Co-Creating Change

1. Suffering: A Choice Forged by Defenses.

The pain of loss, illness, and death is inevitable, but suffering from our defenses is optional—if we learn to see and turn against them.

Pain is inevitable. Life inherently brings pain through loss, disappointment, and mortality. We all face situations where loved ones may disappoint, delay, or depart, and our desires clash with reality. This fundamental conflict between desire and reality is a source of pain.

Defenses create suffering. To avoid this inevitable pain, we unconsciously employ defenses. These defenses, while offering temporary relief from discomfort, distort our perception of reality and prevent us from dealing with it effectively. This avoidance, rather than the pain itself, is the true source of our suffering and symptoms. For example:

• Self-critical thoughts lead to depression.
• Avoidant behaviors sabotage relationships.
• Rationalizing abuse traps individuals in harmful patterns.

Ending self-inflicted suffering. The core task in therapy is to help patients recognize how their automatic, unconscious actions (defenses) perpetuate their suffering. By understanding this causality, individuals can choose to relinquish these self-defeating patterns and engage with reality more adaptively, transforming their lives.

2. The Triangle of Conflict: Unmasking the Roots of Distress.

Every conflict creating the patient’s symptoms has this form: (1) the patient has a feeling, (2) he automatically becomes anxious physically in his body, (3) a moment later he uses a defense to ward off that feeling, and (4) that defense creates his symptoms and presenting problems.

The causal chain of suffering. This "Triangle of Conflict" illustrates the dynamic process underlying all psychological symptoms. A stimulus from reality triggers a feeling, which then activates anxiety in the body. To cope with this anxiety, a defense mechanism is deployed, and it is this defense that ultimately manifests as the patient's presenting problem or symptom.

Understanding the sequence. Consider a woman whose fiancé verbally abuses her.

• Feeling: She feels anger.
• Anxiety: Her body becomes tense, heart races, etc.
• Defense: She rationalizes ("He's stressed"), minimizes ("It's no big deal"), or turns anger on herself ("I deserved it").
• Symptom: Depression (from self-attack) or repeated abusive relationships (from minimization/rationalization).

Therapeutic intervention points. The therapist's role is to identify where the patient is in this cycle. If the patient expresses a feeling, it's explored. If anxiety is too high, it's regulated. If a defense is used, it's identified and addressed. This systematic approach helps the patient break free from automatic, self-defeating patterns.

3. Psychodiagnosis: The Moment-to-Moment Compass for Healing.

Moment to moment, the therapist assesses the patient’s responses of feeling, anxiety, and defense.

Continuous assessment is key. Psychodiagnosis is not a static label but a dynamic, ongoing assessment of the patient's responses in real-time. Every word, gesture, and physiological shift provides crucial information about the patient's internal world and guides the therapist's next intervention. This is the foundation for effective, targeted therapy.

Three core responses. In any given moment, a patient can respond to an intervention in one of three ways:

• Feeling: A clear expression of emotion, deepening the alliance.
• Anxiety: Physiological activation, signaling rising unconscious feelings.
• Defense: A mechanism to avoid feelings or anxiety, weakening the alliance.

Tailoring interventions. The therapist's assessment of these responses determines the immediate therapeutic action. If a feeling is expressed, it's explored. If anxiety is excessive, it's regulated. If a defense is present, it's identified and addressed. This precise, moment-to-moment responsiveness ensures that therapy remains focused on the patient's most pressing internal conflict.

4. Co-Creating the Alliance: A Deliberate Partnership for Change.

To co-create a therapeutic alliance, we mobilize ingredients in a specific order.

Beyond passive presence. A therapeutic alliance is not simply assumed when a patient attends sessions. It's an active, collaborative partnership built on specific, sequential ingredients. This deliberate process ensures both patient and therapist are aligned on the purpose and direction of the work.

Essential ingredients for alliance:

• Declared Internal Emotional Problem: The patient must articulate a personal, emotional issue they want help with, not just external problems.
• Patient's Will to Work: The patient must genuinely desire to engage in the therapeutic process, not be coerced or passively present.
• Specific Example: A concrete instance of the problem allows for focused exploration of the underlying conflict.
• Consensus on Intrapsychic Conflict: Both patient and therapist agree on the specific feelings, anxiety, and defenses causing the problem.
• Consensus on Therapeutic Task: Agreement on the active steps the patient will take: turning against defenses, facing fears, and experiencing warded-off feelings.

Addressing resistance to alliance. Patients often present with resistance at each stage, stemming from past relational hurts. The therapist must identify and address these resistances—whether they are denial, projection, or vagueness—to ensure the alliance is strong enough to support deep emotional work. Without this foundation, therapy risks becoming unfocused and ineffective.

5. Anxiety: Understand Its Pathway to Regulate and Heal.

When anxiety goes into the smooth muscles or cognitive/perceptual disruption, stop exploring feelings and regulate the anxiety until it returns to the striated muscles.

Anxiety's physiological manifestations. Anxiety is not a monolithic experience; it manifests through distinct physiological pathways, each signaling different levels of emotional tolerance. Recognizing these pathways is critical for effective intervention:

• Striated Muscles: Tension, sighing, fidgeting. Indicates the patient can tolerate higher levels of feeling.
• Smooth Muscles: Nausea, stomach cramps, migraines. Signals the patient has exceeded their anxiety tolerance.
• Cognitive/Perceptual Disruption: Blurry vision, confusion, blanking out, dissociation. Indicates severe anxiety impairing cognitive function.

The graded format for fragile patients. For patients whose anxiety quickly escalates to smooth muscle or cognitive disruption (often termed "fragile"), a "graded format" is essential. This involves:

• Stopping the exploration of feelings immediately.
• Focusing on regulating the anxiety until it subsides to the striated muscle level.
• Cognitively summarizing the sequence (feeling -> anxiety -> symptom) to build awareness.
• Then, cautiously re-engaging with feelings, often in a less intense context.

Preventing regression. Ignoring high anxiety can lead to regression, where patients lose reality testing, project, or develop severe physical symptoms. By actively regulating anxiety, the therapist prevents harm, builds the patient's capacity to tolerate emotion, and ensures that emotional work can proceed safely and effectively.

6. Defenses: Unconscious Habits That Perpetuate Pain.

Since defenses happen unconsciously, a patient cannot see them without the therapist’s help.

Invisible architects of suffering. Defenses are automatic, unconscious patterns of behavior learned early in life to cope with threatening feelings or situations. Because they operate outside awareness, patients often mistake their defenses for inherent personality traits ("That's just the way I am"), making them difficult to relinquish without therapeutic guidance.

The three-stage defense work:

1. Identification: The therapist points out the specific defensive behavior in the moment (e.g., "Do you notice you're intellectualizing?").
2. Clarification: The therapist helps the patient understand the defense's function (what it avoids) and its price (how it causes suffering or sabotages goals).
3. Confrontation: Once the patient sees the defense, its cost, and differentiates from it, the therapist challenges the patient to choose between the defense and their healthy goals.

Compassion in confrontation. Interrupting defenses is an act of compassion, as these patterns are the root of the patient's symptoms. The goal is not to strip away coping mechanisms but to help the patient replace maladaptive, unconscious habits with conscious, adaptive actions, fostering genuine self-awareness and freedom.

7. Superego Pathology: Breaking Free from Internalized Aggression.

The patient who turns rage on themselves usually suffered from a traumatized bond in early life.

Internalized aggressors. Superego pathology refers to defenses rooted in pathological identifications, where patients unconsciously treat themselves (or others) as they were treated by aggressive early caretakers. This often stems from a child's need to preserve a jeopardized attachment by turning forbidden rage inward, leading to chronic self-punishment.

Manifestations of superego pathology:

• Judging Oneself (Character Defense): Self-criticism, self-hatred, self-denigration ("I'm stupid," "I don't deserve good things").
• Judging Others (Transference Resistance): Projecting one's own judgment onto others, becoming critical or contemptuous of them.
• Projection of the Judge: Imagining others are critical or punitive, leading to fear or defiance of these perceived external judges.

Restructuring identifications. Therapy aims to help patients differentiate themselves from these internalized aggressors. By mirroring the pathological logic or behavior, the therapist helps the patient observe these destructive patterns as external to their true self. This process allows the patient to reclaim their agency and direct their rage appropriately, rather than perpetuating self-abuse.

8. Transference Resistance: Unlocking Past Relational Patterns.

The highly resistant patient avoids his feelings toward the therapist by using repressive, tactical, and character defenses.

Enacting the past in the present. Transference resistance occurs when a highly resistant patient, to avoid intense feelings towards the therapist, unconsciously enacts a past pathological relationship. This isn't just about individual defenses; it's about a systemic pattern of relating that keeps the therapist at a distance.

Structure of transference resistance: The patient adopts one role from a past relationship (e.g., passive child) and implicitly invites the therapist to take the complementary role (e.g., active, omnipotent parent). This creates an interpersonal conflict that deflects from the patient's internal struggle. Examples include:

• Passive/Helpless: "I can't do it," inviting the therapist to "carry" them.
• Oppositional/Defiant: "I don't want to get better," inviting the therapist to "fight" for them.
• Uninvolved/Detached: "There's nothing there," inviting the therapist to "heal" an empty space.

Deactivating the resistance. The therapist must identify these enacted patterns and deactivate them by:

• Mirroring the resistance: Reflecting the patient's stance to make it observable and dystonic.
• Pointing out reality: Highlighting how the resistance sabotages the patient's own goals.
• Mobilizing the patient's will: Reconnecting the patient to their healthy desires for change.
  This process creates a "head-on collision" between the patient and their self-defeating patterns, allowing buried feelings to emerge.

9. Building Self-Observing Capacity: The Foundation for Inner Freedom.

The patient is unaware of his feelings because defenses prevent him from observing and paying attention to them.

The path to self-awareness. Many patients, especially those in the fragile spectrum or highly resistant, lack the capacity to observe and attend to their internal experiences. Building this "self-observing capacity" is fundamental, as it allows patients to:

• Observe: Recognize feelings, anxiety, and defenses in the moment.
• Attend: Sustain focus on these internal states.
• Differentiate: Distinguish feelings from anxiety, and feelings from defenses.
• See Causality: Understand how feelings trigger anxiety, which triggers defenses, leading to symptoms.
• Disidentify: Separate their true self from their defenses ("That's not who I am, it's what I do").

Step-by-step restructuring. The therapist systematically guides the patient through these stages. For example, if a patient says "I don't know" when asked about a feeling, the therapist explores why they don't know, addressing the underlying defenses (e.g., denial, emptying the mind). Visual metaphors can help patients "see" invisible internal processes.

Empowering agency. By strengthening self-observing capacity, patients gain agency. They move from being passively controlled by unconscious habits to actively making conscious choices about how to respond to their inner world, leading to genuine inner freedom.

10. Defensive Affects: Differentiating True Emotion from Avoidance.

Never explore defensive affects.

Feelings that mislead. Defensive affects are emotions that either result from or function as defenses, rather than being genuine, adaptive responses to a stimulus. Exploring and deepening these defensive affects can actually worsen a patient's condition, leading to increased depression, anxiety, or acting out.

Key defensive affects and their origins:

• Defensive Weepiness: Often covers anger or results from projections (e.g., crying over an imaginary rejection). It brings no relief and maintains tension.
• Defensive Rage: Based on projection or externalization, or used to ward off grief. It's directed at imaginary enemies, brings no relief, and perpetuates destructive patterns.
• Projective Anxiety: Fear of a projection placed on another person, not a genuine threat.

The critical distinction. The therapist must differentiate genuine feelings (which trigger anxiety and defenses) from defensive affects (which function as or result from defenses). Genuine grief, for instance, is a response to real loss and brings eventual relief, while defensive sadness is often a response to imaginary loss or a cover for other feelings.

Intervention strategy. Instead of exploring defensive affects, the therapist identifies and restructures the underlying defenses (e.g., projection, self-attack) that generate them. This allows the genuine, warded-off feelings to emerge, leading to true emotional integration and healing.

11. Breakthrough to the Unconscious: Integrating Buried Truths.

When the patient experiences this rage without defenses, unconscious rage emerges: a fantasy of killing this figure.

Accessing the repressed. After sufficient defense restructuring and capacity building, the patient reaches a point where unconscious feelings can break through. This is signaled by the patient experiencing a powerful impulse in their body (e.g., clenched fists, choking sensation) towards the figure of conflict.

The portrayal phase:

• Portray the Impulse: The therapist invites the patient to vividly imagine this impulse going out onto the person who caused them pain, in fantasy. This allows the full force of rage to be experienced and discharged symbolically.
• Face Complex Feelings: As the murderous impulse passes, a wave of painful, mixed feelings (guilt, grief, love) spontaneously arises towards the "murdered" figure.
• Unlocking of the Unconscious: The patient then spontaneously links these feelings to an earlier, formative figure in their life (e.g., a parent). Memories emerge, revealing how past, repressed emotions have driven current symptoms and behaviors.

Healing through integration. This "unlocking" allows the patient to experience and integrate powerful, mixed feelings towards original caretakers. By feeling these emotions where they truly belong, the patient no longer needs to direct them destructively in current relationships or turn them inward as self-punishment. This deep emotional experience leads to profound character change and a more integrated sense of self and others.

12. Therapy: A Courageous Act of Self-Creation.

In therapy, choosing to go against conditioning (defenses) is our continual act of self-transcendence and self-creation.

Beyond determinism. While past experiences and genetics shape us, therapy reveals that we are not merely products of our conditioning. At every moment, we possess the freedom to choose how we respond to our inner and outer worlds. This choice, to either perpetuate self-defeating defenses or embrace our authentic feelings, is an ongoing act of self-creation.

The therapist's role in courage. The therapist's unwavering persistence in confronting defenses, facing fears, and exploring deep emotions is an act of profound compassion and love. This courage inspires the patient to undertake their own journey of self-transcendence, moving from impersonal, automatic habits to conscious, intentional living.

Embracing the mystery. The patient is not their defenses, symptoms, or even their concepts of self. They are a dynamic, living mystery, constantly becoming. Therapy helps dismantle the "false self" built on defenses, allowing the true, authentic person—with their innate capacity for love, freedom, and truth—to emerge. This direct experience of one's being transforms not just who one thought they were, but who they are becoming.