IBS: An Existential Issue.

There is an absence about Irene. She lives alone in a small village in the Yorkshire Dales, forty miles from the nearest town. Her husband works abroad for much of the time and her children at University and boarding school. It wasn’t always like this. When she was younger, her calendar was always full of dates, she always had a best friend and there was always a group of elderly ladies to help. She worked for many years as a personal assistant to the CEO of a major corporation. There was never any time to think.

Now, her life is empty. It’s not that she lacks social outlets; her friends in the village are always trying to involve her in things, but she would rather stay in by herself. She just does not feel emotionally connected; she has no value or purpose. Besides, even if she wanted to do anything, the fatigue and her constant bowel upset make it impossible. It’s like she has lost her sense of identity, but I wondered if that same feeling has lurking in the background for most of her life.  She told me her childhood was lonely. Her father would disappear into his studio for long periods of time and her mother was always busy. She belonged to the ‘Truby King school of child management’ that advised mothers to leave their infants to cry themselves to sleep rather than go in and comfort them. So Irene grew up needing to make herself busy in order to fill her life with meaning.

For so many of my patients, it seems that their symptoms represent not so much the trauma of what happened, but more the ongoing torment of an existential emptiness; a lack of meaning or purpose that has left them vulnerable to every tragic or upsetting circumstance.

Identity and The Self

The psychologist, Bruce Hood, wrote that our sense of self is an illusion*. It doesn’t exist as a physical or even a psychic structure. We can only perceive it through our personal landscape: our friends, family, children, our home, the city in which we live, the job we do, the team we support, the party we vote for, the paper we read; in other words all those things which create the context and narrative of our lives. This would suggest that our ‘identity’ is nothing more than a collage of interactions and identifications

Developmental theory indicates that if our emergent self is endorsed by good enough parents, who could stimulate us when we were listless, comfort us when we were upset, contain us when we were angry – and later, when we were older, listen to us and respond, perhaps suggesting we might look at things a different way, our interaction with the world would become more confident and flexible.

Good enough parents not only pass on their own ideas and opinions, they also encourage their child’s growing independence as they seek out like-minded friends and build a sense of identification and ownership.  Later, as children begin to separate from their parents, their inexperienced personalities are exposed to many more influences – at school and university.  These are also incorporated into their developing personality.

Allan Schore in his book ‘Affect Regulation and the Origins of the Self’ argued that our sense of self requires a maturing prefrontal cortex that contextualises what happens, puts it into perspective and allows us to think and not just react to situations. If our upbringing fails to provide a sufficiently secure environment to encourage the confidence and spatial ability to think, the prefrontal cortex remains relatively inexperienced and we cannot respond cognitively as individuals to what happens. This gives some credence to Descartes dictum ‘Cogito, ergo sum’ – I think therefore I am.

Children, who has been afforded that combination of containment and graded freedom to create a coherent sense of their own identifications, will have enough self confidence to take their parents and the world around them for granted. They will have the time and mental space to develop their our own identity through secure relationships with the people, situations and objects around them, accreting their experience into a life script, robust enough to cope with all but the most extreme of circumstances.

Psychoanalyst, David Bell and Philosopher, Adam Leite suggest that the sense we have of ourselves develops out of being able to articulate our lived experience. That reminds me of the whimsical aphorism, I once pinned to the notice board above my desk, ‘How do I know what I think until I hear what I say?’. Expressing ourselves to others and accommodating their responses fine tunes our ideas and beliefs to create a more realistic and adaptable identity.

Trauma, illness and a fragile identity.

There can be few people, whose sense of who they are and what they stand for has not been rocked or even shattered by a death in the family, physical or sexual abuse, unemployment, divorce or disaster. Such events can make anybody ill, but if their pre-traumatic experience was sufficiently broad to understand the extremes of what can happen, they are more likely to recover.

The same cannot be said for those whose parents unable to endorse their creative identity either because they were emotionally neglectful or too intrusive.  Some may grow up with a sense of self that is so flexible or fragile, they cling on to anybody who will acknowledge them, leaving them over-dependant and vulnerable to change. Some may adapt to become like actors; emotional chameleons, who can alter their personality to fit in with the background, but who, like Irene, lose their sense of meaning and purpose when they are not needed. And some may find an idiosyncratic creative obsession that captures their entire interest, but are unable to cope with the demands of real life.

For all of them, the vicissitudes of life can cause intolerable tension that may dysregulate their system and result in illness, which is so often expressed by the gut. Their need for approval may cause them to take unnecessary risks, but ensuing trauma can have a devastating effect, stripping away the defences to their fragile identity and causing a loss of a sense of reality. The illness may then become the focus of their identity; a psychic retreat that restricts their life and demands special treatments and diets.

Irene queried how helpful it was to go into what happened when she was a little girl. ‘Should I just accept that as a given and try to work out how to move on?’ I replied that the archaeology of her personality development is useful in that it provides us with insight into what is happening now and may inform how best to find some meaningful solution.  Moving on is not just a matter of filling her life with activity for the sake of it,  it is more about using the insight and the mental space to forge a more resilient sense of her own existence. Decisions about life changes can follow from that. This is where an existential form of psychotherapy can be most useful.

* Hood’s ‘Self Illusion’ sounds a bit like Richard Dawkin’s ‘God Delusion’. They are both identifications by which human beings may use make sense of their world.