Category: Therapeutic Issue

Existential-Humanistic Therapy in the Age of COVID-19 in Vulnerable Populations

Posted on by Psychotherapy.net Team

Challenges

COVID-19 has been a sudden, unexpected, and existentially shattering experience for many individuals, resulting in their questioning their sense of safety and security in the world. Whether facing actual illness or loss, fear of getting sick or infecting others, forced isolation, lack of personal space, or economic hardship, people have now been facing unprecedented stressors for close to a year. With a second wave upon us and new variants emerging, there may be a sense that anyone is vulnerable. While vaccine distribution offers promise for individual immunity, there is protracted uncertainty about the duration of the crisis and its psychological, economic, political, and societal consequences.

These COVID-19 phenomena may exacerbate challenges for individuals with a history of chronic medical conditions and trauma, including feelings of vulnerability, stigma, and lack of control. Having previously confronted and accepted existential truths such as life’s uncertainty, the random nature of events, and the inevitability of death, these individuals may, at the same time, be better equipped to cope with aspects of the pandemic (Gordon, 2020). Existential-Humanistic (E-H) therapy can provide effective therapeutic interventions to aid vulnerable populations in optimizing adjustment, coping, and quality of life during the COVID-19 pandemic.

Existential-Humanistic Therapy

Developed in the 1960s, E-H therapy consolidates central ideas from European existential philosophy—the power of self-reflection, taking responsibility for decisions, and confronting freedom and death—with the American tradition of spontaneity, pragmatism, and optimism (Schneider & Krug, 2017). E-H therapists emphasize several core aims that enable patients and therapists to become more present in the moment: increasing awareness of self-protective patterns that block and restrict presence and personal agency; taking personal responsibility for the construction of one’s life and self-narratives; and choosing or actualizing ways of being in the world that are consistent with values. E-H therapy strives to be a catalyst for individuals to develop their level of curiosity, generate experience that is felt to be enriching, and expand their capacity for personal agency, commitment, and action.

The model emphasizes the “whole-bodied” (e.g., cognitive-affective-kinesthetic) ability to choose, within limits, who one will become, and that fundamental change takes place through experiential learning. Bugental (1987) depicted resistance as analogous to wearing a spacesuit which helps sustain life but also narrows one’s experience of the world. E-H therapists believe that when life-constricting protections are reduced, more meaning, purpose, and joy can emerge. E-H therapists focus on the here-and-now experience of the past as manifested in the present moment, including the patient’s body posture, level and quality of presence, tone or voice, and self-protective patterns.

Viktor Frankl (1992), an Austrian psychiatrist and Holocaust survivor, observed that we do not get to choose our difficulties and challenges, but do have the ability to select our attitudes and responses, decide what we make of them, and maintain a sense of dignity. Rollo May (1985) believed that it takes courage to move forward in life despite adversity.

An E-H theme developed by Irvin Yalom (1980) is the idea that individuals have a basic need to construct meaning through tolerating uncertainty, a passionate engagement in life, and living in the moment. He describes existential anxiety as the result of the confrontation with the givens of existence, including death, freedom, isolation, and meaninglessness. Existential anxiety occurs because of the conflict between these challenges and a desire for its opposite. These universal conflicts include the awareness of death and the desire for immortality, a sense of groundlessness and the wish for structure to provide safety and security, feeling of isolation and the need for connection, and the awareness of meaninglessness of life and the need to construct meaning. As a result of facing death, individuals experience the urgency of time and setting priorities. For Yalom, psychotherapy during times of crisis can heighten existential awareness and help clients put current and ongoing life crises into perspective.

Yalom incorporates the concept of “rippling” into his many writings on existential therapy. This is the notion that we pass parts of our self onto others, even to others we never met, much like the ripples caused by a pebble in a pond—whether a personality trait, an act of kindness, a quote or saying, the impact of our work—which tempers the pain of transiency. Along related lines, Hoffman (2021), guided by the work of Rollo May, discussed the existential guilt that accompanies failure to live up to one’s potential or taking responsibility, while in contrast finding that meaning can transform pain. And finding this meaning, according to Remen (2000), does not require us to live differently, but instead to see our lives differently.

It is in this context of seeing life differently that I ask you, as we might ask our clients, to imagine the consequences of living in a house with only one window. For all intents and purposes, the view from that window will define your reality. Only by experiencing the view from a new window, built perhaps on the other side of the house, will you gradually internalize a degree of perspective and relativity, a sense that vision and meaning involve choice and agency. And with that, I now offer the case of Michael.

The Case of Michael

Michael is a 35-year-old aspiring artist who was referred to me for psychotherapy to develop effective coping skills in his adjustment to his recent diagnosis of Multiple Sclerosis (MS). MS is an autoimmune disease that attacks the central nervous system, which can cause a variety of symptoms, including numbness, fatigue, vision loss, and walking difficulty. He was living with his grandmother and mother and had a strained relationship with his father, whom he had never lived with. He entered therapy three months before COVID-19 rattled the city and shut down services.

At the beginning of treatment, “Michael reported multiple symptoms, frequent incidents of falling and losing his balance, a long-standing history of anxiety and panic attacks, and inhibitions in his ability to commit himself to intimate relationships and professional goals”. Since his adolescence, his anxiety had often resulted in shortness of breath that triggered fears of a heart attack and impending death. He was particularly worried that his physical symptoms would continue to get worse and that he would be totally dependent on others for his physical care.

During his initial sessions, he expressed a great deal of frustration that it took a number of years to get a definitive diagnosis of MS. He felt his family and friends thought he was exaggerating his symptoms to avoid pursuing his educational and vocational goals, which resulted in lack of confidence and trust in expressing his own feelings, needs, and opinions. Even when he was given a definitive diagnosis six months before entering treatment, he experienced others as not fully understanding the impact of his “hidden disability.” He was angry that he developed his medical condition at such an early age, started to doubt his belief that “bad things do not happen to good people,” and felt that he was being punished for his lack of motivation and accomplishments.

Capitalizing on meaning-centered and post-traumatic growth perspectives, therapy began by exploring his strengths—deep-seated values and qualities that did not change due to his medical condition—in order to help him feel more empowered. He identified his compassion for others, creativity, and a sense of humor that could help him cope with his multiple challenges. The only moments when he felt passion in life were when painting or taking pictures of landscapes and city architecture.

In these initial sessions, “Michael was able to express a deep sense of loss and sadness over his physical functioning, as he felt his athleticism had formed a core component of his identity during his adolescence and young adulthood”. He grieved the loss of not being able to play sports with his children, if he became a father in the future. These feelings of sadness triggered memories of his paternal grandfather, who had died of cancer during his adolescence. He was one of the few figures in his life who had confidence in Michael’s talent as an athlete and that he would succeed in the future. Michael identified his grandfather’s resiliency and perseverance in the face of his terminal illness as two of his special qualities. The sessions involved asking Michael open-ended questions, including “What advice would your grandfather give you right now in how to handle your MS?” and “How are you similar to your grandfather?” Michael became more aware of feelings of gratitude toward his grandfather and that he too was a survivor and a determined individual.

When the news of the spread of COVID-19 in March 2020 caused a city-wide lock down, Michael agreed to continue sessions via telehealth. At that time, now on top of his anxiety, panic, and fears of dependency resulting from his medical condition, “he identified the virus as compounding his fears of dying or becoming totally dependent on others”. Shortly after, Michael recalled a series of unsettling dreams. He reported that since his diagnosis of MS approximately nine months before, he had a recurring dream where “Martians shot people and then placed them in upright coffins. They had blank faces and appeared as if in an altered state and could only move their hands in front of them.” Michael’s associations to the dreams were fears of not being able to move, ending up in a wheelchair, and being totally dependent on others. He was asked to retell the dream in the present tense and how he would want the dream to end in order to develop a sense of agency. He said he wanted to be able to fight the Martians like his grandfather had fought his cancer and scare them away.

Two weeks later, Michael reported another frightening dream where he was “trapped in a glass cube in [his] home that was invaded by bad guys who were pumping gas into the cube, and [he] had no way out.” He said he felt terrified of dying and feeling helpless. He was asked to visualize and re-experience how he felt in the dream. He recalled that he felt trapped, his lungs were burning, and he was going to suffocate to death. Michael then spontaneously recalled a memory of escaping from the scene of the World Trade Center Attack. He was at breakfast in a diner across the street and saw the plane hit the building. Michael was numb and could not process what had happened. He was paralyzed by fear, but eventually ran down the street when told to leave by a security guard. He did not remember what happened next, but eventually arrived home covered in ashes and debris, and had difficulty breathing and sleeping for several days. He had not thought about this traumatic event in years.

During this phase of treatment, Michael became more aware of how this traumatic confrontation with the possibility of dying, which occurred shortly after his grandfather’s death, contributed to his panic attacks and fears of dying during his adolescence, which in turn impacted his ability to pursue his educational, vocational, and interpersonal goals. Michael became more aware that his strong needs for safety, security, and protection inhibited his pursuit of taking risks in many aspects of his life. Michael further realized that his avoidance of taking chances and exposing himself to failure and rejection was, as Bugental reminded us, analogous to wearing a spacesuit which is life-affirming but also narrows and inhibits one’s experience of the world.

A major focus of the middle phase of therapy involved his fears of dying and what was meaningful in his life. “Michael acknowledged that part of his death anxiety was that he had wasted many years avoiding pursuing his goals of being an artist and having close relationships”. When asked to project himself a year from now and what new regrets he might accumulate, Michael tearfully stated, “Not completing my college degree and becoming an art teacher, and not living up to Grandfather’s belief in my potential.”

This was a pivotal point in Michael’s treatment, which brought him to enroll in a local college, where he took and succeeded in a number of online courses. He continued to realize on a more experiential level that he had been fearful of taking risks and failing since his adolescence, but that he was paying a significant price for pursuing his strong need for security. When asked “What have you discovered about yourself through the challenge of the pandemic?” Michael reflected that, while the pandemic had added new layers of anxiety, it also had provided him with the space to step back and evaluate what really mattered to him. Rather than continuing his past patterns of avoidance, self-doubt, and comparing himself unfavorably to others, he was determined to focus on his creativity and having an impact on others through teaching. He also realized that his previous contemplation of death anxiety and perseverance in coping with his MS served as protective factors in dealing with COVID-19.

Within a few months, Michael transitioned from feeling overwhelmed and vulnerable in the storm of his MS symptoms and COVID-19 threat to feeling more focused, determined, and resilient. Although he had to maintain cautiousness due to his medical condition and COVID-19, he was able to take the initial steps in pursuing a meaningful career that was consistent with his values and identification with his grandfather. Through the therapeutic process, he came to recognize his own power to choose how he wanted to view and respond to life’s major challenges, including his MS.

Concluding Thoughts

This essay describes my flexible application of E-H approach to psychotherapy when working with a patient with a chronic medical condition and a history of trauma during COVID-19. The case vignette highlights different aspects of the E-H approaches, including cultivating presence in the moment, choosing one’s attitude toward challenge and adversity, increasing awareness of what is most meaningful in life, living in manner consistent with one’s values, and expressing gratitude toward others.

For patients who have chronic and life-threatening medical conditions and a history of trauma, COVID-19 may increase their level of anxiety, fear, vulnerability, and social isolation. On the other hand, “these individuals may have developed a degree of psychological protection and resiliency in having already experienced a prolonged sense of insecurity and uncertainty” involving fears of body integrity and mortality.

In my therapeutic work, E-H therapy provides a safe place for patients to reflect on how COVID-19, while frightening and potentially traumatic, is changing them in unanticipated positive ways, including living life with greater meaning, purpose, and sense of urgency. It is my hope that in reading this, that you may experience this new context as an opportunity to explore existential issues such as uncertainty, vulnerability, meaning in life, and death anxiety with patients in deeper ways than before.

References

Bugental, J. F. T. (1987). The art of the psychotherapist. Norton. https://doi.org/10.1037/h0085349

Frankl, V. (1992). Man’s search for meaning (4th Ed.). Beacon Press.

Gordon, R. M., Dahan, J. F., Wolfson, J. B., Fults, E., Lee, Y. S. C., Smith-Wexler, L., Liberta, T. A., & McGiffin, J. N. (2020). Existential-humanistic and relational psychotherapy during COVID-19 with patients with preexisting conditions. Journal of Humanistic Psychology. Published online: November 2020, https://doi.org/10.1177/0022167820973890

Hoffman. L. (2021). Existential-Humanistic therapy and disaster response: Lessons from the COVID-19 pandemic. Journal of Humanistic Psychology, 61, 33-54. http://doi.org/10.1177/0022167820931987

May, R. (1985). The courage to create. Bantam Books.

Remen, R. N. (2000). My grandfather’s blessings: Stories of strength, refuge, and belonging. Riverhead Books.

Schneider, K. J. & Krug, O. T. (2017). Existential-humanistic therapy (2nd Edition). American Psychological Association. http://dx.doi.org/10.1037/0000042-000

Yalom, I. D. (1980). Existential psychotherapy. Basic Books. 

Caring for those Who Care for Our Pets

Posted on by Psychotherapy.net Team

Stresses on the Veterinarian

We can’t turn on the television or look at social media without seeing evidence of how the pet industry has grown exponentially over the years. We don’t just have pets anymore; we now are the proud parents (and grandparents) of “fur babies.” Rarely, however, do we think about the difficult side of having a fur baby. Yet veterinarians are on the front lines of managing the effects of this fur baby boom; and, as pets age or become ill, veterinarians have the difficult task of working with pet parents and providing the necessary care for their pets. This task, difficult on its own, is compounded when pet owners cannot afford or are astounded by and react intensely about their pets’ cost of care. Still other pet parents are unable or unwilling to accept their pet’s illness and insist on providing treatment, even when the treatment will not extend the animal’s life. Even with these tensions, veterinarians often develop an emotional connection with pet owners and their pets. The emotional connection adds a dimension of stress and emotional pain when pets become ill or must be euthanized. Being a veterinarian is far more than working with animals.

Then there are the kinds of stories that appall the public. In early 2020 in South Florida, it was reported that a local humane society euthanized 198 animals over a two-month period without first requesting any support from rescue groups. The story is certainly shocking, and the tragedy to the animals pulls hard on our heartstrings; yet we don’t consider the impact of situations like this on shelter veterinarians. For this group, the need to euthanize can be emotionally overwhelming, given the number of euthanasia procedures they must perform due to overpopulation.

A review of the literature suggests that there is some training to help veterinarians provide grief support services and resources to clients. Still, there is little available to veterinarians for their own work-related grief work. An example of the need for awareness in this area was noted when one of the authors’ dogs, Riley, had to be euthanized when medications to control his health issues were no longer effective. Riley had been a client at his vet’s practice for seven years, and the hospital staff was also affected by the need to euthanize him. While there is the need to maintain a professional stance in these cases, it is important to note that veterinarians and their staff may have strong feelings for their clients.

Over the last couple of years, we have come to see that, like others in the helping professions, veterinarians face a wide variety of stressors that contribute to issues related to their mental health. Because impairments manifest in varying degrees, it can be challenging to recognize one’s own or a colleague’s impairment, even in the best of times and with experience. This is of particular concern when we consider that this group of professionals is at higher than average risk for suicide.

According to reports from the CDC and other international studies of veterinary professionals, mental health issues amongst veterinarians can be attributed to multiple factors. Compassion fatigue, demands for euthanasia, challenges with workplace relationships, and the demands of supporting and educating pet parents on issues related to their pets all impact veterinary professionals’ mental health. The responsibilities of managing a veterinary practice and exceedingly high levels of veterinary school debt from tuition costs averaging $160,000-$329,000 add additional burdens to veterinarians’ already stressed and challenging careers. Given our current COVID-19 crisis, many veterinarians have been furloughed or laid off or are witnessing their colleagues being laid off, creating a new level of stress. In addition, veterinary office changes were required to help manage physical distancing during COVID-19, causing stress for both veterinarians and pet owners.

While client relationships are primary in veterinary medicine, veterinary practices are also production-based, meaning that the veterinarian must manage what is in the best interest of the pet/client and the need to produce to retain their position. This creates an ethical challenge. In addition, the level of rigor and oversight around medical documentation can vary, with some practices being flexible and accommodating about how documentation is kept and who can sign off on medical records. Some practices allow technicians to sign records for renewing prescriptions or completing medical notes; this can open opportunities for veterinary staff to illicitly take or prescribe medications.

When combining the immense stressors that contribute to depression and other mental health-related issues, a production-based work environment, lax or variable management of documentation, and workplace access to a wide variety of drugs, many of which are highly addictive, there is increased potential for veterinary professionals to become susceptible to drug misuse and addiction to cope with work stress. Dr. Jon Geller noted this danger in his 2016 article in DMV 360 and added that there are insufficient resources to address this concern, including insufficient drug testing in veterinary workplaces, few or inadequate drug control procedures, and limited access to or availability to employee assistance programs.

Veterinarians have access, often with limited oversight, to potentially addictive medications to help with depression, anxiety, and sleep management. While increased levels of scrutiny and oversight have limited opportunities for medical professionals working with human patients to access in-house drugs, this level of oversight has not been implemented in veterinary practices in the United States.

The importance of greater training around and support for prescription abuse for veterinarians is underscored in stories such as John Burke’s Pharmacy Times article (2019), which highlighted the implications of limited oversight in veterinary clinics. As Burke relays, as rates of addiction rise with the growing opioid crisis, there is an increasing need for veterinarians to receive training and support around prescription abuse. His article includes an account of a veterinarian who prescribed unnecessary opioid medications for pets she had placed under overnight observation; pet owners would fill the scripts and return the medications to the clinic for their pets, not knowing that the veterinarian was taking them for herself. This practice continued until a pharmacist learned that the drugs were being returned to the vet clinic for administration and reported it to the authorities.

Addressing the Need

Given these challenges, the increased attention to veterinary professionals’ mental health needs is both timely and necessary. Yet, according to the American Veterinary Medical Association, only 36 states and the District of Columbia have laws and regulations authorizing wellbeing programs for veterinary professionals. Once it is determined that a veterinarian is indeed heading in the direction of impairment, because of the taboo associated with “having” a mental health or substance use disorder, it is often difficult for colleagues to encourage the impaired professional to seek counseling. Seeking the right treatment is important to maintain professional competence. By developing interventions for veterinary professionals along the three levels of prevention (primary, secondary, and tertiary), mental health professionals can intentionally make connections with and offer support to veterinarians. These prevention services can include education, training, and support around mental health and substance use disorders that are focused specifically on the issues faced by veterinarians.

Primary Prevention Interventions

Veterinary training programs may serve as ideal grounds for implementation of primary prevention strategies, which aim to address prevention of mental health and substance use issues before they arise. In many ways, to address the needs of veterinarians, it just makes sense to meet their needs when these professionals are at their most energetic and idealistic—while they are students, before the stressors of the work really start to impact professionals’ mental health. Clinical training faculty; however, may not sufficiently focus on students’ mental health or stress the importance of self-care during training. And conversely, students in these high pressure training programs may be reluctant to admit to that they are struggling emotionally. In a school-based primary prevention intervention, mental health professionals might coordinate with veterinary programs to offer workshops or guest lectures during various points in students’ training to reduce the risk of mental health disorders and/or substance use disorders. Integration of mental health information should not be a one-time occurrence. Instead, this type of programming should be implemented from the initiation of coursework as a prevention strategy for students while they deal with the stress and pressure of training.

A primary prevention strategy also offers an opportunity to plant seeds for when the student is a professional working in the field. In this case, mental health professionals could provide services that educate educators and students in veterinary studies about mental health and substance use disorders as well as the factors that often affect these impairments. Such training should also help educators and students identify the potential signs and symptoms of the impairments. Moving beyond just providing factual information, mental health professionals could work collaboratively with veterinary education programs to develop prevention programs that address and mitigate risks for mental health and substance use disorders amongst students. These programs could include interventions to help students develop self-care strategies, connect students to resources in the community, and support the development of healthy relationships within students’ support networks.

Secondary Prevention Interventions

Secondary prevention strategies involve early detection of issues, usually through screening measures. One example of a secondary prevention intervention would be mental health providers’ working with veterinary professionals to help them recognize when they or their colleagues are impaired. In another intervention, mental health practitioners might help veterinary practices to set up regular mental health screenings of workers (i.e., for burnout, anxiety, or suicidal ideation) to help identify issues in their initial stages. Early detection and treatment are key. In this prevention level, mental health practitioners might provide support to veterinary professionals who were caught using or accessing drugs. Working with individuals at this stage is meant to “catch” the potential problem and prevent it from getting worse.

Mental health professionals can also provide mental health consultation services to help veterinarians develop and establish thorough clinic practice standards. These standards should include steps to obtain due process for individuals who may be impaired. In the case of a veterinarian experiencing opioid dependence, secondary prevention might include providing consultation to the veterinarian and staff to set up a modified work schedule so the veterinarian can return to their job without risk of accessing drugs. In addition to supporting veterinary professionals experiencing mental health or substance use issues, we need to keep in mind the colleagues who may be caught off guard when a veterinary professional seeks or is encouraged to seek help for drug use. Therefore, the services provided to veterinary staff may include counseling to those working with an impaired professional, including grief counseling.

Tertiary Prevention Interventions

Tertiary interventions are necessary when veterinary professionals relapse or have a drug addiction and need rehabilitation and ongoing support. This stage of prevention is meant to keep the situation from getting worse. Again, this stage requires the mental health professional to pull on actions from the previous two stages, ensuring the veterinary professional is safe, connecting them to resources in their community, and assisting them to develop a healthy support network. To further support the tertiary prevention efforts for this group of professionals, mental health practitioners can host support groups for participants to explore their mental health concerns and share strategies for living well. If veterinarian professionals are terminated from their positions, mental health practitioners can advocate for veterinary programs to retrain workers for new jobs when they have recovered as much as possible.

For mental health professionals to provide services to this specialized group, we need to understand that veterinarians and veterinary professionals face unique pressures. Not only are their workloads excessive and their hours long, but they also must face anxious and emotional clients and animals, often having to make life-or-death decisions about unwanted or sick animals. These stressors, along with other practice-related factors, contribute to the veterinary profession’s challenges of burnout and compassion fatigue, which are associated with mental health and substance use disorders, as well as suicide-related behavior.

Case Discussion

Melinda reluctantly came to counseling at her primary care doctor’s urging. Her mother had convinced her she needed help dealing with being overwhelmed, stressed, isolated, and anxious. She told Melinda to speak to the doctor about getting her anti-anxiety medication adjusted, given her stress and lack of sleep. Melinda has been on a low dose of an SSRI since graduating with her bachelor’s degree. She visited her doctor, explained what was going on, and he increased her medication. The doctor also asked her if she wanted something to help her sleep. Melinda became quiet and reluctantly admitted that she had borrowed some medication from the veterinary hospital where she worked to help with sleeping. It was at this time that her doctor told her she needed to seek help.

Melinda learned that the company she worked for offered financial support for those seeking counseling, but she was afraid of what people would say if they knew she needed help. Throughout her years in veterinary practice, she knew that people generally thought veterinarians played with puppies and kittens all day and did not think anyone outside of the profession would understand. She tried to forego counseling and try to resolve the issues herself but realized she wasn't managing well. In the past, Melinda would go to the gym five days a week to help manage her anxiety and stress. She noted that going to the gym always worked for her, but now she didn’t have time to do that. She also indicated that she was having trouble sleeping. All Melinda wanted to do when she got home from work was sleep. Sometimes she was too tired to cook and would pick up fast food on the drive home. Everyone at work thought Melinda was okay but tired due to long hours.

As a young adult, after working diligently to obtain her undergraduate degree and working at a local animal shelter, Melinda had finally been accepted to a veterinary school after three years of submitting applications. Her new friendships at school and enthusiasm for her career helped her manage the program's mental demands. She was concerned about additional student loans but did not consider the future impact of high-interest rates accruing during and after school. The program's high demands and extensive studying prevented any students from getting jobs during school to offset some of these costs. Melinda did her best to live within her means and focused on completing her degree.

Once she graduated, Melinda was selected for a 1-year rotating specialty internship and was excited for the opportunity to improve her clinical skills. Although internships have a low salary despite their highly demanding schedules and on-call hours, Melinda felt the experience would be important when looking for a full-time position. She deferred student loan payments and, upon completing her internship, obtained a small animal general practice position with a five days per week schedule. Melinda was excited about being out of school and moving forward in her career.

When student loan payments came due, Melinda began making payments. She was disheartened to see the amount of interest her loans had accrued but felt empowered to have her dream career and start planning her future. Due to the high cost of living where she lived and her debt-consciousness, she shared a two-bedroom apartment with a roommate.

“Melinda noted that she worked 55-60 hours per week on paper, but she stayed late at work after every shift catching up on phone calls and writing medical records”. Since generating revenue was a high priority in this practice, she picked up additional shifts and was now averaging 60–70-hour work weeks. She felt relieved as she saw the larger paychecks and ignored her exhaustion, telling herself it would pay off in the long run. Feeling pressure from both clients and hospital management, Melinda frequently agreed to squeeze in additional cases during the day, and it was not uncommon to skip lunch. She indicated that she was losing weight but didn't have time to eat. She was increasingly tired but saw opportunities to pick up additional shifts as a good opportunity to help pay off the student loans. She often didn't have enough energy to get to the gym at night, a key stress reliever during college and veterinary school, so she would periodically “find a medication” from the clinic to help her energy level.

Melinda was having trouble sleeping and would wake up thinking about cases. She would replay patient exams and lab results in her mind, worrying if she had missed something. Melinda noticed some cases where she had forgotten to finish typing a medical record, and clients were calling asking for lab results more frequently because she didn't have time to call them with results. When arriving at work, Melinda would often have numerous lab reports to review, refill requests to fulfill, and client calls to return about sick pets. She struggled to find time to get everything done. It was relatively easy to take medications from the clinic without being noticed, and she had been doing so for the last six months before seeking counseling. She began periodically taking a stimulant medication from the clinic to help her boost her energy and then a sedative to help her sleep at night.

Melinda reminisced about the first few years of her career, when she had mentorship, and wished she could go back to those days. She felt increasingly alone both at work and in her social life. When she wasn't in surgery, a large part of her day was spent seeing sick pets, trying to work within owners’ budgets for diagnostics and appropriate treatments without sacrificing quality of care, end of life consultations, and client education for wellness and preventative care. Relationships at work were good, but all the team members were under stress. Some long-term patients had recently been euthanized, which was adding to everyone's emotional strain.

Melinda said she had begun reducing shifts and trying to minimize the extra caseload but started to feel guilty when saying no to additional “fit ins” throughout the day. A client recently posted a review on Yelp berating her for being unable to fit a pet in on the same afternoon the owner called. Another screamed at her on the phone for wanting to charge for the laboratory testing to help figure out the cause of a pet's weight loss and accused her of not caring about animals. She was also worried about a tough case requiring many follow-up visits. The owner had started to have financial concerns, and Melinda was worried that without the continued follow-up to regulate the pet's disease, the pet might start to decline.

Continued negativity from clients, the pressure to meet revenue goals set by the practice, self-care reduction, lack of personal space at home, worry about cases, and financial concerns drove Melinda to wonder if she made the right career choice. Given the high debt and interest rate on her student loan payments, she felt trapped in her current position, since a change for a lesser salary would make it impossible to make loan payments. After five years, she still had never taken time to travel, which had been something she had been hoping to do once she had a stable job. She realized she was not meeting her goals of meeting someone and starting a family. Melinda spoke to her manager and tried to reduce her hours down to four days a week; she then worried about the pay cut's impact on her finances. Melinda used some vacation days but felt she was not able to get her mind off work. She began to realize there wasn't much that she enjoyed in life anymore.

Primary Prevention: If we had been able to work with Melinda while she was still in her training program or as a new professional, primary prevention approaches would have focused on preventing or reducing the chances of acquiring a substance use disorder and/or mental health disorder. Prevention strategies at this level would likely include psychoeducation and skills development focused on awareness of the effects and potential consequences of SUDs and the importance of attending to wellness and mental health (e.g., stress management skills, self-esteem building, problem-solving, recognizing and building protective factors, recognizing risk factors). Given the stigma of seeking therapy Melinda seems to hold, we would work to destigmatize seeking mental health therapy, framing it as a source of support and one way to promote self-care, much like her time at the gym. We would make sure to provide connections to community and profession-specific resources that support veterinarians, such as state wellbeing programs for veterinary professionals. Considering the immense stress associated with student loans, having resource information about debt management training on hand would be another important prevention strategy to assist Melinda.

Secondary Prevention: Melinda is experiencing stress from work, the burden of a sizable student loan, and guilt (and possibly shame) for taking medication not prescribed to her from her place of work. From the perspective of secondary prevention, the focus is on harm reduction. Providing referrals to the resources identified in primary prevention would be appropriate in the secondary prevention process. Melinda will likely appreciate the information to help with her loans, but the referral alone is not enough to help her address her maladaptive behaviors. First, it is essential to assess for baseline severity of symptoms and coexisting mental health disorders. Given her reluctance to therapy, working with Melinda using motivational interviewing therapy might help her work through her ambivalence. Motivational therapies, such as motivational interviewing, encourage a client’s readiness for change and may help Melinda realize and voice her personal goals. To reduce harmful behaviors, for clients whose substance use is mild, CBT and social skills and other skills training (e.g., communication skills, stress management, problem-solving, and identification of the effects of the medication she’s taking without medical oversight) are reported effective. With addiction, a combination of motivational incentives/contingency management rewards and CBT appears to be an effective treatment intervention. Group counseling is especially effective in creating a support network. In addition to group counseling, there are profession-specific support networks available. One such group is Not One More Vet, which came about to prevent suicides among veterinarians. The last element of secondary prevention is to build in a relapse prevention plan into the client’s treatment plan.

Tertiary Prevention: Tertiary prevention would focus on relapse prevention and/or advanced substance abuse, the long-term effects of the abuse, and the impact of complications associated with SUDs. Relapse is common (and often part of the journey) in recovery. So, planning for relapse is an important part of any prevention plan. As a result, there are a number ways mental health practitioners can assist clients incorporate tertiary prevention approaches in their treatment. For Melinda, the following are just a few options. Focusing on relapse prevention, Melinda is encouraged to continue meeting with her therapist. However, the focus in therapy would be less on skill development and more on supporting her practice and implementation of her newly acquired (or reinforced) skills (e.g., stress management skills, self-esteem building, problem-solving, recognizing and building protective factors, recognizing risk factors) in her work setting and personal relationships. These skills are critical in her being able to deal with shifts and changes that happen in life, positive and negative. A related strategy would be to work with Melinda to identify and recognize the shifts and changes in her personal life or career that might negatively impact her sobriety and mental health and potentially open the door for relapse. Melinda’s continued involvement in her support group is also encouraged, so she can keep on learning healthy strategies from her peers.

In the case that Melinda’s substance use progresses and she opts to seek inpatient treatment, it is important for the practitioner to know of or to consult with colleagues about reputable rehabilitation programs. Helping the client research and select a rehabilitation program that best suits her needs fits in with tertiary prevention planning. Finally, should Melinda experience long-term medical or other disability effects of her substance use, she may need the support of a vocational rehabilitation counselor for assistance with employment support.

***

This brief article and case study propose making connections with and offering support to veterinarians and veterinary professionals from a prevention model perspective, engaging with them in training programs during their medical training and in the community. We propose not waiting for veterinarians to enter our practice for intervention, but rather reaching out proactively and identifying opportunities for providing psychoeducation, consultation, and advocacy.

Resources for Veterinarians and Mental Health Clinicians

State Wellbeing Programs for Veterinary Professionals
Debt Management Training
Not One More Vet

References

American Veterinary Medical Association. (n.d.) State wellbeing programs for veterinary professionals. https://www.avma.org/resources-tools/wellbeing

Geller, J. (2016, June 15). Dark shadows: Drug abuse and addiction in the veterinary workplace. DVM 360 Magazine. https://www.dvm360.com/view/dark-shadows-drug-abuse-and-addiction-veterinary-workplace 

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

Posted on by Psychotherapy.net Team

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.
 

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 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!