The Therapist as Regulator

Too much feeling, too little feeling. Moving away or moving closer?

This is Part 9 of a 12-Part Series: The Hardest Things in Psychotherapy

When a patient is dysregulated, flooded, or easily overwhelmed — the therapist moves away. When a patient is inhibited, rigid, vigilant, or paranoid — the therapist needs to move closer.

Therapists often have to help patients learn to regulate their emotions. It’s important to mentalize* or sense the emotional direction most helpful to the patient.

*Mentalization involves reading the patient’s internal thoughts, feelings, behaviors, intentions (motivations), as well as understanding these things in themselves. I’ll be writing a dedicated Substack piece on Mentalization in the near future.

In short: If patients are dysregulated, the therapist has to move more cognitively or intellectually to help provide structure for the patient.

The inversely, if the patient is over-controlled, the therapist has to move closer and warmer, enabling feelings to emerge.

Dysregulation: Overwhelming Emotions

Some patients experience their entire world through feelings such as joy, sadness, anger, or rage, leaving them feeling flooded or easily overwhelmed. In these instances, the therapist moves away: becomes more distant from the emotions, thinks more, gets more structured, helping the patient to feel more grounded and realistic.

This offers stability to the patient, so the patient can explore the meaning and purpose of the dysregulated emotion.

They are the clinician who is rarely, if ever surprised.

Overcontrol: The Absence of Feelings

When a patient is inhibited, rigid, vigilant, or paranoid, the therapist needs to move in the opposite direction.

The therapist SLOWLY moves closer, warmer, to eventually facilitate the patient’s ability to access more feelings without being flooded by them.

Rage: A Common Dysregulated State

Dealing with the dysregulation of primitive rage, seen so commonly in patients with severe personality disorders, is particularly challenging. When rage is directed at the therapist or a particular person, it feels primal and intense. It is easy to be rattled and lose their way.

Rage is the emotion most therapists defend against, most likely to provoke countertransference, and most difficult to work through in the transference without damaging the relationship.

Rage often comes with a demand to manage it, change it, validate it, direct it, to not destroy someone or something.

When it comes to rage, therapists should stay firmly present, avoid withdrawal, trying to soothe it, or collapsing under the pressure. Holding the rage, thinking about it, having the patient get some distance from it — so they can think about it, takes some practice. Working a lot with patients who have severe personality disorders will help in understanding this.

The critical question is: What is the rage about?

It is often a defense against deeper vulnerabilities underneath, such as annihilation fears, envy, existential terror, grief, dependency, or the unbearable need that becomes rage against someone who has left you or hurt you. The work is discovering what is underneath the rage.

Therapists must hold on to their ability to mentalize these patients under the pressure of rage. The therapist needs to notice their fear of rage, and simultaneously think about what the rage means — using their genuine self, staying present, observing and reflecting. Balancing feeling and thought is the therapist’s task, which models exactly what the patient needs to learn.

The therapist’s ability to help a patient regulate their emotions, and especially rage, depends on the therapist’s ability to mentalize themselves — well enough to use their reflective skills and stable enough to be helpful.

Overcontrol

Dealing with patients who are overcontrolled or severely inhibited requires the opposite move.

Overcontrol refects an intense need for safety, so trust with the patient has to be built slowly for the patient to let in more emotions. The therapist slowly move closer, warmer, so the patient can risk feeling something without being overwhelmed.

I often joke with residents that the best way to get a patient with schizoid or paranoid features to get off your caseload is to invite them for very frequent sessions and ask frequently, “How do you feel?”

The work with an overcontrolled patient has to move slowly, as too much curiosity can feel intrusive. Patients have to feel safe as the first step. This means a lot of listening and more benign restatements rather than questions.

As trust is built, asking, “What is the experience of being in therapy like for you?” rather than asking, “What are your feelings?” offers a message of safety. When feelings show up—sadness, fear, or some warmth and interest in you—keep your responses matter-of-fact, slow, not a big deal, as this will help reduce the risk that therapy will be experienced as dangerous or as a humiliation.

Trust is built over the long haul, by allowing a patient to feel your presence while tolerating the slowness of building a relationship.

Final Thought

Experienced therapists help patients regulate their emotions constantly, often unconsciously, without a specific decision to do so. It is important to develop conscious control, attuning your approach by balancing emotion and rationality and by either moving away or moving closer. It is so important use your reflective skills of reading or mentalizing the emotional landscape accurately enough to know which direction will be most helpful.

Other essays in this 12-part series “The Hardest Things in Psychotherapy”

• Part 1: Some traumas are forever
• Part 2: Witnessing is a Skill
• Part 3: What Type of Therapy Do I Want?
• Part 4: Envy: I Want All That You Are (Part 1 of 2)
• Part 5: Envy: I Want All That You Are (Part 2 of 2)
• Part 6: The Therapist Who Can’t Be Wrong Is the Most Dangerous Person in the Room
• Part 7: The Story You Were Given Isn’t the One You Have to Keep
• Part 8:Being Seen Is Not a Technique

Robert E. Feinstein, MD

Professor of Clinical Psychiatry, Zucker School of Medicine at Hofstra/Northwell

Psychiatrist, Psychoanalyst, Educator, and Supervisor Contact: Feinster@RobFeinsteinMD.com

Owner & Founder Empathian LLC ( An Online Mental Health Education Company)

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