Coping Strategies and the Paradox of Change

When patients come to me, they are already using various coping strategies to regulate their emotions, improve their mood and deal with challenges. Their strategies—such as drinking, withdrawing, gambling, eating, or hoarding, as maladaptive as they might be—are seemingly essential to their survival. And they are effective… until they aren’t, which is generally the point at which I meet many of my patients for the first time. In fact, their coping strategies can and often do become the major source of their adjustment problems.

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The paradox of change—“Doc. Please help me to change, but change is scary so I’m going to stay put. Accept me as I am.”—can be more readily seen when viewed in this context. It is vital for the therapeutic relationship to recognize that I am essentially asking my patients to strip away the very things that they have been clinging to for survival.

Among other goals for therapy, such as learning to manage emotions, making sense of their past, and assisting with the other changes they desire, therapy is also about “tool replacement”: I’m helping people replace harmful coping strategies with new, healthier ones.

However, if patients have experienced a great deal of trauma, I must sometimes collude with my patients’ denial to maintain their existing coping strategies before beginning to help dismantle them. To illustrate, I must first work with a patient who has experienced complex trauma to resolve some of the trauma while they continue to drink. Otherwise, a premature referral to AA could be a set-up for therapeutic failure.

Reducing the Layer of Judgment

Not only do my patients have various coping strategies, but they often judge themselves harshly for having to rely upon them. A way of explaining the layer of judgment is to use the metaphor of the panopticon, Jeremy Bentham’s 18th century semicircular prison design that allowed one guard to simultaneously watch all prisoners without their awareness of being watched. In the case of therapy, the all-seeing guard is also the patient. The layer of judgment that patients see as they look down on themselves from the guard tower includes:

“What’s wrong with me?”

“Why can’t I be like other people?”

“Why can’t I just get over it?”

There is a common emotional thread woven through these self-statements, and it is often shame. Therefore, I have to help them identify how they feel. Also, I try to help them understand what shame feels like and what it is. I tell patients that shame feels like “embarrassment times 10.” I also distinguish guilt from shame: “Guilt is feeling bad for what you do. Shame is feeling bad for who you are.”

These self-statements, along with embarrassment, remorse, and shame, create the layer of judgment that can make their difficult situations worse. This layer is like a lid on a pressure cooker: it keeps the entire mechanism in place.

To illustrate, I often use the example of obesity. Obese people generally know about the mechanics of weight loss better than people who have never struggled with weight gain. But if weight loss were about simple mechanics, no one would be obese. For that matter, no one would engage in any unhealthy activity.

But obese people often use food as a coping strategy to regulate their emotions. When they subsequently tell themselves how awful they are, it generates more emotions that they have to manage. And how do they best know to do it? By consuming more comfort. The next day they are filled with remorse and shame—which then needs managing. The result is a vicious cycle: the very coping strategy they feel ashamed of is prolonged.

So, for change to occur, this layer of judgment must be challenged with as much compassion I can offer and self-compassion they can muster. Change comes not from self-condemnation, but from greater acceptance and higher self-regard.

Achieving the “No Wonder” Goal

To achieve greater acceptance while reducing self-condemnation, my role is to help patients find healthier coping strategies both through the process and from the material. One way to ease the layer of judgment and reduce the concomitant shame is to propose working toward what I call the No Wonder Goal.

The aim of the No Wonder Goal is to have an emotional understanding of how and why their coping strategies picked them. Please note the specificity of the language. I often tell my patients, “You didn’t pick your coping strategies. They picked you.” In other words, no one starts out drinking to become an alcoholic or begins collecting to become a hoarder. Rather, the psyche says, “Aha—relief! I found what I need to calm down.” What starts out as a social activity, a hobby, or an adventurous undertaking can turn into a destructive addiction, compulsive activity, or manic behavior.

The purpose of working toward this emotional understanding is to thin the layer of judgment and to soften their self-condemnation. I recently had a patient who developed a driving phobia who was condemning herself for her irrationality. I said to her, “It makes no sense that you’re afraid to drive. It used to be no problem. However, these days, just going to the store can be scary! Your psyche is trying to protect you from harm, perhaps even trying to save your life from COVID. What a better way than to stop going places. Your home is where you are safe, so it’s no wonder that this particular coping strategy picked you.”

I also try to transform what has been concretized back into a metaphor. As an example, a porn actor with severe OCD went through an entire bottle of hand soap daily and washed his face at least 25 times per day. During one session, I said, “Could it be that you wash so much because you feel ‘dirty’ being a porn actor?” Through the No Wonder Goal process, he realized that he felt dirty inside, and no amount of washing would make him clean. He was then able to transform the concretized activity back into a metaphor, and as a result, became less judgmental about his OCD.

Of course, it takes months and possibly longer for this idea to sink in (to be an emotional understanding). But many patients have mentioned without solicitation that in the one session when I introduced the No Wonder Goal, they felt a sense of relief and a little less shame.

For greater acceptance, I can also ask, “Does this self-condemnation sound like someone from your past?” Most of the time, patients will tell us that it sounds like their mother or father. Let’s say the patient’s mother’s name is Katie. I will say something like, “OK, so this is your Katie-brain talking to you. Katie was trying to protect you, but in a misguided way.”

The other intervention is to call the self-condemner a committee member (with a caveat for dissociative patients). “What is this committee member saying to you? Can you let the committee member know that you appreciate the protection but that you don’t need it right now?”

Over time, patients realize that this part of their psyche serves a very important function, and its purpose is to protect them against a real or perceived threat. And how can they hate themselves for that?

Tool Replacement

I’m not going to elaborate on the actual tools, since they are generally known—avoiding withdrawal or being controlling, asserting themselves more, connecting with others, expressing emotions, just to name a few. However, it would not be therapeutic nor practical to try to dismantle patients’ coping strategies without helping them build healthier ones or build onto the ones they already have in place. Sometimes I provide them with new tools while their old coping mechanisms are still in place. At other times, as they use their new tools more, the older ones organically diminish.

One tool that I value is to ask patients to use their feelings. Frustration and anger can be transformed into determination, jealousy can produce striving, and sadness can be used to find acceptance. The example I like to give is MADD, Mothers Against Drunk Driving. They gathered their anger, pain, and despair to become the most effective group to educate others and strengthen drunk driving laws.

Recall that tool replacement exists in the process as well as in the material. The process of opening up about their shameful coping strategies, crying over them, and acknowledging missed opportunities and lost relationships is a form of grieving. Grief must happen for greater acceptance. This process, plus exposing their vulnerability as we accept them as they are, can lead them to feel better about themselves, have greater peace of mind, and enjoy more satisfying relationships.

Reducing harsh self-judgment, knowing how they got to the place where they were when they walked through my door for the first time, and managing their emotions with new coping strategies can truly be transformational.  

File under: The Art of Psychotherapy