Minds made up: a vignette

It is not the content but the conditions of thought that therapy seeks to change

Photo by Brett Jordan on Unsplash

More and more I am convinced that what we call our “mind” is co-created, starting with our earliest environments and the support provided via caregiving, teaching, friendship, and sociocultural influence.  Winnicott understood a young mind is to be nurtured and supported, not controlled or imposed upon.  Otherwise the person learns not to trust their own thoughts, perceptions, or beliefs: potential catastrophe.

Many patients suffer from a debilitating anxiety that gnaws at their ability to think.  Many conclude, and sometimes me with them, that it is not the conditions but the content of the thinking that lies at the heart of the issue—that “better thoughts” might reduce anxiety.  Sometimes that is true, in that positive thinking might lower angst, but the danger is in getting caught up in the letter rather than the spirit of intention.  What most of us need is an accepting surround that assists our independent thinking, within an inter-dependent relationality.

Patients often get angry at the thoughts themselves, as if they are “improper”.  Why am I so negative…I’m super critical of people I love…I don’t know the words to say.  Sometimes having the words is important, but usually the “right words” are found within a nurturing ambience that challenges old, often debilitating ideas, including those “isms” (sexism, racism, anti-semitism) that devalues humanity.  

The problem in other words is not the script but rather the residue of unresolved anxiety that impedes and devours one’s ability ability to write a script of one’s own, think for and like oneself, doubt like a sand creature from Dune: a devouring hunger in the rumbling sands.  The hunger is often for familiarity—the repetition of always being wrong, to keep the (dysfunctional) status quo, not risk alienation of exile. 

No sooner is an original thought constructed or emotion sensed than both are sucked down the gullet of an abyss, with no end in sight.

When Winnicott speaks of a holding environment, I believe he is referring in part to the therapist’s ability to help patients hold their own psyches in the discovery of what they believe and perceive, a giving birth to one’s own mind, a painful process involving the death of long-held perceptions and beliefs no longer useful.  Such a darkness illuminates the affective hunger of one’s environments.

It might involve recognizing the inadequacy of the original scenario, when the patient felt responsible for the caregiver’s failings, or cultural biases, coercively covered up.

Without such a rebirth, the person’s perspective remains unreal, undeserving of loyalty. 

Therapists are not immune, either; it surprises me how my own apprehension contributes to the process. But upon revelation it is plain as day.

I recall a rough stretch with a patient who had trouble starting sessions.  Alan was in his early 30s, intensely smart and successful but very lonely, terrified of intimacy, while wrestling with a devilish mixture of sympathy and rage towards his alcoholic mother; his father, now remarried, kept his distance from his ex-wife and the child who reminded him of the tumultuous marriage. If there was any holding in that early environment, it was provided by Alan himself. 

For any autonomous step of Alan’s prompted his mother’s anger, criticism, and his subsequent guilt.  He was perpetually stuck, and took it out on himself. When he took it out on me, I belatedly saw it as necessary to Alan’s freedom.

Things stalled after a promising beginning of twice-a-week sessions. Soon Alan would pensively say at the start, “everything’s basically ok with me, where should we start?”  I did not want to “rescue” or enable him, and I felt it important to stick to the principle of the patient bringing in what they want to discuss, rather than my doing so and enabling avoidance. 

Yet my attempts to discuss his lack of a topic, the curious statement that he was “fine” while coming to therapy (which he insisted was helpful), went nowhere.  He did want something, but what?  He insisted he didn’t know and wasn’t hiding anything, which sounded genuine. Yet I thought,  He’s dodging something.  I wrestled with frustration as our trial and error went nowhere. I myself was avoiding something, it took time to see.

At times we found rhythm and momentum on a problem to tackle, but then came the brakes, as he returned the next week to say everything was fine and there was nothing “important” to discuss.  Obviously this was our topic, me applying moderate pressure to understand it, both of us going in circles—"well Alan I wonder what’s hard about finding a topic” “If I knew that, doc, I’d tell you!”—until one day he became irritated and snapped, “Why don’t you believe me when I say ‘I don’t know’?  Because I don’t.  I just…lack the vocabulary.”  Here the light went on. I was literally asking the impossible.

Unconscious processes—including resistance, defense or self-protection, wishes and fears—are just that: out of consciousness. Oftentimes it is not that patients are repressing such wishes, they just don’t have the practice or the words to express them, for any number of highly distinctive reasons. 

My frustration had also been his; he was fighting a compulsion to disavow his feelings, as I feared overwhelming him with mine, thus acting like his mother. In other words there were feelings a-plenty we were both avoiding in fear of coming off as inadequate, “too angry”, two nice guys going in circles.

This is why he often interrupted himself during a meaty session to say, “I sound like such a privileged asshole complaining about this.”  Pfffft, like air out of a balloon. This was the maternal repetition; eventually we recognized this as his mother’s way of thinking, imposed on his consciousness to keep him in his place, immobilized, in her own (unconscious) fear of being alone. (Alan’s older sibling lived with dad and easily departed for college, stoking Alan’s envy.)

Meanwhile I myself had been anxious, torn between wanting to “follow the rules” like the Ten Commandments (don’t enable!), as the “therapy police” whispered in my ear.  I missed how dangerous feelings were for Alan, distracted by the nuance of his thought (he was indeed brilliant)—emotion being the white whale I was after and that he (ashamedly) had such genuine trouble accessing.  I tried to “speak his language” in explaining emotion, soon joining him in the sticky web of deadening cerebrality.

Any genuine maternal function of soothing and creative possibility had been sapped via that sandworm, lunching on both of us.

Alan in fact had never been encouraged or shown how to play any basic language game—I’m scared, I want—so constrictive was his home.  After a while he didn’t even think of going there, because the lack of practice meant “there” felt like nowhere.

Why hadn’t I seen this sooner?  Probably because I was caught in parental pressure of my own—namely, an old paternal pressure to “get it right,” not mess up (as with my theoretical inflexibility): stick to the rules, lest my own actual father (martini in hand) again chastise me.

One day Alan tried to apologize for being “difficult,” but I insisted there were two of us here, and we each played a part.  And after all his situation was difficult, his fraught emotional existence, the difficulty of vulnerability, in addition to me avoiding the frustration which served as a window into his own unspeakable struggle—all of this sparked by both his struggle to “bring in a topic” and my self-criticism at not being able to help him.  We were both trying too hard. 

But our co-admission lowered anxiety, at which point he felt freer to lean in and associate more to his thoughts and feelings, with my gentle assistance, a kind of squiggle game.

All I had to do, when Alan became stuck, was to refer to what he referred to as “the usual suspects,” his concerns around dating, mom (still drinking), his own drinking binges, and whether or not to contact his father after many years.

Thereafter I referred to “the usual suspects,” when Alan faltered; I did this a grand total of twice. Afterward he easily got the ball rolling. In other words once it was safe not to be perfect, to have all the answers, to not know the relational game he had never learned, he could open up and more freely access his associative feelings, dreams, and ideas.

We both got tripped up on content of thought versus the conditions of thinking.  Alan did not need prompting on the former; rather, he needed to know it was okay to be “bad” or new at something, lest the paralyzing shame return.

In time he was able to trust his own inherent thought process, and continue on with the solid work he had done all along.  He had after all continued to show up.  My reminding him of this, that struggle does not have to equal failure, certainly didn’t hurt.  In this way his achievements were also made real. 

Ultimately patients must decide and act on their own.  Again, I am not there to make up their mind, but rather to facilitate a surround which enables them to do so.  My faith that they can and will is an aspect of therapeutic holding.