Category Archives: Anxiety

Can happiness trigger anxiety?

“What do you think about fear of positive feelings? Do you notice an aversion to feeling positively in your clients? How do you think this develops, and how would ISTDP handle it? By fear of happiness, I mean avoiding happy feelings to escape negative consequences (such as being happy makes us selfish or immoral, being happy makes bad things happen, being happy makes others jealous of us, being happy draws us away from god, being happy brings sadness, etc.).” Great question! Thanks to Mohsen for posing this.

Of course, many patients avoid happiness. Happiness easily triggers anxiety and defenses. Why? To be happy is a crime because we are breaking the superego’s law that we must suffer. How dare you!!!

In ISTDP the defenses against happiness are covered in the concept: defenses against emotional closeness. To be intimate brings great happiness. Defenses against happiness can be triggered by different dynamic situations. 

If I am happy it may be a crime because I differentiate myself from my mother and our agreement to suffer, be unhappy, and be victims together: the depressive symbiosis.

If I am happy it may be a crime because I will have surpassed my father and achieved an oedipal victory. Therefore, I will become unhappy and deny or minimize my success to avoid my guilt over wanting to surpass him.

If I am happy it may be a crime because my colleagues will become envious. I will deny and minimize my happiness so we will be miserable together. Then they won’t envy me. The problem is that success will aways trigger envy in some people. You cannot avoid it. If you hold yourself back to avoid their envy, you will commit a crime to yourself and to those who would have benefitted from your success.

And finally, if I am happy, I turn against my self-punishment and face my underlying mixed feelings. Otherwise, to avoid guilt over my happiness, success, and pleasure, I will punish myself any time I feel happy to hide my forbidden wishes to succeed, to be happy, and to live a fulfilling life.

We deal with defenses against happy feelings as we would any other defenses.

Mohsen offers some common defenses. 

Pt: “Being happy makes us selfish.” [Self-attack]

Th: “Or is that how you justify punishing yourself?”

Pt: “Being happy makes us immoral.” [I must be unhappy if I am moral = Self-punishment]

Th: “You say you must be unhappy to be moral. Is this how you punish yourself?”

Pt: “Being happy makes bad things happen.” [Self-attack. Possibly a memory being misused for the purpose of self-punishment]

Th: “Being happy doesn’t make bad things happen; self-punishment is making bad things happen in your life.”

Pt: “Being happy makes others jealous. [Self-punishment to avoid envy and competition]

Th: “Yes it does. So are you willing to face that some people will envy your success?”

Pt: “Being happy draws us away from God.” [Being unhappy brings me closer to God = self-punishment + a view of God as someone who wants us to suffer for eternity (the superego masquerading as God]

Th: “So being unhappy will draw you closer to God? What kind of a God would want you to suffer for eternity?”

Pt: “Being happy brings sadness.” [If I am happy I will be sad, so I will become sad right away and beat the rush= Self-punishment]

Pt: “Being happy doesn’t bring sadness. When you are happy, you punish yourself. And this self-punishment makes you sad.”

As you can see, these defenses can develop due to varied conflicts. In ISTDP we deal with these defenses as would deal with any other defenses: identify, clarify, and confront the defenses. Turn the patient against the defenses. Help the patient face his mixed feelings as deeply as possible so he no longer needs to punish himself by avoiding happiness.

Remember that good outcome is not merely the absence of depression or anxiety. It is the presence of genuine happiness that shows the patient has processed his underlying guilt enough that he no longer has to punish himself by avoiding happiness, the birthright of every patient to seek.

How do I understand the anxiety symptoms in this patient?

“I have a question about the level of anxiety of one of my patients. He had a traumatic childhood, with a father who beat him regularly. He has had some jobs, but nothing stable, and he has lived a good part of his life in the criminal world. He abused various drugs, which triggered some psychotic episodes.
In therapy he has stopped using drugs while we have been building his capacity and confronting self-destructive defenses. We used to see dissociation, disturbed thinking and visual disturbance with just a low level of emotional focus. Now there is only a slight tendency to dissociation (which he is able to stop) and no disturbed thinking. He sighs and seems more solid with no regressive defenses like projection and splitting.
But he still reports visual problems at low levels of feeling, similar to what he experienced when he was beaten by his father (together with dissociation). So, I see signs of striated anxiety (sighs, tension) on the one hand and signs of C/P-disruption (the visual disturbance) on the other.
This apparent mixture of anxiety-levels confuses me. Could you could comment on that?” Great question!
Clearly, this patient has been fragile, given the dissociation, projection, visual disturbances, and disturbed thinking you saw in the initial phase of therapy. Working gradually to build his capacity, you have helped him improve. Now at low to moderate levels of feeling he sighs and, presumable, can also intellectualize.
However, when you go to higher levels of feeling you will cross the threshold of anxiety tolerance and at that moment he will begin to disrupt cognitively and resume the use of dissociation and other regressive defenses such as splitting and projection. It is not that he has these signs of striated and cognitive perceptual disruption at the same time. It is that his anxiety will move out of the striated muscles back into cognitive perceptual disruption when he crosses the threshold of anxiety tolerance. It’s just that this threshold is higher now than it used to be, and the words and feeling levels that trigger him to go over threshold are different than what they were earlier in treatment.
As an analogy, think about your work this way. Before, at 5% of feeling he would disrupt and dissociate. You regulated his anxiety, and you helped him bear 5% of feelings without dissociate. Bravo! But now, when you up to 10% or 20% of feeling, he will disrupt again and use dissociation again. Again, you will regulate anxiety and help him bear mixed feelings inside without dissociating. You will keep repeating this process at successively higher levels of feeling until he can bear 100% of his feelings without dissociating or projecting or disrupting. At that point, the resistance system of projection and the anxiety pathway of cognitive/perceptual disruption will be completely restructured.
Until that point, each time the patient crosses the threshold of anxiety tolerance, you will see the anxiety shift back into cognitive/perceptual disruption and the defenses of dissociation, projection, and splitting will occur again.
When reviewing your videos, examine the thirty seconds of video before the patient dissociates or has visual problems. Then you will learn either what you said or what the patient said that pushed him over the threshold. Now you will know the precise words or descriptions of feeling that he has to bear now without dissociating. Use bracing using those specific words until he sighs again.
When we are confused in these matters, it is because we don’t notice when the patient went over threshold and what triggered that shift. Study of your videos will allow you to analyze this in detail so that you become more attuned to the specific “dosage” of feeling he is able to manage and the “dosage” where he starts to have trouble. Then you can work at the edge of his capacity, while building it gradually.
He still has a fragile character structure, most likely. And that will remain so until he can bear 100% of his feelings without c/p or projection. Keep up the good work! Keep working slowly. Given the severity of his past symptoms and his past behaviors, I would guess that this will take a while. Be patient. Keep building capacity. He has a long way to go.
Take home point: the issue is not whether he is “in” striated or “in” cognitive/perceptual disruption. The issue is at what level of feeling does he cross the threshold of anxiety tolerance and shift into cognitive/perceptual disruption. This threshold is higher than it was, but it needs to be raised a great deal until he is able to bear 100% of his feelings.