Monthly Archives: December 2017

Are some people born with the inability to look in our eyes?

“An adolescent walks into my office and says she has panic attacks every day, coming out of nowhere. She has anxiety in the smooth muscles and no signaling in the striated muscles. She says she has a very mild autism diagnosis, and never has been able to look people in the eyes. If she does, she instantly suffers cognitive/perceptual disruption. When she looks at me in the office, she looks only at my nose or between my eyes.
When I ask if she would like to work on this “problem” so she can look people in the eyes and become emotionally closer, she replies that she will not be able to because she has autism. I would like to challenge that understanding, but I´m no expert in autism. Can it be, that some people are born with the inability to look into another person’s eyes without becoming intensely distressed?”
Of course, without looking at a video we have no way of assessing whether this patient has autism or not. Clearly, feelings rise quickly triggering high anxiety that goes into cognitive/perceptual disruption. So she is fragile and this problem could be treated through regulating her anxiety, and developing her capacity to tolerate feelings without excessive anxiety. Rather than go straight to eye gaze, which arouses too much feeling for her to tolerate, you can ask her about her thoughts about therapy, her reactions to therapy, her thoughts about you, and her reactions to you, until you finally ask about feelings toward you. This graded exploration would build her capacity to tolerate increasing amounts of feeling while anxiety remains regulated.
As for the question of eye gaze, in fact, many autistic people have gained this capacity over time with skilled help. What can be forgotten is that most autistic people suffer from terribly unregulated anxiety. Their autonomic nervous systems are dysregulated. See Porges’ writings for more on this. So the first task is to regulate their anxiety and then build their capacity gradually. In fact, as Stanley Greenspan once pointed out to me, autistic people are always making eye contact. However, they do so fleetingly and out of the corner of the eye. So the issue is not black and white, gaze or no gaze. The issue is the dosage of contact the autistic patient can tolerate before becoming dysregulated. At least that is what I understand from people who have treated them.
So your patient need not despair about being able to look people in the eye. But there is no need to propose this goal to her at this time, since it exceeds her capacity for anxiety tolerance. As you work with her in a graded fashion at much lower levels of feeling, you will build her capacity, and her ability to look people in the eye will increase simply because her ability to tolerate emotions will be increasing.
She is very fragile. So just regulate anxiety and invite her to cognize about the therapy relationship. As you explore her thoughts about the relationship, feelings and anxiety will rise. When it’s too high, regulate it, and then continue. Step by step you will build her capacity for affect tolerance so that relationships will be possible.

No answer I ever give is good enough!

A client spent 2 sessions ruminating no matter how much I try to block him, saying he needs to understand the process of therapy before he engages. I identified and clarification to no avail (I didn’t challenge him as he was quite fragile). He just insisted he needed to understand before he continued.

So after a while I asked him if it is his will to do therapy, and he then spent a long time wondering what will is. After a while I mirrored it, “OK sure. Shall we spend 20 sessions understanding what will is, before we finally work on your depression? Let’s leave you drowning in that pit of anxiety and depression while we figure out what will is, then we can pull you out. How many sessions do you think we need?”

He then admitted this made him feel angry at me, while at the same time realizing that all I had done was mirror his words back to him. We had a productive session exploring his anger afterwards to me but I wasn’t sure if that anger was the right anger to explore.

Triangle of conflict: mixed feelings toward you; anxiety; wall of rumination, self-deprivation.

First of all: WOW!! You were fantastic here! You understood that his defense of self-deprivation was syntonic. So you mirrored it. Then he could see how he was sabotaging himself and depriving himself and asking you to collaborate with his self-defeating behavior. Albert, that was just brilliant.  Next, he says he is angry with you. I would still work on restructuring. “Yes, you are angry with me right now. But if I were you, I would be more angry at that self-depriving, self-sabotaging habit that has been hurting you. Do you see what I mean? It sounds like you thought I would hold you back, but now can you see how the rumination holds you back?” See, if he is angry with you as if you sabotage him, he will remain paranoid, unable to have an intrapsychic perspective where he sees the He causes His difficulties. This is a subtlety of differentiating the patient from his defenses, and then establishing correct causality: Albert doesn’t cause his problems, his defenses cause his problems. Always good to help patients get clear about that:-)