The New Harold: Final Instalment

There were two aspects of Harold as a case and Harold as a person that remained opaque despite the success of the therapy described so far. The successes, of course, involved his new-found ability to live in a relationship—to let his feelings be known to Meg so that over time her empathy might be guided by more and more input from Harold, and to accept her feelings as a valid means of communication from which he might take care of her needs better. Despite his fear that more children would mean that he'd "have to work forever," he recognized and accepted Meg's wish to raise her own child; their daughter has been raised in an atmosphere quite different from the home in which Harold was brought up or that he and Martie established. Watching Meg and Anne build a language of affective communication enabled Harold to learn much about interaffectivity and brought further change in his therapeutic style. Even though he remained a somewhat intellectual therapist whose interventions were based more on his cognitive analysis of a case than what he felt during his time with the patient, Harold has mentioned often that he feels both more connected to his patients and more disciplined in his approach to them.

The two areas of his psychological functioning that escaped change were his apparent allergy to situations with intense affect and his ongoing susceptibility to psychosomatic illness. Every once in a while, rarely in comparison to the frequency of such episodes in the past, Harold would tell Meg that he couldn't "take it any more." Those were the times that he'd cancel a day at the office and dash from Philadelphia into New York to see a show or drive to Atlantic City to sit on the beach and walk the boards. Never one to enjoy psychotherapy, which he still associated with the need to talk about his feelings, Harold would visit me only when he was nearly overwhelmed at work (when it was hardest to make time for a session) or when Meg pushed him to see me ("I'm not certain why she wants me to have a session with you, but she's usually right when she tells me to come in. I guess you're going to tell me to slow down.") Even though he hadn't learned enough about his emotional life to prevent such episodes, Harold accepted the reality that our therapeutic relationship acted as a safety switch that prevented "serious problems." To my continuing dismay, Harold maintained with some asperity that there was a sharp distinction between his occasional "medical" problems and the portion of his affect-blindness that had so far eluded our psychotherapeutic attempts.

One of the reasons I feel comfortable asking my psychotherapy patients questions about their medical problems is that before taking a residency in psychiatry I went through a full residency in Internal Medicine/Endocrinology and practiced that craft for a few years. Although I dare not profess enough expertise to practice in those areas today, I still look at x-rays, electrocardiograms, and blood test data accumulated by my patients and enjoy talking with their physicians. Over the years I worked with Harold, I saw him through periods of intense concern about his heart, musculoskeletal aches and pains that he believed were part of a serious collagen vascular disease like lupus or scleroderma, and a gut problem that resembled Krohn's Disease (ileitis/regional enteritis). At no time were his doctors able to demonstrate tissue damage that might explain any of his symptoms, most of which were controlled by benzodiazepines (Xanax, Valium) and anticholinergics. Although Meg tried to convince him to speak with me about these symptoms, it was more than a year before he would admit me to his confidence in this area.

So intent was Harold on proving to me that his illnesses were "real" that we spent the first few sessions going over the tests performed by his physicians, discussing the ease with which doctors dismiss their patients as "crocks," and the callous treatment of patients by x-ray personnel. Treatment, at this stage, resembled the work Lindner described in his famous short story "The Jet Propelled Couch," in which the psychiatrist entered the delusional system of a patient who roamed the galaxy in his dream world. One day, though, I got my opening and marched through to great success.

With an uncharacteristic burst of candor, Harold mentioned that no matter what his illness, his health was worst before vacation and improved after a few days in the sun; in the day or two before he and Meg returned to work, symptoms tended to recur. "Most of us," I explained, "suffer from Reentry Syndrome." The decrease in stimulus density associated with vacation seems to diminish symptoms of all kinds, and our ability to visualize and pre-experience the world to which we will return can bring them right back. What he knew as "overload" was directly analogous to the steady-state, higher-than-optimal stimulus that (within affect theory) we see as the trigger for the innate affect distress-anguish. In infancy, before the organism has learned to modulate its affects, distress-anguish produces steady sobbing at the low (distress) end of its action and a keening wail at the upper (anguish) end of the scale. As adults, cautioned to maintain a "stiff upper lip" at all times so we won't be embarrassed as cry-babies, we push away (ignore or disavow) distress to a large extent.

There are two important results of this learned behavior: Since by its nature, affect is first a somatic experience (it is our appraisal of the facial and bodily effects of the physiological affect protocol that allows us to decide which affect has been triggered), to the extent that we ignore the mild, minor evidence that the affect has been triggered it is more likely it is that the affect system will try to get our attention by affecting its sites of action at even greater intensity. Secondly, to the extent that we ignore any affect, the affect itself becomes a source of stimulation that adds to the general load of the moment. In the case of distress-anguish, an affect that is triggered by a steady-state stimulus and therefore produces a steady-state effect on its sites of action, this shifts the stimulus load toward the profile needed to trigger the innate affect anger-rage, with all the muscular tension associated with its specific physiological action. Disavowed distress is, therefore a trigger for anger, and disavowed anger must be a source of muscular "tension." It is important to note, as Harold and I discussed, that in such a situation one is not "angry at" something or someone—the anger is triggered by stimuli that have nothing to do with the traditional interpersonal reasons given for that complex of emotions, and cannot be interpreted in terms of any traditional psychological focus. Harold, always prone to the muscular tension triggered by the mechanisms described here, had never been able to figure out why he became quick-tempered when his body hurt.

Immediately that he understood this connection between affect and its sites of action, Harold started to laugh. Suddenly he could see that the gut problem involved bursts of pain that occurred at a cadence and speed that mirrored the affect fear-terror in which data comes in to the system more rapidly than the gradient necessary to trigger interest-excitement and less rapidly than the gradient necessary to trigger surprise-startle. "Big guy doesn't get scared," he quipped as he discovered that his disavowal of anxiety (the affect fear-terror) made things happen all over his body at a pace directly analogous to the gradient of "things happening in the office when I'm already overloaded." Now he "confessed" to a lifetime experience of "little bursts of lightening that feel like sudden knife sticks" when something happened suddenly; this was the affect surprise-startle acting as an analogue of any stimulus with sudden onset and sudden offset but disavowed by Harold and relegated therefore to the language of bodily discomfort.

"All this time I've been nodding at your explanations of affects," he said, "but now I see that I've been having them all my life as body experiences. It's going to take a long time to unwind this, but for the first time in years, I'm not afraid I'm going to die of some terrible illness. Wait ‘til I tell Meg about this one. She's too nice to say that I'm a kook, but she's known all the time that the reason I get these things is that I don't pay attention to what I'm feeling. I still think all the doctors are unfeeling sons of bitches for refusing to pay attention to my symptoms, but maybe I can't expect them to understand what its taken me until now to see. And all the patients we've discussed who are overloaded—I've taught them to handle their symptoms exactly the same way I've handled mine. That's going to be a neat one to unwind."

Harold has not had a single episode of psychosomatic illness in the past year, and feels the best ever. Both he and I know that there is a lot more to learn about his affective life, but both of us sense that it is safer for him to have emotions than ever before. From a childhood barren of interaffectivity and reasonable attention to his affective output, Harold has grown into marriage and parenthood characterized by warm and steady attention to whatever affect is expressed in a home that for most of their friends is now seen as a center of warmth.

• Good Bye Harold! by Jessica Broitman:Faculty, 2/3/97