What is Depression?

What is it to be depressed?

Many of us, even those who experience it most deeply, actually have little idea. Sure, by now we all know that, according to the DSM, if you have five of nine certain symptoms, you “have” a depressive disorder. But what does that mean? What does it explain? Does it explain anything at all? Many people think it does: “Ah, I feel so terrible because I’m depressed.” And yet such a sentence is a tautology. In truth, the diagnosis explains very little. It mostly describes; at best it captures a snapshot of something. It provides shorthand for a set of symptoms. But symptoms of what?

When I ask people what they think depression is, often I’ll hear something about being really sad. This is a common understanding of depression: extreme sadness. In truth, not uncommonly, a depressed person isn’t feeling particularly sad; she’s more typically not feeling much at all. She’s stuck, stagnant, in a room with no exit.

I’ve come to best understand depression as a void, as an absence of experience where an emotional life should be. It is a profound alienation rooted in the negative space of disconnection — disconnection from other people, from a place in the world that offers authentic expression, disconnection from oneself, from one’s right to exist in harmony with other living things. In that sense, in its being characterized by a distancing of the self, I see depression as an unconscious defense — a defense against the painful emotions we fear we can’t bear to face, or we fear the world doesn’t want to receive.

Many of us believe we can choose what we feel. We can’t. However, we can in a sense choose whether to feel or not. I see depression as rooted in the largely unconscious choice not to feel.

For many of the depressed people I work with, then, the path is clear, if hugely difficult: We must begin to feel the truth of life. Many people are afraid to. At times, the truth really hurts. Or we don’t trust that the world will accommodate us if we come to face, and name, the truth we’ve been conditioned to bury.

And of course our culture gives us warped messaging about not only what our external appearance should be, but what our internal life should be as well. In short, I should be happy. Beyond happy, I should be joyful. And I should be grateful. I certainly shouldn’t be sad, jealous, or resentful. Maybe I can be privately afraid of death, but I sure as hell can’t be afraid of life. And I shouldn’t be angry — especially if I’m a woman. A woman should be pleasant and easy to be with. Anger is neither pleasant nor easy.

I’ve found that disavowed, stagnant anger is often close to the core of the depressed life. Anger is a necessary emotion for the same reason it can be dangerous: It’s suffused with personal power. (This is in part why our society has “rewarded” women for being pleasant and pathologized their anger.) Healthy anger is rooted in a sense of self-worth; it informs the ways and means of protecting the self, of saying no to transgression, of feeling one’s own agency even in the face of life’s arrows. No doubt in its righteous deliciousness anger can be unskillfully over-deployed, obscuring more tender emotions rooted in vulnerability and connection. And yet so many of us have been taught that there’s no room for the healthy, appropriate experience and expression of anger in response to life’s transgressions. Utterly disconnected from this sense of power, we become more prone to a defeated collapse.

So we must reset our emotional aspirations. Let us aspire to be human. Let us acknowledge what that is, and let us grant each other — and ourselves — permission to be exactly that, in all its complexity, and with all its attendant emotion. If we don’t, we are far more likely to find ourselves in that room with no exit, in the state of profound disconnection from our own aliveness, the state we call depression.

What might this be? Relating in an interpreted world

The famous Rorschach test is administered through the use of a single prompt. The examiner holds up a card and simply asks the subject: “What might this be?” An answer will be given, and the examiner responds, “What else might this be?” This continues until the subject no longer has a response to offer, and the next card is presented.

I used to administer these tests, and I’ve been amazed to discover how rich and textured the portrait revealed by them can be. The cards really are just inkblots, so if a respondent “sees” two baby monkeys fighting to suckle at their mother’s breast, there’s some actual information there. The Rorschach is an example of a projective test, and the information it offers is in the realm of the kind of material a subject would be likely to project upon an ambiguous situation. That is, how does this person interpret the world?

It’s a powerful question, and one that is at the heart of much of the psychotherapy process. Often this process begins with acknowledging that our perceptions of the world, and particularly the hugely complex world of human relationships, rest upon acts of interpretation, and these interpretations are greatly informed by our underlying beliefs about how people operate, particularly in relation to one’s own self.

We tend to think of perception as a one-way process: stimuli reach us through our senses and enter our brains, and we then perceive reality; after all, our eyes are “the windows to the world.” We now understand though that perception doesn’t work this way at all; in fact, as many optical illusions illustrate, our perception of something as “straightforward” as the relative darkness of two squares is largely determined by our preexisting expectation of what we will perceive.

This counterintuitive weaving together of expectation and perception is at the heart of so many relationship issues. By the time we reach adulthood we are possessed of an array of unconscious expectations about what our relationships will bring. These expectations are largely informed by the actual circumstances we were made to navigate in the formative periods of our lives: relationships we had with our parents, siblings, and most influential peer relationships in our youth and adolescence.

If we are lucky, these relationships were kind and satisfying: we felt seen and respected, we were treated with goodness and love. If we were less lucky, we might have experienced any number of dynamics ranging from outright abuse to ostracization to marginalization to an almost imperceptible but chronic misattunement. These dynamics take place during the years we establish lifelong internal representations of what the world is, so inevitably the flavor of these experiences become woven into the basic assumptions we carry forth about what will happen when we relate to other people.

Largely, these assumptions are truly unconscious. They operate at the machine layer of our navigation systems, and most of us go our entire lives not truly appreciating the ways in which our perceptions of “reality” are passed through this particular and wholly personal filter.

One place this process is poignantly on display is the therapy groups I run. These groups typically consist of 5-8 people who meet consistently on a weekly basis. There is very little structure; we sit in a circle and I say “let’s begin.” Ambiguity abounds.

As the members of the group begin to interact with each other, inevitably each participant’s core ways of interpreting the world are activated; that is, their largely unconscious expectations of what will happen within their relationships shape both their behaviors vis-à-vis the other members and their perceptions of what is taking place. The group is a Rorschach test of what happens within each person’s experience in a set of relationships: What might this be?

Vivian, for example, was raised by parents who were entirely misattuned to her needs. Her parents were not abusive or overtly cruel; they were simply distracted by their own needs and desires. More damagingly, they exhibited a subtle (and sadly not uncommon) misogyny, and devoted more resources and higher expectations to Vivian’s brother. Vivian the child was left with an unarticulated sense of being insufficient to the one thing she wanted above all: to feel secure in the loving attention and full support of the people who brought her into the world and were now charged with keeping her safe. Like any child, Vivian didn’t have the capacity to understand that the failure was her parents’ rather than her own (i.e. “a better version of me would have get what I really need”), so she internalized a sense of being inadequate that has lingered into adulthood.

Vivian is now in her mid-40s and comes to the group experience with the utter conviction that she is too boring to hold anyone’s attention. In fact she is quite intelligent and sharp and possessed of an interesting analysis of a wide range of topics. She’s also intrinsically an appealing person, though she is convinced just the opposite is true: she sees the thoroughness of her own mediocrity as quite repellant.

Beyond being merely attuned to confirming evidence of this conviction, she is actually distorted in her interpretation of what is happening within the group in response to her. She believes, for example, that the group member sitting next to her is physically turned away from her because he finds her so repellent. In fact, he is sitting cross-legged and straight-on, in a way that she would have interpreted as being turned away from her no matter which side of him she’d been on.

During one of her first group meetings, Vivian shares the story of how she came to live in the United States (she immigrated when she was a young adult). When she finished, the group was silent. Though she spoke eloquently and the story was fascinating, she was convinced that the group had been bored and had disconnected as she spoke. In fact, each member of the group was silent for his or her own reason (one member was brought back to her own immigration story and was quite stirred; another man found himself attracted to Vivian and felt shy; a third member chronically feels that he too has little to offer of value so tends to stay more inward; etc).

Since this takes place within the context of the group therapy experiment, Vivian’s experiences within her relationships can be named and challenged; hopefully, over time, her perceptions of what is happening can become more clear-eyed and less distorted by the formative, painful dynamics that shaped much of her present experience.

And yet in our day-to-day lives, we can go years – or even an entire life – without challenging the basic distortions within our interpretations of the world. Often these interpretations – these habitual filters - are less egregiously distorted than Vivian’s; yet they still may present no less of a challenge to the creating and sustaining of love that we all so desire.

The call here is not to throw off these filters; they are so deeply conditioned that that would not be possible. We can however increase our awareness of the ways in which our particular filters tend to operate. We can be suspicious of the kinds of stories we tend to tell again and again about ourselves and about our relationships, and in so doing increase our power to be curious about what else is possible other than our reflexive responses. Perhaps we might even find ourselves with a greater capacity to relate with skill and wisdom to a more hopeful investigation of what is actually happening.

I would assert that the maintenance of healthy relationships hinges on our capacity to do exactly this. We must be able to ask ourselves not only “what might this be?” but also “what else might this be?” Perhaps, even, this is close to the essence of what we call maturity.

Banished Anger: Unconscious Punishment and the Silent Treatment

Freud has fallen out of favor in most intellectual and therapeutic circles, in part because he has become more associated with his wackier theories (penis envy?) than those that have become absorbed into our bedrock understanding of how people work. Like many seminal theories that someone had to actually arrive at, those that have become assimilated into our basic assumptions about life are no longer seen as momentous contributions; they now seem rather obvious, the air we breathe. This is the case with Freud’s “discovery” of the unconscious, the basic idea that we are largely unaware of the internal forces that shape many of our emotional states and govern much of our behavior.

In the therapy groups I run, in the marriages I treat, in the therapy relationships I’m a part of, and in all my own personal relationships, I see again and again how we are unaware of what truly compels many of our behaviors, and how often we impact others in ways we would not consciously have chosen.

Often even we are unaware of the extent of our most energetic drives, such as aggression. When we are told by someone we care about “I am feeling X because you are doing Y,” we may sincerely deny the full extent of our role in the dynamic, because even if we can recognize that we might be doing Y, we might not at all recognize that, unconsciously, we are doing Y precisely so that we might induce X in the person we feel not just a need to defend against, but also some shadowy desire to injure. That is, we might have no conscious relationship at all to our own aggression. And the less conscious we are of our aggression, the more likely it is that the aggression will be expressed passively and ineffectively.

Ah, passive aggression. Everyone hates it, but it’s so commonly deployed. Why?

Other people can be quite scary. We have all been profoundly hurt by each other, and we all know that we will be hurt again. Obviously the psyche has a way of promoting behaviors designed to counter the threat of other people, particularly people with whom we feel the most vulnerable. What’s less obvious is that many of these behaviors are designed to counter the threat of others while simultaneously allowing us to retain a sense of ourselves that remains consistent with our self-concept. That is, we might behave in a way that is aggressive, that is hurtful to others, that shuts others out or shuts them down, but we might find a way to do it that would appear – not just to others, but to ourselves - to lack any aggression at all.

One particularly nasty example of this that I see often is the silent treatment, sometimes referred to as stonewalling. The silent treatment is an often unconscious – and particularly aggressive - form of passive punishment. Typically we deploy it when we are feeling wounded by some essential person in our lives; we might feel that that person has somehow broken our implicit contract (“you broke the terms of our engagement”), so in response we tear the contract up (“we no longer have any terms of engagement at all”). The silent treatment is particularly aggressive because it is particularly painful for the receiver, who becomes utterly erased in the transaction. In fact, the receiver is not even a receiver, since there is nothing to receive: where there was once presence there is now absence; where there was once something to engage there is now a vacuum; where there was once the assertion that “you did this” there is now the assertion that “you don’t exist.”

This vacuum can trigger in the person being shut out a kind of existential dread, particularly if the silent treatment is deployed by a spouse or, worse, from a parent towards a child. The silence communicates that “you don’t matter, I don’t need you, I have no desire to repair this.” It often induces in the recipient a primal fear of being ostracized, cast out, abandoned. 

So often though the person deploying the silent treatment, or some less egregious form of disengagement, feels they are taking the high road. They might justify the behavior by asserting that they remained cool, rational, above the fray; they removed themselves from the ugliness of the exchange rather than contribute to an escalation of the pain. And the point here is that such a person might truly believe this. In denying their desire to injure they might pass a lie detector with flying colors.

And yet beneath the rational and rationalizing mind is an animal instinct system that holds within it a capacity for tremendous aggression; a part of us that is utterly disinterested in nuance and instead sees the world in you vs. me, and when faced with a choice between you or me will choose me every time. I am not darkly asserting that this capacity is our essence, our core; I have however observed time after time that our essence, our core, contains this part alongside many others. It is a part that sufficiently frightens us, and that is sufficiently outside the boundaries of who we want to know ourselves to be, that we often relegate the expression of it to the unconscious, even when we are being faced with the fact of its expression in the form of some else’s hurt.

My call here, as it so often is, is towards awareness. Not uncommonly, as we become aware of the unconscious ways our aggression finds expression, we gain increasing control over how we behave with the people most important to us. What we feel and the behaviors we choose given those feelings are two completely different things. Awareness of our emotions and motivations itself often does little to change the power of our internal states; it does however empower us to choose more effective ways of expressing our hurt and anger, and ultimately of making our needs known. The more effectively we exhibit control over how we express ourselves, the more likely we are to signal to other people that we are safe, that they too can lower their more primitive defenses, and join us in the world of truly grown up people.

Living the temporary life

Loss is inevitable and only children don’t know it. It’s a big piece of why they are capable of such unfettered joy. Many people have children—as I have—in part so that we can experience the lightness that comes with entering wholly into the child’s field, and in that entrance, we might forget for a little while that this lovely moment will give way to another one that will be radically different. The adult must live with the knowledge that—if she isn’t already—she will in the future suffer.

Our relationship to this knowledge is hugely determining of the quality of our living. For many people, the awareness of the inevitability of loss and pain dissuades living itself. In our failure to come to a healthy relationship to impermanence, many of us settle into a kind of partial aliveness as an unconscious defense against the pain of the losses to come. The less we live, the less we love living, the less we have to lose.

The defense, this pulling up on the reigns of the heart, might manifest in various forms, including in subtle ways within our most important relationships. One example can sometimes be found in the relationship of a parent to a child. Many parents experience such devotion that they would sacrifice their own lives for their children and only their children. And yet a parent knows that the child will grow and leave the parent for her own life; the sweet, earnest, and quite physical intimacy between parent and small child is temporary. Not uncommonly there is a deep tension between this singular devotion to the child on the one hand and the knowledge of the impending loss of her on the other. Sadly, this tension is sometimes managed unconsciously in the form of the parent throttling back, even if only slightly, on a love that might otherwise be more fully experienced and expressed.

Or we might consider the common assertion of life’s “meaninglessness.” Quite often a patient will tell me that they are struggling deeply with the “meaninglessness of life,” and when I ask them to tell me about what makes life meaningless, almost invariably they will come around to telling me about death. To them, the temporariness of their existence somehow strips it of meaning. Sometimes I’ll ask whether they think meaning would arise from their existence if it could go on forever. Most people will consider this question and conclude that it would not; that the challenge to find meaning in life is not made easier by removing death from the equation, but instead arises from tying one’s days—however many one has—into a deeper sense of aliveness.

So why then the initial assertion of meaninglessness in the face of impermanence? I believe the assertion of meaninglessness is not a function of the awareness of impermanence, but a defense against the pain of it. It’s a way to psychically manage the pain and terror that arises when we consider the inevitable loss of our living; it minimizes the value of the thing that will someday be lost forever. It’s another way we push life away to make some of its truths less uncomfortable.

Aside from the obvious problem of the enormity of the price paid (never gulping life fully when we have the chance) for the hoped for payoff (hurting less later), the biggest problem with this common kind of defense is that it doesn’t even work. In all my sessions with people who have experienced loss – whether it be after the onset of an illness, or the death of a loved one, or the loss of a relationship, or the losses that mount towards the end of life – the most powerful source of suffering I encounter is the pain of regret: the regret of a life, of a love, held at bay, and now it’s too late.

There is no way that we can mitigate the pain of loss; it is woven into the fabric of what it is to exist and there is no defense against it. My concern here is the quality of our aliveness, and that aliveness is most deeply experienced when we lower the defenses that do not serve us, and we confront head on the truth of the thing – the aching preciousness of something we love, of life itself, not despite but because we will lose it.

The Religion of Success

Peer with even modest depth into the heart of virtually any person within Western culture selected at random and you will find a question unmatched in its capacity to motivate, cajole, and shame the human spirit. It is sometimes asked explicitly and daily; it’s more often wholly unconscious for an entire life, directing one’s affairs like the gravitational pull of an unseen star. It can shove us into a career we loathe; it can convince us to surgically alter our faces; it can force us to buy a particular car. It can propel us to cure disease and produce aching works of art and mow our lawn. That question is “How am I doing at life in the eyes of others?”

I recently took a commercial flight and through the sheer volume of the thing was forced to pay attention to the airline’s in-flight self-promotional commercial. As I recall it depicted mothers and fathers waking up at some ungodly hour to kiss their still-sleeping babies goodbye so they could board a flight that would sling them far afield in order to further their business efforts. A mother displays the requisite lamentation as she kisses her angelic son goodbye, but as she enters the airport coffee in hand, her face aglow in the light of the airline’s logo, her self-pleased smile reassures us that she made the right decision. It ends with the zinger: “Keep Climbing.”

Of course the airline cannot and will not ever tell us why we should keep climbing, or where. They are not in the business of “being” anywhere; theirs is the business of “going.” Their service matches our time, an age of going far more than an age of being. Less concerned than ever with the essentially spiritual question of how to be, our culture has become increasingly organized by the notion of continuing to climb a vertical hierarchy to nowhere in particular. The basic organizing social principle of our time is the religion of success.

The pursuit of success within our culture is a religion because it is a robust system of meaning-making that operates at an emotional and cognitive level, guides our decisions, contains its own morality, is buttressed by particular rituals, and is practiced en masse by a group of people sharing a largely unexamined ideology. The success the religion worships is not success as self-actualization, self-defined and self-adjudicated, but is instead success as determined by one’s perceived place in the social hierarchy of one’s given or chosen in-group.

The religion of success is a highly dangerous game, and yet so many of us are unaware of the extent to which we are compulsively laying our lives at the foot of its altar. It is so woven into our way of being, so integrated at the machine layer of our ideology, that we must listen closely in a quiet inner space to hear the ever-buzzing anxiety it produces. “Am I doing all this well enough???”

Many people are brought to therapy in part as a result of this anxiety, consciously or otherwise. In working with it, it is useful to contrast two quite different sources of the concern with one’s place vis-à-vis one’s peers: one healthy and inextricably human, the other a largely cultural artifact of the West that must be worked with well if we are to find the contentment we all seek. In the former we seek to know our sufficiency; in the latter we seek to know our superiority.

Of course, it is deeply, inescapably human to yearn to have our basic sufficiency reflected back to us. We long for inclusion and social safety, for true membership at the very least, and perhaps beyond that for an ascendance to a position so lofty that it lies beyond reproach. And even more powerful than our yearning for inclusion is our terror of exclusion, of being cast out, or of being tolerated virtually unnoticed at the margins, relegated to picking up on the scraps of life left behind by those really living. Such yearning is embedded in the software of what it is to be a person; concern with of our social standing has for millennia driven our evolution. We are the descendants of innumerable individuals who were appropriately concerned with - and successful at navigating – the staggering complexity of social relationships. There’s no other way they could have stayed alive long enough to reproduce and successfully rear their young.

And in this modern time we continue to need each other desperately, both to meet our basic organismic needs for food and shelter, and our loftiest needs for meaning and love. Healthy interdependence is the gateway to both our surviving and our thriving, and our capacity to achieve it is entirely contingent on our own social sufficiency, our being “good enough” for cooperation, for love. Much of the work of healing in our lives revolves around this central question of knowing that we are deserving of the belonging that has always been central to the motivation of homo sapiens. Not infrequently, this work involves confronting and adjusting the distortions of self-concept imparted by caretakers who were unable to lovingly and accurately reflect our basic worth. We must know the fact of this basic worth if we are to move through the world making self-respecting, nourishing choices, if we are to offer ourselves freely and hopefully to our work, our communities, our loved ones.


And yet homo sapiens in the West have become organized by a hyper-individualism that demands even more. For so many of us a sense of one’s sufficiency for membership is, painfully, not enough to quell the inner voice that demands not belonging, but supremacy. The religion of success is unrelenting in its imperative: Keep Climbing.

My practice is full of folks who have ascended to professional heights that exceeded even their own early hopes, and yet remain consumed with a sense of incompletion, fraudulence, and even failure. The problem of course is that their unconfronted narcissism – their hunger for supremacy - has compelled them to keep climbing but has never even hinted at an actual destination; it’s only dangled a vague notion of something that awaits up there that will feel like some sort of arrival, a shimmering Eden perhaps where all feelings are pleasant and all others fawn. Since no reality could possibly match this unarticulated fantasy, it never feels quite right, despite how well and tirelessly they’ve climbed. For so many, it produces a crisis. The more fortunate ones are aware of the crisis and work to confront it. Many others simply keep climbing until the engine gives way.

So what are we to do?

Each of us would do well to discern what motivates us, and come to make life decisions informed by wisdom, rather than compulsion, cultural or otherwise. If I am to truly live, what is there to experience in this brief time? That is, what do I believe will most deeply feed me? And what choices and ways of being are most likely to bring these things to my life?

Perhaps for many of us this would imply the following of a middle path: enjoying the knowledge of one’s own enoughness (and living from that foundation) while also honoring in some measured way the imperative to possess some degree of social status. Perhaps too this middle path would enjoin an internal sense of sufficiency and the social status that is perhaps most nourishing: the deep regard given to the person who knows, and values, who she is.

Shame and the secret self

An oft-told story in meditation circles tells of the time the Dalai Lama was asked by an American about the phenomenon of self-hatred. The Dalai Lama was genuinely confused; he’d never encountered the notion. His ideology held that all people, no matter who they are, at their core contain what he would call “Buddha nature”: the seed of something powerful, perfect, and above all worthy of respect.

As a clinical psychologist I often encounter people who are quite afraid of what they will find at their core, afraid not only of the repressed feelings that once uncovered might be unpleasant or disruptive to the narratives with which they’ve organized their lives, but afraid more deeply of discovering something within themselves that is ugly or even rotten, something that will render them unlovable; something that will reveal as utterly fraudulent their self-presentation as someone worthy of goodness.

Many people in our culture try with great difficulty to move through their days secretly feeling exactly that, believing in some largely unarticulated way that indeed there is something within them so ugly and so horrible that they have forfeited their right to claim the worthiness afforded to any newborn baby. Somewhere along the way such people sense that they have been corrupted by their own foulness.

Of course like just about any other emotional/psychic phenomenon, this one exists on a continuum. There are those, more in number than many would imagine, who have been so lost to such a self-contemptuous notion that they believe themselves worthy of actual physical self-punishment or degradation. And then there are the untold millions commuting to work each morning who move through the world with effectiveness and moments of happiness but on some private level believe that if others knew who they really were they would be cast out. At the least many of us believe that those who know us best would be shocked by what lies within our inner shadow.

Why? When no one is immune to the complexities of being human, when each of us contains both light and dark, when we’ve all experienced insecurity and humiliation and aggression and lust and covetousness and hopelessness and fear, why is there such an epidemic of shame in our culture? Why are we so ashamed of the harder parts of ourselves that are so inextricably woven into what it is to be a person? Why is the more complicated third dimension of what it is to be a human being, the places of insecurity and animal instinct and deep longing, so often kept such a secret, commonly even from ourselves?

My years of clinical work have oriented me to two primary sources of this concealment and shame: our families of origin and our culture at large.

Invariably, those of us who experience the deepest, most intractable, at times most dangerous degrees of shame have been raised in families that taught the child that she wasn’t good enough for the love we are all born craving. The child comes into the world and is entirely dependent on her caretakers to teach her who she is and, above all, what kind of treatment she is worth. This worth is communicated to her not in the best moments but in the aggregate of all the moments, the thousands upon thousands of interactions that felt a certain way for the child, where the child came to “know” exactly what lay at her core through the reflections mirrored by her caretakers’ actions and attitudes. All too often those reflections are enormously distorted by the particular struggles of the caretakers: perhaps their own mental health issues, or the largely joyless grind that is their own life, or an acting out of their own ambivalence around ever having become parents in the first place.

A child does not possess the capacity to identify that the reflections offered back to her are distorted, passed through the prism of her parents’ unique otherness. An adult can come to understand, often through considerable effort, that the way in which she essentially “knows” herself is an echo of this initial reflection, and is largely arbitrary in that it rests far less upon her own relative worthiness than upon the particularities of the family system into which she was unwittingly thrown. This understanding can be hugely soothing, and useful: at its most liberating, this insight (if not just “understood” but actually deeply felt) can serve as the basis for a transformative degree of self-compassion, a loving resetting of the way in which the self is held, a challenge to the notion that the love that is sought is so contingent on personal perfection.

And then there is our culture at large, which has the power to encourage even those of us who were well-loved in our most vulnerable years to conceal our more complicated, most pained inner spaces. Every day in my practice I sit with such deeply lovely and, often, outwardly outrageously successful people who can’t shake the nagging, painful, secret sense of their own inadequacy, their own fraudulence. Such folks often feel utterly alone with the darker parts of themselves they know or perhaps even suspect to be true, parts that they fear they must keep hidden from even those who love them best: their desire, their envy, their self doubt, their loneliness. There is true suffering in this imagined imperative to hide the self that we find most difficult to be, and in the lengths to which so many people go to prove to the world that they are indeed as “pure” and “good” as they believe the world demands them to be.

The fire of this shame is fueled by many macro sources: our capitalist system, in which true satisfaction and personal enough-ness are the obstacles of many a marketing campaign; society’s demand for the presentation of self in everyday life (to borrow a phrase from Erving Goffman), in which impressions are managed and controlled as an actor controls a scene on the stage; and of course the explosion of social media, in which (alongside its facilitation of certain kinds of relationships and the flow of culture) the presentation of self is too often a volley in an unnamed competition for who is living the more “successful” life, which in large part is implicitly defined by the consistency and degree of pleasant emotions on display. Such an unwinnable game deepens even further the gap between what is shown to the world and the self as it is privately, essentially, often ambivalently experienced, sending the latter deeper into the shadows, where secrecy breads shame.

I urge us as I urge myself, to move towards true self-compassion. Co-passion: being with feeling, being with what is human; self co-passion: being with what is human within ourselves. That humanness is by definition and inescapably so many things we do not permit ourselves to be on the larger stage of society, and perhaps so many things that were punished in ways large or small in our early life. And yet what but human, tender fleshed, what but filled with both light and shadow, could we ever hope to be?

Empathy versus Compasion

As a clinical psychologist, I’m often asked by people how it is that I can sit with so much difficulty and suffering. I first reassure these folks that my day is hardly non-stop heaviness. I tend to truly enjoy the people I work with and my day is filled with connection, warmth, and laughter.

But of course life is hard and people come into my practice because they’re needing help with their confusion or their pain. And much of a psychotherapist’s job is being with suffering in ways that are helpful. The way in which I’ve learned to be with the difficulties in my clients’ lives has been tremendously useful in my own life, and I think offers some direction on how we might learn to be with each other generally, and with ourselves.

The psychologist Paul Bloom makes an important distinction between empathy and compassion. Bloom discusses several problems with empathy, which involves feeling within ourselves what someone else is feeling. For one, empathy doesn’t always leave us in the best position to offer someone help. If we too are feeling what is being felt by the other, we might find ourselves in the same need of comfort and wisdom, and without the space required to offer someone the qualities or actions that are beyond their own reach. And even more troublingly, we tend to feel empathy to varying degrees depending upon how like us the person before us is: our child’s sadness can be felt as our own; our neighbor’s grief at losing her house to a fire can be experienced in our own chest. Studies have demonstrated that the suffering of someone who looks unlike us elicits an empathy far less visceral. There are obvious moral implications for this differentiation in empathy, as it’s likely to promote a kind of tribalism that furthers inequality and oppression.

Compassion on the other hand is not the visceral mirroring of another’s experience, but rather a position one might take in response to suffering. To be compassionate is to relate to the suffering of another with kindness, understanding, wisdom. One need not experience the pain of another to occupy a place of compassion. In fact, to be in a position of true compassion, where space can be held for another, something other than the full emotional joining of empathy is demanded.

As a psychologist, if I were to experience full empathy all day, I would be burned out within the month. But compassion, on the other hand, is a true joy to experience. It demands and promotes a certain kind of strength – of heart, of mind, of character.

What we are after, of course, is the occupation of this position both towards others and towards ourselves. We are after this position because it contains love and promotes effective response. We are after this position because it is a more joyful and peaceful way to live. To relate to our own suffering with compassion – that is, to experience self-compassion – necessitates that we cultivate a capacity to relate to ourselves with love, a surprisingly elusive thing to do.

Contrasted with empathy, which again is a kind of unbounded joining, self-compassion also demands the occupation of a position that is in some sense outside of our own suffering. That is, to be in a state of self-compassion we must hold ourselves as we might most compassionately hold another – seeing our own suffering, understanding it, caring about it, but offering too a wider perspective and faith in something other than pain. To do so allows us to create some space around our distress, so that rather than being in the full grip of it, lost in its scary stories, we might be able to offer ourselves a loving reassurance that this is human, this is part of living, this too shall pass.


It’s common for someone to enter my practice with long-standing distress ranging from minor to extreme, and yet have absolutely no idea why, or even much of a coherent understanding of what they are feeling. As therapy progresses the client’s life will unfold and invariably clear themes will emerge. As a life narrative takes shape we can see that of course he feels a, b, c, but also (seemingly paradoxically)  x, y, and z, since they are all reasonable and fundamentally healthy responses to all the stuff that happened to this person born of his particular temperament.

We might consider this place of deeper self-understanding, or self-location, a new way of being with oneself; in fact it’s often the first time anyone at all has ever truly been with the distressed parts of one’s personhood, since those parts have (strangely, remarkably) been simultaneously deeply experienced and yet largely invisible, both to others and to the self.

The website of the psychologist David Baldwin contains this illustration of the phenomenon known as dissociation:


When focusing on the motion of the blue dots most people can experience a form of blindness to the yellow ones, as obvious and “impossible to miss” as they may be. The psyche operates in much the same way. Deeply held emotional states and thought patterns that seem “impossible to miss” are in fact missed all the time, as years of defenses and indoctrination into particular family and cultural systems render us psychically blind. We stop seeing, or never learn to see, that which makes perfect sense.

What a terrible thing to be blind to oneself, to lack an understanding of what one is experiencing, and why. It’s confusing, of course, but it’s also rather frightening, as we can feel out of control, or broken, or deeply alone without the tools to build a bridge to others, since we don’t even know ourselves where we are.

At its best, therapy is a way (though hardly the only way) of locating the fullness of oneself, of seeing the yellow dots. And it is once we are self-located that we are best positioned to build and sustain the features of a satisfying life: relationships that offer true contact; roles in the world that reflect authentic expressions of the deepest parts of ourselves; an open-heartedness that allows for an orientation to others characterized by generosity and integrity.



It can be extremely useful to understand the phenomenon of emotional regression. I don’t know anyone who is immune from it.

When we are under stress, and particularly under stress within an important relationship, we may be far more likely to revert back to a way of being rooted in some earlier stage of development. We may become childlike in our plea for attention; we may uncontrollably cry; we may lash out with a toddler’s rage; we may become shut down in silence and emotional numbness; we may escape to the “shelter” of substances. In these moments the path back to our best, adult self may be entirely blocked, or not even sought. Instead we find ourselves taking on our adult pain with a child’s tools. What is this about?

When we’ve regressed to an early, largely ineffective way of coping with a situation, we have no doubt been feeling unsafe and disempowered. The unsafety is relational; in the moment that triggers a regression, we are feeling unseen by someone important, uncared for, unattended to, perhaps even abandoned. The disempowerment is rooted in our inability to trust that the effective deployment of our adultness will bring about connection; either because we can’t find our own adult powers to know and express ourselves clearly, or because we feel the other person is unable to meet us in our experience for their own reasons, we lose hope in the moment and find ourselves impotent to restore connection.

To be disconnected and disempowered is to be afraid. When we find ourselves regressing, our internal alarm system is going off, alerting us that we are swimming alone, and there’s nothing we can do about it. So we move down the ladder to more primitive ways of self-soothing, of protecting our vital organs from the pain of the moment. In the language of the nervous system, we are thrown into fight/flight/freeze. We might become puffed up with aggression and an empty sort of power (fight); we might become deeply avoidant, either physically absent or emotionally unbridgeable in our internality (flight); or we might become entirely disconnected from our own experience (freeze).  In each of these instances, our true, adult self is moving further and further into alienation.

Of course we all have moments of losing contact with our most developed self, and there is a time and place for testing – consciously or otherwise - any given relationship’s capacity for holding us when we are not at our best. But ultimately regressing simply doesn’t work. It’s not good practice because it is just not effective. Regressive behavior does not in the end bring us closer to what we all want: the experience of being understood, the experience of love. If we are to sustain the love we’ve been lucky enough to find, it is essential to note and understand our moments of regression, and cultivate our adult powers of self-possession and communication.

The Full Spectrum

All too often we imagine the way to contentment is entirely a process of aligning the external world in just such a way that it evokes nothing but pleasant feelings. Much of this comes from the cultural messaging that suggests we’re failing as a human being if we aren’t ceaselessly happy. The implicit message underlying market capitalism is that we should be happy, and if we’re not, there’s a problem to be fixed, and something being sold can fix it. Psychotherapy, firmly rooted in the market economy, is not infrequently marketed in just such a way.

As a clinical psychologist, of course I do - given the right fit between therapist and client at the right time in the client’s life - deeply believe in the value of psychotherapy. And yet the psychotherapeutic process should not be confused with an effort to live entirely on one end of the spectrum of the human emotional experience. As human beings, we by definition experience an endless dance of pleasant and unpleasant moments, emotions that feel great and emotions that are unpleasant, and ultimately there’s very little we can do about this. Yes, through psychotherapy and other healing processes, we can become unstuck from chronic feeling states, we can counter shame, we can cultivate kindness, we can heal trauma, we can live more authentically, etc. But we will forever come back to the limits of the human mind and body, which contain all manner of unpleasant and challenging moments until and perhaps including our final breath.

Of course, we can get stuck in the darker end of the spectrum, and find ourselves impossibly far from joy, love, engagement and meaning. And here good psychotherapy can be enormously helpful, as we might move through that which keeps us stuck in our pain. And yet even once unstuck, we remain human, and challenged by all that that means.

Such a simple notion, that we will forever experience both pleasant and unpleasant emotions; that we can not escape the realities of impermanence and loss; that much of the world evokes sadness, anger, fear; that to be fully alive is to fully experience the entire range of human emotion. In fact, I assert that the lived, allowed experience of the full range of human emotion in response to all that is true in life is the very definition of emotional wellness. And yet it amazes me how frequently people enter my practice feeling such shame about their sadness, their confusion, their fear. When did experiences that are so inextricably human become seen as such a problem?

If the full spectrum of experience is inevitable, my fervent hope for those I treat is that they might cultivate the most useful qualities with which to meet it: courage, integrity, honesty, awareness, wisdom, dignity, acceptance, compassion for others and for the self.


Growth and maturation often lead to a decrease in reactivity. By reactivity, I’m referring to the experience and acting out of feeling states that are more intense or otherwise different than the triggering events would by themselves warrant. Such reactivity is typically sourced in some underlying vulnerability, but might manifest in a number of ways, such as aggression, withdrawal, or emotional numbness. Many of my clients are seeking help for a pattern of reactivity and its destructive consequences within important relationships.

An essential step in working with reactivity is understanding that the intensity of our feeling is often not rooted in the immediate events, as we typically assume. It certainly feels as though it is: a young man’s co-worker made a flip half-joke about his performance in a meeting, and he then felt shamed and deeply angered. The chain is clear: flip comment, then intense feeling. It’s reasonable to conclude that the comment caused the feeling, and the fault is entirely within the co-worker, who then becomes demonized, perhaps for only a moment, perhaps for much longer.

And yet when we look closely at what took place with the co-worker, we see clearly that the moment didn’t contain nearly enough fuel to power the full intensity of feeling the young man had. Perhaps the flip comment was unkind and thoughtless, but ultimately the sting of the comment was merely a match that sparked a reservoir of feeling that was already there. The reservoir of emotion was a dormant powder keg, and had nothing at all to do with the co-worker.

In fact, so much of what we feel is powered far less by the spark of the immediate moment than by our temperament and the years and years of moments and feelings and traumas (big and small) that we carry with us throughout every single day. This is an apparently simple but actually enormously powerful notion to have a good grasp on. Our histories are alive in all of our moments, and in many ways our immediate experiences are passed through the lens of this history. We interpret and react to our worlds in ways that are not dictated solely – or even primarily - by the present situation.

The implication is clear: if we are to meet each moment effectively, if we are to engage other people fairly, we would do well to understand the lens through which we tend to see the world. We would benefit enormously from the ability to discern what is happening “out there” from what we habitually tend to feel as a result of our own deeply held positions. If we believe that what we are experiencing is entirely a reaction to what is happening in the present moment, we are doomed to an eternal repetition, as the underlying patterns and habits simply manifest again and again. 

The Repetition Compulsion

One of the more mysterious processes in the human experience is the repetition compulsion, the pull towards the recreation of the familiar, even when it is ultimately painful. Freud, who first named the process and coined the term, defined it as “the desire to return to an earlier state of things.” The drive towards repetition might play out on as mundane a level as getting the same thing for lunch every Wednesday. Or more interestingly, and strangely, it might mean unconsciously recreating again and again the same relational dynamics that bring about some of our deepest pains.

Any therapist with this concept on their radar will tell you that the compulsion is as common as it is curious. So often I see clients who will choose relational partners (friends, lovers, co-workers) who 1) possess qualities that are reminiscent of earlier, ultimately disappointing important people in the client’s life; and then 2) are engaged by the client in much the same way as they might have engaged the previous, failed relationships.

Unsurprisingly this pattern often results in a repetition of familiar suffering. Sometimes this is quite obvious. The son of an absent father becomes an absent father himself; an abused child marries an abusive spouse. Sometimes the repetition is subtler. A middle aged man who experienced a degree of emotional deprivation within his family of origin, whose father was a workaholic and whose mother was depressed and inward, might again and again choose relational partners who are unable to meet him fully. On the surface, the pattern might not be clear because the partners all seem to have different personalities (perhaps one is narcissistic, another emotionally immature, another married and just looking for sex), but underneath is the persistent dynamic whereby his needs are subjugated, and he feels unseen, undernourished and lonely.

Why do we do this? Freud was deeply perplexed by this question and proposed that it was the flexing of our death instinct – a drive towards self-annihilation and a return to an inorganic state. To me that’s pretty far-fetched. Perhaps brain science will someday conclude that the repetition is compelled on a neuronal level. Until then we might simply assume that the repetition is an expression of our need for the world and our place in it to be familiar, to above all be known and predictable, even when it is enormously painful.

Typically this mechanism is entirely unconscious. One of the most exciting aspects of good therapy is the process of the unconscious becoming illuminated. An essential component of breaking out of the repetition is seeing that it’s happening and knowing clearly our role in the perpetuation of our own suffering. While the assumptions about ourselves and the world that underlie the repetition compulsion are quite durable, we’re not doomed to play the repetitions out for the rest of our lives. It is true that many of us do. And yet many of us don’t. The underlying problematic assumptions can be challenged, unlearned, and replaced. It is my belief that this is most likely to happen within the context of a healthy relationship, perhaps (though not necessarily) a therapeutic relationship, where the engagement is of a very different kind, and the repetition gives way to a new and far more satisfying experience of human connection.

On being cast out

Deep within so many of us is a terrible fear of being cast out. I see this play out again and again with my patients, and particularly within the therapy groups that I run. This fear of being cast out – exiled, ostracized, isolated – often runs close to the core of what motivates our behavior in relation to other individuals and, particularly, to groups, whether at work, within our families, or within our social spheres.

The fear of being cast out is woven tightly with the fear of humiliation, an often trauma-inducing experience that we all have suffered. I see again and again how so many of us carry the burden of this fear of humiliation into many of our encounters, whether at a dinner party or within our most intimate relationships. This fear often runs so deep that it might even be described as a basic terror. And from an evolutionary point of view, this makes sense: we need each other desperately; to be deemed unworthy of membership and to be cast out of the group, to be rendered all alone, has for most of our species’ existence been a literal death sentence.

Ironically this fear of being cast out often induces behavior that makes truly safe connection all but impossible. As is so often the case, the defenses we (typically unconsciously) construct to protect our most tender areas are counterproductive and render what we actually want (belonging, connection, love) all but impossible to achieve. The non-productive ways of defending against this fear of being rejected are many: we might become withdrawn and silent, escaping into a dissociated internal world where “no one can hurt us”; we might become dominant and take up all the space in the room, forcing others into a disempowered position of having to react to us (“the best defense is a good offense”); or we might construct what D.W. Winnicott referred to as “the false self”: an identity and mode of behavior constructed to please others and ensure our continued permission to be in their network.

The deployment of a kind of “false self” is a particularly pernicious and common defense. I encounter many people who have a long list of friends and a successful professional network, and yet long have felt so deeply lonely. Therapy work for such people often uncovers a deeply held fear of rejection that has led them to skillfully and rather unconsciously project an identity of someone far less vulnerable than the authentic, “true self” beneath. So though they may often find themselves at the head of a crowded table, the true self remains largely unseen and unmet.

A fear of rejection and humiliation in and of itself is not a problem. At issue is what we do with it. If our fear drives us to any number of protective behaviors that keep our true self removed and untouchable, we will likely find ourselves toiling away within a deeply dissatisfied life. If the fear can be recognized, tolerated, even (when safe to do so) shared with others, we might still move into the alive spaces of connection and intimacy that form the basis of a life well-lived.

On the experience (or absence) of wonder

When I was a boy of perhaps ten I played “broadcast news” with my friend. We took turns sitting behind the mid-century oak desk in his basement reporting on the day’s events. That summer I had become enthralled with astronomy and had spent endless nighttime hours on my back in our little suburban North Jersey yard, gazing and pondering. I recall taking the broadcast seat and reporting that we continued to live in an infinite universe and we still had absolutely no clue how we got here, or why, or what “here” even meant, that generally speaking we still hadn’t the slightest sense of what the hell was going on. My friend thought this was rather odd but I remember thinking that the nightly news should always begin with such a reminder before moving on to the world’s temporal affairs, that doing so would somehow be extremely useful. To me what seemed so odd was that day-to-day we hardly ever - ever - talked about the astounding mystery that is the sheer fact of existence.

Our day-to-day disregard for this mystery still strikes me as terribly odd, as well as deeply problematic. As a culture we have utterly lost touch with the experience of wonder and the simple facts of existence that naturally induce it. Not coincidentally we are plagued with depression, emptiness, and boredom. What follows is a well-documented story: to combat the discomfort of such states we escape more and more deeply into our technological diversions, which tend to take us further and further from those aspects of life that are truly elevating.

I consider this a spiritual problem because I believe that the spiritual position – as distinct from the religious one – is characterized simply by the experience of wonder in response to the basic fact of being alive. This sense of wonder may be organized in all manner of ways around a seemingly infinite array of stories about the nature of the cosmos and our place in it; or it may not be organized by any particular narrative at all, but instead presents itself as a certain mind-state in the face of unanswerable questions. Why does the universe exist? Why do we? Why should there be something rather than nothing? What the hell is going on here?

In the absence of such wonder, a gnawing boredom commonly pervades, and with it often a terrible ennui or despair. As a clinical psychologist I’ve worked with many people who hold that ennui or despair are the only reasonable responses to what they see as the essential absurdity and meaninglessness of the universe; that is, since (they hold) the universe contains no inherent meaning, and terrible things happen randomly, and it all cosmically amounts to nothing, why shouldn’t one feel a commensurate emptiness?

Yet it is my contention that the basic spiritual position of wonder is available even to those of us who behold an inherent absurdity in the universe. In my experience, and in the teachings of many Eastern and Western traditions, wonder flows very naturally from attention. As the psychologist Fritz Perls has said, “Boredom is simply lack of attention.” The question is, to what are we paying attention?

Typically we pay attention to what is happening in our own personal dramas at eye-level. Over the eons our species developed the amazingly keen ability to survey our landscape, determine sources of threat and pleasure and resources, and plan ways of interacting with the objects and characters in our particular drama. And as we’ve come to master the eye-level world and live lives in which our survival has become more or less guaranteed day-to-day, and we now find ourselves freed in moments to ask if all this living is worthwhile, our hyperfocus on the eye-level world has come to be something of a trap. We find ourselves caught in the absurd, unexamined, and unarticulated assumption that what exists at our eye-level, easily digestible experience of everyday life is all there is to existence.

Certainly the eye-level world is all we ever talk about. In our great cultural turning away from the cosmic answers of the major religions, we have stopped talking about the profoundly moving questions that remain perhaps unanswerable. We’ve thrown the baby out with the bathwater. In so doing we’ve become reductive and positivistic; in becoming reductive and positivistic we’ve become bored and addicted to never ending stimulation.

Wonder is the natural result of breaking out of eye-level obviousness and confronting some piece of the infinitely larger mystery that is the simple truth of the universe. This larger truth need not make any sense, it need only to be encountered. Somehow, for some reason, we all have the capacity to feel awe. Who has stood at the edge of the Grand Canyon and not felt this thing that is typically utterly absent in day-to-day life? Such a moment is a crack in the everyday world through which we effortlessly catch a glimpse of a great vastness - a great vastness that is far too often quite literally ignored.

Judging by the innumerable conversations I’ve had with people struggling to feel deeply interested in life, the question of how we might in our everyday lives shift from emptiness to wonder is of no small importance.

We need not be looking through a telescope to ponder and know the utter strangeness of the cosmos, or through an electron microscope to consider the bizarre nature of the unseen all around us. We don’t have to be particle physicists to mull what strange dance of energy makes up the everyday world that pretends to be so solid, or philosophers to be in awe of the fact that any of this exists at all.

But despite our curious capacity to confront such mystery, far too often we ignore it, shut it out of our minds and conversations and our relationship to being alive. Let this be a call to engage the astounding truth that is sheer existence - to consider and talk to each other about the astounding mystery in which we are engulfed - and in so doing live more deeply.

On Expectations

In the relatively affluent West there is an epidemic of dissatisfaction. So many of us are plagued by a long-standing, gnawing sense that our lives are a disappointment; that the choices we have made have been the wrong ones; that the person we turned out to be is bitter ode to mediocrity.

Now of course it’s true that some of the choices we make turn out to have painful consequences, and no therapist would argue against working towards growth. And yet the problem of dissatisfaction I frequently encounter in my practice is so often rooted not in the insufficiency of the life being led or the person leading it, but instead in the unreasonableness of our expectations.

More than any other people in any other time and place in history, those of us in the relatively affluent West expect so much out of life. Perhaps this is the impact of living in a market economy, where the product-pusher’s challenge is to convince a sated public that it should be living better. Perhaps, as the psychologist Barry Schwarz has suggested, it’s a function of the sheer abundance of choice we are given, which creates the unconscious, paralyzing notion that, given all that choice and freedom, perfection should be possible. Perhaps it’s a function of the modern therapy culture, where all children are above average and hold the promise of something extraordinary to come. Perhaps it’s the enormously status-conscious, individualistic culture we live in, where we value the hero above all else.

Whatever the reasons, so often we observe with such disappointment this undeniable gap between the reality of who we are and our expectations of ourselves. And so often the efforts we make to bridge that gap are entirely on the side of “bettering” the reality, whether it be through working endlessly on self-improvement, obsessively pursuing power and money and status, desperately searching for the perfect romantic partner, or ceaselessly trying to change the one we already have. Far less do we work on challenging the reasonableness of what it is we (often unconsciously) expect out of life.

Life is up and down. We are flawed. We succeed sometimes and fail others. Some people like us and some people don’t. Our relationships are not perfect and go through peaks and valleys. We won’t always get what we want. Sometimes we feel very unpleasant and base emotions. Sometimes we have thoughts we wish we didn’t have.

I hold that we would do well to shrink the gap between the reality and expectations by squeezing it from both sides. Of course we should continue to grow and self-actualize; we must also become aware of the standards by which we measure how we are doing in this life, standards that all too often are a set-up for great dissatisfaction.

The Difference Between a Persona and a Person

A persona doesn’t seek therapy. A person does. And yet often when I begin a new therapy relationship, I find myself sitting across from a persona. Early in my training it was quite confusing for me. I’d wonder why the hell this person was seeking help. She’s so together, successful, confident. She seems… perfect.

Of course, that’s exactly what she would want me to think. The word persona has its roots in the Etruscan word phersu, which means, literally, “mask.” We all have all kinds of masks we wear for the world – different ones for our work environments, for our various personal relationships, for the corner deli. Of course there’s nothing inherently wrong with this; the wheels of society depend upon our successfully employing the right mask at the right time. When I’m checking out at the QFC and the clerk asks me how I’m doing, he sure doesn’t want me to really tell him. If a prospective employer inquires about my passion for selling his widgets, if I want that job I better find the right mask quick.

The problem seems to come when we’re so accustomed to wearing the mask all the time that we forget or have never known or have come to despise the real person that lies beneath. The truth is that the person beneath the persona is a far more complicated character; he’s often less secure, more neurotic, less cheerful, more fearful. She’s likely more judgmental and more coveting. Likely at times he has primitive or animalistic impulses he doesn’t want and doesn’t want others to know about. Maybe she has cravings. In short, he has a shadow, the term that Carl Jung used to capture the darker – perhaps unconscious – side of a person’s being.

Because we typically go around rubbing masks with each other, many people come to therapy confusing other people’s personas for their true selves, which makes their own true selves all the more troubling.

“Everyone else seems so confident.”

“No one else seems to be so lustful.”

“I feel like I’m the only one on the outside all the time, like I’m always faking it.”

All of this contributes to a great shame that I encounter so frequently in the people I work with. I’ve come to see shame as rooted in the space between our persona and our person: that is, in the knowledge and judgment of the difference between the image of ourselves we present to the world and the three-dimensional person we know ourselves to truly be. This difference for so many of us is a great secret that no one knows about, a secret that must be protected at all costs.

The common solution to this problem is for people to strive to become more perfect: that is, to make the person more like his persona, to make his inner experience more like his Facebook profile. Often people come to therapy for precisely this purpose, as though the right therapeutic experience can make them less lustful or perfectly secure or happy at all times. Many people want to actually feel how everyone else seems. I often wish that my patients could know each other and see immediately how much common ground they have; how they all feel what they imagine to be a singular vulnerability. The truth is that the vast majority of us have a more complicated experience of the world and ourselves than we let on.

So much of the power of the therapeutic or any other healthy relationship is rooted not in its capacity to help someone become more perfect, but in its power to help someone shift their relationship to the truth of who they are, to put their imperfection into a wiser context of the full human experience. Truly understanding the ubiquity of vulnerability frees us from the self-judgment and shame that is often the deepest source of our suffering.

Healthy healing relationships invariably are built upon intimacy. Intimacy gently demands that we drop the mask, and it provides safe ground to know the truth of oneself and meet it with kindness, with understanding, with dignity. Unfortunately, many of us have not ever experienced truly intimate relationships, or at least many of us were not born into families where true intimacy was available, and we learned to hide our more complicated aspects behind a thin facade of charm, or stoicism, or some other flavor of okay-ness. Often such people reach adulthood and have not ever allowed their larger, deeper selves to find a place to land in the world, even within their closest relationships and romantic partnerships, even within their own understanding of themselves. Despite perhaps being surrounded by many others, such people often feel a great alienation and solitude, as though they are never really in contact with anyone or anything.

We need both the ability to wear the right mask at the right time and the ability to drop these masks when it is safe and nourishing to do so. Mental and spiritual health is so much rooted in our capacity to know the more complicated aspects of the person we truly are, to work through our judgments of this person, and to find places in the world where the person – not the persona – may be known.

On Gathering Oneself

Our one-year-old daughter has just learned to walk in the last week. She couldn’t walk at all about ten days ago, and now she needs to watched like a hawk lest she toddle right out of the house. She’s pretty good at it now, but until say, yesterday, she’d take a step or two and fall right on her ass. Sometimes she’d fall squarely on the soft fleshy cushion a baby’s butt is meant to be; other times she’d fall on a block or something, or tumble and smack her head, and she’d find herself startled and in some mild pain. A second’s pause, then she’d shriek.

So as I watch all of this go down, what do I do?

Though it’s clear she’s not injured, my instinct is to rush over and swoop her up and bring her to my chest. No doubt this as much (if not more) about my own anxiety in the moment than it is about what I’ve decided she needs. In fact I’ve discovered that my swooping and scooping actually increases her anxiety quite a bit. If I swoop and scoop, I’m communicating to her that she needs me even though she hasn’t asked for me; I’m telling her some distressing story about what’s taken place, and her concern is fueled. I’ve found instead that the best thing to do for her is remain calm, demonstrate my presence, and allow her to gather herself. She’s actually quite good at being able to do this. After the shock of the moment fades, she realizes she’s just fine, she’s not telling herself any tragic story about what has befallen her, and she moves on happily to the important business of emptying the contents of the kitchen drawer.

This capacity to gather ourselves in the face of stress – to feel distressed and then find our center, to remain in contact with the truth of the moment, to respond with dignity – is a hugely important component of living well. I believe this capacity is innate. Animals and young children who have been treated well enough are able to respond to adversity with great resilience. It is cues in our early dysfunctional environments or anxious stories we tell ourselves later in life that bring us away from this natural resilience and into far less skillful modes of self-protection.

Tara Brach, a Vipassana Buddhist meditation teacher I admire, has said that in the space between the stimulus and our response lies our power and our freedom. She calls this space the ‘sacred pause.’ Without this intentional pause between what has just been experienced and what we do in reaction, we find ourselves prisoners of habitual and often totally unproductive ways of responding. This reactivity is designed to protect the self from some perceived threat, but more often than not it increases the danger of the environment and brings us further away from what we really want.

The groups I run are fascinating venues to observe the impact of various ways of responding to difficulty. The relationships between group members, like any real relationships, are fertile ground to find actual or perceived threats to one’s sense of self. In group, someone might say something that triggers someone else, or remind someone unconsciously of their punitive mother or neglecting son, or say something that really was jerky, and suddenly any given member might be feeling all kinds of stress. Maybe this person is angry or sad; likely they are wounded and their psychic safety and sense of self is disrupted.

Now, what does this person do in response?

Let’s agree that this happens all the time in life – at work, with our partners, in our families, in traffic. We get triggered. Maybe we get wounded. We get stressed by the endless stimuli that living throws at us. When we are disrupted by this stimulus, what do we do next?

Many Eastern traditions would say that before we do anything we must stop and pause. Eastern spiritual traditions and the Western therapeutic milieu have much common ground, including the shared emphasis on consciousness, on being aware of what is happening as it is happening. Brach’s sacred pause is the essential moment between the prick of life’s arrow and our next action; it is a time to become conscious of what we are experiencing and intentional about how we move forward.

In the early stages of a new therapy group, as in much of life, there is often a good bit of the two basic forms of maladaptive response to the arrow’s prick: aggression and withdrawal. Both responses are employed to create space for oneself, to carve out a little breathing room and establish one’s boundaries. And in one sense, both are effective in a very limited sort of way; they do in fact serve to keep one’s tender underbelly safely removed from the difficult moment’s sharp edge. The problem is the space created through shoving (aggression) and hiding (withdrawal) are deserts; the stuff of life (intimacy, meaning) cannot be found in the space created through acting out or curling up. In group as in life, the impact of habitually acting without pause – of acting before gathering oneself – is clear and poignant: it is a recipe for alienation, emptiness, and suffering.

And yet if when we are wounded we then gather ourselves – if we recognize what we are feeling and why, if we understand the fuller context and deeper truths of any given moment, if we understand what it is we really want and the best way to bring ourselves to it, if we first take some deep breaths – we may respond with powerful skill. We may meet the inevitable pains of living with dignity and resilience as we stay in contact with the stuff that makes life so rich and worthwhile. I see this so often in group as well.

This ability to gather oneself can be learned. I know it because I see it all the time – both in my patients and in myself. Learning to gather oneself requires knowing oneself – knowing what it is that we tend to feel, understanding what those feelings are rooted in, learning to separate the present stimulus from deeper pains we may carry. It requires seeing the truth of what works for us and what doesn’t; how aggression and withdrawal carry great unwanted consequence; and how taking time in the sacred pause allows us access to a one-year-old’s wisdom.

Primal Fear

So often in my practice – and here I mean both my psychotherapy practice and the practice of my own growth – I see the enormously powerful presence of fear. Fundamental as it may be, the fear is rarely obvious, buried as it is under the more apparent feelings and states of mind that grow out of it. In fact in my experience it often takes quite a bit of work (psychotherapeutic or contemplative or meditative or what have you) to recognize the fear beneath so many of our unhealthy orientations to the world: beneath avarice lies fear of deprivation; beneath exploitative dominance lies fear of humiliation; beneath aggression lies fear of injury. Often in therapy I see how uncovering these fears – and learning a new relationship to them – opens up the possibility of finding more effective ways of navigating the difficult aspects of life.

This fear is often complex and rooted in various aspects of our specific lives and experiences. And yet I believe that much of the fear that shapes our engagement with the world is organismic, an element of the biological instinct system (or what Jung referred to as ‘the collective unconscious’), and it is this more primitive experience of fear that I want very briefly to touch on today.

We are vulnerable. Our hold on life is fragile. We evolved with the highly adaptive capacity to feel primal fear as an appropriate response to the fact that we have always been surrounded by great and very real threats to our survival. This fear is of course adaptive because it calls us to effective life-sustaining action; it is our biological inheritance, naturally selected through all the many thousands of generations of human and non-human ancestors who successfully survived to reproductive ages. We are here because, in part, our forebearers felt appropriately afraid.

For most of us in this present time and place, our survival on any given day is far more assured than it has ever been. And yet we carry around the collective and largely unconscious legacy of a great primal fear. I believe that in our civilized time and privileged place this fear is present and yet so often useless – in fact, typically wholly unused; for so many of us it is unattached to anything real, any truly life-sustaining action – the building of shelter, the acquisition of food – and is thus free-floating and quite maladaptive in its expression.

Depression and anxiety are the great emotional/psychological afflictions of our particular time and place. In my work with so many people who’ve had depression or anxiety as their “primary diagnosis,” I’ve seen how so often beneath the obvious presentation lies a sense of self marked by a deeply held underlying (and often unconscious) primal fear, often exacerbated by life experiences that contribute to a feeling of unsafety. The work of therapy is in part about uncovering the presence and genesis of our fear in all its forms, recognizing its impact and expression, and cultivating a more effective relationship to the fact of one’s vulnerability.

On the Difference Between Diagnosing and Understanding

The Diagnostic and Statistical Manual of Mental Disorders (“the DSM”) is a heavy book used by clinicians to diagnose psychiatric illnesses. According to the National Institute of Mental Health, in any given year over 26% of American adults qualify for having at least one of the psychiatric disorders described in the DSM. Since we’re talking about 60 million people in any given year, one might immediately question the very use of the term ‘disorder,’ since the word suggests something abnormal, something outside the common arrangement of things.

In any given year, 15 million adults qualify for some form of depressive disorder (code 296 in the diagnostic taxonomy of the DSM), and 45 million for some form of anxiety disorder (code 300). I say “some form” because the DSM differentiates subsets of these disorders on such factors as the number of times the “illness” has occurred in one’s life and its severity. (e.g. 296.21 for Major Depressive Disorder, Single Episode, Mild). People presenting with issues that can be captured by these depressive and anxiety codes form the main bulk of the practices of many mental health clinicians, including my own.

Many clinicians – and even unfortunately more than a few patients – have fallen victim to a reification of the diagnostic taxonomy, and confuse a descriptive cataloguing of the complicated aspects of human experience with an actual understanding of the genesis and meaning of someone feeling and thinking and behaving a certain way. Saying someone “has Major Depressive Disorder, Recurrent, Moderate” (296.32) says absolutely nothing about why this person is experiencing himself and life in such a way that lead him to have at least 5 of the 9 symptoms the DSM requires for someone to warrant the official diagnosis. And it says even less about what to do about it.

It does however definitively say something about how appropriate it is for someone to have at least 5 of those 9 symptoms: it says that this person is disordered. It’s in the very title of the manual. In our reification of the taxonomy we have not merely conflated description with understanding, we have perpetuated and reinforced our mainstream culture’s judgment and stigmatization and marginalization of suffering.

Of course pharmacological interventions certainly have their place in the treatment of many people. And yet one might argue that a psychiatric system built on the medicating of distressed people might at times benefit from a conflation of symptom description and true understanding of the meaning and cause – and thus in a deep sense the appropriateness – of one’s suffering. In the medical model patients are often understood (not merely described, but understood) as “having major depression.” In this formulation, there is a problem, and the problem is the symptoms, such as difficult feelings; medicate the patient so that the difficult feelings change and there’s no longer any problem. If the difficult feelings return, the problem has returned.

In contrast, in my own humanistic psychotherapeutic tradition – that is, a system that endeavors via an honest relationship to assist people in accessing their own natural movement towards healing and maturity – the intervention is founded upon the assumption that someone who is depressed or anxious is likely responding in an entirely understandable and very common way to the complexities of life, in particular of course to their own unique life and whatever they have learned to believe and assume about it. The symptoms that inform a diagnosis are thus seen as part and parcel of a complex and nuanced and entirely reasonable lived experience. Much of the work in psychotherapy is in understanding and gaining perspective on this lived experience, and building a new way of relating to it.

In all the hundreds of people I have worked with I have yet to really get to know someone – severely “depressed” or “anxious” though they may be – whose internal experience of life didn’t come to make perfect sense. And it is in this making sense, the making meaning, of one’s experience that we can move away from shame and blame (of self and others) and towards compassion and wisdom. And (as is true in both the therapeutic and spiritual traditions) true, non-judgmental understanding is the keystone of peace and grace.

Diagnostic constructs such as “Major Depressive Disorder, Recurrent, Severe, Without Psychotic Features” (296.33) certainly have their place. They are very convenient. They tell an insurance company that a treatment is warranted and they quickly communicate some features of someone’s life. But let us – as patients and as clinicians – always remember that a convenient diagnosis is just that – a convenience that must not obstruct our efforts to deeply understand, honor, and relate wisely to the nuance within the human experience.

On Longer-Term Therapy

Numerous people, from family to friends to patients, have asked me if I’ve read “that article about therapy in the Times this week”. Yes, I have.

While it’s not uncommon for a newspaper article to provoke a blogger’s response, it is perhaps more remarkable for an article to provoke a blogger to become a blogger so a response could properly be made. Jonathan Alpert has managed to achieve such a feat with his recent New York Times article, “In Therapy Forever? Enough Already.

The vociferous response to the article has come from many corners: from other psychologists online, psychotherapist listservs, my collegial network, and from patients in my own consulting room. Much of the focus has been around Mr. Alpert’s apparent misrepresentation of his credentials, his shameless cherry-picking of the scientific literature, and his nonsensical conflation of “longer-term” and “bad” therapy. There has also been much confusion and disappointment in response to the Times’ strange decision to publish such an insipid bit of self-promotion.

While I share all of these views, I feel most moved to respond with an illumination of the usefulness of longer-term therapy. I would call this a “defense,” but that’s not quite right, since I don’t feel defensive. I do however feel angry – or certainly I did when I first read Mr. Alpert’s article, much as one does when something they love and respect is thoughtlessly denigrated and made feeble through an ignorant rendering. Above all it is my hope that this post might be useful to someone wondering if Mr. Alpert just might be right when he says longer-term therapy is analogous to a “spa appointment” and likely “leads to codependence.”

A couple quick points of agreement with Mr. Alpert: I agree with his point that no one should stay in therapy when they are not being helped or if they feel their therapist is not a good fit for them. Half the therapists in the world are generally less effective than the other half (as are half the arborists). In my practice I explicitly encourage discussions of the ongoing usefulness of the work.

Second, I also agree that for many, a shorter-term approach is useful and warranted. Often people do come in for guidance around a specific situation, a life event, a decision to be made, etc., and for these folks a limited number of more problem-focused conversations is precisely what is sought and needed. A belief in the power and usefulness of longer-term therapy does not mean that a long-term relationship is the “right” option for every patient-therapist dyad, and this sadly includes some dyads that are currently in a long-term relationship.

But what about when the fit is a good one? When the patient that would benefit from working long-term with a good therapist finds a good therapist? What, then, is longer-term therapy about? What happens?

Enough words have been said and written about this to fill the oceans a thousand times. Of course different theoretical schools will use different words. My intention here is to be brief, at the risk of oversimplifying a fascinating and infinitely rich process. So I will say that in essence, I believe the growth that is facilitated across the various longer-term psychotherapies, as distinct from the help that is available in the problem-focused coaching of Mr. Alpert, can be distilled to two very broad factors: 1) the generative power of the therapeutic relationship itself, and 2) the gradual expansion of the patient’s capacity for honesty – both in the form of markedly increased self-awareness and the sparking of an intrinsic desire to engage in authentic discourse with the world. Let me briefly flesh out these factors.

The relationship. Study after study has shown that psychotherapy is effective, and that what makes it effective above all is the relationship between the therapist and the patient. A believer that, as the psychoanalyst Nancy McWilliams put it, psychology may be a science but psychotherapy is an art, I am not one to cite empirical data on therapeutic outcome. Yet my own experience exactly mirrors the overwhelming conclusion from empirical research that the alliance between the patient and the therapist is the single most important factor in the success of therapy. As in any relationship, for this therapeutic relationship to be healing and good, for the affecting ingredients of it to be felt deeply and incorporated into one’s view of oneself and the world, it simply takes time. This is self-evident.

As anyone who has been in therapy for more than a few sessions can attest, the relationship between patient and therapist – and particularly the skilled therapist -becomes extremely powerful. And while the therapy relationship is of its own kind and does not easily fit within other existing relational paradigms in our society (and is thus understandably sometimes described by my patients, particularly as the relationship first deepens, as ‘kind of weird’), it is above all quite real. And it becomes more real as time goes on. In fact, it often becomes the most real – that is, the most honest – relationship that the patient has ever had. More than a few therapists have commented that they themselves are more authentic with their patients than they are anywhere else in their lives. (Note: by “authentic” I don’t mean “self-disclosing”; I mean supremely present with their true selves as they effectively embody the therapeutic role.)

We are social creatures with relational needs: the need to be respected, to be met with compassion, to be understood. When these relational needs are met, consistently and over  time, and when we may trust that the meeting of these needs is not haphazard but may be relied upon, all manner of growth and healing can take place. Within the goodness of this relational field we may respect, accept and understand ourselves. We may cultivate self-compassion. We may grow and heal. This is true within the best personal relationships of our lives, and it is true in therapy.

Honesty and awareness. A cornerstone of the therapeutic stance is that the more aware we are of ourselves, the better our chances to live healthy and satisfying lives. Of course, the self is layered indeed. In the psychodynamic tradition that in part forms the basis of my own work, central to growth in healing is the increased consciousness of the source of our thoughts, feelings, and behaviors. As we better understand both our constitutions and the ways in which our experiences have shaped us, we learn how it is that we make sense. And since compassion – for the self, for others – flows quite naturally from understanding, over time we find self-compassion where there was once judgment and shame.

This self-understanding does not come easily! Much of what is not conscious to us is not conscious for very good reasons. Often these aspects of ourselves are deeply painful, or buried beneath layers of contradiction. The mind is not monolithic; it is incredibly complex and riddled with paradox. To discern the feelings and assumptions that in the deepest way drive our decisions and direct the course of our relationships, to hear the distinct tones in the white noise of our multifaceted self, requires great diligence and a sharpened attunement to nuance. With the help of a skilled therapist, this way of knowing oneself can be reached, and once it is, can be enormously useful in the creation of a satisfying life. Again, to know oneself at this most useful depth takes time (and hard work).

A great advantage of longer-term therapy is that it allows the increasingly aware patient to explore his or her life within the context of a safe and good therapeutic relationship in real time. Life continues to happen while we are in therapy. And as life unfolds and patterns continue to repeat themselves (and repeat and repeat), the patient is supported in her efforts to see these patterns, recognize them, and use this self-awareness to make decisions that are aligned not with reflexive and often counter-productive ways of protecting the self, but with her most deeply held – her truest – values and desires.

Since these deepest values and desires almost always involve the yearning for kind love, and since offering decency is the best way to receive it, patients quite often become more respectful, honest, and compassionate within their most intimate personal relationships. And as we learn what it is that we really want, and we begin to truly feel that we deserve it, we become far more intentional and effective in whom we choose to be vulnerable to.

I hope this very brief sketch is sufficient in giving a taste of what becomes available over time in good longer-term therapy. When the time is right, the therapist skilled, and the relational match favorable, longer-term therapy can be not only useful, but truly transformative, and very beautiful.