Category: Therapeutic Issue

Complex PTSD: From Surviving to Thriving

Posted on by rezendevknowfully.com

Editor’s Note: Following is an adapted excerpt from Pete Walker’s latest book, Complex PTSD: From Surviving to Thriving—A Guide and Map for Recovering from Childhood Trauma. For more information about treating Complex PTSD (CPTSD) and managing emotional flashbacks, read a previously published article by Pete Walker here. 

Attachment Disorder and Complex PTSD

Many traumatologists see attachment disorder as one of the key symptoms of Complex PTSD. In the psychoeducational phases of working with traumatized clients, I typically describe attachment disorder as the result of growing up with primary caretakers who were regularly experienced as dangerous. They were dangerous by contemptuous voice or heavy hand, or more insidiously, dangerous by remoteness and indifference.

Recurring abuse and neglect habituates children to living in fear and sympathetic nervous system arousal. It makes them easily triggerable into the abandonment mélange of overwhelming fear and shame that tangles up with the depressed feelings of being abandoned.

A child, with parents who are unable or unwilling to provide safe enough attachment, has no one to whom she can bring her whole developing self. No one is there for reflection, validation and guidance. No one is safe enough to go to for comfort or help in times of trouble. There is no one to cry to, to protest unfairness to, and to seek compassion from for hurts, mistakes, accidents, and betrayals. No one is safe enough to shine with, to do “show and tell” with, and to be reflected as a subject of pride. There is no one to even practice the all-important intimacy-building skills of conversation.

In the paraphrased words of more than one of my clients: “Talking to Mom was like giving ammunition to the enemy. Anything I said could and would be used against me. No wonder, people always tell me that I don’t seem to have much to say for myself.”

Those with CPTSD-spawned attachment disorders never learn the communication skills that engender closeness and a sense of belonging. When it comes to relating, they are often plagued by debilitating social anxiety—and social phobia when they are at the severe end of the continuum of CPTSD.

Many of the clients who come through my door have never had a safe enough relationship. Repetition compulsion drives them to unconsciously seek out relationships in adulthood that traumatically reenact the abusive and/or abandoning dynamics of their childhood caretakers. For many such clients, we are their first legitimate shot at a safe and nurturing relationship. If we are not skilled enough to create the degree of safety they need to begin the long journey towards developing good enough trust, we may be their last.

Emotional flashback management, therefore, is empowered when it is taught in the context of a safe relationship. Clients need to feel safe enough with their therapist to describe their humiliation and overwhelm. At the same time, the therapist needs to be nurturing enough to provide the empathy and calm support that was missing in the client’s early experience.

Just as importantly, the therapist needs to be able to tolerate and work therapeutically with the sudden evaporation of trust that is so characteristic of CPTSD. Trauma survivors do not have a volitional “on” switch for trust, even though their “off” switch is frequently automatically triggered during flashbacks. In therapy, the therapist must be able to work on reassurance and trust restoral over and over again. I have heard too many disappointing client stories about past therapists who got angry at them because they would not simply choose to trust them.

As the importance of this understanding ripens in me, I increasingly embrace an intersubjective or relational approach. That means that I believe that the quality of the clients’ relationship with me can provide a corrective emotional experience that saves them from being doomed to a lifetime of superficial connection, or worse, social isolation and alienation.

Moreover, I notice that without the development of a modicum of trust with me, my CPTSD clients are seriously delimited in their receptivity to my guidance, as well as to the ameliorative effects of my empathy. In this regard then, I will describe four key qualities of relating that I believe are essential to the development of trust, and the subsequent relational healing that can come out of it. These are empathy, authentic vulnerability, dialogicality and collaborative relationship repair.

1. Empathy

I used to assume that the merits of empathy were a given, but I have sadly heard too many stories of empathy-impoverished therapy. In this regard, I will simply say here that if we are hard and unsympathetic with our clients, we trigger the same sense of danger and abandonment in them that they experienced with their parents.

In terms of a definition, I especially like Kohut’s statement that: “Empathy involves immersing yourself in another’s psychological state by feeling yourself into the other’s experience.”

When I delve deeply enough into a client’s experience, no matter how initially perplexing or intemperate it may at first seem, I inevitably find psychological sense in it, especially when I recognize its flashback components. In fact, I can honestly say that I have never met a feeling or behavior that did not make sense when viewed through the lenses of transference and traumatology.

Empathy, of course, deepens via careful listening and full elicitation of the client’s experience, along with the time-honored techniques of mirroring and paraphrasing which show the client the degree to which we get him.

Noticing my subjective free associations often enhances my empathic attunement and ability to reflect back to the client in an emotionally accurate and validating way. When appropriate, I sometimes share my autobiographical free associations with the client when they are emotionally analogous. I do this to let her know that I really empathize with what she is sharing.

Following is an example. My client tells me with great embarrassment that she stayed home all weekend because she had a pimple on her nose. She is ashamed of the pimple and of her “vanity’’ about it. She moans: “How could I be so stupid to let such a little thing bother me?” I suddenly remember cancelling a date once when I had a cold sore. At the time, I also got lost in a toxic shame attack. I share this with her, minus present day shame about it. She tears up and then laughs, relieved as her shame melts away. Months later, she tells me that her trust in me mushroomed at that moment. Guidelines for being judicious about this kind of self-disclosure will be discussed below.

Of the many benefits of empathy, the greatest is perhaps that it models and teaches self-empathy, better known as self-acceptance. To the degree that we attune to and welcome all of the client’s experience, to that same degree can the client learn to welcome it in her- or himself.

2. Authentic Vulnerability

Authentic vulnerability is a second quality of intimate relating which often begins with emotionally reverberating with the client. I have found that emotional reflection of the client’s feelings is irreplaceable in fostering the development of trust and real relational intimacy.

Emotional reflection requires the therapist to be emotionally vulnerable himself and reveal that he too feels mad, sad, bad and scared sometimes. Modeling vulnerability, as with empathy, demonstrates to the client the value of being vulnerable and encourages her to risk wading into her own vulnerability.

I came to value therapeutic vulnerability the hard way via its absence in my own therapy with a therapist who was of the old, “blank screen” school. She was distant, laconic and over-withholding in her commitment to the psychoanalytic principle of “optimal frustration.” Therapy with her was actually counter-therapeutic and shame-exacerbating for me as we reenacted a defective child/perfect parent dynamic.

Therapeutic Emotional Disclosure
Thankfully, I eventually realized that I had unresolved attachment issues, and sought out a relational therapist who valued the use of her own vulnerable and emotionally authentic self as a tool in therapy. Her tempered and timely emotional self-disclosures helped me to deconstruct the veneer of invincibility I had built as a child to hide my pain. Here are some examples that were especially helpful. “God, the holidays can be awful.” “I get scared when I teach a class too.” “I’m so sorry. I just missed what you said. I got a little distracted by my anxiety about my dental appointment this afternoon.” “I feel sad that your mother was so mean to you.” “It makes me angry that you were so bullied by your parents.”

“My therapist’s modeling that anger, sadness, fear, and depression were emotions that could be healthily expressed helped me to renounce the pain-repressing, emotional perfectionism in which I was mired.” With her, I learned to stop burying my feelings in the hope of being loved. I renounced my just-get-over-it philosophy and embraced vulnerability as a way of finally getting close to people.

I needed this kind of modeling, as so many of my clients have, to begin to emerge from my fear of being attacked, shamed or abandoned for feeling bad and having dysphoric feelings. In order to let go of my Sisyphean salvation fantasy of achieving constant happiness, I needed to experience that all the less than shiny bits of me were acceptable to another human being. Seeing that she was comfortable with and accepting of her own unhappy feelings eventually convinced me that she really was not disgusted by mine.

The therapist’s judicious use of emotional self-disclosure helps the client move out of the slippery, shame-lined pit of emotional perfectionism. Here are some self-revealing things that I say to encourage my clients to be more emotionally self-accepting. “I feel really sad about what happened to you.” “I feel really angry that you got stuck with such a god-awful family.” “When I’m temporarily confused and don’t know what to say or do, I…” “When I’m having a shame attack, I…” “When something triggers me into fear, I…” “When my inner critic is overreacting, I remind myself of the Winnicottian concept that I only have to be a ‘good enough person.’”

Here are two examples of emotional self-disclosure that are fundamental tools of my therapeutic work. I repeatedly express my genuine indignation that the survivor was taught to hate himself. Over time, this often awakens the survivor’s instinct to also feel incensed about this travesty. This then empowers him to begin standing up to the inner critic. This in turn aids him to emotionally invest in the multidimensional work of building healthy self-advocacy.

Furthermore, I also repeatedly respond with empathy and compassion to the survivor’s suffering. With time, this typically helps to awaken the recoveree’s capacity for self-empathy. She then gradually learns to comfort herself when she is in a flashback or otherwise painful life situation. Less and less often does she surrender to an inner torture of self-hate, self-disappointment, and self-abandonment.

My most consistent feedback from past clients is that responses like these—especially ones that normalize fear and depression—helped them immeasurably to deconstruct their perfectionism, and open up to self-compassion and self-acceptance.

Guidelines for Self-Disclosure
What guidelines, then, can we use to insure that our self-disclosure is judicious and therapeutic? I believe the following five principles help me to disclose therapeutically and steer clear of unconsciously sharing for my own narcissistic gratification.

First, I use self-disclosure sparingly.

Second, my disclosures are offered primarily to promote a matrix of safety and trust in the relationship. In this vein my vulnerability is offered to normalize and de-shame the inexorable, existential imperfection of the human condition, e.g., we all make mistakes, suffer painful feelings, experience confusion, etc.

Third, I do not share vulnerabilities that are currently raw and unintegrated.

Fourth, I never disclose in order to work through my own “stuff,” or to meet my own narcissistic need for verbal ventilation or personal edification.

Fifth, while I may share my appreciation or be touched by a client’s attempt or offer to focus on or soothe my vulnerabilities, I never accept the offer. I gently thank them for their concern, remind them that our work is client-centered, and let them know that I have an outside support network.

Emotional Self-disclosure and Sharing Parallel Trauma History
Since many of my clients have sought my services after reading my somewhat autobiographical book on recovery from the dysfunctional family, self-disclosure about my past trauma is sometimes a moot point. This condition has at the same time helped me realize how powerful this kind of disclosure can be in healing shame and cultivating hope.

Over and over, clients have told me that my vulnerable and pragmatic stories of working through my parents’ traumatizing abuse and neglect gives them the courage to engage the long difficult journey of recovering. But whether or not someone has read my book, I will—with appropriate clients—judiciously and sparingly share my own experiences of dealing with an issue they have currently brought up. I do this both to psychoeducate them and to model ways that they might address their own analogous concerns.

One common example sounds like this: “I hate flashbacks too. Even though I get them much less than when I started this work, falling back into that old fear and shame is so awful.”

I also sometimes say: “I really reverberate with your feelings of hopelessness and powerlessness around the inner critic. In the early stages of this work, I often felt overwhelmingly frustrated. It seemed that trying to shrink it actually made it worse. But now after ten thousand repetitions of thought-stopping and thought-correction, my critic is a mere shadow of its former self.”

A final example concerns a purely emotional self-disclosure. When a client is verbally ventilating about a sorrowful experience, I sometimes allow my tears to brim up in my eyes in authentic commiseration with their pain. The first time my most helpful therapist did this with me, I experienced a quantum leap in my trust of her.

3. Dialogicality

Dialogicality occurs when two conversing people move fluidly and interchangeably between speaking (an aspect of healthy narcissism) and listening (an aspect of healthy codependence). Such reciprocal interactions prevent either person from polarizing to a dysfunctional narcissistic or codependent type of relating.

Dialogicality energizes both participants in a conversation. Dialogical relating stands in contrast to the monological energy-theft that characterizes interactions whereby a narcissist pathologically exploits a codependent’s listening defense. Numerous people have reverberated with my observation that listening to a narcissist monologue feels as if it is draining them of energy.

I have become so mindful of this dynamic that, in a new social situation, a sudden sense of tiredness often warns me that I am talking with a narcissist. How different than the elevation I sense in myself and my fellow conversant in a truly reciprocal exchange. Again, I wonder if there are mirror neurons involved in this.

I was appalled the other day while perusing a home shopping catalog to see a set of coffee cups for sale that bore the monikers “Designated Talker” and “Designated Listener.” My wife and I pondered it for a few minutes, and hypothesized that it had to be a narcissist who designed those mugs. We imagined we could see the narcissists who order them presenting them to their favorite sounding boards as Christmas presents.

In therapy, dialogicality develops out of a teamwork approach—a mutual brainstorming about the client’s issues and concerns. Such an approach cultivates full exploration of ambivalences, conflicts and other life difficulties.

Dialogicality is enhanced when the therapist offers feedback from a take-it-or-leave-it stance. Dialogicality also implies respectful mutuality. It stands in stark contrast to the blank screen neutrality and abstinence of traditional psychoanalytic therapy, which all too often reenacts the verbal and emotional neglect of childhood. I believe abstinence commonly flashes the client back into feelings of abandonment, which triggers them to retreat into “safe” superficial disclosure, ever-growing muteness and/or early flight from therapy.

Meeting Healthy Narcissistic Needs
All this being said, extensive dialogicality is often inappropriate in the early stages of therapy. This is especially true, when the client’s normal narcissistic needs have never been gratified, and remain developmentally arrested. In such cases, clients need to be extensively heard. They need to discover through the agency of spontaneous self-expression the nature of their own feelings, needs, preferences and views.

For those survivors whose self-expression was especially decimated by their caretakers, self-focused verbal exploration typically needs to be the dominant activity for a great deal of time. Without this, the unformed healthy ego has no room to grow and break free from the critic. The client’s healthy sense of self remains imprisoned beneath the hegemony of the outsized superego.

This does not mean, however, that the client benefits when the therapist retreats into extremely polarized listening. Most benefit, as early as the first session, from hearing something real or “personal” from the therapist. This helps overcome the shame-inducing potential that arises in the “One-seen (client) / One-unseen (therapist)” dynamic. “When one person is being vulnerable and the other is not, shame has a huge universe in which to grow.” This also creates a potential for the client to get stuck flashing back to childhood when the vulnerable child was rejected over and over by the seemingly invulnerable parent. Consequently, many of my colleagues see group therapy as especially powerful for healing shame, because it rectifies this imbalance by creating a milieu where it is not just one person who is risking being vulnerable.

In this regard, it is interesting to note a large survey of California therapists that occurred about fifteen years ago. The survey was about their therapy preferences, and upwards of ninety percent emphasized that they did not want a blank screen therapist, but rather one who occasionally offered opinions and advice.

For twenty-five years, I have been routinely asking clients in the first session: “Based on your previous experiences in therapy, what would you like to happen in our work together; and what don’t you want to happen?” How frequently clients respond similarly to the therapists in the survey!

Moreover, the next most common response I receive is that I don’t want a therapist who does all the talking. More than a few have used the exact phrase: “I couldn’t get a word in edgewise!” “How I wish there was a way that our qualification tests could spot and disqualify the narcissists who get licensed and then turn their already codependent clients into sounding boards.” This is the shadowy flipside polarity of the blank screen therapist.

Psychoeducation as Part of Dialogicality
Experience has taught me that clients who are childhood trauma survivors typically benefit from psychoeducation about Complex PTSD. When clients understand the whole picture of CPTSD recovery, they become more motivated to participate in the self-help practices of recovering. This also increases their overall hopefulness and general engagement in the therapeutic process. I sometimes wonder whether the rise in the popularity of coaching has been a reaction to the various traditional forms of therapeutic neglect.

One of the worst forms of therapeutic neglect occurs when the therapist fails to notice or challenge a client’s incessant, self-hating diatribes. This, I believe, is akin to tacitly approving of and silently colluding with the inner critic.

Perhaps therapeutic withholding and abstinence derives from the absent father syndrome that afflicts so many westernized families. Perhaps traditional psychotherapy overemphasizes the mothering principles of listening and unconditional love, and neglects the fathering principles of encouragement and guidance that coaching specializes in.

Too much coaching is, of course, as counter-therapeutic and unbalanced as too much listening. It can interfere with the client’s process of self-exploration and self-discovery as described above. At its worst, it can lure the therapist into the narcissistic trap of falling in love with the sound of his own voice.

At its best, coaching is an indispensable therapeutic tool. Just as it takes fathering and mothering to raise a balanced child, mothering and fathering principles are needed to meet the developmental arrests of the attachment-deprived client.

The sophisticated therapist values both and intuitively oscillates between the two, depending on the developmental needs of the client in the moment. Sometimes we guide with psychoeducation, therapeutic self-disclosure and active positive noticing, and most times we receptively nurture the client’s evolving practice of her own spontaneously arising self-expression and verbal ventilation.

Once again, I believe that in early therapy and many subsequent stages of therapy, the latter process typically needs to predominate. In this vein, I would guess that over the course of most therapies that I conduct, I listen about ninety percent of the time.

Finally, I often notice that the last phase of therapy is often characterized by increasing dialogicality—a more balanced fluidity of talking and listening. This conversational reciprocity is a key characteristic of healthy intimacy. Moreover, when therapy is successful, progress in mutuality begins to serve the client in creating healthier relationships in the outside world.

Dialogicality and the 4F’s (Fight/Flight/Freeze/Fawn)
Because of childhood abandonment and repetition compulsion in later relationships, many 4F types are “dying” to be heard. Different types however vary considerably in their dialogical needs over the course of therapy.

The Fawn/ Codependent type, who survived in childhood by becoming a parent’s sounding board or shoulder to cry on, may use her listening defense to encourage the therapist to do too much of the talking. With her eliciting defense, she may even invoke the careless therapist into narcissistically monologuing himself.

The Freeze/Dissociative type, who learned early to seek safety in the camouflage of silence, often needs a great deal of encouragement to discover and talk about his inner experience. Psychoeducation can help him understand how his healthy narcissistic need to express himself was never nurtured in his family.

Furthermore, freeze types can easily get lost in superficial and barely relevant free associations as they struggle to learn to talk about themselves. This of course needs to be welcomed for some time, but eventually we must help him see that his flights of fantasy or endless dream elaborations are primarily manifestations of his dissociative defense.

“Freeze types need to learn that emotionally disconnected talking is an old childhood habit that was developed to keep them buoyant above their undealt with emotional pain.” Because of this, we must repeatedly guide them toward their feelings so that they can learn to express their most important concerns.

The Fight/Narcissistic type, who often enters therapy habituated to holding court, typically dodges real intimacy with her talking defense. Therapy can actually be counterproductive for these types as months or years of uninterrupted monologuing in sessions exacerbate their sense of entitlement. By providing a steady diet of uninterrupted listening, the therapist strengthens their intimacy-destroying defense of over-controlling conversations. Sooner or later, we must insert ourselves into the relationship to work on helping them learn to listen.

As I write this, I remember Harry from my internship whose tiny capacity to listen to his wife evaporated as my fifty minutes of uninterrupted listening became his new norm and expectation in relationship. I felt guilty when I learned this from listening to a recorded message from his wife about how therapy was making him even more insufferable. I was relieved, however, a few years later when a different client told me that Harry’s wife eventually felt happy about this “therapeutic” change. Her husband’s increased self-centeredness was the last straw for her and she finally, with great relief, shed herself of him.

“A therapist, who is a fawn type herself, may hide in a listening and eliciting defense to avoid the scary work of gradually insinuating herself into the relationship and nudging it towards dialogicality.” If we do not nudge the client to interact, there will be no recovering.

The Flight/Obsessive-compulsive type sometimes presents as being more dialogical than other types. Like the freeze type, however, he can obsess about “safe” abstract concerns that are quite removed from his deeper issues. It is therefore up to the therapist to steer him into his deeper, emotionally based concerns to help him learn a more intimacy-enhancing dialogicality. Otherwise, the flight type can remain stuck and floundering in obsessive perseverations about superficial worries that are little more than left-brain dissociations from his repressed pain.

It is important to note here that all 4F types use left- or right-brain dissociative processes to avoid feeling and grieving their childhood losses. As dialogicality is established, it can then be oriented toward helping them to uncover and verbally and emotionally vent their ungrieved hurts.

4. Collaborative Relationship Repair

Collaborative relationship repair is the process by which relationships recover and grow closer from successful conflict resolution. Misattunements and periods of disaffection are existential to every relationship of substance. We all need to learn a process for restoring intimacy when a disagreement temporarily disrupts our feeling of being safely connected.

“I believe most people, if they think about it, realize that their best friends are those with whom they have had a conflict and found a way to work through it.” Once a friendship survives a hurtful misattunement, it generally means that it has moved through the fair-weather-friends stage of relationship.

Synchronistic with writing this section, my son uncharacteristically got into a conflict at school. During third grade recess two of his good friends, also uncharacteristically, started teasing him, and when they would not stop he pushed each of them. This earned them all a trip to the principal’s office. The principal is a strict but exceptionally wise and kind woman. My son’s offense, using physical force to resolve a conflict, was judged as the most serious violation of school policy, but his friends were also held responsible for their part and given an enlightening lecture on teasing.

My son, not used to being in trouble, had a good cry about it all. He then agreed that a one-day loss of recess plus writing letters of apology to his friends were fair consequences. Two days later, I asked him how things were going now between him and the two friends. With a look of surprise and delight, he told me: “It’s really funny, daddy. Now it feels like we’re even better friends than we were before.”

Rapport repair is probably the most transformative, intimacy-building process that a therapist can model. I guide this process from a perspective that recognizes that there is usually a mutual contribution to any misattunement or conflict. Therefore, a mutually respectful dialogical process is typically needed to repair rapport.

Exceptions to this include scapegoating and upsets that are instigated by a bullying narcissist. In those situations, they are solely at fault. I have often been saddened by codependent clients who apologize to their bullying parents as if they made their parents abuse them.

In more normal misattunements, I often initiate the repair process with two contiguous interventions. Firstly, I identify the misattunement (e.g., “I think I might have misunderstood you.”) And secondly, I then model vulnerability by describing what I think might be my contribution to the disconnection.

Abbreviated examples of this are: “I think I may have just been somewhat preachy…or tired…or inattentive…or impatient…or triggered by my own transference.” Owning your part in a conflict validates the normality of relational disappointment and the art of amiable resolution.

Taking responsibility for your role in a misunderstanding also helps deconstruct the client’s outer critic belief that relationships have to be perfect. At the same time, it models a constructive approach to resolving conflicts, and over time leads most clients to become interested in exploring their contribution to the conflict. This becomes an invaluable skill which they can then take into their outside relationships.

As one might expect, fight types are the least likely of the 4F’s to collaborate and own their side of the street in a misattunement. Extreme fight types such as those diagnosed with Narcissistic Personality Disorder have long been considered untreatable in traditional psychoanalysis for this reason.

With less extreme fight types, I sometimes succeed in psychoeducating them on how they learned their controlling defenses. From there I try to help them see how much they pay for being so controlling. At the top of the list of debits is intimacy-starvation. Consciously or not, they hunger for human warmth and they do not get it from those whom they control. Victims of fight types are too afraid of them to relax enough to generate authentically warm feelings.

Finally, I believe one of the most common reasons that clients terminate prematurely is the gradual accumulation of dissatisfactions that they do not feel safe enough to bring up or talk about. How sad it is that all kinds of promising relationships wither and die from an individual or couple’s inability to safely work through differences and conflict.

Earned Secure Attachment
In therapy, clients get the most out of their session by learning to stay in interpersonal contact while they communicate from their emotional pain. This gradually shows them that they are acceptable and worthwhile no matter what they are feeling and experiencing.

As survivors realize more deeply that their flashbacks are normal responses to abnormal childhood conditions, their shame begins to melt. This then eases their fear of being seen as defective. In turn, their habits of isolating or pushing others away during flashbacks diminish.

Earned secure attachment is a newly recognized category of healthy attachment. Many attachment therapists believe that effective treatment can help a survivor “earn” at least one truly intimate relationship. Good therapy can be an intimacy-modeling relationship. It fosters our learning and practicing of intimacy-making behavior. Your connection with your therapist can become a transitional earned secure attachment. This in turn can lead to the attainment of an earned secure attachment outside of therapy. I have repeatedly seen this result with my most successful clients, and I am grateful to report that my last experience with my own therapy lead me to this reward.

Scott Miller on Why Most Therapists Are Just Average (and How We Can Improve)

Posted on by rezendevknowfully.com

Escape from Babel

Tony Rousmaniere: Many people know you as a Common Factors researcher, but recently you’ve transitioned away from that. Could you explain both what Common Factors is and your transition away from it?
Scott Miller: Sure. As old-fashioned as it sounds, I’m interested in the truth—what it is that really matters in the effectiveness of treatment. Early on in my career, I learned and promoted and helped develop a very specific model of treatment, solution-focused therapy. We had some researchers come in near the end of my tenure at the Family Therapy Center in Milwaukee who found that, while what we were doing was effective, it wasn’t any more effective than anything else. Now, for somebody who had been running around claiming that doing solution-focused work would make you more effective in a shorter period of time, that was a huge shock.
All models are equivalent. Pick one that appeals to you and your client.


It was at that point that I started to cast about looking for an alternate explanation for the findings, which concluded that virtually everything clinicians did, however it was named, seemed to work despite the differences. That led back to the Common Factors—the theory that there are components shared by the various psychotherapy methodologies and that those shared components account more for positive therapy outcomes than any components that are unique to an approach. It was something that one of my college professors, Mike Lambert, had talked about, but that I had dismissed as not very sexy or interesting. I thought, how could that possibly be true?

It was at that time that I ran into a couple of people that I worked with for some time, Mark Hubble and Barry Duncan, and we had written several books about this. If you read Escape from Babel, which we coauthored, the argument wasn’t that Common Factors were a way of doing therapy, but rather a frame for people—therapists speaking different languages—to share and meet with each other. They were a common ground.

But by 1999, it was very clear to me that Common Factors were being turned into a model by folks, including members of our own team, and viewed as a way to do therapy. But you can’t do a Common Factors model of therapy—it’s illogical. The Common Factors are based on all models. This caused a large amount of consternation and difficulty, numerous discussions, and eventually I suggested to the team that the way therapists work didn’t make much of a difference.

What was critical was whether it worked with a particular client and a particular therapist at a particular time. Mike Lambert was already moving in this direction and said, “Let’s just measure them. Let’s find out. Who cares what model you use? Let’s make sure that the client is engaged by it and that it’s helping them.” So we began measuring, and what became clear very quickly was that some therapists were better at it than others.

So, since about 2004, Mark Hubble and others at the International Center for Clinical Excellence (ICCE) have been researching the practice patterns of top performing therapists. It’s not that I don’t believe, and in fact know, that the Common Factors are what accounts for effective psychotherapy. It’s just that an explanation is not the same as a strategy for effecting change. And the Common Factors can never be used as such. All models are equivalent. Pick one that appeals to you and your client.

The Siren Song

TR: So Common Factors are a way of studying the effects of psychotherapy, but not a way of actually implementing it.
SM: Well, by definition, you can’t do a Common Factors model because then it’s a specific factor. I’m not saying the Common Factors don’t matter—what I’m saying is that they are a therapeutic dead end. They will not help you do therapy. You still have to have a method for doing the therapy, and the Common Factors are not a method. Why?
What I say is, pick one of the 400 that appeals to you and then measure and see: Does your client like it, too? If not, then it’s time for you to change, not your client.
All treatment approaches return equal efficacy when the data is aggregated and methods compared in a randomized controlled trial. So you still need some kind of way to operationalize the Common Factors.

Since we have 400 or so different models of therapy, why invent a new one? It seems to be because in our field, each person has to have it their own way. The promise of a new model is a siren song in our profession that we have a hard time not turning our ship towards. What I say is, pick one of the 400 that appeals to you and then measure and see: Does your client like it, too? If not, then it’s time for you to change, not your client.
TR: You have an article out in Psychotherapy where you mentioned three keys for therapists to improve their work. Your major focus now seems to be how therapists improve their work with each client. Can you describe those three keys?
SM: The first one is knowing your baseline. You can’t get any better at an activity until you actually know how good you are at it now. We therapists think we know, but it turns out that data indicates that we generally, as a group, inflate our effectiveness by as much as 65%. So you really have to know just how effective you are in the aggregate. That means you’re going to have to use some kind of outcome tool to measure the effectiveness of your work with clients over time.
We generally, as a group, inflate our effectiveness by as much as 65%.


The second step is to get deliberate feedback. So once you know how effective you are, then it’s time to get some coaching, get some feedback, and you can do that in two ways. Number one, you can use the very same measures that you used to determine your effectiveness to get feedback from your clients on a case-by-case basis. Meaning that you can actually see when you’re helping and when you’re not, and use that to alter the course of the services provided to that individual client.

The second kind of feedback to get is from somebody whose work you admire, who has a slightly broader skill base than you do, and have them look at your work and comment specifically about those particular cases where your work falls short. In other words, you begin to look for patterns in your data about when it is you’re not particularly helpful to people, and seek out somebody who can provide you with coaching. It’s like in golf, once you know what your handicap is you can hire a coach who can look at your game and make fine tweaks. It’s not about revamping your whole style, or about learning an entirely new method of treatment, but pushing your skills and abilities to the next level of performance.

The third piece is deliberate practice. The key word in that expression is “deliberate.” All of us practice. We go to work. But it turns out the number of hours spent on a job is not a good predictor. In fact, it’s a poor predictor of treatment effectiveness. So what you have to do is identify the edge of your current realm of reliable performance. In other words, where’s the next spot where you don’t do your work quite as well? And then develop a plan, acquire the skills, practice those skills and then put them into place. Then measure again to see, have you made any improvement?

I can’t take credit for coming up with these three steps. We’ve simply borrowed them lock, stock, and barrel from the performance literature, and in particular, Anders Ericsson’s work, which has been applied in fields like the training of pilots, chess masters, computer programmers, surgeons, etc. If we have any sort of claim to fame, it’s that we’ve begun applying these to psychotherapy for the first time.
TR: One of my first reactions to this is, aren’t some people just born better therapists?
SM: Well Ericsson notes that the search for genetic factors responsible for the performance of eminent individuals has been surprisingly unsuccessful. In sports we often think, “Oh, there must be some genetic component involved here,” or “he just has the gift of music.” But it turns out that virtually everyone that researchers looked at where the “gift” is implied, even with Mozart—he had been playing the piano for 17 years before he wrote anything that was unique, which happened at about age 21. He’d been playing since he was 4. His father had been doing music scales with him since he was in the crib. So once you remove the practice component, you just don’t find any evidence for genetic factors—with very few exceptions.

For example, in boxing it appears that people with a slightly longer reach have a slight advantage. But we also know that if baseball pitchers don’t start pitching at a particular age, their arms will not make the adjustment required to throw the ball as fast and accurately as professional pitchers do.

There was another study that looked at social skills. You often will hear, in addition to the genetic claims, that, “Good therapists just have great social skills.” Well, they’ve measured that. It turns out not to be the case, and the reason is that these kinds of ideas are too high or general a level of abstraction. The real difference between the best and the rest is that they possess more deep, domain-specific knowledge. They have a highly contextualized knowledge base that is much thicker than average performers, and much more accessible to them and responsive to contextual clues.

Deep Contextual Knowledge

TR: Could you give a specific example of what a deep contextual knowledge would look like in a therapy room?
SM: Well the classic one—and I say it to make fun of it—is suicide contracting. Or the suicide prevention interview.
Somebody comes in and says, “I’m going to commit suicide.” And we respond with, “Do you have a plan? Have you ever attempted this before?” Blah, blah, blah. That’s decontextualized knowledge. You could ask those questions to a stick.
Somebody comes in and says, “I’m going to commit suicide.” And we respond with, “Do you have a plan? Have you ever attempted this before?” Blah, blah, blah. That’s decontextualized knowledge. You could ask those questions to a stick.

What a top performer does is ask those questions very differently, nuanced by the client’s presentation, in ways that the rest of us can’t see. Because of their more complex and well-organized knowledge, they can actually see patterns in what clients present that the rest of us would miss and respond to in a much more generic fashion. Is this making sense?
TR: Absolutely.
SM: So the real question is how to help clinicians develop that highly contextualized knowledge. Because once you have it, not only can you retrieve that knowledge at the appropriate moment, but it turns out you can make unique combinations and use them in novel ways that would never occur to the rest of us, or would only occur to the rest of us by chance.
TR: This also doesn’t suggest that treatment manuals are necessarily the best way to train therapists.
SM: We know that following a treatment manual doesn’t result in better outcomes and it doesn’t decrease variability among clinicians using the same manual. So you still get a spread of outcomes, even when everybody is doing the same treatment.

At the same time, I think it’s critical that therapists learn a way of working, and, in the beginning at least, they hew to that approach. Why? Well, if you begin to introduce variation in your performance early on, you will not have the same ability to extend your performance in the future.

Let me give you an example. The first time I had a guitar lesson, I was taking classical guitar with this really interesting teacher. We spent the entire first lesson on how he wanted me to hold the neck of the guitar with my left hand—and I’m right handed. He said, “If you try to vary your hand grip from the outset, you’ll never have the same reach and ability to vary reliably when you need to in the future. So start with a common foundation, and then when we need to introduce variations later, we will.” My sense is that therapists instead begin in a highly complex, nuanced way and introduce variations into their style randomly and without much thought.
TR: So it would be better to begin with a frame or structure that provides a stable base, and then develop the deep contextualized knowledge later on.
SM: And to vary your work in ways that allow you to measure the impact of your variation against what you usually do. This is the key. Otherwise, what you have is a bag of tricks. You can do them all, but there’s no cohesiveness to it, and you can’t explain why you vary at certain times rather than others.
TR: Starting with a manual isn’t necessarily a bad idea then.
SM: Absolutely not. In fact, I would suggest grabbing a manual and going to a place where they are teaching a specific approach that will allow you to practice and also watch others in a two-way mirror. Once you have that foundation down, you can introduce your own variations.
TR: I hear therapists say, “I have 20 years experience,” or “I have 30 years experience.” Does this research find that experience, itself, makes someone better?
SM: No, it doesn’t. We know that not only in therapy, but in a variety of activities. If you think about it, you’ll understand why. While you’re doing your work, you don’t have time enough to correct your mistakes thoughtfully.
The difference between the best and the rest is what they do before they meet a client and after they’ve met them, not what they’re doing when they’re with them.
So what we found, which I think is quite shocking, is that the difference between the best and the rest is what they do before they meet a client and after they’ve met them, not what they’re doing when they’re with them.  Let me give you an example from a field that is similar—figure skating. If you watch a championship figure skater perform a gold medal winning performance, you can describe what they did, but it won’t tell you how to do it yourself. Do you follow me?
TR: Yeah.
SM: In order to be able to accomplish that performance, that figure skater must do something before they go on the ice, and after they leave the ice. It’s that time that leads to superior performance. You can go out and try to turn triple axels during the performances as much as you want. That experience will not make you better. You have to plan, practice, perform, and then reflect. Most of us don’t see all of the effort that goes into that great performance. We just appreciate how good it is.
TR: But one of the tricky differences is that we’re trying to help each client. And if we’re practicing new skills, invariably we’re going to make mistakes. And that’s emotionally harder because you’re making a mistake with a real person sitting across from you.
SM: Well, number one, we’re all already making these mistakes. And the ones that I’m referring to are generally small and not fatal. So your performance doesn’t improve by isolating gross mistakes, or gross skills. Your performance improves when your usual skills begin to break down—meaning they don’t deliver—and remembering those, thinking about them after the session, and making a plan for what to do instead. That’s where improvement takes place.

When I hear people mention this kind of objection, I think they’re thinking that the errors are far grosser than what I’m talking about. Once therapists assess their baseline, most are going to find out—to their, perhaps, surprise—that they’re average in terms of their outcome, or slightly less than average. So if we’re average, then it’s not about bringing your game up to the average level. It’s about extending it to the next. That requires a focus on small process errors.

Let me give you another example. We have a pianist come and perform at one of our conferences. She is eight years old and she is really unbelievably able as a concert pianist. She plays a very difficult piece. I ask her if she made any mistakes. She says, “Of course, I made a lot.” I tell her I didn’t hear any, to which she says, “Well, that’s because you’re no good at this.”

I then say, “What do you mean? And what do you do about your mistakes?”

She says, “Look. I made lots of mistakes, but you cannot get better at playing the piano while you’re performing.” This is an 8-year-old.

I say, “So what do you do?”

She says, “Well, I hear these small errors. I remember them. My coach in the audience remembers them, and then that’s what I isolate for periods of practice between performances.”

Most of Us Are Average

TR: How many therapists really practice between sessions? I mean, that’s pretty rare, isn’t it?
SM: Most of us are average.
TR: Right.
SM: And 50% of us are below average, right?
The best performers spend significantly more time reading books and articles….and reviewing basic therapeutic texts.
So very few people do it, and this is the real mystery of expertise and excellence. Why do some go this extra mile? There’s no financial pay-off. I think this will change in the future, but at the present time, you don’t get paid one dime more if you’re average, crappy, or really good. The fees are set by the service provided.
TR: That is a great problem with our field and I hope that does change in the future.
SM: I think that we’re seeing movement in that direction. I think that our field will become like other fields, where outcome of the process is what leads to payment, rather than the delivery of it.
TR: So back to practicing. Therapists read books and go to workshops, but that’s kind of passive learning. What are your thoughts about that?
SM: That’s a component of practicing. A graduate student that I’ve been working with, Darryl Chow, who just finished his PhD at University of Perth in Australia, did his dissertation on this topic and found that the best performers spend significantly more time reading books and articles. We also know that the best performers spend more time reviewing basic therapeutic texts.

Therapists are often in search of the variation from their performance that will allow them to reach an individual client they’re struggling with. Top performers not only do that, but they’re also constantly going back to basics to make sure they’ve provided those. They spend time reading basic books that may be hugely boring but are nonetheless really helpful. Gerard Eagin’s The Skilled Helper, Corey Hammond’s book on therapeutic communication—these basic texts that remind us of things that we often forget in the flurry of cases we see every week.
TR: So reading counts. What about workshops?
SM:
We don’t know about workshops. I’m cynical about them, simply because they’re not set up in a way that respects any principles of the last 30 years of research on human learning.
We don’t know about workshops. I’m cynical about them, simply because they’re not set up in a way that respects any principles of the last 30 years of research on human learning. Six hours, chosen by the person who needs the continuing education, and there’s no testing of skills, acquisition of skills, no awareness of particular deficits in practice. Greg Neimeyer has done a fair bit of research on this and he finds no evidence that our current CE standards lead to improved performance. None.
TR: There’s a psychotherapy instructor I know, Jon Frederickson, who has his students go through psychotherapy drills, kind of like role-playing drills in a circle. Would that count as practice?
SM: It depends, but I like the sound of it. Not a scrimmage, where you do a whole game, but rather drilling people in very specific small skill sets again and again. That aligns with the principles of Ericsson’s researchers.

If you’re an experienced professional, your motivation for going to a CE event can be really varied. I know for me, I’m often just grateful to have a day off and hang out with friends. The particular content of the workshop, I’m ashamed to admit, is less important. The incentives are just all wrong.
TR: It goes back to your motivation question.
SM: I don’t think our field incentivizes that kind of stuff. In fact, you can be punished.
TR: Well, one incentive I discovered myself in my own private practice was my drop-out rate. That motivated me to get further training. Maybe other therapists don’t have the same problem I had, but I know that was a powerful motivation.
SM: Drop-out can be both a good and a bad thing. For example, our current system incentivizes therapists to have a butt in the seat every available, billable hour. What that means is that therapists may be incentivized—we have some data about this, too—to keep clients, whether they are changing or not. That’s what I mean when I say that the incentives are all screwed up. There are, every once in a while, motivated people like yourself who say, “Wait a second. There has to be something beyond this.” But that requires a degree of reflection that may be difficult for most of us, especially if we are well defended. For these folks, people drop out because they are in denial about their own problems, not because of anything they, themselves, might be doing.

You put those things together and it can be a fatal combination. We need to take a step back as payers for services and as consumers of services and think about the incentives in our current system. I know this sounds terribly economic, but I think it’s important for our field.
TR: That sounds sensible to me. What about watching psychotherapy videos by psychotherapy experts like the ones psychotherapy.net produces. Would that count as practice?
SM: Yes it would. Especially in the beginning, when you have identified a particular area or weakness in your skill set that you may need some help with. In essence, you’re spending more time swimming in it while reflecting, which is the key part.
TR: Do you have other examples of deliberate practice that you’ve heard of therapists engaging in?
SM: Well there’s the stop-start strategies that Darryl Chow has been talking about. And Chris Hall is doing a study at UNC that we’re involved with, where therapists will watch short segments of a video and then they have to respond in the moment in a way that is maximally empathic, collaborative, and non-distancing. So they’re training therapists to develop a certain degree of proficiency with fairly straightforward clients.

Then you begin to vary the emotional context, or the physical context, in which the service is delivered. So now the client’s not just saying, “Hey, I feel sad.” They’re threatening to drop out or to commit suicide. More difficult and challenging things. And then simply spending time outside of the office planning and discussing individual particular cases with peers or consultants is another strategy.

In Darryl Chow’s research, which I think is the most exciting stuff, he found that within the first eight years of practice, therapists with the best outcomes spend approximately seven times more hours than the bottom two-thirds of clinicians engaged in these kinds of activities. Seven times.
TR: Wow.
SM:
The key to this is really starting early and investing a little bit at a time. It’s sort of like how you’re advised to save for your retirement. Not in the last five years. Not in the first five years, but a little bit every year.
The good news is, now that we know this, we can start this process earlier. The bad news is, if you’ve been at this for awhile, it becomes impossible to catch up with the best. We just age out. We can’t do it. The key to this is really starting early and investing a little bit at a time. It’s sort of like how you’re advised to save for your retirement. Not in the last five years. Not in the first five years, but a little bit every year.
TR: One advantage that great athletes have is that their coaches gets to determine day by day what moves or what performances they’re going to practice. I run a training program here at University of Alaska, Fairbanks, at the University Center for Student Health and Counseling, and I don’t get to pick what clients come in day to day. It could be anxiety, depression, any number of different things, so I’ll do a training on, let’s say, working with anxiety, but the client that comes in will have depression. So what do you do about that?
SM: Well, in essence, we’re violating John Wooden’s primary rule, which is, we are allowing students to scrimmage before they drill. And I have to tell you, all students want to scrimmage, but what you need to do more of, before and during, is drilling. The kind of drilling that I think your colleague was talking about. Or you go back to, “Here’s how we hold the guitar.” And we play very simple songs and then we begin varying the drill with greater degrees of complexity once easier tasks are managed.
TR: So you’d recommend a longer period of training and practice and drills before seeing clients.
SM: I’d want to see that kind of mastery. Let me give you an example. Do you want the pilot to be proficient at flying in fair weather, as demonstrated on the simulator, before they fly a plane?
TR: Yes.
SM: You want them to be prepared for all the complications: “Wait a minute, it’s raining,” “Wait a minute, you’ve got problems with your rudder.” These are complex skills and, yes, we can teach people to manage them as one-offs, but then they never integrate it into a coherent package that makes it easier to retrieve from memory later on when they need that skill. If it’s viewed as a one-off—“With the anxiety client, I did this”—it’s not integrated into an organized structure for retrieval later on.
TR: So on a therapist’s resume, you’d want to see not just hours of direct service provided, but also hours spent practicing and learning.
SM: Or, better yet, somebody who has measured results, like yourself. All I need is an average pilot. I don’t need the best pilot in the world, because most of the time there’s not huge challenges. If you can document your results, and if you’re checking in with me, we’re going to catch most of the errors anyway. And then I want a therapist who has a professional development plan, that’s working on the aggregation of small improvements over a long period of time.
TR: So for tracking results, I know you recommend quantitative outcome measures, like the Outcome Rating Scale or the Outcome Questionnaire. But I have found that there are certain clients that quantitative measures just don’t seem valid for. It’s not a large percentage of clients, but there are some that underreport problems at first. So it can look like they’re deteriorating even while they’re improving. Can you recommend any kind of qualitative methods or other methods of trying to accurately assess outcome in addition to those measures?
SM: I don’t buy it. Personally, I just don’t see that stuff and I would offer a very different explanation for it. Let me give you an example.

We know that each time there is a deterioration in scores, the probability of client drop-out goes up, whether or not the therapist thinks that it’s a good sign that the client is “getting in touch with reality and finally admitting their issues,” or had inflated how they really were doing for the first visit. So the key task here is not to say, “There must be another measure,” but to figure out what skills are required for me to get a higher score.

Dig Into the One You Know

TR: That’s a new perspective. To look at what I can change about my performance, rather than a new measure to assess it.
SM: Now you see why I think our field is forever chasing its tail. Because instead of becoming fully connected to our performance, we are constantly looking for the trick that will make us great.
Instead of becoming fully connected to our performance, we are constantly looking for the trick that will make us great.
It’s like a singer looking for the song that will make them famous rather than learning how to sing. We’re forever going to workshops, and the level of the workshops are often so basic even when they’ve claimed to be advanced. The truth is, you can’t do an advanced workshop on psychotherapy for 100 people. You can’t do it. The content is too abstract and too general. You need to see a clinician’s performance and fine-tune it. So therapists go around and around, constantly picking up these techniques that they use in an unreliable fashion, and their outcomes don’t improve, but their confidence does.
TR: So instead of picking up a new modality every year, dig into the one you know, preferably with a real expert, and get individualized or maybe small group training and practice.
SM: I think that once you’ve achieved a level of proficiency, the only hope for improvement is to get feedback on your specific deficits. And yours will be different from mine.
TR: It sounds like you’d definitely be a fan of videotaping sessions and reviewing them and that kind of thing.
SM: Not alone—with an expert eye reviewing small segments. Otherwise the flood of information from video will have you second-guessing yourself, which can actually interrupt the way you work in an unhelpful way.
TR: What about live supervision?
SM: I’m not averse to it, but I think it’s a little bit like a GPS—it can correct your moves in the moment, but you become GPS-dependent and you don’t learn the territory. What’s required in learning is reflection. If you don’t reflect, you can’t learn. As my uncle used to say, “You got to study that thang.”

I actually had great opportunities with live supervision when I was at the Family Therapy Center and got corrected in the moment by two really masterful clinicians. But I also think that what really made a difference was sitting behind a mirror, without any financial worries, watching endless hours of psychotherapy being done, and then talking about it afterwards. “This was said. What could you have said? How come we said this? What do you need to do?” It was a heavenly experience and as a result, I came away with a very highly nuanced and contextualized way of delivering that particular model.

And today, when I’m doing my Scott Miller way of working and I notice that a particular client wasn’t engaged or interested at a particular moment, I think, “What could I have said differently?” It’s at that small micro level that improved outcome is likely to be found. As opposed to just gross generic level.

People go to workshops and say, “I’ve had some traumatized clients. Maybe I’ll learn that EMDR thing.”

“Really?” I think. “Do you know how effective you are in working with these clients already?”

“No, I don’t.”

“What makes you think you need to do EMDR?”

“Well, it just seems so interesting.”

And I think, “Oh, you’re doomed.” Not that there’s anything wrong with EMDR, but I have to tell you, I watched Francine Shapiro do it and it looks a lot different than some other people I’ve seen doing it.
TR: So the problem there is switching modalities rather than getting a lot better at the one you’re currently using.
SM: It’s looking for a trick rather than thinking through, what else could I have said? What else could I have done that I already know how to do? Or getting a little bit of tweaking from a trusted mentor.
TR: I know you present this information all over the world. Do you find therapists are open and receptive to these ideas?
SM: Yes. I think that there are some very real barriers that we need to address, but yes, I do.
TR: This has been a really fascinating conversation. Thank you for making the time.
SM: I like this stuff. I’m fascinated by it and I’m very hopeful about the direction we’re going research-wise, so thank you for giving me the opportunity.

Leave Your Degree at the Door, Dude

Posted on by Psychotherapy.net Team

The late 1960s and 1970s were exciting times for the fields of psychology and psychotherapy. Much of the enthusiasm was spawned by a body of landmark research. At the time experts postulated that humans had two distinct nervous systems: the voluntary and the involuntary. The voluntary nervous system allows you to brew your morning cup of Joe or take out the trash before you leave for work. The involuntary or autonomic nervous system controls your heart rate, blood pressure and the temperature of your baby toe. According to the existing theory, a human being could not control his or her involuntary or so-called autonomic processes. But all that was about to change.

Enter Neal E. Miller, a prominent psychologist and a past President of the American Psychological Association. By paralyzing animals, and hence knocking out voluntary responses, with curare (often dubbed South American dart poison) Miller demonstrated that involuntary or autonomic/automatic responses could indeed be controlled. And although later research would sometimes fail to replicate Dr. Miller's results, the implications for the human potential movement were staggering. If indeed Miller was correct, humans could do things to control their behavior that were heretofore considered impossible!

During this same era, the Menninger Foundation, a longstanding psychoanalytic foothold, located in Topeka, Kansas was doing some experiments that seemed to back up Miller's assertions. Subjects were asked to hold glass mercury thermometers and told to raise their hand temperatures. Not only did many subjects accomplish this, but as an added benefit, these same individuals often experienced relief from migraine headaches. When Miller was informed of this fact, folklore has it that he smiled and merely quipped: "I believe that in this respect men are as smart as rats."

Slowly but surely, thermometers and the like were replaced with sensitive electronic devices called biofeedback meters that gave subjects and clients the superior feedback necessary to make bodily changes at will.
With Menninger at least partially leading the charge, biofeedback seemed to be the coming thing in our field and I wanted to be on the cutting edge of the breakthrough. Luckily Menninger was offering brief biofeedback training sessions and as a graduate student I immediately applied.

I mean how fun would that be? I would get in my favorite car of all time and drive from St. Louis to Topeka—310 miles—to receive the best training of my life. The make and model of my favorite auto of all time are irrelevant to this discussion . . . okay, okay you twisted my arm . . . it was a 1965 Oldsmobile 442 and yes it was fast enough to get even the most conservative driver in a heap of trouble.
But as John Lennon once quipped, life is what happens when you are making other plans. Certainly, it proved true in my situation. I blew the clutch out on my 442 dream machine and thus an intercity bus transported me to the Mecca of biofeedback training.

The training was blow-away awesome and reached a zenith when at the end of the day's workshop we were given the exact temperature feedback monitor units Menninger was using to train clients to take home and experiment with. These biofeedback devices were manufactured in Lawrence, Kansas. Yes indeed, these gems were made in America and resembled a lunch box Larry Mondelo might have been toting in a classic Leave it to Beaver episode. In reality, the unit was a ultra sophisticated thermometer with 3 3/4 inch meter on the front. It would take a baseline, track the client's progress (or lack of it), and even had onboard calibration capabilities. We had the option of purchasing the units if we liked them and I did just that.

As for me, you won't find mine for sale on Ebay. After my brief training at Menninger I used this little gem to help hundreds and hundreds of clients with anxiety, habit control issues, and migraine headaches. It also came in handy for performing hypnosis and systematic desensitization; but that's a tale for another blog.

But here's where the story gets very interesting. On the night I took my unit home I had fairly good success raising the temperature of my hand. This practice was theoretically helpful in combating anxiety and once again helping those with migraine headaches.

As I was walking from my hotel to Menninger the next morning I spied a psychiatrist who was in my training class.

"Hey how's it going?" I asked.

"Not well. This biofeedback stuff is junk," he told me.

"What do you mean?"

"Well," the psychiatrist asked," were you able to make the temperature on your meter go up."

"I was," I proudly announced, "but I take it you could not."

"Right. My meter did nothing," lamented the psychiatrist.

"Look," I said trying to be nice. "It could be the biofeedback meter they gave you is defective."

"Ha. I don't think so," he responded. "I let my five year old son play with it and he was pegging the meter on super hot so easily I had to reset it several times for a higher temperature."

"Okay," I calmly responded. "I think I have an answer for you. You know too much. I mean look. Your five year old doesn't know squat about the nervous system. You tell your five year old that his hand is getting hot or to imagine that he is outside on a warm sunny day and presto . . . his hand temperature genuinely goes up. You, on the other hand are a medical doctor. Therefore, you know all these facts about the central nervous system versus the autonomic nervous system. You know the traditional theory forward and backward. You can tell me with great detail why a person should not be capable of raising his or her hand temperature. Too much traditional knowledge can be a dangerous thing."

"Al-right Rosenthal, maybe, just maybe, you are correct. So what in the heck should I do about it?"
"That's easy," I replied, "Just leave your degree at the door dude!"

"Hmm. Well what about you Rosenthal. Are you going to leave your degree at the door?"

"Not me." I said. My degrees are nonmedical and not focused on physiology. I might just know less about the nervous system than your five-year-old son. So, to put it bluntly, I'm good to go."

Dial-Up Connection

Posted on by Psychotherapy.net Team

Thirty-five years ago I got my first paid therapist job as a second-string telephone counselor for an enlightened radio station in Sydney, Australia. The radio station ran a daily one-hour program called “Kid’s Careline,” and my boss was the first string counselor who fielded on air calls from the radio audience. She was so brilliant at it that she kept three of us second stringers busy 9 to 5 fielding the calls that did not make it onto the air.

It was in this job that I began to learn about the unique power of telephone counseling. Stints of supervising and fielding crisis phone calls at Suicide Prevention and Parental Stress Services in Oakland enriched my learning. These experiences eventually culminated with me adding telephone counseling to my private practice, which I have done for the last 20 years.

I have an Intersubjective/Relational approach and specialize in working with individuals whose traumatic childhoods have burdened them with Complex PTSD. I am excited by my accumulating anecdotal evidence that significant attachment repair work can be done over the telephone. I have especially noticed this with clients whose trauma is so extensive that they are incapable of handling the anxiety of face-to-face work. Some of my clients have lived reclusive lives but sought me out because my website articles explain how their childhood traumas created their attachment disorders.

Complex PTSD survivors typically operate from a deep belief that “people are dangerous,” and feel less endangered on the phone because they know that they can escape in a second if necessary. Moreover, the phone seems to offer them enough protection, that they are able to drop into authentic and vulnerable relating quite quickly with me—often more quickly than new clients in face-to-face sessions. Once again, I believe this is because phone work offers them a greater sense of safety.

Telephone therapy can foster a uniquely rapid building of trust. In best case scenarios, as with in-person work, this eventually encourages some clients to look elsewhere for similarly trustworthy relationships. More than a few of my telephone clients have experienced enough relational repair within two years of weekly sessions to venture out successfully into the world of real live relating. Often this starts with participating in online support groups, and then expands into joining in-person groups.

I believe that part of the healing dynamic in phone work is that voice contact can be as soothing and brain-changing as the eye contact that seems so fundamental to forming attachments. I wonder, in fact, if voice contact is even more fundamental than eye contact, as the soothing sound of a mother’s voice may be laying down the framework for bonding long before the baby is born. Moreover, as most seasoned therapists know, voice tone, timbre and pitch carry a great deal of emotional communication. The client’s voice can tell us a great deal about her unexpressed distress. And our voice can carry our good will, compassion and, dare I say it, love to the client.

As I write this I flash back guiltily to my adolescence and my dog, Ginger. I once unconsciously experimented with teasing her with the tone of my voice. I soothingly and sweetly told her “You are a very, very bad dog Ginger!” and her dog smile lit up her face as her wagging tale oscillated furiously. Then I switched to an angry tone: “Good dog, Ginger, Good dog!” As I vituperated she fawned nervously and her tail disappeared between her legs. Now I flash on my mother lambasting me throughout my childhood: “Of course I love you!” and 60 years later, I feel my whole body contract and imagine my ears lowering like Ginger’s.

And now let me free associate further. I think of three different friends whose parents read to them as kids, and who still love to be read to. My parents, on the other hand, frequently spoke in tones of anger and disgust, and despite a great deal of attachment recovery, I still find little pleasure in being read to. My nine-year-old son, however, drinks it up like soda. When I come home and sit on the couch he often leans into me and croons: “Read to me, Daddy!,” and lucky man that I am, I still get to read to him for hours every week. We’re on our ninth Gordon Korman book this year. (Gordon Korman is a brilliant children’s author whose books are wise, funny and replete with emotional and relational intelligence.)

Coming back to the issue of therapy, I feel I now understand why traditional psychoanalysis works so well for some clients, despite the analyst sitting out of view behind the couch, and despite the criticism some attachment therapists express about it lacking the intimacy of eye contact.

Paradise Lost: When Clients Commit Suicide

Posted on by rezendevknowfully.com

Becky

“May I speak to Becky, please?” I asked the female voice that had answered the phone.

“Who’s calling?”

“Dr. Joyce,” I replied.

“Her therapist?” she asked. I knew I had to protect my client’s confidentiality, so I couldn’t answer that question. I began to feel uneasy.

“I’m sorry," she said softly. "Becky killed herself last night.”

I felt as though underwater, my voice garbled, when I finally managed to say, “Okay, thanks for telling me.”

Becky’s gone? My patient committed suicide? I wandered into my living room, dazed. I stared out the picture window into the courtyard where the heavenly bamboo were growing. I hadn’t noticed how they had reddened, with berries forming, signaling the start of winter. The liquid amber tree was bare, dried leaves cluttering the bed. I need to clean up those dead leaves, I thought.

I looked at the clock. It was 9:45 and I was to meet my husband at our new house at 11:00. On my way over, I began to reflect on my last therapy session with Becky, a mere six days earlier. She had been struggling with depression, but she did not seem more deeply depressed than before, nor did she mention suicide. The only clue I had was a casual comment made towards the end of the session.

“I really don’t know what I’m going to do now. I thought about the Peace Corps,” Becky said. “But I need to be close to a therapist and psychiatrist.”

“Yes. And I wonder if being far away from Matt would also be hard,” I said. Becky was having difficulty recovering from a breakup with Matt.

“Well, that too,” she said. Then she changed the subject.

“I like having more time now that school is over,” she said. “I’ve been reading The Inferno.” I didn’t follow up on her comment and she moved on to a new topic.

At the end of the session, I escorted her to the door and, for some reason, I felt compelled to do “doorknob therapy,” unusual for me. As I opened the door, I said, “Maybe you might try reading something less…less intense than the Inferno?“

“And that is when she beamed that smile, forever imprinted on my psyche, as last looks must always be.”

“Less intense? You mean, like, Paradise Lost?” A wide, brilliant smile. Then she exited down the hallway.

As I later found out, four days later she walked in on Matt with another woman and then drove herself to the emergency room because she was feeling suicidal. Six hours later, she was discharged and ten hours later she was dead. I’ll bet she flashed that same smile to the hospital staff before they let her go.

My husband, Joe, was already at the 1911 arts and crafts house that we had bought three weeks earlier. We were full of optimism and hope for rescuing this gem from neglect, but we hadn’t yet moved in.

“Marian, where do you want to put the bathroom sink? If we put it here,” Joe said, pointing to the back, “there’ll be more room for the closet. Glynn needs to know.” Glynn was our contractor.

I found myself pondering the ideal location of the sink. I imagined all the alternatives and finally settled on placing the sink towards the back.

Then Joe and Glynn were at it again, arguing about where to put the dishwasher. I tuned them out as I thought about the subtext of Becky’s Inferno/Paradise Lost comments. Had she tried to tell me: “I am bad, a sinner. I want to die and I will probably burn in hell”? How had I missed that reference?

Some people think that being a therapist is easy. “All you do is just sit there and listen,” they often say. But sometimes the client’s thoughts swim deep underwater, like fish that surface only briefly. Blink and you will have missed the sighting. Fortunately, clients will find creative ways to draw my attention to what they want me to hear until I finally “get it.” But I wouldn’t have that opportunity with Becky. I was left with so many unanswered questions: Should I have detected something that last session? Was there something I could have done? Why did she do it?

The 1:00 Spot

The next day I opened my planner and saw Becky’s name in the 1:00 spot. I stared at it for a moment. When I wrote that in, Becky was sitting in the room with me. And now she is gone. What was I supposed to do with her name? Crossing it off seemed disrespectful. I decided to leave it alone.

My 10:00 appointment was Sherry, a woman who had been going through a particularly rough patch lately. At 10:10 when she still hadn’t arrived, I began to panic. Where is she? I could feel my heart pounding. I frantically flipped through my planner to find her phone number.

“Hello,” she said. I sighed with relief.

“Hi, Sherry. It’s Dr. Joyce,” I tried to sound calm. “I had you down for a 10:00. Is everything okay?”

“Yeah, I’m on my way. My mother called just as I was leaving and I couldn’t get her off the phone. I’ll be right there.”

After our session, I hurried out of the office to make my appointment with a seasoned psychologist I had sought out to help me with my cases before Becky’s suicide.

“Well, a lot has happened since I made the appointment,” I said.

“Oh really?” she replied. Then she got out of her chair and stood up. “You don’t mind if I stand while we talk, do you? I have a bad back.”

I didn’t know whether to stand up with her, which felt awkward, or remain seated, which made me feel like I was a child. I chose the latter, and proceeded to look up at her intense gaze and recount the story of my patient’s suicide. “I felt shame as I described Becky’s case, her depression, my treatment plan, her ultimate giving up. I waited for her to offer some words of concern or encouragement.”

“Well, why don’t we go over your case session by session so we can find out what went wrong?” she said instead.

All I heard was “wrong.” Did she mean to say that if I had done things differently, Becky would still be alive? The thought of putting the entire year and a half that I treated Becky under the microscope terrified me.

“We could do that,” I said, but I knew I would never perform that “psychological autopsy” with her.

A few weeks later, some colleagues and I went out for a drink at a rooftop terrace overlooking San Diego bay. I began to relax for the first time in weeks as I watched the planes float by at practically eye level. This respite was suddenly interrupted by an emergency call from a client. I found a private corner and spent a few minutes calming her down.

“Sorry, client in crisis,” I said, returning to the table. “Seems like I’ve had a tough caseload lately.”

“You know, Marian,” Gita said, “that’s why we screen our clients and choose them carefully.” Gita knew about my client’s recent suicide.

“I guess I’m not very good at predicting that stuff,” I finally said.

Afterwards, I stopped by one of my colleague’s offices to get a book she was lending me. I found myself studying an abstract painting on her wall that I had never really looked at before.

“That looks like a nasty dragon,” I said. “I never noticed that before.”

She gave me a very concerned look and said, ““Marian, I think this suicide has traumatized you. You are seeing dragons and danger everywhere.”” At first I sighed—she is a classical psychoanalyst and injects meaning into everything—but I could see her point.

“It’s just that I keep blaming myself and I can’t stop visualizing my client’s last moments. I can’t let it go.”

“This is not your fault. You couldn’t have known she was going to do that. We can’t stop someone from killing themselves if they really want to,“ she said.

But I had a hard time believing this. Can’t we stop them? Shouldn’t we know how to do this? Isn’t that just an excuse therapists use to get themselves off the hook?

I was very careful about revealing Becky’s suicide to others. Thinking back on the entire experience, that isolation was the most pernicious aspect of the ordeal. I now realize that most people could not fathom how wounding it is to lose a patient. The slightest nuance or tone of blame from an esteemed colleague could ruin my day.

I had shared my experience with a friend from graduate school whom I thought would be understanding. He responded flippantly, “What did you do wrong now, Marian?” I knew his sense of humor. He didn't mean that, but there it was again… my fault.

The Lawsuit

Shortly after the suicide, I contacted my professional liability insurance company to inform them of the suicide. They asked me a few questions regarding Becky’s case: age, employment status, relationship with parents and so on.

At the end, the person said, “It’s very likely the parents will sue you for wrongful death. Given what you have told me, they will need someone to blame. Please write up a summary of the incident and let us know if you are contacted regarding a lawsuit.”

Most therapists I know live in fear of being sued. I was no exception. And, of course, that is exactly what happened. Approximately three months later I received a request for medical records from an attorney representing the family.

“You must release these records, Dr. Joyce,” she said when I called her.

“I will be happy to as soon as I receive a release from the representative of the deceased’s estate,” I replied, referring to the notes from my conversation with the insurance company.

“You know that her parents can get these records. Your refusal is just causing additional emotional distress,” she said. “I had been warned that the attorney would attempt to control me through intimidation. I thought I was ready for this, but I noticed my hand was shaking.”

“Are you giving me legal advice then, about who holds the privilege?” I said as firmly as I could under the circumstances.

“Alright, then, I will have the parents send you a release,” she finally conceded.

I received the release a day before I was about to leave for vacation, so I wrote to the attorney to say that I would respond to her request when I returned.

When I got back, I was welcomed by more correspondence from the attorney’s office threatening to lodge a complaint with the Board of Psychology. I am able to smile now at my naïveté then, to think that the friendly letter I wrote her before vacation would keep the pit bull from biting.

My insurance company assigned me an attorney before the lawsuit was even filed in order to intercept the badgering correspondence. My attorney arranged to come to my office to meet me in person, dressed very casually in jeans and cowboy boots. It was Friday, but his attire did not inspire confidence.

“So, how long have you been in this office?" he asked me. "I love this part of San Diego.”

"Oh, I've been here for seven years. Yeah, it's great to be so close to the park." He did not seem concerned, which worried me immensely. Perhaps he was trying to set me at ease, but his nonchalant approach was far from reassuring to me.

"Do you want to go over the details of the case?" I said. Why did I feel like the only one ready to work? Don’t you see the danger I am in, I thought. Don’t you understand what is at stake?

"We've got time," he said, "This is sort of a get-to-know you meeting. I already read the report you sent to the insurance company and I think we have a great case. Nothing to worry about."

About a month later, I received a letter, a “90 Day Notice Intent to Sue a Health Care Provider.” My attorney had warned me it was coming, but I was unprepared for the false allegations justifying the lawsuit, written up in a short paragraph, all set in boldface. It didn’t look like a carefully crafted legal document, more like a rushed memo by an employee who would later regret having written it. Like all of the attorney’s previous correspondence, it lacked proper punctuation and spacing—no period after Dr., no comma after however, no spacing between paragraphs. She doesn’t follow the rules, I thought. She doesn’t care about them. This frightened me.

A 90-day waiting period. So I have the summer off, I thought. No more letters in white or gray envelopes or upsetting voicemails from attorneys. It sounded heavenly. I can get a lot of house projects done in 90 days.

I eagerly returned to my current project painting the upstairs bedroom. I opened the can of Benjamin Moore Philadelphia Cream paint and stirred it until smooth and blended. I turned on the radio and the Westerfield trial was on. In February, David Westerfield, a 50-something single man, sexually brutalized and murdered Danielle Van Damm, a 7-year old girl who lived next door to him.

The defense attorney was cross examining Brenda Van Damm, the mother, who had been at a local bar with her friends, drinking, dancing, and smoking marijuana the night of the murder, returning home at 2 am.

“All of the doors were a little bit open,” Brenda said, describing the children’s rooms and then explained that she closed them that night when she returned home.

“Did you look inside?”

“No,” she said quietly.

“Why not?” What is the correct answer to that accusatory question, I thought. It’s going to come out defensive. He’s making her look negligent and wanton, obviously his intent.

“Because when I got—when I went upstairs to tell Damon,” she said, referring to her husband, “that I was home, I asked him how…how the tuck-in went, how everything went that night, if anyone asked for me, and he said that everything had gone fine, that they all had brushed their teeth and been read to and no one asked for me.”

As the defense attorney continued grilling her about her alcohol consumption that night, I felt my stomach tightening, my anger forming. Even if she had been too lax, she wasn’t responsible for her child’s murder. Her husband was home with her daughter. A mother is allowed a night out once in awhile.

I then imagined myself on the stand for the wrongful death of my client:

“Well, Dr. Joyce, did you ask your client if she was suicidal the session before she killed herself?”

“No.”

“And why not?”

“Because she didn’t appear to be more distressed than usual.”

“Than usual? What was her usual distress?”

“She was depressed.”

“And you didn’t think depression was cause enough to inquire about her suicidal thoughts?”

There really was no way to answer these questions. If I said I didn’t detect her distress, I appeared incompetent, but if I said I recognized her distress and did nothing, I was negligent. I’m screwed, I thought. I got down off the step ladder, set the paint brush down, and turned the radio off.

How was I supposed to live with all this uncertainty? I realized that I was deluding myself about a “summer off.” I decided to call my attorney, hoping he could help.

“Did you get the 90-day intent to sue letter?” he asked.

“Yes. It’s a bunch of lies. Where is she getting this stuff?”

“Don’t worry,” he said. “It’s always like this. I told you, you are low on the totem pole of people to sue in this case. It is what it is.” Once again, his cavalier approach was not reassuring

“Hey, have you been watching the Van Dam trial?” I said, changing the subject. “I had to turn it off. I don’t think I can get on the stand like that,” I said.

He laughed. “Relax, Marian. It’s not going to be anything like that. ” I thought of my dentist, needle poised over my gaping mouth: “This won’t hurt a bit.”

That phone call didn’t help, I thought after I hung up the phone. So instead, I popped in a U2 CD, turned up the volume, and went back to cutting in.

The “summons,” an official version of the “intent to sue” letter, arrived in September. I knew that all the allegations were false, but I didn’t trust that the truth would be sufficient. By then, six months into my dealings with the legal world, I was beginning to understand that the lawsuit was solely about money, how much the plaintiff’s attorney could get for her clients, how little the insurance company could pay on my behalf. “My attorney” was really working for the liability insurance company, not for me.

My attorney planned a lengthy phone appointment to prepare me for my deposition. As usual, he was his upbeat self.

“You just need to answer the questions,” he instructed me. “Don’t offer any information that the attorney doesn’t ask for,” he said.

“What if she asks me something way off-base? Will you make an objection?” I was already feeling tense. I found myself drawing spirals on my notepad.

“I can object, but you still have to answer the question. It’s not like in court, because there’s no judge,” he explained. “Don’t worry, Marian. She’s not going to ask you anything you can’t answer.”

I felt dread after our conversation. I went out to get the mail and I brightened when I saw the envelope from Bradbury and Bradbury, a company that makes exact reproductions of arts and crafts wallpaper. I spread the samples out and compared them. I liked the one with a delicate leaf pattern, and the accompanying border with vines and red berries. I called and ordered ten rolls for the dining room, and then impulsively added three of the rose pattern for the powder room.

When people ask me today how I survived a wrongful death lawsuit, I tell them that I threw myself into the renovation of my home. I wanted desperately to bring this house back to life because I could not resuscitate my client.

At the deposition, I finally saw the pit bull in person. She was a stout middle-aged woman with two inch grey roots on her dyed red hair. The attorneys for the hospital, psychiatrist, and emergency room doctor were there as well, dressed in dark suits. We sat around an oval table. I was at the far end seated in front of the plaintiff’s attorney and the court reporter was to my right.

“The plaintiff’s attorney grilled me regarding my credentials for thirty minutes. Then she worked her way line-by-line through the treatment notes.” After four hours, we took a lunch break and then she fired off detailed questions about the week of the suicide.

Afterwards, I met my husband for drinks at the Torrey Pines Lodge, a sprawling, gorgeous building in the Arts and Crafts style of architecture, like our house. I gravitated to the fire in the lobby bar.

“I love the wood tones in this trim,” I said, referring to the honey-colored wood on the fireplace. “It’s so warm, not like our dark mahogany.”

“Hey,” Joe said. I knew that “hey” meant he was coming up with an idea, which usually meant more work. “Let’s take down our wainscoting and trim and plane it. Then we can stain it a lighter, warmer tone.”

Normally I would have dissuaded Joe from such a time-consuming project. But I liked the idea of transforming the dark and dirty into something fresh and light.

“Great idea,” I said. “Let’s do it. It’ll make such a difference.”

That project involved sanding, staining and shellacking yards of wood, a project that outlasted the lawsuit.

After much haggling, the attorneys finally agreed on a settlement amount, which was shared among the defendants. Because it was a settlement, there was no admission of guilt by anyone. That should have set my mind at ease, but by then I knew the case was only about the money.

Grief and Healing

About five months later, I attended a course on clinical hypnosis given by a UCLA professor. He was demonstrating a particular projective device in which clients project unconscious material onto an imagined screen.

"I want you to get comfortable and close your eyes," he said in a soothing voice. I opened one eye to see if everyone was following instructions. They were, so I decided to give this a try.

He began to take us down a spiral staircase and count backwards from ten. When he made the suggestion my arm might lift up, it did. Once established that we were in a hypnotic state, he described the screen where my movie would play out.

“You are sitting in a dark movie theatre facing the screen. Let yourself go and watch the movie that unfolds on the screen.”

It took a minute to see anything on my screen. But then cartoon characters started dancing on a stage and then my sister appeared. The next movie was of my husband calling me from a train and then dancing with me once I boarded. Both movies were joyful.

I suppose I could analyze these for deeper meaning, but what happened next took me by surprise. I began to sob. I knew it was about Becky. I hadn’t yet cried like that about her death, about losing my client. I could finally let myself feel sad that she would never get that rewarding job she desired, or be free of her attachment to Matt to find the love of her life, or even be able to bury her parents.

It was only after that pivotal moment under hypnosis, when I wasn’t looking for it, really, that I was at last able to move past the feelings of guilt, blame, shame, and anger at the lawsuit.

The lawsuit settled, the house renovations finished, Joe and I decided to celebrate with a housewarming party.

Guests gushed over the house as they filed in.

“I can’t believe what you did with this house! Wow! How did you get rid of that dark stain?” a friend asked.

Joe and I looked at each other and smiled.

“It was a big job,” Joe said. “I wouldn’t recommend it for everyone.” I thought back to the evening after the deposition in front of the Torrey Pines fire. I guess we would have never done it if I hadn’t had the lawsuit, I thought. Then it struck me: I was beginning to gain some distance and perspective.

The friend from graduate school whose remark months earlier had so unsettled me came up to me.

“I meant to ask you about your lawsuit. Did it work out okay?” he said.

“Yes, it’s all settled. There shouldn’t be any repercussions,” I said.

“I’m really glad to hear that. I often wondered how you were doing. And I don’t think I ever told you I was sorry that you lost your client. I think I was a little afraid of the whole thing, to tell you the truth.”

“Thanks for that.” I said.

Regarding my work, I have once again recovered my enthusiasm, but it is tempered. I now know that anyone is capable of losing hope at times and even though I listen carefully to the subtle messages my clients share with me, sometimes they choose to keep parts of themselves completely concealed. I know my limitations and that I can’t predict or know what a person will do. And I have to live with that uncertainty and with the consequences that may ensue.
 

 ———————
 

If you or someone you know is struggling or in crisis, help is available. Call or text 988 or chat 988lifeline.org

Infertility on Both Sides of the Couch

Posted on by rezendevknowfully.com

Family Planning

"When are we going to start a family?" asked my husband.

I felt a boa constrictor wrapping around my throat. For months now, the topic of children had evoked tension, leaving us powerless and detached from each other. The argument had become a tradition on Saturday mornings. We would sit in the living room in an awkward silence, avoiding eye contact, until my husband pierced the hush with what he deemed a simple question about our future.

My husband was comforted by having a plan. Three years into our marriage—my second—we were in our mid-thirties, established in our careers, and financially stable. For him the next step in our lives was to start a family, but his need for a plan set off a vicious cycle. I felt ignored and disrespected in our relationship and couldn't justify bringing a child into a fractured marriage. I craved connection and love and was not willing to commit to having a child until we resolved our relationship problems. My resistance made him more insecure and unsure of his focus, and he would ask me about starting a family as a way to relieve his anxiety. Unfortunately, his persistence pushed me away, leaving me feeling trapped and controlled and leaving him stranded without resolution.

“I felt immense pressure both from him and from society to conform and have children. Gradually, I isolated myself from my husband and emotionally shut down, as my sense of self and my voice vanished.” Feeling alone with no one caring about my thoughts and feelings, I believed I was not enough for my husband and that he had married me solely for procreation. Meanwhile, I was inundated with inquiries from our family and friends about when we would be parents.

My mother-in-law often phoned my husband's siblings to convey that her children were failing her since she did not have grandchildren. While growing up, my husband's mother talked a great deal about heirlooms—each piece of jewelry or china was a link between past and future generations. Grandchildren were an essential part of keeping the family traditions alive and to not have them meant the family had failed. She made it clear that my husband was not enough, just as I felt I was not enough as his wife. My resistance to the "plan" was a clear message to him and his mother that I would not conform.

His side of the family was not the only problem. My stepfather had the impression that all couples wanted children. He frequently dropped hints about what a joy they are, pointing to his grandson and saying things like, "See, aren't these fun and not so bad?" For him, family represented connection and closeness. Initially this was endearing but it soon became annoying.

While at a party, I declined an alcoholic beverage, which ignited rumors that I might be pregnant. When I heard the gossip, a wave of heat washed through my body. How dare my friends speculate? It was as if I were starring in the reality show, "When Will Wendy Pop One Out?"

The Family System

In 2005, I started therapy with a psychotherapist who practiced from a Family Systems model, the premise of which is that the family is an emotional unit—systems of interconnected and interdependent individuals, none of whom can be understood in isolation from the system. Over the course of my therapy, I came to understand that my symptoms of sadness, loneliness, and detachment were a consequence of the recurring patterns and interactions within my family. The sense of powerlessness I experienced evolved from my marital dynamics, my family history, and the cultural expectations of a woman in her thirties.

My parents divorced when I was thirteen years old. I was an unplanned pregnancy and the reason my parents had married. It was bad enough that I was a mistake, but I resented my parents even more for their divorce, and the struggles that I encountered during my teens trying to navigate through the turmoil of their divorce played a role in my delaying the start of a family.

During my first marriage, I was enrolled in graduate school and wanted to wait until completing my program to start a family. We would have been in our early thirties by then and my ex-husband wanted to be a father sooner. He had an affair and decided to leave. This time around I wanted to make sure I was in a healthy relationship, that we were not introducing a child into a doomed family. I did not want to recreate my childhood trauma for my own children.

At Christmas in 2006, my stepsister announced over dinner that she was pregnant with her second child. I broke down sobbing at the table. A hush blanketed the room as everyone stared at me. Although embarrassed and humiliated, I could not stop crying.

Two weeks later, my stepbrother shared the news about his wife's first pregnancy. My sister-in-law had planned on not having children but had changed her mind. I was consumed with feelings of betrayal. I was my own childless island in a world that demanded parenthood. I dove deeper into despair.

Couples Therapy

My husband finally realized that our marriage was at stake and agreed to couples counseling, but I wondered whether it was too late, as by this time my rage had evolved into numbness. I recalled our minister's marriage sermon encouraging us never to throw in the towel when things were broken, but another part of me was tempted to do just that. “You don't need a man, you survived a divorce,” the voice said. "Trust me, you’ll be much happier single." I contacted therapists, but they either did not return my calls or have any openings for new patients. Was the universe telling me it was too late for my marriage? The battle inside me grew more crushing until finally after three months, I found us a therapist.

Couples therapy became our new Saturday tradition. My husband had never been to therapy, hated conflict, and had always made choices with tremendous caution, sometimes over the course of many years. Therapy for him was about finding ways to manage his stress. If he knew when we would have a baby, he could plan accordingly. Should we reserve a slot at the day care now, since there could be a waiting list for a couple of years? “Should we start putting money into a college fund? Or should we begin grieving about not having a child?”

For me, therapy was about maintaining autonomy and establishing a healthy marriage. I wanted the freedom to make choices within the marriage, but feared he would leave me if I did not have a baby. It felt like an ultimatum. And for my husband, despite his discomfort about the therapy, he began utilizing what he learned about me. He realized that asking questions about starting a family was torture to me, so he stopped asking. As a result the perceived threat of the ultimatum faded.

In my professional life, I had wanted to open a private practice. Should I be saving money for the grand opening of my business or for a divorce? The marriage had to be healed before the practice could be born.

During our treatment, I wrote my business plan. My husband was proud as a peacock and bragged to others that I was making my vision come alive. I opened my practice in mid-2007, feeling finally alive after an emotional coma. When I purchased the new office furniture, my husband questioned the size of the sofa, believing it should be larger. Prior to our therapy, this question would have offended me and I would have felt undermined in my judgment. Instead, I confidently explained that the sofa worked well in the room. Understanding his tendency to err on the side of caution, I did not personalize.

He went ahead and assembled the office desk and filing cabinet and moved the sofa into the suite. To this day, he tells others it was a good thing that I ignored his advice because the sofa barely fit into the space. This was the sexiest thing he had ever done. Life was wonderful. I was enough as a wife and my business was thriving. Without pressure to conform and have a child, I decided to go off the Pill.

For three years we did not get pregnant.

Mystery Solved

From the time I was a teenager, I had a history with difficult menses. Like clockwork I got my period every 18 days and bled for 10 days, uncertain what PMS symptoms I would experience. My blood flow would be heavy, dark and impossible to keep up with, changing my tampons and pads every four hours and during the night bleeding onto my bed sheets. At times to get through my school day, I took over-the-counter pain pills for heavy cramps, lower back pain, or headaches. For my peers and teachers I maintained a pleasant façade, but what I wanted was to retreat into a corner and savagely eat raw meat and growl or be in my bed weeping and eating salty chocolate. I applied copious amounts of zit cream to my face attempting to fight a hopeless battle with breakouts. My bra and pants would restrict my breathing because I was bloated. During my annual exams, a range of doctors had explained these symptoms were stress-induced by my parent’s divorce, my divorce, and graduate school, and had prescribed birth control pills.

Now while off the pill, my life was good and I had no stress on which to blame the problem. I was receiving holistic care and yet was still physically and mentally suffering. Why was I having the same problems I had as a teenager?

I made an appointment with an OB/GYN specialist with little faith that I would find answers, but for the first time, a medical doctor was eager to learn what was going on with my body. He believed my symptoms were pathological and not related to stress and ordered blood work and an ultrasound.

A month later, the OB/GYN nurse escorted my husband and me to the doctor's office for my consultation. He was perusing my test results with a look of concern on his face when we walked in. Gazing up at us, he said, “I am unsure where to begin.” The blood work was perfect. The ultrasound, however, revealed why I’d suffered for decades and had not become pregnant during the past three years. Both of my ovaries were smothered in various types of growths (some were thyroid tissue), my fallopian tubes had blood, my uterus had polyps and was malformed, and as a result I was unable to carry a pregnancy. The doctor recommended a full hysterectomy.

My symptoms were not stress related. They were not my fault. A sense of calm flowed over me; my eyes welled up with tears. My husband took my hand and asked questions while I continued to absorb the news.

Judging Claire

Meanwhile, my professional life was evolving beautifully. I had the satisfaction of seeing my vision coming to life, and I loved owning my own business. For several years I had been seeing Claire*, a married and successful professional in her mid-thirties with a significant history of depression and anxiety. She had a warm sense of humor and loved to learn about herself. During the first couple of years working together, she feared her future children would be genetically predisposed to suffer from similar aliments and struggled between the desire to feel a child growing inside of her and her desire to adopt.

During the course of our therapy, Claire forgave herself for having a diagnosable mental illness; she realized the illness did not define who she was. She began to consider that she had plentiful and warm offerings as a mother and decided to conceive naturally. After a year of not getting pregnant—this was around the same time I went off the pill—Claire was diagnosed with infertility.

By then I was secure in my marriage and waiting to see if I got pregnant, but I struggled to maintain my alliance with Claire. Still vulnerable with my own triggers, I had my own opinion about the infertility treatment process and our sessions evoked strong emotions for me.

One in ten couples struggle with infertility issues. According to the medical model, infertility is a disease of the reproductive organs, and usually the first option in treatment is a daily injection of medication to stimulate the ovaries to develop eggs in the follicles (the structure in the ovaries that contain developing eggs). The side effects can include bloating, weight gain, headaches, and nausea. If this is unsuccessful, IVF (in vitro fertilization) begins, in which eggs are surgically removed from the ovaries and combined with sperm. Weekly ultrasounds and estrogen blood levels drawn twice a week assist the doctors in determining the best time to retrieve the eggs. The last resort for infertility treatment is the egg donor cycle, where an embryo formed from another woman's egg is transferred to the uterus of the woman trying to conceive. More coordination and time is involved since two women are being monitored for transfer.

As I witnessed Claire’s physical and emotional agony and the suffering in her marriage it caused, I began to judge her harshly. “How could she brutalize her body from treatments and spend so much money to conceive and carry?” I hated her for choosing to participate in the infertility treatment process and holding faith in the medical model. I felt lonely and betrayed that she conformed to society's pressure to attempt pregnancy at all costs. I wanted her to join me in rejecting this awful and debilitating process and to redirect her energies toward adopting a child.

Though I had every intention of becoming a mother, once I realized I was infertile, I never considered infertility treatment or adoption. Both seemed too unpredictable and a setup for repetitive grief and loss. It was disturbing to have such an intensely negative reaction to a client, so I began to repress these feelings and thoughts in an attempt to protect both of us. In the process, however, I became increasingly disconnected from Claire.

What was happening between us put strains on my belief in the humanistic approach, which emphasizes that we are in control of our destiny, our choices, and the discovery of meaning for our life’s narrative, and makes use of the relationship created between the therapist and patient as a catalyst for exploration and change. A safe arena was vital for Claire to share her narrative and to discover the meaning of her experiences—the energy in the room could then provide an atmosphere conducive for healing. Regardless of my opinions and beliefs, I wanted to support her in her destiny and choices. But did I have the freedom to accomplish this?

As a therapist, I participate in a weekly supervision group. While disclosing the pain of my challenges with Claire, I shared about my sensitivity to the fertility topic and my beliefs about the infertility treatment process. My peers validated me and understood why I felt threatened, but also challenged me about my countertransference and helped me to work through it. Other colleagues were offended by the infertility treatment process and called my patient "greedy." A few of them had been adopted, and were exasperated that it wasn't Claire's first choice. Others were sympathetic with her plight and could relate to her need to biologically conceive a child. Through the group process, I was able to witness all the different parts of myself being voiced through my peers, and I felt safe enough and free enough to get to some of my own core fears and doubts about infertility. Ultimately this freed me up to be much more present with Claire in the coming months.

Working Through and Joining With

During a subsequent session, Claire tearfully shared how painful it was to have no control during the infertility treatment process. My inner voice whispered, Ask her if she feels she has the choice to stop the infertility process. Before working through countertransference with my supervision group, I would have suppressed this voice, believing it was my own “stuff" and would not be helpful to Claire. Now my heart pounded; I couldn't help but speak up: “Who says you need to continue to fail with the pregnancy attempts?” Something in the room shifted. After a pause, Claire affirmed, "I could stop." I exhaled. We had finally found a moment of empowerment and connection.

Claire continued to participate in the infertility treatment process, and I joined the emotional roller coaster with her. This freed up much more space to explore her process and mine.

Therapy is not immune to the disruption of the infertility treatment process. “The scheduling of appointments revolved around Claire's menstrual cycle and she cancelled appointments due to the side effects of medications and clinic appointments.” We had lapses between appointments while waiting for the doctors to contact her for the next treatment cycle. All of this meant that I needed to figure out what would take care of me during her infertility series. That involved answering questions such as: How do I cope with my anger? How do I keep from getting stuck in her holding pattern of waiting? Do I charge for missed appointments?

With the ongoing support of my supervision group, I continued to explore my emotional reactions. Claire and I collaborated about payment for missed appointments—she willingly paid and the joint conversation made her an active participant in an otherwise helpless period. The medical doctors had no clear diagnosis about why she didn't get pregnant for three years and she suffered continuously from a sense of loss. She had always dreamed of being a mom and having a family and now she had to face the fact that it might not happen.

Claire tried to detach from her emotional turmoil and did her best to function at work, but the clock ruled her while she anticipated lab results. Her job performance began to suffer and the cost was guilt, shame, and embarrassment. Work became heavy and dreadful. Her depression ignited, leaving her brooding in isolation and sleeping for 17 hours or more every day. Her “should” cognitions were in overdrive and kept her paralyzed.

The Breakthrough

"I'm afraid you're mad at me for the last minute cancellation last week," she said. "I'm failing at everything." In fact I was angry about the appointment. Missed appointments touch on my vulnerability around not being recognized as valuable. But our agreement for her to pay for missed sessions, combined with my own awareness of the reasons behind my countertransference, made it possible for me to process my response outside of session and bring my full attention to figuring out what she was enacting and what it meant for her. I responded, "You think you should be able to manage life better. But things are dropping all around you: your relationship with your husband, your work, your friendships, and especially not getting pregnant. You're feeling so alone." I watched her reach for a tissue, look down at her lap, and wipe her tears. "What are the tears saying right now?”

In her soft voice, Claire answered, “I'm afraid my husband will be angry at me for not controlling my emotions. My anxiety is through the roof. I want to be in my bedroom with the covers over my head. It's unfair to expect my colleagues to do my work. I want to be with my friends but it hurts too much because they have babies or are pregnant.” She believed she needed to be perfect and worried about disappointing everyone around her, including me.

But this conversation about failure and disappointment positioned Claire to begin healing her marriage and bring her husband, family, and friends back into her life. Through addressing her loneliness, Claire articulated her envy about her friends being pregnant or having newborns. “She felt conflicted about whether to maintain her connections or isolate herself because it was too painful to be subjected to swollen bellies and to the innocent scent of newborns.” She also acknowledged she pushed her husband away because she did not want to be perceived as a "burden." He had a demanding job that made him unhappy, but it provided them with medical insurance to pay for the infertility treatment. She secretly fantasized about him attending medical appointments with her and being readily available to abruptly leave work to provide comfort when she received bad news. I encouraged her to share her emotional burdens with her husband, to let him feel her burden, as that is part of what it means to be intimate with another person. She began to feel less guilty and apologetic about her struggles and to share the craziness of the process with him. They became closer and her sex life began to thrive again.

Over the two-year period of her IVF treatments, Claire's visits to the reproductive health center would evoke a sense of helplessness and lack of emotional safety. She often felt rushed because she didn't get satisfactory information to her questions, and the clinic became increasingly more uncomfortable and sterile. As our work progressed, she was more assertive and less apologetic about demanding the attention of the nurses and doctors until she was satisfied with the gathered information. To increase her comfort at appointments, she brought her own pillow and blankets.

Unfortunately, Claire was given a lot of unhelpful advice from her own support system of family and friends, even medical doctors. She was told, for example, to "just relax" because her stress could be interfering with the infertility process. In the therapy sessions, we worked on how to handle unwanted and sometime hurtful advice and not absorb the harmful implications. When she deemed it appropriate, she informed people about what would be helpful or harmful.

Different Kinds of Pregnant

When the IVF failed, Claire opted for the final remaining option: an egg donor. Our sessions were spent with her describing how a donor was selected and the various reasons they donated their eggs. It was a surprisingly fun process for both of us.

After her second cycle with the egg donor, she curled up on the sofa in my office, hugging a pillow with a distant look in her eyes. Her lip trembling, she said, "For four days, I was pregnant. Now, I am pissed off.” Her rage demonstrated no guilt. She did everything right but was unable to carry her first pregnancy.

The following month, her third attempt was successful.

One day, well into her second trimester and beaming with life, Claire effused, “My boobs are huge!” She shared her ultrasound pictures of her healthy son and we talked through her stress about finances with the arrival of her baby. In her desire to save money and prepare for the baby's arrival, she requested a break from therapy. I encouraged her to go and create a loving home for her son. Tearing up, she said, “I can’t believe I can hear ‘my son’ after all of this.” Claire would soon be a mother.

Through quite a journey, Claire and I mirrored each other for a couple of years. My marriage and business were at last breathing life. I scheduled my hysterectomy, knowing my body would be cured. I learned a valuable lesson: Psychotherapy is a fertile process.

* Claire's name had been changed to respect confidentiality.

Calisthenics in Front of the Fun House Mirror

Posted on by Psychotherapy.net Team

Sometimes my days bring to mind a funhouse mirror. I stretch, collapse, widen, or shrink depending on the clinical demands of the moment, fundamentally changing and fundamentally remaining the same, moment to moment and hour to hour.

Yesterday in my first session of the evening I was speaking with a young woman about the reasons for her recent spotty attendance. I fielded an interpretation that I know in every molecule of my being is correct, that she is trying to convince me of her essential badness and test if I will give up on her. She looked me dead in the eye and said “that is probably the stupidest thing I’ve ever heard in my life.” I had to laugh. I can’t in all honesty say I delight in being called stupid, but I do enjoy her feistiness. And I know I have spoken to a part of her, a part she thinks is stupid and vulnerable and wrong: she will show up next week.

In my next session, a client is debating having an extended family session that would include several out-of-town siblings, including a brother who happens to be a psychiatrist. I’m a little excited and more than a little intimidated by the prospect of this highly trained and reportedly difficult fellow professional in the session. My client is talking about who she would like to have present in the session, and I am feeling uncomfortable because I don’t know the answer. Partly I just don’t know, partly my own anticipatory anxieties are getting in the way, and partly I am feeling her anxiety. I feel myself stalling out, but then remember with a sense of relief that I don’t have to know the answer. How is it possible to forget this so many times? We explore her feelings, and the answer reveals itself.

The next session I’m feeling a bit tired, and I don’t know if it is because of the couple I’m about to see, or the time of day. Normally, it would be dinner time, and a handful of almonds and an apple weren’t the dinner my body had in mind. My body clock and the darkness outside are telling me it is time to settle in at home. So I’m not sure if it is my tiredness or my sense of the emptiness between these two, the complete absence of anything that to me feels like love, only the graying embers of duty and convenience, that makes me say “you are trying to live in a house without a roof.” He is sad, she is angry. They leave my office no closer than before. I feel like a dejected salesperson with a useless little pile of tools and skills they don’t want to buy.

I have a second wind for my final client, thankfully, because she is ferociously smart, and not a bit hesitant to call me out on any foolishness, inaccuracy, or inattention. I worry sometimes that the sheer intellectual pleasure of a conversation with her can be a distraction for me, diverting me from the emotional issues that she needs help with. Tonight we talk about lies, and the truth in lies. It is a conversation that seems to twist and skitter with a life of its own; I feel like we are both following this path together, uncertain of its destination. These are the sessions I like the best, when I feel fully engaged as both participant and observer.

By the end of the night, I feel good. It was a satisfying night; I feel like I did my work well. But I’m tired. Really tired. I think to myself, how can it be so tiring, just talking to people? Then I consider: in these four sessions I felt foolish, anxious, sad, excited, inadequate, engaged, uneasy, tired, impatient, admiring, relieved—and that’s just for starters. I have been stretched and twisted and pulled in many different directions. I have had my own feelings, I have had feelings in response to another’s, I have felt the feelings of others. I have seen myself reflected back in many shapes and forms: stupid and clumsy, idealized, frustrating and dangerous, for a beginning but by no means complete list. Odds are I haven’t identified or sorted half of the feelings or realities that have floated through my little office tonight. Four hours of emotional calisthenics in front of a fun house mirror. Oh right, that’s why I’m tired.

George Silberschatz on Psychotherapy Research and Its Discontents

Posted on by rezendevknowfully.com

What is Empirically Known About Psychotherapy?

David Bullard: Let’s start with a little background information about your work. I first met you through the San Francisco Psychotherapy Research Group—can you talk about your involvement there?
George Silberschatz: Certainly. It was originally called the "Mt. Zion Psychotherapy Research Group,” founded by Joe Weiss who was joined by Hal Sampson, both psychoanalysts, in 1971. They were just starting to publish some research papers and were very active teachers at Mt. Zion Hospital when I began working with them in 1975. Their work together formed the basis of what is now known as Control Mastery Theory.
DB: You’ve been in private practice about thirty-five years and are a clinical professor at UCSF with a multitude of research papers on psychotherapy process and outcome.
GS: My book Transformative Relationships (Routledge, 2005) is on Control Mastery Theory, and my papers are almost evenly divided between research and clinical work, because they are so intertwined and I go from one to the other very easily.
DB: You are currently the president of the international Society for Psychotherapy Research, which includes chapters in North America, Europe, Latin America, and Australia. Would you talk a bit about the concepts “empirically-validated” and “empirically-supported therapies.” What are your thoughts about what is truly empirically known from psychotherapy research?
GS: Well, I have very mixed feelings about all of it because I don’t think it’s fundamentally based on scientific evidence.
I believe that the term “empirically-validated” is largely used when people are trying to market their specific brand of therapy.
I believe that the term “empirically-validated” is largely used when people are trying to market their specific brand of therapy. You know, “Our empirically-validated therapy is better than everything and everyone else, so if you need therapy, come see us!"

It seems a bit overdone and over-hyped. A lot of people have started saying “evidence-based therapy” instead of “empirically-based,” but what counts as evidence and how is the evidence portrayed? There’s a great deal of subjectivity in that process.
DB: In the early mention of “empirically-validated treatment,” researchers made another distinction between efficacy and effectiveness. Is there such a distinction in the real world versus laboratory research?
GS: It’s a big controversy. The term “efficacy” is used by people who believe that empirical evidence can only come from randomized clinical trials, i.e. in the lab. It has its roots in both medicine and pharmacology in the way drugs are tested and, basically, the proponents of this research paradigm feel that anything else isn’t empirical, isn’t evidence.
Manuals are essentially useless for practicing clinicians.
I wrote an article about this for the Journal of Consulting and Clinical Psychology called “Are results of randomized controlled trials useful to psychotherapists?” It was basically a debate between myself and my co-author, Jackie Persons, who is a cognitive behavioral therapist. She took the position that people should only be practicing empirically validated therapies—by which she meant Random Control Trial-Based Therapies or RCTS—and that it might even be unethical to do anything other than that.
DB: Which implies following a manual that such studies usually use so that the treatment condition is uniform across therapists?
GS: It does often imply following a manual. They punted on this a little bit and said there was some wiggle room for therapists to stray from the manual, but what’s a manual? I took the position that manuals are essentially useless for practicing clinicians.
DB: That’s refreshing and helpful to hear.
GS: There’s a lot of variability among clinicians, you know? There are a lot of very thoughtful people who think like Jackie, but there are also people that see the limitations of that as a model, especially for psychotherapy.
There is no support for the idea of one therapy being better than another.


The current—and I would say balanced and intelligent—position of the American Psychological Association is that when you really look at the evidence carefully, as they’ve done, there is no support for the idea of one therapy being better than another. But a lot of the proponents of the Randomized Control Trial for psychotherapy use their results to say, “Our results show that our method is better than yours.” That’s led to a rash of people trying to do trials on their new model of therapy. Every time there’s a new therapy, somebody has to do a trial showing that their new therapy is as good or better than some other one. That hasn’t been very productive, in my opinion.

Psychotherapy Works

DB: Overall, what would you say has been shown? For example, Consumer Reports did their research on their readers’ reactions to psychotherapy in 1995.
GS: That was a very large survey of psychotherapy effectiveness. I think it had a very useful purpose because it was actually asking the people who were using the service what they thought of it. It was pretty impressive.
DB: So there have to be quite a substantial number of technical issues within the field of psychotherapy research that we won’t go into today, but I heard Daniel Kahneman, who won a Nobel Prize for Behavioral Economics research, state in a recent interview that the most relevant, reliable outcome measures for a person’s happiness should be based on the report of the person’s friends. In other words, their evaluation would be more valid than anyone else’s. What would you say is the most useful outcome measure for psychotherapy?
GS: Certainly not the therapist’s!
DB: No!
GS: It turns out to be a very complex problem. I respect Kahneman's work very much. He’s a brilliant man. But I’m not sure that I would necessarily agree with him that a friend or significant other in a person’s life would have the best perspective. This is something that has troubled psychotherapy researchers for a long time: How do you measure outcome? Whose perspective do you rely on? There are plenty of people who feel the therapist has the best position. There are other people who feel that the patient is in the best position. There are yet other people who—
DB: How about the patient’s mother?
GS: She may not be in the best position either! Because someone like a mother or a spouse may have a particular vested interest. But it’s a very thorny problem in psychotherapy research and I don’t think anyone’s come up with a definitive answer yet. I think we tend to use multiple perspectives now but that creates its own particular difficulties as well.
DB: You have studied both outcome and process-oriented research. Overall, hasn’t it been shown through meta analyses of lots and lots of studies that psychotherapy works for the vast majority of people who undertake it?
GS: Yes.
DB: And other studies of process show the elements that seemed to have the most impact within a psychotherapy relationship.
GS: Well, you’re quite right that there’s evidence available now that shows unequivocally that psychotherapy works. There should be no more questions about that in anyone’s mind.
Evidence available now shows unequivocally that psychotherapy works. There should be no more questions about that in anyone’s mind….The issue of what it is about therapy that is causing it to work is still up for a lot of debate.
It definitely does work. What that means, concretely, is that a person who is having any one of a variety of psychological, emotional or behavioral kinds of problems will do far better getting psychotherapy than not. The issue of what it is about therapy that is causing it to work is still up for a lot of debate. And, of course, every school of psychotherapy, every brand, has their own particular perspective on that.

One thing that people do generally agree upon is that the therapeutic relationship, the nature of that relationship that some people call the “therapeutic alliance,” is a critical factor. Other people say the relationship is a necessary, but not sufficient, condition, but what is it about the relationship? If you’re a clinician, and you’re about to meet a new patient, the research doesn’t really tell you what you might do to enhance that relationship. What are the things that are involved? What are the steps involved in creating these productive therapeutic relationships?
DB: Versus looking up in the manual to find out which antibiotic to give for which infection?
GS: Yes, but even with antibiotics, it turns out that a lot more of that is art and trial-and-error than we are led to believe. It’s not quite as cut-and-dried and as narrowly evidence-based. People try one thing and that may work on half the patients. But it doesn’t work on the other half, and then you have to start experimenting with tweaking it.
DB: I guess we’d like to pretend that we live in a world of certainty.
GS: Yes. There is something inherently reassuring about that. But it’s also quite elusive, in my opinion.
DB: I’m reminded of an old saying: “There is no Zen, only Zen teachers.” In a way, there is no “psychotherapy.” It’s only each unique interaction between two people (or three people if it’s couples therapy).
GS: I think that framing it this way goes back to a very old argument in psychology. The controversy about nomothetic versus idiographic principles. Ideographic being very individualized kind of principles, and nomothetic applying to large general populations. And in psychotherapy, my own view of it, both clinically and per research, is that it is very individualized.

So what’s going to work well for one person is not going to necessarily work well for another.
Therapy has to be tailored to the particular needs and goals of the patient we’re working with.
Therapy has to be tailored to the particular needs and goals of the patient we’re working with. But, having said that, I also think that there are some general principles, and here is a good example of one: If therapy is tailored to the needs of a particular person, all other things being equal, it will be more effective and more successful.
DB: Your background and your extensive work with Control-Mastery Theory, developed by Joe Weiss and Hal Sampson, is all about that.
GS: Yes. Very much so. It’s one of the things that really drew me to their work. It really takes into account the particulars of a person, the nature of their particular problems, what their particular history is, and how the therapy can address that in a very individualized way.

"We Forgot to Ask the Patient!"

DB: What’s your opinion on getting regular feedback from clients? The research that I’ve seen, both for individual therapy and couples therapy, seems to be clear that having clients give written feedback after every session improved either the alliance or the outcome. Should therapists be encouraged to incorporate that more into their clinical work?
GS: It’s a very good question, and it’s an area that is really taking off like wildfire right now, not just in psychotherapy, but in the field of healthcare generally. One of the biggest initiatives in many, many years, at the National Institutes of Health, is what they call “Patient-Centered Outcomes Research.” A lot of research in healthcare, for decades actually, was really just based on what lab tests showed, or what a physician concluded. Nobody bothered to get the patient’s perspective, and suddenly people are saying, “Oh, my God, we forgot to ask the patient!”

So now there’s this huge catch-up game going on in terms of trying to get the patient’s point of view. In psychotherapy research, we’ve certainly taken the patient’s view into account a lot, but what is newer in psychotherapy is this point that you’re raising about feedback, and getting patients’ feedback after every session. People have tended to use symptom-based measures, so patients fill out a form at the end of each session to see how they rate the severity of various symptom profiles.

I think that getting the patient’s feedback is very useful, but I’m not particularly impressed with symptomatic measures. I think there are probably more important things that one could find out from the patient after a session. What did they find useful? How did they feel the therapist was responding to them? That’s useful information for therapists to know, and historically we just relied on our own impressions to get that kind of information.
Sometimes we’re right; sometimes we’re wrong, and we often don’t know which is which.
Sometimes we’re right; sometimes we’re wrong, and we often don’t know which is which. Having the patient be the arbiter of that information is very valuable.

Even without written feedback, one would hope that an experienced practitioner would draw out the patient’s feelings and perceptions if he’s seeing some kind of transference to what a therapist has said or done. We hope that that would be an integral part of the work.
DB: Sure.
GS: Some therapists, of course, explicitly ask patients at the end of or at some point in the session, “Well, how do you feel things are going today?” Or, “How do you feel you’re doing?” Or, “How are things with us?” That’s a useful thing to do, but the people that are more into systematic feedback would say that you may get more reliable data if the patient is outside of the session, sitting, thinking about the influence of the therapist. You may get a more complete picture of the patient’s experience that way, instead of—what’s that old term in research?—the “socially desirable” answer.

"What Exactly Does 'Cured' Mean, Anyway?"

DB: Let’s switch back to the marketing aspect of “evidence-based therapies.” I recently came across a practitioner’s website where he claimed that his particular brand of marital therapy has proven to be effective with 90% of his couples and 70% were “cured.” What are your thoughts about that?
GS: It strikes me as primarily marketing. It’s hard for me to wrap my mind around numbers like that. What exactly does “cured” mean, anyway?
DB: Talk about the medical model! As if the people came in limping and left skipping merrily along.
GS: There’s plenty of evidence that therapy, including couples therapy, is effective. It works. But there’s no evidence whatsoever to support the idea that one particular brand is systematically better than another. There just isn’t evidence for that. People make all kinds of claims, but it just isn’t supported when you look at it on the broadest possible level.
DB: I found a couple of articles through the American Psychologist with tables about empirically validated therapies. One broad grouping is “well-established treatments.” And then they have “probably efficacious treatments.” I’m sure you’ve seen all of that.
GS: Yeah, absolutely.
DB: And someone cited 420 different defined psychotherapies. Do you think those are also marketing attempts to differentiate themselves from the rest?
GS: Yes, I think it is primarily marketing. I mean, there just can’t be 420 fundamentally different ways of doing this work. It flies in the face of common sense. I see it as what somebody called the “narcissism of small differences.” People have variations on cognitive therapy, to take a few examples. Albert Ellis, “Rational-Emotive Therapy.” You have Aaron Beck’s “Cognitive Therapy.” You have Jeff Young’s “Schema Therapy.”
There just can’t be 420 fundamentally different ways of doing this work. It flies in the face of common sense. I see it as what somebody called the “narcissism of small differences.”


And then there are probably 20 other variations of it. Well, are they really all that different? I don’t think so. I think it’s just people wanting to create a brand rather than looking for commonalities. They’re looking for, “this is my way,” so that they can develop empires and training institutes and all that.
DB: I’ve talked to a number of colleagues, a few of whom I guess may be possibly nearing retirement, and they look back over the years and wonder, “How did I do? How did it all go?” Arnold Lazarus, years ago, did some follow-up with as many of his patients as he could. Could you comment on how he did that, or your knowledge of that?
GS: I don’t know the specifics of Lazarus’ work on that, but I do know therapists who do this routinely. I’ve always had a lot of fascination and admiration for it, where a therapist will, after a number of years, get in touch with their patients and ask them to come back and to check in and to see how they’re doing. This is, obviously, without charging a fee. It’s just the therapist wanting feedback. Lou Breger wrote a book recently called Psychotherapy: Lives Intersecting in which he describes his experience contacting a lot of his former patients, and asking them how they’ve done. I think more of us should do it, probably.
DB: There are ways to do it, obviously, that ensure ethical reconnection with past patients.
GS: Yes. One has to be sensitive to respect their privacy. I mean Lou Breger got permission from all of his patients and any identifying data were disguised in his book. But even if one isn’t writing about it, just for one’s own edification, systematically getting a patient’s point of view several years after the end of therapy—what they felt about it, whether it was helpful or not helpful—could help sharpen us as clinicians.

We Are All Skinner's Pigeons

DB: Do you feel your clinical work with people is impacted by research results and, if so, to what degree? Or are you more impacted by what has happened in the session? One person pointed out to me quite a while ago, that in a sense, we therapists may be similar to Skinner’s pigeons—we get reinforced to do the things that work for us with our individual clients or couples. Research and theory can, perhaps, clarify and codify what we are doing or should do, but meanwhile, we’ve been getting these experiences with people about what works and doesn’t work. Do you have a sense of whether your own direct experience of doing therapy is most influential, versus reading research results?
GS: I’d say that my own work has been more influenced by my patients’ feedback and from teaching and observing what other therapists are doing in their work and how that’s going. In that case, I have the luxury of not being in the room at that point so I can think more broadly about what’s happening or not happening. I would say that those experiences, along with my own supervision—I’ve had therapy supervision for many, many years by really good people—have probably shaped my work the most.

There are some things from research that have also affected me. In my early training, which was largely psychoanalytic in the 70’s, the role of interpretation, particularly transference interpretation, as a primary mutative factor, was thought to be the primary effective ingredient of psychotherapy. My colleagues and I did some research on that and found, along with others, that there was no evidence that transference interpretations were especially powerful.
My colleagues and I did some research … and found, along with others, that there was no evidence that transference interpretations were especially powerful.


So that certainly led me to rethink everything. I thought, “Wait a minute. All the stuff that we’ve been learning from very senior psychoanalysts—there isn’t really any evidence supporting it other than the fact that they say so?” That really led me to question the role of interpretation in psychotherapy.
DB: Is that close to the idea that information—insight—can be imparted that will change people versus people having an experience that changes them?
GS: That’s exactly right. There’s a very gifted psychoanalyst, Frieda Fromm-Reichman, who said patients don’t come for insight; they come for experience. So this view has been around for a while, particularly in the so-called interpersonal school of psychoanalysis. I think that more often than not, people do learn from their experiences.

Having said that, I also want to say that in terms of my commitment to individualizing psychotherapy, it is true that there clearly are people who do learn a lot from new information, so I don’t privilege one or another. I don’t privilege the idea that there’s a particular technique that is across the board better than others. We might even say that for some people, having a new insight, a new thought about themselves or their lives or their childhood or current process, gives them a new experience.
DB: Yes, it can.
GS: Maybe more compassion for themselves.
DB: It could work both ways. It can work that the insight gives them new experiences. It can also work that new experiences opens them up to new insights.
GS: I would say it really does work both ways. And there’s no way to know in advance which it’s going to be for any given individual.
DB: What are your thoughts more generally about the role of research in a practitioner’s life?
GS:
Unfortunately research hasn’t given clinicians and practitioners a lot that they can use.
Unfortunately research hasn’t given clinicians and practitioners a lot that they can use. That is changing and will continue to change in a positive way, but the whole emphasis on the Randomized-Control Trials and so on has not helped clinicians much in my opinion. Other people have different views about this, obviously.

I think what can begin to help clinicians more is the very consistent research finding that “therapist effects” trump treatment effects. In other words, if there are therapists doing a trial of three different therapies, it turns out that there are particular therapists in all three of those conditions who are actually better than their peers.
DB: Those must include what some have referred to as “non-specific treatment effects.”
GS: And those effects are bigger than the particulars of the therapy that’s being practiced. To me, that’s a really interesting finding. And the question that it begs is, well, what are those therapists doing? Let’s figure that out. And, if we can figure out more about that, we could try to train other people to do that or try to incorporate more of that in our own work.

"He Was a Wise Dude, That Buddha"

DB: The final area I’d like to discuss with you is your own interest and involvement in Buddhist concepts. You’ve done very well-received seminars and workshops with Steve Weintraub, a Zen priest and psychotherapist, on Buddhism and psychotherapy. Is there anything that you would like to say about that?
GS: Overall, Buddhism, for me, as well as just the experience doing psychotherapy, has taught me that much in human life seems to get better when you can have more self-compassion. I’ve been interested in Buddhist thought for a very, very long time. My interest in it probably dates back to when I was studying psychology as an undergraduate. I was really interested in Freud. I was interested in Carl Rogers. I was interested in the Human Potential Movement.

Then I had this kind of—I don’t know what to call it—like an insight. I thought, “Wait a minute. People have been thinking about these things way before Freud, way before Rogers or Maslow; there’s a history to this. And it’s a very, very old and long one.” I would say that
Buddhist thinkers have been paying attention to the nature of mind and suffering for longer than just about anybody else.
Buddhist thinkers have been paying attention to the nature of mind and suffering for longer than just about anybody else. They’ve had a lot of valuable insights into what causes people to suffer, and how people’s suffering can be alleviated and reduced and so on. So at that broad level, I think Buddhism has a lot to teach us about just basic human psychology, and particularly the nature of suffering and what causes people’s suffering.

It’s different, in my opinion, from organized religions, in the sense that it doesn’t say one’s salvation will come through this or that route. I would say it’s a very broad model. It allows people to apply the teachings in their own lives in their own way. It doesn’t really require going to church or synagogue every week or every month or that kind of thing. But it does give certain tools that people can use in a very reliable and useful way.
DB: I’ve seen a commentary attributed to the Buddha, where he sounded like an empirically-based fellow. He essentially said, “Don’t believe anything I’ve told you. Try these things out for yourself. And if they work for you, great. If they don’t, go onto something else.”
GS: Yeah. I think that’s one of the things that has contributed to Buddhism gaining enormous popularity in the West right now. We have something that fits very well with the kind of individualized and democratic mindset that we can learn things by seeing what works for us. There is a lot of wisdom in that. He was a wise dude, that Buddha.
DB: They’ve updated it. I’ve run across some people who are espousing “Open-Sourced Buddhism,” that we are free to choose from those schools of Buddhist thought, from the very cognitive-based wisdom of Tibetan Buddhism to the no-thought idea of Zen.
GS: I love the idea, and would love to see more of that open-source thinking applied to psychotherapy. One of the things that we have right now in therapy is the equivalent of proprietary systems, where people develop one of those 420 brands of therapy, and then you just have to get in and do it that way. As opposed to an open-source model, which is people getting in there and using it for their own purposes and contributing to it, growing it in their ways—which is what’s happened to Buddhism. People are growing in all kinds of ways in the West, and I’d love to see more of that actually happen in psychotherapy.
DB: Supposedly a graduate student went to Jung one time and asked, “How do I become the best therapist I possibly can?” And he replied, “Go to the library, read everything good that’s been written about the art and science of psychotherapy, and then forget it all before you peer into the human soul.”

Well, thank you. I really, really appreciate having had this time with you.
GS: Thank you.

Technology and Psychotherapy

Posted on by Psychotherapy.net Team

A recent article on a study from the University of Zurich offered the headline, "Psychotherapy Via Internet as Good as If Not Better Than Face-To-Face Consultations." It does not surprise me when I think about many of my clients’ everyday lives in the Bay Area: technology tends to be seen for the most part as a fun, useful and normal part of life. It also makes sense when I think about the ways that technology, if wielded strategically, can sometimes make things simpler and more immediate. Grandkids and grandparents all over the world would agree (thanks Skype!), as would families with service members deployed in far-off countries.

Here's a quote from the article in Science Daily about the online psychotherapy study, "In the case of online therapy, the patients tended to use the therapy contacts and subsequent homework very intensively to progress personally. For instance, they indicated that they had re-read the correspondence with their therapist from time to time. ‘In the medium term, online psychotherapy even yields better results. Our study is evidence that psychotherapeutic services on the internet are an effective supplement to therapeutic care,’ concludes Maercker [one of the study’s authors].”

Skype therapy could improve outcomes while it lowered the barrier to accessing therapy. In one way of thinking about it, what was once a trip across town and a 2-hour commitment is now 50 minutes at one’s desk.

But I notice a conservatism and even a bit of prejudice against technology use among therapists: Skype, texting, online scheduling, and other things can be treated as if they are volatile substances when in fact they are more and more a part of everyday life, used by lots of people to great effect. Therapists can benefit from remembering the wisdom that often what seems unstable and jarring to an older generation is soon enough just “the telephone”—utterly banal and safe.

A few years ago a former Supervisor warned me against texting with clients about appointments and scheduling shifts. When I questioned him further, however, he admitted that email was ok for this, and that he emailed with clients about appointment times, though not clinical material. Most therapists under forty who I ask about texting with clients say it is the same thing—just a quicker form of email. I have even heard a client assert, “It’s rude to call someone on the phone now. You interrupt their day and make them say ‘how are you?’ Texting is more polite, faster, and doesn’t require needless formalities.”

I think that the obvious insight here, that technology changes and what seems outlandish today will soon be normal, can go one step further. What if therapists could harness the excitement and convenience of technology to improve our usefulness to clients and to improve our ability to help clients change their lives?

I've been thinking a lot about therapists and technology lately, as I have been part of a group testing out a new mood-tracking app called Senti. With Senti, users answer a few relevant questions about mood and emotion throughout the day and Senti keeps track of how they seem to be doing. The questions both track useful information (“Thursday tend to be a rough day for me”) and also function as a mini-intervention, just as if someone had texted you to say, "hey, put your feet on the floor, take a deep breath, and tell me how you're really feeling right now."

But when I described the app to another therapist she was skeptical. "It sounds great," she said, “but therapists are late adopters. You'll never get them to use it with clients." Similarly, The New York Times recently ran an article by therapist Lori Gottlieb with the headline, "What Brand is Your Therapist?" In it, she ponders whether therapy as we know it is a think of the past. "I hate to think that therapy is an outdated idea, too slow and too private to satisfy a population that has come to expect immediate responses and constant gratification."

I see people each day needing help coping with divorce, eating disorders, anxiety, depression, and other problems that cannot be repressed and forgotten and that need attention. There is a great need for inner work and for the relief of human suffering. Rather than thinking technology is a barrier to connection, we can ask what Darren Kuropatwa asks in his presentations about technology and learning: “What can I do now that I could not do before?”

What if instead of a necessary evil, technology could facilitate a different kind of depth—the depth of a therapy that can be held by a client in their hand; where self-support, self-inquiry, and a therapist at the other end of the wi-fi connection make transformative work more possible? After all, there is nothing about Skype or about an email exchange that is inherently glib or false. What matters is the content and the material and the depth to which the client can face themselves, with the powerful support of another person trained to be of use. Whether the therapist is on Facetime or tweeting reminders to followers to pause and breathe when angry feelings erupt, what matters is that people get better and the world gets better. And for that project we need every tool we can get.

Charles Mansueto on Obsessive Compulsive Disorder

Posted on by rezendevknowfully.com

OCD and Its Misconceptions

Victor Yalom: We can assume that our readers who are therapists and students of therapy or counseling or social work know something about obsessive compulsive disorder, but may not have a great deal of expertise. So what are a couple of things that therapists don’t know or may misunderstand about OCD?
Charles Mansueto: Well, the first misconception is that it’s amenable to a broad range of psychotherapeutic interventions. It’s not. It appears that that the treatment that’s clearly effective and has been well tested is cognitive behavior therapy. The second kind of treatment that is available is pharmacological treatment that typically impacts the serotonin system.

The first misconception is that it’s amenable to a broad range of psychotherapeutic interventions. It’s not.

Because it’s widely thought of as a brain-based or biological disorder having a biological substrate, one misconception is that it needs a biological solution, that a person must be treated with medications to correct whatever anomalous conditions exist when OCD is present. That’s not the case. The learning-based treatment, Cognitive Behavior Therapy (CBT), has been established and continues to be emphasized as the treatment of choice in the vast majority of cases.

VY: We hear that about so many conditions now that they are biologically based, and I think many therapists are skeptical. What’s the evidence for OCD being biologically based?
CM: The evidence comes from basic studies of brain scans. Some early research, for example, identified the activity in the brain that occurs when OCD is present as identifiably abnormal. I participated in a study with Judith Rapoport using Pet Scan imaging. We found that when the cortex, the thinking brain, perceives a danger of some sort, it transmits a signal down to deeper structures of the brain. In people with OCD, the caudate nucleus seems to not be able to regulate these worrying signals. But when OCD has been treated successfully, either by the serotonergic drugs or by cognitive behavior therapy, there’s a degree of normalization of brain function. There’s a lessening of that repetitive activity within the communicative structures in the brain.
VY: So with brain studies, there’s some clear differences between people with OCD and the “normal population,” and there’s a difference between pre-treatment and post-treatment OCD. Is that what you’re saying?
CM: Exactly.
VY: But I’m sure looking at the brain you could find brain differences in many groups of people. That doesn’t prove that it’s a neurologically-based. That’s correlation. So what other type of evidence is there?
CM: Well, there’s the family studies that show a greater-than-chance-alone incidence of OCD within families. So there’s a suggestion that there’s a genetic element to the transmission of OCD. There are other possibilities, of course—cultural transmission, social transmission—but there’s strong evidence for some genetic linkage.
VY: And then there’s some more intriguing evidence of OCD being related to Tourette’s syndrome, which I know you have done a lot of research on.
CM: Those of us who treat OCD frequently often come across the co-existence of OCD and tics and Tourette’s syndrome, most often in children. There is often great difficulty in distinguishing between complex tics in adolescents, for example, and compulsions. So the question comes up often: Is this is a tic? Or is it a compulsion? Now those have important treatment implications because we have different sets of tools for OCD versus Tourette’s. But there are a lot of close similarities and an intriguing connection between the two that hasn’t been well-clarified in the literature.]

Strep Throat and OCD

VY: I recall hearing in the past that there was some potential linkage between Tourette’s syndrome and strep throat. Is that true?
CM: Yeah. It’s called “PANDAS,” Pediatric Autoimmune Neurologic Disorder Associated with Strep. Cute name but not a very cute disorder. Sue Swedo and others have pointed out that there seems to be a link between rapid onset in childhood strep infections and, in some case, the emergence of OCD-like symptoms, tic symptoms, and an array of other presumed neurological symptoms, like hyperactivity.

There seems to be a link between rapid onset in childhood strep infections and, in some case, the emergence of OCD-like symptoms, tic symptoms, and an array of other presumed neurological symptoms, like hyperactivity.

More recently, there’s been speculation that other diseases, such as Lyme Disease, might also be able to initiate or exacerbate symptoms of OCD and some of these other related kinds of problems. Now that it’s been identified as such, we’re seeing more and more children who are presumed to have a biological-based onset—or infection-based onset—of OCD and these related problems.

VY: So there are multiple ways that this might manifest, in terms of symptomatology—a lot of complexities there.
CM: Well it adds the possibility of environmental causes. So it’s not just that a traumatic incident or a biological vulnerability are the only causes, but relatively common infections may also be implicated in the etiology of OCD.
VY: Has the traditional psychoanalytic/psychodynamic explanation for it been totally discredited?
CM: Well, it’s certainly very interesting and compelling, but it’s very hard to prove in research, as you might guess. But more importantly, treatments based upon psychoanalytic and psychodynamic presumptions do not seem to have a significant impact on OCD, at least in the cases that have been researched.

OCD and Obsessive Compulsive Personality Disorder

VY: Is there any correlation at all between what we think of as obsessive compulsive personality disorder and OCD? Or are those two really quite distinct things?
CM: Well, they are distinct, but again they’re curiously related. We do distinguish the disorders, putting them in two different parts of the DSM and they’re differentiated relatively easily from diagnostic criteria. However, my own view is that we’re talking often about how ego-dystonic versus syntonic it is. In other words, how much does a person who is extremely orderly and very concerned about germs and cleanliness— how much do they value that? Do they see that as part of themselves, the way they are? Their own characteristics as opposed to something that happened to them that they would like to get rid of?

Treatments based upon psychoanalytic and psychodynamic presumptions do not seem to have a significant impact on OCD.

With OC personality disorder, one distinction that’s made is that the behavior is ego-syntonic. The person doesn’t necessarily want to give up this part of themselves because it’s well-integrated into their overall functioning, their value system, their dispositions to action and their history. With OCD it’s more dystonic. It’s something that happens to me and I want to get it out of me at all costs.

But we do see a continuum here. We see individuals who are more or less committed to maintaining their particular approach to life, their perfectionistic tendencies, their extreme cleanliness, their methodical orderliness, to the point where they are doing more organizing than they are working; it becomes very dysfunctional. So I’m not convinced that we are talking about two totally different populations. But that’s the way we think diagnostically.

VY: Let’s talk about the course of the disorder. Let’s say someone has classic OCD—hand washing, door checking, those types of behaviors. When does this typically start and if left untreated, does it tend to go throughout the course of their life?
CM: Well, we don’t have perfect information on this because we only see people who are in trouble, when things haven’t resolved. So there may be people out there who experience significant OCD that then resolves, but we don’t see those individuals very often. But typically, OCD occurs in children around age eight, nine, ten or there is another onset cluster in late puberty/early adulthood. Whether they’re identical is up for some debate. There do seem to be differences in many of the childhood cases we see. Some of the work I’ve done with what I’ve come to call “Tourettic OCD” tends to appear more typically in childhood.

Whether a person gets it early or later, it seems to be chronic when left untreated.

But whether a person gets it early or later, it seems to be chronic when left untreated. It does wax and wane though. There probably are many individuals who are able to adapt and continue to live reasonably productive and happy lives. But for many individuals it becomes a true disorder, in the sense that it substantially decreases their ability to be happy and satisfied with the quality of their lives.

VY: Right, you said that obsessive organizing behaviors interfere with work, but I imagine it can also interfere with relationships.
CM: Very much so. We work with a lot of families, and a whole family’s life can revolve around the OCD of one individual within that family.

Treating the Family

VY: Does an example come to mind?
CM: Let’s say an older adolescent or a young adult continues to live with the family, with the parents, and the parents realize that the person is impaired, and very dependent on them. Well, as parents often do, they try to keep the person as comfortable as possible, as comforted as possible, and that means they begin to adapt their life to the needs of that individual. Those needs can often be excessive and very bizarre. It may involve cleaning and separating dirty things from clean things. It may involve strange eating patterns. But the family becomes more and more inclined to revolve and have their home life dominated by those requirements. In that case, we have to often treat the entire family.Now that’s more typical of children and adolescents, obviously, but we see people who are up there in age and they worry that their child cannot exist without them and their time is limited. Those individuals often reach out in desperation even though their loved one is unwilling to get treatment and just simply wants everyone to continue to cater to their unique and idiosyncratic needs.

VY: It becomes a kind of codependent situation where their attempts to comply or adapt to the OCD sufferer probably reinforces it.
CM: It’s a big problem. At the OC conferences, we often have rooms full of parents who are there because their children—usually adolescents or young adults— wouldn’t come. They’re trying to figure out how to get their children to agree to participate in treatment.
VY: Let’s delve into treatment. You mentioned that cognitive behavioral therapy is the treatment of choice?
CM: Yes. The expert consensus guidelines were developed in the late 90’s, 1990’s, and haven’t been modified since because, except for the addition of a few medications into the treatment approach, the guidelines are still very solid. About 70 or so treatment experts from around the world were asked to put together the guidelines for those who are not experts at treatment.I think just under two-thirds were medical people, MD’s, and across the board, CBT was recommended for individuals with OCD, sometimes in combination with medication for more severe cases. But medication alone was seen to be a second best treatment, except in the case of more severe adults. Essentially CBT is the treatment of choice, and we do biofeedback, relaxation training, assertiveness training, all under the umbrella of CBT.

The Experts Agree: The Solution is CBT

VY: We’re a field that doesn’t always easily come to a consensus about what to do when you’re sitting with another human being in the room to help them with their malaise, but it sounds like at least for the treatment of OCD, there is a higher consensus than we typically find.Let’s get into the specifics of CBT treatment. Let’s take a prototypal case—a hand washer or a checker who’s checking the locks or checking to make sure that the stoves are turned off. Let’s say this is someone who is coming voluntarily to your office and wants to get some help. How do you start out?

CM: Education first. There are things to know about OCD.

It can feel very mysterious and just because someone has it doesn’t mean they understand it.

It can feel very mysterious and just because someone has it doesn’t mean they understand it. So the first step is to help explain that there are understandable relationships between symptoms and elements within OCD. It’s important to explain this because it suggests that there are proper lines for treatment.

VY: I assume you have to do some kind of assessment on what type of OCD they have, what’s the severity, what they’ve tried so far.
CM: Most people have received some treatment when they first come to our treatment center, but not proper treatment—not CBT and often not even the appropriate medications.The letters themselves tell something about the problem. First there are the obsessions—whether it’s about germs and contamination, or locks and safety from marauders, or fear of displeasing God—whatever the nature of the obsession, there’s typically a belief in a threat that must be avoided at all cost. These obsessions have a negative emotional impact; there’s often a great deal of anxiety and shame that accompanies them.Next we have compulsions. There are two ways of being compulsive. One way of being compulsive is to avoid any circumstance that arouses those ideas and fears associated with the obsession. So I might try to avoid thoughts that are negative towards other people if I fear that God is displeased by that, or lascivious thoughts. Or I might try to avoid touching doorknobs or coming in contact with people’s hands because I fear that I may pick up some disease.

VY: So those are the avoidance type of compulsions.
CM: Yes, those are avoidance compulsions. The other type of compulsions are the rituals, which are used when certain things can’t be avoided. So pleading with God for forgiveness for having improper thoughts, praying over and over in certain ways to ensure that God realizes that I wish to be forgiven and am unhappy with my behavior.Or the washing that’s done in order to get rid of the possibility that there are germs on me, and the obsessive scrubbing and showering and cleansing of clothes and so forth. Or the checking of locks over and over because maybe I missed the lock or I accidentally unlocked it instead of locking it. Or that just looking at it isn’t enough. I have to check it physically or ask others to reassure me that the lock is, in fact, well secured.

VY: Listening to this, I’m imagining psychodynamic-oriented people finding these behaviors rife with potential meaning, but you don’t go there in your approach, right? You don’t put too much effort into figuring out what the meaning of these things are?
CM: Well, there are situations where some traumatic or highly stressful experiences of the individual might have preceded certain kinds of problems. But that’s not critical. The origins of the problem don’t seem at all essential to a successful treatment of the problem. Nor does insight necessarily produce the kind of improvements that one would hope for. So we think of insight into the origin of the problem, or understanding the meaning of it and so forth, as somewhat autonomous from the alleviation of the problem itself.

Avoidance and Its Discontents

VY: So getting back to treatment—once you’ve done some sort of assessment and have a sense of what the obsessions or the compulsions are and how severely they’re impacting that person’s life, then what do you do?
CM: Next you point out the way these behaviors often worsen the condition. Let’s take a common example: A child wants to avoid sleeping in the dark, but the parents insist that they stay in the dark, and maybe give them a little nightlight or open the door a crack. If they scream loud enough, will their parents leave the light on? No. Parents will say, “No, we’re going to turn off the light. You know you have to get back to sleep.” Avoidance is a way of maintaining fears.
VY: So if they cave in to the child’s demands and leave the light on, that’s going to reinforce the child’s fear.
CM: Right. It’s like not swimming in deep water isn’t going to help you get confident in your swimming ability in deep water. Not taking the training wheels off the bike isn’t going to make you a confident two-wheel bike rider. What we need is exposure to the experiences that cause us fear so that we can actually gain confidence and overcome our fear.

The origins of the problem don’t seem at all essential to a successful treatment of the problem. Nor does insight necessarily produce the kind of improvements that one would hope for.

Similarly with OCD, what we do is provide methodical and manageable levels of exposure to the feared elements, with the assumption—and borne out by our experiences—that the person will eventually become less fearful; and when the fear is lessened or extinguished, they have no longer have to perform rituals or compulsively avoid the original cause of their fear.

VY: You’re talking about exposure and response prevention.
CM: Mental exposure to things that cause us unwarranted fear, and then response prevention: encouraging the person to forego any abrupt reductions or eliminations of their fear, because the nervous system needs time to adapt. With repeated exposures, and saying, “Yes I know you’re anxious, but don’t wash your hands. Let’s let your nervous system get used to the fact that you have a great deal of nervousness and fear about this”—over time, what we typically see is a person becoming more comfortable with higher levels of fear-invoking distress.
VY: So how do you actually do that? These people are very invested in their symptoms so it can’t be easy. What are the steps? What do you do in the first session, the second session?
CM:

We have to come across as knowledgeable experts in order to instill confidence in them to allow us to lead them into the belly of the beast.

In orthodox, standard treatment, there’s the cognitive therapy component, where there’s a great deal of education about the way these things work—why their efforts to remain comfortable are thwarting their wishes to overcome their OCD. This educational component is key and we have to come across as knowledgeable experts in order to instill confidence in them to allow us to lead them into the belly of the beast. We have to do it in a way that allows them to experience some of these corrective measures, so that they can say, “Whoa. I’m much more comfortable doing this than I ever imagined I could be.” That’s the first step out of the pit.

VY: So you start by explaining how the treatment’s going to work and establishing yourself as an expert so that they’ll do what you tell them to do.
CM: And the proof’s in the pudding.
VY: So with the hand washer, will you give them some homework in the first week?
CM: Yes.

“Do You Know Somebody Who Got AIDS from Touching a Doorknob?”

VY: Do you tell them to go cold turkey?
CM: Not usually, because these fears are heavily entrenched and have been reinforced over a lifetime. So there has to be a great deal of preparation, cognitive therapy, correcting of misconceptions and identification of distorted thinking to help prepare the person for more experiencing and tolerating of their discomfort.
VY: So how do you do that? If these people have a very strong belief, bordering on delusional, that they’ll get AIDS from touching a door knob, for example, how do you get them to start touching door knobs? Clearly just presenting them with their distorted thinking isn’t going to be enough, right?
CM: Well, you start with simple observations like, “Other people seem to be touching doorknob quite regularly. Are your friends who touch doorknobs dropping like flies from AIDS? Do you know somebody who got AIDS from touching the doorknob? Have you ever heard an expert who understands disease processes suggest that we should all avoid touching doorknobs because AIDS or some other deadly diseases can easily be transmitted?” You start point out flaws in the thinking process.
VY: So having a logical discourse can be effective?
CM: It helps. It establishes a foundation of looking at things differently. These people are not crazy; they’re very intellectually competent, in fact, so they’ll begin to take notice of the many inconsistencies in the way they address these things. They might have a magical way of ensuring that they don’t get a disease—for example rubbing their hands on their pants six times.

We might ask, “What scientific principle suggests that rubbing it six times makes you safe, while rubbing it seven times or five times doesn’t?”

So we might ask, “What scientific principle suggests that rubbing it six times makes you safe, while rubbing it seven times or five times doesn’t?” And they’ll go, “Wow. Yeah, now that you mention it, it sounds kind of silly.” We begin to undermine their notion that this makes sense.

Nobody wants to live life like this. They’re just so afraid of giving it up. So they really want to believe you when you say that they can get over it, because life can be such hell for them otherwise.

VY: So cognitive preparation can be helpful. What do you give them as homework the first week?
CM: Well, homework might be to monitor. The chunks of useful information for setting up treatment are the many things they avoid. Why? Because avoidance exposure is the opposite of avoidance. Anything they avoid doing is potential fodder for the exposure experiences. So they don’t touch doorknobs; they won’t eat off a fork that hasn’t been rubbed with a disinfectant wipe; they won’t shake hands with people; they won’t use public restrooms or touch any surfaces in a public restroom. All of the things they avoid doing become useful information to develop the exposure experiences. And on the other side of the coin, all of their compulsive behaviors—their washing, their separating clean things from dirty things, their asking for reassurance from others—all of those become the elements for response prevention. Those are the easy escapes, and we can’t have that during the course of the treatment, in order for it to be successful. So in the early stages of treatment, our goal is to get a wide array of potential exposure treatments, those things that they tend to avoid that ordinary folks don’t.
VY: So in the early stages of treatment, you first want them to be more aware of what they’re doing. And then you’re giving them some alternatives?
CM: You’re gathering information to become a collaborator in treatment. You’re saying, “You’re going to hate exposure. You’re probably a little nervous about it. But I’m going to help you understand why avoidance has been so detrimental to your life. You’ve worked so hard, but you’re more afraid than you’ve ever been about these things.”Originally they see the compulsions as the solution. “I’m going to avoid touching things that make me feel dirty. I’m going to do things that make me feel clean.” But soon they’re doing those things for hours and they feel more scared than ever.

VY: Okay. So the first week or two, what do you specifically give them to do as homework? Or tell them to do?
CM: There’s no one formula for how you start, how fast you move, and so forth. In fact, individually gearing it to the person, to their readiness, to the level of preparation they need and how much help they need with the exposures—these are all very important elements to ascertain before moving ahead with the treatment. And this is where the expertise of the practitioner comes in.We might do a more traditional once-a-week treatment, or an accelerated treatment where people come more than once a week. There may be in vivo components in or outside the office where they’re getting exposure to the stressor. We can have intensive treatment, where over a shorter period of time, let’s say a month, people are getting very intensive daily hours of treatment.

But the general thrust of early treatment is to gather the correct information to build a road map for the treatment. And that involves the patterns of avoidance, the patterns of rituals that are used, and so forth. Then we develop a hierarchy, which is the essential part of the roadmap. Which things produce very little discomfort, which things seem outrageously anxiety producing, etc. Then we bring them through the different stages. So as they learn at each stage that they won’t meet their demise, we lead them through increasingly more difficult exposures.

Hierarchy for a Hand Washer

VY: What would be a hierarchy for a hand washer?
CM: Early on I’d try to find something relatively easy to work with. So if a client feels safe in their bedroom but not safe touching the bedposts because her mom touches them when she changes the sheet, I’d ask her to rate her discomfort on a scale of 1 to 100. The name of the scale we use is “SUDS,” Subjective Units of Distress. So I’d ask how anxious the bedposts make her and she’d say, “just a little bit.”

Our job is to titrate the exposures so that they are manageable and doable, and to ensure that the person is gaining confidence that the powerful emotional response and the belief in the catastrophic consequences that they fear are both diminishing.

So I would ask, “Would you be willing to just come in contact with that bedpost, and see what the emotional experience is like? Is it going to be awful? Is it going to be reasonable? Can you forego the washing? If so, for how long?” We try to probe into how people actually react. Sometimes it worse than they think, and sometimes it’s easier than they think.

Our job is then to titrate the exposures so that they are manageable and doable, and to ensure that the person is gaining confidence that the powerful emotional response and the belief in the catastrophic consequences that they fear are both diminishing. That’s the only reason why a person would move forward and give up all their safety mechanisms and participate in treatment.

VY: Alright. So in the hierarchy, the bedpost might be relatively low. The refrigerator door might be higher and the faucet in a public restroom might be a lot higher than that.
CM: Right, and typically we start with some exposures in the office, where it’s a safer environment and they don’t have a history of a great deal of compulsivity. The therapist becomes kind of a guide and a confidante and a trusted companion on the journey.As we go, we learn more about how the nervous system reacts and what’s going on in the mind of the individual, and then we can apply cognitive therapy and wait for the habituation as the nervous system reaches it’s kind of asymptote, and then begins to decline. It’s a very interesting and powerful experience for individuals. “Wow. I don’t feel as nervous now. When I think about it, it kicks up a bit, but somehow it doesn’t bother me as much as it did before.”

We emphasize the techniques, but so much of it is the importance of the relationship—the confidence of the patient in their therapist and the therapist’s sure hand on the tiller.

So there’s a lot going on, as you can see. We emphasize the techniques, the exposure response information, but so much of it is the importance of the relationship—the confidence of the patient in their therapist and the therapist’s sure hand on the tiller.Just knowing that whatever comes up, we’re going to know how to deal with it. That’s why the experience and the special training helps. At some point along the way, we’ll touch on how a person might go about getting that additional training that enables them to be confident at whatever their previous kinds of approach to therapy might have been.

No Reassurance Allowed

VY: Let’s carry this through a little further. So in an ideal scenario, you graduate, move up the hierarchy. They may have a feared response but, if all goes well, they’ll find that if they wait a bit and, with repetition, and with reassurance and—
CM: Well, not reassurance so much. Reassurance is an escape mechanism. We might even say, “Who knows? You might get AIDS. I can’t promise you won’t. You know, things happen.” So we can’t reassure them too much in the process, or it can become a type of ritual in itself. We have to allow them to address the uncertainty of their situation.

Reassurance is one of those subtle kinds of variables in therapy for OCD that can easily be mishandled by a therapist who is unaware of the importance of facing uncertainty.

It’s a balancing act. In a certain way, preparing them cognitively is also reassuring them that we know what we’re doing, that they can overcome their problem. But we have to watch out for specific reassurance when their anxiety is up that is designed to reduce it. You see? It feels important to distinguish this because reassurance is one of those subtle kinds of variables in therapy for OCD that can easily be mishandled by a therapist who is unaware of the importance of facing uncertainty. We often reassure our patients in treatment, but with OCD, you have to be particularly careful or you’re just colluding in the compulsivity of that individual.

VY: Coinciding with the publication of this interview, we’re releasing two videos with Reid Wilson, whom you know, and he even takes it a little further than what you’re saying. His approach really emphasizes the lack of certainty—not only do they have to tolerate the uncertainty, but to welcome and invite it.
CM: Yeah. And that’s very important, dealing with uncertainty, because we don’t know everything about this world. Our patients often come to our office on the beltway. They know people die on the beltway. Are they certain that they’ll make it? That they’ll go home? That they’ll be alive when they get home? The answer is no, they’re not certain. I’m not certain. The reality of the world is that uncertainty is part of the picture.We don’t know what happens after we die. We don’t know if there’s a God that is so vindictive that one false move and we’re forever tortured in hell. We don’t know that for a fact. We have to help people live with realistic uncertainty. With kids, you have to be a little more careful. If a kid believes the number 3 is a bad number and if they eat three M&M’s their parents may die, you have to be a little careful about saying, “Your parents may die, we can’t know for sure.” How that’s handled is extremely important. There are certain people who are going to be much more ready to deal with that part early on, and others who have to be handled very carefully along the way.

But Reid and others of us who work in this way realize that reassurance is a way to help people feel safe, and we can’t do that. We have to expose them to the idea that it may not be safe, but that we have to live our life as if it were safe, the same way we do when we go on the highway, or we eat unknown food. The food may send our body into some convulsive shock, but we eat it because we are willing to accept some uncertainty.

VY: So, following the roadmap that you’ve laid out, they would progressively move towards behaviors that are higher on the hierarchy, and in a good case scenario, they would experience some anxiety, but over time it would diminish or eventually even go away entirely.
CM: In most cases, there are some remnants of OCD symptoms. However, it’s like a person who was once a drinker and now is abstaining—they have to be a little cautious, recognize the danger signs, know what to do. An alcoholic wouldn’t go hang out at a bar; somebody who used to be very overweight doesn’t go shopping when they’re hungry or keep Halloween candy around the house for weeks before Halloween. We teach people how to recognize OCD, how it works, and essentially how to become their own therapist.

We don’t have a lot of repeat customers with an OCD treatment. People go out there and, if properly treated, they should have skills that enable them to live a reasonable life.

We don’t have a lot of repeat customers with an OCD treatment. People go out there and, if properly treated, they should have skills that enable them to live a reasonable life. It is important to understand that there is a potential for people to totally overcome their OCD and live a life that’s free of those problems, but realistically speaking, we have to prepare people for the likelihood that they have to remain vigilant to a certain extent, and have to retain the skills necessary to remain functional and symptom-free as possible.

“You Actually Do That?”

VY: With all therapies, there are usually stumbles and hitches along the way—setbacks, relapses. What are some typical challenges therapists and clients face along the way of navigating that hierarchy?
CM: Well, sometimes people cut corners. They cheat a bit. They may succumb to their compulsion and end up washing and separating at some point during the week. So compliance is extremely important. And because we’re dealing with a very anxious group—and rightly so, they’ve lived a life that’s been drastically altered by their fears and beliefs—we have to prepare them for the importance of compliance with the therapy. So that’s one challenge: people who aren’t quite doing what they tell you they’re doing.

Therapy can be a bit odd. We ask people to do things that ordinary folks don’t do—you know, putting a cookie on a public restroom toilet and eating the cookie…

The other, as I mentioned earlier, is people’s families. Families can be a problem themselves. We have kids who we’re trying to wean from hand washings, and Grandma says, “You’re not coming to the table without washing your hands, are you? Go right over there and wash them and be sure and use soap.” Well, that’s a bit of a problem. That’s why it’s important to educate the family about what we’re up to and why we’re doing it. Because therapy can be a bit odd. We ask people to do things that ordinary folks don’t do—you know, putting a cookie on a public restroom toilet and eating the cookie. We don’t think it’s really going to kill us, but it’s a yucky, you know?

VY: You actually do that?
CM: Sure. Because we’re asking people to go far with this, so that when they leave treatment, it goes back to normal. If you just bring them up to almost normal, there’s a tendency to backslide. So we want to take them to some rather “notable experiences,” I’ll call them, “memorable experiences,” where they say, “Wow, I did that, and I survived. So I’m willing to live my life in a more ordinary way.”So we tell them along the way, “This is yucky. I don’t like doing this. I don’t like reaching into a dumpster and rubbing my face with garbage.” But part of the training is to understand that our own sensitivities mustn’t interfere with therapy. It’s important to get experience and training in this so that we really understand what we’re up against, what people are up against.

The stress of life can also undermine treatment. Whatever we’re trying to do—whether it’s exercise more or get along better with our co-workers—when we’re under stress, it’s easy to slip back into old behaviors. That’s why so much preparation goes into relapse prevention. The latter part of treatment is mostly about preparing people to be their own therapist, and creating a plan that they can follow through on for different expected moments of weakness or the recurrence of some feelings that were perhaps attenuated for a while but, for reasons unknown, come back with a vengeance.

VY: So what might be an example of a relapse prevention plan?
CM: Self-managed exposure and response prevention would be one example. Let’s say I have a fear of dust and dirt and I’ve been doing a lot better after treatment, but one day I notice dust on me and I start to worry. I think, “What would my therapist say? Well, he’d say, ‘Hey, it’s just dust. It’s probably not radioactive material!”
VY: It’s not anthrax.
CM: “So now what do I do? I go and intentionally take a little of that dust and perhaps put it on me, put it on my shirt, so that it makes me feel uncomfortable. It’s kind of foolish to do. No normal person would do that, but I understand I have to use the most powerful tools that anybody knows about to fight back against OCD. ERP—exposure response prevention.” So they do those kinds of things. Self-managed exposure response prevention. It’s very important.But if they’re having trouble, they may need to call up their therapist and say, “I need a booster session. I just took a step backward, I tried to handle it on my own, but I think I may need some help.” So we’ll plan a little systematic approach and a little mini-therapy session. Relapse prevention is preparation for the inevitable human failings, setbacks, weaknesses, and so forth.

VY: So even though it’s a fairly structured form of therapy and there is a lot of technique involved—a roadmap—there’s a lot of creativity involved as well.
CM: Absolutely. We learn from every patient. There are always new twists. The OCD is a product of the person’s own imagination and creativity, so everyone has their own twists and turns.

Training for Therapists

VY: From what I can gather, therapists who don’t have specific training in treating this and just kind of incorporate it into traditional talk therapy are unlikely to have effective results.
CM: Well, it depends on the case. Some cases are relatively simple and a highly motivated individual with a therapist who grasps things well enough not to make some of the common mistakes in treatment can do quite well. So it is possible to pick up a book about it—there are some good manuals out there that tell therapists how to do this as well as some good self-help books that therapists can use. It’s possible to be effective in some cases without extensive training.On the other hand, more difficult cases are challenging even to the most experienced therapists. There are going to be cases that are difficult to treat under any circumstances and that’s where more experience, more heads in on the treatment make a difference. Creativity and troubleshooting problems can be essential to moving smoothly through treatment. It rarely goes according to the cookbook, you know?

VY: If someone reading this interview wants to get more in-depth training, where would you suggest they go?
CM: An excellent place to get that is through the International Obsessive Compulsive Foundation’s Behavior Therapy Institute. It’s a wonderful three-day certificate program. It’s been developed over almost two decades, and provides excellent preparation for individuals who may never have had much experience, or any experience, with OCD. After the training there is follow-up guidance, supervision by phone—people can get really a huge jump in competence in treating OCD.It’s so important to develop more practitioners. As it is, there aren’t enough trained competent practitioners to deal with the large numbers of individuals with OCD. There are whole states where there are very few places to get competent treatment. Not only is it important from the standpoint of the sufferer, but for practitioners. This is an extremely rewarding area to work in.

We do get those Hollywood endings where people just shed their symptoms, hug the therapist, and walk out into a whole different kind of life.

We do get those Hollywood endings where people just shed their symptoms, hug the therapist, and walk out into a whole different kind of life. That isn’t so common with some of the problems we treat.

Just the fact that we’re there and we know what we’re doing ensures that we’re going to get lots of love from our patients, because they’ve often been through some harrowing times when they didn’t understand what was going on, when they got misguided advice from professionals; so when they finally feel that they’re getting competent treatment, there is very often a great deal of positive emotion generated by that alone.

And they pay their bills. The OCD persons are often achieving, smart, and conventional in many ways. So it’s very rewarding. Those of us who specialize in OCD treatment never get tired of it. I have almost 20 people in our center who love to treat OCD and get very excited about new cases that, while challenging, are teaching us new things every day.

VY: Do you treat other conditions as well?
CM: Well, once you treat OCD, you’re going to also be treating things under the broader OCD umbrella. There are many disorders that are now considered OC spectrum disorders—things like body dysmorphic disorder, where people perceive ugliness in themselves and are often very depressed and very distraught. Also hypochondriasis or health preoccupations—the person believes that every ache and pain is some deadly disease and bug their doctors to death, or do doctor shopping, looking for someone who will take them seriously.I already mentioned that we see a great deal of commonalities in Tourette’s and OCD. We also treat trichotillomania, hair pulling disorder, and excoriation disorder, skin picking and the picking of acne or the picking of skin around the body, fingers, toes, legs, scabs, mosquito bites. That just made it into the DSM-5, by the way.

VY: I understand there were some other changes in the DSM-V in terms of classifying some of these related disorders?
CM: Tic-related disorders are pulled into the mix. There’s now an identification for a subtype where tics and OCD appear within the same individual. We’ve conceptualized something called “Tourettic OCD” that’s very similar, but we don’t believe that its necessary for tics to be present for it to be Tourettic. It’s more that certain kinds of OCD are really discomfort-driven, rather than anxiety-driven, and therefore it’s similar in many ways to the experience of Tourette’s.Even Asperger’s syndrome, or what the DSM-V now calls Autism spectrum disorders— very often people are referred to us who say they have Asperger’s or they have pervasive developmental disabilities, but they also have OCD. Well, they may or may not. They may fit a sort of OCD configuration, but they may not be exactly OCD. They may have stereotypies, or they may have hyper-interests, where they just love everything about Pokemon or something. But it’s not OCD. These are more repetitively driven things. They’re not driven to do stuff because they feel very uncomfortable and frightened unless they do them. They do things because they just love to do those things.

VY: That’s an important distinction.
CM: It is, because a lot of things we call compulsive—some people love to shop or love to gamble or love to act out sexually—that doesn’t mean they’re obsessive compulsive. They’re exhibiting repetitive patterns of behavior, but the treatment’s quite different. If you treat OCD and identify it as treating OCD, you’ll eventually learn how to distinguish them from each other, and when it’s best to refer them out, in the case of something like internet addiction. People call up all the time saying, “My son is obsessed with the Internet. He plays videogames all the time. I understand you treat OCD.”“Well, yeah, we treat OCD, but that’s not OCD.” The importance of expertise is to be able to distinguish the subtle differences among some of the repetitive patterns of behavior that are often clumped and misidentified as OCD.

VY: Well I want to thank you for taking the time to share your wisdom and experience with us. You’ve gone into a lot of depth and, as is typically the case, though I’ve been in this field for quite a while, there’s always more to learn. I think our readers will have a similarly enriching experience and will be intrigued and interested in getting further training and expertise in treating OCD.
CM: I hope so. And I thank you for inviting me to participate here.