Depression and superego resistance

How to understand the driving force behind syntonic defenses that demand suffering and will undermine treatment efforts. Only once you understand WHY the patient seems to need to suffer can you devise a treatment strategy to address it. Do they get secondary gains from being depressed and helpless? Are they identified with a depressed parent? Are they punishing themselves for guilt over real or imagined harm done? Do they need to defeat you? Ultimately, it is response to intervention that will tell you if you are on the right track. However, we are not omnipotent and no one can successful treat everyone. It may be that the patients "addiction to suffering" (Goethe) is far greater than their desire to heal and you must accept this fact - letting the patient go.

[@micheller6804]

This really hit home. Thank you for sharing your insights.

[@lenavoyles526]

I recently heard it mentioned that self-criticism can actually be a self-soothing technique in someone who had a critical mother. The critical attitude has actually become an attribute of the internalized “good mother”, so the criticism invokes the comfort of the initial attachment bond. Everyone I have worked with who has a very critical Super Ego also reported growing up with a critical mother. Perhaps sometimes our definition of what it means to “get better” could be a little different from the definition held by the person we have set out to help. Food for thought. I really appreciated the caution about “the collusive alliance” - it’s very useful to be encouraged to watch out for that.

[@patriciacoughlinphd1852]

It is not always the case that elf criticism is a manifestation of identification with a critical mother. I have seen cases I which kids were raised by very laid back parents also have this tendency. We must assess the source rather than assume it's simply a matter of identification and internalization.

[@elisabethgusdal5435]

Great post Patricia!

[@MrChronos1971]

You and Dr Abbass are brilliant. I enjoy both of your lectures and books. I had to rewind to hear you, "maintains the bond", so true, my late mother was always depressed, and I find myself slip into the same around holidays and her birthday, death anniversary, even 19 years later. I can see that being the reason why...

[@patriciacoughlinphd1852]

Thanks for your comment. That is a huge loss. I hope you let yourself grieve, rather than just slipping into depression.

[@MrChronos1971]

@@patriciacoughlinphd1852 many time, in ISTDP therapy and out. Just seems to get harder ever y year instead of easier. Thanks for asking.

[@SevenRavens007]

I have found that very often my depressive clients are also actively using substances. I began to realise, with one, that they really wanted to solve all their problems but keep using. So I realised that until they quit their addiction, I was merely colluding with it by trying to treat their depression. My colleagues and I had a good discussion on whether to first tackle addiction and THEN depression. I think one should, really.

[@patriciacoughlinphd1852]

Agreed

[@Native_love]

AWESOME!!! I appreciate your effort to educate and help others!

[@patriciacoughlinphd1852]

My pleasure.

[@yvindschjelderup7906]

Very helpfull, thank you.

[@beaniegirl55]

Yes this is something that I realised from my last session that I have an addiction to hurting myself

[@patriciacoughlinphd1852]

Hope you are able to turn this around.

[@yojohnyyo]

You quite literally hit the nail on the head with describing me. I just hope I can actually apply these lessons in the moment when I need to embody them...but that's the superego trying to resist, right?

[@patriciacoughlinphd1852]

Not sure about that. If you are conscious of guilt about wrong doing you have the option to repair the damage. That is goof for you and the person you have wronged.

[@valeriakontogianni4031]

Hi Patricia, thank you for sharing your knowledge and experience. Wonderful channel. A quick question- in your example your describe a man who has conscious guilt about things that he did that feed his need to self punishment and resistance to treatment - if I understand the process correctly there would also be the unconscious guilt? Or addressing conscious guilt in some cases can be enough to deactivate PSE?

[@patriciacoughlinphd1852]

I actually find that the opposite is true. Once patients experience their previously unconscious rage and guilt they realize how they have been unconsciously expressing this rage in their life and feel real guilt about having been destructive to others. Behavior that was previously minimized and rationalized is now seen for what it was - hostile and meant to cause pain to others. I find the real guilt about actually wrong doing is often even more painful to face and results in substantial change. Patients in ISTDP often become a healing force in their families and commnunities. They are motivated to repair and contribute.

[@rikkehvelplund1920]

Tank you for this post. “The addiction to suffering is the hardest to break”. Who Said that?

[@patriciacoughlinphd1852]

Goethe

[@lenavoyles526]

I just had another thought that might be helpful to the group here. What if in some instances the “I’m a hopeless case” mantra is just a request for co-regulation? What if it is the desire to lay down all responsibility for one’s feelings for a little while and simply be regulated by another human in a way that this person did not get to sufficiently experience as a child? A kind of regression, but maybe not to childhood as it was so much as childhood as it should have been? Obviously as a therapist you can’t get stuck mothering someone forever, but maybe there could be a way to work constructively with that unfulfilled attachment need (assuming it exists) in a way that ultimately leads to the maturity and autonomy that we would consider beneficial.

[@patriciacoughlinphd1852]

This has been tried and tried but is rarely successful. Helping the patient develop their own capacity has a lot to recommend it.

[@ejinchina4630]

Please do a video about patients who literally cannot name their feelings and don’t know what feelings are.

[@patriciacoughlinphd1852]

OK

[@mahsaabbasi4790]

Hi Dr. Coughlin Thanks for your explanation. I had a question about this video: When a patient enters a therapy session for any reason, doesn't it mean that she/he has at least an unconscious therapeutic alliance?! I think it is true that working with ego syntonic patients is difficult, but it is still possible to be aware of the therapeutic alliance and turn them into consciousness…is that true?

[@patriciacoughlinphd1852]

Whether the patient has come to see you of their own will and for a therapeutic reason has to be assessed, not assumed. Perhaps they are under pressure from a loved one or are required to seek help from an employer. The therapist must work, in such situations, to ascertain whether the patient has concerns of their own. If not. you are working for someone else! Patients can also come to therapy for reasons that are not healthy - like getting support for their victimhood or getting someone off their back, "I'm in therapy, aren't I?" Your first job is to get agreement about the problems to be addressed and the goals to be achieved. If you are not able to gain consensus, there is no basis for therapy.