As the season of giving came to a close this year I started to think a way in which I have not been giving to my patients over the years as much as much as I would have liked. To wit, all these years I have been formulating a theory of my patient's psychological functioning using sophisticated tools but have not shared these very same tools with my patients. Long ago one of my teachers told me that the counseling process is socratic, in effect, it is a process in which we teach our patients to become their own therapists. An important part of this endeavor is for them to be able to assess their functioning in a manner similar to the way we therapists do.
When the time is right, I share with my patients a mnemonic. E.I.E.I.O from ‘Old McDonald’s Farm.’ The unique letters stand for ‘Executive functioning,’ ‘ Impulse control,’ and ‘Object relations.’ Patients get an apology from me for the awkwardness of the terms, but I assure them that the concepts behind them are relatively straight forward and very useful.
Executive functioning is the ADD sort of stuff. Is a person organized, keeping a calendar, paying bills on time, etcetera? In effect, do they conduct the logistics of their lives efficiently.
Impulse control relates to the management of feelings. Feelings should constructively color our thoughts and actions, not be a dominant force that leads us to regret actions, or contrary wise, inhibit us. Disturbance in impulse control often shows up in bipolar and borderline diagnoses.
Problems with both impulse control and executive functioning are aspects of functioning which are relatively salient to patients and easy for them to get. The final letter in the mnemonic is far more interesting, subtle, and overarching. ‘Object Relations’ is is at the heart of where much of the tragedy of living comes from, yet is also the domain where the poetry and benefit of of productive psychotherapy often lies. When I introduce the topic my patients will hear me apologize for using such a jagged and unpoetic word as ‘object’ to describe interpersonal relations. Regardless, the imbedded psychology of object relations is a rich aspect of being human, and often the centerpiece of a deep psychotherapeutic experience. A sign that object relations are disturbed is often a history of troublesome interpersonal relationships, difficulties that would fall under the label of a personality disorder. Trauma and the often seen repetition compulsion, such for example what one sees when a patient has a pattern of repeating destructive relationships, also correlates with object relations.
Our relation to others is fundamentally based on our relationship to ourselves. Unfortunately, much of the psychology of the self is unconscious and out of immediate awareness. The insecure person, for example, might well be a braggart, and one who has negative expectations of others may find himself blaming the world rather than realizing that there there is a filter that is distorting his view of others. The world of people we populate in our heads act like ghosts that cloak our perception of others. It is a shadowy and ghostlike world, and attempts by therapists to make these things conscious are often met with resistance, requiring the outmost in psychotherapeutic skills to productively talk about them.
In sharing some of the tools I use to work with my patients, in essence, giving them a fishing rod rather than simply a fish, I feel I am respecting their autonomy. Hopefully I am giving them tools that will be a means of looking at the complexity of their lives enabling them to better counsel themselves once they graduate from counseling with me.