Primal Fear

So often in my practice – and here I mean both my psychotherapy practice and the practice of my own growth – I see the enormously powerful presence of fear. Fundamental as it may be, the fear is rarely obvious, buried as it is under the more apparent feelings and states of mind that grow out of it. In fact in my experience it often takes quite a bit of work (psychotherapeutic or contemplative or meditative or what have you) to recognize the fear beneath so many of our unhealthy orientations to the world: beneath avarice lies fear of deprivation; beneath exploitative dominance lies fear of humiliation; beneath aggression lies fear of injury. Often in therapy I see how uncovering these fears – and learning a new relationship to them – opens up the possibility of finding more effective ways of navigating the difficult aspects of life.

This fear is often complex and rooted in various aspects of our specific lives and experiences. And yet I believe that much of the fear that shapes our engagement with the world is organismic, an element of the biological instinct system (or what Jung referred to as ‘the collective unconscious’), and it is this more primitive experience of fear that I want very briefly to touch on today.

We are vulnerable. Our hold on life is fragile. We evolved with the highly adaptive capacity to feel primal fear as an appropriate response to the fact that we have always been surrounded by great and very real threats to our survival. This fear is of course adaptive because it calls us to effective life-sustaining action; it is our biological inheritance, naturally selected through all the many thousands of generations of human and non-human ancestors who successfully survived to reproductive ages. We are here because, in part, our forebearers felt appropriately afraid.

For most of us in this present time and place, our survival on any given day is far more assured than it has ever been. And yet we carry around the collective and largely unconscious legacy of a great primal fear. I believe that in our civilized time and privileged place this fear is present and yet so often useless – in fact, typically wholly unused; for so many of us it is unattached to anything real, any truly life-sustaining action – the building of shelter, the acquisition of food – and is thus free-floating and quite maladaptive in its expression.

Depression and anxiety are the great emotional/psychological afflictions of our particular time and place. In my work with so many people who’ve had depression or anxiety as their “primary diagnosis,” I’ve seen how so often beneath the obvious presentation lies a sense of self marked by a deeply held underlying (and often unconscious) primal fear, often exacerbated by life experiences that contribute to a feeling of unsafety. The work of therapy is in part about uncovering the presence and genesis of our fear in all its forms, recognizing its impact and expression, and cultivating a more effective relationship to the fact of one’s vulnerability.

On the Difference Between Diagnosing and Understanding

The Diagnostic and Statistical Manual of Mental Disorders (“the DSM”) is a heavy book used by clinicians to diagnose psychiatric illnesses. According to the National Institute of Mental Health, in any given year over 26% of American adults qualify for having at least one of the psychiatric disorders described in the DSM. Since we’re talking about 60 million people in any given year, one might immediately question the very use of the term ‘disorder,’ since the word suggests something abnormal, something outside the common arrangement of things.

In any given year, 15 million adults qualify for some form of depressive disorder (code 296 in the diagnostic taxonomy of the DSM), and 45 million for some form of anxiety disorder (code 300). I say “some form” because the DSM differentiates subsets of these disorders on such factors as the number of times the “illness” has occurred in one’s life and its severity. (e.g. 296.21 for Major Depressive Disorder, Single Episode, Mild). People presenting with issues that can be captured by these depressive and anxiety codes form the main bulk of the practices of many mental health clinicians, including my own.

Many clinicians – and even unfortunately more than a few patients – have fallen victim to a reification of the diagnostic taxonomy, and confuse a descriptive cataloguing of the complicated aspects of human experience with an actual understanding of the genesis and meaning of someone feeling and thinking and behaving a certain way. Saying someone “has Major Depressive Disorder, Recurrent, Moderate” (296.32) says absolutely nothing about why this person is experiencing himself and life in such a way that lead him to have at least 5 of the 9 symptoms the DSM requires for someone to warrant the official diagnosis. And it says even less about what to do about it.

It does however definitively say something about how appropriate it is for someone to have at least 5 of those 9 symptoms: it says that this person is disordered. It’s in the very title of the manual. In our reification of the taxonomy we have not merely conflated description with understanding, we have perpetuated and reinforced our mainstream culture’s judgment and stigmatization and marginalization of suffering.

Of course pharmacological interventions certainly have their place in the treatment of many people. And yet one might argue that a psychiatric system built on the medicating of distressed people might at times benefit from a conflation of symptom description and true understanding of the meaning and cause – and thus in a deep sense the appropriateness – of one’s suffering. In the medical model patients are often understood (not merely described, but understood) as “having major depression.” In this formulation, there is a problem, and the problem is the symptoms, such as difficult feelings; medicate the patient so that the difficult feelings change and there’s no longer any problem. If the difficult feelings return, the problem has returned.

In contrast, in my own humanistic psychotherapeutic tradition – that is, a system that endeavors via an honest relationship to assist people in accessing their own natural movement towards healing and maturity – the intervention is founded upon the assumption that someone who is depressed or anxious is likely responding in an entirely understandable and very common way to the complexities of life, in particular of course to their own unique life and whatever they have learned to believe and assume about it. The symptoms that inform a diagnosis are thus seen as part and parcel of a complex and nuanced and entirely reasonable lived experience. Much of the work in psychotherapy is in understanding and gaining perspective on this lived experience, and building a new way of relating to it.

In all the hundreds of people I have worked with I have yet to really get to know someone – severely “depressed” or “anxious” though they may be – whose internal experience of life didn’t come to make perfect sense. And it is in this making sense, the making meaning, of one’s experience that we can move away from shame and blame (of self and others) and towards compassion and wisdom. And (as is true in both the therapeutic and spiritual traditions) true, non-judgmental understanding is the keystone of peace and grace.

Diagnostic constructs such as “Major Depressive Disorder, Recurrent, Severe, Without Psychotic Features” (296.33) certainly have their place. They are very convenient. They tell an insurance company that a treatment is warranted and they quickly communicate some features of someone’s life. But let us – as patients and as clinicians – always remember that a convenient diagnosis is just that – a convenience that must not obstruct our efforts to deeply understand, honor, and relate wisely to the nuance within the human experience.

On Longer-Term Therapy

Numerous people, from family to friends to patients, have asked me if I’ve read “that article about therapy in the Times this week”. Yes, I have.

While it’s not uncommon for a newspaper article to provoke a blogger’s response, it is perhaps more remarkable for an article to provoke a blogger to become a blogger so a response could properly be made. Jonathan Alpert has managed to achieve such a feat with his recent New York Times article, “In Therapy Forever? Enough Already.”

The vociferous response to the article has come from many corners: from other psychologists online, psychotherapist listservs, my collegial network, and from patients in my own consulting room. Much of the focus has been around Mr. Alpert’s apparent misrepresentation of his credentials, his shameless cherry-picking of the scientific literature, and his nonsensical conflation of “longer-term” and “bad” therapy. There has also been much confusion and disappointment in response to the Times’ strange decision to publish such an insipid bit of self-promotion.

While I share all of these views, I feel most moved to respond with an illumination of the usefulness of longer-term therapy. I would call this a “defense,” but that’s not quite right, since I don’t feel defensive. I do however feel angry – or certainly I did when I first read Mr. Alpert’s article, much as one does when something they love and respect is thoughtlessly denigrated and made feeble through an ignorant rendering. Above all it is my hope that this post might be useful to someone wondering if Mr. Alpert just might be right when he says longer-term therapy is analogous to a “spa appointment” and likely “leads to codependence.”

A couple quick points of agreement with Mr. Alpert: I agree with his point that no one should stay in therapy when they are not being helped or if they feel their therapist is not a good fit for them. Half the therapists in the world are generally less effective than the other half (as are half the arborists). In my practice I explicitly encourage discussions of the ongoing usefulness of the work.

Second, I also agree that for many, a shorter-term approach is useful and warranted. Often people do come in for guidance around a specific situation, a life event, a decision to be made, etc., and for these folks a limited number of more problem-focused conversations is precisely what is sought and needed. A belief in the power and usefulness of longer-term therapy does not mean that a long-term relationship is the “right” option for every patient-therapist dyad, and this sadly includes some dyads that are currently in a long-term relationship.

But what about when the fit is a good one? When the patient that would benefit from working long-term with a good therapist finds a good therapist? What, then, is longer-term therapy about? What happens?

Enough words have been said and written about this to fill the oceans a thousand times. Of course different theoretical schools will use different words. My intention here is to be brief, at the risk of oversimplifying a fascinating and infinitely rich process. So I will say that in essence, I believe the growth that is facilitated across the various longer-term psychotherapies, as distinct from the help that is available in the problem-focused coaching of Mr. Alpert, can be distilled to two very broad factors: 1) the generative power of the therapeutic relationship itself, and 2) the gradual expansion of the patient’s capacity for honesty – both in the form of markedly increased self-awareness and the sparking of an intrinsic desire to engage in authentic discourse with the world. Let me briefly flesh out these factors.

The relationship. Study after study has shown that psychotherapy is effective, and that what makes it effective above all is the relationship between the therapist and the patient. A believer that, as the psychoanalyst Nancy McWilliams put it, psychology may be a science but psychotherapy is an art, I am not one to cite empirical data on therapeutic outcome. Yet my own experience exactly mirrors the overwhelming conclusion from empirical research that the alliance between the patient and the therapist is the single most important factor in the success of therapy. As in any relationship, for this therapeutic relationship to be healing and good, for the affecting ingredients of it to be felt deeply and incorporated into one’s view of oneself and the world, it simply takes time. This is self-evident.

As anyone who has been in therapy for more than a few sessions can attest, the relationship between patient and therapist – and particularly the skilled therapist -becomes extremely powerful. And while the therapy relationship is of its own kind and does not easily fit within other existing relational paradigms in our society (and is thus understandably sometimes described by my patients, particularly as the relationship first deepens, as ‘kind of weird’), it is above all quite real. And it becomes more real as time goes on. In fact, it often becomes the most real – that is, the most honest – relationship that the patient has ever had. More than a few therapists have commented that they themselves are more authentic with their patients than they are anywhere else in their lives. (Note: by “authentic” I don’t mean “self-disclosing”; I mean supremely present with their true selves as they effectively embody the therapeutic role.)

We are social creatures with relational needs: the need to be respected, to be met with compassion, to be understood. When these relational needs are met, consistently and over  time, and when we may trust that the meeting of these needs is not haphazard but may be relied upon, all manner of growth and healing can take place. Within the goodness of this relational field we may respect, accept and understand ourselves. We may cultivate self-compassion. We may grow and heal. This is true within the best personal relationships of our lives, and it is true in therapy.

Honesty and awareness. A cornerstone of the therapeutic stance is that the more aware we are of ourselves, the better our chances to live healthy and satisfying lives. Of course, the self is layered indeed. In the psychodynamic tradition that in part forms the basis of my own work, central to growth in healing is the increased consciousness of the source of our thoughts, feelings, and behaviors. As we better understand both our constitutions and the ways in which our experiences have shaped us, we learn how it is that we make sense. And since compassion – for the self, for others – flows quite naturally from understanding, over time we find self-compassion where there was once judgment and shame.

This self-understanding does not come easily! Much of what is not conscious to us is not conscious for very good reasons. Often these aspects of ourselves are deeply painful, or buried beneath layers of contradiction. The mind is not monolithic; it is incredibly complex and riddled with paradox. To discern the feelings and assumptions that in the deepest way drive our decisions and direct the course of our relationships, to hear the distinct tones in the white noise of our multifaceted self, requires great diligence and a sharpened attunement to nuance. With the help of a skilled therapist, this way of knowing oneself can be reached, and once it is, can be enormously useful in the creation of a satisfying life. Again, to know oneself at this most useful depth takes time (and hard work).

A great advantage of longer-term therapy is that it allows the increasingly aware patient to explore his or her life within the context of a safe and good therapeutic relationship in real time. Life continues to happen while we are in therapy. And as life unfolds and patterns continue to repeat themselves (and repeat and repeat), the patient is supported in her efforts to see these patterns, recognize them, and use this self-awareness to make decisions that are aligned not with reflexive and often counter-productive ways of protecting the self, but with her most deeply held – her truest – values and desires.

Since these deepest values and desires almost always involve the yearning for kind love, and since offering decency is the best way to receive it, patients quite often become more respectful, honest, and compassionate within their most intimate personal relationships. And as we learn what it is that we really want, and we begin to truly feel that we deserve it, we become far more intentional and effective in whom we choose to be vulnerable to.

I hope this very brief sketch is sufficient in giving a taste of what becomes available over time in good longer-term therapy. When the time is right, the therapist skilled, and the relational match favorable, longer-term therapy can be not only useful, but truly transformative, and very beautiful.