Emotional Problems are More Than Skin Deep: A Therapist Reflects on Modern and Classical ways of Giving Meaningful Help to Clients

I knew a very fine therapist who was in his early 70’s when we met. He was “old school” and had been working in classic psychoanalysis for more than 30 years. I remember thinking “What would anyone have to talk about after all that time.” When I asked he just smiled.

Some years ago when I was first entering the workforce as a therapist there was a shift toward effectiveness and efficiency. I had chosen in graduate school to shape my practice around Object Relations and Self Psychology, offshoots of Freud’s psychoanalysis. It made such sense to me that primarily unconscious forces directed human behavior. After all, what else could explain why we do so much that makes so little sense, and can even be destructive?

For a time I followed the natural flow of things. How could I do what my managers and insurance companies demanded of me? How do I maximize benefit and minimize the time it took to achieve it? What is the most efficient way to make folks well enough to fly on their own?

The flow for me was into brief psychodynamic models, and then cognitive behavioral models, and then into Ericksonian therapy, and then into mindfulness based interventions; all in service of the best bang for the consumer’s buck. The problem became obvious over time. Human beings and their experiences from birth on cannot be summarized and addressed simply. Many of the things we experienced, and some very powerfully, are not addressed by skimming along the surface. In addition, what our patients bring to us as the presenting problem is often not the main issue. I have thought deeply about what directs them from beneath the surface but simply identifying the problems does not remedy them. Integration does not always happen so easily. Many of the things that direct us are things we simply don’t like and we try desperately to fight them or get away from them. We become aware of ourselves gradually and then there is the opportunity to work through our problems.

On the neurobiological level we are only just discovering the mechanisms of memory.  How are they created? How are they encoded?  Where do they reside? All of these questions are really too simple. How do we comprehend a system with an estimated 10 to the millionth power of possible interconnections with the whole body itself and our interactions with both the inside and the outside world all working together to comprise our consciousness from moment to moment?

The three emotional regulation systems may give us some idea of the problems at hand. This information is condensed from the book Mindful Compassion, by Paul Gilbert Ph. D and Chodron.

The first is our “threat and protection system”, designed of course, to detect and react to threats real and perceived and these reactions can occur in microseconds. Threats may be external (e.g. the Mack truck coming at you) or internal (e.g. a thought of self criticism, an injury or illness, or an vague feeling of discomfort coming from who knows where). And these threats real or perceived are not always clearly perceived. Our brains and the extended body/brain (more later) reacts throughout the day to threats unconsciously/automatically producing the physiologic changes necessary to make us fight, flee, freeze, or faint. A very helpful system indeed for primitive humans in scary surroundings with no talons, fangs, natural body armor, horns, or wings.

These days the threats are not necessarily so often to physical harm as our ancient ancestors (in this country anyway, or is it?) but we still do what they do and other animals do not do. After escaping a lion a gazelle will quickly return to resting state but humans most often do not. We ruminate about the threats we just avoided and the threats we may have to face in the future. Because of our ruminations we do not return to a resting parasympathetic state very quickly or near often enough and on-going high levels of stress hormones wear us out. Most often we are unaware of these until, say, we develop muscle aches and pains, headaches, fatigue, sleeplessness, etc. Anxiety reactions do take a physical toll and if unattended to may lead to dysphoria or depression, anxiety disorders, addictive disorders of all varieties and medical disorders as well.

The second emotional system is our “drive and resource-seeking system” which directs us to seek pleasure and find the resources we need to flourish such as food, water, companions, a sexual partner, money, education, careers. Any obstacle to seeking or obtaining things we need or think we need may quickly stimulate the “threat and protection” system in certain circumstances. If we think we absolutely have to have something, cannot live without it, and those horrible people are out to insure that I will not obtain it then feelings of anger, anxiety, and, over time, feelings of helplessness, worthlessness, and hopelessness may occur. If, however, one realizes that uncomfortable and even worse things are bound to happen and when they do I will have to adjust to take care of myself in some other creative way to get what I need or think I need (or do without) then the negative effects of the “threat and protection system” may not activate much if at all. “Drive” may simply be all I need.

The third system is the “soothing/affiliation system”. This is associated with feelings such as well being, calm/peace, contentment, security, and connections with significant others or friends. These feelings are slower acting but affect the entire system as do the other two and are quite salubrious. In fact, we know now that most of the systems of the human body operate optimally in this state.

All three of these systems produce physiologic effects in the body, in all places and the body remembers. We all know the phenomenon of muscle memory for instance. As they say, once you know how to ride a bike you always remember how to and even if at first you’re “rusty” in the beginning in a few minutes muscle memory kicks in. Unfortunately the same is true for unpleasant and uncomfortable experiences. Our bodies remember even when sometimes our minds do not. We may develop distress reactions throughout the body without remembering where they came from and we do this from birth on.

An optimal environment of love, nurture, attention to needs, encouragement, affection lends to greater balance among the three systems but the opposite often leads to imbalances and a variety of problems throughout life. The effects can be cumulative and chronic also. Victims/survivors of physical, emotional, and sexual abuse are the most dramatic cases in point. There is evidence that their brains adjust to the out of the ordinary stress and become overly sensitive to threat and other systems are negatively affected.  Long term problems may result because of this.

If our “threat and protection” systems are activated too often in childhood for instance by thoughts and feelings within us because of our reaction to criticism from a trusted person or authority figure then our thoughts and feelings can also become our “threat”. A vicious circle is created and perpetuated. How many times have we heard or said “I am my own worst enemy”?

A balance between these systems is the end goal. The ideal When I need one activated it activates. When I don’t need it it quiets down. But we don’t operate in such a mechanistic way. Each one of our 80-90 billion neurons fires between 5-50 times per second even while we are asleep. They communicate information of various types based on genetics and experiences, and energy to each other almost constantly–thoughts, feelings, sensations, images, impulses, and patterns of these.  Our reactions and responses are no more efficient than the analyses and treatments of brief therapies. They simply cannot account for all of the complexity.

Because our minds do what they do and we must adapt to our immediate environment with its fluctuating demands we cannot be aware of everything about ourselves. And we cannot always stop and think about where and how certain impulses and actions arise. We simply haven’t the time. But we still find ourselves engaging in behaviors and feelings with which we and others may be uncomfortable. The depth and complexity of the multifactorial, multilayered human system precludes simple evaluation.  It simply takes time to unravel all this. Brief therapy may help and for some it may be perceived to be “enough” but  not always.

A patient told me a story a while back about a house she loved in large a northeastern city. She, her husband, and station wagon full of children lived together in a house with what she called a very high grade of carpet. It was beautiful, well maintained, and sturdy. With all those children and their friends coming in and out the carpet would necessarily need some grooming. So her husband would bring out the trusty carpet shampooer and help it out. Over and over the carpet returned to a beautiful mostly unstained appearance and all was well.

When they decided it was time to remove the carpet and either replace it or refurbish the hardwood floors underneath they saw a problem they had not anticipated. The pad underneath was “nasty”. Everything from drink spills to pet accidents were readily seen in the pad and moreover, in some places the stains had discolored the floor itself. She commented on this phenomenon with reference to her own therapy. She was realizing the effects of thoughts, feelings, behaviors on multiple layers of herself”.

Over time in a myriad of age specific phenomena; things done in unconscious or automatic ways, in various settings, with various people, at various times and stages of maturity or development, and in her relations to her self of which she had been unaware. She had discovered that her pain and suffering did not have a either a statute of limitations or an expiration date. She had carried these with her into present existence. It was affecting her moods and interactions with herself and others, and she had not known it. In these “places” she felt somewhat lost. “What do I do with this,” she asked. “I have some new skills to apply to them, that is true, but I’ve never been here before.” Here is where the lasting work really begins.

And my now deceased therapist friend would heartily concur.