The idea that a person’s past could unconsciously and dramatically influence the present used to make me smirk.
When I was a medical student, delving deep into a patient’s early experiences was the part of psychiatry that seemed the most eccentric and the least doctorly. I suspected the whole notion of unconscious connections between past and present was a powerful myth spun by creative minds who had broken with scientific process and wandered to guesswork. I, on the other hand, would keep my feet firmly grounded in fact.
But listening to my patients has proven me wrong. Again and again, decisions they make turn out to have undeniable connections with earlier experiences in their lives. It is as if forgotten or seemingly disconnected chapters in their life stories continue to influence the evolving plots.
One patient came to the clinic seeking treatment for extreme stress. His second marriage was to a chronically sick woman whose care took almost all his time. “I’m at the end of my rope,” he said. “I’m wearing myself out running to doctors, making sure she takes her medicines, taking the kids out so she can rest. I’m beat.” He had been married previously to a woman who ultimately died from a disease that was already taking its toll when they met.
During our fourth meeting, my patient’s devotion to these ill women began to take the tone of servitude. He described the responsibility as inescapable — as if he was destined to forever be both husband and nurse.
“Did anyone get sick in your family when you were a child? Or die?” I asked. “No, no one. Why?” he asked.
“Anyone?” I pressed. “A friend, maybe?”
“Well, sure. Now that you mention it. My best friend in fourth grade . . .” he said, then fell silent for a few moments, his eyes welling with tears. “We were like the same person, see? I remember going to visit him in the hospital.”
“What was that like for you?” I asked.
“The worst thing wasn’t all the tubing they’d stuck in him,” he said. “It was this nurse who kept telling me, ‘There’s nothing you can do. There’s nothing you can do.’ ”
The plot made irresistible sense. Having been told as a boy that he could do nothing to save such a precious friend, my patient seemed to be desperately engaging illness in battle as a man.
Part of the evidence that an unconscious link with the past is truly at the heart of a current behavior pattern is the patient’s response when the connection is uncovered. There is often a moment of astonishment or embarrassment that the relationship could have gone unnoticed so long, the sudden flash of recognition similar to the response of encountering an old friend while traveling in a distant land — a what are you doing here? look.
A woman who was ending a friendship of twenty years described the relationship as “one-sided.” She said she had suffered through decades of supporting her friend emotionally, without the effort being reciprocated.
“Why have you decided to end the friendship now, after so long?” I asked.
“The final straw,” she said, “was when she told me I’d have to cancel my trip to see her because her son would be visiting unexpectedly. There’s only one spare bedroom. I said I’d be happy to sleep on the couch, but she wouldn’t hear of it.”
It turned out that woman had grown up in a family in which she and her siblings had to be adopted. Although she begged to be placed with her sister, none of the adoptive families had room for two children.
When she related the memory of her sadness to me, she suddenly grasped her forehead. She seemed surprised. “When my friend didn’t have room for me to visit, it was just like that, wasn’t it? That’s why it hurt so much.”
Seemingly independent experiences can even cause destructive patterns that include physical symptoms. Months ago, I treated a man who endured bouts of fear, heart palpitations, and sweating whenever his relationship with a woman seemed on the brink of marriage. His heart proved to be perfectly healthy. But three times, his condition became severe enough that the women he loved abandoned him.
In talking about his childhood, he told me of his mother’s cruelty. “She’d say, ‘Come here, my sweetheart,’ and, then, when I did, she’d slap me across the face.” That vivid image from the past seemed like part of the explanation for the patient’s recurrent symptoms. It made sense that being repeatedly seduced and violently rejected by his mother could make him panic at the thought of confessing love. It could also lead him to test the affection of a mate by requiring a demonstration of unwavering commitment — like sticking by him through worsening illness.
Insight-oriented psychotherapy presumes the existence of a core self with real hopes, needs, and emotions that can be misdirected or thwarted by invisible anchors to past traumas, as though the mind is stuck in an oscillating circuit, repeating destructive patterns endlessly.
By connecting forgotten or seemingly unrelated experiences with present emotions and decisions, psychiatrists hope that patients will be free to chart a truer course.
The first man I described, for example, might allow himself more freedom from his current role as his wife’s caretaker. He might better understand his motivation should there come a time when he considers commitment to another debilitated woman.
The woman who decided to end her friendship might reevaluate how much of her anger can be traced to her earlier abandonment. She might wonder whether she seeks out relationships in which she is consistently the more giving partner. And, rather than breaking off, she might be able to help her friend understand her true need for support and reassurance.
Sometimes, people feel that the easy way out is to forget pain, to let “sleeping dogs lie.” But keeping the past buried is not a passive process. It takes mental energy to suppress the painful memories that lead to unhealthy patterns.
One patient, locked in repeated, exhausting struggles with authority figures, had been recounting her physical abuse as a child. When we began touching on the most hurtful aspects, she became evasive. Eventually, she took to starting each therapy session with a long rendition of how her day had been spent. Sometimes, she wandered into her opinion of world events.
“You seem to be spending a lot of your energy and our time avoiding the painful topic we’ve been talking about,” I finally commented.
“I keep running into corners, and you keep trying to flush me out,” she said. Exactly. By exposing memories that wreak havoc under cover, the energy of running away — whether to one’s daily routine or to unhealthy relationships — can be better directed.
As a psychiatrist, I must remain cautious as I settle on these understandings of how earlier chapters in my patients’ lives are influencing their present emotions or behaviors. If the connections I identify make no sense to the people I am trying to help, they will be of little value to them.
I may press my point by reviewing the evidence for the connection or introducing consistent new evidence as it unfolds. But other times I come to feel, far from my patient being resistant, the scenario I have presented has no inherent power to move him or her. The only thing separating fiction from truth in a patient’s life story is, in fact, that individual’s sense of whether the plot feels right, not whether it is historically accurate.
Knowing precisely when to abandon my version of a patient’s life story is difficult because there is no way to objectively confirm or refute it. The original manuscript is unavailable. I can never know for sure whether a patient’s protest against a connection I propose represents a well-defended fortress or is simple honesty. Furthermore, my own life story will influence which themes I identify as compelling, those which I am happy to skim over, and those which never occur to me at all.
I look for hints in my patient’s behavior. Tears, surprise, or anger at a connection I propose make me want to delve deeper. So, too, does a knee-jerk or impassioned rejection. If the patient misses the next appointment, I wonder whether I have hit a raw and true nerve or whether I have wandered hopelessly afar. Considered skepticism makes me feel most strongly that I am off base.
The truth in psychotherapy is ultimately what feels true. The facts are subjective. That doesn’t bother me anymore. The validity of the connections I uncover is determined by whether they alleviate my patients’ pain and improve their lives.
Keith Russell Ablow is a writer and senior resident in psychiatry at New England Medical Center in Boston. This essay first appeared in The Washington Post.
