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Lilia Graue, MDLilia Graue, MD

Hi Becca, thank you for sharing these thought provoking reflections and case.

I have some notes from the EAET & ISTDP training I thought I’d share.

From the EAET training:
A consideration about the “right emotion”, ie what’s appropriate for the situation, and looking for two possibilities:
– secondary (defensive) anger is not the “right”/core emotion, but it is blocking hurt, sadness, connection
– anger is the “right” emotion but at the wrong target
Encourage the person to explore if there is a part of them that feels angry, guilty, ashamed, sad, longing for connection.

From the ISTDP training:
Allan Abbass was very emphatic about the fact that “it’s not about the rage, but about the guilt over the rage” – we feel guilty and/or ashamed that we feel such anger or rage, because we’re good people and we don’t really want to hurt our loved one, even though they might have hurt us. There is guilt laden rage because of attachment. It is really important to keep bringing back the guilt every time the rage arises to protect the patient. He elicits rage and the wish to act it out and then the guilt that the person experiences from having hurt someone in this imaginary scenario, so he’s not encouraging murderous rage or even catharsis, just making space for the complexity of it all. He surfaces how there is a part of the patient that responds somatically to the feeling as though it was the same as the action. And when the activation/anxiety goes up, he goes to recap and reflecting, he doesn’t keep pushing. He helps patients connect to the awareness that they’re a good person, and highlights the need to keep the love and positive feelings in there as well.

He deliberately acts in ways that are mildly irritating for the patient throughout the session, at the same time as building a strong therapeutic alliance to elicit the full range of emotions in the patient, so that anger/frustration will surface in the relationship in real time and it can then be worked with (engaging transference to work with emotions in the context of the therapeutic relationship), at the same time that there is appreciation for the fact that the therapist is there to support the patient in finding freedom from symptoms. He stays steady, careful to keep the patient safe and not push beyond threshold, while at the same time not shying away from anything and staying calm.

Something that has been very clear to me from observing therapists skilled in ISTDP and EAET is that they are incredibly comfortable and skilled in welcoming and handling conflict and frustration, particularly in the context of the therapeutic relationship.