Actions Speak Louder Than Words

One of the greatest lessons that I’ve learned which I try to impart upon my patients is that actions speak louder than words every time. This applies whether we are discussing another person in the patient’s life or the patient herself. In other words, one can deceive themselves and others, either intentionally or not, but if we pay attention to an individual’s behavior, we get a much clearer picture of what is really going on. The unconscious is incredibly powerful and one’s behaviors cannot help but betray one’s true sentiments. We can train ourselves to pay more attention and become better attuned to the non-verbal cues that are being expressed.

These non-verbal cues include subtle facial expressions and body postures as well as more obvious behavioral patterns such as perpetual lateness and cancellations, continued inaction, or repeated substance use. I encourage my patients to “turn off the volume” and pay attention to the non-verbal signals they pick up on from others, rather than the words they are being told. One patient who is having problems in her marriage is continually frustrated and upset when her husband says he wants to fight for their relationship but his actions indicate otherwise. This spouse has taken little to no steps to start individual or couples therapy, has not done anything to improve his health through diet and exercise, continues to drink alcohol excessively, and does very little to help out with the household chores. Another patient often arrives for her appointment ten to twenty minutes late or cancels a day before and asks to wait until the following week to meet. Yet another patient consistently arrives for his appointment thirty minutes early yet “forgets” to pay his co-payment every other week. Therapists have learned to track these behavioral patterns, for they provide a wealth of information about the individual’s unconscious motivations.

I caution my patients not to interpret the behaviors of others. We may hypothesize about what the non-verbal behavior tells us, but we are not mind-readers and we cannot know with certainty the meaning of these behaviors. For instance, the patient who is consistently late for her appointments may be unconsciously expressing anger toward me and/or may be acting on her fears about accessing painful emotions in therapy by attempting to regulate the amount of contact we have to ensure that she not come in contact with these feelings.

Interpreting another’s behavior can lead to confusion, anger, and faulty assumptions; simply paying attention to what the patterns of behavior are is safer, as it is almost always non-disputable. If I point out to the female patient above that she frequently arrives to her sessions late or cancels her therapy appointments, this data is merely observable fact that is indisputable. If I interpret the meaning of this behavior as an expression of the patient’s anger toward me, then I have crossed into the murky territory of attempting to guess the reasons for her behavior. The patient may disagree with my interpretation and a therapeutic rift may occur or my deductions may be incorrect. I caution my patients to stick to the observable behaviors without interpreting the meaning of said behaviors. By strengthening our ability to “mute” another’s words and tune into behaviors, we can develop our ability to accurately pay attention to the incredibly powerful non-verbal communications that are being expressed before our eyes.

The Role of Meditation Practice In Psychotherapy

In recent years I have begun implementing meditation practice during the first ten minutes of a session with some of my patients. The choice whether to meditate or not is always at the discretion of the patient. The purpose of such practice is to help bring awareness to one’s internal world in the present moment. This encompasses improving one’s attunement to emotions and physical sensations that can be detected in the body. I have found that many people are initially uncomfortable being with themselves in the here-and-now, and thus they flee being in the present and resort to living in the past or future, allowing their thoughts to distract them from what is right before them.

Most people do not need my help accessing their thoughts; they can fairly readily identify what they are thinking. It can be a different matter when they are trying to identify what they are feeling. When an emotion is intensely felt, it is likelier that the individual will notice it and be able to describe it. One is more apt to recognize that she is enraged than to recognize that she is mildly annoyed. But if we believe that all people have thoughts, feelings, and physical sensations at every moment, whether we are aware of it or not, then we can begin to see how difficult it can be for many people to access feelings when felt to a lesser degree. This concept that people have thoughts, feelings, and physical sensations at every moment is similar to breathing. Once an individual is encouraged to focus on his breathing, he usually can do so easily. We are all breathing at every moment but often we are not paying attention to our breathing. The same applies for thoughts, feelings, and physical sensations. Some people may find identifying and accessing physical sensations challenging. Still more may struggle to identify and stay with their feelings. Trauma survivors in particular may struggle in this way, given that one of the ways they learned to cope with the trauma they experienced was to numb themselves and dissociate from their internal world. This serves a protective function. As adults many of these individuals have difficulty knowing what they are experiencing when it comes to emotions and physical sensations.

Meditation seems to assist people in building their awareness of what is happening internally. Furthermore, it can help people learn to stay in the present moment and tolerate inhabiting their own internal world without feeling threatened by unpleasant emotions. I’ve witnessed people who initially had trouble sitting still because they were so anxious learn to relax into a ten minute meditation practice and open themselves up to the present. With most patients we start and end the meditation practice with four deep breathing inhalations and exhalations. This seems to help people relax and prepare themselves for the meditation. During the meditation itself, patients are instructed to focus on something simple, such as their breath, that they can keep returning to when their minds start to wander. They simply can notice and be curious about the thought that distracted them and then return to their breathing. With some patients, it is preferred to scan the body from head to toe during the meditation as a way to tune into what is happening internally. By conducting a body scan, one might become aware of tension and other physical sensations that are being held in various body parts. Another option is to draw one’s awareness to the sounds around them, both near and far. I invite my patients to focus on their breathing or to do a body scan, however, because these are ways to increase awareness of one’s internal space, whereas sound brings the individual to something that exists outside of them. Over time, most patients tell me that they have found that the meditation helps them be more aware of what is going on inside them, both with emotions and with physical sensations, and these skills can transfer to the their lives apart from the meditation. For the purpose of developing these skills during psychotherapy, I find that the term “awareness building” rather than “meditation” may be a better fit. People can get confused by what is meant by meditation practice. When we agree that we are working on improving their awareness of their feelings and body sensations, they can best understand how such practice can be of value to them. After the ten minutes, I find it useful to briefly discuss how the patient experienced the exercise and what she became aware of during the time. I also attend to whether starting with this practice has a positive shift for the remainder of the session and can help the patient feel more present and connected to me while engaged in the therapeutic endeavor.

The Plight of the Performing Artist

The gratification of a standing ovation, uproarious laughter when you land your joke just right, the sense of mastery you can experience at reaping the rewards of your hard work and preparation…these are just some of the allures of being a performing artist. Inherently, nothing is wrong with basking in the limelight for a job well done. But when the measure of one’s sense of self-worth is determined by external validation as opposed to internal validation, it may drive that individual into a nonending chase after that all too temporal adoration.

Children develop self-worth by the age of five. In a healthy development, the child learns an intrinsic sense of self-worth and is internally validated. Such a child comes to believe that he is a valuable individual merely because of his existence on this planet, as opposed to because of how good his grades are, how popular he is, how attractive he is, or any other of the numerous false markers of “worthiness” that may be prescribed at a young age. Often when one is seeking elusive validation of their self-worth, that individual may feel incredibly insecure and “less than” on the inside. If that person then pursues a career which is so closely intertwined with the response of an audience, as would be the case of a performing artist, then often the need for external validation becomes the thing that drives the artist’s performance above all else. When one’s primary motivation for one’s art hinges on the accolades of an audience, it is likely that this individual at his core has a depreciated sense of self.

In addition to seeking constant adulation, performing artists may attempt to compensate for a lack that is at their core. Numerous behaviors may be employed to this end: substance abuse, eating disorders, anger outbursts, depression, anxiety, self-harm, and sexual acting out, to name a few. Such behaviors often are attempts to manage underlying feelings of low self-worth.

Psychotherapy can help a performing artist uncover the previously hidden unconscious motivations that have been operating, thereby assisting her in increasing her awareness of underlying relational patterns that get repeated if not addressed. By becoming aware of how one has exhausted herself with this constant drive for validation, one may be better positioned to shift things so that one can learn to derive satisfaction from one’s intrinsic sense of self-worth. Such a person will still have ups and downs, losses and successes, like any individual, but one’s identity can remain solid and intact even during times of hardship because one’s sense of self-worth is no longer dictated by some outside validation over which we have no power.

The Collective PTSD of a Nation

Since the Presidential election of 2016 - even prior to it - there has been a spike in the number of patients who are reporting experiences of anxiety, powerlessness, restlessness, fear, difficulty sleeping, and being more scattered and disoriented than they previously have known themselves to be. This is particularly jarring when their sense of self is shattered and they are exhibiting symptoms that have not materialized before in their adulthood. Still more concerning is when, given the changes in health insurance in recent years, patients can no longer afford their deductibles and therefore opt to discontinue treatment at a time when they might most need to be coming in.

Not long ago I attended a seminar in which the speaker addressed how in ways not previously seen to this extent or magnitude, people seem to be responding to a collective trauma brought on by our current political climate. Clinicians, in addition to our patients, are struggling to manage their own levels of anxiety and powerlessness. Many of the people in our country show a complete dismissal or disinterest in facts, choosing instead the ease of not having to think for themselves and diminishing their personal fears by taking comfort in entrusting those in authority who are disseminating lies and "fake news." On a national (if not global) level, this is incredibly terrifying. Many of us are reeling from the continual onslaught of political egregiousness. This constant bombardment of one horrific incident after another is a form of trauma and the very thing that can disrupt us to such an extent that we are left in the position of having to always be in a reactionary stance, having to brace ourselves for further trauma.

For people who have a history of trauma in their childhood and adolescence, the current political landscape is all the more fraught. It is like walking through a landmine that presents us with ongoing triggers which reawaken those early traumas which may be deeply entrenched. One might react internally in much the way they did when they were young, defenseless children. 

I encourage patients to limit their exposure to the news if it is interfering with their ability to function. Given that it may be crucial to have a safe relationship such as the one that can develop in a therapeutic relationship, I think it is important to work together to figure out how people can continue coming in if their insurance is the barrier that is preventing them from seeking the help they require. Having a support system and appropriate self-care is of the utmost importance for both patients and clinicians during this highly chaotic time. 

Suicide Survivors Part Two: The Parallel Process

In my last blog post, I addressed the topic of suicide survivors, i.e. people who are impacted by the loss of an individual who has taken his or her life. In light of the recent news of the suicides of celebrities who are in the public spotlight, I wish to follow up on my last post by focusing on the issue of "parallel process."

One of the common themes that most survivors will speak about is how powerless they feel in the wake of such a tragic event. Often they feel guilty that they were not able to do more to prevent the suicide. In the presence of the survivor's grief, others can feel powerless as well, not knowing how to best provide support or comfort to the survivor. They may feel compelled to help but are not sure how. I believe that in this particular circumstance, this response differs from other types of losses. We frequently can find ourselves in situations where friends, family members, and colleagues are impacted by the death of someone close to them. Many people have experienced these types of losses themselves and/or have witnessed others who are in mourning.  Yet this may not be as frequent when it comes to suicide. Especially if the person has never experienced a suicide or known a suicide survivor, they can feel ill-equipped to know how to respond.

In psychological terms, we can refer to this experience of helplessness or powerlessness as a "parallel process." It is often the case that the people left behind can experience in themselves a parallel experience to the person who took his or her life, namely that of feeling powerless. We can imagine that the person who saw no alternative to suicide must have felt incredibly helpless, powerless to do anything to improve their situation and feeling utterly hopeless that things can get better. Many of these people have tried multiple things to alleviate their symptoms, such as therapy, medication, meditation, yoga, body work, nutrition and exercise. At the end of the day, none of these things have alleviated the depression, shame, negative sense of self, and other feelings underlying their suicidal ideation and intent.

When others are caught in a parallel process, feeling powerless ourselves, our instinct is often to try to "fix it," to find solutions for the people who are grieving. This stems from the discomfort they have tolerating their own profound sense of powerlessness. I encourage people to sit with this discomfort. Sometimes the most we can do is to simply offer support, communicate that we are thinking about the person who is grief-stricken, and let them know that we care about them. Depending on the specific situation, we may spend time with the survivor, bring them food, and check in with them. It's different for each person. To ask the survivor what would help them can even feel like too much for them; it puts the burden on them to have to respond or even know what they need. Our intentions are coming from a place of a sincere wish to help. It's good to remind ourselves that sometimes just the simple things are a form of help. 

Someone once told me that hearing a friend say, "I'm thinking of you" felt a lot better than if the person asks them, "How are you doing?" or "How can I be helpful to you?" A simple "I'm thinking of you" conveys that you care without requiring anything in return.  

Suicide Survivors

The term "suicide survivor" is unfamiliar to most people. They assume it refers to people who have attempted suicide themselves; in fact, it refers to people who have lost someone to suicide. Whether it is a family member, partner, friend, patient or colleague, losing someone to suicide is incredibly challenging to those who are left behind to grieve. It is a far more complicated type of death that may take a longer time to grieve and can stir up a variety of feelings such as sadness, shock, anger, and guilt. Many survivors feel very isolated, experiencing that those around them cannot understand what they are going through. Also, there is a stigma attached to suicide that often causes people to keep this information a secret. 

Working with suicide survivors is one area I specialize in, although many patients come to me for other reasons and it often isn't until much later in their treatment that I learn they've lost someone to suicide. The impact of this loss can be tremendous. We need to take into consideration the specific relationship to the patient. Losing a friend or sibling is quite different than losing a parent. Losing someone the patient had a close, loving attachment to is different than losing someone where the bond was more fraught. We also want to pay attention to the method of suicide and the patient's unique experience around the death. For instance, the trauma of a survivor who witnessed or discovered the person who committed suicide varies from that of those who were distanced from this immediate visual and auditory trauma. The experience of someone who had a loved one who had previous attempts or threatened suicide for years varies from that of the patient who was completely caught off guard by the loss of one whose death was spontaneous or unexpected. A health care provider who loses a patient to suicide may experience a particular type of guilt, as their colleagues or the institution they work for may consciously or unconsciously fault them for the death. 

As you might imagine, this is a very complex topic that has so many variables that one may have never even considered. In working with survivors, I try hard to not make any assumptions about their experiences. I allow for the space and time for them to tell their story and express their feelings about their loss. Many of my patients have described how I am the first person they talked to at length about their loss because of their shame and their experience of feeling misunderstood by others. I sometimes will encourage survivors to seek out a support group where they can hear other survivors tell their stories so that they can feel less alone with their grief. 

One good resource for more information is The American Foundation for Suicide Prevention, which has information that can be useful for suicide survivors: https://afsp.org/ 

How Women Dis/empower Themselves

I have been struck by how many of my female patients have been incredibly empowered to take action in the world and stand up for social justice issues and causes that are important to them. Yet, when it comes to their personal lives, they struggle to assert themselves with their partners, their families, and their friends. Somehow the strengths they can tap into "out there" fall away when it is much closer to home. Men may also have difficulties with asserting themselves, but in this post I want to focus on the phenomenon I am seeing with so many women. 

Many of these women will talk about how difficult it is for them to ask for what they need and to establish and maintain healthy boundaries. Often they find themselves "over-explaining," which actually is much more disempowering than being simple, direct, and firm. Or they don't even attempt to assert their needs. Some patients have expressed a fear that the response they will get will be an angry one. Or they will disappoint someone and then feel bad. Or they will be ignored and dismissed. Or the other person could leave them and they will be all alone. 

When we consider the ways boys and girls are socialized to express and manage their feelings, typically it is acceptable for boys to be angry but not sad or scared and girls aren't supposed to get angry. Of course this is ridiculous; all people feel the whole gamut of emotions and this is entirely natural and part of being human. Furthermore, when we explore with the patients their specific family and peer experiences growing up, we come to learn more about why they have developed the beliefs and behaviors they have. It is probably much riskier then to express anger toward the people they are closest to and it is safer to express anger and righteousness in situations in which things are a bit removed and there is a distance. 

In treatment with me, these women can have the experience of working with a male therapist who will offer a different alternative by not responding to their anger in the ways they expect and have experienced before. Focusing on our relationship can thus be of utmost importance to their healing process and to helping them practice assertiveness skills, emotion regulation and boundary setting. Over time, they can grow into being strong women who take themselves seriously and are taken seriously by those around them. 

Couples Counseling From a Psychodynamic Framework

I often reflect on how the skills we need to navigate our lives through adulthood were not taught to us in school. Most of us did not get taught how to identify and express feelings. We didn't take classes in how to nurture healthy relationships and how to sustain these throughout one's lifetime. While a great deal of effort may be given to one's career, an equal amount of effort might be missing when it comes to the relationships that we consider most important.

When the issues that bring people into treatment seem to center on their primary relationship, then couples counseling may be warranted as the preferred treatment modality. Unlike individual therapy where we delve into a patient's psyche to understand how one's unconscious processes inform current behaviors, in couples counseling the couple is the patient and the focus of our work shifts to attending to how the partners communicate, manage conflict, and show empathy for each other. Often my role is to teach specific skills along these lines. I might help them learn active listening and empathy skills. Perhaps I may teach effective ways to deescalate fights and constructively handle arguments. I may encourage partners to talk to each other and not simply to me so they can practice communication, thus bringing their relational issues directly into the room so that I can observe and intervene as needed. As the therapist, I am in the unique position of watching how they interact and I can pay attention to the moment to moment shifts in their conversation to see where they might get stuck or how conflict escalates. 

As a psychodynamic therapist, I also place importance on understanding each person's individual history and how these intersect in their relationship. It is not arbitrary when two people find each other and embark on a journey to form and maintain a relationship. Each person brings to the table their individual relational dynamics that they learned as far back as childhood. Often people reenact in their current relationship patterns that they experienced in their parents' relationship or in their own relationships to their parents. These relational patterns continue to get repeated and played out in their subsequent relationships throughout life. When we can identify these relational patterns and how they are reenacted, then we can set about to shift these in healthier directions. When we come to understand how each individual is triggered by their partner and how that may be connected to experiences they had in childhood and adolescence, it helps each person develop a deeper understanding of their partner, an awareness of how their own behavior is impacting their partner, and the potential for greater emotional intimacy. 

Relational patterns tend to get passed from generation to generation until someone takes the initiative to work through these in the context of psychotherapy. One can imagine how complicated this can be when each member of a couple is bringing to the relationship specific patterns that can be traced back to their own early relationships and those of the generations that came before. So a husband's behavior may trigger his wife in ways that are similar to how one of her parents triggered her or similar to how her parents and grandparents related to each other, and the same can be true for how the husband experiences his wife's behaviors. Usually these patterns aren't easily identifiable at the start of couples counseling, but over time, with the help of a trained therapist, they can be elucidated and worked on. The hope is that by working together in this way, each partner can come to experience a more rewarding and intimate coupling into the future. 

The Relational Nature of Shame

In the play (and movie) Proof, the character Hal asks, "How embarrassing is it if I say last night was wonderful?," to which Catherine responds, "It's only embarrassing if I don't agree." This is a great example of illustrating how shame is relational in nature. As Catherine points out, Hal's question might have been met with a variety of reactions. If Catherine were to respond, for instance, by saying she wishes it hadn't happened, Hal might experience shame about what he said and may even regret that they spent the night together. But Catherine agrees with him, they kiss, and he is elated. Without our even realizing it, our experiences of shame are often closely tied to other people's reactions. The key component to hold onto from this illustration is that one may say or do the exact same thing yet have a completely different self-experience based on the reaction of the other.

From a very early age, children may develop positive or negative self-experiences based on how the people closest to them (parents, siblings, peers, teachers) respond to them. If a young boy is expressing excitement and vitality about what he is doing, for instance, his father might respond by mirroring the boy's enthusiasm and encouraging him to engage in the activity. This could lead to the boy developing a healthy sense of himself and his own agency in the world. If the father, on the other hand, were to respond by telling the boy to knock it off, then the boy is likely to believe that what he was doing displeases his father and is wrong. Often, the reaction of the other is much subtler. In this example, the father might simply give a lukewarm response, ignore the boy, or register discomfort on his face. These more nuanced, less apparent reactions can be incredibly impressionable on a child's sense of self. Even if it is not conscious, the boy might come to learn that expressing his vitality is something to be ashamed of, and this might continue to be confirmed by subsequent, similar experiences. Once the boy reaches adolescence and adulthood, a lifetime of such experiences may have led him to squelch his own excitement and dampen his vitality.

I find that by helping patients understand how closely linked their shame is to the reactions of others, it helps them to shift how they view their past experiences. Others' reactions could lead either to greater acceptance or greater shame about the part of self in question. If a female patient comes to learn that her shame about her appearance is tied to comments and reactions she has gotten from other people throughout her life and to images that our society has held up as an ideal, she might begin to reevaluate her own beliefs and self-perception. In this way, having the awareness of just how powerful is the relational nature of shame, one might be better positioned to change one's own deeply held views and challenge distorted beliefs about oneself. 

Mourning Losses

When we think about mourning losses we usually think of grieving a loved one who died or perhaps grieving the end of a relationship. Yet, much of the work of psychotherapy involves mourning losses that are less transparent - losses that can be traced back to childhood. This is the type of mourning that I wish to address in this blog post.

Most adult behavior has its origins in our early childhood experiences. We may unconsciously cling to relational patterns and beliefs that stem from the earliest years of our lives. Oftentimes, the reason we do this is to avoid incredibly painful feelings that may arise and engulf us when we allow ourselves to fully access these experiences. To recognize that one's parent was never able to love and accept them unconditionally, that this parent may never apologize for abuse or injuries they've inflicted, that the parent may never change and one may never have the mother or father they have always longed for and needed, that they will never be truly vindicated for the traumas they have endured - to come to terms with such losses is to open oneself up to tremendous grief. People may spend the majority of their lives engaging in all sorts of behaviors that are attempts to stave off such mourning.

Continued avoidance of mourning unresolved losses from our past comes at a devastating cost. People may suffer from depression, anxiety, and any number of other mental illnesses. They may experience chronic pain and health concerns, abuse substances, repeat unhealthy relationship patterns, and find themselves having ongoing difficulties at work and in their social lives. Even worse, they may inflict the same injuries that they suffered onto their partners and children. 

We can understand how not allowing oneself to mourn the death of a loved one can impede one's healing; we may allow ourselves and encourage others to take whatever time is needed to fully grieve, being gentle in the knowing that mourning can take various forms and evoke a gamut of emotions.  The same concept applies to mourning losses that are much more deeply buried. If working through these losses in therapy didn't have the potential to help an individual achieve greater self-awareness, profound healing, more satisfying relationships and one's personal life goals, then there would be absolutely no good reason to ask our patients to undergo a process which has the potential to stir up such pain. Still, I know of no other way to make long-lasting fundamental positive change. There's a corny saying in the business (alright, there are several) that you have to go through it to get through it. I think this expression is rather apt when it comes to this topic of mourning losses from one's childhood.

Communicating with Text Messages; Don't Text While Driving!

I wonder how many therapy sessions have been spent focusing on the heated arguments that patients have had via text messages. People will engage in lengthy back and forth conversations with their significant other, family or friends that could last for hours. In all the countless times that patients have told me about or shared with me these strings of texts, never once has it gone well.

I believe that texting serves a valuable function, such as coordinating plans, locating each other when you are meeting up, scheduling an appointment, or sending a short "thinking of you" or a funny message with the requisite emoji. Other than in these instances, I find that attempting to have a serious conversation over text messaging is not fruitful. Ditto for Facebook, social media, and possibly even email. These mediums of communication are simply too apt for misunderstanding and an exacerbation of anger and hurt feelings. 

Something gets lost when you don't see or hear the person you are speaking with. Non-verbal communication and tone of voice give us such important information about the other person. We can learn a great deal from someone's body language and the way they sound that is much more comprehensive than you could possibly get from just reading the words that were sent to you. In the absence of such data, people are likely to "mind-read" and interpret the other person's intentions without having access to all the crucial information they would need to truly understand what is being conveyed.

It seems to me that people feel freed up to express difficult thoughts and feelings when there is some distance between them and the person they are talking to. This indirect means of communication may feel easier for many than to talk directly to the other person about how one feels or what one believes. It may be easier to yell at a stranger who cut you off in traffic when you are safely hidden inside the comfort of your car. But when you are face to face with the person who has upset you, that is often another story. Yet, direct and honest dialogue is undoubtedly the most effective means of communication and conflict resolution. 

I encourage patients to learn and practice direct communication skills. I empathize with how scary this can feel for people, but I help teach them that ultimately it is more empowering, healthy, and mature and will usually yield the most positive outcomes. Most of us did not grow up learning how to communicate effectively. In school we took algebra, social studies, and biology but we probably did not take classes in feelings, relationships, conflict management, and communication skills-the things we will benefit from knowing for the rest of our lives. But adults can still learn these skills. Some people may feel pulled into the drama or comfort of shooting off an unfiltered text message or long missive via Facebook, perhaps as a way to discharge one's discomfort with the feelings they are experiencing, but I would strongly suggest that taking time to think and sit with one's feelings rather than impulsively engaging in these behaviors is likely to benefit everyone in the end.

Acting Out Behaviors

In my last blog post I addressed the "acting in" behaviors of depression and anxiety. Here I would like to focus on "acting out" behaviors that people turn to in an attempt to manage uncomfortable internal emotional states. There are many ways that people may "act out," such as putting substances (alcohol, prescription and recreational drugs, nicotine, or food) in their bodies to "self-medicate," overworking, gambling, working out excessively, obsessively turning to plastic surgery for cosmetic changes, excessive shopping, binge watching tv, spending hours playing video games, or engaging in risky and/or excessive sexual activities. When these types of behaviors are being used to unconsciously (or perhaps consciously) manage one's feelings, it probably means that the individual is choosing to flee from living in the present moment or the "here-and-now" to avoid fully inhabiting and experiencing one's feelings.

Cognitive behavioral therapists would focus on these behaviors directly and work on helping their patients learn ways to change the behaviors. Psychodynamic or psychoanalytic therapists like myself view these behaviors as symptoms or coping mechanisms that the patients employ because they might be the most adaptive ways they have learned to regulate the unacceptable, scary, or threatening feelings that are buried beneath. Rather than focus so directly on these symptoms, we believe that if we can help patients access and express the underlying unresolved feelings and come to understand how they are internally organized in relation to their emotions and unconscious processes, then over time people can learn healthier, more effective ways to manage their internal worlds. As a patient does so, we find that the unhealthy symptoms start to dissipate because there in no longer such a strong need to rely on archaic defense mechanisms that served a purpose at one time but now are more likely to be hindering an individual's progress.

A behavior is always a choice (even when it may not feel like a choice); feelings are not. If we subscribe to the belief that most people are well-intended and would choose the healthiest methods available to them, then we can come to see inexplicably harmful behaviors as adaptive attempts to manage difficult internal states. When people are able to learn alternate ways to manage these internal states, they are apt to choose the healthier options. When people learn that they needn't fear nor judge their feelings and begin to practice ways to tolerate, effectively manage, and perhaps even embrace their emotions, then they are better positioned to fill their tool boxes with the most healthy and effective tools. 

Depression and Anxiety as Defense Mechanisms

There is a great deal of confusion between feelings and mood states. Feelings (or emotions) are normal, healthy aspects of being human. Sadness, anger, joy, and fear are all common feelings that every human experiences, often daily. Mood states are not feelings. Depression, anxiety, and Bipolar Disorder (often known as manic depression) are mood states and can be considered mental disorders when severe enough. This isn't necessarily the case, as most people have experienced some type of depression or anxiety in their life time without it being serious enough to constitute a mental illness. We can say that we "feel depressed" or "feel anxious," which adds to the confusion between feelings and mood states.

Mood states may be understood as defense mechanisms that serve to protect us from underlying feelings. For instance, if we experience our anger as unacceptable or threatening, we might "depress" it and end up being "numb," resulting in not being in touch with the underlying anger. People who suffer from depression often describe themselves as being lethargic, fatigued, hopeless, or despairing. We cannot be in touch with our emotions when we are depressed. Reversely, when we are in touch with our feelings, we are not depressed at that moment. Anxiety may also be a way to manage underlying emotions. If our anger becomes too intense, we might react by becoming highly anxious. In this case, the anxiety is in response to a perceived threat induced by our anger. To complicate this further, if our anxiety then becomes too intense, we might then clamp down on it and become depressed. I describe this to my patients as layers upon layers, with the root feeling (which is pure and healthy) being buried deep down. So in this example, anger is the pure, healthy emotion that the individual has come to believe is bad, dangerous, or unacceptable. So Anger -> Anxiety -> Depression. Freud described depression as "anger turned inward." I believe this is what he meant by that explanation. Thus, a person might only experience his depression or anxiety, having suppressed his anger to a point where it cannot be easily accessed. But if a person suppresses one emotion, he suppresses all emotions. So when a person is suffering from depression, he cannot fully inhabit his anger, joy, fear, or sadness.

In psychotherapy I help my patients explore what feelings they might be defending against by employing the defenses of depression or anxiety. By teaching people that their feelings are normal and healthy and not to be feared, they start to shift their relationships to their emotions. Over time, this helps people learn alternate ways to manage their feelings so that they no longer believe they have to push their feelings away at all costs. We may view depression and anxiety disorders as forms of "acting in," i.e. turning inward to try to manage difficult emotions. In my next blog post, I will address "acting out" behaviors that people may employ as alternate ways to attempt to manage internal emotional states. 

The Insidious Nature of Shame

The topic of shame intersects with my previous blog posts and is an incredibly important issue I wish to address. It is unclear as to whether or not shame is truly an emotion like anger, sadness, and joy; I don't imagine that animals other than humans are plagued by it. Nonetheless, shame is pervasive in the world of human beings. Unlike guilt, which is the experience of feeling bad about something you have done or not done, shame is feeling bad about a part of oneself, a part of self that one believes is wrong, unacceptable, or ugly. For example, people may feel shame about their appearance, their sexual orientation, or their ethnicity. Like guilt, shame serves no healthy function and is usually inhibiting people from accepting themselves and living fully authentic lives. 

We are taught to feel ashamed of parts of ourselves from an early age. If our parents, our peers, and our friends and acquaintances believe that something about us is wrong, then the likelihood is that we will believe that what others are saying or thinking about us must be true. We develop in relation to others. If the circles of influence we are most closely surrounded by believe one thing, we are likely to be swayed in the same direction. Thus, young boys and girls who are surrounded by people who believe that boys should not exhibit feminine traits and girls should not exhibit masculine traits will feel shame around their own feminine or masculine parts of self. Teenage girls and boys who grow up in a world where they are taught that having same-sex feelings is wrong will likely develop shame if they are experiencing sexual attractions to people of the same sex. For the fortunate ones who are taught from a young age that there is nothing shameful about normal, human parts of self, these children may grow up accepting the parts of themselves that others learned were shameful. 

In my work as a psychotherapist, I have found that in order to move from a place of shame to a place of acceptance, an individual needs to connect to his or her anger toward the people, institutions, and societies that have perpetuated the myths that have led to the shame in the first place. Keeping with the example of someone who grows up feeling shame about having same-sex feelings, in order to progress from shame to acceptance, one must redirect the anger that is turned against oneself to its proper target(s), the people responsible for the shaming. I use the example of same-sex feelings here, but this concept applies to any parts of one's self of which one has learned to be ashamed. My last post was about the healthy emotion of anger. Here is another way in which anger is essential to the formation of a healthy, authentic self. In psychotherapy, patients have an opportunity to explore the parts of themselves that have caused them shame and learn to access the underlying healthy anger they feel about having been taught the false lessons that any parts of their true selves are bad, ugly, wrong, or shameful.