Can Feelings Harm Us?

The therapist who asked me about the advisability of doing intense, affect focused work with her pregnant patient raised concerns that we’ve probably all had. How many times have we heard the fear expressed that the enormity of our feelings might destroy or damage us or someone who’s in a relationship with us? Usually this is meant in a psychological sense, but sometimes we question, “Is there a medical risk to experiencing too much feeling, especially if in a compromised physical state?”

When one of my patients lost his mother, he believed he had contributed to her death because she repeatedly told him that he was making her sick when he showed emotion (by activating her own feelings). She did in fact contract several prolonged illnesses and he truly believed his feelings had caused her death because she’d warned him! In reality, it did appear that he had acted out and discharged angry feelings at times towards his mother, not healthy for either of them. If his mother converted her feelings towards him into anxiety or self punishment, definitely not healthy for her (although only she could have addressed this). In reality, he had unconscious and unprocessed fury towards his mother whom he cared for and at times wished her dead…quite different from killing her! In my experience, it isn’t feelings that make us ill but rather what we put our bodies through in the effort to push them out of awareness or the toll of relentless self attack.

During this discussion, let’s also remember that the health benefits to processing our feelings constructively within a safe therapeutic relationship are increasingly well documented as are the negative health risks to submerging and internalizing our feelings. Author, researcher, and Harvard psychologist Leigh McCullough’s has said that “Low moderate to moderate emotional experiencing is sufficient to cause behavior change in targeted problems. From 50-70 appears to be even better in promoting change.” Researcher Pennebaker tells us that journal writing about trauma increases immune functioning for several months, if it’s done with feelings activated! The healing effects of affect-focused work has been proven and it does not have to involve extreme emotional states to be effective. Begin investigating Allan Abbass, MD’s considerable and impressive research on ISTDP at http://psychiatry.medicine.dal.ca/people/abbass.htm. There will be more from him next post.

That being said, is there any reality to the fear that intense feelings can tip our bodies over the edge into a medical crisis or death? Are there times when we do need to lay off the emotions? I read a long time ago that there were health benefits in denial for some terminal patients…not sure on current research, but I’ll let you know if I learn more on this. I’ve had patients tell me that their sessions felt like a “good workout.” Almost all of our patients have to combat their own resistances to find emotional freedom and relief, and doing battle between conflicting parts of the self takes psychic energy and can be draining, if only temporarily. So if a patient is in a compromised medical condition, perhaps in treatment for cancer or a heart condition or newly released from a hospital, should we be avoiding intense affective work?

I posed the initial medical question to some colleagues on the IEDTA listserve and expanded it beyond pregnancy to include any physical conditions that might preclude deep feeling work.  I received a plethora of valuable information from several eminent psychiatrists to share with you. So much so that I’m going to add another post on this topic soon with comments from Allan Abbass, M.D. Great thanks to each of them! Here’s what they said, with editing and my commentary:

From Douglas G. Kahn, M.D, Clinical Professor at University of California, Irvine… “I’ve never had to refrain from doing intense emotional work (ISTDP) with patients in the last trimester of pregnancy, or, for that matter, with [anyone] with an ambulatory medical problem…provided it wasn’t a smooth muscle psychosomatic problem.” Dr. Kahn is referencing people with a “history of anxiety-precipitated episodes of asthma, IBS, Crohn’s, etc.” However, Dr. Kahn is not saying that this latter group cannot handle intense unlockings of emotion, but that feelings must be approached cautiously with these patients in a gradual, step-wise fashion that keeps anxiety levels manageable throughout the process. This takes definite skill and deep feeling work with this population should not be attempted without it.

We should all be impressed when Dr. Kahn adds, “Parenthetically, my latest patient with Crohn’s, treated with ISTDP, has had, since his second unlocking, absolutely no Crohn’s symptoms for what is now four years (with no changes in his Crohn’s meds, diet, etc….therapy is the only significant variable). Prior to ISTDP he’d never been without painful and problematic episodes longer than a few weeks.” Is that not marvelous?

He goes on to say, “I’d advise you ask for “medical clearance” from the patient’s relevant medical specialist if/when you are worried about the patient’s ability to survive/handle the emotional “stress” of affectively intense psychotherapeutic work.” He adds, “I wouldn’t be trying it with someone while in the I.C.U. after an M.I. or bypass surgery though,” and we get the point!

Nat Kuhn, MD, a Clinical Instructor in Psychiatry, Harvard Medical School tells us that if someone can climb a flight of stairs without significant difficulty, then they should be fine from a cardiac and respiratory point of view.  People who can’t do that may still be fine, but that’s a case where consultation would be warranted… there are not many situations in which the physiological and/or psychological stress of ISTDP work would pose an actual medical risk, rather than just discomfort…Of course, in this context some prior experience with somatizing patients would be very helpful, to get a sense of what the normal range of discomfort is.  Also, I don’t mean to be dismissive of ‘just discomfort,’ but the risk-benefit profile of discomfort needs to be weighed separately from medical morbidity…The main possibility for serious medical morbidity, I think, would be unstable cardiac disease.  This includes not just people in a cardiac ICU, but also people with “unstable angina,” i.e. cardiac chest pain at rest, or a “crescendo pattern” of increased cardiac chest pain.  The distinction between stable cardiac disease and unstable cardiac disease is of course one that should be made by a cardiologist or primary care doctor, which they would weigh as part of the medical clearance.  There is a risk here not just for patients who go above the threshold for striated-muscle anxiety; cardiac events in unstable cardiac patients can be triggered by any increased metabolic demand, not just by smooth-muscle contraction. For patients who do go into smooth-muscle discharge of anxiety, there is also the possibility of coronary vasospasm.” …”My impression is that it’s relatively unusual; certainly much more unusual than irritable bowel or migraine.”

…”There are some problems that could arise with increased striated muscle tension, e.g. a not-yet-healed surgical (or other) wound, or an orthopedic problem (e.g. a recently broken limb or unstable vertebrae in the back or neck).  Again, medical clearance is helpful; and in most of these situations pain would be a signal to slow down.  For patients with excessive stoicism or masochism it may be important to instruct them explicitly to report increased physical pain to you.

In a typical pregnancy, I don’t imagine that there would be any medical contraindication to ISTDP; the psychological appropriateness is a separate question and my guess is that it will vary widely from one case to another.  In high-risk pregnancies, e.g. women prescribed bed rest or unusually restricted activities there may be a medical contraindication and again medical clearance from the obstetrician would be important.

When seeking medical clearance, it may be helpful to give the physician some guidance.  I might say something like, “The therapy that I do is quite intensive.  In addition to experiencing intense emotional states, patients can experience significant degrees of autonomic arousal, skeletal muscle tension, and/or smooth muscle contractions that can lead to physical symptoms such as irritable bowel symptoms or migraines.”  In general, I would say that the advice is the same as in any other unfamiliar situation: proceed with somewhat more caution than usual, and seek consultation as appropriate.

He adds with honesty that we do not have absolute answers to the questions raised. “The advice to get “medical clearance” from the relevant MD is only partly because of the MD’s knowledge (after all, they don’t have the research either), but also is advisable as medico-legal protection for the therapist.”

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