Elizabeth McCardell, June 2017
Exploring
an approach to restoring reciprocity in the relationship of therapist and
patient in depressed patients with blunted facial expressiveness
In therapy there is not me and not you, but us, as Neville Symington put
it.
In here there is usually connection, contact and relationship. And when
you look at a therapeutic pair (as through a one way mirror, or on a video) you
can see a kind of dance, where mirroring of movement and facial expression and
phrase sharing takes place.
The body is a sensitive “sounding-board” in which every emotion
reverberates both within and between us, at least in the normal course of an
encounter, as William James put it (1884). Emotions are literally e-motions,
that is, a movement between what is felt and displayed and what is visible in
expression (Fuchs and Koch, 2014). Between people, there is in the facial,
gestural and postural expression of a feeling a bodily resonance that feeds
back into the feeling itself, but which also induces processes of
interaffectivity: my expression is affected by your expression which affects my
expression, and so forth. Thus I experience the kinetics and intensity of your
emotions through my own bodily kinaesthesia and sensation.
Merleau-Ponty (1962) describes it this way,
“The communication or comprehension of gestures comes about through the reciprocity
of my intentions and the gestures of others, of my gestures and the intentions
discernible in the conduct of other people. It is as if the other person's
intentions inhabited my body and mine his”.
I can best illustrate this using the möbius strip. There is here a chiasm
of reciprocity
The möbius strip, that mathematical morphological idea that describes a
two dimensional surface , a loop with a single twist, where surface A, when
followed around becomes surface B, also beautifully describes, symbolically,
the therapeutic relationship: not you, not me, but us. There is here not two
surfaces, but one expressed two ways.
I often use the möbius strip as a model to illustrate the nature of
reciprocity, as it provides a useful and graphic account of the chiasm of
relationships. In what I am exploring here is something that is poorly
understood and needs, I think, much more work.
Right now, I’ll do something I did in my doctoral thesis (2001. Then, as
now, I shall attempt an examination of an embodied account of reciprocity by
resorting to its study by an examination of absence, by what is not there, in
order to better comprehend what might be there.
With the PhD thesis, I wanted to examine the cognitive and non-cognitive
realm of relationships within self, self-others, and self-environment, and so I employed a method used by astronomers
whereby the existence of as yet unseen cosmic entities is theorized to exist by
the behaviour of surrounding cosmic entities. It’s a method that then allowed
me to discover, to a degree things like memory, perception of time, interconnections of behaviour and
culture, relationship of body movement and intention, etc, through the
examination of neurological disorders of Tourettes, Parkinsons Disease,
Asperger’s . Absence helped point to presence.
As then, so now, I am moved to attempt to know more of human reciprocity
in the therapeutic encounter by noticing what happens when the other person
presents as somehow unengaged in that dance of reciprocity. I shall use the
flatness of facial expression and its accompanying detachment and feelings of
joylessness as the sign of this.
Blunted affect, or as it sometimes called, anhedonia (where there is no
felt pleasure in life: passive joylessness and dreariness, discouragement,
dejection, lack of zest), can be found in a range of psychiatric conditions
including mood disorders, schizophrenia and post traumatic stress disorder, and
so on, as well as the influence of long term use of some antidepressants.
The lack of felt pleasure is manifest in facial expression, slowed down
body movement, and unengaged posture. Coupled with these signs is a growing felt
sense of isolation and detachment from the lives of other people. The
reciprocity between people is lacking. The “us-ness” is impoverished.
I shall only speak about clinical depression as the kind of clients I
most see are those with depression.
My personal reactions to the client with blunted affect are thrown into
a certain degree of confusion. I am not as able to respond to the person in
front of me, because many of the familiar cues are absent. The give and take of
mirroring, as the dance of interaction is blunted. What is happening and how
can I move this along somehow?
I am remembering here of Jarrah, a 33 year old woman I saw for 6 weekly sessions
last year. Jarrah’s mother rang me to make an appointment for Jarrah. She said
her daughter has anxiety, depression and OCD. I asked then to speak to Jarrah
about times and dates. Jarrah enthusiastically responded and so we organized a
time for the first session.
Jarrah presented with that familiar waxy look and lack of motility in
the give and take of my relationship with her. She described feeling isolated,
and dead inside. She would smile as an actor might, without engagement of
herself and me, and which I felt repelled by, without fully understanding why.
Jarrah was 33, a reluctant mother and one where her deep depression
began when she became pregnant while traveling overseas. Her own mother had been severely
traumatized by her Dutch parents who were absent much of the time during the
war and by their war-time experiences. For her anxiety, Jarrah’s mother took
valium. Her father was similarly damaged by his post-war family life in Holland
and is now alcoholic and living alone. Jarrah, growing up with anxious parents,
was fundamentally deprived of a sound and secure attachment with her primary
caregiver, that is her mother. Whenever Jarrah sought comfort from her mother,
Mum gave her valium. This continued throughout life. Jarrah wanted closeness,
but her mother pushed her away and medicalized her need.
Jarrah
is single and lives on her own and with her young son. Her 9 year old son
spends a lot of time being mothered by his father’s mother. Her son seems to be
getting reasonable and stable support with the grandmother.
I asked Jarrah what her obsessive compulsive disorder looked like.
Interestingly it consisted of checking her body when she was dressing and also
checking her body when preparing food in the kitchen. She avoided the kitchen
because it became extremely tedious having to check her body repeatedly. I was
curious about whether Jarrah had thoughts of suiciding in the presence of
kitchen knives, but did not ask this directly. It seemed that suicidal thoughts
were not there. It was the iterative nature of the OCD that was the problem.
Checking her body repeatedly was like not having much connection with being
embodied; like having a concept of a body without any intrinsic knowing of
being bodied.
What was it like for me being with Jarrah and her feelings of anhedonia?
How was it for me to sit with a woman who was so unengaged at an embodied
level, in the therapeutic conversation, with someone not in emotional affective
exchange? Frankly, it was hard. I
found my mind wandering and theorizing and staying engaged was quite hard work.
It was as though the centre was not holding, as Yeats puts it. I felt in my
body somehow set adrift.
And so I theorized some kind of healing and I suspect now, at least,
that my desire for a solution may well have lacked sensitivity and
understanding given the nature of my patient’s long standing problems. I felt
also a bit pressured by the sense that I didn’t have much time to work with
her.
During the 3rd session I suggested she resume swimming (she
had been a competitive swimmer), doing yoga and dance (activities she loves). I
proposed these to her to loosen her body and get moving. The explanation I gave
her was about endorphins, and the like, but I knew from my doctoral work that
there is more going on than just simply moving. There is patterning and
mirroring and shaping that impels reciprocity between people and it is this
that healing takes place.
By
the 5th session, Jarrah presented as more engaged and her facial
movement of affectivity was more noticeable. There was more mirroring between us, her facial muscles were
relaxed and there was little evidence of the false smile of theatre, and the
dialogue between us was more fluid and natural than previously.
Unfortunately, her medicalized “story” of depression of her life, reinforced by her
mother, kicked in once again and on the 6th and final session, Jarrah
said she couldn’t afford to come any more and her mother said she needed to
resume seeing her psychiatrist, and so that’s what she would do.
I sometimes see Jarrah on the streets of Lismore. She has her waxy
complexion and her stilted smile back again, which is quite disheartening.
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In most social encounters there are two cycles of embodied affectivity
which become intertwined, thus continuously modifying each subject's approach
and response. This complex process may be regarded as the bodily basis of
empathy and social understanding: a dance where each person feels connected to
the other. This happens very quickly and happens to connect each person also to the perceptions of themselves.
There is a feedback loop happening here.
When a person doesn’t feel connected, there is, along with a
constriction, a rigidity, a sort of missing tension-flow modulation, a
numbness, an affective depersonalization.
The deeply depressed are no longer capable of being moved and affected
by things, situations or other persons. They complain of indifference, a
“feeling of not feeling” and of not being able to sympathize with anyone
anymore. They feel disconnected from the world and
they lose their participation in the interaffective space that we normally
share with others.
In a rather splendid book by Jonathan Cole
(1999), called About Face where he
writes of a condition called the
möbius syndrome, Cole captures first person accounts of what it feels like not
to be engaged in the dance of reciprocity.
Named after Paul Julius Möbius, a German neurologist, in 1888 and not
the möbius strip it permits a neat coalescence of ideas surrounding that give
and take of reciprocity.
The Möbius Syndrome is a rare neurological disorder characterized by
weakness or palsy of multiple cranial nerves. This means the fluidity and
flexibility of facial expression is absent. It is an extreme condition, for sure, but what is expressed
by those with the condition tells us a lot about what might be happening with
the deeply depressed client.
People with möbius syndrome feel disengaged and unable to read the
emotions of others. As a patient of Cole puts it, “Mostly I think I exist in my
sub-conscious or preconscious mind,” but [I do not feel real as an embodied
self.] In other words the very capacity to be responsive to the other is
permitting a theory of mind that is more than an idea or concept of one’s own
mind and the minds of others. It is a theory of mind that requires a
psycho-socio engagement, and not merely an abstract thought. I’m intrigued by
this and wonder if a self-other disembodied self is possibly like being in a
trance state.
I’ll leave that out there, and return to the thesis of engagement: a not
you, a not me, but an us.
Feelings and emotions enliven us, but when they are cut off from
experience a whole range of
embodied processes are reduced, and as they are reduced so the person
enters a state of isolation. The
greater the sense of isolation, the greater the break in possible
reciprocity between self and
therapist and other relationships.
Intrinsic to intercorporeality and thus relationality is having a sense
of agency and thus being able to respond to the other person. When this
capacity to respond is diminished and meaningful encounter is less present then
we need to find ways to reconnect ourselves and those we work with.
I suggested to Jarrah swimming, yoga and dance because these are
activities that gives her pleasure. I do not think that these activities would
be universally useful and that reconnecting affectivity would have to be
tailored to the individual. I do not, also suggest that these activities need
to be done in the psychotherapeutic session, but are more usefully to be used
as homework.
What may be valuable is an aware embodied shaping of what is said in the
session. I don’t mean phony modelling of facial expression, or words, or anything
as obtrusive as this, but bringing
a deeper understanding of what an embodied reciprocity looks like in the
therapeutic encounter and somehow bringing this knowledge into some concrete
form within the therapeutic encounter, in session. Neuro-linguistic programming
uses this idea in the conscious therapeutic use of identifying how a patient
operates in the world: kinaesthetically, auditorily, and visually. NLP is, unfortunately frequently rather
clumsily done, and is a bit too obvious for my liking.
The us of the therapeutic encounter is a fertile ground that needs much
more understanding in terms of process, and in terms of a process that can
become more than description to a therapeutic tool in itself. This is in here an
indwelling of the deep structure of a more than linguistic exchange and an
exploration of healing at the heart of a depth psychology of embodiment.
References
Cole, Jonathan (1999) About
Face, The MIT Press, Cambridge, Massachusetts.
James, W. (1884). What is an emotion? Mind 9, 188–205. doi: 10.1093/mind/os-IX.34.188
Fuchs, Thomas and Sabine C. Koch (2014) Embodied affectivity: on moving and being moved, Hypothesis and
Theory Article, published 06 June 2014, fsyg-05-00508.pdf
McCardell, Elizabeth Eve (2001) Catching the Ball: Constructing the Reciprocity of Embodiment, PhD thesis, Murdoch University, Western
Australia.
