Effectively Treating Pathological Self-Criticism in Depressed & Dysthymic Clients

On the last track, we discussed four different types of resistance to treatment of self-destructive criticism in depressed and dysthymic clients.  These four different types of resistance to treatment included:  belief in the truth of the criticisms; settling for mediocrity; morally wrong; and disbelief in efficacy.

Prior to creating a therapeutic directive for pathological self-criticizing clients, I believe it is important to present the directive in such a way as to maximize the probability of the client’s compliance.  Listen to the following steps for minimizing resistance.  Do you agree with these steps?  What would you change?  What would you keep the same?

On this track, we will examine three steps for minimizing resistance to the therapeutic directive.  These three steps for minimizing resistance to the therapeutic directive include:  appeal to what matters; the "positive" connotation; and speaking to the client’s positive.

3 Steps for Minimizing Resistance to Therapeutic Directive

Step # 1. Appeal to What Matters
This step suggests that therapeutic efforts in general, and here directives in particular, be aligned with the clients’ existing motivations.  Rather than declaring certain clients "unmotivated," or appealing to motives, however common, they do not possess, I feel that it is more productive to assess clients’ actual motivations.  Once I can assess these motives, I then frame directives in such a way that clients see their implementations as consistent with their existing motivations. 

Theresa, age 47, was most self-critical in the matter of performing the role of the perfect mother. Because of this, I, obviously, assessed that her major value systems revolved around her home life.  To appeal to this, I asked her how she felt when she was going through an acute self-critical episode.  She stated, "I feel like there’s nothing left for me to do but lay down and die!  I don’t want to do the things that normally would have given me pleasure.  Instead, I just want to sit around and do nothing." 

I stated, "But if you sit around and do nothing, how can you interact with your family?  The more critical of yourself that you become, the less you can meet the standards you have set for yourself in regards to your family.  Do you see the never ending cycle?" 

Think of your Theresa.  What would you appeal to?

Step # 2.  The "Positive" Connotation
 I have found that reframes and associated directives are accepted more readily when problematic behavior is given a "positive connotation."  By this, I mean that the behaviors portrayed as engaging in attempts at "self-improvement," the "pursuit of excellence" or the avoidance of conceit are in general more likely to be accepted than ones wherein the person is portrayed as "ridden with irrational shoulds," "a perfectionistic," or "masochistic."

Giraldo, age 31, had been frustrated by previous therapists.  He stated, "They never looked at me as a person!  They saw me as a problem person who needed to be ‘fixed.’  They said I was irrational and overreacting.  Do they think I don’t know that my fears are stupid and unfounded?  I hear that enough from my wife and kids, I don’t need to pay them to tell me that!" 

As you can see, Giraldo had felt that his previous therapists had been negatively labeling him.  As a result of this, Giraldo felt betrayed and disconnected from his therapist’s goals.  I stated to Giraldo, "In the coming weeks, we are going to be practicing some different techniques.  These exercises are meant to help you become the driven and organized person you wish yourself to be.  Right now, your methods are not working for you, but we are going to try and work together to develop methods that do work for you and will accomplish your goals." 

Think of your Giraldo.  How could you frame the therapeutic directive in a positive light?

Step # 3. Speaking to the Client’s Positive
Some theorists have advocated that therapists consider the client’s entire "position" and custom tailor all reframes and directives in light of this. 

The client’s position comprises such things as his or her:
(1) Current view of the problem
(2) Characteristic language
(3) Favored metaphors
(4) Personal characteristics
(5) Values and
(6) What he or she is seeking from the therapist. 

In general, my policy here is to see that all reframes and directives are carefully designed so that they fit as well as possible with the person’s overall position, and thus make it maximally likely that they will be receptive.

Paul, age 31, was a bright graduate student studying philosophy.  Exploration of Paul’s personal history revealed that, as a child and adolescent, he had experienced a great deal of disparagement and humiliation at the hands of both his family and his peers.  Paul’s response to this degrading treatment was to resolve that one day he would "show them all." 

Paul began to form fantasies in which he developed his talents and became an award winning writer, hailed by scholars and critics alike.  Then, all of his former degraders and tormentors would realize that they completely misjudged him and would bitterly regret that they could not bask now in his reflected glory. 

However, as the completion of this goal appeared more and more distant, he became more and more self-critical of his own abilities.  My colleague, John, was also well-versed in philosophy and stated to Paul, "This reminds me of a Platonic idea.  That is your idea of this triumphant scenario—the one of you in total acclamation—serves as an ideal.  Relative to this ideal, all actual activities, relationships, and accomplishments are being judged by you to be but pale, unfulfilling approximations." 

The language that John used to explain this concept to Paul served not only as a helpful way of reaching the client, but also a means to gain the respect of the client. 

Think of your Paul.  How would you adjust your language and metaphors?

On this track, we discussed three steps for minimizing resistance to the therapeutic directive.  These three steps for minimizing resistance to the therapeutic directive included:  appeal to what matters; the "positive" connotation; and speaking to the client’s positive.

Online Continuing Education QUESTION 11
What are three steps for minimizing resistance to the therapeutic directive? To select and enter your answer go to CEU Test.