Tuesday, March 31, 2009

Getting to Grips with Depression -1

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

When you hear people use the term ‘depression’ the tendency is to imagine that they are talking about one thing. The impression is that depression is a whole and unified experience much like, say,the common cold. But in the same way that the common cold is a collection of symptoms, so too is depression. It is a collection of conditions that differ in their intensity depending on the individual. The word depression, therefore, is a blanket term that, on the one hand, lets us know broadly what we are dealing with but, on the other, can potentially sow the seeds of confusion.
Why confusion? Because in the first instance when we say that someone has ‘depression’ it does not situate us, as therapists, to accurately approach the treatment of that person. As a blanket term, it lures us into the false belief that there is a stock approach, a manual that we can consult and a prescribed set of things we need to do. In other words, it gives the impression that someone with depression belongs to some collective grouping that responds equally to the same treatment.
If that becomes the starting point for therapy, then the person’s individual circumstances and the particular mix of elements that are present will take a back seat to a more generalized, this-works-for-everyone approach.
Secondly, the very label of depression stigmatizes the person who suffers from it and sets them apart from the very society that they are struggling to be part of. Insurance companies load people who admit to having depression and it is one of a select number of subjects that simply do not get discussed by society at large, notwithstanding the ongoing efforts to change that.
Thirdly, it creates the false impression, as does a lot of modern psychology and psychiatry, that by having a name for it we also have the answer or cure for it. Unfortunately this is not the case. Good medicines are available but they do not take away all depressive pain.
So what then does psychoanalytic psychotherapy have to offer? Well to try and answer this as best I can I will take this week and the following two week's to focus on the subject.
The defining psychoanalytic viewpoint is that since depression is a blanket term we must look beyond it for answers. This means taking into account that there is a diversity of depressive symptoms contained in the word "depression" and these include mourning, anxiety, inhibition, rejection of the unconscious, melancholia, dereliction, sadness, self disgust, pain of existence, and, indeed, many others. The attentive psychoanalytic psychotherapist must recognise this.

This is the modern view of depression but it has its roots in Freud who referred to it as melancholia in his paper Mourning and Melancholia (1915). He contends that the difference between mourning and melancholia is that in mourning all that has been lost has been lost from consciousness and there is a necessarily painful withdrawal or regression. But in melancholia (later to become known as depression) it is not clear what has been lost because the identification has involved unconscious components. As the man said himself, “In mourning it is the world which has become poor and empty; in melancholia it is the ego itself.” So, it is 'we' who become the impoverished thing when depression strikes.

Freud was also the first to notice that melancholics were inclined to accuse themselves of many failings in an entirely unjustified way, and noted that their self-accusations could just as easily be directed against someone whom the patient loves or has loved. This led him to theorise that the intense and unreasoning nature of depression indicated that what had been lost was not just the external person for whom one mourns but an internalized idea of that person, or even an internalised idea of ourselves, to which there had been an intense identification by our ego.

As he puts it in a well-quoted phrase from that same 1915 paper: “Thus the shadow of the object fell upon the ego, and the latter could henceforth be judged… as though it were an object, the forsaken object”.

More recent psychoanalysts have moved Freud’s thinking on. Professor Paul Verhaeghe of Ghent University agrees with Freud that the process of identification lies at the heart of both depression and mourning. He says this is evident in the need to dismantle the inner image and, hence, identification with it. In his view depression can be understood as one side of an opposition: the emptiness of it standing in contrast to the fullness of enthusiasm.
At the heart of depression, he says, is a lack of emotion and a confrontation with emptiness and loss of meaning. He says depression can thus be conceived as the reverse of identity acquisition. It is the loss of an identificatory anchoring point in the Other, meaning key figures in our lives or in society generally.
Interestingly, he says that depression begins when, for one reason or another, the person is convinced that she or he no longer satisfies the Other's desire. As a result, the person plunges from a necessary and sustaining fantasy of their place in the human world into the empty void. In short, anything that damages the person's certitude that they satisfy the Other's desire provokes depression.

It might sound like heady stuff but, in fact, it is pointing to a fundamentally simple truth: depression is a result of the human condition in a world where all the old certainties are gone. And it is inextricably linked to our personal development, our reliance on others, our formation through our interaction with others, our relationship to internal and external ideals that sustain us, and our un-ending search for meaning and happiness. If we accept this is the case, then the same logic insists that the solution to depression is also to be found in the equally human framework of a therapeutic endeavour that operates precisely within this field.

Next week I will continue on this theme.

Tuesday, March 24, 2009

The Trouble with High Self Esteem

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

We are used to hearing about the negative effects of low self esteem. It is the thing that holds us back and interferes with our ability to successfully carry out Freud’s two criteria for a fulfilled life: to love and work.
Most psychotherapists will be familiar with it in the consulting room because both men and women suffer from it, each in their own way.
It makes the ordinary business of life more difficulty, it hampers relationships by making them uneven, it turns the effort of putting oneself forward into an insurmountable obstacle, it makes people feel they deserve it when bad things happen to them, and it makes them blame themselves when things fail or mistakes happen.
And yet we rarely year of the damage caused by high self esteem. It too can be damaging, not only to the person generating it but also to those around him or her. It is, however, a difficult thing to recognize because it is wrapped up in so many attributes that we consider positive.
How can you determine if someone who succeeds is genuinely talented or being propelled by negative high self esteem? I was reminded of this reading award-winning financial journalist Kathleen Barrington's new blog on the rise of Irish property millionaires, who risked everything in pursuit of extreme wealth. Her point is that they became the same type of landlords that the British had been when they governed Ireland, consumed with the acquisition of wealth, power and status. She paints a picture of ambition without any sense of proportion.
And so the short answer is it is impossible to tell if someone has a genuine talent for success of whether they are recklessly driven by less admirable qualities such as vanity, greed and this same lust for status and power. At least it is on the upward trajectory of the person’s career. The true test is when the trajectory falters and complications or obstacles or setbacks occur.
We have seen a great deal of wealth created in Ireland over the past 10 years or so. The country has improved enormously but at the top levels of Irish corporate life, particularly in the financial sector, we have seen the emergence of greed and dishonesty that has not been pretty to watch.
Of particular interest are those men, and it is mostly men at the top of the corporate system, who have driven their companies in pursuit of profit to such an extent that prudence and concern for shareholders', employees', suppliers' and customers' interests have taken a back seat.
Even before the recessions the examples were numerous of individuals who had taken decisions to enrich themselves at the expense of everyone else. It's just that in recession those decisions become less admirable. Were those men driven by a conviction of their infallibility and the correctness of their actions? The reasonable answer would be yes they were.
And they would have made their way up the career ladder displaying the same characteristics of single mindedness, a strong belief in their own decisions and a canny knack in making others believe in it too. This can be a good thing if it is part of a well rounded personality that understands limits, fairness, boundaries and the place of others. Enmeshed in this corporate culture is a notion that risk taking comes with the territory, that fortune favours the brave and that the higher the salary and pension you can squeeze out of your organization the better the businessman you must be.
Despite the narcissistic machismo inherent in all this, there can be some good in it. Or rather, had the world economy continued on its merry path, everything would indeed have been well and good.
But things took a turn for the worse. Jobs have been lost, companies have collapsed and economies have gone into a tailspin. In this light, the actions by some of our leading business people to continue their pursuit of power and wealth despite the changing conditions reveals the more damaging side of high self esteem. The over-arching belief that what you are doing is right, despite the objections of others or the moral climate of the time or the economic conditions that prevail, is a clear sign that negative high self esteem is operating. The thing that was unnoticed and often praised when times were good, is now a curiously misplaced strategy when times are bad.
You’ll often hear it said that these people are out of touch with reality, paying themselves hugely despite the reality of the market place right now. But it is just as likely that these people are not out of touch with reality, that they do know the inappropriateness of what they are doing but that their narcissistic compulsion to act in their own self interest is simply too strong for them to overcome. It is an embedded part of who they are, and one that up to now served them well. To continue defending against perceiving themselves negatively – because inappropriate high self esteem cannot allow this – they act in a way that the rest of us can detect, even at an intuitive level, as being out-of-kilter.
We must also remember that a system is in place that actively allows people with this mind-set to scale the heights of success. Concern, sensitivity, modesty, regard for others, a sense of one’s own fallibility and limitations, these are not the qualities we look for in our business leaders. Once they reach the top, they are more than likely surrounded by people of a similar mindset that prop them up in their self-belief. Isn’t it interesting how few organizations have apologized to employees, shareholders or customers who have suffered because of corporate greed and recklessness? Public apologies are simply a rarity in our corporate culture.

But it is by no means confined to the business world. You will find the damaging effects of high self esteem just as easily in interpersonal relationships as you will in organizational culture. Once established, it is a particularly difficult and insidious influence to weed out. The only chance of dealing with it successfully is to evaluate frankly and honestly the impact of a person’s high self esteem on those around them. Confidence is one thing, but confidence at the expense of either a partner’s or an organisation’s well-being is a signal that things are not as they should be and should be changed.

Thursday, March 19, 2009

Working with Men

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

When men come to psychotherapy, it is not a small thing. It usually represents a victory of sorts. It is a victory over all the personal and cultural prejudices and stereotypes that keep them locked in a non-speaking, non-questioning, non-reflective place. More often than not they will have reached a crisis point in their lives and yet they will, generally speaking, do their utmost in sessions to underplay just how big that crisis has been.
Men are not supposed to show any weakness. We have had decades of change and yet that faulty axiom is still alive and well and operating in the male world. Instead they are supposed to tough it out, keep silent about things that bother them, reject any attempt to communicate their more private thoughts, remain loyal to the significant people in their lives at the expense of being truthful about their own ideas and experiences; and on and on it goes.
I was reminded of my colleague’s question about working with men while watching Gabriel Byrne’s excellent hit show ‘In Treatment’, particularly in his dealings with the male patient Alex. It takes time to cut through the male defenses. Often you’ll hear people say that it is about getting to a point where men trust you enough, and trust the process enough, to speak freely. But there is more to it than that.
It is also about bringing them to a point where they accept that life is not a compartmentalized business. We cannot consider an issue in isolation, it is connected to many, many other areas of experience. Nor can we dismiss ideas because they seem trivial.
Some men feel if we are not discussing big issues with big objectives driving them that the therapy is not doing what it should. But trivial ideas contain the key to new material that has never been uncovered before and very often these are the ideas that men defend most strongly against letting out.
Offering the kind of guidance and presence to allow these elements come together is an important part of the challenge. It is like going to the jungle and spending a very large amount of time clearing a space in which you can set up base camp. Huge energy is spent before any exploration even begins.
When I said it was like a wrestling match I was also referring to something else. Often you find with men that they want to be convinced as to why it is they are sitting in your consulting room, despite the fact that they will have elected to come. The process of cultural male stereotyping has been very effective. Some don’t believe that talking is of any value, that it can do any good, and some believe only bad things can come from it. As a therapist you find yourself almost drawn into a subtle debate as to why they should have to talk in order to ‘fix’ something. A man with an irrational fear of random violence will want to know why he should consider having to talk at all, why is it not possible to simply give him a form of words that he can say to himself when the anxiety strikes that will banish it from his mind. A young man in prison for a sexual offence that he says has brought shame upon him and his family cannot see how talking can fix any of that. And yet these men continue to come, for their different reasons. At one level they know the therapy process can offer them answers but at another level they resist it at every turn. Paradoxes abound in the psychotherapeutic world.
For this reason, the business of getting back to basics can take a considerable length of time. I was struck when reading up on the subject of modified psychoanalytic psychotherapy how that shortened form of therapy recommends that the first four sessions be set aside to establish the client’s symptom history. Four weeks, at two sessions a week, is either optimistic, or else the therapist is incredibly good. Particularly if you are dealing with someone who starts each session anew, as if previous sessions have had no effect. Some men begin not with a desire to speak but with a desire to disguise and keep hidden, or pretend there is no issue, or talk about nothing other than the narrow symptom itself, why it is there, how bad it makes them feel and why it simply cannot be made go away.
As a therapist you spend each session returning and returning and returning to the same essential point: the symptom is a result of their whole set of life experiences, not simply a small part of it. Once they arrive at that understanding, the work begins in earnest.

Tuesday, March 10, 2009

Finding Mr. Right

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

You will often hear women say that the business of finding love can be a fraught affair. For the lucky ones it seems to happen with the greatest of ease. They find the perfect partner almost by chance, they live a happy, fulfilled life, achieve all their joint and individual goals and everything in their garden is rosey. I accept that it is an attractive ideal but let’s not get too carried away with imagining just how green the other person’s grass can be. Inherent in this fantasy, alluring as it might be, and no doubt supported here and there by examples in reality, there is a notion of perfection. And as we know from looking around us, perfection does not really exist. When those wiser than us once said that into every life a little rain must fall, they weren’t making it up. So let’s keep that in mind.
Other women, however, never seem to have this ‘finding of the perfect love’ happen to them. Either Mr Right never comes along, or if he does he never stays for very long. Now that can be due to a number of factors. I have come across female clients who often feel they set up their relationships in order to fail. That there is something, not anything particular they can put their finger on, but something in the way they construct and approach the relationship with a man - usually but not exclusively a man - that carries within it the seeds of failure. Needless to say I have come across men who have the same attitude but let’s stick with the woman’s side of things for now.
There are also some women who find the ‘perfect’ man but for some reason he doesn’t love her in the same way, with the same intensity, with the same unconditional passion. No matter what she does she just can’t seem to get him to turn up the intensity. And then there are others who find the right man, one who loves them in precisely the way they want to be loved, but who suffers from that curious male confusion whereby he says he wants to be with them but the next minute says he feels he can’t be with them.
And then we have the more worrying version of the woman who falls head over heels for the wrong guy. Not only do all her friends tell her he’s the wrong guy but, intuitively, she knows it herself. This kind of woman is perfectly capable of telling someone else, should they be in a similar situation, to get out of there as fast as they can. And yet, uncannily, can be incapable of following her own advice when it comes to her own relationship.
What do you call that? What do you call it when a woman is in relationship with someone whom they adore and yet who shows practically no signs of returning the love? That type of unresponsive partner can just as easily slip across the line to being abusive, through verbal, psychological or physical means, and still the woman remains in the relationship.
Modern psychoanalytic theory, particularly Lacanian theory, has spent a vast amount of time writing and researching from the clinical setting on the subject of the sexual relationship. From that perspective, it throws very interesting light on what it is that operates in the woman (or equally the man) who finds themselves in any or all of the situations mentioned above. Although the context is the sexual or romantic relationship, it isn’t purely about sex.
It is as much about being propped up and confirmed as a person. It is about our subjectivity, if you like, the place where our sense of ‘I’ resides. I know that sounds a little high falutin’ but bear with it. In our identifications with those around us, we bring into ourselves the part of others that we most admire. That is generally accepted theory no matter what school you belong to. Lacanian theory goes a step further, in this and many other areas, in that there is another side to this psychical action.
We take into us those parts of others that we like ‘because’ it nurtures and feeds an inner ideal we already have of ourselves. This inner ideal began to form in our first year of life. It is the thing that kick started our ego, our imaginative life and our development as a thinking, speaking being. So you could say the image we fix on is feeding the soul except that while I like the word ‘soul’ the concept doesn’t quite capture the notion of bodily and psychical entirety that I am aiming at. Nevertheless, that is the general idea.
When we fall for someone, it is usually as result of their physical image combined with our imaginative activity. This is what first captivates us. And that image the other person represents feeds, as I said, a very intrinsic and fundamental part of us. That is why, if the reality of that person falls far short of the image, we still find it virtually impossible to stop loving them. The grip the image has is particularly strong and, if the relationship collapses, it continues to have an ambiguous effect: it causes pain if it remains and if attempts are made to dislodge it. That is the delicate conundrum that psychoanalytic psychotherapy regularly comes to grips with in the therapeutic session.
Now you’ll want me to give you the chapter and the book where you can read up on this notion and find a possible cure for love. Sorry to disappoint but there is no single chapter and there is no single book. It is out there in the body of knowledge generally but there is no easy access to it. And if there was it still would not represent a cure in itself. Knowing is one thing but it does not guarantee cure. The route of psychoanalytic therapy is down the particular experience of the particular individual. There is no text book or manual for that. No single book can provide for the detail of an individual’s significant life experiences. Their meaning must be re-encountered, re-established and at times defused through the act of speaking them out, one by one.

Tuesday, March 3, 2009

Making The Call

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

When someone we care about is unwell our natural instinct is to get them help. We see examples of this all the time. The extreme case is when we run into a burning building to save a child or an elderly person. The less extreme case is when we bring our sick friend or child or partner or parent to the doctor for a check-up and hopefully get medicine that will make them better. We are hard-wired to help those we care about.
That’s why it is so difficult for people to come around to a different way of thinking when it comes to therapy. If someone is unhappy or behaving oddly or thinking oddly or feeling bad more often than feeling good, we want them to see someone who can help them. Now that works well if the person who needs help realizes and accepts that they need help. In that case making an appointment for them to see a therapist is a relatively straightforward thing to do. Although I will come back to this point because it is not as cut and dried as all that.
If, however, the person is unhappy or behaving oddly and is unaware or unconcerned or uninterested in changing their behaviour, then the problems start. People in the grip of addictions, for example, are notoriously difficult to persuade to seek help until they themselves come to believe it is necessary. With alcoholism, and it equally applies to gambling, drug and sex addictions, the term is reaching ‘rock bottom’, the point at which there is no opportunity left for the person to deny to themselves how bad things are and how much the addiction has damaged their life and the lives of those around them.
In cases where teenagers are difficult or impossible to deal with, especially those who are obviously hurting inside, it can be difficult to ensure therapy will succeed unless they have the will to engage in it. For some, particularly young men, the notion of ‘submitting’ themselves to another person, either male or female, can represent an insurmountable challenge. Now you won’t know until you try and often the most difficult young people can respond well to a listening ear. But if, as with young men sometimes, their issues are around trying to live out an exaggerated ideal of manhood, for example, then talking confidentially about themselves to another person, no matter how well qualified or trained, does not fit well with that ideal.
With young women, particularly those in the grip of eating disorders, the behaviour actually fits into their lives as a ‘solution’ and as such is something they are unwilling to give up. Only repeated work by their surrounding family on how their illness is affecting loved ones around them can trigger the change of attitude needed to undergo therapy.
You can also find it in adults, particularly those in the grip of anxiety or panic attacks. Anxiety and panic are reactions to fear, you could almost say they are a fear response to fear itself, and so a therapist can often represent one more fear object to them. Equally, if they do manage to come for therapy they can shift that anxiety on to a fear of ‘finding out’ something unpalatable about themselves. This is part-resistance to any form of disclosure in therapy but also part-by product of anxiety itself. They need to find the window of opportunity within their own anxiety in which to decide they are going to try and escape the cyclical pattern in which their lives operate.
With some disorders, the business of avoiding therapy comes with the territory. It is part and parcel of sexual offences for example. The claim by serial paedophiles that what they do is acceptable and that it is society that has the problem is an extreme case of this. It is the nature of their illness that allows them believe it is ok to inflict sexual violence on children. And, you find the same thing with sexual exhibitionism. It is conducted almost exclusively by men and they engage in a specifically unique act of exhibiting themselves to females yet they have no idea why they do what they do nor do they see it as being of any harm. It is denial at one level but denial assumes an acceptance of something to be denied. In these forms of sexual disorder there is no acceptance of something being wrong in the first place. So why need a therapist if you are doing nothing wrong?
Some women who have been traumatized by their childhood can find it difficult to seek therapy, often until their lives become unmanageable. And before that happens, there is usually a high degree of collateral damage to their primary relationships, their career and their relationships with themselves. It can take many and varied forms including addictions, personality-, adjustment- and mood-disorders.
I mentioned above that even with those willing to accept help, the case of ringing up and making an appointment on their behalf is not cut and dried. The key to this is that ‘someone else’ is making the appointment. Now you regularly hear people say that if someone isn’t well enough to make the call, then it has to be made for them. The opposite is equally true: if someone doesn’t make the call then the ‘idea’ of getting help was never really theirs in the first place. They have invested little of themselves in the process of getting well. In the therapeutic world you’ll come across the phrase ‘openness to improve’. It can often signal the difference between those who do well and those who don’t in therapy. It is a small thing but ‘openness to improve’ is an indicator of the person’s own desire to get well. Unfortunately, in all types of disorder, there are those who simply do not want to get well. The surest test is whether they can, in whatever way possible, signal their desire for improvement. That can involve simply saying ‘yes’ or it can involve making the appointment for therapy themselves by lifting a phone or sending an email. 'Saying' we want to get better sometimes isn’t enough. If we are lying in a burning building we have to at least try and crawl our way out instead of waiting for someone else to burst in and save us.