OMG, Do I Have Neurosis?


Paul Simon says it better than anyone, “The nearer your destination, the more you’re slip-slidin’ away.” What I mean is, do you somehow end up missing out on just what you most want in life?  The first few times, you thought it was bad luck, but as you mature, you begin to suspect that somehow it is you? For me, this is the cardinal sign of neurosis.

These are the kinds of problems that affect people who look normal and function reasonably well in the world. Because they tend to target the things that mean the very most to us, they do a great deal of harm. These are the problems that insurance companies don’t want to know about, yet in their quiet way, they tear up as many lives as the more obvious mental disorders.

Neurosis is a term you don’t hear much anymore, but it still has value. Most definitions say that neurosis refers to those emotional problems that are not due to any chemical disturbance of the brain. This means “software,” not “hardware.” On the other hand, we know from computers, that software problems can be as serious as the other kind, and harder to pinpoint.

Even though the dictionary gives a general definition of neuroses as non-physical emotional problems, I prefer to use the psychoanalytic understanding: problems in life that seem mysterious on the surface but are driven by invisible forces from within.

First, let’s look at some self-defeating patterns that are not so mysterious. Early experiential learning, trauma, internalized values and arrested development all can lead to dysfunctional patterns that stop us from achieving. For example, growing up in an untrustworthy environment can lead to problems with trust that undermine success with intimate relationships. Or internalized negative attitudes and can cause low self-esteem and underachievement. The movie “Good Will Hunting” is based on such a pattern. As a final example of a self-defeating behavior based on early learning and development, marrying a person who turns out to have the characteristics of the parent with whom you have unresolved issues often leads to re-creation of the unsolvable conflict. Semi-aware of the goal of “getting it right,” we keep up the hopeless struggle–until and unless awareness clears the way to conscious choice.

No, I’m not talking about those, more clearly understandable problems today, but about patterns with no obvious explanation. A woman in her forties was recognized for her beauty and intelligence, yet she couldn’t make much of her life. She married a man who was no match for her intellectually, and was not even nice. She went to therapy for years with little progress, but stayed. What could be driving such subtle self-defeating behavior? More important, how can these patterns become accessible to change?

This is where the descendants of Freud’s “talking cure,” that is the psychodynamic therapies, provide a unique window on what is happening. Looking through that window, what we find are secret and unacceptable ambitions. It is no wonder that these are not easily revealed. They are so shameful that they have been hidden even from the person who carries them. These are the products of the mind of a child old enough to think and plan and to be aware of right and wrong. At age 4-6 or so, children have a lot of wisdom and sophistication, and are quite capable of coming up with ambitious plans to make things better. I think of these as “someday” plans. Someday I’ll… and that will make life better.

But when it is clear that the plans are not acceptable to the important people in the child’s life, they don’t just disappear, they go underground, out of awareness of the child or anyone else. Wherever it is they go, they remain very powerful and influence behavior in ways that are not obvious. These cherished ambitions are what make us want certain things more than anything else. They can fuel our dreams. When our ambitions are more acceptable, they stay in conscious awareness and are shaped by reality and experience. But when they stay secret, they don’t have a chance to evolve. Furthermore, these plans remain in opposition to our own core values. Those values, an internalized version of whatever it was that made the plans unacceptable in the first place, continue to create opposition to both awareness and fulfillment.

As the woman described above, tried to take better care of herself, she became aware of a powerful and irrational resistance to change. The last thing she wanted to discover was that her ambition was to use her own failure in life as evidence to prove that her parents hadn’t done their job right. She harbored so much guilt about this aggressive goal that her painful failures, in themselves, became punishment. The resulting stalemate is how we get to neurosis, where the things we want most somehow slip through our grasp.

Let’s look at how cognitive therapy approaches this. Cognitive therapy is very ready to take on self-defeating behaviors and specializes in attacking just those dysfunctional values that stand in the way of fulfillment of ambition. On the other hand, part of the behavioral tradition is that you don’t have to know how things got that way. In pure form, cognitive-behavioral therapy doesn’t want to know about the ambitions or the plans, or even why the self-defeating values exist.

CBT will identify the self-defeating behaviors and then go after the internal prohibitions against success. Finding values that make the patient feel guilty and unworthy, CBT will clarify that those values are erroneous and inappropriate. With diligent work, the values may change, and more positive behaviors may be adopted. Even when the treatment goals are achieved, that is, the original self-defeating behaviors have stopped, there may be yet another hurdle. The ambitions may still be in place and are likely still secret. Will the change in values generalize to other manifestations of the same ambitions? It will depend on how thoroughly those values have been addressed and modified.

Psychodynamic therapy will go after the values to some extent, and will also work to bring the ambitions to light. Perhaps not as aggressive in targeting inappropriate values, the psychodynamic therapist will nonetheless be more focused on healing the shame that holds back awareness of the ambition. As these ambitions come more clearly to light, the patient will have a chance to re-evaluate. The solution is to grieve those parts of a five-year-old’s ambition that are not realistic and to adapt those parts that have a place in adult life.

Do you have a neurosis?  Perhaps the best approach of all is to combine the practical focus of CBT with the clarity of a psychodynamic understanding. Why not?


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