I was asked by a fellow blogger to write about Buddhist views on the self. Since my interest in Buddhist teachings originated in my desire to integrate these ideas into my psychotherapy practice, I decided to compare and constrast how the self is conceptualized in Western psychology and in the Buddhist tradition. This is a rather big undertaking, and one that I will not attempt to complete in one blog post. "Self and No Self: Psychology and Buddhism" will therefore be my first "series" of posts on a single subject.
Over the past twenty years, Western psychology has become increasingly interested in ancient Eastern practices and traditions. Among the first to advocate the usefulness of Eastern precepts to Western mental health practice was Dr. Marsha Linehan, the well known pioneer of Dialectical Behavior Therapy (DBT). DBT is built around the Buddhist practice of mindfulness. Since the original publication of Linehan's DBT treatment manuals in 1993, mindfulness and other Eastern ideas and practices have gained widespread use among Western mental health practitioners.
Since the days when Freud fathered psychoanlysis -- the first form of modern psychotherapy -- the self has been among the primary foci of psychotherapy practice. As the number of psychological theories have grown, so have the ways in which the self is conceptualized. Almost every psychological theory has its own unique conception of the self. Thus, it is impossible to make any overarching statement to summarize how the self is perceived in the field of psychology. What can be said is that virtually every school of psychology has some conception of the self that influences its ideas about the causes and treatment of mental illness.
This seems to be completely at odds with Buddhist teachings. Fundamental to the Buddhist worldview is the concept of anatman (roughly translated as "no soul," "no self," or "egolessness"), which asserts that there is no such thing as an immortal soul or core self. The Buddha taught that nothing exists that is permanent. Things come into being and things disintegrate. Humans, like everything else in existence, are made of impermanent substances. Human beings have no separate soul or self that exists apart from our material bodies.
Buddhism asserts that the self, which is of central importance to the field of psychology, does not exist. Just as the concept of self is integral to the understanding and practice of psychology the idea of "no self" is fundamental to the understanding and practice of Buddhism. How is it, then, that psychology has embraced Buddhist teachings when the two fields are built around opposing fundamental tenets?
Despite differences in their basic beliefs, Buddhism and Western psychology share a common goal: they both seek to alleviate suffering. Each field approaches this goal in a manner consistent with its own belief system. The Buddha taught that "the self" is an illusion and that this illusion is the source of all suffering. Consequently, Buddhism asserts that the way to relieve suffering is by seeing through the illusion of self, thereby bringing the self to an end. In contrast, Western psychology tends to view the absence of a stable, integrated sense of self as among the most significant causes of suffering. Thus, many psychotherapists believe that building or restoring a strong sense of self is an important part of the treatment process (the primary goal of which is to alleviate suffering). In short, Buddhist practice aims to alleviate suffering through losing the self; psychotherapy seeks to alleviate suffering by helping to build, rebuild, find, strengthen, or define the self.
These are the ideas I will be exploring over the next few weeks. Next week, I will explore in more detail Buddhist views of the self (or no self). The following week, I will try to provide an overview of the major theories about the self in Western psychology. Finally, I will attempt to tie it all together by addressing questions like, "Are the ideas of Buddhist and Western psychotherapy practitioners about the self fundamentally at odds with one another?" "Is there any overlap betwen how Buddhists and Western psychotherapists think about the self?" and "What aspects of Buddhist practice have Western mental health practitioners embraced and what, if any, impact does this have on their ideas about the self?" This is an ambitious undertaking on my part so I ask that you please bear with me. I am also open to feedback throughout this process.
Thursday, April 26, 2012
Saturday, April 21, 2012
Dream killers
Most of us have had the experience of excitedly sharing a dream with someone only to receive negative feedback about why it won't work. If we're honest, most of us have also had the experience of hearing someone else's dream and immediately putting it down, almost without thinking. How many of us have been encouraged to follow our dreams wherever they lead us? And how many dreams have we decided to abandon because the people we love tell us it's a bad idea?
It always seems to be the people closest to us who put the most effort into killing our dreams. This is almost counterintuitive; shouldn't the people who love us the most be our most ardent supporters? And shouldn't we be among the loudest voices of encouragement cheering on the people we love? Why do we have such a hard time doing something that seems like it should be natural?
I won't pretend to know the answer to this, but I do have some ideas:
1. Selfishness: We discourage someone else's dreams because it interferes with our own interests. For example, it is not uncommon for a parent to have dreams for her child before he is even born. Parents have their own ideas about what their child should do with his life; these ideas are completely independent of what the child wants for himself. Parents often have beliefs about what constitutes success for their child, how their child should behave, where he should live, and what hobbies he should pursue. If the child has dreams that are inconsistent with what his parents want for him, the parents might discourage the child from pursuing these aspirations. Another example of deterring someone else's dream for selfish reasons might be discouraging a coworker from trying for a promotion because you want the promotion for yourself.
2. Jealousy: A friend shares her dream with us. It sounds great. In fact, it is something we want for ourselves. We doubt, however, that we could ever achieve this dream. We can't stand the thought of our friend achieving something we really want for ourselves but could never have; we'd be overcome with envy! Nobody likes to feel jealous (or inferior), so we disparage our friend's dream and discourage her from chasing it.
3. Guilt: The goal someone else is pursuing is one we should be pursuing ourselves. Unfortunately, we lack the motivation, self discipline, or whatever else we need to start working on the goal. We feel guilty about our own inaction when we see someone else working hard and actually making progress towards this goal. If, however, we can distract or deter this person from the pursuit of his goal we won't feel quite so bad. "No, I haven't lost any weight yet, but neither has Tom."
4. Genuine concern for the other person: Your loved one is chasing a dream that is going nowhere (or nowhere good). His goal is completely unrealistic, very dangerous, self destructive, or an otherwise bad idea. In short, your loved one is headed down the wrong path and you're concerned for his well being. You don't want to see him hurt, whether physically, financially, spiritually, or emotionally. You feel obligated to share your concerns with him, at the very least. Some of us feel obligated to do more. We might try to dissuade him from pursuing his chosen course or even to create obstacles to try to deter him. There is certainly nothing wrong with urging a loved one to use caution. The key in this situation is to know when to stop. Providing that the person in question is an adult, in the end he is free to make his own decisions -- even if they are bad decisions. There comes a point when you've said all you can say and have done all you can do. When you reach this point, your job is to accept the decision your loved one has made (regardless of whether or not you approve). Sometimes people have to learn from their own mistakes.
5. Reality testing: Let's face it. Some people have dreams that are so far fetched they could never become reality. Perhaps such dreams would be more accurately described as fantasies. Personally, I would feel bad encouraging someone to chase a dream he has absolutely no chance of ever achieving. It is important, however, to distinguish between having fantastical goals that have no basis in reality and having "big dreams" that, while it might be a long shot, could possibly be attained. Some people dream big and are willing to work hard to try to make their dream a reality. Most of us are inclined to give such people a "reality check." We are quick to point out that the odds are stacked against them. We encourage them to focus on "more realistic" goals. But where would the world be without big dreamers? People beat the odds all the time, with amazing results. Don't discourage someone you love from "dreaming big." You might, however, want to encourage them to have a back up plan, just in case it doesn't work out.
6. Pessimism: Pessimism is the tendency to expect the worst. It is characterized by a lack of hope or confidence in the future. Some people are pessimistic by nature; others have had bad experiences and have learned to view life negatively as a result. A pessimist is a pessimist, either way. If a person is a pessimist, it won't be a secret to the people who know him. Pessimism is not really something you can hide; it's an attitude that will reveal itself in almost everything you say and do. If you want someone to encourage and support you as your pursue your dreams, a pessimist is not your guy. Share your dreams with a pessimist and you can expect that he'll tell you all the reasons it will never work; negativity is a pessimist's default response to everything.
As with so many things, I think the important thing is to become more aware of how you respond when someone shares their hopes and dreams with you. Pay attention to your responses over time; are they unique to each situation or are they habitually the same?
It is also important to be selective in choosing the people you talk to about your hopes and dreams. When you know a person well enough you can often predict how they will respond when you reveal your deepest desires. If the person is always negative, you can assume he will have negative feedback about your goals. If the person is typically supportive, she will probably be supportive. If she isn't, you should listen to her concerns and take them into consideration.
For readers: Do you tend to be supportive when someone shares his dreams with you? Have you ever shared your aspirations with someone and not gotten the response you expected? Is there anyone you would absolutely never share your hopes and dreams with? Why?
It always seems to be the people closest to us who put the most effort into killing our dreams. This is almost counterintuitive; shouldn't the people who love us the most be our most ardent supporters? And shouldn't we be among the loudest voices of encouragement cheering on the people we love? Why do we have such a hard time doing something that seems like it should be natural?
I won't pretend to know the answer to this, but I do have some ideas:
1. Selfishness: We discourage someone else's dreams because it interferes with our own interests. For example, it is not uncommon for a parent to have dreams for her child before he is even born. Parents have their own ideas about what their child should do with his life; these ideas are completely independent of what the child wants for himself. Parents often have beliefs about what constitutes success for their child, how their child should behave, where he should live, and what hobbies he should pursue. If the child has dreams that are inconsistent with what his parents want for him, the parents might discourage the child from pursuing these aspirations. Another example of deterring someone else's dream for selfish reasons might be discouraging a coworker from trying for a promotion because you want the promotion for yourself.
2. Jealousy: A friend shares her dream with us. It sounds great. In fact, it is something we want for ourselves. We doubt, however, that we could ever achieve this dream. We can't stand the thought of our friend achieving something we really want for ourselves but could never have; we'd be overcome with envy! Nobody likes to feel jealous (or inferior), so we disparage our friend's dream and discourage her from chasing it.
3. Guilt: The goal someone else is pursuing is one we should be pursuing ourselves. Unfortunately, we lack the motivation, self discipline, or whatever else we need to start working on the goal. We feel guilty about our own inaction when we see someone else working hard and actually making progress towards this goal. If, however, we can distract or deter this person from the pursuit of his goal we won't feel quite so bad. "No, I haven't lost any weight yet, but neither has Tom."
4. Genuine concern for the other person: Your loved one is chasing a dream that is going nowhere (or nowhere good). His goal is completely unrealistic, very dangerous, self destructive, or an otherwise bad idea. In short, your loved one is headed down the wrong path and you're concerned for his well being. You don't want to see him hurt, whether physically, financially, spiritually, or emotionally. You feel obligated to share your concerns with him, at the very least. Some of us feel obligated to do more. We might try to dissuade him from pursuing his chosen course or even to create obstacles to try to deter him. There is certainly nothing wrong with urging a loved one to use caution. The key in this situation is to know when to stop. Providing that the person in question is an adult, in the end he is free to make his own decisions -- even if they are bad decisions. There comes a point when you've said all you can say and have done all you can do. When you reach this point, your job is to accept the decision your loved one has made (regardless of whether or not you approve). Sometimes people have to learn from their own mistakes.
5. Reality testing: Let's face it. Some people have dreams that are so far fetched they could never become reality. Perhaps such dreams would be more accurately described as fantasies. Personally, I would feel bad encouraging someone to chase a dream he has absolutely no chance of ever achieving. It is important, however, to distinguish between having fantastical goals that have no basis in reality and having "big dreams" that, while it might be a long shot, could possibly be attained. Some people dream big and are willing to work hard to try to make their dream a reality. Most of us are inclined to give such people a "reality check." We are quick to point out that the odds are stacked against them. We encourage them to focus on "more realistic" goals. But where would the world be without big dreamers? People beat the odds all the time, with amazing results. Don't discourage someone you love from "dreaming big." You might, however, want to encourage them to have a back up plan, just in case it doesn't work out.
6. Pessimism: Pessimism is the tendency to expect the worst. It is characterized by a lack of hope or confidence in the future. Some people are pessimistic by nature; others have had bad experiences and have learned to view life negatively as a result. A pessimist is a pessimist, either way. If a person is a pessimist, it won't be a secret to the people who know him. Pessimism is not really something you can hide; it's an attitude that will reveal itself in almost everything you say and do. If you want someone to encourage and support you as your pursue your dreams, a pessimist is not your guy. Share your dreams with a pessimist and you can expect that he'll tell you all the reasons it will never work; negativity is a pessimist's default response to everything.
As with so many things, I think the important thing is to become more aware of how you respond when someone shares their hopes and dreams with you. Pay attention to your responses over time; are they unique to each situation or are they habitually the same?
It is also important to be selective in choosing the people you talk to about your hopes and dreams. When you know a person well enough you can often predict how they will respond when you reveal your deepest desires. If the person is always negative, you can assume he will have negative feedback about your goals. If the person is typically supportive, she will probably be supportive. If she isn't, you should listen to her concerns and take them into consideration.
For readers: Do you tend to be supportive when someone shares his dreams with you? Have you ever shared your aspirations with someone and not gotten the response you expected? Is there anyone you would absolutely never share your hopes and dreams with? Why?
Saturday, April 14, 2012
Supporting others' dreams
My little sister wants to move somewhere far away. She works in the advertising and design field; she says that there are no good career opportunities for her here. She wants to go somewhere like New York, Miami, or Los Angeles, where, from what she tells me, the job prospects are plentiful.
She's talked about this for years, so it's nothing new. She was a bit of a late bloomer though -- she started and stopped going to school several times before she finally earned her degree about a year ago. When she was still in and out of school and jumping from one job to the next, the whole moving away and making it big seemed to me like one of those fantasies we all have when we're young, before reality sets in.
Once my sister finished her degree, she did what we all do -- she found a job and started working. The job wasn't perfect, but she was gaining a lot of experience and seemed to be enjoying it.
A few weeks ago, my sister and I were sitting in my living room, just talking and catching up. We started talking about our goals for the future. She told me that her dream is what it has always been -- to move to a big city to get a good job with a prestigious agency making a lot of money.
I'll admit I was less than supportive. I guess I assumed she'd outgrown her dream. After all, I remember having a similar dream of moving to New York and becoming a famous singer. (This despite the fact that I don't sing very well). At some point I realized that it wasn't a realistic plan and decided on something more practical.
I pointed out to my sister all the difficulties associated with moving to a new place -- saving enough money to pay for the move itself; securing a decent job in a distant city before moving there; finding an affordable place to live; making all new friends; etc.
"See, this is why I don't talk to anyone in the family about my dreams," she said. "You always put them down."
"No we don't," I replied without thinking. But then I thought about it. She had a point. Why was I discouraging her from following her dreams? Why was I trying to convince her that her goals were unattainable?
As it turns out, she had her own hypothesis. "You all want me to be like you. You want me to buy a house next door, get married, and raise a family without ever leaving home."
(Just an aside -- this is a more accurate characterization of my older sister than it is of me. I did in fact, leave home; I just didn't go very far away. I went to college in a city about an hour and half away from where I grew up. I moved back in with my parents for about a year after I graduated. When I moved out, I bough a house in a neighboring city, about forty-five minutes away from my parents' house).
"That's not true!" I protested. "It's just that we'd miss you if you move away," I acknowledged.
"Some families only see each other once a year," my sister countered. "Not that I want it to be like that," she quickly added. "I'm just saying."
I know, of course, that there are families that only see each other on special occasions. Some families are like that; just not our family.
I could be wrong, but it seems to me like most families that only get together once a year do so because they find it difficult to be around one another more frequently. Close knit families tend to see each other more often, even when its members live in different places. (Hell, I see my best friend two or three times a year, and there's a seven hour drive separating us)!
Ultimately, I told my sister that she has to do what's best for herself. Our family is mostly made up of adults; as such, we are responsible for dealing with whatever feelings we have about what she chooses to do.
I thought about it a lot over the weeks that followed our conversation. Shouldn't I encourage my little sister to reach for the stars? Why is it so difficult for me?
Most of it is that I will truly miss her. Somehow, I get the feeling that if she moves away she won't come back very often. (Part of me suspects that she's running away from something that she thinks is here but is really inside her). I fear that the little sister I love so much will become a stranger to me, someone who no longer has a place for me in her life. I'm afraid of losing her.
The other thing is that even though she's lived less than an hour from the family for the past year, she has been distant. She told me she felt like she had to get away from the family if she was ever going to learn to make it one her own. ("Making it on your own" is overrated, I think).
Since becoming an adult, I've always found comfort in my family's unwavering love and support. It makes me sad to think that my sister finds this same love to be stifling and restrictive.
Still, our experiences are different. She is the youngest of my parents' three daughters; I think even now my mother finds it hard to stop babying her.
It's probably selfish of me to begrudge my sister her dreams. Maybe the best thing to do is to share my fears with her. I'm not sure.
She's talked about this for years, so it's nothing new. She was a bit of a late bloomer though -- she started and stopped going to school several times before she finally earned her degree about a year ago. When she was still in and out of school and jumping from one job to the next, the whole moving away and making it big seemed to me like one of those fantasies we all have when we're young, before reality sets in.
Once my sister finished her degree, she did what we all do -- she found a job and started working. The job wasn't perfect, but she was gaining a lot of experience and seemed to be enjoying it.
A few weeks ago, my sister and I were sitting in my living room, just talking and catching up. We started talking about our goals for the future. She told me that her dream is what it has always been -- to move to a big city to get a good job with a prestigious agency making a lot of money.
I'll admit I was less than supportive. I guess I assumed she'd outgrown her dream. After all, I remember having a similar dream of moving to New York and becoming a famous singer. (This despite the fact that I don't sing very well). At some point I realized that it wasn't a realistic plan and decided on something more practical.
I pointed out to my sister all the difficulties associated with moving to a new place -- saving enough money to pay for the move itself; securing a decent job in a distant city before moving there; finding an affordable place to live; making all new friends; etc.
"See, this is why I don't talk to anyone in the family about my dreams," she said. "You always put them down."
"No we don't," I replied without thinking. But then I thought about it. She had a point. Why was I discouraging her from following her dreams? Why was I trying to convince her that her goals were unattainable?
As it turns out, she had her own hypothesis. "You all want me to be like you. You want me to buy a house next door, get married, and raise a family without ever leaving home."
(Just an aside -- this is a more accurate characterization of my older sister than it is of me. I did in fact, leave home; I just didn't go very far away. I went to college in a city about an hour and half away from where I grew up. I moved back in with my parents for about a year after I graduated. When I moved out, I bough a house in a neighboring city, about forty-five minutes away from my parents' house).
"That's not true!" I protested. "It's just that we'd miss you if you move away," I acknowledged.
"Some families only see each other once a year," my sister countered. "Not that I want it to be like that," she quickly added. "I'm just saying."
I know, of course, that there are families that only see each other on special occasions. Some families are like that; just not our family.
I could be wrong, but it seems to me like most families that only get together once a year do so because they find it difficult to be around one another more frequently. Close knit families tend to see each other more often, even when its members live in different places. (Hell, I see my best friend two or three times a year, and there's a seven hour drive separating us)!
Ultimately, I told my sister that she has to do what's best for herself. Our family is mostly made up of adults; as such, we are responsible for dealing with whatever feelings we have about what she chooses to do.
I thought about it a lot over the weeks that followed our conversation. Shouldn't I encourage my little sister to reach for the stars? Why is it so difficult for me?
Most of it is that I will truly miss her. Somehow, I get the feeling that if she moves away she won't come back very often. (Part of me suspects that she's running away from something that she thinks is here but is really inside her). I fear that the little sister I love so much will become a stranger to me, someone who no longer has a place for me in her life. I'm afraid of losing her.
The other thing is that even though she's lived less than an hour from the family for the past year, she has been distant. She told me she felt like she had to get away from the family if she was ever going to learn to make it one her own. ("Making it on your own" is overrated, I think).
Since becoming an adult, I've always found comfort in my family's unwavering love and support. It makes me sad to think that my sister finds this same love to be stifling and restrictive.
Still, our experiences are different. She is the youngest of my parents' three daughters; I think even now my mother finds it hard to stop babying her.
It's probably selfish of me to begrudge my sister her dreams. Maybe the best thing to do is to share my fears with her. I'm not sure.
Saturday, April 7, 2012
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?
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?
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