point
from
the
He
toward
therapist
described
him?
from
impulse
away
Th:
loving
dead.
pretty
Pt:
Pt:
body
mutilated
mixed
What
walking
imagination
because
and
if it is
Th:
portrayed
Notice
price.
you
already
Detaching
After
away
is
complex,
Pt:
body
you
heart
you.
body
to access
But
dont
at
one
walk
time,
away
what
from
do
your
you
feelings,
do
with
his
feelings?
I would
How
the
wash
do
you
patient
it and
prepare
imagine
to
face
washing
her
it for
burial.
his
complex
body
in
mixed
emotions
toward
Vignette:
Pt:
[ Cries
patients
the
murdered
and
points
this
out
its
betrayed
her .]
.]
just
gutted
how
patient
molested
mixed
the
feelings
therapist
his
his
imagined
for
years
what
out
has
her
those
described
cut
complex
by
identifies
devaluing
the
defense
price.
during
him,
their
Notice
the
who
relationship
avoid
figure.
example,
brother
has
who
Devaluation
Sometimes
In
a father
due
body
penis,
Th:
six
years.
to
the
looks
and
murdering
put
her
He
was
neglect
like
her
in her
after
it in his
much-older
she
closest
family.
She
killed
him,
look
at his
had
mouth.
What
is the
feeling
in you
as
you
I just
want
to
put
it in a trash
you
did
with
body?
Pt:
him
out
in the
she
we
years.
said,
care,
the
Even
trash
what
defense,
put
your
do
Just
when
in effect,
dont
your
do
it price,
with
and
as
Defenses
Experience
of
Sometimes
the
judging
over
the
her
really
put
trash
all
feelings
of
and
them
it for
against
his
for
so
molestation,
you
with
did.
But
respect
burial?
[ Point
if
and
out
it .]
abandoned
when
he
got
married.
.]
course,
girl.
You
[ Sobs
.]
of
turn
your
about
to prepare
her
Of
a little
treat
body
alliance
Pt:
Vignette:
his
mother
in the
if we
I felt
Th:
your
feelings
help
therapeutic
to you
told
feelings,
you
[ Unconscious
like
you
Pt:
married
and
trash.
Th:
many
bag
because
had
Splitting
been
and
you
his
felt
secret
Devaluation
he
had
been
wife.
to
Avoid
the
Guilt
person
murderous
patient
she
avoids
killed
rage,
her
in her
she
guilt
over
imagination.
judges
and
murderous
Rather
devalues
rage
than
him,
feel
saying
by
guilt
he
deserved
the
rage
against
facing
her
punish
herself.
In
murderous
rage
and
not
mixed
this
an
Whats
that
patient
the
she
has
who
had
feeling
This
will
just
an
now
defense
continue
to
described
her
affair.
as
you
look
at
his
body?
describe
her
feelings
He
children,
with
Deserved
to
off?
the
all your
man
had
belly
to be
avoid
with
This
you
his
Deserved
you
loved
whom
have
deserved
it.
[ Defense.
She
does
not
.]
Th:
way
the
ex-husband
Pt:
cut
feelings.
means
example,
toward
mixed
feelings
Th:
dead
other
been
slit
run
loved,
with
happy,
open?
over
complex
you
by
deserved
Deserved
a car?
feelings
you
whom
to
Is that
have
you
raised
be
killed?
to
have
his
true?
Or
toward
this
genitals
is that
man
a
you
heart?
Pt:
[ Tears
.] It just
hurts
so
much
to
remember
that.
Th:
your
feelings.
criminal,
But
Otherwise,
and
we
you
know
thats
Pt:
eyes
looking
Vignette:
After
the
experiencing
feelings.
his
father
his
the
In
who
room
whole
any
part
of
a heartless,
truth
you
or
unfeeling
of you.
true.
So
whats
I want
Th:
How
do
Pt:
[ Cries
.]
the
the
the
to say,
Eyes
you
to
feeling
impulse,
guilt
and
mixed
and
encourages
physically
the
eyes.
as
you
look
at
his
sorry.
him?
the
him.
Experience
patient
This
feelings.
patient
abused
tell
the
or
example,
his
Im
Avoid
figure
defense
this
the
Pt:
pictured
murdered
not
this
forget
at you?
Avoiding
having
identifies
up
mustnt
leave
Thats
Th:
dead
we
the
has
may
avoid
defense
is
Notice
how
patient
to
just
of
pictured
the
face
the
Guilt
looking
at
against
therapist
his
mixed
murder
of
Th:
What
Pt:
Hes
Th:
His
Th:
you
as
you
down.
eyes
If
are
at
Well,
now
look
at his
eyes?
.]
over?
closed.
at them.
dont
look
you
[ Defense
.]
[ Defense
.]
open?
look
you
as
[ Defense
him
are
I dont
Th:
feeling
turn
If they
Pt:
in
face
If you
Pt:
feeling
is the
his
avoid
dead
his
eyes
eyes,
what
looking
up
is
the
at
you
deeply
as
lifelessly?
Pt:
Th:
Let
I feel
guilty.
yourself
feel
that
guilt
as
possible.
Patients
avoid
Sometimes
seen
patients
and
to avoid
Vignette:
The
looking
the
gouge
can
murdered
figure.
defense,
or
example,
else
the
imagination.
The
the
is
just
looking
in
figure
Her
feelings
will
experience
the
of
must
patient
has
of
Object
mixed
therapist
the
of
to
guilt.
avoid
being
guilt.
the
facing
avoid
eyes
their
with
avoid
to
the
experiencing
patient
She
eyes
out
Identification
patient
painful
at
take
suffer
face
identifying
care
severe
pictured
his
by
Rage
to
identify
her
In
this
in
her
ex-lover
experiencing
the
this
symptoms.
killing
while
with
powerful
feelings.
Th:
Pt:
Whose
face
Mine.
comes
to mind
[ Identification
with
right
the
now?
murdered
body
.]
Th:
is it you
do
with
your
the
price
it up?
of doing
it is your
body
you
have
murdered.
youve
done
What
body?
Pt:
lifeburn
So
[ Point
I burn
it.
Th:
Isnt
out
how
so .]
Pt:
[ Cries
.]
she
this
turns
what
the
rage
onto
in
herself
your
and
back
onto
you,
whose
Th:
If
face
comes
Pt:
guilt
unfolds
.]
The
patient
turned
the
complex,
facing
the
My
rage
FEELINGS
FEELING
WITH
dont
mothers.
this
murderous
[ Massive
her
feelings
wave
mother
she
AND
A
turn
impulse
to mind?
toward
mixed
INVITING
you
felt
onto
toward
of
grief
herself
her
to
avoid
mother.
BREAKTHROUGH
MODERATELY
and
TO
RESISTANT
PATIENT
The
following
where
the
rageful
patient
turned
toward
Four
we
continues
had
impulse
Vignette
Now
transcript
will
his
unconscious
this
how
in his
disassembly
its
do
you
mind
like,
issue,
you
you
know,
this
impulse
Th:
Pt:
phase
of
you
tear
her
to pieces?
feeling
Just
her?
How
But
This
in
and
chapter
1 ,
experienced
the
breakthrough
to
.]
the
you
her
rage
know,
in his
If
him
body
tear-apart
do
is the
fantasy.
youre
to
picture
.]
disassembly.
never
mind,
pieces?
[ I invite
this
to
Its
gesture
just
].
And,
this.
in fantasy,
[ Remind
thoughts,
the
and
patient
ideas
.]
is fantasy.
If you
This
do
tear
[ makes
I would
Pt:
gesture
like,
know
go
totally
berserk
is fantasy.
Th:
tear-apart
the
do
in his
Pt:
disassemble
defenses
How
while
Th:
to imagine
read
3842)
during
Pt:
again,
his
we
feelings.
honest,
impulse
case
doctor.
Th:
totally
against
(minutes
continue
the
you
You
tear
I just
disassemble
her
grab
her.
How
do
you
apart?
the
arms
and
aaaaarrgh!
[ A
Th:
Tear
Pt:
Tear
Th:
would
Tear!
never,
feeling
ever
earlier
body
below
whose
head
this
off,
you
tear
sadistic
the
off .]
as
her
head
no
Snap!
guns,
Snap!
nothing
as
Yeah,
Th:
And
What
patient
links
During
the
head
and
emotionally
note
that
her
pieces.
All
picture
else?
What
I just
Tear
Pt:
Just
of that
several
brute
nature,
Its
its
just
the
the
out
onto
.]
belief.
tear
her
you
tear?
her
legs
off
arms
off.
Just
tear!
who
too,
reveals
which
his
I mean,
I just
know.
You
know,
no
knives,
snap!
My
his
the
body
bodys
been
symptoms
.]
(minutes
woman
with
you
snap!
Tear
to his
minutes
enraged
snap!
off.
just
to me.
impulse
just
tearing.
disturbed
which
no
arms
visualize
beyond
just,
force,
the
of
her
goes
had
with
do
and
its
legs
makes
to pieces
rage
You
else
Yeah,
eventually
was
he
to
was
fantasy,
tear
in reality
that.
them
her
happening
next
his
rage
Tear
grab
Snap!
Th:
sadistic
he
to tear
just
Pt:
the
you
him
body
really
that
identification
all
his
in
how
in fantasy
so
onto
Mmm-hmmm.
Snap!
been
totally
[ Remember
possible
Th:
Pt:
whats
just
[ Encourage
I just
Yeah
Legs.
Th:
thats
off.
was
but
than
Pt:
head
unconscious
you
rather
Pt:
snap!
an
off,
off.
that
Obviously,
vividly
yeah.
her
anybody.
is torn
in fantasy
tear
to
head:
head
impulse
doctor
You
her
If
the
Th:
off,
.] Tear
Tear!
do
arms
else?
[ Sighs
Tear!
arms.
her
What
Pt:
justTear!
her
4756),
connection
ignored
mother
led
love
and
her,
because
apart.
gazes
his
at
of tearing
guilt,
the
an
feelings.
unconsciously
his
[ The
mother,
patients
to a pattern
for
torn
he
to
the
apart
and
wanted
himself
his
to
rage.
After
his
a brief
mother.
passage
We
of
resume
guilt,
the
been
tearing
But
yourself
Pt:
wanted
to tear
up.
And
Pt:
the
get
rage
really
Pt:
Yeah.
Th:
And
point
Pt:
Yeah.
the
this
who
totally
its
really
been
that
honestly.
need
goes
on
Because
Thats
to
where
your
make
sure
that
the
your
body,
you
know
its
very
first
time,
it belongs
body.
if it keeps
If
you
this
honestly,
and
all the
not
How
we
to
true,
if were
see
understand
connected
from
years.
know
we
not
physically,
now,
we
because
.]
face
Because
yours.
Breakthrough
this
Now
honestly
that,
Second
At
to face
it totally
body
for
honest,
going
on
killed.
uncomfortable
her
toward
Yeah.
Th:
picture
emerges
completely
we
mother
Th:
Pt:
face
now
If we
Th:
could
rage
Yeah.
Th:
personthat
if were
to pieces
[ His
Pt:
right
of
Yes.
Th:
you
impulse
session.
Th:
youve
the
of
the
that
unconscious
physician
patient
to experience
identify
the
repressed
rage
just
the
to his
totally
really,
on
picture
toward
body,
have
how
If its
all
do
you
going
on
it?
repressed
toward
his
unlocking
as
the
Rage
rage
the
that
her
of unconscious
patients
feelings
for
honest.
Murderous
mother,
feelings
if we
went
you
rage
these
unleashI
but
do
true.
totally
unlocking
the
thats
deeply
been
the
physician
mother.
With
begins.
as
his
was
this
We
possible
driving
feelings.
shift
invite
so
the
we
anxiety
can
and
defenses.
Pt:
Arrrrrgh-arrrrrgh-arrrrgh!
Same
thing
again.
Want
to
listen!
grab,
Tell
you
listen?
Why
okay.
Youre
nothing
look
to
just
Im
do
grab.
to control?
to
this,
do
you
know,
this,
you
so
damn
feeling
just
tell
with
you,
you
And
Pt:
The
to
are
just
you
that
you
have
have
to
that,
you
know.
her,
how
hands
let
do
do
grab
you
let
me
you
all
yourself
I just
anymore,
but
go
let
it go
of all that
Let
the
me
spontaneously
his
go!
at
an
afternoon
Vignette
dont
you
sick.
okay.
hands
want
want
Theres
Yeah.
And
to do?
to grab.
you
They
know
to lie
and
tell
Why
are
you
behave
you
rage
in your
just
Why
me
that
you
trying
want
are
have
up
stuff,
have
to
you
you
making
better,
are
this
hard.
go!
You
to
do
control
me
and
his
him,
hers,
Five
(minutes
his
do
are
your
have
boy.
grab
to let
if
you
her,
so
me
out
no
to your
words,
hands
do
but
to
her
do
Again,
damn
I just
hard
grab.
and
say,
go!
dont
how
grabbing,
go!
Let
just
me
hold
you
onto
your
picture
your
rage
hands
rage
mothers
him
some
shaking,
of
6273)
toward
death.
Just
abandoning
friends.
inability
just
saying,
you
mother,
he
GO!
murderous
accusing
and
I just
his
seeing
what
goes
her?
Just
me
If there
Arrrrgh,
into
onto
head
completely
So,
right
Let
that?
talking,
so
remembers
yelled
pain
you
everythings
whos
Why
Arrrrrrrrgh!
rage
experiencing
spent
to
picture
feel
Pt:
she
the
you.
If all that
Th:
While
wrong,
perfectly
like,
trying
say
dont
know,
Why
dont
much?
grab.
letting
Why
right.
person
just
just
to
If you
Why
do
Its
watching
Pt:
just
feel
Youre
hands
are
your
body?
say,
nothing
the
what
people
onto
let
to
hands.
bang.
Why
theres
know.
Th:
want
I dont
Im
at the
Th:
hands
me
know,
look
just
good.
you
want
trying
shake,
fine,
hands,
They
to
not
you
wrong
at the
want
to heal
He
her
his
before
her
sobs
pain.
while
when
she
died,
he
remembering
had
We
return
to experiencing
the
Th:
your
arms
onto
her,
If you
how
do
Pt:
Just
tear
her
apart.
Just
get
out
of my
yank!
I dont
life!
really
hard.
Just
Just
off.
Yeah,
got
the
Th:
Yank
Pt:
Th:
totally
Tear
just
her
apart.
yank!
Tear!
of it!
apart?
Pull
yanked
Yanked
through
grab
hard,
hard!
Pull
off
the
and
just
hard!
Pull
Yanked
the
arms
off.
Arrrrgh.
else?
the
the
the
breasts,
breasts
just
yank!
off.
breasts
off.
Uhm-hmmm.
Just
And
yank!
what
Yank!
else?
Yank!
If
youre
berserk
Pt:
Totally
Th:
No
Pt:
know,
not
attack,
Pt:
sexual
No
No
And
so
long!
just
You
release!
cant
restraints.
are
restraints
over.
are
over.
Sexual
attack,
restraints.
restraints,
Sexually,
and
Pt:
go!
restraints
The
Th:
of his
no
I dont
Th:
of fusion
restraints,
The
Pt:
berserk.
restraints.
No
Th:
dont
you
grab
Yank
hard!
out
Its
rid
arms,
Anything
Th:
Get
the
off.
Maybe
blood.
grab
pull
off
rage.
go
Ahhhh!
her
Arms.
Pt:
her
tear
have
head
in you
you
Just
What
any
with!
murderous
pain
finish
see
do
yank!
this
Ah-haaaah!
it over
How
Pt:
all
of his
finally
even
Get
Th:
head
let
you
Pt:
Just
extent
Arrrrgh!
Th:
yank!
full
Arrrrgh!
date!
how
murderous
I just
You
go
no
in,
I just
cant
restraints,
do
you
impulses
I just
do
this,
attack?
[ Emergence
.]
fing.
release!
I just
Release!
you
go,
Held
know.
go,
go,
go,
me
back
Youre
just
constrained.
just,
youre
No,
you
girls.
cant
have
do
to not
restrain
do
with
girls,
you
You
justyou
know.
know.
You
an
gone,
your
and
incident
to not
illustrating
girls.
You
know,
thats
just
do
know.
conform,
that,
that!
cant
date
notyou
Grandmother
you
you
do
cant
have
to
you
know.
know.
You
You
have
to
Once
on
[ Makes
go,
her
body?
go,
several
go,
over
shots.
Im
go!
me.
Ugh!
Really
been
a bad
during
and
high
gone,
school.
and
gone,
not,
really
sexual
girl,
and
would
totally
honest
stab
body.
rape
would
stab,
knife,
.]
you
her?
Just
throw
it in,
just
go,
.]
else?
Pt:
Beat
her
Th:
How
do
Pt:
Belt.
Its,
you
to
control
rear
end.
you
beat
her
know.
rear
end?
Youve
you
now.
Im
you
beat
been
in
the
one
control,
calling
know
What
her
tension
release.
if were
beI
motions
Anything
you
let
would
Chest/upper
going
do,
else?
there
[ A symbolic
Im
you
Anything
Where
Pt:
just
gone,
stabbing
Th:
Just
youve
else
I think
Th:
in control
problem
Anything
Pt:
go,
this
Yeah.
Th:
theres
have
you
know,
released,
anger,
just
hard.
You
have
Pt:
the
No,
anything
Th:
go,
know.
cant
Pt:
and
you
You
yourself.
recounts
with
that,
relationships.
You
Th:
and
do
have
know.
you
this.
cant
you
toyou
this,
do
to
that,
have
like
you
allowed
cant
you
doesnt
know,
not
You
know,
He
You
Make
have
Th:
really
So,
How
her
over,
hard
and
really
real
damned
deserve
Its
this,
her
like,
ugh!
and
her?
strap
and
release.
beating
do
bend
it good
release,
Reeeeally
you
else?
her
go
you
for
end
itAhhhh,
release
know,
Arrrgh!
beating
rear
here.
youve
Whew.
her,
and
then
theres
a huge
sexual
release.
Pt:
you.
This
has
and
impulse
The
rageful
been
go
really
out
of
impulse
feelings
to
see
feelings
toward
Yeah,
wild,
his
has
if he
his
.]
Th:
Sure.
her
torn
off.
this?
legs
Her
is torn
the
feelings
off.
to
to his
Pt:
could
you
do
this?
How
at her
could
here
and
of
In
material,
following
The
fathers
you
tension
into
inquire
her
torn
body
off.
face
face
to
the
chair.
about
other
mixed
now
Her
look
on
arms
like,
mobilize
the
are
after
all
unconscious
.]
how
do
at
her
rage
could
you
do
this?
How
this?
whats
the
feeling
inside
you,
as
you
with
do
this
to
me?
Im
going
Conflict
the
patient
him
reveals
suffered
childhood.
asking
you
me.
Oedipal
father
patients
did
Um-hmmm.
the
patients
role,
Why
stay
De-repression
the
her
it. [ The
unconscious
are
Like,
And
Th:
during
look
does
at
I will
Thank
eyes?
someplace
history.
look
back
Whew!
it.
breasts
Shock.
Pt:
the
we
murderous
Th:
look
about
What
about
relaxes
Now
yes!
previously
as
Her
off.
patient
related
so
yes,
to talk
he
the
to talk
And
torn
head
[ I invite
guilt
are
I had
as
yes,
passed.
Had
Th:
floor,
but
access
mother
Pt:
yes,
body
finally
can
yes,
a severe,
In response,
to
take
important
on
parts
of
incapacitating
his
mother
illness
put
responsibilities
no
his
him
in the
child
could
bear.
Pt:
why
think
the
frustration.
she
was
me
to be
not
my
the
wife.
I think
With
expecting
husband.
You
are
was
my
father
not
there,
me
to
be
the
husband.
her
husband.
I wasnt
my
something
mother!
Im
your
going
down
because
of his
She
I was
son,
her
not
was
son!
your
here
and
illness,
expecting
You
are
husband!
You
take
So
he
your
didnt
problems
go
time.
So,
he
didnt
dont
cut
him
off
Jim
(the
gets
to
end
up
not
the
This
of
when
the
tell
you,
and
patients
deal
to
Its
de-repression
Oedipal
of the
let
there.
Im
the
let
you
were
dying
out
go
until
my
to have
sudden
not
You
just
Now
to
adult!
to deal
with
and
constitute
Jim
I have
the
awareness
feelings
first
husband.
issues.
Im
the
anymore.
substitute
all
husband.
later.
to you
here!
responsibility
Just
your
with
child
related
trust
the
deal
his
You
find
I dont
unconscious.
Im
you!
analysis
the
beginning
]
it out.
Theres
a lot
of painful
feeling
it out.
Pt:
is not
to
and
of the
didnt
know,
gets
my
conflict,
him
becomes
No,
Th:
Just
you
you
not
told
of memories,
unlocking
here.
and
Jim
Jim.
husband!
doctor
say,
me.
husband!
his
your
pseudonym)
with
talking
to
Yes.
It disappeared.
Breakthrough
of
Grief
The
remainder
of
the
over
numerous
losses
Yes,
yes,
yes!
It wasGod!
session
is
(father,
Th:
Pt:
let
stillMy
[ Begins
a series
mother,
Just
Im
of
childhood
to cry .]
breakthroughs
sister,
and
his
of
own
grief
childhood).
it out.
I nevergoneI
was
supposed
to
have
childhood.
Th:
Just
Pt:
I was
let
it out.
Theres
a lot
of grief,
just
let
it out.
had
to
was
eight
were
be
there!
years
there,
I had
to
anything
but
do
for
so
I had
old.
I had
to
let
the
adult
my
father
to
the
one
to be
be
the
damn
much!
So
For
you.
from
have
who
adult!
damn
too
that
had
I had
much!
to
damn
young!
seizure
stand
to start
Nobody
when
up.
taking
here
You
over!
to
do
me.
Th:
Just
an
watch
I had
damn
just
grief
out.
Theres
Pt:
Just
let
tremendous
Nobody
there
it out.
You
were
all
alone.
me,
damn
pain.
to
do
anything
for
it.
I just
have
to
take
care
of
myself.
Always
have
to
take
care
of
myself.
Th:
By
Pt:
By
Th:
try
and
drugs,
get
go
help
away.
frustration
with
mother:
Just
Pt:
Always
by
myself,
damn
it!
it out.
by
Th:
two
and
myself!
let
No
the
you
it out.
female
women
here,
you
the
know.
who
midst
Got
of
parents
at
age
Indeed,
several
You
dont
underestimated
Given
what
grief
over
mothers
never
he
his
have
to
talk
over
really
his
he
how
a chance
to
his
mother
in
him.
He
pictures
being
guilt
pour
out
as
he
the
help!
know,
You
take
spontaneously
rage
go
some
links
his
toward
his
help .]
mom.
help!
No
help.
Cant
get
any
help
that
family
after
members
family
the
death
offered
assets!
He
of
any
recounts
his
help.
how
his
toughness.
and
saw
you
murderous
reveals
clearly
has
So
I return
death.
body
had
he
with
describes,
dead
damn
elsewhere.
no
mothers
[ He
your
no
No
Well,
and
like
Yep,
nineteen,
doctor
told,
of no
Just
off
myself!
help!
were
grief
ran
get
doctor
to go
deep
by
damn
Pt:
he
say
minutes
able
to
burying
goodbye
because
before
his
him
deal
pictures
to finally
recounts
a great
she
tell
died,
her
regrets
over
unresolved
the
scene
her.
He
says
he
last
time
he
yelling
at
the
she
of his
not
of
love.
being
was
of
His
grief
able
to
his
and
undo
suffering.
Vignette
We
let
Always
Th:
her
Always
pain.
and
In
myself!
Just
Pt:
the
yourself.
return
Six
(minutes
at minute
81105)
81
Pt:
during
I just
another
wanted
wave
to
help
of grief.
you
so
damn
much.
didnt
that
want
to
want
you
happen
my
damn
damn
thing
mother.
to be
way
with
By
he
accusing
for
and
guilt,
identification
with
sick.
I didnt
learn
her
punitive
Th:
could
not
his
he
it on
could
with
through
enraged
could
Now
didnt
so
I couldnt
turn
You
mothers
do
with
his
himself
by
have
done
punish
the
himself
passage
of
accusations
the
and
his
.]
couldnt
stop
I couldnt
Just
her
stop
let
it out.
I couldnt
pain.
her
pain.
I couldnt
help.
You
stop
couldnt
her
pain.
stop
her
I could
pain.
not
help.
help.
Th:
final
to
help!
Pt:
not
rage.
help!
want
you.
to go
been
was
way,
voice
You
Th:
could
to
I didnt
to
to have
had
rage
this
of
Pt:
you
happen
accusations:
murderous
we
to
it. [ He
the
mothers
through!
anything
stop
himself
his
that
do
with
went
want
I couldnt
dealt
you
want
I couldnt
his
unconsciously
what
I didnt
But
to help!
identifying
through
you!
pain!
One
more.
go
to
father
much
rage
to
What
else
would
you
say
to
her,
as
your
goodbye?
Pt:
Only
believe
in
me.
Believe
that
will
succeed.
Th:
Pt:
Believe
Th:
Please
Pt:
Believe.
Th:
Please
Pt:
Th:
final
you.
Believe
Yes,
that
that
I will
I will
succeed.
succeed.
believe
me.
believe
in me.
yes,
yes.
Anything
else
you
want
to
say
to
her
as
goodbye?
Dont
be
Pt:
Dont
Th:
God
be
afraid.
Dont
be
afraid.
God
is
with
afraid.
is with
you.
What
would
you
say
to her
that
you
never
would
want
to
carry
with
Pt:
I am
always
he
continues
her
for
eternity
that
she
could
forget?
During
minutes
details
of
have
84104
her
abandoned
death
him.
wanted,
he
imagines
to
do
by
funeral
pictures
giving
the
family.
sister
the
and
drab
singing
his
younger
mourns
He
not
as
his
her
life
one
at her
He
then
never
got
she
never
with
to
grieve
and
her
she
recounts
the
his
kind
shares
extended
of funeral
received.
she
And
how,
his
mothers
live
one
up
he
to
lost
her
would
he
was
after
the
family
he
to
the
he
something
a chance
and
as
how
actually
funeral,
had
you.
not
sobs
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
overcome
his
co-created
complex,
the
can
face
symptoms
the
following
the
patient
to
these
and
view
the
the
If
unconscious
he
how
on
he
agrees,
therapeutic
Then
the
other
patient
person
and
If he
so
you
the
attacks
portrayal.
so
the
suffered.
emotions
in a consolidation
link
inflicted
task.
buried
suffering.
ingredients
of
feelings
has
he
the
the
breakthrough.
person
therapeutic
previously
of
Then
Show
that
integrated
the
damage
in
was
they
beginning
patient
person
toward
and
a conscious
the
initial
that
unconscious
breakthrough.
attacked
feelings
invite
you
the
body
connections.
to the
the
symptoms
the
to
those
body
has
memories,
outlining
during
present
sees
and
the
in
arose
the
patient
in the
and
self-punishment
body
point
Include
patient
persons
himself
used,
that
by
anxiety
feelings
in
experience
the
feeling
Begin
the
patient
feelings
so
physical
patient.
patients
to
material.
had,
the
unconscious
the
unconscious
the
patient
the
capacity
Once
de-repressed
for
defenses
Link
of
the
session
feeling
aroused,
patients
feeling.
breakthrough
the
conflict,
the
unconscious
experienced
therapist
increase
wants,
he
will
can
have
alliance.
at
the
end
of
the
session:
1.
Outline
2.
experienced
and
the
feelings
3.
session
and
the
symptoms
that
Point
they
the
initial
Point
out
triggered
out
the
cause.
conflict.
the
anxiety
the
patient
it.
defenses
the
patient
used
in
4.
then
link
those
patients
Point
feelings
Point
a more
reasons
complex
for
presenting
her
how
buried
the
inner
life
and
feelings
is
of the
misdiagnosis,
parts
the
patient
and
in
failure
of the
is not
the
driven
to
of
You
the
therapeutic
task
the
patients
problems
the
Help
anxiety
and
to a better
the
and
at
the
the
be
see
creating
outcome.
end
of
the
first
14 .
feeling
to
patient
defenses,
1 and
obviously
failure
relationships
treatment
at in chapters
were
and
in life.
consolidation
diagnose,
enraged
really
with
the
aggressive
on
Right.
And
problem,
was
tremendous
lead
to
others.
problems.
her
feelings
doctors
your
problem
obviously
youre
feeling
very
enraged,
were
enraged.
interestingly.
Pt:
Right.
Th:
Your
that,
problem
when
is not
you
that
you
felt
this
enraged,
see
that
the
it
aroused
anxiety.
Pt:
doctors
it has
mixed
understand
outer
looked
Th:
Your
arose
figures
how
her
and
goals
patient
her
phase
we
out
her
insights
Pt:
which
and
bear
overcome
triggered
These
follows
to
the
Th:
the
that
toward
guilt
patient
point
to achieve
helps
symptoms.
session
the
of herself
Then
it:
symptoms
between
the
experience
undertaking
consolidation
What
feelings
out
Help
7.
her
feelings
self-punishment.
6.
The
mixed
past.
patients
reach
the
to unconscious
5.
the
out
was
with
family
was
not
echoing
members
there
for
Yes.
Th:
And
the
situation
that
you.
[ Link
Pt:
now
again
past
Right.
we
with
your
it was
and
mother,
a situation
present
.]
situation
with
of
your
someone
with
the
sisters,
who
Th:
you,
whos
you,
not
supposed
taking
You
to
care
be
being
rage
really
aroused
tremendous
actually
had
to
greatly,
but
that
control,
her
denying
wanting
to control
any
your
of
unconscious
wanting
to
tear
this
we
also
saw
theres
this
your
[ Link
his
To
mother
love,
the
to
tear
yourself
mother
to
identify
with
his
tear
to
guilt,
this
rage
loved
your
over
her
down
any
which
you
felt
mother
demand,
to know
toward
what
see
she
that
your
her
feelings,
of your
the
feelings,
doctor
to
the
that,
you
felt
wanted.
underneath
wanting
it sounds
the
his
Pt:
Yeah.
Th:
You
like
scene
rage
mixed
had
of
toward
to tear
her
you
felt
to pieces.
such
the
funeral
that
his
mother
to
emotions
a powerful
guilt
about
you
loved
his
guilt
and
.]
love
for
your
mother
Absolutely.
And
that
you
your
mother
to
pieces.
[ Link
the
which
led
her .]
Pt:
you
wanting
rage,
of complex
to
that
apart,
.]
doing
we
And
Th:
wanting
be
from
Pt:
about
tremendous,
Sure.
[ Link
experience
this
doctor
rage
rage
mother
was
that
hold
his
murderous
clear
dearly.
not
and
But
Th:
your
mother.
Right.
Pt:
its
abandoning
Yeah.
Th:
rage,
and
feelings,
toward
saw
tremendous
initiative
Pt:
because
mother
suppress
Th:
this
But
and
tremendous
abandoned
you,
your
we
your
Pt:
this
has
for
neglectfullike
what
with
rage
caring
And
anxiety.
do
who
Yep.
Th:
murderous
someone
responsible,
of you,
Pt:
know,
Sure.
him
to
felt
pieces,
such
that
unconscious
turn
the
rage
tremendous
you
were
rage
upon
guilt
tempted
toward
himself
his
and
Th:
harsh
With
self-criticism,
and
with
very
Yes.
Th:
murderous
would
rage
verbally
unconscious
tear
rage
And
really
to his
your
to sexually
difficulties
being
able
symptom
to
understanding
to tear
to
her
too,
to pieces
pieces
unconscious
for
the
years.
self-punishment
that
way
in
you
[ Link
the
was
also
.]
Yeah.
That
assault
over
were
wanting
Th:
wish
then
yourself
Pt:
this
harsh
self-judgment.
Pt:
this
very
the
there
her,
which
years
ejaculate.
was
helps
about
[ Link
his
in this
rage,
us
there
understand
sexuality
and
sexual/rage
some
the
impulse
of
difficulty
to
his
of
sexual
.]
Pt:
Yep,
Th:
yep,
We
yep.
see
that
that
got
tangled
up
in
there
this
rage
too.
Pt:
Sure
Th:
toward
your
getting
tangled
another
mother
and
up
element.
with
the
her
that
you
even
in the
loved
her
and
Th:
a source
Th:
it was
whether
your
it was
success,
so
also
and
the
on
with
actually
you
that,
with
all
self-punishment,
women,
really
had
scene
wanting
loved
and
that
we
see
your
mother.
the
also
this
terrible
youre
her
situation
imagining
to believe
with
wanting
that
you
your
to
loved
tell
her.
Yes.
That
of tremendous
Pt:
emotion,
And
death
Pt:
been
and
see
Yes.
Th:
that
we
guilt
always
Pt:
mother
And
love
Youd
did.
her
inability
to believe
in your
love
has
sense
that
any
pain.
I think
so.
And
you
your
whether
rage,
were
whether
it was
your
left
with
the
it was
joy,
all
your
of
grief,
these,
whether
you
got
the
impression,
feeling;
quit
would
doing
relationship
that.
with
closeness
with
hurt
And
your
his
mother
template
to
you
transference
hold
She
see
how
wife.
said
this
[ Link
dont
has
his
relationship
bring
me
influenced
your
defenses
with
his
against
wife .]
Yes.
Im
not
back
brought
of his
we
to the
Th:
you
mother.
current
Pt:
requires
your
convinced
emotions
to
that
mother
that
so
her
much.
relationship.
onto
his
wife
diagnosis
think
[ Point
does
not
really
this
out
fit the
is
the
how
reality
the
of
his
wife .]
Pt:
Yeah.
Th:
You
emotions
have
with
your
mother
that
her;
that
if
really
emotions.
to be
you
[ Point
out
held
back
that
closeness
got
someone,
know
rather
you
more
Because
be
with
these
truly
against
Jon?
were
of the
defenses
.]
Pt:
Yeah.
Whereas,
sharing
learned
supposed
to
would
in most
love
hide
your
relationships,
we
emotions.
Sharing
emotions
impression
than
in fact,
you
your
Yes.
give
that
them
is how
sharing
an
we
get
emotions
opportunity
to
close.
And
would
feel
hurt
closer
and
Yeah.
struggling
template
And
emotions
be
you
that
intimately.
were
that
way
origin
Th:
we
the
a sense
because
the
Pt:
what
a woman,
you
by
the
was
with
mother,
Th:
you
from
up
your
Pt:
yet
brought
loved
Th:
achieve
were
with
closeness
me,
we
with
is
was
do
and
And
there:
I really
have
wanting
with
his
the
see
that
sharing
How
even
these
close
have
permission
relief
and
to
mother,
know
his
here
emotions
am
wife,
and
the
with
to
actually
reveal
of
emotions.
part
I wanting
to
comfort
my
today
having
[ Link
therapist
of
me.
really
someone
defenses
.]
all
Pt:
Sure.
Th:
killing
your
what
my
mother,
feelings
Because
there
was
other
me
does
want
peoples
to
rejection
And
mine.
of his
[ Link
feelings
she
you
in
would
feel
and
wanting
the
sudden
seeing
and
how
the
through
Pt:
Yeah.
Th:
Its
exhausting.
at work.
and
exhausting.
the
[ Point
and
comes
to
but
its
not
okay
his
feelings
no
know
for
to
his
But
up
what
look
of
emotions
your
at is
of closeness.
not
knowing
you
feel.
what
in a very
the
sleep
that
note
the
that
the
also
how
of his
question.
And
were
lot
more
see
been
also
been
been
very
loss
was
not
random.
suppression
doing
defenses
No
has
energy
we
youve
certainly
.]
Its
that
were
and
pseudorelaxation
down,
of work.
can
powerful
difficulties
at work,
outside
effect
her
through
symptoms
I should
No
for
happening
holding
the
to really
kind
together
emotion
to his
tensing
much
causing
are
of
It happened
experience
me
thing
of knowing
that
defenses
Th:
feel
that
for
a certain
scary
whats
tension,
out
sense
okay
of
how
her
all
know
Pt:
to
know
yes.
This
Th:
emotion
to
want
the
forth,
one
wife,
allow
Yes,
Pt:
starting
so
rejection
probably
suppression
[ Link
and
Its
that
a closeness
losses
the
on
your
It will
dont
energy
had
emotions.
mothers
with
Th:
we
always
It suggests
to know.
Although
dont
were
Right.
Pt:
way.
you
you
.]
a sense,
like
so
his
Th:
explore
my
and
Pt:
to
youve
to know
emotions,
know
of,
when
Right.
Th:
really
a sense
also,
are.
Pt:
one
remember
would
of the
be
very
.]
question!
able
emotion
to see
that
youre
able
than
you
ever
gave
yourself
credit
for
before.
Pt:
Right.
Th:
deeply
as
you
did,
anxiety
to having
youre
faced
his
a result
[his
wife]
health
more
and,
problems
you
of her
back
is that
guilty
during
thispartI
stuff,
saying,
Let
then
weve
Well,
certainly
it
ticked
me
not
as
a child
your
because
you
of
emotion
[she]
the
two
of you
past
of
simply
being
have
emotional
some.
defense
of
theres
some
does
probably
stuff,
shes
but
do
some
Im
you
give
and
drop
occurring
got
going
to
reasons
wrong.
I shoved
way,
as
but
held
and
felt
off
youre
you
to
some
Ive
issues
soon
talk
through
thyroid
as
that
understand
and
leave
stay
with
emotional
my
fixed,
know
that
you
were
Right,
see
how
[her],
doing
the
best
things.
Its
not
resentment
have
but
and
like
overblowing
dont
my
you
the
isolated
get
she
shes
part
out
can.
not
develop
into
to repeat
the
could
actually
back
price:
he
then.
leaves
.]
of
the
She
caretaker
does
housebound,
that
it at this
much
emotional
possible
with
to
much
relation
wasnt
that
on
how
your
with
got
by
to
You
Ive
wife]
a chance
to let
lonely
[your
abandoned
and
That
with
an
way.
her.
yet,
in
with,
have
that
yourself
distancing
position,
probably
us
yourself
caretaker
abandoned
I mean,
She
first
Ive
of the
were
ways,
intimate
Pt:
thing.
shes
some
helps
could
closeness
in an
in
been
that
one
out
many
could
emotionally
himself
That
dont
more
the
that
fixed
work
in so
a much
Link
that
things
emotions,
position
closeness
his
[ Link
question.
right,
investigating
quite
as
said?
I know
you
emotions
on
revealing
your
connections
I know
get
didnt
other
know,
knew
tense.
No
.] Youre
been
less
question.
[ Sighs
Th:
abandoned
just
own.
those
.]
any
we
Pt:
much
no
Have
of what
experiencing
feelings
Yeah,
Th:
as
by
feeling
Pt:
to you
And
I am
point
picking
in time.
drive
but
up
Th:
something
that
we
there
here,
are
the
the
could
we
therapeutic
After
the
come
probably
more
probably
back
mixed
can
task
patient
Its
to,
because
feelings,
help
your
quite
it
and
tension
strong,
and
would
the
make
more
level
go
thats
we
sense
face
down.
them
[ Point
out
.]
describes
his
work
situation
briefly,
the
therapist
continues:
Th:
with
all
the
dealing
stuff
with
from
thats
these
been
up
you
the
more
we
underneath,
wont
be
feeling
help
you
that
when
such
deal
youre
pressure
underneath.
weve
got
Following
sleep
AND
this
shaking
the
of thirteen
stopped,
after
His
himself
to
his
for
long
returned
to
work
physical
collapse.
patients
the
big
stuff,
which
is what
had
next
in
were
him
two
sleep
to
days
He
headaches
first
never
he
session.
lost
ended
did
bowel
He
drove
time
this
after
day
completely
normal,
of
first
another
His
headaches
reports
laterthe
And
to
his
further
this
ended.
returned
stopped,
no
months.
morning.
His
His
complaints
collapses
drive
session
distance
that
ended.
there
to
TREATMENT
somatic
physical
and
wife
the
OF
years
dramatically,
complaints.
driven
going
COURSE
session,
disorder
lessened
Were
to do.
OUTCOME
by
like
backed
tensions,
Pt:
his
It sounds
he
had
having
of
work
after
to
session
seven.
The
treatment
murderous
rage,
However,
the
pathological
through
continued
guilt,
major
mourning
the
for
grieving,
ten
and
work
over
sessions.
grief
later
in
multiple
overcoming
Many
toward
the
treatment
losses
his
breakthroughs
mother
occurred.
involved
into
transforming
normal
resistances
of
grief,
and,
to
emotional
his
collapses
closeness.
At
the
beginning
of
treatment,
he
was
so
crippled
by
that
he
was
working
was
promoted
to
doctor
exclaimed,
blood
pressure
medications
after
as
his
with
as
said,
more
back.
More
man.
I never
than
Not
there
and
pleasure
but
now
back.
had
level
point
of
years.
my
life.
ever
he
are
family
were
closer.
Im
I got
going
the
This
to
tools.
is
window.
on.
He
got
a new
to
my
life
happy
peak
level.
more
going
His
described
Im
a lot
Life
thought
Ive
is
have
stopped
the
different.
happiness.
all
back
before.
something
stopped
out
lights
ever
His
formerly
thats
His
in years.
He
had
he
had.
headaches
he
says,
ever
looked
His
that
treatment,
he
points.
than
got
of
the
friendly
Ive
this
in
like
and
and
in fifty-two
this
reported
end
position
treatment.
He
wife
open
the
thirty-one
Its
his
At
youve
neurological
introverted,
relationships
best
dropped
session.
he
in bed.
professional
is the
had
Cognitively,
himself
home
highest
This
seventh
of himself
from
the
and
the
from
happiness
be
different
forward.
SUMMARY
Rather
than
the
patient
the
surface.
relevant
speculate
turn
against
Then
interpret
only
after
unconscious
what
is
been
de-repressed.
feelings
his
inner
the
and
therapists
By
understanding
with
his
life
with
to
doing
outer
so,
his
suffering,
expressions.
the
risen.
to
put
we
help
do
bring
here
not
forth
we
only
patient
life
that
links
his
his
past
with
his
to
the
some
interpret
speculate
together
the
rise
Whereas
surface,
We
help
feelings
surface.
and
inner
defenses,
repressed
to the
has
interpret
the
unconscious
material
of
conscious
its
patients
material
We
is underneath
Eventually,
memories
to bring
underneath.
what
them.
trust
feelings
integrated
about
about
what
has
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
this
love
service
to
as
own
against
choice
our
Each
lives.
only
we
choice
choice,
And,
a different
choice,
the
face
face
This
of
growth
are
make
being
her
takes
form
in
patient
past
response
at each
than
the
is
development.
our
by
her
to
(defenses)
is
love.
address
self-creation
by
of
present
and
and
available
rather
you
therapist
moment
fortunately,
the
avoid
patient
is
conditioning
we
can
of
patient
them.
when
and
conditioned
the
avoid
a way
self-transcendence
how
than
to
This
part
the
defenses
and
of our
go
than
rage
courage
rather
help
and
possible.
the
help
hurt
therapist.
patients
of
on
also
have
anxious,
as
out
must
that
her
deeply
must
possible
defenses
courage
therapist
the
of
as
of the
of
matter
always
patient
which
Once
wants
makes
feelings
therapist
a form
go
what
part
in the
act
let
the
choosing
continual
we
on
face
also
task
therapy,
problem,
the
defenses),
symptoms.
she
avoid
the
as
Developing
lifelong
even
And
to
defenses
help
and
which
and
therapist
The
the
Willingness
we
the
courage
in
see
requires
deeply
Persisting
to
warded-off
fears.
emotional
and
her
than
defenses.
feelings
In
is
Likewise,
she
anxiety,
for
causes
we
task.
experience
what
(feelings,
problem
what
the
psychotherapy
problems
the
on
patients
conflict
presenting
consensus
patient.
dynamic
the
remain
and
genetics,
conditions,
attitude
moment
our
(Berdyaev
to
moment,
is
we
take
creates
the
we
the
have
imprisoned
by
our
habitual
defenses.
a question:
The
What
therapist,
defenses
We
this
talking
impersonal
to
of
the
of
why
the
always
my
patient
out
we
defenses.
to
reach
let
life?
go
of
his
back?
suffer.
now
faces
inner
or pull
we
And
patient
Then
we
conclude
by
Defenses
out
to
the
are
person
differentiate
himself.
his
as
himself
He
person.
a person.
These
he
which
The
patient
impersonal
determinism,
not
to
a living
understands
Yet
concepts,
as
himself
is always
can
only
is not
his
innate
as
something
point
to
the
defenses,
automaticities
his
reality
his
only
point
for
love
capacity
freedom.
therapists
the
patient
ego
is the
forget,
and
differentiate
has.
and
and
an
sight
creates
act,
We
this
criticizes
impersonal
of
the
a triumph
person
impersonal
crucial
question:
himself
object
directed
patient
The
living
propose
forget
himself.
a creative
the
as
person
over
the
When
person,
is
not
we
by
an
merely
determinism
of
genetics.
determination
of
himself
from
1944,
2627).
(Berdyaev
past
is impersonal.
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creative
act
This
is why,
when
mystery.
lose
to
he
observes
becomes
who
but
forget
superego
We
center
personality
defenses
who
forces.
contents
defenses
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patient
impersonal
some
also
and
person
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existential
can
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like
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is
reject
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the
or
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Will
find
a dynamic
resistances.
and
Will
suffering.
about
than
him
slavery
entities
This
as
I accept
question
cannot
has
other
his
Likewise,
of
he
in therapy,
conditioning.
often
not
reality
and
the
ideas
and
his
end
task
patient
or
to
Our
object,
habits,
the
habits.
the
greater
with
we
Sadly,
Will
them?
person
underneath
the
with
the
hidden
moment
a choice:
ways
about
static
faces
book
various
each
I choose?
or collaborate
showed
living
will
too,
began
from
At
We
That
in this
asked
are
is why
the
moment
arising
Everything
present
reveals
to define
always
within,
who
a person,
coming
to
out
of
done
moment
the
to
him
is so
patient
Martin
know
freedom,
the
important.
is becoming.
Buber
a
in
is
person,
answered,
whose
potentials
and
being.
living
because
we
to
The
of
As
this
patient
who
she
person
Frieda
not
who
has
but
of
what?
transformed
by
becoming
moment.
With
emerges
in
to face
the
the
with
transforms
the
is why
we
at
she
she
do
of
one
under
was,
point
any
but
to the
larger
interpretation
merely
point
to the
defenses.
does
that
emotional
defenses,
the
something
experience
but,
the
Any
feeling,
direct
in
person.
proposed
This
realized
also
any
patient
being,
but
said,
(Hornstein
Through
only
(1981)
her
the
his
Bakhtin
only
impersonal
she
be
Likewise,
with
the
before.
is becoming
work.
can
The
of her
thought
this
hidden
feeling.
had
as
patient,
(1970)
mystery
she
who
who
of
the
yet
of
not
concepts,
about
experience,
Bion
form
why,
become.
said,
collapse
or ideas
transforms
That
been
may
herself
define
new
experience
thoughts
could
1983),
static
written
about
Fromm-Reichmann
interpretation,
face
been
cannot
our
is
dimensions
(Frank
potentials
That
makes
makes
ever-new
surpasses
what
is and
reveal
unknowable
person.
has
the
therapist
potential
always
know
of
will
always
cannot
word
comment
the
is
reality
be
final
reality
choices
person
because
coming
future
more
not
need
an
2000),
but
an
we
Truth
become
of
the
person
patient
larger
this
comes
than
of her
important,
any
being
it
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inner
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Psychology,
in
Psychodynamic
Jason
Aronson.
of
absoluteness:
especially
20 (2),
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214235.
revisitedrelevant
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irrelevant?
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Psychological
Robertson
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Superego
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D.
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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.,
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,
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),
47 , 57
assessment.
See
psychodiagnosis
association,
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),
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
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,
354
230
pointing
out,
104 , 402
verbalization
Benjamin,
L.,
Benoit,
C.,
92 , 355
N.,
E.,
1 , 8 , 479 , 480
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,
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,
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
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
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.,
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),
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
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
356
402 403
thinking
in,
403
92
J.,
359
choices,
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,
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
417
facilitation
mirroring,
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
confusion
state,
conscience,
causes
of,
116 117
conscious
guilt,
383
consciousness
of feelings,
consensus,
16 . See
also
awareness
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,
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,
354
37
A.,
C.,
4 , 13 , 35 , 36 , 42
13
Davanloo,
H.,
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,
23
psychodiagnosis
detours
208 , 209
107
conscious
inviting
problems,
and
vignettes
resistance,
vignettes),
424
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,
( 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
( 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
defenses)
compliance,
denial
289 290
224
character
creation
of,
patients
( see
responses
identification;
with,
174
identification
enactment)
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,
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
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,
De
E.,
denial,
94
356
of recognition
identification
delusions,
of,
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
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
patients,
graded
format
192 , 213
for
( see
fragile
also
patients
fragile
patients)
(vignettes),
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,
98 99 , 284
detours
from
feeling
( see
interventions
anxiety)
for
anxiety
detours
(examples
and
vignettes),
144
defense
detours
(examples
and
vignettes),
146
146
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
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
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
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.,
of patient
character
Egan,
344
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,
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)
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
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
feedback
feelings,
loops,
anxiety
315
( 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.,
Ferenczi,
S.,
356
focus.
See
also
vignettes
externalizing,
mistakes
resistance
A.,
for
examples
315
maintaining,
Fogel,
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,
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
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
patients)
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
therapy),
also
concept
will
(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
S.,
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.,
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
of neurotic,
unconscious,
Hassin,
against,
of superego
provocation
N.,
of,
manic
H.,
458
function
exhaustibility
harsh
330
16 . See
Hamill,
30
467
avoidance
Haan,
resistance,
J.,
Guntrip,
321
93 , 330
Grotstein,
guilt,
(vignette),
251 252
against
unresolved,
Grigsby,
of oneself
361
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,
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
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,
251
362
aggressors,
character
(vignette),
defenses
as
clarification
of price
of defense
(vignettes),
404
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
interpretive/noninterpretive
interventions.
159 , 359
externalization,
syntonic
internal
67
focus
also
detours
vignettes
92
on
resistance,
for
examples
(examples
and
443
vignettes),
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
pathological,
invitation
to therapeutic
363 367
task,
20 . See
anxiety
during,
decision
tree
decreasing
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,
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,
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
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.,
A.,
Kitraki,
Klein,
E.,
39
M.,
Knight,
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,
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
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
headaches,
Miller,
Mills,
W.,
C.,
65
331
minimization
Minton,
mirroring,
defense,
K.,
120
69
174
defenses,
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
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.,
344
memory,
380
93
35 , 36 , 41 42
focus
normal
170
361
of feelings,
nonproblems,
of,
47
nonawareness
Nunberg,
by,
48
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.,
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,
symptoms,
feelings,
249 254
344
377 378
407
outcomes
of normal
overexaggeration
Pain,
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
pathological
superego.
See
superego
pathology
pathways
anxiety,
68
anxiety
discharge,
unconscious
anxiety,
unconscious
anxiety
139 140
discharge,
assessment
of,
restructuring
Pena,
J.,
people
pleasing,
See
anxiety,
phases
of inquiry,
phobias,
social,
cognitive/perceptual
in psychodiagnosis,
nervous
J.,
disruption
39
activation.
155 156
See
system;
parasympathetic
sympathetic
nervous
nervous
system
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
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
system;
price
of defenses,
ability
of patient
clarification
primitive
to see,
of,
pathological
relationships,
idealization,
222
Prins,
A.,
57
Prinz,
S.,
47
142
102 103
problems
declaring,
in getting
specific
nonproblems,
examples,
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
compared
content
to,
to denial,
of,
parts
deactivation
defensive
defiance
of,
anger
of,
316
of oneself
(vignette),
320 324
to,
297 298
definition/description,
differentiating
314 316
therapist
dispelling,
382
in fragile
patients,
from,
character
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,
429
psychodiagnosis
anxiety,
345
321
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,
response
to interventions,
self-observing
capacity,
superego
pathology,
symptom
assessment,
syntonicity,
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,
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.
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,
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
362
reminders
reality
118 120
360
versus,
pointing
of,
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
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
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,
character
defenses,
countertransference;
409
therapeutic
alliance;
transference
enactment
of past,
parent-child,
past
painful,
pathological,
Reller,
M.,
390
216
representation
repressive
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
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
233 234
superego,
260
71 , 234 235
rage
Ryle,
G.,
396
sadness,
sadomasochistic
enactment
Safa-Gerard,
Safran,
D.,
J.,
Sandler,
Sapolsky,
Scaer,
383
R.,
48
295 297
R.,
Schore,
47 , 69 , 70
A.,
Schulkin,
J.,
57 , 184 , 247
Schwartz,
G.,
Schwartz,
J.,
Segal,
121
J.,
sarcasm,
vignette,
H.,
247
185
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
360
self-mutilation/cutting,
self-observing
assessment
See
and
also
observation/observing
mobilization
of,
capacities
43 , 59 60 , 63 64 , 106
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),
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,
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,
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),
patients
graded
format
with,
for
214 , 217
restructuring,
organized/disorganized
restructuring
rising
somatic
symptoms
in session,
of,
feelings,
headaches,
symptoms,
defenses,
252
255 256
tension
headaches,
therapists
254
understanding
unconscious
of,
identification
vignettes,
245 246
with,
251
Southwick,
S.,
57
speculation
defense,
116 117
patterns/rate,
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,
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,
in cognitive/perceptual
to show
triangle
superego,
causality,
being
healthy
of,
also
disruption,
269
of conflict,
260 . See
aspects
235
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
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
nervous
system,
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,
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,
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
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
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
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
description,
enactment
of past
evolution
relationships,
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
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.,
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
psychodiagnostic
true
Troendle,
P.,
discharge
meaning
of (vignette),
419
to patient,
differentiating
See
part
5 , 46 , 117 , 479
description,
triggers.
as
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.,
R.,
C.,
sites.
to
evasiveness
344
of feeling
states,
specific
defense,
345
intervention,
or
disorder
for
330
93
See
recommended
chapter
G.,
387
weeping.
See
Wegner,
D.,
M.,
breakthrough
330
S.,
Wehrenberg,
also
also
39
Wallerstein,
Warshow,
examples
Vingerhoets,
Waelder,
resistance,
93
of feelings,
vignettes.
Wexler,
92 93
22 , 44 45 , 65 , 332 , 336
vagueness,
verbalization
Weeks,
also
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
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.,
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
Frederickson,
cochair
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MSW,
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