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Medication for life
Some areas of psychiatry would benefit from more controversy. One of them is the prescription of antidepressants to young people dealing with romantic disappointments.
I have seen many young men and women given an antidepressant for the very painful, but ordinary, romantic break-ups characteristic of this phase of life, who then become habituated to the drug. They take the medication indefinitely, their brains accommodate neurophysiologically to the presence of the chemical, and they become unable to discontinue it without intolerable withdrawal symptoms that look like an underlying illness. A parallel phenomenon occurs not infrequently with the use of amphetamines (and other stimulants) for attention-deficit hyperactivity disorder that is at times mistakenly diagnosed in this age group.
Antidepressants for early romantic disappointments
Mr. A, now in his 30s, became sullen and withdrawn at age 16 after a girl refused his romantic approaches. His well-intentioned parents took him to a psychiatrist, who, after a brief evaluation, prescribed fluoxetine. Mr. A is now well adjusted and happily married but unable to get off fluoxetine. Even when it is carefully tapered, 2 or 3 months after it is discontinued, he becomes anxious and depressed. This is an iatrogenic problem. It is not related to goings-on in his mind or his life; rather it is the result of his brain’s accommodation to a medication, producing a serious withdrawal syndrome.
His original psychiatrist made only a descriptive diagnosis. He did not inquire about what was going on in Mr. A’s mind and thus could not make a dynamic diagnosis (that is, a diagnosis of a patient’s central emotional conflicts, ability to function in relation to other people, strengths, and weaknesses). Mr. A, like many adolescents, had a lot of anxiety and guilt about sexual and romantic involvement, and potential success. He defended against his anxiety and guilt by assuring himself life would never work out for him. When the girl he admired rebuffed him, he immediately concluded this would perpetually be his fate, so the girl’s refusal was particularly painful. Mr. A feels that had this dynamic been discussed with him at the time, he may well not have needed medication at all.
Ms. B, like Mr. A, was prescribed antidepressants for depressive reactions to early romantic disappointments. Likewise, she self-punitively convinced herself, despite easily attracting men’s attentions, that these disappointments meant a lifetime alone. Ms. B has a family history of depression (although neither of her brothers struggles with it), and she felt that she needed the medications to help negotiate difficult periods. But should she have been on them for extended periods of time? Therapeutic attention to her emotional conflicts helped her to form lasting relationships, marry, and have children. Unable to get off the medications, she had to deal with the risks of their use during pregnancy, which she then subjected to the same sort of guilty self-accusations as she previously had used to limit her romantic prospects.
Ms. C came to me on three medications – one for each of her significant romantic break-ups. She, too, was depressively self-diminishing, beginning therapy by letting me know all the things she could think of that might make me think less of her. Understanding some of the reasons for her self-deprecation helped her toward better romantic relationships but did not give her the courage to get off her medications. Pregnancy, however, led her to promptly and successfully discontinue an antidepressant and a mood stabilizer (she has never had any symptoms suggestive of manic depression). She remained on a low dose of a selective serotonin reuptake inhibitor, had an uneventful pregnancy, and then fell in love with a charming baby.
Principles for consideration
• Psychiatrists (and other mental health professionals and primary care physicians treating mental illness) should always make a dynamic, and not merely a descriptive, diagnosis. Even with a more clearly biologically driven problem, such as bipolar disorder, the patient’s personality and conflicts matter.
• Psychiatrists should be very judicious about prescribing medications in adolescence and young adulthood, especially for difficulties adapting to the typical events of those phases of life. Expert psychotherapy should be the first choice in these instances.
• Medication, when necessary, should be prescribed for as limited a time as possible. It is important for young people to advance their own development, not feel needlessly beholden to medications, not get iatrogenically dependent on them, and not feel that they have “diseases” they don’t have.
Amphetamines for misdiagnosed ADHD
When Ms. D’s family moved to a new house, she, her brother, and her sister, each attended a new school. Unlike her siblings, Ms. D, who was in high school, had a difficult adjustment. Her grades fell. She was taken to a psychiatrist who diagnosed ADHD and prescribed amphetamines. The psychiatrist paid little attention to her prior lack of difficulty in school or her struggles making new friends. Nor did the psychiatrist learn that Ms. D had to ward off the seductive advances of an older teacher (although Ms. D would likely not have been immediately forthcoming about this at the time).
When Ms. D came to me as a college student, for troubles with anger, anxiety, and some depression, she was religiously taking 70 mg of amphetamines daily. After I learned a bit about her and raised the question of whether she actually had ADHD, and whether it might make sense to consider tapering the amphetamines, she was appalled and looked like a toddler who was afraid I was about to steal her candy. Helping her to get off the unneeded medication was a multiyear process.
First, she had to recognize that it was prescribed to treat a problem she probably didn’t have, and second, that it was failing to help her with the problems she did have. As we attended to some of her actual emotional conflicts, she became willing to experiment with lower doses. She was able to see that her work was little changed as the dose was lowered, and that her difficulties with school had more to do with feelings toward classmates and teachers than with the presence or absence of amphetamines. After a protracted struggle, finally off the medication, she felt in charge of her life and no longer believed there was something inherently wrong with her mind or her brain.
Mr. E was the only son in a high-powered academic family. His older sisters were all intellectual standouts. Early in high school, he received his first B as a grade in a course. He was taken to a pediatrician, diagnosed with ADHD, and put on stimulants. Like Ms. D, he came to believe that he needed them. In college, he began to develop some magical aspects to his thinking, a potential side effect of the stimulants. It was very difficult to help him see either that he had a problem with his thinking or that it might be attributable to the medication.
Principles to consider
• If the ADHD wasn’t there in elementary school or before, it is unlikely that an adolescent or young adult has new-onset ADHD. A new or newly amplified conflict is occurring in the person’s mind and life A dynamic diagnosis, as always, is essential.
• When medication is prescribed for actual ADHD, as with anything else, the question of how long it will be taken must be asked. For life? Until other means of adaptation are accomplished? Until adequate outcome studies of long-term use of the medication are performed?
Helping patients to get off unneeded, or no longer needed, medications can be a difficult task. Their emotional attachments to the medications can be intense and varied. For some, the prescription is a sign of being loved and cared for. For others, it represents a certification of a deficit, appeases guilt about success, and/or attests to the need for special consideration. Insofar as the medication has been helpful, it may have come to be regarded as a dearly loved friend, or even a part of the self.
When medication has been helpful, there is also, of course, concern about the potential return of the difficulties for which it was prescribed. Few patients are told at the time of first prescription that there is potential risk of habituation and return of, or potential exaggeration of, symptoms with discontinuation. This type of discussion is more difficult to have in situations in which a prescription is urgently needed and the patient is reluctant, but is still not often done in those instances in which a prescription is more optional than essential. The picture is seldom simple.
These few comments only scratch the surface of the difficulties doctors and patients face in helping patients to discontinue their medications. Residency programs pay a lot of attention to helping trainees learn to prescribe medications; rarely do they sufficiently educate residents how to help patients discontinue them. The fact that so many residencies currently pay limited attention to interventions apart from medication contributes further to the difficulty.
Medications have saved the life of many a psychiatric patient. Some patients need medication for life. But some end up on medication for life, even in some instances when the medication may not have been needed in the first place. Although it is often a difficult task, we need to do a better job of distinguishing which patients are which.
Dr. Blum is a psychiatrist and psychoanalyst in private practice in Philadelphia. He teaches in the departments of anthropology and psychiatry at the University of Pennsylvania and at the Psychoanalytic Center of Philadelphia.
Some areas of psychiatry would benefit from more controversy. One of them is the prescription of antidepressants to young people dealing with romantic disappointments.
I have seen many young men and women given an antidepressant for the very painful, but ordinary, romantic break-ups characteristic of this phase of life, who then become habituated to the drug. They take the medication indefinitely, their brains accommodate neurophysiologically to the presence of the chemical, and they become unable to discontinue it without intolerable withdrawal symptoms that look like an underlying illness. A parallel phenomenon occurs not infrequently with the use of amphetamines (and other stimulants) for attention-deficit hyperactivity disorder that is at times mistakenly diagnosed in this age group.
Antidepressants for early romantic disappointments
Mr. A, now in his 30s, became sullen and withdrawn at age 16 after a girl refused his romantic approaches. His well-intentioned parents took him to a psychiatrist, who, after a brief evaluation, prescribed fluoxetine. Mr. A is now well adjusted and happily married but unable to get off fluoxetine. Even when it is carefully tapered, 2 or 3 months after it is discontinued, he becomes anxious and depressed. This is an iatrogenic problem. It is not related to goings-on in his mind or his life; rather it is the result of his brain’s accommodation to a medication, producing a serious withdrawal syndrome.
His original psychiatrist made only a descriptive diagnosis. He did not inquire about what was going on in Mr. A’s mind and thus could not make a dynamic diagnosis (that is, a diagnosis of a patient’s central emotional conflicts, ability to function in relation to other people, strengths, and weaknesses). Mr. A, like many adolescents, had a lot of anxiety and guilt about sexual and romantic involvement, and potential success. He defended against his anxiety and guilt by assuring himself life would never work out for him. When the girl he admired rebuffed him, he immediately concluded this would perpetually be his fate, so the girl’s refusal was particularly painful. Mr. A feels that had this dynamic been discussed with him at the time, he may well not have needed medication at all.
Ms. B, like Mr. A, was prescribed antidepressants for depressive reactions to early romantic disappointments. Likewise, she self-punitively convinced herself, despite easily attracting men’s attentions, that these disappointments meant a lifetime alone. Ms. B has a family history of depression (although neither of her brothers struggles with it), and she felt that she needed the medications to help negotiate difficult periods. But should she have been on them for extended periods of time? Therapeutic attention to her emotional conflicts helped her to form lasting relationships, marry, and have children. Unable to get off the medications, she had to deal with the risks of their use during pregnancy, which she then subjected to the same sort of guilty self-accusations as she previously had used to limit her romantic prospects.
Ms. C came to me on three medications – one for each of her significant romantic break-ups. She, too, was depressively self-diminishing, beginning therapy by letting me know all the things she could think of that might make me think less of her. Understanding some of the reasons for her self-deprecation helped her toward better romantic relationships but did not give her the courage to get off her medications. Pregnancy, however, led her to promptly and successfully discontinue an antidepressant and a mood stabilizer (she has never had any symptoms suggestive of manic depression). She remained on a low dose of a selective serotonin reuptake inhibitor, had an uneventful pregnancy, and then fell in love with a charming baby.
Principles for consideration
• Psychiatrists (and other mental health professionals and primary care physicians treating mental illness) should always make a dynamic, and not merely a descriptive, diagnosis. Even with a more clearly biologically driven problem, such as bipolar disorder, the patient’s personality and conflicts matter.
• Psychiatrists should be very judicious about prescribing medications in adolescence and young adulthood, especially for difficulties adapting to the typical events of those phases of life. Expert psychotherapy should be the first choice in these instances.
• Medication, when necessary, should be prescribed for as limited a time as possible. It is important for young people to advance their own development, not feel needlessly beholden to medications, not get iatrogenically dependent on them, and not feel that they have “diseases” they don’t have.
Amphetamines for misdiagnosed ADHD
When Ms. D’s family moved to a new house, she, her brother, and her sister, each attended a new school. Unlike her siblings, Ms. D, who was in high school, had a difficult adjustment. Her grades fell. She was taken to a psychiatrist who diagnosed ADHD and prescribed amphetamines. The psychiatrist paid little attention to her prior lack of difficulty in school or her struggles making new friends. Nor did the psychiatrist learn that Ms. D had to ward off the seductive advances of an older teacher (although Ms. D would likely not have been immediately forthcoming about this at the time).
When Ms. D came to me as a college student, for troubles with anger, anxiety, and some depression, she was religiously taking 70 mg of amphetamines daily. After I learned a bit about her and raised the question of whether she actually had ADHD, and whether it might make sense to consider tapering the amphetamines, she was appalled and looked like a toddler who was afraid I was about to steal her candy. Helping her to get off the unneeded medication was a multiyear process.
First, she had to recognize that it was prescribed to treat a problem she probably didn’t have, and second, that it was failing to help her with the problems she did have. As we attended to some of her actual emotional conflicts, she became willing to experiment with lower doses. She was able to see that her work was little changed as the dose was lowered, and that her difficulties with school had more to do with feelings toward classmates and teachers than with the presence or absence of amphetamines. After a protracted struggle, finally off the medication, she felt in charge of her life and no longer believed there was something inherently wrong with her mind or her brain.
Mr. E was the only son in a high-powered academic family. His older sisters were all intellectual standouts. Early in high school, he received his first B as a grade in a course. He was taken to a pediatrician, diagnosed with ADHD, and put on stimulants. Like Ms. D, he came to believe that he needed them. In college, he began to develop some magical aspects to his thinking, a potential side effect of the stimulants. It was very difficult to help him see either that he had a problem with his thinking or that it might be attributable to the medication.
Principles to consider
• If the ADHD wasn’t there in elementary school or before, it is unlikely that an adolescent or young adult has new-onset ADHD. A new or newly amplified conflict is occurring in the person’s mind and life A dynamic diagnosis, as always, is essential.
• When medication is prescribed for actual ADHD, as with anything else, the question of how long it will be taken must be asked. For life? Until other means of adaptation are accomplished? Until adequate outcome studies of long-term use of the medication are performed?
Helping patients to get off unneeded, or no longer needed, medications can be a difficult task. Their emotional attachments to the medications can be intense and varied. For some, the prescription is a sign of being loved and cared for. For others, it represents a certification of a deficit, appeases guilt about success, and/or attests to the need for special consideration. Insofar as the medication has been helpful, it may have come to be regarded as a dearly loved friend, or even a part of the self.
When medication has been helpful, there is also, of course, concern about the potential return of the difficulties for which it was prescribed. Few patients are told at the time of first prescription that there is potential risk of habituation and return of, or potential exaggeration of, symptoms with discontinuation. This type of discussion is more difficult to have in situations in which a prescription is urgently needed and the patient is reluctant, but is still not often done in those instances in which a prescription is more optional than essential. The picture is seldom simple.
These few comments only scratch the surface of the difficulties doctors and patients face in helping patients to discontinue their medications. Residency programs pay a lot of attention to helping trainees learn to prescribe medications; rarely do they sufficiently educate residents how to help patients discontinue them. The fact that so many residencies currently pay limited attention to interventions apart from medication contributes further to the difficulty.
Medications have saved the life of many a psychiatric patient. Some patients need medication for life. But some end up on medication for life, even in some instances when the medication may not have been needed in the first place. Although it is often a difficult task, we need to do a better job of distinguishing which patients are which.
Dr. Blum is a psychiatrist and psychoanalyst in private practice in Philadelphia. He teaches in the departments of anthropology and psychiatry at the University of Pennsylvania and at the Psychoanalytic Center of Philadelphia.
Some areas of psychiatry would benefit from more controversy. One of them is the prescription of antidepressants to young people dealing with romantic disappointments.
I have seen many young men and women given an antidepressant for the very painful, but ordinary, romantic break-ups characteristic of this phase of life, who then become habituated to the drug. They take the medication indefinitely, their brains accommodate neurophysiologically to the presence of the chemical, and they become unable to discontinue it without intolerable withdrawal symptoms that look like an underlying illness. A parallel phenomenon occurs not infrequently with the use of amphetamines (and other stimulants) for attention-deficit hyperactivity disorder that is at times mistakenly diagnosed in this age group.
Antidepressants for early romantic disappointments
Mr. A, now in his 30s, became sullen and withdrawn at age 16 after a girl refused his romantic approaches. His well-intentioned parents took him to a psychiatrist, who, after a brief evaluation, prescribed fluoxetine. Mr. A is now well adjusted and happily married but unable to get off fluoxetine. Even when it is carefully tapered, 2 or 3 months after it is discontinued, he becomes anxious and depressed. This is an iatrogenic problem. It is not related to goings-on in his mind or his life; rather it is the result of his brain’s accommodation to a medication, producing a serious withdrawal syndrome.
His original psychiatrist made only a descriptive diagnosis. He did not inquire about what was going on in Mr. A’s mind and thus could not make a dynamic diagnosis (that is, a diagnosis of a patient’s central emotional conflicts, ability to function in relation to other people, strengths, and weaknesses). Mr. A, like many adolescents, had a lot of anxiety and guilt about sexual and romantic involvement, and potential success. He defended against his anxiety and guilt by assuring himself life would never work out for him. When the girl he admired rebuffed him, he immediately concluded this would perpetually be his fate, so the girl’s refusal was particularly painful. Mr. A feels that had this dynamic been discussed with him at the time, he may well not have needed medication at all.
Ms. B, like Mr. A, was prescribed antidepressants for depressive reactions to early romantic disappointments. Likewise, she self-punitively convinced herself, despite easily attracting men’s attentions, that these disappointments meant a lifetime alone. Ms. B has a family history of depression (although neither of her brothers struggles with it), and she felt that she needed the medications to help negotiate difficult periods. But should she have been on them for extended periods of time? Therapeutic attention to her emotional conflicts helped her to form lasting relationships, marry, and have children. Unable to get off the medications, she had to deal with the risks of their use during pregnancy, which she then subjected to the same sort of guilty self-accusations as she previously had used to limit her romantic prospects.
Ms. C came to me on three medications – one for each of her significant romantic break-ups. She, too, was depressively self-diminishing, beginning therapy by letting me know all the things she could think of that might make me think less of her. Understanding some of the reasons for her self-deprecation helped her toward better romantic relationships but did not give her the courage to get off her medications. Pregnancy, however, led her to promptly and successfully discontinue an antidepressant and a mood stabilizer (she has never had any symptoms suggestive of manic depression). She remained on a low dose of a selective serotonin reuptake inhibitor, had an uneventful pregnancy, and then fell in love with a charming baby.
Principles for consideration
• Psychiatrists (and other mental health professionals and primary care physicians treating mental illness) should always make a dynamic, and not merely a descriptive, diagnosis. Even with a more clearly biologically driven problem, such as bipolar disorder, the patient’s personality and conflicts matter.
• Psychiatrists should be very judicious about prescribing medications in adolescence and young adulthood, especially for difficulties adapting to the typical events of those phases of life. Expert psychotherapy should be the first choice in these instances.
• Medication, when necessary, should be prescribed for as limited a time as possible. It is important for young people to advance their own development, not feel needlessly beholden to medications, not get iatrogenically dependent on them, and not feel that they have “diseases” they don’t have.
Amphetamines for misdiagnosed ADHD
When Ms. D’s family moved to a new house, she, her brother, and her sister, each attended a new school. Unlike her siblings, Ms. D, who was in high school, had a difficult adjustment. Her grades fell. She was taken to a psychiatrist who diagnosed ADHD and prescribed amphetamines. The psychiatrist paid little attention to her prior lack of difficulty in school or her struggles making new friends. Nor did the psychiatrist learn that Ms. D had to ward off the seductive advances of an older teacher (although Ms. D would likely not have been immediately forthcoming about this at the time).
When Ms. D came to me as a college student, for troubles with anger, anxiety, and some depression, she was religiously taking 70 mg of amphetamines daily. After I learned a bit about her and raised the question of whether she actually had ADHD, and whether it might make sense to consider tapering the amphetamines, she was appalled and looked like a toddler who was afraid I was about to steal her candy. Helping her to get off the unneeded medication was a multiyear process.
First, she had to recognize that it was prescribed to treat a problem she probably didn’t have, and second, that it was failing to help her with the problems she did have. As we attended to some of her actual emotional conflicts, she became willing to experiment with lower doses. She was able to see that her work was little changed as the dose was lowered, and that her difficulties with school had more to do with feelings toward classmates and teachers than with the presence or absence of amphetamines. After a protracted struggle, finally off the medication, she felt in charge of her life and no longer believed there was something inherently wrong with her mind or her brain.
Mr. E was the only son in a high-powered academic family. His older sisters were all intellectual standouts. Early in high school, he received his first B as a grade in a course. He was taken to a pediatrician, diagnosed with ADHD, and put on stimulants. Like Ms. D, he came to believe that he needed them. In college, he began to develop some magical aspects to his thinking, a potential side effect of the stimulants. It was very difficult to help him see either that he had a problem with his thinking or that it might be attributable to the medication.
Principles to consider
• If the ADHD wasn’t there in elementary school or before, it is unlikely that an adolescent or young adult has new-onset ADHD. A new or newly amplified conflict is occurring in the person’s mind and life A dynamic diagnosis, as always, is essential.
• When medication is prescribed for actual ADHD, as with anything else, the question of how long it will be taken must be asked. For life? Until other means of adaptation are accomplished? Until adequate outcome studies of long-term use of the medication are performed?
Helping patients to get off unneeded, or no longer needed, medications can be a difficult task. Their emotional attachments to the medications can be intense and varied. For some, the prescription is a sign of being loved and cared for. For others, it represents a certification of a deficit, appeases guilt about success, and/or attests to the need for special consideration. Insofar as the medication has been helpful, it may have come to be regarded as a dearly loved friend, or even a part of the self.
When medication has been helpful, there is also, of course, concern about the potential return of the difficulties for which it was prescribed. Few patients are told at the time of first prescription that there is potential risk of habituation and return of, or potential exaggeration of, symptoms with discontinuation. This type of discussion is more difficult to have in situations in which a prescription is urgently needed and the patient is reluctant, but is still not often done in those instances in which a prescription is more optional than essential. The picture is seldom simple.
These few comments only scratch the surface of the difficulties doctors and patients face in helping patients to discontinue their medications. Residency programs pay a lot of attention to helping trainees learn to prescribe medications; rarely do they sufficiently educate residents how to help patients discontinue them. The fact that so many residencies currently pay limited attention to interventions apart from medication contributes further to the difficulty.
Medications have saved the life of many a psychiatric patient. Some patients need medication for life. But some end up on medication for life, even in some instances when the medication may not have been needed in the first place. Although it is often a difficult task, we need to do a better job of distinguishing which patients are which.
Dr. Blum is a psychiatrist and psychoanalyst in private practice in Philadelphia. He teaches in the departments of anthropology and psychiatry at the University of Pennsylvania and at the Psychoanalytic Center of Philadelphia.
Madness and guns
“Bang, bang, you’re dead” has been uttered by millions of American children for generations. It is typical of the ordinary, angry, murderous thoughts of childhood; variations of it are universal. We expect children to learn to control their anger as they grow up and not to play out their angry wishes in reality. Unfortunately, this doesn’t always happen.
Following the many recent dramatic, crazed mass shootings, some commentators have called for restricting gun access for those with mental illness, but psychiatrists have rightly pointed out that murderers, including terror-inducing mass murderers, do not usually have a history of formally diagnosed mental illness. The psychiatrists are right for a reason: The potential for sudden, often unexpected, violence is widespread. This essay will employ a developmental perspective on how people handle anger, and on how we come to distinguish between fantasy and reality, to inform an understanding of gun violence.
Baby hyenas often try to kill their siblings shortly after birth. Human babies do not. They are not only motorically undeveloped, but their emotions appear to be mostly limited to the nonspecific states of distress and satisfaction. Distinct affects, such as anger, differentiate gradually. Babies smile by 2 months. Babies’ specific affection for and loyalty to their caregivers comes along a bit later, hence stranger anxiety commonly appears around 9 months. Facial expressions, sounds, and activity that look specifically like anger, and that occur when babies are frustrated or injured, are observed in the second half of the first year of human life. In the second year of life, feelings such as shame and guilt, which are dependent on the development of a distinct sense of self and other, appear. Shame and guilt, along with loving feelings, help form the basis for consideration of others and for the diminishment of young children’s omnipotence and egocentricity; they become a kind of social “glue,” tempering selfish, angry pursuits and tantrums.
There is a typical developmental sequence of how people come to handle their anger. Younger children express emotions directly, with little restraint; they hit, bite, and scream. Older children should be able to have more impulse control and be able to regulate the motor and verbal expression of their anger to a greater degree. At some point, most also become able to acknowledge their anger and not have to deny it. Adults, in principle, should be able both to inhibit the uncontrolled expression of anger and also, when appropriate, be able to use anger constructively. How tenuous this accomplishment is, and how often adults can function like overgrown children, can be readily observed at children’s sports matches, in which the children are often better behaved than their parents. In short, humans are endowed with the potential for enormous, destructive anger, but also, in our caring for others, a counterbalance to it.
The process of emotional development, and the regulation of anger, is intertwined with the development of the sense of self and of other. Evidence suggests that babies can start to distinguish self and other at birth, but that a full and reliable sense of self and other is a long, complicated developmental process.
The article by pediatrician and psychoanalyst Donald Winnicott, “Transitional Objects and Transitional Phenomena – A Study of the First Not-Me Possession,” one of the most frequently cited papers in the psychoanalytic literature, addresses this process (Int J Psychoanal. 1953;34[2]89-97). While transitional objects are not a human universal, the process of differentiating oneself from others, of finding out what is me and what is not-me, is. According to Dr. Winnicott, learning what is self and what is other assists babies in their related challenges of distinguishing animate from inanimate, wishes from causes, and fantasy from reality. Mother usually appears when I’m distressed – is she a part of me or a separate being? Does she appear because I wish, because I cry, or does she not appear despite my efforts? People never fully complete the developmental distinctions between self and other, and between wishes, fantasies, and magic, as opposed to reality.
Stressful events, such as a sudden loss, for example, commonly prompt a regressive denial of reality: “I don’t believe what I see” can be meant literally. When attending movies, we all “suspend disbelief” and participate, at least vicariously, in wishful magic. Further, although after early childhood, problems understanding material reality are characteristic of psychosis, all people are prone to at least occasional wishful or fearful errors in grasping social reality – we misperceive the meaning and intentions of others.
Combining the understanding of the development of how children handle anger and how they learn to differentiate self and other, and fantasy and reality, leads to an additional, important point. Suppose a person can’t tolerate his own angry wishes and he doesn’t distinguish well between self and other. He can easily attribute his own unwanted hatefulness to others, and he may then want to attack them for it. This process is extremely common, and we are all inclined to it to some degree. As childishly simplistic as it sounds, for humans, there is almost always an us and a them; we are good and they are bad. In addition to directing anger inappropriately at others, people can, of course, turn anger against themselves, and with just as much unreasonableness and venom. However much we grow up, development is never complete. We remain irrational, with a tenuous and incomplete perception of reality.
One would never give a weapon to an infant, but in light of these difficulties with respect to human development, should one give a weapon to an adult?
Whether or not humans have the self-control to possess weapons of great power and destructiveness, weapons are part of our evolution as a species. They have likely contributed to our remarkable success, protecting us from predators and enriching our diets. It is worth noting, however, that small-scale societies such as those we all evolved from often have high murder rates, and that lower rates of intra-societal violence tend to be found in larger, more highly regulated societies. People do not always adequately manage aggression themselves and benefit from external, societal assistance.
We humans all have the capacity to be mad: to be angry, to be crazy, to be crazed with anger. Fantasies of revenge are common when one is angry, and expectable when one has been hurt. Yet, expressions such as “blind with rage” and “seeing red” attest to the challenges to the sense of reality that rage can induce. The crucial distinction between having vengeful wishes and fantasies, and putting them into action, into reality, can crumble quickly. In addition to anger, fear is another emotion that can distort the perception of reality. Regular attention to the news suggests that police, whether they are aware of it or not, are more fearful of black men than of other people. They are more likely to perceive them as being armed and are quicker to shoot. For police and civilians alike, the presence of guns simultaneously requires greater impulse control and makes impulse control more difficult. The more guns, the more fear and anger, the more shootings – a vicious cycle.
Most people who commit crimes with guns, whether a singular “crime of passion” or a mass murder, have been crazed with anger. Some have been known to police as angry individuals with histories of getting into trouble, others not. But most have been angry, isolated individuals with problematic social relationships and little warm or respectful involvement with others to counterbalance their anger. Given the challenges inherent in human development, it is not surprising that in most societies there are a fair number of disaffected, angry, isolated individuals with inadequate realistic emotional regulation.
According to the anthropologist Scott Atran, who has studied both would-be and convicted terrorists, in addition to those individuals who are angry and disturbed, many recruits to terrorism are merely unsettled youth eager to find a sense of identity and belonging in a “band of brothers (and sisters).” He has described the “devoted actor,” who merges his identity with his combat unit and becomes willing to die for his comrades or their cause. These observations are consistent with both anthropological ideas about cultural influences on the sense of self in relation to groups, and with psychoanalytic emphasis on the difficulty of achieving a firm sense of self and other. In fusing with the group and its ideology, one gives up an independent self while feeling that one has gained a sense of self, belonging, and meaning. Whatever the psychological and social picture, it is obvious that the angry, isolated individuals who may regress and explode, and the countless unsettled youth of modern societies, cannot all be identified, tracked, and regulated by society, nor will they all seek help for their troubles. The United States’ decisions to allow massively destructive weapons to anyone and everyone are counter to everything we know about people.
Among many other things, Sigmund Freud is known for highlighting the comment that “The first man to hurl an insult rather than a spear was the founder of civilization.” Anger that is put into words is less destructive than anger put into violent action. From this point of view, the widespread presence of guns undermines civilization. Guns invite putting anger into action rather than conversation – they are a hindrance to impulse control and they shut down discussion. Democracy, a form of civilization contingent on impulse control, discussion, and voting, rather than submission to violent authority, is particularly undermined by guns. Congress should know: It has been so intimidated by the National Rifle Association that it has refused to outlaw private possession of military assault rifles and at the same time has submitted to outlawing the use of federal funds for research about gun violence. Despite this ban on research, there is overwhelming evidence that the presence of a gun in a home is associated not only with significantly increased murder rates, but also, as mental health professionals well know, greatly increased incidence of suicide.
As humans, we all have the ability to control ourselves to some degree. But, we all have the potential to become mad and to lose control. Our internal self-regulation is sometimes insufficient, and we need the restraining influence of our fellow humans. This can be in the form of a comforting word, a warning gesture, a carrot or a stick, or a law. The regulation of guns, assault rifles, and bomb-making materials is a mark of civilization.
Dr. Blum is a psychiatrist and psychoanalyst in private practice in Philadelphia. He teaches in the departments of anthropology and psychiatry at the University of Pennsylvania and at the Psychoanalytic Center of Philadelphia.
“Bang, bang, you’re dead” has been uttered by millions of American children for generations. It is typical of the ordinary, angry, murderous thoughts of childhood; variations of it are universal. We expect children to learn to control their anger as they grow up and not to play out their angry wishes in reality. Unfortunately, this doesn’t always happen.
Following the many recent dramatic, crazed mass shootings, some commentators have called for restricting gun access for those with mental illness, but psychiatrists have rightly pointed out that murderers, including terror-inducing mass murderers, do not usually have a history of formally diagnosed mental illness. The psychiatrists are right for a reason: The potential for sudden, often unexpected, violence is widespread. This essay will employ a developmental perspective on how people handle anger, and on how we come to distinguish between fantasy and reality, to inform an understanding of gun violence.
Baby hyenas often try to kill their siblings shortly after birth. Human babies do not. They are not only motorically undeveloped, but their emotions appear to be mostly limited to the nonspecific states of distress and satisfaction. Distinct affects, such as anger, differentiate gradually. Babies smile by 2 months. Babies’ specific affection for and loyalty to their caregivers comes along a bit later, hence stranger anxiety commonly appears around 9 months. Facial expressions, sounds, and activity that look specifically like anger, and that occur when babies are frustrated or injured, are observed in the second half of the first year of human life. In the second year of life, feelings such as shame and guilt, which are dependent on the development of a distinct sense of self and other, appear. Shame and guilt, along with loving feelings, help form the basis for consideration of others and for the diminishment of young children’s omnipotence and egocentricity; they become a kind of social “glue,” tempering selfish, angry pursuits and tantrums.
There is a typical developmental sequence of how people come to handle their anger. Younger children express emotions directly, with little restraint; they hit, bite, and scream. Older children should be able to have more impulse control and be able to regulate the motor and verbal expression of their anger to a greater degree. At some point, most also become able to acknowledge their anger and not have to deny it. Adults, in principle, should be able both to inhibit the uncontrolled expression of anger and also, when appropriate, be able to use anger constructively. How tenuous this accomplishment is, and how often adults can function like overgrown children, can be readily observed at children’s sports matches, in which the children are often better behaved than their parents. In short, humans are endowed with the potential for enormous, destructive anger, but also, in our caring for others, a counterbalance to it.
The process of emotional development, and the regulation of anger, is intertwined with the development of the sense of self and of other. Evidence suggests that babies can start to distinguish self and other at birth, but that a full and reliable sense of self and other is a long, complicated developmental process.
The article by pediatrician and psychoanalyst Donald Winnicott, “Transitional Objects and Transitional Phenomena – A Study of the First Not-Me Possession,” one of the most frequently cited papers in the psychoanalytic literature, addresses this process (Int J Psychoanal. 1953;34[2]89-97). While transitional objects are not a human universal, the process of differentiating oneself from others, of finding out what is me and what is not-me, is. According to Dr. Winnicott, learning what is self and what is other assists babies in their related challenges of distinguishing animate from inanimate, wishes from causes, and fantasy from reality. Mother usually appears when I’m distressed – is she a part of me or a separate being? Does she appear because I wish, because I cry, or does she not appear despite my efforts? People never fully complete the developmental distinctions between self and other, and between wishes, fantasies, and magic, as opposed to reality.
Stressful events, such as a sudden loss, for example, commonly prompt a regressive denial of reality: “I don’t believe what I see” can be meant literally. When attending movies, we all “suspend disbelief” and participate, at least vicariously, in wishful magic. Further, although after early childhood, problems understanding material reality are characteristic of psychosis, all people are prone to at least occasional wishful or fearful errors in grasping social reality – we misperceive the meaning and intentions of others.
Combining the understanding of the development of how children handle anger and how they learn to differentiate self and other, and fantasy and reality, leads to an additional, important point. Suppose a person can’t tolerate his own angry wishes and he doesn’t distinguish well between self and other. He can easily attribute his own unwanted hatefulness to others, and he may then want to attack them for it. This process is extremely common, and we are all inclined to it to some degree. As childishly simplistic as it sounds, for humans, there is almost always an us and a them; we are good and they are bad. In addition to directing anger inappropriately at others, people can, of course, turn anger against themselves, and with just as much unreasonableness and venom. However much we grow up, development is never complete. We remain irrational, with a tenuous and incomplete perception of reality.
One would never give a weapon to an infant, but in light of these difficulties with respect to human development, should one give a weapon to an adult?
Whether or not humans have the self-control to possess weapons of great power and destructiveness, weapons are part of our evolution as a species. They have likely contributed to our remarkable success, protecting us from predators and enriching our diets. It is worth noting, however, that small-scale societies such as those we all evolved from often have high murder rates, and that lower rates of intra-societal violence tend to be found in larger, more highly regulated societies. People do not always adequately manage aggression themselves and benefit from external, societal assistance.
We humans all have the capacity to be mad: to be angry, to be crazy, to be crazed with anger. Fantasies of revenge are common when one is angry, and expectable when one has been hurt. Yet, expressions such as “blind with rage” and “seeing red” attest to the challenges to the sense of reality that rage can induce. The crucial distinction between having vengeful wishes and fantasies, and putting them into action, into reality, can crumble quickly. In addition to anger, fear is another emotion that can distort the perception of reality. Regular attention to the news suggests that police, whether they are aware of it or not, are more fearful of black men than of other people. They are more likely to perceive them as being armed and are quicker to shoot. For police and civilians alike, the presence of guns simultaneously requires greater impulse control and makes impulse control more difficult. The more guns, the more fear and anger, the more shootings – a vicious cycle.
Most people who commit crimes with guns, whether a singular “crime of passion” or a mass murder, have been crazed with anger. Some have been known to police as angry individuals with histories of getting into trouble, others not. But most have been angry, isolated individuals with problematic social relationships and little warm or respectful involvement with others to counterbalance their anger. Given the challenges inherent in human development, it is not surprising that in most societies there are a fair number of disaffected, angry, isolated individuals with inadequate realistic emotional regulation.
According to the anthropologist Scott Atran, who has studied both would-be and convicted terrorists, in addition to those individuals who are angry and disturbed, many recruits to terrorism are merely unsettled youth eager to find a sense of identity and belonging in a “band of brothers (and sisters).” He has described the “devoted actor,” who merges his identity with his combat unit and becomes willing to die for his comrades or their cause. These observations are consistent with both anthropological ideas about cultural influences on the sense of self in relation to groups, and with psychoanalytic emphasis on the difficulty of achieving a firm sense of self and other. In fusing with the group and its ideology, one gives up an independent self while feeling that one has gained a sense of self, belonging, and meaning. Whatever the psychological and social picture, it is obvious that the angry, isolated individuals who may regress and explode, and the countless unsettled youth of modern societies, cannot all be identified, tracked, and regulated by society, nor will they all seek help for their troubles. The United States’ decisions to allow massively destructive weapons to anyone and everyone are counter to everything we know about people.
Among many other things, Sigmund Freud is known for highlighting the comment that “The first man to hurl an insult rather than a spear was the founder of civilization.” Anger that is put into words is less destructive than anger put into violent action. From this point of view, the widespread presence of guns undermines civilization. Guns invite putting anger into action rather than conversation – they are a hindrance to impulse control and they shut down discussion. Democracy, a form of civilization contingent on impulse control, discussion, and voting, rather than submission to violent authority, is particularly undermined by guns. Congress should know: It has been so intimidated by the National Rifle Association that it has refused to outlaw private possession of military assault rifles and at the same time has submitted to outlawing the use of federal funds for research about gun violence. Despite this ban on research, there is overwhelming evidence that the presence of a gun in a home is associated not only with significantly increased murder rates, but also, as mental health professionals well know, greatly increased incidence of suicide.
As humans, we all have the ability to control ourselves to some degree. But, we all have the potential to become mad and to lose control. Our internal self-regulation is sometimes insufficient, and we need the restraining influence of our fellow humans. This can be in the form of a comforting word, a warning gesture, a carrot or a stick, or a law. The regulation of guns, assault rifles, and bomb-making materials is a mark of civilization.
Dr. Blum is a psychiatrist and psychoanalyst in private practice in Philadelphia. He teaches in the departments of anthropology and psychiatry at the University of Pennsylvania and at the Psychoanalytic Center of Philadelphia.
“Bang, bang, you’re dead” has been uttered by millions of American children for generations. It is typical of the ordinary, angry, murderous thoughts of childhood; variations of it are universal. We expect children to learn to control their anger as they grow up and not to play out their angry wishes in reality. Unfortunately, this doesn’t always happen.
Following the many recent dramatic, crazed mass shootings, some commentators have called for restricting gun access for those with mental illness, but psychiatrists have rightly pointed out that murderers, including terror-inducing mass murderers, do not usually have a history of formally diagnosed mental illness. The psychiatrists are right for a reason: The potential for sudden, often unexpected, violence is widespread. This essay will employ a developmental perspective on how people handle anger, and on how we come to distinguish between fantasy and reality, to inform an understanding of gun violence.
Baby hyenas often try to kill their siblings shortly after birth. Human babies do not. They are not only motorically undeveloped, but their emotions appear to be mostly limited to the nonspecific states of distress and satisfaction. Distinct affects, such as anger, differentiate gradually. Babies smile by 2 months. Babies’ specific affection for and loyalty to their caregivers comes along a bit later, hence stranger anxiety commonly appears around 9 months. Facial expressions, sounds, and activity that look specifically like anger, and that occur when babies are frustrated or injured, are observed in the second half of the first year of human life. In the second year of life, feelings such as shame and guilt, which are dependent on the development of a distinct sense of self and other, appear. Shame and guilt, along with loving feelings, help form the basis for consideration of others and for the diminishment of young children’s omnipotence and egocentricity; they become a kind of social “glue,” tempering selfish, angry pursuits and tantrums.
There is a typical developmental sequence of how people come to handle their anger. Younger children express emotions directly, with little restraint; they hit, bite, and scream. Older children should be able to have more impulse control and be able to regulate the motor and verbal expression of their anger to a greater degree. At some point, most also become able to acknowledge their anger and not have to deny it. Adults, in principle, should be able both to inhibit the uncontrolled expression of anger and also, when appropriate, be able to use anger constructively. How tenuous this accomplishment is, and how often adults can function like overgrown children, can be readily observed at children’s sports matches, in which the children are often better behaved than their parents. In short, humans are endowed with the potential for enormous, destructive anger, but also, in our caring for others, a counterbalance to it.
The process of emotional development, and the regulation of anger, is intertwined with the development of the sense of self and of other. Evidence suggests that babies can start to distinguish self and other at birth, but that a full and reliable sense of self and other is a long, complicated developmental process.
The article by pediatrician and psychoanalyst Donald Winnicott, “Transitional Objects and Transitional Phenomena – A Study of the First Not-Me Possession,” one of the most frequently cited papers in the psychoanalytic literature, addresses this process (Int J Psychoanal. 1953;34[2]89-97). While transitional objects are not a human universal, the process of differentiating oneself from others, of finding out what is me and what is not-me, is. According to Dr. Winnicott, learning what is self and what is other assists babies in their related challenges of distinguishing animate from inanimate, wishes from causes, and fantasy from reality. Mother usually appears when I’m distressed – is she a part of me or a separate being? Does she appear because I wish, because I cry, or does she not appear despite my efforts? People never fully complete the developmental distinctions between self and other, and between wishes, fantasies, and magic, as opposed to reality.
Stressful events, such as a sudden loss, for example, commonly prompt a regressive denial of reality: “I don’t believe what I see” can be meant literally. When attending movies, we all “suspend disbelief” and participate, at least vicariously, in wishful magic. Further, although after early childhood, problems understanding material reality are characteristic of psychosis, all people are prone to at least occasional wishful or fearful errors in grasping social reality – we misperceive the meaning and intentions of others.
Combining the understanding of the development of how children handle anger and how they learn to differentiate self and other, and fantasy and reality, leads to an additional, important point. Suppose a person can’t tolerate his own angry wishes and he doesn’t distinguish well between self and other. He can easily attribute his own unwanted hatefulness to others, and he may then want to attack them for it. This process is extremely common, and we are all inclined to it to some degree. As childishly simplistic as it sounds, for humans, there is almost always an us and a them; we are good and they are bad. In addition to directing anger inappropriately at others, people can, of course, turn anger against themselves, and with just as much unreasonableness and venom. However much we grow up, development is never complete. We remain irrational, with a tenuous and incomplete perception of reality.
One would never give a weapon to an infant, but in light of these difficulties with respect to human development, should one give a weapon to an adult?
Whether or not humans have the self-control to possess weapons of great power and destructiveness, weapons are part of our evolution as a species. They have likely contributed to our remarkable success, protecting us from predators and enriching our diets. It is worth noting, however, that small-scale societies such as those we all evolved from often have high murder rates, and that lower rates of intra-societal violence tend to be found in larger, more highly regulated societies. People do not always adequately manage aggression themselves and benefit from external, societal assistance.
We humans all have the capacity to be mad: to be angry, to be crazy, to be crazed with anger. Fantasies of revenge are common when one is angry, and expectable when one has been hurt. Yet, expressions such as “blind with rage” and “seeing red” attest to the challenges to the sense of reality that rage can induce. The crucial distinction between having vengeful wishes and fantasies, and putting them into action, into reality, can crumble quickly. In addition to anger, fear is another emotion that can distort the perception of reality. Regular attention to the news suggests that police, whether they are aware of it or not, are more fearful of black men than of other people. They are more likely to perceive them as being armed and are quicker to shoot. For police and civilians alike, the presence of guns simultaneously requires greater impulse control and makes impulse control more difficult. The more guns, the more fear and anger, the more shootings – a vicious cycle.
Most people who commit crimes with guns, whether a singular “crime of passion” or a mass murder, have been crazed with anger. Some have been known to police as angry individuals with histories of getting into trouble, others not. But most have been angry, isolated individuals with problematic social relationships and little warm or respectful involvement with others to counterbalance their anger. Given the challenges inherent in human development, it is not surprising that in most societies there are a fair number of disaffected, angry, isolated individuals with inadequate realistic emotional regulation.
According to the anthropologist Scott Atran, who has studied both would-be and convicted terrorists, in addition to those individuals who are angry and disturbed, many recruits to terrorism are merely unsettled youth eager to find a sense of identity and belonging in a “band of brothers (and sisters).” He has described the “devoted actor,” who merges his identity with his combat unit and becomes willing to die for his comrades or their cause. These observations are consistent with both anthropological ideas about cultural influences on the sense of self in relation to groups, and with psychoanalytic emphasis on the difficulty of achieving a firm sense of self and other. In fusing with the group and its ideology, one gives up an independent self while feeling that one has gained a sense of self, belonging, and meaning. Whatever the psychological and social picture, it is obvious that the angry, isolated individuals who may regress and explode, and the countless unsettled youth of modern societies, cannot all be identified, tracked, and regulated by society, nor will they all seek help for their troubles. The United States’ decisions to allow massively destructive weapons to anyone and everyone are counter to everything we know about people.
Among many other things, Sigmund Freud is known for highlighting the comment that “The first man to hurl an insult rather than a spear was the founder of civilization.” Anger that is put into words is less destructive than anger put into violent action. From this point of view, the widespread presence of guns undermines civilization. Guns invite putting anger into action rather than conversation – they are a hindrance to impulse control and they shut down discussion. Democracy, a form of civilization contingent on impulse control, discussion, and voting, rather than submission to violent authority, is particularly undermined by guns. Congress should know: It has been so intimidated by the National Rifle Association that it has refused to outlaw private possession of military assault rifles and at the same time has submitted to outlawing the use of federal funds for research about gun violence. Despite this ban on research, there is overwhelming evidence that the presence of a gun in a home is associated not only with significantly increased murder rates, but also, as mental health professionals well know, greatly increased incidence of suicide.
As humans, we all have the ability to control ourselves to some degree. But, we all have the potential to become mad and to lose control. Our internal self-regulation is sometimes insufficient, and we need the restraining influence of our fellow humans. This can be in the form of a comforting word, a warning gesture, a carrot or a stick, or a law. The regulation of guns, assault rifles, and bomb-making materials is a mark of civilization.
Dr. Blum is a psychiatrist and psychoanalyst in private practice in Philadelphia. He teaches in the departments of anthropology and psychiatry at the University of Pennsylvania and at the Psychoanalytic Center of Philadelphia.
Therapeutic euphemism: Niceness isn’t always kind
“Where is the euphemism?” A college friend used to ask this question to point out the silliness of calling a toilet a bathroom. Euphemism in ordinary speech may be amusing, stilted, or polite, but in therapy, it thwarts progress. Patients use euphemistic language for defensive purposes, such as to keep things polite and nice, avoid unpleasant feelings, or prevent deeper inquiry. It is important that therapists be prepared to challenge these avoidances and also that they not contribute their own.
Here are my top three therapeutic euphemisms, terms that appear to offer acceptable, often mollifying explanations, but which usually disguise more than they convey: stress, frustration, and control. That stress, frustration, and control are all significant matters in their own right only adds to their insidious usefulness as disguises.
Stress can be enormously important, but what does it actually mean? A patient says, “I’m stressed.” What is the patient actually experiencing? Is the person stressed from too much work or too little? Are the sources of stress external or internal? Is attention to external sources of stress hiding internal ones? Is the problem best understood as the very general stress, or is it one of coercion, hunger, traumatic loss, guilt, punishment fantasies, or something else? What more specific ideas or feelings are the word stress being used to steer clear of? No one gets better from discussing generalities; people need to understand (and be understood in) the particulars of their individual minds and situations.
Frustration, like stress, often is used both realistically and euphemistically. People really do get frustrated when they are unable to carry out an intention or find the answer to an important question. But usually, the reason for mentioning frustration in therapy is an attempt to avoid acknowledging or feeling anger. And yet angry and murderous wishes and fantasies, and guilt and anxiety about them, are at the heart of many patients’ problems. Tiptoeing around the anger can be like leaving an abscess without lancing it. The pain and unpleasantness of addressing the anger are avoided, but the problem is left to fester, and the patient continues to struggle. Patients’ use of the word frustration, however, can be seen as a great clue that they are trying, as well as they can, to talk about anger.
Control is a word that has many different meanings and connotations. It used to be predominantly a good thing, as in being able to keep control of one’s emotions or behavior in a difficult situation. More recently, in both theraspeak and everyday language, it has lent itself to accusation: He’s so controlling! But most important here is how often it is used as an explanation when it actually explains very little. The therapist remarks that the patient wants to stay in control. Well, so do most people. More important are the questions of what, whom, or how the patient wishes to control. Is the patient trying to control destructive impulses? Sexual ones? His uncomfortable feelings of envy or sadness? Toward his partner? The therapist? By rigidity of behavior or thought? By distraction? By seducing, restricting, or influencing other people? When the word control enters the therapeutic discussion, or the therapist’s mind, it will be useful if it is understood not as an explanation, but as a reminder to ask further questions.
It is important for a therapist to be kind, sensitive, and empathic. But relentless niceness has a downside. Patients need assistance to address their struggles with a tremendous variety of experiences, traumas, feelings, and wishes that are anything but nice. They need the therapist, tactfully, to help them overcome their defensive anxieties and avoidances. One important way of doing this is to explore or challenge patients’ use of euphemism. It is more helpful, and in that way kinder, to help a patient discover what the bland, vague, or overly sunny surface of his story is disguising.
The key is to recognize that even as stress, frustration, and control often are used as attempts to foreclose further inquiry, the very inclination to use them this way can become a great springboard to further questions and understanding.
Dr. Blum is a psychiatrist and psychoanalyst in private practice in Philadelphia. He teaches in the departments of anthropology and psychiatry at the University of Pennsylvania and at the Psychoanalytic Center of Philadelphia.
“Where is the euphemism?” A college friend used to ask this question to point out the silliness of calling a toilet a bathroom. Euphemism in ordinary speech may be amusing, stilted, or polite, but in therapy, it thwarts progress. Patients use euphemistic language for defensive purposes, such as to keep things polite and nice, avoid unpleasant feelings, or prevent deeper inquiry. It is important that therapists be prepared to challenge these avoidances and also that they not contribute their own.
Here are my top three therapeutic euphemisms, terms that appear to offer acceptable, often mollifying explanations, but which usually disguise more than they convey: stress, frustration, and control. That stress, frustration, and control are all significant matters in their own right only adds to their insidious usefulness as disguises.
Stress can be enormously important, but what does it actually mean? A patient says, “I’m stressed.” What is the patient actually experiencing? Is the person stressed from too much work or too little? Are the sources of stress external or internal? Is attention to external sources of stress hiding internal ones? Is the problem best understood as the very general stress, or is it one of coercion, hunger, traumatic loss, guilt, punishment fantasies, or something else? What more specific ideas or feelings are the word stress being used to steer clear of? No one gets better from discussing generalities; people need to understand (and be understood in) the particulars of their individual minds and situations.
Frustration, like stress, often is used both realistically and euphemistically. People really do get frustrated when they are unable to carry out an intention or find the answer to an important question. But usually, the reason for mentioning frustration in therapy is an attempt to avoid acknowledging or feeling anger. And yet angry and murderous wishes and fantasies, and guilt and anxiety about them, are at the heart of many patients’ problems. Tiptoeing around the anger can be like leaving an abscess without lancing it. The pain and unpleasantness of addressing the anger are avoided, but the problem is left to fester, and the patient continues to struggle. Patients’ use of the word frustration, however, can be seen as a great clue that they are trying, as well as they can, to talk about anger.
Control is a word that has many different meanings and connotations. It used to be predominantly a good thing, as in being able to keep control of one’s emotions or behavior in a difficult situation. More recently, in both theraspeak and everyday language, it has lent itself to accusation: He’s so controlling! But most important here is how often it is used as an explanation when it actually explains very little. The therapist remarks that the patient wants to stay in control. Well, so do most people. More important are the questions of what, whom, or how the patient wishes to control. Is the patient trying to control destructive impulses? Sexual ones? His uncomfortable feelings of envy or sadness? Toward his partner? The therapist? By rigidity of behavior or thought? By distraction? By seducing, restricting, or influencing other people? When the word control enters the therapeutic discussion, or the therapist’s mind, it will be useful if it is understood not as an explanation, but as a reminder to ask further questions.
It is important for a therapist to be kind, sensitive, and empathic. But relentless niceness has a downside. Patients need assistance to address their struggles with a tremendous variety of experiences, traumas, feelings, and wishes that are anything but nice. They need the therapist, tactfully, to help them overcome their defensive anxieties and avoidances. One important way of doing this is to explore or challenge patients’ use of euphemism. It is more helpful, and in that way kinder, to help a patient discover what the bland, vague, or overly sunny surface of his story is disguising.
The key is to recognize that even as stress, frustration, and control often are used as attempts to foreclose further inquiry, the very inclination to use them this way can become a great springboard to further questions and understanding.
Dr. Blum is a psychiatrist and psychoanalyst in private practice in Philadelphia. He teaches in the departments of anthropology and psychiatry at the University of Pennsylvania and at the Psychoanalytic Center of Philadelphia.
“Where is the euphemism?” A college friend used to ask this question to point out the silliness of calling a toilet a bathroom. Euphemism in ordinary speech may be amusing, stilted, or polite, but in therapy, it thwarts progress. Patients use euphemistic language for defensive purposes, such as to keep things polite and nice, avoid unpleasant feelings, or prevent deeper inquiry. It is important that therapists be prepared to challenge these avoidances and also that they not contribute their own.
Here are my top three therapeutic euphemisms, terms that appear to offer acceptable, often mollifying explanations, but which usually disguise more than they convey: stress, frustration, and control. That stress, frustration, and control are all significant matters in their own right only adds to their insidious usefulness as disguises.
Stress can be enormously important, but what does it actually mean? A patient says, “I’m stressed.” What is the patient actually experiencing? Is the person stressed from too much work or too little? Are the sources of stress external or internal? Is attention to external sources of stress hiding internal ones? Is the problem best understood as the very general stress, or is it one of coercion, hunger, traumatic loss, guilt, punishment fantasies, or something else? What more specific ideas or feelings are the word stress being used to steer clear of? No one gets better from discussing generalities; people need to understand (and be understood in) the particulars of their individual minds and situations.
Frustration, like stress, often is used both realistically and euphemistically. People really do get frustrated when they are unable to carry out an intention or find the answer to an important question. But usually, the reason for mentioning frustration in therapy is an attempt to avoid acknowledging or feeling anger. And yet angry and murderous wishes and fantasies, and guilt and anxiety about them, are at the heart of many patients’ problems. Tiptoeing around the anger can be like leaving an abscess without lancing it. The pain and unpleasantness of addressing the anger are avoided, but the problem is left to fester, and the patient continues to struggle. Patients’ use of the word frustration, however, can be seen as a great clue that they are trying, as well as they can, to talk about anger.
Control is a word that has many different meanings and connotations. It used to be predominantly a good thing, as in being able to keep control of one’s emotions or behavior in a difficult situation. More recently, in both theraspeak and everyday language, it has lent itself to accusation: He’s so controlling! But most important here is how often it is used as an explanation when it actually explains very little. The therapist remarks that the patient wants to stay in control. Well, so do most people. More important are the questions of what, whom, or how the patient wishes to control. Is the patient trying to control destructive impulses? Sexual ones? His uncomfortable feelings of envy or sadness? Toward his partner? The therapist? By rigidity of behavior or thought? By distraction? By seducing, restricting, or influencing other people? When the word control enters the therapeutic discussion, or the therapist’s mind, it will be useful if it is understood not as an explanation, but as a reminder to ask further questions.
It is important for a therapist to be kind, sensitive, and empathic. But relentless niceness has a downside. Patients need assistance to address their struggles with a tremendous variety of experiences, traumas, feelings, and wishes that are anything but nice. They need the therapist, tactfully, to help them overcome their defensive anxieties and avoidances. One important way of doing this is to explore or challenge patients’ use of euphemism. It is more helpful, and in that way kinder, to help a patient discover what the bland, vague, or overly sunny surface of his story is disguising.
The key is to recognize that even as stress, frustration, and control often are used as attempts to foreclose further inquiry, the very inclination to use them this way can become a great springboard to further questions and understanding.
Dr. Blum is a psychiatrist and psychoanalyst in private practice in Philadelphia. He teaches in the departments of anthropology and psychiatry at the University of Pennsylvania and at the Psychoanalytic Center of Philadelphia.
Can psychoanalysis make you smarter?
No therapy claims to make people smarter, but I wouldn’t be surprised if sometimes psychoanalysis does just that. To be smart, it helps to know things. Yet while infants are born with ample curiosity, as they mature into children and adults, there are many things they prefer not to know. Conflicts between curiosity on the one hand, and anxieties and guilts about knowing on the other hand, are an inevitable part of growing up. Psychoanalytic therapies are those treatments in which the therapist’s job is to help people face what they have repressed and what they don’t want to know.
The Old Testament is one of the foundational texts of Western civilization, and one of the first things it attempts to establish is that one shouldn’t be curious about or know certain things. The forbidden fruit is forbidden knowledge, and, especially, the Bible makes clear, it is sexual knowledge. In fact, the Bible uses the verb “to know” to mean both to understand and engage in sexual intercourse, as though these were one and the same. The story of Adam and Eve and the Garden of Eden is an enduring dramatization of one of the great dilemmas of early childhood: wanting knowledge of sexuality (one’s parents’ and one’s own), along with fear of knowing and expectation of punishment for it.
Babies, necessarily, are born researchers. Some of their earliest efforts are to distinguish between what is “me” and what is “not me.” Transitional objects help with this. Babies are eager to distinguish between male and female, young and old. As children, they want to know where babies come from and how they themselves came to be. When given honest answers, they often refuse to believe them; fantasy, limited cognitive capacity, and limited tolerance of unpleasant feelings readily trump reality. Mommy and Daddy did no such thing!
In our culture, most children who learn about parental sexuality in their first few years manage to forget or repress this knowledge by school age. When there has been excessive exposure to parental bodies and sex, children’s repressive efforts can be particularly strenuous and extensive. Normal, essential curiosity, and interest in learning and knowing, can get inhibited or repressed as well. Learning difficulties may then ensue.
Sexual matters, however, are hardly the only things that people don’t want to know. There are all kinds of wishes that people become expert at avoiding, not knowing, altering, or reversing. How many of us like to acknowledge (note the word “know” in there) our murderous wishes or our envious feelings? Few adults recognize how much children envy grown-ups and how much of childhood is imbued with death wishes. Children often want to magically dispatch their younger and older siblings, not to mention their parents, who tell them it’s time for bed or that they can’t have more candy. Most of these angry, jealous, murderous wishes get repressed as children grow and become more subject to guilt and more oriented toward reality. But this is why people love violent movies: We get the vicarious gratification of seeing other people carry out so much of our own repressed and disowned nastiness.
For the large majority of people with reasonable control of their behavior, it is not the presence of violent or sexual wishes or angry, lustful, or envious feelings that causes trouble; rather it is the ways that people often deal with these wishes and feelings. They inhibit themselves to make extrasure not to carry out wishes that they are not even consciously aware of, and unknowingly punish themselves for them. A doctor who is hyperdedicated to goodness tortures himself with excessive worry about his patients (which can lead to subjecting patients to unnecessary procedures), and a doctor who drives himself to exhaustion with overwork, may be punishing himself for, and trying to compensate for, long-repressed angry death wishes of childhood. Medical smarts need to be accompanied by emotional smarts.
Psychoanalytic work to overcome barriers to knowing may thus make people smarter in an additional way: by raising “emotional IQ.” In psychoanalytic therapies, people get to know their own minds in ways they didn’t imagine, and a frequent unexpected result of this is coming to understand other people better. Learning about one’s own ways of avoiding uncomfortable feelings and unwanted wishes can make it much easier to recognize, and to accept, similar processes in others. It is not a coincidence that psychoanalytically trained psychiatrists have been selected to be deans of medical schools in proportions well beyond their limited numbers. Empathizing with and understanding other people’s personalities and conflicts are as important as understanding molecules or budgets.
For the majority of people in our culture, the biggest barrier to knowledge is not the lack of availability of materials with which to learn. Rather, it is the obstacles within ourselves, the hidden anxieties that make us feel disinterested or avoidant, the guilts that make us deny what we know, that are often most limiting. Mind and experience constantly influence brain circuitry. Psychoanalysis will not alter your brain circuits to give you perfect pitch or make you a math whiz. But can psychoanalysis help to break down barriers to connections in one’s mind, and make the mind run with greater ease? Can it make you smarter in ways that are useful? That’s my bet.
Dr. Blum is a psychiatrist and psychoanalyst in Philadelphia.
No therapy claims to make people smarter, but I wouldn’t be surprised if sometimes psychoanalysis does just that. To be smart, it helps to know things. Yet while infants are born with ample curiosity, as they mature into children and adults, there are many things they prefer not to know. Conflicts between curiosity on the one hand, and anxieties and guilts about knowing on the other hand, are an inevitable part of growing up. Psychoanalytic therapies are those treatments in which the therapist’s job is to help people face what they have repressed and what they don’t want to know.
The Old Testament is one of the foundational texts of Western civilization, and one of the first things it attempts to establish is that one shouldn’t be curious about or know certain things. The forbidden fruit is forbidden knowledge, and, especially, the Bible makes clear, it is sexual knowledge. In fact, the Bible uses the verb “to know” to mean both to understand and engage in sexual intercourse, as though these were one and the same. The story of Adam and Eve and the Garden of Eden is an enduring dramatization of one of the great dilemmas of early childhood: wanting knowledge of sexuality (one’s parents’ and one’s own), along with fear of knowing and expectation of punishment for it.
Babies, necessarily, are born researchers. Some of their earliest efforts are to distinguish between what is “me” and what is “not me.” Transitional objects help with this. Babies are eager to distinguish between male and female, young and old. As children, they want to know where babies come from and how they themselves came to be. When given honest answers, they often refuse to believe them; fantasy, limited cognitive capacity, and limited tolerance of unpleasant feelings readily trump reality. Mommy and Daddy did no such thing!
In our culture, most children who learn about parental sexuality in their first few years manage to forget or repress this knowledge by school age. When there has been excessive exposure to parental bodies and sex, children’s repressive efforts can be particularly strenuous and extensive. Normal, essential curiosity, and interest in learning and knowing, can get inhibited or repressed as well. Learning difficulties may then ensue.
Sexual matters, however, are hardly the only things that people don’t want to know. There are all kinds of wishes that people become expert at avoiding, not knowing, altering, or reversing. How many of us like to acknowledge (note the word “know” in there) our murderous wishes or our envious feelings? Few adults recognize how much children envy grown-ups and how much of childhood is imbued with death wishes. Children often want to magically dispatch their younger and older siblings, not to mention their parents, who tell them it’s time for bed or that they can’t have more candy. Most of these angry, jealous, murderous wishes get repressed as children grow and become more subject to guilt and more oriented toward reality. But this is why people love violent movies: We get the vicarious gratification of seeing other people carry out so much of our own repressed and disowned nastiness.
For the large majority of people with reasonable control of their behavior, it is not the presence of violent or sexual wishes or angry, lustful, or envious feelings that causes trouble; rather it is the ways that people often deal with these wishes and feelings. They inhibit themselves to make extrasure not to carry out wishes that they are not even consciously aware of, and unknowingly punish themselves for them. A doctor who is hyperdedicated to goodness tortures himself with excessive worry about his patients (which can lead to subjecting patients to unnecessary procedures), and a doctor who drives himself to exhaustion with overwork, may be punishing himself for, and trying to compensate for, long-repressed angry death wishes of childhood. Medical smarts need to be accompanied by emotional smarts.
Psychoanalytic work to overcome barriers to knowing may thus make people smarter in an additional way: by raising “emotional IQ.” In psychoanalytic therapies, people get to know their own minds in ways they didn’t imagine, and a frequent unexpected result of this is coming to understand other people better. Learning about one’s own ways of avoiding uncomfortable feelings and unwanted wishes can make it much easier to recognize, and to accept, similar processes in others. It is not a coincidence that psychoanalytically trained psychiatrists have been selected to be deans of medical schools in proportions well beyond their limited numbers. Empathizing with and understanding other people’s personalities and conflicts are as important as understanding molecules or budgets.
For the majority of people in our culture, the biggest barrier to knowledge is not the lack of availability of materials with which to learn. Rather, it is the obstacles within ourselves, the hidden anxieties that make us feel disinterested or avoidant, the guilts that make us deny what we know, that are often most limiting. Mind and experience constantly influence brain circuitry. Psychoanalysis will not alter your brain circuits to give you perfect pitch or make you a math whiz. But can psychoanalysis help to break down barriers to connections in one’s mind, and make the mind run with greater ease? Can it make you smarter in ways that are useful? That’s my bet.
Dr. Blum is a psychiatrist and psychoanalyst in Philadelphia.
No therapy claims to make people smarter, but I wouldn’t be surprised if sometimes psychoanalysis does just that. To be smart, it helps to know things. Yet while infants are born with ample curiosity, as they mature into children and adults, there are many things they prefer not to know. Conflicts between curiosity on the one hand, and anxieties and guilts about knowing on the other hand, are an inevitable part of growing up. Psychoanalytic therapies are those treatments in which the therapist’s job is to help people face what they have repressed and what they don’t want to know.
The Old Testament is one of the foundational texts of Western civilization, and one of the first things it attempts to establish is that one shouldn’t be curious about or know certain things. The forbidden fruit is forbidden knowledge, and, especially, the Bible makes clear, it is sexual knowledge. In fact, the Bible uses the verb “to know” to mean both to understand and engage in sexual intercourse, as though these were one and the same. The story of Adam and Eve and the Garden of Eden is an enduring dramatization of one of the great dilemmas of early childhood: wanting knowledge of sexuality (one’s parents’ and one’s own), along with fear of knowing and expectation of punishment for it.
Babies, necessarily, are born researchers. Some of their earliest efforts are to distinguish between what is “me” and what is “not me.” Transitional objects help with this. Babies are eager to distinguish between male and female, young and old. As children, they want to know where babies come from and how they themselves came to be. When given honest answers, they often refuse to believe them; fantasy, limited cognitive capacity, and limited tolerance of unpleasant feelings readily trump reality. Mommy and Daddy did no such thing!
In our culture, most children who learn about parental sexuality in their first few years manage to forget or repress this knowledge by school age. When there has been excessive exposure to parental bodies and sex, children’s repressive efforts can be particularly strenuous and extensive. Normal, essential curiosity, and interest in learning and knowing, can get inhibited or repressed as well. Learning difficulties may then ensue.
Sexual matters, however, are hardly the only things that people don’t want to know. There are all kinds of wishes that people become expert at avoiding, not knowing, altering, or reversing. How many of us like to acknowledge (note the word “know” in there) our murderous wishes or our envious feelings? Few adults recognize how much children envy grown-ups and how much of childhood is imbued with death wishes. Children often want to magically dispatch their younger and older siblings, not to mention their parents, who tell them it’s time for bed or that they can’t have more candy. Most of these angry, jealous, murderous wishes get repressed as children grow and become more subject to guilt and more oriented toward reality. But this is why people love violent movies: We get the vicarious gratification of seeing other people carry out so much of our own repressed and disowned nastiness.
For the large majority of people with reasonable control of their behavior, it is not the presence of violent or sexual wishes or angry, lustful, or envious feelings that causes trouble; rather it is the ways that people often deal with these wishes and feelings. They inhibit themselves to make extrasure not to carry out wishes that they are not even consciously aware of, and unknowingly punish themselves for them. A doctor who is hyperdedicated to goodness tortures himself with excessive worry about his patients (which can lead to subjecting patients to unnecessary procedures), and a doctor who drives himself to exhaustion with overwork, may be punishing himself for, and trying to compensate for, long-repressed angry death wishes of childhood. Medical smarts need to be accompanied by emotional smarts.
Psychoanalytic work to overcome barriers to knowing may thus make people smarter in an additional way: by raising “emotional IQ.” In psychoanalytic therapies, people get to know their own minds in ways they didn’t imagine, and a frequent unexpected result of this is coming to understand other people better. Learning about one’s own ways of avoiding uncomfortable feelings and unwanted wishes can make it much easier to recognize, and to accept, similar processes in others. It is not a coincidence that psychoanalytically trained psychiatrists have been selected to be deans of medical schools in proportions well beyond their limited numbers. Empathizing with and understanding other people’s personalities and conflicts are as important as understanding molecules or budgets.
For the majority of people in our culture, the biggest barrier to knowledge is not the lack of availability of materials with which to learn. Rather, it is the obstacles within ourselves, the hidden anxieties that make us feel disinterested or avoidant, the guilts that make us deny what we know, that are often most limiting. Mind and experience constantly influence brain circuitry. Psychoanalysis will not alter your brain circuits to give you perfect pitch or make you a math whiz. But can psychoanalysis help to break down barriers to connections in one’s mind, and make the mind run with greater ease? Can it make you smarter in ways that are useful? That’s my bet.
Dr. Blum is a psychiatrist and psychoanalyst in Philadelphia.
Commentary: Growing up without therapy
Now and then I have met someone who seems to have grown up, without therapy, into a relatively balanced, contented person, little encumbered by internal conflicts. As a psychoanalyst and psychiatrist, I continue to wonder how to account for this.
Growing up has so many difficulties and challenges that successfully traversing them all on one’s own seems a daunting task. Where is the child’s guide to developing a sense of personal autonomy while also enjoying relationships with others? How does the child of 3 or 13 figure out how to deal with envy, sexual feelings, and vengeful and destructive wishes? How can the child figure out that her stomachache represents anxiety about going to school, or further, that her worry about school may serve to distract her from more serious concerns about events and fantasies at home?
There is a reason why so many movies about or for children (such as E.T. the Extra-Terrestrial) depict adults as uncomprehending of children’s worlds: There is a certain truth to it. Even the most intuitive and empathic parents can never fully grasp the inner world of a child, even though they were children once themselves. Nonetheless, their efforts are important, and parents routinely help children learn to understand, accept, and regulate their feelings and wishes. But there are always shameful and guilty feelings that children prefer their parents not know, and always feelings and fantasies that parents can’t imagine.
A 4-year-old girl may brazenly tell her mother that she plans to marry Daddy but hide how much she would love to destroy her younger brother – or vice versa. No matter how her mother responds, the little girl still is significantly on her own as she tries to figure out fantasy and reality. With little knowledge or experience, children are called upon to deal with their own imperious wishes, their own self-criticisms, their changing bodies, and parents’ and teachers’ demands, not to mention the existence of gravity, hunger, sickness, sadness, friends’ rejections, baseball strikeouts, and so on. Parents can help and can hurt, but there is always a lot that is beyond their control.
Given their inevitable reliance on their own limited resources, children pass through phases of various fears, quirks, beliefs, rituals, and ways of relating to the world. These adaptations ebb and flow, change, become dormant, and reappear. We all carry at least some of this baggage, some of this crazy-as-it-is-I’m-dealing-with-it-the-best-that-I-can, into adulthood, and we typically want to leave the contents of the baggage unexamined. It’s so hard to see one’s own blind spots and amazing how tenaciously most of us want to hold onto them.
There’s an aphorism that says, “If you think education is expensive, try ignorance.” This is how I feel about psychoanalytic therapy. In my office, I see people all the time who have married so as to avoid deep involvement and then divorce because there wasn’t enough involvement; or who, unconsciously, are trying so hard to marry or to avoid marrying one of their parents, that they can’t make a relationship work with a partner; or who keep playing out, while trying not to, guilty and shameful revenges for childhood traumas great and small. Often they say to me, “I should have come to see you 20 years ago,” and I don’t disagree.
Why didn’t they? Most often it is because the uncomfortable feelings that people tend to have about their emotional struggles are carried forward from childhood into the present. People talk about the stigma of seeking help for emotional problems, but the most important, and overlooked, “stigma” is typically one’s own internal hesitations and self-deprecations. The statement “I need some help, and I’m going to get it” is seldom met with disrespect, but the shame of wanting or needing help with one’s mind is so great that few people are comfortable saying it.
When I was in college, I was as ashamed and scared of needing therapy as anyone else, but there were things troubling me that I couldn’t master. A little bit of psychotherapy at that time helped me recognize how little I understood about myself and my feelings toward my family – a very helpful start. More psychotherapy when I was a medical student helped more. Having a full psychoanalysis as I pursued training as a psychoanalyst provided a tremendously gratifying sense of finally really unraveling the tightest, most hidden emotional knots. How fortunate that I didn’t feel obliged to pretend that I was so grown up as to deprive myself of essential help from others.
Freud suggested it was desirable for people to be able to love and to work, and some might add, to play. These might sound like simple matters – love, work, and play – but they require emotional balance and flexibility, as well as realistic perceptions of oneself and others. Since there is so much of the past in the present, even invisibly, the emotional obstacles to unencumbered work, love, and play are many. Some people do indeed accomplish these seemingly simple but actually very ambitious aims on their own, but it is so much easier when one has help to clarify one’s misperceptions.
It can be difficult at any age to grow up and take the next developmental step forward. And developmental missteps are resolved much more readily, and usually more completely, with therapy than without. Yet so many of us seem to prefer to try to grow up the hard way, stumbling and struggling alone through our own personal obstacle courses. There are other options.
Dr. Blum is a psychiatrist and psychoanalyst in Philadelphia.
Now and then I have met someone who seems to have grown up, without therapy, into a relatively balanced, contented person, little encumbered by internal conflicts. As a psychoanalyst and psychiatrist, I continue to wonder how to account for this.
Growing up has so many difficulties and challenges that successfully traversing them all on one’s own seems a daunting task. Where is the child’s guide to developing a sense of personal autonomy while also enjoying relationships with others? How does the child of 3 or 13 figure out how to deal with envy, sexual feelings, and vengeful and destructive wishes? How can the child figure out that her stomachache represents anxiety about going to school, or further, that her worry about school may serve to distract her from more serious concerns about events and fantasies at home?
There is a reason why so many movies about or for children (such as E.T. the Extra-Terrestrial) depict adults as uncomprehending of children’s worlds: There is a certain truth to it. Even the most intuitive and empathic parents can never fully grasp the inner world of a child, even though they were children once themselves. Nonetheless, their efforts are important, and parents routinely help children learn to understand, accept, and regulate their feelings and wishes. But there are always shameful and guilty feelings that children prefer their parents not know, and always feelings and fantasies that parents can’t imagine.
A 4-year-old girl may brazenly tell her mother that she plans to marry Daddy but hide how much she would love to destroy her younger brother – or vice versa. No matter how her mother responds, the little girl still is significantly on her own as she tries to figure out fantasy and reality. With little knowledge or experience, children are called upon to deal with their own imperious wishes, their own self-criticisms, their changing bodies, and parents’ and teachers’ demands, not to mention the existence of gravity, hunger, sickness, sadness, friends’ rejections, baseball strikeouts, and so on. Parents can help and can hurt, but there is always a lot that is beyond their control.
Given their inevitable reliance on their own limited resources, children pass through phases of various fears, quirks, beliefs, rituals, and ways of relating to the world. These adaptations ebb and flow, change, become dormant, and reappear. We all carry at least some of this baggage, some of this crazy-as-it-is-I’m-dealing-with-it-the-best-that-I-can, into adulthood, and we typically want to leave the contents of the baggage unexamined. It’s so hard to see one’s own blind spots and amazing how tenaciously most of us want to hold onto them.
There’s an aphorism that says, “If you think education is expensive, try ignorance.” This is how I feel about psychoanalytic therapy. In my office, I see people all the time who have married so as to avoid deep involvement and then divorce because there wasn’t enough involvement; or who, unconsciously, are trying so hard to marry or to avoid marrying one of their parents, that they can’t make a relationship work with a partner; or who keep playing out, while trying not to, guilty and shameful revenges for childhood traumas great and small. Often they say to me, “I should have come to see you 20 years ago,” and I don’t disagree.
Why didn’t they? Most often it is because the uncomfortable feelings that people tend to have about their emotional struggles are carried forward from childhood into the present. People talk about the stigma of seeking help for emotional problems, but the most important, and overlooked, “stigma” is typically one’s own internal hesitations and self-deprecations. The statement “I need some help, and I’m going to get it” is seldom met with disrespect, but the shame of wanting or needing help with one’s mind is so great that few people are comfortable saying it.
When I was in college, I was as ashamed and scared of needing therapy as anyone else, but there were things troubling me that I couldn’t master. A little bit of psychotherapy at that time helped me recognize how little I understood about myself and my feelings toward my family – a very helpful start. More psychotherapy when I was a medical student helped more. Having a full psychoanalysis as I pursued training as a psychoanalyst provided a tremendously gratifying sense of finally really unraveling the tightest, most hidden emotional knots. How fortunate that I didn’t feel obliged to pretend that I was so grown up as to deprive myself of essential help from others.
Freud suggested it was desirable for people to be able to love and to work, and some might add, to play. These might sound like simple matters – love, work, and play – but they require emotional balance and flexibility, as well as realistic perceptions of oneself and others. Since there is so much of the past in the present, even invisibly, the emotional obstacles to unencumbered work, love, and play are many. Some people do indeed accomplish these seemingly simple but actually very ambitious aims on their own, but it is so much easier when one has help to clarify one’s misperceptions.
It can be difficult at any age to grow up and take the next developmental step forward. And developmental missteps are resolved much more readily, and usually more completely, with therapy than without. Yet so many of us seem to prefer to try to grow up the hard way, stumbling and struggling alone through our own personal obstacle courses. There are other options.
Dr. Blum is a psychiatrist and psychoanalyst in Philadelphia.
Now and then I have met someone who seems to have grown up, without therapy, into a relatively balanced, contented person, little encumbered by internal conflicts. As a psychoanalyst and psychiatrist, I continue to wonder how to account for this.
Growing up has so many difficulties and challenges that successfully traversing them all on one’s own seems a daunting task. Where is the child’s guide to developing a sense of personal autonomy while also enjoying relationships with others? How does the child of 3 or 13 figure out how to deal with envy, sexual feelings, and vengeful and destructive wishes? How can the child figure out that her stomachache represents anxiety about going to school, or further, that her worry about school may serve to distract her from more serious concerns about events and fantasies at home?
There is a reason why so many movies about or for children (such as E.T. the Extra-Terrestrial) depict adults as uncomprehending of children’s worlds: There is a certain truth to it. Even the most intuitive and empathic parents can never fully grasp the inner world of a child, even though they were children once themselves. Nonetheless, their efforts are important, and parents routinely help children learn to understand, accept, and regulate their feelings and wishes. But there are always shameful and guilty feelings that children prefer their parents not know, and always feelings and fantasies that parents can’t imagine.
A 4-year-old girl may brazenly tell her mother that she plans to marry Daddy but hide how much she would love to destroy her younger brother – or vice versa. No matter how her mother responds, the little girl still is significantly on her own as she tries to figure out fantasy and reality. With little knowledge or experience, children are called upon to deal with their own imperious wishes, their own self-criticisms, their changing bodies, and parents’ and teachers’ demands, not to mention the existence of gravity, hunger, sickness, sadness, friends’ rejections, baseball strikeouts, and so on. Parents can help and can hurt, but there is always a lot that is beyond their control.
Given their inevitable reliance on their own limited resources, children pass through phases of various fears, quirks, beliefs, rituals, and ways of relating to the world. These adaptations ebb and flow, change, become dormant, and reappear. We all carry at least some of this baggage, some of this crazy-as-it-is-I’m-dealing-with-it-the-best-that-I-can, into adulthood, and we typically want to leave the contents of the baggage unexamined. It’s so hard to see one’s own blind spots and amazing how tenaciously most of us want to hold onto them.
There’s an aphorism that says, “If you think education is expensive, try ignorance.” This is how I feel about psychoanalytic therapy. In my office, I see people all the time who have married so as to avoid deep involvement and then divorce because there wasn’t enough involvement; or who, unconsciously, are trying so hard to marry or to avoid marrying one of their parents, that they can’t make a relationship work with a partner; or who keep playing out, while trying not to, guilty and shameful revenges for childhood traumas great and small. Often they say to me, “I should have come to see you 20 years ago,” and I don’t disagree.
Why didn’t they? Most often it is because the uncomfortable feelings that people tend to have about their emotional struggles are carried forward from childhood into the present. People talk about the stigma of seeking help for emotional problems, but the most important, and overlooked, “stigma” is typically one’s own internal hesitations and self-deprecations. The statement “I need some help, and I’m going to get it” is seldom met with disrespect, but the shame of wanting or needing help with one’s mind is so great that few people are comfortable saying it.
When I was in college, I was as ashamed and scared of needing therapy as anyone else, but there were things troubling me that I couldn’t master. A little bit of psychotherapy at that time helped me recognize how little I understood about myself and my feelings toward my family – a very helpful start. More psychotherapy when I was a medical student helped more. Having a full psychoanalysis as I pursued training as a psychoanalyst provided a tremendously gratifying sense of finally really unraveling the tightest, most hidden emotional knots. How fortunate that I didn’t feel obliged to pretend that I was so grown up as to deprive myself of essential help from others.
Freud suggested it was desirable for people to be able to love and to work, and some might add, to play. These might sound like simple matters – love, work, and play – but they require emotional balance and flexibility, as well as realistic perceptions of oneself and others. Since there is so much of the past in the present, even invisibly, the emotional obstacles to unencumbered work, love, and play are many. Some people do indeed accomplish these seemingly simple but actually very ambitious aims on their own, but it is so much easier when one has help to clarify one’s misperceptions.
It can be difficult at any age to grow up and take the next developmental step forward. And developmental missteps are resolved much more readily, and usually more completely, with therapy than without. Yet so many of us seem to prefer to try to grow up the hard way, stumbling and struggling alone through our own personal obstacle courses. There are other options.
Dr. Blum is a psychiatrist and psychoanalyst in Philadelphia.
The magic of psychoanalysis
Psychoanalysis has been pronounced dead so many times that many people don’t realize what a rewarding career it can offer. I’d like to tell you why I love being a psychoanalyst and why you might, too.
If you study psychoanalysis, you might even have more company than you imagine: As psychiatry and psychology begin to draw back from biological and behavioral reductionism, as neuroscience increasingly recognizes that experience influences neurophysiology and neuroanatomy, and as cognitive-behavioral therapy takes more notice of both feelings and the therapeutic relationship, the contributions of psychoanalysis might again attract attention. Throughout its history, psychoanalysis has steadfastly kept its focus on mind, feelings, and the therapeutic relationship. Not only is psychoanalysis as relevant as ever, it also can be magical, fun, suspenseful, challenging, and rewarding. Let’s start with the magic.
A patient starts by telling a psychoanalyst a story, the story of his life, or of his suffering. Gradually, as the sessions progress, the analyst becomes important to the patient, and the patient then incorporates the analyst as a character in the story. The story, remarkably, is suddenly taking place in the office as it is being told! This occurrence can have a quite magical feeling. The analyst’s presence in the story offers a unique opportunity to help people figure out what their stories (their lives and relationships) are all about, and then to "write" better outcomes than would otherwise be possible.
This is serious business and challenging work, but also a form of play. Instead of reading about or hearing about someone’s struggles, to some extent, one participates in them. It’s intimate. The analyst has to be curious, to want to know the patient’s mind (and heart), and to want a relationship. He (or she) has to be ready to participate in the story as it takes place, yet also be able to observe and comment. The central, difficult, task is to allow the patient to form a relationship with the analyst that is determined as much as possible by the patient’s needs and inclinations, and at the same time to observe and narrate the relationship as it develops. Together, the analyst and patient can then examine and learn from this process.
If you’ve read, or been taught, about analyzing transferences and resistances, the process just described is most of what it’s about. Psychoanalysis thus provides an opportunity to be deeply involved with other people in a way that is careful yet also spontaneous, caring, and respectful, even as it is asymmetrical, and certainly nonphysical.
One of the things that helps patients most in psychotherapy is the opportunity to distinguish the ways they view other people (and the world) that are distorted by fantasy from the ways in which they are realistic, in other words, to get the past out of the present. Looking at the ways the patient treats the analyst, or to put it in terms of the idea described above, how the patient brings the analyst into the story, provides the best opportunity for this work. This is why intensive treatments are helpful; they facilitate a more involved relationship with increased opportunities to look first-hand at more intense feelings and fantasies. In less intensive, less frequent psychotherapies, the psychoanalyst brings the same set of skills and can often foster a helpful analytic process in those therapies as well.
It is a major challenge for the analyst to truly allow the patient to make the analyst whatever kind of character in the story that the patient needs him to be, and to facilitate the expression of any and all feelings that the patient may have toward that character. The analyst has to be willing to be loved, hated, envied, desired, condescended to, avoided, mocked, or criticized – and at the same time to maintain his composure, along with his observing, narrative, and interpretive faculties. The analyst also must be alert to the inevitable evidence for, and to help bring into focus, those difficult feelings, especially the anger and hate, that the patient (or analyst) may attempt to avoid, or to express only very indirectly. These difficult feelings are often at the center of the patient’s struggles. Bringing them to life in the relationship, so they can be understood directly, there and then, is typically a high challenge, but high reward, proposition.
Another part of the interest and fun should now be clear: While the work is necessarily deliberate and patience is required, there is always suspense. One can never know how things will turn out. How many of the hurdles will be cleared, which ones, how, and when? This is a sort of theater in which no two performances, no two plays, are the same. At times things may appear similar, but the next act, or the ending, may not be what one expects. Stay tuned! Perhaps this is why so many psychoanalysts work well past the time when colleagues in other fields have retired – the work stays interesting and fun.
What helps prepare a psychoanalyst for this? Everything! Psychoanalysis lives in a great intellectual neighborhood, with stimulating interactions with many nearby disciplines. Anything you’ve learned about people in an English course, in history, sociology, anthropology, psychology, and psychiatry applies. So does neuroscience, which has a greatly increasing exchange with psychoanalysis. With its attention to drives and biology, psychoanalysis connects with the natural sciences; with its focus on interpersonal relationships, it engages with the social sciences; and with its emphasis on individual subjectivity, it is squarely in the humanities.
If your interests are broad, if you are someone who was drawn to psychiatry because you really want to know what makes people tick, you may well find a career in psychoanalysis to be remarkably fulfilling.
Dr Blum is a psychiatrist and psychoanalyst in private in Philadelphia. He also serves as a training and supervising analyst at the Psychoanalytic Center of Philadelphia and a clinical assistant professor of psychiatry at the University of Pennsylvania, also in Philadelphia.
Psychoanalysis has been pronounced dead so many times that many people don’t realize what a rewarding career it can offer. I’d like to tell you why I love being a psychoanalyst and why you might, too.
If you study psychoanalysis, you might even have more company than you imagine: As psychiatry and psychology begin to draw back from biological and behavioral reductionism, as neuroscience increasingly recognizes that experience influences neurophysiology and neuroanatomy, and as cognitive-behavioral therapy takes more notice of both feelings and the therapeutic relationship, the contributions of psychoanalysis might again attract attention. Throughout its history, psychoanalysis has steadfastly kept its focus on mind, feelings, and the therapeutic relationship. Not only is psychoanalysis as relevant as ever, it also can be magical, fun, suspenseful, challenging, and rewarding. Let’s start with the magic.
A patient starts by telling a psychoanalyst a story, the story of his life, or of his suffering. Gradually, as the sessions progress, the analyst becomes important to the patient, and the patient then incorporates the analyst as a character in the story. The story, remarkably, is suddenly taking place in the office as it is being told! This occurrence can have a quite magical feeling. The analyst’s presence in the story offers a unique opportunity to help people figure out what their stories (their lives and relationships) are all about, and then to "write" better outcomes than would otherwise be possible.
This is serious business and challenging work, but also a form of play. Instead of reading about or hearing about someone’s struggles, to some extent, one participates in them. It’s intimate. The analyst has to be curious, to want to know the patient’s mind (and heart), and to want a relationship. He (or she) has to be ready to participate in the story as it takes place, yet also be able to observe and comment. The central, difficult, task is to allow the patient to form a relationship with the analyst that is determined as much as possible by the patient’s needs and inclinations, and at the same time to observe and narrate the relationship as it develops. Together, the analyst and patient can then examine and learn from this process.
If you’ve read, or been taught, about analyzing transferences and resistances, the process just described is most of what it’s about. Psychoanalysis thus provides an opportunity to be deeply involved with other people in a way that is careful yet also spontaneous, caring, and respectful, even as it is asymmetrical, and certainly nonphysical.
One of the things that helps patients most in psychotherapy is the opportunity to distinguish the ways they view other people (and the world) that are distorted by fantasy from the ways in which they are realistic, in other words, to get the past out of the present. Looking at the ways the patient treats the analyst, or to put it in terms of the idea described above, how the patient brings the analyst into the story, provides the best opportunity for this work. This is why intensive treatments are helpful; they facilitate a more involved relationship with increased opportunities to look first-hand at more intense feelings and fantasies. In less intensive, less frequent psychotherapies, the psychoanalyst brings the same set of skills and can often foster a helpful analytic process in those therapies as well.
It is a major challenge for the analyst to truly allow the patient to make the analyst whatever kind of character in the story that the patient needs him to be, and to facilitate the expression of any and all feelings that the patient may have toward that character. The analyst has to be willing to be loved, hated, envied, desired, condescended to, avoided, mocked, or criticized – and at the same time to maintain his composure, along with his observing, narrative, and interpretive faculties. The analyst also must be alert to the inevitable evidence for, and to help bring into focus, those difficult feelings, especially the anger and hate, that the patient (or analyst) may attempt to avoid, or to express only very indirectly. These difficult feelings are often at the center of the patient’s struggles. Bringing them to life in the relationship, so they can be understood directly, there and then, is typically a high challenge, but high reward, proposition.
Another part of the interest and fun should now be clear: While the work is necessarily deliberate and patience is required, there is always suspense. One can never know how things will turn out. How many of the hurdles will be cleared, which ones, how, and when? This is a sort of theater in which no two performances, no two plays, are the same. At times things may appear similar, but the next act, or the ending, may not be what one expects. Stay tuned! Perhaps this is why so many psychoanalysts work well past the time when colleagues in other fields have retired – the work stays interesting and fun.
What helps prepare a psychoanalyst for this? Everything! Psychoanalysis lives in a great intellectual neighborhood, with stimulating interactions with many nearby disciplines. Anything you’ve learned about people in an English course, in history, sociology, anthropology, psychology, and psychiatry applies. So does neuroscience, which has a greatly increasing exchange with psychoanalysis. With its attention to drives and biology, psychoanalysis connects with the natural sciences; with its focus on interpersonal relationships, it engages with the social sciences; and with its emphasis on individual subjectivity, it is squarely in the humanities.
If your interests are broad, if you are someone who was drawn to psychiatry because you really want to know what makes people tick, you may well find a career in psychoanalysis to be remarkably fulfilling.
Dr Blum is a psychiatrist and psychoanalyst in private in Philadelphia. He also serves as a training and supervising analyst at the Psychoanalytic Center of Philadelphia and a clinical assistant professor of psychiatry at the University of Pennsylvania, also in Philadelphia.
Psychoanalysis has been pronounced dead so many times that many people don’t realize what a rewarding career it can offer. I’d like to tell you why I love being a psychoanalyst and why you might, too.
If you study psychoanalysis, you might even have more company than you imagine: As psychiatry and psychology begin to draw back from biological and behavioral reductionism, as neuroscience increasingly recognizes that experience influences neurophysiology and neuroanatomy, and as cognitive-behavioral therapy takes more notice of both feelings and the therapeutic relationship, the contributions of psychoanalysis might again attract attention. Throughout its history, psychoanalysis has steadfastly kept its focus on mind, feelings, and the therapeutic relationship. Not only is psychoanalysis as relevant as ever, it also can be magical, fun, suspenseful, challenging, and rewarding. Let’s start with the magic.
A patient starts by telling a psychoanalyst a story, the story of his life, or of his suffering. Gradually, as the sessions progress, the analyst becomes important to the patient, and the patient then incorporates the analyst as a character in the story. The story, remarkably, is suddenly taking place in the office as it is being told! This occurrence can have a quite magical feeling. The analyst’s presence in the story offers a unique opportunity to help people figure out what their stories (their lives and relationships) are all about, and then to "write" better outcomes than would otherwise be possible.
This is serious business and challenging work, but also a form of play. Instead of reading about or hearing about someone’s struggles, to some extent, one participates in them. It’s intimate. The analyst has to be curious, to want to know the patient’s mind (and heart), and to want a relationship. He (or she) has to be ready to participate in the story as it takes place, yet also be able to observe and comment. The central, difficult, task is to allow the patient to form a relationship with the analyst that is determined as much as possible by the patient’s needs and inclinations, and at the same time to observe and narrate the relationship as it develops. Together, the analyst and patient can then examine and learn from this process.
If you’ve read, or been taught, about analyzing transferences and resistances, the process just described is most of what it’s about. Psychoanalysis thus provides an opportunity to be deeply involved with other people in a way that is careful yet also spontaneous, caring, and respectful, even as it is asymmetrical, and certainly nonphysical.
One of the things that helps patients most in psychotherapy is the opportunity to distinguish the ways they view other people (and the world) that are distorted by fantasy from the ways in which they are realistic, in other words, to get the past out of the present. Looking at the ways the patient treats the analyst, or to put it in terms of the idea described above, how the patient brings the analyst into the story, provides the best opportunity for this work. This is why intensive treatments are helpful; they facilitate a more involved relationship with increased opportunities to look first-hand at more intense feelings and fantasies. In less intensive, less frequent psychotherapies, the psychoanalyst brings the same set of skills and can often foster a helpful analytic process in those therapies as well.
It is a major challenge for the analyst to truly allow the patient to make the analyst whatever kind of character in the story that the patient needs him to be, and to facilitate the expression of any and all feelings that the patient may have toward that character. The analyst has to be willing to be loved, hated, envied, desired, condescended to, avoided, mocked, or criticized – and at the same time to maintain his composure, along with his observing, narrative, and interpretive faculties. The analyst also must be alert to the inevitable evidence for, and to help bring into focus, those difficult feelings, especially the anger and hate, that the patient (or analyst) may attempt to avoid, or to express only very indirectly. These difficult feelings are often at the center of the patient’s struggles. Bringing them to life in the relationship, so they can be understood directly, there and then, is typically a high challenge, but high reward, proposition.
Another part of the interest and fun should now be clear: While the work is necessarily deliberate and patience is required, there is always suspense. One can never know how things will turn out. How many of the hurdles will be cleared, which ones, how, and when? This is a sort of theater in which no two performances, no two plays, are the same. At times things may appear similar, but the next act, or the ending, may not be what one expects. Stay tuned! Perhaps this is why so many psychoanalysts work well past the time when colleagues in other fields have retired – the work stays interesting and fun.
What helps prepare a psychoanalyst for this? Everything! Psychoanalysis lives in a great intellectual neighborhood, with stimulating interactions with many nearby disciplines. Anything you’ve learned about people in an English course, in history, sociology, anthropology, psychology, and psychiatry applies. So does neuroscience, which has a greatly increasing exchange with psychoanalysis. With its attention to drives and biology, psychoanalysis connects with the natural sciences; with its focus on interpersonal relationships, it engages with the social sciences; and with its emphasis on individual subjectivity, it is squarely in the humanities.
If your interests are broad, if you are someone who was drawn to psychiatry because you really want to know what makes people tick, you may well find a career in psychoanalysis to be remarkably fulfilling.
Dr Blum is a psychiatrist and psychoanalyst in private in Philadelphia. He also serves as a training and supervising analyst at the Psychoanalytic Center of Philadelphia and a clinical assistant professor of psychiatry at the University of Pennsylvania, also in Philadelphia.
