Mourning Losses

When we think about mourning losses we usually think of grieving a loved one who died or perhaps grieving the end of a relationship. Yet, much of the work of psychotherapy involves mourning losses that are less transparent - losses that can be traced back to childhood. This is the type of mourning that I wish to address in this blog post.

Most adult behavior has its origins in our early childhood experiences. We may unconsciously cling to relational patterns and beliefs that stem from the earliest years of our lives. Oftentimes, the reason we do this is to avoid incredibly painful feelings that may arise and engulf us when we allow ourselves to fully access these experiences. To recognize that one's parent was never able to love and accept them unconditionally, that this parent may never apologize for abuse or injuries they've inflicted, that the parent may never change and one may never have the mother or father they have always longed for and needed, that they will never be truly vindicated for the traumas they have endured - to come to terms with such losses is to open oneself up to tremendous grief. People may spend the majority of their lives engaging in all sorts of behaviors that are attempts to stave off such mourning.

Continued avoidance of mourning unresolved losses from our past comes at a devastating cost. People may suffer from depression, anxiety, and any number of other mental illnesses. They may experience chronic pain and health concerns, abuse substances, repeat unhealthy relationship patterns, and find themselves having ongoing difficulties at work and in their social lives. Even worse, they may inflict the same injuries that they suffered onto their partners and children. 

We can understand how not allowing oneself to mourn the death of a loved one can impede one's healing; we may allow ourselves and encourage others to take whatever time is needed to fully grieve, being gentle in the knowing that mourning can take various forms and evoke a gamut of emotions.  The same concept applies to mourning losses that are much more deeply buried. If working through these losses in therapy didn't have the potential to help an individual achieve greater self-awareness, profound healing, more satisfying relationships and one's personal life goals, then there would be absolutely no good reason to ask our patients to undergo a process which has the potential to stir up such pain. Still, I know of no other way to make long-lasting fundamental positive change. There's a corny saying in the business (alright, there are several) that you have to go through it to get through it. I think this expression is rather apt when it comes to this topic of mourning losses from one's childhood.

Communicating with Text Messages; Don't Text While Driving!

I wonder how many therapy sessions have been spent focusing on the heated arguments that patients have had via text messages. People will engage in lengthy back and forth conversations with their significant other, family or friends that could last for hours. In all the countless times that patients have told me about or shared with me these strings of texts, never once has it gone well.

I believe that texting serves a valuable function, such as coordinating plans, locating each other when you are meeting up, scheduling an appointment, or sending a short "thinking of you" or a funny message with the requisite emoji. Other than in these instances, I find that attempting to have a serious conversation over text messaging is not fruitful. Ditto for Facebook, social media, and possibly even email. These mediums of communication are simply too apt for misunderstanding and an exacerbation of anger and hurt feelings. 

Something gets lost when you don't see or hear the person you are speaking with. Non-verbal communication and tone of voice give us such important information about the other person. We can learn a great deal from someone's body language and the way they sound that is much more comprehensive than you could possibly get from just reading the words that were sent to you. In the absence of such data, people are likely to "mind-read" and interpret the other person's intentions without having access to all the crucial information they would need to truly understand what is being conveyed.

It seems to me that people feel freed up to express difficult thoughts and feelings when there is some distance between them and the person they are talking to. This indirect means of communication may feel easier for many than to talk directly to the other person about how one feels or what one believes. It may be easier to yell at a stranger who cut you off in traffic when you are safely hidden inside the comfort of your car. But when you are face to face with the person who has upset you, that is often another story. Yet, direct and honest dialogue is undoubtedly the most effective means of communication and conflict resolution. 

I encourage patients to learn and practice direct communication skills. I empathize with how scary this can feel for people, but I help teach them that ultimately it is more empowering, healthy, and mature and will usually yield the most positive outcomes. Most of us did not grow up learning how to communicate effectively. In school we took algebra, social studies, and biology but we probably did not take classes in feelings, relationships, conflict management, and communication skills-the things we will benefit from knowing for the rest of our lives. But adults can still learn these skills. Some people may feel pulled into the drama or comfort of shooting off an unfiltered text message or long missive via Facebook, perhaps as a way to discharge one's discomfort with the feelings they are experiencing, but I would strongly suggest that taking time to think and sit with one's feelings rather than impulsively engaging in these behaviors is likely to benefit everyone in the end.

Acting Out Behaviors

In my last blog post I addressed the "acting in" behaviors of depression and anxiety. Here I would like to focus on "acting out" behaviors that people turn to in an attempt to manage uncomfortable internal emotional states. There are many ways that people may "act out," such as putting substances (alcohol, prescription and recreational drugs, nicotine, or food) in their bodies to "self-medicate," overworking, gambling, working out excessively, obsessively turning to plastic surgery for cosmetic changes, excessive shopping, binge watching tv, spending hours playing video games, or engaging in risky and/or excessive sexual activities. When these types of behaviors are being used to unconsciously (or perhaps consciously) manage one's feelings, it probably means that the individual is choosing to flee from living in the present moment or the "here-and-now" to avoid fully inhabiting and experiencing one's feelings.

Cognitive behavioral therapists would focus on these behaviors directly and work on helping their patients learn ways to change the behaviors. Psychodynamic or psychoanalytic therapists like myself view these behaviors as symptoms or coping mechanisms that the patients employ because they might be the most adaptive ways they have learned to regulate the unacceptable, scary, or threatening feelings that are buried beneath. Rather than focus so directly on these symptoms, we believe that if we can help patients access and express the underlying unresolved feelings and come to understand how they are internally organized in relation to their emotions and unconscious processes, then over time people can learn healthier, more effective ways to manage their internal worlds. As a patient does so, we find that the unhealthy symptoms start to dissipate because there in no longer such a strong need to rely on archaic defense mechanisms that served a purpose at one time but now are more likely to be hindering an individual's progress.

A behavior is always a choice (even when it may not feel like a choice); feelings are not. If we subscribe to the belief that most people are well-intended and would choose the healthiest methods available to them, then we can come to see inexplicably harmful behaviors as adaptive attempts to manage difficult internal states. When people are able to learn alternate ways to manage these internal states, they are apt to choose the healthier options. When people learn that they needn't fear nor judge their feelings and begin to practice ways to tolerate, effectively manage, and perhaps even embrace their emotions, then they are better positioned to fill their tool boxes with the most healthy and effective tools. 

Depression and Anxiety as Defense Mechanisms

There is a great deal of confusion between feelings and mood states. Feelings (or emotions) are normal, healthy aspects of being human. Sadness, anger, joy, and fear are all common feelings that every human experiences, often daily. Mood states are not feelings. Depression, anxiety, and Bipolar Disorder (often known as manic depression) are mood states and can be considered mental disorders when severe enough. This isn't necessarily the case, as most people have experienced some type of depression or anxiety in their life time without it being serious enough to constitute a mental illness. We can say that we "feel depressed" or "feel anxious," which adds to the confusion between feelings and mood states.

Mood states may be understood as defense mechanisms that serve to protect us from underlying feelings. For instance, if we experience our anger as unacceptable or threatening, we might "depress" it and end up being "numb," resulting in not being in touch with the underlying anger. People who suffer from depression often describe themselves as being lethargic, fatigued, hopeless, or despairing. We cannot be in touch with our emotions when we are depressed. Reversely, when we are in touch with our feelings, we are not depressed at that moment. Anxiety may also be a way to manage underlying emotions. If our anger becomes too intense, we might react by becoming highly anxious. In this case, the anxiety is in response to a perceived threat induced by our anger. To complicate this further, if our anxiety then becomes too intense, we might then clamp down on it and become depressed. I describe this to my patients as layers upon layers, with the root feeling (which is pure and healthy) being buried deep down. So in this example, anger is the pure, healthy emotion that the individual has come to believe is bad, dangerous, or unacceptable. So Anger -> Anxiety -> Depression. Freud described depression as "anger turned inward." I believe this is what he meant by that explanation. Thus, a person might only experience his depression or anxiety, having suppressed his anger to a point where it cannot be easily accessed. But if a person suppresses one emotion, he suppresses all emotions. So when a person is suffering from depression, he cannot fully inhabit his anger, joy, fear, or sadness.

In psychotherapy I help my patients explore what feelings they might be defending against by employing the defenses of depression or anxiety. By teaching people that their feelings are normal and healthy and not to be feared, they start to shift their relationships to their emotions. Over time, this helps people learn alternate ways to manage their feelings so that they no longer believe they have to push their feelings away at all costs. We may view depression and anxiety disorders as forms of "acting in," i.e. turning inward to try to manage difficult emotions. In my next blog post, I will address "acting out" behaviors that people may employ as alternate ways to attempt to manage internal emotional states. 

The Insidious Nature of Shame

The topic of shame intersects with my previous blog posts and is an incredibly important issue I wish to address. It is unclear as to whether or not shame is truly an emotion like anger, sadness, and joy; I don't imagine that animals other than humans are plagued by it. Nonetheless, shame is pervasive in the world of human beings. Unlike guilt, which is the experience of feeling bad about something you have done or not done, shame is feeling bad about a part of oneself, a part of self that one believes is wrong, unacceptable, or ugly. For example, people may feel shame about their appearance, their sexual orientation, or their ethnicity. Like guilt, shame serves no healthy function and is usually inhibiting people from accepting themselves and living fully authentic lives. 

We are taught to feel ashamed of parts of ourselves from an early age. If our parents, our peers, and our friends and acquaintances believe that something about us is wrong, then the likelihood is that we will believe that what others are saying or thinking about us must be true. We develop in relation to others. If the circles of influence we are most closely surrounded by believe one thing, we are likely to be swayed in the same direction. Thus, young boys and girls who are surrounded by people who believe that boys should not exhibit feminine traits and girls should not exhibit masculine traits will feel shame around their own feminine or masculine parts of self. Teenage girls and boys who grow up in a world where they are taught that having same-sex feelings is wrong will likely develop shame if they are experiencing sexual attractions to people of the same sex. For the fortunate ones who are taught from a young age that there is nothing shameful about normal, human parts of self, these children may grow up accepting the parts of themselves that others learned were shameful. 

In my work as a psychotherapist, I have found that in order to move from a place of shame to a place of acceptance, an individual needs to connect to his or her anger toward the people, institutions, and societies that have perpetuated the myths that have led to the shame in the first place. Keeping with the example of someone who grows up feeling shame about having same-sex feelings, in order to progress from shame to acceptance, one must redirect the anger that is turned against oneself to its proper target(s), the people responsible for the shaming. I use the example of same-sex feelings here, but this concept applies to any parts of one's self of which one has learned to be ashamed. My last post was about the healthy emotion of anger. Here is another way in which anger is essential to the formation of a healthy, authentic self. In psychotherapy, patients have an opportunity to explore the parts of themselves that have caused them shame and learn to access the underlying healthy anger they feel about having been taught the false lessons that any parts of their true selves are bad, ugly, wrong, or shameful. 

Anger is Not a Four-Letter Word!

Anger gets a bad rap. Almost every patient I've ever worked with and almost every person I've ever met has struggled to view their anger as healthy and to manage it effectively. ALL EMOTIONS ARE HEALTHY! They are neither good nor bad, right nor wrong. Emotions are part of the natural fiber of being human. We don't judge ourselves for being thirsty, sleepy, or hungry. Yet we judge ourselves terribly for having feelings, especially unpleasant feelings. Most of us learned at a young age that these feelings are unacceptable, bad, shameful, even dangerous. But none of us were born this way. We don't come out of the womb judging our normal human emotions as something to be avoided. We learn this along the way, usually from a very young age. More often than not, our parents and their parents learned the same things about their emotions, so these inaccurate messages get passed on from generation to generation. If our parents cannot view their own anger as healthy, how can they teach their children that anger is healthy? 

People also get confused between emotions and behaviors. Emotions are simply the feelings themselves. Anger, sadness, happiness, fear - these are just pure feelings. Behaviors are the strategies we use to express our emotions. We have choice over our behaviors; we have no choice over our feelings. Every human feels every emotion, maybe even each day. Emotions are fluid and can change often throughout the day. We can no more control what we feel than we can choose not to breathe. When people view anger as unhealthy, I believe they are confusing behavior with emotion. Many people have learned unhealthy ways to express their anger. Some people become violent, aggressive, and lash out in hurtful ways. Others turn to substances or sex to attempt to manage their anger. Still others turn their anger against themselves and become depressed and beat themselves up horribly. 

In my last post I discussed pathological accommodation. One of the ways people accommodate others is by splitting off their anger because they view it as bad, thereby becoming inauthentic selves. Therapy can help patients learn about their own relationship to their anger and help them unlearn the faulty beliefs they were taught growing up. It can also help them learn to access and express their anger in healthy ways. This all requires that patients first shift their perspective on the emotion of anger so that they can come to view it as legitimate and valid. I am hopeful when I see that more kids today are being taught about feelings from a young age and being taught how to identify and regulate their emotions. Saying to a child, "You are really mad!" is a great way to empathize with the child and help him identify his anger. To follow it up with, "It's ok to be mad, but it's not ok to hit people" teaches the child to differentiate his emotions from his behaviors. We communicate that our anger is valid and we can learn effective ways to manage it. Psychotherapy can help patients learn the same lessons, which will in turn enable them to become more authentic human beings. Nurturing a positive relationship to one's anger is key!

Pathological Accommodation

"Pathological accommodation" is a term I first encountered through the readings of Bernard Brandchaft and the theories of intersubjectivity. I find this concept transformative to the work I do; it seems to apply to virtually every patient I've encountered (as well as most people I've known in my personal life). I feel compelled to write this at this time, as this subject follows naturally from my previous post about narcissistic mothers.   

At its basic core is the idea that children who are unable to develop authentic selves due to the various barriers put upon them by their parents learn that they must contort themselves into a false self or risk losing the ties to the parent(s) to whom they are most closely attached. This accommodation can manifest in one of three ways. The child who does not want to lose his bond to his caregiver learns to sacrifice parts of himself in order to preserve that bond. Alternatively, a child may decide that she will hold fast to her true self at all costs, only to find herself isolated and alienated from her caretakers. Finally, some children oscillate between these two poles, enacting an ambivalence in which they play the dutiful, obedient child at times and fiercely cling to their own wishes at others. In contrast to a healthy development in which the child is allowed to develop a true self and also maintain a secure positive attachment to one's parents, children who grow up being pathologically accommodating find themselves in a no-win situation, either sacrificing key parts of their identity or losing their close ties to the parents that are so important to them.

Most of the patients I've encountered fall into this first category. They come to me having lived their lives hiding parts of themselves and working hard to be the "good" boy or girl they believe they are supposed to be. They go through life accommodating others at all costs, and the price they pay is incredible unhappiness for having to squelch parts of themselves and contort themselves into who they think others want them to be. These people aim to please, though often while feeling deep-seated resentment and rage for having to do so. Most of the gay men and women I've treated learned to hide their sexual orientation at a young age because they were taught that it was "bad" and "unacceptable." Even more insidiously, most people are taught that their internal world of feelings -- particularly their anger -- is something dangerous, threatening, shameful, or wrong that is to be avoided at all costs. When one learns to split off their feelings instead of learning that all feelings are a healthy part of what makes us human, it becomes impossible to live fully and authentically. 

An intersubjective therapist is trained to look for how these issues show up in the therapeutic relationship. We must expect that the ways our patients have learned to conduct their relationships up until coming to us will also play out in the relationship that develops between therapist and patient. Thus, patients often behave like dutiful students, wanting to do what's "right" for my sake. Others act out by experiencing me as their parent who places demands on them and then they rebel by missing sessions, coming late, not paying on time, or engaging in risky behaviors outside of therapy. It is crucial to track the interactions in the therapeutic relationship so as not to ignore or dismiss these enactments and to not repeat perpetuating the unhealthy relational dynamics established in childhood. When we can speak to what's happening in our relationship and shed light on how the patient may be pathologically accommodating the therapist, then we have a chance to alter these patterns and allow for an alternate positive relational experience in which the patient (maybe for the first time) can learn to have a healthy relationship where she can bring herself fully into the room and be accepted  unconditionally. 

In future posts I will elaborate on some of these ideas -- such as the crucial role that anger plays, the power that shame wields, and the specific ways that people may act out in response to believing that they cannot express themselves authentically. For clinicians interested in learning more about pathological accommodation, I recommend the collection of Brandchaft's essays entitled Toward an Emancipatory Psychoanalysis. 

Children of Narcissistic Mothers

I am astonished by the number of patients I have treated who are children of one or two narcissistic parents. Though we often associate narcissism with males, in most of the cases I've witnessed, it is the mother who appears to be the narcissist. The world of entertainment fascinates us with such women. There's a dramatic example in the cult movie Mommie, Dearest. And one review of a Broadway revival of the musical Gypsy described the stage mother Rose who is determined to see her daughters achieve the success she never did as "the mother who is always there when she needs you." While these make for titillating enjoyment and these characters are extreme examples of narcissistic mothers, both based on actual autobiographies, in my practice the children of such mothers are anything but fodder for amusement.

The child of a narcissistic mother is often put into the role of a "self-object function" for the mother. Whereas in a healthy mother/child relationship the mother is tasked with meeting the needs of her child, the scenario is flipped with a narcissistic mother and the child is treated as an extension of her. Everything becomes viewed through the lens of how the child can serve the mother's needs or how the child's behavior wounded the mother.  Thus, if the child makes any move to separate from the mother and form an authentic identity of her own, this is unconsciously perceived as a threat to the mother. Normal developmental milestones such as puberty, adolescence, going to college, turning 21  and becoming an adult, and forging relationships, getting married, and starting one's own family are all potential threats or "narcissistic injuries." Similarly, if the child chooses to forge a unique identity and follow his own path, one that may differ from the mother's ideas of what the child should do, this may be taken as a direct attack on the mother. I've known patients whose mothers reacted negatively when the individual began a normal sexual exploration as a teenager, when the child moved away from home for school or work, when he announced plans for marriage, or when she announced that she was pregnant. These mothers are incredibly needy themselves and they are turning to their children to fill the expansive gulf of neediness they experience because they are unable to rely on themselves to do so and they most likely did not have adequate parenting in their childhood in which their own emotional needs could be met. 

Narcissism in a parent can take different forms. In some instances, the patient has a mother who martyrs herself, acting as a helpless victim and seeing herself as utterly selfless for the sake of her children and others. Yet this is far from unconditional and often the child experiences an enormous amount of guilt-tripping, with the mother making it clear that the child has disappointed her deeply. In some cases, this takes the form of a mother who suffers from a chronic illness, such as fibromyalgia or acute asthma. Far from being a victim, this mother can actually wield a great deal of power and control with her illness, holding her family members hostage and at her mercy. Once again the child's needs are sacrificed for the sake of the mother's "emergency." Other narcissistic parents may abuse alcohol or other substances in an attempt to fill the profound void they feel inside. Such a parent can hardly be relied upon to be responsible and consistently available for one's child. Often the child develops into a "parentified child," reversing roles with her own parents and having to learn to take care of her own needs as best as she can. Being age inappropriate, she cannot adequately function as a parent to herself, and she often is excessively harsh with herself and her siblings and may hold herself up to unreasonable standards. 

Sometimes the father in these scenarios is also a narcissist, pairing with the mother in using his children for his own purposes. More often, I have found the fathers to be emasculated men who cannot provide an adequate buffer to protect the child from the mother's unreasonable demands. They may appear rather passive, relinquishing their own authority as having equal responsibility in parenting their children, instead meekly backing their wives up and going along with their wishes so as to avoid a storm. The children become the true victims here, unable to defend themselves and unable to turn to their father to be the strong buffer they need him to be. 

The stage is set for this perfect storm. Children of narcissistic mothers, more often than not, find themselves in a no-win situation. There is no chance for a healthy development. Either he can squelch parts of himself and contort himself into the son he believes his mother wants him to be, or he can choose to assert his independence at the great risk of forever severing his bond to his mother. There doesn't appear to be a path in which this child can both develop an authentic identity and maintain a close connection to his mother. The fear of becoming an authentic self that is not reliant on the mother for survival may manifest itself as dependency. The child may have learned that she cannot survive without her mother. She remains anchored to her mother for guidance and direction. The mother's own neediness gets projected onto the child, and the child ends up believing that he is the needy one who is unable to be a self-sufficient adult. He may continue to prove how helpless he is by engaging in acting out behaviors such as financial irresponsibility, sexual promiscuity, and substance abuse to confirm his mother's view. In fact, this child is terrified of separating from his mother because to do so risks losing her entirely. 

I suppose it is not surprising that my caseload consists primarily of these children of narcissists, rather than the parents themselves. One of the hallmarks of a personality disorder is how entrenched it is, and a person with a true narcissistic personality disorder externalizes all his problems and does not take responsibility for any of his egregious actions. Remember, the narcissistic mother firmly believes that it is her child who has wronged her and is at fault for whatever problems ensue. Children of narcissistic mothers who find the strength to engage in psychotherapy have the opportunity to become aware of how profoundly their mother's behavior has impacted them and over time can work toward separating from this mother and genuinely forging an authentic identity of one's own. Even initiating the process of therapy is a step toward  greater empowerment and becoming a self-sufficient adult.