One of my patients feels stuck in her psychotherapy with me. After some gain a cycle of defeat repeats itself. She wants to get off her antidepressant. When she does, she slowly gets more overwhelmed, depressed and hopeless about her progress with me. Without telling me she then goes back on the medication, knowing that it never left her particularly content about her life, but still somewhat better than the strong feelings she has without it. Her sense that she is a hopeless case does not recede, but suddenly she reveals that she believes I also see her as a hopeless case. Although I would not put it in exactly those words, I acknowledge to her that I am at a loss with her. I don’t know how I can help her any further.
This would reasonably be the time to part company or refer her to somebody else. In fact, this is how she came to me after she experienced a similar fate with three therapists before me. The last one sent her to me ‘for mindfulness’. Whenever she goes to see someone new, she creates a fantasy about what this new person will contribute that nobody else before has. The fantasy is always about a new technique she has not yet been exposed to. With me it was ‘mindfulness’, and her attempts at meditating remained fruitless. She got to the point of feeling that she wanted to crawl out of her body and came to the conclusion that meditation is not for her.
Previous therapists and her family physician told her that this is as far as therapy can go, and that with regards to her depression she is like a diabetic, who requires Insulin. Obviously, they said, your brain does not produce enough of whatever neurotransmitters the clinician believes she needs and she will simply have to take the antidepressant for the rest of her life. The fact that she relapses every time she tries to get off it despite having been in psychotherapy, is obvious proof of that theory. Or is it?
So here we are, she and I, both agreeing that we are at a loss. She formulates it in terms of being a hopeless case, while I tell her that I cannot work with her as long as she makes decisions about her medications without asking me first. So she decides to get off it again, and the same cycle begins again. She becomes overwhelmed, feels she cannot cope, is sad and crying all the time, and there is nothing in our psychotherapy that is helping her. This time, she tells me about her wish to go back on medication, and whether I agree that it makes sense. She is afraid of losing her job and not being able to parent her two daughters properly.
I present her with a choice. I am not against medication, by the way. It has its rightful place in the treatment of psychiatric disorders. But medications are over-prescribed, robbing people of the possibility for profound brain rewiring and psychological growth. In addition, psychotherapists trained to access the unconscious more deeply than scratching the surface, are hard to come by. In her case, I am not convinced that there aren’t hidden psychodynamic issues that are very difficult to get at and require an unusual amount of perseverance. So I suggest a shift of view: That her state is not a problem, but an opportunity for deeper exploration. The choice is to go back on medication and essentially stop psychotherapy, since years of it have not gotten her beyond some initial gains she made, or stay in this state and see what happens. The problem, however, is that she has told me everything there is to tell me. On the surface there is no issue to work through anymore, and we both agree that we are at a loss. What is new for her and she did not know until the point of asking me, is that I feel I do not know how to help her any further. She feels like a hopeless case, and I feel helpless to help her any further. This now being consciously on the table, why am I not letting her go, finish the therapy and encourage her to go back on her medication? She can’t see the opportunity I spoke about.
I tell her that there is likely an important difference between the way she and many others have viewed her situation of hoplessness in the past, and the way I see it. Just because she feels there is no more hope for her, I said, and just because I feel unable to help her further at that moment, does not mean that we can not settle into this shared feeling of powerlessness together. In other words, I am not willing to accept that just because we both feel that is the end of it, we actually should part. I am not going to abandon her just because she appeares like a hopeless case. The whole situation of hope- and powerlessness on both our parts is as valuable a phenomenon constructed by both our psyches together in relationship as any other we have explored in the past. Why and how did we get to this point? Telling her that is a pivotal aha-moment for her. This is an utterly different and totally new shift for her.
She begins to tell me how she wants to leave people in her life, particularly her husband, when they disappoint her. She starts to realize how alone she has always felt in life, and that the core of her aloneness never had any place in any relationship. She begins to see a dynamics in her childhood relationships to her parents she never saw before, and she felt deeply understood by me as I did not abandon her in her worst moment of fear of abandonment. To protect herself from this terrible and unmanageable aloneness she could not make sense of, and which is largely outside of her consciousness, she unconsciously sets defense mechanisms in motion that sabotage intimacy and prevent painful healing processes from getting into motion. One of the results is that like all previous therapists before me, I developed a sense of being ineffectual with her and unable to help her any further.
The therapy takes a new turn. While this is happening, she has to live with these intense feelings of overwhwelm, constant sadness, fear of ‘losing it’ and other painful emotions for about three to four months. This is an important point right here: She has to learn to live with the pain and not try to get rid of it or pathologize it as being medical like diabetes. The silver lining during this very difficult time is the fact that, compared to before my intervention of staying present with our mutual sense of helplessness, there now is an unexplainable sense of lightness and safety within her suffering that had never been there before. She feels inexplicably more grounded and solid, and not alone anymore, and can trust in my ability to lend her my MPC (medial prefrontal cortex) while she is rewiring hers. Rather than feeling overwhelmed, she can now feel incompetent and explore this feeling without believing in it; rather than feel she is going to fall apart, she can now consciously allow herself healing moments of falling apart while observing the processes with compassion; instead of feeling like she can not parent properly, she can now accept her present limitations and set clearer boundaries with her children; and rather than always wanting to leave her husband when things do not go her way, she can articulate her fears with him and engage him in supporting her.
And now a nugget for meditators. In the midst of this struggle she starts meditating again and discovers that these unconscious themes that had emerged from the therapy were previously locked in the form of implicit memories in her body. Consequently, being still in meditation means getting in touch with unspeakable emotional pain deeply locked in her body, which is why she feels like she wants to crawl out of it and had to abandon meditation as not being ‘her cup of tea’. Now that she has access to the complex non-verbal attachment processes of her life through her relationship with me, including the narratives that belong to them, but which she previously could not make sense of, meditation can become a powerful tool for her to go deeper into the mechanisms by which she creates her reality. Without the narrative integration of her life stories into coherent ones, she would never have access to meditation, no matter how hard she would try.
About nine months later she is symptom-free, having gradually improved along the way. From then on, whenever her vulnerability gets triggered by stress, she recognizes the early signs, knows what to do and is always able to process it quickly without developing debilitating symptoms. So far, after being off her medication for 2 years, she continues to do well without it.
I would like to close with a word of caution. For various complex reasons this path does not work for all. Sometimes it is obvious from the start that this is not the right path to take. Sometimes one has to try first before finding out whether it works, and sometimes one can be pretty confident that it will work. It all depends on the circumstance of the person involved. One size never fits all. Through this article I wanted to give a glimpse into the laboratory of our psyche when this path is the right one to take.
Copyright © 2016 by Dr. Stéphane Treyvaud. All rights reserved.