To begin with, when I needed continuing education hours to renew my license, I took an online video course a couple of months ago focused on borderline personality disorder. In one segment of this class, the presenter stressed the importance of self-care for people who struggle with BPD. He discussed how sleep deprivation exacerbates their symptoms; he also talked about the role of alcohol and caffeine in aggravating insomnia. Regular exercise (especially cardio-vascular exercise) during the day helps people to sleep better at night. So does limiting exposure to blue light in the evening – the kind of light emitted by TV and computer screens. The presenter also talked about recent studies showing that exposure to bright sunlight helps to alleviate depressive symptoms in most people.
I haven’t written about my opposition to the widespread use of psychiatric medications in quite some time, mostly because I feel I’ve already said most of what I have to say on this issue. (See the collection of posts under the heading “The Medicalization of Mental Health,” to be found at the lower right of this page.) But a new study was recently released which demonstrates a link between the use of benzodiazepines and the risk of developing Alzheimer’s disease. While this study says nothing about the long-term effects of SSRIs, the history of benzodiazepine usage offers a cautionary tale as to how little we truly understand about a drug’s side effects during the years immediately after psychiatrists and physicians begin prescribing it.
During my recovery from overload (the result of having ignored my personal limitations), I’ve found my thoughts turning to the psychodynamics of mania. Over the last few years as my clinical and theoretical focus has shifted to the role of shame in bipolar disorder, I’ve paid less atttention to rage and the sense of entitlement — the way they can often fuel a manic episode. It’s true that I’ve written about these experiences in connection with borderline personality disorder but have neglected their role in manic-depressive illness.
Grandiose or magical thinking reflects the wish to achieve something all at once — to become wealthy or famous, or to complete a creative project without having to undertake the long hard work necessary for authentic achievement. In some cases, the underlying depression is so profound and the psychological damage from a traumatic childhood so pervasive that realistic growth is felt to be impossible — thus the magical all-at-once solution seems the only way out. Think of this as true mania, intimately connected with shame. Other people not so damaged by life, not so riddled with shame may also long to achieve things faster than may be possible in reality; they may resent the self-discipline, patience and deprivation necessary to achieve major goals. Rather than delusional, truly manic states of mind, they may try to achieve their goals through sustained bursts of activity that may last for weeks or even months. Such hypomanic states of mind may actually lead to actual achievement, but they reflect an underlying impatience and, in many cases, an angry denial of the need for a more consistent, slow-and-steady approach to accomplishment.
I have a good friend, a woman close to my own age, who struggles with time management problems. She usually arrives late for social events and often fails to meet deadlines at work. In her free time, she sets time-related goals for projects that mean a great deal to her and consistently fails to achieve them. In general, I’d say she feels very unhappy about her troubled relation to time.
Many clients I’ve seen over the years have struggled with similar difficulties, most notably with procrastination. I’m sure many readers have difficulties in completing their work on time. Often, an underlying perfectionism lies at the heart of the problem. With a harsh superego finding fault with everything you do, you’re often reluctant even to begin: nothing can ever be good enough. Safer to remain in the realm of infinite potential — that ideal in your head — than to suffer your own scorn and self-criticism for attempting to produce something real and inevitably imperfect.
About 30 years ago during analytic training, my good friend Tom Grant was describing a difficult case in seminar — a man in his mid-30s whom Tom had already been treating for quite some time. Tom’s client came from a severely dysfunctional background that had restricted his ability to feel for and depend upon other people. He lived an emotionally isolated life; he was “schizoid,” to use the psychoanalytic term for it — “having a personality type characterized by emotional aloofness and solitary habits.” After years of analysis with this client, Tom had helped him to develop a strong liking for other people; Tom believed that a profound sort of love was likely beyond this client because he had been too damaged, but he could nonetheless sustain relationships and even get married. Tom said he had no problem accepting the limitations of what their work together could accomplishment.
At that time, I had a great deal of trouble with what he said. I was convinced that with enough time and hard work, we could help our clients to transcend their past, to become just as “normal” as anyone who had come from an intact, loving and healthy family. Looking back, I can see I had a highly idealized view of psychoanalysis, largely because I wanted to believe that my own lengthy analysis had made me “normal.” It took me many years to face and accept the ongoing nature of those emotional issues that had driven me into therapy at the age of 19, years to recognize the lasting effects of early damage. In my recent psychotherapy work, I’ve been focusing on similar idealized expectations held by my clients. Sometimes those expectations are conscious; often, they show up as self-loathing.