Part 3: More on Buzzwords

Therapy Gems ©

More on Buzz Words Versus Meaningful Words

Buzzwords III: Why We Use Vague Buzzwords, Psychobabble, and Vague Jargon

The precipitating event for this article is the following comments in an article by Columnist Rex Huppke on how buzzwords are used in the business world.  Huppke wrote “Author explains buzzwords for office English speakers” in the Chicago Tribune, April 17, 2016.  Quoting James Sudakow, author of a book about buzzwords in the business world, Huppke wrote,

‘I think it becomes like this language and it allows people to look like they’re part of a special group that knows what this stuff means’ … [Sudakow] said. ‘I think that’s why its [sic] so prevalent in consulting.  They’re brought in to be experts on stuff and if they have their own language that makes them seem like they’re even greater experts.  It’s the opposite…. It’s like their credibility actually goes down because people wonder, “Why you can’t just use normal words?”’  (Section 2, p3) [italics added].

After reading those comments, I thought I should write about our motivation, as Psychotherapists, to use buzzwords.

The Buzzword Motivation

I have observed eight motivations for using buzzwords.

Shorthand communications

Ease of making a statement

Identification with others who use them

Status or Appearance of being knowledgeable

Credibility, sounding expert

Distance from the object of the buzzword

Purposeful obfuscation, vagueness, or lack of clarity

Lack of understanding of appropriate professional language

Shorthand – The simplest, most benign reason is that we think we are communicating a large concept in a small package.  We may think we are using a robust term in order to convey a complex situation.  We imagine “can’t handle it” or “acting out” shrinks a lot of information about client behavior into a single term that communicates substantial meaning.  If we can access or picture the meaning, we think the word has communicated the meaning we have imagined.  If we see the client’s distress when she uses a buzzword, we think or assume we know what she means – with a lot of emotional disturbance packed into one or two words.

Of course, each person has his or her own connotative imagery for the buzzword. Therefore, what makes it a buzzword is that it no longer has a specific shared meaning.  The ‘large concept in a small package’ is actually ambiguous!  Often it is also pejorative.  The word usually has been co-opted to mean broad categories of meaning which lack the clarity required for professional communications.

Indeed, many of these words developed from meaningful professional jargon. They became ambiguous once they were used imprecisely by professionals.  Or they came into common parlance in which specificity is not only downplayed, it is often avoided!   For instance, when Hans Selye applied the word “stress” – formerly used mainly in engineering — to describe an internal physiological state in which certain organs are activated and bodily damage results, the meaning was clear and specific.  Now, the word is most often used to describe either external stressors or an emotional state of feeling pressure or feeling overwrought with too many challenges.   You can see it has lost most of its connection with the original professional jargon.  It no longer has one clear and specific meaning.

Let’s examine an analogous problem. Jet propulsion, for example, still means causing movement by forcing gasses to travel at high speed.  Imagine if we used it to have emotional meanings such as, “I feel a lot of inner propulsion, jet propulsion.”  “Too much propulsion is coming at me!”  Oh, yes, I can relate to that idea.   But after the term from physics becomes co-opted as an ambiguous term for a mental state, then we would soon have to find a new term for whatever it is that jet engines do.

Many of us worked in settings where buzzwords were commonly used and accepted. In those settings, a buzzword may have had a short-hand meaning understood by practitioners in that institution.  Sometimes, the culture of the workplace includes a meaning for a buzzword, that is, a meaning shared within the institution.  So, for many clinicians in many settings, using the word “issues” or “acting out” may appear to sound professional and comprehensible, a shorthand way of communicating  with other professionals in that setting.  I can imagine in a residential treatment center a statement such as “Because he has so many issues [i.e., emotional conflicts, painful or traumatic experiences with hostile feelings], he acts out [i.e., displays angry feelings and perhaps destructive behavior] when he is frustrated.”   Most of the staff in that setting know the behavior to which the statement refers. 

However, in an outpatient setting, those same terms could have a variety of meanings. When I hear “issues” or acting out,” I often find myself asking, “What do you mean by that?”  The shorthand has ultimately failed to communicate.

Buzzwords obscure deeper understandings.  Buzzwords gloss the surface so the clinician does not have to think more incisively and deeply.  Recently, an Intern used the word “issues” several times in a diagnostic report.  Careful reading of the text showed four meanings for “issues.”  In one place, “issues” meant all the person’s internal conflicts or emotional problems.  In another, “issues” meant foci of concern.  Another meant very serious emotional problems.  The last meant significant deviance from expectations.   I explained that using “issues” obscured the richer thoughts she may have about the client.

I asked her to work to avoid “issues.” That proves to be a challenge; such is the compelling pressure to use imprecise language.  I asked her to re-write those sentences to specify the meaning more exactingly, without using the word “issues.”  The first use of “issues” became “emotional symptoms most distressing to the client” (which she then specified).   That has a more specific meaning than “he spelled out his issues.” The second became “symptoms for which we set treatment goals.”  That has more precision than “he has serious issues.”  The third became “unusual mannerisms, such as frequently tapping on his forehead.”  That also is more specific and more useful.  The fourth became “disagreed with therapist’s assessment of his symptoms as being consistent with PTSD, arguing that something that long ago could not be as crucial to his health as the therapist had asserted.”  The Intern had proven the point that buzzwords obscure more than they reveal.  She also proved that a richer meaning can be hidden behind a buzzword; a little clinical thought leads to deeper insight into the client’s functioning and dynamics.

Ease of making a statement  – Similar to a motivation to use shorthand language, the clinician may find it easy to use buzzwords.  They readily ‘roll off the tongue.’  We often use them in common conversation.  But in the clinical situation, the motivation could also be to allow the clinician to avoid having to stop to think more deeply or even to let the clinician gloss over a client emotion.

Buzzwords can also be used in a highly pejorative or dismissive way. It’s much easier to say “Attention-seeking” than to think out the true dynamics and explain them, such as, “Anxious attachment, leading to behaviors which elicit a response from mother so he knows he has value to her.” So this easy and often pejorative use of buzzwords is a particularly important failure of clinical thinking.  Easy use of buzzwords is inevitably unhelpful to the client, who becomes somewhat distanced.  It causes the therapist to think on the surface rather than fully grasp the client’s emotions and dynamics.

Identification with other professionals – A natural tendency amongst trainees and newer therapists is the quest to know how professionals behave, how to become socialized to the work.  Identification with valued professionals is a process for acquiring those behaviors.  So if a supervisor uses buzzwords, the trainee is likely to do so.  If the supervisor does not ask for clarification of those terms, that omission tacitly reinforces the usage.  It also teaches the trainee to stay towards the surface of behavioral observations.  When I challenge the use of buzzwords, trainees and, sometimes, licensed professionals, tell me they have never before been asked to stop using those words.  I then ask them to look more deeply into the client’s behavior, a task which will lead to better understanding and more effective selection of interventions.

Status or Appearances – As Sudakow pointed out, we may feel a need to enhance our appearance of possessing a) professional status in the mind of the clients or our colleagues, b) a sense of importance in our own minds, or c) belonging in the in-group of the institution, being a member of the team.   If, however, the organization does not support buzzwords, using them reduces status!  If the organization supports them, the clinician can lead by avoiding them, speaking with more depth, and asking others to clarify meanings.

These use of some of the buzzwords may often be judgmental and pejorative! The team objectifies the client by the use of terms which place the person in a pejorative category.

We can counter that by re-framing the behavior upon which we are focusing as protective, adaptive, the best the client can do, motivated by positive purpose, or in other terms which shift the focus to what the client is doing effectively. Recently, for instance, a client whose former use of opiates was extremely heavy lapsed twice in one week.  Rather than use buzzwords such as ‘addict,” “resistance,” or “weak,” I described his behavior as a success in that he cut down his use by 75% in just a few weeks.  The focus of discussion shifted from his pathologies to how to assist his sobriety to get to 100% abstinence.  In fact, he progressed more rapidly than his history and challenges might have predicted.

Credibility – Similar to a motivation of special status, the professional may try to sound more like an expert.   But, when using vague language, have we communicated an unmistakable message which the client can use effectively?  Expertise used for show just does not connect well. It leaves room for misunderstanding.   I once sat with a group of professionals observing a consultant through a one-way mirror.  He told the distressed woman in his office phrases such as “You’re projecting.” “That is passive aggressive behavior.”  “You are needy.”   The observers nodded.  Yes, her behavior could be adequately described by these terms.  But I didn’t think she understood any of it.  In terms used in Motivational Interviewing, the consultant’s labels produced more sustain talk which led to more of these interventions – which seemed more confrontive than interpretive.  That may have gratified the consultant and impressed the professionals, but I did not think the interchange helped the client.  She may have found the doctor to be a credible psychiatrist, but the language did not seem to help her.

Buzzwords obfuscate deeper meanings. They lead us to the surface rather than the depths. They lead us to objectify the client – which is incompatible with core therapeutic conditions.

So, just as we want the client to be clear and to express feelings and thoughts with some clarity, and just as we push the client to probe feelings and thoughts, so we should expect the therapist to think and speak with clarity and accuracy.

Distancing – Buzzwords can be used to maintain emotional distance from another person.  Such words as “over-reactive,” “needy,” or “attention-seeking” set the therapist at a seeming distance – a judgmental distance — from the distress or emotional whirl of the client’s life.  We frequently see this kind of response when the client has a Borderline Personality Disorder, bipolar symptoms, attachment difficulties, substance abuse, or hostile behavior.   By labeling them, respectively, as needy, moody, cold, weak, or full of anger, in effect we are being judgmental and dismissive of the client’s personhood.  The person becomes the disorder rather than a person who is affected by the disorder. The paradox is that the therapist’s emotional distance, which may lead to more punitive or directive interventions, may also be a stimulus for the very emotional reactions the therapist is labeling!  

Purposeful obfuscation — Often, we are intentionally vague.  Perhaps we are writing a report and we conclude the client will be upset by a statement in the report.  Perhaps we create a document that is going to a reader who is unfamiliar with mental health jargon.  Perhaps we want to present the client in a favorable light.  We have many reasons for writing or speaking in vague terms.  But, just as we would not let the client use the defense of vagueness in order to suppress painful feelings and thoughts, we should not let professionals use vagueness in order to obfuscate.

In a recent report to a pediatrician of a seven year-old boy, the psychologist did just that. He used obscure language, such as, “On scale three, the client scored two standard deviations from the mean for global behavioral scores.”  The pediatrician sent the letter back with a note that she could not understand it!  The motive for the original letter was to disguise the worst findings from the client’s mother, who received a copy of the note.  But then she appeared at the clinic asking for an explanation of the letter.   The re-written letter clarified each point in plain language.  “On a scale measuring behavioral problems, such as disturbing others, occasional hitting of other children, and breaking or throwing objects in anger, J’s score suggested he is in the top two percent, meaning only 2-3 children in 100 show disruptive or aggressive behavior to that degree.”

Lack of understanding of appropriate professional language.  A mental health professional has a Bachelors degree with a major or minor in psychology, social work, or an overlapping field, then a Masters degree in a mental health discipline, an internship, and a post-Masters supervised training experience.  The latest standard for a Masters is around 60 graduate hours of course work.  A Psychologist has completed several more courses than that and original research.  During all that intensive training, the professional learns an enormous number of psychological terms, theories, research findings, methods, and principles.  To learn how to apply all those terms to the labeling of client behavior takes years.  I try to model how a professional ought to be able to explain all behavioral phenomena and patterns.  In these papers on buzzwords, a consistent theme has been the proper use of professional terminology.  One reason for the use of vague terms is that trainees may not have been held to the standard of proper labeling of all their observations.  Further, they have learned so much of the jargon in the abstract and may not have enough training in applying terminology to real situations.  Let’s make sure we communicate that learning to explain the client’s actions and one’s own interventions in appropriate professional language is a goal.  We understand this skill is always a work in progress.

In summary, most often the use of buzzwords derives from the needs of the clinician, not the benefit of the client. The clinician may presume the words communicate what the clinician intended.  But that is not often the case.  Clinicians may have learned to use buzzwords in a training situation, but the time has come to stop using them.

I will confess that it is a challenge. In a typical day, my trainees will hear me start the word that sounds like “iss…” or the word “handle” may emerge.  Fortunately, I am able to catch myself and to find a clearer way to explain.  We hear these words so often that we have to work to avoid them so we can speak more clearly.  Doing so will pay off in more effective clinical work.

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© Don D Rosenberg, Version 1.0 2017

More on Buzz Words Versus Meaningful Words

Therapy Gems ©

More on Buzz Words Versus Meaningful Words

Buzzwords II: Adding to Our Lexicon of Buzzwords, Psychobabble, and Vague Jargon

This article comments on more of the troubling buzzwords I have collected since my original article in 2012 (revised in 2017).

First, I want to acknowledge my staff. They quickly respond when I point out a buzzword during a case conference and universally they have cut most of these words out of our meetings.  As a result, case presentations have more clarity and specificity. That leads to a higher quality of suggestions from the team.

The most frequent buzzwords seem to be “attention,” “acting out,” and the word “anger” used as a personal characteristic, as in “he has so much anger inside.” A brief, immediate explanation of the illogic of these terms has helped staff stop using them.

More Buzzwords

I have not come across many buzzwords that were not in my original paper on the subject. I do see some terms that I predict will become buzzwords or which are on the cusp of buzz-word-dom.  Here are some additional buzzwords or future buzzwords in mental health.

Chemical imbalance  — This term is the invention of drug marketers.  It never had a scientific meaning!  Imbalance between what chemicals?  What kind of imbalance?   Every benefit of a psychoactive medication is due to rectifying an imbalance?

It appears problems relate several factors, not to a question of imbalance – i.e., an excess of a chemical or a depletion of the chemical or too few receptor sites. If you have an excess of dopamine in some areas, which we believe has something to do with some symptoms, then you have an excess.  Nothing is in or out of balance. If you have too few receptor sites for dopamine or serotonin, then you have too few receptor sites.  If mono-amine oxidase breaks down mono-amines (nor-epinephrine, dopamine, serotonin), then that is the underlying process.  There is no imbalance between dopamine and serotonin or between any other two neurotransmitters.  There is no definable balance point.

The term was developed for the public as an obfuscating, easily acceptable, professional-sounding, generic explanation for why psychotropic medications may be valuable. Furthermore, research has not conclusively explained why many medications work or the degree to which some of them are actually effective.  Nor has it validated some favorite hypotheses in the explanation of how chemicals work to reduce symptoms.

Unfortunately, this term has come to be reified. Consumers on psychiatric medications often think they have an imbalance.  Using the metaphor of a chemical imbalance suggests a permanent feature of an individual.  Sometimes the brain is in balance and sometimes not.  In most cases, this is unlikely to be accurate an accurate reflection of the neuro-chemical status.   The term also implies medications must be taken for a long time, which also may be doubtful, even for severe symptoms.  The public has come to believe in medication for depression despite the fact that recent research shows about 80% of depressions are not helped by medications.  Furthermore, research shows that psychotherapy alone is effect in a majority of cases, even with severe depressed mood.

Better would be to describe how some symptoms are reduced by certain medications, either without inferring process which we presently do not fully understand or with specifying the processes which we do understand. For example, an SSRI interferes with re-uptake of serotonin into neuron one so that neuron two fires, thereby increasing the intensity of signals in that mood-regulation pathway.  If it is a pleasure, satisfaction, or affect regulating system, the person may feel calmer, more pleasant, or less unpleasant.   Give the client the level of explanation that client wants, needs, or deserves.  But give an honest account.

Co-dependent, co-dependence – When Melanie Beattie and others suggested this term, the meaning was narrow. Co-dependence refers to one type of relationship with someone who is dependent upon alcohol or drugs.  To continue, despite the fact that he or she is not taking drugs, the co-dependent person also has a relationship to those chemicals, mediated by the behavior of the person who takes them.  The co-dependent’s mood, thoughts, and actions are heavily structured around the patterns and behaviors of the person who is using the drugs.  For instance, if one’s spouse uses cocaine, one may be resigned or furious, on the verge of leaving, considering giving the partner another chance or no more chances, sleepless when the partner is out on a binge, mistrustful, or endlessly checking up on the spouse. In other words, much of one’s mental process and behavior is taken up by the partner’s use.  That is co-dependence.  The term was meant to describe the state and behavior of a person who is in a relationship with another and that person’s drugs, a term more comprehensive than the earlier term “enabling.”  In many ways, “enabling” can be a more specific term; it can be used to refer to one particular class of specific behaviors.  “Co-dependent” can be so broad as to be confusing.

However, the term can be quite useful. But I seldom hear it being used correctly.  I have heard a number of people say “co-dependent” when they merely mean “dependent” behavior.  It reminds me of the linguistic conundrum of “regardless” becoming “irregardless.”  I have heard it used to mean having a relationship with someone who uses, but by no means the complex relationship that the term originally described.  So, I suggest the term only be used in its narrow sense or not at all.  Or just describe the behavior.

Denial – I am listing denial with the buzzwords merely because the term is thrown around too easily and is now so popular that its original meaning is diluted.   ‘Denial’ is often used to describe behavior such as rationalizing, minimizing, self-deception, failure to display insight, or refusing to be accountable for the impact of one’s actions.  Denial may be used when the client continues in a self-destructive behavior despite negative consequences from the behavior by downplaying or refusing to accept that the behavior causes problems.  Denial may get used as an accusation or criticism suggesting merely that the person using the word disagrees with the person in so-called denial.  In other words, the term is thrown around too loosely.  That is the very core of the genesis of buzzwords that grow out of professional jargon that originally had been useful.

To use ‘denial’ correctly means going back to its roots when the term was used to describe an immature level defense mechanism in which one, in effect, distorts the perception or interpretation of reality so as to block awareness of the uncomfortable facts, memories, or impulses.  Because the memory or feeling produces threat, anxiety, shame, or guilt, one does not want to acknowledge something is true.  The process is unconscious.  For instance, a person can see his father is drinking a lot, but he has powerful intrapsychic reasons to deny father is actually “an alcoholic.”  It would feel threatening to one’s security to acknowledge it.  A troubled child may be called merely rambunctious, which is a denial-by-minimizing of his aggressiveness, hyperactivity, and mischievousness.

The term also has multiple meanings even in a professional setting. One can “deny” that which is factual because of a) reality distortion, b) not wanting to talk about the subject due to anxiety, c) not wanting to admit the truth and accept the implications due to the threat involved in doing so, d) acting as if it’s not a problem or minimizing (usually because the implications of admitting the problem feel too threatening), e) evading accountability.  In addition, f) one can accept facts, but deny having feelings about the situation.  g) One can accept the behavior, but deny the behavior has negative consequences.  For instance, “Sure I did hit him, but it’s not so bad.  He deserved it and I didn’t leave any marks.”   h) One can accept the behavior, but deny responsibility.  “It was his fault!”  i) One can try to explain or rationalize it away.  “Johnny does it too, and I do it less than Johnny, so I don’t have a problem.”  One can say, “I didn’t get it done, but the real reason I have this problem is Jill’s fault.”  Each of these processes has a common factor, namely, the motivation is to avoid or escape from threat, anxiety, shame, or guilt.

Having so many meanings makes denial too easily thrown around as a catch-all term. The term also gets used as a form of confrontation and criticism.

I suggest the use of the term denial should always be followed by an explanation of the type of denial and a consideration of how the process is the client’s effort to preserve reality as he or she understands it.  Words meant consciously to evade responsibility or justify one’s behavior are not denials and should be label more appropriately as rationalizations or justifications to avoid guilt, shame, punishment, or responsibility.

Energy — “Energy” has numerous meanings – enough so to make the use of the term in psychotherapy often strikingly imprecise.  Let’s look at a few meanings both valid and questionable.  I am not trying to be comprehensive, but rather to show the degree to which the word is a metaphor and how psychotherapists have started to use the term as a metaphor FOR a metaphor, a buzzword.

Freud used the term “psychic energy” to explain the flow of behavior from a presumed source – instinct or drive or wish – through the shaping of drive fulfillment by ego functions. In his approach, which aligned with mainstream concepts in physics, behavior is motivated by internal sources, that is, it is driven by energies arising from drives.  Freud was not alone in this concept of behavior.  Indeed, many motivational theories of behavior in mainstream psychology in the early and middle 20^th century began with concepts of drive or instinct.  Since the body consumes energy (i.e., calories), it makes sense to consider, analogously, that energy operates in personality.  However, such transfers of ideas from the operation of one system to another often lead to the realization that there is no one-to-one correspondence between systems. The mental system uses bodily energies (metabolism), but behavior seems to require far different explanations.  For example, Watson and Skinner later showed behavior can be, in a sense, motivated by the perception (an internal function) of reinforcements.  So the concept of psychic energy, which was inferential, metaphoric, and unmeasurable in the first place, fell out of favor.

More recently, a number of psychotherapies accept categorization under “Energy Psychology.” These approaches accept the Chinese theory behind acupuncture, yoga, qi gong, etc., namely, that the body includes energy fields which may be blocked or functioning inadequately.  Therefore, methods, such as inserting needles along “meridians” or exercises which affect “chakras,” lead to healing, perhaps by unblocking channels and releasing energy.  Thought Field Therapy and Emotional Freedom Technique, popularly known as “tapping,” are energy psychologies.  These approaches, hose mechanism of action is uncertain,  overlap well-proven methods, such as “exposure” and “mindfulness.”   To call them “energy psychology” is to use a metaphor.   No energy can be found or proven.

In the vernacular, “energy” has a variety of figurative meanings besides the physical meaning of power (mechanical), heat (thermal), or quanta (nuclear).

• Energy refers to power, either potential power or kinetic power. So an act can express this power or vigor, either physically or, often, metaphorically, such as “He plays the game with high energy.” “His delivery of the speech was done with high energy.”
• A more metaphoric use of the word is contained in the idea of working off energy, where energy means something akin to tension.
• “Emotional energy” can mean a trait, something akin to get-up-and-go, outgoing personality, or personal activation. The level of energy can refer to a trait in the sense of referring to someone whose arousal and speed of activity is characteristically high or low in presumed energy.
• “Emotional energy” could also mean mood, such as “After the bad news, the room was drained of energy.” The meaning is one of inhibition, heavy-heartedness.
• “High energy” or “low energy” refers to arousal, wakefulness, or a related quality of mood. This meaning can refer to a state, as it is most commonly. “I don’t have the energy for that climb” means a state of lacking the activation for the task.
• Energy can be used to represent a passion or focus as in “He devoted his energy to writing.” Referring in a word to concepts of commitment, expenditure of time, and execution of tasks this use has little to do with the notion of physical energy per se.

Anyone using any of the above meanings probably can be understood clearly by most of us. We can tell from the context whether you mean vigor, power, high level of activity, forcefulness, nervousness, tension, mood level, extroversion, wakefulness, or focus.

But therapists often use “energy” in more ambiguous ways that we should avoid. For example, I have heard this sentence, “I sense your energy.” Not believing in auras, I find this kind of statement so vague as to be muddling.

In another example, I have heard this sentence, “You are full of negative energy. Your negative energy brings me down.” The reference is not energy at all. It could mean dead-end thinking, criticism, finding the problems in any advice, rumination, or other kind of negativity, all of which are subsumed under “negativism.”  If that is what the therapist means, then be precise and give the process an accurate name.

In another example, we often hear, “I like your energy.” I don’t think that is meant to refer to any version of force or power. It is meant to refer to positive personality, enjoyable personality, or getting things done, or any number of positive qualities. That range of meaning alone makes the idea impossibly ambiguous.

In these three above examples, the word “energy” is used to mean something entirely other than energy!

Therapist should be more precise. If referring to energy in the Freudian sense, refer to “psychic energy.” If referring to Energy Psychology, in which the theory is unproven and the results could be attributed to well-known psychological process without reference to “energy” at all, I suggest referring to an “exercise” that helps the way acupuncture does. If using energy to mean one of the usual vernacular meanings, one of the synonyms that convey a meaning closer to what you intend probably will be more appropriate.  But the very metaphoric, vague uses should be avoided. 

Evidence-based — How could such an important term be a buzzword?  Simple.  It is very easy to claim one’s treatment to be evidence-based, but it is very hard to demonstrate.  Marketers and brochure-writers put the term into healthcare ads and brochures.  Is that a guarantee?  No.  The term is now used as a seal of approval.  But it is an over-simplification.

In reality, few mental health patients can simply receive an proven protocol – they are too complex.  Also, many therapeutic efforts are given a name but lack faithfulness to the evidence based therapy.  I frequently see a therapist name the therapy they are doing, giving it the name of a proven technique, but providing a method which is not very faithful to the method.

Let’s look briefly at this term. The term is supposed to refer to therapies for which controlled clinical trials have shown the therapy is better than placebo, wait list, another treatment, or no treatment at all.  The term can be used to refer to meta-analyses showing the treatment has a reasonably strong effect size, roughly an average standard deviation between the treatment group and the control group of .4 or above.

Furthermore, a number of sets of guidelines have been published which incorporate such treatments, among them the Expert Consensus Guideline Series, guidelines by the American Association for Child and Adolescent Psychiatry, and guidelines from the American Psychiatric Association.  Most payers have published guidelines as well.

But then reality always intrudes.   Therapists vary in their awareness of the evidence. Therapists vary in their knowledge and training in such therapies.  They vary in their adherence to these models.   Clients in practice are usually more complex than subjects in trials.

Further, techniques do not account for the major share of the variance in outcomes. Relationship factors including the therapeutic alliance, empathy, and non-specific factors, such as hope, account for more of the variance.

Clients may not accept or want a recommended treatment. Often, other treatment functions must come first, such as stabilization, building resources, developing trust, or managing crises.  So we may say we do evidence-based care, but in reality often we are not providing that care.   The professional’s recommendation may not be evidentiary practice but may nonetheless reflect very good clinical judgment.

Another problem is that therapy can be narrow or broad, focused on one symptom or focused on a broad range of client functions. Some therapies are broad and generic, such as solution focused or psychoanalytic. Some are narrowly focused, such as systematic desensitization, EMDR, exposure, and specific protocols within the CBT world. There is no specific proven technique for many conditions. Harm Reduction, support, and directive counseling are often the main techniques one can offer where no treatment is proven to help.

Often the proven treatment is the wrong treatment for a particular client at a particular time. For example, a patient I’ll call Vicki came to treatment with a major depressive disorder.  But rather than cognitive behavior therapy or interpersonal therapy, two proven methods, the therapist judged that the best choices to initiate were medication and crisis psychotherapy.  Cognitive therapy was added after 6 crisis sessions.  The relief produced by the initial plan led to successful completion of the case in 10 weeks without much use of the “proven” methods.

Often, clinical trials are sometimes not the same as real world situations and would eliminate patients such as Vicki. They compare “pure” diagnostic entities, which are not the same as the usual client seen in the clinic. Clinical trials eliminate patients with complex lives and multiple problems.  When we work with complex cases, complex decisions have to be made which may belie the so-called evidence.

Many therapists depend upon clinical experience and clinical wisdom, often rightly.  Treatment is so complex and difficult and problems are so complex that evidence-based treatments often have to wait until other care is provided in the real world.   Published care guidelines developed by insurance companies may take economic factors too much into consideration, possibly weighing benefit plan structures against optimal treatments.

How good is the evidence?  One critique showed that depression treatment by CBT is more lasting and in the long run more cost effective than medication.  Another showed the so-called evidenced-based use of anti-depressants was no evidence at all – 80% of the cases did not need the medication.

Our comprehension of the evidence changes over time.  From the 1950s declaration that therapy is no better than spontaneous recovery to the 1970s declaration that all therapists are about equally useful to now, the evidence changes and new therapies are constantly in development.  We can assert that there are more proven approaches now.  There are also more types of evidentiary approaches for specific problems.

Based upon cost-benefit considerations, EBT has a political and ideological agenda itself. Consider the case of PSA and mammograms – cost-benefit says to do one thing, clinical judgment another, patient safety another. The final criteria are somewhat ideological.  We find the same biases in trauma treatment.  Prolonged exposure therapy appears to have more of a following in academic psychology while EMDR, which produces equivalent results more quickly, may be downplayed by academics, but may be preferred by non-academic clinicians.

In conclusion, I prefer to use the term Evidence-Informed. This term acknowledges the research and the effective approaches, but with the understanding they must be provided within the larger overall context of the client’s treatment needs and the clinician’s best judgment.

I can’t breathe. You’re smothering me. — Such terms are not actually buzzwords; but they function as buzzwords. The client may mean, among many possibilities, that she feels controlled, her partner demands too much for her, she has no time alone, she uncomfortable in a close attachment, she feels her partner needs to be too close for her own comfort, or she is frightened of a relationship.  “I can’t breathe” can also mean the opposite, namely, “I cane so much it takes my breath away.” Which is it?  What’s the history behind the dynamic? How is it being repeated in her life?  For the client, the term obscures the underlying emotion and memories.  For the therapist, the meaning is too generic to be helpful.  So the term does work like a buzzword – it tells us something we can only partially grasp and we need to ask for much more detail.

Hyper – What comes to mind with “hyper” could be restless, keyed-up, agitated, hyperactive and moving around the room or climbing on the furniture, “bouncing off the walls, anxious, over-stimulated, or hypo-manic. Furthermore, when used to describe a client, the word is more of a pejorative adjective than it is informative.  As with many buzzwords, its effect is one of judgment and distancing.  If we mean hyperactivity, we should say so.  “Child was hyperactive, changing positions on the chair many times over 10 minutes, walking about the room investigating objects in the room, playing with an object briefly before moving to the next one.”  If we mean agitated or anxious, we should use those more specific words.

Manic – For this buzzword, I know I am to a degree splitting hairs. But for professionals, we should speak clearly and use language carefully.  When used to describe a true manic episode, “manic” is, of course, the proper word.  “Manic’ may describe the mood of a manic episode, and doing so with a bipolar patient is entirely appropriate. 

I asked a team of clinicians what they might mean by “manic” and the terms they cited include agitated, excitable, high speed, hyper, keyed-up, on edge, restless energy, and tense. When used to describe the mood of a person who does not have a bipolar disorder, the description of that mood little resembles true mania per se.  Using “manic” merely to describe mood does no justice to the experience of the bipolar patient.  It does not describe the extreme, impairing severity of that mood, the racing thoughts, sleep disturbance, compromised judgment, inappropriate choices, extremes of irritability, and altered sense of self which characterize mania.  In that case, calling a mood manic is a disservice to those who have bipolar disorder.

Move on, Moving on — Similar to “let go,” “move on” is meant to admonish someone to stop focusing on or talking about some troubling event or situation. “I need to move on” is an acknowledgment of a need to resolve a conflict or situation.  People refer to ‘moved on’ in the past tense or ‘moving on’ as if they had accomplished a major step in life.  Somehow, when someone claims to have moved on, I become skeptical.  Have they emotionally resolved the loss or trouble? Or only worked on ignoring or repressing recall of it?  To resolve a painful experience is to reach a psychological point at which the event feels historical rather than current and has the same emotional valance as almost any historically significant event, but no more than that.

The command to “move on” implies no such accomplishment.   How is one to accomplish it?  Where does one start?  What if one cannot move on; is that a failure?  The term should not be used.  The processes of grief work for a loss or of resolution of an emotional conflict or emotionally troubling experience are so rich with possibilities that it is imperative that we specify the processes.  We should guide the client through a process. We should not be telling anyone to “move on.”

People Pleaser — This term has always been a buzzword.   It could be used to describe a passive or compliant person who is taken advantage of. It could be used to describe a peace-maker or a conflict-avoidant person who reduces negative emotional situations by offering solutions, usually ones in which she volunteers to take on a responsibility others should be taking on.  It could mean someone has difficulty saying “No” and takes on too many tasks.  It could mean a person who goes along with others rather than asserting a contrary position.  This person has conflicts over self-assertion, over telling others she can’t or doesn’t want to do something.  She may not ask for what she wants or needs.  This person may present a false self to the world as someone unfailingly agreeable.  She may compromise her position or wants so as to avoid conflict.  Her self-worth may depend upon the approval of others.  She may feel responsible for how others feel and may fear others being angry or disappointed in her.  She may not trust her own perceptions and feelings, so she hides or discounts them. She may enable misbehavior in others and may be miserable about the result.  She may need to be perceived as helpful, and never as lazy.  The term could also mean a kindly person who truly enjoys doing for others.

So which is it? As a term used in therapy, it has so many possible meanings that it lacks meaning.   Is this person supposed to become more assertive?  Or is she to work through her fear of alienating loved ones?  Or her fear of loss?  Or her early training that assertiveness will be punished?  She can’t quite work out how she is supposed to be different once she is called a “people pleaser.”   But she can be helped to work through the dynamic behind her behavior.

Let’s also avoid synonyms, such as pushover or overly nice or patsy. If a person fits any of the dynamics I’ve described, explain the pattern and drop the label.

Resistance – Resistance was first defined by Freud. His German word, “Den Widerstand,” translates as push-back, resistance, opposition.  The term defines a process in which the client is anxious due to the awareness of uncomfortable or unacceptable impulses or painful memories, and that anxiety motivates defenses which aim to repress, block, or constrict awareness or expression of those impulses or memories in therapy.  Then the person ‘resists’ expressing the feelings or memories in therapy.  He or she may suddenly block, may edit comments, may suppress them, may change the subject, or may miss sessions.  The pressure to resist can be primary – avoidance of anxiety – or secondary – meaning the client has reinforcements (secondary gains) for maintain symptoms.  The fundamental techniques of psychoanalysis are analysis of transference and analysis of resistance.

More recently, the topic of resistance has been a focus in the field of Motivational Interviewing (MI). In MI, resistance is defined as statements of “sustain talk,” comments supporting dysfunction and arguing against change.  Studies show that the frequency of sustain talk is directly in proportion to how much the therapist presses the client to change or confronts the client with statements about the client’s behavior.

“Resistance” can become a buzzword when it is used loosely or confrontively. “You are resisting.”  If directly instructing people to change got them to change, therapists would be unnecessary.  Much of the work of therapy is helping people change using techniques therapists spend years studying.  Telling the person to change is quite different from helping the person understand his or her patterns of behavior and understanding the problems with continuing in current patterns.  We know how challenging it can be to help people change over-learned, long-practiced patterns.

The most common loose use of “resistance” is to rationalize why the client has not changed or why the client has missed sessions. In this case, the word is used as a blaming word.  It obscures what may be problems in the therapeutic relationship, the therapeutic alliance, the client’s life challenges, the level of distress caused by symptoms, or more classic problems of resistance.  As with most of the other professional terms in our buzz-word papers, we just want the terms used accurately and we want therapists to push themselves to find and understand the processes at work in the client and in the therapy.

Self-medicate – This term is not yet a buzzword. Soon!  It is used glibly to suggest that some dysfunctional, probably self-harmful behavior is motivated by the need to reduce or eliminate some emotion or discomfort.  It is not meant to suggest a healthy medication used in the intended way for the intended purpose.  Rather, it suggests the

Many people have come to believe we have a chemical solution for every problem or discomfort.

use of a medication in an inappropriate way or in a dosage exceeding the recommended dosage and for the purpose of altering negative mood. It also may mean a behavior, such as self-cutting or gambling, which has the effect of reducing some negative emotions.  However, the term obscures the client’s significant difficulties managing the underlying emotions, the life history behind those emotions, and the history behind the difficulty coping with those feelings.

 

Furthermore, this term is used glibly; but often it may be incorrect. For example, the client may use the medication because the use has reached the point of dependency.  So the use is not to self-medicate some underlying core psychological conflict, but rather to avoid withdrawal symptoms.  Better would be to specify what underlying difficulty the client appears to be avoiding and the source of those difficulties.  For example, “Due to PTSD, when the intrusive images flood his mind, he feels frightened and helpless. He discovered alprazolam calms his anxiety so he can function.” This explanation leads to interventions more effective than the term “self-medicate” conveys.  “Self-medicate” leads mainly to confrontation and promoting abstinence.  When we use a more specific explanation, we can see other possibilities, such as, affect management, trauma exposure therapies, or use of more appropriate medication.

Stuff It  –  This term is used to mean suppressing or trying to block the expression of negative emotions, such as feeling angry, frustrated, disappointed, scared, hurt, etc.  The person may judge the expression of those feelings is unsafe, not tactful for the situation, or likely to be punished or dismissed.  The closest professional term for this behavior is the defense of “suppression,” that is, purposeful restraint of the expression of a thought or feeling.  “Inhibition,” “repression,” “dissociation,” “undoing,” and “emotional constriction” describe less conscious processes for blocking expression of emotion. That at least six psychological processes involve holding back or “stuffing” emotions demonstrates that the term “stuff it” or “stuffed my feelings” is vague, unworthy of expressing the richness behind these processes.  The person may be afraid to express feelings or may be conflict-avoidant.  To help someone, we cannot merely say “You are stuffing your feelings.”  Nor should we accept the client saying, “I stuffed it so we wouldn’t fight over it.”  Rather, we need to know the emotions, their source, and what experiences shaped the defense of suppression, repression, undoing, or whichever process may be present.  We also need to be aware that suppression can be a healthy defense akin to tact.  In that event, the pejorative term, “stuff it,” is just inappropriate.

Supportive – Supportive, as a buzzword, is a global term referring to no one set of well-defined of behaviors. Rather, one uses the feeling of “support” to mean the experience that the Other’s behavior FEELS accepting, validating, affirming, helping, or encouraging.  When a person claims, “You are not supportive,” often the Other is not clear what behavior would produce such feelings or why his or her behaviors are not perceived as supporting.  Often, the Other does not grasp the need to be supportive in a particular interaction and may perceive a different response is called for, perhaps a question or a practical suggestion.   Let’s say one spouse says “You’re not supportive” and the other says “What do you mean?” or “I did [this and that] which I think was supportive.”    The first is actually describing her experience, the feel of the spouse’s behavior.  The Spouse, however, is describing his behavior.  When I have encountered these interactions in couples counseling, it’s clear they are not discussing the same terrain.

To continue, a person may say, “You’re not supportive.” That is a judgment.  A therapist might say, “You didn’t feel supported.”  But the therapist should not empathize with a judgment as it condones that way of perceiving.  But does that mean the client feels disappointed, alone, hurt, abandoned, invalidated, helpless, rejected, OR infuriated?  In therapy, each possible emotion that is covered by the term “not supportive” leads FROM a different underlying dynamic and leads TO a somewhat different intervention.  When the therapist accepts the term or the complaint of “not supportive” in a session without further clarification, he or she condones a surface view without deeper examination: it implicitly sides with the complainant.  Thus, the interaction locates the client’s problem as external rather than as an examination of her need, her expression of her needs and wants, her history of relationships, or whatever other dynamic may be present.  Nor does it lead to a closer examination of the therapist’s behavior that may have evoked the complaint.

Note, supportive does have some highly specific meanings which are not buzzwords. It can be used in an effective way, such as “I am supportive of your idea,” where supportive essentially means agreement or encouragement.  Furthermore, it has been used for 100 years to mean Supportive Psychotherapy.  That is an undefined set of interventions used in a crisis situation, with a patient who has weak ego strength, or with a psychotic patient.  The interventions include empathy, using a calming voice, de-escalating situations, approaching the patient slowly, validating the patient’s point of view, patience, building trust, and highlighting the more effective defenses (e.g., intellectualization) and not reinforcing the less effective defenses (e.g., projection, acting out).  It may mean temporarily accepting denial.  It also mans avoiding confrontive or in-depth methods. So when a therapist refers to “supportive” interventions,  that would be an appropriate use of the term.

More Future Buzzwords

These words still have a precise meaning to professionals. But in common usage they are becoming muddled.  Some day they may be so imprecise that we will need to come up with new terms for the same phenomena.

Authentic – Carl Rogers defined ‘authenticity’ as the therapist’s full awareness and acceptance of his or her emotions and as communicating empathy sincerely (rather than formulaically). Optimally, we want the client to achieve this same state of awareness.  By being authentic, therapists can be more empathic and can better discriminate reality from client transferences.

Now the word is on the move! I have heard it used as a positive trait, as in, “I am being an authentic person.”  I’ve heard it refer to a positive state, as in, “I am being authentic with you.”  As a defect, “You don’t know how to be authentic.”  As a failing or accusation, “You are not being authentic.”  Such claims and criticisms belie the fact that, in ordinary conversation, authenticity is often far from useful.  For many situations in daily life, tact is more crucial than is total emotional honesty.  Total honesty can be used as a form of aggression.  If the opposite of authentic is tactful, acting, or playing a role while hiding one’s self, then often social effectiveness often calls for these niceties of behavior.

Finally, authenticity implies we know our feelings or thoughts in a situation; but we often have complex or even contradictory feelings and reactions. We do not want to dissemble or to be inauthentic, so what one says should be sincere and valid.  Outside of the behavior of therapists working with clients, we would be okay if we left it to mean an optimal or goal state rather than requirement.  Because the word is not all that widely used, it may not make it to buzzword status.

Bipolar, Mood Swings – Popularity may undermine the use of these terms. In common parlance, people are using bipolar to describe mood swings which are unexpectedly large and not immediately comprehensible.  Others use bipolar as if it were a trait, as in “My bipolar,” not because the person has Bipolar Disorder, but merely as a description of mood swings or even as an explanation or excuse for mood-driven actions.  “I’m sorry.  It was my bipolar tendency that caused me to lose my temper.”

Mood swings, as thought of by professionals, mean highly significant shifts in mood. So on a -5 (despair) to +5 (joy) scale or a -5 (raging) to +5 scale (calm, accepting), professionals use mood swings more or less to mean -4 to +4 or the reverse.  But in common usage, I hear mood swings used to describe any undesirable or rapid shift, as, for instance, when a person who is irritable and shifts from -2 to 0 or +1 – not a clinically significant shift.

Professionals may be contributing to this trend. The diagnosis of Bipolar Disorder may be, shall I say, sometimes in the category of a kind of fad, a term too easily applied, too many false positives.  I have three male clients, each of whom has been diagnosed as having bipolar disorder.  Since I have had the opportunity to spend many hours working with these men, I can say with some assurance that none have Bipolar Disorder and so mood stabilizing medications used for true Bipolar have not helped them.  Two of these men have symptoms of Major Depressive Disorder, Recurring, Chronic, without intra-episode remission.

One of them was diagnosed as Bipolar at a time when he was drinking too heavily, combined with taking (prescribed) benzodiazepines, and while also being subject to seizures. Another was diagnosed as Bipolar on the strength of a couple of questions during an outpatient psychiatry visit.  His MDD was determined to be Bipolar II.  He told me he was asked, “Have you even had a time when your mood was overly positive, so much so you had high energy and didn’t need to sleep as much?”  He answered in the affirmative, not because this positive mood was frequent or prolonged, but only because he had fleeting moments of those feelings.  He was given Depakote, but he reported no change in mood.

The third man was diagnosed as Bipolar, but when I took a careful history and asked, as I always do, about gambling problems, he reported a period of severe pathological gambling. That was when he received the Bipolar diagnosis.  Questions about typical behavior in heavy gamblers showed all the so-called “bipolar” behaviors were related to gambling, including not needing sleep, mood swings, irritability, and periods of euphoria.  When I saw him, his gambling problem was in remission and I found nothing more serious than a problem of Adjustment Disorder with Depressed Mood due to events related to a divorce.

These stories are three of a number of times my trainees or I questioned the client’s diagnosis of Bipolar Disorder, especially when the diagnosis was given to youth 10-18 during a crisis situation in an inpatient setting. [Just to be fair, the criteria for Bipolar were met in the majority of cases in which the diagnosis was given. Further, there were some false negatives, meaning cases not given the Bipolar diagnosis who probably should have been.]  My point here is that inaccurate usage by professionals contributes to the imprecise use of the term by the public, and some day “Bipolar” may become a buzz word as a result.

OCD, Obsessive Compulsive – I have heard “OCD” used as an adjective without the speaker intending to refer to ICD-10 or DSM-5 definitions of OCD, as in “That was awfully OCD of you,” meaning, highly organized or persnickety. Many people have very minor impulses towards checking behavior, which, when severe, is a sign of OCD.  Many people have very minor needs to create symmetry or to be overly concerned about odd and even numbers, or some other fairly trivial compulsion.  I say minor in that, unlike a person with OCD, the behavior does not dominate the person.  The person can check just once that she locked the car and then will be satisfied.  In contrast, the person with OCD may have a ritual number of times to check and spends considerable time checking and re-checking when he or she performed the behavior.  True OCD is a problem which can dominate a life.  As with Bipolar, OCD can be used to explain or excuse behavior.  It can be used as a complaint or criticism.  We professionals should use the term with care to use it accurately.

Professionals Using Labels for Methods

In the past couple of years, I have asked people interviewing for jobs at the post-Masters level (mostly recent grads) to describe the treatment approaches they favor. The most common answers are Cognitive Behavioral Therapy (CBT), Solution-Focused Brief Therapy (SFBT), and Motivational Interviewing (MI).  You know by now that I want to know specifics.  “What specific techniques in that approach have you been using most?”  For CBT, not one person in a long sequence of applicants said

Much more than pointing out inaccurate, dysfunctional thoughts. Few labeled them “automatic thoughts” or “core beliefs.”  None identified a single behavioral method within CBT.  None used measurement tools or thought experiments.

If the person mentioned SFBT, he or she didn’t tend to grasp the underlying philosophy that the client has the solutions and we can elicit and amplify them. None understood the idea of exceptions or the importance of subtlety in the use of language.  What many described seemed more problem-focused or more directive in the search for solutions to problems.  A few could reference the “miracle question,” but not its significance in a process.

As for MI, most gave answers inconsistent with the philosophy of empathic guiding. Their concept of MI was rather directive and involved making sure to point to consequences of the behavior.

This is not to indict schools or internships. Well, not severely, anyway.  But rather I am making the same point as with buzzwords.  Our role is to be precise and clear.  If one uses a term, know what it means.  If one knows about a therapy, be able to describe its theory of problems and pathology, its principles of change, and its major interventions.  MI is a form of intervention, not a therapy per se, which posits that much of what is termed “resistance” or “denial” is “sustain talk,” often induced by therapists putting pressure on the individual to change.  If one claims to know this intervention, know what MI research shows to be the factors which reduce or which increase motivation to change.

This difficulty explaining therapies is not limited to new graduates. Many therapists have difficulty explaining the theoretical rationale for interventions or the breadth of concepts in a school of therapy.  My point in presenting these observations is to highlight the tendency to use terms imprecisely until they have lost specificity of meaning.  Therapists should be careful to use words accurately.

The third paper in this series on buzzwords unpacks our tendency to use buzzwords. I suppose that people who came for interviews had some of the motivations I examine in that paper.  They may have been trying to convey a sense of status, of being part of the in-crowd, or of being highly knowledgeable.   They may have been using terminology they picked up in school or at an internship.   Regardless, they conveyed the opposite – lack of understanding and shallowness of thought.  Furthermore, when we use the name of a therapy loosely, we lose the power to explain what we are doing.  If we cannot explain, we cannot select treatments thoughtfully.

In written documents, avoid buzzwords. At the worst, the reader may perceive both the imprecision of meaning and a pejorative tone in the words.  Don’t use buzzwords in notes, reports, or letters.  The purpose of a document is to provide professional clinical assessment and judgment.  The document is meant to communicate to other professionals.  So it must be accurate.

In conclusion, in two papers, I have explicated a number of buzzwords and words that are heading toward becoming buzzwords.

1. Acting out
2. Anal
3. Attention, Attention seeking
4. Attitude
5. Authentic
6. Bipolar
7. Can’t stand it
8. Chemical imbalance
9. Closure
10. Co-dependence
11. Deal with it, Can’t deal with it
12. Denial
13. Empower
14. Energy
15. Evidence-based
16. Feel
17. Fight
18. Handle it, can’t handle it
19. Hyper
20. I can’t breathe, you’re smothering me
21. Issue
22. Let go, letting go
23. Listen
24. Manic
25. Move on
26. OCD
27. Over-reacting
28. People pleaser
29. Process, processed’
30. Resisting, resistance
31. Respect
32. Self-medicate
33. Shut down
34. Space, need space
35. Stuff it
36. Support

We’ll keep our eyes and ears open for precision in language and understanding. We can highlight and reinforce such accuracy in thinking.  We’ll keep our eyes and ears open for imprecise, vague language and work to improve it.

 

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© Don D Rosenberg, Version 1.0 2017

Buzzwords Versus Meaningful Words

Therapy Gems ©

Buzzwords Versus Meaningful Words

Buzzwords I: Common Buzzwords, Psychobabble, and Vague Jargon in Therapy

Version 1.1

LEARNING TO BE SPECIFIC AND DETAILED

One of my supervisors once told me, “Never ASSUME you know what the client means. Ask and analyze.”

As I was presenting the details of a case to another of my supervisors, he often would ask me to stop my presentation and to talk about the meaning to me of a client’s comment. He asked me to free associate to the comment.  From those intense, lengthy explorations, I learned that if we teach ourselves to think deeply about each bit of client ‘material,’ we find the riches contained in every detail and anecdote. Every comment represents a depth of understanding of our client and our own reactions, all of which can help us to help the client.

I once attended a staffing led by the famous psychoanalyst, Karl Menninger. He stopped the presenter after each fact or sentence and invited the group of us therapists to bring out all the meanings we could think of for each fact or detail.  Again, that was a lesson in the wealth of meaning in client communications.

Another influence upon me was the writings of the famous analyst, Theodore Reik, who wrote long, involved treatises exploring his thoughts which had been stimulated by a client’s single gesture or comment.

One of my supervisors, the co-founder of Solution Focused Brief Therapy, Insoo Berg, developed detailed future scenarios with her clients. Carl Rogers reflected specific emotions, working to be accurate and empathic.

All of these supervisors and masters had a common message for our understanding of the client, namely, to achieve specific, detailed knowledge of the meaning of the client’s words and ideas, and to communicate with the client in specific language.

So we see that everything the client does communicates all of herself or himself. Psychotherapy works best when the client experiences the therapist’s empathy and understanding, which in turn requires a depth of understanding.  We need a specificity of knowledge about the client and clear thinking about what each client uniquely presents.

Therefore, to repeat, never assume you know what the client means; ask, ask, and ask. Delve into the meaning.

ON BUZZWORDS

I mention these experiences precisely because I so often hear therapists not only fail in meeting this standard of specific, deep thinking, but almost going in the opposite direction. That is, I hear therapists use ambiguous, abstract buzzwords as if the words had a specific, conventional, consensual meaning.  These buzzwords have different referents for different clients and families.  So we can’t know exactly what the words mean to the client.  We definitely can’t assume the client understands a buzzword when we use one of them ourselves.

And worse yet, when we as therapists use those words frequently, we can assume our message to the client is that we will not think deeply, and we will not ask the client to think deeply; we will not consistently probe the client’s experiences and connect them to his or her difficulties; we will condone moving to the surface of life experiences; and we will partially support the client’s dysfunctional defenses.

Buzzwords are imprecise words, purposely vague words.  Therapists hear clients use these words, but they often do not find out their meaning to the client.

In contrast, jargon or argot means words with precise meanings which are esoteric, that is, known mainly to professionals in a specific discipline.  Psychology has an argot of hundreds of jargon-words which help us define and describe what we are observing.  Sometimes therapists use jargon with clients without explaining the meaning of the terms.  That is also a problem.

Many buzzwords, such as “stress,” began as jargon, but have lost their specificity of meaning as they have passed into popular usage. Eventually, words such as stress acquire a vague or general popular meaning.  Then therapists may use such words in their buzzword status rather than as professional jargon.

Some of the buzzwords are psychobabble, words which are pseudoscientific and always were, and which have an air of being plausible and useful.  But in the end the words are a way of revealing almost nothing specific.

This paper is a compendium of common buzzwords. First, we’ll discuss clarification as a way to underscore the point that buzzwords may block effective care.

CLARIFICATION

The most used of all therapeutic tools is the technique of “clarification,” meaning asking probing questions with the aim of gaining a more in-depth understanding of the client’s cognitions, emotions, motivations, and actions, and those memories which shape behavior. We ask CLARIFYING questions which are different from what may be used in common conversation. We may ask, “What do you mean by that?” “Tell me more about it.” “What comes to mind about _____?”  “When you think of that, what emotions go with that?”  “When you remember that, what do you think or say about yourself?”  “What emotions do you have now?”  “When you stopped talking, what came to mind?”  “Are you saying ______?”

CLARIFICATION gives depth and color to the client’s material.
The magnified anecdote shows us the details and truth in the story.

In common conversation, we may ask, “Why did you say that?” “What do you mean?”  “Explain that.”  As I think about those questions, they usually aim to promote a discourse or to challenge a point.  In contrast to our motives in common conversation, therapy is not meant to be a back-and-forth discourse, to be persuasive, or defeat the client’s point.  Clarification is meant to direct the client to self-understanding or to gather data about the client’s dysfunctional reaction patterns.

In contrast, buzzwords are not meant to clarify. They are more likely to obscure.  We may intend to use words which are intentionally vague in order to soften a message.  When we de-enervate the message in order to be less objectionable, we are not communicating clearly.

For example, let’s say the client has just said, “Two days ago, I was fired from my job for being late again, so I spent the next day in bed and didn’t have any motivation to move the entire day.” Then the therapist said, “That really stressed you out. You just didn’t know how to handle it.”   The client answered, “It sure did.  Right.”   Where do we go now?

The use of the buzzwords “stressed out” and “handle it” obscured the possibility of significant meaning in the client’s statement. Let’s use CLARIFICATION instead of buzzwords.   Let’s say the client has just said, “Two days ago, I was fired from my job for being late again, so I spent the next day in bed and didn’t have any motivation to move the entire day.”   Then the therapist said, “First, let’s go over what happened with the firing and then what happened yesterday.”  Cl: “When I got to the office to punch in, the HR Manager was right by the clock.  She said I was late for the third time and that holds up the assembly line.  ‘Violation of company policy.’  ‘You’re suspended for two weeks.’ I argued I was only 15 minutes late and there was traffic.  She said, ‘You’re supposed to plan for that like everyone else.’  Under my breath, I called her a name.  So she said, ‘That shows you just don’t get it, do you?  Get your things and I’ll escort you out.  You are fired.’  So I called her something nasty, kind of loudly, and she said, ‘That’s it!  Leave the building, now, and we’ll mail your stuff to you.’”

When the therapist tries to empathize without CLARIFYING the story, he or she not only could be way off base, but could be condoning psychopathology. Plus, a marvelous learning opportunity has been missed.  What riches are hidden in this story!  What memories or attitudes regarding authority figures could have been discovered?  Did the client use provocation as a response to feeling small and embarrassed or guilty or ashamed?  Instead of mending his ways, he became defensive and challenging, behaviors which will not work in too many social situations and which have roots we can understand.  What memories may have shaped his perception of the manager and his choice of defenses?

CLARIFICATION is essential in a variety of therapies. For instance, originally a method in psychoanalysis used to gather insights needed in order to make an INTERPRETATION, CLARIFICATION is used in cognitive therapy in order to extract the client’s automatic thoughts and dysfunctional beliefs from his or her experiences. In Solution Focused Brief Therapy, the therapists may seek to learn about an exception to the problem and then use clarifying questions in order to develop the story in detail.  Clarification is used in counseling generally in order to get a clearer sense of the client’s emotions.  Buzzwords and psychobabble fail to help clarify and, therefore, fail to lead to a rich understanding.

COMMON BUZZWORDS

Some of the most common such buzzwords used in therapy include these:

Act out, acting out – It is used to mean hostile behavior, including hostile words and tantrums. This has little to do with the precise meaning of the term. Acting out is a psychological defense in which the client expresses a conflict in action rather than in words.  Acting out is an unconscious process, not necessarily connected with aggression. It is not a label for the manifest behavior, nor is it limited to aggression.  Therapists should avoid the incorrect usage of this term and should rather describe the behavior of the client specifically.  If the person is talking back or swearing, say the person is confrontational, talking back, defiant, swearing, or what have you.  Calling it all “acting out” obscures the meaning and, besides, it is being used in a pejorative, often dismissive way.  For example, I recently received a call from a TV reporter asking me to comment on what parents can “to help their acting out children.”  This statement could have a variety of meanings.  It turns out he meant what can parents do to help children who often act aggressively as a result of a mental disorder.  By helping him ask a more specific question, I had the specificity needed to answer the question.

In another example, a 14 year-old with an Attachment Disorder kicked his mother when he felt criticized. He could not articulate how criticisms feel like statements that he is unlovable and cannot be kept, that he will be abandoned.  So his kicking rejects the statement, rejects to author of so painful and hurtful a statement, and demonstrates his inner hurt.  It gets back at the person who threatened his existence.  If we mean he “acted out” his feelings in the sense of expressing all those reactions through kicking, that is close to the meaning of the term.  If we use it only to refer to kicking as hostile behavior, that is using the term as a buzzword.  The former shows insight and attunement, the latter does not.

Take, for example, a 10 year-old girl with an Attachment Disorder whose first action was to walk briskly into the consulting room and, after the therapist sat down at the desk, to come up close enough to touch her hip against the therapist’s arm, and to say, “You’re my new therapist forever. What will be doing on that computer?”  This is acting out – she was showing through action her rapid, indiscriminate, superficial connecting with another.  But this was approach behavior, not hostile action.  The example shows further that “acting out” should not be used merely as a term for aggressive behavior.

Anal – It is used to mean overly organized or retentive (holding on to items which may not be useful) or retentive of feelings and thoughts. This usage bears little resemblance to the psychological meaning of psychosexual impulses and behaviors characteristic of the second year of life.  It is almost always meant in a critical way.

Attention – This is almost always used pejoratively for a motive for behavior, namely, to be paid attention to for attention’s sake. Attention-seeking is used to mean the attribution of a negative, almost frivolous or invalid motive for a person’s behavior, that is, to have someone notice.

This superficial view of behavior obscures the deeper need behind the behavior – love, connection, approval, attachment.

It is shockingly dismissive of the truth of the client’s behavior.  I heard this term from a mother in a session as she dismissed her daughter’s feelings of being cast aside when the mother remarried, “Oh, she just wants attention.”  Not an hour later, I heard the term used by a mother on a TV mystery show as she chose to dismiss her daughter’s allegation of sexual abuse against a family member as “Nothing but wanting attention.” Yet “attention” refers to necessary and normal interaction with important figures in one’s life, interactions which support sense-of-self and which provide essential positive reinforcement.  Saying a child is attention-seeking actually misdirects us from probing into understanding the child’s legitimate needs.  It implies the family should repudiate and reject the behavior rather than understanding the child’s needs and motives.   Therapists are supposed to use empathy and understanding, not dismissiveness, as a tool for change. It can be heart-breaking when a therapist lets this usage go or, worse, uses it herself or himself, such that a child’s bid for her mother’s love or an act expressing a need to be understood or validated is treated as nothing at all, merely, seeking attention.  Don’t we all need to be attended to?  What is the deeper need the client is showing?

Attitude – This term is used to mean disagreeable behavior, talking back, or non-compliance. But which is it?  It has become a vague global reference.  In psychology, an attitude is a disposition toward some object or situation, that is, a belief and an emotion about something.  Attitude tells us how someone thinks and feels about a thing.  That is an entirely neutral term.  The term should not be used to mean only a negative judgment of a person. When someone is described as having a “bad attitude,” the therapist should learn the detailed meaning of that statement.  What did the person do?  What about it is “bad?”  “What behavior would be preferred?”  “What will happen differently when that preferred behavior occurs?”  The use of the term attitude to mean negative behavior should never go unexamined.

Can’t stand it – This is a vague statement of a strong negative reaction to an event or situation, a reaction which taxes a person. But this phrase avoids speaking to the actual emotions being experienced.  Are they sadness, pain, anger, hurt, exhaustion, disappointment, disapproval, emptiness, resentment, loss, aloneness, frustration, irritation, etc.?  Are they reminiscent of an unresolved past experience?  Clinicians should ask what the client means when using this term.

Closure – Closure is used to mean a sense of being over an unpleasant experience in a way the person considers an acceptable way to complete or to ‘resolve’ that experience. But the word covers up the process and mental work needed to attain that emotional outcome, namely a reduction in emotional response and emotional conflict regarding an experience.  Seeking closure is actually a fantasy of how one hopes to feel given some psychological process by which the complex of thoughts and feelings attached to some event or person will be transformed.  Again, ask the client what is meant by it and how to know when it is achieved.

Closure is an end result. But what is the process? For therapy, the word ‘RESOLUTION’ is a better jargon term with the following referents.

• Memories of the experience cause no significant distress or impairment.
• The person is relatively comfortable talking about it.
• The memories are experienced as part of history, as something from the past, rather than as something vividly and emotionally present.
• The person conceptualizes the event narrative with language suggesting mastery, survival, forgiveness, successful coping, personal effectiveness, or pulling through.

So when the therapist refers to an experience as resolved or unresolved, he or she has in mind specific elements and, in the latter case, techniques to help move towards resolution.

Dealt with, deal with – This is used to mean coped, worked through, or processed. “I can deal with it” may be true, i.e., the person can think about it without impairment, or an untrue statement meant to discourage discussion of the event or memory or situation. “I can’t deal with” is ambiguous, suggesting feeling overwhelmed, easily upset, unable to accept. What does it mean to “deal with” something psychologically?  Talk about it?  Think about it?  Confront someone?  Come to a new understanding?   Stand up to the situation?  Cope effectively?  Assert feelings?  Feel at peace?  The therapist should be looking at the process and not accept vague language.  For example, if the therapist said, “You dealt with that effectively,” the therapist wasted an opportunity to reinforce a specific skill or coping strategy.  It would be better to highlight and reinforce the new skills, saying, “You showed restraint, tact, and thoughtfulness when you spoke with Johnny and tuned into his state of mind empathically.  Think how far you have come from when you used to scold him for this behavior and that didn’t work.  But now you suppressed that urge and really worked to understand his feelings and it helped tremendously.”  So “deal with it” is not an expression a therapist ought to use.

“Deal with” is also used in another way, saying “I can’t deal with that.” What does it mean?  Tolerate? Face the emotions?  Feel overwhelmed? I have heard therapists say something from a class of possible statements such as, “You didn’t deal with the feelings from your divorce.”  What does it mean?  Anything from “You have felt depressed over the sense of loss” on one side to “You have been resentful over how it ended and you’ve been acting hostile and obstructive as a result.”   The escape from specificity in using a buzzword such as “deal with” is virtually anti-therapeutic.

Empower – The term is used loosely to mean to support client autonomy, assertiveness, and self-determination; but generally we see the usage narrowed to encouraging the client to make a decision or take an action. E.g., “I empowered her to stand up for herself.”  Now there is one vague and illogical, but all too common, statement.  Furthermore, by focusing on one action, the therapist has contradicted the very possibilities of the term itself – namely, the possibility of becoming empowered as a person, that is, autonomous and self-determining.   She is taking credit, which is anti-empowering.

The term derives from social, political, and economic processes which help groups of people gain control over their lives in the political arena by acting on the positions in which they believe, specifically, acting against a prevailing power structure. If the therapist means to engage the client to make decisions and follow through, such as to overcome dependency or to develop identity or to use assertiveness skills, then say just what the client does.  To use the word ‘empower’ is to use much more vague language which focuses on the therapist’s actions and not upon the client’s demonstration of competencies which can be reinforced.

In a sense, one can’t really empower someone! The client is demonstrating personal power.  If the power is only given or permitted (by the one empowering), then it’s not true personal power.  So when therapists say they empower the client, they would be advised to describe their intervention in more psychological terms, such as ‘used assertiveness training’ or ‘helped the client lay out pros and cons’ or ‘highlighted the expression of personal authority’ or ‘the client used assertiveness skills such as non-reactively stating her bottom line position.’

Feel – “Feel” is too often misused to mean opinion or attitude rather than emotion. One should be clear whether she is asking “What is your emotional reaction to that?” or “What thoughts or opinions do you have about that?”  When the client talks about a reaction, be clear whether the person has articulated an emotion or an opinion or a judgment.  Has the client given an affect or his/her theory of the situation?  If we accept the vague use of “feel,” we have not asked the client to probe the self first, to come up with an accurate ‘theory’ based upon exploration of the facts and details of his or her reactions and emotions.  When the client responds to a question of feeling by giving an opinion, the therapist might say, ‘Oh, that is your opinion about it, but what did you feel, your emotions?”  “You are giving your notion of why that happened, but first let’s get all the thoughts and emotions out and come to an understanding of what it means for you.”  “ You are coming up with your judgment of the situation before we have explored your emotions and the meaning of it.  Let’s hold off on that judgment and explore it first.” This is a message about the level of specificity required in effective therapy.  One of the most common statements in a therapy session is “What do you feel about that?”  Unless we have taught the client that we mean “What are the emotions you have in reaction to that?” then the answer is just as likely to be an opinion as an emotion.  If we are looking for an emotion or an opinion, we need to be clear which it is that we seek.

Fight – For therapy, fight is a word which could mean difference of opinion, disagreement, argument, quarrel, or some kind of violence. Its meaning must be exactly specified.  Using a word which better conveys the severity and intensity of the situation will help the client better differentiate amongst levels of conflict.  Many clients overstate a disagreement by calling it a fight.  Others understate violence by calling it a fight.  To me, a fight means an upsetting, vociferous, non-violent conflict in which hostile, critical words are expressed.  An argument is a step down.  Hitting or pushing is a step up in severity.  A therapist who finds out the details of the event and labels the event correctly is better positioning the participants to understand the dynamics and learn to change.

Handle it, can’t handle it – [Also look to the paragraph about “deal with” above.] There are used to mean a capacity or incapacity to face a difficult situation. By what means does or did the client work through feelings about a situation?  What coping or defense mechanisms are employed?  What cognitive beliefs?  “I handled it” does not tell us the strengths used.  “I can’t handle it” does not tell us the emotions experienced.  The command, “Handle it” and the similar phrase “Get over it” completely underestimate the psychological work which needs to be done and how it is done.  How can we help encourage successful coping if we do not specify the skills to use and put them into language?

Issue – When I hear the word, “Issue” used in a statement in therapy or in a case conference or even when a therapist is referring to her own internal challenges, I hear the person intentionally softening the statement and presenting an intentionally vague picture. This word “issue” has multiple meanings, such as, an unsolved problem, a difference of opinion, neurotic thinking, etc. It is often used to mean a statement which disagrees with another person or confronts the other person, as in “I have an issue with what you said.”  “You have issues.”  Better would be to say “I disagree” or “I disagree with what you are thinking” or “I am concerned with your thinking on that subject.”  The word ‘issue’ ends up being critical and accusatory, while being meant purposely to be vague.  “I have an issue with that” merely means I disagree.  “You have an issue” means questioning the other’s position or thinking.  It is also meant to mean “You seem irrational or disturbed.”  If the word is meant to be critical, it leaves the recipient with no clarity about what to do, what the objection may be, or what changes may be desirable.  Like “Handle it,” “You have issues” is yet another term which glibly implies the person should repudiate some thoughts, behavior, or opinion. Clinicians know that changing is more complex a process than that!

Let go, letting go  – This is used to signify ending of responding to a loss or a painful experience or dashed hopes, disappointments, and expectations.  This is especially vague as it does not address how the person is to accomplish resolving the experience and what the outcome of that process may be.  Is it a process of mourning?  Adjusting expectations?  What are the emotions the person must work through?  What does it mean to say “I let go of that.”  It also violates normal processes of grief – it takes time and psychological work to recover; one cannot “let go.”  So as with some other buzzwords, it is dismissive.  Find out about the client’s emotional experiencing.

Listen – In today’s parenthood, “listen” is almost always used to mean comply or obey rather than to hear.  If compliance is intended, the therapist will be more effective if words such as comply or obey are used.  Furthermore, the word ‘hear’ might be meant when we communicate with someone with ADHD or a teen fiddling with a smart phone or hiding under a jacket.  Or perhaps both hear and obey are meant.  Get it straight.

Move on – Similar to “let go,” this term is used to mean leaving behind a conflictual or unpleasant situation or an injury. But the term obscures the underlying process, the emotions involved, the reasons the event was troubling.

Overreacting – This is mainly a critical term meaning to respond with excessive drama, emotion, or display. Saying someone is overreacting dismisses what the person is trying to express.  Perhaps drama is the person’s way of showing the event had a major impact.  Perhaps the person doesn’t expect to be heard or understood otherwise.  Or perhaps the reaction is based upon catastrophic beliefs or the reawakened memory of an old hurt.  Clinicians should find out what is behind the reaction.

Process, Processed – “Process” has two meanings. 1) When used as a verb, it means discussed, reviewed, or talked about.  I think therapists use this to mean something much more, namely, coming to the point of understanding or insight, then working it through.  [See the discussion of “closure” above.] The psychological processes involved are much richer than the term “process” implies.  It would be more helpful to spell out the psychological work which has taken place.

2) ‘Process’ can also mean a sequence of interactions in a session, each one stimulating the next, displaying the client’s patterns. This is jargon which has a useful meaning in a case conference, but little meaning in therapy.  “Your interaction” or “The way each reaction followed from the one before” would have more meaning for the client.

Respect – Generally this is used to mean follow directives, complying, speaking courteously to another. But the meaning is idiosyncratic; each person using the term means something different.  One should always make sure to know what the client means by the term and the therapist should not use ‘respect,’ but should use that more specific meaning.  Asking a child to “respect” a parent would give the child no map as to the desired behaviors  — compliance, obedience, fear, mutuality, thoughtfulness, valuing, validating.  Furthermore, the range of behaviors could be so broad that the child would have difficulty approximating what is expected.  The same problem occurs quite frequently in couples counseling.  “You don’t respect me” is more a statement of feeling and judgment and not much of a guide to improvement.  The meaning could be an indictment of the partner as ego centric, a statement about feeling dismissed, a statement about feeling alone and not valued or not appreciated, or any number of others meanings.  Therapists should be getting a specific list of the meanings behind such a statement and of the desired behaviors.

Shut down – This term is used both to mean the client is not talking or the client is not sharing emotions. It could also mean having no feelings.  The term has absolutely no psychological meaning or utility.  Rather, the therapist should refer to the process behind the observation, namely, constriction, flattening of emotion, numbing, inhibition, resistance, suppression, blocking, anxiety, repression, etc.  ‘Shut down’ is a way of characterizing the behavior in vague terms which does not permit us to know the underlying process.  If a client is told he is shutting down, what is he supposed to do with that?

Space, as in “I need more space.” – Also, “I feel smothered [engulfed].” This is not a term therapists are likely to use, but it is one they will hear.  What could this mean?  I want to break up?  I am not comfortable with you?  We are becoming close more quickly than I can trust? I have avoidant attachment style, so increasing closeness makes me anxious?  I feel my independence is compromised?  I have made plans to separate?  I don’t want an exclusive relationship?  You are too demanding?  When this phrase comes up, it is important to clarify the meaning.

Stress, stressed out – This term has an indeterminate meaning, but could refer to one’s reaction to a change or a group of events. It could just be used to mean a pile up of challenges and difficult things to do.  Does it mean pressure, press of events, having too much to do, or deadlines?  The term “stress” as defined by Hans Selye, who introduced it to medicine, has a scientific meaning in psychology of demand for adaptation which elicits adrenal hormones and causes wear and tear on the body.  “Stressor” is the proper term for external events.  Stress is about the body; stressor is about the environment.  Any other use makes the terminology vague and unclear.   Rather than use “stressed,” it is more helpful to refer to the underlying events and to explore the client’s reactions.  “When you say you are stressed, let’s look at what events make you feel that way and just thoughts and feelings they stir up.”  Rather than reflect “You are so stressed,” better would be “Having to react to a loss and then to financial troubles leaves you scared and interrupts your sleep.  You seem to be blaming yourself, and those thoughts make you depressed.”  You can see that getting away from the buzzword leads to more possibilities, such as exploring automatic thoughts, interpreting the defense of turning against self, or reviewing the entire process around the client’s reaction to the loss.

Support – This term is so broadly used that I’m not sure of the meaning of the usage! Some people use it to mean agreement or backing the person up on what they believe and do.  The broadest meaning is encouragement.  Most often it is used to criticize what someone else is or is not doing to agree with, accept, or encourage one.  Again, it is important to ask what the user of this term means by it and then not to use it in therapy.  The therapist uses terms which get at the specifics, such as, “So you think you are being criticized and you feel disappointed.   You were hoping to have your idea encouraged rather than critiqued.”

CONCLUSION

In conclusion, “Never ASSUME you know what the client means. Ask and analyze.”

We can add that when a client uses a buzzword, never assume you understand what the client means. It could be an unconscious attempt to be vague or is overtly dismissive.  It could have a referent for the client which is not shared in the therapist’s mind.

Probe for the meaning. Don’t let it go by.

Furthermore, never use a buzzword with a client or about a client. It shows a lack of incisive professional thinking.  That is counter-productive because it condones the client being imprecise as well and it supports avoidance, which then supports the client’s problems.

Lastly, besides the disservice done to the therapy and the client by using buzzwords and not asking for elaboration, the use of buzzwords does a significant disservice to the therapist as well. It prevents the therapist from developing, that is, from learning some of the hallmarks of good clinical work, such as

1. how to describe the dynamics of the client’s behavior
2. how to delve more deeply into a client’s emotions, cognitions, and memories (clarification)
3. how to perceive and describe deeper patterns (insight)
4. how to explain the thinking behind our choice of interventions
5. how to think incisively and with due complexity about therapy.

If you find a buzzword escaping your tongue before you can catch it, correct it. For example, “How did you handle that?” [Oops] “What was your thinking and feeling then?”  Or “What did you do then? “ Or “What were your responses to that?”

For another example, “You say you are stressed out. That means different things to different people.  So let’s make sure we fully understand how it is for you.  What is it like for you?” Or, “What feelings make you say that?”

For another example, “So you say you want him to show respect. Let’s make it crystal clear what that means to you, what he will be doing that you are looking for and can appreciate.”  Follow up with, “What are the ways you will know it?” and then also “Ok, then also what behavior would you like to see less of?

We guide people to understanding how the assumptions behind their thinking can be examined, challenged, and changed. We guide people to understanding how past experiences shape their reactions so they can change.  All this requires specificity and a detailed understanding of the individual.  Our tool is language and we use it to communicate.  So let’s not obfuscate the meaning; rather, let’s be clear, incisive, thorough, and detailed in our understanding.  Never assume you know what the client means; ask, ask, ask.  Never assume the client knows what you mean; explain, explain, explain in clear language.

************************

© Don D Rosenberg, Version 1.0 2012, Version 1.1 2017

Clinical News You Can Use

Adult ADHD: Medication Plus Cognitive Behavioral Therapy, Latest Research

An article by Sanjay Gupta*, “Talk Therapy Alone for ADHD Doesn’t Cut It,” reviews a recent multi-site study of treatment for Adult Attention Deficit Hyperactivity Disorder [ADHD]. In sum, “talk” therapy does have a significant benefit, but it doesn’t benefit ADHD symptoms quite as much as medication or the combination of medication plus therapy.

Treating ADHD means BOTH

1) improving symptoms of concentration, focus, and memory with medications AND

2) developing skills for organization, social behavior, following-through, remembering responsibilities, and anticipating consequences.

The research addressed mainly the symptom domain.

We have known since the 1980s that “psychosocial” therapy, such as individual psychotherapy, group therapy, or social skills training, does not significantly reduce the symptoms of most children with ADHD unless medication is also used. The most common medications for children with ADHD are formulations of one of four drugs,

1) methylphenidate (e.g., Concerta, Daytrona, Focalin, Metadate, Methylin, Ritalin),

2) dextroamphetamine (Adderall, Desoxyn, Vyvanse),

3) atomoxetine (Strattera), or

4) guanfacine (Intuniv, Tenex).

A child may do well on the first drug chosen. But often, one drug may have unwanted side-effects or weak benefits for that child. So then a different one of these drugs needs to be selected. Sometimes, the child benefits more from taking the drug twice per day. Depending upon other behavioral symptoms besides those of ADHD, some children receive a second medication, such as Clonidine (catapres), riperidone, or an anti-depressant.

Adult ADHD Outcomes

The recent German study published by Alexandra Philipsen, et al, in JAMA Psychiatry shows the same is true for adults with ADHD, adding medication produces more benefit than therapy alone. The researchers analyzed data from 419 patients who had been randomly assigned to one of these four conditions: methylphenidate, individual therapy, structured cognitive behavioral group therapy, or placebo. Simply stated, the methylphenidate group experienced larger reductions in symptoms than patients in the two therapy conditions. The main measure was the ADHD Index of the Conners Adult ADHD Rating Scale.

The implications of these findings are of special importance for mental health professionals and ADHD patients.

1. A reduction of 20-25% in symptoms can be achieved by a combination of therapy and medication.
2. Medication should be added to the treatment regime in order to boost the improvement.
3. Realistic expectations are important. The state-of-the-art approaches lead only to modest gains in ADHD symptoms.

The study only measured the overall ADHD Index on the Conners. (CAARS) Note that in addition to measuring how closely the patient’s symptoms match DSM-IV symptoms for ADHD, the Conners also measures various other symptom domains as well.   We present these in order to clarify that a person with ADHD has both SYMPTOMS, as measured in the study, and IMPAIRMENTS, that is, areas of functioning which are limited by ADHD symptoms.

1) Inattention-Memory Problems – Since Working Memory deficits are thought to be central to ADHD, many patients have problems with concentration, short-term memory, forgetfulness, absent-mindedness, disorganization, and planning.

2) Hyperactivity/Restlessness – Many, but by no means all, patients feel or appear restless and have trouble sitting still.

3) Impulsivity/Emotional Lability – Many experience rapid shifts in mood (not to be confused with Bipolar Disorder), irritability, making snap choices without stopping to think about consequences.

4) Problems with Self-Concept – Lifelong difficulties with relationships, academic performance, and choices lead to a loss of self-esteem, a poor sense of competence.

The study did not determine if the treatments led to improvements in the range of domains and impairments. Nor did the study look at long-term skill improvements specifically. However, since Conners scores did not go down much in the study overall, we see that, without medication, patients lagged in the acquisition of new skills.

 

In recent years, an industry has arisen using coaching as an intervention with adults with ADHD. Motivated individuals can benefit from coaching or working with a psychotherapist to improve follow-through, completing important tasks, social interaction and relationships, and self-concept. The Philipsen study suggests that medication may enhance the ability to learn these crucial skills.

Lastly, ADHD is a lifelong condition. A person with ADHD learns

*to manage the symptoms

*to overcome the impairments,

*to acquire skills for effective performance in school, work, partnering, family life, and in the community

The study should not be read to mean that medication alone if the answer. Therapy or coaching is essential to helping many ADHD patients to manage the social, occupational, and educational effects of their primary ADHD symptoms.

*Click here to read the Sanja Gupta article.

Click here to read the abstract of the Philipsen article. 

The entire article reference is:

Philipsen A, et al (2015). “Effects of group psychotherapy, individual counseling, methylphenidate, and placebo in the treatment of adult ADHD. JAMA Psychiatry, 2146.

If you have more interest in the Conners Adult ADHD Rating Scale (CAARS), here are two sites which give examples of scoring for the CAARS and a breakdown of the symptom domains measured by the Scale, which include the major areas of difficulty in adult ADHD. The scale itself is only available to trained mental health professionals.

CAARS: Long Version (CAARS-S:L)

CAARS: Short Version (CAARS-S:S)

If you want to dig deeper into the professional literature on Cognitive Behavioral Therapy for ADHD, a good place to start is this review:

Knouse, L.A., & Safren, S. (2010). Current Status of Cognitive Behavioral Therapy for Adult Attention-Deficit Hyperactivity Disorder. Psychiatric Clinics of North America, 33 #3, 497-50

This link to the Knouse and Safren article on PubMed brings the reader to a number of other articles on this subject:

Current Status of Cognitive Behavioral Therapy for Adult Attention-Deficit Hyperactivity Disorder

 

Therapy Gems: It’s Okay to Be Yourself in Progress Notes

I never knew myself as “Wr.”

I never referred to myself in written psychotherapy documents as “This Writer.”

The term “This Writer” has always felt to me to be discordant, as dissonant as screeching.

As it seemed to be a harmless practice, I did not tell my trainees to change the habit of referring to themselves in the third person, and I failed to examine my reaction in depth.

A few days ago, Lynn Godec and I were reading the notes of a client we needed to refer after her therapist decided to move out of the state. Reading this note, Lynn and I together grasped the deeper meaning of my displeasure at the terms “Writer,” “This Writer,” or “Wr.”  The therapist’s initials are LY.  The client is referred to by name, by her initials, JZ, or by Cl.

PROGRESS NOTE VERSION W

Cl came for the first of three final individual sessions. Wr. informed Cl at the end of last session that Wr. will be leaving at the end of the month.  Wr. and Cl spent most of the session processing this event, including Cl’s feelings of loss and disappointment, as well as Writer’s recommendation to transition to another therapist in the clinic.   Cl has hx of depression and SI, but reported no SI in this session.  She said she understood, and that she has had to change providers in the past.  Cl is open to Wr’s suggestions.  She reported since last session she was at the ER as a result of a bout of fear, tachycardia, and difficulty breathing which turned out to be one of her panic attacks. Wr. connected that event with the news imparted in last session.  Questioning uncovered her projections around why Wr. was leaving, which Cl had personalized.  Worked on a cognitive restructuring task and forecast other feelings about this transition would come up, to please bring that to the next session.

DR: For such an emotionally intense experience, doesn’t “WR” sound kind of distant.

LG: Yes, it seems too objective

DR: It’s odd.  It denies the intimate connection that Joy (meaning the client) feels, her anxiety, like there isn’t a relationship.

LG: The whole point of the note is the meaningfulness of a relationship and attachment for the client.  If the therapist wants it to sounds to objective all the time, that practice troubles me.

DR: Exactly.  Oh, if the therapist did it so much in this one session, more than in other notes, we could guess she is having a problem with clients’ feelings about her leaving, or is ambivalent about leaving.  It is a hard part of professional life to change jobs, to say goodbye to 30 clients and help that many new ones at a new job all in a couple of months.

As the conversation continued, I realized that in my job in business management before I went to graduate school, I followed the practice in business correspondence of using the first person. If I were giving my opinion, facts, or a promise, I referred to myself as “I.”  If I were referring to a process involving others at the company or a company commitment, I used the first person plural, “We” or the name of the company.

From day one of graduate school, I trained as a psychotherapist. My only jobs in the field over four decades, all three of them, were therapy jobs. The first was as a therapist on an inpatient unit.  The second was in a non-profit clinic. The last 25 years have been in a solo practice which morphed into a large private therapy clinic.  I had not trained in one of the many professions that therapists often do before becoming psychotherapists, especially, nurse, teacher, school social worker, protective service worker, case manager, discharge planner, residential treatment therapist, autism line therapist, psychometrician, and others.  Perhaps in some of those settings, therapists learned to speak of themselves in the third person.

On the other hand, I always referred to myself in notes as “I” or by my initials, “DR.”  For variety, I use “T” for therapist, but mainly to indicate a back and forth dialogue between Cl and T.

DR: Writing notes is almost more subjective than objective. We are not video recording the session.  We choose what to write, what’s salient, want we want to remember, how we will describe what happened.  We analyze the session and record what our clinical thinking tells us is important.

LG: It’s like trying to sound objective by using the third person, as if the therapist were watching the two parties interact and describing that from a step removed from being there.   S, that makes me wonder if therapists who write that way try to place themselves in that stance with the clients!

DR: That’s a scary thought.

So I think we nailed it. Psychotherapy is a process in which the healing factors are a strong therapeutic relationship founded upon these factors:

• genuineness
• emotional honesty
• positive regard
• empathic attunement
• instilling hope
• a therapeutic alliance based upon rapport, the result of all these relational factors, and client-therapist agreement on the goals and methods

Interactional subjectivity, on the one hand, and self-observing objectivity on the other must be present together.  Client and Therapist are in an experiential relationship, the interactional, subjective side, and the therapist is paying attention to the process between them and the process inside each of them, the self-observing, objective side.  However, making the therapist an object also objectifies the client.   That does not seem to fit with the core healing factors.

DR: It feels like “Writer” is a violation of what therapy is about.   I wish our staff would write notes that show how well they are interacting, that they are connected with the client.

LG: Try re-writing that note. See if it makes a difference.

VERSION “I”

Joy came for the first of three final individual sessions. At the end of last session, I told her I will be leaving at the end of the month.  We spent most of this session processing this upcoming event, including Joy’s feelings of loss and disappointment, as well as my recommendation to transition to another therapist in the clinic.   Cl has hx of depression and SI, but reported no SI in this session.  She said she understood, that she has had to change therapists in the past.  Joy is open to LY’s suggestions.  She reported since last session she was at the ER as a result of a bout of fear, tachycardia, and difficulty breathing which turned out to be one of her panic attacks.   LY connected that event with the news imparted in last session.  Questioning uncovered her projections around why LY was leaving, which Cl had personalized.  Worked on a cognitive restructuring task and forecast other feelings about this transition would come up, to please bring that to the next session.

Reading version I, I feel closer to the interaction.  An important therapeutic byproduct is sensing I have a better grasp on the client’s process.

DR: I feel I sense Joy more, understand her better. Feeling her more directly in the first person makes it easier to see what is happening with her.

LG: So, as the author of the note, we aren’t writers; we should write like we are therapists.

Just to be sure it makes a meaningful difference, I read the two notes to a few non-therapists. Here is a sampling of some comments.

“The second one is comprehensible.”

“The first one is confusing.  I had to ask a lot of questions to grasp what she was saying.”

“The second one is more insightful.” I pointed out the content is the same.  “But it feels it has more insight.”

“The first is just inappropriate.”

“That writer is not a writer.  She’s a therapist.”

“It’s like putting the therapist four steps away from her place as therapist.”

“I would not want to see that therapist.  I don’t see she cares.”

So, I am not the only person finds the wording “This writer” to be incongruous with the role of therapist.

My recommendation is that therapists write notes in the first person and my hope is that no one causes me to read such dissonant notes anymore.

P.S. While I am discussing the use of “Writer,” I will add that the word “Provider” has troubled me since around 1988-1992 when the term came into common use.  Our status as Psychologist, Clinical Social Worker, Licensed Counselor, Marriage and Family Therapist, etc., was changed by Managed Care Organizations to “Provider.”   To the MCO, we are all roughly equivalent.  The first tier consideration for how referrals are doled out is by zip code.  Specialty areas are second-tier factors.  Actual profession is not a significant factor in the process.   Strikingly, professionals seem to have accepted the appellation of “Provider,” have signed “Provider contracts,” and, in the case of those companies for which is it difficult to  become a “Provider,” welcomed the opportunity to be on the “Provider panel.”  All that is necessary to survive in the profession; if we want to be paid for our work, we have to do this.  I am not suggesting we all rebel.  What I am suggesting is that we be proud of the arduous paths we have taken to get to be psychotherapists. I am also suggesting we attend to a larger subject, namely, care in the use of language.  Just as the connotative meaning of “writer” can be dissected and produces a different experience than “I,” so too “provider” produces a different experience than “psychotherapist.”  My hope is that therapists will become more conscious of the way in which they use language.

In the News: 30,000,000 Words

At a child’s birthday party one afternoon, while a few of us older folks were watching the kids play soccer and color masks, we were in essence discussing child development. The advancing skills of these children, aged four to six, amazed us. They were learning to play by rules, kick the soccer ball with authority, paste stickers in neat designs, cooperate, share, and focus. They made up cooperative rules for competitive games. They played together without frustration, aggression, or injuries. They played with almost no adult supervision.

Disparity in Childhood Verbal Experiences

Just as amazing is the realization that most children in this age group could master many of these self-control, self-regulation, and social interaction skills. The children we watched are from professional families. That brought to mind a remarkable piece of research. I referred to the study contrasting these children of affluence, from highly educated families, with the many children we see in the clinic who come from less well-off families which have less educational attainment. As I recalled, a study showed a three million word difference between how much verbal input higher income-higher education families provide their children by age four as compared to low income- lower education families. These are the words of interaction from the parents.

I was startled just repeating the number. The others were astonished by that magnitude of difference.

Later, a teacher at the party pointed out my mistake. That figure is not the enormous number of 3,000.000.

No, I was off by a factor of 9, namely, 27,000,000 words. The true figure is 30,000,000.

Thirty Million Words

I double checked the information. Indeed, a long term study by Betty Hart and Todd Risley found the difference by age 4 is 30,000,000 words, about 1200 words per waking hour throughout the first 4 years. Even if we criticize the study on the basis of a small sample or the manner of extrapolation from the limited observations in this study to the child’s entire early life experience, and even were we to do the study with a larger sample, the difference likely to be found in subsequent studies is still going to be so very enormous.   Plus the difference between these class groups is fairly stable over time.

The impact is that by age three, the vocabulary of children from the highest educated group exceed that of the lower economic group by a factor of 2 or 3.

Not only did the less advantaged children have smaller vocabularies. They added new words more slowly. In other words, the gap continued to expand.

Gaps remained mostly stable when the kids who were 2 or 3 were measured again at age 9 or 10. We know that vocabulary size is associated with higher levels of income and attainment. Hart and Risley raised the concern that children in the least advantaged circumstances may not have the vocabulary needed for understanding standard books and high school textbooks.

Furthermore, educational efforts to overcome the disparities were dwarfed by the impact of family communication patterns. Educational experiences did not significantly close the gap.

The children in the study were observed interacting with their families. The children were equally nurtured and well cared for regardless of economic status.. So the findings cannot be attributed to factors other than the amount of verbal communication in the family.

A Discouraging Word

We know that positive reinforcement, celebration of achievements, approval, recognition, and the expectation of succeeding are powerful motivators. Children often need a push in order to try tasks that are difficult. They need positive reinforcement for their new skills and learning. What might happen if they received less of those important positive words and far more negative words – words which prohibit activities, criticize performance, or point to what was not going well?

Children tend to live up to (or sometimes down to) what is expected of them. Expectations of success are often met with greater effort. Expectations of failure can be demoralizing. So the study’s findings about positive versus negative motivators were also astonishing. In the study, it was not merely the volume of words which differentiated the groups. Along with the sheer number of words, Hart and Risley counted words of encouragement and praise versus words of discouragement. They found a large difference in how much praise and encouragement children receive. Higher economic status was associated with about six words of encouragement to each word of discouragement. In working class families, the ratio was about 2:1, meaning life for those children was far less encouraging.

For thirty years, the authors had been focusing efforts on helping children from poorer families to achieve higher educational attainment. Much of their work was at a center which worked with children from poor families or on welfare. So, in what they termed “welfare” families, the ratio of encouraging-to-discouraging words was reversed from other families, that is 1:2, meaning twice as many discouraging words which, in effect, totally dominated the positive words. The authors observed a phenomenon we often see in the clinic, namely, these families used far fewer parent-child interactions, with more of the focus of interactions being centered on prohibiting behaviors, on socialization, and on disciplining. It is not that other families neglect these interactions, but they are more likely to control or socialize by reinforcing desired behaviors and encouraging appropriate responses.

Furthermore, higher economic class families spend a lot more of communications expressing encouragement, with its connotation of higher expectations.   In the professional families, the children heard 560,000 more words of encouragement than discouragement over four years. The gap for a working class family was only 100,000. The raw number of positives was less than half of that in the higher income families. So those children received a great deal less of positive reinforcement and positive expectations.

Children in the ‘welfare’ families received 144,000 less encouraging words than discouraging words. That means they heard 300% more discouraging words than the children from the more educated homes. The number of encouraging words was also far less than those heard by working class families, actually about 140,000 fewer.

Lastly, the authors report the ‘welfare’ families showed far fewer “back-and-forth” conversations, more one-way conversations. This tends to sound as if effort, abstract reasoning, presenting a reasoned argument, discussion, and listening to children were less valued in those families.

We know that a baby’s brain over-produces neurons, those potential connections it will need in life. Then the brain prunes away potential connections which prove to be unnecessary for adaptation to the child’s environment. We know that an enriched early environment leads to more connections, meaning more memory, more verbal capacities, more learning. The brain whose adaptation is stretched in order to manage a richer environment should be better able to manage a variety of environments in the future and to accomplish more problem-solving, more achievement. In earlier life, this would translate into higher school readiness by age 5. In the study, it translated into higher educational outcomes across the board.

Clinical Implications

We want to put these stunning findings to use in our work. Where Hart and Risley are concerned with early childhood education, we are concerned about mental health and behavior change. Psychotherapy has often been mainly a verbal endeavor. But this study is a reality check on the methods clinicians value.

1. Our methods must be adapted for children who may not be as verbally-oriented as may be needed for standard individual therapy or even for cognitive therapy. Clearly, in clinical work with children, we should always check that the child fully understands the clinician’s comments. Children may take language which is figurative in its concrete sense. We also assume children use oral, verbal methods for thinking through problems and making changes. But that may not be the preferred channel for behavior management for the child and family where the child is not used to positive verbal management of behavior.
2. Also cogent is the finding that the parents and children are highly matched in verbal patterns. More of the families in the study relied on approaches which are only somewhat positive and encouraging or predominantly not positive at all. Since we know that positive reinforcement of behavior increases its frequency, and we know it is a more effective strategy than punishment, so our methods must help transform family interaction toward the positive. That means reinforcing both generations for positive behavior, the parents for positive strategies and words as well as the children.
3. Many parents will expect a “disciplinary” or punitive or negative approach. We do not want to argue about that. It may be that the alternative we offer is outside the family’s framework. The clinician will need to find ways to demonstrate a new approach and to shape new interactional behavior without using persuasion or argument.
4. When we use play or activity-based methods of therapy, it seems we should verbally mediate the play – labeling every feeling being expressed, re-stating the child’s actions in words, highlighting in words each skill used by the children. By verbalizing, we are demonstrating a new way of interacting. We are also increasing the reproducibility of the behavior. The same principle applies to the behavior of parents!

I leave it for others to think of even more creative or effective ways to use the 30,000,000 word findings.

For more information, check these sites.

Hart, B. & Risley, T.R. “The Early Catastrophe:The 30 Million Word Gap by Age 3” (2003, spring). American Educator, pp.4-9 http://www.aft.org/sites/default/files/periodicals/TheEarlyCatastrophe.pdf

http://centerforeducation.rice.edu/slc/LS/30MillionWordGap.html

https://www.facebook.com/TMWproject

http://thirtymillionwords.org

https://bridgethewordgap.wordpress.com/white-papers-other-resources/

 

The Lingering Effects of Teasing and Bullying:

I. Traumatic Impacts

I asked Howard, a 60 year-old man with a history of depression, about the social shyness for which he sought my help. Then, he told me the story of how he had been teased and bullied years before.

“When I was in the fifth grade, we moved from a neighborhood where I’d grown up the first 10 years f my life. I had friends and felt pretty good about myself. One of the fastest runners in the school, I could hit a baseball far for a 10 year-old. In retrospect, I guess I felt very equal to my friends. It was back at a time when kids had free run of the neighborhood from the library about half mile away to the big park across a busy street to a neighborhood shopping strip a few blocks away where there was a popular deli. My father used to take me there for breakfast before we would go for an outing on a Saturday. Or give me ten dollars and a list of things to buy from the bakery counter and bring home.

“Then we moved up to a more affluent area where the kids were way more sophisticated than where I had grown up. They dressed in the latest clothes, knew all the latest popular music, even knew how to dance. The athletic boys knew how to play basketball. There was no basket in the play ground at my old school, and I didn’t know anything about the game.

“So, I remember being teased by the popular kids for what we would now call being a nerd. How being clever turned into a bad thing puzzled me completely. My clothes didn’t fit in; I was ashamed of that. Someone teased me for my facial features, which were ordinary, I guess. I have to admit that a couple of years later I joined in picking on another kid for his looks. I guess we knew we were being cruel for no good reason. No, I didn’t have one particular villain. Just that there were several kids who had nothing to do with me except to say derogatory things. That hurt.

“But there was this one kid, Billy, a real troublemaker, who took everything one step farther. He was scary. He ended up in a reform school. That’s what they called it in those days, you know, for the dangerous kids. If one kid would only go so far as to say I was a bookworm – an old term for nerd, I guess – Billy went further, knocking the books out of my hand. Once, he knocked them into a puddle. If a kid might just say my nose was too big, that Billy put his palm over my face and pushed me. He always took it farther than anyone else. If some one said something about my clothes, he’d pull me by a shirt, ripping off a button, or yank the back of my collar until I fell. A real piece of work. We was a mediocre athlete, but he liked to show off that he had the best looking girlfriend or the biggest entourage. So, he would come by the school yard, but not right after school. Later. So, I got to play baseball or learn basketball. I knew to clear out by 4:30 or so, if I remember right, and keep out of his way.

“I tried so hard to excel at what seemed important there. Like learning to dance. Spending hours learning to dribble and shoot baskets and field baseballs. I got some cool clothes – one of the kids who befriended me showed me how to pick.

“But I became a follower, and did not have the same level of self-esteem as in the old neighborhood. I became self-conscious, I always worried about my impression on others. I still am. That was not part of my thinking before moving there. So, then I got to be shy in the sense of afraid to approach people. I thought they would feel I was a bother. I defined myself as unpopular. That’s what I was. My friends could criticize me and I’d take it; I’d think there actually was something wrong with me which I had to fix. As time went on, my distance from the popular kids became a universe; so I just thought of myself as part of the unpopular and different group.

“Even over four decades later, what stands out most immediately from those days is the memory of the ‘lowlights!’ I mean the various teasing comments. I can remember a lot of good things, but the unpleasant stuff is what comes up in my mind first.

“It was not just the kids. My three most immediate memories of high school are a teacher of Spanish mocking me on the first day. It seems the teacher from the previous year must have said to her that I was good in Spanish and I raised my hand a lot. So a source of self-worth by being smart got put down on the first day in her class when she said in a critical way which was, I am sure, meant to put me down, “Oh, Howard ______, I heard about you, yes, Howard _______, I heard about you.”

“I remember feeling now there was almost nothing I could do to be accepted anymore. An English teacher made fun of me in class for a silly mistake on a test. I guess being a good student gets you blasted when you screw up. And a physics teacher did the same. I had winged it on a test – my fault for not studying more – and got a very poor grade. But the teacher didn’t have to announce it in class. I spent a week feeling two feet tall.

“After that, I felt equally bad when I aced a test and set a curve. Like no one would like me for that.”

“Fortunately, the skills I had shown when we moved to the neighborhood, which included spending hours practicing and a determination to master skills, helped me a lot. In my mind, getting near perfect grades in physics, a compulsion with me the rest of that year, showed up the teacher. Of course, that’s how the bullied think, that any future performance is in some kind relationship to the teasing. Proving you are better than they say. Or confirming you are as bad as they say. Now, it dawns on me the teacher probably felt reinforced by my improvement; she could get the impression that, if you mortify the kid, then he’ll do better!

Howard concluded, “I’ve been reasonably successful. But still I am afraid to approach people for fear of what they may say. Still I wonder if someone will sting me about my hair, of which there is obviously so much less, or my features or my clothes. So I pay too much attention to trying to impress people with my sports car, my bold colored clothes, art work, my upscale address, being in shape, playing great golf, trying to fit in. It’s a battle that can never be won. Each day that feels good and I think I am something special runs into the next when I am low and have to prove myself. So I’m depressed.”

Brittany told a different story.   At 56, she told the story of events 40 years before. More emotional than Howard, she was too upset to get into all the details. “I was slow to mature. So already when I was 13 or 14, I was noticed for being different, the outsider. But then the acne came. All kids got it in those days. Is it my imagination or it way less prevalent today? Look,” she said, pointing to her face, “pock marks. Lots of them. That’s why I wear a lot of make up.”

“The boys would call me names I won’t repeat. The girls, well, some took pity, which made me feel worse somehow. A few understood. There just wasn’t much you could do for it. Antibiotics. Washes. Visits to the dermatologist. Didn’t help all that much.

“Then there were the girls – nowadays we would call them ‘Mean Girls.’ Wow. They were brutal. I also had big cystic pimples on my back and the girls could see that in the locker room. They said and did things to make me feel contaminated, like it would infest them. I still can’t stand being looked at too much.

In fact, Brittany did far more to compensate than her story suggested. She developed an obsession with her appearance and a ritual compulsion to armor herself with medications, makeup, scarves, and a hairdo which would mask her scarring as much as possible. She had to get up an extra hour early in the morning in order to go through the ritual. Spontaneity was forbidden in her world.

These stories came to mind when I read a Chicago Tribune article, “The debilitating scars of bullying” by Candy Shulman (February 8, 2015)*.   Her brave disclosures demonstrate the inner experience of someone being teased. She notes that some years later, the bullied continue to think about the mistreatment while the bully often remembers nothing of his or her behavior.

Shulman’s story mirrors the stories of Howard and Brittany*. Particularly noteworthy is how the object of teasing and bullying develops a mindset that she is being bullied and has to protect herself from it even when it is no longer happening. Shulman thinks of it as a victim mind set.

She also points out how bullying shapes social perception and expectations. For example, she mentioned the expectation of hurt and loss, behaviors engendered by her childhood bully, which generalize to new situations later in life and throughout adulthood.

Similarly, Howard and Brittany spent their adult lives continuing to stave off teasing and trying to achieve a feelings of acceptance, feelings of which they had felt deprived during adolescence. Each forecast a likelihood that new situations and new people would treat them in the same humiliating and hurtful ways as they had experienced in adolescence. They compensated in ways they imagined would fend off attacks. This is classic avoidance behavior – continue to react as if the assault is coming even after the threat no longer occurs. We carry the threat around mentally and act as unremitting victims.

One of the most extreme reactions to bullying is to identify with the perceived violence of it and then to perpetrate violence upon the self or upon others. That makes the news. Suicidal thinking and suicidal actions as a result of bullying are amongst the strongest of reactions to it. Completed suicides attributed to bullying are often reported by the media. Mass shootings by teens and young adults are often explained as associated with chronic bullying. They have led to a movement to shift the attitudes of educators from overlooking bullying or rationalizing it to the expectation they will prevent it or stop it.

But one in five children report being bullied. Sometimes, the damage may be significant enough to shape lives, as we see with Howard, Brittany, and Ms Shulman.

In these days, one can cyber-bully, namely, leave teasing or hurtful comments on the Internet or in a chat or email or on Facebook. The cruel words do not vanish, but remain visible. Rather than delivering teasing in person, the comments can be hurled from a safe distance.   I wonder if that makes it easier to issue teasing. I wonder if the words are more impactful when on the Internet.

Another example comes to mind. Jesse* was 16 when his mother brought him to see me. It was March. He went to school for sophomore year for about two weeks back in September. Since then he had not been back to school. This was before schools had to have programs for children who were unable to go to school due to illness or, in Jesse’s case, emotional problems.

I had previously treated a number of children with school phobia, a form of separation anxiety in which the child is afraid to be away from parents or home. Often the child fears some dire event may take place when he or she is away or the parent may leave the family.

With Jesse, we found no evidence for school phobia. He was depressed, sad, and soft-spoken. He showed little emotion overall. A behavioral analysis of his problem with school showed that he feared two situations. 1) If kids in the hallways were loud, the noise startled him. He expected a fight would break out. He assumed it would become violent, and he could be hurt in the melee. While he had seen fights, he had never actually been harmed. 2) If he walked into class and anyone was already in the room, he expected to be watched and judged. He thought the other kids would think he was strange. He would feel embarrassed. He then thought that he would be singled out to be victimized. The escape from social situations due to the fear of being judged by others is a symptom of a mental disorder known as Social Phobia.

That particular situation in class had actually never happened. However, he had often been teased by an older brother. So the memory of that teasing was being generalized to the school setting. Furthermore, Jesse believed his father sided with his brother. So Jesse generalized that school employees – teachers and administrators – would not protect him. He expected they would join in the negative behavior. So in his world, there was no protection except to avoid the situation and hide at home. In his belief system, he had defined himself as a vulnerable victim.

At home, he did not feel entirely safe. His imagined fears made him anxious even there. But he felt relief that as a result of his avoidance no new episodes of harm could occur.

In order to motivate him, Jesse’s father took a stance many parents might take. In hopes of motivating the young man, Father admonished him, told him that at this rate he would not amount to anything, and said high school should be a good time in life. To Jesse, however, these efforts confirmed his feeling of being misunderstood, unprotected, and not measuring up to other children. In contrast to Father, Jesse’s mother tried to comfort him. She pleaded with him to go to school. She felt helpless to motivate him. As a result, many days would pass when she said nothing about his avoidance. When she backed off, Jesse experienced what we call intermittent negative reinforcement, namely, the relief that he could stay home while the unpleasant interactions in the family would not occur that day. Such avoidance behavior is remarkably stable and long-lasting.

Jesse’s mother had gone to school to complain to the Assistant Principal. However, the latter did not give her and Jesse a sense that the young man could be protected. Rather, the school threatened the family with repercussions for their son’s truancy.

In contrast to school phobia, Jesse presented with Social Phobia and school avoidance, failure to attend school due to a fear of the school setting or of other children. He had experienced some teasing, and he had witnessed bullying.

Can one be affected vicariously by witnessing bullying? Yes, indeed. Jesse projected himself into the shoes of kids he witnessed being bullied. He imagined what it would be like if that happened to him. He felt terrified by his thoughts. He imagined the helplessness that he felt standing by as a witness would be magnified if he were the actual victim. By remaining on the periphery of his school mates, he had few ties at school to motivate him to go just for positive social interactions with friends.

Whereas Howard’s and Brittany’s stories show the lasting effects of teasing and bullying, Jesse’s story shows the impact at the time it is happening. It even shows how witnessing others being bullied can affect bystanders. The story demonstrates how difficult it can be for parents to select an effective strategy to manage the situation.

The good news here is that Howard and Brittany had compensated effectively. So for them, the task in therapy was to help them desensitize the memories, change beliefs about themselves, and free themselves to experience contemporary life as it is, not as an echo of the past. In contrast, the therapeutic task for Jesse was more challenging. Namely, he did not have the successful life experiences Howard and Brittany could use in order to shift their thinking. He had limited emotional and family resources.   Furthermore, the changes needed to help him were not going to be mainly internal changes as we saw with Howard and Brittany. Jesse actually had to overcome inertia, avoidance, and fear and start going to school. In school, he would need a more positive set of experiences so that he would experience positive reinforcement for going rather than negative reinforcement for staying home. Also, both of his parents would need to learn more effective strategies for managing the situation.

And they did. While Jesse participated in a program of reprocessing his fears, Mother was willing to participate in a graduated program in which Jesse dressed for school and she drove him to the school, then home, without going in. When his anxiety at that subsided, she could escort him to the door, then home. After a few days of that, she escorted him through the hallway to the office. Later, she stood by the office and watched him walk through the hall on his own, even when other kids were present. Meanwhile, we reprocessed the fear of walking into a classroom and rehearsed going into class. Eventually, Jesse managed to go and to sit through a class. He used some tools we had discussed and practiced, including some 3 X 5 cards on which we wrote statements to help him cope, such as, “I can sit quietly. After one minute, when I look around, I see no one is paying attention to me.” “My prime job is listening to the teacher.” The following September, Jesse was going to school full days. We had rehearsed strategies for having his parents interrupt any negative interactions with his brother, and family life became more pleasant for everyone in the home.

As a psychotherapist, I come into the picture after the damage has been profound. The treatment approach is to desensitize memories and experiences of teasing and bullying, overcome avoidance, increase skills to manage the situation, shift thinking from victimhood and defectiveness to assertiveness and adequacy, re-design family interactions, and enlist supports from school personnel. In a follow-up essay, we will discuss some ways for parents to work with children to prevent or stop teasing and bullying before damage occurs, before psychotherapy may be required.

*Reference for the Schulman story:

http://www.chicagotribune.com/news/opinion/commentary/ct-bully-bullies-anxiety-panic-attack-perspec-0208-jm-20150205-story.html?dssReturn

*Note: The names and details of the stories of Howard, Brittany, and Jesse have been altered in order to substantially disguise the identities of real individuals.

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Posttraumatic Stress Disorder (PTSD) is a reaction which often occurs when a person has been exposed to extreme stress, trauma, or painful experiences. In other words, the person has experienced or witnessed actual or threatened bodily injury or some other extreme situation.
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