According to a recent article in the New York Times, the revision to the APA's Diagnostic and Statistical Manual currently underway will reconsider not only the personality disorders (rumor has it that Narcissistic Personality Disorder may be eliminated) but also the autistic disorders. In particular, it looks as if Asperger's Syndrome will be eliminated as a separate diagnosis and subsumed within the more tightly focused Autism Spectrum Disorder. Read the entire article for an understanding of how the skyrocketing medical and social costs of treating autistic disorders are driving this revision, at least in part.

This change once again throws into question the validity of psychological diagnosis as a scientifically precise methodology. If Asperger's Syndrome can be written out of the DSM by committee, one has to wonder if it was ever as distinct a disorder as many people have wanted to believe. Even though I object to the very idea of a diagnosis manual akin to the ICD-10, I'm moderately hopeful that the current revision to the DSM is a step in the right direction: the new name, at least, seems to acknowledge that there's an entire spectrum of autistic disorders. Still, with its focus on symptoms and behaviors (rather than psychodynamic process), this new Autism Spectrum Disorder continues to reflect the kind of pseudo-scientific precision that characterizes the APA and all its efforts.

In working on my book about defense mechanisms, it has become increasingly clear to me that the problem with modern psychiatry is its renunciation of its psychodynamic roots. Whereas psychoanalytic thinking once dominated the American Psychiatric Association of 50 years ago, the continuing revision to the DSM that began in the 1970s has "re-medicalized" psychiatry -- that is, made it more scientific, with identifiable diseases leading to sanctioned cures. Psychodynamic thinking has been written out of the clinical picture so that today, we talk about bipolar disorder, borderline personality disorder and post-traumatic stress disorder as if each was as consistent and identifiable a medical syndrome as diabetes, but with no understanding of their underlying psychic processes. (For more on the medicalization of psychiatry, see Robert Whitaker's excellent book, The Anatomy of an Epidemic, which I reviewed in a series of three articles, beginning with one on the chemical imbalance theory of depression.)

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Anxiety Symptoms, Mindfulness and the Enlargement of the Self

In an early post about anxiety symptoms, I discussed my personal experience with a panic attack several years ago. In particular, I talked about the fear of falling to pieces, a kind of disintegration anxiety; it involved the feeling of a threat to my self in the most physical sense, to my bodily integrity, and the terror that I wouldn't hold together. Anyone who has gone through anxiety attacks or has any kind of anxiety disorder will likely understand what I mean.

Although I've since learned how better to manage my anxiety, and have never experienced another panic attack, this period of intensified stress only recently came to a complete close. Now that I'm on the other side, I've begun to realize the toll it took on me, and the ways that my anxiety symptoms affected me in an ongoing way, much more than I realized at the time. I'd like to talk about the experience, my sense of self and how mindfulness meditation techniques have proven useful to me.

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anxiety symptoms defense mechanisms mindfulness panic attacks

Depression Symptoms and the Role of Rage

Joseph Burgoin

Defense Mechanisms

Depression and Bipolar Disorder

The Psychotherapy Relationship

Unbearable Emotion

January 1, 2012

Before I began taking on new clients for online counseling in November, it had been quite a while since I'd started therapy with someone new; for the most part, my practice had involved ongoing work with long-term clients who were no longer struggling with depression. A number of people have recently come to me with depression symptoms and I've been struck once again by how important it is to understand the role that anger and rage play in so many depressive conditions.

In an earlier post about different types of depression, I discussed severe cases that result from intensely destructive but unconscious rage; I believe unconscious anger plays a major role in less severe conditions, as well. You've probably heard depression described as "aggression turned inward"; accordingly to this view, depression symptoms are the result of unresolved and unexpressed anger that is turned inward upon the self instead of being directed outside, at other people. This might account for the apparently unjustified feelings of guilt that often accompany depression symptoms: while the depressed person has no real reason to feel guilty -- that is, they haven't actually done anything in the external world about which they might legitimately feel guilty -- their (unconscious) enraged fantasies of wanting to hurt people around them nonetheless inspire feelings of guilt. As therapists, instead of treating the feelings of guilt as irrational and unjustified, we might instead wonder what the person has done (in unconscious fantasy) to justify those feelings.

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Countertransference Issues in Treating Depression

Joseph Burgoin

Depression and Bipolar Disorder

The Psychotherapy Relationship

Unbearable Emotion

November 15, 2011

Countertransference was a term originally used by Freud to describe a client's influence on the analyst's unconscious feelings. Freud believed that no psychoanalyst "goes further than his own complexes and internal resistances permit," and for this reason, having a personal analysis as part of training was considered essential. In other words, Freud viewed countertransference as arising from unresolved and unconscious issues within the analyst. Since then, our conception of the countertransference has grown to include all of the therapist's reactions to the client, including his or her conscious experience during the session. From this point of view, as a working therapist, your own feelings, thoughts and fantasies provide important information to further your understanding of your client. This latter view is exactly the way I think about countertransference; during sessions, I rely heavily on my internal process to help me understand the person I'm working with.

In my recent post on repression, I gave a simple example: a client who communicated a lot of pain to me during session (that is, I felt pain) but seemed not to be feeling it herself. I often have similar experiences in session, where I'm listening to someone talk; feelings will start to stir within me but my client doesn't seem to be conscious of any particular emotion. Working this way, you have to be cautious not to assume that everything you feel comes about because of the client's issues; you need to listen for other material that gives you a basis for believing that it's a projection or unconscious communication. After a while working this way, you begin to trust your reactions (your countertransference in the broad sense) and feel confident about when and how to use them.

Part of that trust depends upon your comfort level with certain emotions. Remember Freud's remarks about how unresolved complexes and resistances will limit a therapist's effectiveness. If you're the kind of person who has trouble bearing anger or grief, it may limit your ability to understand your client's experience. This is especially true when dealing with certain types of depression. I'm thinking in particular of one type I discussed a while back, where unconscious and destructive rage plays a major role. Therapists who have a hard time acknowledging their own anger and aggression will struggle with this particular client because they don't want to feel the emotions aroused by treatment. Therapists who believe they should only have kind and loving emotions toward those in their care will also have a hard time. Such therapists may often dislike the client without quite admitting it. Their interpretations may come across with an edge; or they may become much more directive and impatient because they want the client to "move on." They may secretly dread that particular session in their day.

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Not Your Usual Anger Management Techniques

[First of all, I'd like to enlist everyone's support in identifying a possible Trojan horse virus on my website. I was alerted by one of my readers, as well as a directory website, that such a virus had been detected. I believe I found and deleted the infection; at the same time I changed all my passwords. Going forward, if you get a warning from your anti-virus software that my site contains a threat, please send me an email at once, and tell me exactly the threat message you received. Thanks.]

Because chemical imbalance and cognitive-behavioral theories dominate my profession, any approach that addresses unconscious sources of anger receives virtually no attention. For example, I was reviewing this brochure about anger management techniques on the official website of the American Psychological Association; it repeats the familiar CBT methods for defusing anger or learning appropriate ways to express it, but says nothing about the kind of anger that might be numbered among the defense mechanisms-- that is, anger whose role is to ward off some other, more threatening experience.

In an early post about disintegration anxiety, I described a client who would become enraged whenever she felt in danger of falling apart. She described herself as a drowning kitten: on an unconscious level, whenever she felt overwhelmed by her emotions, in danger of disintegrating under their pressure -- quite literally, on a felt physical level -- she often became explosively angry, lashing out and "clawing" at her partner in a way that held her together psychically. This is an extreme version of a process that many of us go through, where anger is secondary, a way of escaping some other emotion.

I've seen this process in many of my clients, but the freshest example comes from my own experience. Late last year, I wrote a post about panic attacks and my anxiety in coping with intense financial pressure. Since then, worries about my investments have slowly abated, but I've been working too hard -- pushing myself to do too much in too many directions. I get up very early to practice piano because it's the only time I can find to do what matters so very much to me. In addition to my practice, I've been developing and promoting this website since last summer, and struggling to keep up with the Movies and Mental Health blog. Now I'm writing a book under a deadline. I'm not complaining: I love doing all these things. But occasionally over this year, I've felt deeply weary and emotionally thin.

I've also been more grouchy and irritable than usual. I try very hard to keep this to myself, but occasionally, I've been snappish about something minor that normally wouldn't have bothered me. More often than is usual for me, I've become quite angry this past year about little things other people have done -- nothing deliberately hurtful or malicious on their part but more in the realm of insensitive behavior, the kind of casual slights we all have to deal with. You might say I've been overreacting. Mostly, I've managed to keep these overreactions to myself, but on a couple of occasions, I've spoken out and regretted it.

To me, the part of my anger that is an overreaction stems from my fatigue, my emotional thinness and my failure to take better care of myself. As a therapist, and also for my own unhealthy reasons, I tend to focus a lot on what other people need, often neglecting my own needs in the process. (I suspect that many therapists have a similar dynamic.) I also have some grandiose expectations of myself -- after all, there's that Carnegie Hall gig awaiting me, and I'd better practice as much as I can if I'm going to get there. While I'm not conscious of any disintegration anxiety, my run-down emotional state has depleted my usual coping skills and made me feel more vulnerable; looking back, I think my anger this past year has had a kind of "hardening" effect. I think you'll know what I mean when I say that anger can make you feel strong, even powerful, when you might be feeling too thin, scared or vulnerable to bear.

In the past two weeks, as I've finally emerged on the other side of my long investment crisis, achieved a major life goal by selling my book, and made some other changes in commitments and relationships that were draining me, I've noticed that I'm not so grouchy, and much less prone to anger. I feel much more able to "roll with the punches" than I have for a while now. I'm trying hard to take rest when I need it, sleep more and give myself time off from work; as a result, I'm feeling happier and more content with my life than I have in years.

So here are my personal anger management techniques for you to consider: 1. If you're angry and overreacting, take a look at your work load and social commitments; maybe there's a weary part of you that needs a rest and a good cry. 2. If you feel grouchy and like pointing the finger because someone was insensitive, maybe you're actually the responsible party and you need to take better care of yourself. 3. If you're raging in your thoughts, make use of all those good mindfulness techniques to quiet them; but in the silence, look around for the part of you that's scared and feeling way too vulnerable.