Phase 2: Identifying and Dealing With Shifts in State of Mind

The phenomena identified in the earliest phase of therapy will not be stable. Symptoms and styles of interpersonal behavior may vary from one state of mind to another. The patterns of state transition may be abrupt, leading some observers to conclude that emotions are volatile and shallow. But emotions are not shallow experiences to the individual patient; rather, they are often felt to be unbearably intense and out of control in some states, ones that may as well appear undermodulated to others. Identifying and dealing with undermodulated states is an important aspect of therapeutic techniques.

After a few sessions, the therapist will sense when the patient is about to have a transition from a well-modulated to an undermodulated state. The aim at such times is to stay with the line of emotional ideas, maintaining work on that emotional theme in a well-modulated state and preventing shifts into states in which the patient feels too flooded to work effectively. The therapist may use clarification and repetition in a calm, gradual way that offers empathic support and slows down the patient's associations enough to prevent the shift into an undermodulated state. This activity also models for the patient how the therapist remains in a working state, rather than responding to provocations to shift out of a working state and into a social situation of providing what the patient feels he or she needs from others at the moment.

After the patient's ability to remain in well-modulated, working states is strengthened, the therapist may also help the patient avoid shifts into overmodulated states. These are states in which the patient contrives emotional displays but feels alone inside, because the emotional expressions do not feel authentic. One such overmodulated state led to the committee choice of a criterion in DSM-IV: the theatrical and self-displaying exaggeration of emotion. Another overmodulated state that may be of equal or greater importance is that of inhibited expression and withdrawal from closeness with others. Both of these states may serve defensive aims: the inhibited and withdrawn or "mousy" state is used to reduce the risks of animation eliciting an overwhelming interest from others, whereas the theatrical display state is used to obtain attention and get excited in order to ward off despair, fear, rage, guilt, and shame states.