Therapy

Compulsives make frustrating clients. Ironically, although they tend to work in earnest in therapy, many eventually fold under the collective weight of their own traits. For one thing, a corrective emotional experience is often part of successful therapy, but compulsives often find it difficult to connect emotionally with anything. Emotions are equated with being out of control, and that scares them. Some eventually complain that their time, money, and, ironically, their hard work have all been wasted.

Therapeutic Traps

At the beginning of therapy, most clients naturally defer to the therapist as an authority or expert. The therapist, after all, holds an advanced degree, has thousands of hours of clinical experience, and so on. As therapy proceeds, however, these expectations loosen somewhat as client and therapist develop a sense of mutual trust and get to know each other as genuine human beings. Clients may initially believe that therapists have all the answers, but they eventually learn that every person is different and, consequently, that psychotherapy is based on a body of principles that rest on probabilities, and there is no "direct line" to normal functioning. They also learn the importance of sharing and reflecting on their innermost feelings and experiences and of using these to help identify dysfunctional patterns in their relationships.

Compulsive personalities, however, possess several characteristics that undermine this natural progression. First, most compulsives are cooperative, friendly, and conscientious as a result of their developmental history and the dynamics of the therapeutic situation. Thus, Donald seems invested in being the perfect patient and provides exhaustive answers to the intake questions. Motivating this fa├žade, however, are punitive introjects. Donald would not dare give an incomplete answer; the therapist, representing authority, may be seen as an extension of Donald's own harsh superego. Consequently, there is the risk that any therapeutic interpretation could be transformed into something judgmental and condemning.

Therapists who are naturally more directive or confrontational, then, may inadvertently recapture compulsives' early developmental experiences, thus reinforcing their tendency toward self-criticism, suppressed defiance, and unvoiced irritation. In the worst-case scenario, a vicious dynamic develops: The therapist feels mystified and frustrated with the compulsive, who repeatedly intellectualizes and rigidly refuses to open up; in turn, the compulsive feels rebuked and shamed, withdraws even further, and fights the therapist behind a barricade of logic and rationality.

Second, even when the therapist is consistently warm and accepting, the desire to pull emotion from compulsives must be controlled and their exposure to affect paced. Unstructured therapies can evoke anxiety in the compulsive, who feels most comfortable only when conforming with some known structure. Therapists who like to move things along, especially with insight-oriented approaches, may find themselves frustrated by the compulsive's need to consider things factually, to deliberate over the possibilities, and to squelch emotional conflict to the point that insight becomes impossible. Constancy is a form of defensive armor, purposely constructed to resist emotional experience, even the corrective emotional experience of therapy. Change means vulnerability, and affect means vulnerability, instability, and insecurity. Compulsives typically not only minimize emotions but also do not know what emotions to feel. Therapy thus becomes an ambiguous situation in which they feel paralyzed by indecision and terrified by novelty.

Therapeutic Techniques and Strategies

Working from an interpersonal perspective, Benjamin (1996) emphasizes that therapy with the compulsive personality may degenerate into a struggle for power. Sometimes, compulsives want control; sometimes, they want others to take control. However, compulsives can be engaged through their rationality. Benjamin advocates her SASB model, but compulsives should be interested in any therapeutic plan explained to them in a point-by-point, logical manner. Compulsives are also likely to agree that exploration of early developmental influences is necessary to the understanding of current problems. The notion that each person is the product of experience connects the past and present in a way that should appeal to them. By casting therapy as a process not unlike scientific research, their rational mode can be engaged, while the therapist helps them gain perspective on and establish empathy for that young, malleable child who was subjected to such cold and demanding parental control. Such compassion frees them from a constant, overbearing need to secure approval from internalized, condemning parental images and opens the way to warmth in current relationships. Identification with critical parents and the internalization of their relentless faultfinding can then be seen as an adaptation to a pathological family situation that is now no longer necessary and is maladaptive in the present. Excessive self-criticism, for example, is a major pathway to subtle feelings of depression.

Broader interpersonal interventions may also be helpful. As Benjamin (1996) also notes, couples therapy may be especially helpful because compulsives tend to marry other personality patterns whose dependency complements the compulsive's need to control, such as dependents and histrionics. Sexual problems are frequent and often crystallize larger pathologies in the relationship. For example, compulsive females may feel such a strong need for constant self-control that orgasm becomes impossible. When their mate does not want to have sex, male compulsives may feel that sexual withholding is really a play for control. Finally, compulsives can be enlisted to help establish rules for negotiating trouble spots in the relationship, be it money, leisure time, or sex. Because compulsives understand rules, this technique serves as a paradoxical means of coercing them into relinquishing control while establishing precedents of egalitarianism with their spouse. Other interventions include having the compulsive parent begin to spend time playing with the children, who naturally pull for joy, affection, and spontaneity. Otherwise, compulsives may remain so engrossed and engulfed by work that they continue to neglect their families.

Techniques drawn from other domains of personality can be useful in amplifying the effectiveness of interpersonal interventions. Because compulsives are vulnerable to chronic tension and anxiety, behavioral techniques such as relaxation training may be used to help them cope in anxiety-provoking situations and can be effective in loosening them up at the beginning of a session, prior to other interventions. Cognitive interventions should follow the general plan of cognitive therapy using techniques aimed at modifying the compulsive's maladaptive beliefs as well as emotions. Listing goals and assigning value and ranking to these objectives will likely appeal to the compulsive's sense of structure. Easy goals can be solved first to give a sense of accomplishment, providing support for the idea that change is possible and motivating patients with experiences of success. Once rapport has been established, beliefs can be tested with an attitude of scientific discovery rather than confrontation, which only recaptures the developmental past. Thought stopping can be used between sessions to decrease the amount of time spent in ruminative worry.

Psychodynamic approaches can be used to interpret displaced and repressed elements that have manifested as overt symptoms. Object-relations approaches are particularly relevant. Although discussion of the transference relationship provides a starting point, many patients are so affect-denying that other techniques must be called into play. Dream interpretation and free association can be helpful in getting past intellectual guardedness and uncovering deep-seated fears, such as making a mistake or incurring the disapproval of authority figures. Subjects may be surprised at the blatant and emotionally revealing content of their dreams. Uncovered fears can then be discussed in the context of the therapeutic relationship and linked to compulsives' rigidity and their insistence on discipline, perfection, prudence, loyalty, and, especially, reaction formation. Unfortunately, many compulsives defend against such psychodynamic techniques, viewing them as an unscientific waste of time.

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