We are always filtering the data out patients share with us through the lens of our training and previous experiences. We would not be very functional if we didn’t. 

I have noticed a pattern in trainees where perceptual flexibility is sometimes lacking and they too quickly assume things about what happens in the clinical encounter. 

Let me give an example:

A colleague describes a patient who says he fears being judged by the therapist unless he goes along with the therapist’s agenda. The colleague responded to the patient by saying something to this effect:

“So you are now seeing me as a judge, and it’s getting in the way of us connecting and the help you want. Would you like to see what’s behind this judge that you bring in between us so you can get the help you need?” 

This can be an excellent intervention, but my colleague sprung this intervention onto the patient at the first sign that the data called for this intervention. As always, the measure of a good intervention is how the patient responds, and this patient at this juncture was not receptive to this intervention (at a different juncture, the patient may well have been receptive and responded with openness). 

My colleagues’ intervention reasonably assumes  that the patient is in projection, and the rationale seems to be to help the patient see that he is projecting by explaining this to the patient, and then inviting the patient’s will to let go of the projection and look at what is behind it. 

First of all, by not carefully inquiring into the nature of the patient’s communication, what appears to likely be a projection is actually reinforced — the therapist actually comes across as assuming he knows what is going on for the patient, which is akin to pre-judging them (even if this assumption is correct, it may still not be the best way to de-activate the projection). 

Consider an alternative. 

First, not categorically rejecting the patient’s view that he may be judged. 

Th: In what way do you think I would judge you, and for what? 

— Already by taking an interest with an open mind, projective processes are mitigated, as a judgmental person is not likely to take such an approach of genuine interest and open-mindedness. 

Pt: Like you’ll be disappointed in me if I don’t do the right thing in here. 

Th: I am not immune from being disappointed in my patients when they don’t reach their goals — it’s a real possibility that I could feel that way. But if I am, what would that mean to you? Why is that on your mind?

Pt: I really don’t like it when people are frustrated with me, or disappointed in me. 

Th: I understand. Are you thinking that if I were to be frustrated with you or disappointed in you, that I would think less of you, or be less interested in working with you?

Pt: Let me think. I think I may have been worried about that, but as I get to know you a bit better, I actually don’t think you would, though at some kind of non-rational level I still dread the idea that you could. 

The projection is becoming ego-dystonic and reality testing is shored up (assuming the therapist would not think less of the patient). 

Th: I appreciate how forthcoming you are being, it sounds like being a disappointment to others is a pretty raw place in you — would it be in line with your priorities to look at why the idea of me being frustrated or disappointed in you seems to take on catastrophic proportions for you? 

Pt: It would actually. The more I think about it, the more I realize I am actually not used to not being a disappointment to others. 

Th: Got it. Could it be that you are actually not sure how to be in a relationship without feeling like a disappointment, and if the other isn’t disappointed in you, or more precisely, not thinking less of you even if you frustrate or disappoint them, that you make the other person out to be that way in your mind?

Pt: Definitely. 

Th: Could that be a way you keep me and maybe others at an emotional distance? Because who can really get close to you when you are in that frame of mind?

Pt: I see what you mean. I never saw it that way before, but I think I do distance like that. I don’t know how else to be.

Th: Is that something you would like to address in here, so you can get the full benefit of our work — for your sake, not for my sake? 

Pt: Yes I want to do that, but even as I am clear on that, I notice a part of me feeling the need to please you.

And the patient and therapist are off and running. 

In this, what might be termed ‘relational’ way of working, we first leave room for the idea that there could be truth to the patient’s view — we really may be disappointed in them, and second, we explore if this means that the patient believes we would devalue them or think less of them as a result. The patient might say, “No, I don’t think you would do that,” in which case this was not much of a projection at all, but  a realistic assessment that the therapist indeed has feelings and preferences for how the treatment will go.

But even if the patient’s concerns are founded on defensive processes (projection, displacement, transference, etc.) — consider which approach is more likely to undo the defenses, build rapport, yield clarity, and further the treatment? Explaining that the patient is projecting a judge, or taking steps to make sure we do not come across like a judge by exploring the details and nuances of the patient’s communications and state of mind? 

It comes down to perceptual flexibility — not necessarily jumping to an intervention when a certain wire is first tripped, but staying open to explore the meaning of the patient’s experience, acknowledging that indeed we may have feelings and be disappointed — distinguishing between being disappointed and writing off the patient — and ultimately undoing projective or transference dynamics not by explaining them to the patient, but by being different from those projective processes, while learning more about the details of the patient’s state of mind through open-ended investigation.  

This relational stance requires the ability to hold space for not knowing, thoughtful self-disclosure (or ‘use of self’), and prioritizing an investigative spirit over trying to get the patient to be different. 

Author: Johannes Kieding

I have a passion for practicing ISTDP informed psychotherapy and I enjoy writing about it. For more information and what I do, visit my website: www.johanneskieding.com