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Affect: Primary or defensive?
Tears, anger, sadness, depression, excitement, fear and anxiety
Chapter 7: Reacting to Distressing Emotions
Emotional activation is a prerequisite for psychic change. Much of the time, the presence of strong affects indicates that our efforts have been successful and the patient is in a position where internal changes can take place. However this is not always the case. Sometimes, feeling can be a defense. How we respond to a defense is very different from how we respond to healthy processing of emotion and cathartic healing. What follow are some thoughts on how to interpret and react to the emotions you encounter.
Tears
Tears are a prime example of emotion that can have different meanings. Tears of protest are the angry tears we shed when boxed into a situation without recourse. These tears probably represent a wish for the other person (the therapist for example) somehow to reverse the painful reality. These tears represent a resistance to change, which needs to be treated like any other resistance.
In contrast, tears of acceptance come when it is clear that there is nothing left but to accept. This is when cathartic healing takes place. In this case, the patient acknowledges a painful reality and begins the process of making peace with it. These tears communicate the sadness and bind the patient empathically with the therapist/witness.
It is often hard to tell exactly which kind of tears you are seeing. It is your job to clarify. I recall a time when a patient became tearful and I realized with some discomfort that I had no idea what the tears were about. I wanted to say something sympathetic, but I didn't feel anything. Instead I said,"I want to understand your tears. What were you feeling just now?" Without understanding, you cannot have real empathy. It may be appropriate to wait a few moments, but eventually, you must do whatever is necessary to find out. The same inquiry will help to clarify whether you are dealing with tears of protest or of acceptance.
Anger
Anger is complex. The same key distinction exists between anger that serves as a defense and anger that does not. Perhaps it would be helpful to call the latter a "primary" affect to indicate that there is no other feeling or issue lying behind it. The importance of the distinction is that "primary" affects heal by catharsis, and once healed, no longer cause great discomfort. On the other hand, anger that serves a defensive purpose is not subject to cathartic healing. People may feel temporary relief when they act out or express such anger, but there is no permanent healing. The relief is temporary, and soon the feeling reoccurs.
Like other primary affects, anger that is not defensive calls for the same empathic witnessing that helps to heal other painful affects. On the other hand, defensive anger calls for further exploration to understand the nature and purpose of the defense.
The following is a rough categorization of anger that might be expressed in therapy:
1. Anger directed appropriately at someone else: This is the easiest situation. Your understanding will lead to cathartic healing. The anger should dissipate. If it doesn't, it is likely serving as a defense and warrants further exploration.
2. Anger directed at the therapist: Do you deserve the anger? First you need to understand what the patient is angry about. You owe it to yourself and to your patient to evaluate thoughtfully and with an open mind whether you have made an error. As in any human encounter, an acknowledgment is a very important beginning to the apology you need to make. (Lawyers sometimes advise otherwise, but failure to acknowledge your error will surely have a negative impact on your relationship with the patient and on any hope of a successful therapy.) If you are able to change, then again the human thing to do is to take measures to make sure you do not repeat the error. Finally, an apology is appropriate. After you have done these things, then your role is to understand the patient's feeling as you would any other feeling. Even though you are the object of the anger, the empathic connection, if accepted by the patient, may allow healing to begin. On the other hand, if you have not erred, then the patient's anger comes from somewhere else. In that case, the situation demands further evaluation. The categories that follow describe types of anger that may be directed at the therapist, someone else or no one in particular.
3. Displaced anger: This kind of anger is partially defensive. When the content or magnitude of the anger does not seem to fit the situation, you can suspect displacement. That is to say that anger that cannot be expressed directly is "piggy backed" onto a situation where a lesser degree of anger seems warranted. Displaced anger will not heal. It's expression may give temporary relief, but will be repeated over and over without healing. Displacement is a defense or resistance, and should become the focus of your inquiry (metacommunication). If the original anger is displaced, it was probably experienced as unacceptable in some way. Overcoming resistance to acknowledgment of the original source of anger may be a major therapeutic task. As you and the patient become clear about the original source of the displaced anger, then the anger in it's original form will heal.
4. Developmental anger. Normal development leads naturally to feelings of anger where no one is at fault. The one-year-old may feel as if he or she were emperor of the world. It is part of the human condition that this early sense of supreme mastery leads inevitably to the two-year-old discovery that others do not always agree. Ideally during the "terrible twos" the child learns one temper tantrum at a time to accept a more realistic assessment of his or her individual power in the world. Under less favorable conditions, the human capacity to avoid pain through psychological defenses can lead to partial failure to learn these hard lessons. Needed developmental experiences are in effect, deferred. In such cases, the patient, now an adult in therapy, may experience shock and anger just like a young child faced with limitations he or she doesn't accept. In addition, there will be shame associated with awareness that the anger is inappropriate. The result is very painful, and will require careful pacing, tact and education before cathartic healing can lead to new progress along developmental lines.
5. Acted out Anger: During the 1890s, when Freud first described the concept of acting out, he was clear that action was a defense against remembering and feeling. Destructive acting out may look angry, but the person doing it may not feel much. Since feeling is required for healing, this kind of anger does not help the therapy. Patients who act out may not realize that what they are doing is different from feeling. Those who systematically act out will be surprised and uncomfortable with the affect of anger when they first experience it. Acting out may be accompanied by other affects, such as frustration with those who try to thwart the destructive actions. This feeling is real, but is secondary and has little to do with the anger that originally led to the acting out. The therapist's job is to help the patient let go of the acting out defense, then deal with the newly exposed emotions.
For children, physical expression of anger may be age-appropriate until brought under control. Occasionally with adults, some degree of physical expression of anger may be more expressive than destructive. In the opposite direction, words can be used to hurt when they are more destructive than expressive. It is appropriate to ask yourself whether an expression of anger is communicative or destructive. Destructive anger can be thought of as acting out.
The following additional types of anger may be encountered in therapy. There may be others, but these are important categories.
Paranoid Anger: Anger inappropriately directed at others who seem to be motivated by the desire to cause pain to the patient may actually be a primitive way of coping with aloneness or the threat of aloneness. This is a very specific dynamic that calls for aloofness not empathy on the part of the therapist. Attempting to "empathize" may support a flight further from reality and may be harmful. (More on this topic is beyond the scope of this essay.) An appropriately therapeutic response might be, "I really don't know about anyone plotting against you. It doesn't seem likely to me, but I will have to be neutral about what you are describing."
Anger to Intimidate: Slightly different from acted out anger is anger that is a tool of intimidation. Where angeer is used to manipulate the other, it has little to do with any "genuine" primary affect.
Anger Covering Tears: Finally, anger can at times be a cover for tears.
Sadness and Depression
What follows represents one way of classifying these feelings. It is different from current official diagnosis, but has been useful in deciding on psychotherapeutic interventions.
1. Sadness: One definition of the blues states that, "The blues is a good person feeling bad." This could just as well be a definition of sadness. It is the affect that accompanies loss but does not involve shame or guilt. Sadness heals through catharsis. For therapists, the hard part is realizing that your empathic presence is really all that is needed. Efforts to "fix" or otherwise intervene are distracting and unhelpful. Simply listening is all that is needed.
Grief is the extreme form of sadness. It is not depression, but can cause many of the physical symptoms we associate with depression: Loss of appetite, sleeplessness, early morning waking, low energy, etc. Grief heals by catharsis as well, but the process may take months and can occasionally turn into depression as in "pathological grief."
Sadness, like other affects can also serve defensive purposes. When cathartic healing fails, then it is time to explore the function of the sadness.
2. Reactive Depression: Conflict between the patient's perception of reality and his or her internalized values leads the ego to turn against the self. The symptoms can range from loss of energy to full blown melancholia (weight loss, early morning waking and extreme pessimism). Often the patient is caught in a conflict between anger, directed at someone outside, and internalized values that prohibit the same anger and turn it into self-blame. This is the classic "anger turned inward." Healing will require modification of internalized values, which, of course, are tightly held and resistant to change.
From the point of view of psychotherapy, cathartic healing is not enough. As clarified earlier, modification of internalized values is a slower and more challenging job. In addition, when reactive depression has progressed to involve physiological symptoms, the patient may not be accessible to to talk therapy until medication or other biological treatment has facilitated some degree of resolution.
3. Endogenous Depression: It is my personal experience and belief that there are conditions (in particular, forms of bipolar illness) where patients experience depression that is truly more chemical than psychodynamic. Patients experience distinct episodes of depression as deviations from a more normal baseline. In such cases, psychotherapy may be helpful, but should not be thought of as curative.
Excitement
Not all excitement is mania, nor are all high-energy people bipolar. It has been my experience that two situations may involve high energy and excitement that is not pathological in that it does not lead to loss of control.
The first is that there do seem to be people who live their lives in a high energy state. They may not require much sleep and are able to make healthy use of their energy. Their high energy is an asset in life. It is not episodic and does not lead to loss of control.
The second group are people coming out of reactive depression. For a period, they may feel a rush of energy and elation. The elation in this situation does not necessarily represent bipolar pathology. Elation is sometimes a healthy reaction to the lifting of depression. The potential danger of missing the diagnosis of bipolar illness makes careful evaluation and follow-up necessary.
Fear and Anxiety
Fear is focused on some adverse event that could conceivably happen. By contrast, anxiety is a good word to describe the same kind physical feeling but without an identifiable reason. People do generally feel better when their fears and anxieties are heard by another person, but true healing will not come out of listening to anxieties. Cathartic healing only applies to "primary" fears where the object of the fear is something in the past that no longer poses a threat. Anxiety that has no real basis can be thought of as a an affect with some combination of defensive and/or biological underpinnings.
The therapeutic approach is to listen and witness, probing further where the object of fear or anxiety is not clear. When the affect does not clear, or comes back later, then you can conclude that more exploration of the defensive function of the affect may be useful.
Anxiety seems to have a developmental aspect as well. It appears that experience can strengthen the individual's ability to cope with fear and anxiety. Cognitive-behavioral approaches focus on tools for coping with anxiety, such as inducing relaxation and turning attention away from the exclusive focus on eliminating the feeling. It appears that doing this habitually and repeatedly increases the patient's resistance to the grip of anxiety, and very likely results in biochemical and/or synaptic changes in the brain.