Anxiety disorders are the most common psychiatric illness in the United States. Around 40 million people struggle with anxiety that is at debilitating levels. That's one in five people!
So what's going on in anxiety? Basically your sympathetic nervous system, which is designed to help you fight or run from predators (think a bear chasing you in the woods) has gone a bit haywire. Things that should not provoke this response (racing heart, dilated pupils, cold sweat, massive amounts of adrenaline in your bloodstream) have triggered this response. Which feels pretty terrible. Some people experience intense anxiety only occasionally, like before giving a talk in front of an audience, but other people experience anxiety on a daily basis.
Regardless of how much anxiety you have or when it comes on the treatments are essentially the same (except for simple phobias like fear of snakes or fear of flying, which really needs exposure therapy). You can reduce your overall anxiety by following any of these tips:
As always wishing you health and happiness,
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It should be no surprise with the rapid advances in genetics these days that they have identified a gene that may help to explain what a lot of folks call the Highly Sensitive Person. A researcher at the University of California Berkeley, Dr. Levenson, postulates that a variation of the serotonin transporter gene on chromosome 17 may may account for people who feel their emotions very acutely. This serotonin transport gene can have two common variations-- the "short allele" or the "long allele" version. It's the short allele version that seems to be responsible for some people feeling things more intensely. This gene variation also seems to be correlated to higher rates of depression, anxiety and ADHD. Which bolsters what clinicians who work with those populations have noticed for decades-- that if you have anxiety, depression or ADHD, you are likely to have not just one of those but two or even all 3. And that if you have some of those difficulties you are also likely to see those same problems in blood relatives, hinting that there is a genetic linkage.
Dr. Levenson posted a fantastic youtube video that explains his research in a very understandable and fun format (he even uses emojis!). If you resonate with the idea that you tend to feel things more deeply than others you may want to look at other sources of information about this trait such as the wonderful website The Highly Sensitive Person which has books, videos, research links, self-tests and more.
So if you are a highly sensitive person what can be done about it? Well, years ago I encountered a theory in psychology that seemed so completely WRONG to my therapist's ear-- that the goal of therapy should not be to change people but teach people who they already are and how to live the in the world given who they are.
Anyone who reads my blog or does therapy with me knows that I am a huge fan of splitting the difference, finding the middle path or blending opposing ideas. So while at first I balked at what sounded like a completely hopeless perspective-- that we should not try to help people even try to change-- I came to realize that there is room for some of this perspective in my view of personal growth. Whether you are a Highly Sensitive Person, someone with ADHD (you can be both of course), an extrovert or on the spectrum, all of which are known to be highly genetically determined, or have some other genetically linked trait, you CAN make some changes to how you operate in the world. And, at the same time, there WILL be things you cannot change and, as the old 12-step saying goes, it's learning "the wisdom to tell the difference" that is the key to really thriving. So if the idea of a highly sensitive person resonates with you I encourage you to learn more about it and educate those that are close to you so that your behaviors do not get misinterpreted. Then set about learning how you can navigate the world with a little more comfort.
A few examples of HSP that I have known or worked with-- one woman notices that too much noise is very overwhelming for her, so she has skin-colored ear plugs that she wears if she is going out in public (like the mall, a noisy restaurant, etc). They dampen the ambient sound but she can still hear the people she is talking to just fine. If this idea appeals to you I suggest trying the off-the-rack cheap kind first and if you really love them you can order ones that are more high-end or even have them custom made by shops that cater to musicians.
Another HSP I know gets a lot of anxiety when entering into social situations because of the increased complexity of interactions. The combination of more voices, conversations bouncing around, more eye contact, etc. just jangles her nerves and she used to find herself making excuses and not joining into groups. Once she learned that she was an HSP she experimented with different methods of entering into groups that reduced her feeling of exposure to the increased input. She found that when she enters a room, house, venue, etc. if she can wait a minute (she can pretend to check her cell phone, go find a restroom, etc.) her nervous system has time to acclimate to the new environment. Once she has done that if she is still feeling a bit overwhelmed she can stand sideways to the group (this does not have to be too noticeable, the main thing is the have your torso perpendicular to the group but your head can be facing them). This has an interesting impact on the mammalian nervous system. Mammals are most physically vulnerable when their guts are literally exposed. So when one mammal faces another mammal if their torso is exposed the mammalian brain notices this and there is a deep evolutionary alarm that can sound and may feel like anxiety. This is especially likely if the group includes people you don't know or if you are in an environment you have never been in before (a new restaurant, a new friends house, etc). But by simply turning your torso 90 degrees, like you would if you were fencing, your mammalian brain is more likely to ratchet down the threat level and you will relax more.
For this particular person she even had a third level of "defense" for her nervous system if the first two things did not help enough-- she to develop particular imagery that was settling to her nervous system (if you are not familiar with the amazing power of guided imagery I recommend taking a look into it!). For this person imagining standing behind a huge one-way mirror when she was entering a new group was helpful. In the mental image she could see others but they could not see her. This deactivated her fight-flight response that was predicated on the idea of being seen. Again --to go back to how we are just large bipedal animals dressed in clothing-- being seen is the first step to being eaten. So for some HSP just being looked at can trigger a lot of anxiety. Because the brain, while in some ways is extremely sophisticated, in other ways it is very dumb. Sometimes the brain does not always know the difference between a very well rehearsed imagery and reality (just try thinking about biting into a lemon and see what your salivary glands do). So once this person had locked-in to that image as one that reduced her anxiety and she had rehearsed it numerous times she could call it up when under stress in social situations and it would reduce her feelings of being overwhelmed.
Again I am not suggesting that a HSP can turn themselves into a non-HSP. On some level we are who we are. But learning strategies to help modulate one's innate responses can give us more flexibility in our lives and lead to less stress and anxiety.
If you feel you are an HSP therapy can be a wonderful way to learn about yourself and get some help managing your beautiful but slightly tricky nervous system. Our office offers FREE 30-minute consultations so you can see if any of our therapists would be a good "fit" for you. And if you are an HSP in a relationship couples therapy can be a wonderful way not only to learn about yourself but to have your partner also learn about you in ways that can deepen the intimacy and de-personalize some of the problematic things that can crop up with a HSP in partnerships.
As always I wish you well in all of your endeavors and explorations in life, whether you are an HSP or not. The world has room for all of us and we all contribute in meaningful ways to create the rich diversity of the human condition.
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I have written about shame before but wanted to expand on my earlier blog with some new information on how exactly we learn to be shame prone.
James Harper has written about this subject and explains that families that promote shame lack certain fundamental qualities that protect against shame. These qualities are accountability, intimacy and dependency. If these qualities are present in sufficient amounts in a family system children can grown up without undue amounts of shame. To break these
Again if these qualities are not present enough kids will end up feeling toxic amounts of shame. When kids experience shame a lot they naturally begin to internalize it. That emotional state gains preference in the nervous system and is more easily accessed. I compare this to driving down a dirt road every day for several week. Over time you will notice grooves getting established in the dirt so that it gets harder to deviate from the path you have been taking each time. This is similar to the way our brains respond-- the more we feel something (or think something, or do something) the more that pathway is reinforced and becomes easier for the brain to find the next time. So numerous experiences with shame as a child make is "shame prone" in adulthood.
“Children are especially vulnerable to shame." commented Sarah MacLaughlin, LSW in this article in Huffington Post. "Self-centered and dependent, young humans will easily translate, “You did something bad,” into, “You ARE bad.” We need to be aware and careful about the messages we send.
One potent quote I heard about shame was this --
Shame is a lie someone told you about yourself
(that you believed).
Whether it is intentional or not we need to be careful about the messages that we transmit to kids. That they are frustrating, that they are "too much", too needy, too demanding, incompetent, embarrassing or not measuring up to our standards. They may believe these falsities many, many years into the future.
Perhaps one of the reasons that shame is such a persisting emotion and so hard to "un-learn" is that it is tied to our very survival. Shame is centered in the autonomic nervous system. Unfortunately the human brain, in some ways, is pretty dumb. It cannot distinguish between physical threat and emotional threat, just like on a brain level it does not distinguish between physical pain and emotional pain (see my earlier blog on this). When the brain perceives any kind of threat it responds by booting up "crisis mode"-- the autonomic nervous system. This is the response of the brain to shame, probably because shame implies a threat to important relationships. Especially in childhood our relationships with caregivers are life and death matters. If we are being shamed by our caregivers we respond as if our survival has been threatened-- because it has. Just like being attacked by a bear we have the urge to hide or flee. If that does not work we resort to attack. Shame is hard-wired in to these deep areas of the brain (the ANS) that are designed to protect us from actual annihilation. So once these areas have been reprogrammed to feel shame it can be very hard to root out.
Shame proneness in kids is sadly predictive of numerous problems in adulthood, including alcohol abuse, high risk sexual behavior, legal problems, suicide attempts and social isolation. Shame proneness, while not associated with age or socioeconomic level, is also associated with low self-esteem and PTSD as well as the problems mentioned above (Ashby et al. 2006, Crossley & Rockett 2005, Feiring & Taska 2005, Stuewig & McCloskey 2005). Shame-proneness assessed in the fifth grade predicted later risky driving behavior, earlier initiation of drug and alcohol use, and a lower likelihood of practicing safe sex (Tangney & Dearing 2002). Similarly, proneness to problematic feelings of shame has been positively linked to substance use and abuse in adulthood (Dearing et al. 2005, Meehan et al. 1996, O’Connor et al. 1994, Tangney et al. 2006). For people who are HIV positive, having persistent feelings of shame predicted t-cell decline, showing compromised immune function (Weitzman et al. 2004).
Shame-prone people also engage in aggressive acts more than those who are not shame-prone. For example they tend to verbally attack, blame and externalize as well as the more passive-aggressive option of simply talking badly about someone behind their back. Shame-prone folks are also more aggressive physically, either interpersonally or by attacking objects/possessions important to the person they are angry at (think keying someone's car). Sadly the shame-prone person may also harm themselves or simply ruminate in their unexpressed anger. Interestingly these individuals admit that their anger gets them into trouble and is destructive of relationships but they seem to have trouble not being triggered into these negative behaviors.
Brene Brown has written and talked extensively about shame and how to become less shame-prone. She suggests the following steps to help recover from a shame-prone upbringing:
For more help with shame I recommend Brene Brown's Ted Talk or her book on shame. She also has other resources available on her website.
Therapy can also be a wonderful tool to work on deep feelings of shame or surviving a shaming childhood. People can heal from toxic shame and learn to more fully love themselves and live the lives they truly deserve.
Wishing you happiness and peace,
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For anyone who has wondered how Dr. Tatkin came to develop his theories this is an old interview on Shrinkrap Radio from 2008 in which he talks at some length about his early training experiences. As always Dr. Tatkin is clear, coherent and incredibly articulate. He explains his circuitous route to becoming a relationship expert, starting as a professional musician (drummer!) and weaving through inpatient psychiatric hospitals with John Bradshaw where he learned Gestalt therapy and psychodrama, to working in addiction treatment, on to studying American Object Relations with Dr. James Masterson, to training in the Adult Attachment Interview with Drs. Mary Main and Erik Hesse and finally to studying infant brain development with Dr. Alan Schore. Once in private practice Dr. Tatkin realized a strong interest in working with some of the more severe personality disorders such as narcissism which lead to his epiphany that prevention was where he wanted to put his focus. This lead him into looking at infant attachment and eventually to adult attachment in romantic relationships. In working with couples we not only help the adult dyad we also increase the security of the system in which any children are reared. This pays forward in building more relational security in the children as well.
For anyone wanting a brief and very understandable explanation of the Avoidant attachment style he does so right around minute 40. And of course if you want to get the major download of all of Dr. Tatkin's wisdom I recommend Your Brain on Love, his audio program in which he explains to lay people how his theories explain why relationships go awry in the short and long term.
In this interview Dr. Tatkin also references a film about infant attachment called When the Bow Breaks which drew him in to the field of infant attachment and lead him to the work of Dr. Allan Schore. He also mentions several of Dr. Schore's books, including Affect Dysregulation and Disorders of the Self if you want to get deeper into some of his "source" material. All in all it's a great 50-minute interview with someone who I feel is at the leading edge of relationship science.
Wishing you the best in your relationships and connections,
PS If you have enjoyed this blog/link to Dr.Tatkin's interview please consider "liking" it on fb and/or tweeting this post. That helps other people find my blog and connect to these topics. Thanks!
First a note on semantics. The "Island" under consideration is a romantic partner who has what would, in research, be called an "avoidant" attachment style. Attachment research goes back many years (to the 1940's) and involves classifying people into different categories based on how they relate to their primary caregiver in early childhood. For more information on attachment see my earlier blog on the subject.
As some of you know when I work with couples I use the PACT model of therapy (the Psychobiological Approach to Couples Therapy). The PACT model has re-labelled the attachment styles as follows: Islands (avoidant), Waves (resistant) and Anchors (secures). It would be too complicated to explain the model here but see earlier posts of mine on the classification system and how our attachment styles impact our romantic relationships. Dr. Stan Tatkin's audio program, "Your Brain on Love", provides a wonderful explanation of the theory and how to apply it to your relationship.
OK, now on to those islands. For those of you who love someone who is often island-ish it can be confusing to understand them if you are not one yourself. Now of course to be fair, island-ish people often don't understand non-island-ish people either!
However, human behavior is often predictable if you know what to look for. So if you know that your partner is "island-ish" then you can predict what is going to bug them and what will really make them purr. I am summarizing here points made by Dr. Stan Tatkin in his wonderful audio program Your Brain on Love. If you haven't listened to it I strongly suggest you give it a try! While I have provided a link via Amazon above you can also buy it on iTunes, Audible and soundstrue.com.
Now before proceeding I need to make something REALLY clear. What I am about to say may make you think "sheesh, why would I want to commit to an island if it will turn out this way?". So PLEASE understand something-- everyone, regardless of their style (Island, Wave or even Anchors) will get harder to handle after commitment. Dr. Tatkin refers to this as the "marriage monster". It's the unstoppable dynamic that gets activated when we pledge ourself to someone for all eternity. This just naturally turns up the heat and starts to show the cracks in our structure. So if you are wave-ish please realize that commitment also makes you more wave-ish and therefore harder to handle. It's not that island-ish people are worse than you. There is enough bad behavior to go around ;-)
OK so as long as you proceed without judgement, here are a few things that are predictable about people who are island-ish (or avoidantly attached):
Remember that all of the above is NOT personal, NOT conscious and NOT immediately under their control. Like any human being island-ish partners can learn about themselves and can learn new behaviors. But this often takes time and some professional coaching.
And one final tip on not triggering your island-ish partner--
I hope these tips have been helpful. Look for my upcoming blog on "The Care and Feeding of Your Wave". Remember, about half of us have "insecure" attachment styles (meaning we are not "anchors" or "secures"). So if you find yourself relating to the Island or Wave types don't feel bad. There are plenty of folks in your company. And if your partner is willing to learn your style they can take great care of you (and vice-versa!).
Many people who contact me are suffering from anxiety. Anxiety can cause a number of problems ranging from irritability, depressed mood, lack of productivity or insomnia.
The first thing I always want to know is are they exercising? Most of my patients who have anxiety find that exercising vigorously most days of the week will reduce their anxiety a considerable amount.
That said exercise is not usually sufficient to remove all anxiety from someone who struggles with it. We almost always need to look at other lifestyle factors (like reducing caffeine and other stimulants) as well as other techniques such as diaphragmatic breathing, guided relaxation practices and mindfulness meditation practices. What follows are some basic videos that people can watch in order to learn how to use these techniques to help with anxiety.
The first link is for teaching diaphragmatic breathing. Some people call it "belly breathing". The reason it's helpful to learn this technique is that if you can fully engage your diaphragm by doing this type of breathing it stimulates the parasympathetic part of your nervous system. That part of the nervous system is what causes your body to relax. If you have been stressed out then your nervous system most likely is sympathetically activated, meaning that the sympathetic branch of the nervous system is dominant. This part of the nervous system (the sympathetic branch) dumps a lot of adrenaline and cortisol (stress hormone) into your bloodstream which causes symptoms of anxiety like shallow breathing, sweating, hot flashes, increased heart rate, stomach upset, headaches, muscle tension, etc. The way to stop this stress response is to activate the parasympathetic nervous system by doing diaphragmatic breathing.
This link will give you a super simple explanation of diaphragmatic breathing :
This link will show you a person doing diaphragmatic breathing so you can follow along and practice it:
This next one is a specific pattern of breathing that also activates the relaxation response and this is another good tool for turning off the stress pattern if you have started to feel anxious:
You can also do the diaphragmatic breathing with a 4-7-8 pattern, or if you prefer you can use any pattern where you exhale longer than you inhale (so for example inhale for 5, hold for 2, exhale for 6, or any other variation as long as the exhale is longer than the inhale).
In order to maximize benefit you should try to practice some form of relaxation breathing at least 2x/day for at least 5 minutes each time. Once you have the hang of it you can increase to up to 10 min each day. Many folks make one of those times when getting ready to fall asleep. It can help you relax and fall asleep if anxiety tends to keep you awake.
The next tool in the anti-anxiety arsenal are mindfulness meditations. These have been shown to reduce anxiety and depression, improve concentration and attention and even improve control over your emotions. Studies show that doing this just 11 minutes each day will produce actual structural changes in the brain (increased activity of the frontal lobe). It helps reduce symptoms of ADHD, depression and anxiety as well as increasing emotional control.
At first you should probably just try 3-4 minutes of mindfulness at a time. Doing too much at once can make it annoying and then you might get turned off to it. Try to start with 3-4 minutes each day and after a few days add another minute, do that for a few days, then add another minute and so on. Eventually you will want to do at least 11 minutes each day of mindfulness meditation.
All of the following videos have good technique so you can try them all and see which ones you like. You can also search yourself on youtube for other ones. But remember even if the video is 20 or 30 minutes just do 3-4 minutes at first. You will not be able to empty your mind, it is totally normal to have thoughts intruding constantly. That's fine. The goal is just to notice the thoughts and then let them go. I think of them like people walking into the room and I notice them and say "hi" and then let them walk away and I let them go. The goal is not really to empty your whole mind because the human brain does not work that way. It's just the process of acknowledging the thoughts and letting them go that builds the brain in the areas that benefit you.
And finally here are links to guided imagery for sleep. These are great to help you fall asleep. You just start playing it when you lay down to sleep and usually folks fall asleep before the whole program finishes.
If you don't like any of these you can search with keywords "guided imagery for sleep" or "hypnosis for sleep" to try some other ones. You can also specify in your search male or female voice, music vs. nature sounds, etc.
If you have other youtube videos that you have found useful for managing anxiety or for falling asleep I would love to hear about it! Send me an email or post your comment below.
Thanks and stay tuned to more ideas on managing symptoms of anxiety without medications.
Have you ever wondered how a text stands up to a phone call? Or a phone call to an in-person meeting? What about emails? How have all of these modern developments affected our human relationships?
There is new research coming out now that these forms of electronic communication are NOT equivalent to the old-fashioned face-to-face talking/interacting. Which makes sense when you consider that the human brain would have a lot of trouble evolving at a pace to keep up with the latest iPhone app or emoticon. Our brains were wired for in-person interactions in which we can use data from the visual stream, and vocal tone, volume and pitch. We intuitively know what a frown means even when no words accompany it, and we also know that even if said with a smile certain words uttered in a snarly tone mean a fight is brewing. These kinds of nuances cannot be parsed out by the human brain when the message is communicated via text or email and may only be partially correctly decoded in a phone-call or audio message. Furthermore not only is it likely that the message can be mis-interpreted but our poor brains also can't derive the type of support that they need from these relationship proxies.
In one study done with girls who were put into a stressful situation it was shown that being able to either talk to a comforting person (their moms) over the phone or meeting up with this person after the stressor reduced physical signs of stress (levels of cortisol) compared to texting, which did nothing for stress. Additionally being able to talk on the phone or in person with the support-person caused a release of oxytocin, a hormone that helps us bond and mitigates the effects of stress. Again this effect was not seen with texting.
In another study done on adults over 50 researchers found that the probability of having depression increased as the frequency of in-person contact with other people decreased. Meaning that the less real-live contact that these people had with other humans increased the likelihood that they would suffer depression. Humans need other humans and we need to be with each other in ways that are not purely viritual.
So keep those you love close-- close enough to see, touch and hear without the interloping of wires and circuitry. And reach out to them frequently for contact and connection. Save the less personal forms of communication for business and less significant relationships if you want to be happy and healthy. At least until Mother Nature comes out with thehumanbrain2.0. But I'm not holding my breath.
Wishing you happiness and connection,
Okay the truth is a you can't really "read" this and I listened to it over a year ago. But I should have posted about it then so I am trying to make up for that now. This is Dr. Stan Tatkin's masterful audio program explaining the Psychobiological Approach to Couples Therapy, or PACT. I have been using this approach with couples for the past 6 years and cannot offer enough endorsement of it's principles and techniques. PACT has helped me help countless couples of all races, religions, sexual orientations, economic classes and with every problem you could imagine. The best explanation I can give about PACT is that it addresses the "bios" level of programming (patterns) in our hard-drives (brains) so that everything we do in relationships runs more smoothly. For those of you who are technophobic (which I am but I just happen to have had the "bios" thingy explained to me once), the bios level of your computer is the level you are almost never aware of. It is operating all the time in the background, quietly running the show. If it gets messed up though, look out. None of your other programs will run. The whole computer will seize up. So that's the level that you need to make sure is running smoothly or else the rest of it doesn't even matter. PACT hits the bios level.
A couple I finished working with not too long ago proved by "bios" theory beautifully. They came in one day and said "we've been thinking it might be time to stop seeing you regularly". They went on to say that they both looked at the lists that they had made before seeking me out. These lists were the things that they both wanted to see change in the relationship. The amazing thing to me was that now they said "we looked at the lists and realized that all of those things are either fixed or no longer important to us but we don't remember discussing them in here with you!". Ah, bios. See, we fixed the deeper problems that were quietly running their relationship amok but that they did not know were there. They were so stuck on fixing the "I hate it when you don't do your share of housework" programs/patterns that they did not realize that there was a deeper level that was driving the rest of the mess. When we worked on that everything else miraculously (or really not so miraculously!) shifted. The rest of the stuff either got fixed without my help or they no longer cared about it because they were so thrilled about the rest of the relationship that those things seemed trivial now.
To me, that's the elegance of PACT. It gets right to the underlying issues without getting stuck in the daily "who left the cap off the dang toothpaste" stuff. It's surgical. Which makes is not only more effective but so much faster than other theories I have been exposed to. And as much as I love doing therapy, no one wants to be in therapy forever.
So there you go. Buy it. Listen to it. If you are a therapist it will improve your work. If you are in a couple it will improve your relationship. If you aren't currently in a couple it will give you some great stuff to think about before you get into the next relationship. The whole download takes about 5 hours, which sounds like a lot but I found that if I just played it while I was driving back and forth to work each day that I had listened to the whole thing in less than a week. So don't let the length intimidate you. Also don't let the idea that it has some neuroscience intimidate you. As much as I love the brain that was NOT my best class in graduate school. Dr. Tatkin is gifted at making difficult stuff easy to understand so that even those of us who could not currently pass a high school chemistry class can still understand his work.
I hope you give it a try.
First let me say that this blog topic has been on my "to do" list for months. I keep putting it off, frankly, because it's complicated. Psychotherapy has been around formally for about 200 years. However scientific studies explaining exactly how therapy causes change have only been around for about 50 of those. Studies that are able to look inside the brain and show brain changes associated with psychotherapy have been around even less.
Furthermore there are a lot of really good articles on whether or not therapy works. See for instance Jonathan Shedler's article from the University of Colorado Denver School of Medicine entitled "The Efficacy of Psychodynamic Psychotherapy" published in the American Psychologist (2010, 65(2), 98–109). Schedler makes an impressive case for the fact that psychodynamic psychotherapies are very effective and that their effects persist for years after finishing treatment. However, his article, and many others that I have read do not explain HOW psychotherapy works.
While I am prone to want to explain as much as possible through the physical sciences there are a number of theories that are worth exploring as well. So I will put off the neuroanatomy and biochemistry piece until the end of the blog. We'll get there but let's first look at some of the theories that make a lot of sense even without the functional MRI's to back them up.
If you start with Freud you would find that surprisingly some of his ideas still make sense in terms of how therapy works. Freud believed that we repressed things that were too painful or triggering to manage on a conscious level. These could be aggressive feelings, love feelings, sexual feelings or any manner of things. He felt that urges were going to seek expression one way or another and that it was up to the person to try to find a socially and morally acceptable way to express these baser "drives". So for example a person with a high aggressive drive could become a professional football player (an acceptable "sublimation" of the drive) or could become a thug who goes around beating up people. Some people, for various reasons usually stemming from their early childhood experiences, may have trouble finding acceptable expressions for their not-so-nice drives. Those people might, in Freud's opinion, develop symptoms like panic attacks, bouts of depression, or even more bizarre neurological problems like sudden blindness. He felt that by helping the patient to reconnect to those baser drives and accept their existence, and then find a more appropriate form of expression, patients could be freed from their neurotic suffering. While a lot of what Freud believed now feels outdated and archaic, I agree with his central idea that when we cannot accept parts of ourselves and instead shove those into the unconscious realm we may develop painful symptoms that then lead us to therapy. Many of the different styles of therapy that came after Freud actually took pieces of his theory and modified them, indicating that at least some of what he postulated continues to be useful.
One group of clinicians that I think do a good job of explaining how therapy works is the "(intensive) short-term dynamic psychotherapy" group, also called STDP or ISTDP. Authors in this area include Habib Davenloo (it's originator), David Malan, Robert Neborsky and Marian Solomon. This camp of therapists believe that therapy works in a very predictable (and thankfully replicable) way. First, they conceptualize emotional problems as stemming from fear of experiencing certain painful emotions. These tend to be anxiety, shame, guilt, pain, contempt and disgust. Due to our inability to tolerate these intensely negative feelings we respond in maladaptive ways. For example due to intense shame a person may hide aspects of themselves which leads to feelings of loneliness, disconnection and an intensifying of the shame. From the ISTDP perspective therapy works by helping the client to 1) recognize that they have defensive habits (such as attacking the self), 2) be motivated to change this defensive habit, 3) identify the feelings that are being avoided, 4) allow themselves to experience the avoided feelings within the therapy session (where it can be supported), 5) learn to express those feelings in more adaptive ways outside of the therapy sessions and 6) recognizing that by acting differently with others you have created a new identify for yourself that has replaced the defensive pattern with a more adaptive one. According to research in the Harvard Review of Psychiatry in 2012, is a highly effective type of therapy. For those of us who use psychodynamic theory in our practices ISTDP has many elements that are common to psychodynamic therapy in general. Indeed other studies have shown that psychodynamic psychotherapy is also a very effective form of treatment.
Another theory about how psychotherapy works was highlighted in an article on time.com recently. The article discussed the idea of "narrative". Each of us has a story that we tell ourselves (and others) about our lives. When this story is incomplete or flawed in major ways it can interfere with our happiness. For example if our "narrative" is that we were lazy and never tried hard and that's why we quit college and have never achieved much that story could easily lead us to feel depressed and self-loathing. What if the real narrative was more like we had an undiagnosed learning disability, making it hard for us to learn in a traditional environment, causing us to fall behind due to lack of educational success? That narrative leaves much more room for healthy self-esteem and hope for the future. Some therapists believe that helping patients "rewrite" their narrative or life story in a way that is more balanced can lead to letting go of old pains, shame, guilt and negativity. I do think that this is often a component of successful psychotherapy and have seen this alone change people's lives in dramatic ways.
OK now that we have considered some theories and research on technique we can move on to my beloved psychoneurobiology explanation. In an article published in 2011 in Psychiatric Times numerous brain changes were identified as related to psychotherapy. Some of those were similar to the effects of antidepressants but some were distinctly different. Some of the effects reported included changes in activity/metabolism in various areas of the brain (such as the medial frontal cortex or the hippocampus) while others showed changes in the chemical serotonin and it's transport within the brain. Finally more recent studies have looked at structural changes in individual neurons that are thought to be produced by learning. So while the results of various studies differ in terms of how or where the brain changes are taking place, the overall conclusion is that psychotherapy DOES change the brain chemically and anatomically, and that those changes are related to a reduction of symptoms in the therapy graduates.
While there are other explanations of how therapy works I hope that these at least give you an overview of some of the more well-researched ones. As new research emerges I am sure I will be making updates to this particular blog for those of you who are interested in the underlying curative factors of this strange and powerful endeavor we call psychotherapy.
We've all been there. Someone cuts you off in traffic, or your spouse pushes a particular button, or your child whines for just a few minutes too long and...wham! You have devolved into a stress-ball and can no longer stay calm and act rationally. You yell, or snipe, or attack, or shut down. In short, you have "flipped your lid". The "smart parts" of your brain have been hijacked by the emotional center and you now cannot access the higher areas of your brain that normally allow us to be rational and reasonable people.
As the "hand model" of the brain to the left illustrates, our brain is made up of lots of different parts. If your hand is clenched in a fist the fingers that are visible will represent your higher cortical areas such as the frontal lobe. This is, as I like to refer to it, the "Spock center". It's the part of the brain that can help us not intentionally ram the car in front of us when they cut us off in traffic. It helps us to inhibit responses and respond rationally and calmly.
Sadly that part of the brain gets disconnected under high levels of stress. Yes, folks, just when we need it most our higher cortical areas literally go "off-line". So who is running the show at that point? You guessed it, our emotional center. The limbic system, represented in our hand model by the thumb, is now in charge. Which is why when we are highly triggered we tend to say and do things we regret later, when our higher cortical areas come back online and assess the damage.
Under normal circumstance when we are not too stressed out our limbic system is still active and reacting but the cerebral cortex is "wrapped" around it (as in the illustration of the fist) so that it "hugs" the emotional center and keeps it relatively quiet. There are literally bundles of nerves that carry information from our frontal lobe to our limbic systems when things are running smoothly. This keeps us from killing people whenever we get slightly stressed out. Normally this system works well enough to keep most of us out of trouble most of the time. However, when the stress gets too high, those fibers stop carrying information from the cortex (as in the illustration with the hand extended upwards) and the limbic system has free reign. It's like letting your 3 year old drive the car on the freeway. Not such a good idea and we should not be surprised when there is a multi-car pile-up!
So, what can one do in this situation? Well, here is what most of us try, which incidentally doesn't work: we try to talk rationally to the other person. We try to explain or rationalize or educate them out of their feelings. The problem here is that we are talking from our cerebral cortex and their cerebral cortex is not operational. So it can't hear us. And the limbic system doesn't speak that language. In fact it doesn't really understand language. It's much more influenced by things like tone and volume of voice, gestures and facial expressions. So if you can see that someone has flipped their lid, the best thing you can do is to show that person that you understand how they feel. This is creating a connection between your limbic system/emotional center and theirs. So if my friend is frustrated with me and I show her that I understand that feeling through my facial expressions, voice and gestures our brains are now connected. At that point I have the opportunity to influence her brain because we have an "open channel" between the two systems. So I can now start to offer calming words, sounds and gestures (such as smiling, gentle touching, quiet and low tones of voice) that will start to calm down her nervous system. As her limbic system begins to get more calm her cerebral cortex will come back on-line and now I can communicate with her logical brain from my logical brain.
Notice that this strategy is about how to manage another person when they come unglued. That's because the fastest and most efficient way for a human brain to get calm is to use another human brain. If we have to calm ourselves it takes more oxygen and glucose (the power sources for our brains) so it's more resource-intense. We can, of course, calm ourselves if we have to. Other people are not always available. But the optimal way to handle a flipped lid is to have another person who can connect to our brains and calm us down. Humans are, after all, pack animals and we derive numerous benefits from living in groups.
So next time you flip your lid, or observe one of your pack flip theirs, remember to get the emotional connection established FIRST and then, only after the emotional intensity has dissipated, try to connect to the logical parts.
For more information on interpersonal neurobiology and the science of our connection to others see the work of Dan Siegel, MD, and Stan Tatkin, PsyD. Or stay tuned for more blog posts on this website.
Krista Jordan, Ph.D.
Dr. Jordan has been in private practice for 20 years in Texas. She is passionate about helping people to overcome hurts and obstacles from their past to find more happiness and health in their current lives.