About Resistance to Medication

It is a human reaction to resist the idea of any form of illness, especially one that is chronic and requires long term decisions about treatments and their possible side effects on the body. It is rare that when a person is first diagnosed with clinical depression that she will embrace this idea and all that treatment can entail. For someone who has struggled for some time with the various symptoms, however, there can be a sense of relief to finally have a name and a possible path forward with their trouble.

Sometimes a person who comes to see me has been told by another doctor or therapist that she suffers from depression but she has rejected their evaluations and refused further treatment. By the time she comes to see me she may have tried multiple methods of improving her mood and energy levels or dealing with other markers of the depression syndrome. Some of these methods are definitely helpful: exercise, a healthy diet, or weaning from the use of alcohol or other drugs used to mask or relieve her symptoms, for example.

When I suggest that she appears to be struggling with depression and speak of the possibility of medication as one path to a better quality of life, and in fact, a path that can facilitate and speed the work done in psychotherapy, I am often met with variously intense levels of refusal. Some have simply not returned to talk further with me; some have made it clear that this path will never be taken and that, if we are to continue to work together, I am forbidden from discussing the topic with them in the future; others tell me that they would prefer to “work their issues through” in psychotherapy rather than taking meds.

The latter statement reveals the commonly held idea that emotional/psychological difficulties are a function of some undefined part of ourselves distinct from our brains. Such a distinction can be made only in an intellectual fashion. In the lived reality all elements of our beings are interactive. A deeply successful psychotherapy experience, or an on-going meditative practice, can modify brain and nervous system functioning. By the same token a medication can allow a healthier functioning of the brain to provide greater focus and nervous system grounding. This in turn will facilitate the development of toleration for and understanding of feelings and experiences that formerly overloaded and overwhelmed the client, making the odds of her learning new approaches to and resolving her troubles quite problematical.

For some clients the suggestion that their troubles may have a physiological component can be quite threatening. The spectre and stigma of “mental illness” still hold sway for most people even though socially we are making strides in this regard. Problems with any other organ in the body can be diagnosed and treatments suggested without this intensity of reaction. It’s not a great thing to be told, for example, that I have developed diabetes or that my lungs have been compromised, but these problems fall with the realm of “normalcy” and are not the stuff of fear and shame. I can talk with my family and friends easily about what is happening. This is not true when it comes to the acknowledgment that one’s brain is not functioning properly. We are simply not logical when it comes this part of our being. We might have sympathy for and be supportive with a friend who is on a medication but shy away from its use ourselves.

It is my sense that much of the resistance that is advanced to taking psychotropic medications stems from fears – perhaps at root a primitive fear of being poisoned. Many rationales are given for a refusal: I don’t want to gain weight; I never take medication of any kind, not even an aspirin, so why would I take this stuff; It might make me into a different person whom I wouldn’t recognize; It might take the creative edge off my work; I know someone on medication and I can’t see that it’s helping her; I don’t want to feel drugged; It’s a panacea dreamed up by pharmaceutical companies to make profits; The world is being drugged and medicated and I’m against it. The list of reasons for refusal is endless.

Generally people will take other medications recommended by their doctors without difficulty. Not so when it comes to these. Absolutely, it takes courage to embark on a course of drugs that have, like all medications, a list of possible side effects, when we are conscious of the fact that the intention is to change the current functioning of our brains. It’s a hard decision to make, one that some people defer for a long time until convinced that other ways that they are using to climb out of their periods of depression are inadequate. Is it true that Big Pharma is making lots of money from these meds? For sure. Is it true that too many drugs are being prescribed to people? Very possibly. Having a prescription and compliantly taking the medication are not the same thing, however. If someone is taking a medication for depression and after a few months there have not been discernible changes, she is unlikely to continue with it. With these meds the proof in the pudding shows up fairly quickly. It takes several weeks to a couple of months for the benefits to fully kick in, though some experience a lift in energy within a week or two.

When talking with a client about the possibility of her going on an anti-depressant medication, I have had to learn to be sensitive to the indications that she gives me that this is a scary area for her. Because from my perspective I can see that meds would give a tremendous boost to her in many of the areas that she chronically struggles with, I have at times been too strident about my recommendation. Some years ago a fellow in my men’s group accused me, mostly in jest though of course reflective of his suspicions and fears, of having shares in a pharmaceutical company. Full disclosure: I don’t. These days I mainly lay the options before someone who comes to see me clearly suffering from depression and try to listen more deeply to the responses she gives me. Recently a graduate student who had been floundering in her work despite clearly being a talented researcher decided to try meds in spite of her initial reactions against the idea. As a scientist she understood all that I said to her about the potential of the meds to bring her out of the malaise of exhaustion and anxiety which was threatening her graduate status. Fear overruled knowledge. I presented it to her then as a scientific experiment: go on a medication for a three month period and be a critical observer of any and all results. Then make a decision to continue or to stop taking them, based on your own experience rather than on things you have read or heard from others. She rose to the challenge and since has gone from success to success not just academically but in her personal life as well.

Some people with whom I have worked over the years resisted the idea of medication as they worked through some of their problems with me but later decided to try it to see if it could help them, for example, with continuing levels of anxiety. The experience of most of these people has been positive. One woman spoke of the sense she had gained of feeling truly herself for the first time in years. It was as though the chronic low-grade level of depression with which she lived kept her in a perpetual state akin to having a cold on a bodily level. The “emotional” cold kept her off her game, feeling always somewhat anxious and troubled by obsessive negative thoughts and self-doubts. Once on the medication she felt clearer within herself and with others, more a mistress of her life than ever before. Others have told me that in retrospect they wished that they had begun medication years earlier. It is likely, however, that the psychotherapy that they had had gave them sufficient security to allow, what had been for them, the risky decision to take a medication and see if it was helpful.

Therapy and Medication

Like any organ in the body the brain will not work properly if enzymes needed for its functioning are in low supply. In the brain these are called neurotransmitters because they allow the transmission of the impulses or messages from one neuron cell to the next. Without enough serotonin, for example, the messages lag or simply don’t make it. The effects of this insufficiency are experienced throughout the brain, not just in the areas affecting mood. There are cognitive and physiological effects as well. Put together these effects constitute what we identify as depression. The term itself causes confusion, however, as most of us suffer from periods of sadness or feeling down when dealing with normal life experiences: loss of a loved one, financial difficulties, or family and relationship problems, for example. These dips in mood and confidence are usually short-lived as we rally and learn to strategize and deal with our issues.

What is meant by the term depression clinically, however, entails a much broader canvas. Someone who has never experienced the devastation of a clinical depression cannot understand or judge what may be happening within their friend or family member who clearly is suffering. Advice or admonitions may be given: get over yourself; just get on with things; we all get down sometimes but we don’t let it get the better of us. Already overwhelmed with a true mental (ie, brain) illness, the sufferer must handle also the shame placed on them by others and by their own inner fears that they are operating out of moral weakness.

When a client presents herself clearly experiencing a generalized malaise, or suffering from severe anxiety and/or irritability, a good beginning is to go through the list of indicators for a diagnosis of depression: Difficulties with memory or concentration? A sense of being overwhelmed by ordinary tasks? Insomnia or over-sleeping? Low energy? Under- or over-eating? Physical pains related to tightening of muscles, especially in the chest or abdomen? Low self-esteem? A sense that life is just too hard and that one will be better off when it is over? Active or passive thoughts of suicide? Crying easily for little cause? A somewhat pervasive sense of sadness, anxiety, or irritability – sometimes alternating with one another? Anyone acknowledging a significant number of these symptoms ought to be made aware that she is likely suffering from the complex syndrome of depression. A visit to her doctor for a physical examination and discussion of her symptoms is important. Other conditions can trigger depression or be masked by it. If no other physical ailments are found to possibly explain the client’s depression, anti-depressants can be prescribed by her doctor, especially if the symptoms she is experiencing are inhibiting a healthy enjoyment of her daily life.

Our clients teach us lots of things about ourselves and about areas that we have little knowledge or experience with. About 20 years ago a young woman came to see me who was truly felled by acute depression. She was on a disability leave from her job. At least 20 of every 24 hours were spent in her bed or on her couch. She simply could not function in her day-to-day life. About the same time that she started to see me her GP prescribed anti-depressants. I was dubious about the wisdom of this approach as I had learned my trade within a therapeutic community that was aggressively anti-medical model. In the 1960s while this group was in its formative phases it is true that medicine had few effective solutions for mental health problems. Following a psychodynamic psychotherapy tradition and experimenting with newer, body-based therapies, the community was never able to expand toward a rapprochement with research into the functions of the brain and newer pharmacological directions that were beginning to emerge.

It was with astonishment then that I witnessed the transformation in my client’s energy levels and general competence over the next several weeks. Her doctor had recommended two books to her – books which I quickly acquired and read. One was “Listening to Prozac” by Peter Kramer, a psychoanalytically trained psychiatrist who as a resident had had a revelatory experience with a patient on his ward similar to my own. It had revolutionized his thinking, allowing him to operate on the two fronts of medicine and “talk therapy.” His book gives an overview of the symptoms of depression, some historical information about the development of psychotropic medications, and examples from his own practice of ways that the medications changed the lives of his patients in somewhat surprising manners.

The other book was provocatively titled, “You Mean I Don’t Have to Feel This Way?” by a writer named Charlotte Dowling. When her adult daughter was stricken with a major depression not dissimilar to that of my own client, Dowling put her research skills to good use, learning all that she could about the illness and its possible treatments. She connected with some of the leading researchers at the time, picking their brains for whatever was available to help her daughter. Placed on one of the newly developing SSRI medications, her daughter was brought out of her deep depression and was able once again to resume an independent existence. Dowling then set about writing her book, giving information and hope to many who until this period had few options available to them.

Since these books were published there have been many advances in understanding and maping brain dysfunction. For example, research has shown that considerable stress of any nature in early development can result in chronically low levels of serotonin, leaving a child vulnerable to later cycles of depression. Long term studies indicate that the best treatment for depression is a combination of medication and psychotherapy. As Kramer found in auditing the subtle effects of medication on his patients, restoring optimum neurotransmitter levels in the brain gave what he called "a floor" to his patients. When stress or crisis occurred, rather than falling as it were through to a place of panic or despair, they were more able to absorb the impact and to deal more competently with the situation before them. Of course people are often reluctant for many reasons to take anti-depressants, but that is another, rather lengthy conversation.

What the Client Brings and What the Therapist Needs

The vast majority of emotional/psychological problems have their origins in early relationships. Genetic and cultural imperatives play a role, in some cases more strongly than others, but formative relationships most clearly set the child on a road toward relatively healthy or troubled adult interactions. We learn to relate to others by the way that we have been related to. We learn to look after ourselves and others in the way that we have been looked after. When parenting or life’s conditions are such that we falter in establishing good relations with others and in knowing how to take good care of ourselves, we may have to, in a sense, begin over again. If our troubles have their origin in relationships, their solutions can be found in that same place. More important than any theory or technique that a therapist may espouse is the relationship that she endeavours to establish with her client. Her relation to the client is not one of a friend, a parent, a teacher, or a professional exchanging services for fees, yet all of these components play a part in their relationship.

Anyone who comes to see a therapist is looking for far more than she is conscious of. By this stage she has already gone through a considerable period of awareness that she is struggling with troubles that seem beyond her capacity to deal with alone or with the resources that she has at hand. It can feel something like going to a dentist for a person with a bad tooth but who is reluctant to having it cared for. It makes her feel vulnerable, it hurts, and it is expensive. As pressure from the day-to-day pain increases, however, she takes courage in hand and makes an appointment.

Leaving this analogy behind, we will now follow her into her first appointment with the therapist: she brings with her not only the problems that are clear to her at that time, but also the whole of what she is about. However she has been treated up to that moment and the way that internally she treats herself, is present in that first exchange. Her defences, the ways that she has learned to protect herself from possible injury, the ways that she has learned to charm or to annoy, and the narrative about herself and her life that she has honed to serve up to those whom she meets, all are there in that first meeting. The problems that she presents are but the upper layer of the complexities that she brings to that table. Without her deeper pains, longings and fears, most issues could be dealt with by some judicious counselling. The very fact that they cannot points to places within that are as yet unacknowledged, even unknown, places that are cut off from her conscious awareness.

Whether a therapist or a client, we bring all of ourselves to every relationship that we enter into though we are selective about which components are visibly on the surface. This selection process is mostly unconscious and reflexive and follows patterns that we have shaped and made use of in many locations in our day-to-day lives. It is a truism that a teacher can take a student no further than she herself has gone. This is eminently true in the realm of therapy. Whatever lies within me that I know nothing of, that I fear, or that I have learned to make use of to gain my own emotional needs, will play out within the therapy relationship with my client. The degree to which I have faced and am struggling to resolve my own troubles and confusions, to that degree I can assist the client in her quest for liberation. Otherwise it’s simply a case of the blind leading the blind – and, as we know, lots of accidents can happen that way!

The training of the vast majority of mental health workers does not take this reality into account. Rarely does a program acknowledge in a practical manner that its trainees need their own emotional education every bit as much, and maybe more than, an academic and practical one. This is the root cause of “burn-out” and even of the unusually high rate of suicides among, for example, psychiatrists. If we only do short term, fairly practically-based counselling work or use a strictly patterned technique like some cognitive behavioural programs, we can avoid interacting at a level with the client that might engage our own deeper selves. In longer term, psychodynamic psychotherapy, however, this is not possible. Or, perhaps I should say that to the extent that we hide our own feelings and reactions to the client from ourselves, to that extent we will block the work that we are attempting to do with her. It can happen that we believe the client to be blocked in her therapy work when, in fact, it is we ourselves that are blocking her. Just as we pick up her emotional nuances in a session, so she picks up ours. These may not be conscious to her but they can be confusing and may in some fashion dovetail with issues from her own background that she is struggling with.

A therapist who has an on-going therapeutic and supervisory relationship with a seasoned worker has a location of her own in which to examine the problems arising in her work. This is of tremendous advantage both personally and professionally to the therapist. In every area of our beings, we are changing all of the time. Just as we are always engaged in physical and intellectual changes throughout our lives, so too we are constantly changing emotionally. Each new experience can confirm or disconfirm patterns that have their origins early in our lives and can bring us new, unknown feelings that can set us on wholly different paths. It isn’t true that people are set by the time they are six, or sixteen, or even sixty. Emotional development is a life-long process. Having a good foundational therapy at the outset of her training and an on-going connection with a supervisor and/or a community of other workers with whom to share her experiences and problems allows her as well as her client the possibilities of on-going growth and development.

Some Therapy Modalities

In the years that Paul spent living with his family after arriving in Canada his fields of operation were several. There was home, school, and the neighbourhood. Because he was an intelligent boy, he was able fairly quickly to pick up his new language and find a niche for himself at school. There, like at home, he engaged in struggles for attention and to experience some sense of power in his relations with teachers and other kids. His behaviour led to conflicts, recriminations, and further frustrations both at school and at home. Outside of school he would escape family bounds by engaging with a series of local kids, playing baseball or other sports with them but never staying long enough with any group to develop deeper loyalties and friendships.

As an adult Paul maintained a similar pattern: domestically with a partner he engaged in a dance similar to that played out with his mother. At work he did well though was always involved in some form of struggle with a co-worker or boss -- not enough conflict to threaten his job security, but enough to maintain a level of personal stress and to justify his conviction of being unjustly treated. Apart from being with his girl friend Paul’s social life consisted of playing or watching sports with other men, more and more frequently as he grew older, at a bar. He studiously kept all areas of his life separate from one another. Not having developed good relations with his father or brothers, Paul had no template from which to move beyond superficial connections with other men. Visits to his family were awkward and stressful and over the years became infrequent.

Because Paul’s world of intimacy was so narrow and chronically dissatisfying, I invited him to join a men’s group that I had been working with for a couple of years. Initially resistant, he did agree to come. At the time there were eight or ten men in the group. We met weekly for an hour and a half and would begin with a brief go-around in which each person would say a few words about how he was doing. The material for the group work would usually emerge from this introduction. I had often to remind the men not to make successes in their work lives the focus of their remarks, but to speak rather about incidents during the week that had troubled them, or about things they were struggling to understand. The cultural inhibition of men openly speaking about personal and painful things, in particular with other men, is very strong, however, and they needed constant reminders about why we were getting together.

Paul said little about himself in the group for some time but it impacted him powerfully nonetheless. He was experiencing for the first time being with men who would risk sharing vulnerable thoughts and feelings with one another. Issues that emerged in the group would resurface in his individual sessions as he gave himself permission to consider how they affected him. Someone might speak of difficult relations with a parent, a problem at work, or a conflict with a partner that would throw light on nuances of his own situation that he had not considered. A few of the men who had been together for awhile had developed a palpable sense of trust and support with one another. The security this afforded them in the group led to their encouraging and showing an interest in the newer people. This atmosphere was truly beyond Paul’s experience. It was hard for him to believe in and to be at ease with this aspect of the group for some time, but gradually he also began to relax his fears and to speak more directly in the group about his reactions to our talks. His input usually came in the form of acknowledgements toward the end of the group that he had experienced or felt things like those that others were elaborating upon. His comments almost always would be in a response to my asking those who had said little if they had any reactions to the material at hand. He remained reticent about his own issues.

During this period our private sessions had several foci, often examining the most recent events in his relationship with Jane and talking about his ways of dealing with his reactions, always looking at his motivations, justifications, and behaviour, always considering other ways that he could deal with the intensity of his reactions. But there were other areas to look at as well, especially that of the fears and suspicions of men that came more into his consciousness as he attended the men’s group. In our sessions we often made use of hypnotherapy for at least one portion of the hour. In the beginning it was very difficult for him to close his eyes and allow his focus to be within his body, with his breathing, rather than staying alert, watchful for any sign that I might intend to harm him in some way. Consciously, rationally, in his adult self, he was clear that I had no intention of doing so, but the conditioning of his nervous system and musculature was such that it took some months before he was able to more deeply let go in his body. As he did so he became more aware of the chronic tensions and anxieties with which he lived. He began also to experience a space of relative ease in the presence of another person. This kind of experience had been available to him only in periods of harmony with his mother, especially in his early life before they came to Canada. His other experience was during a “honeymoon” with a new girl friend when all was promise and delight, and later during their times of making up. Developing a relationship with a woman who was consistently present to him in our interactions and who had no personal needs or demands in the connection, was an important step for Paul toward greater emotional autonomy.

Some Barriers to Intimacy

In my last post I outlined some of the problems that my client, Paul, dealt with in trying to establish a good relationship. He was obsessively jealous, using the slightest pretext as a basis for accusations that questioned his girl friend, Jane’s, fidelity. Needless to say, their relationship was tempestuous, mirroring in many ways the climate of stress, blow-ups, recriminations, unhappiness, and ultimate reconciliation that he had played out with his mother prior to leaving home. Early in our sessions much of this terrain became fairly clear to both Paul and me as we talked. As I have written earlier, however, intellectual knowledge and understanding do not necessarily allow a person to resolve at an emotional level the patterns that have been in operation for many years. The connection of my behaviour or feelings in the present with antecedents from early childhood might make perfect sense to me, but do little or nothing to prevent me from feeling and reacting in an identical manner when under stress.

A significant barrier to connecting what we feel and experience today with our early histories lies in a method that we all necessarily use to defend ourselves from otherwise completely debilitating depression and unhappiness. If I have been badly frightened or physically hurt by a parent, one that I must look to for safety and nurture, I have complicated processes to complete in order to make this experience manageable psychologically and emotionally. I cannot keep the reality of what at that moment I experience as betrayal and abuse at the forefront of my consciousness. If I was to do so how could I carry on with the relationship of trust and dependency with my parent that I absolutely need for survival? On the other hand I can’t totally ignore the fact that my parent can be dangerous and that I must find ways of keeping him or her under some surveillance in order to be ready if the bad moment is likely to recur. In that way I can prepare myself for an attack which will be less severe if I am not completely at ease and am thus more vulnerable. This does not occur at a conscious level for the very young child. It is simply the development of wariness found in any mammal that has experienced fear or abuse.

As well as wariness I have to adjust myself in a manner that allows me to continue my sense of my parent as a kind of god – the all-seeing, all-knowing, all-powerful one. If there is fault it must be mine. To view it as that of the parent is to take her from the pinnacle where I need her to be as my place of safety and security. In adolescence or later in adulthood my relative independence will allow me a different location from which to view and to criticize her behaviour. But as a young child my only location is that of dependency. I learn how to please even as I develop my own degree and form of wariness.

At the same time I have been modeled behaviours that I can adapt and shape to suit my own needs. My parent has been unable to calmly deal with her feelings and has used her physical strength to overpower me. In extreme cases of abuse a child may be so entirely overtaken that she loses all sense of herself and becomes profoundly bonded with the abusive adult, following even into adulthood the beliefs and activities that she has witnessed and experienced. More commonly, however, the child will adapt various parts of the parent’s repertoire as a way of gaining psychological and emotional solace. She hits and yells at me but I can do the same – maybe not to her if I am too afraid of her, but possibly to others. Younger siblings, pets, fellow students might feel the power that like my parent I know how to exert. I have learned how to bully. As an adult I am likely to continue patterns of this kind, being “good” or appropriate among people whom I respect (or am intimidated by) and less than kind, “bad” with those whom I sense that I can intimidate in turn. I reside along a ladder of ascending and descending rungs of a power hierarchy.

The wariness that I have perforce developed creates in me a sensitivity for the actions and feelings of others. But because it stems more from fear than from interest it contains much that will compromise my establishing intimacies that are the grounding of a healthy and happy social and sexual life. To the degree that I have had to spend energy as a child monitoring the behaviour of others and in general the world around me, to that degree I have been robbed of an essential formative period in which to discover my own self, my own inner world, the things that are of acute interest to me, the feelings that I must master in order to better live well with adults and other kids. I grow up more attuned to the nuances of other’s behaviours and feelings than my own and am affected by these in ways that I can only understand within the framework of my early experiences.

The deepest challenge of therapy then is to alter these patterns, to re-frame one's understandings, and more importantly, to learn to connect the reactions which are tied to present circumstances and people with the origins more deeply lodged within – not at an intellectual level but within the core of one's emotional formation. For some this task is not possible. The hurts are such that they can never be approached directly but only approximated in the day-to-day manner to which the person is accustomed. In some instances a client is very ready to make these connections, perhaps after certain life experiences or therapies have brought her to this point. Especially in hypnotherapy she is gradually able to link painful feelings to actual circumstances or people who have occasioned them. In the supportive climate of the therapy sessions and with her adult strength and capacity for absorbing and dealing with pain, she is able to feel and remember on an emotional level trauma that as a small child she had been unable to bear. No longer completely overwhelmed by the hidden locus of pain, she absorbs it into the whole of her personality, able to connect with it in ways that allow her deeper self-knowledge and compassion as well as an increased understanding of others.

For most though this process is quite gradual. Paul, for example, despite his awareness that his behavior with Jane was often unjustified, had little control over his emotions and the ways that he acted upon them. Early in his therapy I worked to help him develop a conscience about the way that he treated her. Because his parents had acted out of frustration with him, he felt an entitlement to behave similarly with an intimate. It is true that after a hurtful outburst with Jane he would be remorseful and contrite, making up with her and promising not to do it again. But this did not come from a well-formed conscience. It was merely another phase of the circle of emotional exchange honed through the years with a succession of other intimates. His remorse didn’t have the legs to persist into the phase when his jealousy and anger were building to their inevitable climax. If we genuinely repent of behavior we will work hard not to repeat it. This was something Paul needed to understand and to learn to do. He needed strategies to intervene before he reached the stage of blowing up.

Talking with someone who did not condone his behavior began to undercut his sense of entitlement and self-justification. He experimented with the practice of taking a time-out when his feelings began to spiral toward rage and recrimination, struggling not to take his reactions to Jane but to contain them, sometimes working off some of their intensity by going for a long walk. This period was marked by successes and at least as many failures but it was an important on-going process in which Paul began to take more responsibility for his actions,developing greater self-control and hence more adult strength. Becoming an adult is much more complex than simply physical, intellectual, and social role progressions. Emotionally and psychologically we become adults by learning to deal with people and issues in an adult manner – never a simple or easy process to be sure, but one that is essential for a satisfying life.

Residues of Childhood Trauma

To illustrate how early experiences can set the stage for life-long patterns and difficulties, I will relate the history of a client who came to see me some years ago. Shortly after WWII Paul’s father left his wife and family behind, immigrating to Canada in search of work and the resources to establish his family in this country. Paul, at one and a half, was the youngest of four children. Four years later the family came to Canada, seeing their father for the first time since his departure. As the baby, Paul had been especially close to his mother during this period, sharing her bed and being her special pet. Suddenly he was confronted with a man who was a stranger to him, replacing him in his mother’s bed and, as he experienced it, in her affections. He had the usual immigrant terrain to manage as well: starting school without benefit of the language spoken by most if not all of his classmates. Before long his busy mother had the care of two more babies to occupy her. His older brothers, closer to each other in age, would tease and pick on him, excluding him from their games. Both parents, worn with work and cares, would yell and hit him in their exasperation with any misbehaviour.

Misbehaviour became for Paul a way of expressing his frustration and unhappiness but also a vehicle for attention, especially from his mother. A pattern developed of activities designed to annoy her, an explosion of her anger, a deluge of unhappiness followed by tears, repentance, and reconciliation. 

This mode of communication was replicated in Paul’s adult life with his partners. He had come to see me originally because of the troubles in his most recent relationship. He had come to understand that he was behaving in ways that maintained a current of disturbed interaction. There was no peace or consistency with his girl friend. One of the main issues that would surface between them was his jealousy. Convinced on some level that like his mother, who had “replaced” him with his father when they came to Canada, any woman would ultimately betray and abandon him. He was hyper-sensitive to the slightest indication of friendship or regard that his partner had toward another man. By turns sullen, angry, or suspicious, Paul continually provoked his partner in ways that would lead to the familiar round of fighting, estrangement, and tearful reconciliation.

There were no simple or quick passages through this thicket of emotional reactions for Paul. An intelligent man, he was able to appreciate the underlying triggers and patterns that were being repeated with his girl friend. This in itself could not rapidly lead to changes, however. Our intellectual understanding and our emotional lives are not entirely coincident. Coming to knowledge at the intellectual level and developing an emotional connection leading to deep changes in behavior have rhythms of their own, not at all co-terminus. We are more deeply attached to our emotional responses and change them more slowly precisely because of their connections to elemental factors like pleasure and pain, fear and safety.

Wounded emotionally when young, we can grow up around that wound, developing physically, socially, and intellectually, all the while living with the unhealed pain within. It functions somewhat like a break in a bone that wasn’t properly repaired. Other systems may be functioning fairly well, but the slightest pressure on the area of the break will provoke severe pain. Growing up with an inner place of unresolved trouble one finds ways of dealing with it, ways which are particular to the nature of the injury and to the individual’s personality and circumstances. Paul dealt with his pain through anger and provocation. Physiologically and emotionally he found much to confirm him in this outlet. He had the excitement of rebelling and of rousing his mother to rage, exercising a power in the home that his youth would otherwise belie. Suffering the inevitable punishments meted out by her or his father, he could release pent-up emotions with his tears and self-pity. Abasing himself and seeking reconciliation with the loved one, his mother, he could bathe for a brief time in the warmth of her closeness and love.

The adaptations -- mental, physical, and emotional -- that we form during childhood to deal with painful experiences can be successful in the sense that they allow us to maintain a connection to the source and nature of our pain by re-enacting it in some form over and over, while still being able to move forward in other essential areas of development. As we come to maturity, however, these adaptations, by their very origin immature, hamper our quest to fulfill adult roles in a satisfying manner. Recognizing that something is not working and developing insight about the nature and origins of the behaviour that is thwarting one’s desires is but a beginning. 

On Self-Awareness and Self-Consciousness

One way of distinguishing between self-awareness and self-consciousness is to view the former as more cognitive and the latter as more emotive. As teens we tend to be highly self-conscious as we rapidly undergo brain development, have hormonal and physical changes, and move into a more expansive social canvas. With an already more or less solid beginning we can emerge from this crucible with a fair amount of confidence and social ease. For many, however, self-consciousness, painful and even debilitating, can persist into adulthood. Suffering in this way I can experience society of any complexity overwhelming. With others I am anxious; often I will imagine that they are perfectly at ease, that they see through my façade, or, that they are uninterested in me or find me boring/incompetent/unattractive. Because these feelings are so painful, I seek refuge in withdrawal from company, the development of a mask behind which I conceal myself, or possibly, the use of alcohol or drugs to literally spirit myself away.

Self-awareness, on the other hand, is a capacity to view somewhat dispassionately one’s behavior and feelings in order to more deeply understand oneself and by extension, others. It is an ability which in good circumstances, one can grow up with. It also can be developed later in an intentional fashion. What is most needed is a space in which this can occur. A therapeutic relationship is one such space, but by no means the only one where this can happen. Ideally, the therapist in a non-judgmental fashion can feed back to her client the things that she is aware of in the session. It can be as simple as to say, “You seem to be rather nervous.” If I have developed the habit of hiding my nervousness with others, I may even have hidden it from myself. Feeling so vulnerable may not coincide with the view that I want or need to have of myself. When the therapist gives me her observation, because I have sought her help and because I can sense that her words are not an accusation or a put-down, I may be able then to acknowledge to her and to myself that I am indeed nervous. Expanding within this terrain we may then jointly look more closely at what I might be afraid of in the encounter with her: criticism? an attack? humiliation? dismissal? a lack of understanding? We might also consider other milieu in which similar feelings arise. Are there similarities and/or differences in those situations? After this talk I may begin to find myself more aware of my nervousness in other places, talk with the therapist about these, and begin to understand more deeply their origins.

Any space that we carve out to be with ourselves can also facilitate greater self-awareness and knowledge, if this is indeed our intention. Meditation, for example, is a practice whereby I set aside time to be quietly with myself focusing on my breathing and allowing myself to dwell within my body within the moment. Much of our lives are spent in the midst of various stimuli from without and within. Our thoughts speed along from past to future events or concerns. Developing an ability to situate ourselves in our bodies and in the present is a valuable antidote to these consuming and distracting forces. But it is not an easy practice to acquire. Being aware of the thoughts that arise and quietly returning oneself to a focus on breathing requires constancy and determination. It is not necessarily a peaceful practice especially as one works herself into it more deeply. During my meditation I simply allow thoughts to come unbidden and rather than go along with them, leave them and return my focus to my breathe and to being in my body in that moment. Staying there, I will inevitably come face to face with thoughts and feelings about myself and perhaps of others with which I had not been connected and which I find disturbing or at least uncomfortable. Because of these experiences some people who practice meditation find themselves a coach or teacher with whom they can explore and gain perspective on these facets of their practice.

Journal writing is another venue for greater self-awareness. Julia Cameron’s workbook, The Artist’s Way, outlines a program of daily journal writing in a stream-of-consciousness manner. Her personal work and later, doing workshops with others, taught her that blocked artistic energies could be tapped as a person relinquishes some control over her output. The stream-of-consciousness technique, if regularly pursued, can open areas within that the writer has avoided often out of fear or shame. As these are revealed to the writer in this private and thus safe experiment, she can come to a greater understanding of her inner self and a greater freedom of self-expression.

Any activity that promotes a connection with the whole of one’s being can aid self-awareness, activities as simple as going for a walk by oneself, especially in an area which connects one with nature. Listening to contemplative music, watching a film with resonant issues, reading novels or non-fiction books that open unexplored but relevant vistas, or, talking with a friend whom one trusts and respects, can be helpful. Indeed all of life’s experiences invite us to deeper understanding if we can but be attuned to them without fear.

On Developing Self-Awareness

Socrates famously told his students that the unexamined life is not worth living. For most of us, vast areas of our lives are rarely examined. We dwell within the necessities of daily life and but seldom find the inner leisure and motivation to look more deeply at ourselves. People come into therapy because they are unhappy. The cause of their unhappiness may be focused specifically on one or two areas: a troubled relationship, an illness, or difficulties at work. Rather than having a specific content, their unhappiness might be experienced more as an unexplained over-all sense of malaise. Going to a medical doctor because we are ill or in pain, we seek an explanation and hopefully, a cure. Seeing a therapist, we look for a similar outcome. Like the doctor, the therapist must bring all of her knowledge and experience to play in assessing the client’s situation and formulating a direction for their work together. A general sense can emerge from the first session but the process of assessment is on-going, as the partners in the therapeutic endeavor reach deeper and deeper into the ways in which the client’s troubles are enacted and perpetuated in her daily life.

Talking about her troubles and receiving feedback can move a person closer to an awareness of dynamics in her present life which she experiences but may not be fully in touch with. This awareness can be expanded when, for example, her therapist enquires about her physical and feeling state in the session itself. For many of us reflection of that nature is quite foreign. Our consciousness is focused on the interaction itself. At another level, however, we are reacting mentally, emotionally, and physically to the person with whom we are talking. For example, though I might be speaking of a conflict with someone at work, internally whole other things can be going on. I might feel intimidated by the therapist whom, without realizing it, I have elevated to the role of an authority, someone who could judge me pejoratively. Alongside this reaction can be one of resentment for what I experience as being actually or potentially criticized and dismissed. At the same time I likely have other feelings, for example, longings to be understood and cared for at levels that have never been fully met. In my body are chronic tensions exacerbated by the intensity of this encounter with a person who so clearly is focused upon my words and feelings in a way rarely experienced. 

Exploring some of these reactions in the session can help me to be more aware of the quality of my interactions with others and thus to more deeply understand them. Especially when my inner responses to people and situations are viewed within the context of the dynamics of my formative years, I can develop an appreciation of the ways in which these dynamics have shaped my approaches to the world and to others. In itself this broadening perspective allows me a space to explore the possibilities of other ways of viewing and responding to the exigencies of life.

In my next post I will write about efforts that I can make between sessions that can further expand this “terra incognita,” the inner life which proceeds with or without my conscious awareness.

On Anxiety and Agitation

The kind of agitation that I wrote about in my last post can serve a variety of purposes in the inner economy of emotion. It is a stimulant, in the sense that it produces and is produced by increased levels of adrenalin in one’s body. This process can be helpful in situations where we need an extra bit of energy to protect ourselves or to complete a task. It can also have detrimental effects, especially if one lives in a fairly chronic, possibly unperceived state of heightened alertness. It is possible to exist in a manner comparable to that of a bird or small mammal, much of our energy focused on scanning the environment (physical and social) for any hint of threat, ready to react. Chronic stimulation of this nature depletes our bodies, however, and over time can compromise our immune systems. Moreover, it limits the scope of our lives, the capacity we have for taking risks, whether in personal relationships or in other areas. It also lessens our capacity for more deeply knowing and understanding our own selves. 

Focused as we are upon the possibility of threat, we have not the inner leisure and calm needed for self-reflection. We exist with a mentality and an emotional life not unlike that experienced by people living in a war zone. Life is lived, in a sense, within the confines of a state of emergency, with its concomitant stimulations, terrors, and despairs.

A reasonable enquiry from someone beginning to tune in to this dynamic within her body might be: how did I get this way? It’s an important question, but one that may never be fully or adequately answered. Nor is a full answer essential to change or healing. Information of this nature can be interesting, perhaps even enlightening, and can to a certain extent assist change. In and of itself, however, it cannot bring about the transformation of body and mind that is needed to liberate a sufferer from debilitating anxiety and the agitation that it produces. Early in my work with someone I ask her for a general description of the emotional climate within which she was raised. Who were the members of her family? How did they relate to one another and to her? How were conflict and anger managed within the household? In what manner was discipline maintained? Moving more and more deeply into the marrow of the client’s answers of these and other queries, over time we conduct a kind of archeological expedition through the heart and history of her background. We seek an understanding and delineation of the influences that have contributed in myriad ways to her formation and in a sense constitute the framework of the person that she is now in her present life.

Some clever person has come up with an analogy likening the world in which we develop to a fish bowl. Fish breathe in and out the water that surrounds them, drawing into their bodies whatever nutrients and pollutants it contains. From the earliest moments of our existence, certainly in the womb, we are permeated with whatever of good or ill circulates within our mother’s being. As our nervous systems develop receptivity, we are affected not only by the foods ingested by her, but also by the emotional climate in which she dwells. When that space is charged with fears – from conditions of war, extreme poverty, domestic conflict, or from irrational reactions to imagined threats – her anxiety and its hormonal concomitants are in the same manner made a formative part of our being. As very young children, before our brains have developed cognitively, we experience the same instinctive responses to threat as any mammal. Loud noises, yelling, fighting in our vicinity, the face of an enraged parent close to ours, or sustaining blows for offenses we are incapable of understanding, can trigger feelings of real terror. It is not hard to see insecurity manifested in the stance and behavior of cats or dogs that have been frightened or mistreated when young. Our responses are similar to theirs. Threatening experiences or chronic, adverse conditions lay down physiological sensitivities to similar stimuli, even expanding to fields greater than those which have caused our responses.

No one has escaped frightening or hurtful experiences in their formative years, but there is clearly a wide spectrum of the severity and persistence of these events. The extent to which we are affected relies on where we lie on that spectrum, as well as on other factors. People differ vastly in their temperamental make-ups. Some are constitutionally more able to deal with stress than others. Location in the family structure can play a role, as can many other factors such as the degree of support given by other members of the family or community. Genetics also is important: we can be more or less susceptible to mental health difficulties as our experiences intersect with any underlying predisposition to these troubles. Teasing out the threads that have woven the matrix of someone’s anxiety is not a simple task, but a perspective on various pieces can often help a person to better understand what they are dealing with and even prompt strategies for diminishing its effects.

On Listening

Reading Alain de Botton’s book, How Proust Can Change Your Life, I am aware that reflecting deeply on the ideas he is presenting can indeed change one’s life. Botton’s look at the author highlights the way in which Proust goes beyond the surface and the obvious, to a realm where to understand one must simply let go. Not an easy thing to do, to just let go, to be in the present and to allow the realities of the present in all of their simplicity and complexity to affect one. But it is exactly this skill or habit or way of being that can situate a therapist to most deeply be of assistance to her client. Theodore Reik called attention to a skill of this kind, calling it, “listening with the third ear.” To me this means “listening” with the whole of one’s being, past, present, and future, body, mind, and spirit. I think of all of us as, in a way, holograms of the whole of our existences. When we meet with others in any setting these holograms interact with one another on both superficial and profound levels. 

If I am able to some extent to be connected to the whole of the being that is myself in that moment of intersection with another, I can then most openly and meaningfully recognize and “be with,” that is, deeply “listen” to the other. The act of listening occurs on mental, emotional, and physical levels. Aware of, though not reflecting on especially, my own history, experiences, physical and emotional states, I am simultaneously receptive to, though again not necessarily reflecting upon, parallel dimensions in my client. I take in, to the extent that I am wholly present to her, all that she is communicating to me, verbally and by hundreds of unspoken messages given through gestures, tone of voice, bodily arrangement, facial expressions, eye contact, and so on. Just being in the presence of the client in a state of presence with myself, I am then able to “hear” and respond to this myriad of communications in ways that can be revealing to us both. In the things that she says to me I may be aware especially of a word or tone that expresses and conceals at the same time.

An example: A woman relates to me a series of circumstances that have caused her agitation and unhappiness in recent days. What most catches my attention as she speaks is her mounting agitation. I stop her and ask what she is aware of within herself at that moment. She pauses and acknowledges that as she is talking she is becoming more agitated. From past sessions and work we already know that the regular discourse of her family of origin involves the mutual sharing of stories of thwarted goals. Each actor in a scene recounts in escalating crescendo the horrors of recent experiences. One revelation prompts another. The agitation of one stirs that of another and a growing pool of unhappiness, indignation, and cynicism regarding the possibility of life being lived peacefully, settles about the group, pervading and maintaining the tone of their interactions. In our session my client was engaged in this familiar pattern as she gave me her recitation of unhappy circumstances. 

My interrupting and questioning her about her feeling state during the speech allowed her to move out of the environment of her family in which she had been mentally and emotionally dwelling as she spoke to me, and back into the space that she and I share when she comes to see me. Within this space she has, over time, developed sufficient security to risk letting go of some automatic defensive locations, still maintained to a certain degree with her family and others. As a way of feeling relatively safe in what seems a chaotic arena, being annoyed and indignant can work. Giving one some sense of personal power, it is certainly safer than displaying vulnerability and openness. 

As I spoke with her about the effect that her tale of the day’s or week’s misfortunes has had upon herself, and usually upon her listener, she began to calm down and to understand at another level the reasons and effects of her behavior. We went through once again a quiet exchange about the importance of letting go of minor agitations, of seeing these as a normal part of life, rather than excuses for maintaining, nurturing even, a chronic state of unhappiness and discouragement. In recognizing the pattern that she is falling into she has at her disposal a couple of simple, though not necessarily easy to acquire habits: take a few deep breathes and repeat to herself, out loud if possible, “Just let it go.”

The reader may be skeptical about the effectiveness of such a simple process, but certainly my client, over time, as she has reminded herself to use this method, is learning to calm herself and to establish an inner perspective on the relative necessity for alarm and rage about life’s ordinary difficulties.

About Fear

Some time ago I read an article about a biologist named Savolina. He looked at a study done in the 1950s by Balyav with foxes. People in the fur industry were concerned about the amount of aggressive behavior among their foxes. On their behalf Baylav looked at a feature of the foxes that he identified as “flight distance,” that is, how tame or frightened the animal was. Flight distance was measured in relation to the proximity of humans. If food was put out by someone who remained close by, individual foxes observing this, would differ in how far they would stay from the person and the food. If the person was to advance toward them, all of the foxes would run away but they would run different distances, depending upon how reactive they were to the fear of humans -- basically the fear of being captured or killed. One fox might run a half a mile, another 500 feet, and another 100 feet. When the human left, whoever was closest to the food would get there first and would eat it. This proved to be adaptive. Savolina related this behavior to the evolution of dogs from wolves in their interactions with humans. Those less frightened, would gradually be able to connect with and become a part of the human “pack” and be rewarded with food.

I considered Savolina's ideas in relation to human’s relationships to danger or perceived dangers. All sentient beings have a “hard-drive” response to danger. In mammals this is regulated by the autonomic nervous system fight-flight reactions. These reactions take over in cases of perceived danger. This is not taught behavior. Rather the reactions are “encoded” in the brain and nervous system. All mammals have these same automatic reactions. The world that we must navigate now is not the world humans lived in 100 years ago, 1000 years ago, or 100,000 years ago. In today’s world we very rarely fear being eaten by large animals or attacked by wild beasts. In some contexts we can fear being attacked by wild human beasts during war, for example, or in places where the rule of law is non-existence or perhaps in areas of our own country or city where we don’t feel safe. In those contexts we learn how to navigate: we learn a flight distance. Most of us simply stay away from places of war or areas of our cities where we feel unsafe. We have a sense of things of which to be wary by paying attention to signals that are real, not only from our bodies, but also which have been transmitted by media or by our community.

But there are many people who are over-reactive to signals of danger. They suffer anxiety or fears that are not even conscious. Discomfort is felt in various contexts – for example, social situations or ones in which a performance of some nature might be expected. Fears of this kind can take many faces and have a huge impact on a person’s daily life even though she may not have a particular consciousness of being afraid. She may have learned to distance herself from people, places or situations where she feels discomfort and does not necessarily examine or understand the sources of the discomfort. She may only be aware of a stomach upset or a shortness of breath and not recognize these feelings as bodily signals of fear. She may simply have a sense of not feeling well, a reaction which would further validate her withdrawal physically or emotionally from the context in which she feels her discomfort. More subtly, someone may adapt by living in a way that allows her to experience fewer signals of fear – either overt panic or anxiety or the unrecognized signals in the body. For example, she may not move from home or from her community. Perhaps she won’t travel abroad or even on the subway. If she does go away, she may feel a discomfort that is identified as homesickness. She goes home in order to feel better but does not understand that the real difficulty lies in her fear of unfamiliar settings and dangers that she fears may lie within them.

“Programmed” fear responses occur in situations which are not in themselves threatening. It is not, for example, particularly dangerous to travel on the bus or subway if one takes normal safety precautions. Nor is it an inherently scary thing to go out socially or communally; ordinarily people whom we meet are not going to punish or criticize or humiliate us. But fear, even an unconscious fear, that something of that kind could occur, will greatly curtail one’s ability to get around in the world. In my practice I am constantly struck with how often people present with difficulties in their lives which at bottom have their root in fear. There are tremendous elaborations resulting in physical problems, mood disorders, relationship problems, troubles with intimacy, with work, creativity, or with parenting. As I pursue different pieces that people bring, the greatest common denominators seem to be various levels of anxiety. In some, bodily reactions to threats have overwhelmed the person on a physiological level and become a kind of habit of the body – the way that Wilhelm Reich talked about the body carrying tensions to hold in threatening emotions.
With this awareness I work to discover the parameters of fear as they operate within the difficulties a person presents when she comes for therapy. Often I am aware of nervousness in her, manifested in agitated movements, a discomfort with silence, difficulty maintaining eye-contact, and the kinds of tensions that the person is obviously holding in her body.

When we come to doing relaxation, these anxieties become even more visible. In relaxation one listens deeply to the voice of another telling her muscles and nervous system and whole body to relax. In order to yield fully to these instructions, she will necessarily go closer to places of discomfort and fear that chronically lie within her body. Experiences which one has had when young, perhaps of which she has no memory, can have made her suspicious of being fully relaxed in the presence of another person. Her eyes are closed and she is in a semi-recumbent position with her legs and arms uncrossed. She is deliberately trying to let go of muscles that are ordinarily kept tight. She has discovered a long time ago that when she holds herself tightly, she feels more alert, more ready for the scary thing that has happened and could happen again. So when someone tells her to relax and let go, she will move toward those things that she doesn’t want to feel and there will be a reaction. This may take the form of tensions in her legs: those legs want to be ready for running – to get out away. Or she may be aware of the tensions in her neck and shoulders. She keeps herself tight in her upper body with energy concentrated in her head – keeping alert and ready. Her eyes may twitch as she struggles to comply with the therapist’s directive to keep them closed. Her body’s reaction is to keep “the other” in view.

Letting go deeply enough to gradually connect with the feelings of terror that underlie her body’s tensions is a slow process that requires patience and a great deal of trust. It is the gradual evolution of this trust that over time can operate on many levels within the therapeutic relationship to allow an easing of the fear that she has carried and the development of strategies that allow new forays into a world once boundaried by threat.