As a therapist working with diverse people who have diverse minds and diverse emotional struggles, I call upon a diverse range of ideas and skills for helping. I try (emphasis on try) not to idealize or devalue any one style of therapy, and to learn as much as I can from books, teachers, and colleagues. I know only about 50% of people in therapy get better (e.g., Lambert, 2013), so at this point, no style of therapy offers a “cure-all.” We’re all doing our best to help as many people as we can, but we’re also failing a lot.

Because of my familiarity with the mixed outcome data about psychotherapy, I get a bit concerned when I hear someone refer to any one school of therapy as a “gold standard,” or when one school of therapy becomes the “go-to” referral. The “gold standard” designation does not square with my awareness that the field of psychotherapy is quite young (around 120 years old if you start with Sigmund Freud) and still has a lot to learn. Nonetheless, proponents of cognitive behavioral therapy (CBT) make this claim (e.g., Cristea & Hoffman, 2018). Naturally, claims like this can influence people’s decisions when making referrals to therapy or when choosing a therapist.

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And who can blame us for believing a “gold standard” exists? It’s comforting to believe the treatment your doctor refers you to is the best treatment for your suffering, or that your therapist practices the best therapy out there. The idea alone can be relieving. But how do we decide what is or is not a “gold standard” treatment? Do we have adequate information for any therapy to make such a claim? What does the therapy research literature say about this?

Is CBT a “Gold Standard” Therapy?

In the 50 years since its founding, cognitive behavioral therapy (CBT; e.g., Beck, 2011) has developed a reputation as a “gold standard” treatment. It appears to be a first-line intervention for people with any kind of emotional difficulty and some physical difficulties. In my experience, most people who seek treatment for emotional struggles are initially referred to CBT. Medical colleagues have mentioned that CBT is the only therapy they are introduced to in school or encouraged to refer to, and I know of psychology programs that focus on CBT to the exclusion of other approaches to the mind, such as psychoanalytic and systems approaches. My observations indicate there is a general movement away from diversity in psychotherapy approaches to a “monoculture” of CBT and models derived from it.

There is no doubt some people benefit from CBT, but is it a true “gold standard”? Does research about CBT support its heavy use compared to other models? Has CBT demonstrated itself to be better than other therapies?

I do not claim to have decisive answers, but what I do have are two recently published journal articles that review the evidence regarding the effectiveness of CBT versus other therapies. I have picked out some findings from those articles that seem important to me, and I will share them below. Those who are interested in exploring the original sources in more detail can do so here and here. Both articles are concise and highly readable, even for people without advanced training in research and therapy.

Is CBT Effective?

In response to claims by CBT-oriented researchers that CBT is a “gold standard” treatment, Leichsenring, et al. (2018) and Shedler (2018) reviewed evidence. You can explore their article for details, but here I will restate their conclusions:

This is important information for anyone considering therapy, or who has been referred to CBT to the exclusion of other therapies. It may be especially important for people who have tried CBT, not benefited, and, sadly, blamed themselves or concluded therapy won’t work for them.

• Effectiveness vs. placebo. Some of the research cited by Leichsenring, et al. (2018, p. 3) suggests that while CBT may outperform the placebo effect slightly in a research setting, it does not outperform placebo enough to be considered more effective than placebo in a real-life clinical setting. Theoretically, that suggests that taking a sugar pill is equally effective to CBT.
• Effectiveness vs. control groups. The cited studies also show that CBT has only “limited superiority” to the control conditions it is compared to for research purposes (p. 3). Control conditions are comparison groups in which no treatment is given; for instance, one group in a study tries CBT, while the other group receives no intervention, such as remaining on a waiting list. In this sense, some evidence suggests CBT is only slightly superior to being on a waiting list and receiving no treatment.
• Remission rates. According to Leichsenring, et al. (2018, p. 3), only about 25% of people who tried CBT in the studies reviewed experienced remission, meaning only a quarter of people in the studies no longer had the condition they sought help for by the end of the study. Shedler’s (2018, p. 321) review supports this finding.
• Effectiveness vs. other therapies. The studies reviewed by Leichsenring, et al. (2018, p. 4) found no research evidence that CBT was superior to any other therapy.
• Effects of treatment can be short-lived. Shedler (2018, p. 322) notes a finding that 50% of people treated with CBT seek treatment for the same difficulties again within six to 12 months.
• No increases in effectiveness across decades. According to the Leichsenring, et al. (2018, p. 4) review, CBT research has not demonstrated an improvement in outcomes of CBT across five decades of research.

Based on this information alone, you may find yourself questioning why anyone would claim CBT is a “gold standard”—it has not demonstrated superiority, and the research seems, more than anything, to have demonstrated the limits of its effectiveness. This is important information for anyone considering therapy, or who has been referred to CBT to the exclusion of other therapies. It may be especially important for people who have tried CBT, not benefited, and, sadly, blamed themselves or concluded therapy won’t work for them.

Conclusion

No approach to therapy is a cure-all, and in fact there is much evidence for equivalence between therapies. If this is the case, though—that all therapies are limited and all produce roughly equivalent results—why are so many people referred to CBT? Why is there, as the review article claims and as I have observed, a “monoculture” of CBT?

A discussion of the scientific, economic, political, and ultimately human forces that have led to and perpetuated the myth of CBT as a “gold standard” is beyond the scope of this article, and readers interested in exploring that topic can check out the Leichsenring, et al. (2018) and Shedler (2018) articles in the references section below; both are quite articulate concerning these questions.

Whether we understand the reasons for the perpetuation of this belief or not, what is important is that consumers of mental health care are educated and aware of the well-documented limitations of CBT that seem to have been obscured by its self-presentation and public image as a “gold standard.”

Without a clear understanding of the virtues and limits of CBT, we may not consider other options that may be at least equally helpful. Even worse, we may blame ourselves and think we’re treatment-resistant when CBT doesn’t help. We may think we failed at the therapy when in fact the therapy failed us, as it does many people. If CBT fails us, we may think, “Therapy won’t work for me,” when in fact only one therapy out of many possible therapies didn’t work. Without more information about other evidence-based treatments, we may feel unnecessarily hopeless. That is why I felt these papers were important enough to share.

It may take some time before the medical and psychotherapy communities begin to recognize and respond to the research evidence that CBT is, like all therapies, helpful but limited. For now, however, we can help people make informed choices about their care. I hope you find this useful and look forward to your comments below.

References:

1. Beck, J. (2011). Cognitive behavior therapy, second edition. New York: Guilford Press.
2. David, D., Cristea, I., & Hofmann, S.G. (2018) Why cognitive behavioral therapy is the current gold standard of psychotherapy. Frontiers in Psychiatry, 9. doi: 10.3389/fpsyt.2018.00004
3. Lambert, M. J. (2013). The efficacy and effectiveness of psychotherapy. In M.J. Lambert (Ed.), Bergin and Garfield’s handbook of psychotherapy and behavior change (169-208). Hoboken, NJ: Wiley.
4. Leichsenring, F., Abbass, A., Hilsenroth, M. J., Luyten, P., Munder, T., Rabung, S., & Steinert, C. (2018). “Gold standards,” plurality and monocultures: The need for diversity in psychotherapy. Frontiers in Psychiatry, 9, 1-7.
5. Shedler, J. (2018). Where is the evidence for “evidence-based” therapy? Psychiatric Clinics of North America, 41, 319-329.

The decision to initiate any interpersonal relationship is anxiety-provoking, and the decision to talk with a therapist might be uniquely so. When we decide to meet with a therapist, we are faced with numerous challenges: allowing ourselves to depend on someone else for help and support; revealing our problems; risking trust in a stranger; facing what we have avoided; and relinquishing long-held, sometimes beloved habits, to name a few.

When we refer someone to therapy, it is important to keep this in mind. Though the statement “I recommend you talk to a therapist” sounds simple and benevolent enough, we cannot lose sight of the fact our caring act is simultaneously an anxiety-provoking challenge to the would-be person in therapy. So how can we go about this in a way that doesn’t provoke any additional, unnecessary worries or fears?

The following is a list of principles one can consider when making a referral to a therapist. While these ideas do not guarantee a certain outcome, they may reduce the chances of triggering anxiety that could promote avoidance.

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1. Make it about their needs and goals.

Therapy is much more likely to succeed if the person is there of their own free will, motivated by their own goals, trying to meet their own needs. External pressures to be there and pressures to work on problems that other people see, but that we do not see, can lead therapies to get stuck. The last thing we want to do is refer someone to therapy because we want them to change or conform to some goal that we have for them. That’s usually a recipe for someone either avoiding therapy or showing up but hating it.

Good therapy involves difficult, anxiety-provoking work, so most people will want to do that only if it is their only option for reaching specific goals. That is why it can be important for your referral proposal to include a reference to those goals, and to the way their emotional difficulties hold them back. An example could be: “Seems like the headaches you are getting are really hassling you at work, and it seems like they get worse with stress. Therapy can help with that and it might make you less miserable at work and home.” In this example, it is clear the referral is in the service of the person’s feelings and interests, done out of care and concern for them and not out of some demand or expectation by the referral source.

2. Make it optional.

I encourage you to make your recommendation optional, with liberal use of comments such as, “It’s really up to you,” “I’m not sure if I’m right, but it’s something you can decide for yourself,” and, “It’s not a requirement, just a thought.” I encourage you to phrase your referral as optional because going to therapy is optional. Therapy is anxiety-provoking enough to begin with, and we only add anxiety if we make the person feel like it’s an expectation, a demand, or a requirement.

When we approach therapy as a demand or requirement instead of an option, we can trigger a few responses that decrease the effectiveness of our referral. If the person we are hoping to refer has submissive tendencies, they may comply with our wish that they be in therapy. That will get them as far as a therapist’s office, but because they are not there of their own free will, they may not get the full benefits of the therapy. Other people may respond to our demand that they seek therapy with defiance or stubbornness. Rather than consider the option, they may say no just to spite you and to stymie your efforts to control them, even if they feel therapy could help.

Therapy has the highest likelihood of helping if the person is there of their own volition, not out of compliance, so be sure to remind yourself and the person you want to refer that the referral is optional.

If we’re clear about the reality of therapy—that the length of treatment and the level of commitment is up to them—they may find it less threatening and be more likely to try it.

3. Make it conditional.

What do we commit to when we commit to meeting with a therapist? Many people fear that by meeting with a therapist, they are committing to a long-term relationship. They sometimes also fear the therapist will decide how long the therapy lasts. These are anxiety-provoking preconceptions, and they are incorrect. When we try to refer people to therapy, it is important that we remind them of the truth—they are agreeing to one session at a time, and the length of the treatment is their choice, based on their goals and preferences.

It may help to be frank about what an initial therapy session is: a test drive. You can say, “You can meet with Maury and decide if you’d like to meet with him again. The first session or sessions can help you decide if you think he might help. You may know right away you’d like to meet with him more, but sometimes it can take a few sessions to decide if it’s worth continuing to invest in the therapy. Either way, it’s up to you how many sessions you go for. A therapist is an employee whom you can hire and fire.”

When we present the idea of therapy as a test drive, something the person can continue for as long as it meets certain conditions for them, we take away anxieties that therapy will be more of a commitment than the person may want. If we’re clear about the reality of therapy—that the length of treatment and the level of commitment is up to them—they may find it less threatening and be more likely to try it.

4. Do not make promises.

Ethically speaking, even a therapist cannot make promises, predictions, or guarantees about what they can do. We do not have a crystal ball with which to see the future. Often, my initial phone call with a new referral includes a difficult conversation along these lines:

Person: “So, do you think you can help me?”

Me: “Well, for better or worse I can’t know that just yet. We’d have to meet for you to form an opinion about that.”

Even if it’s a bit disillusioning, this is the truth. Like physicians or personal trainers, therapists can’t know whether their efforts will turn out to be helpful—only time and a careful, continuous, collaborative assessment will tell. We find out if our treatment plan is helpful once it helps.

There is great danger when a referral source makes promises about therapy or a therapist. Any expectations you give to the person you’re trying to refer can give them false hope or make them unnecessarily anxious and avoidant.

Every therapy session is, like every day of life, an experiment—we assess the problem that’s going on, pick an intervention or style of intervention we think might help, try it out, see what result we get, and adjust our treatment plan according to what works and what doesn’t. There is no magic to it, just a workaday process of trial and error, where we work hard to tailor a unique therapy to the unique person and their unique goals. In that sense, any preconceived expectations about therapy, just like in any other relationship, will be false.

For these reasons, there is great danger when a referral source makes promises about therapy or a therapist. Any expectations you give to the person you’re trying to refer can give them false hope or make them unnecessarily anxious and avoidant.

For example, a referral source could say, “He specializes in depression—he gets great outcomes.” Even if that is true, no two depressions are the same because no two people are the same. Likewise, no two treatments are the same because no two therapy teams are the same. Making promises or suggestions regarding a particular outcome can promote misleading or false hope. It may also distract from the fact it’s the work of the person in therapy, not the work of the so-called “expert in depression,” that makes or breaks the therapy.

Referral sources sometimes also make claims about a therapist’s technique when making a referral. For example: “He’s a very confrontative therapist—he’ll bust right through your defenses!” While it may be true that a therapist is capable of being confrontative, and while that kind of therapy may be appropriate for some people’s needs, presenting a referral in this way can be problematic. Good therapists base their technique on a careful assessment of the unique needs of the person in therapy, not based on what the therapist is good at or known for. Because of that, there is no guarantee the person you’re referring will ever have their defenses “confronted”—it all depends on the therapist’s assessment of what might help in the moment. Making such claims about a therapist can set up false expectations or give a person something to fear. Imagine already being nervous about letting go of certain defense mechanisms and then hearing a therapist is going to “bust right through” them.

For these reasons, when I refer someone to a therapist, I say something like, “There’s no way of knowing how it will go in advance, so the best way to find out whether the therapist can help is to go and check them out, assess how you feel with them, and make the best decision you can about whether to keep investing in the therapy. Hopefully they’ll be flexible and you two can make a therapy together that meets your needs.”

5. Let go of your desires!

If you haven’t caught it yet, my main thesis here is that while we can suggest that someone goes to therapy, or reveal our desire that they go, it is up to them. Pressuring people into doing something that is anxiety-provoking will usually lead to avoidance, submissive compliance, or stubborn defiance.

It is hard, but we must accept that we all have the right to avoid therapy and the anxieties that are built into it. No matter how badly we want to see a friend, loved one, or other person get help, our wanting it cannot make them want it. Only their inner desires can do that. So, while we can feel free to make suggestions to people about going to therapy, we must remember that they can do it only for them, not for us. Our desires for them can play only a very limited role in someone else’s therapy journey.

Example of Referring Someone to Therapy

Here is an example, based on the principles above, of what I might say to refer someone to a therapist:

“You seem to be suffering a lot and you’ve been clear that you’re not liking that, so I’ve been thinking that therapy might be useful to you. Obviously, it’s up to you if you want to go, but I do have the name of a person who I think might be able to help. Of course, that’s no guarantee, and you may have to shop around a bit to find someone who is a good fit. Either way, if you want to check this person out, they could be helpful. Do you want me to pass their contact info along?”

You can phrase this any way you like, but I think the key points for any referral are here:

1. Seems like you’re hurting, so therapy might be worth a shot.
2. It’s up to you.
3. You’re not committing to a lifetime on the couch, just one initial session.
4. There’s no guarantee it’ll be worthwhile, but the only way to find out is by trying.

Of course, this approach does not guarantee a specific outcome, but I believe it gives the best possible chance that the person will feel cared about by you, make the decision for themselves, and have the most realistic expectations possible going into therapy. Let me know if this helps!

“I know I shouldn’t think this, but …”

“This is going to sound completely crazy, but …”

“I hate myself for feeling this way, but …”

Wouldn’t it be great if we had only thoughts and feelings that we liked and wanted and could simply eliminate the rest? I would just love it if every thought or feeling that entered my mind fell within my definition of rational, normal, and good. What a victory that would be—the psychological perfection I have always longed for.

I don’t think I’m alone in wishing my mind was like a placid temple garden, a place where only soothing, constructive, politically correct, and sensible thoughts showed up. Many people come to my therapy office with presenting problems like, “I don’t want to think about _______ anymore,” or, “I want to stop having these ________ thoughts.” These apparently reasonable goals can sometimes hide a secret goal of self-perfection: “I want to purify my mind of the things I judge as irrational, bad, or sick.” We want our wild thoughts out and our “sane,” civilized, “good” thoughts to rule. And there is nothing wrong with wishing for that.

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When we chase this ideal and try to make it a reality, though, we chase an impossible fantasy of unattainably perfect control; we forget that though we appear to be highly civilized animals, we are still animals, with automatic, uncontrollable aspects to our brains and nervous systems. We forget that though we are now physically adults, we were once children, and we carry a legacy of childlike thoughts, feelings, and experiences that we can never fully outgrow or forget.

Sadly, sometimes we task ourselves with the impossible: gain total control of a brain that relies almost entirely on non-conscious, automatic, non-controlled processing. When we take up this task, and when we ask our therapists to join us in this task, what can happen to us and our therapy? Can we learn to live with a mind that can produce both rational and “wild” thoughts? Do we have a choice?

Understanding Omnipotent Control

When we hold the expectation that we can or should perfectly control our thoughts through sheer effort and self-policing, we are striving toward what psychodynamic therapists have called “omnipotent control” (see, for example, Kernberg, 1975). We use the term omnipotent, meaning all-powerful, to suggest that in omnipotent control we strive for a degree of control that is beyond the realm of human powers and abilities. When striving for omnipotent control, we deny our human limitations and pressure ourselves (or others) to control the uncontrollable, in this case our wild thoughts. We try to use effort, often in the form of self-shaming, to purify ourselves of any “out-of-control” parts, something that no amount of effort can achieve.

In therapy, omnipotent control tactics can manifest in ways like these:

“How do I stop caring about my ex?” (Here, the person in therapy tries to engage the therapist in the task of achieving omnipotent control over feelings. Another way to read this is, “How can I transform the reality of what I do feel into my fantasy of what I think I should feel?”)

“There I go again attacking myself! I should know better by now!” (Translation: “I should be perfectly in control of my mind by now! I’m mad at myself for not having achieved my fantasy of omnipotent control.”)

“I couldn’t handle that our relationship was over, so I lashed out at him.” (Translation: “I’m having trouble accepting that some pain in life is out of my control, so I take omnipotent control of the pain by becoming the one who gives it.”)

As you can see in these examples, for some reason, some of us, maybe even all of us, sometimes, will ask ourselves to do the impossible, and we will burden our therapy with an impossible task: “Give me omnipotent control! I want to control what no one controls!”

Suffering Under Impossible Demands

Naturally, it can be tempting to burden ourselves with this desire for omnipotent control—it does sound pleasant to always be in control of our minds—but the results of this pressure can be depressing because when we give ourselves an impossible task, we always fail.

For those of us who haven’t accepted that omnipotent control is impossible, we may get depressed when our wild thoughts or uncontrolled feelings visit us—we may feel like failures rather than appreciate yet another reminder that we are humans, with human limitations. Paradoxically, we preconceive that perfect control over our minds will help us feel better, but when we show up as human instead of perfect, we learn that pressuring ourselves toward superhumanness can only make us feel worse.

When we impose the demand for perfect control of our thoughts and feelings upon ourselves, we inevitably will hurt ourselves because we will always be asking ourselves to do the impossible. However, knowing this does not always stop us from trying. So why is omnipotent control such a compelling fantasy?

Reality Bites Sometimes

Let’s face it: human reality is distinctly lacking in control. Whereas other species are born with the ability to motor around and do some things from the first moment of life, human babies are helpless; we have almost no control and authority until relatively late in our development. If we’re lucky in our development, we have experiences where we feel in control, even though for the most part those experiences are created for us by caregivers. Those of us who are lucky are slowly disillusioned and come to understand our limited capacity for control over time. Others suffer an abrupt, early, and often traumatic lesson—“You’re not in control of very much at all.”

When we try to reject our wild thoughts and feelings rather than accept them, we miss out on an opportunity to understand their meaning. In this way, rejecting our wild thoughts and feelings limits the effectiveness of therapy—whatever we try to get rid of by omnipotent control, we will not learn from.

Regardless of our upbringing, as we grow up we are required to face and learn about all the things we don’t control. We learn we can’t control how others think or act; we can’t control when we will die or whether we will get sick; we can’t control when the people we love will die; we can’t control the historical, political, or economic climate we are born into. With so much out of our control, no wonder we want to at least be able to control our minds!

The bad news is our minds are yet another thing we have an unfortunately small amount of control over. Sigmund Freud got a bad reputation for asserting as much—that our mind is “just like an iceberg, with 1/7 of its bulk above water,” meaning we can only see and control a small part of our minds. Although many of us do not want to believe Freud’s dictum, contemporary cognitive and affective neuroscience supports this claim with empirical evidence (e.g., Ledoux, 1996).

If you think this aspect of reality bites, I am with you. It is not fair. We did not ask to be born into this set of rules and limitations. But alas, here we are, and so it is understandable that sometimes we will pressure ourselves toward omnipotent control as an attempt to create a sense of stability and power, even if it’s only an illusion.

So I Can’t Control My Thoughts at All?

It may sound like I am encouraging hopelessness about gaining control of our wild, unwanted thoughts and feelings. Some may even wonder, “Are you saying therapy is hopeless?” In a certain way, I am. I am saying that if our therapy goal is perfect, total, omnipotent control over our minds, then yes, the therapy is hopeless—for this is a goal that, as far as I know, no human can hope to achieve. I am writing this to encourage realistic hopelessness about this realistically impossible goal.

That does not mean, however, that gaining some control over our minds is impossible. We all have mental processes that we control. However, we have to accept that we will never have total control, and that there is no magic, instantaneous technique for achieving control. That is simply not possible for the human mind. So what can we hope to gain control of? What can we get out of therapy if we give up on the goal of perfect, omnipotent control?

Can I Accept What I Cannot Control?

Ultimately, we can control what we can control, and we can’t control what we can’t control. That will always be the case. The challenge of therapy (and life), then, is can we accept that? Can we accept our inner paradoxes: we have some control and some lack of control; some rational thoughts and some incomprehensible, wild ones; some love and some hate inside; some goodness and some badness? Can we accept the thoughts and feelings that show up—the ones we didn’t ask for, the ones we didn’t expect, that we did not initiate?

When we strive for omnipotent control over our wild thoughts, we are unintentionally trying to reject and eject our humanity, our complexity, our mysteriousness, the paradoxical elements of human nature. Though we are attempting a kind of therapy on ourselves—“Get rid of the bad stuff”—we are also repeatedly harming ourselves, trying to cut off built-in parts of us that are most likely there for a reason. When we try to reject our wild thoughts and feelings rather than accept them, we miss out on an opportunity to understand their meaning. In this way, rejecting our wild thoughts and feelings limits the effectiveness of therapy—whatever we try to get rid of by omnipotent control, we will not learn from.

We all have a right to go on trying to control what we can’t control, what no one controls. Some of us may need to keep at that strategy for a long time before we’re ready to try anything different. That’s okay. When we’re ready, though, we can pick up the challenge: “Can I accept these wild thoughts?” From there, we can begin the immense journey of letting go of our fantasies of perfection and control, and begin to embrace ourselves as we are, wild thoughts and all.

References:

1. Kernberg, O. F. (1975). Borderline conditions and pathological narcissism. New York, NY: Aronson.
2. LeDoux, J. E. (1996). The emotional brain. New York, NY: Simon & Schuster.

I do not like to suffer, and I do not like for others to suffer. I avoid unnecessary suffering as much as possible, and as a therapist I try to help people to see and stop the unintentional, accidental things they do that add unnecessary suffering to their life. To me, that is one of the most realistic benefits of therapy, and I am always happy when I can help with that.

If I’m honest, though, when I first approached training to be a therapist I was possessed by the fantasy that therapy could create a suffering-free and, if I stay honest, perfected life. I remember reading a quote by Sigmund Freud in which he said the goal of analysis was to help the person overcome “neurotic misery” so they can deal with “normal human unhappiness,” and I wondered, “Why is Freud so pessimistic?” I had the fantasy that therapy could make us somehow super-human, able to transcend “normal human unhappiness”—the aches, pains, and anxieties that come with living. Over time, I have come to see that (1) I was somewhat deluded, and (2) I am not the only one who suffers under that fantasy.

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In fact, many of us long to transcend our humanity, to somehow outsmart or shortcut the painful stuff that is built into life—the loss of loved ones through their death or ours, the breakdown of our bodies, the inevitability of failure, pain, loss, and frustration, the impossibility of endless perfection or bliss, etc. Those things sound terrible, so no wonder we long to somehow avoid them. However, when we start asking ourselves, others (e.g., our therapists), and life to somehow grant us the power to not suffer the realities of human life that we all face, we are in pursuit of an impossible and potentially self-destructive goal.

When we refuse to suffer, we refuse life on life’s terms, imperiling our relationship with the realities around us. What are the consequences of trying to actualize the fantasy that we are somehow bigger than suffering, or that we can somehow not suffer in a perfect life? Is some suffering possible to overcome or do we have to accept all the suffering in our lives? What suffering is necessary and unavoidable, and what kind of suffering is not? What happens to our therapy when we give ourselves and our therapists the magic task of making life into something it’s not—perfect and comfortable? We can explore some of these questions here.

Ways We Refuse to Suffer

If some suffering is simply built into life, what are the ways we try to avoid suffering? There are many, but most are based in the psychological defense mechanism known as denial.

Remember the now-famous meme of the cartoon dog, sipping coffee as the room is burning around him, saying, “This is fine!”? The dog’s reaction is profoundly human, and perhaps that’s why it’s so funny to us. We, too, have the ability to un-see the painful or anxiety-provoking things we see, to un-feel those bad feelings, and to undo our reality through denial. Under the influence of denial, our house may still burn down, but we will not experience (read: suffer) the emotional impact of it.

Denial can take many forms in our efforts to refuse suffering: We can deny our love of someone so we won’t suffer the pain of their loss. We can deny our feelings are important so we will not suffer pain when we are cruel to ourselves or treated cruelly by others. We can deny the humanity of others so we will not suffer guilt when we harm them. We can even deny that life is real in an effort to not suffer the aches and pains that come with living.

As a species, we are highly capable of denial, and we often do it unintentionally and automatically. But what price do we pay for this way of (not) dealing with reality?

Costs of Refusing to Suffer

What happens when we deny our feelings and our reality and refuse to suffer? We certainly experience a temporary no-feeling state that can be blissful, or even a kind of excited feeling of perfection, and that can be comforting or even addictive. We can go on in denial for a long time.

But like the dog in the meme, the house keeps burning around us no matter how long we deny it. Denial of loss and refusal to suffer the grief of loss does not make the loss any less true or real. Denial of our pain and refusal to suffer it will not take the damage caused by a cruel tormenter away; it will make us perfect victims. Denial that our lives are real and important, and refusal to bear the feelings that come with reality, leaves us in an aimless state, unable to connect to our desires and pursue things we might want.

Good therapy can help us learn to suffer and learn from the unavoidable pains of life, and help us see and stop our tendencies to add extra, unnecessary suffering to life. However, the process of learning about ourselves, our feelings, and our lives can be painful in and of itself, as can the process of change.

Fundamentally, refusal to suffer makes it impossible for us to learn from our experiences: If I never experience the pain of my hand being burned by the stove, how can I learn not to do it again? If I never feel the stinging pain of someone hurting me, how can I realize the importance of setting a protective boundary with them? If I deny the pain I cause myself through self-attacking thoughts or self-harm, how can I develop the compassion and concern for myself that I will need in order to stop?

If we refuse to suffer the feelings that come with life, we may not fully learn about ourselves, the people around us, and our environment. Without opening up to the experience of all our feelings, we will never learn the “rules” of reality, the limitations of being human, the costs and benefits of our behaviors, and as a result we will fail to adapt. We will be in a chronic state of “surprise” when we keep doing things the same way, not experiencing and learning from the consequences of our actions, and then keep getting the same result.

If we refuse to suffer, we will fail to learn from the experiences that create our suffering. We can further wonder: if we refuse to bear the pains that come with life, can we truly be available to experience the joys? What happens to our lives if we don’t learn from our joyous experiences either?

Is Suffering Inevitable?

Some suffering in life cannot be avoided. The emotional suffering attached to everything—from accidentally stubbing one’s toe to saying goodbye to our loved ones and to life at the moment of our deaths—is a built-in part of the human program. We can avoid our feelings about these experiences through denial, but they happen to us no matter what.

But not all suffering is so inevitable. In life, we can create additional suffering beyond what is simply required. Paradoxically, one of the major ways we add unnecessary suffering to our lives is through the ways we try to avoid the necessary suffering. Here’s how:

• If I use drugs or alcohol to numb myself to the pain of a loss, rather than bearing the grief of that loss, then I have created additional suffering and damage in an effort to avoid the unavoidable suffering and damage that life created.
• If I tell myself “I’m fine” after my partner has hurt me, my denial of the suffering my relationship has caused me allows me to perpetuate additional suffering by staying in hurtful relationships.
• If I refuse to suffer the anxiety I feel when I am not taking good care of myself, I may not feel a need to change and will likely create more suffering as I continue to hurt myself.

We never intend to add long-term suffering to our lives when we choose short-term ways to refuse suffering, but this is often the result. The unintended consequences of our refusal to suffer what life is presenting us often lead us to seek therapy. In therapy, our task becomes to stop avoiding and denying these very real pains and anxieties, face our feelings, and learn to bear the suffering that is a natural, unavoidable part of our lives, so we can put an end to the suffering that we add to life through avoidance and learn to live with the suffering we cannot control.

Refusing to Suffer in Therapy

Good therapy can help us learn to suffer and learn from the unavoidable pains of life, and it can also help us see and stop our tendencies to add extra, unnecessary suffering to life. However, the process of learning about ourselves, our feelings, and our lives can be painful in and of itself, as can the process of change. In order to change, we may be required to suffer feelings we would rather avoid. What happens when our impulse to avoid or refuse suffering shows up in our therapy?

Our desire to refuse or avoid the built-in sufferings of life can show up in therapy in a variety of ways. We can ask our therapist to “teach” us some “skill” or give advice with the hope they know some magical routine or mantra that will help us avoid the unavoidable or numb us to what we all must feel. We can prefer the fantasy that we can learn from the therapist’s experience rather than experience or suffer life for ourselves. We can ask the therapist to answer questions there are no answers to yet, hoping we won’t have to bear the pain of not knowing or do the hard work of finding out for ourselves. We can take on a passive role, hoping the therapist will change us, with the secret hope we will not have to suffer the pain, time, and effort required to change ourselves. We can fire the therapist with the secret hope that, in doing so, we will fire the uncomfortable realities we are facing in therapy. The list could go on and on.

It is always possible we are simply not ready to face, accept, and live (read: suffer) the truth of our lives, and if so that is okay. I think many people quit therapy when they realize that, for the therapy to work, they will have to face some suffering—whether it’s the hard work of change, the pain of saying goodbye to the past, or the confusion and frustration that are sometimes inherent in change. Not everyone wants to face these things; they are far from blissful and perfect. However, when we are ready, a good therapist will help us to suffer the feelings that life is asking us to suffer and help us stop adding suffering to our lives through our refusal and avoidance. Then, we can learn from our experiences and use our new knowledge to bear the sufferings and joys that life hands us, rather than increase our suffering by refusing what life hands us.

We do not get to choose the content of our minds, but we certainly try. There are many things in life—inside and outside of us—we do not choose or control, and that fall short of our ideals of perfection, and we have a great deal of trouble accepting this. Our work with acceptance versus rejection of the realities that are beyond our control or outside our definition of perfection can help us build resilience but can also lead to emotional suffering.

Take, for instance, the lack of choice or control we have in how our minds develop: We do not choose to be born; we do not choose the parents we are born to; and we do not choose the point in their lives we are born to them. We do not choose the parenting style of our parents (or that of their parents); we do not choose the trauma they endured before and after our birth; and we do not choose how their trauma history impacts their parenting. We do not choose our parents’ strengths; we do not choose their weaknesses; and we do not choose the parenting style we learn from them. In that sense, we do not choose how our parents teach us to parent ourselves, how they teach us to relate to our needs, thoughts, and feelings.

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Our earliest experiences and the echoes of those experiences—the ways of thinking, feeling, and being that now exist inside our minds—were not installed by us nor elected by us. Much of how we think and feel is an accident of whom we are born to and when; as a result, much of our mind is there by accident. We do not choose our psychological strengths, and, perhaps more regrettably, we do not choose our neuroses.

This is an uncomfortable reality to face, especially in this age in which we strive toward images of perfection and pride ourselves on feeling in control. Sigmund Freud joked that his theories were rejected mostly because they suggested people are not fully in control of their minds, and it is not surprising his theories remain unpopular. You may be tempted to stop reading this for the same reason. We humans do not like accidents, especially ones that happen to us. We work hard to prevent them. So it is hard to accept that much of what is in our minds is there more by accident than by some careful plan that we intentionally laid out.

It is especially hard to accept this when we find things inside our minds that we identify as “bad,” and as a result it can be tempting to construct the illusion of control over the “badness” so we can become our idea of “perfection.” We like to tell ourselves, “Don’t think that way,” or “Just be positive,” or “There’s nothing to be anxious about; just act natural.” We fancy that saying such things to ourselves can help us control the programming of our minds or make our habitual responses go away. We tell ourselves we can overpower our conditioning through force of will or through self-criticism. We try hard to reject the things inside ourselves that we don’t like, to make ourselves “better” or even “perfect.” “It’s bad enough I can’t control when I was born or when I’ll die,” one person in therapy told me, “but I should be able to at least control my mind!”

We try and try to suppress our “bad” thoughts. We come up with “techniques” that help us avoid the “bad” feelings or behaviors and “get better.” We think these acts of self-rejection will remove the “badness” from ourselves. But this “badness”—this confluence of thoughts and feelings that are inside us that we do not want—remains there despite our efforts to reject and banish it.

So, what then? What can we do when we find things inside ourselves that we didn’t choose to put there, that we don’t want there, that we identify as “bad,” but that are there anyway? Must we go on forever trying to cast out something “bad”? If we accept the “badness” we identify in ourselves, is that just complacency, giving up? What are the benefits of accepting our reality and giving up our fantasies of control and perfection? Let’s explore these questions around the emotional impacts of self-rejection and self-acceptance.

Why We Turn to Self-Rejection

In a certain way, we are all therapists. Each one of us has a unique style of self-help that we have learned and cultivated through our development. “Cure through self-rejection” is a common way to attempt self-therapy. Now, no one ever calls it that—we have fancy cover words for cure through self-rejection, such as “self-improvement” or “making progress,” and we do it with the best of intentions. When we analyze our thinking, however, we find many of us approach self-improvement, a seemingly benevolent endeavor, from a starting point of self-rejection: “I have identified something inside me as bad; I did not put it there and I do not want it there, as it challenges my fantasy of becoming perfect. Now I must ‘improve myself’ by finding some technique to rid myself of this badness to regain perfection. Immediately if not sooner, please!”

Self-acceptance does not promise us the sense of purification, perfection, and control that self-rejection tempts us with, and in that sense it may be less attractive in moments when the need for change feels dire. However, if we’ve tried self-rejection, seen its results, and understand why we thought it was a good idea at the time, perhaps we can begin to accept ourselves and see what happens then.

Self-rejection can lead to some forms of change, at least temporarily. In the name of “self-improvement,” I can suppress a particular thought for as long as I have the energy to do so; I can force myself to like things I don’t like or to stop liking things I do like for as long as I can put up the necessary effort. I can use “logic” to talk myself out of what comes naturally to me. But for those of us who have lied before, we know it takes a great deal of effort and energy to suppress what is true and keep the lie going; the liar faces the truth more than anyone. In the cure through self-rejection, we have to perpetuate a lie to ourselves—“I don’t feel/think/need that anymore. I’m perfected/fixed now”—even when we see how the “bad” thought or feeling we try to reject continues to pop up.

We approach our efforts at “self-cure through self-rejection” earnestly—we really think self-rejection will help us! We fantasize that self-rejection strategies will remove from us the burdens that were accidentally placed upon us by our early experiences. We think self-rejection will produce the self-love and sense of perfection we all long for. Many of us come to find, however, that in the end practicing self-rejection only helps us get better at self-rejection, which can lead to self-hate, depression, and other forms of suffering. Faced with that new knowledge, what do we do then?

We may be tempted to reject this self-rejection we have come to recognize in ourselves, as though rejecting our self-rejection will help us stop rejecting ourselves. It sounds silly on paper, but you might be surprised just how tempting this approach can be! Then therapy can become like a never-ending home improvement project in which we keep finding new self-rejections to “fix,” but our tool for fixing (self-rejection) keeps making us feel more broken. This inevitably leads us to feel like we are failing at therapy and at life; some people quit therapy as a result. But what if we are not the problem? What if self-rejection is the problem? If so, what then?

Why Self-Acceptance Offers More

We are then left with a question: Can I accept the rejecter that I am in this moment? Can I accept that it is tempting to reject the rejecter I see in the mirror right now? Can I accept that it has just felt natural and important for me to reject the real me that I find when I look inside? That it has been habitual for me to hate me when I find I don’t match a fantasy of perfection? Can I accept the strategy I have tried for self-therapy has failed, even though it felt so smart and useful all this time?

These can all be hard to accept. It can be hard to accept that there are things inside us that we do not like. It can be hard to accept that things are inside our minds that we did not choose to put there, that are there by accident. It can be hard to accept that the best strategy we had learned was a doomed, failed strategy. It can be hard to accept that we are not and cannot be fantasy people, just real people. Can we accept that the truth is sometimes hard to bear? Can we embrace that it has been important to become proficient at rejecting the truth and that there must be some good reason we got so good at rejecting the truth of ourselves and our lives? That it has been important and necessary in our lives to learn to compare our reality to an impossible fantasy of perfection, and call ourselves “not good enough,” “failure,” etc. and reject our real selves? Can we wonder about why learning to self-reject was so necessary and important?

Self-acceptance is not guaranteed to cure anything or to even feel good. All self-acceptance guarantees is we will be in touch with the clearest and most realistic picture of ourselves in this moment, beyond our fantasies of how we “should” be.

We may believe self-acceptance will lead to stagnation or complacency or that self-acceptance is like giving up on changing. But what if self-rejection is what has been leading to stagnation? What if continued self-rejection will require you to become complacent with the stagnation that self-rejection has been inducing? What if we need to give up on the fantasies of perfection and control that have been keeping us stuck if we are ever going to achieve realistic change based on a realistic assessment of ourselves and our lives?

Self-acceptance is not guaranteed to cure anything or to even feel good. All self-acceptance guarantees is we will be in touch with the clearest and most realistic picture of ourselves in this moment, beyond our fantasies of how we “should” be. Accepting our real strengths and resources and our real hurdles can give us a starting point for realistic change based on the facts of who we are in this moment, rather than based on the fantasy that if we just reject ourselves long and hard enough we will somehow become purified and perfected.

Self-acceptance does not promise us the sense of purification, perfection, and control that self-rejection tempts us with, and in that sense it may be less attractive in moments when the need for change feels dire. However, if we’ve tried self-rejection, seen its results, and understand why we thought it was a good idea at the time, perhaps we can begin to accept ourselves and see what happens then. And if we need to go on rejecting ourselves for now, which we might, can we accept that, too? Can we let go of the fantasy self who is perfect and in control, accept who we are right now, and see how that feels? We may not be able to choose the content of our minds and the events of our lives, but perhaps through self-acceptance we can come to choose how we relate to our reality.

Unanswered questions exist in everyone’s lives, and looming unanswered questions are part of what brings many of us to therapy: Should I leave or stay? Is this right for me? Why do I feel this way? How can I change? Who am I?

Sometimes simple and direct answers are available and advice will be a sufficient salve for what ails us. Sometimes advice is all we want. Much more often, however, the trajectory between our questions and answers that will help us is much less simple, and a pat, direct response from a therapist or friend, such as advice, will fall terribly short in helping us learn, grow, and heal.

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Even so, unanswered questions can be uncomfortable things to hang onto. They beg for answers, and in living with the unknown we are asked to bear an aching tension that I can only compare to the anticipation of waiting for a child being born. We long to fill our empty hands with newborn knowledge, and for the relief of seeing that our nascent answer is strong and viable. With modern obstetrics, we can set a delivery date to suit our desires and induce birth at our will, but previous generations were forced to tolerate that the baby comes when the baby comes, regardless of our preferences. Have modern advances in the answering of questions given us any more control over the arrival of answers to the inner questions that bring us to therapy?

We live in an age where some answers are quite easy to find. Like me, you may be in possession of a magic phone that answers almost any question in seconds. Science, philosophy, the study of history, and many other fields of knowledge have made satisfying answers easy to find, but any serious student will tell you that for every answer obtained, many new questions arise. And, perhaps more problematic for us seeking answer to inner questions, there is no credible internet database (yet) that can tell us who we are, what we feel, and what we ought to do with our lives.

So, then, what do we do with questions that our magic phones—or our teachers, our friends, our parents, or our therapists—cannot answer? How do we tolerate the fact some answers come when they come and cannot be forced out into the light? Perhaps most importantly, what strategies do we use to avoid the necessarily realistic pain and anxiety of not knowing, and what price do we pay for our efforts to foreclose the unknown with false answers just for the sake of tension relief?

The Only Certainty Is Uncertainty

In therapy and in life, we can learn a lot about ourselves, answer some of life’s questions, and increase our ability to make decisions that suit us. Problematically, however, even when we have more answers about ourselves, we will have to face questions that cannot be answered. Sure, thanks to therapy or other life experiences we can feel secure enough in a relationship to decide to move in together or even get married. How wonderful! But then new questions come: Will we be this happy forever? Do they really feel the way about me that they say they do? What if something happens?

Insofar as we still lack a crystal ball (or maybe I have just not yet downloaded the crystal ball app to my magic phone), these are questions that will likely remain questions for some time. The answers cannot yet be known because the answers do not exist. When we decide to enter a relationship, take a job, pursue a degree, move out, in, or away, we step into a mystery. We have made the best choice we can with the data we have—our feelings, our thoughts, our knowledge, etc.—but after that, we, like any good scientist, are running an experiment, awaiting the revelation of new discoveries. We cannot know how our results will turn out in advance.

Living with these unknowns, especially in life-defining matters such as relationships and career, is difficult. I prefer certainty! However, when it comes to questions that can only be answered in the future, any certainty I have now will inevitably be false certainty. To get truthful answers, I will have to bear all my questions about the future until the future. No wonder the feeling of certainty, even if it is unrealistic certainty, is so tempting!

Temptations of False Certainty

Many of us spend time trying to answer questions that simply cannot be answered in this moment. We call this “anticipation” or “planning,” in which we imagine every possible outcome and what we would do. Then we feel “prepared.” Another approach is to accumulate all the known facts we can with the hope of being able to predict unknown outcomes. This is not inherently wrong—it is always good to use our knowledge and power to increase the probability of a desired outcome for ourselves to whatever degree we can.

However, in almost every human endeavor there exist circumstances that cannot be controlled, and our efforts to control the uncontrollable through prediction, projection, conjecture, and accumulating facts cannot change or stop this. More often, these strategies for dealing with unanswerable questions about unknowable outcomes will give us either (1) a false sense of security or (2) analysis paralysis.

Only when we have stopped trying to control life can we begin to discover life. Only when we give up on trying to know what we can’t know in advance can we make our minds available to experience life on life’s terms, and possibly receive answers from those experiences.

1. False Sense of Security

In scenario 1, the fact gatherer has done so much research, and calculated the outcomes so many different ways, they become convinced of their image of the outcome. Sometimes we get lucky and the forces that are beyond our control help push events in the direction of our preferences, confirming our preconceptions and reinforcing a gratifying sense of control. That can be a great feeling, even if it is somewhat illusory.

More often, however, reality does its own thing regardless of our fantasies of what we think it should do. If we have bought into our image of how things should have gone (e.g., “I should have gotten that job,” “We should have been together forever”) and felt overly secure in our predictions, it can be painful to accept that reality shows up instead, unmoved by our research and planning. We fail to achieve our secret goal of omniscience and have to face that we are just regular people without crystal balls, vulnerable to the unpredictable and unanswerable questions of life. Ouch. People often come to therapy when they have difficulty tolerating this disillusionment.

2. Analysis Paralysis

Sometimes, our need to answer questions that can’t be answered requires long periods of planning and fact gathering, and the risk is that because the question cannot be answered, we can spend forever trying to answer it and never succeed. Sadly, opportunities to roll the dice on life, take a risk, or run an experiment to collect real data pass us by while we are busy trying to achieve certitude about the outcomes. We hesitate to change jobs, start a family, or buy a new refrigerator until we know we’re “ready,” that it’s the “right choice,” or that things will “work out.”

In our effort to achieve omniscience through seeking possible answers to our questions, we can miss the opportunity to find out the real answers that life experience would provide. In analysis paralysis, we sacrifice the vulnerable potential of the unknown for the stagnant security of rumination, worry, planning, etc. The only way to know if you’ll like your next job is to take it. The only way to know if your partner will say “yes” is to ask. Sadly, many people come to therapy in the grips of analysis paralysis, hoping the therapist will be able to help them make a better prediction about the future. Hopefully, our therapists can help us begin to accept our human limitations and help us begin to live in the mystery rather than avoid it. Only when we have stopped trying to control life can we begin to discover life. Only when we give up on trying to know what we can’t know in advance can we make our minds available to experience life on life’s terms, and possibly receive answers from those experiences.

Living with Questions That Can’t Be Answered

I read many books about psychology and philosophy. They offer many possible answers about what makes a good life or a suffering life. However, despite my best efforts, I have not yet found the “Guidebook for the Life of Maury Joseph.” As a result, I am challenged to accept a life with many unanswered questions.

Believe me, I have tried false certainty, analysis paralysis, and a million other strategies for filling the void of the unknown with some feeling of omniscience, and I will do it again later today, I am sure. But in my best moments, I try to challenge myself to embrace the unknown. I challenge myself to bear the discomfort of holding a question, the anxiety of, “I guess we’ll have to wait and see. We can’t know now.” Though I am no fan of discomfort, I have begun to find the discomfort of not knowing to be far easier to bear than the pressured, overwrought feeling that comes with calculating probabilities; worrying about what I’ll say or do given a particular outcome; or trying to control the future through sheer effort.

So next time you’re faced with a question you cannot yet answer, you have an opportunity to ask yourself: Can I bear this question for this moment? Am I willing to let my mind be the location where an unanswered question lives? Can I accept that this question is unanswered whether I like it or not, no matter how hard I try? What do I notice thinking and feeling as I try to embrace not knowing? Can I be grateful to this question for helping me face the limits of being human: that I can’t predict the future or know everything? Can I thank this question for showing me what I can’t know right now? Can I enjoy the answers that living does provide, and not force life to give me more than what it gives?

Try it out and let me know how it goes! In the meantime, I’ll just be here in Washington, D.C., doing my best to bear not knowing.

A recent randomized controlled study of therapy for treatment-resistant depression produced evidence that a brief trial of intensive short-term dynamic psychotherapy (ISTDP) may have large advantages in outcome over a “treatment-as-usual” approach, including counseling, cognitive behavorial therapy (CBT), CBT group therapy, and increased medication (Town, et al., 2017). This study expands upon previous studies that support ISTDP as an effective first-line treatment for depression (Driessen, et al., 2015), treatment-resistant depression (Abbass, 2006; Solbakken and Abbass, 2015), other treatment-resistant conditions (Solbakken and Abbass, 2014), and for depression complicated by co-occuring personality issues (Abbass, Town, and Driessen, 2011).

This new study supports what I and other clinicians practicing ISTDP have long observed in our practices, and may signal hope for the 20%-50% of people with depression who do not derive satisfactory benefits from treatment (e.g., Lambert, 2013). In this article, I will contextualize these results by discussing the psychological factors that can make a depression “treatment resistant” and highlight the features of ISTDP that may make it uniquely effective in addressing these factors. I will also reflect upon and review in detail the results of the study.

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What Factors Can Make a Depression “Treatment Resistant”?

To understand what makes ISTDP useful for treatment-resistant depression, it is important to understand factors that can make a depression treatment resistant (Abbass, 2015). Here are a few:

Relationship Difficulties with the Therapist

Even if your therapist uses a structured or systematized approach to therapy for depression, the therapy is always more than just a technique—it is a relationship. Many of us have difficulties in approaching relationships of all kinds, and the therapeutic relationship is rarely an exception. Some of us withdraw and detach from the opportunity for closeness. Some of us become fearful and hide or attack. Some of us take a passive role, a controlling role, a codependent role, etc., and we often have a variety of roles we switch between at different times.

These roles or interpersonal stances are often learned in our developmental history. They usually occur automatically and habitually, and they can have real advantages in certain situations—it’s not always smart to be honest and close with everybody in our lives. However, when we take on certain automatic interpersonal roles with our therapist, these can become barriers to engagement in therapy and can render the treatment less helpful.

For instance, if I am passive with my therapist, I may shirk the aspects of therapy only I can do for myself. If I am scared of my therapist, I may spend sessions shaking or attacking rather than feeling safe to communicate my needs. If I withdraw and detach from my therapist, I won’t be able to form the secure attachment that can help me explore my inner world and learn from my experiences. Needless to say, when we take on roles in therapy that form barriers to optimal engagement with our therapist, treatment efforts can fail and our depression may be labeled “treatment resistant.”

Self-Worth Difficulties

People tend not to do nice things for people they don’t like. But what if the person you don’t like is you? If therapy, or recovery from depression in general, involves acts of kindness toward oneself, can difficulties with self-worth make depression resistant to treatment?

Absolutely. Many kinds of self-hatred arise in and can be addressed in therapy. A sense of worthlessness or unworthiness, hopelessness, self-doubt, withholding from oneself, wanting to hurt oneself—all of us are capable of feeling this way, and usually these feelings and attitudes contribute significantly to depression. These ways of relating to ourselves can come up in therapy, and if they are not addressed adequately they can interfere with the progress of therapy, rendering depression “treatment resistant.”

People tend not to do nice things for people they don’t like. But what if the person you don’t like is you? If therapy, or recovery from depression in general, involves acts of kindness toward oneself, can difficulties with self-worth make depression resistant to treatment?

Repression

Repression is an unconscious (read: automatic, unintentional) psychological mechanism that can contribute to worsening depression. In repression—used differently here than in Freudian psychoanalysis—when anger is stirred up toward people we love, the anger unconsciously reflects back against ourselves. This symbolically “protects” the loved person from our anger. Because of our guilt about our anger, it is channeled into punishing us. In an unconscious effort to protect our beloved from our anger, our unconscious mind can shut down our body to prevent the anger from being felt or thought about. This can be an emotional root of the “vegetative” symptoms of depression, such as feeling heavy, weak, and tired, and can contribute to the physical pain that can come with depression—in repression, the body can become the target of our angry feelings.

Many therapy models attempt to address unconscious repression processes with conscious techniques, such as behavioral activation, education, or medications, which can all help. However, behavioral changes, education, and medications alone cannot help people overcome the unconscious repression process. When repression is contributing to the depression and not being addressed adequately, behavioral activation techniques or medications may fail and the depression may be deemed “treatment resistant.”

Why Choose ISTDP?

Intensive short-term dynamic psychotherapy (ISTDP) has distinctive features that target specific factors that can make a depression harder to overcome in therapy:

Addressing the Therapeutic Alliance

As described above, interpersonal barriers, such as passivity, dependency, opposition, or detachment, can hamper the therapeutic alliance, limiting the effectiveness of any therapist and any therapy approach. For that reason, ISTDP therapists are trained in specific techniques for assessing the intensity of people’s interpersonal barriers and then helping people with them. A good ISTDP therapist will notice and then help you see the ways you wall off from interpersonal contact, and can help you see the damage this is doing in your therapy, your relationships, and your depression. With this new information, you may become more motivated to overcome the barriers you put up, and a good ISTDP therapist will have a variety of ways to support you in that process. Once these interpersonal barriers begin to come down, which can only occur when you are ready to bring them down, it can become possible to get to the root of your depression and resolve it together.

Addressing Self-Defeating Tendencies

In the same way certain interpersonal tendencies can become a barrier between you and the therapist, your tendencies toward self-defeat, self-neglect, and self-attack become a barrier between you and self-compassion. This can severely hinder your ability to let yourself engage in and benefit from therapy. A good ISTDP therapist will make efforts to help you see the ways you treat yourself, notice how they impact your ability to use the therapy, and see how entrenched these patterns have become. Sometimes this process can reignite the self-compassion that is necessary to get a good therapy result. Once you can begin to see yourself with more positive regard, the therapist can support you in getting to the roots of why you had to turn against yourself and become depressed in the first place.

Overcoming Repression

An unconscious and thus out-of-awareness emotional process like repression cannot be overcome unless your therapist can help you see it, which will make it conscious and help you gain some control over it. In ISTDP training, we learn about the verbal and nonverbal cues that let us know repression is occurring, and we learn skills for helping people begin to become consciously aware of their unconscious emotional processes so that they can begin to think about how they feel rather than automatically and unconsciously have those emotions convert into physical symptoms and depression. When people can consciously recognize, reflect upon, and feel the feelings that get buried by repression, this is the antidote to the unconscious repression process, which can help relieve a major contributor to treatment resistance in depression (Abbass, 2015).

Anxiety and Treatment-Resistant Depression

One final dimension of ISTDP that may make it uniquely effective for treatment-resistant depression is the therapist’s ability to optimize the intensity of the work by paying careful attention to the level of anxiety you are experiencing, and tailoring the therapy to your unique anxiety tolerance. ISTDP therapists are trained to observe bodily patterns of anxiety. Some bodily anxiety signals (such as muscle tension) tell us, “We are on the right track, and this is a level of anxiety I can cope with,” while other signals, like stomachaches or dizziness, say, “We are over my threshold of anxiety tolerance. Time to slow down, regulate anxiety, and understand what’s happening.”

This ability to carefully track and work with anxiety signals from the body can help therapists optimize your therapy experience, and can help prevent a situation in which either too-low anxiety (such as boredom) or too-high anxiety (flooding, dissociation) becomes a barrier to treatment. This systematic attention to bodily anxiety signaling does not exist in any other therapy model, and can help ISTDP therapists to optimize your therapy in a unique way, reducing the likelihood your depression will not respond to treatment (Abbass, 2015).

Results of the Study

The study lasted six months and included 60 participants who were randomly assigned to two groups: ISTDP and “treatment-as-usual,” which included counseling, CBT, CBT group therapy, and increased medication. Self-report measures and observer ratings were used to assess outcomes, and were taken at baseline, three months, and six months from the start of therapy. Here are some of the results found at the six-month mark:

• Symptom remission: Thirty-six percent of treatment-resistant depression participants who received ISTDP had total symptom remission, compared to only 3.7% of the “treatment-as-usual” group.
• Partial symptom remission: Forty-eight percent of participants who received ISTDP had a partial remission, compared to 8.7% in the “treatment-as-usual” group.
• Medication changes: In the “treatment-as-usual” group, 53% of participants required increases in their psychiatric medication doses; only 10% required this in the ISTDP group.
• ISTDP treatment length: The average number of sessions of ISTDP in the study was 16 (Town, et al., 2017).

Reflections on the Results and Limitations

The study is limited by its duration, sample size, and the fact it took place in a clinic that has highly focused ISTDP training for its clinicians. Further studies are needed before we can assess the strength and duration of outcomes and the applicability of these findings to people in other settings.

However, the study provides evidence of large, significant effects—including full remission in some cases—of a brief trial of ISTDP for treatment-resistant depression. It also shows ISTDP had a significant advantage over the counseling, CBT, CBT group therapy, and increased medication approaches that were included in the “treatment-as-usual” group. This may be useful information for those experiencing treatment-resistant depression and finding unsatisfying results with treatment-as-usual, secondary care approaches.

While there is much research to be done to learn more about therapies for treatment-resistant depression, the Town, et al. (2017) study is a promising contribution that may pique the interest of clinicians, researchers, and people in therapy interested in a cutting-edge, efficacious approach for treatment-resistant depression.

References:

1. Abbass, A. (2006). Intensive short-term dynamic psychotherapy of treatment-resistant depression: A pilot study. Depression and Anxiety, 23, 449-452.
2. Abbass, A. (2015). Reaching through resistance. Kansas City, MO: Seven Leaves Press.
3. Abbass, A., Town, J., & Driessen, E. (2011). The efficacy of short-term psychodynamic psychotherapy for depressive disorders with comorbid personality disorder. Psychiatry, 74, 58–71.
4. Lambert, M.J. (2013). The efficacy and effectiveness of psychotherapy. In M.J. Lambert (Ed.), Bergin and Garfield’s handbook of psychotherapy and behavior change (169-208). Hoboken, NJ: Wiley.
5. Solbakken, O.A., & Abbass, A. (2014). Implementation of an intensive short-term dynamic treatment program for patients with treatment-resistant disorders in residential care. BMC Psychiatry, 14, 516-522.
6. Solbakken, O.A., & Abbass, A. (2015). Intensive short-term dynamic residential treatment program for patients with treatment-resistant depression. Journal of Affective Disorders, p://dx.doi.org/10.1016/j.jad.2015.04.00
7. Town, J.M., Abbass, A., Stride, C., & Bernier, D. (2017). A randomized controlled trial of intensive short-term dynamic psychotherapy for treatment-resistant depression: The Halifax depression study. Journal of Affective Disorders, 214, 15-25.

Labeling pathology in another person is easy. One teacher of mine said it’s like “shooting fish in a barrel.” Think of any person you know and, unless you’ve totally idealized them, I bet you can find some psychological diagnostic label to pin on them. “So neurotic!” “So hysterical!” “So narcissistic!” We all have the ability to spot apparent pathology. But we all, therapists included, sometimes have a much more difficult time recognizing health—the healthy strivings of others and of ourselves.

So why is so much mental health education, from graduate programs to popular blog posts, focused on helping people identify and label (aka diagnose) pathology? What problematic dynamics are evoked when the therapist and others function only as pathology detectors? How can we reorient ourselves toward detecting human complexity, the complex intertwining of “health” and “pathology” within ourselves and each other?

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Why Is It Useful to Be Sensitive to Pathology?

Imagine if you went to your car mechanic because something is wrong—your car would not accelerate past 25 mph. Imagine the mechanic takes a thorough look at your car and says, “Well, I can’t see anything wrong. I think your car is fine.” You might be more than a little concerned about your difference of opinion with the mechanic, and you’d probably look for a second opinion.

The same is true with therapists. Some emotional problems show up in big, visible ways—a depression that makes it hard to get out of bed, for example, or panic attacks. However, some mental health conditions and—more importantly—the underlying emotional processes that contribute to them are quite subtle and difficult to detect. Without thorough and nuanced training in detecting the manifestations and drivers of people’s issues, therapists are at risk of looking a suffering person in the eye and saying, “You seem fine to me.” For this reason, we need a refined understanding of all the parts in the engine of the human mind, and we need to know how a person looks when some part of that engine is malfunctioning.

As important as it is to be able to see and understand a person’s issues, the therapeutic relationship is deeply compromised when the person’s issues are all we can see.

When All We See Is “Resistance”

Realistically, some people come to therapy in a near-total state of resistance:

“I didn’t want to come today.”

“I’m only here because my partner said I need to be here.”

“Does therapy even work?”

It can be hard to imagine how progress can be made in the face of attitudes like these. It seems like “pathologies” like defiance, passive compliance and hopelessness have totally taken over the people quoted above. It’s hard to find any overtly “healthy” dimension of their comments.

As a therapist, I encounter statements like these with great regularity, and I’ve seen plenty of instances of “resistance” and “pathology” that are even more bold and provocative. It is incredibly easy to hear these comments and become hopeless—if all we see is resistance, we may begin to doubt whether a healing-oriented part of the person even exists for us to build an alliance with.

In moments like this, we forget that, though the person’s words are defiant, passive, hopeless, or whatever else, they still arrived for their session. Not only are they present for the session despite this resistance, they are making an effort to be honest about how they feel. When we relate only to a person’s resistance and “pathology,” we forget that their sharing of their resistance and sharing of their “pathology” is a vulnerable attempt at forming an alliance with us. When we relate only to the resistance described by their words and not to their efforts to reach out through sharing, we miss an important opportunity to connect with the healing-oriented forces buried under the surface behaviors. When all we see is “resistance” and “pathology,” we miss out on the full complexity of the person we are trying to get to know.

Consequences of Seeing Only Pathology

When we fail to recognize and acknowledge the “resistant” person’s profound efforts to reach out to us by sharing their resistance openly, certain problems can plague the therapy alliance.

The person will not feel heard. Generally speaking, we can sense when someone is “pigeonholing” us or seeing us in a one-dimensional way, and we tend not to like that. Conversely, we tend to appreciate it when people have a complex understanding of us, with honesty about our inner “bad” and “good” and “mixed”-ness.

This ability to see and embrace our complexity is perhaps one of the great challenges of growth in therapy and elsewhere. Every day and every therapy session reveals new truths about us, presenting anew the challenge, “Can I accept this part of me?”

When we as therapists relate only to the “pathology” and “resistance” people show us, rather than convey our appreciation for the fact they are showing up to willfully tell us about it, they may feel, and rightfully so, only one part of them is being heard. When we fail to acknowledge the healthy efforts that emerge alongside or are veiled by their “resistance,” we relate only to their “badness,” which can have a severely negative impact on our alliance and lead people to feel more hopeless. Sadly, in cases like these, people often blame themselves for their therapist’s error: “It’s my fault the therapy didn’t succeed. I’m just too resistant!”

The person sitting across from us is already good at criticizing themselves. An expert ability to see and criticize our own foibles is part of what brings many of us to therapy in the first place. I have noticed when therapists relate only to a person’s pathology, one common response is for the person in therapy to join in with the therapist, criticizing their thoughts, feelings, and behaviors. This may look like helping a person “turn against their defenses” or helping them to “see their resistance,” but so often it is the establishment of an alliance built around change via criticism, which never seems to yield the desired therapeutic result.

The person may try to change, but not to please themselves. People in therapy tend to respond to the therapist’s tendency to notice only their pathology by trying to change. In these instances, they tend not to be changing for themselves or changing in directions they desire for their own well-being; instead, they tend to change in the direction they believe their therapists would prefer with the hope of no longer being criticized or related to as “bad.” This can be a reenactment of problematic attachments from the person’s past.

The Therapist’s “Pathology”

Your therapist’s difficulty seeing your complexity, the ways your healthy efforts coexist and intertwine with your struggles, is a reflection of their difficulties seeing and accepting their own complexity. Remember, we tend to treat others the way we treat ourselves, and to see others through the lenses we see ourselves through; as a result, the tendency of a therapist to pigeonhole a person as “pathological” suggests the therapist may tend to devalue themselves that same way.

I can only accept the complexity of the people I help to the degree I can accept my own complexity. As therapists, and as people in general, whenever we meet a new person or a new part of ourselves we are called upon to face deeper and deeper levels of the complexity that is humanity. In that moment when we meet a new person, a new truth, will we accept it in all its complexity or will we reduce it to “pathology”?

Can We Accept the Complex Beings We Are?

So how can we see each other as complex people? How can we manage to hold both our health and our destructiveness in mind simultaneously so we have the most complete information about ourselves to work with? How can we gain an appreciation for the complex intertwining of our efforts to communicate and our efforts to wall off, such that our moment of greatest “resistance” may actually be our most profound effort to reach out? Can we accept our “resistance” as simply the most health we can muster at the moment?

This ability to see and embrace our complexity is perhaps one of the great challenges of growth in therapy and elsewhere. Every day and every therapy session reveals new truths about us, presenting anew the challenge, “Can I accept this part of me?” So often in therapy, when we discover something previously unknown about ourselves, we are tempted to reject and pathologize it. It is even tempting to pathologize and reject our tendencies to pathologize and reject ourselves! The human mind is incredibly adept at making an enemy of itself.

So can we accept that? Can we accept the conflictedness about self-acceptance that is part of our humanity at this moment? Can we initiate the journey of acceptance by loving and embracing the pathologizer and rejecter inside right now? That tendency must have been important to learn; otherwise, we would not have learned it. What if the goal in psychotherapy is not about finding health or finding pathology, but about attempting to embrace all of ourselves?

When I educate medical health professionals about the complex links between emotional functioning and physical health, many express a fear that their patients will respond to a referral to therapy by saying, “So, are you saying this is all in my head?” I will try to provide a useful, realistic answer to this potentially thorny question.

Body, Mind, or Bodymind?

Modern neuroscience has helped us begin to see that the separation of body and mind is more a matter of grammatical convenience than scientific truth. Our nervous system, the network of cells that helps our brains connect with the rest of our organs, links our emotional processing center to every structure of our physical being. This has led some to use the term “bodymind” in recognition of the idea we gain nothing by continuing to arbitrarily separate mental life and physical life when they are so clearly interwoven (e.g., Keleman, 1989). When we think about ourselves as bodyminds, it begins to make sense that many physical symptoms are exacerbated or caused by emotional processes.

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How Emotions Become Physical Symptoms

Much developmental theory and research has helped demonstrate that experiences in our development, especially with our caregivers, shape our relationship to our emotions (e.g., Felitti, et al., 1998). We tend to treat our emotions similarly to how they were treated by others (Frederickson, 2013). As a result, those of us who had parents who responded to our emotions with anxiety, misattunement, or even punishment may develop anxiety about our own emotions. Many people experience anxiety when emotions are triggered by relationships and events in their day-to-day lives.

Maybe someday, rather than feeling afraid of the notion some aspect of their physical problems is “in their head,” people will feel hopeful about the possibility their symptoms might finally be explained and treated with psychotherapy.

Anxiety can manifest physically in the body in many ways. It can cause our skeletal muscles to tense, leading to pain and cramps. It can cause tension in the smooth muscles of the bowels, vascular system, urogenital system, and bronchi, leading to a variety of symptoms such as irritable bowel, hypertension, sudden urge to urinate or defecate, and difficulty breathing. Anxiety at very high levels can even cause changes in the flow of blood and oxygen to the brain, leading to difficulties thinking and perceiving the world, such as dizziness or blurry vision (Frederickson, 2013).

I point all this out to illustrate that anxiety triggered by the emotionally evocative events of our daily lives can produce a huge variety of physical symptoms. These symptoms can easily be, and often are, diagnosed and treated as if they are purely somatic, without considering the possibility emotional factors might be a major contributor. This can result in failed treatments and frustrated patients. See my other articles for more detailed information on the links between emotions and physical symptoms.

So, Is It All in Your Head?

The fact that emotional factors are contributing to your symptoms does not mean your symptoms are fake, as the notion of “all in your head” seems to suggest. Emotional factors create very real physical symptoms that are often mistaken for symptoms that have a purely medical origin. A recent study even showed that the brain of a person in emotional pain, when observed under fMRI, has a similar appearance to the brain of a person in physical pain (Kross, et al., 2011).

When we treat emotion-driven symptoms as if they are purely physical, and deny the component that is “in the head,” health care costs go up, symptoms persist or worsen, and frustration grows. Alternatively, evidence is beginning to show we can save time and health care costs by treating medically unexplained physical symptoms with psychotherapy (Abbass, et al., 2010).

Despite this evidence, it seems many medical practitioners fear their patients will be hurt by a referral to psychotherapy. There is some truth to this: many health care consumers are upset by the possibility their physical symptoms may have an emotional engine, and sometimes they exhaust all other diagnostic and treatment options before pursuing counseling. I hope the information presented here and in my other posts on somatization will help patients and practitioners to reap the benefits of a clearer understanding of the bodymind and the links between emotions and physical symptoms. Maybe someday, rather than feeling afraid of the notion some aspect of their physical problems is “in their head,” people will feel hopeful about the possibility their symptoms might finally be explained and treated with psychotherapy.

References:

1. Abbass, A., Campbell, S., Hann, G., Lenzer, I., Tarzwell, R., & Maxwell, D. (2010). Cost savings of treatment of medically unexplained symptoms using intensive short-term dynamic psychotherapy by a hospital emergency department. Journal of the Academy of Medical Psychology, 1, 34-43.
2. Felitti, V., Anda, R., Nordenberg, D., Williamson, D., Spitz, A., Edwards, V., Koss, M., & Marks, J. (1998). Relationship of childhood abuse and household dysfunction to many of the leading causes of death in adults. The adverse childhood experiences (ACE) study. American Journal of Preventive Medicine, 14, 245-258.
3. Frederickson, J. (2013). Co-creating change: Effective dynamic therapy techniques. Kansas City, MO: Seven Leaves.
4. Keleman, S. (1989). Your body speaks its mind. Berkeley, CA: Center Press.
5. Kross, E., Berman, M.G., Mischel, W., Smith, E.E., & Wager, T.D. (2011). Social rejection shares somatosensory representations with physical pain. Proceedings of the National Academy of the Sciences of the United States of America, 108, 6270-6275.

Anxiety can manifest in a variety of ways in the human body. It can make us tense in our large, voluntary muscles, activate the involuntary muscles of our internal organs, and even cause changes in our thinking, sensation, and perception. I want to focus here on one particular pattern of anxiety—anxiety in the smooth muscles—and the style of self-punitive thinking that is associated with it.

Smooth muscle anxiety is linked with a wide range of physical problems that are emotional in origin but can be mistaken as medical, which can lead to misspent health care dollars, lost time, and dashed hopes. It is my hope to help you identify manifestations of smooth muscle anxiety, learn about the thoughts linked with smooth muscle anxiety, and gain exposure to intensive short-term dynamic psychotherapy, a model that has demonstrated effectiveness in treating smooth muscle anxiety.

What Are the Smooth Muscles?

The smooth muscle systems of the body include the gastrointestinal system, the vascular system, the bronchi, and the urogenital system. There are also smooth muscles in our skin and eyes. The muscles are called smooth because they are made up of small, mushy, somewhat elastic cells. They differ from our skeletal muscles, which have long, striated fibers that are less flexible.

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When our smooth muscles are functioning as they should, they regulate our blood pressure, digestion, sexual and excretory functions, and breathing—functions that are essential to human survival. However, the smooth muscles are linked to the emotional center of the brain by the nervous system, and they can be activated in response to anxiety (Janig, 2003). So what happens when anxiety impacts the smooth muscles? What symptoms are linked with dysregulation of the smooth muscle systems?

Conditions Linked with Smooth Muscle Activation

The following conditions are associated with involuntary tensing of the different smooth muscle systems (Abbass, 2015):

• Vascular system: Hypertension, migraine
• Gastrointestinal system: Irritable bowel syndrome (e.g., acid, spasms, diarrhea, nausea), ulcerative colitis
• Bronchi: Reactive airways (e.g., asthma attacks)
• Urogenital system: Sudden urge to urinate or defecate

Are Types of Thoughts Associated with Smooth Muscle Anxiety?

Clinical researchers, especially in the literature on intensive short-term dynamic psychotherapy, have noted an association between self-attacking thoughts and smooth muscle symptoms. While it is not clear whether the self-punitive thoughts can cause a stomachache or migraine, harsh thoughts and smooth muscle symptoms do seem to show up together.

In ISTDP, we use collaborative, exploratory questions to support people as they learn to reflect on the emotions that are making them anxious and triggering self-attack.

Here’s a smattering of thoughts I have heard lately that have shown up alongside smooth muscle symptoms in people I work with:

• “These symptoms will never get better. I’ll be crippled by this.”
• “The fight we had was my fault. How could I have been so stupid?”
• “I’m a letdown.”

As these examples from my practice demonstrate, negative thoughts going against the self seem to co-occur with nausea and migraines. If you find that these kinds of thoughts co-occur with your IBS, migraine, or other physical symptoms, or seem to trigger them, you may be experiencing smooth muscle anxiety that has been diagnosed as a medical syndrome.

What Triggers Self-Attack and Smooth Muscle Anxiety?

Clinical research in ISTDP has demonstrated a link between complicated, mixed emotions toward loved ones, tendencies toward self-attacking thinking, and smooth muscle anxiety (Abbass, 2015). The theory of smooth muscle anxiety in ISTDP, which has been repeatedly supported by my experiences as a therapist as well as in case series data (Abbass, 2002) and empirical research (Creed, et al., 2003; Guthrie, et al., 1993), is that mixed emotions toward our attachment figures trigger anxiety. These mixed emotions are anxiety- and guilt-laden because it feels dangerous to have rage toward people whom we long to be close with and depend on.

Because of the anxiety and guilt associated with these feelings, the feelings are repressed—not thought about or reflected on. In fact, self-attacking thoughts seem to have the function of turning the anger toward the loved one back against the self with harsh thoughts and against the body with smooth muscle activation. The beloved person is protected from the anger, and the body and the self are punished. It is almost as though an unconscious, automatic part of the mind says, “How dare you have rage toward your beloved! You must redirect the rage toward yourself and your stomach to protect them!”

The Role of ISTDP in Healing

In ISTDP, we use collaborative, exploratory questions to support people as they learn to reflect on the emotions that are making them anxious and triggering self-attack. Increased reflective awareness of emotions seems to reduce the anxiety connected to them—if it can be thought about, talked about, and felt, it is no longer as scary or guilt-ridden. The complicated emotions we have about our loved ones are no longer unconscious (out of awareness) and frightening but can be seen and felt by the light of day and recognized for what they are—just feelings! People learn that they have been getting punished for emotions, which are mental, bodily events that are not inherently dangerous or wrong. Fear and guilt about emotions are replaced with thoughtfulness, openness, and comfort (Abbass, 2015).

If you are experiencing self-attacking thoughts and smooth muscle anxiety and are looking for systematic support in overcoming the automatic emotional factors that trigger your symptoms, ISTDP may be a useful treatment for you.

References:

1. Abbass, A. (2002). Office based research in ISTDP: Data from the first 6 years of practice. Ad Hoc Bulletin of Short-term Dynamic Psychotherapy, 6, 5-14.
2. Abbass, A. (2015). Reaching through resistance: Advanced psychotherapy techniques. Kansas City, MO: Seven Leaves Press.
3. Creed, F., Fernandes, L., Guthrie, E., Palmer, S. Ratecliffed, J., & Read, N. (2003). The cost-effectiveness of psychotherapy and paroxetine for severe irritable bowel syndrome. Gastroenterology, 124, 303-317
4. Guthrie, E., Creed, F., Dawson, D., & Tomenson, B. (1993). A randomized controlled trial of psychotherapy in patients with refractory Irritable Bowel Syndrome. British Journal of Psychiatry, 163, 315-321.
5. Janig, W. (2003). The autonomic nervous system and its coordination by the brain. In Davidson, R. J., Scherer, K. R., & Goldsmith, H. H. (Eds.), Handbook of affective sciences (pp. 135-187). Oxford: Oxford University Press.