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Patient, Know Thyself

Alcoholics Anonymous is a powerful self help movement that over decades has accrued wisdom on how people can help each other. A powerful element is the concept of 'The 12 Steps.' I'd like to borrow from step 4, 'Taking a Moral Inventory,' and see how we might apply this in the ordinary process of counseling.

The idea of a moral inventory to the AA member is to enhance self awareness in a way that promotes growth. Rather than 'moral inventory,' we therapists might consider helping our patients develop a psychological inventory, that is, an awareness of ones psychological strengths and weaknesses. We can do so using an ego-psychological model.

Ego psychology has a number of roots and arcane differences between various schools have led to squabbles. Nevertheless the 'nuts and bolts' of its' clinical contributions is something that most of us will reasonably agree upon. One hopes that what follows will make this evident.

Under the term 'Ego,' I shall refer to subcategories such as 'executive functioning,' 'object relations,' and manner of 'psychological defense.' Just as a skilled athlete is exquisitely aware of her weakness, tempered by the enjoyment of being aware of her strengths, so too will our patients benefit from a similar awareness. They too are playing a game, the game of life. Let's consider for a moment some of the constituents of ego psychology while at the same time asking ourselves in what manner we as therapists might most constructively help our patients become more self aware.

Executive functioning has to do with the practical day to day decision making and course of actions that patients take in conducting their lives. Does the patient plan reasonably, does she have sufficient self control to temper her decisions leading to optimal outcomes. Does she have the kind of judgement that avoids unnecessary hassles? The latter might be exemplified by someone who buys a car from a second hand car lot without availing themselves the opportunity to get the car checked out by a competent mechanic. Is the patient equipped with good 'working memory,' organizing her time by minimizing instances in which she takes 5 steps to accomplish a task when it might be done in 3- a substantial savings! Problems with executive functioning are often one the first things to become evident at the outset of treatment and it can typically one of the easiest things to talk about.

'Object Relations,' is a universal and important part of our personhood with a number of dimensions and subtleties. Because the issues related to it are often highly personal and an awareness of this aspect of personality becomes emergent as the counseling relationship matures.

Essentially, object relations bears on the quality of ones relationships. Its foundations are based on a set of both conscious and unconscious expectations that have arisen during development as a function of nature and nurture. Optimally, in instances of good mental health, relationships have a degree of smoothness, free from drama, or ambivalence. Individuals with mature object relations experience others with a degree of predicability such that they are seldom blindsided or disappointed with people in their lives.

Amongst some of the subtleties of object relations that we become concerned about are narcissism or its complement, narcissistic vulnerability. We also might become aware of dependency, cynicism or lack of trust, and repetition compulsion- the tendency of people to repeat maladaptive patterns in relationships, something we often see in people who repeatedly get into abusive relationships. As we get to know our patients and a trusting relationship develops, we will do well in a timely tactful way help our patients become aware of their weaknesses in the object relations sphere. As is true with many aspects of psychological functioning, patients will typically be much more aware of the consequences of their personality style than of the underlying aspects of their functioning that give them trouble. Helping our patients become self aware of what is going on behind the scene leading to their overt life circumstances is like giving them a fishing rod rather than just a fish.

Finally, let me elaborate a bit on defensive mechanisms. Hopefully our patients are largely imbued with mature psychological defenses. Winnicott, the pediatrician and master psychoanalyst, beautifully wrote on how the childhood defense against abandonment, the transitional object, evolves when maturation goes well into comfort with ones culture. Another common mature defense is sublimation, the evolution of ones personal pain or insecurity into creative expression and the wish to help others.

Many of our patients have primitive defenses such as denial, or projection. We often encounter, for example, patients who have a sense of bitterness and anger toward the world. These patients find it much easier and safer to experience anger rather than the hurt and vulnerability that may be the basis of their anger. A successful counseling experience helps patients soften primitive defenses, often by allowing them to experience more tender emotions that are hidden under the surface.

Working with a patient to develop self awareness is a progressive process. As was mentioned earlier, it is natural for patients to be acutely aware of their life circumstances and a much more difficult task to become aware of their psychological underpinnings.

Insights we offer to patients are timed and based on the evolution of each patient's treatment. Patients are understandably dependent on us to help them develop insight. It's said that 70 percent of coaching is providing an external set of eyes. We therapists are like coaches who can and should reflect back to our patients aspects of their functioning in a manner that allows them increased functioning and autonomy. Years ago a teacher of mine stated that the counseling process is socratic. When patients are ready to leave us they have learned a good deal about how to coach themselves. A sophisticated understanding of ones psychological functioning is a gift for a lifetime.

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