Thursday, May 28, 2009

Seeing the Wood from the Trees

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

A client, who shall remain anonymous, said some things in the course of a session once that have stayed with me a long time. This particular client was suffering from a severe form of depression. What does that look like in reality? Well, it includes an inability to consider anything good about themselves, an inability to motivate themselves, a profound sadness and regret at who they are and what their lives have turned out to be, an absence of any hope for the future, and a harsh sense of judgement of themselves and their abilities.
It is depression and that is the diagnosis you would expect from a psychiatrist or a psychologist, which is valid in its own right. Psychoanalytic psychotherapists use the word too, in fact the theme for the 16th Annual Congress of the Association for Psychoanalysis and Psychotherapy in Ireland (APPI) next November is ‘Depression and Melancholia in Modern Times’. But where we differ is that this word depression is a starting point, rather than an end in itself. It is the place we begin a search, if you like, rather than the place where we settle down to consider the nature of the symptoms.
As I have said before, depression is a broad diagnostic label, one of many that give us the impression of understanding the issues involved when in fact they are only a very general guide. Description is not the same thing as understanding.
Taking the client I mentioned above, the things this client said in that session I referred to were that they (I use the plural to ensure confidentiality) were completely stuck on three ideas that had an almost persecutory quality.
One was the idea that the future would turn out bad. Something that had happened in their life was going to come back and haunt them in the form of unforgiveness from other people. There was some degree of reality in this, given the nature of this client’s background.
Secondly, this client was unable to stop thinking about a former lover, one that had since moved on to another relationship. The client felt extreme regret at having ‘lost’ this person through their own choice and now wanted this partner back even though the likelihood of that happening remained very slim.
And thirdly, as a result of this threat from others in the future, different options were constantly being considered to escape this threat. But the client experienced a deep depression around any of these options. In short, no matter where this client pictured themselves in the future, it was going to be awful.
The upshot of all this was a person who was deeply depressed about their situation and who was on the strongest depression medication available which, while keeping them from experiencing extreme pain, was far from blocking out all negative feeling.
The resonances I spoke of in this case were that this client was, while on the face of it anxious and depressed about the possibility of real things either happening or not happening in their life, the psychical reality was they were completely stuck. The ideation, or rather the process of idea formation, was almost exclusively centered around three identifiable issues, each with a modicum of real possibility about them. The tendency and indeed the temptation would be to work on the rationality behind these ideas and consider whether they might or might not happen while, along the way, work out options or strategies that might stave off the more unpleasant outcomes from taking place.
And yet that would be to ignore an essential point. It was not the content of the ideas themselves that was the source of distress for this client, even though at one level that was the case. It was more to do with the fixedness of the ideas; the fact that they could not escape thinking these ideas, despite the strong medication; that they could not escape the frightening and paralysing effect that these ideas had on them.
This form of thinking was, when we examined it more closely, quite similar to a style of thinking that this client had put into operation in many other areas of their life, both past and present. The gripping on to notions, and the worrying about them to an extreme degree, was part of a complicated internal defence strategy that they had learned over many, many years.
The issue was not what they needed to do about these ideas in themselves but what they needed to do about this kind of thinking. It sounds a bit like a behavioural approach to therapy doesn’t it? Simply teach the person to think in a different way. But it is not as simple as this either.
This kind of thinking is not simply un-learned and another more positive type inserted in its place. This style of thinking is, at a hidden level, designed to blot out many other aspects of the person’s life. It is, quite literally, a screen behind which the realities of their existence are kept concealed. So it is not a question of re-learning anything. It is, rather, a question of patiently and carefully dismantling a very sophisticated form of defence system in order to allow for a consideration of the fullest aspects of the life it seeks to conceal.
Now we are firmly back in the realm of psychoanalytic psychotherapy. A place where one takes one’s time and proceeds with the sense of caution and respect necessary to do a delicate job well. Unveiling things that have remained veiled for a great many years needs patience and care. It also needs a robust theoretical framework which allows for it to be recognised for what it is in the first place.

Friday, May 22, 2009

Working with the Couch

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

As a piece of furniture the couch probably attracts more interest than anything else in my consulting room. Of course when I say couch I should more accurately describe it as a chaise longue, which is defined as an upholstered couch in the shape of a chair that is long enough to support a person’s legs. But calling it a couch works just as well.
I suppose it attracts interest because over the past 150 years, since Freud first gave us psychoanalysis as the original form of psychotherapy, the couch has become very much more than a piece of furniture. It has come to symbolize a great many things, possibly even psychotherapy itself.
In the process it has had its detractors from other schools of therapy who have seen in it an opportunity to criticize, sometimes with merit, sometimes not, custom and practice and, with much less success, the underlying theory.
You could say it has almost become a touchstone for inter-disciplinary strife, which is a great pity because we are all trying to achieve the same objective and at the end of the day it really is only a couch.
Freud began using it because his first forays into probing the unconscious mind of a Victorian-era clientele was through hypnosis. And when you hypnostise someone you want them to be in a comfortable position so they don’t fall over. When he left hypnosis behind and discovered the ‘talking cure’, in doing so founding the beginnings of all psychotherapies, he kept the couch.
Following his death, and even during his lifetime, splits and differences led eventually to what we have today in the form of three broad streams of psychotherapy. There is psychoanalysis and psychoanalytic psychotherapy which continues to use the couch and which, despite the claims from other branches of psychotherapy, is alive and well throughout the world.
Then there is the humanistic stream and the behaviourist stream, the former giving privilege to the notion of the conscious mind and the intrinsic wholeness of the person, the latter giving privilege to actively re-learning and retraining the person to more effective modes of both physical and mental behaviours. These two streams don’t have too much in common except they do not use the couch.
So what is it about the couch? The idea behind it, officially, is that Freud wanted to increase the ability of the client to allow ideas and thoughts, without censorship or editing, enter their mind. This happens because the client, by lying in a comfortable position facing away from the therapist, is not being impeded by the facial gaze of the therapist or the surreptitious body language that might inhibit this process. To this day, this objective has and continues to be fully met by the use of the couch.
Clients who work on the couch will tell you that it allows them the freedom to both relax and focus on their thoughts without have to attend to every little bodily cue that emanates from the therapist. It also, and more importantly, frees up the thinking process so that ideas come much more easily that can then be brought into the session.
That’s not to say that those of us who work with the couch are impervious to the cultural stereotyping that goes with it. Psychoanalysis has been around for a long time and it will continue to be. It also, by its very nature, deals with fundamental issues in people’s lives. The cultural stereotype of being ‘on the couch’, when it pokes fun at our doings, is a useful puncturing of the balloon and ensures we never get to complacent or smug or self-righteous. And that’s a good thing. It means we who practise have to be constantly reviewing its effectiveness and clarifying for ourselves the rationale for using the couch.
Psychoanalysis has become a classic target of cartoonists. Freud said that cartoons represent "a rebellion against [...] authority, a liberation from the oppression it imposes". So it was perhaps only fitting that the cartoon should be the medium for the longest-running and most iconic piece of send-up in the history of psychotherapy.
The ‘On the Couch’ cartoon that appears in The New Yorker magazine documents nearly 80 years of this send-up or rebellion against authority. The magazine published its first “psychoanalytic” cartoon in 1927 and since then its cartoonists have continually renewed the topic within the context of their own times.
So does everyone end up on the couch? No is the answer to that. Some clients sit in a chair facing me and do so for the duration of their therapy. The criterion for who uses and who does not use the couch is a detailed one. People in a high state of anxiety or in deep depression are not suited to it until their symptoms have reduced; nor are those who come with a rejection or a refusal to accept the notion of therapy and, believe it or not, some people do. And equally people with relationship issues who come to discuss the issues at hand as to why they are in or have endured in a relationship that is unfulfilling are not necessarily candidates for the couch. Often some people simply need to talk. As Freud is reputed to have said: sometimes a cigar is just a cigar.
But for the vast majority who come with a question, albeit one that may not yet be formed but which is forming within them, then the couch is the most effective form of therapy. For those who live lives of constant doubt, anguish or repetition and who question why their life is that way and how it can be changed, the effectiveness of the couch and the freedom – because freedom is really what it is – it offers is unparalleled anywhere, in any other form of therapy.
Not only is it a powerful method which allows people access parts of themselves they never thought possible. But to engage in the important business of examining one’s life in the presence of a trained other and without the gaze of that ‘other’ distracting them at every turn is the ultimate respect that can be paid to anyone.

Wednesday, May 13, 2009

What Should We Talk About?

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

What is it that we are supposed to talk about in therapy? It seems an obvious question, doesn’t it? Presumably the answer is that we are supposed to talk about the very thing that is bothering us most. Or put it another way, the very thing that brings us to therapy in the first place. Yes that makes sense.
But what about someone who, for example, feels bad all the time? Are they supposed to talk about how bad they feel every time the come to a session? Certainly it is necessary to describe it at the outset, and there are times when it is necessary to describe its variations. But if it is the only thing that gets spoken about, is there a value in that?
And this feeling bad need not always be out-and-out depression. Often people can conduct a life for themselves, but there is always a heart-stopping worry going in the background, a fear that something dreadful will happen. Sometimes it stops them going out of the house, or relaxing around their family, and instead makes them irritable all the time and turns them into the kind of people they don’t want to be.
Or what if the thing that someone has come to talk about is the fact that they cannot talk? The very act of saying a simple thing about themselves is too difficult, too fraught with danger and so they cannot risk exposing any detail about themselves. They have, instead, learned over many, many years to say nothing. So what is someone like this supposed to say?
And what about someone who has been severely sexually abused as a child? The thing that brings them to therapy is so painful to talk about that they prefer to say as little about it as possible. Sessions are spent on other details of their lives, how they feel about current experiences, how they manage their relationships, and so great effort is spent not talking about the trauma.
So what then are we supposed to talk about in therapy? Well, as far as psychoanalytic psychotherapy is concerned the best way of looking at this question is to tell whatever stories we feel we can that have happened in our lives, either currently or in the past. The thing we are expected to search for are those scenes from our lives that we gravitate too most easily in our speaking out of our story. Now, the chances are that we don’t have any idea of what these are going to be when we begin the session. But experience shows that when we begin by speaking about the first idea that enters our head, and continue speaking in as uncensored a way as possible, that these scenes emerge, often to our great surprise. And, spoken out afresh, it is constantly surprising how people find a new added detail that they had not realized before that gives the situation or the event a whole new meaning.
You often find some people will want to know why it is so important to talk about these so called obvious details of their lives? Why is that they should talk about scenes from a life that we already know inside out? Surely recounting them won’t make any difference or change anything? Shouldn’t the therapy be focused on what is actually wrong or going wrong or causing the problem?
In the first place, therapy is not trying to change things that happened because there is no way of doing that. What it is trying to change, is our view or perception or understanding or or relationship to those same things. Focusing exclusively on the problem, as it presents itself, is usually a sure way of picking up the wrong end of the stick. What most therapists will tell you is that the act of describing an emotional problem is only half the story when it comes to finding a solution. Someone suffering from anxiety, say, is in the grip of a fear that is there all the time. Describing the many and different ways that this fear manifests becomes a self-defeating exercise. The inventive ways that the psyche can find to be afraid, and the objects which can loom up, real or imagined, to become the cause of that fear, are as varied as the number of individuals in the world. Setting oneself up to describe all these variations and to look for answers in them is a recipe for disappointment.
Psychoanalytic psychotherapy operates on the basis that a person experiences these things, and many other and varied kinds of symptoms and disorders, as a result of their life experiences and the way they have either accepted or rejected those experiences. The answer is not to be found in the end result of these experiences but in the primary experiences themselves, no matter how small or insignificant.
The hard part is staying focused on talking about these often incidental details of our lives. The tendency is to retreat into generalizations, and vagueness and conceptual fuzziness. The test of this is to ask yourself to give an example, a situation or a scene that actually happened in your life that could describe what it is you are trying to say in a general way. That is not as easy as it sounds but persevere because the answer lies in the specifics.
Why? Because the actual things that happened to us or the actual things that were said to us, or the actual ideas that we had about others around us are, no matter how trivial they might seem, specific to us and only us. It doesn’t matter if others might remember things differently or put a different interpretation on things that happened. It is the memory we have, the perception we have, the interpretation we have of real events or situations that really happened to us. And don’t get me wrong, even therapists undergoing therapy fall into this same trap. It is easier to be general and vague and fuzzy with the details.
But the only way of truly examining a lot of our preconceptions about ourselves, our assumptions about who we are and how we came to be where we are today, is to deal with specifics, to focus on things that actually happened and to paint as accurately as we can our place in them. We are unique in that our set of experiences, even if we share many of them with others, are different and specific to us. Psychoanalytic psychotherapy and psychoanalysis give centre stage to this specificity. When we take this notion fully on board then at least we have something concrete to work on.

Friday, May 8, 2009

A Different View

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

It was coincidental that my last blog happened to be on the subject of madness while at around the same time Dr Paul Williams, a leading UK psychoanalyst and a former co-editor of the International Journal of Psychoanalysis was in Dublin giving a lecture on the topic ‘Madness in Society’. He was the guest speaker at the Irish Psycho-Analytical Association’s annual public lecture.
He covered many topics, including a historical perspective of how madness has been viewed by different stages of developing society. And as he steadily built up his argument about the current place of madness in modern society, he made the interesting point that psychoanalytic therapy does not set out to ‘cure’ in the bio-medical sense. That was why there are so many healers and so few effective psychotherapists. This was because psychotherapists, the good ones, that is, understand that successful therapy is only possible if there is ‘immersion in’ and not ‘control of’ uncertainty, contradiction and paradox.
People have problems, he said, not only because of the social conditions under which they operate, or what we know broadly as the civilized world. But added to this, each of us has to deal from infancy with an inheritance, as he called it, of powerful and contradictory capacities. A particular line I liked was his statement that our human instincts, strength and intelligence exceed our capacity for judgment and that is why we require a longer period of maturation of any primate. In other words, we come into the world as possessors of powerful engines that can take us a long time to figure out how to harness and drive in the direction we want to go. And usually we want to go in the direction of being successful in our human relations, in connecting with those around us, in finding our desire in and through others.
In addition to what he termed the impact of modernization of society and its ever growing need to control every aspect of people’s lives, we each have our own personal endowment of sexuality. Each of us has to come to terms with our sense of sexuality and often society, because that is what it does, tends to understate the impact of this. The passage from boys and girls to men and women can often be a difficult one and that has to be continually recognized.
On top of that we have the impact of the twin psychical forces of aggression and narcissism as we make our way along the path to becoming the individuals we would like to be. All in all it adds up to a busy and complex process that is rarely given much credence by social commentators. And so this brings us to the concept of madness.

According to Dr Williams, the individual suffering from psychosis (or madness in plain English) suffers both a fracture and dissolution of their thinking so that their dependence on human relations, the one most of us learn to accommodate, is ‘abolished’. In its place comes a seriously skewed relationship to fellow humans, often to the point of non-relationship. Or indeed, instead of human relationships, fantasy relationships are substituted which keep the person ‘preoccupied, isolated and ill’, as he put it.
So, he asked, is it any wonder that our caring agencies behave defensively when faced with such a task. Nor are they the only ones. Patients who are deemed mad are put in hospital as part of a collusion between family and doctors because the family cannot deal with the behaviour any more. So now the caring agencies take on a responsibility that is beyond their capacity to resolve. And to defend themselves against the anxiety that this produces, they introduce ‘devices’ such as work routines and division of tasks that preclude them relating ‘as a whole person, to the patient as a whole person’, Dr Williams said.
On this point it is interesting to note in my last blog on the madness experienced by London-Irish poet John O’Donoghue, that it was not the electric shock treatment or the drugs or the psychiatrists that he said cured him. It was the unexpected experience of going to university where he discovered poetry and, also, where he met the lady who was to become his wife.
And I am also reminded of a particularly evocative lecture given by Dublin psychoanalyst Dr Helen Sheehan at a conference on Schizophrenia last December at St. Vincent’s Hospital, Elm Park, Dublin organized by the Irish School for Lacanian Psychoanalysis. She spoke eloquently about the place of the psychotic person in our Celtic heritage and consciousness and reminded us that even in mythical times there was a place for them, not behind high walls but somewhere radically special. And it is still there today.
Gleann-na-nGealt is a valley in the Dingle peninsula, Co. Kerry and in English it means the Valley of the Mad, because of a belief that a cure for insanity exists in a well which is situated in the valley. Legend has it that the name is associated with Gall, who was king of Ulster and was cured of madness when he drank from the well and ate the watercress growing in its waters. Ancient history also tells of "Bolcan" King of France who was also restored to full health when he drank from the well fleeing from the battle of Ventry harbour. In the 12th. century tale of "An Bhuile Shuibhne", Gleann-na-nGealt is said to be the place where Mad Sweeney found peace when he was banished to wander Ireland for a year and a day. Mad Sweeney was one of the early kings of Munster and recent historians link him with King Arthur’s Merlin the Magician.
So our own history tells us that there once was a place for those who were deemed mad, but it was a natural setting, in relative harmony with the world at large where they could recover and come back again.
Dr Williams in his lecture said the madness that exists in society is created within us and within society itself. It is partly a result of living in a complex, confusing, contradictory and very often de-stabilising world. He acknowledged that the work of caring agencies is a difficult one because the nature of the work is undoubtedly difficult and the demands placed on care workers at the coal face is quite often unrealistic, as is the caseload of most public sector psychiatrists. But he ended by saying that, difficult and painful as it can be, the only chance for improvement is to pay close attention to the individual who suffers, to the personal and social contradictions that created them and to do so in the context of authentic therapeutic relationships.