BECOMING ATTACHED TO ATTACHMENT THEORY 1

Having studied many books on theories, modalities, and techniques of psychotherapy, I have come to believe that they are born from the culmination of their author’s autobiographical experiences. Reflecting on my own personal penchants for certain theoretical orientations toward therapy, I found that my character and life experiences also shaped my beliefs and preferences for certain therapeutic models.

          I lived at a time when psychoanalysis was the rock of psychotherapy. However, even though I had only a vague awareness of the importance of Freud, I naturally found myself searching past relationships and early childhood experiences (while I was still a child) in an effort to understand who I was and why my family and I behaved in certain ways.

No doubt, cultural influences affected my beliefs on how to answer questions about relationships. However, I am not consciously aware of the depth to which a Freud-revering culture directly affected me. I do know, however, that as far back as I can remember, it always made sense that people “acted like” or “reacted to” their primary caregivers. The following years of my life have only served to strengthen my belief that understanding and helping others and myself depended on an understanding of early human patterns of behaviors and experiences. Therefore, in a sense, this post is also somewhat autobiographical.

Psychodynamic vs. Psychoanalytic Theory

Since my childhood and adolescence, the field of psychotherapy has rejected much of Freudian theory and has infused many other therapeutic approaches, all which have merit and contain helpful insight and information. I found truth in them all. Yet my earlier psychoanalytic penchant for approaching therapy keeps bubbling to the surface.

I believe the similarity of psychoanalysis with psychodynamics is why some aspects of psychodynamic therapy appeal to me more than other modes of therapy. To clarify, the governing principles of psychodynamic therapy have its roots in psychoanalysis. However, major differences exist between these two theories to the extent in which each theory attempts to enact and support change.

Psychodynamic theory has at its core the alleviation of symptoms and some character change: limited but significant. Psychoanalysis has as its goal “major and pervasive character change along a number of dimensions”. Yet psychodynamics has its roots in the same constructs that govern psychoanalysis. The guiding principles they share include:

1.     the impact of early relationships on adult functioning, the unconscious as a motivational force,

2.     the compulsion to repeat patterns,

3.     the avoidance of remembering that which is too painful to remember,

4.     And transference of clients onto therapists of the attachment style influenced by one of their primary caretakers.

          In an ideal world of treating clients, I prefer to have the time, resources, and suitable type of clients with which to practice psychodynamic therapy, believing it to be more appropriate for more clients than psychoanalysis. However, the state of psychotherapeutic practice today is usually far from this ideal.

Helping others in whatever way is most appropriate and effective must be the main goal of psychotherapy. Clients return to mental health is paramount, not the clinician’s private enjoyment in using certain theories over others. Even though at times I have adopted a whatever-it-takes approach to therapy, using eclecticism (for lack of a better technique) to weave a pathway into understanding clients’ issues, I have tried to create building-blocks and bridges to help them find a solid road out of the morass of pain, confusion, and self-sabotaging behaviors. These efforts are always accompanied by maintaining a psychoanalytic perspective in creating the hypothesis and treatment with clients.

(continued...)

SEE POSTS:  BECOMING ATTACHED TO ATTACHMENT THEORY 2 and 3

WHAT IS THE BEST RESOURCE FOR YOUR PSYCH MEDS? Part I

While I wrote these articles for the psychology and counseling student and clinicians, present and prospective clients can glean much useful and important information from them as well.

Do you know someone who is considering taking anti-depressant medication?  The information below is important to know.

 

ADDRESSING PHYSICIANS' PRESCRIPTIONS SSRIs

Buelow et al. (2000) state that 60% of prescriptions written for SSRIs are from medical doctors. Due to the stigmatization of going to psychiatrists, clients are more likely to go to their family doctors for depression medication. Therefore, therapists commonly treat clients whose SSRI prescriptions were “…obtained from family physicians and other doctors not extensively trained in psychiatry” potentially complicating the therapeutic process.

When confronted with clients’ questions regarding their doctors’ SSRI prescription, therapists need to consider many important aspects of protocol and communication to insure full and proper client treatment. Clinicians help clients more adequately by fully answering client questions and educating them about the side effects and contraindications of their medication. 

In an effort to secure effective relief for clients, therapists need to inform them about uses and indications of SSRIs as well as precautions they need to take. However, asking pertinent and specific questions surrounding their clients’ SSRI use is also imperative if therapists hope to make accurate conclusions and recommendations for their clients.

THERAPIST QUESTIONS

According to Rankin (2000), over-distribution of SSRIs is common. Therefore, therapists need to ask clients the right questions to help determine if using an SSRI is appropriate for them. Clinicians need to explore reasons for clients’ going to a regular doctor instead of a psychiatrist to better understand if possible issues of shame or embarrassment may be posing obstacles to treatment. 

Skillful questioning can also draw out information regarding client symptoms, attitudes, and beliefs surrounding their SSRI prescription. Therapists can then challenge any myths or misconceptions clients may have about medications or disorders helping to insure continued use and facilitating more effective therapeutic treatment.

To better establish the appropriateness of SSRI use, therapists also need to ask clients questions about their symptoms both before and after taking SSRIs. Prescribing SSRIs for depression symptoms without considering other psychological aspects of clients can be damaging. 

For example, Lithium is also commonly prescribed to mitigate the manic phases of bipolar clients. If clients with bipolar depression take SSRIs without mood stabilizing medication (e.g., antimanics, benzodiazepines, and anticonvulsants), they may be put at risk for suicide. In addition, medications for the depressive phases of bipolar depression are usually different from those prescribed for unipolar depression. 

Risk of suicide is also an important consideration because antidepressant medication helps some clients feel more capable of carrying out their suicide plans. Therefore, support during the initial phases of SSRI use is crucial.

Clients need to be aware of the possibilities of depression relapse when discontinuing SSRIs. Reinecke and Davison (2002) cite Angst (1990) and Kupfer (1994) in stating that the recurrence of depression is 70% after two episodes of depression and 90% after three episodes.

For some clients, therefore, encouragement for continued use of SSRIs is important for avoiding risky behavior and failure in therapy. In addition, if therapists ask questions to examine client cognitions, they can challenge thinking that may lead clients to poor drug compliance. Ultimately, however, “Physicians should aggressively pursue recognition and treatment of depression and suicidality but not put their entire faith in medication” (Sakinofsky, 2007, Abstract).

SSRIs are commonly prescribed for symptoms such as “…pain, headaches, fibromyalgia, premenstrual syndrome, peptic ulcer, and chronic fatigue syndrome” (Rankin, 2000, p. 77). If therapists ask questions about the indications for their clients’ prescriptions, they can better understand and address therapeutic needs and underlying client issues. Furthermore, because secondary depression is often caused by physical disease processes, examining the possibility of the link between pain, fatigue, fibromyalgia, depression, and other illnesses helps therapists determine the correct causes of clients’ depression.

Therapists who assume that SSRIs are being given only for depression may miss other diagnoses for which they are prescribed such as anxiety, eating, and sleep disorders, attention deficit hyperactivity disorder, and substance abuse. Clinicians also need to consider that some depression drugs work better for some disorders than others. Therefore, therapists need to ask the right questions to help them ascertain if the use of SSRIs drugs is appropriate for their clients.

When therapists ask questions they can also determine the level of understanding of their clients leading them to use appropriate language when conveying information about clients’ prescriptions. Rather than using technical terms such as “monoamines,” “inhibitors,” “pharmacokinetics,” and “antagonist,” clinicians should use lay terms to convey SSRI concepts to uneducated or lower functioning clients.

If clients’ functioning and education indicate, clinicians may decide to use more technical terms that explain the effect of serotonin re-absorption on neurotransmitters and possibly include diagrams of brain functioning to better facilitate client understanding.

If clients obtain their SSRI prescriptions from doctors because they were uncomfortable with the stigma of mental disorders, therapists may want to impress on clients the biological explanation of depression to help clients understand that depression is not a result of moral weakness, thereby reducing self-blame.

(Continued...)

SEE POSTS:  WHAT IS THE BEST RESOURCE FOR YOUR PSYCH MEDS?  Parts II and III

WHAT IS PASSIVE AGGRESSIVE PERSONALITY DISORDER?

PASSIVE/AGGRESSIVE PERSONALITY DISORDER

We throw around the term "passive/aggressive" (PA) these days quite frequently.  Probably everyone has acted in passive/aggressive ways at some time.  It almost seems in today’s insincere culture, trying to navigate double messages, PA is a useful, even a required tool.  Work and family environments are probably the most popular areas to showcase this behavior.  What is the saying?  It is easier to get forgiveness than permission?  There is a lot of PA in that statement!

 
 
Ever wonder, though, if you or someone you know or love has a serious issue with passive/aggressiveness?  Does PA behavior negatively affect your relationships?  Your work satisfaction?  Your life?
 

There is actually a set of PA behaviors that, when significantly disruptive, can be diagnosed as a disorder—as a personality disorder.


WARNING:  DO NOT ATTEMPT TO DIAGNOSE AND TREAT THIS DISORDER UNLESS YOU ARE A CLINICIAN AND NOT RELATED TO THE CLIENT!

 

 

 

DEFINITION OF PASSIVE/AGGRESSIVE PERSONALITY DISORDER

(PAPD) is a controversial personality disorder proposal, said to be marked by a pervasive pattern of negative attitudes and passive resistance in interpersonal or occupational situations.

The military in WWII first used the term when officers noted that some soldiers seemed to shirk duties by adopting passive-aggressive type behaviors.

If we turn to the diagnostic manual of psychiatric disorders, the DSM IV describes the PAPD essential feature as a pervasive pattern of negativistic attitudes and passive resistance to demands for adequate performance in social and occupational settings.  (The pattern must NOT occur exclusively during periods of major depression nor can it be accounted for by dysthymia.  However, PAPD clients are most likely to experience chronic dysthymia.)

INTERNATIONAL CLASSIFICATION OF DISEASES (ICD-10) CRITERIA:

To be diagnosed with PAPD client must have at least five of the following:

1.  Procrastination and delay in completing essential tasks—particularly those that others seek to have completed.

2.  Unjustified protests that other make unreasonable demands, sulkiness, irritability, or argumentativeness when asked to do something that the individual does not want to do.

3.  Unreasonable criticism or scorn for authority figures.

4.  Deliberately slow or poor work on unwanted tasks.

5.  Obstruction of the efforts of others even as these individuals fails to do their share of the work.

6.  Avoidance of obligations by claiming to have forgotten them.

 

SUBTYPES?

• those with anxiety or depression (about one third)
• those who are self-defeating and locked into punishing relationships
• those who are vindictive
• those who begrudgingly put their lives on hold to care for others, e.g. an ill parent

ONLY ADULTS CAN BE DIAGNOSED WITH PAPD.  Because the pattern is similar to that of Oppositional Defiant Disorder (ODD), this diagnosis should be considered for children.

WHY ISN’T IT LISTED IN THE DSM IV-TR?  (The latest “bible” on diagnosing mental disorders in America)

• It was listed in DSM-IIIR but moved to Appendix B in DSM-IV (Criteria Sets and Axes Provided for Further Study) because of controversy and need for further research

CURRENT CRITERIA FOR PAPD AS PROPOSED BY THE PERSONALITY DISORDERS WORK GROUP FOR THE DSM-IV:

• passive resistance to fulfilling social and occupational tasks through procrastination and inefficiency
• complaints of being misunderstood, unappreciated and victimized by others
• sullenness, irritability, and argumentativeness in response to expectations
• angry and pessimistic attitudes toward a variety of events
• unreasonable criticism and scorn toward those in authority
• envy and resentment toward those who are more fortunate
• self-definition as luckless in life and an inclination to whine and grumble about being jinxed
• alternating behavior between hostile assertion of personal autonomy and dependent contrition
  

COMMON SIGNS/SYMPTOMS:

• Ambiguity
• Avoiding responsibility by claiming forgetfulness
• Blaming others
• Chronic lateness and forgetfulness
• Complaining
• Does not express hostility or anger openly
• Erratic
• Fear of competition
• Fear of dependency
• Fear of intimacy – difficulty expressing warm feelings
• Fears authority
• Fosters chaos
• Intentional inefficiency
• Indecisive
• Making excuses and lying
• Obstructionism
• Preaching
• Procrastination
• Resentment
• Resists suggestions from others
• Sarcasm
• Sullenness
• Negativity/Constant Complaints.  Some professionals are considering calling PAPD “Negativistic Personality Disorder”.
• Unpredictable

People with PAPD appear to comply with wishes but the action is performed too late to be helpful, or done in a way that is useless, or otherwise sabotaged to express anger they cannot verbalize. (National Institute of Health, 2006)
 

WHAT IT ISN’T

• “Not all passive behavior is problematic or a sign of the disorder.”  Wikipedia (2006)

• Merely being passive-aggressive isn’t a disorder but a behavior—sometimes a perfectly rational behavior, which lets you dodge unpleasant chores while avoiding confrontation.  It’s only pathological if it’s a habitual, crippling response reflecting a pervasively pessimistic attitude.

• May result from society’s conditioning that direct confrontation can be dangerous.

• Insincerity accepted in cultural communication.

WHAT ARE THE CAUSES?:  They are unknown but probably a combination of genetic and environmental factors.

Probable Environmental Factors (This is especially valuable information for parenting!):

• Child has extreme feelings of rejection or inadequate nurturing by the mother figure that results in extreme anger (attachment issues).
• Child has fear of expressing anger toward the parent, setting up the PA behaviors.
• Person with PAPD has a need to play out anger toward parent through other relationships.
• Models the PA parent.
• Exhibits an opposite reaction to a violent parent.
• Was abused through punishing, dominating, judging, and/or shaming for aggressive behavior.
• Power struggles with parents:  PA behavior was used as a face-saving technique

WHAT IS THE UNDERLYING THOUGHT OF PEOPLE WITH PAPD?

I WILL FAIL IN ORDER TO PRESERVE MY AUTONOMY.  They purposely fail in a way that indirectly expresses anger and defeats others in order to preserve autonomy in the only way they can because aggression is not allowed (and they do not have assertiveness skills).
 

SOME DISTORTIONS OF THEIR PERCEPTION:

• Sees self as cooperative
• Sees people who are controlling as assertive
• Sees people who are judgmental as perceptive

 

 

SEE POST:  TREATMENT ISSUES FOR PASSIVE AGGRESSIVE PERSONALITY DISORDER

DISCUSSION ON THE LINK BETWEEN MENTAL ILLNESS AND CREATIVITY 4

          SALVADOR DALI

 

   

                                VIRGINIA WOOLF   SYLVIA PLATH 

 

THIS IS PART FOUR IN THE SERIES "IS THERE A LINK BETWEEN MENTAL ILLNESS AND CREATIVITY"

Discussion of the Link Between Mental Illness and Creativity

Although the motivations of subjects in the rumination study may be questionable, the sample size small, and the measure of creativity limited, most other aspects of the study appear to be solid and valid. The discrepancy of past studies on creativity and mental illness and the difficulty in defining those terms have been considered.

They, then, creatively implemented a study to show support for a new view on the mental illness/creativity causal link. A relatively recent study in 2005 provides a solid basis from which to formulate their hypothesis. It appears that the link of rumination may indeed be the key between creativity and mental illness. According to their findings, the 2005 study states, “…that self-rumination independently (a) increases the risk for depression and (b) spurs interest in and ability for creative behavior.”

Despite the contradictions and flaws in the many studies cited above, it seems overwhelmingly possible that the creativity/mental illness link exists when taking into account the numerous possible connections made by these studies.

How to be Effective with Highly Creative Clients

How can this information help counselors become more effective when treating highly creative clients? A goal for mental health professionals is to help clients find the most healthy way possible to live with mental illness and yet not sacrifice creativity. Creativity is generally considered valuable. Abraham Maslow (1971) and Carl Rogers (1970), two important and innovative founders of psychology theory, both support the notion that “…creativity is the epitome of mental health.” The flexibility inherent in the creative process is necessary to help people navigate our present world where things are constantly changing. Much of the research shows that creativity is beneficial and healthy. Creativity helps people to problem solve, and problem solving is essential in therapeutic treatment.

Not only counseling professionals, but also the public, need to understand better the causal links between mental disorders and creativity. Not every creative client is affected or responds in the same way.  For example, even though the manic swings in bipolar individuals can be both inspirational and debilitating, the disorder ultimately appears to cause more suffering than good.

Can the creative process be used to help soothe individuals with mental illness? Many of the abstractionist artists used their creativity to help their dysfunction, therefore, demonstrating that creative expression is healing to both clients and others. However, the self-reflective rumination involved in creating poetry may increase symptoms of mental illness in poets, especially female poets, according to Kaufman and Baer (2002). By understanding these differences counselors can apply more sensitivity and individuality in their individual treatment approach!

Is creativity a good thing or a bad thing? Should counselors encourage creativity in their clients? One researcher maintains “…the line between creativity and madness is a fine one, probably permeable.” To cross the line into the primitive self too often is dangerous, however—like bouncing between insanity and sanity. This bodes especially badly for abstractionists.

Perhaps one of the best methods of helping creative clients with their issues is to educate others. Debunk traditional beliefs:  (1) that suffering for art and an imbalance of emotions is inevitable in the creative process;  (2) that even though creative people are necessarily original and therefore, deviate from the norm, creative achievement and deviant behavior do not necessarily go hand-in-hand;  (3) that, contrary to the opinions of many mentally ill creative clients, diminishing the symptoms of mental illness will help, not hurt the creative process.

These creative clients need help with coping strategies in managing moods and improving self-care. It is important to apprise clients of the psychological risks associated with the creative process and ways they can avoid these risks. Be aware that the thought process of psychosis and bipolar illness are fundamentally different from the thought processes of highly creative people, and learn to distinguish between creative thinking and disturbed, psychotic thinking.

MORE TO COME...