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.

“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.

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, and medication management in the treatment of patients suffering from anxiety, depression, or bipolar disorder. Epigenetics means “over or above genetics,” and refers to how both the external environment and internal physiologic environment can interact with the DNA within the nucleus of each cell in the body, to alter how these cells function. In psychiatry, this field brings us knowledge regarding the epigenetic influences on brain cell function in patients suffering from mood disorders and anxiety. This knowledge carries profound implications for how we live our lives.

In mood and anxiety disorders, there is no “depression gene” or “anxiety gene.” One inherits a susceptibility to these conditions through multiple different genes, but the genes alone do not cause the illnesses. The genetic material within the nucleus of brain cells must first be influenced by epigenetic factors that come from outside the brain, such as external environmental or internal physiologic factors. Certain types of interpersonal stress with loved ones, or colleagues at work; inflammation, such as that caused by fat cells; and alcohol or drugs of abuse; can interact with these susceptibility genes to cause major depression or bipolar disorder; or cause anxiety disorders such as generalized anxiety, obsessive compulsive disorder (OCD), or panic disorder.

Two types of interpersonal stress can contribute to triggering psychiatric disorders. The first is called “learned helplessness,” defined as “a behavioral state of a person who believes that he or she is ineffectual, his or her responses are futile, and control over the environment has been lost.” The second is termed “social defeat stress,” and is defined as “relationships characterized by aggression, bullying, chronic subordination and humiliation.” Research has demonstrated that both learned helplessness and social defeat stress are epigenetic factors associated with psychiatric disorders.

Drugs of abuse such as cocaine trigger epigenetic changes in certain brain regions, affecting hundreds of genes at a time. Some of these changes remain long after cocaine has been cleared from the body. Research suggests that some of the long-term effects of drug abuse and addiction (including high rates of relapse) may be written into the epigenetic code (again, the interaction between the environment and the genes). Cocaine not only alters the epigenetic status of genes but also induces specific epigenetic modifications depending on how often the drug is used. Certain genes are switched on by infrequent administration, while others are switched on only after chronic administration (such as in addiction). Some are switched on by both This may relate to cocaine’s ability to “kindle” mood disorders Alcohol abuse has also been associated with epigenetic changes to the chromatin of the DNA in brain cells, predisposing to anxiety symptoms. And at a recent Society for Neuroscience meeting, marijuana use in teens was associated with cognitive deficits, reduced executive functioning (attention, focus and decision making), and changes in brain function in the frontal cortex. Whether marijuana asserts its effects through epigenetic mechanisms is the subject of ongoing research.

Obesity and nutritional aspects of a person’s lifestyle can also have profound effects on mood regulation and the onset of depression. We now know that fat cells release cytokine and C-reactive proteins. These proteins are known to cause inflammation throughout the body, and are associated with psychiatric disorders in the brain. They lead to alterations in neurotransmitter levels, neuroendocrine systems, and how brain synapses function. This leads us to conclude that obesity is also a type of stressor that contributes directly to altered brain function associated with mood disorders – more specifically depression.

How do these multiple internal and external influences interact with the genetic material within our brain cells to initiate the onset of an emotional disorder? In the brain, an important function of the DNA that makes up our genes and chromosomes is to code messenger RNA, which in turn codes so-called neuroprotective proteins. These protective proteins, for example BDNF (Brain Derived Neurotrophic Factor), support and protect normal brain cell structure and function, and enhance memory, learning, higher order thinking, and neurogenesis – the growth of new brain cells which occurs throughout the lifespan.

Below is a picture of how depression and anxiety are triggered by the interaction between various types of stressors and the DNA found in every brain cell. As depicted from left to right, multiple different genes predispose the patient to developing depression or anxiety, as they are exposed to one or more of the stressors cited above. The genes are necessary but not sufficient to cause the illness by themselves. In response to the stressors, the genes are suppressed in their ability to manufacture the neuroprotective proteins such as BDNF; and Bcl-2, which prevents brain cell death. As the levels of these protective proteins drop, the brain cells begin to function abnormally; and the energy centers of the cells, the mitochondria, begin to malfunction as well. This in turn affects the function and structure of the brain cells that form information processing circuits, which then results in the changes in mood, behavior and thinking we see in those who suffer from depression, bipolar disorder, and anxiety.

Neurogenesis is also critically important in the recovery from mood disorders, and can be positively affected by exercise, antidepressant medication, and through psychotherapy. Psychotherapy enables the patient to overcome the causes of learned helplessness and socially induced defeat-stress, characterized by repeated experiences of being overpowered and feeling helpless and trapped, whether in relationships at home or at work. Therapy empowers patients and enables them to leave behind destructive relationships from the past which have been internalized (for example damaging childhood experiences with a parent); and to modify or end current relationships that are characterized by repeated emotional battering. These emotionally damaging relationships may originate in one’s immediate or extended family, or in the workplace. In learning how to better manage or separate oneself from these types of stressful internal and external relationships, it can lead to increased resilience, new and richer social experiences, and result in neurogenesis.

Healthy nutrition can also play a key role in the recovery from a major mood or anxiety disorder. Reducing one’s body fat percentage to reasonable levels, for example 21% to 24% for women, and 13% to 17% for men, will reduce the release of the inflammatory proteins from fat cells. This not only has a salutary effect on brain cell function, but also reduces the likelihood of developing Type 2 Diabetes, coronary artery disease, hypertension, and stroke. Diets rich in lean protein, such as chicken, fish, egg whites, turkey, and whey protein shakes blended with fresh or frozen fruit; and filled with low glycemic index carbohydrates, such as fresh fruits and vegetables; with the use of olive oil (and not other vegetable oils or butter); combined with aerobic exercise three to four times per week; can assist in achieving these important goals of reducing body fat percentages. A sustainable program with proven success in accomplishing these objectives is The Joe Dillon Difference. Joe Dillon has coached many business executives, professionals and their families, in addition to 22 Olympic medalists who have won 60 medals, in a lifestyle for busy people with demanding schedules, that provides for increased energy, improved mood, and less anxiety and stress. I met with Joe along with other professional and executive colleagues of mine. Many of us have adopted his lifestyle recommendations, achieved positive results, and hold him in high regard.

Through the use of therapeutic interventions such as psychotherapy, healthy nutrition and aerobic exercise that reduce body fat percentage, and antidepressant medication, the destructive epigenetic processes may be reversed. As demonstrated in the picture below, these healing influences can activate so-called DNA “promoters” that enable the brain cell to code the RNA responsible for the production of neuroprotective proteins, resulting in increasing levels of these proteins. This restores normal cellular and mitochondrial energy functions, which in turn improve the information processing capabilities in multiple interacting circuits of the brain. This results in the normalization of emotional, cognitive and behavioral functioning.

These events are illustrated in the picture below. On the left hand side, the DNA is “promoted” to produce increased levels of BDNF. On the right hand side from top to bottom, in response to increased BDNF, the dendrites of the brain cells then regrow their branches, and the axons of the brain cells become re-enriched with dense packets of neurotransmitters. This restores and enhances healthy emotional functioning.

In viewing this process of regeneration, one can imagine that the implementation of psychotherapy, proper nutrition, and antidepressant medication is akin to the arrival of Spring, when tree limbs (and the human spirit) blossom, and experience a rebirth!

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 work? How do I know if my antidepressant treatment should be modified, or changed altogether?”

It is important to note that depression is a major health problem worldwide. The World Health Organization (WHO) predicts that by 2020 depression will be the second largest cause of the global health burden – and major depression is already the central nervous system (CNS) disorder with the highest prevalence. There are about 40 million diagnosed cases in the United States, France, Germany, Italy, Spain, United Kingdom, and Japan. The lifetime prevalence of major depression across the population ranges from 3% in Japan, to 17% in the United States, to 30% of men and 40% of women in the Netherlands and Australia.

In 2008, global sales of antidepressants totaled $20 Billion. In the United States, the use of antidepressants doubled over one decade, from 1996 to 2005. Antidepressant drugs were prescribed to 13 million people in 1996 and increased in number to 27 million by 2005. In 2008, more than 164 million prescriptions for antidepressants were written in the U.S. alone. It is fair to say that there is an epidemic of depression in the civilized world, and fortunately our understanding of how to treat depression has become increasingly sophisticated, through advances in molecular biology and neurophysiology that tell us how brain cells function in their normal state and in a depressed state, leading to more effective and targeted therapies.

Given the prevalence of depression throughout the world, and the deep and pervasive emotional pain it causes to patients and their loved ones, it is not surprising that the pharmaceutical industry would endow physicians with an extensive armamentarium of medications to treat major depressive disorder. As a result there are multiple drugs within each of several different classes of antidepressants, that boost levels of certain neurotransmitters such as serotonin, dopamine, or nor-epinephrine in the mood-regulating regions of the brain. Mood regulating brain cells are organized into circuits, within which the cells interact with one another using electrochemical mechanisms. The mechanism by which they interact, and how antidepressant medications work to enhance these interactions is simple, yet elegant, as illustrated in the picture below:

When the first brain cell (the presynaptic neuron) “fires,” it releases neurotransmitters into the synaptic cleft. Some of these transmitters then travel across the synapse and bind onto receptors of the next brain cell (the postsynaptic neuron), which can then cause that cell to fire (as illustrated in pathway #1 in the picture above). Other transmitters do not make the journey safely across the synapse, because they are reabsorbed back into the first cell (called “reuptake”) or are degraded by enzymes such as COMT and MAO (as illustrated in pathway #3 above). If the neurotransmitter levels are low in depression, it makes sense to block the reuptake, or block the enzymes that degrade them, to increase their numbers in the synapse, thereby increasing the likelihood that they will bind to the next brain cell

The most popularly prescribed antidepressants are the “SSRI” or “SRI” group, standing for serotonin-specific reuptake inhibitors. Examples are Prozac (Fluoxetine), Zoloft (Sertraline), Paxil (Paroxetine), Celexa (Citalopram), and Lexapro (Escitalopram). A different antidepressant, Wellbutrin (Bupropion), inhibits the reuptake of dopamine. Another class of antidepressants works to boost both serotonin and nor-epinephrine. These “SNRI,” serotonin/nor-epinephrine reuptake inhibitors include medications such as Cymbalta (Duloxetine), Effexor (Venlafaxine), and Remeron (Mirtazepine). Still another class is called the “MAOI” or monamine oxidase inhibitor antidepressants such as Parnate (Tranylcypromine) or Nardil (Phenelzine). These work by blocking the enzyme MAO (monoamine oxidase) that breaks down the neurotransmitters, but these are not widely used because they interact with many foods and drugs.

Successfully treating the symptoms of depression with an antidepressant is both an art and a science, and the choice of antidepressant can depend upon a variety of factors. Family history of response to a particular medication among genetically-related family members can be a helpful predictor, as can the presence of certain symptoms to target, which are known to respond to increases in one or more of the neurotransmitters noted above. For example, panic attacks may respond to SRIs or SNRIs and be worsened by Wellbutrin. Social anxiety and obsessive–compulsive disorder symptoms may respond to SRIs and also be worsened by Wellbutrin. ADHD symptoms may respond to the dopamine increase provided by Wellbutrin, but not to SRIs. In patients with depression, social anxiety, and ADHD, an SNRI may be helpful by boosting both serotonin and norepinephrine to address their broad spectrum of symptoms.

Not uncommonly, the patient’s depressive symptoms will only partially respond to the first medication selected, or they may not respond at all. In the event of a partial response, and where there are no troubling side effects, the medication is not switched but is “augmented” to make it more effective. Adding one or more “augmenters” to the antidepressant is analogous to adding a turbocharger to a car engine – they both provide a boost – they add power. Antidepressant augmenters include Folic Acid (a B vitamin), Omega 3 fish oil, thyroid hormone, testosterone, lithium, a second antidepressant from a different class (e.g. adding Wellbutrin to an SRI), an atypical antipsychotic medication (e.g. Abilify), and N-Acetylcysteine. The use of each of these augmenters may have a different rationale – for example Abilify may be used in the depressed patient struggling with many negative thoughts or mood instability – while Wellbutrin could be used to boost the energy level of a patient who has partially responded to an SRI, but continues to suffer from a lack of motivation and drive. In the more treatment-resistant patient, multiple augmenters may be used.

If there is no response whatsoever to the initial antidepressant, and it was given an “adequate trial” (defined as six weeks duration of treatment, at the maximum dose of the medication compatible with not causing side effects), then a different class of medication should be considered. Sometimes medications will be combined to boost all three neurotransmitters – for example using both Cymbalta and Wellbutrin – in certain patients with a treatment resistant depression that is not responding to the methods described above.

Our knowledge of antidepressant treatment continues to advance. Having been trained in “The Golden Age of Psychiatry”, I have been inspired by the evolution of pharmacologic treatment of depression over the past several decades – from the unsophisticated early days which offered limited choices of medications that caused dry mouth, constipation, lightheadedness, and other unpleasant side effects – to our present-day level of advanced knowledge with the ability to choose among many “clean” drugs that are tolerated so well that most patients forget that they are taking them. While researchers in some circles doubt the effectiveness of antidepressant medications, my experience over the years is that the efficacy of antidepressants is unequivocal. Responses to these medications range from enhanced self esteem and improved quality of life for those patients who are mildly to moderately depressed, to restoring basic daily functionality and providing lifesaving benefits for those who are moderately to severely depressed.

Used alone, or in combination with psychotherapy, antidepressants are life-altering; and offer the hope to millions of patients and their loved ones that they can climb out of that deep dark hole into daylight, and even into radiant sunshine.

Marriage may be the most challenging relationship in one’s life. Loving feelings are precious, and can be fragile and difficult to sustain. Many times when a couple enters the office in a crisis, the issues and problems they bring up in therapy have developed over a period of years, and have become compounded by a recurring cycle of disappointment, feeling wounded, and being ignored or taken for granted. Often times the drive, energy and focus devoted to one’s career and children are exhausted, and little is left over to nurture the marriage. As a result of this neglect, a valuable life together built upon the foundation of marriage begins to crumble. Every divorce is tragic, even when justified.

Marriage counseling is designed to surface and explore the root causes of marital conflict and distress; reconstructing how, when and where the relationship went off-track; hopefully bringing understanding to the inevitable misunderstandings that have been created and amplified over time; and learning how to implement new tools, for more effective emotional connection and problem resolution. Understanding one another can help to reduce the feelings of anger and hurt, and break the negative cycle that threatens to destroy the marriage. How are feelings of love restored in a battered marriage? The most important ingredient is listening, truly listening to one another. Exactly what does that mean in practice?

Listening has an enormously powerful effect when a loving relationship has been damaged. The most effective type of listening is best characterized as empathic and compassionate. Listen from your heart. Pay attention without interrupting. Take note of what is being said, and really try to understand what you are being told, even if you don’t agree with it. Put yourself in your partner’s place and work hard to understand what he or she has experienced. Listen with a spirit of cooperation, of jointly embarking on a journey of discovery, even when it is painful. Convey your understanding without hostility, and whenever possible, and where it is true, take responsibility for what you are being told about your own destructive or neglectful behavior.

Empathic, thoughtful listening creates a feeling of safety in the relationship. A readiness to blame your partner is the surest way to reinforce feelings of vulnerability and rejection, and discourage the honest sharing that is needed. How often in our lives do we feel listened to and understood by those we care about? The healing power of empathic and compassionate listening should never be underestimated. Injecting a needed dose of hope into the relationship, it enables one’s partner to feel special, and loved. It helps to restore a caring emotional connection and positive momentum.

Mignon McLaughlin once said, “A successful marriage means falling in love many times, always with the same person.”Falling in love once again with your spouse protects and enhances the life you have built together, and is energizing and rejuvenating. It can bring newfound satisfaction and joy to the other areas of your life as well.

A stable, positive feeling about oneself is to be cherished. For many people it is hard to come by, at least for extended periods of time. Some patients report that they may feel good about themselves from time-to-time, yet they can be plunged into the depths of despair and emotional vulnerability seemingly without cause and with no warning. These episodes may be mild and short-lived, lasting a few hours to a day or two; or they may be more severe and incapacitating, and last for several weeks to a number of months. Others report that as far back as they can remember they have lacked positive self-esteem, and have been unable to experience joy. Still others report that their feelings about themselves are quite unstable, ranging from times where they feel inadequate, helpless, hopeless and have difficulty getting out of bed and functioning; to other times where they are filled with great energy, sleep very little, are immensely productive, and may come across as abrasive or aggressive to loved ones and colleagues.

Self esteem regulation is a central problem for all patients with mood disorders, and difficulties with self-esteem can have neurobiological, psychological, social, and existential origins. Let’s explore each of these potential causes under the BioPsychoSocial Model of emotional illness.

Beginning with the biology of mood disorders, normally the DNA in a brain cell codes messenger RNA that then codes what are called “neuroprotective proteins,” that protect the normal structure and function of the brain cells from the negative effects of stress. While there is no “mood disorder gene,” we now know that certain types of repetitive stress such as learned helplessness, defeat stress, substance abuse, and oxidative stress; when experienced by individuals who have a genetic susceptibility to a mood disorder; may cause serious problems in maintaining a stable feeling of self worth. Learned helplessness (“No matter what I do it doesn’t make a difference – I have little or no power in the relationship – I feel helpless and powerless”) and defeat stress (“In the relationship I frequently feel emotionally abused or neglected”) interact with the DNA in the nucleus of the brain cells to cause fundamental changes in the type of messenger RNA and proteins that are coded, such that the neuroprotective protein levels decline, the structure and the function of the brain cells are adversely affected, and self-esteem regulation may be severely impacted. Here is a picture that summarizes how this works:

At the top right of the next picture, the unprotected brain cells are shown to have shrinkage of their branching portions, called dendrites, and a decline in the number of chemical transmitters available to make the multiple interacting circuits work. With effective treatments such as medication and psychotherapy, these changes are reversed and normal function is restored as demonstrated at the bottom right of the picture. The treatments restore positive feelings of self-esteem and self worth, or in some instances enable the patient to experience healthy self-regard for the first time in their entire life.

With respect to the psychology of mood disorders, what life events predispose a person to developing low self-esteem as a child, which is then carried over into adulthood? There are many unconscious psychological influences on self esteem that have their origins in childhood, ranging from sibling rivalry, to being raised by a critical or unempathic parent, to suffering from ADHD or other disability, to parental divorce or death, to physical or sexual abuse.

A sibling who is perceived as favored, or more talented and capable, can cause one to feel demoralized and stir up feelings of competitive envy and jealousy, which can undermine the development of self-confidence. The child may feel that no matter how hard they try they simply can’t compete, which creates for them the experience of learned helplessness.

A parent who is excessively critical and demanding, and who lacks compassion and empathy can also predispose the child to feel “not good enough,” even unlovable. This can of course create an emotional environment of defeat stress for the child.

A disability such as ADHD may undermine the feeling of positive self worth. Chronic feelings of frustration and humiliation develop as a result of the struggle to absorb, retain, and effectively work with information presented in class or through reading and homework assignments. Increased conflicts at home may occur due to what is perceived as “not listening” to parents; along with messiness and procrastination. Because fellow students seem to “get it” faster and better, and the child with ADHD frequently misses important social cues, feelings of low self regard can intensify all the more. The pervasive effects of ADHD in a child’s life can create both learned helplessness and defeat stress.

Parental divorce or death, and various forms of abuse, can destroy the “protective envelope” of childhood. These events constitute losses of one form or another, which breach a child’s sense of stability and security, disrupt and disturb feelings of trust, may lead to feelings of guilt and self-blame, and serve to undermine or erode the development of positive self regard. Since the child is helpless to prevent these losses or abuses, learned helplessness stress can bring about the alterations of brain cell activity depicted above.

A number of childhood psychological stressors can predispose the child, adolescent or adult to developing a major mood disorder. What determines whether this becomes a Major Depressive Disorder or Bipolar Disorder? Here is where the genetic contributions play a key role. Most people with major depression do not have close relatives with bipolar disorder, but the relatives of people with bipolar disorder are at increased risk of both major depression and bipolar disorder. With this in mind, what childhood experiences conclusively interact with a genetic predisposition to increase the likelihood of developing a major mood disorder? The answer to this question has the potential to help us prevent the development of a major depressive or bipolar disorder in childhood or later in life.

The interaction of psychological factors with specific family genetics certainly play a role in the development of Major Depressive Disorder. The heritability of major depression is probably 40-50%, and may be higher for severe depression. This means that around 50% of the cause is genetic, and around 50% is unrelated to genes (with contributions by psychological or physical factors).What we don’t know is whether this means that in some cases of depression the tendency to become depressed is almost completely genetic, and in other cases it is not really genetic at all. We do know that severe childhood physical or sexual abuse, childhood emotional and physical neglect, and severe life stress are probably all risk factors. Losing a parent early in life probably also increases risk to some extent.

Psychological factors interacting with family genetics also plays a role in the development of Bipolar Disorder. Studies show a 10 times greater risk of developing bipolar disorder if a first degree relative, such as a parent or sibling, has the disorder, for an overall 8.7% chance. How do we know whether this is from a genetic susceptibility or results from how the child is raised? The answer lies in the fact that there is a much greater chance (around 65%) that identical twins will share the disorder, vs. around a 5% to 20% chance for fraternal twins. Since the figure for identical twins is 65% and not 100% science has determined that certain environmental factors also predispose to the development of Bipolar Disorder; such as sexual abuse, highly critical parents, and low levels of maternal warmth. Substance abuse can also “kindle” abnormal activity in the temporal lobes of the brain, the so-called “seat of emotions,” resulting in a higher likelihood of developing Bipolar Disorder.

Social factors in the immediate or extended family also play a role. Divorce, death of a child or spouse, severe setbacks in ones career, economic reversals, or a child with a physical or mental illness can all contribute to feelings of despair and hopelessness, and engender both defeat and learned helplessness forms of stress. A major mood disorder including severely disrupted self esteem can then ensue. Once again the common theme is the experience of specific types of stress that involve loss, and real or perceived powerlessness to effect a different outcome, that interact with a genetic susceptibility to Major Depression or Bipolar Disorder.

Finally, existential factors can contribute to a diminution of self-esteem. At significant transition points in an individual’s life, one may experience an “existential crisis.” A useful framework for understanding the developmental challenges at each life stage, and the corresponding opportunities for emotional growth, is provided by psychologist Erik Erickson’s Stages of Psychosocial Development. In Erickson’s description of eight life stages, an “identity” or “existential” crisis may develop in stages five through eight, if the developmental challenges of one or more of these stages is not successfully confronted, negotiated and mastered. This may be manifested as an identity crisis in the adolescent or young adult, failure at achieving intimacy and commitment in early adulthood, a career that lacks a sense of accomplishment and social value in middle adulthood, or despair in late life when reminiscence brings regret and a sense of failure.

In “The Psychiatrist as Psychotherapist” I wrote about the psychiatrist’s capacity to integrate a knowledge base comprising neurobiology, general medicine, the unconscious, behavioral science, family systems, workplace/environmental stressors, and nutrition, to design and implement holistic treatment plans. To create positive feelings of self worth for the very first time in a patient’s life, or to restore confidence following the onset of a major depression, or to stabilize wide swings in self esteem in someone suffering from bipolar disorder, necessitates drawing from all of these knowledge bases, and is both a science and an art. Influence is brought to bear at the level of gene expression, brain cell circuit function, the unconscious, family interaction, and existential meaning and purpose.

A psychiatrist is privileged when he or she is able to work with a determined and earnest patient, as they embark upon a journey toward that cherished place – the achievement of stable, positive feelings of self-regard. This cherished place includes an abundance of newly discovered riches: such as the ability to enter into a committed relationship and feel safe; looking at yourself in the mirror and liking what you see; hopeful feelings about the future; an end to comparing yourself to others, and coming up short; no longer being your own harshest critic; and leaving behind those self-sabotaging behaviors that preclude a more joyful experience of self and others. As their work together creates both social value and a great sense of accomplishment, the journey provides one additional benefit – it is exceptionally good for the middle-aged psychiatrist’s own self esteem!

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 that ADHD is a neurobiological condition with a likely genetic component, wherein critical circuits in the frontal cortex of the brain responsible for sustained attention, organization, planning, and various other executive functions are not functioning properly. The speed and efficiency of information processing is inconsistent, and compromised. These circuits mainly rely upon two neurotransmitters to function (dopamine and nor-epinephrine), and most medications used to treat ADHD increase the availability of one or more of these two transmitters. Additional treatments typically include education, cognitive/behavioral techniques, and cardiovascular fitness exercise. Exercise activates the frontal cortex in all age groups, and increases levels of both dopamine and nor-epinephrine.

If you are a patient suffering from ADHD, or a family member living with someone with ADHD , what is the impact on your life?

For the patient with ADHD, living in reality feels like a “discontinuous experience.” Because they are frequently distracted by wandering thoughts, excessive daydreaming, and external motion and sounds in the environment when trying to focus on a task, they miss out on a number of important environmental cues, and struggle harder to learn new information. This has nothing to do with their level of intelligence, as I have treated many outstanding students, executives, and professionals with ADHD. These highly capable individuals have become overwhelmed and emotionally depleted from the challenge of processing increased volumes of information. Certain information from the environment therefore never “gets inside” their brain, and therefore is unavailable to be processed, particularly when their “supply” of information processing is exceeded by the “demand” to process information while at school or in the workplace.

A useful analogy to assist in explaining this experience is to imagine for a moment that your computer suffers from ADHD. As a result, an average of one out of every ten keystrokes that you type on the keyboard never register in the computer – that portion of the data never gets entered. In addition, the keystroke data that is “dropped” on the way in is random and unpredictable. The computer then inconsistently processes the information that has been entered – at times with the latest Intel Core 2 Duo Processor, and at other times with an Intel 386 microprocessor designed 20 years ago. The end result is that this computer could run Windows 95 just fine, but what about Windows Vista? For simpler processing tasks it would function just fine, but as processing complexity increased, it would begin to function poorly, if at all. How well would the computer function with its varying processors that are commanded to process incomplete information? What would the work product (for example the text or financial information you have created), look like when displayed or printed out?

While our brains may function in certain respects like a computer, a machine lacks a heart. Having ADHD is not just cognitively challenging, it is emotionally painful, as learning becomes more of a struggle, social cues are missed, distractibility is interpreted as a “lack of interest” or “rudeness” by others, and self-esteem is diminished over time. Anxiety and depression may set in. Patients with ADHD are twice as likely to develop a major depressive disorder, significant anxiety disorder, or substance abuse problem as the general population. Social development is slower and more challenging due to missed social cues and delayed brain maturation. Symptoms may be masked by high intelligence and a strong work ethic, which provide for a temporary “work around” the ADHD processing deficits. But as the complexity of life increases at certain transition points (for example moving from middle school to high school; taking standardized tests such as the SAT, LSAT, medical boards or bar examination; or receiving a significant promotion at work) the attentional system may become overwhelmed, emotional symptoms become more pronounced, and psychiatric care becomes necessary.

Living with a loved one suffering from ADHD is also emotionally painful. Life with someone who frequently misplaces or loses belongings, forgets to accomplish chores or duties that were seemingly explained and understood, procrastinates, is disorganized leading to messy bedrooms and assignments, acts impulsively due to a lack of planning, and is distractible in a way that seems like “they just don’t listen,” can lead to feelings of anger, frustration and exasperation. There is also the experience of sadness in watching a loved one struggle with some of the routine demands of everyday life.

The good news is that ADHD is highly treatable, and that medication, education, exercise, and cognitive/behavioral therapy can be “game changing.” Not uncommonly a stimulant medication can improve symptoms 80% to 90% by improving the speed, efficiency and consistency of information processing. Typically the most stubborn symptoms to treat are procrastination and disorganization, which often respond to higher doses of the stimulant (which mainly boosts dopamine levels), or require the addition of Strattera (which boosts nor-epinephrine). Simple organizing techniques such as the use of a PDA, a spiral notebook (not Post-its), and habitually returning personal belongings back to the same location, can be helpful. Specialized neuropsychological evaluations, psychotherapy and educational services, providing tangible techniques to improve study skills and workplace performance, can also bring about increased feelings of mastery and success, and result in improved self-esteem. Effective treatment of ADHD not only enriches the life of the person suffering from the condition, it also enhances those important relationships at work and at home.

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 at the psychoanalytically-oriented program at Tufts New England Medical Center in Boston, I traveled to London to learn about the emerging and exciting field of psychopharmacology. This was a conscious decision to round out my education and become exposed to new ideas that I would not receive in Boston, as the Tufts program focused on providing some of the top psychoanalysts in the country teaching residents how to perform intensive psychotherapy of hospitalized patients as well as outpatients. As the Tufts program lacked a psychopharmacologic curriculum, I felt that I needed to go to London.

Upon arriving I was surprised to learn that there was a severe dichotomy between the teachings of the psychopharmacologists, and those of the psychoanalysts. In short, not only did they vehemently disagree as to the origin and treatment of serious emotional problems, there appeared to be a lack of respect for or synthesis of differing points of view.
Nonetheless, I was there to learn about how medications could assist in restoring the brain’s emotional functioning, and I excitedly engaged with my professors at England’s Maudsley Hospital and Institute of Psychiatry, who were pioneers in the research and clinical use of medications to treat emotional disorders. It was a wonderful experience that I treasure to this day.

Now flash forward several months to the beginning of my residency training at Tufts. I was in my first month of the program, and I was on weekend emergency call at the New England Medical Center emergency room. A nineteen year old young man came in who was in a highly agitated manic state. Armed with my newfound European knowledge about the use of Lithium to treat Manic Depressive Psychosis (later renamed Bipolar Disorder), I admitted him to our inpatient unit and confidently placed him on Lithium. I was really proud of myself. That feeling of pride would turn out to be very short-lived.

On Monday I received an urgent call from the Director of Residency Training at Tufts, who insisted upon seeing me immediately. Nervously entering his office (he was a world famous psychoanalyst), he sat me down and proceeded to rake me over the coals for placing my patient on this “unknown” and “dangerous” substance, Lithium, which I had no right to do, particularly since I hadn’t discussed it with my supervisor (who as a social worker could not advise me on prescribing any medication, so I didn’t see much sense in that requirement).
I was crushed, and when he dismissed me from his office I was convinced that he would terminate me from the program. Shaken by the experience, and looking for an immediate reality check and some support, I went to see one of my supervisors (also a world famous psychoanalyst, with a kindly demeanor) and asked him whether I would be terminated, and what I needed to do to restore my good graces with the Director. My supervisor patiently listened as I described my experiences in London, and what I had learned that I simply tried to apply to my poor manic patient to alleviate his suffering. The supervisor told me that he would intervene with the Director on my behalf, and asked if I could provide him some articles on “that Lithium medication” as he was curious about it. (Interestingly, Lithium was first used to treat patients in Australia by John Cade in 1949 , and this was 1975, one year after the FDA had approved it for use in the United States, so it was not as if I was some wild-eyed radical psychiatrist).

Relieved, I left his office and was not bounced out of the program. I provided him two articles on the use of Lithium, and we discussed how the Lithium, combined with my seeing my manic patient five times per week in intensive therapy, worked together to help him. Two years later Tufts brought in a new Department Chairman- trained as both a psychoanalyst and a psychopharmacologist. I went from being the radical first year resident to being selected as Chief Resident in my third year, and a member of the medical school faculty the following year.

The Golden Age was underway.

Of course what was interpreted as a reckless and a bold move by me at that moment in history is now routine practice, and today treating a manic patient with psychotherapy alone would be considered malpractice. The Biopsychosocial Model of psychiatry is in full bloom – integrating a number of knowledge bases and databases to optimize the care of our patients.

It was my great privilege to go to London to learn psychopharmacology, and an even greater privilege to train in psychotherapy under the tutelage of top psychoanalysts in Boston. I feel grateful for these experiences every day, and remember with fondness and humor my turbulent initiation into The Golden Age of Psychiatry.

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.”

For much of the twentieth century psychiatry had few medications to offer, and those that were available had significant side effects, and poorly targeted the underlying symptoms of anxiety, depression, ADHD, psychosis, and substance abuse that bring about emotional pain. Prior to the “Revolution,” psychiatry was considered the “black sheep” of medicine – looked down upon as “voodoo science” by our medical colleagues – and occupying the bottom rung of respectability among medical specialties. Some doctors even questioned why psychiatrists needed to graduate from medical school, as their practices were almost exclusively oriented toward psychotherapy.

All of that changed with the Psychopharmacologic Revolution, as first generation medications were introduced and found to be effective, and second generation medications were equally or more efficacious with far fewer side effects. Psychiatry rapidly and dramatically began to achieve documented positive outcomes that rivaled or exceeded most of the other fields of medicine, exerting a profound effect on psychiatric training programs, as this newfound “respectability” dramatically transformed these programs into a biologically-oriented curriculum focused almost exclusively on medication management. At the same time, managed care companies were providing negative financial incentives for psychiatrists to perform psychotherapy. The net effect is that newer generations of psychiatrists are not as solidly grounded in the fields of psychotherapy as their predecessors.

Those psychiatrists trained in “The Golden Age of Psychiatry” received intensive training in various modalities of psychotherapy, such as psychodynamic, cognitive-behavioral, and family systems; as well as learning the science of psychopharmacology. These fortunate physicians are able to evaluate and treat the whole person, including the ability to address biological, psychological, social/environmental, and existential issues throughout the course of therapy with their clients, according to the Biopsychosocial Model.

There are many fine non-medical therapists who work closely with psychiatrists to support the medical aspects of treating their clients. What is unique about the psychiatrist as psychotherapist is his or her capacity to integrate a knowledge base comprising neurobiology, general medicine, the unconscious, behavioral science, family systems, workplace/environmental stressors, and nutrition, to design and implement holistic treatment plans. These doctors utilize the latest psychopharmacologic science combined with an eclectic use of psychotherapy, to help provide symptom relief and put an end to the self-sabotaging behaviors that serve to undermine personal growth and diminish the quality-of-life of their clients. As physicians, psychiatrists have received broad training in the science and art of general medicine, surgery, neurology, and other medical specialties in addition to their psychiatric training – including decisions that involve life and death responsibility – which adds another dimension to the psychotherapy that they provide. It is truly a gift for those of us psychiatrists who were trained during “The Golden Age,” to have the privilege of being able to care for the whole person.

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 and even feel like an impossibility. Most marriages are characterized by highs and lows – times of joy and times of despair – tender intimate moments and periods fraught with conflict and emotional distance. What makes a marital relationship so complicated?

To begin with, marriage is the most intimate of all human relationships. Emotional and sexual intimacy stirs up deeply felt and largely unconscious conflicts, feelings and fantasies. Dependence and independence, loyalty and betrayal, need satisfaction and disappointment, commitment and fears of abandonment, trust and mistrust, narcissistic love and mature love, freedom and self-sacrifice are just some of the contrasting and conflicting conscious and unconscious emotions that characterize any intimate relationship, and are most intensely experienced in a marriage.

Our relational experiences with our mothers and fathers, stemming from early childhood, become significant determinants in how these unconscious emotional issues are played out in a marriage. How our parents behaved in their own marriage are also influential factors. Later disappointments in the love affairs of adolescence and young adulthood also shape ones feelings and expectations in adult relationships, as can a prior divorce. In addition, biological, social/environmental, and existential issues can come into play. If one’s spouse has ADHD, depression, anxiety, or a substance abuse problem, additional burdens are placed on what is already a complex relationship.

Not uncommonly, when a couple presents for marital therapy, there is a true feeling of crisis in the marriage, and fears that the marriage is over. What happened? Not uncommonly, the marriage went off track and the couple did not become aware of this until much later. The pressures of careers, raising children, and finances often result in the marital relationship being relegated to second, third or fourth place in the hierarchy of what is attended to, cared for, and nurtured. This neglect, along with one or more unrecognized and unspoken major disappointments and emotional wounds, derails what had once been a stable and mutually satisfying marriage. Gradually the marriage deteriorates and may be characterized by hostility, indifference and escalating conflicts.

At the outset, the goal of marital therapy is neither to “save” nor to “civilly end” the marriage – there is no preconceived agenda – it is to create a safe and open environment to begin to explore what happened to a previously satisfying relationship, and determine where it went off track, and the circumstances surrounding those events. Not uncommonly, there was a deep misunderstanding that developed, and mutual hurtful actions served to usher in a period characterized by a downward spiral in emotional relations. Once the initial causes are identified, talked through, and understood, forgiveness and empathy can begin to develop. Neurobiological factors such as ADHD, depression, anxiety, substance abuse or bipolar disorder can be addressed by medication management and individual therapy. Earlier passions, whether they are physical or experiential, can be rediscovered as a result of initial healing, which in turn can transform a downward spiral into a more hopeful situation for the future, enabling the development of new positive experiences together and upward momentum in the marriage.

Mignon McLaughlin once said that “A successful marriage requires falling in love many times, always with the same person.” If a couple has the courage to face up to and work through their feelings of disappointment, hurt, and anger, they can rediscover their loving feelings and begin to delight once again in each other’s company.