Friday, September 25, 2009

Refusing to Get Help

By Kevin Murphy MSc.,
Psychoanalytic Psychoanalyst,
Dublin, Ireland.

A question I get asked regularly is how can someone get their son, daughter, husband, wife or partner who is in bad need of therapy to agree to go? It is usually asked by a distraught loved one who has watched, witnessed, or taken the brunt of some pretty bad behaviour over an extended period of time.
And it is usually asked because the person in need of help is refusing to entertain the notion.
The problems can range from the sexually inappropriate, to aggressive acting out, to binge drinking and other addictive behaviours, on to emotionally manipulative and controlling acts. There is no end to what some people can inflict on those around them in a seemingly unending cycle of unhappiness and negativity.
So, is there a way of ‘getting’ someone to go to therapy when they don’t want to? The short answer is no. Therapy is often the last thing that these people will want to undergo. They are, to put it this way, in love with their way of doing things. It brings them a form of pleasure – one that may come disguised as un-pleasure – and they are usually very unwilling, or unable, to give it up.
It is only when, like those addicted to alcohol, they hit a personal ‘rock bottom’ that they eventually wake up to what it is they have been doing. But there is still no guarantee that everyone will do so. One person’s ‘rock bottom’ is another’s ‘half way down’ and vice versa. And there are those who, despite having chaotic lives, continue to blame everyone else for their woes.
Sometimes an extreme outcome makes them see sense. It is when a loved one has been driven away, or when their mental or physical health or their financial independence is at risk, or when their actions have brought them to the attention of the law, or when they have simply had enough of their own downward descent, that’s usually when they choose to seek help on their own account.
I was reminded of this reading Sigmund Freud’s 1937 paper ‘Analysis Terminable and Interminable’ in which he talks about resistance. Resistance is a classic psychoanalytical concept in which the person in therapy actively ‘resists’ letting out any information about themselves. Freud argues coherently that our defense mechanisms are laid down at an early age in our lives when we are facing external and internal experiences that may not be pleasant and so constitute threats that we are pretty much powerless to deal with.
In order to deal with external threats we can complain, or cry, or move away in what ever way we can. But internal threats, such as anxiety or surges of energy, or fear or discomfort, or anything unpleasurable that causes us to resist the experience, means we must put into effect defense mechanisms.
These mechanisms can be denial, repression, shock reaction, introverted-ness, a splitting off of ourselves from reality and so on. The point Freud makes is that while they were once directed against former perceived dangers they recur in the therapy in the form of resistances. And what do these resistances act against? They act against recovery itself, he says. Or as he put it: “It follows… that the ego treats recovery itself as a new danger.”

Taking this concept and applying it to those who refuse, despite the evidence all around them, to accept that they need help of some kind, we come to an interesting perspective. If you accept what Freud says, then you are left with a picture of people who are resisting anything that might help them recover. This not only happens within the therapeutic setting but it is also a factor in people deciding not to enter the process in the first place. The difference being, however, that while resistance can be a challenge within therapy, at least the person has entered the process to begin with so their resistance can be dealt with in that context.
The person who refuses to go at all is a bigger challenge. Usually it is not until their own defenses have broken down, and so allow for the desire to recover to take root, that they can begin to help themselves.
Even getting someone through the door of a therapist’s office is not the victory that it might seem. If someone is unwilling or unready to undergo the necessary engagement and examination of themselves, then it will be just a sham. And do people engage in it for spurious reasons?
Unfortunately they do even if thankfully it is the exception rather than the rule. Why? Sometimes it is to keep troublesome family members off their backs. Sometimes it is to make it look like they are doing something about the problem when in fact they have no interest in doing so.
Some people like being the way they are. You could say they like their symptom and they can’t imagine life without it.
The harsh fact is that like so many endeavours in life, the more people put in to therapy the more they get out of it. It’s a simple proposition. But convincing some people of that idea is not simple at all.

Friday, September 18, 2009

Acting Out in Violent Ways

By Kevin Murphy MSc.,
Psychoanalytic Psychoanalyst,
Dublin, Ireland.

Another young man in Germany has attacked a school and caused bodily harm to his peers. Probably like so many of the cases we hear about, and Ireland has its own recent examples of young men being unexpectedly violent, we will discover that he was a quiet person who gave no sign of being capable of doing such a thing. Friends will probably recall that he was a doer of good deeds if a little shy, a bit withdrawn even. And yet he was probably friendly when people did talk to him.
His bewildered parents will probably remember him in their grief as a conscientious boy who had been a wonderful son. But in recent years he had become somewhat introverted. They first noticed this when he had a setback with school or friends or a girlfriend. He was not into drugs or drink. He was polite with most people. They cannot understand it.
I am not trying to read the future but rather draw on what we know from past experiences of this kind. In most of these cases that you read about, the individuals who are almost exclusively young or young-ish males have shown no sign of pathology. That is, they have not shown any obvious signs of being mentally ill. They have - up to the moment of their attack on friends, or school mates, or family –been living relatively normal lives that are subject to the same ups and downs that everyone experiences.
But what marks them out is that the act they committed involved, to a greater or lesser extent, some degree of planning, some degree of having been thought out beforehand. This makes what they chose to do rather different from blind rage.

French clinical psychiatry and Lacanian psychoanalysis, which is also French in origin, has a phrase called ‘passage à l’acte’ or passage to the act. It designates impulsive acts, of a violent or criminal nature, which sometimes mark the onset of an acute psychotic episode.
These acts mark the point when the person moves, almost in the blinking of an eye, from a violent idea to the carrying out of the act. Because these acts are attributed to the action of madness, however temporary it might have been, French law says that the person does not have civil responsibility for them. One could call them crimes of passion.
It was French psychoanalyst Dr Jacques Lacan who spotted the difference and laid out the finer points of the distinction between this kind of action and what is more commonly known as ‘acting out’. For him, both sets of actions were last resort defences against extreme anxiety but there is a distinct difference.
The person who ‘acts out’ remains within the scene he or she is creating. That is to say they ‘remain’ in that they have a knowing sense of what it is they are doing, despite it being wrong or harmful. This same sense of knowing allows them prepare petrol bombs or buy weapons and plan out their attack.
By contrast, in a ‘passage to the act’, the person who commits the offence or the crime does not stay in the scene but effectively exits from the scene altogether at the moment it happens. This is best illustrated by someone who, pushed to an arbitrary and personal limit of endurance, strikes out at someone they love in such a way that causes catastrophic damage and they remember practically nothing about it afterwards.
The action feels as if it is over in an instant, almost before they know it. In this sense the person they normally are leaves the scene momentarily, even while carrying out the attack, only to return ‘to their senses’ and the consequences of what they have done.
For Lacan, ‘acting out’ is a symbolic message addressed to the bigger society in which we live. It is a message sent to the big ‘out there’, to no one in particular and yet to everyone. It is one that wants its meaning to be inscribed on the person’s own past as well on our communal present and our future. It seeks to insert itself into myth, history and even language itself. It says ‘I have suffered and the world must know’.
A ‘passage to the act’ is the opposite. It is a flight, albeit one that takes place at an automatic level, from language, experience, interpretation and the salvation of the human relationship into the raw, unmediated, beyond words, almost too-real dimension of physical destruction. In carrying out a ‘passage to the act’ therefore the person is exiting from the intricate network of symbols, signs and language that tie us all together in the social bond.
The person who ‘acts out’ is having the same destructive effect except they are very much present in the scene. And while the rage that drives the desire to harm is similar, it has risen to consciousness much earlier and embraced the idea to strike out over a longer period of time.
The symptoms of internalized rage are obviously difficult to see. Especially when you consider how many times the acts of violent young men are described as ‘out of character’ by those who knew them well. So if they are not obvious, then perhaps it is time we paid attention to the less obvious, less observable, almost invisible signs.
For over 150 years, psychoanalysis has posited that aggression and the potential for violence lurks within us all. It is part of our structural framework but for most of us the effects of parents, family, society, our personal constitution and personalities ensure that we remain able to contain and master it. But it lurks there in our unconscious nevertheless. Maybe an approach that took more account of this aspect of our mental life could make us more astute in seeing the signs.

Friday, September 11, 2009

Allowing the Therapy Speak for Itself

By Kevin Murphy MSc.,
Psychoanalytic Psychoanalyst,
Dublin, Ireland.

Two separate clients decided to finish up their treatment at around the same time recently because each said they were feeling better. When I asked how they felt at the end of treatment compared to how they felt when they started, the first client said the things that were worrying them when they first came weren’t a worry anymore. These things hadn’t gone away and yet for some reason over the course of the treatment they had ceased to be a major, all encompassing worry in their life.
The other thing this client said was that before they started treatment they could not imagine a future in which things got any better for them or improved in any way. They said they had felt destined to live a life that was pretty much stuck in the same way of dealing with things, getting hurt at the same situations, at the same negative ideas that occurred to them, and they had become resigned to nursing themselves through life with practically no sense of self belief or joy in what they did.
By comparison, this client said that they were now experiencing optimism for the first time in a long time and that the future seemed to hold out a range of different possibilities and opportunities for improvement.
When I asked this particular client what they thought it was within the therapeutic process that had brought about such a change, they replied: ‘I don’t know.’
The second client I referred to had come to treatment because a particular compulsion was taking over their life. This particular compulsion had put their main relationship under pressure and it was threatening to make life difficult in terms of family and work relationships.
When this second client decided to finish up treatment I asked the same question about the difference between before and after. Before treatment this client had tried to hide the compulsion, disguising its effects in all sorts of ways from their partner, and had become obsessed with the negative implications it held for them. A lot of worrying and stress was carried out in private in case anyone should find out about it.
At the end of treatment, the client said they were no longer compulsively engaging in this behaviour and had stopped completely. Needless to say, I had not made any suggestions in this regard during the therapy. The client also said their main relationship had improved hugely and their sense of relief and self-belief had returned.
When I asked the same question about what they thought had taken place in the therapy to bring this about, they gave the same reply as the first client. They didn’t know.
It’s nice to see therapy work. But it is not always possible to say why it works, particularly from the client’s perspective. Not that it matters to someone very much if they manage to pass from fear or compulsive behaviour or whatever, to a more balanced, optimistic position.
But it points to the essence of what goes on in therapy. Psychoanalytic theory is rich in explanations and theories as to what the process does: it lifts repression, restores inner energies to their rightful places, brings into consciousness new understandings and meanings, undoes some of the damage of faulty ideas or imagined notions and concepts, allows us reconfigure past experiences that have remained unresolved, and places it all in a current context that allows us get on with our lives, right here, right now.
But from the client’s point of view, there is no direct experience of these things. There is often no putting a finger on exactly what it is that has made the positive changes take place. The experience of therapy will have felt like simply talking. And sometimes it will have felt like talking about the most random, most trivial aspects of one’s life. And yet somehow this activity contributes to a gradually improving sense of one’s self.
The act of speaking, in its fullest sense, in the choice of what one chooses to speak about, in the choice of words one uses to describe those things, in the way the thing spoken about before that or immediately after that might signal a connection or no connection at all with anything else. It is in these things that meanings make themselves felt, not always and exclusively between the client and the therapist because frankly not ever therapeutic session ends with a neatly wrapped up set of meanings that flood the client with insight.
No, it is more a gentle accumulation of meanings within the clients themselves, often not recognised at first, but over time these newer meanings insist their way into the person’s way of thinking about the world and their place in it.
It is not an obvious process. It creeps up on you before you realize it. That’s why the two clients above could point to definite improvements in their quality of life but were unable to say why it had taken place.

Friday, September 4, 2009

Losing Our Sense of Who We Are - 4

By Kevin Murphy MSc.,
Psychoanalytic Psychotherapist,
Dublin, Ireland.

To conclude on the subject of anxiety, I finished last week on the idea that in anxiety we revert from having an objective sense of who we are, from a position in which we can stand back, evaluate, view ourselves relatively dispassionately, to an almost primal sense of vulnerable subjectivity. We come to painfully inhabit ourselves in a way that is so intense it paralyses us and shows us a frightening and fragile sense of control and incompleteness within ourselves.
Our identity establishes itself with an embrace of the visual image while the reality of fragmentation and un-coordination are essentially repressed, a point of division if you like. So, modern Lacanian psychoanalytic theory proposes that anxiety brings this moment of division crashing back into consciousness: it undoes our defenses, breaks the bonds that hold our sense of who we like to think we are, and so it leaves us open and vulnerable. But to what?
I cited a fascinating article two week’s ago that appeared in the 2002 edition of the International Journal of Psycho-Analysis and that was written by Dublin psychoanalyst Dr Olga Cox Cameron. It looks at the question of anxiety by considering the characters in Ian McEwan’s novel ‘Enduring Love’.
According to Cox Cameron, under the pressure of severe anxiety, and remember this is an invisible fear that has very primal roots in all of us, the visual image, or rather the object-ness on which our identity has been formed, collapses.
But, she says, it does not collapse into nothingness. Instead, and much more disturbingly, it collapses in a way that brings about an excess of our sense of ourselves as someone without supports. We are an object of our own anxiety but this time an object that is acutely, painfully and helplessly aware of the experience.
The intensity of anxiety can range all the way from mild but uncomfortable self consciousness to anxiety- ridden panic attacks and beyond. But this excessive experience of self is at the core of the anxiety experience that prompts people to seek treatment.
It is a ‘too much’ of ourselves, an intense focus on ourselves and on the uncontrollable fear that ruptures all other connections to the world around us and the supports and anchors that normally operate. We are cut loose, free floating, with only fear and an intense sense of our isolated presence to accompany us.
It is this experience, as Freud pointed out in his 1894 ‘Anxiety’, that is the polar opposite or the reverse side of, desire. It is marked by the lack of comfort, security, happiness, confidence, wholeness and peace of mind. And not only is it lacking in these ‘anchors’ but it is characterized by an excessive sense of ourselves as being present in the experience.
The final conundrum is why some experience it and others don’t. Some experience it acutely but most experience it in a mild and controllable or less disturbing form. Either way, it is part of the human condition, a result of childhood experiences and re-ignited or reinforced by life experiences and the stresses and strains of living.
The pressure of modern life is keenly felt by some, particularly those whose sense of identity is prone to being unsettled or whose sense of confidence and happiness is delicately balanced. Anxiety shatters the careful and, in some cases, tenuous bonds that tie us together and give us a sense of wholeness.
Along with wholeness, these bonds give us a comfortable sense of who we are as complete, coordinated and grounded individuals by sustaining a necessary distance from our weaker qualities. It is the overwhelming sense of ourselves as less than capable or competent or resilient or whole that anxiety floods us with.
Psychoanalytic theory offers practical tools with which to examine the particular experiences of anxiety that particular clients undergo. This is not a one-size-fits-all therapy. It is the therapy of the individual, and everyone is different, everyone has a particular set of meanings, non-meanings and truths that are not the same for anyone else.
So, what does the theory offer us in terms of searching out meaning, non-meaning and particular truths? It asks where the person is situated in terms of their network of human relations. What is the quality of relationships? Is there a sense of connection or rupture in them? If rupture, what are the parameters of that? It also asks about the nature of the person’s identity, their real bodily image, their imaginary image of themselves, and where both fit in relation to the ideals they might have about themselves and the ideals they feel others have for them? This is not the complete list but the psychoanalytic approach offers a matrix of essentially human guy-lines along which the often complex nature of therapy can steer itself.
But in the same way that it is not a ‘one-size-fits-all’ therapy nor is it a quick-fix therapy. By the time some people come for help they want an instant cure. Years of ignoring the signs have allowed anxiety build to the point of being unbearable.
Anxiety is experienced directly as a confusing and overwhelming fear. But behind the scenes it is usually made up of a number of different strands. Its power derives from the fact that its energy comes from a number of different sources, much like a powerful river with a number of tributaries feeding into it.
The work of psychoanalytic psychotherapy involves an investment of time in picking out these various strands so that the force with which anxiety strikes can be lessened and dissipated.