Cross-posted from “Sacramento Street Psychiatry“.
In dynamic psychotherapy, patients often say how hurt and victimized they feel as a result of unkind judgments or criticisms by others:
“My coworker called me a hypocrite!”
“My mother told me I neglect her by not visiting enough.”
“My husband complains I’m too self-centered.”
Although sharing such complaints with a caring listener is basic human nature, in therapy it is also recognized as a defense mechanism called externalization. A fundamental tenet of psychotherapy is that change comes from within. The hurtful coworker, mother, or husband is not present in the room, and cannot be influenced directly by the discussion. It is the patient’s reaction that can be examined and perhaps modified.
I tend gently to move things along in therapy, as opposed to letting them unfold at their own pace. I often question this in myself, sometimes wondering if I am too results-oriented. On balance, though, I believe it saves time, money, and tedium for both of us if I focus on issues that can actually make a difference. With this in mind, I don’t let externalizations just sit there. I playfully illustrate how harsh judgments only sting if the patient accepts or endorses them at some level: The hurt is really self-criticism, and the solution is really a new self-appraisal.
If I accuse you of being a dirty rotten Martian, it isn’t apt to have much impact. You may question my sanity, but you are not put on the defensive or moved to offer a spirited rebuttal. Nor do you engage in sober soul-searching to assure yourself I’m mistaken. You already know you are not a Martian, so the putdown rolls off your back.
In contrast, what if I accuse you of being selfish? This charge is harder to dismiss. We are all selfish to some degree; it’s a judgment call where to draw the line between self-interest on the one hand and self-sacrifice on the other. Moreover, as Sigmund Freud describes in Civilization and its Discontents, humans are able to live together in society because we repress many self-gratifying urges into the unconscious. We are, in other words, more selfish (and narcissistic, and greedy, and hypocritical, and childish…) than we like to think.
The criticisms that sting are the ones that stir up our own self-doubts. Maybe we are hypocritical, neglectful, self-centered. Perhaps our shameful defect has been exposed. This is what calls up anxiety, reactive anger, and defensiveness.
Such self-criticism is unpleasant when made conscious in therapy. Yet this is the path toward change. For the problem is not in the external world after all. It resides in the mind of the person in the therapy room, a person who now more clearly sees where his or her troubling feelings originate.
I really do use the Martian example all the time in my work with patients. It’s a thing of joy to watch how something so apparently frivolous can shift the focus from unhelpful externalization to honest insight.
So what do you do when someone’s presenting problem really is something external? I know someone who has been depressed for two years because her husband was killed by a drunk driver. I know someone else in deep psychological anguish because his partner suffers from ALS and is going to die, but he doesn’t exactly know when.
If someone’s presenting problem really is something external, then he or she doesn’t need psychotherapy. This is more subtle than it probably sounds. To take your first example, the line between normal bereavement and clinical depression is certainly fuzzy and has long been a matter of debate. In Freud’s famous paper “Mourning and Melancholia” he tries to tell them apart based on clinical features like guilt. However, most mental health professionals admit it is very hard to tell bereavement from clinical depression unless the time factor is considered. If you told me your acquaintance has been depressed for two weeks or two months after her husband was killed by a drunk driver, I would say she most likely is having a normal grief reaction and doesn’t need therapy or any other mental health treatment. But two years is a long time, longer than most loved ones suffer depressive symptoms, even after a horrible loss like this. Therefore, in this case I would likely advise psychotherapy, not for the external loss itself, but to explore why your acquaintance has not yet worked through the usual grieving process. Sometimes conflicting feelings about the deceased stall this process, or perhaps the issue is an inability to reach out to others, and thus the bereaved lacks alternative sources of emotional support. These “internal” issues can be helped in therapy.
Your second example is similar to the first, in that deep anguish in such a situation may be normal. Life is cruel at times, and mental health does not mean always being happy. Nonetheless, there may be internal factors that magnify the anguish: feelings of guilt or remorse, conflicts about the partner, and so forth. No psychotherapy can change the reality of ALS, or make it other than terribly sad. If the problem is purely external, there is no role for therapy other than simple emotional support. And frankly, the person should turn to family and/or friends for that, not pay a therapist. It is only when internal factors come into play that therapy may help.
By the way, my view of emotional support in therapy recounts the old saying, “Give a man a fish and he eats for a day. Teach him to fish and he eats for a lifetime.” There is certainly a place for emotional support in the process of doing therapy. However, the aim of therapy is not to offer such support, but to help the patient develop emotionally supportive relationships outside of therapy.
Thanks for writing.