“How can I be sure that the patient’s emotional reaction is a feeling to be explored or a defensive affect to be blocked? When I asked the patient about feelings toward a dismissive father, she said anger. But when I asked how she felt the anger, she started crying and felt sad. I thought her sadness was a defensive affect, making her depressed (her main symptom). So I tried to help her become aware of this defense and face her anger.
My supervisor was puzzled by this observation. He didn’t know the concept of defensive affect. He said I should have explored the sadness rather than a defensive anger. I thought this would reinforce a defensive affect and suppress her true feeling toward her father. I’m still confused.” Thanks to Alessandro for sharing this important question!
True feelings bring us closer, thus they trigger anxiety and defense. Why? Emotional closeness led to pain and hurt in the past. A defensive affect, since it functions as a defense, triggers no anxiety or defense. So we watch for signaling. When you explore a feeling, does the patient’s anxiety or defense rise? If so, it is a true feeling. If not, then it is a defensive affect. Simple. So let’s get complex!
The patient reported feeling angry toward her father. Rather than elaborate on her anger, she shifted to sadness and cried. The sadness, a defensive affect, covers or washes away her anger. And this defensive affect will make the patient depressed. Address it right away.
Th: “Notice how these tears come in to wash away your anger? Could we put the tears to the side and take a look at the anger underneath those tears?” [Help the patient see the defense and invite her to look at the feeling underneath that defense.]
When patients have feelings, they can resist those feelings in several ways:
Isolation of affect: “I think I’m angry because he is a jerk.
Th: That’s your thought, how do you experience this anger toward him?
Projection: “I think you are angry with me!”
Th: What is the evidence for that?
Repression: I’m such an ungrateful daughter.
What would you say?
With isolation of affect, the patient detaches from her anger. She knows she is angry but not how she feels it.
With projection, the patient does not see she is angry. She thinks you are!
With repression, the patient turns anger onto herself through teariness, depression, conversion, or self-attack. Then she quickly becomes depressed, as we saw in the case example. In this case, we use a different intervention to address repression specifically.
Th: Notice how these tears come in to cover up your anger? Could that be making you depressed? Could that be hurting you? Could we take a look under the sadness? What feelings were coming up here toward me that could be under the sadness?
Why did I bring the therapist in? The patient describes her anger in front of the therapist. As she does so, she becomes more intimate with him than with most people in her life. This raises feelings toward him. As these feelings rise, some patients protect the therapist by repressing those feelings through self-attack.
Thus, we identify the defense and ask for feelings toward the therapist. Now her feelings can go outward rather than back onto herself. She will not know initially what her feeling is since she has been focused on the sadness. However, after five or six times of asking what the feelings are toward you, the patient’s weepiness and depression will drop, and she will become more tense with anxiety in the striated muscles.
Right before your eyes she will feel better, look better, and sound better. When you work with highly resistant patients with repression, this intervention is essential: identify the self-attack then focus on feelings toward you. If you don’t, the patient will remain weepy, depressed, and sad. She will not feel better.
Now the final problem: the supervisor had not heard of defensive affects and did not recognize repression. In this day and age, we are often taught within intellectual silos otherwise known as psychotherapy schools. As a result, we may not read books outside of our specialized area. This cripples us because we don’t experience the intellectual biodiversity that is essential for complex scientific thinking. Even if your supervisor has not read about defensive affects or repression, you can. Go out there, read, and get some good supervision.
A recent study found that 93% of psychotherapy supervision is inadequate and 35% harmful! In order not to become part of that cohort, read widely and deeply. Get the best supervision you can find. I was in individual supervision for 25 years, and I still show my videos to colleagues for help and supervision. Learning is a lifelong journey.
Hint: there is an entire chapter on defensive affects in Co-Creating Change: Effective Dynamic Therapy Techniques, available at http://www.istdpinstitute.com