OCD

August 20, 2016

Treating Insecurity and Anxiety: Eight Roads to a Solution

512px-Anxiety_cloudImagine you are considering therapy for the first time. Or perhaps your treatment isn’t working. You stand at a crossroads, like the hub of a wheel where eight spokes beckon for attention. How should you choose among them?

Not all are good and you may even realize that as you decide. Here is a guide to thinking about what to do (and what not to do) with the weighty package of insecurities velcroed to your life. Click the link for a comprehensive list of the signs of insecurity.

ALCOHOL AND DRUGS. The issue of substance dependency should not be ignored. Recall the old Chinese proverb, “First the man takes the drink, then the drink takes the man.” Alcohol’s comforting relief and buoyancy is commonly replaced by longer term emotional darkness. Marijuana (cannabis) might mellow the smoker out but leaves underlying insecurity and anxiety untouched when sober. If you are attempting psychotherapy, best to tell the counselor the extent of your substance use straight away. The deepest wounds are slippery things. Grasping them is harder (if not impossible) when alcohol or drugs add to the excess lubrication.

WILLPOWER AND SELF-ANALYSIS. The old saying tells us, “When the going gets tough, the tough get going.” Yes, some few people manage their own psychotherapeutic project. Indeed, Freud analyzed himself. What is required? Although I know of no research on this, I suspect one needs a strong capacity for self-reflection, high intelligence, some degree of emotional openness, the courage to look in the mirror, tenacity, and knowledge gained through reading about treatment. Willpower is necessary because the self-analyst must inevitably get out of his head and leap the wall of fear to master behaviors blocked by insecurity: good eye contact, self-assertion, saying no, asking for things, making uncomfortable phone calls, inviting someone on a date, public speaking, etc.

THE SEARCH FOR A STRONGMAN. Some rely on a mate to perform avoided tasks. The significant other becomes a caretaker or body-guard, an individual who is sought to do the jobs the hesitant one believes he cannot: return a product to a store, accompany him to events otherwise avoided, and so forth. This is no solution to anxiety or insecurity, but a human crutch to sidestep the need to change. Another danger: too often the protector becomes an overlord, pushing you around or worse; the mister turned monster you hoped he would protect you against.

PSYCHOTROPIC MEDICATION. Medications, like other drugs, carry possible side-effects. Antidepressants can impair sexual performance, anti-anxiety tablets often have addictive properties. While a good psychiatrist will carefully watch for these, pharmaceuticals do not create a sense of security and confidence beyond the time you use them. Moreover, to the extent that the psychotropics help you feel better, your motivation to tackle underlying reasons for your symptoms may be reduced. That said, sometimes susceptibility to anxiety and depression is inherited and biologically-based, making the booster of drugs a necessary and permanent mode of treatment.

Girl_suffering_from_anxiety

AVOIDANCE AND THE INTERNET. Anticipation of discomfort, humiliation, or failure translates to turning down invitations — limiting chances for growth, accomplishment, and joy. The troubled soul is assaulted by hatchet-bearing ideas that have become permanent, non-rent-paying residents in the head. The data set of the insecure is based on an unfortunate history. The job of recovery translates to writing over your old history by gradually taking on social challenges and accumulating successes reinforcing your effort.

Beware the false god of the internet! The more time you worship at its alter and “let your fingers do the walking” on the keyboard, the less you have for direct human contact (involving actual walking out of the apartment). For all its marvels, this deux ex machina can become a screen behind which to hide the human face, trading yours for a virtual one. Yes, social media can be a stepping stone to a life beyond the keypad. For many, however, it’s another form of concealment and self-distraction. You can identify too fervent online social network disciples by the pain they will suffer for their god: a malady called text neck, the product of bending over their smartphone.

PSYCHODYNAMIC PSYCHOTHERAPY. Psychodynamic treatment, the traditional talking cure, can be a foundational part of counseling. It helps one clear the life-history undergrowth undermining a healthy self-image, planting  seeds of sturdiness to deflect the inevitable defeats we all encounter. Such counseling also lifts the weight of self-blame by recognizing the fingerprints of others on one’s problematic background story. It cannot stop there, of course. Grief and grieving demand attention.

Beyond relieving submerged pain, one must eventually take psychoanalytic insight for a test-drive: try new behaviors just as one would a new car before purchase. However much a “depth psychology” approach is needed, empirically based (research supported) interventions provide the practical impetus for emotional availability, symptom reduction, and behavioral change.

COGNITIVE-BEHAVIORAL THERAPY (CBT). Many of the well-researched and effective treatments just referred to fall into the category of CBT. Obsessive-Compulsive Disorder (OCD), for example, is among those problems amenable to this set of tools. Indeed, attempting a solution for OCD psychodynamically is, in contrast, a therapeutic cul-de-sac. CBT can often, however, be combined with more traditional talking therapy to join the best of both worlds.

ACT (ACCEPTANCE AND COMMITMENT THERAPY). ACT is described in the following way on its website: “Developed within a coherent theoretical and philosophical framework, Acceptance and Commitment Therapy (ACT) is a unique empirically based psychological intervention that uses acceptance and mindfulness strategies, together with commitment and behavior change strategies, to increase psychological flexibility. Psychological flexibility means contacting the present moment fully as a conscious human being, and based on what the situation affords, changing or persisting in behavior in the service of chosen values.”

Plowing through this technical language, ACT deals with the losses most patients have sustained, traveling from a grieving process toward acceptance of those life circumstances that can’t be changed, reduced avoidance, learning to live in the moment via meditation, deciding what is most important to you, and choosing behavior consistent with your stated values.

WE ALL TAKE TURNS at life’s crossroads. Sometimes the best advice is to make no movement, patiently waiting for the traffic to clear. Do remember, however, not choosing is also a choice. The clock is always ticking, even if, in the digital age, we must strain to hear it.

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The top image by John Hain is called Anxiety Cloud sourced from Wikipedia Commons. The photo beneath it is Girl Suffering from Anxiety by Bablekahn at Kurdish Wikipedia.

May 1, 2016

Can You Always Trust Your Therapist?

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Any seasoned therapist knows a fair number of other counselors, some casually, some quite well. We refer patients to a few of these people and steer clear of making referrals to others. The reason for the latter is pretty simple: doubts about their skills. That raises a second question: should their patients have the same uncertainties?

Going to the doctor in the days before there were lots of different types of medical professionals was a no-brainer. The doc was the expert. The medical model required the patient to submit to the physician’s ministrations. You were passive, he was active, and everything was supposed to work without much thought on your part.

No more.

To begin, there are many different types of counselors: clinical psychologists, psychiatrists (some of whom only prescribe medication), psychiatric social workers, marital and family therapists, licensed clinical professional counselors, and other titles. The first two are doctoral level practitioners, the rest most often hold masters degrees. The type and extent of training varies.

Then there are an enormous number of therapeutic approaches. Here, for example, you will find descriptions of 30 different kinds and this list does not include all the specialities within each type: http://www.counselling-directory.org.uk/counselling.html

The plethora of therapy modes creates a dilemma for the patient. At bottom, the issue is trust:

  • Is the doc expert at the precise model of treatment best suited to my condition?
  • Is the type of therapy he might recommend for me empirically validated? Empirical validation refers to a large body of well-controlled research demonstrating that therapy approach X for diagnosis Y produces better results than either no treatment or a placebo.

If you multiply the number of diagnoses by the number of approaches to treatment, you come up with a number so large as to confuse many patients. Indeed, we can say with certainty that there is no therapist who is expert in each approach for every type of diagnosis. Mental health professionals must therefore narrow their focus to a limited number of diagnoses and a small selection of approaches to those diagnoses.

Most practitioners possess training and experience in one or more forms of healing Depressive and Anxiety Disorders. They may not be prepared, however, to take on all subtypes under these headings. Thus, for example, a person who accepts patients with Anxiety Disorders might not be prepared to work with all 10 of the coded diagnoses listed below the broad descriptor “Anxiety Disorders:”

ANXIETY DISORDERS:

  • 309.21 Separation Anxiety Disorder
  • 312.23 Selective Mutism
  • 300.29 Specific Phobia
  • 300.23 Social Anxiety Disorder
  • 300.01 Panic Disorder
  • 300.22 Agoraphobia
  • 300.02 Generalized Anxiety Disorder
  • 293.84 Anxiety Disorder Due to Another Medical Condition
  • 300.09 Other Specified Anxiety Disorder
  • 300.00 Unspecified Anxiety Disorder

Why an Empirically Validated Treatment is Important? An Example:

Given all the issues mentioned, consulting a therapist who can diagnose and recommend the treatment most likely to help is crucial.

Here is an example of how this might best work in practice. The recommended and empirically validated treatments for Obsessive Compulsive Disorder (OCD) include Exposure and Response Prevention (ERP) or medication, with a 70% effectiveness rate overall. Our hypothetical patient is hamstrung whenever leaving his home, his office, his car, etc. He checks over and over whether he has locked everything for fear of an irrational catastrophe. This causes him to waste an hour or more a day. Our friend is late for appointments, work, and social events, angering many people and placing his job and family relationships in jeopardy.

If one were to treat this gentleman with ERP, the therapist and patient would together rank those situations that are the least anxiety provoking to the ones most upsetting. The client would then be exposed to a fear-inducing event at the low end of the list, having agreed not to engage in his usual compulsive checking despite his turmoil. The patient’s fight against the urge to check is the portion of treatment called response prevention. The expected outcome is a diminution in his fear and checking as he repeats these exposures without confirming the security of the lock. The patient gradually faces the more unsettling items on the hierarchy until the troubling behavior is eliminated.

Traditional talk therapy, designed to uncover the underlying “reasons” for such compulsivity, is ineffective in treating OCD. At this point in the history of this condition, if a therapist chooses to provide a treatment not meeting the standard for “best practices,” he risks not only his patient’s well-being, a waste of his money, and a squandering of his time, but a malpractice suit.

What Increases the Risk of a Therapist Not Choosing an Empirically Validated Treatment (Assuming It Exists)?

At least three possible reasons:

  • He is unaware of the research pointing to the recommended approach.
  • He doesn’t “believe” in the validated mode of therapy.
  • He doesn’t possess the training to deliver it properly.

As noted above, therapists are not schooled in every method of doing their job. They perform in a competitive field, especially in large urban areas, and are under downward pressure from insurance companies regarding their fees. There is the possibility of unconscious self-persuasion of the knowledge and skill to treat a wider range of conditions than close scrutiny would justify, thus enlarging the potential pool of patients who might consult them. All health practitioners are required to spend more time documenting their work than previous generations of peers. Therapy clients also often desire evening or weekend appointments, creating an incentive for the doc to be available for sessions during “leisure” hours. Any of these factors can unintentionally limit the time needed to keep up with the latest research and receive the necessary training.

Depending on the practitioner’s location and discipline, there are requirements for continuing education. Licensed psychologists in Illinois must take at least 24 hours of continuing education every two years to maintain their practice. At least three hours cover professional ethics. No other directives point him toward a particular area of knowledge. In other words, these requirements are not guaranteed to remedy any shortfall in competence to treat OCD or any other particular disorder.

What You Can Do:

Where does this leave you, the present or future patient?

Counselors almost all mean well, but we all should recognize “the road to hell is paved with good intentions.” It is in your power to do the following:

  • As early as possible, understand what the initials after your therapist’s name mean, e.g. M.D., Ph.D., L.C.S.W., etc. This is not meant to disparage any particular group, all of whom include excellent practitioners. Rather, knowing this gives you the most basic information about the counselor’s background.
  • Learn about the kind of training he received subsequent to his degree and what he specializes in, both in terms of diagnosis and approach to treatment.
  • Ask him why he is suggesting a particular approach and find out what other approaches exist, and, especially whether they have been empirically validated. It should be noted empirically validated therapies do not exist for every diagnosis.
  • Be sure to confirm, as much as possible, whatever you are told by doing your own research.

Once again, I’m not assuming any wrong doing by your counselor. However, remember, you are dealing with another human being, no matter how kind or intelligent.

As an old Russian proverb tell us, “trust but verify.”