INTIMACY, THE HUMAN HEART, AND PSYCHOTHERAPY

July 13, 2011

I’ve been lonely
I’ve been waiting for you
I’m pretending and that’s all I can do
The love I’m sending
Ain’t making it through to your heart
You’ve been hiding, never letting it show
Always trying to keep it under control
You got it down and you’re well
On the way to the top
But there’s something that you forgot

What about love
Don’t you want someone to care about you
What about love
Don’t let it slip away
What about love
I only want to share it with you
You might need it someday

I can’t tell you what you’re feeling inside
I can’t sell you what you don’t want to buy
Something’s missing and you got to
Look back on your life
You know something here just ain’t right

What about love
Don’t you want someone to care about you
What about love
Don’t let it slip away
What about love
I only want to share it with you
What about love
Don’t you want someone to care about you
What about love
Don’t let it slip away
What about love
I only want to share it with you

In listening to lead singer Ann Wilson belt out these lyrics from the rock band Heart’s famous song, “What About Love,” I was mindful of how music can capture the emotions we all feel when we are in love. Ann’s rendition of these lyrics poignantly expresses the challenges of establishing and maintaining intimacy. What makes it difficult to establish and maintain long-lasting feelings of love? What are the trials we go through that challenge our ability to sustain love over the course of a lifetime?

Our capacity for intimacy begins in childhood, as we establish the initial emotional bonds with our mother and father. Typically these are our first experiences with another human being, and they have a profound influence on our emotional development, and later capacities to form intimate relationships. For some, these child-parent bonds may be rock solid, trustworthy and secure; in which case our capacity for intimacy will be well developed and stable. For others, during the course of our childhood years our parents may be unavailable, inconsistent and self-absorbed, emotionally volatile, and/or physically or sexually abusive; and in these instances our capacity for later-life intimacy will be damaged. These emotional wounds may be expressed in a number of ways, as our yearnings for a stable love relationship encounter our fears of commitment, feelings of mistrust, and narcissistic injuries that form the residue of the damaging parental relations of childhood. “What About Love” captures the lingering effects of this trauma beautifully, as Ann sings:

I can’t tell you what you’re feeling inside
I can’t sell you what you don’t want to buy
Something’s missing and you got to
Look back on your life
You know something here just ain’t right

As we move into adulthood, love relationships that don’t work out may further wound the human heart. A series of disappointing love affairs, the breakup of a long-term committed relationship, or marital separation and divorce may leave lasting emotional traumas that play out to damage or destroy the possibility of later intimate relations. At times the breakups are the result of making poor choices, for example repeatedly engaging in relationships with people suffering from Narcissistic Personality Disorder. At other times we might select someone capable of providing us adult love, empathy and compassion, yet our own conflicts over intimacy may contribute to or cause a breakup.

As a result of these negative childhood, adolescent or adult experiences a “repetition compulsion” may develop, where one unconsciously repeats earlier traumas through patterns of self-sabotaging behavior carried out in existing or new relationships, time and time again. These unconscious behaviors may interfere with or destroy intimate bonds. Feelings of love and tenderness may develop toward one another, but difficulties in trusting and expressing these emotions directly, out of fear of further hurt, loss, or a lack of reciprocal feelings from one’s loved one, complicate the relationship. The number one hit song by Heart, entitled “Alone” poignantly captures aspects of these conflicts:

I hear the ticking of the clock
I’m lying here the room’s pitch dark
I wonder where you are tonight
No answer on the telephone
And the night goes by so very slow
Oh I hope that it won’t end though
Alone

Till now I always got by on my own

I never really cared until I met you
And now it chills me to the bone
How do I get you alone
How do I get you alone

You don’t know how long I have wanted
to touch your lips and hold you tight
You don’t know how long I have waited
and I was going to tell you tonight
But the secret is still my own
and my love for you is still unknown
Alone

Till now I always got by on my own
I never really cared until I met you
And now it chills me to the bone

How do I get you alone
How do I get you alone
How do I get you alone
How do I get you alone
Alone, alone

In these lyrics the singer describes someone who is deeply in love, who has previously tried to get by on their own without depending on another, and now she or he finds themself alone and feeling somewhat desperate. Perhaps it is because they have not expressed their tender feelings to the one they love, or their loved one is afraid to spend intimate time alone with just the two of them because it feels too close and threatening. Fears of further hurt, rejection, a lack of reciprocal feelings of love, dependency and vulnerability can all play a part in interfering with intimacy.

Examples of self-sabotaging repetition compulsions include the young adult woman who acts out sexually with a series of young (or older) men, in a futile attempt to find emotional intimacy, love and affection. Or the young man who engages in a series of meaningless hookups to prove his prowess, and gain narcissistic gratification, because of underlying self-esteem problems that began as a child, perhaps resulting from repeated disappointments in his relationship with his mother or father where he felt powerless. Some of these young adult relationship themes are captured in the song by Pat Benatar entitled, “Love is a Battlefield”

We are young, heartache to heartache we stand
No promises, no demands
Love Is A Battlefield
We are strong, no one can tell us we’re wrong
Searchin’ our hearts for so long, both of us knowing
Love Is A Battlefield

You’re beggin’ me to go, you’re makin’ me stay
Why do you hurt me so bad?
It would help me to know
Do I stand in your way, or am I the best thing you’ve had?
Believe me, believe me, I can’t tell you why
But I’m trapped by your love, and I’m chained to your side

We are young, heartache to heartache we stand
No promises, no demands
Love Is A Battlefield

We are strong, no one can tell us we’re wrong
Searchin’ our hearts for so long, both of us knowing
Love Is A Battlefield

We’re losing control
Will you turn me away or touch me deep inside?
And before this gets old, will it still feel the same?
There’s no way this will die
But if we get much closer, I could lose control
And if your heart surrenders, you’ll need me to hold

We are young, heartache to heartache we stand
No promises, no demands
Love Is A Battlefield

We are strong, no one can tell us we’re wrong
Searchin’ our hearts for so long, both of us knowing
Love Is A Battlefield

We are young, heartache to heartache we stand
No promises, no demands
Love Is A Battlefield

We are strong, no one can tell us we’re wrong
Searchin’ our hearts for so long, both of us knowing
Love Is A Battlefield

Another example is when one repeatedly and unconsciously picks a fight following intense closeness and feelings of happiness (for example, following highly passionate sex), as a way of creating emotional distance because of feeling vulnerable, a loss of control, and the fear of dependency that is engendered by intimacy. And not uncommon is the adult who has lived through a painful divorce, who dreads what he or she believes may become another conflict-ridden relationship. Consciously or unconsciously they avoid falling in love again, or sabotage the development of intimacy in a new love relationship, because of the unresolved emotional trauma resulting from the prior marital separation and divorce.

And then there are the life stage crises that test the bonds of love and marital fidelity. Our life cycle brings different challenges to the human heart at each phase. These trials may include: a fear of commitment during courtship and early marriage; the demands of child rearing that make intimate moments difficult to establish, with longings to return to a simpler time with fewer responsibilities and more romance and freedom; conflicts over how to raise children; a mid-life crisis where one may have intense doubts about choices they have made, or feel highly dissatisfied with their level of professional or financial accomplishment; periods of financial distress; the death of one’s parents; and the realization of one’s own mortality, and the issues surrounding growing old and dying (such as a loss of power, chronic health problems, and major life regrets).

Sometimes a couple may grow apart as they evolve in different directions, or one member may outgrow the other emotionally or intellectually. This can place significant strains on the relationship, as compellingly characterized in the movie, “The Blue Valentine.”

The human heart is complicated, isn’t it?

Psychotherapy can be very helpful in uncovering the unconscious causes of repetitive failed relationships, and the difficulties in establishing or maintaining intimacy. The therapist engages the patient in a caring and trusting relationship, encourages the patient to free associate about their thoughts, feelings, fantasies and memories related to the current and earlier love relationships, and over time the unconscious conflicts emerge. Both the therapist and the patient need to commit to a longer-term therapy to work through the emerging issues that interfere with intimacy. This takes courage. At times it involves emotionally painful sessions, as the patient intensely relives earlier traumatic relations in what is called “abreaction.”  The therapeutic process uncovers prior experiences of conflicted relationships that damaged feelings of closeness and intimacy, and the development of trust. The patient grieves the loss of what had been yearned for yet remained unfulfilled, and reaches an understanding that puts into perspective the reasons for the earlier disappointments and heartbreaks. This process enables one to let go of the traumatic experiences, bringing with it a freedom to experience healthier adult love. It is very gratifying for the therapist to see the patient emerge from this process happily engaged in a more mature love, with their heart finally released from the emotional bonds created by the past traumas. What is learned in therapy will hopefully be applied time and again over the course of one’s lifetime; because intimacy, once achieved, is fragile.

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PSYCHOTHERAPY AND COURAGE

March 18, 2011

“Knowing yourself is the beginning of all wisdom.” This quote from Aristotle is the cornerstone of all insight-oriented psychotherapies. I genuinely admire those who engage in psychotherapy and commit to seeing it through – thereby bringing about personal emotional growth and a more satisfying life. Patients enter therapy for a variety of reasons. Perhaps they want to end a pattern of self-sabotaging behavior; where they may deny themselves the experience of true intimacy with another, behave in ways that preclude the possibility of joyful living, repeatedly choose narcissistic personalities with whom they fall in love, or find other ways to unconsciously live out what is known as “the repetition compulsion.” There may also be recurring symptoms of anxiety or depression for which they seek understanding and symptom relief. A life crisis around the end of a love relationship, the illness or death of a loved one, or severe job stress may lead one to seek therapy on an urgent basis, seeking immediate relief.

What is necessary in making this commitment to therapy, in sitting with a psychotherapist and examining one’s life? At its core, the psychotherapeutic relationship requires shared courage on the part of the patient and the therapist. At the beginning of psychotherapy, and from time-to-time throughout its course, the experience can feel quite scary for the patient. Coming to terms with certain realities heretofore avoided is emotionally challenging, and may feel daunting and overwhelming. At times extremely painful feelings, embarrassing or shameful fantasies, and troubling memories will arise during the course of therapy, all demanding the courage to confront, explore, understand, and resolve them.

Then there is the phenomenon known as “resistance” that develops during the course of psychotherapy. Resistance is based in defense mechanisms that protect the conscious mind from experiencing emotionally threatening unconscious memories, fantasies and feelings. Sometimes resistance is experienced as an urge to run – to avoid facing these issues – as it is human nature to seek pleasure and avoid pain. Internal conflicts also arise over feelings of dependency toward the therapist, in opposition to feelings of wanting to remain independent and self-sufficient. This is often manifested by the belief that seeking treatment is “a sign of weakness” and that “I should be able to manage my problems without the help of a therapist.” To the contrary, when one commits to the therapeutic process and sees it through to conclusion, it is a sign of admirable strength of character.

Two novel perspectives on therapy were recently shared with me. A young patient of mine – a tough, charismatic, and highly talented college football player – put it like this, “You have to man up, and face yourself in therapy.” Another patient, a middle-aged professional woman from the financial services industry, described therapy as a place where “You are not a side effect of your life, you are an active participant in your own well-being.”

Patients will commonly develop unconscious and conscious feelings and fantasies toward the therapist, called “transference,” that must be openly discussed in the session, no matter how embarrassing it might feel. The patient “transfers” onto the therapist feelings and fantasies they had toward important figures from their earlier life, such as their parents. These may include longings to be loved, fearfulness, erotic fantasies, yearnings to be taken care of, and so on. If the transference feelings are not candidly revealed, the therapy will grind to a halt. An open and honest discussion will pave the way toward uncovering important unresolved issues with one’s mother or father that, once resolved, enable one to move on with his or her life and love relationships in a healthier fashion.

The therapist in turn will develop a “countertransference” toward the patient. Countertransference occurs when the patient elicits conscious or unconscious feelings, fantasies and memories in the therapist based upon how the therapist was raised by his or her parents, and from other important relationships. It is important that the therapist have engaged in his or her own personal psychotherapy or psychoanalysis, to be able to identify and analyze their countertransference reactions (particularly the unconscious ones), so as to not act them out on the patient, or contaminate the therapy through imposing their own personal neurotic agenda. Among the most challenging and beneficial experiences in my own life were the years I spent on the psychoanalysts’ couches – first as a psychoanalytic institute trainee – and later following the death of my father – both of which helped to forge my identity as a psychiatrist. A personal psychoanalysis enables the psychiatrist or psychotherapist to more effectively empathize with, support, and emotionally “hold” their patient while being mindful of the potential interference from one’s own childhood relationships.

An important element in longer-term psychoanalytic or psychodynamic therapy is analyzing the unconscious causes of self-sabotaging behaviors that often originate in childhood relationships. In the course of therapy, as the patient grows increasingly familiar with the technique of “free association”, he or she will speak whatever comes into their mind, without holding back or censoring their thoughts, fantasies or feelings. As free association proceeds, the patient may re-experience prior events in his or her life with great emotional force, at times so powerful that they literally believe that they are actually living through the experience at that moment. This is called abreaction. As a result of the abreactive experiences, and the caring and empathy provided by the therapist, the traumatic event may be recast in a new cognitive framework, and be viewed without distortion through adult eyes, enabling the patient to finally let go of the trauma and leave it behind.

The foundational elements of a successful therapy include tenacity, the development of trust, feeling understood and cared about, feeling emotionally “held” through difficult and painful moments, mutual respect, a high level of technical skill on the part of the therapist, and a shared optimism regarding the outcome. The therapist must also embody a deeply held belief in the human spirit’s capacity for growth and change. Ultimately it takes heart, and a strong belief in the patient’s (and one’s own) courage, to forge ahead into the unknown.

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GENES, STRESS, NUTRITION, AND ANTIDEPRESSANTS – HOW THEY AFFECT ANXIETY, DEPRESSION, AND BIPOLAR DISORDER

January 4, 2011 For Men

The brain is the organ of the mind. Our ability to think, feel, and experience life is dependent upon neurobiological processes governed by the interaction between our genes and various types of psychological, environmental, and physiologic influences and stressors. New research in the field of “epigenetics” offers compelling support for the combination of psychotherapy, nutrition, [...]

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October 25, 2010 For Men

It seems like almost every other week that we are introduced to a new antidepressant medication through an ad on TV. For patients suffering from depression and their worried family members, they may wonder, “Why are there so many antidepressants on the market? What are the differences in how they treat depression? How do they [...]

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SELF ESTEEM, DEPRESSION, AND BIPOLAR DISORDER

August 2, 2010 For Men

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LIVING WITH ADHD

June 30, 2010 For Men

In the United States, an estimated 4.4 percent of adults ages 18-44, 4 percent of children ages 4-8, and 9.7 percent of children ages 9-17 experience symptoms and some disability from ADHD. As such, ADHD is one of the most common of all psychiatric disorders. It is also among the most treatable. Research has established [...]

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THE PSYCHIATRIST AS PSYCHOTHERAPIST – A TALE FROM “THE GOLDEN AGE OF PSYCHIATRY”

June 2, 2010 For Men

In a prior blog posting entitled “The Psychiatrist as Psychotherapist” there was a reference to the privilege of being trained during “The Golden Age of Psychiatry.”As the following story illustrates, This Golden Age had a somewhat turbulent beginning… When I completed my medical school education at Georgetown in 1975, and prior to beginning residency training [...]

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THE PSYCHIATRIST AS PSYCHOTHERAPIST

May 11, 2010 For Men

Many psychiatrists are expert at prescribing medications to treat the variety of symptoms that accompany the cognitive, emotional and behavioral problems that afflict their clients. Why do fewer psychiatrists engage in psychotherapy as well? One reason is that newer generations of psychiatrists were trained in residency programs that were heavily influenced by the “Psychopharmacologic Revolution.” [...]

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ADULT RELATIONSHIPS 103 – MARRIAGE

April 16, 2010 For Men

Marriage is one of the most challenging of all human relationships. It can also be one of the most rewarding. True intimacy, including friendship, compassion, empathy, sharing and realizing dreams, advising, comforting and supporting each other through life, sexual satisfaction, and deep love and affection, are all possible – yet at times can be elusive [...]

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