My client, Betty, was told that she has treatment resistant depression, bipolar 2, and borderline personality traits. She started each new type of therapy or program believing that it was the magic bullet. This would inevitably result in disappointment. Psychiatrist appointments, medications, cbt, self compassion groups, dbt worksheets, and help from exercise therapists and dieticians didn’t succeed at helping Betty to extricate herself from the jaws of lifelong depression. In the meantime, the deep, pervading sense of worthlessness that lived in her implicit emotional memory remained untouched.
“I am so numb and shut down,” she said. “I don’t know what I feel”.
For a long time I struggled in my efforts to help Betty. Again and again I conveyed my care and compassion. I role modeled kind, and self respecting ways to treat herself. We used DBT worksheets such as Opposite Action, Crisis Survival Skills and Accumulating Positive emotions. These efforts were intended to help Betty challenge damaging patterns such as impulsive binge eating and spending, negative self-talk, suicidality, as well as isolation and shame.
I shared Emotion Regulation strategies, and offered an Internal Family Systems lens through which Betty could begin to see intense emotions and suicidality as rogue parts of herself. Despite my efforts, Betty inevitably left our sessions, and spent the rest of the week shut down, isolated from the world, neglecting and sabotaging her health. I came to understand that both the self attack, and the shut down, were defenses against the deeper emotions that Betty had buried.
As Hilary Jacobs Hendel explains, core emotions are hardwired into the middle of our brain. They are survival emotions meant to inform us about our environment, and relationships. Each core emotion – fear, anger, sadness, disgust, joy, excitement, and sexual excitement – helps us to determine whether we are safe, vulnerable to threat, or have needs or wants.
When our parents role model kindness, understanding and encouragement of our core emotions, they teach us how to do this for ourselves. The emotional attunement that we receive from our parents, is internalized and we develop the capacity to tolerate and respect our own emotions. The parent who provides us with a safe haven for our pain and emotional stress, as well as a secure base for exploration, helps us to build the foundation for our healthy self (Powell el al, 2014). The healthy self can be curious about core emotions, recognize what we need, who we are, and when we need to assert ourselves or repair hurts we’ve caused. Core emotions help us to make choices that serve our growth and wellbeing.
The turning point for me, and for my work with Betty, came in supervision. My supervisor, who has advanced training in Intensive Short Term Dynamic Psychotherapy (ISTDP), was watching a video of myself working with Betty. My supervisor pointed out that based on Betty’s presentation, it was clear that she was repressing emotions, and engaging in self attack.
ISTDP psychodiagnosis is helpful in deciphering which system of resistance is operating within the client in front of us, and whether the client is fragile, repressed, or detached/resistant. Through psychodiagnosis we can discover the cause of the client’s symptoms by assessing the client’s responses of feeling, anxiety and defense. Feelings with which the client struggles, the anxiety discharge pattern in the body, the defenses that create the symptoms, and his self-observing capacity all become clear through moment to moment psychoassessment (Frederickson, 2013, p. 138).
At the front of Betty’s system was passivity and helplessness, a defense which got triggered in our relationship when core emotions were rising. Defense against anger was her implicit, or procedural learning in her relationship with her parents. Her parents failed to acknowledge Betty’s anger for feeling rejected, criticized, and for missing out on the affection, closeness, and acceptance that she needed to thrive. The rage that Betty felt had nowhere to go but against herself.
For Betty’s healthy will to come out of the fortress of lifelong depression, she needed me to provide pressure to turn against her self attack, self neglect, and shutting down. Pressure is encouragement to be emotionally present, to identify processes and emotions, and to overcome defenses that keep a person in pain and suffering (Abbass, 2015, p.69).
Defenses arise automatically and unconsciously to ward off aspects of reality, and feelings that trigger anxiety. Defenses are not a coping mechanism which is a conscious strategy we use flexibly to solve an external problem. While conscious strategies decrease distressing feelings and help us to function better, defenses cause the presenting problems that bring clients to therapy (Frederickson, 2013, p. 91). As Frederickson states, “..every defense originally had a self-affirming, positive effect. It reestablished a fit with someone in the past. However, defenses, which originated as adaptive regulators for relationships, become maladaptive perpetuators of the past” (ibid).
My supervisor’s guidance, and my own self supervision and deliberate practice with my video of my sessions with Betty, helped me to realize that my struggle to help Betty was not due to a deficit of skill, empathy or training on my part. My difficulty with Betty was due to an emotional block within myself!
It works like this: when I am faced with Betty or anyone in my life who has a problem taking healthy action to address their own self neglect, my tendency is to take over, and be the healthy will that that person fails to hold for themselves. Working with my own countertransference, well buried emotional reactions to Betty’s helplessness came into focus. I realized that this pattern in myself is how I try to avoid the other person’s helplesness by injecting my strength and capacity into them.
If it had a voice, my defense would express its mistaken belief this way: “If I work really hard, I can make up the difference for the healthy will that you lack. When you give up on yourself, I need to work harder so I don’t have to watch you fall apart, and be left all alone, and then feel like a failure for not saving you from yourself”.
My supervisor’s voice was kind and heartfelt as she gave my defense with Betty a voice, “My capacity, I hope, will overwhelm you in a way, and kind of go into you so that you can be capable with me and I don’t have to be alone”.
She said, “That’s the responsability you feel, that your capacity inside someone else will help them join you.”
I began to cry as she put into words something that had operated inside and outside of me for so long without my being conscious of it. Rather than face my own core emotion, this defense of overfunctioning to get others to take care of themselves was so automatic. The problem for me, and for the people I use this misguided strategy with, is that it’s not very effective, and it is very exhausting for me! In truth, my healthy will is impotent to help anyone unless that person truly wants to awaken their own capacity to hold that healthy will for themselves.
Suddenly I understood both Betty and myself way better than I had before. In subsequent sessions I worked on not letting my own defense take over so that I could help Betty to connect with the healthy will, and core emotions inside of her. She had internalized her anger toward her parents for their failure to cherish, appreciate, and nurture her, but this had left her shackled with an excruciating sense of worthlessness.
The Change Triangle, ISTDP supervision, and deliberate practice help me to clarify and address client defenses, as well as my own countertransference. It is compassionate to help a person see their defenses, and clarify the price of those defenses, so they can choose to face their feelings, and heal from past hurts. Clarifiying the logic and cost behind defenses and anxiety, and accessing clients’ healthy will and core emotions, has made my work more sustainable, and rewarding.
Abbass, A. (2015). Reaching Through Resistance: Advanced Psychotherapy Techniques. Seven Leaves Press.
Ecker, B., Ticic, R. & Hulley, L. (2012). Unlocking the Emotional Brain: Eliminating Symptoms at Their Roots Using Memory Reconsolidation. Routledge.
Frederickson, J. (2013). Co-Creating Change: Effective Dynamic Therapy Techniques. Seven Leaves Press.
Jacobson-Hendel, H. (2018). It’s Not Always Depression: Working the Change Triangle to Listen to the Body, Discover Core Emotions, and Connect to Your Authentic Self. Spiegel & Grau.
Powell, B., Cooper, G., Hoffman, K., & Marvin, B. (2014). The Circle of Security Intervention: Enhancing Attachemnt in Early Parent-Child Relationships. Guilford Press.
Rousmaniere, T. (2019). Mastering the Inner Skills of Psychotherapy: A Deliberate Practice Manual. Gold Lantern Press.
- Self supervision is done with video of a client session. Therapist watches the video and analyzes her responses to determine if she was asking for a feeling, regulating anxiety, helping patient to see and let go of a defense, or just intellectualizing or reflecting back what the client said (Frederickson, 2018, Facebook post on self supervision steps).
2. Therapist efforts, also with video of client sessions, to develop the inner skills and psychological capacity, i.e. to see their own experiential avoidance in real time, and work on engaging the client in the presence of experiential avoidance (Rousmaniere, 2019).