Sunday, 24 May 2009


I was recently asked to give a 12 minute presentation on mental health difficulties in adults. Quite a tall order! I thought it might now be instructive to set down in writing the thoughts I used to structure my somewhat off-the-cuff talk. I'm writing off-the-top of my head, using the concept of 'anxiety' to structure the presentation. What interests me is whether some such basic scheme could survive my own and others' critical scrutiny in the future.

1. Anxiety is the experience of a threat to the self. A healthy self is internally coherent, continuous over time, well delineated from others.

2. The development of a healthy self depends upon background neurological and environmental factors. Of the former a well developed CNS is essential, a CNS which can then selectively degrade (apoptosis) as required by development (to not be overwhelmed by too confusing a diversity of experiences), which is not too chronically dysregulated, and which is responsive in its development to environmental organisation which eventuates in self-regulation.

3. The most potent environmental organiser of basic selfhood is the attachment relationship with the primary caregivers. Through an adequately containing and mirroring attachment relationship, I develop a sense of the boundaries of my selfhood (the scope and delimtation of my physicality, my agency, moral responsibility). Having a caregiver who can hold me in mind over time also allows me, gradually, to develop a sense of myself as continuously existing over time as a self-same subject. A stable physical environment is of course also essential (although we can take this for granted far more frequently).

4. These factors allow for the development of selfhood, without which I will not even be able to experience anxiety (since there would be nothing which could be feared to be damaged). They also allow for the development of a stable sense of selfhood - without which I will be prone to recurrent anxiety.

5. Psychological disorders are principally due to anxiety - i.e. due to a sensed threat to the self. This can arise either because of an insecurely developed self to start with (for biological or attachment-based reasons) and/or because of environmental trauma (in which the self has come largely under threat. Very shameful experiences are good examples, or physical traumata in which one thinks one is going to die, or rape or other such extreme experiences of violation of the self, etc.).

6. Different psychological disorders result from different ways of managing different kinds of anxiety. (By 'different kinds of anxiety' I mean: the felt threat to different aspects of selfhood.)

7. Agoraphobia results when, to prevent the feared damage or death of the bodily self or of the self's psychological continuity (i.e. its sanity), the sufferer stays in a safe environment (their home). Panic attacks are cases of runaway anxiety where what is feared is actually the anxiety experience itself (although it is often not recognised as such).

8. Social phobia (extreme shyness) results from a disturbance in my social going-on-being-with-others. I fear that my social self will fall apart - I fear that I will no longer be able to go on being someone. Self-consciousness further disrupts the going-on-being of myself.

9. The obsessive-compulsive attempts to compensate for basic anxieties by inhabiting a semi-delusional alternative reality. In this world they can control outcomes with the power of their own mind, and are not therefore so subject to the vagaries of fate and its impacts on the self. Bad happenings can then be imagined to be magically prevented through performing rituals. However the self which takes itself to have more power than it does is left with a sense of hyper-responsibility; this causes its own further worries, which usually constitute the presenting problems.

10. Many specific anxiety disorders that appear to concern the subject in relation to him or herself (e.g. some health anxieties, or some obsessive compulsive anxieties, etc.) typically cover over - provide substitute foci for powerfully anxiogenic - more basic anxieties regarding the self in the context of interpersonal relations.

11. Depression results (at least sometimes?) when the sufferer retreats inwards, away from their situation, and away from their future, in order to keep themselves safe from destabilising experiences (such as major disappointment) which would otherwise threaten to plunge the self into crisis.

12. The person with psychosis so greatly fears the loss of the self boundary that they create an alternative reality to inhabit (hence delusions, hallucinations, etc.).

13. The person with a personality disorder finds intolerable the vulnerability of their self to the impacts of others. They either withdraw or merge with others, and often unconsciously 'project' or 'selectively disown' their disturbance into/onto others. These are then encountered in these others who are experienced as fearful. Intolerable anxieties may also be treated in a highly concrete way rather than be allowed to be felt, and so the patient may try e.g. to physically cut or eat them away. (We are all a bit personality disordered.)

14. Addictions to alcohol and heroin and barbiturates are attempts to manage anxiety through self-medication.

15. The task of therapy is to strengthen the self. The therapist trusts that, although when they are terrified their self may indeed be falling apart, the patient will return to themselves - that the anxiety will pass by itself. They convey this to the patient, as much through their attitude as through what is explicitly said. Over time, and if therapy works, the patient comes to internalise at least some of this confidence.

16. The therapist provides an external support to the patient as the patient allows herself to drop conscious controlling modes of managing themselves - which modes have previously massively constrained their lives - and instead to immerse their selves in non-reflective encounters with their expanding worlds. Some of the new experiences which consolidate the self take place between patient and therapist (e.g. I risk not controlling my feelings when with my therapist; I risk looking at them and thereby fail to avoid potentially (but not actually) seeing them scowling at me, etc.); others take place in the patient's world; the exposure to these is however facilitated through discussion and goal-setting etc. in the therapy sessions.

17. Patients who have a fairly stable and well developed sense of self, or who only suffer a disturbance or weakness in one limited aspect of their identity, can often be helped with a more discursive, shared-formulation-based approach. Patients with a more fundamental disturbance will require a longer and more 'in depth' therapy. This does not mean one which explores 'deeper into the psyche', but one which works more through an implicit quasi-re-parenting approach (the tacit containment of anxieties by the therapist etc.).

18. Much effective therapeutic theory and practice consists not of techniques to positively influence the patient, but instead of the exercise of skills in using internal reflection to resist being drawn into the patient's anxieties and into the defences they use to manage them. Ordinary conversation - the meeting of civil minds offering one another recognition - is itself curative. This ordinary conversation is what is often impossible for the patient who has erected powerful interpersonal defences. The therapist's - often largely intuitive - skill consists in negotiating these defences so that ordinary conversation, play and symbolism can once again become real possibilities. ("Medicus curat, natura sanat": it is nature that cures, the doctor merely facilitating nature to do its normal work in abnormal circumstances. Well, that's the kind of thing - but transcribed into the psycho-social setting - where the therapist's job is to make it possible once again for (human) nature to restore itself to itself.)