Anxiety and ego strength

In my last post, I talked about what happens when a person reaches his or her "breaking point."  I have a particular interest in this topic because I think about it a lot when working with patients.  It is important for me to have at least some idea of how much anxiety a patient can tolerate; this is especially true with those patients who have experienced some sort of trauma. 

Even a single traumatic experience can leave a person feeling vulnerable and out of control.  It can shatter a person's sense of safety and cause him to view the world as a dangerous place.  This creates a significant amount of anxiety.  (In fact, Posttraumatic Stress Disorder is classified as an anxiety disorder).  The person becomes hypervigilant in an effort to identify and neutralize potential threats (which he believes are everywhere).  Maintaining this level of emotional arousal is exhausting.  His need to be ever alert and on guard, however, prevents him from relaxing to the degree necessary for truly restful sleep.  As a result, he becomes even more exhausted.  His functioning begins to deteriorate.  What little energy he has is directed towards trying to keep himself safe from threats, both real and imagined. 

This is often the state in which I first encounter a patient.  His symptoms have started to become overwhelming and he is doing everything he can to "keep it together."  Before I can even think about trying to help him I need to assess his "ego strength." 

According to Brown, et. al. (1979), ego strength refers to an individual's ability "to hold on to his own identity despite psychic pain, distress, [and] turmoil, [from] internal forces as well as the demands of reality."  In other words, how much distress can a person tolerate without falling apart?  In her "Nueroscience and Relationships" blog (http://blogs.psychcentral.com/relationships/), Dr. Athena Staik describes ego strength as "the resiliency or strength of your core sense of self, the extent to which you can face challenging events or persons, without feeling so overwhelmed that you take desperate action, perhaps with little or no thought to consequences." 

Exposure therapy (or prolonged exposure therapy) is one of the most effective treatment approaches for overcoming a traumatic experience.  The treatment requires a person to access his memories of the traumatic event and to allow himself to experience whatever feelings these memories evoke.  It also asks the patient to confront situations that now feel unsafe to him but that are, in reality, perfectly safe.

Exposure therapy can be pretty intense and would probably be overwhelming for someone with very low ego strength.  (There are plenty of other treatments that are beneficial for patients with low ego strength).  The problem is, it is not always easy to determine which patients have good ego strength and which do not.  I've had the unfortunate experience of believing a patient could handle exposure therapy only to have him decompensate a few sessions into it.  (This has happened on multiple occasions, actually, and not just to me.  Several of my coworkers have had simliar experiences). 

When I say a patient decompensates I mean that the therapy pushes him past his breaking point.  I've seen patients become suicidal.  One of my coworkers had a patient check herself into the psychiatric hospital because she couldn't guarantee she wouldn't try to kill herself.  Some patients start to have intrusive flashbacks or their nightmares get so bad that they become afraid to go to sleep.  A person who decompensates completely will become psychotic (and would probably have to be hospitalized), although this has never happened with any of my patients. 

So therein lies my dilemma.  How do I know when to "push" (i.e., encourage) a patient to stick with the treatment and when to back off?  Is it my job to say to a patient, "Look, I don't think you can handle this?"  And what if I'm wrong?  Then I'm depriving him of treatment that could really be helpful.  But what if I keep pushing and the patient decompensates?  Is it my fault?  Am I responsible for having pushed the patient "over the edge?"

There doesn't seem to be a clear cut answer to this.  My solution has been to put the ball in the patients' court.  I say something like this: "Only you know where your limit is.  My job is to push you to that limit, but not beyond it.  If you feel like you're close to going over the edge, please let me know.  We'll stop, regroup, and figure out where to go from there." 

Of course, the assumption here is that people know their own limits.  This may not always be true.  In fact, I cannot say for certain where my own breaking point lies.   I know there have been times when I felt so overwhelmed that I wished I would just fall apart completely; at least it would provide an escape from myself and my life.  In reallity though, I suspect I've never even come close to my breaking point.  I am fortunate enough never to have been faced with stressors so overwhelming that I was not able to cope with them.

What about you?  Where is your breaking point?  How do you know when you're too close for comfort?