The Importance of the Therapeutic Relationship

Until the past several decades, psychotherapists believed they were a blank canvas onto which their patients projected all their unresolved issues from their childhood and their internal relational experiences with their parents. Nowadays, we believe that there is a close, real relationship between the patient and therapist that develops over time and may become the most important agent for change in the patient’s treatment. Both the patient and therapist bring to the relationship their own unconscious past relational patterns that originated in early childhood experiences, often between them and their parents.

It is crucial that the therapist monitor the nuanced interactions and enactments that occur over the course of the therapy. The danger in not paying close attention to the shifts between them and their patients could lead to serious negative consequences, such as repeating unhealthy relational patterns or driving the patient out of treatment. I recently encountered one example of such an enactment in my practice. Twice I mistakenly got the time wrong for one patient and I either had booked someone else during his time slot or I forgot to come to my office to see him. If I wasn’t monitoring the shifts in our relationship, I may have dismissed this as a simple error on my part instead of an interaction between us, and it could have well marked the end of his therapy. Luckily I was aware of how unusual this behavior was, as I have never mistaken a patient’s time slot in my 20 years of practice. This signaled to me that there must be an enactment between us that tells us something essential about the patient’s relational experience in the world. Sure enough, after exploring this together, we discovered his experience of feeling like an afterthought to his parents and friends most of his life. Instead of driving him away from treatment, this enactment elucidated something important about this patient’s relational dynamics and became an essential part of his healing.

I sometimes think that if a patient and I focus on nothing else but the twists and turns in our relationship, we still might be engaged in the vital process of therapeutic action that enables the patient to make long-lasting positive changes to his or her life. This relationship is unique in that I am a part of it, unlike all other relationships that I only hear about through the lens of their point of view. I can help patients come to understand deep-rooted relational patterns and have a positive experience of a relationship that might be unlike any other past or current relationships they have ever experienced. Such a healthy relationship can be a “corrective emotional experience” that can have everlasting changes for the patient.

Feelings 101

I occasionally think how backwards it is that we go to school to learn math, reading, and science but we didn’t take classes on feelings or relationships, things that will impact us for the rest of our lives. Many of my patients struggle with identifying and expressing feelings. Often, they grew up learning that certain emotions were “bad,” and they received little to no help from their parents in educating them about affect management. Nowadays, many children are learning in school and at home essential skills to help them identify and regulate their feelings, something of which most adults today could definitely make use.

When working with patients who need help developing a language for their emotions, I encourage them to begin with what I label “primary feelings,” akin to primary colors. They start by learning the basic emotions of anger, sadness, happiness, and fear. Or as some therapists say, “Mad, sad, glad, and scared.” These are the red, blue, and yellow of feelings. If we put each of these feelings on a scale from 1 to 10, with 1 being the mildest degree of the emotion and 10 being the most intense, we can start to differentiate the varying degrees of an emotion. For example, if we have a scale for anger, we put “angry” in the middle at 5. Along the anger scale, we can put feelings such as irritated and annoyed at the low end of the scale - around 2 or 3 - and a feeling such as enraged at a 10, on the high end of the scale. These feelings all are different forms of anger, just to varying intensities of this emotion. On the “happy” scale, with “happy” a 5, we might label a 1 or 2 “satisfied” or “content,” while a 9 or 10 might be “ecstatic” or “exuberant.” Additionally, some feelings are a combination of primary ones. For instance, “hurt” might be a combination of sad and angry. “Surprised” may be a mixture of fear and happiness. When we peruse lists of feelings, we start to see how most labels for feelings can be either a degree of a primary feeling and/or a combination of multiple primary feelings.

The other skill that most patients need help with is differentiating feelings from thoughts and behaviors. If we stick with the core emotion of anger, then anger is the feeling, while slapping is a behavior used to express this feeling, and “I hate you” is a thought that is attached to this core feeling. Most people confuse these and think that “getting angry” is the same as hitting and screaming. We have choice about which behaviors we want to employ to express a feeling; even when it feels “out of control,” we can choose not to hit or scream. We do not have choice about the feeling itself. Feelings are neither good nor bad, they simply “are,” the same way thirst and hunger simply are physiological states. People rarely judge themselves for being thirsty but people often judge themselves for being angry or sad. We cannot choose if we are angry or not, but we can choose how we respond to that anger.

Much of my work with patients around feelings is to educate them about the differences between thoughts, behaviors, and emotions and to help them learn that emotions are not something “bad” they need to run from. I can help them learn various healthy and effective ways to express feelings, in contrast to unhealthy, maladaptive expressions of emotions they may have learned up until now. Most importantly, I help my patients learn that feelings are not something they need to avoid at all costs, but rather essential parts of being human.

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. 

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. 

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. 

Anger is Not a Four-Letter Word!

Anger gets a bad rap. Almost every patient I've ever worked with and almost every person I've ever met has struggled to view their anger as healthy and to manage it effectively. ALL EMOTIONS ARE HEALTHY! They are neither good nor bad, right nor wrong. Emotions are part of the natural fiber of being human. We don't judge ourselves for being thirsty, sleepy, or hungry. Yet we judge ourselves terribly for having feelings, especially unpleasant feelings. Most of us learned at a young age that these feelings are unacceptable, bad, shameful, even dangerous. But none of us were born this way. We don't come out of the womb judging our normal human emotions as something to be avoided. We learn this along the way, usually from a very young age. More often than not, our parents and their parents learned the same things about their emotions, so these inaccurate messages get passed on from generation to generation. If our parents cannot view their own anger as healthy, how can they teach their children that anger is healthy? 

People also get confused between emotions and behaviors. Emotions are simply the feelings themselves. Anger, sadness, happiness, fear - these are just pure feelings. Behaviors are the strategies we use to express our emotions. We have choice over our behaviors; we have no choice over our feelings. Every human feels every emotion, maybe even each day. Emotions are fluid and can change often throughout the day. We can no more control what we feel than we can choose not to breathe. When people view anger as unhealthy, I believe they are confusing behavior with emotion. Many people have learned unhealthy ways to express their anger. Some people become violent, aggressive, and lash out in hurtful ways. Others turn to substances or sex to attempt to manage their anger. Still others turn their anger against themselves and become depressed and beat themselves up horribly. 

In my last post I discussed pathological accommodation. One of the ways people accommodate others is by splitting off their anger because they view it as bad, thereby becoming inauthentic selves. Therapy can help patients learn about their own relationship to their anger and help them unlearn the faulty beliefs they were taught growing up. It can also help them learn to access and express their anger in healthy ways. This all requires that patients first shift their perspective on the emotion of anger so that they can come to view it as legitimate and valid. I am hopeful when I see that more kids today are being taught about feelings from a young age and being taught how to identify and regulate their emotions. Saying to a child, "You are really mad!" is a great way to empathize with the child and help him identify his anger. To follow it up with, "It's ok to be mad, but it's not ok to hit people" teaches the child to differentiate his emotions from his behaviors. We communicate that our anger is valid and we can learn effective ways to manage it. Psychotherapy can help patients learn the same lessons, which will in turn enable them to become more authentic human beings. Nurturing a positive relationship to one's anger is key!

Pathological Accommodation

"Pathological accommodation" is a term I first encountered through the readings of Bernard Brandchaft and the theories of intersubjectivity. I find this concept transformative to the work I do; it seems to apply to virtually every patient I've encountered (as well as most people I've known in my personal life). I feel compelled to write this at this time, as this subject follows naturally from my previous post about narcissistic mothers.   

At its basic core is the idea that children who are unable to develop authentic selves due to the various barriers put upon them by their parents learn that they must contort themselves into a false self or risk losing the ties to the parent(s) to whom they are most closely attached. This accommodation can manifest in one of three ways. The child who does not want to lose his bond to his caregiver learns to sacrifice parts of himself in order to preserve that bond. Alternatively, a child may decide that she will hold fast to her true self at all costs, only to find herself isolated and alienated from her caretakers. Finally, some children oscillate between these two poles, enacting an ambivalence in which they play the dutiful, obedient child at times and fiercely cling to their own wishes at others. In contrast to a healthy development in which the child is allowed to develop a true self and also maintain a secure positive attachment to one's parents, children who grow up being pathologically accommodating find themselves in a no-win situation, either sacrificing key parts of their identity or losing their close ties to the parents that are so important to them.

Most of the patients I've encountered fall into this first category. They come to me having lived their lives hiding parts of themselves and working hard to be the "good" boy or girl they believe they are supposed to be. They go through life accommodating others at all costs, and the price they pay is incredible unhappiness for having to squelch parts of themselves and contort themselves into who they think others want them to be. These people aim to please, though often while feeling deep-seated resentment and rage for having to do so. Most of the gay men and women I've treated learned to hide their sexual orientation at a young age because they were taught that it was "bad" and "unacceptable." Even more insidiously, most people are taught that their internal world of feelings -- particularly their anger -- is something dangerous, threatening, shameful, or wrong that is to be avoided at all costs. When one learns to split off their feelings instead of learning that all feelings are a healthy part of what makes us human, it becomes impossible to live fully and authentically. 

An intersubjective therapist is trained to look for how these issues show up in the therapeutic relationship. We must expect that the ways our patients have learned to conduct their relationships up until coming to us will also play out in the relationship that develops between therapist and patient. Thus, patients often behave like dutiful students, wanting to do what's "right" for my sake. Others act out by experiencing me as their parent who places demands on them and then they rebel by missing sessions, coming late, not paying on time, or engaging in risky behaviors outside of therapy. It is crucial to track the interactions in the therapeutic relationship so as not to ignore or dismiss these enactments and to not repeat perpetuating the unhealthy relational dynamics established in childhood. When we can speak to what's happening in our relationship and shed light on how the patient may be pathologically accommodating the therapist, then we have a chance to alter these patterns and allow for an alternate positive relational experience in which the patient (maybe for the first time) can learn to have a healthy relationship where she can bring herself fully into the room and be accepted  unconditionally. 

In future posts I will elaborate on some of these ideas -- such as the crucial role that anger plays, the power that shame wields, and the specific ways that people may act out in response to believing that they cannot express themselves authentically. For clinicians interested in learning more about pathological accommodation, I recommend the collection of Brandchaft's essays entitled Toward an Emancipatory Psychoanalysis. 

Children of Narcissistic Mothers

I am astonished by the number of patients I have treated who are children of one or two narcissistic parents. Though we often associate narcissism with males, in most of the cases I've witnessed, it is the mother who appears to be the narcissist. The world of entertainment fascinates us with such women. There's a dramatic example in the cult movie Mommie, Dearest. And one review of a Broadway revival of the musical Gypsy described the stage mother Rose who is determined to see her daughters achieve the success she never did as "the mother who is always there when she needs you." While these make for titillating enjoyment and these characters are extreme examples of narcissistic mothers, both based on actual autobiographies, in my practice the children of such mothers are anything but fodder for amusement.

The child of a narcissistic mother is often put into the role of a "self-object function" for the mother. Whereas in a healthy mother/child relationship the mother is tasked with meeting the needs of her child, the scenario is flipped with a narcissistic mother and the child is treated as an extension of her. Everything becomes viewed through the lens of how the child can serve the mother's needs or how the child's behavior wounded the mother.  Thus, if the child makes any move to separate from the mother and form an authentic identity of her own, this is unconsciously perceived as a threat to the mother. Normal developmental milestones such as puberty, adolescence, going to college, turning 21  and becoming an adult, and forging relationships, getting married, and starting one's own family are all potential threats or "narcissistic injuries." Similarly, if the child chooses to forge a unique identity and follow his own path, one that may differ from the mother's ideas of what the child should do, this may be taken as a direct attack on the mother. I've known patients whose mothers reacted negatively when the individual began a normal sexual exploration as a teenager, when the child moved away from home for school or work, when he announced plans for marriage, or when she announced that she was pregnant. These mothers are incredibly needy themselves and they are turning to their children to fill the expansive gulf of neediness they experience because they are unable to rely on themselves to do so and they most likely did not have adequate parenting in their childhood in which their own emotional needs could be met. 

Narcissism in a parent can take different forms. In some instances, the patient has a mother who martyrs herself, acting as a helpless victim and seeing herself as utterly selfless for the sake of her children and others. Yet this is far from unconditional and often the child experiences an enormous amount of guilt-tripping, with the mother making it clear that the child has disappointed her deeply. In some cases, this takes the form of a mother who suffers from a chronic illness, such as fibromyalgia or acute asthma. Far from being a victim, this mother can actually wield a great deal of power and control with her illness, holding her family members hostage and at her mercy. Once again the child's needs are sacrificed for the sake of the mother's "emergency." Other narcissistic parents may abuse alcohol or other substances in an attempt to fill the profound void they feel inside. Such a parent can hardly be relied upon to be responsible and consistently available for one's child. Often the child develops into a "parentified child," reversing roles with her own parents and having to learn to take care of her own needs as best as she can. Being age inappropriate, she cannot adequately function as a parent to herself, and she often is excessively harsh with herself and her siblings and may hold herself up to unreasonable standards. 

Sometimes the father in these scenarios is also a narcissist, pairing with the mother in using his children for his own purposes. More often, I have found the fathers to be emasculated men who cannot provide an adequate buffer to protect the child from the mother's unreasonable demands. They may appear rather passive, relinquishing their own authority as having equal responsibility in parenting their children, instead meekly backing their wives up and going along with their wishes so as to avoid a storm. The children become the true victims here, unable to defend themselves and unable to turn to their father to be the strong buffer they need him to be. 

The stage is set for this perfect storm. Children of narcissistic mothers, more often than not, find themselves in a no-win situation. There is no chance for a healthy development. Either he can squelch parts of himself and contort himself into the son he believes his mother wants him to be, or he can choose to assert his independence at the great risk of forever severing his bond to his mother. There doesn't appear to be a path in which this child can both develop an authentic identity and maintain a close connection to his mother. The fear of becoming an authentic self that is not reliant on the mother for survival may manifest itself as dependency. The child may have learned that she cannot survive without her mother. She remains anchored to her mother for guidance and direction. The mother's own neediness gets projected onto the child, and the child ends up believing that he is the needy one who is unable to be a self-sufficient adult. He may continue to prove how helpless he is by engaging in acting out behaviors such as financial irresponsibility, sexual promiscuity, and substance abuse to confirm his mother's view. In fact, this child is terrified of separating from his mother because to do so risks losing her entirely. 

I suppose it is not surprising that my caseload consists primarily of these children of narcissists, rather than the parents themselves. One of the hallmarks of a personality disorder is how entrenched it is, and a person with a true narcissistic personality disorder externalizes all his problems and does not take responsibility for any of his egregious actions. Remember, the narcissistic mother firmly believes that it is her child who has wronged her and is at fault for whatever problems ensue. Children of narcissistic mothers who find the strength to engage in psychotherapy have the opportunity to become aware of how profoundly their mother's behavior has impacted them and over time can work toward separating from this mother and genuinely forging an authentic identity of one's own. Even initiating the process of therapy is a step toward  greater empowerment and becoming a self-sufficient adult.