Tales from the Therapist's Couch

The trouble with diagnostic labels is that they have a habit of sticking well past their sell-by date. Patients who had a psychological term attached can burden themselves with the label for years, and too readily attach any fragility to past problems, which can get in the way of change.

The trouble with diagnostic labels is that they have a habit of sticking well past their sell-by date. Patients who had a psychological term attached can burden themselves with the label for years, and too readily attach any fragility to past problems, which can get in the way of change.

Let me give an imaginary example. I am working with a recently married man in his early thirties who is using therapy to explore his early history. Fostered from a young age, he spent most of his childhood moving between homes. Although he never had the security of one constant environment, he seems, to me, emotionally robust. He tells me that he developed the knack of fitting in with what others wanted early on, and was perceptive enough to know that this was his way of trying to prevent rejection.

What was not developed was any secure showing forth of strong emotion. He remembers a screaming fit with a new foster-mother, but must have learnt to put a lid on distress, as it never augured well to show it. Distress was mostly turned inwards. For a short time, he developed a habit of self-harm. His then foster-mother referred him to a psychiatrist, who saw him regularly for a year. He found the sessions helpful, but was hugely hurt by the labels "depressive anxiety", "deprivation" and "acting out", which he saw by chance in his file.

In adult life, the pattern continues in a modified form. Although still prone to fit in too easily with what others want, and still susceptible (usually after drinking) to distressed outbursts of emotion, he mostly manages to return to his "workable" persona.

A short time into our work, the issues he wants to focus on suddenly shift. His marriage, which has been in the background, begins to eclipse the questions around origin and abandonment that had first brought him to therapy. He adores his wife, and she him. But, he confesses to me with some shame, he has uncharacteristically been lashing out at her recently, treating her with an unkindness he knows she doesn't deserve. Is he just stuck in being an angry, emotionally deprived boy?

His wife is less bothered about the unkindnesses, and in fact thinks them quite tame. He is, she tells him, in a new job, under a lot of stress, and facing painful issues in therapy. They have only been married a few months, and although they have known each other for several years, it is the first time they have been under one roof for any length of time. She is far from condoning his unkind tantrums, but sees them as a transient phase, connected to his fear that what he needs might abandon him again.

Unfortunately, this magnificent understanding on the part of his wife doesn't release him from self-loathing at his "bad" behaviour. He is, he tells me, "emotionally deprived, a depressive, inherently bad, or mad. Or both." I tell him I doubt the latter very much, and that it strikes me something more positive is going on. For the first time ever, he's in an environment in which he feels safely loved. In the language of the psychoanalyst Wilfred Bion, he has found, at last, a "container" to securely hold what has for too long been hidden. Little wonder there is a firework display of all that has been concealed for fear of rejection.

At one level, there is a kernel of truth in the labels he still carries. There is a sense of emotional deprivation about him. But his unkindnesses have more in common with what often happens between partners after the "honeymoon phase" is over than any pathology. The unpleasant compliment we pay to those we feel most comfortable with is to show them our shadow side: the anger, anxieties and fears that get dumped on a "containing" other. In everyday language, it is the familiarity that breeds contempt.

What my patient needed now was to loosen his identification with the labels, which paralysed him into feeling that he lacked the capacity for intimacy, and accept his place in the "normal" pitfalls of relationship. What could then follow was the hard but rewarding work at what Eric Fromm so rightly calls "the art of loving".

Elizabeth Meakins is a psychoanalytic psychotherapist in private practice. No clinical material refers to specific cases

Elizabeth.meakins @blueyonder.co.uk