סיכום מפגש למידה מספר 4 - הבניית הגנות רגרסיביות ויצירת מיקוד פנימי במטופל עם מבנה אישיות גבולי

במוצאי שבת, 5.3.2022 נפגשנו 60 מטפלים מכל העולם ללמוד ממקרה של ג'ון פרדריקסון עם מטופל בן 48, מכור לסמים לשעבר, הומוסקסואל אשר עדיין לא יצא מהארון, אשר נמצא בטיפול במרכז לגמילה מסמים, היה הומלס בעברו, מקבל תרופות אנטי פסיכוטיות ולא מצליח להשתתף בקבוצות במרכז הגמילה מחשש שאחרים ישפטו אותו.

בטיפול הראשון עם ג'ון פרדריקסון אשר נמשך שעתיים ראינו יחד כיצד ג'ון מנווט בין מאות הגנות אשר קפצו על המטופל בכל רגע ורגע בטיפול ולא נתנו לשניהם לעבוד ביחד. כאשר מטופלים סובלים מכל כך הרבה הגנות וחרדה, יצירת ברית טיפולית וברית עבודה בריאה היא צעד קריטי (כמו בכל טיפול) אך כל כך קשה. מצד אחד המטופל הצליח להרגיש חלק מהרגשות שלו, אבל מצד שני כל כך הרבה הגנות והשלכות פעלו שהרגשות לא יכלו לעלות באופן משמעותי.

העבודה בהבניית הגנות רגרסיביות היא עבודה קשה עד מאוד, ויש לעשות אותה בסבלנות, באופן שיטתי, לאט ובהתמדה כאשר מזמינים רגשות ועוקבים אחר ההגנה והרגשות אשר עולים כדי להבנות מחדש את נתיבי פריקת החרדה וההגנות.

הבניית ההגנות מחדש היא עבודה קריטית, לכל הגנה ובמיוחד להגנות רגרסיביות. ראינו איך ג'ון התחיל את הטיפול במיקוד על החרדה והפחתת החרדה לשרירים הרצוניים והפחתת ההשלכה עליו, ואיך לאחר שעה ורבע של טיפול, לאחר שהמטופל עמד בפני דמויות מעברו והרגיש כעס כלפיהם, ניתן היה לראות איך ההשלכה חזרה ושוב איימה להלך אימים על הטיפול ועל הקשר הטיפולי.

אז ג'ון בעדינות יתרה הסיט את המיקוד לעבודה על המבט בעיניים, התמקד באפשרות של המטופל להביט בעיניו, לראות את עיניו, ולראות בעצמו מה הוא רואה בעיניו, במקום להמשיך להתייחס לדמות אשר הוא שם עליו ועל אנשים בחייו. ואיך באמצעות המבט בעיניים, חזרה על ההשלכה ועל היכולת של המטופל לראות איך הוא שם שופטים על אנשים אחרים בחייו לרבות עם ג'ון - המטופל הצליח לסיים את הפגישה עם מיקוד פנימי! אני רוצה להיות אני! מרגש. אני מניח כאן קטע מהטיפול.

תודה רבה לכל המשתתפים ונתראה במפגש הבא בחודש מאי!

Th: And as you look in these eyes, are these eyes accepting your feelings? [Inviting him to compare the reality of my eyes with the fantasy of his projection.] Pt: You make me feel comfortable. [He is less anxious, but he does not answer whether he sees my eyes accepting him = defense.] 42 Th: By these eyes accepting your feelings, yes? And can we accept your feelings together? [Mobilize him to the therapeutic task in a way that counters his projection.] And what do you notice feeling as we make this choice to accept your feelings together? [Invite him to notice the rise of feelings and anxiety when we collaborate. Collaboration is healthy. The feelings and anxiety are simply the history of his suffering: what happened when he tried to collaborate in the past.] Pt: What am I feeling? Th: Yes, as we see these eyes accepting your feelings? [Inviting him to compare my face with his projection.] Pt: Comfortable. [Stroking fingers: anxiety] Th: So let’s just notice what you’re feeling as you see these eyes that are accepting you? [Inviting him to compare my face with his projection.] Pt: Trust, honesty. [Laughs: anxiety] Th: What do you notice feeling as you see these eyes trusting you and accept your feelings? [Inviting him to compare my face with his projection.] Pt: What do I notice? Th: What do you notice feeling as you see these eyes? [Inviting him to compare my face with his projection.] Pt: Relief. [Drop in anxiety due to the projection] Th: That you and I can accept what you feel. Pt: I feel relief. Th: Yes and how do you experience these feelings, this relief, as you and I accept you (patient has big smile) just as you are? [Inviting him to compare my face with his projection.] Pt: I can excel. Th: What do you notice sensing as you and I make this choice to accept you as you are? [Inviting him to notice his feeling as we engage in the therapeutic task without the projection between us. We want him to notice that I am not the same as his projection and to notice what he feels when he is in relation to me.] Pt: I mean a little nervous but more relaxed. Th: So just notice this because this is really important [Patient’s brows furrow], that as you and I make this choice to accept you. We have this old information in your body come up, this nervousness. It’s almost as if an alarm bell goes off as if it would be dangerous for you and I to accept you, right? [Clarify causality.] Pt: Right. Th: So let’s just notice that, as if it would be dangerous for you and I to accept you the way you are. Isn’t that wild? Pt: Yeah. [Clasps hands in front of face] Th: So it’s just really important as we are noticing that that feels a little risky to just make this choice, you and I to accept you now and to just notice that now. And do you notice the alarm bell going off right now as we make this new choice right now? [Help him observe this pattern in the here and now.] 43 Pt: Uh hum. Th: Isn’t that fascinating? Pt: Uh hum. Th: Yes and what’s it like to notice how this old information comes up because it’s like a policeman comes in? [Patient laughs] It’s like a policeman comes in and tasers you with it. ZZZZZt. It tasers you because it’s against the law for you and I to accept your feelings, to accept your feelings together. Do you notice that too? [Clarifying causality] Pt: Something like that. Th: So are you willing to break the law yet? [Inviting him to let go of the defense and engage in the therapeutic task. Inviting him to “break the law” helps him differentiate himself from his defense.] Pt: Yeah [Smiling, chuckles], yeah, in this sense. Th: Yeah, for you and I to accept all your outlandish feelings every one of them. What do you notice feeling as you make this choice together with me to break the law and except to accept all your feelings no matter how outlandish they are? [As soon as he lets go of his defense of self-judgment, feelings and anxiety will rise. So I invite him to notice them to build his self-observing capacity.] Pt: There’s a little fear there. Yeah, there’s a little fear. Th: So notice how the policeman comes in and tasers zzzzt, zzzzzt, right, as if it is against the law for you to take accept you as you are. [Clarifying causality in the here and now.] Pt: Police is like, stopping me from doing what I’ve got to do for me. Th: Even on a basic level, this policeman comes in and attacks you as if it’s against the law for you to accept yourself the way you are. And it comes in to attack you as if it’s against the law for you and me to accept you together. [Clarifying causality in the here and now.] Pt: Ok. Th: As if it is against the law for you and I to have an accepting relationship. Pt. Yeah. Th: What do you notice feeling as you notice that? That as you notice that policeman coming in to command. Policeman comes in and says, “Okay, break it up you guys”. [Inviting him to compare my face with his projection.] Pt: Stops me. Yeah he stops me. Th: How wonderful that you could notice that. And what do you notice feeling as you are able to see that, how that policeman comes in to stop us? [Inviting him to compare my face with his projection.] Pt: How, how could he do that? How could he do? Th: That it’s just a habit. It’s not like you try to avoid it. It’s not like you wake up in the morning and say, “Make sure not to accept my feelings today.” Right? Pt: Yeah. I feel, “Damn him. How dare you do that!” [The patient sees the defense of self-judgment more clearly and sees that I am not judging him.] 44 Th: How dare he do that! Exactly. So would it be fair to say that this policeman is like your enemy? [Help the patient differentiate himself from his defense of self-judgment.] Pt: Yeah. Th: Yeah, so this policeman just keeps giving you false information. Pt: Yeah, as if he doesn’t want to see me get better. [The patient has a clearer sense that his conflict is internal, within himself, rather than between him and me.] Th: And he doesn’t want to see you accepting your feelings. Pt: Yeah. Th: Yeah. He doesn’t want to see you accepting yourself as you are, and he doesn’t want us to do that. Pt: He wants me to carry around all the bad stuff, and not get better. Th: And would you like to accept your feelings? [Mobilize his will to the therapeutic task.] Pt: [Pause] Yeah