Skills for Working with Fragile Patients

Introductory skills for working with Fragile Patients

Includes 21 introductory skills
Audio course: $97

Comprehensive Skill Building for working with Fragile Patients

Includes all of the 21 introductory skills plus 40 more skills
Audio course: $197

Please note: These products have many hours of audio content. You will be sent several files to download – we appreciate your patience with the downloading.


Do your clients get flooded with anxiety? Do your clients sometimes confuse you with their projections? Do you have clients whose denial prevents them from forming a productive therapeutic alliance? Then these skill-building exercises are for you.

For the first time, we’re making these psychotherapy skill-building audio studies public. Previously, only some of these studies were available through multi-year training programs. Now, this audio course will teach you how to quickly identify and address subtle defenses used by fragile patients. You will learn how to build capacity in fragile patients gradually and safely. If you have tried to explore feelings with fragile patients and got nowhere, these studies will show you how to tailor your work to the patient’s capacities.

How It Works

In this practice-oriented course, you are the therapist asking me scripted questions. And I am your “patient”, responding with excessive anxiety or defenses. You will intervene. Then I will give you a recommended answer and teach and supervise you along the way, showing you how to assess the patient’s strengths and weaknesses, so you can help the patient. Through the alternation of teaching and skill building, I’ll show you how to put your knowledge into effective practice.

As we explore numerous examples of each defense, you’ll have ample practice time to learn how to recognize defenses immediately and intervene effectively. You’ll rapidly improve your skills and learn to handle problems easily that would have stumped you in the past.

Skills You’ll Acquire

Stage one: Establishing an internal problem to work on

Detour one: Anxiety

  • Assessing anxiety
  • Exploring symptoms to regulate anxiety
  • Anxiety identification and regulation
  • Mobilizing attention to anxiety
  • Identifying defenses which prevent anxiety regulation
  • Blocking those defenses, and then regulating anxiety
  • Building the capacity to pay attention to anxiety

Stage one: Establishing an internal emotional problem

Detour two: defense

  • Non-problems
  • Diversification: changing the topic
  • Vagueness
  • Intellectualization and rationalization
  • Projection of awareness onto others (“they think I have a problem”)
  • Projection of awareness onto the therapist (“you think I should…”)
  • Review exercise
  • Denial (“I don’t have a problem”)

Stage two a: Declaring will to work on the problem

  • Inviting the experience of will
  • Projection of will onto others
  • Projection of will onto the therapist
  • Deactivating defiance
  • Anxiety when patients declare their will
  • Review exercise: Moving from no alliance to alliance

Stage two b: Mobilization of Will to the Task

  • Deactivating projection of will
  • Mobilizing will to the task
  • Resistance to the task: regulating anxiety
  • Deactivating Defiance
  • Deactivating Projection of will (You think I should…)
  • Deactivating Projection of Will by Using the Patient’s Metaphors
  • Denial through fantasy
  • Denial through fantasy II
  • Denial through fantasy III
  • Denial through words
  • Denial per se
  • Identifying and deactivating projection
  • Identifying and deactivating projection
  • Projection of the ability to think
  • Projection of criticism (“I’m afraid of what you think of me.”)
  • Dishonesty with the therapist—the patient who lies
  • Reflection to build motivation for change in severely mentally ill patients
  • Reflection of ambivalence (“I want to and I don’t want to.”)
  • Reflection for psychotic patients
  • Reflection with a Drug Addict Who Wants to Relapse

Drop out warnings

  • Discussing lack of change
  • How to see warnings of drop out—-how to hear unconscious communications in the patient’s words
  • Learning to identify behaviors in life that predict dropout in therapy

Stage three: Declaring a specific example

  • Defenses against giving a specific example
  • Vagueness
  • Where are we on the triangle of conflict?
  • Formulate the conflict that causes the patient’s problems

Stage Four a: Building Capacity in the Fragile Patient:

Tolerating Feelings inside without Projecting them Outside

  • Inviting feeling gradually—dosing your language to the patient’s capacity
  • Inviting consciousness of splitting
  • Deactivating projection through inviting internal experience
  • Intervening before patients project their will
  • Building capacity when the patient’s anxiety goes too high
  • Building capacity with patients who engage in self-attack and self-neglect
  • Building consciousness of splitting: learning to tolerate conflict
  • Deactivating a paranoid transference

Stage Four b: Building Capacity in Repression: Pressure to Mixed Feelings Toward the Therapist—-concept of thresholds

  • Building the capacity to bear feelings without self-attack or depression
  • Addressing somatization due to tension
  • Building the capacity to bear feelings without somatizing


  • Identify and address defenses immediately and effectively
  • Study from 11+ hours of studies to learn 60 new skills
  • Become proficient at identifying and blocking defenses that can stop a therapeutic alliance from forming
  • Get moment-by-moment analysis and coaching
  • Practice at home or on your commute
  • Thousands of hours of experience distilled into over 11 hours on mp3 files
  • Learn sixty skills so well that they become automatic


We tested the effectiveness of ISTDP in a pilot study working with an inpatient ISTDP drug rehab unit. After six months, 17% of the patients from the control group were still sober in contrast to 48% of the patients in the ISTDP group. The ISTDP group of drug counselors studied almost forty of these skill-building exercises. Follow-up research on skill-building is occurring at four facilities this year.

See What Therapists Say About these Audio Studies

“Jon Frederickson has created a superb set of audio training programs… These recordings have added a dimension to my skill building that I have not been able to achieve through my other learning methods. To me the secret lies in the succinct introduction of the skills and the repeated exercises. Jon guides the listener in an interactive way through various therapeutic scenarios. Each module is clearly introduced and focused on a single skill, with various examples given on each technique. Jon then takes you through various practice runs to help you think through and internalize the skill. He builds your confidence gradually to deal with complexity so that you never feel overwhelmed. 
I noticed the effects in my clinical practice immediately. Jon’s clear instructions are sound bite long and easy to remember, and because of the practice runs with the tapes, I found myself able to immediately incorporate the skills within my established practice. Importantly, the recordings highlight the core ISTDP skills so succinctly that it has given me a renewed appreciation of how important it is not to rush the basics (such as clarifying the problem and the client’s will/motivation). I would recommend these recordings to anyone who is interested in learning the ISTDP method. Thank you for making this available Jon. These skill-building guides have proved an essential aid to my learning the ISTDP method through your clear and focused introduction to the therapeutic skill set. I look forward to future releases.”
 Anthony Theuninck, Psychologist, United Kingdom

“The Skill-building audio course is a great learning tool for ISTDP practitioners at all levels. The exercises are very well structured, the learning objectives and how to get there are crystal clear, and Jon Frederickson is, as always, a very inspiring teacher. I can highly recommend the skill-building audio course. Thanks again, Jon!” Allan E. Larsen, Clinical psychologist, President, Danish Society for ISTDP

“I want to thank Jon Frederickson for making this audio course available. Even though I have been studying ISTDP literature and in a core study group for three years, this audio course still proved to be a wonderful learning experience. It reviewed how to handle defenses that are blocks patients frequently (and unconsciously) erect. Jon acts in the course as the patient in role-plays and then waits as the listener gives a response. Then Jon gives a response that would probably be effective. The repetition and drilling helped my competence in ISTDP.”

 Deborah Cole, Ph.D., USA 

“I’m so glad that I purchased these skill building audio recordings. For several years I have been seeking guidance as to how to work around patients’ defenses to help them tap into their emotions. The books that I have read and the psychologists with whom I have consulted have failed to address the techniques that Jon addresses in these recordings. They are basic concepts but they had never occurred to me and they are really important. For example, you ask a patient how her father’s behavior made her feel and she responds “It made me feel disappointed.” That’s actually not a feeling, that’s what happened to her, her father disappointed her. So you can’t just take that as the answer to how that made her feel. You’ve got to dig deeper and he teaches you how. I also like that these are in an audio format so you can put them on your iPod. The other day I listened to 3 hours of them while I was painting my office and it made the time go much faster and I learned a lot. I think I will end up listening to them over and over again to solidify the concepts. Looking forward to the release of the next set of recordings!”

 Jeremy Bartz, Ph.D., USA

“Love so much the first set. Can’t wait to have the next series of skill building exercises. When will they come out?” Nicole Lediard, MSW, Indonesia

With these mp3 files, therapists around the world are becoming more skilled!