Tuesday, February 24, 2009

The Latest on Panic Attacks

By Kevin Murphy, M.Sc.,
Psychoanalytic Psychotherapist
Dublin, Ireland.

Hot on the heels of a blog I posted on January 20 last, in which I referred to new research in the States that showed very positive outcomes for long term psychoanalytic therapy, comes another survey from the same neck of the woods.

This time, however, it is research that shows how modified and shortened psychoanalytic therapy of 12 weeks duration works for panic disorder.

It might seem like just another piece of research but in the field of psychoanalysis the existence of research is a quite a rarity. That’s why a recent report in the New York Times is interesting. A team of New York analysts published the first scientifically rigorous study of a short-term variation of analytic therapy for panic disorder, a very common form of anxiety. The study was small, the report said, but the therapy proved to be surprisingly effective in a group of severely disabled people.

The research paper appeared in American psychiatry’s premium journal, The American Journal of Psychiatry. The therapy it tested, unlike traditional psychoanalysis, focused on relieving symptoms quickly, and was time-limited. Previous studies had found that other therapies — including exposure techniques such as Cognitive Behavioural Therapy, in which people learn to diffuse their anxieties by facing them one small step at a time — can relieve panic attacks in half to two-thirds of patients, depending on the severity and type of anxiety.

In the new experiment, Dr. Barbara L. Milrod, a psychiatrist at Weill Medical College of Cornell University, led a team of therapists who treated 49 men and women with a variety of anxieties. Some were agoraphobic, unable to ride the subway or visit certain parts of town. Others had symptoms of depression or of personality problems, like a disabling dependency on other people or an avoidance of social situations.
Half of the group received a form of relaxation training, in which they learned how to moderate their arousal by tensing and relaxing specific muscle groups. The other half received psychodynamic therapy, working with their therapist in two weekly sessions to understand the underlying meaning of their symptoms — when the reactions first started and how they might be linked to loss, broken relationships or childhood experiences that unconsciously haunted their current lives.
After 12 weeks, 39 percent of those working with relaxation techniques improved significantly on standard measures of anxiety and reported fewer panic-related problems in their relationships and work. But almost three-quarters of those receiving psychodynamic therapy reported similar benefits.
So, again the principles of psychoanalysis have been tested and found to be robust. Granted the above study modified the therapy, thus satisfying the need for speed that is a hallmark of modern living, but the underlying principles held fast. It might not be enough to re-train behaviours and thoughts on the basis that new habits help us overcome old ones. What the outcome is saying is that there has to be fundamental change in the person’s understanding of what is going on, why it is happening, how that fits in with the entirety of their lives to date and how new possibilities can emerge in place of old, unhelpful solutions.
The only thing that should be added, and I fall on the side of traditionalists in this regard, is that the race to do things quicker is not always better. In most areas of human endeavour you will see an example of this: the food industry has given us fast food but has it improved our nutrition? Banking raced to speed up ways to give us large wads of cash. It led to an inevitable crash. Technology has speeded up our access to great vistas of knowledge and entertainment. But has it freed up our time to be more human and build better communities?
In this regard, the current study has an interesting quote from one of its authors. “This is best response rate I’ve seen in a controlled trial for panic,” Dr. Barbara Milrod said. “And the therapy was time-limited. I don’t think anyone would care if psychoanalysis cured panic in six years — snore. We wanted to know that what we were doing worked, that it wasn’t malpractice.”
Note the word ‘snore’. That is not the language of classical psychoanalysis, not because it is against someone coming for 12 weeks or even 6 and then finishing. The fact is, they do. No, it is because 12 weeks does not suit everyone and to suggest it does is misleading. When people come for therapy, some want to be out as quick as possible but others don’t. And for those who don’t, that choice has to be there.
To assume there is nothing other than a panic disorder sitting in one’s consulting room is the ultimate disrespect. Panic disorder is a symptom, a sign that many other things are operating at an unconscious level for the client. Putting a short term focus on the symptoms runs the risk that deeper issues get ignored.
Yes, it is good to see positive results appearing in respected medical journals about psychoanalysis. But let’s not forget that psychoanalysis is different because it invests time - in the person who presents for therapy, in the human complexity that person represents and in the person behind the person telling us their story.

Tuesday, February 17, 2009

Taking It To Art

By Kevin Murphy, M.Sc.,
Psychoanalytic Psychotherapist,
Dublin, Ireland.

You can always tell how useful something is by the number of applications it can be used for. This general rule applies equally to a workman’s tool, or a piece of clever software or even a theory of the mind. This notion struck me when I was asked recently to write a psychoanalytic review of Samuel Beckett’s play Happy Days*. The play ran at the Abbey Theatre, our national theatre, during the Theatre Festival at the end of 2008.
Setting out to apply a therapeutic theory that is used daily in consulting rooms around the world to explain a 1961 play by the Irish playwriting genius appeared daunting at first. But then I remembered that psychoanalytic theory has a long history of interpreting works of art.
Even in Dublin today there is a vibrant discussion group of working psychoanalysts that focuses on cinema. And Jacques Lacan, Freud’s re-inventor in the 1960s and 1970s, was a friend and physician to Picasso, a collector of his paintings, and someone who also used Shakespeare’s Hamlet to explain aspects of his theory on human desire. Freud himself wrote about writers and the creative drive.
In that sense I was in good company and the more I worked on my humble offering, the more I began to see how versatile psychoanalytic theory can be.
The Abbey Theatre’s recent production had Fiona Shaw (Aunt Petunia in the Harry Potter movies) as Winnie and Tim Potter as her rarely seen husband, Willie. For those who are unfamiliar with it, the first act consists of lonely Winnie stuck in her mound under a hot sun, constantly talking and obsessively fiddling with the contents of her handbag, being interrupted by a loud bell-buzzer that marks out the divisions of her day.
There is a twist in the second act. The mound after the interval is larger so that only the head of Winnie is visible. Meanwhile in the back, mostly out of sight, is Willie, who lives in a hole and who, unlike Winnie, enjoys the relative luxury of crawling about on all fours, fiddling with his genitals, reading an out of date newspaper and saying the occasional word or two.
In the sense that it is the same day being lived over and over, the play is a bit like the movie ‘Groundhog Day’ except Winnie never reaches the Zen state of perfection from endlessly repeating the same rituals and experiences as Bill Murray's cynical TV weatherman. Rather she stays stuck; much like her body is stuck, in a state of unchanging imperfection.
Peppering the play are typical Beckett themes such as loneliness and the need for companionship; stagnation masquerading as change; and the failure and emptiness of language. With its focus on this last one, the failure of language to change anything, ‘Happy Days’ could be interpreted as Beckett’s criticism of psychoanalysis which, after all, depends on words and language for its very existence. This could be further supported by Beckett’s attitude towards his own analysis with renowned analyst Wilfred Bion at the Tavistock Clinic in London from 1934 to late 1935. Afterwards Beckett remained doubtful and hostile towards psychoanalytic theory and practice. And yet one of Beckett’s biographers said he retained a secret curiosity about it. French psychoanalyst Didier Anzieu goes further and believes Beckett's mature, post-War work is a direct response to his experience of analysis.
In this light, therefore, when you step back from ‘Happy Days’ you could be looking at the analytical space. Winnie, unwittingly, is undergoing an analysis, except instead of lying on a couch she is bolt upright. She speaks like a client, freely, with associations following one after another. Occasionally resistances break out too, stopping her in her tracks as she shifts to new ideas.
Behind her, unseen, is Willie, a presence that says very little but which is essential to her because she is terrified of being alone and unheard. He is her husband, lover, analyst and the bigger cultural backdrop of society dramatically condensed into a single figure. His main role is to listen and only rarely speak. This is a two-handed relationship in which one party is searching for some semblance of meaning while the other listens. And so then if words fail, in a curious way they also offer salvation. They are the only things Winnie has – or indeed Beckett has – to deal with the emptiness with which she - and he - is grappling. If language is nothing, therefore, it is also everything.
But for all the bleakness, Beckett’s characters do not succumb to madness. How do they do that? What sustains them?
The short answer is it is the power of speech, the very speech act through language – for all its imperfections and inadequacies – that keeps Winnie and Willie anchored in their imperfect world, buttoned down with meaning of sorts. So without perhaps intending it, rather than an anti-psychoanalytic criticism, Beckett has written a grand advertisement, in the old style, as Winnie herself might say, for the usefulness of the ‘talking cure’.
And why does psychoanalytic theory have such a wide application, whether interpreting organizations, art, society, human relations or the inner psyche? Perhaps it is because, as humans, we all travel a similar path to get to where we are and psychoanalysis travels that same path. We are born, raised by parents, are joined by siblings and, regardless of how we emerge as sexualised individuals from our earliest experiences, we are called upon to deal with life’s tumbling mix of confusions, setbacks, traumas and disappointments, as well as its achievements, joys, beauties and happiness.
* In 'The Review', newsletter of the Association for Psychoanalysis and Psychotherapy in Ireland (APPI), Issue 14, Spring 2009, pp. 24-26.

Tuesday, February 10, 2009

Understanding a Little More About Anxiety

By Kevin Murphy, M.Sc.,
Psychoanalytic Psychotherapist
Dublin, Ireland.

Anxiety is probably the most common ailment of the modern age, ranking up there along with depression and addictions. But that doesn’t make it any easier to deal with. We may know a whole lot about it but for anyone experiencing regular anxiety attacks, the reality is frightening.
What makes it even more frightening is that, by its nature, it appears to arise without any particular trigger. It begins as a bad feeling inside that builds and builds until it has the person on the verge of an indescribable blind panic; with all the associated physical symptoms that entails. The other nasty thing about it is that it can happen anywhere, in a restaurant, at home alone, among friends, on a walk in the country.
The text books say that anxiety is a psychological and physiological state characterized by cognitive (Mind), somatic (Body), emotional, and behavioural components that combine to create an unpleasant feeling that is typically associated with uneasiness, fear, or worry.
The fact that it has no identifiable trigger is the very thing that distinguishes it from fear, which in contrast happens when a real, external threat appears. If something nasty and real appears in front of us we have the ability to run or fight – the fight or flight strategy. But with anxiety the threat is internal and is perceived to be uncontrollable or unavoidable. That is the kernel of the threat which these bad feelings represent – they threaten to overwhelm us in a way we can’t avoid.
In this regard nothing much has changed in our basic understanding since Sigmund Freud mapped out the territory of anxiety almost 120 years ago. In fact, he was the one responsible for separating out anxiety from a whole host of other ailments comprising ‘neurasthenia’ back in 1894 because he felt it was an enormous subject in its own right. Be that as it may, there is a normal side to anxiety too. It is a normal reaction to stress and can help us deal with difficult situations by making us concentrate and cope. But when anxiety becomes excessive, it is classified as an anxiety disorder.
There are a large number of anxiety disorders in the psychiatric profession’s manual, the DSM (Diagnostic and Statistical Manual) and they all have the main criterion of abnormal or inappropriate anxiety. So if you start sweating, your heart starts racing, you become breathless, your muscles tense and you experience intense fear all for no reason then you are experiencing inappropriate anxiety.
Provided there is no medically explainable reason, it is considered an anxiety disorder. And with the psychiatry profession’s love of new disorders, you have many to choose from. There is acute stress disorder; there is agoraphobia – phobic fear of open spaces (with or without panic disorder); there is generalized anxiety disorder; there is our old friend obsessive compulsive disorder; there is panic disorder (with or without agoraphobia); there are phobias generally (including social phobia) and finally there is post traumatic stress disorder.
So now you can begin to see why anxiety is one of the most prevalent and unpleasant conditions in contemporary society. It is the common element in so many varying ailments, either appearing on its own or in combination with a host of other factors such as stress disorders, phobias, compulsions and obsessions.
If we go back for a moment to the later Freud of 1926, he said there were two types – one a very primitive and primary anxiety that stems from our helplessness as infants and recreates the traumatic experience of overwhelming bodily sensations that threaten us with total disintegration and possible annihilation.
Remember, in psychoanalytic thinking, helplessness is the prototype of trauma. And when flooded by overwhelming quantities of instinctual tension as infants, that we have no way of dealing with, it heightens our helplessness and this is therefore traumatic. In turn, each time we are subjected to such a ‘flooding’ as adults it is also traumatic because we are confronted with the same uncontrollable flow of excitations.
But as we progress through infancy we begin to learn to defend against this primary anxiety by using Freud’s second type of anxiety - signal anxiety – which warns us about the potential emergence of the first or automatic anxiety i.e. our fear of annihilation. So, as infants, we cry or reach out or call out to our primary carer.
In short, the first warning we get is signal anxiety. It warns us through an increase in our bodily or mental tension. It is the mind’s way of adapting itself to take defensive action against something overwhelming that is about to happen from within. It is our human way of ensuring that we take whatever precautions are necessary so as we do not experience the more serious primary and overwhelming anxiety.
And so we come to a key concept around dealing with anxiety. The rise in mental or physical tension is, if we take Freud’s view, a signal that an anxiety attack is building. But who in our fast-paced world of short deadlines, work pressure, performance targets and so on is not subject to rising tensions? How do we recognize the signal when it comes?
Add into the mix, possible variables such as a lifestyle that includes an amount of alcohol or drugs, personality factors such as dependency or depressive or self-critical tendencies; and not forgetting the normal ups and downs of relationship and emotional issues. It all adds up to an impossible task to monitor or even recognize the stresses and strains that our psychophysical systems are under.
There are therapies that can offer solutions to anxiety attacks – usually they focus on teaching the person to listen out for these very signals. That is a skill that modern living, particular in Western culture, has blunted for many of us. And that is why spiritual solutions such as meditation or Yoga or old fashioned prayer offer comfort to so many.
Psychoanalytic psychotherapy offers its own solution – a talking experience in a professional relationship with a trained ‘other’ person in which ‘the pain of detachment’ as the anthropologists call it – the gap that exists between our natural and our civilized, technology-oriented selves – is made understandable and bearable.
Anxiety has a natural defense. It is called signal anxiety but its defensive purpose is redundant if we lose our ability to hear the signals.

Tuesday, February 3, 2009

Learning From Things That Go Unsaid - 2

By Kevin Murphy, M.Sc.,
Psychoanalytic Psychotherapist
Dublin, Ireland.

I’m picking up where I left off last week on the concept of the client gaining self-knowledge through the unspoken actions between him or her and the therapist. Before I go into that, let me just say that the same things apply all the time in our relationships with people in our daily lives. It’s just that we tend not to notice them.
For the purposes of the therapeutic setting, however, the relationship with the therapist is a key factor in the whole thing. You have to believe that the therapist you have chosen is the right person for you. That’s usually done by checking out the person’s qualifications. If they haven’t spent time studying to be where they are then you are right to be wary.
But what of the person who has all the qualifications necessary and the client still doesn’t feel they are the right person for them? Is the therapist cold, uncaring, unresponsive? Sometimes that can happen and it isn't very nice. But most therapists are respectful and welcoming while trying to retain a professional sense of distance. They want to help the client overcome whatever it is that is holding him or her back but, equally, they don't want to be a surrogate ‘buddy’.
If there is nothing obviously amiss with the therapist but the client still feels they are in the wrong place, where then do we look for explanations? Is it the client’s own view, a privately held opinion, a vibe, a vague feeling? If so, then we are moving into the area of unspoken, and unconscious, repetitions of earlier relationships. The therapist, without doing or saying a single thing, has taken up the position of someone else from the client’s life, for the client.
When the therapy begins the client may think the therapist has all the answers, can put his finger on exactly what it is that is wrong. But after a few sessions, when the client realises that there is still an amount of work to be done and things haven’t changed as quickly as they would have liked, the positive feelings can turn negative and the therapist is now useless or uncaring or badly qualified or has an office that is too far away or the fee is too expensive.
Nothing has changed on the surface of things. And usually, none of this is ever spoken out. But the client is firmly convinced of these view and attitudes.
The therapist has taken up the position of important ‘other’ person from the client’s present or past life and one that is failing to help, is failing to get them out of their misery, or pain, or confusion. The therapist fails to love them, know them, understand them or even care about them. And yet, nothing could be further from the truth.
In reality, what the psychoanalytic psychotherapist contracts to do is to pay full attention to everything the client brings to the session ‘every single time’ the client turns up for their appointment. The therapist contracts to be there on time; not to exploit the relationship in any way; not to charge anything other than the agreed fee and to remember at all times that the client will have a certain amount of dependency on the therapist while getting stronger in themselves.
But therapy is a relationship and if relationships, either current or past, have been problematic for the client then this is going to surface in the therapy. If someone has been damaged by relationships, they will have difficulty trusting the therapist as ‘other’ to help. If relationships, particularly early ones, have been disappointing then the client will not allow themselves to even like the therapist. All of this is usually unspoken and yet it impacts directly on the therapy.
So if you accept that psychoanalytic psychotherapy is founded on a professional, talking relationship through which a cure is being sought, then how you ‘handle’ that relationship, just like any other relationship in your life, tells you a great deal about yourself.
In this light, what if you end your therapy half way through the treatment without any notice, by simply not turning up anymore and never explaining why? It’s a bit like ending a relationship by text, isn’t it? Ask yourself what it tells us about someone when they end a relationship by text? Or what if every week you arrive late, or don’t show up every second week without giving the standard 48 hours notice? Or after just two sessions begin asking how much longer will it take?
It’s a way of saying you don’t want to be there in the first place, isn’t it? That’s fair enough, but then why are you there at all? Because to be human is to live in that paradoxical place where we need other people and yet we don’t like having to need people. And that in turn leads us to why the business of conducting a relationship in a mutually respectful way with another human being is so fraught with difficulties.
The option of a talking therapy is always going to be a problem for those who see relationships as a threat because relationships are a two-way street on which they risk having something of themselves exposed. As such they will try at every turn to get away and hide. For these people there are always lesser demanding therapies that can be short term, non-speaking or pharmaceutical. But the best way of curing the human problem of psychical pain and unhappiness is through engaging in a professional relationship with another human being in the search for one’s own particular truth.