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 Both of these states may serve defensive aims: the inhibited and withdrawn or “mousy” state is used to reduce the risks of animation eliciting an overwhelming interest from others, whereas the theatrical display state is used to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.

It is helpful to teach the patient the concept of well-modulated states of mind, ones in which there is thought before action, spontaneity without pretense or exaggeration, and contemplation about how to cope with problems that can lead to effective and responsible action. The patient can then learn about cycles of states of mind and how impulsive shifts in state can have threatening consequences. Gradually, the patient can learn to tolerate feeling sad, angry, and fearful in well-modulated states. Appropriate uses of self-dramatization and exhibition may be discussed as part of a repertoire of social skills and routes to satisfactory experiences.

Through such work, the patient may learn to describe highly individual states of mind. Inquiry can extend to which states are most dreaded and most desired and which ones serve as defensive compromises to avoid an entanglement of wish and fear, a dilemma in which wishes always seem in interpersonal patterns to lead to fearful consequences. This sets the stage for deeper inquiry into the self-images and views of relationship that lead to such dilemmas.

Along with such approaches to regarding problems as varied in different states of mind, Horowitz has suggested an interesting “shimmering” state of mind that may be prominent in the therapy process with this type of patient. The shimmering state is marked by both a direct emotional display and signs of either avoidance or alternative emotionality. The cues and features of more than one state oscillate rapidly and seem to occur together. The patient is both expressing and warding off or contradicting. The emergent contents may be especially relevant to formulating conflict. In the middle phase of therapy, the shimmering state is often a working state, and the therapist need not intervene to avoid an undermodulated state. Shifts to an overmodulated state are also transitory, and the therapist may not have to intervene to shift back into a shimmering or well-modulated state from the period of defensiveness leading to a restored sense of ability to be in control. Some of these techniques are summarized in

Table 84-3.