Treating the Compulsive Personality: Transforming Poison into Medicine

Posted on by rezendevknowfully.com

One summer during my analytic training, I committed myself to study, outline, and completely internalize Nancy McWilliams’s Psychoanalytic Diagnosis (1994). The idea that you could be more effective with clients by understanding their specific patterns ran contrary to the anti-diagnosis attitude at my training institute. But it appealed to my eagerness to be helpful.

Not long after I began, I recognized myself in the chapter on the obsessive-compulsive personality. While I didn’t meet the DSM-5 criteria for obsessive-compulsive personality disorder (OCPD), I certainly had my compulsive traits: perfectionism, over-working, and planning, just to name the obvious. McWilliams’ description elucidated who I could have become, had I not had a supportive family and lots of analysis to rein in those tendencies.

But this wasn’t just personal or theoretical. I recognized the collection of traits found in the personality style in my many driven, Type A, and perfectionistic clients working in law, finance, and publishing in work-crazed midtown Manhattan. And I saw the suffering it caused.

The Unrecognized Stepchild of Personality Disorders

Captivated by the subject, I eventually got involved in some online OCPD support groups. There, I read many stories of people who thought they had OCD for years before finally realizing that their entire personality was characterized by compulsive tendencies. They had known that their struggles weren’t just with specific obsessions and compulsions, but that was the only diagnosis they were aware of that was even close to describing them. And in many cases, OCD was the diagnosis a clinician had given them.

This pattern of misdiagnosis became even clearer once I began receiving comments and emails from people reading my new blog, The Healthy Compulsive Project, and my book, The Healthy Compulsive.

While OCPD is one of the most frequently occurring personality disorders of the ten listed in the DSM, it is under-recognized and probably underdiagnosed (Koutoufa & Furnman, 2014). Far too often, it’s confused with OCD by both the public and clinicians. One study indicates that the lack of recognition of the condition leads to a lack of empathy for it (McIntosh & Paulson, 2019). And far more people suffer from obsessive-compulsive personality traits than those who meet the full criteria.

It doesn’t help that it’s ego syntonic not just for the sufferer, but to some extent for our culture as well. Capitalism doesn’t care if you work too hard. According to psychologist and researcher Anthony Pinto (2016), there is no empirically validated gold standard treatment for OCPD. I suspect that this is a function both of our tolerance of it and of the difficulty in treating it.

What’s the Meaning of This?

As I filtered all of this through my training as a Jungian analyst, my curiosity about the underlying meaning of the disorder was piqued. Jung emphasized the importance of asking what symptoms and neuroses were for. What potentially adaptive purpose did symptoms serve in the patient’s life, or for humankind at large? Could there be meaning under something so destructive? Was there some underlying attempt to move toward individuation gone awry?

Looking up the etymology underlying the word “compulsion,” I realized that it wasn’t originally a bad thing. A compulsion is an urge that’s almost uncontrollable. A drive or force. And that’s not all bad. Many of these urges lead to creative and productive behavior. But “before I could find any possible light in the condition, I had to acknowledge how dark it could be”.

The Cost of OCPD

The more I observed the world of the obsessive-compulsive personality, the more I came to see its destructive potential. A review of OCPD by Deidrich & Voderholzer (2015) tells us that people who have OCPD often have other diagnoses as well, including anxiety, depression, substance-abuse, eating disorders, and hypochondriasis. OCPD amplifies these other conditions and makes them harder to treat. People with OCPD have higher than average rates of depression and suicide and score lower on a test called the Reasons for Living Inventory (Deidrich & Voderholzer, 2015).

Medical expenses for people with OCPD are substantially higher than those with other conditions such as depression and anxiety. And the study indicating this only included people who had sought treatment—which excludes the many with more serious cases who don’t (Deidrich & Voderholzer, 2015).

The cost for couples and families is great. People who are at the unhealthy end of the compulsive spectrum can be impossible to live with. They can become mean, bossy and critical, and their need to control often contributes to divorce. Much of the correspondence I receive is from partners of people with OCPD who are at the end of their rope, looking desperately for hope that their partner can change.

Parents with OCPD often place unreasonable demands on their children. This can interfere with developing secure attachment and may also increase the chances of a child’s developing an eating disorder.

It also causes problems in the workplace. While some compulsives are very productive, others become so perfectionistic that they can’t get anything done. Still others prevent their coworkers from getting anything done because their criticism disrupts productivity.

Similar problems happen in other organizations such as volunteer groups and religious institutions. People with compulsive tendencies often become involved in community groups, and they’re so convinced that they’re completely right, and that they should control everything, that they contribute to the deterioration of the organization, partially because others don’t want to work with them (Deidrich & Voderholzer, 2015).

Just as disturbing is knowing of the many personal, community, and cultural benefits that the condition prevents when it hijacks energy that would otherwise have led to leadership, creativity, and productivity. Compulsives can be movers and shakers, but instead they often end up being blockers and disruptors. The people who shape the world are the ones with the most determination, not the ones with the best ideas. And compulsives have lots of determination.

The Adaptive Perspective on OCPD

As I looked more deeply into the condition, I could see that the original intention beneath compulsive control is positive: compulsives are compelled to grow, lead, create, produce, protect, and repair. It seemed to me that the obsessive or compulsive personality is not fundamentally neurotic, but a set of potentially adaptive, healthy, constructive, and fulfilling characteristics that have gone into overdrive.

I’m certainly not the only one to make this observation. A dimensional perspective of personality disorders is gaining momentum (Haslam, 2003). But this viewpoint is still sorely needed for sufferers, partners, and clinicians.

Realizing that evolutionary psychology might provide an understanding of the adaptive potential of obsessive-compulsive tendencies, I contacted psychologist Steven Hertler, who has been on the front lines of thought in this area. His ideas resonated with what I had suspected about the survival benefits of obsessive-compulsive tendencies: the behavior that those genes led to made it more likely that the offspring of those with the genes would survive (Hertler, 2015). For instance, being meticulous and cautious is part of what Hertler (2015) refers to as a “slow-life strategy,” which increases the likelihood that those genes will be handed down.

Most importantly, though, a perspective which highlights the possible benefits of a compulsive personality style has significant clinical benefits. Conveying the possible advantages of this character style to clients lowers defensiveness and encourages change.

There is a wide spectrum of people with compulsive personality, with unhealthy and maladaptive on one end, and healthy and adaptive on the other end. Clients on the unhealthy end of the spectrum can be very defensive about their condition. They tend to think in black-and-white terms, good and bad, and their sense of security is dependent on believing that they are all the way on the good side. This makes it hard for them to acknowledge their condition, enter therapy, and get engaged in treatment. When they do come in, it’s usually because their partner is pressuring them, or because they have become burned-out or depressed.

If we are to help people suffering from obsessive-compulsive personality disorder, we need to find a way to get under their defenses so that they can make use of therapy. When we understand and convey that OCPD is a maladaptive version of something much more positive, we begin to forge a good working relationship.

But as therapists, we should also acknowledge that some individuals are so far to the unhealthy end of the continuum that even if they were to enter therapy, we might not be able to help them. It was important for me, at least, to be realistic, so that I didn’t set myself up to feel that I had failed if I wasn’t able to help someone.

Characteristics of the Obsessive-Compulsive Personality

The DSM-5 says that OCPD is defined by a “preoccupation with orderliness, perfectionism, and mental & interpersonal control at the expense of flexibility, openness, & efficiency” (American Psychiatric Association, 2013). It goes on to list eight criteria; since these criteria are readily available, I won’t list them here. But I do want to emphasize what the DSM-5 (2013) points out in the first criteria: people with OCPD are preoccupied with details, rules, lists, order, organization, or schedules to the extent that the major point of the activity is lost. I have found this to be a defining characteristic of people on the unhealthy end of the compulsive spectrum—they’ve lost the point of their rules and efforts to control. They’ve lost their original intention, the thing they first felt compelled to do.

I remember being struck the first time I noticed this. A female client was talking about how she had berated some people for not following the rules. It struck me that she was so adamant about the rules that she had forgotten who the rules were meant to help and protect—the very people she was berating.

One goal of treatment should be to help clients recover, or uncover for the first time, the original impulse, the deeper motivation that has compelled them. I may be biased because I practice psychodynamic treatment, but it seems to me that because OCPD affects the entire personality, psychodynamic treatment will be the most effective. I say this because cognitive and behavioral treatments are most effective for very specific issues, less so for the sort of global issues that characterize OCPD.

But those of us who work psychoanalytically may need to budge a little on maintenance of the frame, disclosure, the use of goals, and our reluctance to diagnose. Just as the saying “the only way to peace is peace” goes, “the only way to flexibility is flexibility.” We need to be mindful of our own personal need to control, and a certain rigor that our training may have encouraged: we might think or feel that we are doing the “right” thing by following the rules. But in particular aspects of the work with compulsives, we may gain more through example than through analysis.

Eight Key Points

I’ve found that there are particular themes and tasks that I usually need to work through with compulsive clients over time. I don’t believe that these are unique to OCPD, but rather that they usually require more emphasis than might with other conditions. I outline these below with the suggestion that they be used in a flexible and organic way, rather than as hard and fast steps.

In each of these steps I try to enlist clients’ adaptive compulsive characteristics to foster change.

  1. Create a narrative respecting inborn characteristics. To help compulsives diminish insecurity and develop self-acceptance, “I’ve found that it is important to create a narrative which distinguishes authentic, organic aspects of their personality” from those which were the result of their environment. Compulsives are born with traits such as perfectionism, determination, and attention to detail. They usually like constructive projects, and this can be a joint project that nurtures the working therapeutic relationship.
  2. Identify the coping strategy they adopted. If there was a poor fit between the client and his or her parents, the child may have used their inborn tendencies, such as perfectionism, drive, or self-restraint, to find favor and to feel more secure. Most unhealthy compulsives become so when their energy and talent are hijacked and enlisted to prevent feelings of shame and insecurity, and to prove that they are worthy of respect, inclusion, and connection.
  3. Identify when their coping strategy is still used to cope with anxiety. Recognize if and how they still use that coping strategy as an adult. Most coping strategies used to ward off anxiety will diminish if the anxiety is faced head on rather than avoided with compulsions.
  4. Address underlying insecurity. Question their self-criticism and replace it with appreciation for their inherent individual strengths, rather than pathologizing or understanding them as reactive or defensive. Reframe their personality as potentially constructive. I’ve seen this perspective help many people as they participate in OCPD support groups.
  5. Help clients shift to a more “bottom-up” psychology. Nurture their capacity to identify emotions and learn from them rather than use compulsive behavior to avoid them. Help them to identify and live out the original sources of their compulsion, such as service, creation, and repair, actions that would give their lives more meaning. Help them to make choices based on how things feel rather than how they look.
  6. Identify what’s most important. Most compulsives have either lost track of what’s most important to them, or never knew. Projects and righteousness that they imagine will impress others fill the vacuum. Instead, once they can feel what they were naturally compelled to do, they can use their determination to fulfill it in a more satisfying way.
  7. Identify personality parts. Compulsives try to live in a way that is entirely based on direction from the superego, and they attempt to exclude other aspects of their personality. I have found it very helpful to have them to label the dominant voices in their head (Perfectionist, Problem Solver, Slavedriver), and to identify other personality parts that have been silenced or who operate in a stealth way. Depending on what the client is most comfortable with, we can use terms from Transactional Analysis (Parent, Adult, Child), Internal Family Systems (Exiles, Managers, Firefighters), or a Jungian/archetypal perspective (Judge, Persona, Orphan).
  8. Use the body, the present moment, and the therapeutic relationship. Compulsives rarely experience the present and usually drive their bodies as vehicles rather than nurture them. Bringing their attention to their moment-to-moment experience and using their experience of you as their therapist can help. For instance, bring their attention to tension in their body and, if possible, connect that with any feelings that they have about you. For instance, do they feel a need to comply with you, or any resentment about complying with you?

The Case of Bart

Background

A man in his early forties, whom I will call Bart, came to see me when his wife said she could no longer tolerate his worrying and unhappiness. To his own surprise, he found himself tearing up as he described his life to me. He didn’t do that kind of thing. Ever.

Bart was handsome, fit and bright. Yet he was very self-deprecating.

He told me that he worked in finance and had done well enough to provide comfortably for his family. But his success didn’t register with him at all. He worried about what others thought of him. He feared that people would discover that he was a hoax at his job; he believed his success was accidental and that he could lose it all at any time. At this point in his career, he was just coasting and didn’t find any meaning or challenge in it.

Bart imagined that his family tolerated him only because he provided for them. During our initial consultation, he said he wasn’t feeling bad. But it was clear that he had experienced serious depression in the past, and I suspected that he was still depressed but couldn’t acknowledge it.

His wife was lively, talkative, and highly social, but their relationship was flat at best. He made it a point to say that he did not want to blame her for any of his problems or theirs as a couple. Nor did he want to assign any blame to his parents. Any problems he had were of his own making.

He admitted that he found it difficult to engage feelings. He avoided reflection, journaling, and talking. Like most compulsives, he controlled not just the outer world, but also his inner world. It was hard for him to tolerate uncertainty.

He played organized sports about four days a week, and he had great difficulty tolerating any mistakes on the field or court. He constantly monitored success and failure with a scoreboard in his head. He had quit playing golf because he got too upset when he didn’t play well.

At the end of our initial consultation, I told him that it seemed to me that while he had adapted very well to the external world, he had not adapted well to his inner world. Achieving that would be one of the goals of our work together. I was confident that if he could put the same energy and attention that he had put into career success into his psychological well being, he would see change.

He told me that his impressions of therapy were based on media examples and that he didn’t have any idea how this worked. I told him that I was glad he was asking because we as therapists don’t always do a good job of explaining how the therapeutic process works. I agreed to be transparent about the course of our work, to share how I believed we needed to proceed, and to explain the rationale behind my suggestions. In particular, I would try to be clear about his role in the work.

Narrative

His mother was depressed and a classic martyr. Masochistic, even. She seemed to enjoy her suffering. His father worked as a salesman and was willful, driven, and judgmental. He insisted on success: winning was his religion. For Bart this meant that if his behavior didn’t lead to points on the scoreboard in terms of some productivity or success, it was meaningless. His father said, “it’s good to win.” Bart extended this to “it’s terrible to lose.”

Bart internalized the strategies of both parents, and it caused a terrible conflict: he had imperatives both to lose and suffer (his mother’s masochism), and to win and achieve (his father’s need to triumph). He chose to be more like his father from his teens until he was 25; then he switched and became more like his mother. But he couldn’t let go of the feeling that he should still be winning all the time, in addition to learning, producing, and working all the time. He had lots of “shoulds.”

He had concluded that people want compliance rather than authenticity. He was raised Roman Catholic, and he’d make up things he had done wrong to have something to admit when he went to confession. He told me that he no longer believed in God, so he had to punish himself now. He felt guilty about any sort of self-assertion. He loved post-apocalyptic films because “in that setting, you don’t have to worry about being good anymore.”

Yet Bart didn’t feel that his parents or his environment had any bearing on his current struggles. So I said that the most important thing for us now was to understand how he had adapted to the situation he was raised in.

Coping Strategy

One aspect of Bart’s strategy was trying to control people by giving them what they wanted. Meeting his father’s expectations was only the beginning. Among the four types of compulsives, he was clearly a follower/people-pleaser. He tried to achieve self-acceptance through others’ opinions of him, but it didn’t work, even when he did get accolades.

Another aspect of his strategy was to not depend on others. To do so would rob him of control. It would take time for him to realize that he actually did have social needs, but that, so far, those needs had only gone into impressing others, rather than relating to them. As with many compulsives, Bart felt it was safer to seek respect than to want love.

In his martyr mindset, being a victim implied that he was good. So he often became very negative about his life to prove to himself that he was a victim. He wouldn’t complain verbally to others, but he did need to show himself, at least, how bad his life was. Later he came to realize that his depressed moods were also unconscious attempts to communicate the misery that he could not reveal directly.

He was aware that he had adopted a strategy of planning and perfecting to try to pre-empt the utter self-contempt he unleashed on himself when things didn’t go well. “But why the self-contempt?” I asked. “If I’m self-critical, it will show other people that I won’t tolerate mistakes. But it’s become habitual. I do it even when other people aren’t looking.”

Engaging Feelings

Much of our work involved learning to identify feelings and excavating different levels of feeling so that he could operate from a more “bottom-up” approach. We spoke of therapy as a gymnasium for exercising his capacity to tune into feelings. As with many compulsives, framing our work in terms of a project was helpful in engaging him. I tried to bring attention to what he was feeling in his body and to the present moment.

Most of his feelings were about “shoulds.” Desires were few and far between. Tuning in to desires was a heavy lift for him, but with time he began to be more aware of the difference between acting on fears versus acting on desires.

At times Bart felt like giving up, whatever that might mean. I recommended that he take that seriously but not literally: What is it that you really need to give up? What is the control that you would be happier without?

As he let go of self-control, anger began to surface and eclipsed his sadness and anxiety. Part of him believed that he always did the right thing, and he got angry at those who didn’t. While he was typically self-effacing, it was new for him to acknowledge that in some ways he felt superior.

But we also needed to continue to excavate even more deeply beneath his anger and judgement to see if there were yet other levels of fear or sadness. While it was scary and sad to acknowledge how much was out of his control, it was a relief not to be avoiding it.

When he first came into treatment he had imagined that therapy would remove all his uncomfortable feelings. But with time he came to realize that it was okay to have feelings—sad, anxious or angry—and that he could learn not to amplify those feelings or carry them needlessly. With time, he didn’t need to avoid them so thoroughly.

Identifying What’s Important

Even as he learned to turn his focus inward, he found it hard to articulate his goals in life, career, and therapy. He had lost track of himself and what he really wanted long ago.

Because he had little access to feeling, he was unable to find direction. He obsessed about his job and whether to change companies or even careers. He liked the idea of a new career, especially one with a new identity, but he couldn’t follow through on that. He feared losing the fantasy of what it would be like if he did change.

As he navigated his professional and personal world, I often had to ask him what was most important to him. At first this was distressing, since he had no idea who he was or what he wanted. He was always climbing mountains, but he wasn’t sure whether taking on challenges was something he felt he was supposed to do or something he wanted to do. This skill of distinguishing how something looks from how it feels has been essential to the improvement of most of the people I work with. He couldn’t tell the difference, and we kept revisiting the distinction.

In his efforts to succeed, he’d lost track of why he wanted to succeed. Any sense of fulfillment in accomplishments was replaced by the need to achieve to prove to others and himself that he wasn’t a fraud. Over time he came to recognize that taking on challenges was fulfilling, that he genuinely enjoyed it, and that it was vital to his feeling better. But to enjoy it, he had to let go of using the challenges to prove his worth.

He had similar realizations when telling me about learning: this wasn’t just something he should do to silence his father’s demanding voice, it was something that was very satisfying. He didn’t have to do it, he wanted to do it. And that made it more pleasurable.

We explored his feelings about his marriage. He did value his marriage but was reluctant to depend on his wife: “I’d like to think that I don’t need my wife, but I do. And because I don’t want her to be too important, I don’t take in her support.” This would have made him too vulnerable and would have gone against the masochism he adopted from his mother.

It was a small revelation to him when he was recounting his weekend and noticed that spending time with his son had actually been pleasurable. It wasn’t just a “should.” Noticing this feeling of pleasure was a small window into what was most important for him. “I’ve been putting points in the wrong basket all along, thinking that making money was most important…I have to challenge the idea that piling one more dollar on the stack will make me feel better.”

He came to value more peaceful emotional states—being more present and accepting, and less regretful and judgmental.

Transference & Countertransference

Coming to therapy was not comfortable for Bart, partially because he felt he wasn’t “good” at it. “I remembered that he had quit playing golf because he wasn’t good at it and wondered to myself if the same could happen with therapy”. Still, his ability to speak to me directly about his discomfort was a success. Doing so served as a sort of psychoanalytic exposure therapy, staring down his deep fear of being real and of being known, with the added advantages of eventually understanding the causes and functions of those fears.

He once asked whether therapy was like confession. I explored what it was like in that regard for him and reminded him that when he was young he would make up sins to take to confession. Would he need to do that here? He didn’t think so.

He admitted that he wanted to learn the language of psychotherapy to please me. “Sometimes I tell you what I think you want to hear. I never lie to you, but I do try to figure out what you want.” He felt pressure in the silence to figure out what he was supposed to say. We explored this as a good example of his strategy.

“I’m afraid you think I’m a dick,” he said. “I’ve got so much, what’s my problem? Why am I complaining? You must think I’m just indulging here.” Was this feeling unique to our situation, or was this actually typical of how he felt with most people? He acknowledged that he never felt that it was okay to feel even tolerably accepting of himself, much less feel really good. That would be indulgent and arrogant. And it would invite humiliation.

He had imagined that I would give him a thumbs up at some point, certify him as mentally healthy, and send him on his way. We used this as an opportunity to distinguish what was more important: what I thought about him or how he felt about himself.

Allowing me to know him, and questioning how he imagined I saw him, was a step in the direction of being more open with people in general. Looking for parallels with what he imagined I thought of him, we explored the difference between what he imagined his wife thought of him, and what she really thought of him. As he felt less criticized, anxious, and depressed, she scrutinized him less, and he began to feel more comfortable with her.

“I also experienced my own discomfort with him”. I feared that he would run out of things to say and that I would be exposed as not having anything to offer him. I was not able to work this through completely, but in retrospect I suspect that my fears of being found inadequate were both induced and my own.

He missed a fair number of sessions. Even accounting for the fact that business meetings came up last minute, it still seemed that he avoided his issues at times by not coming. I thought it might be fitting for this to be an imperfect therapeutic process, and that my accepting that was going to be instrumental in his progress.

Despite how imperfect it was, he did make progress. Candor, which had been ego dystonic, was becoming ego syntonic. His coping strategy was changing, and we both came to enjoy his increasing freedom to be himself in the sessions.

Treatment Process: The Agents of Change

My goal in treatment with most compulsives is to enlist their natural impulse to become a “better” person and put it in service of their psychological growth. With Bart I never used the word compulsive, much less mention the diagnosis “OCPD.” But I did note his strong, natural drive to succeed and to be a good person.

Bart did seem to get this eventually: “It's kind of like I'm waking up and realizing that the game I was playing, putting points on the scoreboard, was meaningless, but this process of understanding myself and feeling better is more important. It feels good when I get it, when I master it.”

These realizations included questioning the narrative that he had to be like either of his parents. Near the end of his treatment he told me, “I want to take the best of my mother and father, and not be so black-and-white about it.”

Another aspect of his narrative that we needed to question was whether his family needed him only for money. Maybe they wanted him to be happy as well. Accepting this as a possibility required some vulnerability on his part. He couldn’t remain aloof if they actually cared about him. I believe that his work on opening to feelings in our sessions was instrumental in allowing him to feel closer to his family.

On occasion he wanted assignments for the week. I chose exercises to help him become more aware, in the moment, of how his old coping strategy affected him. For instance: “Try to notice when you stop yourself from feeling good. Count the times you do it. Just noticing it is great.” And, “Notice how many times perfectionism leads you to attack yourself.” Compulsives love to count. What he counted was changing.

We explored different parts of his personality. “What if I’m an asshole that just likes money? What if I just like being seen as generous but I’m really not?”

“Yes, part of you likes money, and part of you likes being seen as generous. Those are both okay. And there is more to you. There is also a part that genuinely likes to be generous whether anyone sees it or not.”

He wondered if it was okay to be ambitious. Somehow it didn’t feel right. The more we processed this, the clearer it became that it wasn’t so much money that was important to him, but achievement and mastery. There was a part of him that loved challenges. To say what he loved was a new expression and marked acceptance of a part of him that he had only vaguely recognized before.

Accepting his introversion was another challenge. He definitely liked his time alone but felt guilty about it, which of course meant that spending time with his wife and others felt like it was in the “should do” column, not the desire column. In the long run, he came to appreciate both being alone (without guilt) and spending time with his family, because it was no longer a “should.” As different parts of him came out of hiding, it became clearer what was important to him.

All these elements served to reduce the insecurity he felt, so that he didn’t need to prove himself…as much.

Termination

After 19 months Bart felt well enough to end treatment. We spent a few weeks processing the termination, especially what it was like for him to end it rather than me. I would have liked to see him longer, but that may have come out of my own perfectionist ideas about how long treatment should go on and what it should accomplish.

I would like to have seen him develop more comfort with the therapeutic process itself, but that too comes from someone whose intense interest in psychology developed when he was a teenager. Maybe not everyone needs to be comfortable with therapy, much less actually enjoy it. It was a very good sign that he decided to end treatment rather than feel he needed to stay to please me. I hope my acceptance was healing.

“I will never know how much, if any, of his progress was a well-performed recovery”. But I suspect that even if his first efforts to be authentic were to please me, they eventually became truly authentic. I suspect that he had experiences and insights that will help him change and be more fulfilled, even well after our work is finished.

Working with compulsives has forced me to examine my own biases, my own need to control, and my own rigidity. If nothing else, I learned that I can’t expect my patients to become any more flexible than I am myself. This includes challenging my own fixed ideas of how treatment should go with each new client.

Conclusion: Poison as Medicine

Jung said that individuation is a compulsive process, that we are compelled to become our true, authentic selves. When that process is blocked, neurotic compulsion ensues.

When we recognize the constructive potential of the obsessive-compulsive personality, we can help make it less “disordered.” When we recognize the energy that’s gotten off track, we can help direct that energy back toward its original, healthier path. The adamancy about doing the “right thing” that turned against the client and the people around them can be enlisted to help them find their way to a more satisfying way of living.

The alchemists were known for trying to transform lead into gold, which was really only a metaphor for transforming the poisonous, dark struggles of our lives into the incorruptible gold of character. But I think that this metaphor works best when we understand that the gold was there all along, obscured and waiting to be released.

References

American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). https://doi.org/10.1176/appi.books.9780890425596

Diedrich, A., & Voderholzer, U. (2015). Obsessive-compulsive personality disorder: a current review. Current Psychiatry Reports, 17(2), 2.

Haslam, N. (2003). The dimensional view of personality disorders: a review of the taxometric
evidence. Clin Psychol Rev, 23(1), 75-93.

Hertler, S. C. (2015). The evolutionary logic of the obsessive trait complex: Obsessive
compulsive personality disorder as a complementary behavioral syndrome. Psychological
Thought, 8(1), 17-34.

Koutoufa, I., & Furnham, A. (2014). Mental health literacy and obsessive–compulsive personality disorder. Psychiatry Research, 215(1), 223-228.

McIntosh, P., Paulsen, L. Mental health literacy of OCD and OCPD in a rural area. The Journal of Counseling Research and Practice, 4(1), 52-67. Available at https://egrove.olemiss.edu/jcrp/vol4/iss1/4.

McWilliams, N. (2014). Psychoanalytic Diagnosis. The Guildford Press.
Pinto, A. (2016). Treatment of obsessive-compulsive personality disorder. In E. A. Storch & A. B. Lewn (Eds.), Clinical handbook of obsessive-compulsive and related disorders (pp. 415-429). Springer International Publishing AG. 

The Four Brahmaviharas and the Quiet Inner Voice

Posted on by Psychotherapy.net Team

My patient, whom I’ll call Andrea, is a lovely woman in her 60s. She wakes at 4 am each night, stomach clenched with worry about her adult son, who just left his job without a clear plan for his next move and appears quite depressed. My patient leans her head against her hand, and through the video screen, I can see the worry lines tight across her face. She is terrified that he has made a terrible mistake in leaving his job, and she is fighting the urge to micromanage his every decision. “Feeling his pain is so much worse than feeling my own. I just want to make it stop,” she tells me. She and her husband have been at odds about the situation—he tells her she worries too much, and she thinks he isn’t worried enough. “I am all alone in this.”

We explore her good reasons for feeling anxious through a “Positive Reframe” exercise, which comes from TEAM therapy, developed by David Burns. In this exercise, we explore how painful negative symptoms can be useful and can reflect our most deeply held values. “It shows I’m paying attention, it keeps me vigilant about the situation,” she reflects. Indeed, she has been very proactive about helping her son find a good therapist and has been brainstorming with him about leads for a new job. She identifies the values that underlie her worry—“Seeing his pain hurts so much because I care so much about him. But I know my reaction pressures him, and that’s not helpful. I just want him to be happy!”

Most recently, Andrea and I discussed the Buddhist concept of the Four Bramaviharas or the “divine abodes.” They are 1) Metta—loving-kindness or goodwill, 2) Karuna—compassion, the awareness of the suffering of others and the desire for it to stop, 3) Mudita—sympathetic joy in the happiness of others, and 4) Upekkha—equanimity.

When she examines her underlying motivations, it is clear that Andrea is manifesting Metta for her son. She wants him to be happy. She is also demonstrating Karuna, compassionate awareness of his suffering and desire for it to stop. And by coming to see me, she demonstrates both Metta and Karuna for herself: she recognizes a need to bring things into balance and bring down the level of her suffering, which she can see does not help either of them.

She finds this part of our conversation helpful: “It’s a good reminder that I don't need to believe all the things my mind tells me, like that I’m not a good mom. I’m feeling pain because I care about him, not because I’m doing something wrong.”

“And what about the thought, ‘I’m all alone?’” I ask her. “Could there be a kinder way to speak to yourself?”
“What do you mean?”

“Well, what if instead of saying ‘I’m all alone,’ you said, ‘I’m with myself’?” Changing the words we use is an example of one of Burns’ cognitive methods, the “Semantic Technique.”

She looks up thoughtfully as she tries that on. “My first response is that I don’t really want to be with myself. No wonder I feel lonely! It’s interesting to imagine being ‘with’ myself.”

“Are you willing to try that right now?”

She nods.

“Go ahead and turn your attention inward. When you think about your son’s suffering, what comes up for you?”

Her face tightens into a grimace. “I feel a strong tightness in my chest—right here,” she gasps. I feel a swell of admiration for her as she stays with the difficult sensations.

“That’s great, keep going. What else do you notice?”

She falls silent. “Yes,” she says finally. “I have a teacher who says, ‘the wise voice is quiet.’ When I listen more carefully, I hear a voice that says that what my son needs is this, what’s happening right now, this kind of being-with. I can’t fix his depression or make him find a job. But I can be with him. And I can be with myself.” She smiles. “If I’m listening to a wise voice, I’m not all alone, am I?”

We sit together in silence. Then she continues, “I feel less helpless and desperate. His depression, my anxiety, they are part of being human. It’s okay.”

She has hit upon the fourth Bramavihara—equanimity. The willingness to be fully present with things as they are. Equanimity acts as a natural brake on compassion and our tendency to become preoccupied with the feelings of others.

“My teacher has taught me an equanimity prayer,” I offer. “I call it ‘a mother’s prayer’. I’ve found it helpful in parenting, if you’d like to hear it.”

“Sure,” she replies.

“It goes like this: ‘Things are just as they are. Joy and sorrow arise and pass away. Your happiness depends upon your intentions and your actions, not upon my wishes for you. I love you, but I cannot prevent your suffering.”

“That’s nice, I like that.”

“I added a line: ‘I delight in your capacity to make your own decisions, even if I don’t agree with them.”

She laughs. “Oy. That’s a tough one. What if his decisions are making us both miserable?!” She pauses and answers her own question. “I understand. I want him to be his own person, and he has to figure out his life from his own experience.”

Mudita, the third Bramavihara, fills us with sympathetic joy in the happiness of others, even if we did nothing to create it.

“I’m grateful for all the times my parents let me make my own mistakes, I suppose I can take pleasure in his being able to do the same. I guess I know what I’ll be practicing this week.”

***
 

And so, by sitting with herself, Andrea weaves together the message of the four Bramaviharas, guided by the wisdom of her quiet inner voice.
 

What the APA Apology Means for Black Psychiatry

Posted on by Psychotherapy.net Team

On January 18, 2021, the world of psychiatry experienced something historic when the American Psychiatric Association acknowledged and issued an apology for their part in a history of racism¹. There is no doubt it was time for this monumental moment, which markedly took place on this year’s celebration of Martin Luther King, Jr. Day.

This apology doesn’t erase all of the history that is behind it, and it doesn’t solve everything that may come. Yet after the history that has led to the APA’s need for an apologetic statement, this is an important step forward. This is a milestone for Black psychiatry and for all of us, really, in the African American community. I believe it may even deserve its own place in the history books.

For Black American, the history of our country has been paved with injustices, many of which have had a lasting effect on every facet of mental health, from assessment to treatment. The trauma of the African American community goes back many generations to slavery. The history behind the need for the APA’s apology goes deep into our past and can still be seen in the current practice of psychiatry². Going back all the way to the very beginning, the necessity of this apology is painfully clear.

The roots of racism in the psychiatric field go back a very long time. Diagnoses of mental illness were used to justify the view of Black slaves as inferior human beings. A supposed mental illness invented by Samuel Cartwright called “dysaethesia aethiopica” was used to explain a slave’s “laziness” and disinterest in their forced lifestyle³. In those days, the work of mental health professionals was only used to harm Black Amercians, not help, as it is meant to do.

The APA was meant to be an institution that kept racism from being fully actualized. The organization should have been there for the mental health support of all Amercians. Instead it was founded on principles that allowed Black patients and White patients to receive separate and vastly different levels of quality in care. It should be clear who was given real support, and who was left to suffer.

Time and time again, injustices were suffered by the Black community, and APA was among those who remained silent. Again and again, the mental health of Black Americans was both damaged and neglected while society stayed silent. Racism remained an issue within American psychiatry and someone should have spoken up, but APA didn’t.

APA repeatedly did not support civil rights legislation meant to improve psychological conditions for Black people. They neglected at the most crucial of times to do anything more than offer mere consolation to the people who were really hurting. Regardless of how widespread race-related inequality was at the time, the APA has missed many opportunities to speak up before this recent apology.

This history has piled onto the state of mental health for Black patients today, and it is about time that we hear the APA take accountability for its actions and inaction. Racist beliefs were integral to the damage that has been caused in the long history of Black psychiatry in this country. African Americans were declared biologically inferior, and that bias never fully went away. From Cartwright’s categorization of an entire race of people as simple and lacking emotional complexity, to the still very recent disproportionate diagnosis of schizophrenia in the BIPOC (Black, Indigenous, and People of Color) community?, systematic racism runs through the field of mental health and has done so for a very long time.

The APA’s apology is a small step in the right direction. The damage done has been far too great, but this is not insignificant. Truly, it represents something incredible. Mental health treatment is so important for people, especially for those in the Black community. This is the work that helps people heal from trauma and address the disorders and mental struggles that make everyday life difficult. With the apology we have received from APA, we can gladly find ourselves so much closer to reaching what the mental health system in this country should be.

What this represents is hope. We have made it a great deal forward, and now we can continue to find hope for better in our future. On the day that I saw this apology, I celebrated, not just for the moment itself, but for what this means for what may come. While I’m glad for the APA’s apology, I’m excited to see more medical organizations stepping up to do the same. I have hope that this is only the beginning, and that this apology truly represents a positive move towards improved mental wellness in our community.

References
American Psychiatric Association. (2021, January 18). APA apologizes for its support of racism in psychiatry. American Psychiatric Association. https://www.psychiatry.org/newsroom/news-releases/apa-apologizes-for-its-support-of-racism-in-psychiatry.

American Psychiatric Association. (2021, January 18). Historical addendum to APA's Apology to Black, Indigenous and People of Color for Its Support of Structural Racism in Psychiatry. American Psychiatric Association.
https://www.psychiatry.org/newsroom/historical-addendum-to-apa-apology.

In 1851 a scientist “discovered” a disease that caused slaves to run away, this was the prescribed cure… (n.d.). Watch the Yard. Retrieved 16 March, 2021, from https://www.watchtheyard.com/history/drapetomania-dysaesthesia-aethiopica/.

Schwartz, R. C., & Blankenship, D. M. (2014). Racial disparities in psychotic disorder diagnosis: A review of empirical literature. World Journal of Psychiatry, 4(4), 133–140. https://doi.org/10.5498/wjp.v4.i4.133

Understanding the Pandemic’s Impact Through a Developmental Lens

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Rounding the Corner?

As we round the corner on the first year of living with COVID-19, it behooves us to ask the following questions: where is the intersection between developmental theory and the pandemic, and how can therapists use this information in their clinical work? Despite similarities in our clients’ experiences, there are significant differences, due solely to age, in how the pandemic has affected their lives. Although the pandemic has been discussed from a multitude of perspectives, such as race and socioeconomic status, most commonly it is referenced as a singular event, i.e., the pandemic. In fact, our clients’ age at the time of the pandemic is bound to influence their life both now and in the future. For many, the pandemic has had a devastating impact on their health, food security, learning, and living environment, but even for the more fortunate, living through a pandemic has had an impact on their long-term development as well.

The landmark study by Wallerstein and Kelly, Surviving the Breakup: How Parents and Children Cope with Divorce (2008), changed the conversation about the consequences of divorce on children as a function of their age at the time the marriage ended. As I reflected on that study, I thought a similar examination of the significance of the pandemic across ages would be valuable. Since we have yet to experience the true end of the pandemic, these are preliminary musings meant to be formative rather than summative; I offer them with the hope that as therapists our voices will contribute to writing the history of the consequences of living through a pandemic. 

The fields of psychology and psychotherapy are often bifurcated along normal/abnormal lines on the individual level, but what does it mean developmentally when entire populations have been thrust into the abnormal state that has resulted from COVID? We are living through abnormal times, and our clients are expressing their desire for normalcy. And the various ways they are expressing their yearning for normalcy are not merely a reflection of their pre-COVID lives, they are a function of the developmental tasks that were thwarted by the pandemic. 

Across the Lifespan

Infants and very young children have a multitude of developmental milestones to meet. The tasks of language development and early socialization were severely challenged by mask wearing and lockdown restrictions. Children as young as preschoolers have been taught to stay away from others and not to share their toys. We can only imagine how hard parents and teachers will have to work in an attempt to reverse the message that the world is a dangerous place when these children return to in-person early education programs. Maintaining six feet of separation and wearing a mask is a challenge for most adults, let alone three-year-olds. Starting life from the vantage point of mistrust has far-reaching implications. Healthy autonomy rests on a foundation of trust in the adult caregivers in a young child’s life. For those young children who fear venturing into the world, critical developmental tasks will be harder to achieve.

In addition to falling behind academically, latency-age children lost many opportunities for extracurricular activities and the friendships they foster. Rather than having the typical, slow movement toward freedom, their options for exploration were limited. Adolescents were deprived of the chance to stretch their wings and assert their independence. One father in my practice said, “I hate seeing my kid on the couch hour after hour. He has nowhere to go, but I’ve got to wonder, what is he really learning about life?” Will our younger clients’ sense of the world and themselves be forever diminished by learning how quickly everything can be upended?

As college students returned home, frustrated at having their longed-for college years reduced to online classes in their childhood bedrooms, the rise in reports of depression were significant but not unexpected (Anderson, 2020). Young adults couldn’t find jobs and “failed to launch.” Some of my young adult patients adapted easily to working remotely and created pods with a select group of friends. This was true for some older adults as well, and many families came to appreciate the opportunity to spend more time together. Those who did date tended to commit quickly to each other to feel COVID-safe. In many cases, their friends and family never got to meet their partners, and couples had few opportunities to explore activities together as a way to assess compatibility. Depending on how many of these relationships stand the test of time when the world reopens, we may see a delay in marital age for this generation.

Other adult patients put significant life markers, such as having children, on hold due to the restrictions of lockdowns and the fear of spreading or contracting the virus. It is too soon to know how these delayed rites of passage will impact their futures. One mother in my practice, who has a toddler, is rethinking her desire to have more children as she waits for the data on the safety of the vaccines and pregnancy to be made public. Parenting as a rule presents inherent challenges, but as the toll of the pandemic has worn on, many of the parents in my practice voiced concern about their ability to juggle the responsibilities of work and home. Those parents with children enrolled in remote learning were at great risk both emotionally and practically. Some quit jobs or cut back their hours, while others relaxed their previous sanctions against “screen time” and abdicated specific parental responsibilities out of desperation. Mothers, in particular, were burdened with trying to fill in the gaps created by changes to routines and schedules. As their own needs went unmet, reports of depression and substance abuse increased.

Some adult clients also felt angry that the rug had been pulled out from under them just as they were about to advance in their jobs. The loss of economic stability is bound to have far-reaching consequences for their own futures as well as those of their dependents. As opportunities grew limited, those who had the ability to pivot and embrace a different career or lifestyle fared much better than those for whom the losses are permanent. The long-term implications of either outcome on self-esteem needs to be addressed.

For many of my middle-age and older adults, this time has been one of intense grieving. Many of them experienced their own version of “failure to launch.” Travel plans were canceled, downsizing was put on hold as adult children returned home, and retirement was delayed or accelerated due to economic changes. A patient in her sixties said, “I’d planned to work until 70, but it’s clear with cost-cutting measures (at her company), I’m being forced out. I’m just not ready. And with nowhere to go, what am I going to do with all my time?” She became quite depressed and worried about the quality of her “last chapter.” Others lamented the inability to hug their elderly parents or their grandchildren. The geographical separation from family and friends was heartbreaking and it led to revising priorities. Another patient, a wealthy man in his late fifties, decided to take an early retirement. His response to COVID-19 was to devote himself to his family. After some initial missteps, his family adjusted to this new arrangement. His increased presence in his children’s lives is bound to influence their development as well as his own.

The elderly, who are most at risk of dying from the virus (Centers for Disease Control, 2021), have the least opportunity to make up for lost time. News reports were filled with harrowing photos from nursing homes and hospitals. The lack of stimulation accelerated cognitive decline. Due to the lockdowns, many of the elderly suffered from increased isolation and loneliness. What was lost for this generation may be the hardest to calculate, but their deaths will reverberate in the lives they left behind for years to come. We can only hope that the horrific images of people dying alone in hospitals may inspire a change in how we view the needs of the elderly and end-of-life concerns in this country.

Several of my patients lost parents or grandparents to COVID-19 and other illnesses. Unable to have funerals or attend services, their grief has been much more complicated. Some are living with the pain of knowing their loved one died alone. It has made them rethink their own plans for growing old. Aging in place seems much more attractive to many at this point. As a society, how we manage the grief and devastation of the pandemic will shape the values and aspirations of generations to come.

Hopeful Signs

Across age groups, there have been hopeful signs that some consequences of the pandemic may have changed the culture in ways that might promote successful development. This is by no means to imply that the loss of life and cost to our economy were worth a pandemic, but it is helpful to consider what positive learnings we can take for ourselves and for our clients into a post-pandemic world. Awareness of climate change and the Black Lives Matter movement took on heightened significance around the globe. These attentions will hopefully have long-reaching consequences for improving the lives of younger generations and those with whom we work. Also, out of the necessity of scaling back our lifestyle during lockdowns, many people deepened relationships with a few key people in their lives, improving their feelings of being connected in the world. Time and again, what I heard from clients was an appreciation for the slower pace of life necessitated by pandemic protocols. The opportunity to work remotely enhanced job happiness for many. The absence of commuting and the limited availability of extracurricular activities was a game changer in terms of time management. As one client said, “I never had time to think before, I just did. Now I’m asking myself, what do I really want in my life?” Reconfiguring work/home boundaries is likely to be one of the most significant by-products of the pandemic.

Some found comfort through a heightened relationship with nature, which deepened their life satisfaction. Seeking time outside was a positive outlet. One client, who is a runner, appreciated the decrease in traffic and went on longer runs since he no longer commuted to work. “As I watched the seasons change and heard the birds like never before, I found renewed energy,” he said. In general, there was an appreciation for the preciousness of life and a sense of urgency to not waste time.

Personal Reflections

As I reflect on my own experience during the pandemic, I am reminded of the influence another historical event had on my life, albeit indirectly. My parents were both children of the Great Depression, which had a devastating impact on their formative years. They did not have to maintain social distance or wear masks, but each of their families suffered significant economic loss. Worries about money and food scarcity were constant themes in my house as I was growing up, even though by then my parents were leading a solid 1960s middle-class life. Both their scars and their ability to survive were underpinnings in how they made choices as adults and parents, and what they wished for their own children’s futures.

It is still too early to comprehend the full impact of the pandemic, but we already know that the longevity of American citizens dropped by a full year due to COVID (Andrasfay and Goldman, 2021). Nonetheless, it is not just the loss of a single year that will define the lasting impact of the pandemic. As I listen to my patients grappling with life during and, hopefully, post-pandemic, I applaud their resilience while acknowledging to them what they have lost during the pandemic. As the fear of the virus abates and we move out of abnormal times, our challenge will be to understand what normal development will look like in a post-pandemic world and to support each person’s quest to become their best self.

Reference:

Anderson, G. (2020, September 11). Mental Health Needs Rise With Pandemic. Inside Higher Ed. https://www.insidehighered.com/news/2020/09/11/students-great-need-mental-health-support-during-pandemic

Andrasfay, L. and Goldman, N. (2021). Reductions in 2020 US life expectancy due to COVID-19 and the disproportionate impact on the Black and Latino populations. Proceedings of the National Academy of Sciences Feb 2021, 118 (5) e2014746118; DOI: 10.1073/pnas.2014746118

Centers for Disease Control. (2021, February 26). Older Adults. https://www.cdc.gov/coronavirus/2019-ncov/need-extra-precautions/older-adults.html
Wallerstein, J. S., & Kelly, J. B. (2008). Surviving the breakup: How parents and children cope with divorce. Basic Books.

3. https://health.clevelandclinic.org/pandemic-isolation-can-be-especially-hard-on-older-adults/

Termination: A Process by Any Other Name

Posted on by Psychotherapy.net Team

My client, a psychologist by training and fellow traveler through COVID’s unforgiving landscape, had initially visited with me because of anxiety and his growing difficulty managing it. Accustomed to a take-charge style that centered around scanning his environment for potential threats to his family, he had grown tired, not just of the challenges COVID presented, but from the sheer effort and energy it took to manage his anxiety. The details of our work can be found in a recent blog I wrote, so I will fast forward to the later portion of our time together when we began reviewing the path forward for him (and us)—life after therapy.

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As we reviewed his progress, it became clear to both of us that he had made significant gains in managing anxiety, breathing a bit more into his life and enjoying moments with his wife and children. All of this without the pressure that came from constantly scanning his inner and outer worlds for threats and subjugating himself to a harsh inner list-maker. His goals were being addressed and he was making significant changes and progress. The time for planning an ending to our work was approaching, so I broached the subject.

The conversation quickly pivoted to the word “termination,” and although I had used it numerous times with past clients and in my teaching and writing, it suddenly felt quite leaden rather than a natural part of the therapeutic process. Perhaps because I was particularly fond of this client, termination felt like a loss and triggered my own attachment issues and deeper existential concerns around loss.

I considered each of these and sought the wisdom of those who had come before me in order to move more comfortably into this uncomfortable space with my client (and myself). From a developmental perspective, termination suggested a separation/individuation process that, while inevitable and painful for some clients, was a harbinger of growth. From a traditional analytic perspective, termination followed resolution of the transference, awareness of defenses, strengthening of the ego, and a lifting of repression, while more contemporary analytic theory favored a more natural progression in the relationship between therapist and client. Jung believed that termination reflected the client’s awareness of a new philosophy for living—an awakening—and as such carried a more growth-oriented valence. Anchored in a more positivistic appreciation of the role of therapy, humanistic theory suggested that the final phase of treatment focused around movement towards growth and accomplishment. Finally, from a more pragmatic and behaviorally-oriented perspective, termination is the logical and planned conclusion to a predictable, scientifically-grounded, ends-oriented intervention.

And then I came across an interesting article (Maples & Walker, 2014) that reviewed and critiqued the label “termination.” I liked what these authors had to say because they, like I, had considered that termination and its historical associations and connotations were weighted down by historical attempts to find just the right name for the final episode of the therapeutic relationship, and that most of these attempts had resulted in a negativistic perception of termination, mostly around loss. In response, they proposed the concept of “consolidation,” which suggested a normative process centered around the stabilization, strengthening, and reinforcement of therapeutic gains—a preparation for the client’s journey ahead without the therapist.

All of these concepts, particularly the latter, made sense but left me wanting more. I sought something a bit more post-modern: a collaboratively derived and meaningful frame for this particular moment in the therapeutic portion of my client’s journey with me in therapy.

***

So, in our most recent session, I asked my client, “what would you like to call this phase of our work together?” And he simply said, “I’d like to call it the comfort zone!”

Seemed simple enough, but I sought clarification. What did this actually mean? His response was “I’ve gotten to a place where I am comfortable with myself.” There it was! My client was not deeply immersed in labelling this latter phase of our work, nor was he reflecting on our separation. He had done what he came for. The simplicity of his “comfort” was comforting to me because our work, and I, had helped him find his way there.

What’s in a name? Everything, as long as it is of the client’s making.

References

(1) Maples, J. L., & Walker, R. L. (2014). Consolidation rather than termination: Rethinking how psychologists label and conceptualize the final phase of psychological treatment. Professional Psychology: Research and Practice, 45(2), 104-110.

The Thought Process Underlying Perfectionism and How Therapists Can Help

Posted on by Psychotherapy.net Team

As I listen to my clients describe their “maladaptive” ways of functioning, I usually discern adaptive elements in the patterns they perceive as dysfunctional. This surprised me at first but doesn’t anymore.

It is as if their symptoms have a point, and the problem is that they have taken this point too far. If so, the solution is not to reverse the problematic way of functioning but to dial it down into a more moderate range—a smaller and more readily attainable goal.

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But not necessarily an easy one. Research indicates that black-and-white thinking lies at the root of many mental health problems. Thinking in simple binaries makes it impossible to dial behaviors down because, if it’s not black, it must be white—there is nothing in between. There are many examples of this pattern, and perfectionism is one.

Perfectionism is a schema that recognizes just two categories of performance: perfect and unsatisfactory. There is nothing in between.

Perfectionism doesn’t work. Research indicates that it is associated with low self-esteem, depression, eating disorders, and, ironically, poor productivity. Nonetheless, perfectionism has a valid purpose: it can be rewarding to strive for high levels of performance.

Kirsten was a middle-level manager who looked successful from the outside but suffered from anxiety that was mostly related to her job. She worked long hours but said she was always behind. She had nothing but critical things to say about her performance, although she acknowledged that her evaluations were more than satisfactory. I also noticed that Kirsten frequently disparaged her performance as a therapy client: I found what she said quite clear, but she often interrupted herself with comments like “That didn’t make sense” and “I’m all over the place in the way I’m telling you this.”

Replacing Binaries with Spectrums

The alternative to black-and-white cognition is to think of psychological phenomena in terms of spectra. The spectrum relevant to perfectionism concerns personal standards for performance. The question is: what is good enough? Here is the continuum of possible answers:

1———-2———-3———-4———-5———-6———-7———-8———-9———-10
Horrible      Bad      Mediocre      Okay      Good      Excellent      Perfect

Clients with whom I have worked vary in how they answer this question. Almost none think that performances in the 1-3 range are good enough, but then variability kicks in. Some are content with performances that are below average but halfway decent, and standards range from there all the way up to perfectionism, with lots of gradations in between. I ask clients to mark the point on the scale that represents their answer to this question. Fractions and decimal points are often given by perfectionistic clients, who like to be precise, and Kirsten’s answer was 9.3

In black-and-white thinking generally, spectra are chopped into dichotomies. The two halves might be very unequal in size, because the dividing line might not be anywhere near the midpoint. We can understand clients’ thinking at a deep level by asking ourselves the question, “at what point does the client dichotomize the continuum?”

In black-and-white thinking about performance quality, perfectionists divide the continuum with a cut-point so close to its end that almost all of the spectrum is viewed as representing failure, with just a thin slice for success. On the above spectrum, the cut-point would be between 9 and 10. This lop-sided dichotomy results in constant failure experiences; it helped to explain why years of positive performance evaluations and promotions had not ameliorated Kirsten’s feeling that she was barely keeping her head above water as a professional.

To provide a visual illustration, I draw an arc over each side of the binary, label the large one “failure,” and label the small one “success.” This diagram illustrates the onerous nature of the standards by which perfectionists evaluate themselves.

The Goldilocks Zone

I generally try to help perfectionistic clients moderate their standards, but at first the idea of doing so makes many of them anxious. Their fear of lazy laxity may be so strong that it propels them to the opposite end of the spectrum: perfectionism.

Kirsten acknowledged that she strove for near-perfection in her approach to tasks, but her understanding of the problem was not that her standards were too high but that her performance level was too low. She said, “I need to strive for perfection to improve. If I start going easy on myself, I’ll become lazy and do even worse.”

This fear is the result of dichotomous thinking: if standards are not perfectionistic, they will be loose and sloppy. The solution is to replace this binary with another spectrum:

1———-2———-3———-4———-5———-6———-7———-8———-9———-10
Lazy slacker      Easy-going      Average      Conscientious      Perfectionistic

This diagram shows that perfectionism itself can be understood as an extreme on a spectrum of self-evaluative standards that vary in stringency. This spectrum maps onto the previous one—it is about how good a performance must be to be considered good enough. Again, I ask clients to mark their point on the scale. (Kirsten gave herself a 9.2.)

When I help clients move beyond black-and-white cognition to think in terms of spectra, possibilities open. Rather than making either/or choices, clients can learn to think in nuanced ways about the personal standards they would like to have—not too low and not too high.

Not a Point but a Range

This spectrum shows that perfectionism is not so much a bad thing as too much of a good thing. Perfectionists are not wrong to value high standards, but they take a good idea too far.

I have found that it is not necessary to reverse high standards, but only to adjust them toward moderation. Nor is it necessary to adopt the standards of the average person. The solution is to move into the Goldilocks Range, which is an area around the midpoint of 5.5, say between scale-points 4 and 7, or even 3 and 8.

Previously perfectionistic people usually feel most comfortable around scale-points 7 or 8, and Kirsten was no exception. We had some careful discussions about the difference between excellence and perfection and about how a person could be conscientious, exacting, and achievement-oriented without being perfectionistic. I validated the value of high standards and made it clear that I was not suggesting she become easy on herself and satisfied with mediocre work. The modest but important changes she made preserved her rigorous, hard-working style but moderated it enough to allow some flexibility and satisfaction. Her anxiety level decreased, and she began to enjoy her job for the first time.

This post focuses on perfectionism, but the spectrum strategy applies to a wide variety of mental health and relationship problems, as described in my book, Psychotherapeutic Diagrams. I have found that clients generally function best when they move from the extreme end of a spectrum into the part of the Goldilocks Range that is closest to their original style. For example, aggressive clients become assertive, anxious clients become cautious, and oppositional clients become independent.

A small- to medium-sized adjustment usually changes a maladaptive style into an adaptive version of itself and transforms a problem into a strength. My clients are glad to discover that resolving their difficulties does not require them to become a different kind of person. I ask clients to mark the point on the scale where they would like to be, and the distance from their current position is usually about 2 scale points; this makes the goals of therapy seem quite attainable.

There is a big practical problem with perfectionism: People have only limited amounts of time and energy, life has many aspects, and being perfectionistic about some aspects means short-changing the others, because there are only so many hours in a day. The goal of living a well-rounded life requires us to give up perfectionism.

***

Trying to reverse clients’ habitual ways of functioning can feel like swimming upstream, with opposing currents such as genetics and long-term histories—difficult factors to overcome. When clients realize that the changes they need are not dramatic or wrenching, and a 2-point adjustment on a 10-point scale could change them from an unhappy perfectionist to a hard-working, conscientious person, they feel more relaxed and optimistic, and so do I. Thinking in terms of spectra has brought my therapeutic efforts into accord with my clients’ natural styles and made our work together more harmonious.

References

Shapiro, J. P. (2015). Child and adolescent therapy: Science and art (2nd ed.). Wiley.

Shapiro, J. (2020). Finding Goldilocks: A guide for creating balance in personal change, relationships, and politics. Amazon.com Services.
 

Accurate Empathy is the Heartbeat of Rogerian Psychotherapy

Posted on by Psychotherapy.net Team

Person-centered therapy (PCT) is a radical therapeutic ethic that leads to therapeutic discipline. It is not purely idiosyncratic, with therapists doing anything willy-nilly with their clients, reacting to compulsion or fancy. That is not person-centered therapy in the slightest. Person-centered therapy is a refusal to either disempower clients or to kowtow to scientism. It is a commitment to seek understanding over giving advice and to express genuine regard for humanness.

Unfortunately, critics of PCT often cast it as a kind of therapeutic anarchy or as lacking an empirical research base. While I do not intend this as an opportunity to refute baseless critique, I do wish to convey a more objective view, at a glimpse, of one of the pioneering PCT models: Rogerian therapy. I will also share, acknowledging my own bias against it, a contrast to PCT by one of the many CBT-like therapy models currently being held out as an “evidence-based practice” therapeutic approach. And I’ll provide a glimpse into accurate empathy in action.

Accurate Empathy

Carl Rogers had a highly disciplined view of the person-centered approach. He said many times that therapists should be careful to “reflect the emotionalized attitude being expressed.” In his 1942 volume, Counseling and Psychotherapy, he used this phrase again and again. What he also said again and again is that you should not reflect emotions or aspects of the client’s mindset that you think are there but have not yet been revealed—Rogers said that although you may suppose a client feels a particular feeling or that you suppose a client thinks a particular thought, you should stay with what we now term the intersubjective experience between you and the client. As these “attitudes” surface—not as you surface them—you reflect them in a way as a hypothesis. “When you say _______, or when I experience you _______, you’re bringing in this therapeutic material in a way that we can work with together. Am I getting this right?”

Those outside the fold who don’t understand the person-centered approach may wrongly assume such therapists think of themselves as clairvoyant empaths—that they claim psychic intuition. Person-centered therapists don’t believe they’re clairvoyant; quite the opposite. They deeply value checking their intuitions with clients as necessary for promoting true understanding. At the same time, no model can be purely logical, rational, or objective, and so that perhaps hints at the dialectic inherent in a person-centered paradigm.

The most powerful condition that Carl Rogers talked about was an intersubjective experience that he called “accurate empathy.” What Rogers meant by accurate empathy wasn’t that sometimes there is a kind of clairvoyance—that a therapist who is super-empathic can sense someone’s emotions better than someone else or can better identify with someone else’s experience than another. Rather, he was talking about this way of checking in with the client in an open-handed way: “When you say _______, is _______ what you mean?” “When I felt _______ from you when you said _______, I get a sense from you but want to better understand: are you feeling _______? Or maybe kind of _________?” And if you learn from the client that you were wrong, you gain in trust and in insight; and if you learn that you were right, you gain in trust and in insight.

It’s this careful dance of intersubjective experience—respectful warmness, genuineness, not presuming to know another’s experience—that is what Carl Rogers described when he spoke about “accurate empathy.” It’s why he cautioned us to reflect only the emotionalized attitude being expressed and not to reflect other things—other thoughts, other feelings that we think that the client might be having that they have not said anything about explicitly and would amount to mere conjecture. If we’re truly Rogerian, we can conjecture on the basis only of what the client has expressed to us, not on the basis of what the client has not expressed to us. By doing so, we stay firmly in the flow of the dance with a client rather than putting ourselves in the position of expert, as if we have on one extreme, pure logic, or on the other extreme, clairvoyance. Accurate empathy is the bullseye of Rogerian psychotherapy.

When Evidence-Based Claims and Person-Centered Practices Collide

There is a kind of protocol, then, within a Rogerian approach, but it is important to contrast this with the kinds of protocols we see within “evidence-based practice (EBP)” therapy manuals. One model, which is an offshoot of CBT for which I received training, provides clinicians with a literal “intervention flow.” In the model, called the Common Elements Treatment Approach (CETA), clients experiencing “predominantly anxiety problems” should be treated by (1) Engagement/Encouraging Participation, (2) Psychoeducation, (3) Cognitive Coping, (4) Gradual Exposure: Memories and/or Live, and (5) Cognitive Reprocessing. This explicit ordering directs clinicians in how to provide the moment-to-moment therapy, and these intervention protocols correspond to semi-scripted guidance for the clinician to follow.

To the extent that the clinician diverges from this semi-scripted methodology, they are considered noncompliant with the model’s so-called “evidence-based” methodology. There are similar intervention flows to be utilized with clients who are predominantly experiencing depression symptoms and for those predominantly experiencing symptoms of both anxiety and trauma, for instance.

At the CETA training I participated in, we role played. It was a humorous experience for me and my therapist colleagues as we literally read through scripts and were then evaluated by the trainers on the basis of how we pieced together modular scripts—that is, on the basis of whether the flow of scripts we utilized matched well with the recommended treatment “flow” prescribed by the name-brand EBP treatment model. It felt artificial. It felt antithetical to a person-centered approach. That was a great example of the kind of collision I think many therapists are experiencing within managed care systems that are increasingly requiring fidelity to evidence-based practice models.

These sort of “evidence-based practice” therapies are clearly antithetical to intersubjective experiencing, the fundamental therapeutic factor in a person-centered approach. Imagine how much room a semi-scripted approach like CETA, with its prescribed intervention flow, leaves for personal choice, for client agency, and for intersubjective experience. Almost none.

Leaving Room for Clinical Expertise and Patient Values

In 2005, the American Psychological Association published their Report of the 2005 Presidential Task Force on Evidence-Based Practice. This report is frequently cited as a defense of evidence-based practice. I have heard many who defend the sort of approach that I am criticizing here cite this very report. I am a bit baffled by that when I read from the report myself, which provides this definition of EBP: “Evidence-based practice is the integration of best research evidence with clinical expertise and patient values.” Here lies the hope that EBP does provide space for clinical expertise and patient values. Hope, anyway.

The report also says “the use and misuse of evidence-based principles in the practice of health care has affected the dissemination of health care funds, but not always to the benefit of the patient.” It goes on: “Even guidelines that were clearly designed to educate rather than to legislate, were interdisciplinary in nature, and provided extensive empirical and clinical information did not always accurately translate the evidence they reviewed into the algorithms that determined the protocol for treatment under particular sets of circumstances.”

And, finally, I’ll share this third excerpt: “The goals of evidence-based practice initiatives to improve quality and cost-effectiveness and to enhance accountability are laudable and broadly supported within psychology, although empirical evidence of system-wide improvements following their implementation is still limited. However, the psychological community—including both scientists and practitioners—is concerned that evidence-based practice initiatives not be misused as a justification for inappropriately restricting access to care and choice of treatments.”

I really appreciate this APA report. They provide the cautions, caveats, and contours of getting it right—of the necessity of integrating clinical expertise and patient values. But unfortunately, what I’ve seen is that many times evidence-based practice initiatives are misused.

For those who would defend the promise within evidence-based practice research and implementation efforts, I would have a very difficult time doing anything else but agreeing with the ideals and the shining examples of EBP. My greatest concern is the way that the research on EBP is systematically used to promote scripted approaches that do not leave room for a person-centered approach. Misunderstandings about EBP have been translated into manualized practice and into public managed care contracts, which shapes the terrain of outpatient systems of care and, consequently, the types of therapeutic modalities that in actual fact are being practiced across the world. These contracts have power to reshape our field in really significant ways.

In December 2017, I attended the Evolution of Psychotherapy conference in Anaheim, California, which was attended by many psychotherapy pioneers, including Aaron Beck, the father of cognitive behavioral therapy. Interestingly, in a workshop of Beck’s, he expressed a lot of caution about some of the directions of CBT as a field in itself, and about some of the ways that managed care has misused some of the research findings. But I was utterly stunned by his statements during the Q&A portion of the workshop, when someone asked 96 year-old Aaron Beck what wisdom he might give to young therapists just entering the field. His response? “Read Carl Rogers.”

Unfortunately, many of the so-called evidence-based practice therapies we see in the market now do not leave sufficient space for the type of therapeutic relationship that is most therapeutically beneficial. Some agency settings will provide the space and bandwidth that are necessary to practice with fidelity to your own training, values, and the disciplines within the therapeutic relationship. If you are fortunate to practice in a setting that allows you such space—to practice at a level of integrity—then you are fortunate indeed. I must be careful to acknowledge that honing great skill in this practice requires a great deal of intention and discipline. Some settings simply will not provide the space and support necessary to develop the craft of a skillful person-centered approach. Therapists must evaluate their values and act accordingly.

Accurate Empathy in Action

I can remember that initially Karys was not too happy to sit with me during our weekly sessions. Having experienced a childhood of broken trust and sexual trauma, and after having bounced around between too many foster homes over too many years, she—an older middle schooler—was understandably reluctant to relax into my couch and lean into our relationship.

I administered a simple self-assessment that helped me learn whether Karys had any enjoyment of expressive activities such as writing stories, poetry, and song lyrics, sketching drawings, or sculpting clay. She indicated a particular interest in drawing.

As I maintained a collection of colored pencils and drawing paper in my office, I offered them to her, and, another common practice of mine, I showed her an array of different colored folders she could choose to keep her drawings in at my office, so they would be available to her each week. She was welcome to take any of her drawings home, but I asked that she allow me to make a copy of any piece she would be taking with her. If she did not wish for me to have a copy, I would honor her decision.

Every time that she came to see me, I had art paper and colored pencils waiting for her. I sat with her and attempted to get to know her and to work with her to help her organize her emotions into reflections and her reflections into meaning. All the while, she organized her troubles into sketch art. On one occasion, while telling me the story behind something she had drawn, she fell apart into tears. In the midst of that, she cursed so loudly that I could hear the footsteps on creaky hallway floors of a coworker come to discreetly check on things at my door.

Karys entered therapy oscillating between expressive anger, reflective sadness, and emotional distance. These matched her foster parents’ reports from home. During our first two months of therapy, I observed difficult interactions between Karys and her foster parents, especially highly defensive behaviors by her. In her first several sessions with me, she had seemed emotionally rigid. As time wore along, I began to experience Karys differently. She seemed, in the context of our conversations over her sketch art, to be appropriately vulnerable, emotionally pliable, and more deeply reflective. As I tentatively checked with her my understanding of the feelings she was beginning to express—through her art and verbally—”she seemed to be enlivened by the sheer honesty and authenticity of these encounters”. However, her parents’ reports to me were nearly unchanged; the Karys living at home remained stuck in an alternate dimension.

The difference, in my view, between the kind of expression and interaction that Karys experienced in therapy (eventually) versus the kind frequently experienced during the rest of her weeks was a difference of control. During the week—during the course of her life, for that matter—she felt little of it. There were a number of reasons this could be said to be true. Yet during our sessions, she had a great deal of control. And she liked that.

With her permission, I invited Karys’s foster parents, Boyd and Angie, to join us for three sessions, in which I set the tone with a few rules, designed to keep Boyd and Angie from utilizing our time to provide me information or to bring any other agenda into session. In short, Karys would guide us, with the caveat that, as the therapist, I would take some liberties in providing gently offered facilitation as I saw fit. My goal for my own facilitative efforts was, in essence, to model for Boyd and Angie the rhythm and rhyme, give and take of noticing and asking, along with tentatively checking my understanding of what Karys was communicating about her own thoughts, attitudes, and feelings. According to Karys, I often got it wrong. She boldly corrected me again and again, and I’d check again to make sure I understood as fully as possible. She sometimes expressed irritation when I was “being weird” or dense, yet she was generous in spirit, even still. I’d defend myself playfully.

We’d laugh.

I wondered if Boyd and Angie noticed the elegance of empathic exchange, yet out of conviction, I took care not to slip into a mode of teaching reliant on conveying insight in a way that might be perceived as patronizing. I trusted that their experience would generate a more powerful and sustaining insight. Some time later, Boyd asked to speak briefly with me after Karys had achieved her treatment goals and was discharged from care. He said, “It’s like the light in her has been turned brighter, and she’s opening up in a new way. She actually has begun talking to me about past abuses, just matter-of-factly, really…and what’s more, she’s been kidding around with us a lot more lately.” He also acknowledged, “It really is something, how when we shifted over to what you had modeled for us with Karys, we were able to better understand what she was experiencing. And how she seemed to be able to better understand, of us, the love we had been trying so hard to show. It’s as if we were a threat before. Now we’re getting somewhere.”

*****

Beyond their use in justifying health insurance reimbursement, terms like “pathology” and “disorder” are often untenable and, more importantly, unhelpful categorizations of a person’s experience. Treatment should be no more modular than the person. A wise mentor once contrasted for me the importance of conceptualizing effective psychotherapy as a process of “puzzling through a process with someone,” rather than the kind of rote application of skills characteristic of current forms of “evidence-based practice.”

To become increasingly flexible and resilient, clients must experience freedom within felt pushes and pulls of powerful forces in which problems maintain themselves. Therapists have skillful empathy to offer, and “empathy at its best has power to re-shape experience”. Once clients experience themselves feeling more understood in the therapeutic setting, they often experience themselves feeling more understood in life. Do not underestimate the value of feeling understood.

Accurate empathy is the heartbeat not only of Rogerian psychotherapy, but also of all modes of psychotherapy. Whatever specific model of intervention is being employed, if a therapist is not fully present as a warm, accepting, genuine, and caring person who is truly seeking to understand, then the power center of therapy remains turned off and, for all practical purposes, ineffective. Ultimately, a person-centered process—not a manualized technique—is the most essential active ingredient in therapy.

References

American Psychological Association, Presidential Task Force on Evidence-Based Practice. (2005). Report of the 2005 Presidential Task Force on Evidence-Based Practice. Retrieved from https://www.apa.org/practice/resources/evidence/evidence-based-report.pdf

Beck, A., & Beck, J. (2017, December 16). New breakthroughs in cognitive therapy: Applications to the severely mentally ill, presented at Evolution of Psychotherapy conference, Anaheim, California, USA, December 13-17, 2017.

Merchant, L, Kirkland, C. & Ranna-Stewart, M. (2016, March 10-11). Common Elements Treatment Approach (CETA) Learning Collaborative training, Spokane, Washington, USA.

Rogers, C.R. (1942). Counseling and psychotherapy: Newer concepts in practice. The Riverside Press.

Tokophobia: Recognizing the Multifaceted Fear of Pregnancy and Childbirth

Posted on by Psychotherapy.net Team

“The pregnancy test was negative,” Gretchen recounted through tears. Her tears were not a straightforward reflection of disappointment and longing, as one might assume. They accounted for a complex stew of relief, guilt, and shame about the relief and fear of this ongoing cycle that was proving to be torturous and emotionally exhausting due to Gretchen’s unmanageable anxiety.

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Gretchen and her partner had been trying to get pregnant for several months. Having a biological child was something they both very much wanted. Each month, in the weeks leading up to a possible positive pregnancy test, Gretchen would be excited about the prospect in theory, but utterly terrified about the reality. She often had panic attacks, was inundated with worries about the ways pregnancy and childbirth can go wrong, and was physically repulsed by the idea of a human life growing inside her. The idea of pregnancy made her feel trapped—the state being inescapable and the thought of that, unbearable.

Even before trying to get pregnant, Gretchen had struggled for years with tokophobia, an intense fear of pregnancy. Her extreme difficulty with managing even the process of trying to conceive reinforced Gretchen’s belief that she certainly couldn’t handle an actual pregnancy.

Another client, Octavia, had also been struggling with tokophobia, although hers looked quite different. In our most recent session, she was also in tears. After hooking up with a man she’d gone on a few dates with, Octavia had “spiraled” for days after. “I just couldn’t stop thinking that I’d somehow gotten pregnant,” the notion of this outcome intolerable to her. She was consumed with fear, despite the fact that they hadn’t had sex, let alone gotten fully undressed in their encounter.

Octavia recounted to me the hours she’d spent researching obscure ways of getting pregnant and the repeated phone calls to friends and family seeking reassurance. She knew logically, somewhere in her brain, that it was impossible and felt embarrassed, but Octavia couldn't shake the fear. In the end, she cut things off with the guy.

***

Pregnancy understandably creates a certain amount of anxiety (with a whole extra layer heaped on top given current pandemic circumstances), but for some, the concept itself prompts excessive fear, strong physical responses of anxiety and repulsion, and behavioral avoidance that is debilitating and outside the norm.

Tokophobia wrecks a person’s ability to move forward with their life goals or get close to people—or allows them to do so only under extreme and unrelenting distress. Both Gretchen and Octavia exist in a state tinged with deep pain and impairment—a life not quite lived.

Unfortunately, although this phenomenon is widely experienced, it is not thoroughly researched. There are some, but not enough, comprehensive studies and little in the way of specific treatment guidelines. People are suffering and likely not getting much help—or even realizing that what they are experiencing has a name.

In the literature, tokophobia is broken down into two main types: primary (fear of pregnancy/childbirth without having direct experience) and secondary (fear following a traumatic pregnancy or childbirth experience). In doing more reading and reflecting on my clinical observations of clients like Gretchen and Octavia, I came up with the following distinctions, or subtypes, with the idea that each requires a tailored therapeutic approach, and therefore it’s important to make the distinction.

  • Reluctant: A person with tokophobia who wants to get pregnant
  • Avoidant: A person with tokophobia who avidly does not want to get pregnant and experiences obsessive and extreme worry as well as significant OCD-like avoidance and compulsions.
  • Ambivalent: A person with tokophobia who is uncertain about whether to pursue pregnancy.

For an avoidant tokophobic like Octavia, it wouldn’t make sense to delve into the meaning and source of each of her thoughts or try to dispute each specific worry, when an approach like Exposure and Response Prevention (ERP)—the most effective treatment for OCD—is more likely to ultimately bring some relief. And while it is tempting to treat Gretchen’s reluctance as ambivalence, helping her explore alternative options for growing her family, she is clear in her conviction, but unequipped to manage her physical and psychological anxiety.

Most importantly, I think our job as therapists when working with a client with tokophobia is to 1) take it seriously and 2) conceptualize and treat it appropriately.

My sense is that those struggling with phobic fear of pregnancy and/or childbirth typically feel dismissed, confused, and ashamed (related either to the fact that they feel such fear and aversion to something they expect “should” come naturally to them or to their avoidance and rituals that they recognize as embarrassing/extreme/out of touch with reality).

So when I encounter a client with tokophobia, I often say something like, “Yes, this is a real thing, you are not alone, and furthermore, we can take steps to reduce the shame and nudge you towards the life you want.”

I can offer legitimacy to their experience and compassion to their suffering, while paying attention to the distinct ways tokophobia can manifest person to person. Clients like Gretchen and Octavia don’t have to feel so isolated or hopeless.

The Secret Sauce for Mixing up a World-Class Psychotherapy Blog

Posted on by Psychotherapy.net Team

This won’t sound very scholarly, but for me, the best part of high school began after school let out for the day. It was then I would rush to a small hamburger stand within shouting distance of my home and order a burger, a Cherry Coke, and an order of fries. Just the thought of it is still enough to make me salivate like Pavlov’s dogs. Classical conditioning is not quick to dissipate. Truth be told, both the fries and the burger were just a tad above average. But OMG—and everybody agreed—the sauce was to die for. Virtually every single customer requested burgers and fries with double or even triple sauce. The sauce tasted like catsup, BBQ sauce, and salad dressing combined on steroids. What made the sauce so darn jaw-dropping good? Well, quite frankly, nobody knew. It was a secret. No surprise. The containers behind the counter had the labels removed. For many years after graduation our high school’s yearbook and even the local papers would “reveal the recipe for the secret sauce.” But there was only one problem: every year and every article described a different recipe. Worse yet, about the time I received my high school diploma, this tiny eating establishment, which would hold all of five or six customers on a good day, closed- up shop. A few former employees stepped up to the plate revealing recipes that were too vague to muster up the secret sauce. Sadly, I don’t have the recipe for the secret burger and fry sauce, but I do have the secret sauce for creating a winning psychotherapy blog, and it works nearly every time. And unlike the sauce, the mixture of ingredients need not be perfect. So if you’ve been wanting to serve up your insights but haven’t been sure of how or where to start, I’ve got a recipe for you. Often a little story like the one you just read is a great way to begin. But here are some of the best ingredients that I have mixed into my own recipe. Ingredient #1: Begin with a compelling title. Consider my first-ever blog for psychotherapy net. It was titled, It’s the Psychiatric Meds, Stupid. I wanted the reader to be saying, “What in the heck is Rosenthal talking about? Are psychiatric meds good or evil? I absolutely, positively, need to read his blog and find out.” Direct marketing experts discovered years ago that an advertisement or press release with a good title is more likely to be read than a terrific document with a weak title. Why would a blog be any different? Hint: It isn’t. Some other titles from my own trophy closet include: Alcoholics Anonymous Founder Bill Wilson’s Long-Lost Treatment Paradigm. In case you haven’t read the blog, I’ll guarantee you he wasn’t pushing merely the merits of Alcoholics Anonymous. Nope. In fact, I explain to the reader in the first few sentences I am going to tell them something they don’t know. If you think about it, entertainment aside, isn’t the entire purpose of reading a blog to learn something you don’t know? An excellent question to ask yourself is: Will the reader learn something new from my blog? The ideal answer is yes. Titles with numbers can be powerful attention grabbers. My blog Conduct Therapy Sessions Like Ellis or Rogers in 7 Days or Your Money Back is a great example. The word “how” or the words “how to” are some of the best words to use in a blog title. Imagine combining these words in a title and teaming them up with a number, such as my blog Gone in 60 Seconds: How to Handle a Mental Health Workshop Heckler. And believe me, I’m not the only blogger with killer titles. This site is inundated with bloggers who created world-class titles. Surfing the site for just seconds revealed 20 Seconds: Coming Out to a Client, by Alex Stitt, and Closing the Deal: The Art of Selling Yourself to New Clients, by Robert Taibbi. Ingredient #2: See what everybody else is writing about, and then write something totally different. Indeed, you can write about what is trending or popular and often this will work well. The problem is after an exceedingly short period of time the topic is totally covered in a traditional fashion by a host of bloggers. When this occurs, why not take the road less traveled? Even if you are covering a traditional or trendy topic, why not cover it in an innovative fashion? In my blog In Search of the Perfect Private Practitioner, I weave in the story about the pitfalls in my own private practice. Had I created a blog titled My Private Practice, readers might have been recommending it to others as sleep therapy, or more likely would have never read it at all. At one point in my career, I penned over 20 pieces for a publication in our field. My secret sauce, if you will, was I never wrote a single entry about a mainstream topic. Topics that are historical, or have not been covered in years, often work well. Case in point, my blog The Gloria Films: Candid Answers to Questions Therapists Ask Most showcases a landmark psychotherapy movie shot in the mid-sixties, or roughly the time Ford was releasing the Mustang. Ingredient #3: Write the blog in your own voice. When I entered the field of psychotherapy, I not only wanted to become a great therapist, but I also wanted to become an accomplished writer. Some of my therapeutic literary heroes included Albert Ellis (who originally wanted to write the Great American Novel), Andrew Salter, Lewis Wolberg, Jay Haley, Gerald Corey, and Arnold Lazarus, to mention just a few. I thus began to emulate their writing style. But there was just one problem with my strategy. If somebody wanted to read Ellis or Corey they would pick up something penned by these experts, not something cloned by yours truly. The very best advice I can give you is to merely write your blog as if you are talking to a friend over lunch or a latte. As yes, this could be virtual during COVID. My college students often verbalize this principle in a more eloquent way. “You know, Dr. Rosenthal, when we read your books, articles, and blogs, we know you really wrote them. They sound exactly like you in class.” Ingredient #4: Whenever possible, use a trick or so-called surprise ending. In my blog It’s the Psychiatric Meds, Stupid, you will discover that perhaps it wasn’t the psychiatric meds which impacted my client and why. In my aforementioned In Search of the Perfect Private Practitioner blog, you will discover that maybe . . . just maybe . . . the perfect practitioner wasn’t so perfect after all and why it mattered! In my blog centering on Bill Wilson, I revealed near the conclusion of the blog that on his deathbed Wilson did not want to be remembered for Alcoholics Anonymous, but rather for a treatment paradigm unknown to most readers. (Hello: read the blog, did you really think I was going to spill the beans without your reading the blog? No spoiler alert here, therapy fans!)

***

Try on these four ingredients, add a pinch of your own creativity, and I look forward to reading your blog in the very near future. So how will you begin your first blog? Hmm. Try this. “Well, when I was in high school there was a great burger joint nearby, and they had the best BBQ sauce I had ever tasted” . . . or maybe not.

The Queen’s Gambit and Me: The Surprising Similarity Between Therapy and Chess

Posted on by Psychotherapy.net Team

I was mesmerized from the first frame of The Queen’s Gambit, a Netflix mini-series about a Kentucky orphan girl in the 1960s and her passion for chess. Thoughts of the show colonized my thinking for the three days it took me to get through its seven episodes. I loved it, it intrigued me, and I cared deeply about the characters. It was a perfect jewel. But little did I know how those seven hours would change my life.

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I don’t remember how it happened, but a week or so after the final credits rolled, I started to research chess. I’d never played before and didn’t even know how the pieces moved, so I typed “chess for beginners” into YouTube and curiously, like Alice, fell down the rabbit hole.

I find that I’m dreaming about chess these days and have started to see chess tactics and strategy in everything. I’ve been a psychotherapist for thirty-five years and it's become clear to me since I started playing how a course of therapy conforms, in many ways, to a chess game, with its well-defined opening, middlegame, and endgame.

The first few therapy sessions, when you’re learning about your new client, are like the opening. You start slowly and respectfully, using moves that you’ve used many times before to get a feel for the person sitting across from you. You’re getting situated, knowing that you’re at the very beginning of an important relationship.

For example, I start the first session with my new client, Isabelle, with the opening move I’ve used so many times before—a variation of the question “What brings you here today?” Everything is possible at this point, and I have no idea where this exchange will take us.

During this opening phase, I’m getting a sense of the pacing. Will she jump right in with a cascade of emotion (making dizzyingly fast moves) or sit quietly waiting for me to ask questions (establishing a pensive introspective pace to the “game”)? In this case, holding back and very reserved (not making risky moves), 28-year-old Isabelle explains that she wants to improve her relationships. She’s on pause with her boyfriend, who has not treated her well, and is wracked with indecision about whether to go back to him. She doesn’t trust herself. But when asked her biggest goal in life, she says she wants to meet the love of her life.

A session later, in a latter part of the opening, Isabelle tells me about the struggles she faced in childhood. I learn that her much-loved mother, whom she describes as an angel on earth, suffered mental health problems that were so severe that when she was eight and her parents divorced, she was sent to live with her father’s parents. They were very strict remote old-fashioned immigrants who did not speak English, and she did not speak Italian. She rarely saw her mother and felt alone and abandoned.

More complexity is introduced in a later session as Isabelle reveals that no matter what has happened in her childhood, she’s determined to build a wonderful future and has enrolled in a course to become a life coach. With this goal in mind, at the turn of new year, she’s started to eat more healthily, is trying to exercise, and has incorporated a meditation practice into her day.

In this part of the therapy, the middlegame, I’m searching for patterns. It’s both a science and an art. Isabelle relaxes, and story after story comes spilling out. I’m receiving reams of information and have to make continuous decisions about which pieces are vital to attend to and which not to “take.” I could focus on a tantalizing piece of information that Isabelle shares (capture a knight that’s available to take but which won’t advance my position), but I have to make sure not to make a move unless it contributes value. There’s no doubt that I could chase the pieces all over the board, but I need to develop a plan that will guide my choices.

Over time, the essential issues are brought into focus and, in the endgame, many of the peripheral bits have been eliminated so that only the primary core issues remain. There are fewer pieces on the board, but every one is vitally important. We’re narrowing our focus on the need for Isabelle to forgive herself for having left her mother, who later died of cancer, and working on helping her develop a deep well of self-compassion. The search for the love of her life will have to wait until she’s very comfortable with the love of herself.

Isabelle is not, of course, my opponent, and a course of therapy is certainly not a process of win or lose, but I like to think of strategizing how to help my client in her struggle (our chess game) as the mutual challenge for both of us. The pleasure of checkmate comes from feeling that we’ve shared a profound experience together resolving something important, and that now Isabelle and I can celebrate that positive change has happened in her life.

I've found that there have been many surprisingly meaningful aspects about life during the pandemic, and discovering chess is certainly high up on my list. I smile when I think about it and look forward with anticipation to the next game. Where it’s going to fit into my uber busy life, I’m not sure. But for the moment, hey, set up the board and let’s play!