Saturday, March 5, 2011

Psychology Today: Despair & Psychotherapy

A Forensic Psychologist on Anger, Madness and Destructive Behavior
by Dr. Stephen Diamond

Existential psychiatrist Viktor Frankl, whose concentration camp experience during the second World War made him somewhat of an expert on the subject, defined despair as meaningless suffering in the simplistic but powerful formula D=S-M: despair equals suffering minus meaning. The clinical implication here is that despair can be treated by helping the patient attribute to or discover some meaning in his or her personal suffering, misery and symptoms. Indeed, when a psychiatrist diagnoses the patient's despair as stemming from clinical depression or bipolar disorder, he or she has provided some meaning to their suffering, and also some hope for psychopharmacological salvation. Unfortunately, this too often turns out to be a disappointing, false or fleeting hope, which then tends to exacerbate and reinforce the patient's already devastating clinical despair. The same may be said of psychotherapies, both brief and longer-term, that offer patients the perhaps overly optimistic hope of relieving their clinical despair and then do not deliver.

Philosopher Soren Kierkegaard, in his Sickness Unto Death (1849), suggested that despair could be understood as comprising three stages: Spiritlessness, which applies to those who outwardly seem well-adjusted and successful yet inwardly live in a state of deep and perilous despair; despair in weakness and despair about weakness, which has to do with a refusal to become authentically and fully one's self and the existential guilt (what Sartre called mauvaise foi or "bad faith") of this cowardly refusal to move forward and frustrating inability to retreat back to their former identity; and, thirdly, the despair of defiance, which pertains to the capacity of despair to turn, sometimes quite suddenly, to elation, excitement, optimism, enthusiasm, hypomania or mania and frenetic creative activity as so often seen in extremis during the manic phase of bipolar disorder. For Kierkegaard, the cure or antidote to despair is religious faith, in his case, Christianity or what he called Christian existence. (For this brief section on Kierkegaard, I am mainly indebted to Dr. Robert L. Moore's paper titled "Theory Matters: Analytical Psychology and the Human Experience of Despair")

Commonly, clinical despair results from the chronic repression of what existential psychologist Rollo May called the daimonic: the ultimate source of our vitality, will, power and creativity. When, for example, we habitually deny or repress our anger, sexuality, passion, spirituality, sadness, anxiety, creativity-and even our existential despair--we are cutting ourselves off from the daimonic and our true selves, and drifting toward clinical despair, apathy and depression. Clinical despair, which often contains a kind of embitterment, typically stems from chronically repressed anger or rage about how unfairly life has treated us, and how powerless and helpless we are to do anything constructive about it. This is why it can be vitally important for the patient to get in touch with this daimonic anger and harness its power and motivating energy to courageously change themselves and their lives for the better. Otherwise, clinical despair festers, sometimes expressing itself in self-destructive and even violent behavior.

As Sartre suggests,
"Human life begins on the far side of despair."
Instilling some hope in the patient suffering from clinical despair seems an obvious and simple therapeutic ploy, but in practice proves much easier said than done. Counterintuitively, confronting clinical despair can be closer to taking Dante's sojourn through Hell in The Inferno, where he anxiously reads the daunting inscription on the gate:
" Abandon all hope all ye who enter here."
Clinging desperately to false hope, whether in childhood, adolescence or adulthood, can paradoxically be a neurotic defense against despair, a defense which, while serving the valuable purpose of survival in some cases, ultimately prevents one from facing and moving past the despair of abandonment, abuse, neglect, loss and other traumas. This is what Jung may have meant when he noted that
"neurosis is always a substitute for legitimate suffering."

Sometimes clinical despair, it seems, must simply be patiently accepted, tolerated and suffered through with the stabilizing and supportive presence and accompaniment of the compassionate psychotherapist until it eventually turns into something else: courage, hope, joy, love, rage, passion, spirituality, faith or creativity. (This subtle shift is something fundamentally different in intensity from the radical, dramatic, transitory, destabilizing and dangerously exaggerated mood swings seen in bipolar disorder.) Moving through this excruciating process can be likened to both a terrifying death of one's old self, and a birth of the new self, with despair being the prolonged pregnancy and painful labor. But when clinical despair is totally avoided or prematurely aborted during treatment by pharmacological and/or psychological means, there can be no true transformation. Tragically, the patient remains stuck in the destructive vicious cycle and potentially deadly snare of clinical despair.

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