Back when all the children were still at home and we took family vacations, I'd always get excited beforehand, beginning each journey convinced we'd have a wonderful time together. I'm a devotee of ideal family life, forever in pursuit of the Father Knows Best type of vacation where everyone gets along and we have a meaningful experience together. As the first day or two of those trips passed by, I'd struggle to stay upbeat in the face of the predictable bickering, complaints about the amount of time spent in the car, indifference or hostility to the activity we had planned. Eventually I'd snap and get surly, utterly disillusioned by the experience.

During the year we lived in France, we drove from Burgundy down to Barcelona and then to San Sebastian -- all five of us in the minivan for horrendous hours on end. In a series of photos over that week, you can see my mood degenerate until finally, near the end when we were visiting the Guggenheim Museum in Bilbao, I am stony-faced and angry. My children like to tease me about my absurd optimism concerning family life, and about vacations in particular. They all know better.

I found myself recalling those vacations this past week as I was looking forward to Thanksgiving with buoyant spirits. Oldest son coming in from Chicago, middle son flying in from California, my 13-year-old daughter eager to participate in preparing the feast. She and I made happy plans to do the marketing together Tuesday afternoon. All five of us would finally reunite for a holiday meal, glad to see one another after this time apart. Good food, meaningful conversation at the table, and maybe we'd play some games in between the main meal and dessert, just to let our food settle.

Now wait a minute.

Even a pathological optimist like me sometimes wakes up in time. I reviewed prior holidays and revised my vision of this coming Thanksgiving to conform with past reality. The boys will be eager to see their local friends and probably won't want to hang out much at home. While they're more or less past the phase where they bicker all the time, I wouldn't call them close. And playing any kind of game as a family is absolutely out of the question. We're all so ruthlessly competitive that a round of cards could easily end in bloodshed. I imagined myself feeling disappointed and depressed by Friday. Then my daughter told me she'd made other plans for Tuesday afternoon and I'd have to do the marketing without her. So much for my visions of blissful family togetherness.

For those of us who came from very troubled backgrounds, the dream of happy family life is a potent one. Many of my clients are often tortured by the thought of happy families during the holiday season. A deep sense of shame pervades their experience of Thanksgiving or Christmas, because other people -- the winners in this world -- are having the kind of ideal holiday I had envisioned for myself this week. So my first bit of advice, for those pathological optimists like me, is to ramp down your expectations. Rather than trying to enact the ideal holiday, where one size is supposed to fit all, plan one that fits your actual family. How much time is too much? Maybe everyone doesn't need to come over at noon, sit in front of the TV for one or two football games, eat too much and then spend another hour or two trying to make space for dessert. Just because our culture has enshrined the all-day family event, that doesn't mean you have to do it that way. Even if you mom told you to arrive at noon, you can still show up at three, in plenty of time for dinner. White lies are permissible.

Sometimes it seems to me that the people who have the most satisfying holidays are those who spend them with their closest friends. Too many families I know feel compelled to celebrate the holidays in traditional ways that make everyone unhappy. Surely it's possible to celebrate Thanksgiving or Christmas in a more satisfying way. In my family of origin, we of course used to spend all day together; once we kids grew up and started drinking, we'd invariably consume way too much alcohol, partly because that's just what my family did, but also because it helped us get through it. There would be a lot of laughter, but I invariably came away feeling poisoned. Too much alcohol in my system, and too much pain -- other people's pain that I had absorbed on top of my own. Especially as the younger generation grew up, I found it excruciating to watch their lives blow up or deteriorate.

On the other hand, I have very happy memories of spending time in the kitchen with my sister. Since I left Los Angeles and moved to North Carolina, we both miss those holidays cooking together. Cooking is what I enjoy most about Thanksgiving. I enjoy eating the meal, but I like preparing it even more, especially when I'm doing it with people I love. So as I was marketing alone this morning, bringing my expectations in line with reality, I decided to focus on that part of the experience. I felt better, less exposed to disappointment, when I thought about it this way. Everyone in our family likes to cook, and they'll be a lot of time -- maybe even enough time -- spent together in the kitchen, though the kids will likely criticize one another while we're doing it and then disappear not long after we eat. An hour or two of reasonably placid (for us) family time, doing what I like to do best -- that's what I should expect, rather than looking forward to my idyllic togetherness marathon which will invariably be followed by disappointment when it falls apart and we turn out to be the same contentious, prickly crew.

And that leads me to my second bit of advice. Put yourself first. Instead of succumbing to all the sentimental messages you receive, about feeling love and gratitude during this season of giving, make sure you spend the holidays the way you'd like to spend them. If you look after your own needs first, and don't expect too much from other people, you might find yourself having a few intermittent exchanges of meaning with the people who matter most to you. That's something to be truly grateful for.

Happy Thanksgiving, everyone!

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.

Continue "Countertransference Issues in Treating Depression"

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.

The Fear of Change

It would seem obvious that people decide to start psychotherapy because they want to change something about themselves. Maybe they're depressed and want relief. They might have some compulsive habits they need to break. Or they tend to over-react and want to gain control of themselves and their emotions. When clients consider changing, they invariably think about changing for the better; at least consciously, they view change in a positive light.

In general, if we strive to change our lives, it's usually in order to improve them. Sometimes we'll work very hard to alter the conditions that prevent us from succeeding in our careers or being fulfilled in our relationships. Most of us like that kind of change and believe we want it. Why is it, then, that so few people actually do change? Why do so many people stay in unsatisfying jobs and unfulfilling relationships? Why don't more people who need it seek professional help?

As I discussed in this early post, part of the answer is that authentic change takes a lot of very hard work over time and usually involves facing pain. But another reason concerns the very nature of change itself, its unpredictability: while most of us want positive change, we also know that giving up the status quo means confronting the unfamiliar and all the
unknown feelings that might arise. There's no guaranty that change will be for the better; you don't know for sure how you're going to feel when your world changes. For this reason, many people have a strong fear of change; they cling to the familiar, even if it's not especially satisfying. I find that most of the people who seek out psychotherapy usually do so only because they're in so much pain they can't bear it, so much pain that it overcomes their fear of change. People with manageable amounts of pain or whose defense mechanisms work for the most part rarely come for treatment. They stick with the everyday unhappiness they know.

I've also found, with nearly every client I've seen over the years, that change unconsciously (sometimes consciously) stirs up an unpleasant awareness of time passing. We all understand that time is passing, of course; but most people live in a kind of denial about where that passage will ultimately lead us. You can't live every minute with the awareness that you're traveling toward death, so you repress it. Change, especially dramatic change, makes the awareness of time more acute and for that reason, unconsciously links up with the idea of death. In order to escape that knowledge, many people exist in a kind of stasis, as if time has stopped moving for them. Because they dread real change and where it will one day lead them, they cling to routines and repetition, as if every day were the same, as if time stood still.

One of the ways you can see the fear of change, even pleasant change, is by observing people's behavior when they travel. I've know many people, both men and women, who become constipated the day before they go on vacation. If it were during the trip, you might say it was their body's reaction to an unfamiliar diet or climate; but when it happens prior to departure, it has to be a psychological event. Consciously, they're looking forward to vacation; on another level, they fear the impending changes -- in routine, environment, etc. In the clients I've seen, their constipation always involved an (unconscious) attempt to gain control over those changes, as if by clenching tight, their bowels could stop anything unpredictable from happening. In my personal life, all the people I've known who suffered from pre-travel constipation had "control issues", you might say: two neat freaks, another compulsively well-organized woman, a man who has his emotional life under severe restraint.

All of these ideas came up for me again this last week when I was having dinner with a friend I hadn't seen in about a year. We were discussing his young children, and in particular, his oldest daughter who left her beloved pre-school this past summer and started kindergarten. A little girl who had formerly been cheerful and outgoing, who looked forward to school, loved her teachers and her classmates and was popular with everyone had become anxious and miserable at her new school. She seemed to have undergone a complete character transformation. Getting her dressed and ready to leave the house each morning has turned into an ordeal; she now "hates" her teachers and classmates and never wants to go to school. She feels worried and unhappy much of the time.

My friend was also telling me that they have two aging dogs, one of whom will likely die in the next few months. He and his wife have been trying to ready their daughter for this loss, preparing her for the grieving process (which already seems to be underway). At first, she wanted to have the dog stuffed and kept on permanent display in the house (a kind of denial of death); now they've settled on cremation, with the ashes to be enshrined in place of honor.

This little girl is struggling with both the unpredictable nature of change (how your world can suddenly alter and present you with an entirely different set of experiences), as well as with the passage of time and the inevitability of death. I was reminded of a night about 14 years ago when my oldest son came downstairs at around ten o'clock, sobbing to his mother and me that he didn't want to die. Lying in the darkness, the fact of his mortality had suddenly come over him. He was six years old at the time. As with my friend's daughter, it was a time of major changes for him, as well: we'd moved away from Los Angeles and he'd left behind everything he knew.

My friend and his wife have taken the whole family to a therapist who seems to be doing an excellent job, advising them on how to establish routines and predictability, helping their daughter to feel as if she isn't entirely helpless in the face of change, with some control over her environment. As for the issue of death, the dog will soon die and I'm sure it will be traumatic for her. But with the help of her parents, she'll get through and the anxiety about her own mortality will succumb to repression ... as it did for my own son, as it usually does for most of us.

Defense Mechanisms VI: Repression (and Resistance)

Joseph Burgoin

Defense Mechanisms

The Psychotherapy Relationship

October 29, 2011

Although this post comes late in my series on defense mechanisms, it really should have been the first one: in a way, all but the most primitive defense mechanisms are forms of repression. When you're in denial, you repress the awareness of unwelcome truth. When you idealize someone, you must repress those perceptions that would undermine the idealization. If you were to develop a reaction formation such as homophobia, you would repress your attraction and physical desire. It's worth noting that, in each of these cases, it's actually the awareness of some aspect of your psyche that is repressed.

Freud originally discussed repression as it related to trauma, leading to his famous formulation from the Studies on Hysteria (1893-95) that hysterical symptoms actually symbolize the repressed traumatic memory. In these early years, he used the words "defense" and "repression" almost interchangeably. He soon expanded his conception of repression as pertaining to instinctual drives of all kinds, not traumatic memories. (As I discussed in my piece about Freud's id ego superego theory, I have a problem with this kind of language. "Instinct" doesn't really capture what Freud what trying to describe in his native German). He also distinguished between a primal repression and repression proper, which I won't get into as it's theoretical and doesn't feel clinically relevant.

There are places, however, where Freud speaks very simply and elegantly about repression: "the essence of repression lies simply in turning something away, and keeping it at a distance, from the conscious." That "something" could be an unacceptable emotion, either about someone else or yourself; it might be a perception of reality you'd rather not acknowledge. While Freud largely thought of the motive for repression as evading conflict -- between id drives and superego prohibitions, for example -- I find it more immediate and clinically useful to remember Donald Meltzer's formulation, that all defenses (including repression) are essentially lies we tell ourselves to evade pain. When we repress something (i.e., keep it at a distance from consciousness), it's because we're trying to avoid pain of one kind or another. There's an idea everyone can understand.

Freud also made clear that repression isn't something that happens just once; it's a process that requires a continual expenditure of energy to keep the repressed from returning to consciousness. In other words, we tend to develop strategies that are designed to keep the repressed feelings from breaking free of their dungeon. I've seen a number of clients with eating disorders who used binge-eating in this fashion: whenever some repressed emotion threatened to come up, or they faced a new and threatening experience, they would overeat in order to ward it off (see my earlier post about unbearable emotion in bulimia). You could think of this defense in different ways: as an anesthetic, for example, or as "shoving" the feelings back down along with the food. (In my experience, binge-eating is one of those symptoms whose meaning is usually "over-determined", as they say -- it might also be a kind of self-soothing, or even a kind of punishment. It's not a simple issue.)

Anyone who has been in psychodynamic therapy or practices in that modality most likely regards repression as an accepted fact of life, but there are many scientists and mental health professionals in other disciplines who will dispute its existence. If you browse through books in the self-help section at Barnes & Noble, you'll rarely find a reference to repression and the unconscious. In my view, without an understanding of repression, real growth is nearly impossible since you're unlikely to come into contact with that pain you're trying to ward off. Even if you do manage to overcome some kind of maladaptive behavior or thought pattern, you're likely to develop another equally maladaptive strategy to keep the repressed at bay.

Freud came to understand repression through his clinical experience with resistance. In the very early days, when he thought it was enough for his patients to recover their lost traumatic memories, he found that they didn't want to recover those memories and fought him in his efforts to bring them to light. He decided that there must be some psychic force keeping the traumatic memory from entering consciousness. Likewise as a practitioner, your day-to-day encounters with resistance show you repression at work. Now and then you identify something clearly in a client -- some pain they're not facing, some level of shame they can't bear to face -- and when you try to help them to look at it, as empathically and sensitively as you can, they'll often deny they feel that way or appear to agree with you and then change the subject. Sometimes they'll just tell you that you're wrong (and of course, on occasion, you are!).

In more serious cases, they'll quit treatment if you get too close to the repressed material. I had a recent experience with a new client, a woman with a horrendous past, obviously in excruciating emotional pain. As she talked in session, she communicated that pain to me on a non-verbal level while she herself didn't seem aware of feeling it; when I tried on several occasions to draw her attention to that pain, reminding her of all the very good reasons she had for suffering, she halfheartedly agreed. She then began to have scheduling conflicts, telling me she couldn't make our next session because she had a conference the next day and didn't want to be "distracted". After three sessions, she decided not to come back.

There are other possible explanations, of course. For one, it could be that, as gently as I tried to put it, I was premature in addressing the issue. When someone terminates without an explanation, you never really know. But to me, the experience spoke powerfully to the enduring power of repression, and the resistance so often aroused in your clients when you try to address it.