loneliness and therapy

I recently gave a talk on loneliness and was afterwards struck that I failed to say that which was perhaps somehow too obvious to be said but which, I realised from the Q&A, yet needed to be said.

My understanding of loneliness is that it's no registration of being alone - no synonym for a feeling of oneliness -  and no simple recognition of current unlovedness -  but rather the feeling of being unloved because being unlovable. This I did share in the talk. And I ended that talk by giving four suggestions - all of which I described as manifestations of love - for how to get a therapeutic handle on the patient's loneliness.

One had to do with challenge and play: to challenge the patient who relentlessly and unconsciously positions herself in phantasy as on the outside of human relations, and then consciously complains of what are the consequences of that. (Jonathan Lear has a lovely example of this, in which he says to a patient who complains that she has never heard him speak (i.e. give a paper) 'Can you hear me now?' as if he was testing a telephone connection.)  

The second had to do with the offering of loving recognition to another, a kind of recognition which reveals the full humanity (hence lovableness) of that which it responds to. (Raimond Gaita's famous example of the nun in the psychiatric hospital provided the example here.) 

Another concerned the work one needs to do on oneself as a therapist to tolerate the patient's tragic loneliness rather than deflect from it and flee into understanding or action. 

The fourth concerned the importance of work to inculcate dignity. Dignity, I suggest, is a non-perverse form of self-love which has to do with valuing oneself in such a way that one troubles to act on one's values and so can take pride in so doing. Dignity works to help prevent the sense of the good always being located outside the lonely subject so he's left pining and outcast. Instead it can now be located inside. One can know oneself as lovable, even if one happens to be unloved, because one's done one's duty. 

Despite sharing these four suggestions, I still received questions of the 'what shall I do with my lonely patient' sort, and I was a little puzzled by that. I found it hard to say anything that didn't refer back to what I'd already said. But yesterday I realised what I should have said is this:

Psychotherapy is, as I believe we all know, primarily about helping the patient identify and disidentify from and challenge critical or otherwise unhelpful inner voices, voices which demoralise. Along with this comes the installation of a 'good' inner voice - one that is on the patient's side, an aptly respectful self-relation, one which takes him seriously, as someone worthy of care and attention. It's also about helpful and tough challenge of the patient himself in his self-defeating laziness and corruption - since who could see himself as lovable who acts in unloving ways? 

Now, my claim was (to recall) that loneliness comes from a sense of unlovableness. What keeps this in play? Well, it's the earned and unearned self-disrespect, warranted and unwarranted expectations of un-love, which populate the patient's psyche. But the work of therapy is precisely the work of challenging the patient to act in ways that he can respect, and moreover challenge his appraisal of himself and his acts as unworthy of love. The work can be hard because the patient may hang on tenaciously to his introjects (in effect he is using a repetition compulsion to manage the hurt of un-love.) Yet my point is that the work of psychotherapy, as we've always practiced it, is itself precisely what's required for the true amelioration of loneliness.

I had another thought which has to do with dependency: we sometimes hear the worry expressed that therapy may create emotional dependency on the therapist. But from the point of view expressed here, this is peculiar, since what it actually suggests is a failure of the therapy to promote the actual internalisation of a good object and the extrication from the psyche of the bad objects. Nevertheless it is a significant worry, since it's hard to fully achieve the disidentification from the bad object and the introjection of the good. It can feel unsafe to do so, and it can simply be hard to not slip back into the sense of self supported by the negative introjects. For this reason the patient may end up unhelpfully relying on the therapist's resource rather than developing their own. And we know from our experience that there are specific situations - e.g. when in a crowd of unknown people who yet know each other, or when spending a lot of time alone - that are more likely to inspire loneliness. That is, we know that all of us find it easier to hold onto our sense of lovableness when we are with loved ones, and that the fear of unlove and sense of banishment lurks not far away.

The question for the therapist is, then: How can I help my patient to move beyond experiencing the therapy session as mere palliation of loneliness - the relief from the hegemony of the bad object that pervades time spent alone, the balm of the therapist's solicitude - and to actually internalise a good object and eject a bad? Yet that's not a question that needs a general answer. Or, to the extent that we can give it one, the answer is: do the skilful work of therapy! Extirpate the underlying assumptions and hostile introjects that lurk under the lonely affect. Challenge again and again the repetition compulsions and the collapsing identifications with critical objects. But above all, show love.