On common unhappiness

In Studies on Hysteria (1895) co-wrote with Breuer, Freud wrote about “transforming your hysterical misery into common unhappiness”. What is common unhappiness and what can we take from it that can help us to better understand the way we suffer?

Freud appears to suggest that a state of unhappiness is an unavoidable norm:

“No doubt your fate would find it easier than I do to relieve you of your illness. But you will be able to convince yourself that much will be gained if we succeed in transforming your hysterical misery into common unhappiness. With a mental life that has been restored to health you will be better armed against the unhappiness.”

Is he being a fatalist or a realist here?

The well-known statistic 1 in 4 seems to suggest he was being fatalistic:

1in4

This statistic is often banded about on social media. It is catchy and easily understood. However, it came from studies carried out in the 80’s and 90’s using structured interviews. More recently the WHO assessed rates of depression in the population, the results far exceeded 1 in 4 and ended up being reported as a crisis.

There is another explanation for these results however and it resides in the flaws in the measures used to assess the symptoms of subjective experiences of things like depression and anxiety. The reality is that no one really knows how many people suffer from “mental health problems”.

There have been efforts made to diagnose mental illness only when it starts to impair abilities in functioning. In the DSM-V the language has shifted from:

“clear evidence of clinically significant impairment in social, academic, or occupational functioning.”

to

“clear evidence that the symptoms interfere with, or reduce the quality of, social, academic, or occupational functioning.”

Perhaps this is where we can make the differentiation between mental health problems and ordinary unhappiness? If the symptoms we experience are getting in the way of us doing things like having relationships or going to work, does that tip the balance into having a clinically significant medical illness? What if I’ve just been diagnosed with cancer and how I feel about this is making me not want to go to work or see my friends?

There does not appear to be an accurate and precise definition that will define in absolutes whether the subjective  pain and objective symptoms experienced by someone is an illness or not. This is not to say in any way that mental illness does not exist, it is more to highlight the difficulty in recognising subjective states of distress that would benefit from some sort of supportive approach (mindfulness, therapy, medication), while at the same time not medicalising ‘normal’ reactions to life events.

What sort of paradigm or approach does a good-enough job of recognising this dichotomy?

For the majority of people in the UK going to a Dr with a complaint about mental health will involve being diagnosed with an illness, such as Generalised Anxiety Disorder, being prescribed medication and a referral for CBT to learn skills to cope. For some this will be the best approach and have the best outcome for the individual. For others short term therapy is not wanted or is not helpful. If someone is willing and able they could choose to access a different type of therapy.

Psychoanalysis first put forward the idea that the inner world of humans can be understood. Not by carrying out large statistical studies (that seem to tell us a lot, but actually tell us very little about someones unique experience) but within the inter-subjective analytical relationship. Psychoanalysis has an important part to play in giving unhappiness a space to be explored without making judgements about whether it is “ordinary” or not.

Perhaps there is an argument for offering longer term therapy on the NHS.

What does a hole in your chest have to do with attachment?

Psychoanalysis has attempted to put forward answers to this particular question for decades. The contemporary psychoanalytic attachment theories of  Paul Verhaeghe and Peter Fonagy throw up interesting perspectives, but to discuss this one has to touch on the pioneering literature on attachment.

Take Balint’s ‘basic fault’, this describes an experience felt by some that something universal and essential is missing inside. He theorises that it stems from a ‘failure of fit’ between a babies needs and the primary caregivers responsivity to these cues (crying, smiling, yawning, etc). Winnicott and Balint both stress the importance of a holding environment (a secure, safe and loving environment where emotions can be safely expressed in a reliable and trustworthy relationship) without which there may be an experience of an internal/external black hole.

If there is a ‘failure of fit’ and the child is unable to form a secure attachment it sets the child up for a higher risk of suffering in later life, as Winnicott states in one of his earliest works:

‘I find it useful to divide the world of people into two classes. There are those who were never ‘let down’ as babies and who are to that extent candidates for the enjoyment of life and of living. There are also those who did suffer traumatic experiences of the kind that result from environmental letdown, and who must carry with them all their lives the memories of the state they were in at moments of disaster. These are candidates for lives of storm and stress and perhaps illness.’

We know that around 60% of people have a secure attachment style. Does that mean 40% of us are walking around with a painfully empty chasm in our chest, feeling not quite ‘real’ inside and desperately trying to fill our lack?  Or is this phenomena to a lesser extent an intrinsic part of being a human subject?