“How do we understand somatization on the triangle of conflict?” Patients suffer bodily symptoms in psychotherapy for three reasons: 1) medical causes; 2) anxiety; and 3) the defense of somatization. Assuming the patient has been medically evaluated, we then explore the psychological causes for somatic symptoms.
The most common source of somatic symptoms is anxiety. As you know from our videos and previous blogs, anxiety can be discharged into the somatic and autonomic nervous systems. When anxiety is discharged into the somatic nervous system, the patient’s voluntary muscles tighten up causing back pain, neck pain, tension headaches, vulvadynia, and many other complaints. When the patient’s anxiety is discharged into the voluntary muscles, we pursue the patient’s feelings and help him let go of his defenses. Once he feels his feelings as deeply as possible, his anxiety drops, and his symptoms disappear. Any of you who have followed John Sarno’s work know that he helps patients face their anger so that they can feel their feeling rather than cover with anxiety in the form of tension. That is consistent with the way ISTDP thinks about somatic symptoms that result from tension in the striated muscles.
If anxiety is discharged into the parasympathetic nervous system, the patient will suffer migraines, cognitive problems, immune system problems, and digestive tract problems such as diarrhea, nausea, and irritable bowel syndrome. Here, the therapist must regulate anxiety as soon as these symptoms occur. Bring anxiety back into the striated muscles. Then explore feeling again. As the patient’s feeling tolerance increases, eventually her anxiety will no longer go into the parasympathetic nervous system and her somatic symptoms will disappear. This change is what we call restructuring the pathway of unconscious anxiety discharge.
For some patients somatic symptoms do not result from anxiety but from the defense of somatization itself. In the defense of somatization, the patient unconsciously identifies with the body of another person with whom she has mixed feelings. A patient, unable to bear the loss of her mother who died of lung cancer, was troubled by a chronic cough (identification with her mother’s symptom). Once she could grieve the mother’s death, her cough disappeared. Another patient imagined putting an ax to his father’s head. A moment later he had a “splitting” headache. Due to guilt over his rage toward his father, he identified with his father’s body, as if the murderous blow had gone onto him, not his father. In this case, due to unconscious guilt over the murderous rage, the patient identified with the body as if to say, “Don’t worry father, the rage went onto me instead.” Once we can help the patient face his rage and his guilt, he no longer has to punish himself for his unconscious crime through the defense of somatization.
When patients use the defense of somatization, we help them see the defense, then encourage them to face the feelings the defense wards off. When the patient can bear the warded off feelings, the defense of somatization is no longer necessary.
Thus, when working with somatic problems, assess whether the symptom is caused by the discharge pattern of unconscious anxiety or whether it is caused by the defense of somatization. In my forthcoming book, Co-Creating Change, an entire chapter is devoted to treating the fragile spectrum, including somatizing patients. You can also read the case of the depressed patient on the resources page for a case of somatization that resolved very quickly after a breakthrough to the complex mixed feelings.