Maybe You Should Talk to Someone
- Lori Gottlieb
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It’s not that people want to get hurt again. It’s that they want to master a situation in which they felt helpless as children. Freud called this “repetition compulsion.”
(I immediately applied the standard therapeutic calculation used when somebody seems defensive about drug or alcohol use: whatever the total reported, double it.) Eventually I learned that Charlotte’s nightly alcohol consumption averaged three-quarters of a bottle of wine, sometimes preceded by a cocktail (or two).
People often think they go to therapy for an explanation—say, why Boyfriend left, or why they’ve become depressed—but what they’re really there for is an experience, something unique that’s created between two people over time for about an hour each week. It was the meaning of this experience that allowed me to find meaning in other ways.
During an initial burst of pain, people tend to lash out either at others or at themselves, to turn the anger outward or inward.
There’s a term for this irrational fear of joy: cherophobia (chero is the Greek word for “rejoice”). People with cherophobia are like Teflon pans in terms of pleasure—it doesn’t stick (though pain cakes on them as if to an ungreased surface). It’s common for people with traumatic histories to expect disaster just around the corner. Instead of leaning into the goodness that comes their way, they become hypervigilant, always waiting for something to go wrong.
Not speaking about something doesn’t make it less real. It makes it scarier.
“What do you wish people would say?” I ask. Julie thinks about this. “They can say, ‘I’m so sorry.’ They can say, ‘How can I be helpful?’ Or ‘I feel so helpless but I care about you.’”
Julie gives more examples of what helps when she tells people she’s dying. “A hug is great,” she says. “So is ‘I love you.’ My absolute favorite is just a plain ‘I love you.’”
As a therapist, I know a lot about pain, about the ways in which pain is tied to loss. But I also know something less commonly understood: that change and loss travel together. We can’t have change without loss, which is why so often people say they want change but nonetheless stay exactly the same.
Study after study shows that the most important factor in the success of your treatment is your relationship with the therapist, your experience of “feeling felt.” This matters more than the therapist’s training, the kind of therapy they do, or what type of problem you have.
It was the psychoanalyst Harry Stack Sullivan who, in the early twentieth century, developed a theory of psychiatry based on interpersonal relationships.
Generally what happens between therapist and patient also plays out between the patient and people in the outside world, and it’s in the safe space of the therapy room that the patient can begin to understand why.
there are times when something just isn’t right between therapist and patient, when the therapist’s countertransference is getting in the way. One sign: having negative feelings about the patient.
Therapists use three sources of information when working with patients: What the patients say, what they do, and how we feel while we’re sitting with them.
Our experiences with this person are important because we’re probably feeling something pretty similar to what everyone else in this patient’s life feels.
What makes therapy challenging is that it requires people to see themselves in ways they normally choose not to. A therapist will hold up the mirror in the most compassionate way possible, but it’s up to the patient to take a good look at that reflection, to stare back at it and say, “Oh, isn’t that interesting! Now what?” instead of turning away.
as Fitzgerald put it, “In a real dark night of the soul, it is always three o’clock in the morning, day after day”),
What most people mean by type is a sense of attraction—a type of physical appearance or a type of personality turns them on. But what underlies a person’s type, in fact, is a sense of familiarity. It’s no coincidence that people who had angry parents often end up choosing angry partners, that those with alcoholic parents are frequently drawn to partners who drink quite a bit, or that those who had withdrawn or critical parents find themselves married to spouses who are withdrawn or critical.
In projection, a patient attributes his beliefs to another person; in projective identification, he sends them into another person. For instance, a man may feel angry at his boss at work, then come home and say to his spouse, “You seem angry.” He’s projecting, because the spouse isn’t angry. In projective identification, on the other hand, the man may feel angry at his boss, return home, and essentially insert his anger into his partner, actually making the partner feel angry. Projective identification is like tossing a hot potato to the other person. The man no longer has to feel his anger, since it’s now living inside his partner. I talked about John’s session in my Friday consultation group. Just as he had been lying in bed with a metaphorical circus in his mind, I told the group that now I’d been doing the same thing—and since I was holding all of his anxiety, he was probably sleeping like a baby.
Irvin Yalom, the scholar and psychiatrist, often talked about therapy as an existential experience of self-understanding, which is why therapists tailor the treatment to the individual rather than to the problem. Two patients might have the same problem—say, they have trouble being vulnerable in relationships—but the approach I take with them will vary. The process is highly idiosyncratic because there’s no cookie-cutter way to help people through what are at the deepest level existential fears—or what Yalom called “ultimate concerns.” The four ultimate concerns are death, isolation, freedom, and meaninglessness. Death, of course, is an instinctive fear that we often repress but that tends to increase as we get older. What we fear isn’t just dying in the literal sense but in the sense of being extinguished, the loss of our very identities, of our younger and more vibrant selves. How do we defend against this fear? Sometimes we refuse to grow up. Sometimes we self-sabotage. And sometimes we flat-out deny our impending deaths. But as Yalom wrote in Existential Psychotherapy, our awareness of death helps us live more fully—and with less, not more, anxiety.
In the 1980s, a psychologist named James Prochaska developed the transtheoretical model of behavior change (TTM)
Unlike Freud’s stages of psychosexual development, which end at puberty and focus on the id, Erikson’s psychosocial stages focus on personality development in a social context (such as how infants develop a sense of trust in others). Most important, Erikson’s stages continue throughout the entire lifespan, and each interrelated stage involves a crisis that we need to get through to move on to the next.
It turns out that sessions to which patients come with neither a crisis nor an agenda tend to be the most revelatory ones. When we give our minds space to wander, they take us to the most unexpected and interesting places.
There’s no hierarchy of pain. Suffering shouldn’t be ranked, because pain is not a contest.
Sometimes in their pain, people believe that the agony will last forever. But feelings are actually more like weather systems—they blow in and they blow out. Just because you feel sad this minute or this hour or this day doesn’t mean you’ll feel that way in ten minutes or this afternoon or next week. Everything you feel—anxiety, elation, anguish—blows in and out again.
Do I want advice (counseling) or self-understanding (therapy)?
In couples therapy, therapists talk about the difference between privacy (spaces in people’s psyches that everyone needs in healthy relationships) and secrecy (which stems from shame and tends to be corrosive). Carl Jung called secrets “psychic poison,”
“It’s a funeral, for God’s sake,” she said. “All these people in my cancer group say, ‘I want people to celebrate! I don’t want people to be sad at my funeral.’ And I’m like, ‘Why the fuck not? You died!’”
I thought about how I did this with Wendell—how I’d internalized his lines of questioning, his way of reframing situations, his voice. This is such a universal experience that one litmus test of whether a patient is ready for termination is whether she carries around the therapist’s voice in her head, applying it to situations and essentially eliminating the need for the therapy. “I started to get depressed,” a patient might report near the end of treatment, “but then I thought of what you said last month.” I’ve had entire conversations in my head with Wendell, and Julie has done the same with me.
I think of something else Wendell once said: “The nature of life is change and the nature of people is to resist change.” It was a paraphrase of something he’d read that had resonated with him both personally and as a therapist, he told me, because it was a theme that informed nearly every person’s struggles.
I told Rita what I tell everyone who’s afraid of getting hurt in relationships—which is to say, everyone with a heartbeat. I explained to her that even in the best possible relationship, you’re going to get hurt sometimes, and no matter how much you love somebody, you will at times hurt that person, not because you want to, but because you’re human. You will inevitably hurt your partner, your parents, your children, your closest friend—and they will hurt you—because if you sign up for intimacy, getting hurt is part of the deal. But, I went on, what was so great about a loving intimacy was that there was room for repair. Therapists call this process rupture and repair, and if you had parents who acknowledged their mistakes and took responsibility for them and taught you as a child to acknowledge your mistakes and learn from them too, then ruptures won’t feel so cataclysmic in your adult relationships. If, however, your childhood ruptures didn’t come with loving repairs, it will take some practice for you to tolerate the ruptures, to stop believing that every rupture signals the end, and to trust that even if a relationship doesn’t work out, you will survive that rupture too. You will heal and self-repair and sign up for another relationship full of its own ruptures and repairs. It’s not ideal, opening yourself up like this, putting your shield down, but if you want the rewards of an intimate relationship, there’s no way around it.