Between Scylla and Charybdis : A Dynamic-Existential approach to
Anxiety Disorders
Tsvi E. Gil (1,2), Jennia Vilinsky (1), Anna Iofan (2,3), Juan Bar-El (1)
(1) Acre Community Mental Health Clinic, Mazor Psychiatric Center
(2) Annafa Institute for Psychotherapy, Haifa
(3) Haifa Community Mental Health Clinic for the Youth, Maale Carmel Psychiatric Center
Address for correspondence: Tsvi Gil, POB 3626 Haifa 3103601, Israel, tsvigil13@gmail.com
Keywords: Anxiety; Dynamic psychotherapy; Existential; Case illustration;
Abstract: We present an approach to the understanding of the nature of anxiety disorders, one which we call 'dynamic-existential'. The dynamic share imbibes from the school of object relations. We hypothesize that people who suffer from anxiety syndromes have unresolved unconscious conflicts concerning their relations with significant others, and mainly conflicts around separation and dependence. The existential share of this approach relies on Rollo May's theory of human development along the life circle. According to May, starting in adolescence, people develop through phases from Rebel to Decision to Ordinariness to Creative. Relying on this theory we hypothesize that anxious people are stuck on the passages between those phases. Life demands people to make choices, and anxious people get panicked when they face the necessity to make a choice, especially when this choice involves relations with significant others. We illustrate our presentation with clinical examples.
? What is the solution-
. There are no solutions: only choices-
(From Solaris, directed by Tarkovsky)
Scylla and Charybdis (in ancient Greek: (Σκύλλα, Χάρυβδις) were mythological marine monsters, who were used to thwart ships trying to cross the Messina strait. Scylla, situated in the Italian side of the strait, was described as a monstrous creature having six heads, who was used to kidnap sailors and grabbed them into the depths of the sea. Charybdis, on the Sicilian side of the strait, was described as a terrifying turmoil which drowned both ships and their sailors. Anyone who wished to cross the Messina strait had to deal with those monsters, forced to make an impossible choice to approach nearer one or the other side.
In the movie 'Solaris', directed by the Russian director Andrei Tarkovsy (1932-1986) in tribute to the Polish writer and physician Stanislaw Lem (1921-2006), Chris gets into a space station and meets there an impossible existential situation. "What is the solution?" he cries desperately to his colleague, Snaut, and the latter, though being in a similar impossible situation, replies in serenity: "There are no solutions, my friend; there are only choices".
Anxiety disorders are amongst the most frequent in the mental health field, and recently deem to proliferate (Stossel, 2014). A thorough comprehension of the anxiety phenomenon requires accounting for physiological, genetical, evolutionary, cognitive, emotional, and psycho-dynamic considerations. Accordingly, there are a variety of approaches and techniques or treatments, both medical and psychological (see discussion in Stein, Hollander, & Rothbaum, 2009). How to treat an anxious patient is a question of the therapist's choice rather than a consensual solution.
Here we would like to make a further glimpse to the hypothesized origin of the anxious experience. We will demonstrate our approach with the assistance of Joe (a made up name, but a real figure). Joe was in his fifties when he attended psychotherapy due to anxiety attacks, which he described plastically: He would take a joyful walk, but then started to feel anxious: his heartbeat got faster; he sensed a chest pain, sweat, felt gloomy. He called his brother and asked him to stay on line with him while he was striving to get to a `secured place'. In the following period he would attend doctors frequently, checking his blood pressure and heart activity (EKG). The doctor prescribed him some medications aided to lower his blood pressure, and Joe would inspect his blood pressure measures with fervor.
Joe is unique; but his experience is widespread. People who suffer from anxiety commonly experience physical symptoms and consequently attribute their suffering to some physical disease. The nature of the diseases an anxious person creates in order to explain to himself his symptoms is innumerable: mostly heart diseases, naturally, because of the typical symptoms; but also cancer, this horrifying word ("The illness as Metaphor", Sontag, 1979), as well as skin diseases, digestive diseases, and brain diseases. While the anxious person characterized by being concrete, he is at the same time highly innovative in explanations he gives to his inner experience. We explain this attitude in repressive mechanisms, which hide from the patient's consciousness the psychological nature of his symptoms. Here is the paradox: The anxious patient is terrified by the possibility that something terrible is being happening to him (lethal disease, an acute attack, losing one's mind), but at the same time refuses to admit that actually he is not having any physical problem but rather a psychological one. It looks like the possibility of having a psychological origin for his symptoms is more intolerable for him than believing in having a severe disease.
Consequently, anxious people are commonly heavy consumers of medical services. Here the anxious patient inescapably meets the impatient physician who would tell him: "You don't have anything", which the patient would experience as lack of empathy. And we believe, though, that this happens to him not for the first time in his life. Actually, we incline to believe that lack of appropriate empathy to his inner experience is one of the origins of his anxiety syndrome.
An essential component in the dynamics of being anxious is the partition between experience and its cause. Popularly said, a gap between brain and heart, between ratio and emotion. Defense mechanisms may include repression (lack of consciousness to the intra-psychic conflict which causes the anxiety), dissociation (between strata of the psychological functioning), displacement of the core of the conflict from psychological level to the physical one, or from one personality system (e.g., oedipal conflict) to another (e.g., bodily functioning); or somatization – a physical manifestation of a mental conflict. The massive usage of such mechanisms hampered the treatment of anxious patients: While the psychotherapist tries to address one system (mental, conflictual, inter-personal), the patient is immersed in quite different system (his body).
However, since we mentioned a mental conflict, what is actually this conflict? Harry Stuck Sullivan (Sullivan, 1953) hypothesized that anxiety has to do with fear of disapproval of a significant caregiver in earlier phases of development. WRD Fairbairn (Fairbairn, 1952) dealt with conflict between dependency and the fear of being engulfed and losing one's identity. Melanie Klein (Klein, 1948) associated the adult's anxiety to the toddler's fear that it would be deprived of his needs to be supplied by its caregiver. All of those models assume internalized representations of self and others that are reactivated in adult life and which affect ones inter-personal relationships. Paul F. Crits-Chrstoph (2002) hypothesized that a serial traumatic experiences may lead to a series of desires, wishes, expectations, believes and feelings concerning oneself and others. Such desires and wishes are related to attainment of love, stability, and protection, and involve fears of being abandoned, abused, or criticized. The anxiety that arises from all of this is so intense that the patient prefers to avoid thinking – or even being conscious – about the wishes, feelings, and memories, that are associated with his fears, and replaces them with a cognitive apprehension about daily issues. Differently from the 'classical' psychoanalytical theory, this approach does not limit the hypothesized aetiology to early childhood only. Anxiety is conceived to have various origins, most common is the fear to be frustrated in significant relations, e.g., to lose or to weaken relations that are perceived as imperative, intimate, or indispensable. The apprehensiveness that characterizes anxiety syndromes is truly a defense against experiencing the more original and more authentic fear. Similarly, somatic symptoms are a masking defense against awareness to feelings, emotions and conflicts concerning those relations. A 'healthy' worry, in Gunter Ammon's terms (Ammon, 1986), which is inseparable and necessary part of life, may be twisted to an over-preoccupation and pathological apprehension.
Let us go back to Joe. Joe was bachelor. During his life he conducted several relations, some of them short, mostly flirting with women whom he did not feel in love with, and a few relations in which he did experience emotional involvement. Most of his life he lived with a sense of 'limitless time', namely, that he should not hurry himself and can enjoy irresponsibly all the range of relationships he could have at hand. Having an unsatisfying relation, or being alone for a while, did not worry him, because he trusted life to bring him unexpected surprises. His subjective time was, though, eternal, interminable: a child's time. But now – after he passed his fifties – he felt anxious.
Indeed, the present attack was not his first. The first attack of anxiety he felt occurred some years before. It happened while he was traveling abroad with a girlfriend. Shortly prior to the departure Joe realized that actually he was rather fond with another woman, whom he felt attracted to, and with whom he felt a wish for having a meaningful bonding. But, alas, he was committed to the present girlfriend, the tickets had been already bought, and Joe found himself traveling with the wrong woman. The travel itself was not, after all, so bad, but then came the anxiety attack. Joe received medical care, returned home, and attended his family doctor. He broke up with his girlfriend. And he did not go to travel abroad, since.
Avoidance is quite common within the field of anxiety. Anxious people tend to avoid objects, places, activities, which are associated somehow – realistically, symbolically, or fictionally – to their anxieties. As more generalized the anxiety is so broader is the range of avoidance. Dan, another anxious patient, experienced his first anxiety attacks in a crowded street. Since then he used to avoid crowded or public places, fearing that he might have the anxiety attack again, in similar circumstances. Having an attack while being 'on stage' in front of curious strangers is a common frightening imagination of anxious people. Its resemblance to a common dream in which one finds oneself completely naked in public is not incidental, we think. Both reconstruct an experience from early childhood (mostly repressed from conscious memories) of being in center of negative attention of other people (often older). In other words, we reconstruct in adult life a presumed early experience of being anomalous.
Joe, then, restricted his life, to life without going abroad. This was not the only constraint he had been taking on himself. When he was younger he searched his way in life in several ways. He attended university for a couple of years (though did not complete a degree), attended some less conventional paths of learning (e.g., alternative medicine, Zen-Buddhism), and eventually found a practical vocation to make of his living. It was important for him to be independent and not subordinate to an employer.
So we can conclude that Joe limited his restriction not only to avoidance of traveling abroad, but generalized it to avoidance of new learning, experiences, or new insights. He lived alone in his little apartment, devoted to his daily routine, met only a few people. Anxious people habitually tend to believe that by restricting their life to the minimal necessities and smallest number of encounters they would be better protected against what they are afraid of – while, actually, they are not aware of what they are afraid of. They remind us a child who protects himself by bundling into the blanket and burying his head under the pillow, convincing himself that if he does not see others, the others do not see him.
When Joe attended therapy he experienced anxiety attacks in spite of his severe avoidance style. It should not surprise us, since avoidance, by its very nature, is a self limiting, short term means. Ultimately, the basic conflict which was deemed to be silenced had returned to action, and reactivated the hibernating anxiety.
We infer our hypothesis about the nature of anxiety from Busch et al book (2012) on the subject. This theory combines temperamental and constitutional vulnerabilities, on one hand, with childhood experiences, on the other. People who are sensitive by their nature ("The highly sensitive person", Aron, 1998) may easily get into anxiety when they experience a real, imagined, or anticipated loss or separation. Therefore they tend to develop an anxious dependency in caregivers, whom they experience as disapproving or unreliable. Autonomy is experienced as dangerous since it may lead to lose of the caregiver or of other significant persons. The patient imagines that signs or slight manifestations of negative feelings, such as anger or dissatisfaction, would destroy his relations with those figures. Following are feelings of guilt emanate from (unconscious) phantasies of vengeance directed to those figures whom he depends on but afraid of being abandoned or abused by. The child strives at dealing with those negative feelings and attitudes by developing mechanisms of defense which attempt at masking them, mostly by mechanisms of denial, reaction formation, undoing, or somatization. Additionally, due to their inclination to refrain from the emotional and phantasmagoric levels of mental life, these people characteristically have difficulties in employing the activity of mentalization, namely, the ability to see and grasp things from the points of view of other people. As grownups, an experience of bonding, while is consciously wished for, evokes regression to this world of conflicts, anger, guilt, and fears. In addition, episodes of anxiety may evoke emotional excitation of a masochistic nature. To conclude, we may propose that the central conflicts which are involved in cases of anxiety concern ambivalence toward essential developmental tasks of separation.
A common central phantasy of anxious people (one which is usually unconscious) is that they are incapable or inadequate, and therefore are desperately in need for other figures for their own survival. Such patients may experience themselves as passive, childish, helpless, and hence the anxiety attacks are experienced as without a cause, unexpected, not understood, and with no ability to predict them or overcoming them. But complementary fantasy is that by their helplessness and neediness they will keep receiving aid from others, thereby they would not be left alone. The type of relations that they generate supplies them caregivers rather than mature, mutual, integrative relations. The mere need, or possibility, of having the other as equal may threaten them of losing the dependency relations which they rely on.
Paradoxically, the anxiety syndrome is of a shielding function, against the deeper fears that may arise from the unconscious aforementioned conflicts and phantasies. We will bring, as a brief example, Mrs. Adele. Adele is a lady in her early sixties. She widowed in relatively early age but succeeded in dealing with her situation with distinguished bravery, raising up her children by tough work. Years passed by, the children grew up and were at the period of leaving home and building their own, independent lives. At that point in time Adele begun to suffer from chronic anxiety. Her subjective experience was that she "did not feel good", as if she was physically sick, which drove her from one doctor to another, from one medical examination to another, and made her receiving numerous treatments. Eventually she was referred to mental treatment, which she complied, but without giving up her allegiance to medical services as the solution for her suffering. In our interpretation Adele was devoted to the condition of anxiety because it enabled her to keep her offspring close to her. Recovery from her suffering, though apparently desired, would have afford her children complete their process of separation and distance themselves from their mother. Therefore, for Adele, choosing to recover was an impossible choice, challenging her unfulfilled dependency needs, conveying her from suffering to loneliness. Adele’s case demonstrates that on many cases the choice is between different aspects of object relations. Therefore, a dynamic exploration of the patient’s significant object relations, including those created in the treatment itself – namely, the transference and counter-transference – is essential for therapy to take place, and to make possible the departure from the vicious circle of impossible choices that characterizes the anxious patient.
Paradoxically again, aside the fear of lack of control which is characteristic of anxiety attacks, the anxiety provides the patient means for control over those conflicts, emotions, and phantasies. Those patients often fear from being flooded by feelings, mainly of the kind of resentment, anger, violence; or love, sexuality, or neediness. Strong feelings are experienced as potentially harmful or dismantling, as well as may not be accepted by others, or that would have shown the patient as weak or problematic. The central phantasy here, so we hypothesize, is that sincere and unregulated self-revelation would lead the responsible adult, the caregiver, to disapprove or abandon the patient. This anticipated disapproval or abandonment is of crucial importance for those patients, experienced as intolerable, due to their past with anxious or depressed parent (as Joe had, as we will present below). Strong feelings, either negative (anger, resentment) or seemingly positive (neediness, sexuality) lead to threat of demolition of self or others. The defense the patient puts to action is to feel or behave as he is sick, weak, helpless, problematic, or impoverished. Physical symptoms, in particular, may be welcomed, since they necessitate and justify a great deal of care and medical concern.
Common psycho-dynamic constituents present in anxiety syndromes include conflict around separation and autonomy, for instance, the patient’s thought (either conscious or unconscious) that should he give up the regressive condition created by his anxiety, he would not be able to function autonomously or alternatively, will be deserted by his caregivers or significant others. Akin conflict is a need in dependency aside the denial of that need. This kind of conflict Is expected to be manifested in the therapeutic relations, for example, the patient become worried that he would not be ‘too much dependent’ in the treatment or in the therapist. Alternatively, he overreacts when the therapist does something he does not like (e.g., says something which can be experienced as criticizing).
Anxious patients commonly find it difficult to tolerate and regulate negative feelings, mainly resentful. Fantasies of revenge give rise to anxiety, for example, the magic fantasy that their anger would lead to real harm to the object of that anger. When this object is a significant one, the fear exemplifies to be abandoned by. In general, anger and anxiety are interchangeable or perceived as such. For example: a parent is anger at a son, and the anger is contaminated with the worry that something would happen to him. Another version is the fear that expressing negative emotion would lead to loss of control over it.
Back to Joe: At the time he referred to therapy he was in a condition in which he restricted his life to the minimal, so he had very little to lose. Theoretically it might be an ideal state; in reality it is a desperate one. This is a state in which a person is bound almost to nothing, nothing is precious for him, nothing is perceived as important or meaningful.
Rollo May, the existential philosopher and psychologist (1909-1994) claimed that Rebel is a necessary phase in personal development; but in its earlier level it manifests the need in freedom without understanding the responsibility involved. The consecutive phase is called the Decision, which we conceptualize as parallel to the separation phase in the psychoanalytical theory of human development. Following this phase arrives the phase of Ordinariness, in which the individual accepts the responsibility involved in the separation and independence; but this ordinariness may be burdensome as well, and may progress to the Creative phase, in which the individual develop an authentic self. The term May used was not ‘authentic’ but rather ‘existential’, meaning the individual lives the wholeness of his existence, while dealing with the inevitable anxieties which are part of existence. Using this terminology, we can say that Joe was successful in rebelling at his family, he searched for his decisions, stacked in his ordinariness, but failed when he needed to make a creative choice. Generally speaking, we believe anxious people are stacked in the passage between one of those phases, according to the developmental phase they are staying in. Adolescents and young adults may experience anxiety in the phase of Rebel. Don, whom we already mentioned, was in his thirties when he experienced anxiety for the first time, prior to his marriage, namely, in his passage to the phase of ordinariness; and Joe was in his fifties when he came to treatment due to panic symptoms, when he was not able to find creative pathways for authentic existence on the way he chose to live.
We may turn to a short glance in Joe’s psychological background in order to deepen our understanding of the nature of his anxiety. His mother, so we learned in the therapy, suffered from a serious mental disorder. Therefore for Joe she was perceived as an impossible mother, and his parents' marriage as an impossible couplehood. It is easy to conclude, then, that Joe was afraid that the woman with whom he might bind himself would be found, after all, as similar to his mother, and the connection he might found with her would resemble his parent’s. The fear arises from these scripts seems obvious, and Joe’s solution as reasonable: he would stay single, independent, free, unbound and autonomous, thereby protecting himself against being woven into one of those scripts.
Why, then, Joe became ill with anxiety? Because his fears of those aforementioned scripts were not the only motive in his life. Another, no less important, was his need in object relatedness, or in simple words – his need for human connection. This is an essential need in every human being, probably with the exception of autistic people. In Joe’s life we can see the efforts to fulfill this need in the connections he had had – women, friends, family members, colleagues, as well as hobbies, subjects of interests, the therapist. Aside of his understandable fear of reconstructing his parent's pattern of couplehood Joe also was afraid that he would not be able to make a meaningful connection, that he would remain single, lonely, and miserable. Most of his life he had lived with the belief that he was taking painstaking to avoid falling in the net of an abusive woman (representing his mother); but when he reached his fifties he had started to realize that this ‘self preservation’ was so successful that he is going to remain alone for the rest of his life. And then he panicked. In Alan Schore (2000) terms (the socioemotional theory of development, which encounters neuropsychology with attachment theory) the most crucial task of the child development is to learn how to create connections. Joe personal learning was that making connections is risky: but avoiding them is risky as well. What a man should do, then? Joe, as many anxious persons, was in this strait. Keeping his freedom endangered him in becoming a lonely bachelor; connecting with a spouse endangered him of being engulfed by an abusive woman resembling his mother, and caging him in miserable couplehood resembles what he had observed in his parents' marriage. What should he do, then?
In this article we do not discuss the treatment modality that is derived from our approach to anxiety syndromes. We would leave this important subject to other paper. We may refer the reader to a rich list of literature that had been accumulated around psychodynamic approaches to treatment of anxiety disorder (see Bucsh et al, 2012). In our practice we do not offer our patients a panacea, a kind of solution which they yearn for (but do not believe in its realization, because realization means a choice). However, we make great effort to assist our patients in facing those issues which they fear, and to realize that they are, after all, nor in theirperceivingly hazardous surrounding but rather in their inner, mental constituents, their object relations and ways of existence. We hope that these encounter – there, in the treatment, in us, in the counter-transference, and here, in this article – promote us toward a more mature coping with our choices.
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