the fear of rejection and challenges self-esteem at the same time that it exerts its
powerful attraction. If you've ever been paralyzed in ambivalence for long ("I want to
… no, I don't … yes, I do ..."), you'll recognize this acute discomfort and the relief that
comes when something beyond your control makes your mind up for you. A broken-
out face removed this patient's uncertainty (" can't …"), providing protection against
risk along with a rationalization ("I would if only my skin would clear up"). It's very
common to ascribe to a skin problem our inability to do things we really don't want
to do or fear doing. Chapter 7's exercise is devoted, in part, to unmasking such self-
deception.
"People are nice to me … I get lots of sympathy." For some, skin problems remain
a permanent conversation piece, a constant stimulus to solicitous questions about
their health and well-being. Instead of talking about the weather or baseball, they can
talk about their skin, an advantage not to be dismissed lightly for those who have
extreme difficulty making small talk and socializing.
Skin illnesses unquestionably garner sympathy, and sympathy is something we
all need in a world full of burdens and setbacks. Something as visible as problem skin
will generate sympathy where less tangible troubles will not. There's nothing wrong
with needing sympathy, of course – the problem is that this is a particularly costly
way to get it.
"If I wasn't worrying about my skin, I'd probably be worrying about something
even worse." This intriguing advantage came from a patient with unusual insight. We
all have our share of free-floating dreads and anxieties simply as part of our share in
the human condition. A specific, concrete focus for our worries can, paradoxically, be
helpful, even comforting. It contains our anxieties. While you're lying in bed trying
not to scratch yourself into a bloody pulp, you won't be worrying about the
unnameable things that may be lurking in the dark around and within you.
"It provides something to focus my anger and disappointment on – something to
bitch about." This actually contains two distinct advantages that many people find
hard to separate in their minds. Life is full of irritation and frustration, and most of us
have a reservoir of anger that sometimes demands release. Often we displace our
anger on those close to us – the classic example being the man or woman who comes
home from a frustrating day at the office and starts yelling at the kids. A chronic skin
condition is a safe, guilt-free, and reliable target for the discharge of anger.
Disappointment is more complex. Many people fasten on one turning point in
their lives where it all went wrong – where they went off the track and slipped
irretrievably toward failure, such as the former boxer played by Marlon Brando in
the movie On the Waterfront. Some time before the movie takes place, Brando threw
a fight, his career went off the rails, and his whole life, in his mind, went into a
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nosedive that he could never pull up out of. "I coulda been a contender, instead of a
bum, which is what I am," he mutters. A patient of mine, a lawyer, felt the same way
about the fact that he couldn't get into the Ivy League college he preferred and had
had to settle for a (to him) third-rate institution. Thus, he thought himself
condemned to lifelong mediocrity, out of the mainstream.
It's illogical, of course, but there's satisfaction in the ability to focus one's
disappointment in life on a single event or situation and say, "There. That's where I
lost it, and that's that."
"It hurts so nice when I scratch." This surprising response points out that there is
a very real satisfaction – almost a sexual one – in the immediate relief you get from
scratching an itch. In fact, "scratching where it itches" is a figure of speech for
satisfaction. (Squeezing pimples and tearing off scabs provide similar pleasures,
although many adults find it hard to admit.) The moments of intense relief don't
balance the tormented hours of itching but they do give periodic gratifications that
one can look forward to.
"The boss knows I'll be out from time to time. Otherwise, he'd give me grief if I
asked for days off." Not only do people give you sympathy when you're ill, they give
you special consideration. We can all use occasional "mental health days" when we
aren't expected to show up for work. Unfortunately, all we're entitled to are "sick
days." A chronic illness means allowances are made for your special needs, a
privilege that is understandably hard to give up.
"It gives me an excuse to avoid lovemaking with husband." It's been said that "I
have a headache" is quickly being replaced by ''My herpes is active" as a sexual
sidestep. Here again we're dealing with an advantage that's often well hidden. We
like to think of ourselves as highly sexed beings – many men in particular have been
led to expect themselves to perform like a furnace with a pilot light that's always
burning. For a whole host of reasons, ranging from deep-seated sexual conflicts to
fatigue, worry, and the vagaries of daily life, we may not be as eager for sex as our
self-image demands.
The pain, irritation, or annoyance of an established skin condition provides a
convenient rationale for avoiding sex without raising self-doubts about one's
sexuality or getting into lengthy discussions on the nuances of your relationship.
"I have a whole wardrobe of special fabrics, which would be wasted if I didn't have
an allergy." This is to remind you to include the seemingly trivial with the serious, in
considering those advantages that keep you holding on to your skin troubles. The
lightest additional weight swings the balance toward illness and away from health. In
compiling your list, include even the most easily overlooked fringe benefits you give
if your skin troubles continue and try to imagine the most minor, inconsequential
difficulty that will ensue if it improved.
Because they're important so often, I'd like to mention two other areas in which
secondary gains can keep skin problems holding on: love and money.
People typically lapse into customary roles in long-standing relationships,
particularly marriage: one person is the leader, the other the follower; one the
dreamer, the other the voice of reality. In some marriages, one partner takes the sick
role, the other is the healthy spouse, and this becomes a fundamental basis of the
relationship. It's a medium of giving and receiving affection, a division of power, a
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constant shared interest, and a way to avoid conflict. If the sick spouse suddenly
threw away his crutches (or her steroid creams) and became whole, the entire
marriage would have to be reshuffled and redefined – a frightening prospect.
Money can also complicate skin problems. A full half of workers' compensation
claims involve skin conditions. There's nothing phony or trumped-up about such
claims, and few if any claimants are sick for profit. Rather, the high rate of skin
problems authentically related to working conditions and office and industrial
chemicals testifies to the callous disregard of workers' health that has long
characterized American business.
Anyone whose health has been tarnished by his work fully deserves
compensation, but it carries a hidden tax. No matter how the condition started, no
matter how eager and willing you'd be to exchange a compensation check for your
original health, as long as you receive money for being ill, this "reward" can be a
powerful weight in the balance to keep you from getting well.
In doing the "advantages" exercise, a key is to suspend your normal common
sense notions about proportion and cause-and-effect. You're not consciously staying
sick to reap these rewards: logic isn't what's holding them on, so logic can't always
figure them out. These are simply the small, unasked-for dividends you get on a very
large expense of energy and pain. Even the smallest of them add to the forces that
keep your skin troubled, opposing the difficult work of change to make it better, and
while they may be easier to unearth than the emotional tasks in which your skin
problem may be more deeply rooted, they can persist with a tenacity completely out
of proportion to their real-life importance.
Don't be troubled or blocked by the sense that these advantages are base or
unworthy. Again, they correspond to needs we all have – for love, for protection, for
respect – and you're certainly getting them the hard way. Even advantages that seem
dubious to you, like attracting attention or receiving sympathy, should be considered
seriously. There may be a part of you that revels in sympathy even while your stoic
self recoils. Above all, remember the differences between taking responsibility and
blaming yourself.
As with the deeper emotional tasks, bringing these advantages to light is a first
step. If you learn to gain similar satisfactions straightforwardly, you'll weaken the
hold of your illness – you won't "need" to be sick. For example, if you recognize that
your relationship with your dermatologist and her periodic treatments are a
significant reward for your illness, consider alternatives: other relationships that
may fill the same need, such as an ongoing involvement with the dermatology clinic
as a volunteer.
If you've had a serious skin problem for some time, you may be surprised to
discover how your skin has become a tyrant, dictating much of your life. The problem
is there, and so it's taken on the satisfaction of various needs that you might well
resolve in healthier ways if it were not. How would you live without it? One step
toward making the secondary gains of illness unnecessary is to imagine what life
would be like if your skin cleared entirely. In particular, this will help clear away the
self-deceptions that give certain of the gains we've discussed their power. This, in
fact, is the subject of the next exercise in chapter 7.
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xxxv A very good survey is D. E. Bresler, Free Yourself from Pain (New York: Simon & Schuster, 1979).
II. What You Can Do About It
8.The Healing State: Your Untapped Resource
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7. What If It Got Better?
What If It Got Worse?
A GOOD NEWS – BAD NEWS STORY
Suppose your prayers were answered. When the clock struck midnight, you felt a
tingle all over and . . . Shazam! Your skin problems were gone. All gone! Your skin was
fine and healthy from head to toe. Wouldn't that be wonderful? All your troubles
would be over!
Don't be so sure. Look at all your friends with healthy skin: are they perfectly
happy? Was your life a bowl of cherries before your skin started giving you grief? The
point of this exercise is realism – not to rain on your parade but to help you
appreciate what role your skin symptom plays in your life and what role it doesn't
play. The question "What if it got all better?" is another way to get a handle on what
your problem is doing for you and to help you know it well enough to let it go.
Sit down and ask yourself: “What if my skin disease were suddenly cured at
midnight?" or noon, if you prefer daytime miracles. "How would my life be different?"
Make a solid effort to imagine your life without troubled skin. You'd still get up in the
morning and brush your teeth but perhaps you'd spend less time looking ruefully in
the mirror. You'd still eat breakfast. You'd still dress (but would you wear the same
clothes?). Go through your daily routine in fantasy, noting how it would change in big
and little ways. Take notes.
Freely imagine all the areas of your life that would change. What would you do
then that you can't do now? What would happen to your relationships with other
people? To your work? Your friendships? Your sex life?
The first payoff of this exercise is simple. It's hard to accomplish what you can't
imagine, and forming a clear mental picture (it will probably grow clearer as you
practice the exercise over time) is an important first step to making a dream come
true; this is the true power of "positive thinking." Physiologically, our bodies respond
to imaginary life much as they respond to real life, and imagination is in a great
rehearsal stage. In doing this exercise, you are rehearsing healthy skin.
The exercise can do even more. Looking closely at the dreams-come-true that
follow your imaginary total recovery, you'll tap into the fantasy world of emotions
that got your symptom started, that heightens it, and that keeps it hanging on.
Thirty-five-year-old Andrew M. came in for psychotherapy for a different
problem but it was immediately evident that his acne caused him great distress. He
had had a severe case on his face and back since his early teens. While exploring his
feelings about this symptom, I raised the question: ''What if it suddenly got better?"
For one thing, Andrew said, he could leave his girlfriend, with whom he'd been
living for two years. This desire to part hadn't come up in our earlier sessions; as we
explored it further, it came out that while Andrew was quite fond of Jane, she was,
well, plain. She was attractive enough, bright, caring, creative, but she just wasn't the
girl of his dreams, the glamorous, sexy woman he imagined as his proper partner …
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the girl he could get if only his skin were not such a mess!
If only! We'll return to this magic phrase shortly and dwell on it at length. For
now, though, let's consider the truth about Andrew and Jane. There was a sense, he
admitted, in which he was angry at his hapless housemate for being just herself – for
not having the larger-than-life sparkle he craved; for not being, as he put it, "a prom
queen."
Dating the luminous prom queen, the movie star, was, I pointed out, a delightful
and nearly universal fantasy but at its root an adolescent one. There was something
adolescent, too, in some of Andrew's other fantasies of what he'd do if only his skin
cleared. He could travel widely. He could run for public office. He could do just about
anything. If only his skin would let him.
In fact, the fantasy world that Andrew brought forth was, more or less, the
dream of unlimited potential that properly belongs to the high school years. The
adolescent is full of potential; he's not yet fully formed and he hasn't chosen his path
through life. In theory, he can be an astronaut or a president. Andrew had a
particularly strong reason to freeze time and remain an adolescent in spirit: his true
adolescence had been stunted and blighted by serious family turmoil and divorce.
He'd spent his high school days sad and isolated.
Although the acne had troubled him for years, Andrew had given up on
dermatologists, and this in itself suggested that something in him wanted, needed, to
hold on to the problem. His disease, acne, symbolically extended adolescence. Equally
important, it cushioned reality to protect his treasured sense of adolescent
potentiality. No, perhaps he wasn't living with a movie star and his job, while
respectable, was neither exciting nor glamorous. Sure, he was living an ordinary life
like millions of other ordinary folks, equally ignored by People magazine and Who's
Who, but this was only because his skin prevented him from realizing his true
potential.
Andrew's acne was explicitly bound up with the emotional task of freezing time
and maintaining adolescence, but this particular role, the buffer between the real
world and precarious self-esteem, is shared by many dissimilar skin problems. Bad
skin can be a permanent exemption from the testing process that life constantly
inflicts on our self-image.
If only the lupus went away, we'd look good enough to attract rich, caring men. If
only that maddening itch would quit, we could devote our energies to our studies and
graduate summa cum laude. If only the warts shriveled up, we could be happy! We all
achieve some dreams and have to forget others, and life being what it is, we
inevitably fall short of the satisfaction we crave, but when self-esteem is fragile, such
setbacks are too heavy to handle. Instead, we tell ourselves: "I could do it, I could
have done it, I would do it – if only my skin would let me!"
Bad skin is not the only resource we use to shore up our egos. We fall prey to
similar self-deceptions when we tell ourselves: "If only I could get it together and
move to California, then life would be great" or "If only I had a hundred thousand
dollars, then I could take a year off and write the novel I know I could write if I didn't
have to earn a living" or "If only I could find the right man/woman (or if the
man/woman I've got now would disappear), I could be happy and fulfilled." They are
all one-shot, simplistic explanations to excuse why we haven't become the person we
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want to be or that someone said we should be. They mask the complex push-and-pull,
the needs and fears that make "what we want to be" so complicated and that make its
achievement so difficult. The skin is a particularly convenient and convincing "if
only." It can serve this purpose indefinitely.
A major goal of this exercise is to bring the if only ways you rely on your
troubled skin out into the open to help you judge for yourself how much of your
healthy skin fantasies express wishes; these, as we've discussed earlier, are sisters
under the skin to fears, and understanding both can illuminate the hotbeds of
emotional action that stir up symptoms and keep them active.
When I asked one of my patients what he could do if his dermatitis cleared, he
answered: "If I didn't have that constant, draining aggravation, I could get it together
and start my own business!" As he said it – and imagined the process – he noted
within himself a wave of anxiety along with the pleasant feelings of pride and
achievement. As you imagine life without your skin affliction, be sensitive to your
own feelings: the same shiver of fear may pass over you as you imagine “I could date
lovely women" or "I could set out with a backpack and hike the Appalachian Trail
alone."
Your problem skin may be the most visible obstacle between you and your
ambitions, but behind that are very likely subtler, deeper impediments – fears and
anxieties. By stripping away the obvious obstacle, in imagination, this exercise brings
you face-to-face with them. Anxiety is such an uncomfortable state that we'll go to
great lengths to avoid it. Remember the fellow in chapter 6's exercise who listed “I
can't ask that beautiful woman out with my face like this" as an advantage of his
eczema? He understood that his skin was protecting him against his anxieties. It's a
secondary gain of many skin disorders.
Once more, we're in the closed circle of paradox, where wishes and fears,
drawbacks and advantages come together. The thing you would do with healthy skin
– go after sex, success, or adventure, for instance – is something you're not doing
today. Why not? Is there something under your skin stopping you, a fear masked by
the obvious obstacle? Is your skin, perhaps, actually resolving the conflict between
the part of you that wants to go after sex, success, or adventure and the part that is
afraid to try? For example, if you fantasized that with healthy skin you could "go out
and have a busy, satisfying social life," you should at least consider the paradoxical
possibility that your skin isn't inflicting isolation on you but allowing you to isolate
yourself and avoid the anxieties of social contact.
There's a human tendency to lump separate problems together, a process I call
agglomeration. A person who is troubled by severe acne and who has fewer friends
than she wants will say: "I don't have any friends because my skin looks so terrible."
Only after a period of soul searching may it become clear that she had as few friends
before her skin troubles started. This is something to ask yourself as you go through
the "What if it got better" exercise. Did you do the things you yearn for (date
handsome men/lovely women, start your own business, travel the world) before you
developed your problem? Are they really out of the question with your skin as it is
now? Are your unsatisfied ambitions and skin, in fact, two different things?
You must untangle the agglomeration of skin problems and other problems if
you want to work on either effectively. Lumped together, dermatitis, feelings of
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isolation, and a fear of sexual encounters form a mountain of difficulty so massive
that any attempt to scale it is doomed. Only by separating them can you cut it down
to size. It's like any big project: wake up and think of cleaning your entire apartment
and your instinct may well be to curl up under the covers indefinitely, but break it up
into manageable steps – pile up the newspapers, take them out, vacuum the living
room, dust the furniture – and it begins to seem not easy, perhaps, but possible.
With Dan G., a twenty-two-year-old contractor from western Massachusetts,
separating a big problem into its component parts was a dramatic therapy
breakthrough. Dan, a quiet, socially isolated fellow who lived with his parents, had
painful, persistent warts on his hands. They interfered with his work, and his
dermatologist was powerless to help. In sheer numbers they were overwhelming –
layers and layers of warts that made their treatment wart by wart unthinkable.
At first, therapy went smoothly. A single session in which we used hypnosis
relieved the pain of the warts, but the warts themselves hung in there. They
remained through months of psychotherapy, even through repeated hypnotic
sessions where I used every unblocking technique I knew.
After a frustrating year, I was trying to help Dan get in touch with his feelings
with a technique called the Inner Adviser, which aims to set up a dialogue with the
deepest parts of the self (you'll learn about this in detail in chapter 9). Under
hypnosis, I asked why progress was so slow. What would happen, I asked, if the warts
went away? The answer was finally released: "I'd have to deal with the problem of