The Triad of Experiencing

How I understand patients' reported self-experience--and its impact on me

Three…that’s a magic number. ~ De La Soul

In this column I describe patients’ presented self-experience into three broad categories, depending on which of them “presents” at the forefront of conversation. These categories are the conceptual/cognitive, the embodied, and the contextual/relational.

These are necessarily simplified, each with many “sub-categories.” And ideally they overlap. But for the sake of discussion, I employ these three broad umbrellas.

This three-sidedness is not coincidental. The triangle is a compelling symbol for recovery groups, a couple of which saved my life; here the triangle symbolizes the triadic program of service (action), stepwork (self-appraisal), and fellowship (community.) This echoes Buddhism’s three “jewels” of activity, consisting of the sangha (community), dharma (study), and the Buddha (enlightenment.) (I dabbled in Buddhism for a while and still practice meditation.)

There is also Freud’s trinity of Id, Ego, and Superego, and the tripartite model of analytic training (clinical work, supervision, and personal analysis.)

We also have the holy trinity of Christianity, and Judaism’s Star of David, with its two overlapping triangles. (I could go on and on—with the Three Stooges, for instance, but should probably stop here.)

These somewhat contrived categories overlap at any given moment, working (ideally) in harmony. When watching a movie, for instance, there are the concepts of a story—hero, antagonist, their goals and obstacles—combined with the embodied visual and audio experience, along with the shifting contextual or relational interpolations. It is the affective experience of the story that bridges these together, as in experience itself.

In the context of therapy, these sides are also (again ideally) blended, or at relative proximity, except of course in cases of dissociation or intellectualization—for what of anything is ideal?

In fact these category headings are most useful when one side is stubbornly foregrounded, crowding out the others: if for instance the conceptual is monolithically positioned, throwing shadow against the embodied, a Cartesian separation of mind/body, an isolative decontextualization of experience: an arid language game of “ideas” about life which belies its enervated quality.

Consider another instance, where depression or anxiety present as overly embodied (sluggish or “wired”)—or conceptually overloaded, as in obsessive or intrusive thoughts, where even attempts to locate (let alone contextualize) affect also runs the risk of being conceptualized en toto.

Let us look closer then at this first category, the conceptual, inevitable in any treatment theme or thread—and I daresay my longstanding nemesis.

Conceptuality “runs amok” when (in another example) thought or rationality attempts to control embodied terror, leading to obsessive-compulsive fears unresponsive to therapeutic dialogue. We begin to see the isolating nature of such foregrounding.

I would argue in fact that the potentially grounding impact of a cognitive-behavioral therapeutic approach is rooted in the embodied alliance or empathic authority of the analyst, who offers protective or hopeful guidance (as with a sponsor in recovery.)

Patients often present long-held concepts or ideas about themselves, seemingly cast in cement, with or without (obvious) accompanying affect; this holds even when said concepts are harrowing to my ears. I’m a piece of shit, Doc…. Or they may be seeking conceptual “answers” to complicated psychological problems which, in practice, involve some lived, interactive blend of all sides of the triangle.

This is where self-numbing is frequently utilized, minimizing the (unacknowledged) embodied suffering brought by depressive or anxious stuckness, where many if not most patients, being highly intelligent, attempt to think their way out of quicksand": a concept-heavy modality weighing the person down.

Again, my main point is the overwhelm of one “side” becoming over-prominent, where balance becomes precarious and threatens collapse. This involves, in the treatment scenario (given the intersubjective nature of any relationship), my own over-reliance on the intellectual. I cannot but think of Theseus here, lost in the labyrinth, stalked by the Minotaur of repetitive trauma or agony.

I’m thinking of one former patient of mine from years back, a newly retired math professor who spent the months of therapy offering modest but positive self-descriptions, highlighting his sensitivity, intelligence, and generosity most of all. It began to sound like the closing argument of an attorney (albeit dozens of hours long.) But I failed to understand what or who was on trial, or what the charge was.

It took me a long time—a bit too long, in retrospect—to see that this Kafka-esque process foregrounded an anxious demand upon himself hovering in the margins, defending against even a whiff of ingratitude or volatility: a family command of old to “stay positive” lest he be seen as selfish or self-centered, thus worthy of rejection by caregivers.

This was his relational dilemma: it was risky to offer anything but positive feedback to others, even when he felt hurt or slighted (which was, we discovered, more often than he thought.) He twisted himself in pretzels trying to “stay positive,” which led to anxiety attacks upon awakening. But it was my dilemma too, as he remained highly reluctant to discuss any of his own emotional conflict or uncertainty.

The anxiety of straying from this line of discussion, increasingly stifling, kept both of us stuck. Eventually I risked an aside, telling him I knew he was really angry at someone when he got them a gift. He laughed at this, with relief perhaps at having to put down the enormous globe. And frankly he was not alone.

It was then I saw that his descriptions were in part a gift to me, in his indirect insistence of not being a “difficult” patient. In fact I often wish patients would be more difficult! For many, the only thing worse than suffering in isolation is overburdening others.

This kind of imbalance, an imprisoning concept-heavy mode of relating, keeps affect in abeyance. This carries resonance for me in that I was raised by an intellectually-defended albeit volatile father, vulnerable to the seduction of the conceptual as a means of seeking balance. This hearkens to Wittgenstein’s line about “the bewitchment of language by means of our intelligence.” (At the same time, patients might find the well-timed offering of concepts very useful, in that they feel seen or understood.)

This notion of resonance is straightforward: as one who is sensitive to words, I am prone at times to becoming word-struck.

We cannot live without the cognitive; it is impossible to separate mind from body, even when we are urged to “get out of our head” or “go with our heart” (themselves concepts). Terms like transference or “the body keeps the score” (somaticized trauma) are concepts accompanying embodied experience, essential to understanding.

Embodiment in other words gives dimension to thinking and vice-versa, enabling symbolization or giving context to our story and our lives with others.

Meanwhile our lived concepts organize our conscious maps of meaning: signifiers of our prioritized values, a named partner in our cognitive-affective schemas (or organizing principles), illuminating our forward navigation, the contexts of our forms of life.

Many patients’ concepts of themselves and/or others have freeze-dried into psychic wallpaper, lacking any psychic “charge” whatsoever. The person’s inadequacy is a given, foreclosing exploration. Such concepts are protective and imprisoning both.

Patients often begin with received concepts about how relationships and/or therapy “works,” potentially influencing my own mode of relatedness, when for instance rigidity sets in (on the patient’s part or mine) about the “rules.” I too might become frozen, holding fast to notions that “therapy ‘works’ by revisiting and integrating past trauma,” full stop. But not every patient responds positively to well-traveled concepts.

Any axiom, however useful, threatens to become shibboleth. This holds true as well for the contextual as well, as I will discuss next time.

Often a patient’s longstanding family portrait—painted in the adaptive compulsivity of avoidance, following caregivers’ injunctions—forecloses all but one mode of framing. I think of these as doorstoppers preventing entry, e.g. “my folks did the best they could, let’s move on please.” The framing disappears in the foregrounding of the immovable image.

Many patients furtively attempt to reason their way out of problems—the “paralysis of analysis”—in hope of embodied relief, provided so effectively by drink, drugs, adrenaline, and so on. (Addiction is one of the most dramatic examples of such overemphasis)

And, one might ask, where does affect fit in ? In fact it is precisely this which binds the triangle in porous formation, energizing the lived dimensionality of all of these categories (and their descendants.) It is love or empathic surrounding which leads to the play and creativity of agentic development, the potential space Winnicott spoke of, which caregivers (and analysts) facilitate but don’t control, that gives value to lived understanding and investment (what Freud called libido), enriching the value of balance itself and the possibility of new encounters.

However, the burdening of a young psyche under pressure of a chaotic or parentifying system begins to favor one “side” of the mind-body-other triad (another way to think of the triangle), depleting the oxygen of development, like a credit card which buys temporary sanity at the cost of a derailed selfhood, with accruing “interest” in perpetuity.

I will say more about the other two sides, embodiment and the contextual/relational, and how dreams (and the unconscious) factor into this means of sorting.

Until then, please leave any questions or observations in the comments section. May there be some trace of comfort for us all in these fraught times, relational or otherwise, some semi-balance or equanimity despite such mass uncertainty, as the end-of-year season approaches. And thanks to those who have subscribed and/or just read this, my fiftieth column.