Distinguishing between externalization, projection and transference

0:00 hi everybody patricia coghlan wishing you a happy new year i've taken a bit of a break here um with everything going on in this country all the turmoil i've really felt so preoccupied that it's been difficult to think about getting on here and posting something but i'm hoping that in two days biden will be inaugurated in a peaceful manner and we can begin to come together if anything has taught us

0:46 how essential it is to come together in order to heal it's the coronavirus right as long as we keep asserting our individual rights i'll do whatever the hell i want the virus will continue to spread and so we really have to do this together so speaking of being together i was thinking that what i could offer today is something around the diagnostic significance of accurately assessing the nature and tenacity of a patient's defenses in istdp

1:33 i think people have become so focused on anxiety and just looking for signs of striated anxiety the sigh the hand clenching that they're almost using a single data point to decide when and how to intervene and obviously things are much more complex than that and so what i'm finding is as soon as somebody sees that sigh or that anxiety they're jumping to feeling even when the patient is deeply ensconced in defenses and really require defense restructuring before they can gain any significant access to their feelings and i wanted to talk about distinguishing between

2:20 externalization projection and transference somehow these are getting muddled up and why is it important right what we call something i mean especially the word projection it's used all the time in common discourse you know don't project that onto me you know people are very people who've never read freud or had a psych 101 are using those kinds of terms so are we using it colloquially are we using it sort of in a philosophical manner right some people will say everything is a projection

3:07 uh there is no objective reality um so it's all a hologram or something or other right or are we gonna stick to our prof the terms as they have been defined in our field starting with anna freud true projection what we might call a capital p projection by definition involves distortions in reality testing the person is seeing an unacceptable part of themselves right so a part of themselves that they are utterly denying and then projecting out and seeing it in the other person

3:54 so and and they really believe it so if you have a patient who is truly paranoid they believe you are a threat they believe you are there to hurt them it's not just you know a thought of what might be oh i'm thinking you might judge me um is very very different and of course it matters because these have diagnostic significance if someone is truly paranoid and actually projecting onto you um that first of all indicates a severe level of pathology and the existence of that kind of defense is going to preclude a working therapeutic alliance and something's going to have to be done

4:39 about that before you could even get to work so much more often we're talking about externalization uh patients who simply externalize the cause and solution to their problems or they're spending their time again talking about other people and theorizing about what might be going on with them again this is extremely common and is not necessarily a sign of severe pathology i had an example just last week of a woman who's you know quite well put together absolutely no evidence of any fragility or uh anything but she was talking about the recent holidays and how her mother

5:26 who's elderly had decided not to come to her house for the holidays and she kept going on about what she imagined right but sort of you know knew she says and i know she told me right it was because of covid and concerns about health and safety but i know that she really didn't want to come to my house because she's never preferred me and she really wanted to be with my brother and all of this so again understanding what that is which is externalizing the problem then helps you what's your therapeutic task it's to block that and to see if you can create an internal focus so

6:12 you know i said actually we have no idea what motivated your mother all we know is that she said no i'm not gonna come right so if we just look at your feelings towards your mother instead of theorizing about what her motives might have been you know is that going to be helpful to you is that why you're here right to deal with your own feelings because again warded off feelings will lead to uh these kinds of uh you know they end up being destroyed they're big stories you know and human beings are meaning making machines we're storytellers so just because someone is mind mapping right and and trying to imagine the internal state of the other um doesn't mean that they're projecting

7:00 something in them that they're denying right they're just trying to figure out right what's going on the other person but there's no way for them to know and spending time in your therapy wondering about that is not likely to lead to uh much progress so again that is easily just blocked right we really have no idea of your mother's internal state or her motives what we know is that she said no to your invitation and you have feelings about that is that what we can look at okay and it's also very important to be able to tell the difference between a patient projecting let's say they're angry at you because you took a long vacation and

7:48 they're really not aware of that and they start to indicate that they're worried you might be angry with them um the real issue here is you know again is this projection or transference right depending on what they're saying if they say you know i think you're judging me um i might ask you know where is your evidence for that in what way have i judged you and sometimes people might say well you know you said i was looking away you said i had my arms crossed and i said well those things are true right those are simply observations you're looking away and your arms are crossed right that's not a criticism

8:37 you know you're a stupid idiot is a criticism right so the fact is i'm making observations and it looks like you're having an emotional reaction to that so again in your clarifications there in your questions it's the response the patient's response to that intervention that's really going to tell you again whether this is some transference right really that you are representing they're seeing you as somebody else seeing you as mother father brother right or whether they're projecting their own disavowed feelings right that's a big difference right that i'm projecting my anger into you

9:24 or i'm seeing you as somebody else and you're going to deal with those differently so i think it really is important to ascertain through your inquiry whether the person is externalizing projecting or is experiencing a transferential reaction again these have diagnostic significance but they also are going to lead to different interventions on your part okay so i i hope this helps to start to make some distinctions i'd really welcome your questions and uh comments so again happy new year and i look forward to having more conversations this year bye-bye