03/19/2026
Why don't I feel better?
Sometimes clients say they feel good during the session, but afterward, their problems return, and they feel hopeless. As a result, they have difficulty trusting the process of therapy. Even though previous therapy tools/tips were only temporary band-aids, it was still soothing to have something concrete to work on in between sessions. So, when they're working in a more open-ended way, they sometimes feel lost and hopeless. A couple of clients have said that if not every session feels good, they doubt the process and feel hopeless. And some clients appreciate their insights from the work but want actionable steps to use that insight. Otherwise, they see the insight as useless. How do you conceptualize this in ISTDP?
What causes symptoms and problems? Defenses. So if symptoms returned after the session, defenses returned. Why? Feelings were triggered after the session. So the return of problems is a great opportunity to inquire. When did the symptoms return? What was the triggering relational event?
The patient may distrust the therapy, thinking the therapy is causing their problems. The problem is that they are trusting the defenses that cause their defenses. If they don't see the defenses and how they cause the problems, naturally, they will assume therapy is the problem. Instead, we must help the patient see the sequence of causality: a relational event triggers feelings, feelings trigger anxiety, anxiety triggers defenses, and defenses cause symptoms and presenting problems. Unless that causality is clear and EXPERIENCED in the therapy room, the patient will mistakenly think therapy is the cause, or the patient may have a cognitive insight but without an emotional insight. And then, no change occurs.
The patient wants something to work on. Wonderful! A big sign of motivation! Here are some options: "So this week, whenever you have critical thoughts or are feeling depressed, ask yourself this question: "If this anger were not going onto me, where would it go instead?" "Whenever you feel really anxious this week, ask yourself, "What happened with a person just now that would have triggered these feelings and anxiety?" "Whenever you are tempted to provoke your wife to be angry, ask yourself, "What am I feeling guilty about that is making me want her to punish me?"
You see, any therapeutic focus in the therapy room is something the patient can continue to work on during the week, if you give them the right questions to continue their self-inquiry. Remember that one goal of therapy is teaching patients how to continue their own self-analysis after therapy.
Now for actionable steps. The patient wants to know how they can do the opposite of their defenses that cause their problems. "We have seen how asserting yourself with your boss makes you anxious, and to deal with that anxiety, you do whatever he wants even though those fall outside your job description. So the next time, he asks you to rub his back, what would be the opposite of saying yes to his request?" She will, say, "No." Then you might say, "So this week, how would you like to practice saying no to him instead of yes?"
Remember: an actionable step for the patient is doing the opposite of her previous defense. And you ask her what step SHE would like to take to avoid being another boss to whom she would submit!
The patient says that insights are useless unless they lead to action. The patient is right! We come to therapy to change, not to continue suffering from our defenses. So join her! "Of course, an insight by itself doesn't help you. Based on what you have learned today, what is causing your problems? If you face what makes you anxious this week, how might you do the opposite of your previous avoidance strategies?"
