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It's November. The Thanksgiving holiday is fast approaching; Hanukkah and Christmas are not far behind. Everywhere cheerful holiday music pours forth from loudspeakers in the market and department stores and on the radio. Children are excited, eagerly anticipating the upcoming festivities. Meanwhile, in psychiatric emergency rooms the staff are gearing up with thinly stretched resources for an expected increase in admissions. Clinic patients miss their appointments and "forget" to take their medications. In our consultation rooms we hear over and over again from patients, "I can't stand the holidays! I just have to get through them!"
There are many different reasons for these conflicting reactions. Is the patient experiencing an anniversary action, unresolved developmental conflict, regression, or true depression? Or is it demoralization, loneliness, isolation, and the associated despair? Exploring the particular meaning for each patient's distress can point to psychotherapeutic work that enables the patient to move beyond "getting through" the holidays.
Ten years ago, on the day before Christmas, Ms. J's brother was killed in a car crash. Do we take it as a given that every Christmas Ms. J needs to enter a period of mourning? November, December, and January—one-fourth of the year—are all months usually associated with "the holidays." Statistically, one would expect one-fourth of life's tragedies to occur during that time, forever linking the season with a potential for anniversary reactions.
Mr. G grew up in a family in which the father's everyday alcoholic excesses, such as family fights and alcoholic outbursts, became accentuated during the holidays. These events appear to account for a seasonal increase in the incidence of Mr. G's panic attacks during the holidays. Need this be repeated in his emotional experience year after year?
Ms. A always goes home for the holidays. She is 40 years old, is a successful lawyer, and has been married for ten years. She and her husband have chosen not to have children. Each Christmas they spend the holidays with their respective parents. Ms. A flies across the country to her hometown, excited about the prospect and bringing many gifts for her parents and her married sister's family. Each year she returns in a state of despair. Her parents, as usual, have been absorbed and delighted by the antics of their grandchildren and uninterested in Ms. A's career successes. Her sister, jealous of Ms. A's independence and success, has made obliquely negative comments about the gifts she chose for the children.
A video replay of her childhood would reveal the same dynamics in progress. Ms. A's parents were more interested in her sister, and her sister was quietly jealous of her achievements. Ms. A, in a supplicant mode, has tried with smiles, compliance, and gifts to make it all different. She has freed herself physically from the family situation by moving across the country, but during the holidays she returns. The old fantasies and wishes also return, and she regressively slides into the role of the hurt, ignored little girl she had left behind. Her parents and her sister may never be different, but in psychotherapy Ms. A can become aware of her wishes, fantasies, and conflicts about the past and be free to choose another path.
Is it depression, or demoralization and despair? The Random House dictionary defines "demoralize" as follows: "1. to deprive (a person or persons) of spirit, courage, discipline…2. to throw (a person) into disorder or confusion." Himmelhoch (1) opines that in the whirl of the holiday season it is no mean task to maintain a normal mood. He identifies demoralization and despair as the main elements of holiday dysphoria, not depression. During the holidays, lonely patients are more aware of their loneliness, and grieving patients are more sensitive to their losses. The effects of life's hardships evoke a keener sense of the indignities when one is surrounded by evidence of what appears to be the joy and happiness of others. This year, with stock market losses, company downsizing, and many people unemployed and without health insurance, financial problems will loom especially large.
It is important to distinguish between demoralization, disappointment or the revisiting of intrapsychic conflicts, and the stress-induced decompensation of a DSM axis I condition. Stress is known to play a role in decompensation in schizophrenia as well as in other axis I disorders. Beratis and colleagues (2), searching the records of 358 patients with a mood disorder over a seven-year period, found that the timing of the recurrence of a mood disorder for four of the 41 patients who had three or more hospital admissions was clearly related to anniversary reactions. The mood disorder recurred at times that were associated with intense traumatic experiences in the patients' childhood, adolescence, or adulthood. The time and sometimes the place of the traumatic event acted as a trigger that elicited the clinical symptoms. Although the results were not statistically significant, they demonstrate that such an association is possible. In psychotherapy, as one slowly peels back the veil surrounding the romanticized memories of childhood, it is not unusual to uncover repressed and traumatic memories of alcoholic outbursts that disrupted idyllic memories of the holidays. The adults in these examples also had their own current traumas, with which they were dealing poorly. Festivities are associated with an acceptance and expectation of heavy drinking, late nights, and overeating, all of which diminish one's control of irrational outbursts and impulsive behavior.
Mr. S's reminiscences were filled with memories of eager anticipation, excitement about possible gifts, and a happy gathering of grandparents, aunts, uncles, and cousins. However, intermixed with these anticipations was a sense of foreboding. This foreboding was founded on the past unpredictability of his father, an alcoholic, which had always darkened the holiday scene. Sometimes the day would pass uneventfully. At other times his father's violent outbursts would result in loved ones' making a hurried departure to save the family embarrassment. The result was unexpressed tension as family members held their breath, feeling helpless to avoid an unpredictable disaster. What Mr. S came to understand in psychotherapy was that in his current life he need not continue to be held hostage to these automatic anxieties. As an adult he need not recreate the scenes of his childhood. If problems arose, he could choose to confront them. There need be no hiding of problems, no scurrying away to avoid the facts, no passive resignation or fear of his own suppressed rage. This was the manner in which his parents and family had dealt with the matter when he was a child, but Mr. S need not recreate this scenario in his adult life.
Such stories are not unique. Boyer (3), writing about what he termed Christmas neurosis, described a patient whose father's alcoholism hit a crescendo during the holiday season. The patient recalled times when her father, tortured by alcoholic hallucinations and delusions, ran around the house naked, brandishing a loaded revolver and threatening to kill his family.
Those who devote their expertise to working with patients who have lost loved ones recognize that the holiday season is a time of special vulnerability. At a time when the whole family normally gathers together, the absence, the empty place at the table, and the rearrangement of the seating pattern call explicit attention to the loss. The first holiday after the death of a spouse, a parent, or a child is a painful crisis, often accompanied by a degree of stunned disbelief. This was probably the case for many who lost family members in the tragic events of September 11. The second holiday season often carries a different set of emotional experiences. The stunned disbelief has faded, and reality has set in: the absence at the family table was not temporary but a permanent condition, requiring new reflections and reconfiguration of each person's sense of "the family."
A number of dynamics and interlocking forces contribute to the frequent occurrence of what some call the holiday blues. The holiday season reawakens the dreams, hopes, and longings of childhood as well as memories of early deprivations and affects that may have been repressed but that now reappear with renewed intensity. For many, like Ms. A, there is the fantasy that family conflicts will be put aside and holiday cheer will prevail. Even with the experience of past events to the contrary, there often persists the expectation that this year will be different. But unresolved issues of jealousy, sibling rivalry, envy, and an intensification of childhood wishes are often rekindled rather than dissolved by exhaustion, alcohol, exaggerated hopes, and the unfamiliar intensity of contact with family members.
Longings for the fantasized security of childhood and anxieties about the realities of everyday life is such a universal human theme that Charles Shultz (4) made it the subject of one of his Peanuts cartoons:
Peppermint Patty: "What do you think security is, Chuck?"
Chuck: "Security? Security is sleeping in the back seat of the car when you're a little kid, and you've been somewhere with your Mom an Dad, and it's night and you're riding home in the car. You can sleep in the back seat. You don't have to worry about anything. Your Mom and Dad are in the front seat, and they do all the worrying…they take care of everything."
Peppermint Patty: "That's real neat!"
Chuck: "But it doesn't last! Suddenly you're grown up, and it can never be that way again! Suddenly it's over, and you'll never get to sleep in the back seat again! Never!"
Peppermint Patty: "Never?"
Chuck: "Absolutely never!"
Peppermint Patty: "Hold my hand, Chuck!"
Most people have an implicit memory such as Chuck's, a metaphorical and symbolic representation of "security" tucked away in their neurobiologic receptor system that gets fired up during the holiday season. But, as Chuck says, "It can never be that way again." Our psychotherapeutic task is to enable patients to move forward developmentally rather than to be continually scrabbling to try and recreate the security—real or imagined—of their past. In facilitating conscious awareness of unconscious fantasies and unresolved conflicts, we enable people to become masters of their fate rather than helpless victims.
Dr. Goin, who is editor of this column, is clinical professor of psychiatry and behavioral sciences at the Keck School of Medicine at the University of Southern California in Los Angeles. Send correspondence to her at 1127 Wilshire Boulevard, Suite 1115, Los Angeles, California 90017 (e-mail, email@example.com).
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