24 Jan

Resisting Change in Psychotherpay

“A world that can be explained even with bad
reasons is a familiar world”. (Camus)

People seek the guidance of a therapist when there is disruption and distress in their lives and their usual self-limiting, risk-avoiding way of operating are not paying off. Such patients arrive full of fear, pain, and turmoil expressing strong and genuine wishes to deal with their situation. As surprising at it may seem however, most of these people are not truly serious about actually doing something to change. Rather, their primary motivation is to get the pain to stop.

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13 Jan


Studies indicate that 15-30% of adults in the general population experience depressive episodes often of moderate severity at some time in their lives. While many individuals will be seen by their family physicians and G.P`s, only only a minority of people with clinical depression seek professional health from psychologists, psychiatrists, and other mental health workers. Because of difficulties in gaining access to treatment, financial disadvantages, stigma and shame etc., most people suffering from depression do not receive professional help.

Symptoms of Depression
Clinically, people with depression almost always experience one or more of the following symptoms

1) Depressed mood characterized by reports of feeling sad, low, blue, despondent, gloomy, hopeless etc.

2) Inability to experience pleasure
This symptom is almost universal in that almost all people report that previous sources of gratification such as food sex, hobbies, sports social events or time spent with children family or friends no longer provide pleasure

3) Loss of energy, fatigue
This is also associated with reduced social, familial, occupational and sexual activity and feelings of being run down, of heaviness in the arms and legs and of energy being drained from the body. Often these feeling states are interpreted as nervous exhaustion, overwork, nervous breakdown, or vitamin or nutritional deficiency. In severe forms the person may believe, sometimes with delusional intensity, that she is suffering from a life threatening malady such as AIDS

4) Retardation of speech, thought and movement
Psychomotor retardation manifests as slow physical movements. Speech is slower and reduced in volume, answers to questions are delayed, and content of the verbal response is sparse (yes or no answers). Depressed patients often complain of diminished ability to think or concentrate with complaints and often experience mixed up thoughts

5) Changes in appetite, usually weight loss
Approximately 70% of patients experience loss of appetite and weight loss.
A minority, especially younger patients with milder forms of depression may experience an increase in eating often in the evening and at night

6) Sleep disturbances, usually insomnia
Depressed individuals may have difficulty in falling asleep with ruminations (thoughts about events and experiences that won’t stop and endless re-examination of details of life circumstances). Others may awaken early in the morning or be awakened in the middle of the night by frightening dreams or uncomfortable body sensations. Not surprisingly, they often feel tired throughout the day

7) Bodily complaints
This symptom involves complaints that include headaches, neck-ache, back pain, muscle cramps, nausea, vomiting, constipation, heartburn, indigestion, gas, blurred vision etc.. In fact, almost every organ may be involved often leading family physicians to prescribe expensive medical tests and work-ups

8) Agitation (increased motor activity experienced as restlessness)
With this symptom there is increased psychomotor activity experienced as ego-alien (i.e. why is this happening to me) and typically reported as restlessness or tension. The person may complain of being unable to relax or sit still, or being fidgety
Efforts to release this tensions are often seen in the wringing of the hands, nail biting, or increased smoking.

9) Decrease in sexual interest and activity
Impotence in men is a frequent distressing symptom that may aggravate marital tension and further diminish a persons self-esteem.

10) Loss of interest in work and other activities
Although loss of interest may occur the persons actual level of performance may not fall. In severe states the depressed person may be unable to assume his ordinary responsibilities or family role claiming nervous exhaustion or inability to cope.

11)Lowered self-esteem.
Persistent feelings of inadequacy and inferiority are often present during an acute depressive state. This especially troubling when the patient feels that family members, friends and work associates also feel this way about them.

12)Feelings of helplessness
In more severe depressions patients complain they cannot cope even with simple tasks of dressing, self-care or grooming. Parental, household or occupational tasks are even more difficult to negotiate

Handicapped by feelings of low self-esteem and helplessness, depressives patients also report feeling pessimistic and hopeless. In addition to fears and worries about health, finances, family affairs and their careers, such patients tend to anticipate misfortune, experience gloom and forecast doom.

In its most severe form despair may be all encompassing and may be associated with suicidal thoughts and acts.

Among patients with recurrent depressions death by suicide occurs at the rate of about 1% per year. The highest period of suicidal mortality occurs 6 to 9 months after symptomatic improvement has occurred. In these instances the patient’s apparent symptomatic improvement reflects an inner decision to commit suicide and the outer calm covers the further development of plans for self-destruction.

10 Jan

A Therapist’s View Of Human Suffering

“We are the hollow men
We are the stuffed men
Leaning together
Headpiece filled with straw. Alas!Shape without form, shade without colour
Paralyzed force, gesture without motion;…”
(“The Hollow Men”, T.S. Elliot)

Across the years of offering psychotherapy  with thousands of patients, I have been continuously struck by one remarkable and puzzling phenomenon. Almost without exception, psychotherapy patients seem to have tremendous difficulty in presenting the subjective experiences associated with their reported problems.

For example, they might say they are sad, but they smile; they say they are angry but they cry. At first glance, this may seem to suggest an intentional hiding or distorting of what they actually feel, a willful attempt to disguise or hold back.

In fact, this is not the case.

Let me try to clarify.

At the start, most patients are eager and willing to “talk” about their problems: their careers, their spouses, or whatever else they feel is causing distress in their lives. With a little encouragement most are also willing to “describe” their feelings surrounding these events; “I feel depressed”, “I feel angry”.

But these same people are very cautious and even reluctant to allow these experiences to actually manifest in our sessions (i.e. they say they are angry but they appear very calm). And sometimes, when feelings actually do surface they are often not congruent with what the patient described (i.e. they say they are angry and smile at me.)

But why should this happen? Why should a person who may have been suffering for many years have such difficulty in actually allowing that suffering to be present during our sessions? And why, when certain emotions do show through, do so many patients seem embarrassed or anxious, as though something slipped out that wasn’t supposed to.

This apparent difficulty and reluctance in presenting more than a superficial amount of one’s subjective experience to another is not an uncommon phenomenon, and is certainly not restricted to the interaction between therapist and patient. Rather, it seems to me quite clearly a “normal” quality of social life, an accepted and expected part of our day to day interactions.

Ask someone, anyone, how they truly and deeply feel about themselves, or their partner, their parents, or you, and see what happens. Not far beyond the simple explanations, the pat answers and the clichés, there seems to be an amazingly sensitive and protected area of subjective reality; a restricted access zone seldom offered to anyone.

The significance of this issue is not simply that we are careful about letting anyone get too close to us. Rather, it is that we are remarkably uncomfortable about even letting ourselves get too close to us. As strange as this may sound, clinical and personal observation confirms that we are basically and fundamentally uncomfortable with , if not afraid of ourselves; with precisely those experiences that centrally define what it means to be ourself.

In truth we don’t know what we really feel because we won’t allow ourselves to feel it. We don’t show this to another because we can’t.

Depending on your relationship to your own subjective reality this observation may seem puzzling, perhaps even inconsequential. But it is not. Consider this following observation by Rollo May, a psychoanalyst in New York City, who defines the chief problem of people in the 20th century as “emptiness”. As he describes it,

not only do many people not know what they want, they often do not have any clear idea of what they feel. When they talk about their lack of autonomy or lament their inability to make decisions, it soon becomes apparent that their underlying problem is that they have no definite idea of their own desires or wants. Thus they feel swayed this way and that, with painful feelings of powerlessness, because they feel vacuous, empty”.

Indeed, the significance of this phenomenon has been recognized, discussed, and debated for hundreds of years by every major thinker of the human condition from Kierkegaard, to Rank, Jung, Freud, and Maslow, as each has attempted to explain this curious and remarkable fact.

The real world significance of this issue is far reaching. Regardless of whether we are talking about personality disorders, depression, anxiety, physical illness, domestic violence, or social unrest, there is always some connection back again to this central aspect of the human condition. Call it alienation, existential anxiety, repression, disassociation, emptiness, or any other term that points in this direction. The failure to recognize and deal with the fact that we are all strangers to ourselves, and by extension,  with others, has lead to immense human suffering. This is a remarkably complex subject requiring considerable clarification. In subsequent issues I will present some of these ideas in more detail.

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