Truth is not necessarily a virtue when it comes to your relationship with yourself.  Universal concepts such as Truth, Morals, Ethics, Rules etc, are really meant for your relationship with the others.  It is very hard to apply them to your inner world.   Are you allowed to lie to yourself? Can you keep a secret from yourself? Can you punish yourself for punishing yourself?

Think about it:  most rules and regulations – whether written or unwritten, culturally sanctioned, or ordained from heaven – take on a very different meaning when applied to your inner world.  In your relationship with your own self, most do not make sense at all.

In my work as a psychiatrist, I help others examine and create their inner rules.  Often the biggest hurdle is convincing my listener that he or she is entitled to do so.  We are so paralyzed by our adherence to the social rules, that we dare not abandon them at the gates to our inner world.  And by dragging them inside, we violate one of the only sanctuaries we can depend upon.

Many of us spend a great deal of energy disagreeing with our own thoughts and feelings. When we say:  “I should not be thinking or feeling this way”, we assume that we can  control our emotions or thoughts.  Yet, at most, we can control the active/external expression of our thoughts and feelings (and even that can be very taxing and often impossible).

We cannot control our thoughts and feelings.  We have no easily available mechanism to do so.  Our brain is so busy with the immeasurable amount of tasks it constantly performs  – the vast majority we are not conscious of – that preventing it from thinking or feeling something, is futile.  The most we can do is ignore the thought or the feeling and let it slip away.  The unfortunate catch is that exactly the thoughts and feelings we do not want to have are the ones that stick longer in our awareness.  And as each one of us knows, the harder we want to get rid of them the more stubborn and sticky they become.

And so, working to prevent unwanted thoughts, or shove them away, is not practical. The trick is not to assign value to one’s thoughts or  feelings.  If we do not exercise an appraisal of a thought, it cannot have a “wanted” or “unwanted” quality.  This brings us back to the issue of inner rules.

Our thoughts and feelings have no inherent moral or legal value.  So long as we keep them to ourselves, they do not exist in the outside world, and have no impact. Thoughts and feelings that make their way to the outside world, acquire the power to affect the others.  This power is checked by our social rules lest we devolve into chaos.  But the majority that floats through our mind, some lazily, some frantically, and some almost imperceptibly, those thoughts exist only for us.

Obviously some guiding principles exist for our inner world. Otherwise, it could also devolve into chaos.  But they are not the same principles as the social ones. (Nor do they have to be, as you have already realized.)  One of the most important principles for our inner world is authenticity.  By “authenticity”, I do not mean a factual truth.  “Facts” are also meaningless in the inner world.  Authenticity is the ability to know when you are lying to yourself and to be able to acknowledge it.  You are welcome to lie to yourself as much as you want to, so long as you are able to be authentic about it.  Most of us need to learn how to do it.  We are so frightened of our thoughts and feelings (and even worse; the interaction between them) that we spend time lying to ourselves about it with the hope that we would “buy the lie”  and put it to rest.  But we cannot fully lie to ourselves since we also know the truth.  And, the bigger the lie,  the more emotionally costly its maintenance becomes.

Self lies, or in psychological parlance, denial, often help us cope with unpleasant reality.  And since lies, in the inner world, have no qualitative value, i.e., are not “bad” or “good” – their service should be recognized for what it is.  They become a problem when we try to convince ourselves that they are not lies.  The truth of course, interferes with our ability to believe in the lie. That is where authenticity comes in handy.

I will give an example: One of the most commonly encountered inner lies is that of a spouse trapped in unhappy and distant relationship.  I am not talking about abusive relationship.  In abusive relationship the abuser “casts a spell” on the abused and is actively promoting the lies.  I am talking about the familiar slow grind of parallel lives, growing emotional distance, and low level, chronic mutual resentment.  Sadly, this common condition can start quite early in relationship, peek after a decade together and continue unabated until the end of the life together.  Eventually, and often later in the game, the spouse that suffers the most from the relationship ‘s poor quality, simply gives up trying.  And that is a good thing: the one who gives up, does not need any longer to maintain the lie.  Hence, the energy required to maintain the self -lie is freed up for other, hopefully healthier, pursuits.

If we are scared of the truth, we are unlikely to abandon the lie.  Hence, we may continue on an increasingly depleting and depressing trajectory.  Learning to observe the lie without having to abandon it, makes it much more possible to plunge into a trajectory of change.

To summarize:

1. The rules and morals that we apply in our dealing with the others have no real meaning in our relationship with our own self.

2.  In our inner world we cannot truly lie to ourselves since deeper inside we also know the truth.

3. Some self -lies are harder to maintain than others.  Some (for example denying the inevitability of our death) are becoming harder to maintain with time.  But the more poignant and urgent the truth, the higher levels of energy is needed to stifle it with an inner lie.

4. Our self- lies, much like our fantasies, often serve a purpose in making our life more tolerable, or enabling us to distract ourselves from a painful reality.

5. Authenticity in our inner world, is not giving up the lie or adhering fanatically to what we know is the truth.  Rather, authenticity is the ability to acknowledge the fact that we are not truthful to ourselves about something.

For myself, I have always believed in the adage “the unexamined life is not worth living”.  Obviously, it is not in my purview to decide the worth of other people’s life. So I offer you a milder version: The authentic inner world makes life easier and lighter.   And that is a positive gain in and off itself, isn’t it?

The Holiday Season, so exciting in childhood and adolescence, tends to weigh gloomier with the years.  “Tis the season to be merry” and yet you are not.  You already know you cannot force yourself to be “merry”: most adults realize it sooner or later.  We are offered many suggestions to help us “become happy”: numerous techniques, medicinal compounds, and often alcohol and drugs appear necessary to become joyous.  

But what if that “urgency to be happy” is simply misguided: What if happiness is the wrong pursuit?

I know I am not original on that.  Schools of thoughts, spirituality and the arts have contemplated the pursuit of happiness for millennia.  But I have a very simple way of looking at happiness. If indeed happiness and unhappiness are emotional opposites, it seems that unhappiness is an easy winner.  It is very easy to become unhappy when you are happy, yet it is hard to become happy when you are unhappy. It is very easy to sustain unhappiness and very hard to sustain happiness. So, it seems that with regard to happiness, our emotional balance is heavily tilted toward the gloomy side.

Sounds depressing, literally.  But what if happiness is not necessary to reach a satisfying emotional existence? Can this finicky emotion be replaced by another, more stable, controllable state?  A state of mind not so dependent on the vagaries of life?

My quest to offer a tangible, alternative goal for emotional well-being, has led me to substitute happiness with contentment.

Contentment is a decision, a state of mind, something that can be attained by one’s own powers – irrespective of one’s circumstances.  Contentment is the outcome of the relationship between you and yourself.  No one can take it away from you, and once attained, it can be sustained no matter what comes your way. You can practice contentment just like anything else, if you know how.

 You know the pleasure that comes from being commended on a job well done. It is so satisfying that we sometimes “fish for compliments”, or any form of recognition. Too much “fishing”, and we feel and are perceived as pleasers that would do anything for positive feedback. Done too little, we are viewed as aloof or disinterested. Indeed, reliance on others’ compliments is very problematic. We should not want to spend our lives hoping to please others to get approval. But there is someone, whose constant presence in your life assures that no positive thing you do would go unrecognized.  It is, of course, you. Yet, we are so prone to torture ourselves for mistakes while taking the good aspects of our daily life for granted, thereby missing out on constant and readily available sources of pleasure.

So here is a simple exercise: try to say to yourself “good job” for everything you do well.  It does not matter if you always do it well.  In fact, this is even a more reason to congratulate yourself.  You brushed your teeth for two minutes? “Good Job!”.  Made yourself a good cup of coffee? “Good Job!” got to work on time? “Good job!” etc. You get the idea.

Congratulate yourself on things well done in your everyday life. Nothing is too small, nothing is too embarrassing – you are doing it in the privacy of your inner world!! Try it for a week, and you will see how much nicer it is to spend time with yourself.  Enjoying your own company is one of the major tenets of contentment.

(what would the others think?)

 Relinquishing your self definition to others. The case of “Lara”

We care deeply about what the others think of us. In fact, many of our activities are intended to affect the perceptions of those around us. While one of our most basic freedoms is to define ourselves to ourselves, many relinquish this freedom. Instead, we let the others define us and, by doing so, we give the power to others, even total strangers, to shape the way we see ourselves. This self-imposed vulnerability interferes with our emotional self -reliance and is a major contributor to the sense of insecurity so prevalent in the human experience. Insecurity is the outcome of reliance on the others for the sense of self esteem (no wonder we associate insecurity with little self esteem). Self-esteem is literally how we value ourselves. Your sense of self-esteem, when dependent on others’ opinions, is not in your possession.  It is merely borrowed from the others and as such cannot be seen as self.  Borrowing your self-esteem is very precarious: one day, when you do not meet the terms of the “lease” it can be taken away from you. Even the most complacent narcissists, know in their heart of hearts how fragile their position is. Ultimately the absence of a solid, independent sense of who we are renders us insecure and scared of life.

Lara came to therapy complaining of “paranoia”. “I feel very self conscious; everywhere I go I feel that people are looking at me and judging me”; she feels people think she is ugly and a “loser”. In reality, Lara, a 24-year-old graduate of prestigious masters program, is pretty and personable and does not posses any trait that can attract negative attention.  She recently accepted a job offer at a prominent institution but feels so overwhelmed she in not sure that she can actually start working there. Being so hard on herself, her family and friends try reassuring her that what she feels is just her imagination. Lara is not persuaded “They are just trying to make me feel good, but I know better”. Over the years L. has restricted her social interaction, finds it hard to walk into a crowded place and despite experiences to the contrary, has a very low self-image.

Trying to understand how she views herself; it quickly becomes apparent that Lara does not know “who she really is”. When asked to describe herself, she finds it extremely difficult. She states – with little conviction – some external facts while looking uncomfortable and seeking assurance and approval. Not having a good sense of herself, Lara is very vulnerable to how other people see her. She constantly scans the others for their reactions whether real or imagined (Most probably imagined, as she is most vulnerable to random strangers on the street, who are unlikely to form any opinion either good or bad.)

If you ask “How come you are so willing to accept imagined opinions from total strangers and not the positive feedback from people who know you well?”  Lara would agree: “It is weird, why do I care so much about random strangers who do not know me at all?”

Actually this is not so weird: strangers can only see the exterior, i.e., your appearance. Conversely, family and friends know you on a deeper level: your history, your personality. In reality your appearance receives little attention from people who know you well, as they are used to the way you look. When you do not know yourself you tend to view yourself like a stranger would; you see only your exterior. No wonder we give so much credence to the opinion of strangers: Being strangers to ourselves we identify with their “point of view”. Much like strangers we connect with the superficial aspects of our existence – for example our looks –rather than the deeper layers that are “unfamiliar” to us.

The price for not defining ourselves to ourselves is a shallow self -perception, that of a stranger. Constructing your self definition around the way you appear to others renders you vulnerable and insecure. (A whole industry is based on this vulnerability: since in the Western culture good looks is equated with youthful looks, those invested in their looks are forever doomed to fight a losing battle against the ravages of time, and are susceptible to any method that offers “age reversal”.

The work with Lara is focused on helping her develop a solid definition of herself.   She can benefit tremendously from uncovering her authentic and consistent self-definition: This may sound straightforward, but actually it is one of the most difficult endeavors in psychiatry as we are usually terrified of facing our authentic self. However, refusing to face ourselves is akin to a child covering his eyes so the scary thing would “go away”.  Whether we look or not, our own self is always here with us, and ignoring it would not make it go away. The sooner we face ourselves, authentically and courageously, the better is our chance to live at peace with ourselves. No wonder Lara needs much support as she struggles to overcome her fear: “what if I hate whom I really am? “.

In my years of work I often encountered the inner “bogey man” phenomenon.  My patients being scared of discovering a fearsome – hitherto unknown-  inner secret. Yet, you are very unlikely to find something in your inner world you never knew about. In actuality you do know who you are, warts and all – you just do not want to look there.  Perhaps at some point in your past it was useful to distract yourself from yourself and forgo introspection. By now, alienation from yourself has become the problem even if it once was your “solution”. True: while facing your authentic self you may not like everything you see: however, you are unlikely to discover a dark secret about yourself you were truly unaware of.

Acquainting you with yourself is only the beginning of the process.  Imagine returning to your childhood room: The posters you once loved seem quaint and outdated, your bed is too small, the chairs too low: it is still your room but does not meet your needs any longer. You need to reassess and examine your notions about your life: Slaughter some “sacred cows”, connect with inner instincts rather than borrowed notions. Most importantly, you need to get rid of unnecessary “garbage” you hoarded inside and were never able to sift through. Almost like “interior redesign” of your inner world.  Once Lara was able to face herself, the work became increasingly rewarding for her. As she began to realize that her inner world is in fact a fascinating place, and highly worthy of her attention, her sense of self got better formed and her dependency on external definitions became greatly diminished.    Lara dared for the first time in her life, to define herself for herself. !

Do you suffer from the “Borrowed dignity Syndrome? Questions to ask yourself:

1. Do I often feel that I do not know who I really am?

2. Do I constantly seek approval from the others?

3. Do I often wonder what kind of impression I make on the others?

4. Do I try to be what I think the others want me to be?

5. Am I very preoccupied by my looks, my image, and my presentation?

6. Am I very sensitive to criticism?

7. Do I get very angry and/or depressed when I feel disrespected?

8. Can I be described as having a “thin skin”?

If you answered yes to five or more of the questions you may suffer from the “Borrowed Dignity” syndrome.

Steps to reclaim your sense of identity and fully own it:

1. “A Penny for your Thoughts”: Ask yourself how you know what the others (especially strangers) think about you. The more you consider it the clearer it should become to you that unless you are a mind reader (which no one is, not even an experienced psychiatrist…) you cannot know what another person thinks. We often can tell how another person feels even if he says nothing. There are many non verbal cues we use to convey our feelings.  Being sensitive to others’ emotional or nonverbal cues is a survival mechanism that helps us navigate successfully among our fellow humans. In fact, a hallmark of the autism spectrum – such as Asperger’s Disorder – is inability to “read” others’ emotions.  But we cannot know what the others think.  When we say we read someone’s mind, we mean his or her feelings. At times we can decipher very crude thoughts from reading one’s cues:  Frowning usually means “I do not like it” and smiling broadly mean “I like it”. But this is the tip of the iceberg when we ponder the myriad of thoughts that can swirl behind a smile or a frown (not to mention that we are highly adept in masking our feelings behind a fake expression: a politician’s smile can mean no more than a professional tic).

2. Consider:  most of your conscious thoughts are centered around yourself:  Unless you are obsessed with someone, you do not spend that much time thinking even about people close to you not to mention total strangers. It is not a mark of self-centeredness:  you can be compassionate and generous and still think primarily about yourself.  We need to think about ourselves since we operate this complex machine in space and time: imagine a pilot or a driver focusing mostly about other planes or vehicles: you would not want to be driven or piloted by them. In that context, preoccupying yourself about what the others are thinking about you is a waste of your energy. I am not suggesting you should not care; it’s that they simply do not think about you – they think about themselves!

3. Consider:  How much time do you devote into thinking about random strangers on the street? When you see someone unusual, strikingly beautiful, or shockingly eccentric how long does their image stay with you? Unless they do something extraordinary to you or your child (which is thankfully very rare) you don’t remember them even a day later.  If that is the case with striking stranger, regular ones may not even register in your short time memory. That is exactly the way others see you. It may be humbling ( or even distressing) to think that the rest do not really care about you. But it is the truth nonetheless. Human behavior is governed by predictability. We operate according to expected norms in order not to keep the rest guessing about our next move.  That is why most of us are trying to attract the least attention as we are passing by random strangers. In other words, the others are not really thinking or judging you one way or the other. Being hypersensitive to what the others think about you is really the outcome of not knowing who you are and seeking this knowledge from the others.  In truth they are not thinking about you at all and even if they were there is no way for you to know what they think.  It is you, attributing to them those thoughts, and not their own.   By allowing others to define you for yourself all you do is project your insecurities upon them.  Unless you define yourself to yourself you would continue projecting your insecurities unto the casual observer- thereby getting an imaginary “proof” to your perceived deficiencies.

4. Decide to break out of this negative feedback loop:  be truly self-conscious: i.e., think about yourself. Define for your self who you are in any number of areas. You may not like what you find which is probably one of the reasons you chose not to do it in the first place.  But at least, it would be an authentic assessment of yourself. Frankly, allowing the others to define you was definitely not conducive  to your self image.  The more you own your sense of self, the less susceptible you would be to the others’ “impressions” of you.

Thinking back at your childhood, you may realize that a lot of time was spent instructing you how to get along with the others.  And yet,  surprisingly little attention was paid to how you get along with yourself.   It is not so strange: in order to be a member of any community or society you need to learn how to submit your personal will to the communal one. Otherwise you become “asocial” and unwelcome.  But if you torture yourself , no matter how harshly, you can still be a highly functioning member of any society.  Frankly, no one truly cares if you criticize yourself.  Especially if like most of us you do it in the isolation of your inner world.  

I called the following TIIPS “Making peace with yourself”.  Indeed, in my decades of psychiatric practice befriending oneself is probably the most universal goal of any human intervention.  It is possible, and easier to achieve than is commonly believed.  You do not need to spend 10 years untangling 10 years of self-hostility.  The ratio is in your favor and the progress is exponential once you get ”the hang of it”!

The “Martyr” Syndrome: Sacrificing your needs for the Communal ones.  The case of “Marcia”

Marcia is a 46 year old,  mother of three.  When we first met, Marcia described herself as being selflessly dedicated to her family.  She said it gives her great joy to cater to her family’s needs and she feels no need to make demands on her husband and children.  She said she does not need any reward; her sole gratification is to see her family happy. However, as is often revealed in therapy, beneath her seemingly cheerful facade, Marcia is actually bitter and depressed: By convincing her family that sacrificing her needs makes her happy, she conditioned them to accept her “services” as a matter of fact.  For years, she partook in these family dynamics without any reservations.  But recently, she finds herself getting upset with her family members for the most trivial reasons.  She told me they constantly “get on her nerves”.  Many evening and weekends, once a bastion of family bliss, she is sulking, feeling disappointed and empty.  She feels that nobody in her family respects her, that they do not care about her and that she is “merely a maid” in her own house. When I met with her husband, he was very aware of this situation. He had been telling her for quite some time to start taking care of herself.  He tried to convince her that their children and him do not really need this selfless attention from her.  Instead of appreciating his understanding, Marcia responds in angry outbursts and hurt feeling:  She accuses him of being unappreciative of her efforts; she feels her family does not need her, and grows increasingly morose at feeling disposable and useless.  She often feels angry with herself for being such a “patsy”.

In midlife, Marcia finds herself trapped in her own lie.  We are not meant to be selfless: Quite the contrary, our first responsibility is to take care of ourselves.  When you think about it, the opposite of selfless is not selfish; it is self-fulfilled.  Those who make selflessness a central virtue in their lives are locked in a paradox: they ostensibly fulfill their needs by denying them to themselves. Noble as selflessness may seem, it carries with it a concealed need: the need to be recognized as a “martyr” by the beneficiaries. However, the mere requirement for recognition spoils the mantle of selflessness which creates a “Catch 22”.  By presenting ourselves as giving and kind to the exclusion of our own needs, we trap ourselves into maintaining an impossible image.   Over time, our need for recognition of our sacrifice by those around us exceeds the others’ ability to be grateful:  They simply get used to our generosity!  Fulfilling others’ needs at the exclusion of our own, while contending ourselves with this position is humanly impossible.  Sooner or later we find ourselves bitter and angry and trapped.

we can learn how to break away from the “martyr syndrome” and do it in a way that would not destroy the carefully crafted selfless image we have unwittingly created. Once the boundary between generous and selfless is clarified, the positive trait (generosity) rather the unattainable (selflessness) will reveal itself and the road to recovery is short.  In that context, my work with Marcia was very rewarding.  She learned that she is a generous and loving person and that “going all the way” is a millstone she had tied around her neck, unnecessary and removable.

Are you a “Martyr”?  Ask yourself the following questions:

1. Do I consider myself selfless?

2. Do I often volunteer to do something for others even before being asked?

3. Do I often feel resentment towards those whom I volunteer to help?

4. Do I often feel I am being taken advantage of or exploited?

5. Do I ask people whom I help not to thank me since being helpful is my reward?

6. Do I feel that my efforts on others’ behalf are not recognized accordingly?

7.  Do I often feel that people are ungrateful?

8. Do I wish I could break away from my image as a “nice person”?

If you answered yes to 5 or more of the above, you may suffer from the “Martyr Syndrome”.

There are several steps you can take on your own to get off the “martyr” perch:

1. 1. Clarify for yourself the difference between being selfless to being generous.
2. 2. Spend some time thinking about your needs.
3. 3. Identify those needs that clash with the needs of others.
4. 4. Learn to separate between true needs of others and those that you imagine are expected of you.
5. 5. Start by preferring your needs over those you imagine the others have.  Realize that you gave up your own legitimate needs for the sake of imagined needs of the others that you merely fabricated in your own mind.  The others would not even notice as they never expected you to do it in the first place

Altruism is universally respected but rarely practiced.  Somewhere inside our own needs vie for attention and make the sacrifice unsustainable over time.  Martyrdom works only for martyrs, i.e., those who die through acts of radical selflessness.  For the rest of us generosity should be good enough.  I like to use the airplane safety instructions as a metaphor: You have to put the oxygen mask on first in order to effectively help the others. Only those who take care of themselves are free to take care of the others.

Almost any scientific innovation is doomed to have unintended consequences. Medicine is no exception. As soon as a new breakthrough gets mainstreamed, the threshold for using it gets exponentially lower: recent publicity about gross overuse of stimulants, unnecessary back surgeries and coronary bypass, to name but a few, illustrates an important principle: the mere existence of a new treatment is not a license to use it indiscriminately.

I think such a trend is at play in the area of fertility treatment, especially that of IVF (in vitro fertilization).

I have deep respect for IVF and its practitioners. I had just graduated medical school in 1978 when Louise Brown, the first “test tube baby” was born. I remember the pride I felt in being part of a professional community that makes such wonders come true. IVF offered a way for infertile women to become mothers – something most of us feel entitled to by nature, literally.

IVF was originally developed for women who had some mechanical obstacle to becoming pregnant. In most cases it was some form of obstruction in the Fallopian tubes – the organs that transfer the egg from the ovaries to the uterus- and where the first few days of gestation take place. The obstruction made it impossible for the sperm and egg to meet and so IVF was a clever way to circumvent the obstacle.

Sooner or later women who had perfectly open tubes but experienced other difficulties in getting pregnant, joined the group of IVF beneficiaries.

Predictably, as the technique got increasingly popular and transformed from a medical miracle into a routine, it became so widely available, that nowadays it is offered to almost anyone who can afford it.

Consequently, IVF is now routinely considered even for women who may not need it to conceive and whom I call the “the worried thirty something”.

Why is it a problem?
In principle, I believe that any treatment modality should be evaluated by its ease of administration, the availability of other, less risky methods, and the financial burden it places on the individual and/or society at large.

IVF is not an easy way to conceive: it is very expensive, success is not assured and often times one needs multiple cycles until a pregnancy “holds”. Also the process itself entails daily injections of hormones, painful procedures and a great expenditure in time and emotional energy.

Clearly those who can become pregnant only through IVF should definitely try it. However, for those who do not really need it, it should be only a last resort rather than a first impulse.

What is preventing many women who have no obvious mechanical obstacle, who ovulate regularly and have a benign obstetric history from becoming pregnant? I believe that the main contributing factor is stress. It is well established that stress can actually become a major cause of infertility, since it interferes with the hormonal balance essential for conception and maintenance of pregnancy.

Is getting pregnant these days more stressful than it used to be?

In my experience the higher the age of first pregnancy the larger the role that stress plays in infertility. According to the Centers for Disease Control (CDC) first births among women ages 30 to 39 have doubled in the past 15 years, and those for women 40 and older have increased 50 percent. This is another example the way social trends affect everyday biology and psychology. As more women become pregnant for the first time much later in life than it used to be, stress becomes a major factor for their infertility.

Why is getting pregnant for the first time at a later age so stressful?
Women over 30 who try to become pregnant for the first time often carry a complex emotional burden. Their gynecological history may include bouts of STD, abortions, and prolonged contraceptive use. They are more exposed to “horror stories” from their peers who find it hard to conceive, and the inevitable biological clock is running out of time. A woman in her mid to late 30’s is under pressure, that she has less fertility time, more possibilities for complications, and higher rates of miscarriage: all those factors make the woman feel rushed into pregnancy if she wants to have children before the window of opportunity closes.

Not surprisingly these women approach their potential pregnancy with trepidation and worry. Every month that passes by without conception, increases their anxiety about their prospects of becoming pregnant. Sooner than later, the notion of infertility treatment becomes a reality. And it is easier than ever to become a candidate: advances in the field of In Vitro Fertilization (IVF) and Embryo Transfer (ET), have lowered the threshold for the procedure. But even when IVF is administered, stress remains an important factor in the success of the treatment.

Since stress interferes with hormonal balance and adds to difficulties in getting pregnant, (and maintaining a healthy pregnancy) it makes sense to address it before a woman embarks on the exhausting journey of infertility treatments. The reality is that many obstetricians often lend only a cursory acknowledgment to this issue. The way healthcare is delivered nowadays is by busy specialists who have little time to address emotional difficulties. It is much easier to send a woman to fertility treatment than to spend the time discussing with her the fears she has about her ability to become pregnant. Even younger women in their early 30’s who have plenty of time to get pregnant naturally, are rushed through the “time is running out” path where IVF appears to be a compelling option. Whether stress is a cause for infertility, a contributing factor or “merely” an added difficulty, it should be addressed before costly and painful treatment would become a path of no return.

Saying to the concerned person “just relax and don’t worry” is an exercise in futility. Worse, many doctors and close friends and family often say to her ” you got to stop worrying about it as it compromises your chances of actually getting pregnant”. This is obviously the worst tact as no one can relax on command and the suggestion that the stress is contributing to the problem only causes further stress. It also fosters a sense of guilt in the person, thinking that her anxiety is undermining her chances to become pregnant.

In founding the Institute for Integrative Psychiatry our goal wasto call attention to exactly such issues. Our biology and psychology are so completely intertwined that relating to oneaspect while ignoring the other is simply mistaken. In many conditions the mutual impact of psychology and physiology is crucial for recovery and health. I believe that we need to address the impact of stress in every woman who presents for infertility evaluation. Our goal is to educate the public as well as clinicians dealing with infertility about ways to identify and treat stress as a part of infertility work -up.

Do we have to understand how the brain works in order to promote integrative approaches?

I am often asked how we can discuss the body/mind connections when we do not understand the workings of the brain. After all the brain is the location where presumably the body/mind interaction takes place.

This is of course a very valid point. The short answer is it makes sense to operate with some unknowns, rather than not move forward at all.

To answer that more broadly, the advent of modern medicine has afforded formidable progress in our understanding of anatomy, physiology, pathology and disease formation. Those discoveries have shed important light on the structural and physiological aspects of the brain and its unique position regulating itself and the rest of the body. However, despite heroic efforts by neuroscientists, the way the physical brain interacts with the more abstract aspect of its function such as memory, thoughts, and feelings, remains for the most part elusive and poorly understood.

Needless to say the brain is distinct from all other elements of the body since, to put it simply, your brain IS you. The aspects of the brain that make you who you are, your memories, experiences, moods, thoughts, feelings do not yield their secrets easily to our sophisticated exploratory tools. It is already clear that modern medicine will eventually be able to replace (or grow) almost any organ of the body. But there is no question that your brain cannot be transplanted without killing what makes you who you are. If you get a new, different brain you simply stop existing.

Since all attempts to link the abstract workings of the brain to their material basis have so far been thwarted, rather than “wait” for the brain to become comprehensible, medicine has forged ahead without this complete knowledge. As a result, the idea that medical models can be explained without the role of the brain, especially as it pertains to the mind, has become the prevailing principle of contemporary medicine. It is not based on science but rather on convenience. It is the “looking under the lamppost” phenomenon of medicine.

It is conceivable that the brain would remain an unsolved mystery for a very long time. But Integrative Psychiatry is not presuming to unlock the mysteries of the brain. Rather, it proposes to examine, and integrate the dialogue between the brain and the body in health and illness. For that we do not need to know how the brain works. We need to know how it interacts with the body and how, through the brain, our thoughts and feelings influence the body and vice versa. For instance, we know that premenstrual hormonal changes cause irritability and depression in women. We do not know how mood and thoughts are influenced by hormonal changes: but we can examine the connection. Indeed, after millennia of misunderstanding or ignoring the monthly emotional suffering of countless women, recognizing the phenomenon resulted in research and effective treatments while the exact mechanisms in the brain remain unknown.

By focusing on the interplay between the brain and the body, we can identify numerous cross influences (i.e., the influence of the body on the thoughts and feelings and vice versa) and their effects on health, and recovery. While such observations have been made sporadically throughout medical history, we would like to come up with a coherent, encompassing approach to such integration, and help medicine recognize and incorporate that crucial “missing link”.