Do your genes determine your entire life?

Do your genes determine your entire life?

Some scientists claim that new discoveries have proved free will is an illusion. Nonsense, says Julian Baggini

 

Thursday 19 March 2015 06.00 GMT

Whenever you read stories about identical twins separated at birth, they tend to follow the template set by the most remarkable of them all: the “two Jims”. James Springer and James Lewis were separated as one-month-olds, adopted by different families and reunited at age 39. When University of Minnesota psychologist Thomas Bouchard met them in 1979, he found, as a Washington Post article put it, both had “married and divorced a woman named Linda and remarried a Betty. They shared interests in mechanical drawing and carpentry; their favourite school subject had been maths, their least favourite, spelling. They smoked and drank the same amount and got headaches at the same time of day.” The similarities were uncanny. A great deal of who they would turn out to be appears to have been written in their genes.

Other studies at the world-leading Minnesota Center for Twin and Family Research suggest that many of our traits are more than 50% inherited, including obedience to authority, vulnerability to stress, and risk-seeking. Researchers have even suggested that when it comes to issues such as religion and politics, our choices are much more determined by our genes than we think.

Many find this disturbing. The idea that unconscious biological forces drive our beliefs and actions would seem to pose a real threat to our free will. We like to think that we make choices on the basis of our own conscious deliberations. But isn’t all that thinking things over irrelevant if our final decision was already written in our genetic code? And doesn’t the whole edifice of personal responsibility collapse if we accept that “my genes made me do it”? To address these concerns, we first need to look a bit more closely at what the experiences of identical twins really show.

Professor Tim Spector has been studying identical twins at King’s College London for more than 20 years. From the start of his research in the early 1990s, it became evident to Spector that identical twins were always more similar than brothers or sisters or non-identical twins. At the time, however, “social scientists hated the idea” that genes were an important determinant of who we were, “particularly in those rather controversial areas like IQ, personality and beliefs”. As “one of the many scientists who took the gene-centric view of the universe for granted”, Spector wanted “to prove them wrong, and to prove that there’s nothing that’s not genetic to some extent”. Today, he looks back on this as part of his “overzealous genetic phase”.

It is perhaps understandable that Spector got caught up in gene mania. The launch in 1990 of the Human Genome Project, which aimed to map the complete sequence of human DNA, came at the beginning of a decade that would mark the high point of optimism about how much our genes could tell us. Daniel Koshland, then editor of the prestigious journal Science, captured the mood when he wrote: “The benefits to science of the genome project are clear. Illnesses such as manic depression, Alzheimer’s, schizophrenia, and heart disease are probably all multigenic and even more difficult to unravel than cystic fibrosis. Yet these diseases are at the root of many current societal problems.” Genes would help us uncover the secrets of all kinds of ills, from the psychological to the physical.

Ten years later, Bill Clinton and Tony Blair were among the guests gathered to “celebrate the revelation of the first draft of the human book of life”, as Francis Collins, the director of the Human Genome Project, put it. “We try to be cautious on days like this,” said the ABC news anchor, “but this map marks the beginning of an era of discovery that will affect the lives of every human being, with implications for science, history, business, ethics, religion, and, of course, medicine.”

By that time, genes were no longer simply the key to understanding health: they had become the skeleton key for unlocking almost all the mysteries of human existence. For virtually every aspect of life – criminality, fidelity, political persuasion, religious belief – someone would claim to find a gene for it. In 2005 in Hall County, Georgia, Stephen Mobley tried to avoid execution by claiming that his murder of a Domino’s pizza store manager was the result of a mutation in the monoamine oxidase A (MAOA) gene. The judge turned down the appeal, saying that the law was not ready to accept such evidence. The basic idea, however, that the low-MAOA gene is a major contributing cause of violence has become widely accepted, and it is now commonly called the “warrior gene”.

In recent years, however, faith in the explanatory power of genes has waned. Today, few scientists believe that there is a simple “gene for” anything. Almost all inherited features or traits are the products of complex interactions of numerous genes. However, the fact that there is no one genetic trigger has not by itself undermined the claim that many of our deepest character traits, dispositions and even opinions are genetically determined. (This worry is only slightly tempered by what we are learning about epigenetics, which shows how many inherited traits only get “switched on” in certain environments. The reason this doesn’t remove all fears is that most of this switching on and off occurs very early in life – either in utero or in early childhood.)

What might reduce our alarm, however, is an understanding of what genetic studies really show. The key concept here is of heritability. We are often told that many traits are highly heritable: happiness, for instance, is around 50% heritable. Such figures sound very high. But they do not mean what they appear to mean to the statistically untrained eye.

The common mistake people make is to assume that if, for example, autism is 90% heritable, then 90% of autistic people got the condition from their parents. But heritability is not about “chance or risk of passing it on”, says Spector. “It simply means how much of the variation within a given population is down to genes. Crucially, this will be different according to the environment of that population.

Spector spells out what this means with something such as IQ, which has a heritability of 70% on average. “If you go to the US, around Harvard, it’s above 90%.” Why? Because people selected to go there tend to come from middle-class families who have offered their children excellent educational opportunities. Having all been given very similar upbringings, almost all the remaining variation is down to genes. In contrast, if you go to the Detroit suburbs, where deprivation and drug addiction are common, the IQ heritability is “close to 0%”, because the environment is having such a strong effect. In general, Spector believes, “Any change in environment has a much greater effect on IQ than genes,” as it does on almost every human characteristic. That’s why if you want to predict whether someone believes in God, it’s more useful to know that they live in Texas than what their genes are.

Statistical illiteracy is not the only reason why the importance of environmental factors is so often drowned out. We tend to be mesmerised by the similarities between identical twins and notice the differences much less. “When you look at twins,” says Spector, “the one thing that always seems to come out are the subconscious tics, mannerisms, postures, the way they laugh. They sit the same, cross their legs the same, pick up cups of coffee the same, even if they hate each other or they’ve been separated all their lives.” It’s as though we cannot help thinking that such things reflect deeper similarities even though they are actually the most superficial features to compare. If you can stop yourself staring at the similarities between twins, literally and metaphorically, and listen properly to their stories, you can see how their differences are at least as telling as their similarities. Far from proving that our genes determine our lives, these stories show just the opposite.

***

When Ann and Judy from Powys, mid-Wales were born in the 1940s, they were the last thing their working-class family with five children needed. So, identical or not, Ann and Judy were packed off to live with different aunts. After three months, Judy returned to her biological mother, as her aunt could not manage raising another child. But for the childless 50-year-old couple who took on Ann (without ever formally adopting her), the late opportunity for parenthood was a blessing and she stayed.

Ann and Judy, who are now well into retirement, told me their story in Ann’s home in Crickhowell on the edge of the Brecon Beacons, over coffee and home-made Welsh cakes. Their experience is a valuable corrective for anyone who has been impressed by tales of how identical twins show that we are basically nothing but the products of our genes.

Although the girls grew up in the same town, they ended up living in different areas and went to different schools. The two households in which Ann and Judy grew up were very different. Judy’s father drove trains inside the steelworks, and her mother, like most women at the time, did not have a job. The family lived in a basic two-up, two-down house with a toilet at the bottom of the garden. Judy’s four older brothers were all out working by the time she was five and she was left with her older sister Yvonne.

Ann was brought up in a newly built, semi-detached house, with a toilet indoors. Her father was also a manual labourer in the steelworks, but they were relatively well off, partly because they hadn’t had children but also because they were “very careful with

money”. Ann recalled that “the sugar bowl was never filled so as not to encourage people to take too much”.

Where Judy told me she “was a street kid, always out”, Ann said she always had her “nose in a book because I was on my own”. And while Ann passed the 11-plus exam and got into the grammar school, Judy didn’t, and ended up at the secondary modern. Although, aged 15, Judy was offered a place at a grammar school, when she got there she found herself suddenly studying algebra and geometry in a class where everyone else had already being doing it for three years. Unsurprisingly she struggled. After four months, Judy quit and went to work in a furniture shop.

Ann, meanwhile, breezed through school, although she, too, left early because her now 66-year-old father was retiring. “I just felt that it wasn’t fair for me to stay on at school when they were on a pension,” she said. At 16, Ann began her white-collar job in the local council offices, not long after Judy had started working on the shop floor.

Although the twins’ paths had diverged up to this point, the next stage in the story is the moment where their stories converge in an uncanny way. Less than six months into her job, Ann got pregnant and quit. Two months later, Judy also got pregnant and quit the nursing course she was enrolled in. Not only that, but both fathers, soon husbands, turned out to be very violent.

However, the differences in what happened next are instructive. Ann didn’t stay married for long. “I left and went back home, and they were very supportive when they found out what was going on.” Judy, in contrast, stayed with her husband for 17 years. “I did leave him, mind, but I kept going back. I didn’t have the support. I had three children by the time I was 21.” Her mother was no help. “My mother’s attitude was, you made your bed, you lie on it,” Judy explained. Ann understands Judy’s acquiescence perfectly. “Imagine being at home, with three children, no qualifications, nothing on the horizon to see your life was going to get better, which I did have.”

The two only really started a proper sibling relationship after Ann read about the Minnesota University research in the paper and wrote to the university about her and her sister. When they were 48, they travelled together to Minnesota to meet scientists there. Now the twins are both retired. Judy says, “I think from where we started we’ve travelled the same distance.”

But there were important differences in how their lives went, and so too in the people they became. Most obviously, Ann has always had more money, but you can also see the effects of their different backgrounds on their health. “Judy’s had a hysterectomy, I haven’t,” says Ann. “Judy’s got a problem with her kidneys. I don’t. Judy’s got blood pressure, I haven’t. But she’s stronger than me.”

There are also differences in how they think and behave socially. Although their political views are very similar, Judy says, “I’m a Christian, well, probably agnostic, I think,” whereas Ann is “a confirmed atheist”. Ann also thinks she’s “much more diplomatic. Judy is just rude. That’s probably the educational background coming through. ‘Interfering’ is

too strong a word, but Judy is more involved with her children and grandchildren in an advisory capacity, whereas I wouldn’t do that.” Much of this, they agree, is surely down to culture, with Ann being encouraged to adopt more genteel middle-class ways.

Ann and Judy’s story illustrates that our genes only set down what might be described as a field of possibilities. These set limits on what we are to become – so whatever our upbringings, most of us will tend towards introversion or extroversion, jollity or sobriety, facility with words or numbers. But this is far from the claim that we become is essentially written in our genes. Rather, various options are pencilled in, and our life experiences determine which get inked.

***

Tim Spector’s view that environment is almost always more influential than genes is clear in the case of Ann and Judy. The sisters shared the same genes but with a middle-class background Ann did better at school, earned more money and has enjoyed better health. Too much attention to genes blinds us to the obvious truth that access to financial and educational resources remains the most important determinant of how we fare in life.

Although being more middle class might improve your odds of success in life, other non-genetic factors play a huge role. Take the war babies Margaret and Eileen from Preston, Lancashire, another set of identical twins who were brought up in different families. Margaret’s adoptive parents owned their own house. Eileen’s toilet was at the bottom of the garden. And yet it was Margaret who flunked her 11-plus, simply out of nerves, while Eileen passed hers. Margaret’s adoptive mother was “hard”, and when her daughter passed her 11-plus on the second attempt she said she couldn’t go to the grammar school anyway because she had already bought the uniform for the other school. As Margaret says to Eileen now, “Your mum told you you were loved and you had to be adopted. My mum never said that. I remember waking up when I was eight years old and thinking, somebody had me and they didn’t want me. It’s horrifying, really traumatic for an eight-year-old.”

Eileen agrees that she came out better when it came to love and affection. “My mother always said Ellen [the twins’ birth mother] was very good to give me to her. She always pointed that out, and they picked me because they wanted me. I was secure despite the fact that I had to go and live in this tatty bungalow.”

Another difference in how their lives have progressed has been their choice of husbands. “You’ve been further afield than I have,” says Eileen to Margaret, turning to me and adding, “I think she’s more or less finished her bucket list. My husband won’t go. He’s not interested in travel. I’ve had to drag him out of the country.”

***

Identical twins show us that in the nature-versus-nurture debate, there is no winner. Both have their role to play in shaping who we are. But although we have reason to doubt that our genes determine our lives in some absolute way, this does not solve a bigger worry about whether or not we have free will.

Who we are appears to be a product of both nature and nurture, in whatever proportion they contribute, and nothing else. You are shaped by forces beyond yourself, and do not choose what you become. And so when you go on to make the choices in life that really matter, you do so on the basis of beliefs, values and dispositions that you did not choose.

Although this may appear troubling, it is hard to see how it could be any other way. For example, say you support a more redistributive tax system, because you think that is fair. Where did that sense of fairness come from? You may well have thought it through and come to a conclusion. But what did you bring to that process? A combination of abilities and dispositions that you were born with, and information and thinking skills that you acquired. In other words, a combination of hereditary factors and environment. There is no third place for anything else to come from. You are not responsible for how you emerged from the womb, nor for the world you found yourself in. Once you became old enough and sufficiently self-aware to think for yourself, the key determinants in your personality and outlook were already set. Yes, your views might be changed later in life by powerful experiences or persuasive books. But again, you do not choose for these things to change you. The very way we speak about such experiences suggests this. “This book changed my life,” we say, not “I changed my life with this book”, acknowledging that having read it, we did not choose to be different; we simply could never be the same again.

The literature on free will tends to focus on moments of choice: was I free at that point to do other than what I did? When we ask this, it often seems to us that only one option was viable. Sometimes this is because we think circumstances constrain us. But perhaps a more fundamental reason why at the moment of choice we cannot do otherwise is that we cannot be other than who we are. The nature of the chooser is the key determinant at the moment of choice: who we are comes first and what we do follows.

To be considered truly free, then, it would seem to be necessary for us to be in some sense responsible for being the people we are, and that responsibility needs to go “all the way down”: it has to be up to you and you alone what values and beliefs you hold dear and act upon. If we are not responsible for who we are, how can we be held responsible for what we do? But when we consider the dual roles of nature and nurture, the values we hold and beliefs we assert do not appear to be a matter of choice. We are formed by forces ultimately beyond our control. This thought, once made explicit, leads many to the conclusion that free will and responsibility are impossible. If you dig deep enough into what made us who we are, eventually you come across some key formative factors that we did not control. And if they are beyond our control, how can we be responsible for them?

***

On reflection, though, we ought to be more sanguine about not having complete control. The first step towards acceptance is to realise that it would be a very odd person whose actions did not in some sense flow from her values and beliefs. And yet the more strongly we hold these, the less we really feel free to choose other than the way we do. In 1521, the Reformation priest Martin Luther, for example, is reported to have told those who accused him of heresy at the Diet of Worms, “Here I stand. I can do no other.” This is not a denial of his freedom but an assertion of his freedom to act according to his values.

We cannot change our characters on a whim, and we would probably not want it any other way. A committed Christian does not want the freedom to wake up one day and become a Muslim. A family man does not want to find it as easy to run off with the au pair as to stick with his children and their mother. A fan of Shostakovich does not, usually at least, wish she could just decide to prefer Andrew Lloyd Webber. The critical point is that these key commitments don’t strike us primarily as choices. You don’t choose what you think is great, who you should love, or what is just. To think of these fundamental life commitments as choices is rather peculiar, perhaps a distortion created by the contemporary emphasis on choice as being at the heart of freedom.

What’s more, the idea that any kind of rational creature could choose its own basic dispositions and values is incoherent. For on what basis could such a choice be made? Without any values or dispositions, one would have no reason to prefer some over others. Imagine the anteroom in heaven, where people wait to be prepared for life on Earth. Some angel asks you, would you like to be a Republican or a Democrat? How could you answer if you did not already have some commitments and values that would tip the balance either way? It would be impossible.

Throughout human history, people have had no problem with the idea that their basic personality types were there from birth. The idea of taking after your parents is an almost universal cultural constant. Discovering just how much nature and nurture contribute to who we are is interesting, but doesn’t change the fact that traits are not chosen, and that no one ever thought they were.

Accepting this is ultimately more honest and liberating than denying it. Recognising how much our beliefs and commitments are shaped by factors beyond our control actually helps us to gain more control of them. It allows us to question our sense that something is obviously true by provoking us to ask whether it would appear so obvious if our upbringing or character had been different. It is only by recognising how much is not in our power that we can seize control of that which is. Perhaps most importantly, accepting how much belief is the product of an unchosen past should help us to be less dogmatic and more understanding of others. It doesn’t mean anything goes, of course, or that no view is right or wrong. But it does mean that no one is able to be perfectly objective, and so we should humbly accept that although objective truth is worth striving for, none of us could claim to have fully attained it.

***

Some may not be convinced yet that we should be so relaxed about our debt to nature and nurture. Unless we are fully responsible, it might seem unjust to blame people for their actions. If this seems persuasive, it is only because it rests on the false assumption that the only possible form of real responsibility is ultimate responsibility: that everything about who you are, what you believe and how you act is the result of your free choices alone. But our everyday notion of responsibility certainly does not and could not entail being ultimately responsible in this way. This is most evident in cases of negligence. Imagine you postpone maintaining a roof properly and it collapses during an exceptionally fierce storm, killing or injuring people below. The roof would not have collapsed if there had not been a storm, and the weather is clearly not in your control. But that does not mean you should not be held responsible for failing to maintain the building properly.

If the only real responsibility were ultimate responsibility, then there could never be any responsibility at all, because everything that happens involves factors both within and outside of our control. As the philosopher John Martin Fischer succinctly and accurately puts it, “Total control is a total fantasy – metaphysical megalomania.”

Many arguments that purport to debunk free will are powerful only if you buy into the premise that real responsibility is ultimate responsibility. Almost all those who deny free will define responsibility as though it must be total and absolute, or it is nothing at all. The Dutch neuroscientist Dick Swaab, who calls free will “an illusion”, does so by endorsing the definition of free will by Joseph L Price (a scientist, not a philosopher) as “the ability to choose to act or refrain from action without extrinsic or intrinsic constraints”. No wonder he is forced to conclude that, “Our current knowledge of neurobiology makes it clear that there is no such thing as absolute freedom.” Similarly, he claims that the existence of unconscious decision-making in the brain leaves “no room for a purely conscious, free will”. That’s true. The only question is why one would believe such absolute or pure freedom is possible or necessary.

The answer would appear to be to justify eternal damnation. As Augustine put it in the fourth century, “The very fact that anyone who uses free will to sin is divinely punished shows that free will was given to enable human beings to live rightly, for such punishment would be unjust if free will had been given both for living rightly and for sinning.” If the buck doesn’t stop with us, then it can only stop with the one who created us, making God ultimately responsible for our wickedness. Hence, as Erasmus put it, free will is theologically necessary “to allow the ungodly, who have deliberately fallen short of the grace of God, to be deservedly condemned; to clear God of the false accusation of cruelty and injustice; to free us from despair, protect us from complacency, and spur us on to moral endeavour.”

The ultimate punishment requires an ultimate responsibility which cannot exist. That is why we should not be worried to discover that factors outside our control, such as our genetic makeup, are critical to making us the people we have become. The only forms of freedom and responsibility that are both possible and worth having are those that are partial, not absolute. There is nothing science tells us that rules out this kind of free will. We know people are responsive to reasons. We know we have varying capacities of self-control which can be strengthened or weakened. We know there is a difference between doing something under coercion or because you decide yourself you want to. Real free will, not a philosopher’s fantasy, requires no more than these kinds of abilities to direct our own actions. It does not require the impossible feat of having written our own genetic code before we were even born.

If we become accustomed to thinking of freedom as completely unfettered, anything more limited will at first sight look like an emaciated form of liberty. You might even dismiss it as mere wiggle room: the ability to make limited choices within a framework of great restraint. But that would be a mistake. Unfettered freedom is not only an illusion; it makes no sense. It would not be desirable even if we could have it. Quite simply, the commonplace idea of free will we must ditch was always wrong. Good riddance to it.

Do your genes determine your entire life?

Therapy wars: the revenge of Freud

An interesting article from the Guardian about the waning supremacy of CBT..

Cheap and effective, CBT became the dominant form of therapy, consigning Freud to psychology’s dingy basement. But new studies have cast doubt on its supremacy – and shown dramatic results for psychoanalysis. Is it time to get back on the couch?

Oliver Burkeman

Dr David Pollens is a psychoanalyst who sees his patients in a modest ground-floor office on the Upper East Side of Manhattan, a neighbourhood probably only rivalled by the Upper West Side for the highest concentration of therapists anywhere on the planet. Pollens, who is in his early 60s, with thinning silver hair, sits in a wooden armchair at the head of a couch; his patients lie on the couch, facing away from him, the better to explore their most embarrassing fears or fantasies. Many of them come several times a week, sometimes for years, in keeping with analytic tradition. He has an impressive track record treating anxiety, depression and other disorders in adults and children, through the medium of uncensored and largely unstructured talk.

To visit Pollens, as I did one dark winter’s afternoon late last year, is to plunge immediately into the arcane Freudian language of “resistance” and “neurosis”, “transference” and “counter-transference”. He exudes a sort of warm neutrality; you could easily imagine telling him your most troubling secrets. Like other members of his tribe, Pollens sees himself as an excavator of the catacombs of the unconscious: of the sexual drives that lurk beneath awareness; the hatred we feel for those we claim to love; and the other distasteful truths about ourselves we don’t know, and often don’t wish to know.

But there’s a very well-known narrative when it comes to therapy and the relief of suffering – and it leaves Pollens and his fellow psychoanalysts decisively on the wrong side of history. For a start, Freud (this story goes) has been debunked. Young boys don’t lust after their mothers, or fear their fathers will castrate them; adolescent girls don’t envy their brothers’ penises. No brain scan has ever located the ego, super-ego or id. The practice of charging clients steep fees to ponder their childhoods for years – while characterising any objections to this process as “resistance”, demanding further psychoanalysis – looks to many like a scam. “Arguably no other notable figure in history was so fantastically wrong about nearly every important thing he had to say” than Sigmund Freud, the philosopher Todd Dufresne declared a few years back, summing up the consensus and echoing the Nobel prize-winning scientist Peter Medawar, who in 1975 called psychoanalysis “the most stupendous intellectual confidence trick of the 20th century”. It was, Medawar went on, “a terminal product as well – something akin to a dinosaur or a zeppelin in the history of ideas, a vast structure of radically unsound design and with no posterity.”

 

A jumble of therapies emerged in Freud’s wake, as therapists struggled to put their endeavours on a sounder empirical footing. But from all these approaches – including humanistic therapy, interpersonal therapy, transpersonal therapy, transactional analysis and so on – it’s generally agreed that one emerged triumphant. Cognitive behavioural therapy, or CBT, is a down-to-earth technique focused not on the past but the present; not on mysterious inner drives, but on adjusting the unhelpful thought patterns that cause negative emotions. In contrast to the meandering conversations of psychoanalysis, a typical CBT exercise might involve filling out a flowchart to identify the self-critical “automatic thoughts” that occur whenever you face a setback, like being criticised at work, or rejected after a date.

CBT has always had its critics, primarily on the left, because its cheapness – and its focus on getting people quickly back to productive work – makes it suspiciously attractive to cost-cutting politicians. But even those opposed to it on ideological grounds have rarely questioned that CBT does the job. Since it first emerged in the 1960s and 1970s, so many studies have stacked up in its favour that, these days, the clinical jargon “empirically supported therapies” is usually just a synonym for CBT: it’s the one that’s based on facts. Seek a therapy referral on the NHS today, and you’re much more likely to end up, not in anything resembling psychoanalysis, but in a short series of highly structured meetings with a CBT practitioner, or perhaps learning methods to interrupt your “catastrophising” thinking via a PowerPoint presentation, or online.

Yet rumblings of dissent from the vanquished psychoanalytic old guard have never quite gone away. At their core is a fundamental disagreement about human nature – about why we suffer, and how, if ever, we can hope to find peace of mind. CBT embodies a very specific view of painful emotions: that they’re primarily something to be eliminated, or failing that, made tolerable. A condition such as depression, then, is a bit like a cancerous tumour: sure, it might be useful to figure out where it came from – but it’s far more important to get rid of it. CBT doesn’t exactly claim that happiness is easy, but it does imply that it’s relatively simple: your distress is caused by your irrational beliefs, and it’s within your power to seize hold of those beliefs and change them.

Psychoanalysts contend that things are much more complicated. For one thing, psychological pain needs first not to be eliminated, but understood. From this perspective, depression is less like a tumour and more like a stabbing pain in your abdomen: it’s telling you something, and you need to find out what. (No responsible GP would just pump you with painkillers and send you home.) And happiness – if such a thing is even achievable – is a much murkier matter. We don’t really know our own minds, and we often have powerful motives for keeping things that way. We see life through the lens of our earliest relationships, though we usually don’t realise it; we want contradictory things; and change is slow and hard. Our conscious minds are tiny iceberg-tips on the dark ocean of the unconscious – and you can’t truly explore that ocean by means of CBT’s simple, standardised, science-tested steps.

This viewpoint has much romantic appeal. But the analysts’ arguments fell on deaf ears so long as experiment after experiment seemed to confirm the superiority of CBT – which helps explain the shocked response to a study, published last May, that seemed to show

CBT getting less and less effective, as a treatment for depression, over time.

Examining scores of earlier experimental trials, two researchers from Norway concluded that its effect size – a technical measure of its usefulness – had fallen by half since 1977. (In the unlikely event that this trend were to persist, it could be entirely useless in a few decades.) Had CBT somehow benefited from a kind of placebo effect all along, effective only so long as people believed it was a miracle cure?

That puzzle was still being digested when researchers at London’s Tavistock clinic published results in October from the first rigorous NHS study of long-term psychoanalysis as a treatment for chronic depression. For the most severely depressed, it concluded, 18 months of analysis worked far better – and with much longer-lasting effects – than “treatment as usual” on the NHS, which included some CBT. Two years after the various treatments ended, 44% of analysis patients no longer met the criteria for major depression, compared to one-tenth of the others. Around the same time, the Swedish press reported a finding from government auditors there: that a multimillion pound scheme to reorient mental healthcare towards CBT had proved completely ineffective in meeting its goals.

Such findings, it turns out, aren’t isolated – and in their midst, a newly emboldened band of psychoanalytic therapists are pressing the case that CBT’s pre-eminence has been largely built on sand. Indeed, they argue that teaching people to “think themselves to wellness” might sometimes make things worse. “Every thoughtful person knows that self-understanding isn’t something you get from the drive-thru,” said Jonathan Shedler, a psychologist at the University of Colorado medical school, who is one of CBT’s most unsparing critics. His default bearing is one of wry good humour, but exasperation ruffled his demeanour whenever our conversation dwelt too long on CBT’s claims of supremacy. “Novelists and poets seemed to have understood this truth for thousands of years. It’s only in the last few decades that people have said, ‘Oh, no, in 16 sessions we can change lifelong patterns!’” If Shedler and others are right, it may be time for psychologists and therapists to re-evaluate much of what they thought they knew about therapy: about what works, what doesn’t, and whether CBT has really consigned the cliche of the chin-stroking shrink – and with it, Freud’s picture of the human mind – to history. The impact of such a re-evaluation could be profound; eventually, it might even change how millions of people around the world are treated for psychological problems.

How does that make you feel?

***

“Freud was full of horseshit!” the therapist Albert Ellis, arguably the progenitor of CBT, liked to say. It’s hard to deny he had a point. One big part of the problem for psychoanalysis has been the evidence that its founder was something of a charlatan, prone to distorting his findings, or worse. (In one especially eye-popping case, which only came to light in the 1990s, Freud told a patient, the American psychiatrist Horace Frink, that his misery stemmed from an inability to recognise that he was homosexual – and hinted that the solution lay in making a large financial contribution to Freud’s work.)

But for those challenging psychoanalysis with alternative approaches to therapy, even more troublesome was the sense that even the most sincere psychoanalyst is always engaged in a guessing-game, always prone to finding “proof” of his or her hunches, whether it’s there or not. The basic premise of psychoanalysis, after all, is that our lives are ruled by unconscious forces, which speak to us only indirectly: through symbols in dreams, “accidental” slips of the tongue, or through what infuriates us about others, which is a clue to what we can’t face in ourselves. But all this makes the whole thing unfalsifiable. Protest to your shrink that, no, you don’t really hate your father, and that just shows how desperate you must be to avoid admitting to yourself that

This problem of self-fulfilling prophecies is a disaster for anyone hoping to figure out, in a scientific way, what’s really going on in the mind – and by the 1960s, advances in scientific psychology had reached a point at which patience with psychoanalysis began to run out. Behaviourists such as BF Skinner had already shown that human behaviour could be predictably manipulated, much like that of pigeons or rats, by means of punishment and reward. The burgeoning “cognitive revolution” in psychology held that goings-on inside the mind could be measured and manipulated too. And since the 1940s, there had been a pressing need to do so: thousands of soldiers returning from the second world war exhibited emotional disturbances that cried out for rapid, cost-effective treatment, not years of conversation on the couch.

Before laying the groundwork for CBT, Albert Ellis had in fact originally trained as a psychoanalyst. But after practising for some years in New York in the 1940s, he found his patients weren’t getting better – and so, with a self-confidence that would come to define his career, he concluded that analysis, rather than his own abilities, must be to blame. Along with other like-minded therapists, he turned instead to the ancient philosophy of Stoicism, teaching clients that it was their beliefs about the world, not events themselves, that distressed them. Getting passed over for a promotion might induce unhappiness, but depression came from the irrational tendency to generalise from that single setback to an image of oneself as an all-round failure. “As I see it,” Ellis told an interviewer decades later, “psychoanalysis gives clients a cop-out. They don’t have to change their ways … they get to talk about themselves for 10 years, blaming their parents and waiting for magic-bullet insights.”

Thanks to the breezy, no-nonsense tone adopted by CBT’s proponents, it’s easy to miss how revolutionary its claims were. For traditional psychoanalysts – and those who practise newer “psychodynamic” techniques, largely derived from traditional psychoanalysis – what happens in therapy is that seemingly irrational symptoms, such as the endless repetition of self-defeating patterns in love or work, are revealed to be at least somewhat rational. They’re responses that made sense in the context of the patient’s earliest experience. (If a parent abandoned you, years ago, it’s not so strange to live in constant dread that your spouse might do so too – and thus to act in ways that screw up your marriage as a result.) CBT flips that on its head. Emotions that might appear rational – such as feeling depressed about what a catastrophe your life is – stand exposed as the result of irrational thinking. Sure, you lost your job; but it doesn’t follow that everything will be awful forever.

If this second approach is right, change is clearly far simpler: you need only identify and

correct various thought-glitches, rather than decoding the secret reasons for your suffering. Symptoms such as sadness or anxiety aren’t necessarily meaningful clues to long-buried fears; they’re intruders to be banished. In analysis, the relationship between therapist and patient serves as a kind of petri dish, in which the patient re-enacts her habitual ways of relating with others, enabling them to be better understood. In CBT, you’re just trying to get rid of a problem.

The sweary, freewheeling Ellis was destined to remain an outsider, but the approach he pioneered soon attained respectability thanks to Aaron Beck, a sober-minded psychiatrist at the University of Pennsylvania. (Now 94, Beck has probably never called anything “horseshit” in his life.) In 1961, Beck devised a 21-point questionnaire, known as the Beck Depression Inventory, to quantify clients’ suffering – and showed that, in about half of all cases, a few months of CBT relieved the worst symptoms. Objections from analysts were dismissed, with some justification, as the complaints of people trying to protect their lucrative turf. They found themselves compared to 19th-century medical doctors – bungling improvisers, threatened and offended by the notion that their mystical art could be reduced to a sequence of evidence-based steps.

Many more studies followed, demonstrating the benefits of CBT in treating everything from depression to obsessive-compulsive disorder to post-traumatic stress. “I went to the early seminars on cognitive therapy to satisfy myself that it was another approach that wouldn’t work,” David Burns, who went on to popularise CBT in his worldwide bestseller Feeling Good, told me in 2010. “But I passed the techniques to my patients – and people who’d seemed hopeless and stuck for years began to recover.”

There’s little doubt that CBT has helped millions, at least to some degree. This has been especially true in the UK since the economist Richard Layard, a vigorous CBT evangelist, became Tony Blair’s “happiness czar”. By 2012, more than a million people had received free therapy as a result of the initiative Layard helped push through, working with the Oxford psychologist David Clark. Even if CBT wasn’t particularly effective, you might argue, that kind of reach would count for a lot. Yet it’s hard to shake the sense that something big is missing from its model of the suffering mind. After all, we experience our own inner lives, and our relationships with others, as bewilderingly complex. Arguably the entire history of both religion and literature is an attempt to grapple with what it all means; neuroscience daily reveals new subtleties in the workings of the brain. Could the answer to our woes really be something as superficial-sounding as “identifying automatic thoughts” or “modifying your self-talk” or “challenging your inner critic”? Could therapy really be so straightforward that you could receive it not from a human but from a book, or a computer?

A few years ago, after CBT had started to dominate taxpayer-funded therapy in Britain, a woman I’ll call Rachel, from Oxfordshire, sought therapy on the NHS for depression, following the birth of her first child. She was sent first to sit through a group PowerPoint presentation, promising five steps to “improve your mood”; then she received CBT from a therapist and, in between sessions, via computer. “I don’t think anything has ever made me feel as lonely and isolated as having a computer program ask me how I felt on a scale of one to five, and – after I’d clicked the sad emoticon on the screen – telling me it was ‘sorry

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to hear that’ in a prerecorded voice,” Rachel recalled. Completing CBT worksheets under a human therapist’s guidance wasn’t much better. “With postnatal depression,” she said, “you’ve gone from a situation in which you’ve been working, earning your own money, doing interesting things – and suddenly you’re at home on your own, mostly covered in sick, with no adult to talk to.” What she needed, she sees now, was real connection: that fundamental if hard-to-express sense of being held in the mind of another person, even if only for a short period each week.

“I may be mentally ill,” Rachel said, “but I do know that a computer does not feel bad for me.”

***

Jonathan Shedler remembers where he was when he first realised there might be something to the psychoanalytic idea of the mind as a realm far more complex, and peculiar, than most of us imagine. He was an undergraduate, at college in Massachusetts, when a psychology lecturer astonished him by interpreting a dream Shedler had related – about driving on bridges over lakes, and trying on hats in a shop – as an expression of the fear of pregnancy. The lecturer was exactly right: Shedler and his girlfriend, whose dream it was, were at that moment waiting to learn if she was pregnant, and desperately hoping she wasn’t. But the lecturer knew none of this context; he was apparently just an expert interpreter of the symbolism of dreams. “The impact could not have been greater,” Shedler recalled, if his “words had been heralded by celestial trumpets.” He decided that “if there were people in the world who understood such things, I had to be one of them.”

Yet academic psychology, the field Shedler next entered, meant having that kind of enthusiasm for the mysteries of the mind drummed out of you; researchers, he concluded, were committed to quantification and measurement, but not to the inner lives of real people. To become a psychoanalyst takes years of training, and it’s compulsory to undergo analysis yourself; studying the mind at university, by contrast, requires zero real-life experience. (Shedler is now that rarity, a trained therapist and researcher, who bridges both worlds.) “You know that thing about how you need 10,000 hours of practice to develop an expertise?” he asked. “Well, most of the researchers making pronouncements [about which therapies work] don’t have 10 hours!”

Shedler’s subsequent research and writing has played a significant role in undermining the received wisdom that there’s no hard evidence for psychoanalysis. But it’s undeniable that the early psychoanalysts were sniffy about research: they were prone to viewing themselves as embattled practitioners of a subversive art that needed nurturing in specialist institutions – which in practice meant forming cliquish private bodies, and rarely interacting with university experimenters. Research into cognitive approaches thus got a big head start – and it was the 1990s before empirical studies of psychoanalytic techniques began hinting that the cognitive consensus might be flawed. In 2004, a meta-analysis concluded that short-term psychoanalytic approaches were at least as good as other routes for many ailments, leaving recipients better off than 92% of all patients prior to therapy. In 2006, a study tracking approximately 1,400 people suffering from depression, anxiety and related conditions ruled in favour of short-term psychodynamic therapy, too. And a 2008 study into borderline personality disorder concluded that only 13% of psychodynamic patients still had the diagnosis five years after the end of treatment, compared with 87% of the others.

These studies haven’t always compared analytic therapies with cognitive ones; the comparison is often with “treatment as usual”, a phrase that covers a multitude of sins. But again and again, as Shedler has argued, the starkest differences between the two emerge some time after therapy has finished. Ask how people are doing as soon as their treatment ends, and CBT looks convincing. Return months or years later, though, and the benefits have often faded, while the effects of psychoanalytic therapies remain, or have even increased – suggesting that they may restructure the personality in a lasting way, rather than simply helping people manage their moods. In the NHS study conducted at the Tavistock clinic last year, chronically depressed patients receiving psychoanalytic therapy stood a 40% better chance of going into partial remission, during every six-month period of the research, than those receiving other treatments.

Alongside this growing body of evidence, scholars have begun to ask pointed questions about the studies that first fuelled CBT’s ascendancy. In a provocative 2004 paper, the Atlanta-based psychologist Drew Westen and his colleagues showed how researchers – motivated by the desire for an experiment with clearly interpretable results – had often excluded up to two-thirds of potential participants, typically because they had multiple psychological problems. The practice is understandable: when a patient has more than one problem, it’s harder to untangle the lines of cause and effect. But it may mean that the people who do get studied are extremely atypical. In real life, our psychological problems are intricately embedded in our personalities. The issue you bring to therapy (depression, say) may not be the one that emerges after several sessions (for example, the need to come to terms with a sexual orientation you fear your family won’t accept). Moreover, some studies have sometimes seemed to unfairly stack the deck, as when CBT has been compared with “psychodynamic therapy” delivered by graduate students who’d received only a few days’ cursory training in it, from other students.

But the most incendiary charge against cognitive approaches, from the torchbearers of psychoanalysis, is that they might actually make things worse: that finding ways to manage your depressed or anxious thoughts, for example, may simply postpone the point at which you’re driven to take the plunge into self-understanding and lasting change. CBT’s implied promise is that there’s a relatively simple, step-by-step way to gain mastery over suffering. But perhaps there’s more to be gained from acknowledging how little control – over our lives, our emotions, and other people’s actions – we really have? The promise of mastery is seductive not just for patients but therapists, too. “Clients are anxious about being in therapy, and inexperienced therapists are anxious because they don’t have a clue what to do,” writes the US psychologist Louis Cozolino in a new book, Why Therapy Works. “Therefore, it is comforting for both parties to have a task they can focuson.”

Not surprisingly, leading proponents of CBT reject most of these criticisms, arguing that it’s been caricatured as superficial, and that some decrease in effectiveness is only to be expected, because it’s grown so much in popularity. Early studies used small samples and pioneering therapists, enthused by the new approach; more recent studies use bigger

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Therapy wars: the revenge of Freud | Oliver Burkeman | Science | … http://www.theguardian.com/science/2016/jan/07/therapy-wars-re…

samples, and inevitably involve therapists with a wider range of talent levels. “People who say CBT is superficial have just missed the point,” said Trudie Chalder, professor of cognitive behavioural psychotherapy at the King’s College Institute of Psychiatry, Psychology and Neuroscience in London, who argues that no single therapy is best for all maladies. “Yes, you’re targeting people’s beliefs, but you’re not just targeting easily accessible beliefs. It’s not just ‘Oh, that person looked at me peculiarly, so they must not like me’; it’s beliefs like ‘I’m an unlovable person’, which may derive from early experience. The past is very much taken into account.”

Nonetheless, the dispute won’t be settled by adjudicating between clashing studies: it goes deeper than that. Experimenters may reach wildly different conclusions about which therapies have the best outcomes. But what should count as a successful outcome anyway? Studies measure relief of symptoms – yet a crucial premise of psychoanalysis is that there’s more to a meaningful life than being symptom-free. In principle, you might even end a course of psychoanalysis sadder – though wiser, more conscious of your previously unconscious responses, and living in a more engaged way – and still deem the experience a success. Freud famously declared that his goal was the transformation of “neurotic misery into common unhappiness”. Carl Jung said “humanity needs difficulties: they are necessary for health.” Life is painful. Should we be thinking in terms of a “cure” for painful emotions at all?

***

There’s something deeply appealing about the idea that therapy shouldn’t be approached as a matter of science – that our individual lives are too distinctive to be submitted to the relentless generalisation by which science must proceed. That sentiment may help explain the commercial success of The Examined Life, Stephen Grosz’s 2013 collection of tales from the analyst’s couch, which spent weeks on UK bestseller lists and has been translated into more than 30 languages. Its chapters consist not of experimental findings or clinical diagnoses, but of stories, many of which involve a jolt of insight as the patient suddenly gets a sense of the depths he or she contains. There’s the man who lies compulsively, in a bid for secret intimacy with those he can persuade to join him in deceit, just like his mother hid evidence of his bedwetting; and the woman who finally realises how effortfully she’s been denying the evidence of her husband’s infidelity when she notices how neatly someone has stacked the dishwasher.

“Each life is unique, and your role, as an analyst, is to find the unique story of the patient,” Grosz told me. “There are so many things that only come out through slips of the tongue, through someone confiding a fantasy, or using a certain word.” The analyst’s job is to stay watchfully receptive to it all – and then, from such ingredients, “help people make meaning of their lives.”

Surprisingly, perhaps, recent support for this seemingly unscientific perspective has emerged from the most empirical corner of the study of the mind: neuroscience. Many neuroscience experiments have indicated that the brain processes information much faster than conscious awareness can keep track of it, so that countless mental operations run, in the neuroscientist David Eagleman’s phrase, “under the hood” – unseen by the conscious mind in the driving-seat. For that reason, as Louis Cozolino writes in Why Therapy Works, “by the time we become consciously aware of an experience, it has already been processed many times, activated memories, and initiated complex patterns of behaviour.”

Depending on how you interpret the evidence, it would seem we can do countless complex things – from performing mental arithmetic, to hitting a car’s brakes to avoid a collision, to making a choice of marriage partner – before becoming aware that we’ve done them. This doesn’t mesh well with a basic assumption of CBT – that, with training, we can learn to catch most of our unhelpful mental responses in the act. Rather, it seems to confirm the psychoanalytic intuition that the unconscious is huge, and largely in control; and that we live, unavoidably, through lenses created in the past, which we can only hope to modify partially, slowly and with great effort.

Perhaps the only undeniable truth to emerge from disputes among therapists is that we still don’t have much of a clue how minds work. When it comes to easing mental suffering, “it’s like we’ve got a hammer, a saw, a nail-gun and a loo brush, and this box that doesn’t always work properly, so we just keep hitting the box with each of these tools to see what works,” said Jules Evans, policy director for the Centre for the History of Emotions at Queen Mary, University of London.

This may be why many scholars have been drawn to what has become known as the “dodo-bird verdict”: the idea, supported by some studies, that the specific kind of therapy makes little difference. (The name comes from the Dodo’s pronouncement in Alice in Wonderland: “Everybody has won, and all must have prizes.”) What seems to matter much more is the presence of a compassionate, dedicated therapist, and a patient committed to change; if one therapy is better than all others for all or even most problems, it has yet to be discovered. David Pollens, in his Upper East Side consulting room, said he had some sympathy for that verdict, despite his passion for psychoanalysis. “There was a wonderful British analyst, Michael Balint, who was very involved in medical training, and he had a question he liked to pose [to doctors],” Pollens said. It was: “‘What do you think is the most powerful medication you prescribe?’ And people would try to answer that, and then eventually he’d say: ‘the relationship’.”

Yet even this conclusion – that we simply don’t know which therapies work best – might be seen as a point in favour of Freud and his successors. Psychoanalysis, after all, embodies just this awed humility about how little we can ever grasp about the workings of our minds. (The one question nobody can ever answer, writes the Jungian analyst James Hollis, is “of what are you unconscious?”) Freud the man scaled heights of arrogance. But his legacy is a reminder that we shouldn’t necessarily expect life to be all that happy, nor to assume we can ever really know what’s going on inside – indeed, that we’re often deeply emotionally invested in preserving our ignorance of unsettling truths.

“What happens in therapy,” Pollens said, “is that people come in asking for help, and then the very next thing they do is they try to stop you helping them.” His smile hinted at the element of absurdity in the situation – and in the whole therapeutic undertaking, perhaps. “How do we help a person when they’ve told you, in one way or another, ‘Don’t help me’? That’s what analytic treatment is about.”

Therapy wars: the revenge of Freud

In the shit again

It all went to shit again – completely lost it, clenching teeth, yelling, hitting myself on the head. I’ll admit I did not do DBT in the moment, but sometimes I just don’t feel the rage coming nor any of the precipitating events (there weren’t any) – it’s instantaneous.

My wife is getting sick of it. I think she stopped loving me a while back, after I had lost my first job. I don’t think I was ever taken much by her following the initial ‘honeymoon’ period. But now we have a child. And I still don’t have a job. And even if I were to get a job, it is very likely I could lose it again. I just don’t want my offsprings to be like me.

In the shit again

Unstable self-image

francis_bacon_as_a_kid_by_vangelismor-d5ovraxUnstable self-image; struggles with identity or sense of self

How do you respond under stress? Are you more of an extrovert or an introvert? Are you shy and quiet or a loud social bee? Do you consider yourself to be a confident person? Describe yourself in a few words?

To these questions I have been asked by an interviewer, a friend, colleague, acquaintance or even myself, I feel like the answer is always the same – it depends on the context, it depends on who I am with, where and how I am feeling in that moment.

It’s always been like this – the feeling of first the world, and then me; of me and my body not occupying a full space; of the context being bigger than me, defining me – I have always been its victim. More precisely, I have always fallen victim to the turbulence of emotions set off by the context. I feel I have no control over my reactions, over what I will say next – I know rationally and intellectually what the appropriate or even the ideal behaviour and verbal response would be – but that’s lost. The intense anger or panic will control me. So how do I know how I react in certain situations? Well it all depends on my interlocutor – always. No wonder I don’t know who I am.

The only times I feel like a person occupying a space is when I take on another personality – whether it’s taking on a southern US accent and feeling like ‘coach’ from Friday Night Lights or behaving like my friend Francois who is very charismatic and quintessentially French, or thinking I am some tough fighter who could take on any situation.

But that feeling of wholeness from a derived identity is very fleeting – maybe I was able to manage situations a little better for a while being ‘coach’ or ‘Francois’, but you cannot carry a caricature forever, not even for a whole day.

So who am I? A sensitive person with rich emotional experiences.

Unstable self-image

Secondary Emotions

So I got angry today – I clenched my teeth and right fist – the reaction was disproportionate, as usual. And I tried applying my DBT bespoke process, but it’s hard to do so as you are having a conversation with someone who pisses you off as you are trying to exit the building.

I could not count breaths. I did try to keep my jaws and palms open. I could not have held my middle finger – it would have looked odd. But one thing I did manage to do is to act the opposite to my automated response – I would usually raise my voice, swear and shout – but instead I spoke softly, through grinding teeth, but softly. So out of the multiple steps that are part of my DBT process, at least one worked.

However, following that event, I now feel ashamed, angry and hopeless. These are ‘secondary’ emotions – reactions to my initial reaction. All they do is make me feel worse. However, I know how to reduce them. Thiswas the first positive result of DBT – getting rid of the vicious cycle of secondary emotions which, ultimately, only had the effect of worsening my primary emotion. Thinking about what happened won’t change it.

Writing it down, even at work, making sure noone is looking at my screen, helps reduce my shame/guilt/anger following an event.

The attached template can be used ex-post facto. There are many more on a very useful site: Get Self Help

EmotionsWorksheet.jpg

Secondary Emotions

Self-Judgement

Last night, as I was reviewing  the DBT  Skills Workbook, I was taken by a section about negative judgements that I had glossed over in the past. And this morning, as I was working, I made a conscientious decision to be mindful of every time I made a negative judgement – I was amazed at how many negative comments I was making about myself every nanosecond!

And the internal comments were very short and happened in quick succession:

  • I was lifting a  book, and thought ‘I’m not strong enough
  • I felt my shirt brushing my tummy – ‘I am overweight
  • People in front of me walked too slow – ‘fucking assholes!’

I’m going to try keeping track of my negative judgements for the rest of the week – and every time I catch myself judging, I’ll say to myself – ‘judgement’.

 

NegJudge.JPG

Self-Judgement

Impulsive Anger 2

Medication enabled me to apply DBT (dialectical behaviour therapy) and other techniques – I still remember the moment, approximately 2 weeks after beginning to take Fluoxetine, when I suddenly felt I had some control over the impulse; I could actually choose to shout or respond differently. Before then, no matter how much mindfulness/dbt I attempted, the impulse would still often win, albeit delayed by a few seconds. I had also tried EFT (Emotional Freedom Technique), which helped reduce temporarily mild anxiety. For more on EFT.

However, medication is not a panacea. Eventually, outbursts would come back, though less severe and less frequent. That is where dialectical behaviour therapy (DBT) came in handy. The key with DBT is practice. The brain is a muscle, and as with any part of the body, you can train it – practice enables the brain to build new neural pathways. The BPD brain treads on beaten paths that have been used over and over again, creating automatisms. Now you need to cut a new path through a thick jungle, and to achieve this you need to tread on this path over and over again. Doing it with a therapist is ideal, but in addition DBT requires a lot of ‘homework’, daily.

There are two very useful books I recommend, which you should read to create your own bespoke emotional management procedure:

Aguirre, Blaise and Galen, Gillian, mindfulness for borderline personality disorder – relieve your suffering using the core skill of dialectical behaviour therapy.

McKay, Matthew; Wood, Jeffrey; Brantley, Jeffrey, The Dialectical Behaviour Therapy Workbook.

Based on these approaches, you need to create your  bespoke mindfulness procedure. Try to keep it simple and tailored to your personality and prevailing surroundings. Below is an example:

  1. Register sensations – what am I feeling in my body? Where?
  2. Identify action urges – I want to attack, scream, hit the wall
  3. Determine emotions – i.e  anger
  4. Verbalize emotional state outloud  – ‘I feel angry right now
  5. Open palms & jaws

As mentioned earlier, this is just an example. There are many different versions that can be created – i.e asking yourself why you are feeling that way as a step 4, or  squeezing the middle finger for step 5 (for more on this acupressure point, see Anger & Rage Relief using Acupressure Stress Management )

 

Impulsive Anger 2

Impulsive Anger

1538_Robert_De_Niro_in_Cape_Fear_211056I don’t think we should confuse the impulsive anger that is symptomatic of BPD with issues broadly addressed by ‘anger management’ techniques.

I never found the recommendations from anger management literature realistically applied to my explosive type of impulsive rage – there was no conscious build-up (I stress conscious) of stress I felt I could become aware of with practice, let alone mitigate by counting to 10 or breathing.

I stress ‘conscious’ because someone not suffering from BPD is better able to consciously recognize a change in his/her emotional state (and therefore count to 10) than a BPD sufferer.  Why? Well, the assumption is that a BPD sufferer’s baseline (the emotional state that is most prevalent under prevailing conditions)  is always ‘pathological’ (an ugly term for saying you feel always stressed or angry or depressed, etc..) , so an increase in that emotional state will be harder to identify than for someone whose baseline is initially stress free.

Ultimately, there are multiple elements which, when applied together, have helped mitigate my impulsive anger – no one of the below solution though,  was effective in and of itself:

  • Medication (fluoxetine)
  • DBT/Mindfullness and other techniques

………more to come

Impulsive Anger

Feelings of emptiness

I feel like I carried a pervasive sense of emptiness for decades. A powerful physical sensation of chills and weight on my chest – a weight that pulls within, as in a black hole, affecting my breathing. These physical sensations accompanied a sense of utter loneliness, isolation, abandonment, alienation – despite I could be with my parents, or in a crowd of people having fun. There was no direct contextual cause for it – it was just there, with me, in me. And as far back as I can remember, I always felt distant from my parents, as if I had been born alone, despite the fact they could be standing right beside me. Already in reception I remember crying every time my parents came to pick me up – even though many healthy children display this behaviour which has nothing to do with BPD and is considered normal – I just clearly remember the contrast between the feeling of loneliness I carried and the realization, upon seeing my parents,  that I am not alone, I have parents!

As I grew into my teens, that feeling of distance morphed with a generalized feeling of depression – worthlessness, desperation, suicidal thoughts. The only thing that helped was drinking – so I would spend hours drinking beer alone, day dreaming of a better me in a better life.

No medication or therapy had ever taken that away.

In 2014 I had decided to quit the medication I had been taking for years (Lamotrigine & Escitalopram) as I had found I was not reaping the benefits I was looking for – I feel the medication at that time had become a safety blanket rather than a real help. I have been back on medication since  (Fluoxetine) and I am very satisfied with the effects. However, for six months I had gone ‘dry’ (which good psychiatrists do recommend, under their supervision) .  During that period, I had decided to go ‘alternative’ and speak to a hypnotherapist. I had just found a new job and I did not want to lose it (even though less than two years later, I still would). The guy I had spoken to was no therapist of any kind – he simply attended courses available online selling the latest solution to life’s troubles. However, he  had also suffered in his life and had tried the techniques he as recommending.  I was sceptical, but at the same time, ready to try something different after having been on medication and in therapy for almost 20 years. He introduced me to PSTEC – it’s freely available on the internet (though I paid him a hefty sum for the session) and, despite the fact I would eventually go back on medication and also lose my job,  it did take away that feeling of emptiness. All the other symptoms were still there, but for some reason, that particular one went away. In addition, though I never had a drinking problem, I do not drink any kind of alcohol anymore.

PSTEC is simply an MP3 audio track where someone speaks  words of encouragement, while you distract your conscious mind tapping your fingers  to a sequence of beeps. I’m not saying PSTEC will surely take away your feeling of emptiness, but as the track is free and lasts 15 minutes or so, why not give it a go?

Feelings of emptiness